[Radiofrequency ablation of hepatic metastases: clinical results].

AIM: To establish the effectiveness of radiofrequency ablation in the treatment of metastatic hepatic lesions. PATIENTS AND METHODS: 104 pts with 231 metastases were treated with RFA. The volume of achieved destruction was assessed using imaging method and cytology. Patients were followed-up for 1-37 months. RESULTS: 87.3% of metastases < 3.0 cm, 50.9% of tumors sized 3.0-5.0 cm and 14.3% of metastases > 5.0 cm were completely destroyed. Major complications occurred in 7.5% of the patients. 34% of the ablated tumors recurred. CONCLUSIONS: The effectiveness of RFA metastases depends on the size and location of the lesion. Lesions adjacent to the gallblader and main bile ducts are risky for manipulation.

[Bolus percutaneous ethanol injections in hepatocellular carcinoma--clinical results].

AIM: To establish the effectiveness of large-volume percutaneous ethanol injection under general anesthesia (Shot-PEI) as a local method for destruction of large hepatocellular carcinoma (HCC). PATIENTS AND METHODS: 46 patients with 48 HCC were treated with Shot-PEI. 1-4 sessions per lesion were performed with 12-138 ml ethanol per session. RESULTS: Complete destruction was achieved in 43.8% of the tumors. Major complications occurred in 10.9% of the patients. Local recurrences were 19%. CONCLUSION: Shot-PEI is an effective method for destruction of large tumors and multiplies the therapeutic options in HCC.

[Cytomorphological features of the fatty tissue tumors of the liver]. / Tsitomorfologichni osobenosti na tumorite na mastnata tukan s lokalizatsiia v cherniia drob.

The necrotizing soft tissue infection caused by anaerobic microorganisms or by mixed aerobic-anaerobic flora is one of the most severe infections in surgical practice with a mortality rate up to 75%. Of great importance for successful treatment are the early diagnosis followed by aggressive debridement and adequate antibacterial therapy. Depending on the studies of 358 isolates made in the Clinic of Septic Surgery, we specify the most often used antibiotics in cases of severe anaerobic surgical infection. It is established that the incidence of this severe infection is unpredictable and its spreading depends on the immune answer the concomitant illnesses and the previous undertaken surgeries of the patient.

[The rare combination of liver echinococcosis and beta-thalassemia]. / Riadko suchetanie na chernodrobna ekhinokokoza s beta-talasemiia.

A rare case of an unusual association of liver hydatidosis (LH) and beta-thalassemia (beta-Thal) was reported. In a 43 year old white man, who has no connection to endemic areas of echinococcosis or beta-Thal (but was operated probably for splenic echinococcus 25 years ago), an intermediate form of beta-Thal according hematologic morphologic, and hemoglobin-electrophoretic criteria was diagnosed. Common and different criteria to another anemias (especially of iron deficiency) was discussed and authors believed that this splenomegaly (as specific sign of hereditary beta-Thal) isn't indication for operation. Conventional X-ray, US, and CT was characteristic for LH, and intraoperative cytology was performed. Correlation to a very interesting and rare analogous case, but of homozygous hemoglobinopathy C was made.

[Classifications and prognosis of hepatocellular carcinoma]. / Klasifikatsii i prognoza na khepatotselularniia kartsinom.

In this study are included 78 patients with hepatocellular carcinoma (HCC). In 22 the diagnosis is verified pathologically (obduction), while in the other patients the diagnosis is made by laparoscopy, laparoscopical ultrasonography and morphological verification (through FNAB cytology and/or histology). In 69.2% HCC is associated with cirrhosis. The prognosis of HCC associated with cirrhosis is evaluated through the classification of S. Chevret et all., and is compared to the Child-Pugh scoring system. 38.9% of patients in Chevret's class C score are in class B in the Child-Pugh score, while 25.9% of patients are in class C in both classifications, but Child-Pugh's class C patients are most often in B-C transition. It might be assumed that the prognosis of HCC depends more on the tumor prognosis than on the prognosis of the liver cirrhosis itself. Every classification which does not take in to account the liver function (like TNM system) and the whole characteristics of the tumor, would be incomplete, in some extent, in the prognosis of HCC with cirrhosis. In HCC without cirrhosis, the BCLC classification reflects both the liver function and the tumor characteristics. In BCLC class A patients hepatic resection or transplantation is recommended but hyperbilirubinemia and ascites, which might be seen in A3 and A4 classes contraindicate resection of the liver. All scoring systems define lower HCC stage than it is really found (personal and reference data), so there are no arguments to take classification scores as absolute treatment decision making rules.

[The role of laparoscopy and laparoscopic ultrasonography in the diagnosis and differential diagnosis of nodular hepatocellular lesions]. / Rolia na laparoskpiiata i laparoskopskata ekhografiia v diagnostikata i diferentsialnata diagnoza na nodularnite khepatotselularni lezii.

