Complicated small bowel diverticulosis--a case report and literature review.

We report herein the case of a small bowel diverticulum perforation which has caused peritonitis and consequently has led to operation. The patient, a 79-year old woman, was hospitalized due to etiological clarifying and specifying of a newly diagnosed diffuse liver pathology. During the hospital stay, she has received severe abdominal pain with features of peritonitis. Suspecting perforated appendicitis she has undergone an operation. The explorative laparotomy has identified a purulent exudation in the abdominal cavity, resulting from a perforated inflammatory jejunal diverticulum and multiple middle-size diverticula all along the small bowel and the colon. The reported case as well as the review of the literature have shown that various and sometimes potentially fatal complications could occur even for such a relatively banal insignificant entity as is diverticular disease in elderly patients.

[Hepatorenal syndrome]. / Khepatorenalen sindrom.

Functional renal disorders commonly complicate cirrhosis and ascits, and in its terminal stage is known as hepatorenal syndrome (HRS). HRS is defined as the development of renal failure in patients with advanced liver failure (acute or chronic) in the absence of other identifiable causes of renal pathology. It is a syndrome characterized by oliguria, severe renal sodium retention, circulatory instability with marked systemic arterial vasodilatation and activation vasoactive systems. Signs of renal functional impairment may be observed in more than 30% of patients with cirrhosis and ascites, but only about 5% showed typical signs of HRS. In patients with decompensated cirrhosis, HRS has been found in about 18% after 1 year and in 40% after 5 years of follow up. In this survey are showed the diagnostic criteria for HRS as set out by the International Ascites Club. According to this criteria HRS was considered present when serum creatinine was > 1.5 mg/dl and creatinine clearance < 40 ml/min. Several therapeutic approaches have been proposed to modify the altered systematic and renal hemodynamics occurring during HRS. Administration of plasma expanders or vasoconstricting drugs, peritoneovenous shunting, portosystemic shunts and transjugular intrahepatic portosystemic shunts have been used to reverse peripheral vasodilatation and improve vascular underfilling. Renal vasodilatators and prostaglandins have been administered to reduce renal vasoconstriction. Theoretically the ideal treatment for patients with HRS is liver transplantation. The prognosis for HRS is poor and treatment almost always unsatisfactory when liver transplantation is excluded. The best treatment of HRS is preventing precipitating factors.

[Iatrogenic lesions of hepatocholedocus in cholecystectomy]. / Iatrogenni lezii na khepatikokholedokha pri kholtsistektomiia.

This is a report on nine patients presenting different intraoperative lesions to hepatocholedochus, some of them diagnosed in the course of operation, and others- after the intervention. A variety of plastic repairs of the hepatocholedochus, including simple suture, Saple's operation or hepatodigestive anastomosis after Longmayre are performed. The probability of inflicting lesions, the underlying causes and the therapeutic approach to concrete cases are analyzed. Abiding to the principles of surgery is strongly recommended, such as: sufficient and appropriate operative access, atraumatic manipulations, drainage of the gallbladder bed and the like, with a view to perclude serious and sometimes fatal complications' occurrence, as well as making early diagnosis and accordingly taking the most opportune surgical solution to the problem faced.

[Francke's operation--a resolution for deep small echinococcal cysts of the liver]. / Operatsiia na Francke--reshenie pri dulboki malki ekhinokokovi kisti na cherniia drob.

The operation of Francke in hydatid disease treatment is described--puncture, aspiration, sterilization--with emphasis laid on the technical details. The indications for its practical implementation are specified--small echinococcus cysts, deeply located within the parenchyma of the organ, or diffuse abdominal echinococcosis. In diagnosing such cysts intraoperative ultrasonography is considered as absolutely necessary and mandatory. The operation is practicable in handling first-stage cysts according to Volynkin, containing thin echinococcus liquid only, whereas in the presence of daughter vesicles it is not indicated. Postoperatively, dispensary outpatient observation and chemotherapy of the hydatid disease are recommended with a view to promote radical cure.

[Primary malignant appendiceal tumors]. / Purvichni apendikularni maligneni tumori.

Primary appendicular malignant tumors are rarely met with, and account for 0.5 per cent of all intestinal tumors. Of them 99 per cent are assigned to four types of neoplasms--carcinoid tumors, mucinous cystadenocarcinoma, adenocarcinoma and adenocarcinoid. These tumors are discussed under a separate heading owing to their location, clinical manifestation and characteristic features of the therapeutic approach. All patients presenting malignant neoplasms should be mandatorily subjected to follow-up study, insofar as 15-20 per cent of them develop secondary malignant processes located in the gastrointestinal tract mainly. Appendectomy is a sufficient in size operation done in carcinoids up to 1.0 cm in diameter; right hemicolectomy is indicated in carcinoids exceeding 2 cm in diameter; in adenocarcinoma measuring 1 to 2.0 cm, the extensiveness of intervention depends on the presence of infiltration into the mesoappendix. In mucinous cystadenocarcinoma right hemicolectomy is the operation of choice. In adenocarcinoma and adenocarcinoid tumor right hemicolectomy is proposed as a radical intervention, in conjunction with oophorectomy in menopausal patients.

[Nonparasitic liver abscesses]. / Neparazitni abstsesi na cherniia drob.

Abscess of the liver is a comparatively rate, but very serious disease, necessitating the undertaking of diagnostic and therapeutic measures on an emergency basis. The principal diagnostic method currently in use includes two imaging techniques--echography and CT. In therapeutic respect the target puncture under echographic or CT control has rather limited scope of application. Surgical therapeutic approach is the leading one--laparotomy, drainage of the abscess, and arbitrary use of a Kerr drainage for the choledochus and regional antibiotic therapy.

[The surgery of huge retroperitoneal tumors]. / Vurkhu khirurgiiata na ogromnite retroperitonealni tumori.

Observations of successfully operated huge retroperitoneal tumors, one of them weighing 14.700 kg, are reported. The advantages for precise diagnosis of modern visualizing techniques--echography and computer tomography--and the inability to establish always an exact cytologic diagnosis by puncture aspiration biopsy are demonstrated. Total extirpation of the tumor with subsequent combined chemo-, radio- and immunotherapy is advised.