MANAGEMENT OF ESOPHAGEAL PERFORATION: A CASE REPORT.

Esophageal perforation (EP) is a devastating condition. In modern times it is still associated with substantial morbidity and mortality. 62-year-old male patient came to Surgical Department of the First University Clinic of Tbilisi State Medical University on 17.10.2018 15:00. The patient complained of pain in the chest cavity, especially after eating, shortness of breath, fever, chills, weakness. The patient felt pain in the chest cavity after eating 4 days before hospitalization. CT scan revealed pneumomediastinum, extravasation of contrast medium at the level of the 8th thoracic vertebra. Esophagogastroduodenoscopy revealed a defect in the esophagus at the level of 32 cm from the incisors. Dimensions of defect were 2.0 - 3.0 cm. An urgent operation was performed. Left-sided posterolateral thoracotomy, mediastinotomy, suturing of the defect, buttressing of the sutures with the mediastinal pleura, washing and drainage of the mediastinum and left pleural cavity were performed. A Witzel gastrostomy was performed. After the operation, the patient's treatment continued in the intensive care unit. Since leakage was noted, it was decided to place an esophageal stent in the area of the defect. Stenting was performed on 05.11.2018. A complication in the form of bleeding was noted on 01.12.2018. Bleeding was controlled conservatively. Finally, stent was removed and the patient was discharged from the clinic in good condition on 07.12.2018. New interventional endoscopic techniques, including endoscopic clips, covered metal stents, and endoluminal vacuum therapy, have been developed over the last several years to manage esophageal perforation. Surgery should be undertaken in all patients who do not meet non-operative management criteria. Buttressing the esophageal repair with surrounding viable tissue has been recommended to decrease the risk of leakage. If direct repair of thoracic EP is not feasible esophageal exclusion, diversion, or resection should be performed. Repair over a large size T-tube can be used to create a controlled esophago-cutaneous fistula and minimize mediastinal and pleural contamination. Thus, esophageal perforation continues to present a diagnostic and therapeutic challenge despite decades of clinical experience and innovation in surgical technique.

[GENOMIC VARIABILITY IN PATIENTS WITH DUCTAL FORM OF BREAST CANCER AND THE POSSIBILITY OF CORRECTION THE PEPTIDE BIOREGULATOR AND METAL IONS].

Level of genome stability (structural aberrations, aneuploidy and fragile sites) was studied in cells of the lymphocyte culture of ductal breast cancer patients (DBC). Was studied the correctional influence of separate and combinative action of peptide bioregulator (Ala-Glu-Asp-Gly) and heavy metal - nickel. It is shown that DBC patients are characterized by high level of genome instability, which is the result of the chromatin changing state. The used tests makes it possible to conclude that in the case of this form of cancer subordinates to specific epigenetic variation as a hetero- also euchromatic regions of genome. The agents - peptide bioregulator (Ala-Glu-Asp-Gly) and nickel ions, used in cell culture of ductal breast cancer patients, revealed the protective effect what indicates the prospects to further study for their involving purpose in combined therapy of this form of cancer.

HYPOGENESIS OF RIGHT LOBE OF LIVER ACCOMPANIED BY PORTAL HYPERTENSION AND ESOPHAGOGASTRIC VARICEAL BLEEDING; A RARE ANOMALY: A CASE REPORT.