The diagnostic relevance of laparoscopy (LS) and laparoscopic echography (LE) in nodular hepatocellular lesions is studied. LS is done using a R. Wolf laparoscope, and LE--with a 7.5 MHz linear transducer, obtained from the Aloka Company. A total of 250 patients presenting 288 nodular hepatocellular lesions are investigated over 15 years (1983-1998), including: focal nodular hyperplasia (FNH)--1, nodular regenerative hyperplasia (NRH)--1, hepatocellular adenoma (HCA)--1, adenomatous hyperplasia (AH)--38, hepatocellular carcinoma (HCC)--58, Budd-Chiari syndrome--2, primary sclerosing cholangitis (PSCh)--2, and cirrhosis of liver--185. The lesions are distributed according to the updated classification of the International Working Party, published in 1995. In addition to the latter, a case of cholangiocellular adenoma undergoing malignant degeneration and a case presenting carcinoma, giving rise to differential diagnostic difficulties are also described. Some of the aforementioned diseases are reported for the first time in the Bulgarian literature. Emphasis is laid on the practicability of combining endoscopic with imaging diagnostics, attributable to laparoscopic echography and to the advantages of echolaparoscopic biopsy. Almost half of the foci (46.1%) are morphologically verified. The aim of cytological assessment is to establish the malignant character of the lesion, first and foremost, while the histological finding is essential for making a correct diagnosis.

[Percutaneous puncture in hepatic echinococcosis]. / Perkutanna punktsiia pri chernodrobna ekhinokokoza.

This is a report on a case of severe anaphylactic shock and hemorrhage following liver puncture with diagnostic purpose. Based on literature data and personal experience, percutaneous puncture of a parasitic expanding cyst, done with diagnostic and therapeutic purpose, is discarded, assuming the method as an error of art. Its performing using updated imaging techniques--echography and computerized tomography--by no means reduce the risk of anaphylactic shock and secondary echinococcosis. In the event of being accidentally done, emergency operation followed by chemotherapy to preclude secondary echinococcosis is recommended. In cases with unspecified diagnosis, puncture under echographic control is done on the operating table with urgent cytological assessment of the punctate. The demonstration of echinococcosis is an indication for immediate operation. The percutaneous method is used in handling nonparasitic cysts.

[Pancreatoduodenal resection for carcinoid of Vater's papilla]. / Pankreatoduodenalna rezektsiia za kartsinoid na papilla Vateri.

Papilla Vateri carcinoid is among the very rarely occurring locations of the lesion. The small lumen of the papilla is the underlying cause of becoming clinically manifest with icterus rather early. Accessibility of the process for endoscopic biopsy facilitates the diagnosis. Even histologically it is very difficult to differentiate benign from malignantly altered carcinoids. Only the existence of metastases confirm with certainty their malignant nature. An observation on papilla Vateri carcinoid in a 60-year-old woman, proved preoperatively through cytological study, is reported. Intraoperative--no metastases are discovered. Sparing pancreatoduodenal resection is performed with a good functional outcome, recorded at the checkup examination after two years.

[Fine needle aspiration cytology of liver and pancreas tumors]. / Feinnadelaspirationszytologie der Leber- und Pankreastumoren.

The authors' experience on the liver and pancreas tumours diagnosis by fine needle aspiration biopsy (FNB) performed percutaneously with ultrasound guidance (partly on blind) or intraoperatively is reported. Two hundred and eleven patients in total have been investigated. In 82 patients a FNB of the liver was performed and in 70 patients a FNB of the pancreas was done and for comparison 59 "macrobiopsies" (MB) of the liver were examined cytologically. The FNB made success fully permitted a complete cytologic investigation to be done and approached the possibilities of the MB. By FNB 67 out of 71 liver neoplasms and 29 out of 30 neoplasms of the pancreas have been diagnosed, i.e. the diagnostic sensitivity was 0.94 and 0.97 respectively. No false positive results were established and the diagnostic accuracy was 0.95 for liver tumours and 0.99 for pancreatic tumours. The possibilities for typification of the neoplasms by means of the FNB are enormous. The liver and the pancreas FNB proved to be a most helpful method for diagnosing the tumorous processes and could save a number of invasive, expensive and labour-consuming examinations.

[Effect of carsil and legalon in treating chronic liver diseases]. / Efekt na karsila i legalona pri lechenieto na khronichnite chernodrobni zaboliavaniia.

The clinical effect from the treatment of 48 patients with carsil and 24 patients with legalon is studied. The patients were subdivided into three groups in the base of the clinical, laboratory-chemical and instrumental examination: light hepatic lesions--hepatic steatosis, chronic persisting hepatitis (ChPH), post-hepatitis states, chronic active hepatitis (ChAN) and cirrhosis of the liver (CL). Both preparations were administered 3 three times, 2 tablets daily for 3 months. The results obtained revealed that the bioflavonoid preparation carsil did not much differ in its clinical effect from the preparation legalon. The preparations carsil and legalon had a good effect, but not with statistical significance, on the subjective symptoms--pain, sense of heaviness and upper dyspeptic syndrome in the patients studied. Both preparations had a good effect on the biochemical indices: thymol test, SGOT, gamma-globulins, immunoglobulin G, blood bilirubin. The three month administration of carsil and legalon did not essentially change the histological findings in liver. The preparations carsil and legalon are indicated in light and moderate hepatic affections--hepatic steatosis, ChPH, post-hepatitis states. No contraindications have been reported for the administration of those preparations even in advanced hepatic disorders where they could be included as "basis" therapy.

