Rare case of enteric type of urachal adenocarcinoma: A case report.

Urachal adenocarcinomas, constituting 10 % of bladder adenocarcinomas, pose a significant challenge with limited literature. A 43-year-old male presented with haematuria and abdominal pain, leading to surgical intervention for a 13 cm pelvic tumor. Histopathology identified an intestinal-type primary urachal adenocarcinoma, staged as IIIA, no recurrence on follow-up. Early detection is crucial for improved outcomes in these rare malignancies. While surgery remains the primary treatment, outcomes vary, emphasizing the need for research on standardized protocols. Enhanced awareness and interdisciplinary collaboration are vital for effective management. Comprehensive guidelines are essential for optimizing patient prognoses in urachal adenocarcinomas.

Diagnostic and prognostic role of serum interleukin-6 and carotid ultrasonography to detect subclinical atherosclerosis in patients with RA and ANCA-associated vasculitis.

ANCA-associated vasculitis (AAV) can affect multiple organs with severe life-threatening manifestations. Disease monitoring is difficult due to a lack of defined biomarkers. We aimed to assess the diagnostic role of serum interleukin-6 and vascular ultrasonography in AAV and subclinical atherosclerosis. The study included 20 AAV patients and two control groups of 34 patients with rheumatoid arthritis (RA) and 35 healthy controls. The levels of Il-6, carotid intima-media thickness test (CIMT), atherosclerotic plaque, and degree of stenosis were investigated. A GRACE-risk score was calculated for AAV and RA patients. The AAV patients had elevated levels of IL-6 (115 ± 23.96) compared to the RA patients (91.25 ± 42.63) and the healthy controls (15.65 ± 3.30), p < 0.001. IL-6 showed a diagnostic accuracy of 73% in distinguishing AAV from RA patients (AUC = 0.730; 95% CI 0.591 to 0834). In the AAV group, CIMT was 1.09, above the upper reference value of 0.90, p < 0.001. The AAV patients had a higher median GRACE risk score, and 60% of them had a high risk of cardiovascular events as compared to 35% of the RA patients. Sonography of extracranial vessels and serum levels of IL-6 can be used in daily clinical practice to diagnose and monitor patients with AAV.

Hepatico-Duodenal Fistula Following Iatrogenic Strasberg Type E4 Bile Duct Injury: A Case Report.

INTRODUCTION: Gallstone disease (GSD) is among the most common disorders worldwide. Gallstones are established in up to 15% of the general population. Laparoscopic cholecystectomy (LC) has become the "gold standard" for treatment of GSD but is associated with a higher rate of certain complications, namely, bile duct injury (BDI). Biliary fistulas (BF) are a common presentation of BDI (44.1% of all patients); however, they are mainly external. Post-cholecystectomy internal BF are exceedingly rare. CASE REPORT: a 33-year Caucasian female was admitted with suspected BDI after LC. Strasberg type E4 BDI was established on endoscopic retrograde cholangiopancreatography (ERCP). Urgent laparotomy established biliary peritonitis. Delayed surgical reconstruction was planned and temporary external biliary drains were positioned in the right and left hepatic ducts. During follow-up, displacement of the drains occurred with subsequent evacuation of bile through the external fistula, which resolved spontaneously, without clinical and biochemical evidence of biliary obstruction or cholangitis. ERCP established bilio-duodenal fistula between the left hepatic duct (LHD) and duodenum, with a stricture at the level of the LHD. Endoscopic management was chosen with staged dilation and stenting of the fistulous tract over 18 months until fistula maturation and stricture resolution. One year after stent extraction, the patient remains symptom free. DISCUSSION: Management of post-cholecystectomy BDI is challenging. The optimal approach is determined by the level and extent of ductal lesion defined according to different classifications (Strasberg, Bismuth, Hannover). Type E BDI are managed mainly surgically with a delayed surgical approach generally deemed preferable. Only three cases of choledocho-duodenal fistulas following LC BDI currently exist in the literature. Management is controversial, with expectant approach, surgical treatment (biliary reconstruction), or liver transplantation being described. Endoscopic treatment has not been described; however, in the current paper, it proved to be successful. More reports or larger case series are needed to confirm its applicability and effectiveness, especially in the long term.

Surveillance Value of Apparent Diffusion Coefficient Maps: Multiparametric MRI in Active Surveillance of Prostate Cancer.

