Massive Abdominal Bleeding Research Articles

Development of a two-hit lethal liver injury model in swine.

Noncompressible truncal hemorrhage remains a leading cause of preventable death in the prehospital setting. Standardized and reproducible large animal models are essential to test new therapeutic strategies. However, existing injury models vary significantly in consistency and clinical accuracy. This study aims to develop a lethal porcine model to test hemostatic agents targeting noncompressible abdominal hemorrhages. We developed a two-hit injury model in Yorkshire swine, consisting of a grade IV liver injury combined with hemodilution. The hemodilution was induced by controlled exsanguination of 30% of the total blood volume and a 3:1 resuscitation with crystalloids. Subsequently, a grade IV liver injury was performed by sharp transection of both median lobes of the liver, resulting in major bleeding and severe hypotension. The abdominal incision was closed within 60s from the injury. The endpoints included mortality, survival time, serum lab values, and blood loss within the abdomen. This model was lethal in all animals (5/5), with a mean survival time of 24.4 ± 3.8min. The standardized liver resection was uniform at 14.4 ± 2.1% of the total liver weight. Following the injury, the MAP dropped by 27 ± 8mmHg within the first 10min. The use of a mixed injury model (i.e., open injury, closed hemorrhage) was instrumental in creating a standardized injury while allowing for a clinically significant hemorrhage. This novel highly lethal, consistent, and clinically relevant translational model can be used to test and develop life-saving interventions for massive noncompressible abdominal hemorrhage.

Case report: Resuscitative endovascular balloon occlusion after iatrogenic injury of the common iliac artery during neurosurgical dorsal lumbar microdiscectomy.

This case report describes resuscitative endovascular balloon occlusion (REBOA) of the aorta in a patient with life-threatening iatrogenic bleeding of the right common iliac artery during elective dorsal lumbar spine surgery. REBOA is an emergency procedure for temporary intra-aortic balloon occlusion being increasingly reported and published since its inauguration in 1954. The interdisciplinary management of hemorrhage and technical notes for a successful REBOA procedure will be presented. A 53-year-old female patient was admitted to the neurosurgery clinic suffering from left-sided L5 radiculopathy. During surgery, the anterior longitudinal ligament was perforated and an arterial vessel was lacerated. The patient became hemodynamically unstable demanding prompt supine repositioning and cardiopulmonary resuscitation (CPR). REBOA enabled cardiovascular stabilization after 90 min of CPR and laparotomy with vascular reconstruction and contributed to the survival of the patient without major clinical deficits. The patient was discharged from the ICU after 7 days. Resuscitative endovascular balloon occlusion of the aorta is an emergency procedure to control life-threatening hemorrhage. REBOA should be available on-scene and applied by well-trained vascular surgery personnel to control vascular complications or extend to emergency laparotomy and thoracotomy with aortic cross-clamping in case of in-hospital non-controllable hemorrhages. In case of ongoing CPR, we recommend surgical groin incision, open puncture of the pulseless common femoral artery, and aortic balloon inflation in REBOA zone I. Hereby, fast access and CPR optimization for heart and brain perfusion are maintained. Training for REBOA is the decisive factor to control selected cases of in-house and outpatient massive arterial abdominal bleeding complications.

Safety and feasibility of indocyanine green injection through accessory incision in laparoscopic right hemicolectomy