Hypo-agenesis of the right lobe of the liver is an extremely rare finding. It is defined as the complete or partial absence of liver tissue on the right side without previous disease or surgery. It is usually an incidental finding. A 32-year-old female patient came to Emergency Department of TSMU the First University Clinic 22.10.2015 with an initial diagnosis of upper gastrointestinal bleeding. Her medical history showed no previous diseases of the liver or episodes of hemorrhage. Dizziness, nausea, vomiting with red blood, melena was presented on admission. Esophagogastroduodenoscopy revealed III degree varicose of veins from middle part of the esophagus to cardiofundal part of the stomach. Hemorrhage was observed from cardial part of the stomach. Control of bleeding was not achieved endoscopically. Sengstaken-Blakemore tube was used to stop bleeding temporarily. Computed tomography with angiography was performed. Right lobe of the liver was presented with VII and VIII segments. Medial edge of the left lobe of the liver is located near the spleen. Liver parenchyma is homogenous. No thrombosis of the portal or hepatic veins was revealed. Gallbladder was dislocated laterally and cranially without pathological changes. Extra- and intrahepatic biliary ducts were not dilated. There was colonic interposition between the liver and diaphragm. Diagnosis was established - hypogenesis of right lobe of liver, atrophy-hypertrophy complex, portal hypertension, varicose of the veins of the esophagus and cardiofundal part of the stomach, hemorrhage from variceal vein of the cardial part of the stomach, acquired coagulation factors deficiency, functional hypersplenism, posthemorrhagic anemia. In our case there was congenital hypogenesis of the right lobe of the liver. Five months follow-up showed no recurrent bleeding.

PARTIAL ANOMALOUS PULMONARY VENOUS CONNECTION WITH INTACT ATRIAL SEPTUM: A CASE REPORT.

Partial anomalous pulmonary venous connection (PAPVC) is a type of left to right shunt, when one or more lung veins drain to right atrium directly or indirectly via systemic veins. PAPVC is a rare condition, discovered by 0.4 to 0.7% of cases in autopsy series. It is often associated with atrial septal defect, but can be found with other congenital anomalies such as ventricular septal defect. Our report is about 42-year old woman who has right sided PAPVC draining into right brachiocephalic vein, which was incidental finding during pulmonary CT angiography. Patient had no symptoms associated with PAPVC and had no accompanied congenital anomaly, which is more rare condition. After consultations by surgeons, decision of conservative follow up was made, because of the fact that patient was asymptomatic. After performed multidetector computed tomography and image analysis in coronal, sagital and 3D reconstructions gave us superior quality images for data analysis. Once more, it confirms the role of modern high quality computed tomography in the diagnostic abilities of PAPVC.

Topical diagnostics of traumatic condylar injuries and alloplastic reconstruction of temporomandibular joint heads.

Condylar fractures have an important place in facial traumatic injuries. Classification of condylar fractures according to clinical-anatomic picture is common in clinical practice. According to this classification there are: 1) fractures of mandibular joint head, aka intraarticular fractures, 2) condylar neck fractures or high extra articular fractures, 3) condylar base fractures. Radiographic imaging plays important role in diagnosing condylar fractures along with knowledge of clinical symptoms. We used computer tomography imaging in our clinical practice. Three-dimensional imaging of computer tomography gives exact information about location of condylar fractures, impact of fractured fragments, displacement of condylar head from articular fossa. This method is mostly important for the cases which are hard to diagnose (fractures of mandibular joint head, aka intraarticular fractures). For this group of patients surgical treatment is necessary with the method of arthroplasty. We have observed 5 patients with bilateral, fragmented, high condylar fractures. In all cases the surgery was performed on both sides with bone cement and titanium mini-plates. Long-term effects of the treatment included observation from 6 months to 2 years. In all cases anatomic and functional results were good. Shape of the mandible is restored, opening of mouth 3-3.5 cm, absence of malocclusion.

Clinical manifestation and management of intravenous mercury injection: a case report.

