Doppler-guided transanal hemorrhoidal dearterilization versus conventional hemorrhoidectomy for treatment of hemorrhoids - early and long-term postoperative results.

BACKGROUND: A variety of effective methods for treatment of hemorrhoids has been proposed. In recent years, there has been an increasing number of studies comparing transanal hemorrhoidal dearterilization (THD) and conventional hemorrhoidectomy (CH), but the focus of most studies has been about the early postoperative results. The data about long-term outcomes is still limited. We aimed to compare Doppler-guided THD and CH with regard to early and long-term postoperative results. METHODS: The conducted prospective research included 287 patients who underwent CH (167 cases) or Doppler-guided THD with mycopexy (120 patients) between November 2010 and December 2015. Information on hemorrhoidal stage, demographic data, presenting symptoms, complications, duration of hospital stay, postoperative pain, patients' satisfaction and follow-up were obtained. Statistical tests were performed by SPSS 19.0. RESULTS: There was no significant difference between the studied groups according to gender, mean age, preoperative prolapse, pain and pruritus, hemorrhoidal stage and postoperative complications. Preoperative bleeding was more frequent in THD group (p = 0,002). The mean visual analog scale (VAS) pain scores in CH and THD groups on days 1, 2 and 7 were 7.01 vs 5.03, 5.07 vs 2.98, 2.39 vs 0,57 (p = 0,000). Practically, there was no difference in VAS on day 30 and patients' satisfaction at the 18th month. Mean hospital stay was 5,13 (CH) and 3,38 days (THD), p = 0,000. The postoperative follow-up was between 18 and 78 months (mean 46 ± 16 months). During this stage, 5 patients (2,99%) in CH group required surgery for recurrence. In THD group, 3 patients (2,5%), all with 4th-degree hemorrhoids underwent additional procedures (p 0,802). CONCLUSIONS: Doppler-guided THD seems to be an efficient and safe option for treatment of hemorrhoids, related to lower postoperative pain and excellent, similar long-term outcomes compared to CH. For advanced grades of hemorrhoids, Doppler-guided THD could be a valuable alternative, but there is a need for patients' selection. TRIAL REGISTRATION: (retrospectively registered) researchregistry 3090 .

RECTOCELE - A LITERATURE REVIEW WITH A CASE REPORT.

Rectocele is defined as an herniation of the rectal wall through a defect in the posterior rectovaginal septum in direction of the vagina. A great variety of factors can cause a rectocle. Small rectoceles are asymptomatic, but the big ones are appearing with a great variety of symptoms. Diagnosis of a rectocele is based on the clinical signs, physical examination and imaging tests. There are nonsurgical and surgical methods for treament of rectocele. Here we share our experience of successful surgical treatment of a big, sacculiform, high rectocele appeared soon after a vaginal hysterectomy.

Liver hemangiomas--surgical point of view.

UNLABELLED: Most of the liver hemangiomas do not change substantially their size for years. In some of the cases they grow, which may correlate to complaints and a risk of complications. Due to the rarity and the benign nature of the pathology, the surgical tactics and the technical methods have not been fully clarified. The goal of the present study is to present the experience of the Department of General and Liver-pancreatic Surgery in the surgical treatment of liver hemangiomas against data of the specialized literature. MATERIALS AND METHODS: In the January 1995-March 2013 period, 101 patients were subjected to liver hemangioma surgery at the Department of General and Liver-pancreatic Surgery, UH "Alexandrovska" Sofia. Main demographic, clinical, diagnostic and surgical procedures have been analyzed. RESULTS: Of 101 operated patients, 27 (26.7%) were male and 74 (73.3%)--female, aged 25- 77, mean age--50.7. The focal lesion was successfully diagnosed with diagnostic imaging methods: 96.9% with US, 98.3% with CT and 100 % with MRI. We established diagnostic specificity of 60.3%, 55.0% and 85.7%, respectively. The following interventions were performed: 14 large liver resections of three and more segments, 35 left-side lobectomies, 35 enucleations and enucleoresections and 30 mono- and bisegmentectomies. Post-operative complications were observed with 6 (5.9%) patients. None of the patients died. CONCLUSION: The combination of modern non-invasive imaging methods reaches diagnostic sensitivity and specificity sufficient to identify the liver hemangioma and take a decision on the therapeutic conduct. The possibilities for surgical treatment is limited and is applied upon strict indications. Liver resections in different volume and enucleations should be applied after correct selection of patients, so as to ensure minimum risk of morbidity and mortality.

