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The frequency of upper gastrointestinal hemorrhage as a postoperative complication of cephalic duodenopancreatectomy remained constant for decades despite the overall decrease in the incidence of mortality occuring after cephalic duodeno-pancreatomy. It is the second most common complication after anastomotic fistulas, but more frequently fatal, especially when the pancreas is anastomosed with the stomach. The case presented here is of a patient of 55 years age, diagnosed in our clinic with vaterian ampuloma for which was performed cephalic duodenopancreatectomy and gastrointestinal and hepatobiliary continuity was restored by performing terminolateral pancreato-gastric anastomosis, termino-lateral hepato-jejunal anatomosis and termino-lateral gastro-jejunal anastomosis on a jejunal loop ascended transmezocolic. Postoperative evolution of the patient was marked by appearance of two episodes of upper gastrointestinal hemorrhage, the first being solved by relaparotomy and the second benefiting from the contribution of an endoscopic intervention. From this case, we analyze risk factors for upper gastrointestinal hemorrhage appearing after cephalic duodeno-pancreatectomy and its therapeutic modalities, starting from the fact that currently there is no consensus among experts on this matter.

It is well known that the diverticuli of the colon gets inflamed in 10-15% of cases, thus becoming clinical symptomatic as a diverticulitis, while in other 15% they will bleed, with the clinical aspect of an inferior digestive bleeding. Our study presents some clinical observations with diverticuli of the colon, that raised diagnostic and therapeutic problems.Between 2001-2010, 17 patients were admitted in the 3rd Surgery Clinic, University Hospital "St.Spiridon", Iasi, with asymptomatic diverticuli of the colon, that were put in evidence imagistically, intraoperative or on specimens after removal of the colon for other conditions;meanwhile, there were 15 patients admitted with complications of the diverticuli:5 patients had perforated diverticulitis (4-pericolic abscesses and one with peritonitis in the lower abdomen), 4 had rectal bleeding and the other 6 raised particular problems of diagnostic and treatment, being included in the present study.Five out of six underwent operation. One patient refused the surgical treatment. Postoperative evolution was favorable in 4 out of the 5 operated patients.The complications of colonic diverticuli present on admission under clinical aspects that usually mimic a colonic cancer. In these situations the imagistic examinations do not offer enough details to elucidate the diagnosis. Our six particular observations strengthen the dictum of avoiding the "mirage" of the first lesion. The extent of the surgical procedure in the case of patients with colonic diverticuli admitted under the clinical aspect of a complication is sometimes disproportionate and encumbered of increased mortality and complication rate.

We report the case of a patient operated in 2003 for renal clear cell carcinoma (CCRC), when left nephrectomy was performed. In the years following occur: lung (2004) and brain (2006) metastasis, pathological bone fracture in right femur (2007), which needed a complex treatment: polichimiotherapy, cobaltotherapy, right temporal metastasectomy, right femoral fixation with metal rod. In our clinic was hospitalised for serious upper gastrointestinal bleeding, severe anaemia (haemoglobin 5.8 g%, hematocrit 18.3%) produced by a ulcerated gastric metastasis. The inefficiency of medical treatment, patient and family desire to operate, have led us to practise Péan type gastrectomy necessary for palliative role (raising the hemorrhagic metastasis). Scarcity of the gastric metastasising of CCRC are discussed and also the surgical indication in the context of a plurimetastatic patient.

Since the introduction of capsule endoscopy (CE), several studies suggested a higher frequency of small bowel tumors (SBTs) than previously reported.We evaluated the prevalence, presentation and diagnostic work-up of SBTs in patients undergoing CE in a single referral center. During 2003 - 2009, 102 patients underwent CE. For each patient with suspected SBT at CE, with subsequent histological confirmation, we registered clinical and biological features, imaging methods performed and management.SBTs were detected in 4.9% of patients undergoing CE. The main indication for CE was obscure gastrointestinal bleeding. All patients had undergone, before CE, at least one procedure evaluating the small bowel. All patients had iron-deficiency anemia, some presented also other gastrointestinal symptoms. The main SBT type was gastrointestinal stromal tumor. Three patients underwent single-balloon enteroscopy; surgery was performed in all patients. No retention of capsule occurred. CE could be used as first choice as diagnostic tool when SBTs are suspected.

Gastrointestinal stromal tumors represent a heterogeneous group of mesenchymal tumors that can develop throughout the gastrointestinal tract. We present the clinical case of a patient with such malignancies occurred in the proximal jejunum and clinically manifested by a severe digestive hemorrhage with hemorrhagic shock and severe posthemorrhagic anemia. Pre-operative diagnosis was possible only through the Entero-MRI. The evolution was favorable after surgical extirpation. It's being discussed particular aspects of this lesion's entity and post-operative optimal attitude in this case.

