Doppler-guided transanal hemorrhoidal dearterilization versus conventional hemorrhoidectomy for treatment of hemorrhoids - early and long-term postoperative results.

BACKGROUND: A variety of effective methods for treatment of hemorrhoids has been proposed. In recent years, there has been an increasing number of studies comparing transanal hemorrhoidal dearterilization (THD) and conventional hemorrhoidectomy (CH), but the focus of most studies has been about the early postoperative results. The data about long-term outcomes is still limited. We aimed to compare Doppler-guided THD and CH with regard to early and long-term postoperative results. METHODS: The conducted prospective research included 287 patients who underwent CH (167 cases) or Doppler-guided THD with mycopexy (120 patients) between November 2010 and December 2015. Information on hemorrhoidal stage, demographic data, presenting symptoms, complications, duration of hospital stay, postoperative pain, patients' satisfaction and follow-up were obtained. Statistical tests were performed by SPSS 19.0. RESULTS: There was no significant difference between the studied groups according to gender, mean age, preoperative prolapse, pain and pruritus, hemorrhoidal stage and postoperative complications. Preoperative bleeding was more frequent in THD group (p = 0,002). The mean visual analog scale (VAS) pain scores in CH and THD groups on days 1, 2 and 7 were 7.01 vs 5.03, 5.07 vs 2.98, 2.39 vs 0,57 (p = 0,000). Practically, there was no difference in VAS on day 30 and patients' satisfaction at the 18th month. Mean hospital stay was 5,13 (CH) and 3,38 days (THD), p = 0,000. The postoperative follow-up was between 18 and 78 months (mean 46 ± 16 months). During this stage, 5 patients (2,99%) in CH group required surgery for recurrence. In THD group, 3 patients (2,5%), all with 4th-degree hemorrhoids underwent additional procedures (p 0,802). CONCLUSIONS: Doppler-guided THD seems to be an efficient and safe option for treatment of hemorrhoids, related to lower postoperative pain and excellent, similar long-term outcomes compared to CH. For advanced grades of hemorrhoids, Doppler-guided THD could be a valuable alternative, but there is a need for patients' selection. TRIAL REGISTRATION: (retrospectively registered) researchregistry 3090 .

[Parosteal osseous lipoma of the temporal bone concurrent with involvement of the parotid salivary gland]. / Parosteal'naya ossifitsiruyushchaya lipoma visochnoi kosti v sochetanii s porazheniem okoloushnoi slyunnoi zhelezy.

The paper describes a case of parosteal lipoma of the temporal bone, by simultaneously involving the parotid salivary gland. Computed tomography performed in a 48-year-old man showed that in the area of the posterior edge of the glenoid fossa of the right temporal bone there was a massive (1.5×1.7×0.9-cm) exostosis extending down from the skull base. The exostosis was surrounded by a 3.5×3.6×5.3 soft tissue mass that was located in the projection of the right parotid salivary gland with a capsule and minor calcifications. Morphological examination determined a sessile exostosis-like mass in the area of the periosteum of the temporal bone. Foci of desmal and enchondral ossification (types III and IV according to the classification of Miller et al.) could be seen in the adjacent fatty tissue. The tumor underwent necrotic and dystrophic changes (Milgram's Stage 3). Temporal bone involvement was accompanied by osseous sialolipoma of the right parotid salivary gland. In this case, the fatty component accounted for 60-80% of salivary gland volume. Terminal secretory segments, ducts, and bone trabeculae with calcification foci and hematopoietic elements were uniformly distributed among the fatty tissue. None similar case has been found in the literature.

[Immunohistochemical assay of murine liver tissue using monoclonal antibodies to NO-synthase 2 and TNF-α under tetrachloromethane toxic injury conditions].

Experimental data showing a significant role of enzyme NO-synthase type 2 and cytokine TNF-α enzymes in pathogenesis of CCl4-induced liver injury have been obtained by immunohistochemical assay. It is established that the hepatotoxic agent leads to an increase in NO-synthase 2 and TNF-α levels. The use of both studied phytoadaptogens (eleutherococcus extract and ginseng tincture) at a doses of 48.5 mg/kg and 47 mg/kg, respectively, and the reference drug karsil (100 mg/kg daily for 5 weeks) prevented to a significant degree the accumulation of enzyme NO-synthase 2 and the cytokine TNF-α, which is apparently one of the mechanisms of hepatoprotective action.

Clinical case of neuroendocrine malignant tumor with unusual localization in the adrenal cortex.

