[Hepatocellular carcinoma complicated with echinococcal cyst of the liver].

AIM: We present a rare case of concomitant echinococcus and hepatocellular carcinoma in a single lesion, and discuss the possible pathogenesis. MATERIAL AND METHODS: A 64-year-old woman was admitted to the hospital with a few months' history of weakness, weight loss and abdominal discomfort. Ultrasonography and computed tomography showed a cystic lesion measuring 10 cm in diameter in the segments 2 and 3 and multiple well-enhanced nodules adjacent to the cystic portion in the segments 4,5,8. RESULTS: The diagnosis was confirmed intraoperativelly--a hepatocellular carcinoma complicated with echinococcal cyst of the liver. A left trisectionectomy was performed. Mebendazole treatment was begun. CONCLUSION: The simultaneous occurrence of echinococcosis disease and hepatocellular carcinoma is quite rare. Both of these diseases are chronic processes, and this further raises the possibility that echinococcosis could have had a role in the development of the liver cancer.

[Rare endocrine tumors of the pancreas with secretion of cortisol].

UNLABELLED: The endocrine part of the pancreas consist 2% from the mass of the gland and it is built from little cells with name Langerhan's islands. The increased secretion of cells provokes to appearance of classic clinical syndrome, which is conditioned by large quantity of hormone in circulation of the blood. The endocrine tumors of the pancreas (ETP) are arisen out of cells that have large quantity to APUD-system. MATERIAL AND METHOD: We present a case report of rare ETP with secretion of cortisol (MEN2 syndrome), which is of interest by reason of the fact that this case report is the first announce in Bulgaria about similar tumor. Corporocaudal resention of the pancreas with spleenectomy has been made. RESULTS: Tumor cells with highly expresion (+++) of hromogranin were determined. The histological conclusion was malignant ETP (APUD system tumor)with secretion of cortisol. A decrease of the level of glucose in blood circulation, a decrease of blood pressure and reduction of the body weight were determined with range of first three postoperative weeks. CONCLUSION: The aims of the surgical therapy are a control over the level of hormones, clear resection and maximal organ saving operation.

[Particularities of splanchnic innervation of the upper abdomen organs - clinical experience].

Due to pain because of supramesocolic malignancies of the upper abdomen organs in 50 patients at nonoperative stage, we have performed 18 right sided, 11 left sided and 21 bilateral TSS interventions. Video recordings of all operations have been examined postoperatively and have been registered the anatomical variations of the splanchnic nerves formation. There have been made conclusions concerning the intraoperative behavior and tactics for surgical pain control in pancreatic, distal esophageal, gastric, extrahepatic bile ducts and liver neoplasms in nonoperative stage.

[Surgical pain control and quality of life improvement in patients with nonoperable supramesocolic neoplasm by using thoracoscopic splanchicectomy (TSS)].

In patients, suffering from malignancies, pain is still predominant symptom. The control of carcinogenic pain has to be led with all known sources and methods: medications, surgical methods and interventional methods. Since august 2004 in a period of 34 months there have been examined 50 patients with abdominal viscera malignancies, located in between transversal colon and diaphragm, i.e having the same sympathetic innervations and suffering from pain, located in the upper abdomen, due to the illness. There have been examined the influence of pain level and quality of life improvement after TSS of the investigated group. TSS is easy to perform surgical method with good possibilities in visceral pain control in supramesocolic neoplasmas, with insignificant intra and postoperative complications. TSS improves the quality of life of patients with nonoperable supramesocolic neoplasms.

[A rare case of short bowel syndrome].

A rare case of short bowel syndrome combined with mechanical ileus due to numerous strictures of duodenum, a large part of the small and a half of the large bowel complicating radiotherapy after radical right nephrectomy for Wilms tumor 31 years ago was reported. The proximal 60cm of the jejunum were preserved only. A by-pass latero-lateral isoperistaltic retro-colonic gastrojejunoanal anastomosis was performed in combination with antiperistaltic interposition of 15cm of intact large bowel between the first proximal 40cm and the distal 20cm of the intact jejunum. The distal part of the intact jejunum was included in an isoperistaltic latero-lateral anastomosis with a normal colon segment. The success of the operative intervention depends on patient's age, intestinal residual, the presence of pre-stenosis dilatation, intestinal function and correctly selected surgical method to maintain the energy balance in the organism with oral feeding only.

[Operative-technical special features of the left lobectomy in colorectal cancer liver metastases].

