DISSEMINATED PERITONEAL LEIOMYOMATOSIS - A RARE ENTITY, COMPLICATED BY LATE BLEEDING FROM THE ILEOCOLIC VEIN.

Leiomyomatosis peritonei or disseminated peritoneal leiomyomatosis (DPL) is an extremely rare condition affecting mainly women of childbearing age with estrogen hypersecretion. It is characterized by the presence of multiple histologically benign smooth muscle nodules on the peritoneal surface and subperitoneal tissue mimicking peritoneal carcinomatosis. There are no clear guidelines for the primary management and follow-up o these patients. Case report: We represent a 44-years-old woman admitted due to two retroperitoneal tumors diagnosed on routine ultrasound screening. There was a past history of hysterectomy for uterine leiomyoma. The blood assay was normal. MRI revealed two well-circumcised tumors with a size of 15 cm and 6 cm, respectively, with a characteristic of leiomyoma. The tumors were removed completely. Macroscopically, they appeared as well-circumscribed masses with grey to white color, a rubbery texture, and a whorled cut surface. On the first postoperative day, due to a sudden drop of hemoglobin from 127 g/L to 6.8 g/L and clinical signs of acute intra-abdominal bleeding, the patient was reoperated. The site of bleeding was from the ileocolic vein located at the lower pole of the tumor. It was successfully controlled by ligation. The patient had an uneventful recovery. After five years she is free of recurrence. DPL is a rare disease, sometimes mimicking peritoneal carcinomatosis. The preoperative diagnosis should be suspected in women of childbearing age with estrogen hypersecretion and concurrent uterine leiomyomas. The management depends on the patient's age, reproductive plans, multiplicity, and symptomatology of DPL. Single tumors are best treated by surgery with synchronous hysterectomy or myomectomy in case of uterine myomatosis. In the case of symptomatic multiple DPL and fulfilled reproductive plan, bilateral salpingo-oophorectomy or treatment with Gonadotropin-releasing hormone analogs is indicated. In asymptomatic multiple DPL, the removal of all nodules is not mandatory because of the benign indolent course. The long-term prognosis of DPL is excellent.

An analysis of missed cases with surgical emergencies admitted in non-surgical departments. Case series and а review of the literature.

INTRODUCTION: The delayed diagnosis in emergency surgery can be associated with significant morbidity and mortality and often lead to litigations. The aim of the present work is to analyse the outcome in cases with non-trauma surgical emergencies wrongly admitted in non-surgical departments. METHODS: A retrospective trial in two independent University hospitals was conducted. The first group encompassed the patients worked-up in the Surgical unit of Emergency department (2014-2018). The second one included all cases visited Emergency department (2018). Only cases with acute abdomen and delayed diagnosis and operation were included. The analysis included the proportion of the delayed diagnosis, time between admission and operation, intraoperative diagnosis, complications and mortality rate. RESULTS: In the first group there were 30 194 visits in the surgical unit with 15 836 hospitalizations (52.4%). Twenty patients of the last (0.13%) were admitted in the Clinic of Infectious disease and subsequently operated. The mean delay between hospitalization and operation was 3 days (1-10). Seventeen patients (85%) were operated with mortality of 10%. In the second group, there were a total of 22 760 visits with 11 562 discharged cases. Of the last, 1.7% (n=192) were re-admitted in a surgical ward, 25 of which underwent urgent surgery (0.2%). CONCLUSIONS: The missed surgical cases represent only a small proportion of the patients in emergency department. The causes for wrong initial admissions in our series were misinterpretation of the symptoms, insufficient clinical examination and underuse of US and CT. The careful clinical assessment, point-of care US and CT may decrease the rate of the delayed diagnosis.

Endoluminal negative pressure therapy in colorectal anastomotic leaks.

