CHEK2 I157T and colorectal cancer in Bulgaria.

PURPOSE: Germline variants of the CHEK2 gene have been shown to act as low-penetrance cancer susceptibility alleles for a wide range of human malignancies. CHEK2 I157T has particularly been linked to colorectal cancer (CRC) risk. We aimed at establishing the population frequency and contribution of this variant to colorectal carcinogenesis in Bulgaria. METHODS: We have genotyped 802 population controls and 343 CRC patients from Bulgaria for the CHEK2 I157T variant. RESULTS: Heterozygous were 9 of 343 patients (2.62%, odds ratio/OR=1.0, 95% confidence interval/CI = 0.42 - 2.33, p=0.99% and 21 of 802 controls (2.62%). Higher frequencies were found among patients with multiple polyposis (2/40, 5%, p=0.28) and the rarer mucinous histology (1/11, 9.09%, p= 0.26). CONCLUSION: We conclude that CHEK2 I157T is not relevant for CRC risk in Bulgaria, but studies on a larger scale might help evaluate its possible significance in respect to disease characteristics.

A case of exocrine-endocrine neoplasm of the pancreas in a patient with ulcerative colitis with literature review.

Until now only Japanese authors have reported 4 cases of pancreatic neoplasm associated with ulcerative colitis (UC). We report on a case of a 44-year-old woman who was operated on for complicated UC and an exocrine-endocrine neoplasm of the pancreas, where the endocrine component was presented by pancreatic polypeptide (PP)-producing cells. By means of molecular genetics methods we found microsatellite instability (MSI) in the markers D18S35, FGA and p53 in the colonic lining, and loss of heterozygosity (LOH) in the p53 marker in the pancreatic tumor. A literature review concerning the coexistence of these two conditions showed that PP is involved in the pathogenesis of the UC and that UC increases the risk of development of extracolonic neoplasms.

[A case of a 47 years old hydatid cyst of the liver]. / Sluchai s 47-godishna ekhinokokova kista na cherniia drob.

This is a presentation of a clinical observation of a hydatid cyst of the liver, accidentally diagnosed 47 years before the first complains. There were no calcifications on the X-rays before the operation, besides the long duration of its existence. There were no complications before the surgery, and the operation and postoperative period were smooth. The case is presented, mainly because of its extraordinary long period of existence of the parasite in the liver, without any symptoms. This shows, that the processes of aging of the hydatid cyst in the liver, under certain circumstances, can be very slow and asymptomatic. Two of these conditions are intrahepatic (intraparenchymal) localization, and the lack of adjacent large biliary ducts.

[Pancreatitis accompanying inflammatory bowel diseases, and our observations]. / Pankreatitite pri vuzplaitelnite chrevni zaboliavaniia i nashite nabliudeniia.

According to the literature data the modern concepts of the etiological factors, the pathomorphological features, the diagnosis, the clinical features and the treatment of the drug-induced and the idiopathic pancreatitis, accompanying the IBD are reviewed. The results of a retrospective review of the clinical data of 50 patients, operated on--16 with Crohn's disease and 34 with ulcerative colitis, are shown. Postoperative hyperamylasemia was found in 2 patients with Crohn's disease and in 3 patients with ulcerative colitis. One of them also had primary sclerosing cholangitis. All patients were treated with Metronidazole and Cortizone. Nine years after the operation one of the patients with ulcerative colitis had acute pancreatitis, treated conservatively.

[Polyposis of the colon and cancer]. / Polipoza na debeloto chervo i rak.

Polyposis of the colon is a colon cancer predisposition syndrome. Familial adenomatous polyposis (FAP) accounts for 1% of the cases of inherited colorectal cancer (CRC). The National Register of inherited CRC and polyposis of the intestines keeps track of 18 patients from 14 families with FAP. Eight of them have been operated of CRC, on 6 patients preventive colectomy with ileorectal anastomosis has been done and four patients refused surgery. Colectomy has been done due to the malignant development also on a female patient with difused juvenile polyposis with adenomatosis. Of three patients under surveillance with the Peutz-Jeghers syndrome, surgery has been done on one female patient with ileus and bleeding large polyps.

[Pros and cons of some conventional groin hernioplasties used for repair of combined hernias]. / Za i protiv niakoi konventsionalni slabinni khernioplastiki s ogdel izpolzvaneto im pri kombiniranite khernii.

Using their experience the authors analyze the surgical methods of repair of groin hernias of McVay, Kukudjanov and Shouldice as a method of choice for combined groin hernias. Using their own anatomical researches, the authors prove that it is possible to explore and using Cooper's ligament extrafascially. The combination of duplication of the transversal fascia (as in Shouldice repair) and moderate change of the medial insertion point of the internal oblique abdominal muscle and the transversal abdominal muscle and suturing the Cooper ligament (as in Kukudjanov repair method), but extrafascially, a new repair method evolve, which strengthens the three weak points in the area. This method would meet to the highest extend the requirements for a correct anatomo-physiological strength of the groin area.

