Romanian Journal of Emergency Surgery

Oclussive bowel obstruction caused by an Unusually Late Case of Metachronous Colorectal Cancer After 22 Years

2026-05-28T19:46:52-07:00

Introduction: Metachronous colorectal cancer (CRC) refers to a new primary colorectal malignancy developing at least six months after the initial diagnosis and treatment of a primary CRC. While most cases occur within the first 5 years postoperatively, delayed presentations beyond a decade are rare and poorly characterized.

Case Presentation: We report the case of a 62-year-old male with a history of transverse colon cancer resected in 2003 and treated with adjuvant chemotherapy. In 2025, after experiencing multiple episodes of bowel obstruction and initially refusing surgery at another clinic, he presented to our surgical department with diffuse abdominal pain, nausea, vomiting, altered bowel habits, and bloating. Imaging revealed a thickened segment of the descending colon with near-complete luminal narrowing and upstream distension. Surgery confirmed two synchronous tumors: (A) a low-grade adenocarcinoma of the descending colon infiltrating to the subserosa without nodal metastasis (pT3N0R0) and loss of MSH-6 expression; and (B) a mucinous adenocarcinoma of the rectum infiltrating the muscularis propria without nodal metastasis (pT2N0R0) and also with loss of MSH-6 expression. The patient underwent total colectomy with ileorectal anastomosis and segmental jejunal resection. Postoperative recovery was favorable.

Conclusions: This case highlights the possibility of extremely delayed metachronous CRC, occurring over two decades after initial treatment. It underscores the importance of individualized long-term surveillance strategies and the role of colonoscopy in detecting asymptomatic lesions. Recognition of atypical recurrence patterns is essential for timely diagnosis and intervention.

Keywords: Metachronous colorectal cancer; colonoscopy surveillance; delayed recurrence; total colectomy; colorectal neoplasia.

Extensive Hemorrhagic Ascites and Peritoneal Necrosis in Acute Pancreatitis: Case Presentation and Review of Literature

2026-05-28T19:46:40-07:00

Introduction: Severe Acute Pancreatitis may rarely progress to catastrophic intra-abdominal complications including hemorrhagic ascites and diffuse peritoneal necrosis. These findings reflect advanced enzymatic tissue destruction, severe systemic inflammatory response, and high mortality risk. Emergency surgical intervention remains challenging, particularly in patients presenting with acute abdomen and rapid hemodynamic deterioration.

Material & Method: We present the case of a patient admitted with severe acute pancreatitis complicated by extensive hemorrhagic ascites and diffuse peritoneal necrosis requiring emergency surgical management. Clinical presentation, laboratory findings, computed tomography imaging, intraoperative findings, surgical treatment, and postoperative evolution were analyzed. A focused literature review was additionally performed using PubMed/MEDLINE and Google Scholar databases regarding necrotizing pancreatitis associated with hemorrhagic ascites, pancreatic necrosis, vascular complications, abdominal compartment syndrome, and emergency surgical intervention.

Results: Computed tomography demonstrated severe acute pancreatitis with extensive intra-abdominal fluid collections and suspected pancreatic necrosis. Due to progressive clinical deterioration and signs of surgical abdomen, emergency exploratory laparotomy was performed. Intraoperatively, large-volume hemorrhagic ascites associated with extensive peri-pancreatic and diffuse peritoneal necrosis was identified. Surgical management included evacuation of hemorrhagic collections, necrosectomy, extensive abdominal lavage, and drainage. Postoperatively, the patient required intensive multidisciplinary support because of persistent systemic inflammatory response and severe metabolic imbalance.

Conclusion: Hemorrhagic ascites associated with diffuse peritoneal necrosis represents a rare but severe manifestation of necrotizing acute pancreatitis. Early recognition, prompt multidisciplinary assessment, and individualized surgical management are essential in critically ill patients presenting with advanced intra-abdominal complications.

Bouveret Syndrome: Diagnostic and Therapeutic Challenges – A Retrospective Case Series and Literature Review

2026-05-28T19:46:33-07:00

Introduction: Bouveret syndrome is a rare variant of gallstone ileus characterized by gastric outlet obstruction secondary to the migration of a gallstone through a cholecystoenteric fistula. Due to its low incidence and nonspecific clinical presentation, diagnosis is frequently delayed, contributing to increased morbidity and mortality, particularly in elderly patients with significant comorbidities.
Material & Method: A retrospective observational study was conducted including all patients diagnosed with Bouveret syndrome between January 2018 and December 2024 at the Emergency County Hospital Târgu Mureș, Department of General Surgery I. Diagnosis was established using imaging, endoscopy, or intraoperative findings. Clinical, laboratory, imaging, and therapeutic data were collected from medical records. The primary endpoint was therapeutic success, while secondary outcomes included postoperative morbidity, length of hospital stay, intensive care unit admission, and in-hospital and 30-day mortality. Statistical analysis was descriptive, using medians (IQR) and proportions. In parallel, a narrative literature review was performed using PubMed, Web of Science, and Scopus databases to identify relevant studies addressing the diagnosis and management of Bouveret syndrome.
Results: Seven patients were identified, with a median age of 73 years and a predominance of female patients (71.4%). All patients presented with symptoms of gastric outlet obstruction. Computed tomography was performed in all cases and identified Rigler’s triad in 71.4% of patients, while a cholecystoenteric fistula was detected in 85.7%. Endoscopic treatment was initially attempted in 71.4% of patients but achieved a low success rate (20%). Surgical intervention was required in 85.7% of cases, with enterolithotomy being the most frequently performed procedure. Postoperative outcomes reflected the high-risk profile of the cohort, with frequent ICU admissions, major complications in over half of the patients, and a 30-day mortality rate of 42.9%. The literature review confirmed similar findings, highlighting the predominance of elderly patients, the diagnostic role of computed tomography, the limited success of endoscopic therapy, and the frequent need for surgical management.
Conclusion: Bouveret syndrome is a rare but severe cause of gastric outlet obstruction in elderly patients. Computed tomography plays a pivotal role in diagnosis, while surgical intervention remains the definitive treatment in most cases. The integration of institutional experience with current literature underscores the importance of early recognition and individualized management strategies to improve clinical outcomes.