Advantages of transanal hemorrhoidal dearterialization as compared to other surgical techniques for the treatment of hemorrhoidal disease.

UNLABELLED: Transanal hemorrhoidal dearterialization (THD) is a new surgical technique used for the treatment of hemorrhoidal disease. It is known for its easy performance and low perioperative risk. 44 patients have been operated by this method at the Clinic of General, Liver and Pancreatic Surgery for a period of 22 months. A comparative analysis was performed between the postoperative results with the use of transanal hemorrhoidal dearterialization, modified hemorrhoidectomy of Milligan-Morgan, and Whitehead's hemorrhoidectomy. CONCLUSIONS: When comparing transanal hemorrhoidal dearterialization with other methods, we found that it has an excellent aesthetic effect, requires shorter hospital stay and less analgesics, and causes less discomfort in the postoperative period.

Diagnosis of liver hemangioma.

BACKGROUND: Benign liver tumors are now being diagnosed frequently with the advent of the greater use of imaging investigations. The most common lesion is the liver hemangioma 0.4-7.3%, with an incidence rate at autopsy ranging from 3% to 20%. MATERIAL AND METHODS: One hundred and one patients underwent operative treatment in the Department of General and Liver-pancreatic Surgery, UH "Alexandrovska" Sofia from 1995 to April 2013. There were 74 (73.3%) females and 27 (26.7%) males. Mean age was 50.7 years (range 25 to 77). Seventy-four patients (73.3%) had a solitary tumor. Methods for diagnosis included history of the disease, routine haematological and liver function tests, ultrasonography, CT, MRI or a combination of more than one technique. RESULTS: The diagnostic sensitivity of the imaging procedures was U/S 96.9%, CT scanning 98.3% and MRI 100% .The diagnostic specificity--U/S 60.3%, CT scanning 55.0%, MRI 85.7%. CONCLUSION: Hepatic hemangioma is diagnosed in most patients using non-invasive studies such as US, CT and MRI or a combination of them.

[Cystopericystectomy for the treatment of hepatic hydatid disease].

UNLABELLED: Hepatic hydatid disease is current problem in Bulgaria as the country in endemic region. The treatment include PAIR, various type surgical procedures and medical therapy. Surgical treatment is conductive. Cystopericystectomy is one of radical procedures. AIM: The aim of this study is to present the experience of Department of General and Liver-Pancreatic Surgery in Uiversity Hospital "Alexandrovska", Sofia with cystopericystectomy. MATERIAL AND METHODS: During the period of 18-years (1988-2005) done 90 cystopericystectomies on the 79 patients--57 (72.15%) female and 22 (27.85%) male. Diagnosis has become easier with advances in ultrasonic imaging, immunological tests and CT scanning. The cysts ware localised in left lobe--56 (62.2%) and right lobe--34 (37.8%). RESULTS: There was complication in 4 (5.0%) of patients. Median postoperative stay is 10.3 days. There wasn't reoperacions and lethal outcome. CONCLUSION: Cystopericystectomy is difficult operative procedure, but it followed with better results. It's necessary strictly abidance of the evidences.

[A variant of hepatico-jejunostomy in Klatskin tumors]. / Variant na khepatiko (khepatitse-) ieiunostomiia pri Tu Klatskin.

