[Inguinal endometriosis: two case reports and literature review].

Endometriosis is a common gynecological disease that is characterized by the presence of endometrial glands and stroma outside the uterus. Ectopic endometrial tissue can be localized in all organs of the human body, but it affects most often organs in the pelvis. The localization in the inguinal canal is extremely rare - 0.3% -0.6% of all cases of endometriosis. We report two cases of inguinal endometriosis in patients with a history of previous surgery in the pelvis. Both patients is formation in the inguinal region of increasing volume, accompanied by severe pain especially in the premenstrual period. The diagnosis was based on an exact medical history and histological examination. The main methods of treatment of inguinal endometriosis is radical surgical excision of the lesion. We recommend hormone therapy as an adjunct to treatment.

LAPAROSCOPIC TREATMENT OF RECTAL CANCER.

There is an established standard for the surgical treatment of rectal neoplasms. Every conventional operation can be performed by means of laparoscopy, if the complex approach to the disease and classical oncological principles are observed. Depending on the height of tumor, surgical operations, different in tactical and technical terms, are performed. The correct preoperative staging, planning, and securing of resources guarantee the favorable outcome of therapy. The main advantages are the less postoperative pain and briefer hospital stay. The better visualization of pelvic organs and routine use of high-energy sources reduce the blood loss and potential complications. With a view to ensure modern treatment of this major group of patients, the input of the required resources, for turning into one of the routine methods of rectal cancer treatment, is a necessity. ABBREVIATIONS USED: LAR (laparoscopic anterior resection), LLAR (low laparoscopic anterior resection), LIsRR (laparoscopic intersphincteric resection of the rectum), TME (total mesorectal excision), TATME (transanal total mesorectal excision), LER (laparoscopic extirpation of the rectum), IMA (inferior mesenteric artery), and IMV (inferior mesenteric vein).

PRIMARY RETROPERITONEAL EXTRA-ORGAN TUMORS (PRET) - SURGICAL TACTICS.

INTRODUCTION: Retroperitoneal tumors, in general, are rare tumors which histopathological characteristics and biological behavior can be considered as benign or malignant. They originate from various tissue elements located in the retroperitoneal space. They often cover Anatomical structures of varying importance - mainly retroperitoneal vessels and organs, which determines the type of surgery - radical or palliative. They are composed of adipose tissue, vascular elements, smooth and striated muscle, neural elements germline structures. There are three main types of retroperitoneal tumors: mesodermal, neurogenic and teratosarcomas. As mentioned above each can be either benign and malignant. In most cases there are no specific symptoms except general weakness, heaviness in the abdomen, loss of appetite, progressive weight loss, headache and fever. The pain is most often located in the lumbosacral area. The tumor can also cause disturbances in urination. In patients with advanced stage can be observed significantly symmetrical or asymmetrical tumor growth in the abdominal area. The most commonly used techniques for the diagnosis of the disease are X-ray, CT-scan and MRI. MATERIAL AND METHODS: Retrospective study involving 112 cases operated in the clinic for 14-years period (2000-2014) - 101 patients, 11 of them were operated on twice in a different time interval on the occasion of relapsed malignant process. RESULTS: Out of all operated cases, 42% are males (47 cases) and 58% - women (65 cases). In most cases (72% - 81 cases) tumors are malignant. All patients were treated surgically. There were followed up a total of 89 patients over a period of 3 months to 8 years (96 months) as of the studied malignant cases 3 year survival was observed in 21 patients, and one patient has survived 96 months after total extirpation of fibrosarcoma. Early postoperative mortality (till 20th postoperative day) was registered in 3 patients - 2.67% of all operated cases. DISCUSSION: About 80% of primary retroperitoneal extra-organ tumors are generally malignant. People of all ages are affected equally and no statistically significant difference in the number of men and women is detected. There are many theories about the emergence of retroperitoneal tumors, but currently none of them has not been fully proven. Treatment depends on the type of the lesion. Surgery is the main approach and it should be applied to both benign and malignant lesions. In the case of malignancy other methods than surgical are chemo- and radiotherapy but they are less effective.