Intentional self-injection of metallic mercury case report is presented. A 22 year old man with a past medical history of ethylene glycol suicidal poisoning was admitted to a Acad. N. Kipshidze Central University Clinic in Tbilisi, four months after deliberate intravenous injection of an unknown quantity of metallic mercury from several thermometers into his antecubital vein. After 2 months of asymptomatic period, the patient began to complain of pain and tremor in limbs, fatigue and skin rash. CT scan of the thorax and the abdomen confirmed multiple small opacities of metallic density in both lungs, liver and right kidney. After the procedure the patient was transferred to the toxicology center in Baku, Azerbaijan for chelation therapy. On arrival no biochemical abnormalities in hepatic or renal function or clinical pulmonary malfunction were detected, despite presence of slight symptoms of erethism, tremor mercuralis, knee joints arthralgia and lower extremities weakness. Chelation therapy with intramuscular injection of Unithiol (DMPS) was started in dose of 20mg/kg/day. After one month of chelation therapy, mercury blood concentration slowly decreased from initially 134 microgram/L to 105 microgram/L. This case report demonstrates mild acute toxicity following intravenous administration of unknown amounts of elemental mercury. Because of chelation therapy can remove approximately 1 mg of mercury per day the patient was recommended further long-term DMPS treatments under the control blood mercury levels. It is concluded that clinical manifestations of intravenous elemental mercury intoxication may be delayed despite significant increase in blood mercury level.

[The biliary intestinal obstruction].

The successful experience of treatment of 3 patients with biliary intestinal obstruction is depicted. The most informative means of diagnostics was the multispiral computed tomography. Authors state, that the volume of the operation should include only the liquidation of the intestinal obstruction. The simultaneous biliodigestive fistulae closure should be performed only in rare situations.

The role of multislice spiral computed tomography in the diagnosis and management of acute facial trauma in patients with multiple injuries.

Using of mutislice spiral CT as first line examination for the diagnosis of Acute Facial trauma in the setting of Polytrauma reduces both: valuable time and cost of patient treatment. After a brief clinical examination, MDCT was performed depending on the area of injury, using a slice thickness of 0.65 mm. The obtained data were analyzed using 3D, MIP and Standard axial with Bone reconstruction protocols. 64 polytrauma patients were evaluated with both Anterior and Lateral craniography (plain skull X ray: AP and Lateral) and Multi Slice CT. Craniography detected only 18 cases of traumatic injuries of facial bones, but exact range of dislocation and accurate management plan could not be established. In the same 64 cases, Multislice CT revealed localization of all existed fractures, range of fragment dislocation, soft tissue damage and status of Paranasal sinus in 62 cases (96.8%). In two cases MS CT missed the facial fracture, in one case the examination was complicated because of bone thinness and numerous fracture fragments, in another multiple foreign body artifacts complicated the investigation. The study results show that, CT investigation based on our MDCT polytrauma protocol, detects all more or less serious facial bone injuries.

[Role of multislice spiral computed tomography in diagnosis of spinal injuries in polytrauma patients].

Spinal injury in poly trauma patients is serious problem, because they cause high mortality and morbidity. According to WHO statistics, there are registered 30 million cases of spinal injuries annually, 50% of them die before reaching the hospital. In last 5 years incidence of spinal traumas has increased 2.6 fold and is about one third of all spinal diseases. That is why spinal injuries remain a challenge. The purpose of our study is to assess diagnostic efficiency of multislice spiral CT in diagnosis of spinal injuries in poly trauma patients. We randomly assessed data from 200 poly trauma patients, who underwent multislice spiral CT in poly trauma mode. In 92 (46%) patients different types of spinal fractures and injuries were detected. Age distribution was 16-72 (mean age 52 years). Out of 92 patients, 9 (4.5%) had isolated trauma, 83 (41.5%) had multiple trauma. Solitary injury of spinal column was detected in 30 (32.6%) patients, 54 (58.6%) had combined spinal injuries. In spinal injury patients the most common trauma mechanism was MVC - 56 patients (60.86%), fall from height 27 (29.36%) patients, diving 5 (5.43%) patients, gun shot wound 3 (3.26%) patients, industrial injury 1 (1.08%) patients. The most common location of the injury was lumbar vertebra (55 patients), thoracic vertebra (39 patients), cervical vertebra (28 patients). After assessing MDCT and MRI results 37 patients were operated, 6 of them underwent surgical intervention urgently, 31 had delayed surgery, that was performed after treating other life threatening injuries. Indications for surgical intervention were spinal cord compression and non stable vertebral fractures. According to our study results, MDCT is the study of choice for the diagnosis of spinal injuries in poly trauma patients. It helps to detect type and extension of the bony injury and visualize fragments in the spinal canal. It is superior to other radiological studies. 3D, MIP and MPR reconstruction gives information about spatial location of the fracture and helps to timely plan correct management.