The authors present their own variant of performing anastomoses between the common hepatic duct/right and left hepatic ducts and the jejunum in radical treatment of Klatskin tumors. The procedure is indicated in cases of proximal (hilar) resection of both hepatic ducts, in technical difficulties for performing the standard drainage protected end-to-side anastomosis between the right and left hepatic ducts on the one hand and the jejunum on the other as well as a method for double biliary derivation. The advantages of the procedure include decreased incidence rate of bile leakage in the subhepatic region, low risk of diffuse biliary peritonitis respectively and restricted possibility of intestinal reflux into the biliary tract.

[Anterior approach for major hepatic resection for large liver malignancy]. / Chernodrobni rezektsii tip ANTERIOR APPROACH -- pri golemi maligneni tumorina cherniia drob -- 2 sluchaia ot praktikata.

The large liver cancers in the right lobe are difficult to be resected with conventional approach. We report for 2 cases--43 old year man with cholangiocellular carcinoma and 50-old year woman with metastatic liver tumor from breast cancer, both with diameter of 30 cm, successfully resected using nonconventional "anterior approach". The postoperative period was uneventful. They were discharged from hospital in 10 and 14 days.

[Postoperative liver failure after hepatic resections for hepatocellular carcinoma]. / Postoperativna chernodrobna nedostatuchnost sled chernodrobni rezektsii pri bolni s khepatotselularen kartsinom.

Postoperative liver failure is a life-threatening complication after hepatic resection. The purpose of this study was to review the liver failure as a result of hepatic resection and to propose strategy for decreasing the risk of its developing. From January 1991 to December 2000 73 patients with primary liver cancer (PLC) were operated and identified in a retrospective database. Seven (13.2%) of resected 53 patients developed postoperative liver failure. There were 4 male and 3 female with mean age 52.3+/-29.2 (from 1 to 78). 3 patients had underlying cirrhosis. Major resections were 5 and minor--2. Mean hemotransfusion was 1012, 13 ml (370-2000 ml). Five patients (71%) died by the 30th day. The causes of liver failure were analyzed, based on both the preoperative data and the intraoperative findings. Significant prognostic factors were the preoperative serum level of bilirubin (p=0.024) and intraoperative hemotransfusion (0.031). The right hemihepatectomy was a prevalent hepatic resection in these patients.

[Central segments resections in primary liver neoplasms--three clinical cases]. / Tsentralnosegmentni rezektsii pri purvichni neoplazmi na cherniia drob--opit ot tri klinichni sluchaia.

BACKGROUND/AIMS: The resections of the central paramedial hepatic sectors are most rarely reported due to their technical complexity. We present three cases in which we carried out this rare operative intervention for occasion of primary hepatic neoplasm in the central hepatic segments. MATERIAL AND METHODS: In three cases (two of primary hepatic cancer and one of sarcoma) we carried out resection of the central segments in the following steps: mobilization of the liver, subhepatic approach to the inferior v. cava, preparation for vascular isolation of the liver by Pringle's maneuver, dissection of the biliary, arterial and venous vessels in the hepatic hilus, intraoperative assessment of the involvement of these structures in the neoplastic process and subsequent hepatic resection. RESULTS: For a period of 5 to 24 months of follow up we have not established a relapse of the disease in the cases ascribed. CONCLUSION: The outcome of the hepatic resections strongly depends from the various factors including accurate preoperative diagnosis, the assessment of the resection volume according to the involvement of the hepatic vessels in the neoplastic process. Hepatic resection can be performed with the same degree of confidence and similar low morbidity as any other major surgical procedure.

[Hepatic echinococcosis: radical or conservative surgical treatment]. / Chernodrobna ekhinokokoza: radikalno ili konservativno khirurgichno lechenie.