BACKGROUND: This study aims to establish the value of apparent diffusion coefficient maps and other magnetic resonance sequences for active surveillance of prostate cancer. The study included 530 men with an average age of 66, who were under surveillance for prostate cancer. We have used multiparametric magnetic resonance imaging with subsequent transperineal biopsy (TPB) to verify the imaging findings. RESULTS: We have observed a level of agreement of 67.30% between the apparent diffusion coefficient (ADC) maps, other magnetic resonance sequences, and the biopsy results. The sensitivity of the apparent diffusion coefficient is 97.14%, and the specificity is 37.50%. According to our data, apparent diffusion coefficient is the most accurate sequence, followed by diffusion imaging in prostate cancer detection. CONCLUSIONS: Based on our findings we advocate that the apparent diffusion coefficient should be included as an essential part of magnetic resonance scanning protocols for prostate cancer in at least bi-parametric settings. The best option will be apparent diffusion coefficient combined with diffusion imaging and T2 sequences. Further large-scale prospective controlled studies are required to define the precise role of multiparametric and bi-parametric magnetic resonance in the active surveillance of prostate cancer.

Prophylactic Central Neck Lymph Node Dissection Adds No Short-Term Benefit to Total Thyroidectomy for Differentiated Thyroid Cancer.

Background and Objectives: To answer the research question: "Is prophylactic central neck lymph node dissection (pCNLD) beneficial among differentiated thyroid carcinoma (DTC) patients?" Materials and Methods: This was a retrospective cohort study enrolling DTC patients treated at the University Hospital Kaspela, Bulgaria, from 30 January 2019 to October 2021. The predictor variable was presence of pCNLD (total thyroidectomy with vs. without pCNLD). The main outcome variables were postoperative complications (i.e., vocal cord paralysis, hypoparathyroidism, postoperative bleeding, and adjacent organ injury) and recurrence parameters. Appropriate statistics were computed with the significant level at p ≤ 0.05. Results: During the study period, 300 DTC patients (59.7% with pCNLD; 79.3% females) with an average age of 52 ± 2.8 years were treated. The mean follow-up period of the entire cohort was 45.8 ± 19.1 months. On bivariate analyses, TT with pCNLD, when compared to TT alone, required longer surgical time (mean difference: 9.4 min), caused nearly similar complications (except transient hypothyroidism: p = 0.04; relative risk, 1.32; 95% confidence interval, 1.0 to 1.73), and no significantly different recurrence events, time to recurrence, and recurrent sites. The benefit-risk analyses using the number needed to treat and to harm (NNT; NNH) also confirmed that TT plus pCNLD was not very beneficial in DTC management. Conclusion: The results of this study refute the benefit of pCNLD in DTC patient care with TT. Further well-designed studies in a larger cohort with a longer follow-up period are required to confirm this conclusion.

Clinical Outcomes of EUS-Guided Choledochoduodenostomy for Biliary Drainage in Unresectable Pancreatic Cancer: A Case Series.

Introduction. Pancreatic ductal adenocarcinoma (PDA) is associated with poor prognosis and 98% loss-of-life expectancy. 80% of patients with PDA are unfit for radical surgery. In those cases, emphasis is set on management of cancer-related symptoms, among which obstructive jaundice is most common. Endoscopic ultrasound-guided biliary drainage (EUS-BD) emerges as a valid alternative to the well-accepted methods for treatment of biliary obstruction. Patient Selection. Five consecutive patients with unresectable pancreatic malignancy, were subjected to EUS-BD, particularly EUS-guided choledochoduodenostomy (EUS-CDS). Ethics. Oral and written informed consent was obtained in all cases prior procedure. Technique. EUS-guided puncture of the common bile duct was performed, followed by advancement of a guidewire to the intrahepatic bile ducts. After dilation of the fistulous tract with a cystotome, a fully covered self-expandable metal stent was inserted below the hepatic confluence and extending at least 3 cm in the duodenum. Technical and clinical success was achieved in four patients without adverse events. In one patient procedure failed due to dislocation of the guidewire, with consequent biliary leakage requiring urgent surgery. Recovery was uneventful with no further clinical sequelae and there was no mortality associated with procedure. Discussion. Introduced in 2001, EUS-guided biliary drainage has become an accepted option for treatment of obstructive jaundice. According to recent guidelines published by European Society of Gastrointestinal Endoscopy (ESGE) in 2022, EUS-CDS is a preferred modality to percutaneous transhepatic biliary drainage (PTBD) and surgery in patients with failed ERCP, with comparable efficiency and better safety profile, which is supported by our experience with the procedure. Conclusions. Our case series suggests that EUS-CDS is an excellent option for palliative management of malignant distal biliary obstruction, emphasizes on the importance of adequate technique and experience for the technical success, and urges the need for future research on establishing the best choice for guidewire and dilation device.

