Appendiceal mucocele - Case Report and Review of the Literature.

Appendiceal mucocele (AM) was described for the first time by Rokitansky in 1842.1 Its incidence is 0.2 - 0.4% of all apendectomies performed, as it is observed predominantly in women with the ratio of 4/1 versus men and most frequently at the age of 50.2,3 We present to your attention a 64-year-old woman, who was referred to diagnostic further clarification after a preventive gynaecologic exam. Appendiceal mucocele with retrocecal location, enveloped by additional Jackson'™s membranes was determined intraoperatively. The formation has been dissected and appendectomy was performed without mucocele integrity being compromised. The permanent histological specimen revealed mucinous cystadenoma with clear resection lines, without any data on the appendiceal base being affected. The patient was discharged on the third day after surgery without any complications, and further follow-up was scheduled in 6 months.

Extraskeletal Osteosarcoma of the Omentum with Aggressive Development.

For the first time extraskeletal osteosarcomas (ESOS) were described by Wilson in 1941. They are extremely rare neoplasms, presenting 4% of all osteosarcomas and 1,2% of all soft-tissue sarcomas. About 300 cases have been reported in the literature up to date. We present a 66-year-old female patient, admitted in the clinic because of acute bleeding in retroperitoneal space. Revision of the retroperitoneal space and haemostasis were performed. The patient was re-operated because postoperative bowel obstruction. The reason for it was intestinal infiltration from large tumor of the omentum, determined histopathologically as ESOS. The case was considered as an unresectable neoplasm so a colostomy was performed. In the literature we found 3 case reports of ESOS, originated from omentum.

Recurrent perineal hernia -- case report and review of the literature.

Perineal hernia is the protrusion of intra-abdominal viscera through the pelvic floor. We present a patient with recurrent perineal hernia - 12x9 cm with a palpable soft, hardly adjustable in the pelvic tunnel formation and attenuated skin over it. The patient was operated by abdominoperineal approach. We performed two layer Titanium mesh plasty of the pelvic floor with the use of the omentum and the pelvic muscles.

Management of recurrent or metastatic retroperitoneal soft-tissue sarcomas.

UNLABELLED: Retroperitoneal soft tissue sarcomas remain a serious therapeutic problem. The aim of the study is to define the optimal treatment strategy of patients with locally recurrent or metastatic retroperitoneal soft tissue sarcomas. MATERIAL AND METHODS: A retrospective study was performed.Between 2001 and 2013, 89 patients with retroperitoneal soft tissue sarcomas were surgically treated in the University Hospital Queen Joanna ISUL and the Specialized Hospital for Active Treatment in Oncology Sofia. Clinicopathological data were investigated with SPSS 19. RESULTS: The mean time of onset of the first and second relapse of sarcomas was 23 and 13 months, respectively. Over 40% of the studied patients underwent more than one operation because of recurrence. Ability of radical extirpation of the tumour decreased with each subsequent relapse. The 5 year survival rate was 60% for patients with primary combined radical resection versus 28% for patients with partial resection. In the presence of metastatic lesions the 3 year survival rate was only 22%. CONCLUSION: Local recurrences, the presence of distant metastases and the ability of radical extirpation are the main long term prognostic factors.

[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.

[Endoluminal echography in rectal cancer--preoperative staging and postoperative control]. / Endolumenna exografiia pri rak na rektuma -- predoperativno stadiirane i sledoperativen kontrol.

The aim of this study is to determine the diagnostic potential of endoluminal echography and the pitfalls sources in the preoperative staging and postoperative follow-up in patients with rectal cancer. 245 patients with rectal carcinoma are evaluated during 10 years period (Jan. 1993-Jan. 2002 years). 96 patients are monitored in the early and late postoperative periods for the early detection of local recurrence as well as for the anorectal physiology assessment after low anterior rectal resection or coloanal anastomosis. Lineal transducer UST-657-5MHz (Aloka 620) and 10MHz miniprobe are applied. The accuracy for T-staging is 84% and for N-staging is 82%. The local recurrence is detected in 21 patients, on average 12.6 months after curative surgery. The local recurrence is more often in cases of lymph node involvement as well as if some specific echographic features for extramural vascular invasion are present. Endoluminal echography provides individual therapeutic management and postoperative control in patients with rectal cancer.