The indications of the liver resection are the primary and secondary malignant neoplasms of the liver, the benign liver tumors and some inflammatory diseases. Approximately 10-30% of the patients with colorectal cancer liver metastases are suitable to a curative liver resection. The aim of the study is to presenti of the operative-technical special features of the anatomical left lobectomy of patients with colorectal cancer liver metastases. In the course of 24 months we carried out 9 anatomical left liver resections. The indications of the operation of eight of them were solitary metastases, which had appeared after an operation on colorectal cancer and at one of them the resection was performed due to an angiosarcoma of the liver. The operative blood loss was in the order of 100 ml. The operative mortality and postoperative morbidity were 0%. The anatomical knowledge of the Rex's recessus is a key of utmost importance for the performance of a left lobectomy. The Rex's recessus is a physiological enlargement of the left branch of v.porta in the region of the clamping of ligamentum teres. The liver resection highly improves the prognosis on the following conditions: a radical treatment of the primary tumor, an absence of local recurrence, an absence of an extrahepatic incidence of the primary tumor and a preservation of a sufficient capacity of the liver.

[Duct-mucosa pancreaticojejunostomy].

The subject of the study is operative-technical special features by fashioned a duct-mucosa pancreaticojejunostomy, which has been done by 15 patients. Three of the patients have been operated on a multivisceral caustic injury of an alimentary system and the rest twelve patients on a carcinoma of the pancreatic head or chronic pancreatitis. A subtotal duodenopancreatic resection has been performed on the cases with a carcinoma of the pancreatic head and chronic pancreatitis. A duodenopancreatic resection (n=3) have been done by the patients with caustic injure after a removal of an esophagus, a stomach and a part of the proximal jejunum. The operative-technical special features of the duct-mucosa pancreaticojejunostomy have been described. The postoperative mortality was 18% (n=2). The postoperative morbidity was 36% (n=4) and an anastomotic failure of the duct-mucosa pancreaticojejunostomy has been reported on two patients (18%). The consistence of the pancreas and the width of the pancreatic duct don't exert substantial influence on the leak tightness of the duct-mucosa pancreaticojejunostomy, which is an alternative operative method. A stenting of the anastomosis saves a lumen of the pancreatic duct, decreases a pressure in the jejunum and prevents an activation of the pancreatic secretion near the anastomosis.

Emergent off-pump complete myocardial revascularization in dextrocardia.

Dextrocardia is a rare condition not spared by coronary artery disease. We report the case of a 72-year-old patient with dextrocardia associated with situs inversus totalis who presented to our Institution with acute myocardial infarction complicated by congestive heart failure. Due to the severe general conditions of the patient, an emergent off-pump complete myocardial revascularization was undertaken. The patient tolerated the procedure well and was asymptomatic at discharge. The technical aspects encountered in the setting of mirror-image anatomy and the advantages of off-pump myocardial revascularization in the critically ill patient are discussed.

[Pseudocontinent colostomy - a manometric study]. / Psevdokontinenten protivoestestven anus - manometrichno prouchvane.

The intraluminal pressure in terminal segment of colon has been studied at 42 patients undergone an exterpation of rectum and taken out pseudocontinent colostomy onto a front part of the abdomen. Schmidt's pattern smooth muscle muff, modified in the Clinic Surgery and Coloproctology at MU--Varna, has been transplanted around the colon, taken out as continent colostomy. The intraluminal pressure in the terminal segment of colon has been identified with an index of resistance on the side the smooth muscle muff against the spontaneous evacuation of the colon content. The pressure has been registrated at rest and after the mechanical dillatation of muscle muff. The pressure at the check group of 20 patients with taken out continent colostomy has been investigated manometrically. The basal intraluminal pressure at the patients with a transplanted smooth muscle muff has been 30 +/- 2.9 mmHg at the end of the first postoperative month, as it has been sustained permanent (29.7 +/- 3.0 mmHg) up to the second postoperative jear (0.001). The pressure has been increased up to the mean value of 42 +/- 2.5 mmHg, as it has been sustained at this level for a period of 120 sec. The basal intraluminal pressure at the patients with transplanted smooth muscle muff has been more then four times higher in comparison with the pressure in c. sigmoideum, which has been a prerequisite for stopping of the spontaneous evacuation. A conclusion has been done that the index of resistance in the terminal segment of colon has been depended on a functional potential of the smooth muscle muff directly. The transplanted muff has been an anatomic structure manifested a functional activity in terms of isolation.

[Continent colostomy and colon irrigation]. / Protivoestestven anus i kolonirigatsii.

The authors have studied a functional activity of a continent colostomy at 20 patients, undergone an abdomeno-perineal extirpation of rectum and carried out periodic colonirrigations, during a period of 6 months. A conus type, closed irrigating system has been used. The degree of an incontinency at patients has been compared before and after the beginning of the colonirrigations. The irrigating procedures have reduced spontaneous defications at patients during a week 28 times and have improved the quality of life significantly. The application of colostomy bags has been restricted in 8 (40%) patients. An intraluminal ultrasonographic investigation has been done at 12 (60%) patients at the end of 6 month irrigating period. No changes of the ultrasonographic image of the precolostomic segment of colon has been observed.

