Objective.This prospective study accessed the lymph node involvement in patients with resectable pancreatic head or uncinate process adenocarcinoma undergoing pancreaticoduodenectomy (PD) with standard lymphadenectomy. Material and Methods.Medical records of 116 consecutive patients treated for adenocarcinoma in the head or uncinate process of the pancreas (AHUPP) at Naval Hospital (Varna, Bulgaria) between January 2004 and December 2012 were analyzed. Patients underwent a classic Whipple?s procedure or pylorus preservation with standard lymphadenectomy. We studied the frequency of lymph node involvement, the lymph node stations most commonly affected by metastases as well as the interdependence between the frequencies of the regional nodal metastases and the local/distant recurrence. Results.Out of 116 patients, 81 (69.8%) were lymph-node positive. The lymph-node stations most affected were station 13 (n=24), 17 (n=17) and 14 (n=13 each), 12 (n=5) and 8a (n=2) (P=0,016). The lymph node involvement affected the rates of local recurrence, which occurred in 20 of 75 (26,6%) and in two of 35 (5,7%) patients with and without lymph-node involvement (P=0,024). Regional nodal metastases from primary tumour correlated with the development of distant metastases, which oc-curred in 68% (51 of 75) and 28,5% (10 of 35) of patients with and without positive regional lymph nodes, respectively (P=0,011). Conclusion.PD with standard lymphadenectomy should be the procedure of choice in patients AHUPP. We establish a directly proportional correlation between the presence of metastatic lymph nodes independently of their number and the development of local recurrence and distant metastases.

Aims. This study aimed to assess whether lactate levels taken at the time of admission may be used to predict outcome in pa-tients with acute pancreatitis. Additionally, we aimed to ascertain whether admission lactate levels correlated with currently recognised prognostic predictors (modified Glasgow and CRP). Methods. Data from 183 patients presenting with acute pancreatitis was collected, including initial lactate, modified Glasgow score, 24 and 48-hour CRP and outcome. Results. A significant moderate strength correlation exists between both admission lactate and Modified-Glasgow Score (0.38); and between admission lactate and both 24-48 hour and 48-72 hour CRPs (0.37 and 0.42 respectively). We revealed significant strong correlation between the initial lactate and patient outcome of 0.62 (outcome determined by patient status of dis-charged/still inpatient/deceased at seven days post-admission). In addition, risk-ratio of HDU/ITU admission, between those with a lactate below 2.5 mmol/L and those with a lactate above 2.5 mmol/L, was 0.36 and the risk-difference 13% (p<0.05). Conclusions. Admission lactate levels correlate with outcome in acute pancreatitis and also with other recognised prognosis pre-dictors. Measurement of admission lactate represents a novel prognostic predictor adjunct that may enable earlier identification of patients with poorer prognosis, and thus should be measured on admission in all patients with acute pancreatitis

Background: Abdominal wall retention sutures are widely used in every-day surgical practice, but their potential effect on intra-abdominal pressure (IAP) has not been studied. Methods: we conducted a non-randomized prospective, double-blind clinical trial that enrolled a total of 37 patients who un-derwent elective surgery for abdominal pathology. Measurement of the intra-abdominal pressure was performed on the first post-operative day using the Kron method. The control group consisted of 20 individuals that underwent a lower abdominal lap-arotomy procedure, with no use of retention sutures. The study group included 17 patients receiving a lower abdominal laparot-omy procedure with the use of retention sutures. Results: Mean values of IAP for patients belonging to control group was 18,78 (SD 3,61) mmHg, while mean IAP value in the study group was 16,58 (SD 3,82) mmHg, a difference that was not statistically significant (p=0,08). Conclusions: the use of retention sutures for abdominal wall incision closure does not affect intra-abdominal pressure in elective surgery patients.

The lymphangioma is a rare benign tumor that usually develops during childhood asymptomatic. Rarely is located in the mediastinum and less than 1% of cases occur in the mesentery and retroperitoneum. This case report describes a case of a forty-six years old woman with giant mesenteric lymphangioma. The diagnosis was confirmed by abdominal CT of the patient. The patient who underwent complete resection of the lesi?n. She had an uneventful recovery. The lymphangiomas are usually asymptomatic and are often incidental findings on imaging studies. Differential diagnosis can be complex and the treatment of choice is surgical resection.

