[Changing susceptibility patterns of surgical site infection pathogens after the introduction of modern perioperative chemotherapy in the emergency surgery clinic]. / Promeni v chuvstvitelnostta na prichinitelite na raneva infektsiia sled vuvezhdaneto na suvremenna perioperativna khimioprofilaktika v klinikata po speshna khirurgiia.

993 surgical site infection aerobic pathogens are isolated over a six-year period (I.1994-I.2000) by the Microbiology Laboratory at University Hospital "Tzaritza Joana". 224 (22.6%) of them are isolated from patients undergoing abdominal surgery in the Emergency Surgery Clinic. The period covers 3 years before the introduction of current single-dose perioperative prophylaxis (i.e. under the conditions of long-term one) as well as the next 3 years following its introduction in the Emergency Surgery Clinic. The changes of pathogens susceptibility patterns to single-dose drug schemes in both hospital elective abdominal surgery and emergency surgery clinics are followed during the whole period. Our microbial susceptibility data support the ecological expedience of single-dose approach categorically.

[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.

[The pathomorphology of complicated colorectal cancer and the stages in the development of the tumor process]. / Patomorfologiia na uslozhneniia kolo-rektalen rak i stadii na razvitie na tumorniia protses.

A comprehensive pathomorphological assessment is done in 385 patients presenting complicated colorectal carcinoma, covering the period 1990 through 1995. The patients are distributed in 4 groups according to stage, with those in stage III being the most numerous--141 cases. The growth pattern of the neoplasm is as follows: exophytic growth--110 cases, ulcerous growth--57, cup-like growth--13, and endophytic growth--205 cases. On establishing metastatic lymph nodes within I and II lymph collectors, prophylactic postoperative chemo- and immunotherapy are undertaken. In case of lymph nodes present in III lymph collector, the operation is taken to be relatively radical, and for that reason chemo- and immunotherapy assume a therapeutic character.

[The long-term results in complicated colorectal cancer (survival for over 3 and 5 years)]. / Dalechni rezultati pri uslozhnen kolo-rektalen rak (prezhiviaemost nad 3 i 5 godini).

Colorectal cancer survival depends on: stage of primary neoplastic process development, clinical complication pattern and clinical course of the disease, type (radicalism) of the surgical intervention done and histological verification of blastoma. As shown by the results, postoperative lethality in complicated colorectal carcinoma cases amounts to 17.1 per cent, whereas in those undergoing radical surgery for uncomplicated carcinoma it amounts to 6.8 per cent. Patients presenting complicated colorectal carcinoma are admitted to the clinic with diagnosis advanced stage of development of the disease which explains the lower survival rate. The studies performed show that five-year survivorship in patients with complicated colorectal carcinoma amounts to 33.3 per cent, while among those operated for uncomplicated colorectal carcinoma it is 62.7 per cent in the average.

[Our experience in introducing current antibiotic prophylaxis into abdominal surgery--the initial results]. / Nashiiat opit pri vuvezhdane na suvremenna antibiotichna profilaktika v koremnata khirurgiia--nachalni rezultati.