The authors present unusual clinical case with atypical diagnostic work-up and histological result of adrenal neuroendocrine carcinoma.

Diagnosis of liver hemangioma.

BACKGROUND: Benign liver tumors are now being diagnosed frequently with the advent of the greater use of imaging investigations. The most common lesion is the liver hemangioma 0.4-7.3%, with an incidence rate at autopsy ranging from 3% to 20%. MATERIAL AND METHODS: One hundred and one patients underwent operative treatment in the Department of General and Liver-pancreatic Surgery, UH "Alexandrovska" Sofia from 1995 to April 2013. There were 74 (73.3%) females and 27 (26.7%) males. Mean age was 50.7 years (range 25 to 77). Seventy-four patients (73.3%) had a solitary tumor. Methods for diagnosis included history of the disease, routine haematological and liver function tests, ultrasonography, CT, MRI or a combination of more than one technique. RESULTS: The diagnostic sensitivity of the imaging procedures was U/S 96.9%, CT scanning 98.3% and MRI 100% .The diagnostic specificity--U/S 60.3%, CT scanning 55.0%, MRI 85.7%. CONCLUSION: Hepatic hemangioma is diagnosed in most patients using non-invasive studies such as US, CT and MRI or a combination of them.

[Sepsis--current aspects].

Sepsis is defined as a clinical syndrome of systemic response to infections. With progression of the disease develop organ failure (i.e. severe sepsis) and hypotension (i.e. septic shock) and mortality increases significantly. Sepsis is an interdisciplinary problem, cause significant morbidity and mortality and higher hospital costs. Deepening ofinflammation, immunity distortions, coagulation and oxygen perfusion have a major role in organ dysfunction and death. Proper diagnosis of sepsis requires an understanding of risk factors, a high index of suspicion and anatomic approach to the localization of the infectious focus. Early detection of septic patients is crucial for the outcome of disease in the application of reasoned therapy. Future treatment of sepsis associated with a better understanding of the molecular bases of pathological process.

[Contemporary surgical treatment for unresectable periampullary tumors. Double or tripple by-pass surgery].

BACKGROUND/AIM: Pancreatic neoplasms continues to be a highly lethal disease with poor prognosis. This single-institution experience reviews the palliative surgical techniques used in a group of patients with periampullary tumors accenting to a technique of pancreato-wirsungo-jejunostomy, protesed with "perdue"-drain and combined with gastroenterostomy. MATERIALS AND METHODS: For the period of 01.01.2006-31.12.2007 in the Clinic of General and Liver-Pancreatic Surgery of University Hospital "Alexandrovska" are operated 162 patients with pancreatic cancer. 113 of them are with periampullary localization of the tumor, 49 are with localization at the body or at the tail of pancreatic gland. In 97 of the cases a different palliative procedures was performed. In two cases the technique of pancreato-wirsungo-jejunostomy, protesed with "perdue"-drain and combined with gastroenterostomy was performed. RESULTS: The levels of the postoperative mortality and morbidity in patients with palliative surgical procedures are 6.2%, respectively 39.2%. The level of early pastoperative morbidity and mortality in cases with pancreato-wirsungo-jejunostomy, protesed with "perdue"-drain and combined with gastroenterostomy is 0%. CONCLUSION: For patients with advanced periampullary malignacies, the prevention and alleviation of suffering due to obstructive jaundice, gastric outlet obstruction, cancer-related pain and pancreatic exocrine insufficiency is of primary importance. We think that the operative technique is represented by us useful often at patients with chronic pancreatitits, but the tehnique will be useful in given conditions for patients with unresectable periampullar pancreatic neoplasms.

[Improved technique for internal biliary-digestive drainage during conventional palliative procedure of nonresectable tumors of periampullary region].

AIM: We represent variation of bilio-digestive stomy with "lost" protecting drainage during conventional palliative procedure of nonresectable tumors of periampullary region. MATERIALS AND METHODS: During the period 01.01.2008 -31.05.2008 in the Clinic of general and liver-pancreatic surgery-"Aleksandrovska" Hospital, Sofia, we applied modified technique for internal bilio-digestive prosthetic drain with "lost" drainage, protecting choledocho-duodenostomy in 12 patients with nonresectable tumors of periampullary region. Eight of them are males and 4--females, with age between 60-82 (average 64,5). In 8 patients we found nonresectable malignancy of the head of pancreas and in 4 nonresectable malignancy of distal part of the common bile duct. RESULTS: We follow the early postoperative results and postoperative period during tree months. We did not have insufficiency of the choledocho-duodenostomy and that afford early discharge of the patients. At the end of third month we haven't observed jaundice or other complications cause of obstruction of protecting drainage. CONCLUSION: We consider that the technique is useful and appropriate when doing choledocho-duodenostomy cause of nonresectable periampullary neoplasms. The using of this technique don't increase the postoperative morbidity and improve early postoperative results.