AIM: The aim of the present work was to perform an up-to-date review of the literature on endoluminal negative pressure therapy for colorectal anastomotic leak. METHOD: An electronic search in PubMed and Google Scholar and a manual search without language restrictions were performed on 25 January 2019. Only original series reporting endoluminal negative pressure therapy in colorectal anastomotic leaks were included. The primary outcome was the success rate (complete closure of the abscess cavity). The secondary outcomes were the rates of complications and stoma closure. RESULTS: Nineteen series with a total of 295 cases were analysed. The median distance of the anastomosis from the anal verge and the size of the abscess were 5.65 cm (4.9-10) and 6.0 cm (5-8.1) respectively. In 84.5% (78%-91%) the stoma was created at the first intervention. Neoadjuvant therapy was performed in 48.6% (3%-60%). Median 7 sponges (2-34) were used with median negative pressure 150 mmHg (125-700) for a median of 31 days (14-127). The success rate was 85.4% (80%-91%) with ileostomy closure in 72.6%. Complications were observed in 19% (13%-25%): abscesses 11.5% and anastomotic stenosis 4.4%. Laparotomy was required in 15% of the complications. The stoma was the only significant predictor for the success of the therapy (0.007, SE 0.004, P = 0.040). CONCLUSIONS: The initial experience looks promising with an 85% success rate, which precludes risky re-resections with redo anastomosis or Hartmann's procedure. Despite the good initial results, definitive conclusions cannot be drawn because of the small sample size and the lack of high-quality comparative studies.

A rare case of life-threatening extra-peritoneal bleeding a.

INTRODUCTION: Although inguinal hernia repair is a routine procedure and frequently performed as one-day surgery, we should be particularly aware of the possible complications, which could be life-threatening if not recognized in due course. CASE REPORT: We report a case of life-threatening extra-peritoneal bleeding after open inguinal hernia repair requiring damage control surgery. DISCUSSION: Several vessels can be responsible for massive extraperitoneal bleeding - external iliac vessels, lower epigastric artery, crema steric vessels and corona mortis. Although damage control surgery was developed to treat the severe trauma, it can also be a life-saving maneuver in cases as the presented one. Hemodynamic instability with distended abdomen is a primary indication for laparotomy, but in some cases the contrast CT provides valuable information about the location and the size of hematoma and can guide the operative approach - midline laparotomy or revision of the wound as in our case. To the best of our knowledge, this is the first reported case of life-threatening retroperitoneal bleeding after open inguinal hernia repair. The present case is a good example for the application of damage control in pathology considered as one-day surgery. CONCLUSIONS: Although casuistic, the life-threatening bleeding after open hernia repair should be suspected. The prompt surgical response with damage control can be life-saving maneuver even in the routine hernia surgery. Detailed knowledge of the anatomy and carefull dissection are required to avoid this kind of complications.

[Attempt for etiopathogenic treatment of acute superior mesenteric artery occlusion by combination of small bowel resection and percutaneous artery stenting].

Acute mesenteric ischemia secondary to arterial occlusion is a highly lethal condition, mandating early diagnosis and prompt therapy, to prevent, or at least to minimize, bowel infarction. Progress in understanding the pathophysiology of mesenteric ischaemia has led to novel methods of treatment, so that in some circumstances therapy may be purely medical. More often surgery is demanded and is frequently life saving. Percutaneous transcatheter procedures are increasingly employed in both diagnosis and treatment. Close collaboration between surgeons, radiologists, physicians and anesthesiologists is therefore necessary if clinical outcome is to be improved. This conclusion is drawn by the presented case report.

[Attempt for etiopathogenic treatment of acute superior mesenteric artery occlusion by combination of small bowel resection and percutaneous artery stenting].

Acute mesenteric ischemia secondary to arterial occlusion is a highly lethal condition, mandating early diagnosis and prompt therapy, to prevent, or at least to minimize, bowel infarction. Progress in understanding the pathophysiology of mesenteric ischaemia has led to novel methods of treatment, so that in some circumstances therapy may be purely medical. More often surgery is demanded and is frequently life saving. Percutaneous transcatheter procedures are increasingly employed in both diagnosis and treatment. Close collaboration between surgeons, radiologists, physicians and anesthesiologists is therefore necessary if clinical outcome is to be improved. This conclusion is drawn by the presented case report.