The purpose of this study is to review our postoperative outcomes with liver packing in complex abdominal trauma.76 liver trauma were admitted for operative procedures in the Surgical Department of City Hospital Timisoara between April 1994 - September 2009 and 16 cases were identified in our series as requiring liver packing. In all cases, this method was efficient, with no postoperative bleeding. In the same time, there were specific complications such as bile leak or abdominal collections.despite a second procedure for packs removal and the possibility for specific complications, liver packing is an efficient method for severe liver trauma or complex abdominal lesions.

The aim of the study is to evaluate the outcome of a selected group of 24 patients who underwent surgery for refractory ascites, in a 10 years period, 1995-2005.Alcoholic cirrhosis (n=18), inferior cava thrombosis (n=2), splenic vein thrombosis (n=1), cryptogenic cirrhosis (n=3), with association of variceal bleeding and refractory ascites. The surgical procedures consisted of porto-sistemic shunts (n=12), peritoneo-saphene shunts (n=10), mesenterico-caval shunt (n=1), mesenterico-right atrium shunt (n=1). Early results were very good: no postoperative mortality, no general haemo-dinamic failure, no renal fonctional failure, no encephalopathy. 7 of 10 peritoneo-saphene shunts had an excelent evolution, but in three cases the results were unsatisfactory, the patients continuing the medical treatment. Except one patient who died after 2 years, for B virus and alcoholic abuse, all the patients survived 5 or more years. There was not evidence of digestive hemorrhage or uncontrolable encephalopathy and thrombocytopenia. The grade of esophageal varices was mantained lower than II, ascites remained minimum or absent, and biological parameters were normal or slightly elevated.In the absence of the technical and economical possibilities of TIPS and liver transplantation, surgery for intractable ascites is a good option in selected patients, especially in the absence of viruses and alcohol consumption, and can improve complications in the natural evolution of the disease.

Angiodysplasia (AD) of the gastrointestinal (GI) tract is a rare cause of surgical GI bleeding. It frequently poses difficult problems in diagnosis and treatment. The purpose of this study is to find answers to these problems for a better management of the AD patients.From 1982 to 2006 a total of 75 patients suffering of AD of the GI tract were operated in our center. They represent about 3.6% of total patients operated for GI bleeding in the same period. The age of the patients was between 9 and 81 years old, with two peaks: one between 21 and 40 years old and the other between 51 and 70 years old. The localisation of the lesions was: righ colon +/- ileum 31 patients (41.33%), stomach 13 patients (17.33%), jejunum 6 patients (8%), descendent colon +/- sigmoid 5 patients (6.66%), rectum 4 patients (5.33%), pan-colonic 4 patients (5.33%), sigmoid colon 2 patients (2.66%), cecum + transverse colon 2 patients (2.66%), ileum 2 patients (2.66%), sigmoid colon + jejunum 1 patient (1.33%), cecum + sigmoid colon 1 patient (1.33%), cecum +/- sigmoid colon + jejunum 1 patient (1.33%), jejunum + ileum 1 patient (1.33%), pan-colonic + rectum 1 patient (1.33%). According to Moore classifications 29 patients were type 1 (38%) and 45 patients were type 2 (60%). In one patient AD was associated with Crohn disease (type 4 Fowler).The main symptom in AD was repetitive GI bleeding, of various amplitude, often obscure in origin, the patients having many hospital entries. The medical examination that give us the best help was selective angiography which was positive in 34 of 40 patients (85%). Upper and lower endoscopy were give to 50 surgical patients, being diagnostic in 32 (64%). Histopathologic examinations confirm the diagnosis of AD in all cases, without using injection techniques. All patients were operated for symptomatic AD. Other 11 patients non included in this study were find to have angiodysplastic lesions on operatory specimens for other diseases. The main indications for operative in AD were: continuing digestive hemorrhage of growing amplitude with detected source (54 patients = 72%), inefficient endoscopic and angiographic hemostasis (8 patients = 10.66%) and patients with massive bleeding without any preoperative evaluation (13 patients = 17%). Intraoperative exploration produced little information because of the mucosal and submucosal localisation of the lesions. Operative panendoscopy was the most rewarding investigation. Various types of resections were practiced depending on the site(s) known or presumed of the lesions. Perioperative morbidity was 23% (21 patients), rebleeding being in 4 patients (5.33%). Perioperative mortality was 12% (9 patients) a consequence of advanced age, comorbid conditions and frequent extreme emergency of the operations.Although rare as a cause of surgical digestive bleeding, AD poses often difficult problems of diagnosis and treatment. In patients with GI bleeding, without evident cause, multiple investigated, especially elderly but not always, we must think of an AD.