UNLABELLED: Hydatid liver disease remains an actual medical and social problem for Bulgaria as an endemic region. Because of the lackage of medicines with satisfactory therapeutic effect the surgical treatment is still the treatment of primary importance. AIM: The aim of this study was too check the correctness of the following hypothesis: "Radical surgical procedures on hydatid liver disease have lower rates of morbidity and mortality compared to conservative ones". MATERIAL AND METHODS: In order to achieve the above mentioned aim we analysed the results of 361 patients with hydatid liver disease (267 (74%) of whom retrospectively and 94 (26%) prospectively), treated at the Clinic of General, Liver and Pancreatic Surgery during the period 1st, Jan., 1985-1st, Jan., 2001. The patients were divided in two main groups: 102 (28.25%) of them received radical surgical procedures and 250 (69.25%)--conservative ones. Nine of the patients (2.50%) had multiple echinococcal cysts and received surgical procedures of both types. That's why the results of those patients did not correspond to the aim of the study and they were not included in it. The analysis consisted of a comparison between the two main groups according to several criteria: sex, age, location and average size of the cysts, postoperative complications, reoperations, mean postoperative stay at hospital and mortality rate. RESULTS: There was a prevalence of the female in the ratio male/female in the group of patients who received a radical procedure. The location of echinococcal cysts in the left hepatic lobe was found to be more frequent. In the group of radical surgical operations the postoperative morbidity and mortality rates were lower and the postoperative stay at hospital was shorter, compared to the group of conservative procedures. CONCLUSION: Radical surgical procedures showed better postoperative results. But those procedures had to be performed only on patients who had certain indications and according to criteria described in surgical literature. The proper surgical equipment and well experienced surgical team were the other important conditions for good outcome.

[Anterior rectal resection--early postoperative results]. / Predna rezektsiia na rektuma--ranni sledoperativni rezultati.

BACKGROUND: The development of the mechanic staplers gave the opportunity to perform sphincter-saving operations in patients with middle and low rectal carcinoma. It has been gained experience in performing this operation as the anastomosis was sewed in both ways--manually and mechanically. PURPOSE: The purpose of this retrospective research is to analyse the early postoperative results after anterior rectal resection with manually and mechanically made anastomosis. MATERIAL AND METHODS: For the period 01.01.1995-01.012000 in the DEPARTMENT OF GENERAL, LIVER AND PANCREATIC SURGERY, 69 patients with rectal carcinoma underwent the operation anterior rectal resection. In 60 cases (89.96%) the anastomosis was made manually and in 9 cases (13.04)--with mechanical staplers. Both patient groups are studied and classified by sex, age, tumor localisation, type of anastomosis, early postoperative results. RESULTS: From the group with manually sewn anastomosis 6/10%/ of the patients had complications in the early postoperative period, one of them terminated (1.7%). From the second group 3 (33.3%) of the patients had complications in the early postoperative period. The average postoperative hospitalisation was 13.5 vs. 19.2 days. CONCLUSION: The results achieved in anterior rectal resection depend on a complex of factors among which more important is the early diagnosis of the disease and the skills of the surgeon in coloproctology.

[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.

[Echinococcosis of the spleen-notes on some diagnostic and therapeutic problems]. / Ekhinokokoza na slezkata-vurkhu niakoi diagnostichni i terapevtichni problemi.

Twenty patients with hydatid disease of the spleen--14 presenting isolated location within the spleen, five--combined with liver cyst, and one--polyorganic involvement--are operated in the Department of general and operative surgery--Sofia over the period January 1985 through December 1998. The currently used methods of echinococcosis diagnosing are described, and the indications for splenectomy and organ salvaging echinococcotomy in the aforementioned localization are discussed.

[Widened right paramedial segmentectomy comprising IV hepatic segment in a patient with primary liver carcinoma]. / Razshirena diasna paramedialna sektorektormiia, vkliuchvasht IV chernodroben segment pri bolen s purvichen kartsinom na cherniia drob.

This is a report on a rare operative intervention undertaken for primary liver carcinoma, located in the central hepatic segments (after Couinaud). The operative technique, intraoperative carcinoma resectability and the tools of hemorrhage control are discussed.

