[Postoperative entero-cutaneus fistulas--a study of 24 cases].

AIM: To perform a retrospective study on the experience of the Clinic of General, Liver, Biliary and Pancreatic Surgery, Alexandrovska Hospital in the diagnosis and treatment of patients with acquired entero-cutaneus fistulas and to analyse the early postoperative results. MATERIAL AND METHODS: We treated 24 patients with postoperative entero-cutaneous fistulas in the period Jan., 2000 - Aug., 2004. The male sex and the age above 50 were dominent. The primary disease was of oncological origin in 22 cases (91.66%). Anemia, hypoprotenemia and hypoalbuminemia were predisposing and risk factors in 19 cases (79.17%). Fistulography was routinely used for establishing the diagnosis. Surgical treatment was received by all the 6 patients (100%) with small bowel fistulas and by 15 from the 18 patients with large bowel fistulas (83.33%). EARLY POSTOPERATIVE RESULTS: The mortality rate was 4.54% (1 fatal outcome from 22 operated patients). The morbidity rate was 36,36% (8 cases) but none of the complications needed a reoperation. CONCLUSIONS: 1. The most frequent causal factor for entero-cutaneus fistulas in our material was an anastomotic leakige after bowel resection (95.83%); 2. The risk for such a coplication is higher in cancer patients with other predisposing pathological factors; 3. From the pahtological and clinical point of view the entero-cutaneus fistulas caused significant disturbances in base-alkaline and electrolyte balance, malnutrition and cahexia; 4. The clinical signs and the fistulography prooved to be reliable diagnostic methods; 5. The preoperative substitution and nutritional therapy had a significant benefit on the postoperative results, especially in cases of small bowel fistulas; 6. The open surgery was the main therapeutical method in the complex treatment of those patients.

[Acquierd entero-cutaneous fistulas--diagnostic and therapeutic approach].

The acquired entero-cutaneous fistulas are a current problem in the field of abdominal surgery. Most of them are postoperative--after an intestinal resection and/or anastomosis. Crohn's disease and coplicated colonic diverticulosis rank second as causal factors. The risk factors for the development of an entero-cutaneous fistula and for the poor prognosis at the same time are the next: (1) Most of the patients suffer of severe main and co-exhisting diseases; (2) The presence of previous laparotomies, radion and chemotherapy, significant disturbances in the base-acid and water-electrolyte balance; (3) The fistula itself worsens these disturbances and may doom to fail the substitutional and nutritional therapy. The diagnostics of a fistula, including its location is comparatively easy. The surgical treatment plays an important role in the therapeutic scheme, especially in cases of high-output fistulas of the small intestin. At the same time the adequate total parenteral nutrition and correction of the base-acid and water-electrolyte disbalance is also very important. Recently there are some new diagnostic methods and alternatives of the basic surgical procedures, some of them quite contraversial.

[Internal biliary fistulas--diagnostic and therapeutic problems].

BACKGROUND: Internal biliary fistula (IBF) is still a challenging condition. The preoperative diagnosis is established in less than 50% of cases. Treatment is based on individual approach but postoperative morbidity and mortality rates are high. AIM: To study the experince of our clinic in the diagnosis and treatment of IBF's and to make a review of the literature. MATERIAL AND METHODS: a retrospective analysis of the data of 7 patients with IBF (0,53% of all surgical interventions on the biliary system during a 4-years period). The preoperative diagnosis was correct in only 2 cases. All the 7 patients were treated surgically. RESULTS: The early postoperative mortality and morbidity rates were 0% and 42,86% respectively. The data of literature are reviewed and discussed. CONCLUSION: IBS is a rare condition affecting more often women above 65 yrs suffering of gallstones. There are no typival clinical and laboratory data but US, CT-scan, ERCP and MRI might be a 100% informative. Open surgery remains the basic method of treatment.

Intra-individual comparison of the cutaneous safety and efficacy of calcitriol 3 microg g(-1) ointment and calcipotriol 50 microg g(-1) ointment on chronic plaque psoriasis localized in facial, hairline, retroauricular or flexural areas.