The tumors of the small bowel are rare entities, whose incidence comprises ca. 1-5% of the total amount of tumors in the digestive tract. Most of the cases involve the ileum and duodenum is least involved. The most frequently encountered duodenal tumors are the Brunner's Gland Adenomas. We can encounter unique or multiple lesions, sessile or pedunculated which develop proximal to duodenal papilla and are usually less than 1 cm in diameter although 12 cm lesions have been reported. In most of the cases they remain asymptomatic and constitute incidental discoveries. Sometimes they can present complications such as obstruction, hemorrhage and malignant transformation. Diagnosis is difficult due to the lack of symptoms and is delayed by an average of 6 months from symptoms onset. Barium contrast studies and superior digestive endoscopy is performed in most of the cases to reveal the diagnosis, but other methods, such as CT or ultrasound can be useful. A case of duodenal adenoma is described; the patient was admitted suffering digestive hemorrhage, which resulted in melena, secondary anemia, and ulcerous dyspeptic syndrome.

Patients with cardio-vascular surgery are at risk for upper digestive bleeding due to several factors.To determine the utility of medication and endoscopy in preventing gastrointestinal bleeding (GB) after cardiovascular surgery.79 patients (60 males and 19 women, mean age 61 +/- 16.1 years) were prospectively included in the study from the 850 patients operated in the period 2004 - 2006. Inclusion criteria were: patients with digestive symptoms (dyspepsia) and with risk for GB (personal history of peptic ulcer, gastroduodenitis, esophagitis, hiatus hernia, gastric cancer, gastric surgery and GB). All patients with symptoms and partially patients with risk were evaluated by endoscopy. Patients received standard medication for prevention of GB.Prophylactic medication was partially efficient in GB prophylaxis vs. no prophylaxis (7% vs. 11% p0.05). Patients with endoscopy examination before surgery had significantly lower incidence of bleeding (6.6% vs. 10.9%, p0.05%).Gastrointestinal bleeding may occur despite prophylactic medication. Gastrointestinal endoscopy prior surgery may be useful in preventing the bleeding.

Variceal bleeding in liver cirrhosis is a medical emergency with a high mortality. The therapeutic options in patients with portal hypertension are: treatment of acute bleeding from varices, prevention of the first bleeding episode and prevention of rebleeding. Treatment of acute bleeding from varices includes: blood volume restitution, use of antibiotics for preventing bacterial infections, vasoactive drug therapy (terlipressin, somatostatin, vapreotide, octreotide), endoscopic band ligation for acute esophageal bleeding and endoscopic therapy with tissue adhesive (cyanoacrylate) for acute gastric variceal bleeding. Endoscopic treatments are best used in association with pharmacological therapy. In primary prophylaxis non-selective beta- blocker therapy and endoscopic band ligation are useful. Beta blockers, band ligation or both should be used for prevention of recurrent bleeding. In patients who fail endoscopic and pharmacological treatment for prevention of rebleeding TIPS and transplantation should be considered.

Gastrointestinal bleeding (GIB) is a frequent finding in intensive care unit (ICU) and has considerable morbidity particularly for the elderly. The most common etiology for upper digestive bleeding is the stress ulcer and for the lower bleeding the diverticular disease of the colon. The predictive risk factors for GIB are age, organ failure, mechanical ventilation and length of stay in ICU. Even though a 4.5 times increase in mortality is seen in these patients it cannot be directly correlated to the bleeding. Routine use of H2 inhibitors is effective only in high risk patients, opposing enteral nutrition which is valuable in all patients. Prophylactic measures resulted in a 50% decrease in incidence of GIB in ICU and also of the mortality. Most of the patients are now treated non-operatively.

Aorto-esophageal fistula is a rare entity, determining huge digestive bleeding with a very poor prognostic most often. We present the case of a patient with aorto-esophageal fistula of unknown origin, treated successfully in the Center of Surgery and Liver Transplantation from Fundeni Clinical Institute. A young man, 21 years old, was admitted in our clinic from another hospital for repetitive severe upper gastrointestinal bleeding, with hematemesis and melena, pale, asthenia, without any pain; the bleeding stopped when he was admitted. The upper digestive endoscopy and esophago-gastro-duodenal radioscopy with barium did not show any lesion. During the 7th day the patient presents sudden massive hematemesis with hemodynamic instability; during the surgery we found two subcardial ulcers (stress ulcers?) for which we have done excision and suture which temporary stopped the bleeding. After 14 days, the patient had another massive bleeding; the upper endoscopy shows 28 cm far from the dental arch a protrusive formation of 6-7 mm with a telangiectasis aspect and with a white spot (possibly a central ulceration); 1 ml pure alcohol was injected inside it with temporary bleeding ceasing. After 3 days the patient is bleeding again, with marked decrease in blood pressure; a Blakemore tube stopped the bleeding until surgery was performed. During the intervention an aorto-oesophageal fistula is detected; we made the excision of the fistula with simple suture of the aorta, subtotal esophagectomy, cervico-stoma and gastrostomy, with good postoperative evolution. After 4 months the digestive transit is restored by esophagoplasty with tubulized stomach placed behind the sternum. The diagnostic and treatment difficulties encountered in these kind of cases need to consider also an aorto-esophageal fistula diagnosis, especially for the cases with Chiari triad (mild thoracic pain, sentinel digestive bleeding and exsanguination). The Blakemore tube can save patient's life by ensuring temporary hemostasis and allowing the time for a definitive surgical intervention. The subtotal esophagectomy with cervicostoma and feeding gastrostomy, followed after few months by a esophageal reconstruction , is a solution for this extreme severe cases.