[Laser use in various fields of surgery]. / Lazer't v niakoi oblasti na khirurgiiata.

A total of 236 patients presenting various pathological conditions are operated in the Department of General and Operative Surgery of the Medical University--Sofia over the period 1993 through 1998, using laser radiation--CO2-laser in 216 cases, ans Nd-YAG laser--in 20 cases. Both focused and unfocussed laser beam is applied. The superiorities of laser surgery in definite diseases and the results thus far obtained are analyzed.

[Carcinoma of the stomach - our experience with surgical treatment]. / Kartsinom na stomakha - nashiiat opit v khirurgichnoto lechenie.

Carcinoma of the stomach is among the commonest malignancies of the gastrointestinal tract regardless of the permanent tendency of its diffusion to decrease, observed in the last 25-30 years. The readily accessible methods of diagnosing the disease contribute greatly to its early detection. However, owing to diverse causes, in over 70 per cent of cases the diagnosis is usually made as late as in the advanced III-IV stages. The latter circumstance preordains largely the unfavourable long-term results of the treatment undertaken where surgery plays a major role. It is the purpose of this study to analyze the surgical strategy and tactics currently used in the management of gastric carcinoma. Over a 5-year period (Jan 1995 through Dec 1999), in the Chair of General and Operative Surgery of the Medical University--Sofia a total of 184 gastric carcinoma patients, including 116 men (63.1%) and 68 women (36.9%) with age ranging from 23 to 80 years, undergo operation. Diagnosing is based on past history, physical, laboratory and x-ray data, but first and foremost on evidence from FGS and histological assessment of biopsy material (carried out in all patients). With a view to precise preoperative staging of the lesion, roentgenoscopy + roentgenography of lungs, USD and CAT of the abdominal organs are also done. The following intervention are performed: gastrectomy 18 (9.8%), upper pole resection 43 (23.4%), subtotal resection of stomach 4 (2.2%), prosthetic replacement of cardia 8 (4.3%), derivations 22 (11.9%), and explorative laparotomies. Combined subtotal gastric resections of gastrectomies are necessitated in 73 patients (39.7%) because of carcinomatous infiltration of contiguous organs and/or presence of liver metastases. Morbidity involves 29 patients (15.7%) with lethality amounting to 16 (8.7%). The long-term postoperative results are discussed under a separate heading. Operative treatment of gastric carcinoma patients is the only chance of survival. The scope of indication for more aggressive surgical interventions, including combined resections and gastrectomies, are broadened leading in turn to a considerable reduction of the proportion of explorative laparotomies.

[Carcinoma of extrahepatic bile ducts - operative management of lesions located in the distal segments]. / Kartsinom na ekstrakhepatalnite zhl'chni p'tishta - operativno lechenie na lokalizatsiite v distalnite otdeli.

Experience with operative management of patients presenting carcinomas located in the distal third of the extrahepatic bile ducts, accumulated in the Department of General and Operative Surgery of the Medical University--Sofia, is analyzed. The condition is characterized by manifestation of clinical signs typical of a well advanced pathological process, found in a considerable number of patients with obstructive jaundice syndrome, and necessitating surgery on an emergency basis because of the danger of hepatorenal failure development with a fatal outcome. Over a 10-year period (1989-1998), a total of 219 patients with histological evidence of carcinoma in various segments of the extrahepatic bile ducts are operated on. The series includes 107 men (48.9%) and 112 women (51.1%) at mean age 59.2 years. In 64 cases (29.2%) the process involves the distal third only (terminal choledochus and papilla Vateri). In this group 41 radical and 23 palliative operations are performed. The indications for radical resection, the basic principles of radical and palliative interventions, and the results of their practical implementation are comprehensively discussed. The basic parameters--resectability, survivorship, early postoperative lethality (EPL) and morbidity--are comparable to the ones presented in recently published reports on biliopancreatic oncosurgery.