Evaluation of Liver Stiffness Measurement by Means of 2D-SWE for the Diagnosis of Esophageal Varices.

Portal hypertension (PH) and esophageal varices (EVs) are a matter of extensive research. According to current Baveno VII guidelines, in patients with compensated advanced chronic liver disease (cACLD), liver stiffness measurement (LSM) < 15 kPa and PLT count > 150 × 109/L, upper endoscopy (UE) is not mandatory, and the emphasis should be set on non-invasive methods for evaluation of clinically significant portal hypertension (CSPH). The aim of this study is to establish whether liver stiffness (LS) measured by 2D-SWE could be used as a predictor for the presence and severity of EVs in cirrhotic patients. In total, 86 patients of whom 32 with compensated liver cirrhosis (cLC) and 54 with decompensated liver cirrhosis (dLC) were examined in the Gastroenterology clinic of University hospital "Kaspela", Plovdiv, Bulgaria. Each patient underwent LS assessment by 2D-SWE and EVs grading by UE. EVs were detected in 47 (54.7%) patients, 23 (49%) of them were stage 4-high-risk EVs (HREV). The cut-off value for LS that differentiates HREV from the rest was set at 2.49 m/s with 100% sensitivity and 100% specificity (AUC 1.000, CI 0.925). Conclusions: 2D-SWE can be used as a non-invasive method in the assessment of only high-grade esophageal varices. For the other grades, upper endoscopy remains the method of choice.

Estimating reference values of parenchymal stiffness of normal pancreatic parenchyma by means of point shear wave elastography.

INTRODUCTION: There are numerous imaging modalities available to describe pancreatic parenchyma. None of the broadly accepted diagnostic methods uses elasticity as an indicator of tissue damage.

Surgical Innovations in Tracheal Reconstruction: A Review on Synthetic Material Fabrication.

Background and Objectives: The aim of this review is to explore the recent surgical innovations in tracheal reconstruction by evaluating the uses of synthetic material fabrication when dealing with tracheomalacia or stenotic pathologies, then discussing the challenges holding back these innovations. Materials and Methods: A targeted non-systematic review of published literature relating to tracheal reconstruction was performed within the PubMed database to help identify how synthetic materials are utilised to innovate tracheal reconstruction. Results: The advancements in 3D printing to aid synthetic material fabrication have unveiled promising alternatives to conventional approaches. Achieving successful tracheal reconstruction through this technology demands that the 3D models exhibit biocompatibility with neighbouring tracheal elements by encompassing vasculature, chondral foundation, and immunocompatibility. Tracheal reconstruction has employed grafts and scaffolds, showing a promising beginning in vivo. Concurrently, the integration of resorbable models and stem cell therapy serves to underscore their viability and application in the context of tracheal pathologies. Despite this, certain barriers hinder its advancement in surgery. The intricate tracheal structure has posed a challenge for researchers seeking novel approaches to support its growth and regeneration. Conclusions: The potential of synthetic material fabrication has shown promising outcomes in initial studies involving smaller animals. Yet, to fully realise the applicability of these innovative developments, research must progress toward clinical trials. These trials would ascertain the anatomical and physiological effects on the human body, enabling a thorough evaluation of post-operative outcomes and any potential complications linked to the materials or cells implanted in the trachea.

Diverting ileostomy in low anterior resection: single center retrospective analysis.

<b> Introduction:</b> Low anterior resection (LAR) is the standard procedure for distal rectal cancer allowing anal sphincter preservation. Anastomotic leakage remains one of the most dangerous complications following LAR and its management is difficult. </br></br> <b>Aim:</b> This study reviews our experience of LAR with and without protective ileostomy (PI). </br></br> <b> Methods:</b> One hundred ninety-nine patients undergoing LAR resection for low rectal cancer in this centre during the period 2015-2019 were divided retrospectively into two groups. Group A underwent rectal resection and coloanal/rectal anastomosis with diverting ileostomy and group B without ileostomy. </br></br> <b> Results:</b> Among our patients, 20 had a covering ileostomy (stoma group);179 did not (control group). The stoma group comprised 14 men and 6 women ranging in age from 36 to 89 years (mean, 64.2 ± 10.5 years). Conventional v. minimally invasive surgery was 6/14. Anastomotic leakage occurred in 16/179 (8.93%) patients without a PI, and in 6/20 (30%) with a stoma (Tab. I.). Of the 16 patients experiencing an anastomotic leak, 3 (18.75%) from Group A and 5 (83.33%) from Group B were classified as Grade B leakage and were treated conservatively. As many as 13/16 (81.25%) in Group A and 1/6 (16.77%) in Group B were classified as Grade C leakage and required emergency surgery. </br></br> <b>Conclusion:</b> These results do not show a preventive effect on the occurrence of anastomotic leakage in low anterior resection, but may significantly reduce the need for further surgery due to septic complications in the early postoperative period. Selection of patients for protective ileostomy requires great care as its creation and closure are associated with severe complications.