Understanding of the pathogenesis, diagnosis, and treatment of lower GI bleeding has drastically changed during the last 50 years, but it continues to be a frequent cause of hospital admission and also a factor in hospital morbidity and mortality. Acute lower gastrointestinal hemorrhage (ALGIH) represents only 20% of the GI bleeding and the small intestine is the site of hemorrhage in about 1% of cases. Although in the last four decades, diagnostic methods for locating the precise bleeding point improved greatly, still the adequate localization of the lesion is very difficult to achieve through algorithmic approaches. We performed a clinical study and we retrospectively analyzed 5 patients (mean age = 59,8 years, 1 female) who had a surgical intervention for acute lower GI hemorrhage in the last decade, in order to emphasize diagnosis difficulties when the bleeding arises from small lesions in the small bowel that is not easily accessible for direct visualisation. Surgery was the treatment of choice in every case consisting in segmental resections of the involved small bowel, along with viscerolysis and exploratory gastro-jejunostoma. The mortality rate was 20% (1 postoperative death of cardiac etiology). There have been no specific postoperative complications in the other four patients and a good outcome was reported. The diagnosis is particularly difficult and when colonic and upper gastrointestinal evaluations fail to identify a source of bleeding, a small intestinal source should be considered. We can conclude that the most important factor in the management of ALGIH is determination of specific localization of the lesion.

Small bowel diverticula are usually asymptomatic and rare. Digestive bleeding is a rare complication of jejunal diverticulum whose diagnosis and treatment are difficult. We report a rare case of hematochezia whose origin was a proximal jejunal diverticulum and not determined by endoscopic investigations. Bowel resection with primary anastomosis was the chosen surgical procedure. There was no complication until discharge nor was any recurrent bleeding or functional disorder of the bowel reported during follow-up. The clinical presentation, the different value of diagnostic tools and the therapy are discussed.

Gastrointestinal stromal tumors are those gastrointestinal tumors , which expression antigens for CD 117 and CD 34. GIST arise from c - kit gene mutation through inadequate function of KIT enzyme (thyroxine kinase). However, the name is gastrointestinal stromal tumor, their localisation maybe under esophagus, stomach, duodenum, small bowel or colorectal.. CT scanning shows tumoral mass with nonspecific affiliation thanks to this development extraluminal and exophytic. Digestive hemorrhage, through GIST with small bowel localisation was called "obscure" because of impossibility to detect preoperative a bleeding source. We present, two cases of hemorrhage through GIST with jejunal localisation, male 70 years old with 10 cm tumor, discovered through CT scanning such as tumoral mass in left hypochondrium and female 55 years old, with 3 m tumor, discovered through emergency laparotomy for severe digestive bleeding. Also, it is discussed the possibility of intraoperative diagnosis, criterion to appreciate benign and malign features of the tumors and to determine their mitotic index for the supervision of these two cases.

Although Meckel's diverticulum is the most common congenital abnormality of the gastrointestinal tract, complications in adults are rare, especially in the elderly. Lower gastrointestinal bleeding as a result of Meckel's diverticulum with ectopic gastric mucosa is unusual among the elderly. The case we report involved a 69 year old man with gastrointestinal hemorrhage found to be due a stromal tumor developed on Meckel's diverticulum. We considered our case interesting because of its rarity and of preoperative diagnosis difficulty.

Lower gastrointestinal haemorrhage (LGH) is a frequent reason for medical referral. It has an annual incidence ranging between 17 and 20.5 cases per 100,000 adults and represents 20-30% of all gastrointestinal haemorrhages.To evaluate the evolution of the etiologic spectrum of lower gastrointestinal bleeding.All the files of patients with lower gastrointestinal bleeding admitted in our unit between 1990 and 2001 were reviewed retrospectively. The annual admission and annual admission rates for each disease (disease/total LGH in a specific year) were analysed using linear regression.We identified 2565 patients with LGH (mean age 50.8+/-8.7 years, 1338 (52%) men and 1227 (48%) women). The annual number of patients had a linear increase (p0.05) from 103 in 1990 to 399 in 2001. The mean age of the patients increased linearly from 48.5 to 53 years (p0.05). The annual rate for some specific diseases has changed over time. There was a trend of increase for the colorectal cancer and polyps, which reach statistical significance for diverticular disease and haemorrhoids (p0.05). While the annual incidence for ulcerative colitis remained constant the annual rates decrease. For Crohn disease, angiodysplasia and radiation colitis no changes was found.

