[The place of Hartmann's resections for some advanced distal rectal cancers].

UNLABELLED: ADRC involves the adjacent structures and systems in the minor pelvis and the achievement of the importent for the prognosis Ro resection is technically challenging. The main problem is to obtain the circumferential clearance and it could require a hysterectomy, vaginal, ureteral, bladder resection or exsenteration. The restoration of the urinary tract integrity is obligatory, but the complications are common if the gut passage is restored too. An additional indication for a two-stage operation is the high rate of LR for ADRC. MATERIAL: 14 ADRC with T4 lesions are treated radically with Hartmann's procedures. Fore interventions were with left ureter resections, another one was complete both ureters resection and their implantation in the bladder. The posterior minor pelvis eviscerations were 8. RESULTS: The urine leakage was found in three cases. The complications were treated successfully with an active aspiration through the urethral catheter for 10-15 days. No complications were observed after pelvic eviscerations, but LR were developed after 2 of them. The one was founded after a year and another--two years from the restitution of the gut's tract. There was one LR after Hartmann procedure with ureter resection. No operative mortality was registered. CONCLUSION: The Hartmann's operations are indicated for some ADRC when preservations of the sphincters is possible. An bloc of the parts from urinary system requires restoration of their integrity. The simultaneous gut restitution increases the risk for complications. The high LR rate by ADRC and the adjuvant radiotherapy are also an indication for a Hartmann's procedure. The most of the LR are developed till end of the first year from the operation and the reasonable term for gut restoration is at same time.

[Case of massive bleeding from diverticulosis of the colon in high risk mechanically ventilated patient].

This 81 years old man with chronic obstructive pulmonary disease (COPD), chronic sepsis, chronic renal failure dependent on mechanical ventilation presented in the course of treatment with massive lower gastrointestinal bleeding (LGIB). Selective angiography of inferior mesenteric artery was performed 18 hours after first bleeding and localized source of bleeding at the distal colon as a contrast in the lumen of the gut. Direct intraarterial injection of 3.4 micrograms Vasopressin was carried out in inferior mesentery artery for preparation of surgery. During surgery the colonoscopy was done and despite of the high operative risk total colectomy with ileostomy was performed. This case confirms that there are not alternatives of colectomy in continuing LGIB from colonic diverticula even in the high risk patients.

[Assessment of the surgical approaches in liver hydatid disease].

Surgery has major role in liver echinococcosis. Different types of operation techniques are being analyzed in the complicated and uncomplicated forms of the disease. The less traumatic closed methods are preferred, as the best results have been the modified operation of Lagro and Coria by bonding the veil with BTG on fibrous plate. In the yeast echinococcosis with best result has been the half-closed method with permanent lavage of the residual cavity. Different complications and behavior have been interpreted. There are offers in the surgery of the uncomplicated echinococcosis to introduced resection of the convex dome with application through pulverization of tissue glue on the remaining fibrosis. Theoretical advantages proved this method.

[Enzymology of the liver in hydatidosis].

A research has been conducted studying the enzyme system of the liver using biopsy material of the organ taken during the operation from patients with echinococcosis and an experiment with infantile white mice. It is proved reduction of the activity of the alkaline and acid phosphatase as well as of the glycogen along with their progressive reduction during the disease progression. Compared with the other researches--histological and by electronic microscope, etc.--there are proved great hepatic damages due to the echinococcosis that have caused change of the treatment tactics: large preoperative period, including reconstructions of the glycogenic depot in the organ, gentle to the liver anesthesia, exact postoperative reanimation. Very good results have been obtained concerning the postoperative complications and operative mortality: observing the developed acute liver insufficiency--in the past the mortality has been 27.60% throughout 2.49% of the operated patients; after those measures the acute liver insufficiency after this kind of operation is seen just once (0.40% of the patients) and the mortality is 0.

Preoperative diagnosis of jejunal adenocarcinoma--a case report.

We report herein the case of a preoperatively diagnosed small bowel adenocarcinoma. A 57-year-old man was hospitalized twice for a month in the Gastroenterology Clinic due to complaints lasting a year before hospitalization and consisting of heaviness and spastic pain in the left upper abdomen. None of the numerous methods used in this case (fibrogastroduodenoscopy, ileocolonoscopy, barium series and CT) could reveal a tumor. Ultrasound (US) examination showed a polycyclic formation in the left hypochondrium with enlarged regional lymph nodes. An US-guided fine (20 gauge) needle aspiration (FNA) cytology of the mass was performed and showed moderately differentiated adenocarcinoma of intestinal origin. Thanks to Doppler US guidance during FNA a massive bleeding from an identified arterial vessel with high systolic speed was avoided. On surgical exploration a jejunal tumor of high consistency was found, located 15 cm distantly from the Treitz ligament, infiltrating up to 2/3 of the bowel circumference and partly obstructing its lumen. The histological evaluation of the resected material showed highly to moderately differentiated adenocarcinoma with 5 regional lymph node metastases. The combination of US with Doppler and FNA established preoperatively the malignant small bowel disease.

