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.

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.

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.

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.

[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.

[Tactics and approach to the treatment of choledocholithiasis--7-year follow up study].

Laparoscopic surgery approved itself as "golden standard" in treatment of cholelithiasis. However, in cases with common bile duct stones (CBDS), still there are several methods of management: 1.) Preoperative Endoscopic Retrograde Cholangio-pancreato graphy (ERCP), endoscopic papiloshpyncterothomy (EPS) and stone extraction, followed by Laparoscopic cholecystectomy (LC). 2.) LH with intraoperative common bile duct exploration and stone extraction. 3.) LH, followed by EPS and CBDS extraction. CBDS are present in about 10-15 % of patients, treated by laparoscopic cholecystectomy. In most cases choledocholithiasis is suspected. In small percentage it is unsuspected and it's found during the operation. In present days still there is no clear conclusion about treatment of CBDS. In our clinic we use a multidiscipline method - ES with stone extraction on first stage and LC on second stage. In small percentage of patients we use LC with intraoperative common bile duct exploration and stone extraction, and LH, followed by ES and CBDS extraction. Our aim is to represent a prospective study of our results.

[Gastrointestinal stromal tumors (GIST) - clinical experience and current therapeutical aspects].

Gastrointestinal stromal tumors (GIST) are specific, generally Kit (CD117) - positive, mesenchymal tumors of the gastrointestinal tract encompassing a majority of tumors previously considered gastrointestinal smooth muscle tumors. They are believed to originate from interstitial cells of Cajal or related stem cells. Diagnosis is based on histological and immunohistochemical examination, and these rare tumors are characterized by c-kit (CD117) staining. We present an analysis of clinical presentation and course, surgical management and pathological features of 11 patients with gastrointestinal stromal tumors treated in our institution from 2002 to 2007. 2 patients with malignant retroperitoneal GIST had disease progression/recurrence and died. They received adjuvant imatinib therapy. 9 patients are disease free on the 3-d year of the follow-up. Our results confirm that in stromal tumors complete surgical resection remains the mainstay of treatment in localized gastrointestinal stromal tumors. Complete removal of the tumor is often curative in localized gastrointestinal stromal tumors and is always recommended. Clinically, their behavior is difficult to predict, and mitotic count and tumor size seem to be the most effective prognostic factors. It is conceivable that treatment and prognosis of metastatic and non - resectable gastrointestinal stromal tumors, as well as the adjuvant treatment of high-risk, radically excised gastrointestinal stromal tumors will be strongly impacted by the c-kit target therapy.

[A 10-years experience in the treatment of the acute peritonitis].

The contemporary classification of the acute peritonitis, the etiology, the special features of the pathogenesis, the difficulties of the diagnostics with some of the kinds and the contemporary aspects of the healing tactics related to the clinical experience of the treatment of that severely and life-threatening disease are included in the present report for 10 years period. 341 laparotomies because of various kinds of peritonitis with patients aged 11-89 years old were performed at the Department of Surgery, University Hospital "Aleksandrovska" -Sofia for the period of 1996-2006. A diffusous fibrino-purulented peritonitis was founded out in most of the cases (41.6%) and the perforations constituted the most common etiologic cause. Total mortality is 25.8% (88 cases). The cause of death was not directly connected to the surgical suffering in 2.34% (8 cases). The death rate is high as expected with the groups of pregressed widespread peritonitis, the 3rd group by Mannheim peritonitis Index (MPI), the postoperative peritonitis, accompanied usually by atypical clinical features, for the elderly patients and patients with worsening the prognosis with premorbid pathology. A complex approach was applied not only for the peritonitis but also for the pathologic processes caused life-threatening complications. The applied treatment depends on the contemporary methods. The results are in accordance with those of the international experience.

[Economical and social effectiveness of one day surgical treatment in patients with hernial defects of anterior abdominal wall - results of 7 year study].

A hernia is a protrusion of a tissue, structure or part of a organ through the muscular tissue or the membrane by which it is normally contained. Most frequently hernial deffect is seen in anterior abdominal wall. Usually contents of hernial sac are abdominal organs or portion of organs. Hernia is classified according to the operating methods combining with type and grading of hernia. Recent surgical treatment of hernia can be divided in to 3 major groups: 1) Hernioplasty with double breasting techniques ( Bassini, McVay, Schouldice, Halsted). 2) Hernioplasty using tension free techniques (Lichtenstein, Gilbert-Rutkow). 3) Laparoscopic hernioplasty. One day surgery is a diagnostic and operative procedure in hospitalized patients in a single day, without night stay in hospital.

[Clinical experience and current aspects of treatment of abdominal actinomycosis].

Actinomycosis is an uncommocn inflammatory entity caused by the universally distributed anaerobic bacterium, Actinomyces Israeli. The most common sites of the abdominal form of the disease are the transverse colon and the cecum with the appendix. Actinomycosis can mimic other abdominal diseases as diverticulitis, abscesses, inflammatory bowel disease and malignant tumors, presenting a diagnostic challenge. In most cases surgical intervention is performed. Antibiotic administration should be a part of the complex treatment of the disease.

[Pseudomyxoma peritonei--a case report].

Pseudomyxoma peritonei is a rare condition consisting of mucinous ascites, most commonly arising from mucinous tumors of the appendix and occasionally from the ovary. Ronnett et al. have suggested a classification based on tumor pathology where they place all pseudomyxoma peritonei in three groups in order of decreasing prognosis: disseminated peritoneal adenomucinosis (DPAM), peritoneal mucinous carcinoma with intermediate or discordant features (PMCA) and peritoneal mucinous carcinoma (PMCA). Treatments are now standardized as a combination of cytoreductive surgery and perioperative intraperitoneal chemotherapy.