Objective: To explore the safety and feasibility of indocyanine green (ICG) injection through accessory incision in laparoscopic right hemicolectomy. Methods: A descriptive case series study was carried out. Clinicopathological data of 29 patients with colon cancer undergoing right hemicolectomy at Department of General Surgery, Guangdong Provincial People's Hospital were retrospectively analyzed. All the patients received ICG injection through accessory incision at the beginning of operation. Results: Among 29 patients, 13 were male and 16 were female with a mean age of (60.8±7.7) years and mean body mass index of (24.3±2.8) kg/m(2); 3 were stage I, 19 were stage II, 7 were stage III. Pericolic, intermediate and main lymph nodes could be detected under near infrared fluorescence imaging (NIRFI) in all the cases. No.6 lymph nodes were observed in 3 cases, while no lymph nodes around superior mesenteric vein (SMV) were found. The average number of fluorescent lymph node was 14.2±6.1. The average developing time of fluorescence was (36.2±3.7) minutes. The average number of harvested lymph nodes was 22.4±8.2. There was no extravasation of imaging agent during the operation, and there were no intraoperative complications such as allergies, massive abdominal bleeding, peripheral organ damage, etc. Operative time was (113.1±10.7) minutes, blood loss during operation was (22.4±3.9) ml, ambulatory time was (1.2±0.4) days, time to the first flatus was (1.7±0.7) days, time to the first fluid diet was (0.7±0.4) days, and postoperative hospital stay was (5.8±1.5) days. No operation-associated complications such as anastomotic bleeding, anastomotic leakage, peritoneal bleeding, peritoneal infection, incision infection occurred after operation. Conclusion: ICG injection through accessory incision in laparoscopic right hemicolectomy is safe and feasible.

Biomarkers of lung damage with possible predictiveness of ARDS within CS in super high-risk patients with germ cell tumors.

411 Background: Germ cell tumors (GCTs) represent a highly curable disease; however, a small proportion of patients with super-high-risk characteristics (choriocarcinoma, massive lung metastases, choriogonadotropin > 50 000 mIU/ml) can develop choriocarcinoma syndrome (CS) and consecutive acute respiratory distress syndrome (ARDS) shortly after the chemotherapy start with high mortality rate. This study aimed to evaluate biomarkers of lung damage as predictive biomarkers for ARDS development within CS in poor-risk GCTs patients. Methods: This study included 23 poor-risk GCTs treated from November 2000 to May 2018 in National Cancer Institute in Slovakia for whom plasma samples before chemotherapy initiation were available. Plasma levels of lung damage biomarkers (surfactant protein (D-SPD), receptor of advanced glycation end-products (sRAGE), and club cell secretory protein – (CC16)) were evaluated by ELISA assays. Results: Five (22%) of 23 patients developed CS, and all of them died shortly after the chemotherapy start. with median of 7 days (4 - 35 days). Four of them developed ARDS within CS, while one patient died due to massive abdominal hemorrhage. Pre-treatment levels of s-RAGE and SPD but not CC-16 were significantly associated with CS development ( P = 0.03 and P = 0.04). Level of sRAGE and SPD correlated significantly with dyspnea, weight loss, extent of metastatic lung involvement and need of mechanical ventilation after chemotherapy start, as well as with PFS and OS, while CC-16 did not correlate with any of these factors. Conclusions: In this study we identified new predictive biomarkers for CS development in poor-risk GCTs. Abovementioned factors might help to improve the risk stratification of these patients with GCTs as well as discover new treatment approaches preventing ARDS development within CS which may result in enhanced treatment outcome.

Application of Chen's pancreaticojejunostomy technique in laparoscopic pancreaticoduodenectomy (116 cases report)

Objective: To investigate the safety and feasibility of longitudinal transpancreatic U-sutures invaginated pancreatojejunostomy (Chen's pancreaticojejunostomy technique) in laparoscopic pancreaticoduodenectomy (LPD). Methods: Clinical data of 116 consecutive patients who underwent LPD using Chen's pancreaticojejunostomy technique in Hunan Provincial People's Hospital from May 2017 to December 2018 were retrospectively analyzed. Among these patients, 66 were males and 50 were females. The median age was 58 years old (32-84 yeas old). All 116 patients underwent pure laparoscopic whipple procedure with Child reconstruction method, using Chen's pancreaticojejunostomy technique. The intraoperative and postoperative data of patients were analyzed. Results: All 116 patients underwent LPD successfully. The mean operative time was (260.3±33.5) minutes (200-620 minutes). The mean time of pancreaticojejunostomy was (18.2±7.6) minutes (14-35 minutes). The mean time of hepaticojejunostomy was (14.6±6.3) minutes (10-25 minutes). The mean time of gastrojejunostomy was (12.0±5.5) minutes (8-20 minutes). The mean estimated blood loss was (106.0±87.6) ml (20-800 ml). Postoperative complications were: 11.2%(13/116) of cases had postoperative pancreatic fistula (POPF), including 10.3% (12/116) of biochemical fistula and 0.9%(1/116) of grade B POPF, no grade C POPF occurred; 10.3%(12/116) had gastrojejunal anastomotic bleeding; 3.4%(4/116) had hepaticojejunal anastomotic fistula; 3.4%(4/116) had delayed gastric emptying; 4.3% (5/116) had localized abdominal infection; 12.1%(14/116) had pulmonary infection; postoperative mortality were 0(0/116) and 1.7%(2/116) within 30 days and 90 days, respectively. One patient died of massive abdominal bleeding secondary to Gastroduodenal artery pseudoaneurysm rupture, the other patient died of extensive tumor recurrence and metastasis after surgery. Conclusions: Chen's pancreaticojejunostomy technique is safe and feasible for LPD.It is an option especially for surgeons who have not completed the learning curve of LPD.