[The implementation of the automated information systems in health management of regional level].

In public health, the problem of professional community staff disbalance is rather critical and the training of medical professional personnel is deficient. The decisive role in the solution of the mentioned problems belongs to the automated information systems and computer-based technologies. In the Nijegorodskaya oblast, the accessible and effective system of training executive personnel reserve is developed and implemented to strategically develop the executive mangers potential and to enhance the effectiveness of functioning of the curative preventive institutions.

[Biliurolithiasis - a classification of a disease with complex characteristics].

The development of the medicine itself, meets the current question of the common, interdisciplinary method of approach in the treatment of a series of diseases, such as biliurolithiasis. The attempt to make a classification is basic for making an optimal method of treatment of the biliurolithiasis. The biliurolithiasis is a disease influencing some new strategies of treatment in the combined efforts of the urologist and the surgeons both.

[Gastric cancer - current state of the problem. Part I. Epidemiology. Pathology. Classification. Staging].

Gastric cancer is still rampant in several countries around the world. His incidence exhibits significant geographic variability. The disease is most common in East Asia, and high rates of occurrence have also been reported in Central and South America, Eastern Europe, and parts of the Middle East. In Japan, gastric cancer remains the most common type of cancer among men. The overall incidence of this condition has decreased in the past few decades, nonetheless, gastric cancer remains a major public health issue as the fourth most common cancer and the second leading cause of cancer death worldwide. The reported reductions in gastric cancer mortality may be linked to better refrigeration and a concomitant decrease in the intake of salted, pickled, smoked, and chemically preserved foods; however, this link remains controversial. Another relevant change in the epidemiology of gastric cancer is a shift in the distribution of primary lesion sites within the stomach. In the first quarter of the 20th century, two thirds of gastric cancers were located in the antrum and the prepyloric area, and only 10% arose in the cardia or the esophagogastric junction. Since the 1970's, however, adenocarcinoma of the proximal stomach has become increasingly common.

[Chondrosarcoma of the larynx].

Patients with chondrosarcoma of the larynx are diagnosed at the III-IV stages. Nevertheless, they have a relatively good prognosis. The tumor grows lowly, metastases develop late.

[Gastric cancer - current state of the problem (II part). Surgical treatment of gastric cancer ( stage IB, II, IIIA)].

Gastric cancer, though decreasing in incidence worldwide, remains a major health problem in many countries. R0 (no residual disease) resection is the only curative measure. Surgical extirpation of gastric cancer is indicated in patients with stages I, II, and III disease, with minimal lymph node involvement. Tumor size and location dictate the type of surgical procedure to be used. The type of gastrectomy and the extent of lymphadenectomy must be carefully planned for each individual patient with gastric cancer. Current issues are - subtotal versus total gastrectomy, extended lymphadenectomy and "prophylactic" splenectomy.

[Cystopericystectomy for the treatment of hepatic hydatid disease].

UNLABELLED: Hepatic hydatid disease is current problem in Bulgaria as the country in endemic region. The treatment include PAIR, various type surgical procedures and medical therapy. Surgical treatment is conductive. Cystopericystectomy is one of radical procedures. AIM: The aim of this study is to present the experience of Department of General and Liver-Pancreatic Surgery in Uiversity Hospital "Alexandrovska", Sofia with cystopericystectomy. MATERIAL AND METHODS: During the period of 18-years (1988-2005) done 90 cystopericystectomies on the 79 patients--57 (72.15%) female and 22 (27.85%) male. Diagnosis has become easier with advances in ultrasonic imaging, immunological tests and CT scanning. The cysts ware localised in left lobe--56 (62.2%) and right lobe--34 (37.8%). RESULTS: There was complication in 4 (5.0%) of patients. Median postoperative stay is 10.3 days. There wasn't reoperacions and lethal outcome. CONCLUSION: Cystopericystectomy is difficult operative procedure, but it followed with better results. It's necessary strictly abidance of the evidences.

[Postoperative entero-cutaneus fistulas--a study of 24 cases].