Clinical and prognostic significance of pathological and inflammatory markers in the surgical treatment of locally advanced colorectal cancer.

BACKGROUND: Locally advanced colorectal cancer (CRC) may vary in its clinical and pathological appearance. It is now accepted that progression of disease in patients with locally advanced CRC is determined not only by local tumor characteristics but also by the immune system and inflammatory response in the body. METHODS: We investigated patients with confirmed CRC who were treated in the surgical clinic at the University Hospital Alexandrovska over a 10-year period and retrospectively evaluated the histological features of the preoperative biopsies and operative specimens removed during radical multivisceral resections. We also collected prospective data for serum C-reactive protein levels and Jass-Klintrup score, Petersen Index score, and Glasgow Prognostic Score in patients with locally advanced CRC. RESULTS: Of 1,105 patients with CRC, 327 (29.6%) were diagnosed with locally advanced disease. In total, 108 combined multivisceral resections (79 for primary tumors and 29 for recurrent tumors) were performed. Overall survival was 34 months for pR0 cases and 12 months for pR1 cases (P<0.05). Our data confirmed that C-reactive protein is a prognostic marker of overall survival. Data for 48 patients with histologically confirmed locally advanced tumors showed significantly increased survival with a higher Jass-Klintrup score (P=0.037). In patients with node-negative disease, 5-year survival was 49%. However, where there were high-risk pathological characteristics according to the Petersen Index, survival was similar to that for node-positive disease (P=0.702). Our data also showed a significant difference in survival between groups divided according to whether they had a modified Glasgow Prognostic Score of 1 or 2 (P=0.031). CONCLUSION: In order to maintain a reasonable balance between an aggressive approach and so-called meaningless "surgical exorbitance", we should focus on certain histopathological and inflammatory markers that can be identified as additional factors for planning the type and volume of surgical treatment.

A Meta-Analysis of Quality of Life, Estimated by Questionnaires of the European Organization for Research and Treatment of Cancer (EORTC) after Rectal Cancer Surgery.

BACKGROUND: Rectal carcinoma is one of the most common cancers on a global scale. Although there were major improvements in its treatment during the last two decades, surgery is still the only curative method. However, is often complicated and can cause disorder of different aspects of the patients self-perception of health. The aim of this study is performing ofa meta-analysis for evaluation and comparison of the quality of liferesults after rectal cancer treatment. METHODS: Search of relevant articles, which were published between 2000 and 2015, was performed. The outcomes of abdominoperineal resection and anterior resection were analyzed with the EORTC's quality of life measuring instruments - quality-of-life questionnaire C30 (QLQ-C30)and quality-of-life questionnaire CR38 (QLQ-CR38). The assessment score, appropriate for the survey, was established at least one year after radical surgery. The Statistical Package for Social Sciences (SPSS) package of IBM Statistics, version 19 was used for the statistical analyses. RESULTS: 13 studies, published between 2001 and 2015, have been presented in this meta-analysis. Data from 1805 patients,with a mean age of 64.7 years, have been included. When comparing Miles extirpation and sphincter-sparing operations,statistical significance was detected for the following variables:social functioning (74.6 ± 8.5 vs. 83.4 ± 8.6, P = 0.045),constipation (11 ± 8.4 vs. 22.6 ± 8.3, P = 0.032), and body image (67.9 ± 14 vs. 82.5 ± 9.1, P= 0.01). CONCLUSION: Preservation of the sphincter is a better treatment option that should be carefully considered. Dependently registered differences, our conviction for the rectal cancer care concern needs individualization of the approach in this surgery.It is essential that the policy of avoidance of abdominoperineal resection (APR) cannot currently be justified on the grounds of quality-of-life (QoL) results alone.