Postoperative Catheter-Directed Thrombolysis Versus Systemic Anticoagulation for Acute Superior Mesenteric Venous Thrombosis

Little data evaluate catheter-directed thrombolysis (CDT) therapy as a sequential treatment of emergent surgery for patients with acute superior mesenteric venous thrombosis (ASMVT). We compared the outcomes of ASMVT patients receiving CDT via superior mesenteric artery (SMA) with those who had systemic anticoagulation after emergent laparotomy. A single-center retrospective study of ASMVT patients receiving emergent laparotomy from May 2012 to April 2014 was performed. Patients in group I had postoperative systemic anticoagulation and patients in group II underwent postoperative CDT. The demography, etiology, imaging features, clinical outcomes, and complications were compared. Moreover, univariate analysis was performed to identify confounding variables of 30-day mortality. Thirty-two patients (20 males, mean age of 44.9±10.6years) were included, 17 in group I and 15 in group II. No significant differences of demographic data, etiology, baseline value, and perioperative comorbidity were found. The rate of complete thrombus removal was significantly higher in group II than group I (29.4% vs. 80.0%, P=0.001). The second-look laparotomy and repeat bowel resection (58.8% vs. 13.3%, P=0.002) were required in fewer patients in group II (20.0% vs. 70.6%, P=0.001). The incidence of short-bowel syndrome (SBS; 41.2% vs. 6.7%, P=0.001) and 30-day mortality (41.2% vs. 6.7%, P=0.001) were lower in group II. The 1-year survival was also better in group II (52.9% vs. 93.3%, P=0.014). The incidence of massive abdominal hemorrhage requiring blood transfusion and surgical intervention was 11.8% in group I and 20.0% in group II (P=0.645). The age, serum D-dimer level, SBS, and postoperative CDT were significant risk factors of 30-day mortality in this study. For ASMVT patients receiving emergent surgery and intraoperative thrombectomy, the algorithm with postoperative CDT via SMA is associated with more favorable clinical outcome compared with systemic anticoagulation.

A spindle cell anaplastic pancreatic carcinoma with rhabdoid features following curative resection.

Anaplastic pancreatic carcinoma (ANPC) accounts for ~5% of all pancreatic ductal adenocarcinoma cases. Due to its rarity, its clinical features and surgical outcomes remain to be clearly understood. A 74-year-old woman was admitted to Onomichi General Hospital (Onomichi, Japan) in April 2015 without any significant past medical history. Contrast-enhanced computed tomography (CT) revealed a 9.5×8.0 cm tumor in the body and tail of the pancreas. The patient developed acute abdominal pain 3 weeks later and the CT revealed massive abdominal bleeding caused by tumor rupture. The tumor increased in size and reached 12.0×10.0 cm in maximal diameter. The tumor doubling time was estimated to be 13 days. 18F-fluorodeoxyglucose (FDG) positron emission tomography/CT confirmed the absence of distant metastasis since FDG accumulation was detected only in the tumor lesion. Emergency distal pancreatectomy and splenectomy were performed. Histologically, the tumor was classified as a spindle cell ANPC with rhabdoid features. The patient succumbed to mortality 8 months following the surgery while undergoing systemic adjuvant chemotherapy for multiple liver metastases. ANPC is difficult to detect in the early stages due to its progressive nature and atypical radiological findings. Long-term survival can be achieved only by curative resection; therefore, surgical resection must be performed whenever possible, even if the chance of long-term survival following surgery is considered dismal. As the present case suggested, spindle cell ANPC with rhabdoid features is highly aggressive and curative-intent resection must not be delayed.