BACKGROUND: Psoriasis involving sensitive skin areas remains difficult to treat because of the side-effects of topical corticosteroids and the irritancy potential of vitamin D3 derivatives. Several clinical trials have demonstrated that calcitriol, the naturally occurring and hormonally active form of vitamin D3, is effective and safe at the dose of 3 microg g(-1) for the treatment of psoriasis affecting the trunk and limbs. METHODS: We compared the safety and efficacy of calcitriol 3 microg g(-1) ointment and calcipotriol 50 microg g(-1) ointment in a multicentre, randomized, investigator-blinded, left-right comparison in mild to moderate chronic plaque psoriasis affecting sensitive areas, defined as being the face, hairline, retroauricular and flexural areas. One pair of symmetrical and bilateral target lesions was selected from each area and assessed for perilesional erythema, oedema, and stinging/burning. Global assessment of local tolerability and global improvement were rated by the investigator, and the subjects were asked to evaluate the tolerability and efficacy of each product and to express their global preference. RESULTS: In the 75 subjects, calcitriol and calcipotriol both led to clearing of at least one target lesion in 21 (28%) of the subjects each. Perilesional erythema (P < 0.001), perilesional oedema (P < 0.02) and stinging/burning (P < 0.001) were all significantly less severe with calcitriol than with calcipotriol. The subjects' evaluation of local tolerability was significantly (P < 0.0001) in favour of calcitriol. Ten treatment-related dermatological events occurred in eight subjects, including one subject who experienced skin discomfort on both sides. All other events occurred only on the calcipotriol-treated side (irritant dermatitis, six subjects; contact dermatitis, one subject). Global assessment of improvement from baseline by the investigators was significantly greater for the calcitriol-treated lesions (P < 0.02). The subjects' global preference was significantly in favour of calcitriol (P < 0.02). CONCLUSIONS: In the present study, calcitriol ointment was found to be better tolerated and would appear to be more effective than calcipotriol ointment in the treatment of psoriasis in sensitive areas.

[Modified method of Sugiura-Futagawa for surgical treatment in patients with portal hypertension and esophageal varices]. / Modifitsiran metod na Sugiura-Futagawa za khirurgichno lechenie na patsienti s portalna khipertoniia i ezofagealni varitsi.

BACKGROUND: The esophageal transection and devascularization (Sugiura-Futagawa's operation) is the most frequently used ablative procedure in Japan for the treatment of patients with portal hypertension (PH) and esophageal varices (EV). Recently many authors, who are followers of this method, try to find an alternative one, aiming to shorten the skin-to-skin time and achieve better early and late results. AIM: To study the postoperative results of our modification of the original Sugiura-Futagawa's method and to conclude whether it is good and reliable or not. MATERIAL AND METHODS: From Jan. 1988 till Apr. 2001 we operated 25 patients with liver cirrhosis, PH and previous hemorrhage from EV, of whom 12 were male (48%) and 13--female (52%). Age of the patients--26-67 years. The ethiology of cirrhosis was alcoholic in 8 cases (32%) and post viral hepatitis--in 17 cases (68%). All our patients belonged to Child-Pugh's group A. The operative technique of our modification is described--transabdominal esophageal devascularisation, deconnection and reanastomosis. RESULTS: The early postoperative mortality rate after our modification of the Sugiura-Futagawa's method was 12% (in 3 cases). Death cause--fulminant hepatic failure with hepato-renal syndrome (in all three cases). The mortality rate was also 12% but no one of the complications was life threatening or an indication for reoperation. The 5-year survival rate accounted 78%, recurrent esophageal bleeding--7.14% and late hepatal encephalopathy--also 7.14% of the followed patients. DISCUSSION: The surgical treatment is of main importance for better survival in cases of PH and previously bled EV. A comparison between the results of other authors and our results is made. CONCLUSION: The proposed by us transabdominal esophageal devascularisation, deconnection and reanastomosis as a modification of the Sugiura-Futagawa's procedure is easy fro the technical point of view and leads to good results.

[Mesenteric-inferior-renal shunt--alternative of proximal and distal spleen-renal shunt for surgical treatment of portal hypertension]. / Mezenteriko-inferior-renalen shunt--alternativa na proksimalniia i distalniia spleno-renalen shunt za khirurgichno lechenie na portalna khipertoniia.