[Causes for liver echinococcosis reccurence].

Recurrence of the liver echinococcosis is established in 22,30% of the surgically treated patients. Long-term research of the capsula fibrosa is conducted with histological, immunofluorescent and biological experiment with implantation in test animals and histological research of the hepatic parenchyma for presence of protoscolekses in the capsule and beyond its limits. The Napalkov theory for this type of recurrence mechanism is not confirmed. The exact reasons for recurrence are revealed: not diagnosed during the operation smaller cysts (38.89% in the analyzed specimens); intraoperative dissemination of germ elements' incomplete sterilization of the echinococal cyst during the operation; recontamination with oncospheres. A new method for 100% sterilization of the fibrous cavity is introduced. Conclusions are made over the types of operations and the safest of them are recommend in connection with the research.

[Liver cirrhosis caused by liver echinococcosis].

Systematic histological and ultra structural studies over operated patients and in experiment on white infantile mouse have revealed very serious liver alterations, when affected by echinococcosis. Alterations advance with disease progress and lead to cytological alterations in the organ in significant percent of the patients. Echinococcosis is accepted as etiological factor for cirrhosis. Echinococcosis should be included in the existing etiological classification: alcoholic, posthepatical, metabolic, biliar and cardiac. Early diagnosis and surgical treatment is recommended for prevention of development of cirrhosis and irreversible changes in the organ. Intensification of the prophylactic measures among population for reducing of morbidity are also recommended.

[Attempt for etiopathogenic treatment of acute superior mesenteric artery occlusion by combination of small bowel resection and percutaneous artery stenting].

Acute mesenteric ischemia secondary to arterial occlusion is a highly lethal condition, mandating early diagnosis and prompt therapy, to prevent, or at least to minimize, bowel infarction. Progress in understanding the pathophysiology of mesenteric ischaemia has led to novel methods of treatment, so that in some circumstances therapy may be purely medical. More often surgery is demanded and is frequently life saving. Percutaneous transcatheter procedures are increasingly employed in both diagnosis and treatment. Close collaboration between surgeons, radiologists, physicians and anesthesiologists is therefore necessary if clinical outcome is to be improved. This conclusion is drawn by the presented case report.

[Immunity changes in liver echinococcosis].

A research is conducted over the Circulating immune complexes (CIC) of the T- and B- immunity blood cell systems. Statistical significant increase of the CIC is established and decrease of the T-lymphocytes, without changes in the B-lymphocytes count. The immunosuppressive effect of the echinococcosis over the T-lymphocyte system and the increase of the activity of the B-lymphocytes, without changes in their count is demonstrated. CIC deposits in the capilar intima causes allergic immunocomplex glomerulonephritis and other systemic damages. The research proves the necessity for immunomodulating therapy in the preoperative preparation of the patient and after ehinococcectomy.

[Historical review and contemporary trends in the surgical treatment of the rectal cancer].

A historical review of the surgical treatment of rectal cancer is done. Along with the increasing knowledge about the intramural cancer spreading in distal direction, the indications for sphincter-preserving operations expand. In practice, the ablasticity of the surgical intervention in 90% is assured by resection line at 2 cm from the distal margin of the macroscopic tumor. It is underlined the importance of the mesorectal excision for decreasing the local recidives rate. According to review of the available scientific data and to the personal experience during the last 10 years, the author recommends sphincter-saving procedures by localization of highly and moderately differentiated tumors at 1, 5-2cm above dentate line. Since long it has been preferred the straight manual transanal termino-terminal coloanal anastomosis or the latero-terminal coloanal anastomosis with 5-6cm long J pouch. This type of surgical interventions is highly attractive because of the opportunity to preserve the sphincter apparatus, which is of a great importance for the good life quality of the patients. The eventual later local recurrence could be easily diagnosed and treated by abdominoperineal extirpation and total pelvic exenteration.

[Pathologic and anatomic preconditions for radical sphincter preserving operations in carcinoma of the medial and distal rectum].