[Hartmann's operation--urgent operative technique in complicated colorectal cancer].

In 1923 the French surgeon Henri Hartmann described an operation for resection of a cancer in the distal sigmoid and upper rectum, resulting in a permanent sigmoid colostomy. In the subsequent years, the indications for performing the Hartmann procedure have broadened to include complicated diverticulitis, ischemic bowel, iatrogenic perforations, volvulus, and colitis. Hartmann's procedure is recognised by most colorectal surgeons to be a blunt but effective method of dealing with left-sided colonic emergencies. Hartmann procedure is a safe and efficacious option for the surgeon confronted with the complex pathology of the rectosigmoid area, with acceptable morbidity and mortality.

[Acute upper gastrointestinal tract haemorrhage: tactics and treatment].

Haemorrhage due to upper digestive tract diseases is one of the major complications and is relatively common. The cause for haemorrhage depend on the main disease and in many cases has complicated mechanism. The frequency is 100 cases over 100 000 people. There is no proven alternative to the surgical treatment. The issue with second time haemorrhage is controversial. The goal of every surgeon, when dealing with haemorrhage from upper digestive tract, especially with patient with bleeding ulcer, is surgical treatment, when conservative and endoscope treatment have failed. Every patient with bleeding stomach or duodenal ulcer should undergo FGS for Forrest haemorrhage demonstration, endoscope haemostasis and HP examination. Eradication should be applied to every HP positive patient for haemorrhage prevention.

[Laparoscopic excision of non-parasitic splenic cyst--case report and literature review].

INTRODUCTION: Non-parasitic splenic cysts are rare condition and are mostly asymptomatic. They are usually found on abdominal US or CT investigation. The indications for operative treatement are exesive size and complications. MATERIALS AND METHODS: 18-years old women was admitted with a history of pain in the left upper abdominal quadrant. US and CT revealed 70/40 mm multilocular splenic cyst, negative serologic tests for E. granulosus. We performed spleen-sparing laparoscopic excision of the cyst in typical supine position using Harmonic scalpel. No intra- and postoperative complications were observed. DISCUSSION: Symptomatic and complicated spleen cysts are surgically treated. Total splenectomy, which traditionally was the procedure of choice, recently has been changed to more conservative approaches. Several spleen-concerving surgical methods have been proposed - deroofing, partial splenectomy, fenestration, excision, etc.

Dijet production by double pomeron exchange at the fermilab tevatron

We report the first observation of dijet events with a double Pomeron exchange topology produced in &pmacr;p collisions at sqrt[s] = 1800 GeV. The events are characterized by a leading antiproton, two jets in the central pseudorapidity region, and a large rapidity gap on the outgoing proton side. We present results on jet kinematics and production rates, compare them with corresponding results from single diffractive and inclusive dijet production, and test factorization.

Measurement of the decay amplitudes of B0 --> J/psiK*0 and B(s)(0) --> J/psistraight phi decays

An angular analysis of B0-->J/psiK(*0) and B(0)(s)-->J/psistraight phi has been used to determine the decay amplitudes with parity-even longitudinal ( A0) and transverse ( A( parallel)) polarization and parity-odd transverse ( A( perpendicular)) polarization. The measurements are based on 190 B0 and 40 B(0)(s) candidates obtained from 89 pb(-1) of &pmacr;p collisions at the Fermilab Tevatron. The longitudinal decay amplitude dominates with |A0|(2) = 0.59+/-0. 06+/-0.01 for B0 and |A0|(2) = 0.61+/-0.14+/-0.02 for B(0)(s) decays. The parity-odd amplitude is found to be small with |A( perpendicular)|(2) = 0.13(+0.12)(-0.09)+/-0.06 for B0 and |A( perpendicular)|(2) = 0.23+/-0.19+/-0.04 for B(0)(s) decays.

Production of Upsilon(1S) mesons from chi(b) decays in p&pmacr; collisions at sqrt

We have reconstructed the radiative decays chi(b)(1P)-->Upsilon(1S)gamma and chi(b)(2P)-->Upsilon(1S)gamma in p&pmacr; collisions at sqrt[s] = 1.8 TeV, and measured the fraction of Upsilon(1S) mesons that originate from these decays. For Upsilon(1S) mesons with p(Upsilon)(T)>8.0 GeV/c, the fractions that come from chi(b)(1P) and chi(b)(2P) decays are [27.1+/-6.9(stat)+/-4. 4(syst)]% and [10.5+/-4.4(stat)+/-1.4(syst)]%, respectively. We have derived the fraction of directly produced Upsilon(1S) mesons to be [50.9+/-8.2(stat)+/-9.0(syst)]%.

Search for a fourth-generation quark more massive than the Z0 boson in p&pmacr; collisions at radicals = 1.8 TeV

We present the results of a search for pair production of a fourth-generation charge -1 / 3 quark (b(')) in sqrt[s] = 1.8 TeV p&pmacr; collisions using 88 pb(-1) of data obtained with the Collider Detector at Fermilab. We assume that both quarks decay via the flavor-changing neutral current process b(')-->bZ(0) and that the b(') mass is greater than m(Z)+m(b). We studied the decay mode b(')b(');-->Z(0)Z(0)b&bmacr; where one Z0 decays into e(+)e(-) or &mgr;(+)&mgr;(-) and the other decays hadronically, giving a signature of two leptons plus jets. An upper limit on the sigma(p&pmacr;-->b(')b(');)x[B(b(')-->bZ(0))](2) is established as a function of the b(') mass. We exclude at 95% confidence level a b(') quark with mass between 100 and 199 GeV/c(2) for B(b(')-->bZ(0)) = 100%.