SINGLE-ACCESS TRANSUMBILICAL LAPAROSCOPIC APPENDECTOMY USING CURVED REUSABLE INSTRUMENTS: AN INITIAL REPORT OF THREE CASES.

INTRODUCTION: The continuous evolution of laparoscopic surgery and the ambition of better cosmetic results raise the need for less invasive procedures. The umbilicus represents a natural scar and constitutes a well-healing site of access to the peritoneal cavity. Single-access Transumbilical Laparoscopy (SATL) is gaining popularity and can be an alternative surgical treatment for acute appendicitis. We report three cases of SATL appendectomy using curved reusable instruments. PATIENTS AND METHODS: Three female patients, wanting minimal scarring (mean age - 30 years) were admitted to our hospital in April 2015 with acute abdominal pain in the right iliac area. A SATL appendectomy was performed using a standard 11-mm reusable trocar for a 10-mm, 30 degrees- angled, rigid scope and curved reusable instruments according to DAPRI (Karl Storz-Endoskope, Tuttlingen, Germany) placed transumbilically. RESULTS: Neither a conversion to open surgery nor an insertion of extraumbilical trocars was necessary. The mean operative time was 101.6 ± 24.66 minutes and the mean blood loss 6.66 ± 11.54 mL. The mean scar length was 16.66 ± 0.57 mm. No intraoperative complications were registered and the use of minimal pain killers allowed the discharge after 2 or maximum 4 days. After three months of follow-up no late complications occurred and the umbilical scar was not visible. CONCLUSION: In young and scarless-demanding females with acute appendicitis SATL appendectomy can be performed safely and offers the possibility of surgical treatment without a visible scar.

Long-term consequences of anesthetic technique after cancer surgery.

UNLABELLED: The main treatment for most types of malignant tumors is their surgical removal. During the past years there has been a growing interest in the anesthesia effects on long-term surgery results in connection with cancer. Modern clinical and laboratory data indicate that the anesthetic technique may play a role in tumor dissemination and recurrence. The purpose of this study is to review the available literature data on the anesthetic techniques applied in oncology surgery, long-term consequences of anesthesia/analgesia and their relation to tumor progression. MATERIAL AND METHODS: We have reviewed the specialized medical literature and have analyzed the effects of anesthesia/analgesia on long-term results of surgical treatment--incidence of local recurrence, metastases and patients' survival. RESULTS: The hypothesis about the influence of the anesthesia type on long-term results after cancer surgery is generated. The use of anesthetics and analgesics with low potential for immunosuppression may reduce the relapse. This is a useful approach for patients with cancer. IN CONCLUSION: Further randomized controlled trials are required for extensive research of this problem.

Peutz-Jeghers syndrome--a rare case and a literature review.

The Peutz-Jeghers syndrome is inherited condition, characterized by hamartomatous gastrointestinal polyposis and with mucocutaneous pigmentation. We have experienced a case with typical clinical features, diagnosed before complication's development. In order to prevent cancer setting it is recommended to perform aggressive screening and high-technological procedures.

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.

ASSESSMENT OF THE SEXUAL FUNCTION AFTER RECTAL CANCER SURGERY.

INTRODUCTION: Introduction: Sexual functioning is one of the most important components of subjective term quality of life. The growing incidence of rectal cancer recent decades lead to a tendency to optimize the diagnostic and therapeutic process, to perform better staging and postoperative disease control. Clearing the operational plan to achieve radicality and preservation of pelvic autonomic innervation are key components affecting sexual function and subsequent quality of life of patients. MATERIALS AND METHODS: It was used data from questionnaires QLQ C30 and QLQ C38 to assess sexual function, according to the methodology of the EORTC (European Organization for Research and Treatment of Cancer). Information was collected of 71 patients operated and monitored in Complex Cancer Center of Veliko Tarnovo during the period 01.2005-06.2010 year. It compares 38 underwent sphincter-sparing operations and 33 abdominoperineal resections having definitive stoma. Patients had fulfilled questionnaires more than six full months after surgery forming a functional scale related to sexual function. RESULTS: A significantly higher number men after abdominoperineal resection have trouble to ejaculate compared to patients after anterior resection of the rectum. Statistically significant difference in sexual function between studied groups was observed in the male sex. CONCLUSION: The psychometric values of the self-perception of health were highest after treatment of high rectal carcinomas. Sphincter-spared men after rectal resection had significant fewer problems with ejaculation, compared with patients suffered abdominoperinealna cutter. Sexual dysfunction was significantly more common in men underwent rectum extirpation compared to patients undergoing conservative surgery.