[A modified autotransplantation method providing for continence in preternatural anus]. / Modifitsiran avtotransplantatsionen metod za obezpechavane na kontinentnost pri bolni s protivoestestven anus.

Over the period 1996 through 1998, a series of 58 patients undergo operation in the clinic of coloproctology--Medical University, Varna and in the clinic of surgery at the Naval Hospital--Varna, for continent preternatural anus formation on the anterior abdominal wall. A personal modification of Schmidt's (1978) method is used where a smooth-muscle cuff exerting pressure on the terminal segment of the large bowel, brought out as an artificial anus, is created. The operative procedure is combined with periodic colon irrigations in the postoperative period for the purpose of stimulating controlled intestinal content evacuation. The degree of continence is evaluated clinically and manometrically in all cases at termination of the first postoperative month, and in 31 of them--at the end of the second postoperative year. The early and late results are good.

[Pseudocontinent colostomy - comparative experimental study]. / Psevdokontinentni kolostomi - sravnitelno eksperimentalno prouchvane.

The possibilities of smoothmuscle sphincteroplastic have been researched experimentally at 29 mongrel dogs. Six types smoothmuscle plastics have been studied--a method of Feodorov and Odariuc, a method of Musiani, a pylor as a sphincter, an own operative method in three versions. A comparatively research upon a functional fitness of the offered plastics and Schmidt's method has been done. The level of intraluminal pressure into the precolostomy segment of colon and a functional status of the taken out colostomy have been compared. The reliable lower level of intraluminal compression has been established (p < 0.05), using longitudinal muscle as a plastic material. The intraluminal pressure into the end segment of colon has been sustained raised, permanently, due to the tonus of circular muscle in to the transplant's wall. The degree of intraluminal compression seems to be directly proportional to the volume of stretching of smoothmuscle transplant (p < 0.001). There has been done a conclusion, that the smoothmuscle plastic gives operative-technical possibilities for raising of intraluminal pressure by changing the volume of stretching of the transplant.

[Post-gastrectomy reconstruction versus enteral alimentation--a one year follow-up study]. / Rekonstruktsiia sled gastrektomiia i enteralno khranenie--ednogodishni rezultati.

This is a report on various post-gastrectomy reconstructive procedures, proceeding from personal experience had with 14 patients undergoing gastrectomy for carcinoma of the stomach and five patients with operations of esophagus and stomach for various pathological conditions. An assessment is done of the reconstructive methods used on the ground of objective indicators. All patients are subjected to enteral alimentation through nutritive jejunostomy. In the pre- and postoperatived periods, the trophic state of patients is evaluated on basis of biochemical, anthropometric and immunologic study data. Postoperatively, in those with small-intestinal reservoir a lower degree negative symptomatology is established, along with life style improvement. Post-gastrectomy patients presenting I-II (UICC) stage of the oncological disease are indicated for small-intestinal reservoir formation. In the overall therapeutic approach to post-gastrectomy patients adequate clinical therapeutic feeding proves absolutely indispensable.

[Continent preternatural anus--histomorphological and functional aspects]. / Kontinenten protivoestestven anus--khistomorfologichni i funktsionalni aspekti.

Transplantation of a free smooth-muscular cuff around a terminal large-intestinal segment, brought out as preternatural anus, secures high-degree continence and controlled evacuatory rhythm of the intestinal content. The preserved structure of the muscular layers in the cuff wall and the myogenic nature of smooth muscle tone are preconditions for functional activity manifestation in conditions of denervation, isolation and even after block of neurons and intramural ganglia. Five preparations comprising the smooth muscle cuff and recipient large-intestinal segment undergo histomorphologic and electromyographic study within a year of transplantation. In a series of 31 patients with drawn out continent preternatural anus the thickness of the abdominal wall together with the smooth muscle cuff graft is echographically registered at the end of the first postoperative year. The echographically documented abdominal wall thickness is compared with the histomorphologically established values of the indicator under study. Analysis of the functional activity of the smooth-muscle-cuff transplant is also done.

[Pulse oximetry and capnometry in the prevention of perioperative morbidity and mortality]. / Pulsni oksimetar i kapnometar u prevenciji perioperativnog morbiditeta i mortaliteta.

