Spontaneous Heterotopic Pregnancy as an Uncommon Clinical Problem.

BACKGROUND: Heterotopic pregnancy refers to the simultaneous coexistence of an intrauterine and extrauterine pregnancy. In natural conception it is very rare, with a rising incidence in patients undergoing assisted reproduction technologies. It presents a serious diagnostic problem which is often misdiagnosed. Currently, there are no standard protocols for the treatment and diagnosis of heterotopic pregnancy. METHODS: Two rare cases of spontaneous heterotopic pregnancy are presented. RESULT: The first patient had a complete abortion upon which an extrauterine pregnancy was detected. The second patient, after an extrauterine pregnancy removal, progressed with an intrauterine pregnancy until full term and it ended with the delivery of a healthy infant. CONCLUSION: Two demonstrated cases underscore that whenever abnormal adnexal findings are presented and the beta-hCG blood test is positive, the possibility of a heterotopic pregnancy should be suspected.

Percutaneous embolization of persistent low-output enterocutaneous fistulas.

OBJECTIVES: To present and retrospectively evaluate the technique of percutaneous embolization of chronic enterocutaneous fistulas (ECFs) using n-butyl-2-cyanoacrylate and Lipiodol under fluoroscopic guidance. METHODS: Six patients with a total of seven post-operative low-output ECFs of the large intestine were treated. After fistulography a hydrophilic guide wire and a catheter were advanced through the ECF into the intestine. After dilation of the bowel with saline and contrast medium, the catheter was withdrawn into the enteric orifice and glue together with Lipiodol was injected while simultaneously pulling the catheter. RESULTS: Complete closure of all seven fistulas was achieved. There were no peri-procedural complications. In one patient 1 month following embolization a low-output enteric discharge was observed, but the ECF spontaneously healed 5 days later. In one patient 18 months after the embolization a new perforation due to diverticulitis close to the embolization site occurred and resection of the sigmoid colon was performed. One patient needed reoperation due to a recurrence of rectal carcinoma. CONCLUSIONS: In our series of patients, the presented technique of percutaneous embolization proved to be efficacious and easy to perform. It may have potential as a first-line treatment of low-output ECFs but a prospective study with a larger series of patients and a longer follow-up is required.

Necrotizing fasciitis: literature review of contemporary strategies for diagnosing and management with three case reports: torso, abdominal wall, upper and lower limbs.

Necrotizing fasciitis (NF) is an uncommon soft tissue infection, usually caused by toxin-producing virulent bacteria. It is characterized by widespread fascial necrosis primarily caused by Streptococcus hemolyticus. Shortly after the onset of the disease, patients become colonized with their own aerobic and anaerobic microflora from the gastrointestinal and/or urogenital tracts. Early diagnosis with aggressive multidisciplinary treatment is mandatory. We describe three clinical cases with NF. The first is a 69 years old man with diabetes mellitus type II, who presented with NF on the posterior chest wall, shoulder and arm. He was admitted to the intensive care unit (ICU) with a clinical picture of severe sepsis. Outpatient treatment and early surgical debridement of the affected zones (inside 3 hours after admittance) and critical care therapy were performed. The second case is of a 63 years old paraplegic man with diabetes mellitus type I. Pressure sores and perineal abscesses progressed to Fournier's gangrene of the perineum and scrotum. He had NF of the anterior abdominal wall and the right thigh. Outpatient treatment and early surgical debridement of the affected zones (inside 6 hour after admittance) and critical care therapy were performed. The third patient was a 56 year old man who had NF of the anterior abdominal wall, flank and retroperitoneal space. He had an operation of the direct inguinal hernia, which was complicated with a bowel perforation and secondary peritonitis. After establishing the diagnosis of NF of the abdominal wall and retroperitoneal space (RS), he was transferred to the ICU. There he first received intensive care therapy, after which emergency surgical debridement of the abdominal wall, left colectomy, and extensive debridement of the RS were done (72 hours after operation of inquinal hernia). On average, 4 serial debridements were performed in each patient. The median of serial debridement in all three cases was four times. Other intensive care therapy with a combination of antibiotics and adjuvant hyperbaric oxygen therapy (HBOT) was applied during the treatment. After stabilization of soft tissue wounds and the formation of fresh granulation tissue, soft tissue defect were reconstructed using simple to complex reconstructive methods.