[Serum immunoglobulin levels and histomorphological changes in the liver in chronic liver diseases]. / Nivo na serumnite imunoglobulini i khistomorfologichni promeni v cherniia drob pri khronichni chernodrobni zaboliavaniia.

The level of serum immunoglobulins were juxtaposed, in the paper, to the histomorphological liver changes of 121 patients with chronic liver diseases. Immunoglobulins were also studied in 33 patients with alcoholic cirrhosis as well as in 66 healthy control subjects. Myelogram was performed to 40 patients. The authors' own actualized histomorphological classification of the chronic liver diseases was used. The patients with chronic hepatitis and cirrhosis have an elevated serum level of immunoglobulins G, A and M, proportional to the degree of the histomorphological liver changes. Most manifested was the increase of IgA in alcoholic cirrhosis, and steatosis, alone or in combination with inflammatory process, induces no substantial changes in serum immunoglobins. Increased number plasmatic cells was established in the bone marrow of the patients with chronic liver diseases, with cirrhosis in particular, suggesting an extrahepatal participation in immunoglobulin biosynthesis.

Phlebotomy treatment in porphyria cutanea tarda combined with beta-thalassaemia.

In 74 patients with porphyria cutanea tarda, 11 (14.9%) cases of beta-thalassaemia were found. The incidence of beta-thalassaemia in porphyrics is not greater than in non-porphyrics and it seems that beta-thalassaemia is not a factor triggering the development of porphyria cutanea tarda. The phlebotomy treatment is also a convenient method for porphyria cutanea tarda combined with beta-thalassaemia.

[Serum immunoglobulins G, A and M in patients with liver carcinoma]. / Serumnite imunoglobulini G, A i M pri bolni s kartsinom na cherniia drob.

The level of immunoglobulins, G, A, M was determined via radial immunodiffusion in the sera of 70 patients with primary and metastatic hepatic carcinoma. Patients with extrahepatic carcinoma without metastases and patients with cirrhosis of the liver were studied for a comparison. A moderate elevation of IgA in all cases with carcinoma was established, the changes intensified with the spreading of the tumour. In those patients, no essential deviations were established in the other immunoglobulins with the exception of a light increase of IgM in case of primary hepatic carcinoma. Immunoglobulins in cirrhosis manifest a characteristic increase in all three classes, regardless if an additional carcinoma has originated. For the present, it is difficult to present a thorough interpretation of the deviations in immunoglobulins and to evaluate their values in the establishment and follow of up hepatic carcinoma.

[Cytodiagnosis of colorectal precancers and cancer]. / Zytodiagnostik kolorektaler Präkanzerosen und Karzinome.

In this study, 244 samples from 206 patients with precancer and cancer of the large intestines and rectum have been investigated. The material was divided into 4 groups: non specific inflammatory diseases, ulcerative colitis, adenomas and cancer. All patients were examined endoscopically (rectoscopy and coloscopy), and purposeful biopsies under a visual control have been performed. From the bioptic material and the totally extirpated adenomas, whether endoscopically or surgically, imprints for cytologic investigations and histologic preparations have been made. For the cell imprints a panoptic staining after Pappenheim was used. The comparison of the endoscopic, histomorphologic and cytologic data demonstrated the considerable possibilities of the cytologic method. The latter was particularly effective for the establishment of the cell atypia and the diagnosis of the early forms of cancer respectively. In 95.1 per cent of the neoplasm cases (n = 123), the cytologic method has given a true response. The method was also useful for the typifying of adenomas and neoplasms. The greatest possibilities for early detection and typifying of colorectal neoplasms were offered by the combination of the cytologic and histologic investigations, the so-called "cyto-histology".

[Advantages of cytodiagnostics in ascites (author's transl)]. / Möglichkeiten der Zytodiagnostik von Aszitesflüssigkeit.

Investigations were made on 253 patients. In 44 patients with peritoneal carcinosis, cell imprints and histological investigations of tissues from the changes in the peritoneum, taken during laparoscopy have been performed. In 122 out of 151 patients with neoplastically stipulated ascites (80.8 per cent) tumour cells have been found in the ascitic fluid. The false negative results represented 19.8 per cent and the false positive results--2.0 per cent. In all cell imprints from peritoneal tissues tumour cells have been detected even when these were absent in the ascitic fluid. In 2 out of 49 patients (4 per cent) the histological investigation of bioptic material from the peritoneum showed no neoplastic changes. The activity of gamma-glutamyltransferase and alkaline phosphatase in the ascitic fluid of patients with carcinosis was higher than in the remaining patients, whilst the 5'-nucleotidase did not show particular deviations. The cytologic method was well tolerated by the patients and showed higher specificity, sensitiveness, simplicity and realization and in 80.8 per cent solved the diagnostic problems and made useless the application of other labour-consuming, burdensome and more expensive methods of investigation.