The impact of preoperative correction of coagulation disorders on massive abdominal bleeding during splenectomy plus perifundal devascularization for portal hypertension

The impact of preoperative correction of coagulation disorders on massive abdominal bleeding during splenectomy plus perifundal devascularization for portal hypertension

Predictors of Conversion in Laparoscopic-assisted Colectomy for Colorectal Cancer and Clinical Outcomes

This study investigated risk factors and impact of open conversion on outcomes of 207 consecutive patients who had laparoscopic resection of colorectal cancer at our institution. Conversion occurred in 15.9% of patients, mostly because of invasion to adjacent structures (30.3%), bulky tumor (21.2%), and adhesions (18.2%). Converted patients had significant larger tumor size, advanced stage, increased operative blood loss, time to walk independently, prolonged hospital stay, number of massive hemorrhage, ileus, anastomotic hemorrhage, abdominal hemorrhage, peritonitis/septic shock, and wound infection than completed laparoscopy patients. Factors associated with conversion were obesity [relative risk (RR)=6.92; 95% confidence interval (CI), 1.7-28.09], date of operation (RR=0.37; 95% CI, 0.15-0.95), advanced tumor stage (RR=7.67; 95% CI; 1.19-49.2), size (RR=1.97; 95% CI, 1.42-2.72), and rectum location (RR=2.73; 95% CI, 1.09-6.84). Converted patients had worse cumulative disease-free (P<0.001) and overall survival (P<0.001) than laparoscopic completed patients.

Self-expanding polyurethane polymer improves survival in a model of noncompressible massive abdominal hemorrhage

Intracavitary noncompressible hemorrhage remains a significant cause of preventable death on the battlefield. Two dynamically mixed and percutaneously injected liquids were engineered to create an in situ self-expanding polymer foam to facilitate hemostasis in massive bleeding. We hypothesized that intraperitoneal injection of the polymer could achieve conformal contact with sites of injury and improve survival in swine with lethal hepatoportal injury. High grade hepatoportal injury was created in a closed abdominal cavity, resulting in massive noncoagulopathic, noncompressible hemorrhage. Animals received either standard battlefield fluid resuscitation (control, n = 12) or fluid resuscitation plus intraperitoneal injection of hemostatic foam (polymer, n = 15) and were monitored for 3 hours. Blood loss was quantified, and all hepatoportal injuries were inspected for consistency. Before intervention, all animals initially experienced severe, profound hypotension and near-arrest (mean arterial pressure at 10 minutes, 21 [5.3] mm Hg). Overall survival at 3 hours was 73% in the polymer group and 8% in the control group (p = 0.001). Median survival time was more than 150 minutes in the polymer group versus 23 minutes (19-41.5 minutes) in the control group (p < 0.001), and normalized blood loss in the polymer group was 0.47 (0.30) g/kg per minute versus 3.0 (1.3) g/kg per minute in the controls (p = < 0.001). All hepatoportal injuries were anatomically similar, and the polymer had conformal contact with injured tissues. Intraperitoneal polymer injection during massive noncompressible hemorrhage reduces blood loss and improves survival in a lethal, closed-cavity, hepatoportal injury model. Chronic safety and additional efficacy studies in other models are needed.

Early and Late Presentations of Graft Arterial Pseudoaneurysm Following Pancreatic Transplantation

Graft pseudoaneurysm (PSA) following pancreatic transplantation (PT) is a rarely reported complication that has significant morbidity and mortality. Few case reports and small series of this complication exist. Retrospective review of files of 106 patients who underwent PT at the Tel-Aviv Sourasky Medical center between 1995 and 2010. Accessible asymptomatic patients (n = 35) were referred for graft PSA screening using ultrasound-Doppler. Eight patients developed graft PSA (8 %). All had early posttransplant sepsis. PSA incidence among patients who had perioperative sepsis is 13 %. Three patients developed early postoperative PSA, presenting as massive abdominal bleeding requiring urgent laparotomy and graft resection. Five patients were diagnosed with late-onset graft PSA between 3 months and 11 years posttransplant: clinical presentations were massive gastrointestinal bleeding (n = 2), acute renal failure (n = 1), and asymptomatic finding on screening ultrasound-Doppler (n = 2, 6 % of screened patients). PSA following PT occurs in 8 % of patients. Perioperative infection is a risk factor. Early PSAs present as massive intra-abdominal bleeding. PSA may develop years posttransplant, may be asymptomatic, but late rupture is possible and presents as gastrointestinal bleeding. We recommend screening of patients at risk with ultrasound Doppler for early detection and treatment of asymptomatic PSAs.