Postoperative complications after Nissen fundoplication.

Anti-reflux laparoscopic operations replaced conventional surgery and are now widely available, because of the advantages of this type of surgery. One of the main reasons for the high complications rate in this type of operations is the lack of experience of the surgeons, although recently in the reports of most leading authors complications and increased mortality rate is due to the older patients undergoing this type of surgery. The main causes of death were gastrointestinal hemorrhage, necrosis with perforation of the esophagus or stomach, cardiac arrest, respiratory and inflammatory complications, and pulmonary thromboembolism.

En bloc laparoscopic sigmoidectomy, left adnexectomy, small bowel loop and piece of urinary bladder resection for advanced sigmoid tumor.

UNLABELLED: The laparoscopic surgery of colon increasingly replaces the conventional surgery of colon on a global and regional scale. Many randomized studies demonstrate the advantages with regard to the shorter postoperative hospital stay, faster recovery, and identical results of the indexes of survival and frequency of relapses. The en bloc resection in cases of locally advanced colon cancer is the most secure method for achieving of R0 resection . The growth of the tumoral mass towards the adjacent structures manifests with histological tumor invasion in approximately 50% of the cases. The cases of laparoscopic en bloc resection for the treatment of colorectal cancer, which are described in the literature, increase. In this report we present a clinical case of substenotic sigmoid colon cancer and perioperative finding of infiltration towards a small intestinal loop and part of the urinary bladder, as well as towards the left uterine tube and the left adnex. In the case of this patient laparoscopic en bloc resection of the tumor formation was performed according to the so called "laparoscopic no touch technique". Approximately 15-20% of the cases of colorectal cancer are still in T4 stage, with involvement of the adjacent organs (1), despite the advance of the examination methods. CLINICAL CASE: A 67 year old female was admitted to the hospital for a substenotic sigmoid colon lesion, syndrome of anemia, resulted adenocarcinoma at colonoscopy. Endoscopy showed an endoluminal tumor at 25 cm from the anal margin and preoperative work-up did not evidence any secondary lesions or invasion of other organs. METHODS: Four abdominal trocars were placed. The laparoscopic exploration of the abdominal cavity showed the presence of a colic mass with suspected invasion of a small bowel loop and part of the urinary bladder, the left uterine tube, and the left ovary. The tumor formation was dissected en bloc with resection of the left uterine tube and ovary, the urinary bladder, and a small bowel loop. Colorectal anastomosis with laparoscopic manual technique was performed. The anastomosis was tested for leak-tightness. The specimen was removed by enlargenemt of the 5 mm. suprapubic trocar. RESULTS: The mean operative time was 285 minutes with blood loss of 300 ml. Patient was discharged on Postoperative Day 5. The histological result verified tumoral invasion towards the urinary bladder, the small bowel, and the ovary. The final staging according to the TNM classification is pT4N0Mx. CONCLUSION: The en bloc laparoscopic resection for the treatment of sigmoid colon cancer, engaging the adjacent organs, is indicated and feasible, with surgical results, comparable with a conventional surgical intervention at the same volume.

Per magna-ovarian metastases from primary locally advanced colorectal cancer--a review of the literature with a description of three clinical cases.