COVID-19 Mortality and Related Comorbidities in Hospitalized Patients in Bulgaria.

Until now, the COVID-19 pandemic has resulted in at least 27 million cases and over 900,000 deaths worldwide. Bulgaria is one of the countries that is the most severely affected by the COVID-19 pandemic, and the mortality rate is among the highest registered in the world. The aim of this study is to investigate and analyze mortality rates due to the fact of COVID-19 in addition to the most common related underlying medical conditions in those hospitalized to outline the factors that have an impact on the mortality rate due to the fact of COVID-19. A descriptive cross-sectional research design with a retrospective analysis was used to collect data from a total of 128,269 hospitalized patients during the period from April 2020 to November 2021. During the study period, the number of hospital admissions due to the fact of COVID-19 was 5200. The patients' mean age was 67.34 (SD ± 19.65), and 51.7% (2689) of the patients were men. Only 10% of out of a total of 5200 patients did not test positive for COVID-19 upon admission based on the antigen or PCR test. Out of all patients, 41.5% had no underlying medical conditions upon presentation, and the remaining 58.5% had diagnosed comorbidities, varying from one to five. One-third (1470) had a lethal outcome, and the remaining 71.7% recovered from the infection and were discharged from the hospital. Based on the analysis of our results, there is definite evidence that the CFR and susceptibility to symptomatic COVID-19 were higher in the elderly, men, and patients with more comorbidities, especially chronic cardiovascular, metabolic, and respiratory disorders, as well as in those admitted to hospital within 6 h after an emergency ward visit and who had a shorter mean hospital stay.

Comparative Assessment of the Level of Patient Safety Culture between Surgical and Nonsurgical Units in Bulgarian Hospitals.

Patient safety culture is a key component of the organizational culture and a critical measure of the quality of healthcare. The aim of this study was to gain an insight into the problems concerning patient safety culture, based on the analysis of data, collected after interviewing healthcare specialists working in surgical and nonsurgical units in selected Bulgarian hospitals. This was a cross-sectional online study using a web-platform and the Bulgarian Version of Hospital Survey on Patient Safety Culture. It was conducted among healthcare workers (n = 620) in 2021. The B-HSOPSC incudes 42 scales grouped in 12 different domains. We compared the percentage of positive ratings and outcome dimensions between surgical and other hospital departments with the nonparametric Mann-Whitney U test, χ2 tests, Fisher's Exact Test, and OR. The results showed that there are no statistically significant differences between the ratings on Patient Safety Culture given by the surgical and the nonsurgical staff except for the dimension "Hospital management support for patient safety". Results from the study highlighted that the most important aspect of hospital patient safety is the shortage of medical staff in both surgical and nonsurgical hospital units. Communication, work shift organization, handoffs and transitions between shifts and among different hospital units, as well as communication with line managers were rated as satisfactory in Bulgarian hospitals.

Robotic-assisted colorectal surgery - initial results.

INTRODUCTION: The mini invasive procedure in colorectal surgery is gaining ground as an alternative to conventional surgery. Colorectal surgery has significantly evolved since the advent of the automatic stapler devices and subsequently with the minimally invasive approach. The next logical step - the robotic assisted surgery was developed to satisfy surgeons' needs to the area of colorectal surgery and to offer a new and safer method to patients. The evidence for benefits of its use in this area appears to be promising.

Prophylactic central lymph node dissection in differentiated thyroid cancer - benefits and risk.

INTRODUCTION: Papillary thyroid cancer is the most common thyroid malignancy. Lymph nodes involvement is common in differentiated thyroid cancer, and cervical lymph node micrometastases are observed in up to 85% of patients with papillary thyroid cancer during surgery. While the therapeutic central lymph node dissection has been accepted, the debate on the prophylactic in differentiated thyroid carcinoma (DTC) continues.