The risk factors in the immediate outcome of gastrointestinal bleeding were examined in a prospective study of 134 patients with liver cirrhosis. The hemorrhagic episode has a negative prognosis in the immediate outcome (p0.01), recording 48 (35.82%) deaths. The deaths occurred in the acute phase of bleeding (n = 18; 13.40%), after recurrent hemorrhage (n = 24; 17.23%) and in 6 other cases (4.47%) after sclerotherapy or surgical treatment of varicosities. After varicose veins sclerotherapy (n = 8), 2 deaths were recorded and 4 other after surgery (n = 22). The advanced stage of cirrhosis, Child C stage, (n = 62) was accompanied by most of deaths (n = 38; 61.29%) (p0.01). Among the risk factors responsible for death, there were recorded: encephalopathy (p0.05), jaundice (p0.01), altered general status ((p0.01) and increased seric level of bilirubin over 3 mg% (p0.001). Jaundice is among the risk factors with the highest sensitivity (83.33%) and seric bilirubin over 3 mg% has the highest positive predictive value (64.28%).

Authors present a rare case of upper digestive bleeding, the etiology of which is represented by a pancreatic papillary adenocarcinoma placed in the body and tail of the pancreas, with bleeding through the Oddi's sphincter, which causes difficult problems of medical and surgical diagnosis and treatment. The patient was known with acute cholecysto-pancreatitis of lithiasic cause, which has been surgically cured in 1977, being under treatment in the last years for the pancreatic injury which had been chronic pancreatitis and for hyperglycemia. The laboratory explorations emphasized a severe anaemia which was identified through upper digestive endoscopy (intermittent active bleeding from the major papilla) confirmed by echo and CT exam (heterogeneously body tissue of 10/8 cm diameter, involving the body and the tail of the pancreas). The medical treatment was complex, including proteic, hematologic, acido-basic, balance of hyperglycemia, and was followed by the surgical intervention consisting in body and tail pancreatico-splenectomy, followed by a postsurgical abscess, which required drainage. The surgical evolution was favorable. 6 months after leaving the hospital, the patient was admitted to medical diseases clinic with the diagnosis of deep right ileofemoral thrombophlebitis, duodenal acute ulcer and acute pneumonia of average right lobe, causing difficult problems of medical treatment. On this pathologic background, the diabetic failure also appears and the echo exam showing multiple secondary hepatic and peritoneal metastatic determinations. In medical literature we only met 13 similar communications, problems of diagnosis and treatment being very much alike to those presented.

A recent case of a Meckel's diverticulum diagnosed and successfully laparoscopically treated, triggered off a retrospective study on a series of 34 cases with Meckel's diverticulum admitted to the First Surgical Clinic between 1990-2003. We encountered 12 uncomplicated cases and 22 cases with a large panel of complications: 11 intestinal obstructions (volvulus 9, intussusceptions on a tumor-2), 9 cases with diverticulitis, 1 gastrointestinal bleeding and 1 case with Littre's inguinal hernia. Positive diagnosis was established intraoperatively and the surgical treatment was adapted according to the local situation (excision of the diverticulum or enterectomy). Out of 12 patients with uncomplicated Meckel's diverticulum 8 were subjected to prophylactic excision of the diverticulum. In 6 of these microscopic examinations were inclusions of gastric mucosa. Laparoscopy is safe, relatively inexpensive and efficient in the diagnosis and treatment of Meckel's diverticulum.

Pancreatic pseudo-cyst (PKP) represents a late complication of acute and chronic pancreatitis and of pancreatic trauma. Male sex is predominant (22/27). Average age is 43.9. PKP was most frequently associated with chronic ethylism (16), chronic pancreatitis (14) and acute pancreatitis (9), cancer (1). Ultrasonography (US) is the method used for surgical indication (parietal maturation, content) and lesion follow up. Internal drainage was used for 15 patients: 13 Jurasz cystogastroanastomy and 2 transduodenal cysto duodenostomy. External drainage was used with 9 patients. Topography was: cephalic (4), corporeal (6) corporeo caudal (13); with 4 patients topography could not be set (PKP over 15 cm). Postoperative complications occurred with 7 patients: upper digestive bleeding (4), pancreatic abscess (2), hemi-peritoneum (1). Surgical abstention (3 patients) was determined by: lack of cyst parietal maturation, progressively reduced dimensions and an acute pancreatitis episode. One patient deceased due to haemorrhagic recurrence in tryptic erosion of the portal vein. Surgical decision is supported by US. Surgical tactics shall be adapted to the topography and lesion. Inner derivation represents election indication in mature PKP. In some circumstances, external drainage is however necessary.