Extracellular matrix thermostability of breast gland carcinoma.

Thermostability of epithelial cell matrix in composition of normal and breast ductal carcinoma tissues at various stages of the disease has been studied in the temperature range 40-90°C with help of differential scanning calorimeter (DSC). It has been shown that the denaturation process has three stages of transition in both cases. The temperatures corresponding to maxima of these structural transitions (Td) in case of normal and ductal carcinoma tissues equals to 55 , 66,78 C and 48, 55, 60, 85°C, respectively. Denaturation enthalpy (∆Hd) reflects contribution of hydrogen bonds, electrostatic and hydrophobic interactions in stability of native structures of biomacromolecules; in case of normal tissues, it equals 68,5±6.0 J/g dry biomass and decreases up to 52.5±6.0 J/g dry biomass in stage III of the disease. On the basis of presented and published experimental data, it is affirmed that the dominant transitions with Td around 66 and 60°C in case of norm and carcinoma, accordingly, correspond to denaturation of collagen IV fibers--the main component of microenvironment of duct epithelial cells (ECM)--and weakly expressed transition stages at 55, 78, 85°C correspond to denaturation of cytoplasmatic proteins. It is supposed that the observed significant differences in thermostability, in particular, 6° decrease of the ECM main component collagen, 7° increase of cytoplasmic proteins, and a significant decrease of total ∆Hd in case of ductal carcinoma compared to norm may be used as a new express test together with other existed tests for diagnosis of breast cancer at early stage of disease using some mg quantities of biopsy tissue.

[Diagnostic possibilities of multilayer computer tomography in blunt abdominal trauma].

The purpose of our study was to determine MDCT diagnostic possibility in blunt abdominal trauma. Our work was based on MDCT results of 84 blunt abdominal trauma patients with stable hemodynamic status (28 (33.3%) female and 56 (66.6%) male). Age ranges from 17 up to 64 years. The CT scan showed obvious organ and system injuries in 82 poly-trauma patients. Injuries of craniocerebral region, also of facial bones, chest and spine were determined in two patients; in one of which, however, it was not possible to differentiate subcapsular spleen hematoma accurately because of left upper joint metallic holder artifacts. In second patient the liver injury was accurately diagnosed, but there were visualization problems caused by the massive retroperitoneal hematoma from right adrenal gland injury. The investigation showed that sensitivity of CT scan data was 98%, specificity-97% and accuracy rate-98%. All above mentioned clearly states the importance of MDCT in the emergency department. MDCT ensures precise diagnosis in maximally short period of time and thereby helps to choose proper treatment and decreases post-traumatic complications.

[The role and place of helical ct for preporative diagnosis of acute appendicitis].

The goal of our study was to ascertain the role and place of helical CT for preoperative diagnosis of acute appendicitis. Our study relied upon the results of helical CT scans of 60 patients, which were diagnosed probable acute appendicitis based upon clinical signs. Of these 60 patients 49 (81,6%) were female, 11 (18,4%) male. For all patients laboratory studies of blood were made, 31 patients were examined by ultrasonography. Among this group the diagnosis of acute appendicitis was verified by CT scan in 41 patients. In the case of 5 patients the scan was equivocal because of smaller amount of omentum; in this subgroup of 5 patients (5% overall) three were given radiocontrast dye, and two (3,3% overall) were not. In 11 (18,3%) cases the diagnosis of acute appendicitis was not verified, and in three cases the diagnosis was incorrect. According to data of our study and intraoperative data analysis, sensitivity of this method approaches 93% and the specificity - 92%, and overall diagnostic accuracy 93%. Helical CT may be stated as diagnostic method of choice in the diagnosis of acute appendicitis. It is helpful in clinical decision making, and reducing the amount of false appendectomies.