The contemporary knowledge of the intramural and the extraluminal spreading of the rectal carcinoma in distal direction is taken into account. Based on these data, it is accepted as ablastic, the surgical procedure with resection line at 2 cm below the lowest tumor margin. It is highlighted the value of the total mesorectal excision for decreasing the local recurrence rate. After processing the available scientific data, a conclusion is made, that by localization of differentiated carcinoma at 1.5-2 cm above dentate line, a sphincter preserving operation should be done. A priority is given to the direct manual coloanal, transanal anastomosis. This type of surgical procedures is attractive because of the possibility to preserve the anal sphincter apparatus, which extremely benefits the life quality of the patients. The eventual local recurrences could be easily recognized and treated with abdomino-perineal extirpation. In this way the last could be put off in the time, although most of the patients do not have the need of it at all.

[Two cases of multifocal colorectal cancer--polypoid tumor of the colon and small flat carcinoma of the rectum]. / Dva sluchaia na multifokalen kolorektalen kartsinom--polipoiden tumor na kolona v suchetanie s maluk plosuk kartsinom na rektuma.

The two cases of multifocal colorectal cancer are described and the proximal tumors are located at right and left colon. The distal tumors are small flat rectal carcinomas, rear with bad prognosis and the first scientific reports for this kind of lesions are dated from less than 20 years. The authors prefer colonoscopy instead of irigography for the diagnosis of the small flat colorectal carcinoma because of the limited possibilities of irigography for lesions less than 2 cm. It is necessary to perform intraoperative endoscopy for the exact localization of the small lesion of the rectum that define the level of resection. Different surgery tactics are applied determinably of the site of the polypoid tumor. In the case when the large tumor was localized in the right colon the operation is finished with temporary ileostomy. In the other case left-colectomy with Dixon's operation are done. The study is interesting because of the rare cases of the small flat carcinoma of the colon.

[A case of metachronous carcinoma of the colon diagnosed and radical operated with restorative anastomosis after more than 5 years from the first left hemicolectomy]. / Sluchai na metakhronen kartsinom na kolona, diagnostitsiran i radikalno operiran s restorativna anastomoza sled poveche ot 5 godoni ot prekhodnata liava khemikolektomiia.

The authors described their observation about the female patient with an advanced carcinoma (T4) of the descendent colon where left hemicolectomy was done in the beginning of 1998. The patient is operated again after more than 5 years because of the cancer in the site of the anastomosis. Radical reresection with restorative anasomosis is performed and for this reason the colon is putting via mesenteric radix. The case is analyzed and there are suggestion about is this a local recurrence or "de novo" carcinoma It is important to follow up the patients during lifetime for early uncovering of local recurrence. Endocoloscopy and scener are preferable for this aim.

[A case of two simultaneous carcinoma lesions of the colon and rectum with different differentiation and stage of neoplastic process]. / Sluchai s dve simultantni kartsinomni lezii na kolon i rektum s razkichna diferentsiatsiia i stadii na neoplastichniia protses.

It considers a patient with simuitant colorectal carcinoma. Both tumor lesions are from different stage and different histological type. The grade of invasion of tumor process does not correspond to the histological type of neoplasma and nider to the size of the primer tumor. The different evolution of those simuitants lesions does not correspond with criteria for histological type and with the stage of primer tumor as a prognostic factors.

[Continence of anorectal sphincter complex in the early postoperative period after direct colo-anal anastomoses with colo-colic J pouch]. / Kontinentnost na anorektalniia sfinkteren kompleks v ranniia sledoperativen period sled direktni koloanalni anastomozi i koloanalni anastomozi s kolokolichen J pouch.

UNLABELLED: According to up-to-date concepts for local spread of a rectal cancer it is possible to perform a radical rectal resection with a restorative anastomosis inspite of the fact that the tumor is located in the middle or the distal third of the rectum. Usually a total resection of the rectum and coloanal anstomosis have to be performed. There are two ways to restore the continuity of the gut: a straight coloanal anstomosis or J pouch anastomosis. 22 patients with rectal cancer localized between 4 and 9 cm from the anal verge, were operated and restorative anastomoses were performed. The first 18 patients were with a straight coloanal anastomosis. In the last 4 cases coloanal anastomoses were done between the anus and colocolic 7 cm J pouch. During the first month there were 6 patients with total and 9 with partial incontinence in the group with straight coloanal anastomosis. Transrectal sonography confirmed contractility of the puborectal muscle and sphinctermanometry showed lower resting tone and squeeze pressure in cases with incotinence. No incontinence was observed in the group with J pouch and the shinctermanometry data were the same as these of healthy controls. CONCLUSION: The rectal ampula has reservoir function and its loss after total resection of the rectum is the reason for frequent bowel movements, urgency and leakage. Reconstruction with a colonic J pouch is associated with better bowel function compared to the straight coloanal anastomosis.