We report on a cirrhotic patient, with history of colecistectomy, admitted for acute digestive bleeding. Esogastric causes were excluded by endoscopy; due to continuous hemorrhage, the patient was operated in the next 20 hours. The cause was established during the operation; solitary omfalo-enteric varices, with active vascular fistula. Preoperative etiology of acute intestinal bleeding may be difficult to establish, sometimes even during the surgical intervention. We comment upon rare causes of acute intestinal bleeding, mainly ectopic varices determined by portal hypertension.

Incidents and postoperative complications of laparoscopic cholecystectomy (LC) are analyzed based on a series of 8002 patients who underwent the procedure during a period of seven years. Conversion rate was 2.02% (161 cases) and 6 (0.07%) death were encountered. Intraoperative hemorrhage (2.43%) could be controlled by intraoperative haemostasis in all but 8 patients (bleeding from the hepatic bed and from the cystic artery) which required conversion. Lesions of the bile ducts occurred in 16 patients (0.2%), 13 of them being identified during the operation and solved by conversion or laparoscopic choledochorraphy (for a tangential lesion). Postoperative complications required re-intervention in 45 patients: 11 for bile leak, 19 for choleperitoneum, 6 for hemorrhage, 4 for subhepatic abscesses and 5 for remnant CBD lithiasis. There was 1 puncture of the Douglas pouch in a case of choleperitoneum, 7 laparoscopic re-interventions and 25 open surgery re-interventions. EST solved postoperative bile leaks (from the gallbladder bed) successfully in 7 cases and remnant CBD lithiasis (5 cases). So, 44% of the cases were treated by minimally invasive means (laparoscopic re-interventions or endoscopic procedures). The majority of the incidents and postoperative complications were linked to the presence of an acute cholecystitis and were partially due to some technical limits of the laparoscopic technique of the gallbladder bed peritonisation. The minimally invasive treatment of postoperative complications, was very efficient and offered optimum healing conditions.

The authors present a case of recidivated upper digestive tract hemorrhage, in which the bleeding initially stopped under conservative treatment. Imagery showed a piloro-duodenal stenosis. During the preoperative care the hemorrhage is resumed abruptly imposing emergency operation. The lesion was an intraoperative surprise imposing the hemostasis at first, and then the surgical management of lesions of the digestive tract.

The transabdominal extensive oesophagogastric devascularization with gastroesophageal stapling, known as modified Sugiura procedure, together with other nonshuting operations are widely performed as the operations of choice for bleeding oesophageal varices, world-wide when the non surgical hemostatic procedure are not suitable. We present our experience in 10 selected cases, which have been operated on since 1994 till now in our unit, 6 elective and 4 as emergency, using the stapling technique of oesophageal transection. The results were good with no recurrence of re-bleeding in the postoperative period, with 1 death due to acute liver failure. We consider this procedure a good alternative, which remains the ultimate direct operation to control the variceal bleeding due to portal hypertension despite of many other procedures used to get the hemostasis in these cases of upper digestive tract bleeding due to portal hypertension.

This study present the "N. Gh. Lupu" surgical experience with Sugiura technic for bleeding caused by oesophageal varicose. Is a 5 years retrospective study with 30 patients who are submitted of this operation. After the results analysis our opinion is to do this operation in stabilised patient, but she is possible even in emergency.

The study is based on the analysis of 158 patients admitted in the "Fourth Clinic of Surgery" with diagnosis of "Upper Digestive Haemorrhage" (U.D.H.) between 1998-2002, emphasising the importance of the physiopathological chains induced by the ulcer bleeding; 119 cases (76%) were diagnosed with gastro-duodenal ulcer, 20 with portal hypertension (20%), 14 subjects were with gastric carcinoma (8.8%) and 5 with miscellaneous etiologies so called "rare circumstances" of U.D.H. (two patients with Idiopathic Thrombocytopenia, one case with Dieulafoy gastric ulceration and two subjects with Haemorrhagic Gastritis). All the patients were admitted in the first moment in the Intensive Care Unit where haemostasis were successfully obtained with drug therapy adapted to the physiopathological changes induced by bleeding, in the majority of cases with light bleeding (8 cases, 5.4%) or medium bleeding (139 patients, 87.4%); only in 9 subjects (6%) with severe haemorrhage surgery was indicated (posterior bulbar ulcer in which the surgical haemostasis was necessary). In 88 patients (55%) surgery was performed as an elective procedure--74 from them had haemorrhagic gastric or duodenal ulcers with a medium amount of bleeding and 14 observations for gastric carcinoma with a chronic bleeding. In most all the cases the postoperative evolution was in good terms. Two observations with severe U.D.H. due to rupture of esophageal varices occurred on hepatic cirrhosis were out of therapeutical proof (1.2% deaths from all the admitted patients with U.D.H.).