Cardiopulmonary Arrest on Arrival in an Infant due to Ruptured Hepatoblastoma

Cardiopulmonary Arrest on Arrival in an Infant due to Ruptured Hepatoblastoma

Recombinant factor VIIa and factor VIII treatment for acquired factor VIII deficiency: a case of repeated thrombotic endotracheal occlusion in a mechanically ventilated patient

Acquired hemophilia A is caused by autoantibodies to coagulation factor VIII (FVIII). Preoperative diagnosis is impaired by the lack of a personal or family history of bleeding episodes. Therefore, surgical procedures can lead to life-threatening hemorrhage [1]. We present a case of a 72-year-old woman who had no history of coagulopathy and who was undergoing hysteroscopy and abrasion in a district hospital. Persistent vaginal bleeding began immediately after surgery, resulting in vaginal hysterectomy on postoperative day (POD) 7 and multiple re-laparotomies with intermittent abdominal packing between PODs 8 and 37. Acquired FVIII deficiency was suspected on POD 30, but a disseminated intravascular coagulation and treatment with various pro-coagulants made the definitive diagnosis difficult. Bolus applications of recombinant factor VIIa (rFVIIa) and von Willebrandt factor-FVIII complex between PODs 33 and 38 plus prednisolone pulse therapy remained ineffective. Acquired FVIII deficiency was finally diagnosed upon admission of the intubated and ventilated patient to the intensive care unit of a university hospital on POD 40. Further FVIII was administered because of persistent surgical bleeding. Following massive abdominal bleeding on POD 44, the patient received FVIII for the next 24 hours and rFVIIa until POD 49. On POD 47, the abdominal bleeding ceased. Three life-threatening airway complications occurred under rFVIIa and FVIII therapy. On POD 40, the endotracheal tube (ETT) was completely obstructed by blood clots. On POD 46, pulmonary gas exchange rapidly deteriorated because of a huge thrombus in the left main bronchus (2 × 5 cm). On POD 49, a large endobronchial thrombus (2 × 7 cm), which was attached to the tip of the ETT, was fortunately extracted during the emergency removal of the ETT (Figure ​(Figure1a1a). Figure 1 A bronchial thrombus critically obstructed the airways in a long-term ventilated patient under recombinant factor VIIa and factor VIII therapy. (a) The thrombus (arrow) was still attached to the tip of the removed endotracheal tube. (b) The detached thrombus ... Each time, bronchoscopy showed only moderate diffuse bleeding from minor mucosal erosions. After the critical incident on POD 49, the patient was weaned from the respirator and eventually fully recovered. Intravascular thromboembolic events under treatment with rFVIIa and FVIII present a well-known complication [2,3]. Life-threatening thrombotic airway obstructions in a mechanically ventilated patient, however, are a rare complication. The fact that activated partial thromboplastin times (aPTTs) were spontaneously prolonged (53 to 66 seconds) and active bleeding was present during these events highlights the unpredictable local imbalance of pro- and anticoagulant effects during such a treatment. In conclusion, intensive care clinicians should be aware that minor lacerations of the bronchial mucosa in mechanically ventilated patients could lead to blood clots and critical airway obstruction under the treatment with rFVIIa and FVIII.

Strategies to Control Massive Abdominal Bleeding

Abdominal trauma is divided into blunt and penetrating causes. Massive intraabdominal hemorrhage after injury represents the most dangerous precipitating factor that can affect survival if not promptly managed. The first target to achieve management of bleeding patients is control of the source, and then adequate resuscitation and optimization of hemostasis. New procoagulant drugs as recombinant activated factor VII (rFVIIa) seem to play an interesting role in bleeding control after trauma. Our experience with rFVIIa in six patients who were refractory to standard treatments demonstrated a good survival rate after massive abdominal bleeding. Regardless of new drugs and new technologies, a multidisciplinary approach is the cornerstone of the primary care of the these patients.

