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Citation: Gencheva DG, Menchev DN, Penchev DK, Tokmakova MP. An incidental fi nding of heart echinococcosis in a patient with infective endocarditis: a case report.

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Enteroatmospheric fistulas (EAFs) are still the worst complication of the open abdomen. They lead to a significantly prolonged intensive care unit and hospital stay and to high mortality. Despite the various techniques described in the literature EAFs remain “a nightmare” for the patient, the surgeon, and the hospital. Here we describe a case of right colectomy for obstructing Crohn’s disease in a 26-year-old. On the 19th postoperative day, he developed a superficial EAF. Due to the frozen abdomen, neither resection of the anastomosis, nor implementation of the known techniques for treatment of EAFs were possible. This prompted us to modify the Pepe technique. The EAF was isolated from the upper and lower parts of the wound through deep-skin and subcutaneous sutures and the application of two small pieces of non-adherent plastic foil. The lower holes of a single drain, put through a piece of black foam, were placed over the fistula. The upper holes, which were enveloped with the foam, remained in contact with the wound. The drain was connected to a negative pressure of 125 mmHg. NPWT (negative pressure wound therapy) was also applied by two separate sponges and drains in the upper and lower part. The mainstay of EAF treatment is the isolation of the EAF from the abdominal cavity and subcutaneous tissue, supported by control of the sepsis and adequate nutrition. The proposed technique is applicable in cases with a single, superficial EAF on the background of the frozen abdomen with minimal lateral fascial retraction. As of today, due to the rarity of the condition and lack of randomized trials, EAFs still represents a unique challenge often requiring improvisation.

Background: Rectal cancer located in distal third still remains a technical challenge for surgeons. Transanal total mesorectal excision with laparoscopic assistance is quite new surgical approach for rectal cancer treatment that seems to solve some of the associated technical issues. The aim of the study was to present our experience in laparoscopy-assisted transanal total mesorectal excision. Materials and methods: After obtaining approval from the local Ethics Committee, a single centre prospective double-arm comparative non-randomized trial was initiated. With recruiting still in progress at present, between 27.02.2017 and 01.10.2017 four laparoscopy-assisted transanal total mesorectal excision procedures and two laparoscopic total mesorectal excisions were performed in the department of Endoscopic Endocrine Surgery and Coloproctolgy at the Military Medical Academy in Sofia. Results: There is no conversion in both groups. No postoperative mortality 30 days after surgery. The quality of total mesorectal excision was satisfactory in all patients estimated by the Quirque classification. There was no distal or proximal tumor involvement of surgical margins. In one of the cases, we reported positive circumferential resection margin. We had two cases with postoperative morbidity. Conclusion: Transanal total mesorectal excision with laparoscopic assistance is quite new minimally invasive surgical approach for rectal cancer treatment. Avoiding the procedure-related complications during the learning curve is essential before applying the method to every patient. Multicenter randomized control trial is needed so that we could answer the questions raised in this study.