The article presents the case study of a 78-year-old , female patient with a gastric schwannoma, with the symptoms of a superior digestive hemorrhage and secondary anemia. A surgical operation was performed and the patient was healed. The preoperative diagnosis carried out by means of echographic, endoscopic and computed tomography examinations was gastric tumour. Histopatological examination performed during the operation led to the final diagnosis of gastric schwannoma.

7 cases, considered as being true etiological exceptions selected from 756 upper gastrointestinal bleeding, are presented. The causes of bleeding were: pancreatic pseudocyst with intracystic hemorrhage broken into duodenum (2 cases), the nonepithelial gastroduodenal tumor (3 cases), the aneurysm of gastroduodenal artery broken into duodenum (1 case) and the aortoduodenal fistula in one patient with a bilateral aorto-iliac by-pass (1 case). The etiological diagnosis could not be established in any cases before the operations. All the cases were operated on, the operation being imposed by the severity of bleeding and having the haemostasis as a main purpose.

According to literature the gastroenterologic consultations for iron-deficiency anemia are quite frequent. The aim was the evaluation of the part played by gastrointestinal examinations for the diagnosis of iron-deficiency anemia. There were 115 patients admitted in the Medical Clinic between 1998-1999, with iron-deficiency anemia in the absence of macroscopic bleeding who carried out upper or lower endoscopy. A digestive lesion which account for iron deficiency anemia was identified in 35% of the cases. In the upper digestive tract there were 60%, in decreasing order of frequency: peptic ulcer, gastric cancer, erosive gastritis, angiodysplasia. In the lower digestive tract were 35% of the cases (colorectal cancer, polyps, angiodysplasia and hemorrhoids). In 5% of the cases there were found synchronization of the digestive tract lesions. So the digestive tract examination is worth doing because it establishes the diagnosis in 35% of the cases with few symptoms. The digestive tract lesions are more frequent in the upper tract, but they are more severe in the lower digestive tract. The possibility of the synchronization of lesions proves the necessity of carrying out the complete examination of the whole digestive tract.

The author presents a rare case of postoperative gastrointestinal bleeding due to a hepatic vascular fistula. This was the result of corrosive attack on the liver in the portion who covered an acute perforate ulcer.

A patient, 23 years old, is presented. He was admitted on in our clinic for a lower, very bleeding rectal tumor, the macroscopically characters evoking quite sure a malignant neoplasm. Three successive histopathologically examinations remained inconclusive and only the fourth suggested the diagnosis of benign glandular polyp. That conclusion strongly contrasted with all the data obtained by the macroscopically examinations. Nevertheless the therapeutically option was in favor of a sphincter-saving surgery, the practiced operation being a pull-through rectosigmoid resection (Babcock). Recovery of the patient which is in a good condition at present (two years after surgery). The histopathological examination of the operative specimen stipulated like diagnosis: rectal haemangioma with component parts of lymphangioma. Carrying on, the paper presented a review of the literature data referring to the very limited experience of others authors, regarding clinical aspects, diagnostics and therapeutically problems of the rectal haemangioma. In similar cases presenting voluminous rectal (or colonic) possibly benign tumors, haemangioma like, macroscopically diagnostic being difficult or unsure, but also without a certitude for a malignant tumor, it is recommended a sphincter-saving operation, adapted to the general status of the patient. In cases with malignant characters at the final histopathological examination, on the operative specimen, the transformation of the initial intervention in a amputation type surgery may be a possible alternative.

Out of 584 cases submitted to colorectal surgery 461 (78.92%) were performed for cancer. Thirty-three patients (7.16%) necessitated immediate (1) or precocious reinterventions for bleeding, fistulae, peritoneal infections, bowel occlusion, necrosis or stenosis of the iliac anus. We are out the technical procedures chosen for each class of complications asking for reintervention. We registered 4 deaths, in aged patients with hard associated morbidity, with emergency reinterventions. We appreciate that a correct preoperative preparation reduces the rate of reintervention and an early reintervention reduces the post-operative mortality.

Despite all the diagnosis's technical progress achieved in the past years, there are possible haemorrhagic complications after abdominal surgery, creating problems of diagnosis and treatment. The author presents a rare case of postoperative gastrointestinal bleeding due to an ulcer of the jejunal mucosa, located quite close to a hepaticojejunostomy. The mucosal ulcer, with consequent severe, massive bleeding was caused by the migration of a thread from the hepaticojejunostomy, proved by histopathological examination.