[Reservoir ileo-anal reconstruction in the surgical treatment of ulcerative colitis]. / Za rezervoarnata ileo-analna rekonstruktsiia pri khirurgichnoto lechenie na ultserozniia kolit.

The authors describe the evolution of the conception and the realisation of the ileo-anal anastomosis (IAA) in the surgical treatment of the ulcerative colitis. Thus, one can get a better idea of the problems of this reconstruction in that disease. On the basis of the review from the available literature, the authors make a summary of the basic factors, responsible for the functional results in the reservoir IAA: physiologic disturbances from the operative destruction; physiologic disturbances from the operative trauma; anatomic reconstruction; the possibilities for a functional adaptation to anatomic reconstruction; postoperative complications.

[Problems in the surgical treatment of Crohn's disease and our experience]. / Problemi na khirurgichnoto lechenie na bolestta na Crohn i nashiiat opit.

The analysis of the surgical treatment of 16 patients was made according to the modern concept for the role of the surgical treatment of Crohn's disease. The surgical methods for treatment of the perineal disease, Crohn's disease with acute onset and the complications of the chronic disease are discussed. The long-term results at 1 patient with double stricturoplasty is the basis for our opinion, that this procedure should be the alternative of the resection at the most serious forms of the disease--at patients with multiple resections for multifocal intestinal stenoses, which inevitably lead to the development of the short intestine syndrome.

[Basic principles of conventional inguinal hernioplasty without prosthesis]. / Za osnovnite pravila pri konventsionalnata slabinna khernioplastika bez proteza.

Probably in the near future the conventional hernioplasty without prosthesis will be applied, so it is important its basic principles to be well-known. According to literature data they are: the sac of the indirect hernias should be ligated high; the suture line must not be under tension; the repair of the defect in f. transversalis is mandatory; identical tissues of the same layer should be sutured together. Today the critical notes for any method are based on these principles. As far as the anatomical accuracy of the repair of f. transversalis is concerned, there still is discussion which should be the supporting structure of the hernioplasty--lig. inguinalae or lig. Cooperi.

[Pouchitis, on the basis of a single observation]. / Za pauchitite po povod edno nabliudenie.

The observing of pouchitis at a patient with ulcerative colitis with onset 4 months after the closing of the ileostoma, protecting the reservoir and with good response to metronidazole, was the reason for performing a literature review of the modern problems of this complication. The suspected pre-, intra- and perioperative factors, taking part in its pathogenesis, its clinical features and treatment are reviewed. We share most authors' opinion that this complication probably is connected with the disease.

[About the protective physiologic mechanisms of the groin area]. / Kum vuprosa za zashtititnite fiziologichni mekhanizmi na slabinnata oblast.

Each anatomic structure in the groin area has certain function, which is demonstrated during the increases of intraabdominal pressure. Functionally, the area is a multi-element perfectly synchronized system. According to the literature data its physiologic protective mechanisms against the pressure are: the oblique direction of the inguinal canal in the abdominal wall; the tension mechanism of transversal fascia; the internal and the external mechanism for protection of the inguinal canal; the sphincter mechanism of Lytle; the tamponade function of cremaster muscle; the mechanisms for constricting the internal femoral ring. Each of them is discussed according to the opinion of leading surgeons and the author's opinion on the basis of his experience.

[About the endometriosis and its intestinal localization, an observatio in one case]. / Za endometriozata i chrevnite i lokalizatsii po povod edno nabliudenie.

A clinical case of endometriosis of the distal part of the sigmoid colon in a 57 year-old woman is shown, with a clinical presentation of incomplete bowel obstruction. The patient underwent a total hysterectomy and bilateral salpingo-oophorectomy for the chocolate cysts of the left ovary 16 years ago. The condition was estimated as a carcinoma of the sigmoid colon, on the basis of the contrast enema studies and clinical presentation, despite of the endoscopic changes. A basic for that assumption was the progressing bowel obstruction (3 months), and the long interval from the gynecological operation--16 years, as well as her surgically induced menopause with the same duration. The diagnosis was confirmed with a biopsy. A survey of the available literature concerning the case was made, discussing the nature of the condition, its clinical presentations, the diagnostic possibilities and its treatment management.

[A case report of vascular tumors of the spleen]. / Vurkhu sudovite tumori na slezkata s opisanie na sluchai.

The authors present literature data on the problem of vascular tumours of the spleen and describe clinically and morphologically primary epitheloid hemangioendothelioma. They paid attention on detailed characteristic of the tumours and differential diagnosis of with vascular neoplasms of the spleen.

[Pancreatic cancer. The experience with its surgical treatment]. / Rak na pankreasa. Opit vurkhu khirurgichnoto lechenie.

