GIANT MORGAGNI HERNIA IN A FEMALE WITH MALROTATION SYNDROME AND THORACIC TRANSPOSITION OF SMALL BOWEL, COECUM, ASCENDING AND TRANSVERSE COLON.

The sterno-costal hernia of Morgagni is a congenital vice in which is represented unfinished fusion of the transverse septum and the muscular diaphragmal wall. The malrotation syndrome is an embryonic vice as well, with various degree of incomplete and even reverse rotation of the gut, because of disturbed or unfinished development of the midgut. The described case presents a 37 years old female without anamnesis of any previous complains, who was pointed to the clinic after a X-ray photograph because of breathless and asteno-adynamic syndrome. After a precise CT investigation performance was found the presence of the above described anomalities, as well as ectopy of the right kidney and the right liver part. An operative treatment was performed with correction of the hernia and the bowel malrotation. The patient was followed up to the 12th month post-operatively. After a review of the literature in the discussion we inspect the diagnostics and the definition of the right surgical tactics and operative approach in this case with combined malformative pathology.

Follow up by CT-colonoscopy of patients with colostoma after resection on the occasion of colorectal cancer.

The follow up of patients operated for colorectal cancer (CRC) and the early detection of recurrences and metachronous tumors improves significantly the results of treatment and the survival of the patients. Computed Tomography (CT) and fibro-colonoscopy (FCS) are the main applied image diagnostic methods for this aim. Alternative unified method is the CT colonoscopy (CTC -"virtual colonoscopy" ) with i.v. appliance of contrast. A particular group of patients liable to control are those after Miles and Hartmann operation with created colostoma. The performance of CTC and its informativeness in these cases is specific and represents a challenge. For a two-year period were implemented generally 48 "virtual colonoscopies" (CTC) in stoma patients--21 male and 27 female, average age 53.2 ± 9 years. The postoperative interval to the CTC varied 8 to 29 months. The studies were performed on a 32 detector CT - GE: 32 x 0.625mm and rotation time 0.6 sec. with automatic modulation of the dose. The CT images are processed with special software for CTC and analyzed according to standardized system for reporting of findings in CTC - C-RADS. The specific technique for CTC in stoma patients is described. CTC was entirely accomplished in all 48 cases (100%). The duration of the studies varied 10 to 25 min. (average 17 min.). No essential side effects or according to the procedure complications were marked. To one patient a conventional FCS was recommended for accurate assessment of a collapsed bowel segment. Adequate marking of the fecal odds with barium sulfate was marked in all cases. The CTC findings were assessed as normal in 23 cases (48%). In 25 patients (52%) were described pathologic findings of colonic and extra-colonic origin. Conclusions that CTC in patients operated according to the methods of Miles and Hartmann is technically feasible and could be executed for complex assessment of large bowel and extra-colonic abdominal structures. CTC possess the advantage of the possibility for synchronous assessment of the organs and structures in the abdominal cavity, which is economically profitable, saves time and psychical suspense for the patients and avoids the risk of complications and unpleasant experiences of the patient durinf a conventional FCS.

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.

Crypto-glandular fistulous paraproctites--is the surgical prophylaxis of reccurences imperative?

It is done an analysis of 191 patients operated on for crypto-glandular chronic fistulous paraproctitis. The age of the patients vary 21 to 76 years and the male:female proportion is 2,25 to 1. In 164 patients it was first operation for fistula-in-ano and in 27 cases it was a consecutive one for reccurence. There was intervened a concomitant other disease of the anal channel which pathogenetically predispose the development of fistula in 54 (28%) cases. The patients were discharged 1-3 days after surgery. Ambulant control and ligature procedures up to the 30th day were done. A follow up was done of 118 patients (68%) for period of 3 to 12 months. In all the followed up patients was registered full continence and good tonus of the anal sphincters. Recurrences were registered in 8 cases with fibrin glue occlusion of the fistula. There are no registered cases of recurrences by the followed up patients after fistulotomy and excision-ligature methods. The authors review in the discussion the pathogenetical predisposition for paraproctitis in consequence of other diseases of the anal channel and the necessity of surgical prophylaxis of recurrences.

[Laparoscopic repair of umbilical hernias--initial experience].