Krukenberg tumor is defined as metastatic lesions of gastrointestinal cancers. Several specific immunohistochemical methods can identify the main focus of malignant neoplasm. Ovarian metastases from colorectal cancer are rarely seen phenomenon. The authors examine in detail the literature on this issue and describe three own clinical cases of metachronous ovarian meta lesions in women undergoing surgery for locally advanced colorectal cancer--two of these metastases are unilateral, while one--bilateral established in a short time interval despite the casuistic nature of the pathology. One of the patients died in the early postoperative period of co-morbid complications unrelated to the underlying disease, and the other two monitoring continues during the adjuvant. Krukenberg-metastases from colorectal cancer occur in the blood-vascular pattern in time without damage to the left or right ovary. Metachronous development and operative treatment of ovarian metastases is far better prognosis of the cases with and operated simultaneously established metastases in the ovaries.

Single-access retroperitoneal adrenalectomy.

AIM: To report the first case in our country of a single access--adrenalectomy with lateral retroperitoneal approach by using SILS port and to evaluate the feasibility and safety of this new technique. MATERIALS AND METHODS: A 50-year-old man presented with 38 mm right adrenal incidentaloma, functionally nonactive and without radiologic characteristics suggestive of a malignant lesion, discovered on abdominal computed tomography for nephrolithiasis. The single access adrenalectomy was attempted with multichannel SILS port (Covidien), inserted through a 3 cm transverse incision at the tip of rib XII on the right side. RESULTS: The single access retroperitoneal adrenalectomy (SARA) was successfully completed without any intraoperative complications. An additional lateral 5-mm port was needed for retraction of the kidney and for tubular drain in the end stage of the surgery. The operating time was 120 minutes with 40 mL of blood loss. Postoperative recovery was uneventful. The patient was discharged from the hospital on the second postoperative day. Pathologic examination confirmed cortical adenoma of the adrenal grand. No morbidity within one month of follow-up, and excellent cosmetic results. CONCLUSION: This is the first case of a single access retroperitoneal adrenalectomy (SARA) by using SILS port was performed in our country. Based on our primary experience, we believe that SARA is a safe and feasible procedure for selected patients with adrenal tumors and when performed by a surgeon experienced in laparoscopic and adrenal surgery. Although initial technical adjustments are inevitable, simplifying the procedure. However, more surgical experience using this technique is required to confirm our initial impressions.

[Lymph nodes metastases in differentiated thyroid cancer--prognostic value and syrgical results with 430 patients for 30 years period (1980-2010)].

In this we review 430 differentiated thyroid cancer patients underwent surgery for 30 years period since 1980 to December 2009. The stage of disease was T1-3.Na-b.Mo(TNM). Papillary thyroid cancer patients were 77.2% and folicular thyroid cancer--22.8%. The regional lymph nodes metastases distribution were analyzed according to the age, sex, of the patients and tumor histology. Preoperatively,clinically involved were neck nodes in 35 patients 8.3%--26 patients with PTC and in 9 patients with FTC. Surgical procedures for low-risk group of patients were variable from lobectomy and istmusectomy to near total thyroidectomy and modified radical lymph node dissections of the neck and patients in high risk group underwent total thyroidectomy and radiojodine therapy. The level of regional recurrences was 1.7 folds higher in patients treated by total thyroidectomy and radiotherapy J131.

[The value of endo rectal ultrasound].

