[Firs Case Report of Intraoperative Radiotherapy (IORT) for Early Breast Cancer in Bulgaria].

The intraoperative radiotherapy (IORT) is an innovative method for treatment of breast cancer, which can be used as a substitute of postoperative external beam radiotherapy )EBRT), or boost treatment to EBRT (1). Radiobiological advantages of IORT compared to EBRT are higher relative biologic effectiveness of low-dose radiation therapy and the presence of high dose in the tumor bed (where the possibility of remaining vital tumor cells is the highest), as this dose reduces rapidly with the distance from the applicator (2). Important feature of IORT alone is that it can be applied as a single fraction during the surgical intervention and spares 3 to 5 weeks of following radiation therapy. This means less time spent in hospital for the patients and for the radiotherapeutical units - reduced waiting lists and more machine time for other patients. Prolonged operative time as well as the need of additional staff are assumed as relative flaws of IORT (3). The INTRABEAM® system (Carl Zeiss Surgical Gmbh, Oberkochen, Germany) uses a single high dose of low-energy X-rays (mas 50kV), applied to the tumor bed immediately after the surgical excision of the tumor. These rays have high degree of absorption and low penetrating ability. This determines their advantage in comparison to EBRT to protect the surrounding healthy tissues (2). The data from the Targeted Intraoperative radioTherapy (TARGIT-A) and the Intraoperative radiotherapy versus external radiotherapy for early breast cancer (ELIOT): a randomized controlled equivalence trial show that when following the recommendations of The Groupe Européen de Curiethérapie-European Society for Therapeutic Radiology and Oncology (GEC-ESTRO) Breast Cancer Working Group (2009) for an accelerated partial breast irradiation (APBI), IORT can be used as an equivalent of the postoperative radiotherapy (1,4,5,6). The purpose of this article is to show the results of the performed on 15 December 2015 for the first time in Bulgaria breast conserving surgery with intraoperative radiotherapy on a patient with early breast cancer.

Appendiceal mucocele - Case Report and Review of the Literature.

Appendiceal mucocele (AM) was described for the first time by Rokitansky in 1842.1 Its incidence is 0.2 - 0.4% of all apendectomies performed, as it is observed predominantly in women with the ratio of 4/1 versus men and most frequently at the age of 50.2,3 We present to your attention a 64-year-old woman, who was referred to diagnostic further clarification after a preventive gynaecologic exam. Appendiceal mucocele with retrocecal location, enveloped by additional Jackson'™s membranes was determined intraoperatively. The formation has been dissected and appendectomy was performed without mucocele integrity being compromised. The permanent histological specimen revealed mucinous cystadenoma with clear resection lines, without any data on the appendiceal base being affected. The patient was discharged on the third day after surgery without any complications, and further follow-up was scheduled in 6 months.

Extraskeletal Osteosarcoma of the Omentum with Aggressive Development.

For the first time extraskeletal osteosarcomas (ESOS) were described by Wilson in 1941. They are extremely rare neoplasms, presenting 4% of all osteosarcomas and 1,2% of all soft-tissue sarcomas. About 300 cases have been reported in the literature up to date. We present a 66-year-old female patient, admitted in the clinic because of acute bleeding in retroperitoneal space. Revision of the retroperitoneal space and haemostasis were performed. The patient was re-operated because postoperative bowel obstruction. The reason for it was intestinal infiltration from large tumor of the omentum, determined histopathologically as ESOS. The case was considered as an unresectable neoplasm so a colostomy was performed. In the literature we found 3 case reports of ESOS, originated from omentum.

Management of recurrent or metastatic retroperitoneal soft-tissue sarcomas.

UNLABELLED: Retroperitoneal soft tissue sarcomas remain a serious therapeutic problem. The aim of the study is to define the optimal treatment strategy of patients with locally recurrent or metastatic retroperitoneal soft tissue sarcomas. MATERIAL AND METHODS: A retrospective study was performed.Between 2001 and 2013, 89 patients with retroperitoneal soft tissue sarcomas were surgically treated in the University Hospital Queen Joanna ISUL and the Specialized Hospital for Active Treatment in Oncology Sofia. Clinicopathological data were investigated with SPSS 19. RESULTS: The mean time of onset of the first and second relapse of sarcomas was 23 and 13 months, respectively. Over 40% of the studied patients underwent more than one operation because of recurrence. Ability of radical extirpation of the tumour decreased with each subsequent relapse. The 5 year survival rate was 60% for patients with primary combined radical resection versus 28% for patients with partial resection. In the presence of metastatic lesions the 3 year survival rate was only 22%. CONCLUSION: Local recurrences, the presence of distant metastases and the ability of radical extirpation are the main long term prognostic factors.

EPIDEMIOLOGICAL REGISTRY OF NEUROENDOCRINE TUMORS IN BULGARIA--A PILOT SURVEY.

