Haemobilia - A Rare Cause of Upper Gastro-Intestinal Bleeding

Haemobilia is a rare cause of upper gastrointestinal bleeding that consists of haemorrhage within the biliary tree. Most cases of haemobilia are due to iatrogenic cause, laparoscopic or open cholecystectomy, abdominal trauma, gallstones, hepatic tumours, vascular aneurism. We present the case of a male patient admitted in the surgery department for epigastric and right hypochondria pain, nausea and vomiting. Open cholecystectomy was performed with a trans-cystic tube drainage. Postoperative outcome was favourable but with a continuous decrease in haemoglobin level. In the 13th day postoperatively biliary drainage was 800 ml - haemobilia. Patient health status altered and melena and hematemesis occurred. Endoscopy, cholangiography and abdominal computer tomography (CT) were performed. The episode repeated in day 27 after initial surgery. Duodenotomy and exploration of the biliary tree was performed. Angiography was performed next day that revealed biliary-arterial fistula within segment IV of the liver followed by embolization. Haemobilia reoccurred fifteen days later and colonoscopy and angiography were performed. Embolization with metallic coils was performed. Patient outcome was favourable and was discharged 13 days after second embolization. Interventional angiography remains the first treatment option of haemobilia. Selective arterial ligation or hepatectomy remain the options in case of lack of angiography or insufficient results after embolization.

Primary umbilical endometriosis (Villar's nodule) - case study, literature revision

Spontaneous umbilical endometriosis, also known as Villar's nodule, is an unusual location of the endometrial tissue.Whilst in the case of umbilical locations secondary to surgical procedures endometriosis occurs quite frequently,the frequency of the primary umbilical location is lower than 1% of all endometriosis locations. The authors present such a case diagnosed in a young, nulliparous patient with no history of surgical procedures, the diagnosis being suggested by the presence of an umbilical tumor mass whose symptomatology concurs with menstrual periods. The aspects regarding differential diagnosis and the therapeuticoptions for the surgical cure of this type of lesion are discussed.

Abdominal compartment syndrome -- a major complication of large incisional hernia surgery

The incidence of Intraabdominal Hypertension (IAH) and Abdominal Compartment Syndrome (ACS) is underestimated within the surgery of large size parietal-abdominal defects, with the maximum transverse diameter above 10 cm, being considered the main risk factor for the development of intra abdominal hypertension, together with ventilatory restraint under 60% and obesity. Intraabdominal hypertension has a prevalence of at least 50% among critical patients and was identified as an independent life-threatening risk factor.However, doctors do not evaluate it properly and do not realize the potential lethal consequences of untreated intraabdominal hypertension. These consequences may be abdominal compartment syndrome, followed by multiple organ dysfunction and even patient death. The paper intends to highlight the importance of the early recognition of this pathology, as a key factor in the correct management of these complications.

[Surgical management of Meckel's diverticulum in adults--retrospective analyses of 62 cases]

Meckel's diverticulum (MD) is the most common congenital anomaly of the small intestine. We searched and analyzed the records of 62 cases with MD admitted in University Emergency Hospital Bucharest between 2001-2009. Sex ratio was M:F 3:1, with 74% male and 26% female. 51.6% (n = 32) of this where symptomatic and 48.4% (n = 30) asymptomatic, discovered during laparotomy for other reasons. The analysis highlights an increased frequency of symptomatic diverticulum at early ages, with a medium age of about 39.2 years comparing to asymptomatic group with a medium age of about 54.2 years. The diverticulum complication generated: occlusion--43.7% (n = 15), inflammation--37.5% (n = 12), bleeding, two cases of diverticulum tumor, an intussusception case and a perforation case with unknown object. 25% of the diverticulectomies were followed by postsurgery complications, the parietal suppuration being the most frequent (50%). Three patients died independent of the diverticulum or its resection, all three having an asymptomatic diverticulum. The difficult diagnosis and the seriousness of diverticulum complications force us to take into consideration DM in all cases of severe or chronic abdominal pain. The diverticulum has to be surgically removed to all patients under 50 years, especially men.

[Complicated Meckel's diverticulum in adult pathology]

Meckel's diverticulum is the most prevalent abnormality of the gastrointestinal tract seen in approximately 2% of the population. Diagnosing complicated diverticulum is difficult, for its capacity to mime multiple disorders such as appendicitis, ulcer disease, enterocolitis, Chron disease, sigmoid diverticulitis, cholecystitis, and it should be considered in all patients with unexplained chronic abdominal pain, nausea, vomiting, gastrointestinal bleeding, unexpected cause of intestinal obstruction or acute abdomen. Herewith we provide an illustrative presentation, emphasizing the difficulties in preoperative diagnosis of complicated Meckel's diverticulum and underlining the nonspecific nature of the subjective and objective findings. Both cases were admitted to our clinic with acute abdomen diagnoses--first case as a intestinal obstruction and in second case was acute appendicitis. Laparatomy ascertain that the cause of symptoms was the complicated Meckel's diverticulum.

[Late pancreatic metastasis from primary Grawitz tumor--surgical management]

Renal cell carcinoma (Grawitz tumor) is an epithelial tumor able, to develop, in some cases, very late metastases. The most frequent localization are: lung, bones and liver. Pancreatic metastasis are rare and appear late, sometime even after 12 years from primary renal tumor. In this cases the differential diagnosis must be made with primary pancreatic tumors. We present a case report of pancreatic metastatic tumor developed 5 years after right nephrectomy for renal cell carcinoma. We decide to perform cephalic duodenopancreatectomy (Wipple type).

[Incisional hernias with particular topography--alloplastic procedures]

The aim of the study was to analyse the particular features and treatment difficulties of paramedian incisional hernias.

MATERIAL AND METHOD

A retrospective study was performed on a series of 64 patients operated for incisional hernia with particular topography: right subcostal, right iliac and suprapubic area (following a Pfannenstiel incision). These cases represented 17.8% of the 360 patients with incisional hernias operated in our unit in the interval 2003-2007.

RESULTS

The majority of the cases were right hypochondrum (34 cases), followed by suprapubic (16 cases) and right iliac fosse incisional hernias (14 cases). An alloplastic reconstruction procedure with retromuscular polypropylene mesh was carried out in all cases. The follow-up was made at 1, 6 and 12 months. The most frequent local complications were juxtaprosthetic serohematic collections (4 cases - 6.3%), frequently associated with an extensive abdominal lipectomy (3 patients). Reccurence of the hernia was noticed in one case only (1.5%).

CONCLUSION

Mesh repair is the procedure of choice in incisional hernias, including those with particular locations, as justified by the low reccurence and morbidity rate.

[General principles of abdominal wall reconstruction--20 years of experience]

After 20 years of reconstructive abdominal wall surgery and almost five thousand surgical interventions for this pathology, most of them resolved with prosthesis, authors present a retrospective study concerning to increased biocompatibility, world dynamics of alloplastic solution and also the technical surgical problems that appears in incisional hernia repair. There are underlined two concepts: first--the maximal transversal diameter--that define the size of musculo-aponeurosis defect and the span of alloplastic substitution, in opposition to the old idea that allude to the size of hernia sack; the second concept--receptor prosthetic layer--define the interface between abdominal viscera and prosthetic material. This is not just a mechanical divider, being also a conjunctive and vascular support, helping prosthetic tissue integration.