[Total mesorectal excision in the surgical treatment of rectal cancer of middle and distal third of the rectum--precondition for local recurrences]. / Totalnata mezorektalna ekstsiziia pri operativnoto lechenie na raka na srednata i distalnata treta na rektuma--predpostavka za snizhenieto na lokalnite retsidivi.

The author presents his own results of surgical treatment of 54 patients with rectal carcinoma. The point of view is total mesorectal excision as a condition for reducing of local recurrence. The anatomic preconditions and the surgical technics for total mesorectal excision are described. The observing of the rules of an ablastic surgical intervention with exact total mesorectal excision follow to an increase of the treated patients with restorative anastomoses (70%), in spite of the the fact that 75% of the patients are with tumor located at the distal third of the rectum. The postoperative mortality is 3.7% and the local recurrencies are 7.4%.

[Endoluminal echography in rectal cancer--preoperative staging and postoperative control]. / Endolumenna exografiia pri rak na rektuma -- predoperativno stadiirane i sledoperativen kontrol.

The aim of this study is to determine the diagnostic potential of endoluminal echography and the pitfalls sources in the preoperative staging and postoperative follow-up in patients with rectal cancer. 245 patients with rectal carcinoma are evaluated during 10 years period (Jan. 1993-Jan. 2002 years). 96 patients are monitored in the early and late postoperative periods for the early detection of local recurrence as well as for the anorectal physiology assessment after low anterior rectal resection or coloanal anastomosis. Lineal transducer UST-657-5MHz (Aloka 620) and 10MHz miniprobe are applied. The accuracy for T-staging is 84% and for N-staging is 82%. The local recurrence is detected in 21 patients, on average 12.6 months after curative surgery. The local recurrence is more often in cases of lymph node involvement as well as if some specific echographic features for extramural vascular invasion are present. Endoluminal echography provides individual therapeutic management and postoperative control in patients with rectal cancer.

[Iatrogenic lesions of hepatocholedocus in cholecystectomy]. / Iatrogenni lezii na khepatikokholedokha pri kholtsistektomiia.

This is a report on nine patients presenting different intraoperative lesions to hepatocholedochus, some of them diagnosed in the course of operation, and others- after the intervention. A variety of plastic repairs of the hepatocholedochus, including simple suture, Saple's operation or hepatodigestive anastomosis after Longmayre are performed. The probability of inflicting lesions, the underlying causes and the therapeutic approach to concrete cases are analyzed. Abiding to the principles of surgery is strongly recommended, such as: sufficient and appropriate operative access, atraumatic manipulations, drainage of the gallbladder bed and the like, with a view to perclude serious and sometimes fatal complications' occurrence, as well as making early diagnosis and accordingly taking the most opportune surgical solution to the problem faced.

[Local recurrence after radical surgery for rectal carcinoma]. / Lokalni retsidivi sled radikalni operatsii po povod kartsinom na rektuma.

The incidence rate of local recurrences after radical operative treatment of rectal carcinoma and the risk factors involved, methods of early diagnosis and surgical therapeutic approach are comprehensively analyzed. Reference is also made to 86 scientific publications on the issue. During the 20-year follow-up period, no tendency of the incidence of local rectal carcinoma relapses to decrease is noted. The risk factors contributing to their occurrence are distributed in two groups depending on the primary tumor characteristics (location, stage of development, locoregional spreading, differentiation degree, genetic features), and operative intervention used (type, distal resection line, application of total mesorectal excision, extensive minor-pelvis lymph dissection etc.). The early diagnosis is based on mandatorily performed procedures, such as rectoscopy (coloscopy), endo-ultrasonography with purposeful thin-needle biopsy, assessment of tumor markers and immunoscintigraphy. The surgical tactics in coping with a local recurrence of rectal carcinoma becomes increasingly aggressive and radical by resorting to re-resection, abdomino-perineal extirpation, en-bloc resections and even minor pelvic exenteration. Postoperative 5-year survivorship amounts to 54.5 per cent.

[Francke's operation--a resolution for deep small echinococcal cysts of the liver]. / Operatsiia na Francke--reshenie pri dulboki malki ekhinokokovi kisti na cherniia drob.

The operation of Francke in hydatid disease treatment is described--puncture, aspiration, sterilization--with emphasis laid on the technical details. The indications for its practical implementation are specified--small echinococcus cysts, deeply located within the parenchyma of the organ, or diffuse abdominal echinococcosis. In diagnosing such cysts intraoperative ultrasonography is considered as absolutely necessary and mandatory. The operation is practicable in handling first-stage cysts according to Volynkin, containing thin echinococcus liquid only, whereas in the presence of daughter vesicles it is not indicated. Postoperatively, dispensary outpatient observation and chemotherapy of the hydatid disease are recommended with a view to promote radical cure.