The National registry of patients with neuroendocrine tumors (NET) in Bulgaria was established in 2013 as a joint initiative of the Bulgarian Surgical Society and the Institute for Rare Diseases. The register aims to explore the epidemiology of NET in Bulgaria, as well as the different diagnostic and treatment approaches for the disease throughout the country. This the first of its kind retrospective study of NET in the country is covering the period January 2012 - January 2013. A total of 127 patients with NET were identified. At the time of the survey the average age of patients with NET was 58.61 ± 15.59 years. The data show almost equal distribution between the genders with a slight predominance of women. The largest relative part of NET is those of NET located in the gastrointestinal tract (54.10 ± 4.51%), followed by those located in the pancreas (12.30 ± 2.97%) and in the lungs (10.66 ± 2.79%). In 72.44 ± 3.96% of the patients a immunohistochemical diagnosis was performed. The study confirmed the leading role of the surgery method of the NET management. In 65.83 ± 4.33% of the patients a radical removal of the tumor was conducted, while the relative part of the undertaken partial resection was 7.50 ± 2.40%. A statistically significant association between the type of surgical treatment and during the follow-up of patients was found. An update of the information in the register will allow a more precise determining of the distribution and management of NET in Bulgaria.

[Study on the efficacy of famotidine (Quamatel) in the complex treatment of erosive gastroduodenitis, stress stomach ulcer and peptic duodenal ulcer]. / Prouchvane vurkhu efekta na famotidine (Quamatel) v kompleksnoto lechenie na uslozhnenite s khemoragiia ostur eroziven gastroduodenit, stres stomashna iazva i peptichna iazva na duodenuma.

The haemorrhage of upper gastrointestinal tract is one of the serious problem in urgent surgery. Clinical effect of treatment with Quamatel purposely research was holded comparison of results in two groups patients. In group A with general medical treatment was included Quamatel--2 x 20 mg i.v. a day. In group B the patients was treated without H2 blocker. In cases of erosive gastritis was reported favorable effect in 76.47% at second day. The patients with stress stomach ulcer same effect was observed in third day--83.3%. In cases with peptic duodenal ulcer in I B--Forest group the bleeding was taken possession of 61.9%, in group II--79.31% and III--90.91% of patients.

[An attempt for the creation a united working scheme for the comparative analysis of peritonitis]. / Opyt za suzdavane na edinna rabotna skhema za sravnitelen analiz na peritonita.

Many attempTs have been made to create an universal classification of peritonitis. The aspirations of many authors to work out a scheme that is able to be in one and the same time thorough, simple and appLicable in practice, have been found to be unrealizable. This blank stimulate us to work up a scheme which will facilitate showing the nature of the pathological process, the analysis of the clinical data, the similarities and the differences in the development of the illness and the most important--to direct to the most rational operation. We offer the following United working scheme for comparative analysis of peritonitis. It includes: Classification of mixed type formulated on the base of anatomical and etiological background; Modified classification of V. Feodorov about dissemination of peritonitis; Classification based on pathophysiology of the peritonitis; Classification system for estimation the seriousness of the illness MPI-modified.

[Bacterial translocation from the gastrointestinal tract: catalyst of multiple organ dysfunction syndrome]. / Bakterialna translokatsiia ot gastrointestinalniia trakt: katalizator na sindroma na multiplena organna disfunktsiia.

The abnormal colonization of gastrointestinal tract (GIT), the loss of the intestinal barrier function, the bacterial translocation (BT) are signs of intestinal insufficiency which are supposed to be involved in the pathogenesis of MODS. This worsens the condition or leads to lethal outcome in patients after major abdominal surgery in ICU. The goal of this investigation was to consider the scientific and clinical evidence for the BT role in the pathogenesis of MODS and to present evidence about the advantages and the efficiency of antibiotic combination Amikacin plus Clindamycin as a new therapeutic strategy for the improvement of the outcome in patients with MODS and sepsis. To that purpose patients with diffuse peritonitis of different origin were analyzed. After surgery some patients were left with laparostomy. This gave the possibility for revisions and lavages of the abdominal cavity and for taking material for microbiological analyses. The patients were grouped into two subgroups according to antibiotic treatment: 1st group--combination of usually used antibiotics; 2nd group--Amikacin plus Clindamycin. The second group patients showed good tolerance to this antibiotic combination and good therapeutic effect.

[Tactics and operative methods in treating complicated colorectal cancer]. / Taktika i operativni metodi za lechenie na uslozhneniia kolo-rektalen rak.

Over the period 1993-1998, a total of 385 patients with complicated colorectal cancer are subjected to treatment in the clinic of emergency surgery--University Hospital "Queen Giovanna", Sofia. Obturation is the commonest form of complication--43.8 per cent, perforation within the tumor or diastasis noted in 27 cases (7.01%), paratumor abscesses and infiltrates--in 8.3 per cent and rectohemorrhage--in 4.2 per cent. The therapeutic and operative approach, and the scope of surgery are dependent on a multitude of factors which should be given due consideration by the surgeon. In each patient presenting complicated colorectal carcinoma it is mandatory to make a precise and individual choice of the extent of operative intervention, consistent with the patient's general condition and contributing to eliminate the life-endangering underlying cause.