Oxygen saturation (SaO2) and end tidal CO2 determined by pulse oximetry and capnometry were monitored in 2440 surgical patients during elective head and neck, abdominal, traumatologic and orthopedic surgery. The incidence, severity and duration of hypoxemia and hypercarbia were studied as well as their causes. Equipment disconnections alarmed by capnometry were noted separately. Hypoxemia was defined as SaO2 < or = 90% and graded into three values of SaO2 and hypercarbia was defined as EtCO2 > or = 50 mmHg. Severe hypoxemia (SaO2 < or = 80%) occurred in 170 (8%) patients. A greater number of severe events occurred in children under 2 yr of age (p < 0.02). The pulse oximeter diagnosed hypoxemia before the signs and symptoms of hypoxemia were apparent (cyanosis or bradycardia). Severe hypoxemic episodes were unrelated to the duration of anesthesia. Equipment disconnections alarmed by capnometer were most frequent in head and neck surgery (p < 0.02). Capnometer alarmed disconnections before the signs of hypoxemia and hypercarbia occurred. No morbidity was documented in any patients who suffered an hypoxemia event. Pulse oximetry and capnometry enable early detection and removal of the majority of the ventilation mishaps before damage or even death occur.

Intensive care of severely wounded military and civilian casualties in Zadar, Croatia.

From August 1, 1991, to May 30, 1992, 148 severely wounded military and civilian casualties with the injury severity score of 3 to 5 were treated in the intensive care unit of the Zadar General Hospital. There were 138 male and 10 female patients; their mean age was 32 years. There were 64 wounded civilians and 84 wounded soldiers. The average evacuation time was 3 hours. Twelve (8%) severely wounded persons died. The cause of death was craniocerebral injury in 7 patients (58%) and hemorrhage in 4 patients (33%). Complications following shock-like acute renal failure, gastrointestinal bleeding, coagulopathy, and hepathopathy developed in 18 wounded persons (12%).

[Our experience with the diagnosis and treatment of biliary pancreatitis]. / Nashiiat opit vurkhu diagnozata i lechenieto na biliopankreatita.

The diagnostic and therapeutic problems faced during treatment of thirty-nine patients presenting biliopancreatitis (BP) are discussed. BP diagnosis is made on the ground of clinical picture, laboratory indicators, abdominal ultrasonography, intraoperative cholangio-pancreatography and cholangioscopy. Patients with cholelithiasis (ChL) of long-standing in the previous history are predominant, with the age group exceeding 50 years of age being most numerous, and the female gender prevailing. All patients undergo conservative pre- and postoperative treatment. Operative treatment in BP is performed as an emergency intervention. Cholecystectomy is done in all cases, and in 56.3 per cent of them it proves sufficient to promote a favourable outcome of the pathologic condition. External or internal drainage of the choledochus is necessitated in the presence of definite indications (obstruction of extrahepatic biliary ducts and pancreas documented by operative cholangiography, choledochoscopy and probing). Dilatation of the papillary sphincter is carried out in five patients (12.8 per cent) because of partial papillary stenosis. The destructive forms of pancreatitis are treated by gland draining in conjunction with necrectomy and drainage of the extrahepatic biliary ducts. A correlation is established between the incidence of destructive forms of pancreatitis and therapeutic results, on the one hand, and timing of the operative intervention, on the other. Operative management of BP is a method of choice insofar as it contributes to the complex and thorough treatment of the condition. Preoperative BP diagnosis is still a problem not well enough clarified which leads to delayed operation with an adverse impact on the prognosis of the disease.

[A retrospective survey study of diagnosis and surgical treatment in peptic ulcer]. / Obzorno retrospektivno prouchvane vurkhu diagnozata i khirurgichnoto lechenie na iazvenata bolest.

A total of 239 patients of which 183 operated over the period 1987 through 1992 are reviewed. Cases with duodenal location of the lesion predominate (84 per cent), next ranking gastric ulcers (14 per cent), and type II according to Johnson (2 per cent). Among the patients operated on resection methods, type Billroth II, with antecolic gastroenteroanastomosis and Braun's anastomosis, accounting for 84.1 per cent of the total of planned operations, are mainly used. Retrocolic gastroenteroanastomosis type Hoffmeister-Finsterer is performed in five, and Billroth I-in one patient. Three patients presenting gastric ulcer, free of malignization signs, are subjected to pylorus-preserving resection according to MacKee. Resection methods as a definitive therapeutic approach to ulcers, at that according to Billroth II, are predominant owing to the fact that most patients operated on present ulcers penetrating the pancreas, involving ligamentum hepatoduodenale and the descending portion of the duodenum, and pyloric stenosis, making impossible the restoration of passage by Billroth I or other operations. A lasting good result is attained in 92 per cent of cases, minor complaints are recorded in 6 per cent, and substantial complaints-in 2 per cent. The study results lead to the inference that standard resections with anterior gastroenteroanastomosis in complicated ulcers, ruling out other alternatives, yield a permanent therapeutic effect. The approach to individual patients should be by no means unified, and the most expedient operative procedure should be used. Owing to delayed operative treatment and numerous complications, the classical resection methods prove to be the method of choice in the surgical management of ulcers.