AIM: To perform a retrospective study on the experience of the Clinic of General, Liver, Biliary and Pancreatic Surgery, Alexandrovska Hospital in the diagnosis and treatment of patients with acquired entero-cutaneus fistulas and to analyse the early postoperative results. MATERIAL AND METHODS: We treated 24 patients with postoperative entero-cutaneous fistulas in the period Jan., 2000 - Aug., 2004. The male sex and the age above 50 were dominent. The primary disease was of oncological origin in 22 cases (91.66%). Anemia, hypoprotenemia and hypoalbuminemia were predisposing and risk factors in 19 cases (79.17%). Fistulography was routinely used for establishing the diagnosis. Surgical treatment was received by all the 6 patients (100%) with small bowel fistulas and by 15 from the 18 patients with large bowel fistulas (83.33%). EARLY POSTOPERATIVE RESULTS: The mortality rate was 4.54% (1 fatal outcome from 22 operated patients). The morbidity rate was 36,36% (8 cases) but none of the complications needed a reoperation. CONCLUSIONS: 1. The most frequent causal factor for entero-cutaneus fistulas in our material was an anastomotic leakige after bowel resection (95.83%); 2. The risk for such a coplication is higher in cancer patients with other predisposing pathological factors; 3. From the pahtological and clinical point of view the entero-cutaneus fistulas caused significant disturbances in base-alkaline and electrolyte balance, malnutrition and cahexia; 4. The clinical signs and the fistulography prooved to be reliable diagnostic methods; 5. The preoperative substitution and nutritional therapy had a significant benefit on the postoperative results, especially in cases of small bowel fistulas; 6. The open surgery was the main therapeutical method in the complex treatment of those patients.

[Clinical risk score in patients selection for surgical treatment of liver metastases].

Liver metastatic disease is the most common malignancy of the liver. The aim of our study was to elaborate criteria for selection of patients for surgical treatment based on definite preoperative characteristics. Results from the surgical treatment of 233 patients operated in the Liver-pancreas Surgery Clinic at the University Hospital "Aleksandrovska" for the period January 1990-December 2003 have been analyzed. On the bases of the results form the study we propose a modified clinically applicable risk score for patients' selection in lever metastatic disease surgery.

[A variant of hepatico-jejunostomy in Klatskin tumors]. / Variant na khepatiko (khepatitse-) ieiunostomiia pri Tu Klatskin.

The authors present their own variant of performing anastomoses between the common hepatic duct/right and left hepatic ducts and the jejunum in radical treatment of Klatskin tumors. The procedure is indicated in cases of proximal (hilar) resection of both hepatic ducts, in technical difficulties for performing the standard drainage protected end-to-side anastomosis between the right and left hepatic ducts on the one hand and the jejunum on the other as well as a method for double biliary derivation. The advantages of the procedure include decreased incidence rate of bile leakage in the subhepatic region, low risk of diffuse biliary peritonitis respectively and restricted possibility of intestinal reflux into the biliary tract.

[Anterior approach for major hepatic resection for large liver malignancy]. / Chernodrobni rezektsii tip ANTERIOR APPROACH -- pri golemi maligneni tumorina cherniia drob -- 2 sluchaia ot praktikata.

The large liver cancers in the right lobe are difficult to be resected with conventional approach. We report for 2 cases--43 old year man with cholangiocellular carcinoma and 50-old year woman with metastatic liver tumor from breast cancer, both with diameter of 30 cm, successfully resected using nonconventional "anterior approach". The postoperative period was uneventful. They were discharged from hospital in 10 and 14 days.

[Postoperative liver failure after hepatic resections for hepatocellular carcinoma]. / Postoperativna chernodrobna nedostatuchnost sled chernodrobni rezektsii pri bolni s khepatotselularen kartsinom.

Postoperative liver failure is a life-threatening complication after hepatic resection. The purpose of this study was to review the liver failure as a result of hepatic resection and to propose strategy for decreasing the risk of its developing. From January 1991 to December 2000 73 patients with primary liver cancer (PLC) were operated and identified in a retrospective database. Seven (13.2%) of resected 53 patients developed postoperative liver failure. There were 4 male and 3 female with mean age 52.3+/-29.2 (from 1 to 78). 3 patients had underlying cirrhosis. Major resections were 5 and minor--2. Mean hemotransfusion was 1012, 13 ml (370-2000 ml). Five patients (71%) died by the 30th day. The causes of liver failure were analyzed, based on both the preoperative data and the intraoperative findings. Significant prognostic factors were the preoperative serum level of bilirubin (p=0.024) and intraoperative hemotransfusion (0.031). The right hemihepatectomy was a prevalent hepatic resection in these patients.