Experience had with the surgical management of 483 patients, operated for cancer of the pancreatic gland in the Clinic of Abdominal Surgery over the period 1971 through 1994, is presented. Distribution of the patients by gender and age shows noteworthy consistency. Preoperatively, exact diagnosis in the clinic is made in 91.1 per cent, but usually the patients are admitted in advanced stage of the disease (91.6 per cent). Merely 42 cases (7.6 per cent) are free of metastases in regional lymph nodes or carcinomatous infiltration. The neoplasm is located in the head of the gland in 350 patients (66.5 per cent) with resectability attained in 10.1 per cent, in the body and tail--in 96 patients (19 per cent) with resectability 6.5 per cent; the neoplasm involves the total gland in 55 cases (10.2 per cent), and derives from the papilla in 25 (5.2 per cent) with operability 44 per cent. Operability for the total group amounts to 9 per cent, morbidity--17 per cent and overall lethality--15 per cent; of the latter following radical interventions 4 per cent, palliative interventions 8 per cent and explorative laparotomy 3 per cent. The details of the operative technique are comprehensively discussed.

[Postoperative peritonitis]. / Sledoperativen peritonit.

This is a report on retrospective summed-up analysis of the therapeutic approach to 296 patients presenting postoperative peritonitis (PP). They account for 1.4 per cent of the total number of patients operated on in the clinic. The latter percentage differs in the single groups of patients, distributed by organic localization of the pathological process, as follows: 1.3 per cent in hepatobiliary and pancreatic diseases, and 1.9 per cent in gastroduodenal ones. In colorectal diseases the percentage grows to 8, and after the 80th year of life it falls to and below 4, amounting to 2.2 per cent during the last five years. The overall mortality rate is 69 per cent--57.7 and 72.5 per cent respectively for the three separate groups-mainly at the expense of patients presenting oncological diseases, 73.5 per cent. The underlying causes of PP development comprise: insufficiency of the anastomosis, intraoperative contamination and infection of the abdominal cavity, intraoperative oversights-technical errors, iatrogenic and foreign body, circulation derangement in the organ operated on, suture applied to cancer infiltrated and infected tissue and persisting peritonitis for which the intervention is undertaken. The diagnosis is difficult regardless of the biochemical, instrumental and microbiological examinations performed. Early relaparotomy is the only possible life-salvaging approach to the patient, its immediate goal being sanation of the source, peritoneal lavage, wide drainage and ileostomy. PP remains a problem difficult to handle irrespective of the progress of antibiotic and resuscitation treatment.

[The gastrointestinal tract as the possibility for a reservoir for the urinary system. A modification of the Mainz pouch technic]. / Gastro-intestinalniiat trakt kato vuzmozhnost za rezervoar na pikocho-otdelitelnata sistema. Modifikatsiia na Mainz-pouch tekhnikata.

Experience accumulated over the past decade with utilization of the gastrointestinal tract in the formation of a reservoir of the urogenital system shows that the Mainz-pouch technique contributes greatly to obtain a continent reservoir, mainly by Bauhin's valve reconstruction. A procedure is suggested enabling retroperitoneal implantation of the reservoir, formed by the original Mainz-pouch technique, in the lower right quadrant of the posterior abdominal wall, instead of suspending it in the abdominal cavity where it anastomoses with the umbilical anulus and augments the hazard of ileus. The 63-year-old woman with urinary bladder carcinoma, operated according to the modification described, tolerates the intervention free of complications with very good immediate outcome in terms of continence.

[The choice of the operation and management in cholangitis]. / Izbor na operatsiia i povedenie pri kholangit.

Irrespective of the high rate of bacterial flora (intestinal, respectively) penetration into the biliary apparatus, clinically manifested cholangitis cases are relatively seldom met with. The predisposing factors involved are: penetration of virulent flora (anaerobic inclusive) into the bile ducts, presence of conditions promoting delay or discontinuation of the bile passage (biliary hypertension), and longstanding of the disease. Cholangitis associated with cholangiohepatitis development is one of the severest conditions of cholelithiasis (ChL), being observed as an independent nosological entity also. Over the period 1974 through 1993, in the clinic of abdominal surgery a total of 144 patients presenting cholangitis undergo treatment, of which in 74 (8.7 per cent) it is associated with ChL, in 58 it is discovered during reoperation on the biliary apparatus, and in twelve it is diagnosed as an independent disease, unrelated to calculosis. Acute cholangitis runs a foudroyant course with a poor prognosis, whereas the chronic form is characterized by larvate (masked) development with exacerbation periods. The clinical picture is dominated by Charcot's triad. The disease runs a rather severe course in the contingent liable to reoperation. As a rule, it occurs as the result of stricture of the bile ducts or obliteration of bilidigestive anastomosis. 58 per cent of the patients are older than 50 years. Operative intervention in acute cholangitis should be done on an emergency basis. External drainage insertion is a palliative measure, practicable in heavily damaged patients. The operation in acute and chronic cases is aimed at maximum possible healing of the biliary tract and elimination of the underlying causes of obstructed passage. Lethality is higher than the medium rate, and the prognosis remains serious.