Polytrauma—pathophysiology and management principles

Multiple injury results in a complex pathophysiological and immunological response. Depending on the individual injury pattern, the time elapsed after injury, and the systemic "danger response", the surgical treatment has to be modified. This overview provides new insights in the pathophysiology of the early danger response after polytrauma and outlines the main resulting consequences for surgical management. First, synchronically to the clinical assessment, life-saving procedures need to be performed rapidly, such as control of massive intra-thoracic or abdominal bleeding and decompression of the chest and brain, as standardized by advanced trauma life support guidelines. During the second phase of "day-one-surgery" damage-control interventions such as debridement, decompression and temporary fracture stabilization are needed to avoid an excessive molecular and cellular danger response. Trauma-adjusted surgical techniques are crucial to limit the systemic response known to put remote organs at risk. In the "vulnerable phase" when the patient's defense is rather uncontrolled, only "second look" debridement to minimize a "second hit" is recommended. After stabilization of the patient as indicated by improvement of tissue oxygenation, coagulation, and decreased inflammatory mediators, "reconstructive surgery" can be applied. Individually adjusted surgical "damage control" and "immune control" are important interactive concepts in polytrauma management.

Massive Abdominal Wall Hemorrhage from Injury to the Inferior Epigastric Artery: A Retrospective Review

To identify the etiology of inferior epigastric artery injury (IEAI) in patients referred to the interventional radiology service and determine the efficacy of diagnostic imaging and embolization in these patients. A retrospective review of patients referred to the interventional radiology departments at three university-affiliated hospitals from 1995 through 2007 was performed. Patients were identified and data were extracted from case log books and the electronic medical record. Twenty IEAIs were identified in 19 patients. The etiology of arterial injury was paracentesis in eight (40%), surgical trauma in three (15%), percutaneous drain placement in three (15%), blunt trauma in two (10%), subcutaneous injection in one (5%), stabbing in one (5%), and unknown in two (10%). Fifteen of 19 patients (79%) had an underlying coagulopathy. The diagnosis was confirmed by contrast medium-enhanced computed tomography (CT) in 14 (70%), tagged red blood cell scan in two (10%), and noncontrast CT in one (5%). Three patients (15%) had no diagnostic imaging. Contrast medium-enhanced CT showed active extravasation in nine of 14 patients (64%) and 13 of 14 exhibited active extravasation on subsequent arteriography. The sensitivity and specificity of contrast medium-enhanced CT for demonstrating active arterial bleeding were 70% and 100%, respectively. All 20 IEAIs were treated with transcatheter embolization, with an overall success rate of 90% and no complications. IEAI is most often an iatrogenic injury in a coagulopathic patient. Contrast medium-enhanced CT can be diagnostic for active bleeding, but in the setting of ongoing hemorrhage a negative study result should not preclude arteriography. Embolization is an effective means to control hemorrhage.

Gelatin Thrombin Granules for Hemostasis in a Severe Traumatic Liver and Spleen Rupture Model in Swine

Treatment of traumatic liver and spleen rupture is a major challenge for the surgeon. Because of their excellent blood supply and tissue structure, rupture of the liver and spleen is often associated with massive abdominal hemorrhage. Frequently the surgeon's only feasible option is partial or total resection of the organ. The purpose of this study was to test the hemostatic efficacy of gelatin thrombin granules (FloSeal) in a standardized severe traumatic liver and spleen rupture model in swine (representing a grade IV-V rupture) during severe hemorrhagic shock and coagulation disorder. Standardized combined penetrating liver and spleen rupture was inflicted in 10 anesthetized swine. Hemorrhagic shock was induced after heparinization. Gelatin thrombin granules were used to treat both the ruptured liver and the ruptured spleen. Blood loss, hemostasis, and 48 hours survival rate were quantified. Cardiorespiratory parameters, activated clotting time, and plasma fibrinogen level were monitored. After 1 hour and 48 hours a second look evaluation was performed to detect any postoperative hemorrhage. Ruptures were then examined macroscopically and histologically. Hemostasis was achieved with FloSeal in all swine. The mean amount of FloSeal used was 14 mL +/- 2.5 mL. Macroscopic and histologic findings after 48 hours showed excellent clot integration into the surrounding tissue without any adverse effects. Gelatin thrombin granules (FloSeal) are effective in treating severe penetrating rupture of the liver and spleen even during hemorrhagic shock, retransfusion conditions, and coagulation disorder.