Evaluation of Ultrasound-Based Point Shear Wave Elastography for Differential Diagnosis of Pancreatic Diseases.

INTRODUCTION: A variety of imaging techniques exists for the diagnosis of pancreatic disorders. None of the broadly applied diagnostic methods utilizes elasticity as an indicator of tissue damage. A well-known fact is that both chronic pancreatitis (CP) and pancreatic ductal adenocarcinoma (PDA) are associated with the development of prominent fibrosis (increased tissue stiffness). PURPOSE: To prospectively assess the accuracy of point shear wave elastography (pSWE) in differentiating between benign and malignant pancreatic diseases, establish a cut-off value for the diagnosis of PDA, and evaluate the influence of certain variables on the obtained results. MATERIALS AND METHODS: The present study included 78 patients who were admitted at the Department of Gastroenterology at the university hospital "Kaspela" between December 2017 and August 2021 for diagnosis and/or treatment of pancreatic disorders. Based on the clinical criteria, diagnostic imaging, and histological findings, patients were divided into the CP and PDA group. The ultrasound based pSWE technique was applied and shear wave velocity (SWV) was measured. The depth of region of interest (ROI) and successful measurement rate were also recorded. RESULTS: The mean ± SD SWV values established through pSWE were 1.75 ± 0.34 m/s and 2.93 ± 0.91 m/s for the CP and PDA, respectively. With a cut-off value of 2.09 m/s, we calculated the sensitivity (Se), specificity (Sp), and accuracy for differentiating between CP and PDA of 89.47%, 91.20%, and 88.60%, respectively. Of the examined variables, BMI and depth of ROI in the CP group and sex in the PDA group showed a statistically significant influence on the obtained results. CONCLUSIONS: pSWE may be utilized as a differential diagnostic modality in patients with suspected CP or PDA.

Factors Affecting Residual Stone Rate, Operative Duration, and Complications in Patients Undergoing Minimally Invasive Percutaneous Nephrolithotomy.

Background and objectives: Although minimally invasive percutaneous nephrolithotomy (MPCNL) has demonstrated its efficacy, complete stone clearance was not always achieved, necessitating a second procedure. The purpose of this study was to evaluate factors associated with residual stone rate, operative duration, complications, and hospital stay, in order to develop algorithms for pre-operative prognosis and planning. Materials and Methods: This retrospective study involved 163 Bulgarian patients who underwent MPCNL with Holmium: YAG lithotripsy for the treatment of kidney stones. Patients were considered stone-free if no visible fragments (<3 mm) were found on nephroscopy at the end of the procedure, as well as on postoperative X-ray and abdominal ultrasound on the first postoperative day. Results: Immediate postoperative stone-free outcome was attained for 83.43% of the patients (136/163). Residuals were associated with staghorn stones (OR = 72.48, 95% CI: 5.76 to 91.81); stones in two locations (OR = 21.91, 95% CI: 4.15 to 137.56); larger stone size (OR = 1.12, 95% CI: 1.006 to 1.25); and higher density (OR = 1.03, 95% CI:1.005 to 1.06). The overall categorization accuracy for these factors was 93.80%, AUC = 0.971 (95% CI: 0.932 to 0.991), 89.71% sensitivity, and 96.30% specificity. Predictors of prolonged operative duration were staghorn stones and volume, R-square (adj.) = 39.00%, p < 0.001. Longer hospitalization was predicted for patients with hydronephrosis and staghorn stones, R-square (adj.) = 6.82%, p = 0.003. Post-operative complications were rare, predominantly of Clavien-Dindo Grade 1, and were more frequent in patients with hydronephrosis. We did not find a link between their occurrence and the outcome of MPCNL. Conclusions: Staghorn stones and stones in more than one location showed the strongest association with residual stone rate. Staghorn stones and larger volume were linked with a longer operative duration. Hydronephrosis increased the risk of complications and longer hospitalization.

Comparison of short term results following robotic and laparoscopic total gastrectomy and D2 lymph node dissection.

INTRODUCTION: In the last decade, there has been a progressive shift from open to mini-invasive operative techniques for surgical resection of gastric cancer. Advanced equipment of surgical robots, with its 3D visualization, steady camera view, flexible instrument tips, attracts more and more practitioners in performing robotic gastrectomy with D2 dissection in gastric cancer patients. Thus, the comparison of some basic oncological as well as some surgical variables related to laparoscopic and robotic gastrectomy and D2 lymphadenectomy is necessary.