Effects of fulvestrant 250mg in premenopausal women with oestrogen receptor-positive primary breast cancer.

Fulvestrant (Faslodex) reduces markers of hormone sensitivity and proliferation in postmenopausal women. This Phase II double-blind, randomised, multicentre study compared the effects of a single 250mg intramuscular dose of fulvestrant and placebo 14-21 days prior to surgery of curative intent on the oestrogen receptor (ER), progesterone receptor and Ki67 levels in 66 premenopausal women with ER-positive primary breast cancer. There were no statistically significant differences between fulvestrant and placebo with respect to any of the three markers analysed. The most common adverse events in both groups were nausea, headache and pyrexia. Fulvestrant 250mg had no effects on markers of hormone-sensitivity and proliferation in premenopausal women with primary breast cancer when measured at 14-21 days after injection. These findings suggest that a higher fulvestrant dose may be required in this patient population. Further clinical trials are necessary to evaluate the efficacy of fulvestrant in premenopausal women.

[Complex treatment of mastopathy patients with concomitant diseases].

Efficiency value of complex treatment of patients with cystic disease during side-illnesses. The aim of the article was to study the efficiency of complex treatment of mastopitia patients with concomitant diseases. The complex therapy of 1044 patients was carried out. Patients with cystic disease who does not suffer concomitant diseases (152 patients) where treated with mastodinon, vitamins, ginsheng, dehidratation, trancvilizators, antihistamines, drugs of K. After 24-26 months of treatment 144 (95%) patients fully recovered. The subjective progress was found in 8 cases (4%). In group with hormonal disorders recovery was in 120 cases (90%) and the subjective progress was in 13 patients (6%). Apart, the hormonal drugs had been used considering hormonal profile. 401 patients with concomitant diseases of genitals were treated with hormones, iodinotherapy and mastodinon. The best result in this group has been shown in patients with uterus fibromiomas - 110 patients and with ovarian micro cists with no need of surgical treatment - 78 patients compared with chronic adneqsitis (213 patients) - 90 (82%) patients; 67 (86%) patients; 162 (76%) patients. In case of concomitant diseases of liver and gold bladder, the treatment was effective in 113 (89%) patients. Ineffective treatment has been discovered in 5% 6 (5%) patients with hepatopathia and 28 (22%) patients with cholecistitis. The L-thyroxin was included in treatment in case of hypothyreosis (66 patients). Positive effect has been reached in 52 (78,5%) patients and progressive recovery was found in 13 (20%) patients. The complex therapy was effective for 648 (62%) of 1044 patients. Positive development was in 238 (27,8%) cases. In the group of patients who did not suffer concomitant diseases 4,9% has shown progress in treatment and 92,6% fully recovered.

[Treatment of patients with breast cancer during lactation and pregnancy].

Breast cancer is the most frequent form of malignant tumor detected during lactation period and pregnancy. The aim of the research was the examination of the efficiency of breast cancer patients' treatment. 17 women diseased with breast cancer of the T1-2N0-2M0 stage during lactation and pregnancy period were involved in the study. The results of the research have exposed the high efficiency of the complex medical care of breast cancer patients at the early stages of the disease. At the T1-2N0M0 stage, the showings of 5-year common and recurrence-free probability of survival have made 52,9 and 47,0%, at T1-2N1M0-23,5 and 11,8%, at T1-2N2M0 - 5, 9 and 5, 9%. Common probability of survival in the examined group of patients has made 82,4% and recurrence-free probability of survival - 64,7% (p<0,1). Lethality index was 17,7% (3 patients).

[About correlation of dysfunction of the thyroid gland with fibrocystic diseases in women].