[Percutaneous puncture treatment of hepatic cystic echinococcosis under ultrasound guidance]. / Perkutanno punktsionno lechenie na kistichnata chernodrobna ekhinokokoza pod UZ kontrol.

Introducing of the alternative PAIR (puncture-aspiration-injection-reaspiration) method for treatment of hepatic echinococcosis in practice dates from 1992 year. A Working group dealing with the problems and standardization of the method has been created by WHO. The major aspects of this treatment are summarized in the bulletin of WHO of 1996 year. On the last World Congress of Ultrasound, held in Florence, Italy in 1999 this method was reported as safe and effective treatment modality. The necessity for further prospective studies was also emphasized. The aim of the Working group for performing of PAIR, created at the Clinical Centre of Gastroenterology, University Hospital "Queen Joanna" in 1999 is to report the preliminary results and declare the possibilities for its application. Nine patients (6 males, 3 females) with 11 cysts (I, II and IIIa types after Gharbi) measured 3-9 cm were punctured and followed up for a 6 months period. 95% ethanol was used as protoscolicidal agent with concomitant preventive oral treatment with Mebendazole. No serious complications were observed. In all patients separation of the germinative membrane was verified. 2/5 cysts < 3.5 cm completely disappeared, 7/11 diminished their size without signs of vitality, while 2/11 remained vital. One ofe the cysts had a biliary communication which necessitated the injection of 20% NaCl instead of ethanol. The serological ritres significantly decreased in all patients. The risk of anaphylaxis and seeding is negligible while keeping the technique of PAIR precisely. The PAIR treatment of hepatic echinococcosis presents great progress with its safety, low risk and excellent therapeutic results.

[Local recurrence after radical surgery for rectal carcinoma]. / Lokalni retsidivi sled radikalni operatsii po povod kartsinom na rektuma.

The incidence rate of local recurrences after radical operative treatment of rectal carcinoma and the risk factors involved, methods of early diagnosis and surgical therapeutic approach are comprehensively analyzed. Reference is also made to 86 scientific publications on the issue. During the 20-year follow-up period, no tendency of the incidence of local rectal carcinoma relapses to decrease is noted. The risk factors contributing to their occurrence are distributed in two groups depending on the primary tumor characteristics (location, stage of development, locoregional spreading, differentiation degree, genetic features), and operative intervention used (type, distal resection line, application of total mesorectal excision, extensive minor-pelvis lymph dissection etc.). The early diagnosis is based on mandatorily performed procedures, such as rectoscopy (coloscopy), endo-ultrasonography with purposeful thin-needle biopsy, assessment of tumor markers and immunoscintigraphy. The surgical tactics in coping with a local recurrence of rectal carcinoma becomes increasingly aggressive and radical by resorting to re-resection, abdomino-perineal extirpation, en-bloc resections and even minor pelvic exenteration. Postoperative 5-year survivorship amounts to 54.5 per cent.

[Mucinous breast carcinomas with neuroendocrine differentiation]. / Mutsinozni kartsinomi na g'rdata s nevroendokrinna diferentsiatsiia.

Mucinous breast carcinomas, denominated also gelatinous, mucoid and colloid (collomas), represent a heterogeneous group of neoplasms. More than half of them exhibit signs of neuroendocrine differentiation. Eighteen mucus producing carcinomas of the breast are subjected to morphological study. On the ground of demonstrating argyrophilia by the methods of Grimelius and Churukian--Shenk, and presence of secreting granules during electron microscopic study, they are assigned under the heading apudomas, i.e. tumors of the diffuse endocrine system, or the so-called APUD-system. The important practical implications of demonstrating neuroendocrine cells with a special reference to the biological patterns of this particular type of tumors are discussed.