In the last twenty years, endorectalultrasound (ERUS) has become the primary method for locoregional staging of rectal cancer. ERUS is the most accurate modality for assessing local depth of invasion of rectal carcinoma into the rectal wall layers (T stage). Lower accuracy for T2 tumors is commonly reported, which could lead to sonographic overstaging of T3 tumors following preoperative therapy. Unfortunately, ERUS is not as good for predicting nodal metastases as it is for tumor depth, which could be related to the unclear definition of nodal metastases. The use of multiple criteria might improve accuracy. Failure to evaluate nodal status could lead to inadequate surgical resection. ERUS can accurately distinguish early cancers from advanced ones, with a high detection rate of residual carcinoma in the rectal wall. ERUS is also useful for detection of local recurrence at the anastomosis site, which might require fine-needle aspiration of the tissue. Overstaging is more frequent than understaging, mostly due to inflammatory changes. Limitations of ERUS are operator and experience dependency, limited tolerance of patients, and limited range of depth of the transducer. The ERUS technique requires a learning curve for orientation and identification of images and planes. With sufficient time and effort, quality and accuracy of the ERUS procedure could be improved.

Lymph nodes metastases in differentiated thyroid cancer--prognostic value and surgical results with 430 patients for 30 years period (1980-2010).

The papillary cancer and the follicular cancer are the most common forms of thyroid malignitet. Based on 30-year follow up of 430 patients, who underwent differentiated thyroid cancer surgery, the incidence of the lymph nodes metastases and the rate of postoperative recurrence of the disease was studied and the performance criteria of modified radical lymph node dissection of the neck were specified. Papillary cancer patients were 77.2% (332 people) and follicular cancer patients were 22.8% (98%). At the time of the diagnosis 8.2% (35 people) of the patients had palpable lymph nodes metastases. All patients with lymph nodes metastases, which developed after the surgery, underwent successful treatment with a modified lymph node dissection of the neck. In none of the cases the lymph node metastases led to a fatal outcome.

Multifactorial nature of high frequency of mitochondrial DNA mutations in somatic mammalian cells.

The high frequency of mitochondrial DNA (mtDNA) mutations in somatic mammalian cells, which is more than two orders of magnitude higher than the mutation frequency of nuclear DNA (nDNA), significantly correlates with development of a variety of mitochondrial diseases (neurodegenerative diseases, cardiomyopathies, type II diabetes mellitus, cancer, etc.). A direct cause-consequence relationship has been established between mtDNA mutations and aging phenotypes in mammals. However, the unclear nature of the high frequency of mtDNA mutations requires a comprehensive consideration of factors that contribute to this phenomenon: oxidative stress, features of structural organization and repair of the mitochondrial genome, ribonucleotide reductase activity, replication errors, mutations of nuclear genes encoding mitochondrial proteins.

[The effect of intraperitoneal levobupivacain (Chirocaine) application on postoperative pain in laparoscopic cholecystectomy--a prospective study].

BACKGROUND AND OBJECTIVE: A prospective comparative trial was performed to evaluate the effect of intraperitoneal Ievobupivacaine administration on postoperative pain in patients undergoing laparoscopic cholecystectomy. MATERIAL AND METHODS: Patients received a standardized procedure and were allocated to receive either (I) 0.25% 20 ml levobupivacaine or (II) normal saline 20 mL to the bed of the gall bladder and to the subdiaphragmal region above the liver at the end of the operative intervention. VAS (0-10) on 2-nd, 6-th, 12-th and 24-th hour as well as postoperative analgesia requirements were evaluated. RESULTS: Mean abdominal pain in the levobupivacaine group was significantly lower than that in the 0.9% Na Cl group on the 2nd (p = 0.038) and 6-th (p = 0.028) postoperative hour. There was reduction in postoperative analgesia requirements in levobupivcaine group, but no statistically significant difference between the two groups was detected. CONCLUSIONS: Intraperitoneal administration of levobupivacaine is associated with modest analgesia following laparoscopic cholecystectomy.

[Retrosternal thyroid goiter: 20 years experience].

Retrosternal localization of thyroid pathology is not rare. We present a retrospective 20-years' research on 4225 patients with different thyroid diseases. 803 of them were with a different level/stage) of retrosternal localization of the gland. Our analysis reveals that the possibility of malignancy and difficult diagnosis make surgical treatment obligatory. It should be performed only by experienced in thyroid surgery specialists.