The reference data contain a lot of information on the interrelation between destroying of a thyroid gland and fibrocystic diseases. However contradictions in these data proves that this issue is not solved completely. The aim of the given study was the investigation of interrelations between frequency of occurrence of pathology of a functional condition of the thyroid gland and the frequency of occurrence of fibrocystic diseases. 90 women aged 23-50 were investigated. Concentration of thyroxin (FT4), thyrotrophic hormone (TSH), titers of antibodies to thyreoperoxidase, microsomal fraction of thyreocytes and thyreoglobulin were measured by ELISA. Palpation and ultrasonic investigations of thyroid and mammary glands were used, morphology of central formations of mammary glands according to indications was also carried out. A special questionnaire was completed for each patient. Our investigations showed that along with the declining of function of thyroid gland and the increased level of TSH in the blood, the risk of development of fibrocystic diseases is increased twice.

[Efficiency of lymphatic mapping by intradermal injection of vital blue dye for sentinel node identification in T1-2 N0-1 M0 stage breast cancer patients].

The lymphatic mapping and sentinel lymphadenectomy procedure is a highly accurate method of axillary staging in breast cancer. Because no other method accurately predicts axillary node status without complete axillary dissection, this technique has a potential to become the standard method of axillary staging for breast cancer in near future. The aim of the study was to evaluate efficiency of lymphatic mapping by intradermal injection of vital blue dye for sentinel node identification in T(1-2) N(0-1) M(0) stage breast cancer patients. The sentinel lymph node biopsy with total axillary dissection was performed in 36 patients. The efficiency of lymphatic mapping by intradermal injection of vital blue dye (identification rate) was 97,2%, specificity--100% and the false-negative rate was 2,8%.

[Sentinel nodes identification efficacy prognostic criteria in breast cancer].

The sentinel node concept assumes that a malignancy that metastasizes by the lymphatic route will initially travel to one or a few lymph node(s). Although a tumor may disseminate to other nodes, it will remain in the sentinel node, and therefore the status of the entire basin is predicted by the sentinel node. The sentinel lymph node biopsy with total axillary dissection was performed on 99 patients. The identification rate was 69,7%, specificity 62,6%, and the false-negative rate was 7,1%. The impact of some prognostic factors on efficacy of visualization was also investigated. It was shown that the age of patients, stage of disease, localization of primary tumor, and method of injection of methylene blue were important prognostic factors for effective identification of sentinel lymph nodes in breast cancer patients.

Continent urinary diversion (Gotsadze Pouch) after pelvic exenteration for gynaecological malignancies.

The problem of urinary diversion is of major importance in patients requiring pelvic exenteration for advanced gynaecological malignancies. Eight patients underwent pelvic exenteration (4-total and 4-anterior) at the Georgian Oncologic Centre, 7 of them for recurrent cervical carcinoma after combined treatment and 1--for primary advanced cervical carcinoma. The original surgical technique for construction of detubalarized ileal reservoir with continent umbilical stoma (Gotsadze Pouch) is described. Six patients underwent this type of urinary diversion with successful results. Urination is patient-controlled via self-catheterization every 5 to 6 hours. The results obtained by operation can be considered as optimal for their functional and rehabilitational properties.

[Primary-multiple malignant tumors of the colon, uterus and breast]. / Pervichno-mnozhestvennye zlokachestvennye opukholi tolstoi kishki, matki i molochnoi zhelezy.

A study of 94 case histories of primary multiple tumors of the large bowel, uterus and breast showed relative risk of development of uterine body cancer in patients with colonic cancer to be 37 times that for a general population of healthy females over 40 years of age. Post-treatment risk of breast cancer in cases of large bowel cancer increases 17-fold, uterine body--15-fold and cervix uteri--10-fold. Risk for large bowel cancer increases 179-fold in patients treated for uterine body tumors. On the whole, it serves as a confirmation of a possible role of endocrine-metabolic disorders played in the pathogenesis of primary multiple tumors of the large bowel and uterus. Radiation is the key factor of induction of rectal and rectosigmoidal tumors as a result of radiotherapy for cancer of the uterus. The results of the study make the case for timely diagnosis of primary multiple tumors of the large bowel, uterus and breast and adequate follow-up, no matter at what site the first tumor was found.