In this study the autors present their initial experience with 8 patients with umbilical hernias, operated laparoscopically in the surgery clinic of the university hospital "Sweta Anna" in Sofia for the period from 2002 to 2005. There were no intraoperative complications as well suppurations detected for a 18 months postoperative follow up. We found out lesser postoperative pain and shorter reccurence period by the laparoscopically operated patients in comparison with these, who had undergone a conventional repair. The autors made a review of the related literature and the conclusion, that LVHR is a effective, suitable method for operative treatment of umbilical hernias greater than 4 cm and recidive ones.

[Spontaneous stercoral perforation of colon and rectum with contribution of five cases]. / Spontanna sterkodekubitalna perforatsiia na kolon i rektum s prinos ot pet sluchaia.

The authors report five cases of spontaneous perforation of the large bowel for a five year period. The clinical symptoms were dominated by the feculent peritonitis. There were found no data of previous diseases of the colon during the operations and hystologically. By all five patients was manifested severe constipation before the incident. During the operation the recto sigmoid and the left colon were found plugged by stercolithes with "stone density". A hypothesis of stercoral pathogenesis of the perforations is suggested. Conclusions for the surgical tactics in the conditions of large bowel peritonitis due to benign perforation are done.

Laparoscopic repair of traumatic rupture of the left diaphragm cupola with prosthetic mesh.

We present the case of a 23-year-old patient who had a car accident with a steering wheel trauma 6 months previously. The patient complained of abdominal pain, getting easily tired, and breathing difficulties. A diagnosis of traumatic diaphragmatic hernia was established by a contrast radiographic examination. Laparoscopy confirmed a rupture of the left diaphragmatic cupola and prolapse of the stomach, small intestine, and colon in the left thoracic cavity. Laparoscopic repair of the diaphragm with polypropylene mesh was performed. The patient recovered rapidly and was discharged 72 h after the operation. The control radiographs and computed tomography (CT) contrast investigations showed no recurrence. The patient's preoperative complaints had resolved completely. The case is interesting because traumatic diaphragmatic hernia is sometimes difficult to diagnose. Its laparoscopic treatment is still a challenge for modern surgery, and there are not enough publications on the problem.

[Comparative study between laparoscopic "TEP" and "tension-free" repair of groin hernia]. / Sravnitelni prouchvaniia mezhdu endoskopska "TEP" i "svobodna ot naprezhenie" plastika pri slabinna kherniia.

The "Tension free" and TEP (total preperitoneal repair) of groin hernia gained more popularity in surgical practice in the last five years. The aim of the study was to reveal our experience with these two surgical techniques. The TEP procedure was done in 29 cases, till "Tension free" herniorraphy was performed at 32 cases. Postoperative complications in the group with TEP hernia repair were found in 1 case. Two complications were observed in the "Tension free" group. The follow up of the patients revealed I recurrence in the group of TEP herniorraphy and no recurrence in "Tension free" group. These two techniques for repair of groin hernias had several advantages and in spite of increased operating theater costs should be adopted on a routine basis in some cases than conventional techniques for repair of groin hernia.

[Hemorrhoidal disease. Current surgical treatment and the place of Whitehead's operation]. / Khemoroidalna bolest. Suvremenno khirurgichno lechenie i miasto na operatsiiata na Whitehead.

In the presented material a review of the current data and comprehensions of the anatomy and physiology of the hemorrhoids is made, as like of the ethiology and pathogenesis of the disease. The new conceptions of the surgical treatment of the disease are pointed out. An attempt was made to differentiate the operative methods in patogenetical principal. The operative results of the General Surgery Clinic by the University Hospital "St. Ann", Sofia for the period 1991-2000 of 157 treated patients with hemorrhoidal disease are presented. Based on these results the authors come to a conclusion, that the Whitehead's operation remains "the golden standard" as a choice of an operative method for the treatment of the hemorrhoidal disease in advanced stages (III-d or IV-th).

[Changes in protein spectrum of cattle blood serum with lympholeukosis].

The protein spectrum of blood serum was studied in healthy cows and those suffering from leucosis. The total amount of protein at the early stages of the disease is established to be unchanged. But with lympholeucosis the content of the globulin fraction increases with a simultaneous decrease in the amount of albumins within 20%. The globulin fraction content rises due to immunoglobulin G. The albumin: globulins coefficient is 0.56 for animals with leucosis and 0.84 for the healthy ones. A problem on possible qualitative changes in this fraction similar to those occurring with other forms of malignant growth is under discussion.