Fishbone is a rare cause of perforation of the digestive tract. We report a case of bowel perforation due to a fishbone, especially by its mode of revelation and the ensuing treatment. We present the case of an 46 year old male, who presented with inflammatory swelling of the left flank without gastrointestinal symptoms. In the recent past, the patient reported an accidental ingestion of a fishbone. Computed tomography showed a large abscess in the left side in which a fish bone adjacent to the digestive tract was noted. Laparotomy showed an abscess of the left flank abutting a blocked perforation of the transverse colon by an excluded fishbone. A flattening of the parietal abscess associ-ated with a toilet and drainage was performed without any action on the transverse colon. The postoperative course was une-ventful.

Biloma is a rare abnormal localized accumulation of bile outside billiary tree due to an injury. Spontaneous occurance of biloma is rare and may be associated with choledocholithiasis (3,6). A 15 years old male presented to us with complaint of bilious discharge from abdominal wound and abdominal distension with local-ized bulging for 3 days. Patient was giving history of blunt abdominal trauma 3 months back for which he had undergone laparoto-my. At laparotomy we found loculated collection of bile measuring 20 x 15 cm. Collection was drained and wall sent for histopatho-logical examination. Histopathological report is suggestive of fibrous wall. Diagnosis of biloma should be considered in any patient presented with bilious discharge from post-operative wound.

Spontaneous intramural small bowel hematoma is a rare complication of anticoagulation. Its clinical display is usually non typical and abdominal computed tomography yields the diagnosis. Medical management is usually sufficient in most of cases. We re-port a case of small bowel obstruction due to an intramural small bowel hematoma induced by an overdose of vitamine K an-tagonist with surgical management. A 68 year-old male with a 4-year history of stroke and use of vitamine k antagonist was admitted for mechanical small bowel obstruction. The diagnosis of intramural small bowel hematoma induced by overdose of vitamine k antagonist was confirmed through abdominal computed tomography and laboratory examinations. The patient underwent first a medical management. But as the clinical display was worsening, he underwent secondly a surgical management. Laparotomy found a massive intraper-itoneal hematoma, a thickening of the small bowel wall with multiple intra-mesenteric hematomas and scattered petechias. The patient died on the day 3 after surgery by a cardiogenic shock. Spontaneous intramural small bowel hematoma occurs rarely and medical management is sufficient in most of cases. Surgery is indicated in case of complications or signs of severity. The mortali-ty is most often due to cardiogenic shock by massive hemorrhage on a poorly heart monitoring course as it was the case in our patient.

Intramural gallbladder lithiasis is the condition where gallstones are located within the gallbladder wall. A 73-year-old man pre-sented at our department with right upper quadrant pain. Upon ultrasound, acute lithiasic cholecystitis was diagnosed and he was scheduled for laparoscopic cholecystectomy. During post-operative gallbladder dissection, along with intraluminal lithiasis, small greenish stones located within the gallbladder wall were identified. The pathological investigation confirmed the diagnosis of intramural gallbladder lithiasis with concurrent fibrosis and adenomyomatosis of the wall.

Vanek?s tumor is a rare and benign inflammatory fibroid polyp of the gastrointestinal tract. We present a case of a 76-year-old female patient with history of upper gastrointestinal hemorrhage. Endoscopy showed a sub-mucosal lesion of the antrum but the biopsies were inconclusive. The patient underwent an exploratory laparotomy with an-trectomy and Billroth II anastomosis. The histopathological examination confirmed the presence of an inflammatory fibroid pol-yp of the antrum. The inflammatory fibroid tumor of the stomach is an unusual lesion which can mimic many others benign or malignant patholo-gies. The complete excision of the lesion represents the treatment of choice. More extensive surgical resection is usually per-formed due to suspected associated malignancy.

Up to 15% of patients develop moderate to severe pain after hernioplasty. Surgical intervention is suggested when nonsurgical measures including medications and nerve block or ablation have failed to control pain. Removal of hernia mesh alone generally does not lead to lasting pain relief and neurectomy is often required. The main problem is the identification of the nervous structures in a surgically modified field. We propose the mesh removal, ethanol infiltration of fascia transversalis and spermatic cord, and a new preperitoneal mesh repair as an alternative in cases of post-hernioplasty neuralgia.