[Large-intestine perforations caused by primary colorectal cancer]. / Debelochrevni perforatsii, predizvikani pri purvichen kolo-rektalen rak.

Twenty-seven cases of perforation, produced by primary colorectal carcinoma over the period 1993-1998, are described. The underlying causes of colorectal carcinoma complication and types of perforations observed are discussed. This is a report on personal experience with the therapeutic approach and operative management of this severest complication of colorectal carcinoma.

[Combined and extended radical operations in colorectal carcinoma patients]. / Kombinirani i razshireni radikalni operativni interventsii pri bolni s kolo-rektalen rak.

This is a report on radical operative interventions performed in 273/385 patients presenting complicated colorectal carcinoma, covering the period 1993 through 1998. Fifty-four patients are subjected to combined and extended operations, distributed as follows: 31 combined and 23 extended. In fifteen patients with abdomino-perineal extirpation the combined interventions include: hysterectomy (6), ovariectomy (8), resection of vagina (7), prostate gland resection (3) and bladder resection (2). In case of resection of rectum after Hartmann, combined intervention is done in five patients--small intestine resection, ovariectomy, appendectomy and cyst extirpation from pelvis minor, respectively. Postoperative lethality amounts to 12.9 per cent, or 7/54 patients with complicated colorectal carcinoma undergoing combined and extended surgical interventions.

[Primary colorectal carcinoma as an underlying cause of obturation of the ileum]. / Obturatsionen debelochreven ileus, predizvikan ot p'rvichen kolo-rektalen rak.

This is a report on 169 patients presenting colorectal carcinoma with complication assuming the form of occlusive ileus, observed over the period 1993 through 1998. Obturation is the commonest complication of colonic carcinoma (48.9%) with the left colon being more often involved (58.3%), recorded in a total of 108 patients. During the same period of time, occlusive ileus against the background of carcinoma of the rectum is diagnosed in 61 cases, representing 37 per cent of complicated forms of this malignant neoplasm. The scope of operative management and the procedure used are largely determined by the location of primary malignancy. The timing of undertaking one or another operative intervention depends on the efficacy of preoperative preparation, degree of occlusive ileus progress, patient's age, concomitant diseases and the like. Failing to comply with or overlooking some of the aforementioned factors invariably exerts an unfavourable effect on the final outcome of treatment. In each patient presenting colorectal-carcinoma-induced occlusive ileus it is mandatory to precisely specify the scope of surgery, consistent with the patient's general condition, and eliminate the underlying cause jeopardizing his life.

[Transendoscopic drug denervation of the stomach in emergency surgical diseases of the gastrointestinal tract (a preliminary report)]. / Transendoskopska medikamentozna denervatsiia na stomakha pri speshni khirurgichni zaboliavaniia na gastrointestinalniia trakt (predvaritelno suobshtenie).

This is the first, preliminary report on the implementation of transendoscopic medicamentous denervation of the stomach as a therapeutic approach to acute surgical diseases of the gastrointestinal tract. Diminishing the vagus nerve influence after the method described contributes to a substantial improvement of the treatment results in acute pancreatitis patients by shortening the term of therapeutic fasting, avoiding nasogastric tube insertion, and making unnecessary H2-blockers application. TEMDS is indicated in all instances of acute pancreatitis, bleeding duodenal ulcer, bleeding ulcus pepticum jejuni following BII resection of the stomach.

[Anaerobic surgical infection and septic shock]. / Anaerobna khirurgichna infektsiia i septichen shok.

In the period 1990 through 1995, one-hundred patients operated for acute abdomen or admitted on a routine basis, presenting evidence of anaerobic infection, undergo treatment in the clinic of emergency surgery. Septic shock develops in 10/100 patients (10 per cent). In six of the latter the outcome is fatal--three with infection caused by spore-forming anaerobes (gas gangrene of the inguinal region--of Fournier, and anterior abdominal wall--anus praeternaturalis--two), and three with infection caused by non-spore-forming anaerobes (mixed anaerobic-aerobic infection). Anaerobic surgical infection and septic shock specificity is discussed, with an algorithm of therapeutic approach, based on clinical experience had with 100 patients, being proposed in either of them. Special emphasis is laid on antibiotic prophylaxis against anaerobic surgical infection. Its implementation in the concrete clinical conditions in this country demands a clearcut hospital drug policy (adoption of the "Drug Formularies" system), and elaboration of a new economical approach to the choice of antibacterial agents (using some of the forms of pharmaco-economical analysis, practicable with a view to the Bulgarian health-care model).