[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.

[Reoperations on the biliary system]. / Reoperatsii na zhluchnata sistema.

Reoperations of the biliary apparatus is a branch of biliary surgery still not well enough clarified and difficult to cope with. A total of 169 patients are subjected to operation and investigation in the clinic of abdominal surgery. In 71 of them reoperation is undertaken over the period 1952-1973, and in 97--in the period 1974 through 1993, representing 8.7 per cent of all biliary operations done for benign diseases of the biliary apparatus. In 95 per cent of cases the primary operation is related to cholelithiasis (ChL). One-hundred fifty-five cases (92.6 per cent) are reoperated once, nine (5.3 per cent)--twice, and four (0.7 per cent)--three, four and five times. What is more, 56 of the patients are operated in the clinic of abdominal surgery, and 112--elsewhere in surgical units and departments throughout the country. The severer clinical picture, prolonged postoperative period, increased operative risk and worsened prognosis in the latter group are underscored. The underlying causes necessitating secondary corrective intervention are analyzed--76 per cent are conditioned by ChL, and 24 per cent--by the primary operation. The indications for reoperation are classified in three groups: a) failure to remove or partially removed gallbladder, b) in case of preexisting primary, or secondary postoperative development of various forms of cholelithiasis, c) in surgery induced morbid conditions. A table is presented illustrating the character of secondary operations, performed in the series of 168 patients under study, namely: in 20 per cent the gallbladder is operated on, and in 80 per cent--the extrahepatic bile ducts. Postoperative morbidity is higher as compared to the one in primary operations and not infrequently it is conditioned by preexisting complications. Postoperative mortality rate amounts to 10 per cent.

[The indications and choice of the technic for pancreatic resections]. / Pokazaniia i izbor na tekhnika za rezektsii na pankreasa.

The progress of pancreatic surgery naturally leads to broadening the scope of indications for resection of the gland. Over the period 1970 through 1993, in the Clinic of Abdominal Surgery are performed 99 pancreatic resections for carcinoma of the pancreas (including cancer of papilla Vateri (45), endocrine-active tumor of pancreas (5), benign tumor (1), chronic pancreatitis (4), pseudocysts of the pancreas (4), cancer of an adjacent organ infiltrating the pancreas (36), benign lesions to a neighbouring organ (4). The size of resection depends on a number of factors of which location of the neoplasm and stage of the disease are the leading ones. Operations done: duodenopancreatic resection--47, left side hemipancreatectomy--13, resection of the body region and tail of pancreas--14, and partial resection--19. The choice of operative technique is discussed against the background of the variety of indications for pancreatic resection. Special attention is focused on the operative technique used in pancreatoduodenal resection. The practicability of performing pylorus-preserving intervention, the need of vagotomy and its scope are precisely determined. Also discussed are issues relating to the choice of organ for anastomosis with the pancreas and its protection, as well as the variants of successiveness of anastomoses with the biliary canal, residual pancreas and stomach. Morbidity and mortality rates show a decrease parallel to the surgical experience gained.

[Endocavitary echography following abdominoperineal extirpation of the rectum]. / Endokavitarna ekhografiia sled abdomino-perinealana ekstirpatsiia na rektuma.

Transrectal echography using a high-frequency transducer is a well established method for preoperative rectal carcinoma assessment, and for postoperative follow-up of patients with anterior resection for rectal carcinoma. Having in mind the impossibility for follow-up study of patients with abdominal perineal extirpation of the rectum by transrectal echography, a new pattern of application of the transducer employed for endorectal examination is suggested. In five patients (4 women and 1 man) endocavitary echography through the anal canal is done. In women the examination is supplemented by transvaginal echography. A local recurrence in the course, of transvaginal study is recorded in one patient. The technique of examination and the superiorities of the procedure are 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.