Over a one-year period (Nov. 1996-Nov. 1997), a total of 154 patients are admitted on an emergency basis, with deferred emergency and for routine treatment in the Clinic of Emergency Surgery. They are distributed in three groups, as follows: patients not requiring perioperative antibiotic prophylaxis and postoperative antibiotic therapy--27, patients subjected to perioperative parenteral antibiotic prophylaxis under adequate hospital conditions--121, and patients undergoing antibiotic prophylaxis in conditions inappropriate for its application--six. The drug schemes elaborated are in conformity with worldwide and Bulgarian experience along this line, and with the concrete hospital and economical conditions in this country. In all patient indicated for antibiotic prophylaxis the listed below antibacterial agents (presented as drug schemes) are administered i.v. a single time prior to anesthesia induction: in operations on the gastrointestinal tract except for interventions in acute appendicitis: cephalotin/cefazolin 2.0 g and metronidazole 0.5 g i.v.; in operations for acute appendicitis: amoxicillin/clavulanate 1.2 g and petronidazole 0.5 f i.v.; biliary surgery free of extrahepatic cholestasis: cephalotin/cefazolin 2.0 g i.v.; biliary surgery with present or preceding extrahepatic cholestasis: cefotetan 2 g i.v.; contaminated liver cysts (parasitic and nonparasitic): cefotetan 2 g i.v.; abdominal trauma without perforation of a hollow organ: cefotetan 2 g i.v.; in plastic repair of the anterior abdominal wall (congenital defects, postoperative eventration) and in poor risk patients (local and general status: cephalotin/cefazolin 2.0 g i.v. In 135 patients the postoperative period runs a course free of complications worthy of notice. Complications directly linked to introduction of the method proposed are recorded in ten cases: operative wound suppuration (4) and hospital infection (6). Complications not related directly to the procedure are observed in nine cases: urinary tract infection (4), bronchopneumonia (2), fever with unknown source of infection (including negative hemoculture) necessitating additional antibiotic therapy (2) and secondary infection (within a week of intervention) necessitating further therapy with antibiotics. The specific features of antibiotic prophylaxis used in the various types of operative interventions are discussed from microbiological, clinical and pharmacotherapeutic viewpoints. The obtained results are compared with pertinent literature data on the issue with a special reference to the clinical efficacy attained. They mirror the approach against the background of the concrete hospital conditions in this country. The method developed is fully consistent with the level of surgical expertise in Bulgaria. All efforts should be aimed at intrahospital environment improvement by means of meticulous asepsis and antisepsis.

[Acute surgical abdomen in middle and old age]. / Ostur khirurgichen korem v naprednala i starcheska vuzrast.

Proceeding from a comprehensive literature survey the urgency of acute abdomen conditions in elderly and senile patients is thoroughly discussed. Not infrequently, geriatric surgeons face serious difficulties of diagnostic and therapeutic character relating to the severity of clinical picture and elevated postoperative lethality, explaining in turn the great surge of interest in the problem. Recent achievements along this line, surgery in particular, provide for adequate conditions for performing early surgical interventions with reduced intraoperative risk in elderly and old age patients presenting acute abdomen.

[The pre- and postoperative monitoring of the immunological indices and tumor markers in colorectal carcinoma]. / Pred- i sledoperativen monitoring na immunologichnite pokazateli i tumorni markeri pri kolorektalen kartsinom.

UNLABELLED: The onset of immunological reaction against colorectal carcinoma is based on superficial changes in the malignant cell components following the formation of antigen structures. This explains the interest in the issue and defines the aim of the study. Over a 5-year period, in the Emergency Surgery Clinic, 86 patients with histologically diagnosed colorectal carcinoma (46 men and 40 women) are examined prior to surgery, and 107 patients (55 men and 52 women)--after the operation. The tumor markers CEA, CA 19-9, AFP and immunoglobulin IgA are tested using ELISA and RIA methods. Conventional ultrasound, scintigraphic and CT studies are carried out to detect liver metastases. The obtained results undergo statistical processing with correlation analysis and sensitivity and specificity coefficients. Among those examined preoperatively elevated CEA levels (CEA > 2.5 ng/ml) are recorded in 42 cases (48.9%), and for CA 19-9 (CA 19-9 > 37 E/ml)--in 40 (46.5%). From the patients with complicated colorectal carcinoma in the postoperative period 83 are clinically healthy (77.6%); of the latter marker-positive are 16 (19.3%), and marker-negative--67 (80.7%). Relapses and metastases are registered in 24 cases (22.4%) of which marker-positive--19 (79.2%). Liver and abdominal lymph node metastases are detected by US, scintigraphy and CT study. All three imaging methods contribute to diagnose liver metastases in 14 patients (13%). In 32 patients (18 men and 14 women) postsurgical monitoring of immunological IgA levels and tumor markers is done over period ranging from 7-10 days to 2 years postoperatively. Correlative dependences between IgA and CEA (R = +0.99), and between IgA and CA 19-9 (R = +0.97) are also documented. The sensitivity of both markers (CEA and CA 19-9) is low, varying between 38 and 51 per cent, with specificity amounting to 61-67 per cent. The paradoxically high elevation of tumor markers prior to operation shows a constant decrease at 3 months after surgery. CONCLUSIONS: 1. The sensitivity of both markers (CEA and CA 19-9) is low (38-51%), and that is why their use in screening examinations lacks clinical relevance. 2. CEA specificity is by no means high (61-67%), and it may become positive in a number of nononcological diseases (liver cirrhosis and hepatitis, inflammation diseases of GIT and lungs). 3. Plasma CEA and CA 19-9 levels correlate well with the neoplastic process progression/regression. 4. Preoperative CEA level has a prognostic value for postsurgical relapses. 5. High IgA levels are indicators for relapses or metastases from colorectal carcinoma. 6. Tumor histological verification correlates also with the high CEA levels and with the depth of tumor infiltration into the intestinal wall. 7. The dynamic assessment of tumor markers postoperatively has a high informative value in all colorectal carcinoma patients. 8. Pre- and postoperative high CEA levels are observed in patients assigned to the poor prognosis group, and should be given adjuvant therapy.

