A case of synchronous bleeding from esophageal varices and appendixin a patient with decompensated liver cirrhosis.

UNLABELLED: Lower gastrointestinal bleeding is defined as any bleeding localized distally to Treitz's ligament. The massive bleeding from the appendix is extremely rare and only 21 cases described in the English literature. CASE PRESENTATION: We present a 61-years-old patient with decompensated liver cirrhosis and bleeding from esophageal varices. He underwent band ligation by Six Shooter (Cook Medical, USA). Due to a massive bleeding from the lower gastrointestinal tract and a rapid decline of hemoglobin level to 3 g/dL, angiography was performed. It revealed a bleeding from distal branches of ileocolic artery, confirmed by the followed computed tomography angiography. The patient underwent appendectomy and was discharged in a good condition on the 6th postoperative day. CONCLUSION: The synchronous bleeding from upper and lower GIT should be considered, especially in the cases with portal hypertension. The angiography and computed tomography angiography are valuable diagnostic methods, able to localize the bleeding a thus to reduce the morbidity and mortality.

A modern combat trauma.

INTRODUCTION: The world remains plagued by wars and terrorist attacks, and improvised explosive devices (IED) are the main weapons of our current enemies, causing almost two-thirds of all combat injuries. We wished to analyse the pattern of blast trauma on the modern battlefield and to compare it with combat gunshot injuries. MATERIALS AND METHODS: Analysis of a consecutive series of combat trauma patients presenting to two Bulgarian combat surgical teams in Afghanistan over 11 months. Demographics, injury patterns and Injury Severity Scores (ISS) were compared between blast and gunshot-injured casualties using Fisher's Exact Test. RESULTS: The blast victims had significantly higher median ISS (20.54 vs 9.23) and higher proportion of ISS>16 (60% vs 33.92%, p=0.008) than gunshot cases. They also had more frequent involvement of three or more body regions (47.22% vs 3.58%, p<0.0001). A significantly higher frequency of head (27.27% vs 3.57%), facial (20% vs 0%) and extremities injuries (85.45% vs 42.86%) and burns (12.72% vs 0%) was noted among the victims of explosion (p<0.0001). Based on clinical examination and diagnostic imaging, primary blast injury was identified in 24/55 (43.6%), secondary blast injury in 37 blast cases (67.3%), tertiary in 15 (27.3%) and quaternary blast injury (all burns) in seven (12.72%). CONCLUSIONS: Our results corroborate the 'multidimensional' injury pattern of blast trauma. The complexity of the blast trauma demands a good knowledge and a special training of the military surgeons and hospital personnel before deployment.

[Laparoscopic treatment of Morgagni diaphragmatic hernia]. / Laparoskopsko lechenie na diafragmalna khernia v otvora na Morgani.

Morgagni-Larey diaphragmatic hernias are very rare. The defect of diaphragm is usually small and the disease passes asymptomatically. If complaints are present and surgical treatment is needed, two types of operative access could be performed--thoracic and abdominal. A 18 years old man with asymptomatic flow of the disease is presented. The laparoscopic treatment was successful. The possible aspects of operative technique are discussed.

[Padua ileal bladder--surgical technique for bladder replacement with continent ileal reservoir]. / Padua Ileal Blader--khirurgichna tekhnika za zamestvane na pikochniia mekhur s kontinenten rezervoar ot ileum.

A new technique for detubularized and originally reshaped ileal total bladder replacement following radical cystectomy for bladder cancer is described. The operative method is named "Padua ileal bladder". For first time it is described by Prof. Pagano et al., from the Institute of Urology, Padua University, Italy. The operative method was performed on a patient with invasive bladder carcinoma. The result was evaluated clinically, radiologically and urodinamically with follow-up from 6 months. The patient had perfect daytime and nighttime continence. The reservoir features were: high capacity of 550 ml, low pressure of 17 cm H2O and 30-50 cm H2O at the micturation. There was no ureteral reflux and we achieved complete emptying of the bladder using abdominal straining and perineal relaxation.