A Case Report of Preoperative Diagnosis and Laparoscopic Resection of a Non-communicating Rudimentary Uterine Horn Pregnancy

A unicornate uterus with a rudimentary horn is a rare Mullerian duct abnormality. This uterine anomaly may cause variable gynecologic complications, including hematometra, endometriosis leading to acute pelvic pain, infertility, and obstetric complications, including miscarriage, preterm delivery, and rupture of the uterus, especially when the pregnancy implants in the rudimentary horn. To date, the standard treatment for the latter condition has been laparotomy, as patients usually experience massive abdominal hemorrhage or pregnancies too large to attempt laparoscopic removal. We report a case of a non-communicating rudimentary uterine horn pregnancy which was preoperatively diagnosed by ultrasonography, hysterofiberscopy, and magnetic resonance imaging, and then subsequently resected laparoscopically.

Giant ovarian cancer weighing 100 kg with poor prognosis

We encountered a patient with giant ovarian cancer with a tumor weight of 100 kg. The patient's girth measured 198 cm after approximately 4 years' duration, and she complained of dyspnea and inability to walk. Adnectomy was performed with intensive intraoperative monitoring. The ovarian cancer was entirely adherent to the parietal peritoneum. However, 10 h after adnectomy, she died of massive abdominal bleeding from extremely redundant parietal peritoneum caused by disseminated intravascular coagulation.

Interventional Radiology for Management of Celiac Trunk Bleeding after Pancreatic Surgery

A 58-year-old woman had massive abdominal bleeding from the splenic artery and the celiac trunk (A) 1 month after pyloruspreserving pancreaticoduodenectomy for duodenal adenoma with high-grade intraepithelial neoplasia. The bleeding was successfully controlled by interventional radiology. The splenic artery was occluded completely with 12 microcoils (A-E; large arrows), and a covered stent was placed into the left gastric artery (A, E, small arrows) by superselective catheterization. The liver received sufficient arterial blood supply from an abberant left liver artery (A, asterisk) arising from the left gastric artery, instead of the usual right liver artery. CT scan shows sufficient perfusion of the liver 9 days after the intervention (F, black asterisks), and shows the gastric artery stent (F, small arrows) and the microcoils (F, large arrows) in the splenic artery. Initially, the arterial perfusion of the liver and stomach appeared sufficient, but the splenic artery was at risk for splenic infarction. Later a 5 5-cm gastric ulcer developed at the lesser curvature, and was managed conservatively. Because of sufficient blood supply through the stented gastric artery, the ulcer healed without perforation. Splenic infarction (F, white asterisk) did occur from the compromised perfusion after occlusion of the splenic artery. The excess fluid surrounding the spleen was managed with interventional CT-controlled drainage (G). Perfusion of the left liver lobe segments II and III appeared diminished (H, asterisk), while the right liver lobe had sufficient blood supply from the portal vein. These complications were negligible compared with the life-threatening bleeding complications, which were successfully controlled. If surgical reintervention had been necessary, gastrectomy and splenectomy would have been the consequence. After full recovery the patient was discharged home from the hospital in fine condition. Six weeks after the procedure, repeat CT-angiography showed good blood flow in the stented left gastric artery and left liver artery. Bleeding from eroded vessels is a frequent complication after pancreatic surgery, especially after radical resection for pancreatic cancer, 8.6% in a series by Rumstadt and coworkers. Vessels in the immediate area are at risk of septic complications, for example the branches of the celiac trunk, which are dissected free during lymphadenectomy. Intestinal contents and pancreatic fluids from anastomotic leakage may cause erosion of vessels or A