[Volvulus of the small intestine]. / Volvulus na tunkoto chervo.

Volvulus of the small intestine is a condition of bowel obstruction due to knotting and twisting of the small intestine. Two types of volvulus are described: 1) primary small intestinal volvulus where no predisposing factors exist, and 2) secondary volvulus where congenital or acquired conditions promote twisting of the small intestine. Over a 5-year period, 18 patients (eleven men and seven women) presenting volvulus of the small intestine are operated in the Emergency Surgery Clinic of the University Hospital "Queen Giovanna", representing 8.7 per cent of the total of 206 cases of small intestinal mechanical ileus (incarcerated herniations involving the small intestine are not included in the series). Primary volvulus is found in one patient. In those presenting secondary volvulus adhesions are the commonest underlying cause of small intestinal rotation--13 cases, next ranking primary tumor of the small intestine--one case, Meckel's diverticulum--one, carcinosis of peritoneum--one, and one patient with small intestine volvulation around colostomy. The most frequently encountered symptoms and laboratory examinations performed are analyzed. Intestinal necrosis is established in four instances (22 per cent). One patient dies of peritonitis and polyorganic insufficiency. Volvulus of the small intestine should be mandatorily considered in patients presenting mechanical ileus of the small intestine. Early operative intervention is a therapeutic approach contributing to preclude intestinal necrosis.

[Current antibiotic prophylaxis in colorectal surgery]. / Suvremenna antibiotichna profilaktika v kolorektalnata khirurgiia.

Over a one-year period (November 1996 to November 1997), in the Emergency Surgery Clinic perioperative parenteral antibiotic prophylaxis during colorectal operations is performed in a series of 32 patients, admitted on an emergency and deferred urgency basis, or for routine operative treatment. Of them 30 present malignant processes involving colon and rectum, and two--inflammatory diseases. All patients receive single i.v. injections with Cephalothin/Cefazolin at dose 2.0 g and Metronidazole 0.5 g immediately after anesthesia induction. In nine cases additional early treatment is necessitated--within 24 hours after the operative intervention--by administration of the same drug combination 4 times at 6-hour intervals, and in another two prophylaxis is substituted for continuous 5-day treatment using the same therapeutic scheme. In 30 patients the postoperative period runs a course free of noteworthy complications. In two instances there is evidence of operative wound suppuration, and in further two--urinary tract infection development unrelated to the antibiotic prophylaxis applied. The specific features characterizing the application of antibiotic prophylaxis during colorectal surgery are discussed, and appropriate drug therapy schemes are recommended, consistent with worldwide and Bulgarian experience along this line, as well as with the concrete hospital and economical conditions in this country. Special emphasis is laid on two aspects: optimization of the timing of antibiotic agent/agents injection, and reaching peak serum and tissue bactericidal concentrations in the immediate vicinity of the surgical incision; optimization of the duration of antibiotic prophylaxis on the ground of well established indications for the application of antibiotic prophylaxis in colorectal surgery in compliance with the dynamic patterns of intra- and postoperative septic risk. The modest number of patients subjected to updated parenteral perioperative antibiotic prophylaxis does not warrant a definitive interpretation of the data from the comparative clinical and pharmaco-economical analyses performed. Nevertheless, the preliminary results point to the economical expedience of the therapeutic approach suggested.