Surgical operations are important for the prevention of recurrent bleeding and better survival rates in patients with portal hypertension and previous haemorrhage from esophageal varices, stopped by conservative treatment. Spleno-renal shunts are among the most frequently used procedures in these cases. Sometimes the proximal spleno-renal shutting operation of Linton or the distal one of Warren may be impossible from the technical point of view due to anomalies or varieties of the lienal vein. This makes it necessary to look for an alternative decision. This case report is about a 33-year old man indicated for surgical treatment because of portal hypertension, caused by prehepatic portal vein obstruction and esophageal varices with previous bleeding. Performing Linton's or Warren's procedure was not the proper decision. That's why we made a shunt between the inferior mesenteric vein and the left renal vein. The surgical technique and the postoperative results are described and discussed.

The effects of divided attention on encoding and retrieval processes: the resiliency of retrieval processes.

We have recently cast doubt (Craik, Govoni, Naveh-Benjamin, & Anderson, 1996; Naveh-Benjamin, Craik, Guez, & Dori, 1998) on the view that encoding and retrieval processes in human memory are similar. Divided attention at encoding was shown to reduce memory performance significantly, whereas divided attention at retrieval affected memory performance only minimally. In this article we examined this asymmetry further by using more difficult retrieval tasks, which require substantial effort. In one experiment, subjects had to encode and retrieve lists of unfamiliar name-nouns combinations attached to people's photographs, and in the other, subjects had to encode words that were either strong or weak associates of the cues presented with them and then to retrieve those words with either intra- or extra-list cues. The results of both experiments showed that unlike division of attention at encoding, which reduces memory performance markedly, division of attention at retrieval has almost no effect on memory performance, but was accompanied by an increase in secondary-task cost. Such findings again illustrated the resiliency of retrieval processes to manipulations involving the withdrawal of attention. We contend that retrieval processes are obligatory or protected, but that they require attentional resources for their execution.

Depot sulfonamid associated linear IgA bullous dermatosis with erythema multiforme-like clinical features.

A case of erythema multiforme-like reaction, following therapy with sulfadimethoxynum is reported in a 19-year-old male patient. Histological examination demonstrated a subepidermal bulla and direct immunofluorescence revealed linear deposition of IgA at the dermoepidermal junction. These observations illustrate that linear IgA bullous dermatosis can mimic the clinical features of erythema multiforme and suggest the possibility of drug-induced pathogenesis.

[Dyskeratosis congenita (Zinsser-Engman-Cole syndrome)]. / Dyskeratosis congenita (Zinsser-Engman-Cole).

We report on a 23-year-old white Cuban suffering from congenital dyskeratosis. In addition to the obligatory triad of poikilodermia, onychodystrophy, and leukoplakia, the patient showed congenital stenosis of the esophagus and extreme seborrhea of the scalp.

[Carcinoma cuniculatum]. / Kartsinoma kunikulatum.

A 62-year-old male subject has developed carcinoma cuniculatum on the sole. The authors consider that the physician should bear in mind the possibility of a diagnostic error when selecting the therapeutic method. They suppose that carcinoma cuniculatum should be referred to verruciform carcinomas.

Psoriasis and drugs: influence of tetracyclines on the course of psoriasis.

Patients with psoriasis vulgaris (462) were studied by questionnaire to find the effect on psoriasis of drug therapy for intercurrent diseases or focal infections. Of 462 patients with psoriasis, in 76 (16.45%) the disease became more severe during drug therapy. Of these, 19 worsened after administration of tetracyclines, and in five psoriasis was precipitated after therapy with drugs of the tetracycline family. We suggest that tetracyclines should be avoided in patients with psoriasis and in healthy persons with a genetic predisposition (positive family history, human leukocyte antigens B13, B17, B27).

[Pachydermoperiostosis (Touraine-Solente-Golé syndrome)]. / Pachydermoperiostose (Touraine-Solente-Golé-Syndrom).

We report on a 38-year-old male patient suffering from pachydermoperiostosis (Touraine-Solente-Golé Syndrome), who underwent a cosmetic operation without success.