Between 1994 (December)-1996 (May) 150 patients have been operated on using one or many stapling devices. The staplers disposable to us were the "Linear Cutter" or GIA (Gastrointestinal Anastomosis), "Linear Stapler" (TA) and "Intraluminal Circular Stapler" or EEA (end-to-end anastomosis) types, produced by ETHICON (Johnson and Johnson Ltd. Company). The principles operations performed were various digestive resections, intervisceralis anastomosis and interventions of reconstructions (in oesophagus surgery, ileal pouch etc.). The advantages of staplers applications are: a) the reduction of the time of operation, of the anesthesia, of the blood loss; b) a soft manipulation of the tissues; c) a smaller inflammatory reaction and the prevention of intraoperative septic contamination and d) a better and faster take back of the functionality of the anastomosis. There were only 4 intraoperative haemorrhages easy controllable. Postoperative complications: a) 3 haemorrhages medically treated; b) immediate leakage 1 patient after colorectoanastomosis, treated by Hartman colostomy; precocious, 7 patients and after 4-6 month, 2 patients. Corrective iterative interventions were necessary only in 5 patients. The operative mortality-1 patient, the cause of death being a bronhopneumonia after a radical oesophagectomy with oesophagoplasty (oesophageal cancer). There was not postoperative mortality depending of stapling application. We don't observed late postoperative complications like stenosis of various anastomosis, quoted in the literature, because the time of following of our 150 patients is too short (maximum 18 months). The conclusions are that the stapling devices are a real surgical progress with the conditions of a correct indication and adequate tactics and operative technique. The economical effort is justified and entirely compensated by the major benefits obtained for the patients.

The injection sclerotherapy of esophageal varices is an important path in the treatment of acute bleeding. This procedure is carried out either in emergency conditions concerning bleeding varices or in the chronic status, the sclerotic drug being injected into and round the dilated infraesophageal veins. This study shows the authors' experience beginning with 1992; since then, at Children's Hospital of Iaşi the injection sclerotherapy has become an usual method in the management of the oesophageal varices, especially in the chronic status. This method turns out to be very useful, because nu matter the etiology would be, allows the postponement of decompressive procedures until the child has a proper age.

Forty-five acute complications (perforations and upper digestive hemorrhages) occurring in 650 admitted and operated gastric cancer patients were investigated. Despite all problems raised by these complication (gastric cancer, most commonly in advanced stages and invading the neighboring areas, the poor general condition of the patients, age-related deficiencies), the authors regard the removal of the complicated tumor and sometimes wide gastrectomy (the concomitant resection of gallbladder, spleen, atypical liver resection transverse colon resection) as the only solution for the complications, the postoperative complications and early recurrences of the complications as well as mortality rate being at the same time reduced.

The meta-analysis of 5 trials for primary prevention and of 18 trials of secondary prevention emphasizes the effect of beta-blockers in the decrease of variceal bleedings in cirrhosis. Beta-blockers are reducing the bleeding events with 32% in the primary prevention and with 28% in the secondary prevention. The mortality is reduced by 15%, respectively by 23%. This is the first meta-analysis reported in the Romanian gastroenterological literature.

We proposed to investigate the following parameters regarding upper gastrointestinal hemorrhage occurring in the patients with acute pancreatitis: incidence, form of manifestation, severity, correlated to the clinical and morpho-pathological form of acute pancreatitis, cause (direct causality or morbid association). The study was carried out on the inpatients of the internal-medicine and surgery units over a period of one year. For sake of accuracy the study also included the cases submitted to necropsy over a period of 5 years. The practical experience has revealed that though gastrointestinal bleeding is not a frequent complication--9.1% in the patients with acute pancreatitis and 36.3% of the necropsied cases--it is often severe, which imposes the early recognition for its adequate management.

A study was made of 129 cases of upper digestive hemorrhage in patients with portal hypertension admitted at the Surgical Clinic of the Institute of Medicine of Chişinău. About 30% of the patients were late admitted, this delay being due to a misjudgment of patients' state and unawareness of the possibility a new and fatal hemorrhage may occur. A change in Blakemore tube design was done. Its use together with the routine hemostatic therapy resulted in hemostasis and discharge of 42% of the admitted patients. When conservative treatment failed and a recurrence of hemorrhage was imminent, emergency surgery was performed. The Tanner-Petrov surgery, splenorenal anastomosis and various types of organopexy combined with splenectomy proved to be the most successful. General lethality in the patients subjected to these surgeries was 6.2%, a smaller figure than that mentioned in the literature.

One hundred twenty-two benign tumors of subdiaphragmatic digestive tract admitted in the interval 1975-1988 at the III-rd Surgical Clinic of Iaşi are reported. Out of these patients 120 required surgical treatment, the remainder of 2 being treated conservatively (diffuse intestinal angiomatosis, Peutz-Jeghers' syndrome). The clinical evolution being atypical, the surgical intervention was required, in most of the cases, due to hemorrhagic and occlusive complications. Histologically, the polyps and schwannomas were prevalent. The diagnostic difficulties, especially in the cases with jejuno-ileal localization, are mentioned.