[Complicated colorectal cancer--new trends in its diagnosis and surgical treatment]. / Uslozhnen kolo-rektalen rak--novi nasoki v diagnostikata i operativnoto lechenie.

Colorectal carcinoma is among the commonest cancer diseases of the alimentary canal in this country. The morbidity and mortality rates show an increase on an annual basis. A total of 1094 patients presenting colorectal carcinoma are analyzed over the period 1985 through 1996. In 690 cases (63.1 per cent) a complicated form of the basic disease is established. For the first time in this country, assessment of the total amount of bile acids in feces using thin-layer chromatography is done, as well as of cholesterol, beta-lipoproteins and triketosteroids in the serum. As shown by the investigations, there is a correlation between increased bile acid concentrations in the feces, decreased values of serum cholesterol, high concentrations of triketosteroids and severe dysbacteriosis, revealing in turn new aspects in the etiopathogenesis, early diagnosis and prophylaxis against colorectal carcinoma. The new principles of surgical management in complicated colorectal carcinoma improve considerably the 5-year survivorship, amounting to 22.1 per cent for T4.

[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).

[The views and attitudes of the Clinic of Emergency Surgery of the Clinical Emergency Medical Center at the Queen Ioanna State University Hospital on the potentials of surgical endoscopy in upper digestive hemorrhages]. / Niakoi vizhdaniia i stanovishta na Klinikata po speshna khirurgiia pri KTsSM pri DUB "Tsaritsa Ioanna" po otnoshenie na vuzmozhnostite na operativnata endoskopiia pri gornodigestivnite kruvotecheniia.

Transendoscopic sclerotherapy of esophageal varix in children and adults is introduced in the clinic of emergency surgery ever since 1973. In children aged 3 to 14 years presenting preportal block a 100 per cent survivorship is recorded 20 years after the manipulation. The outcome of endoscopy in adult patients is successful in 57.69 per cent. Perilesional sclerosing is introduced in the CES in 1982, with a complete and definitive hemostasis attained in 46.7 per cent of the cases. In 1983, transendoscopic electrocoagulation is practically implemented in the CES, with the rate of successfully cured amounting to 55.49 per cent. Having in mind the limitations and contraindications of therapeutic transendoscopic hemostasis in massive hemorrhages, particularly those of ulcerative origin, preference is given to the safer hemostasis by surgical means.

[Endoscopic sphincterotomy in choledocholithiasis and an intact gallbladder]. / Endoskopska sfinkterotomiia pri kholedokholitiaza i zapazen zhluchen mekhur.

Endoscopic sphincterotomy (ES) with extraction of calculi is a basic method of treating choledocholithiasis in post-cholecystectomy patients (8, 9). Endoscopic treatment contributes to a considerable reduction of the indications for reoperation. The existing views concerning ES done in patients with preserved gallbladder, especially in the era of laparoscopic surgery, are still conflicting (3, 6). There are several options: cholecystectomy with removal of calculi in the common bile duct by ES in a subsequent stage, or vice versa-primary ES with ensuring cholecystectomy. The undertaking of independent surgical or endoscopic treatment is likewise practicable (2, 6).

[The place of endoscopic transpapillary (peroral) cholangioscopy in the diagnosis and treatment of biliary tract diseases]. / Miastoto na endoskopskata transpapilarna (peroralna) kholangioskopiia v diagnostikata i lechenieto na zaboliavaniiata na zhluchnite putishta.

The introduction of intraoperative, and later postoperative cholangiography, results in the reduction of residual concrements in the bile ducts, but by no means in their total removal. Cholangioscopy was used as an alternative to this method (1, 5, 10). In 1923, J. Bakes employed a rigid choledoscope, and in 1970 J. M. Shore-a flexible one. Nowadays, technical improvement of the procedure makes possible to use cholangioscopy by one of two basic routes--transhepatic and peroral transpapillary (4, 6, 7, 9, 11). The former is recommended in the event of impossible or failing examination through papilla Vateri, or in the presence of stones and strictures within the intrahepatic bile ducts which cannot be reached by transpapillary route (4, 6, 9, 11). Peroral choledoscopy is used in clinical practice for a short time, and the early experience is still insufficient for definitive evaluation (2, 3, 7, 8, 9, 11).