[Results from application of a portal vein ligature at surgical treatment of primarily unresectable colorectal liver metastases].

Introduction: Selected patients with unresectable colorectal liver metastases (CRLM) may become resectable using a two-step approach with portal vein ligature (PVL). The purpose of this study is the evaluation of the results of the tow-staged liver resection (LR) using PVL for CRLM in our clinic. Material and Methods: During the period 2005-2015 year at the Clinic of hepatobiliary and transplant surgery, MMA-Sofia 290 curative LR for CRL were carried out. In 17 (5.9%) of them is used a two-stage approach with an initial PVL. Results: The reasons for unresectability were multinodularity of the disease in 70.6%, the size of LM (11.8%), poor location (17.6%). Synchronous LM was at 94% of the cases. Simultaneous resection of the primary tumor at the first operation carried out in 58.8% of the cases. During the second operation, at 94% of patients require a major LR. Patients completed a two-staged approach median survival was 40.43 m., with a found that extended right hemihepatectomy adversely affect survival in patients with two-stage hepatectomy (p=0.023), increasing the risk over 6 times. Conclusion: The multidisciplinary approach is the most precise form, ensuring proper selection and behavior in patients under consideration for two-stage approach to optimize the therapeutic behavior and clinical outcomes.

MULTIVISCERAL RESECTIONS FOR GASTRIC CANCER.

BACKGROUND: Multivisceral resection for locally advanced gastric cancer is necessary to achieve R0-margins. This surgical option is accompanied by short- and long-term outcomes that still remain questionable. AIM: Our aim was to evaluate the efficacy of "en bloc"-resections as an "aggressive" surgical approach with regard to postoperative morbidity, mortality and survival. MATERIAL AND METHODS: Postoperative morbidity, mortality and survival rates of 60 patients with locally advanced gastric carcinoma, who underwent total or subtotal gastrectomy with multivisceral resection between 2004-2014, were retrospectively analysed. RESULTS: The most common adjacent organs resected were spleen (n = 46) - 76.7%, pancreas (n = 24) - 40%, colon (n = 11) - 18.3%, liver (n = 9) - 15% and duodenum (n = 4) - 6.7%. Resection of more than one organ was performed in 70% of cases, R0-resection was achieved in 75%, histopathologic examination confirmed involvement of adjacent organs (pT4) in 42 patients (70%). Surgical mortality and morbidity rates were 6.7% and 28.3% respectively. The overall 5-year survival rate was 24.1% (R0 vs R1 resections - 32.6 vs 0%, p < 0.05). There is a 10-year survival rate of 5.2% registered. CONCLUSION: R0-multivisceral resection is the key therapeutic option for advanced gastric cancer. It appears to be feasible in selected patients on providing adequate selection and surgical expertise and can be achieved with relatively low mortality and morbidity, offering good overall and 5-year survival rates.

AN APPROACH TO THE DETERMINATION OF A PROGNOSTIC INDEX FOR THE SCOPE OF SIMULTANEOUS RESECTION IN PATIENTS WITH SYNCHRONOUS COLORECTAL LIVER METASTASES.

Based on the results of 62 simultaneous operations in patients with synchronous liver metastases from colorectal cancer, an attempt was made to calculate the index, assisting the surgeon in the selection of the liver resection, considering the sensitivity and specificity of the test. The index is calculated using equations based on variables and their coefficients from Cox regression analysis. The type of surgery is associated with prognosis for survival of the operated patients. The results can serve as a basis for further research in this area.

Liver transplantations in Bulgaria--initial experience.

The filed of liver transplantation (LT) continues to evolve and is highly effective therapy for many patients with acute and chronic liver failure resulting from a variety of causes. Improvement of perioperative care, surgical technique and immunosuppression in recent years has led to its transformation into a safe and routine procedure with steadily improving results. The aim of this paper is to present the initial experience of the transplant team at Military Medical Academy - Sofia, Bulgaria. For the period of April 2007 - August 2014 the team performed 38 liver transplants in 37 patients (one retransplantation). Patients were followed up prospectively and retrospectively. In 36 (95%) patients a graft from a cadaveric donor was used and in two cases--a right liver grafts from live donor. The mean MELD score of the transplanted patients was 17 (9-40). The preferred surgical technique was "piggyback" with preservation of inferior vena cava in 33 (86%) of the cases and classical technique in 3 (8%) patients. The overall complication rate was 48%. Early mortality rate was 13% (5 patients). The overall 1- and 5-year survival is 81% and 77% respectivelly. The setting of a new LT program is a complex process which requires the effort and effective colaboration of a wide range of speciacialists (hepatologists, surgeons, anesthesiologists, psychologists, therapists, coordinators, etc.) and institutions. The good results are function of a proper selection of the donors and the recipients. Living donation is an alternative in the shortage of cadaveric donors.

Single centre experience with surgical treatment of hilar cholangiocarcinoma.

UNLABELLED: BACKGROUND /AIMS: Surgical resection is a radical treatment option for hilar cholangiocarcinomas. However it is still difficult to cure and patient prognosis is poor. An evaluation of the surgical options and results may elucidate effective treatments. METHODOLOGY: We retrospectively examined the demographic characteristics, surgical records and outcome in 64 patients with hilar cholangiocarcinoma undergoing surgical resections or palliative surgical procedures for the period of 2004-2012. RESULTS: The patients included 43 males and 17 females with a mean age of 61.4 ± 10.4 years (±SD, range 35-81 years). Forty four resections were done - R0-22 cases (34.4%), R1 - 10 (15.6 %) cases, R2 -12 cases (18.7%) and 20 palliative (31.3%) operations were performed. R0 - resection of common bile ducts with right hepatectomy with Sg 1 was done in 8 cases, resection of common hepatic duct with left hepatectomy with Sg 1 in 9 cases and resection of common hepatic duct in 5 cases. The total percentage of postoperative morbidity is 51.5 %. The types of complications are as follows: intra abdominal bleeding 31.25 %, temporary biliary leakage - 26.56 %, leakage of hepatico-jejunostomyâ7.81 %, biliary fistula 7.81%, liver insufficiency 17.18 %, pleural effusion 48.13 %, intraabdominal abscess 28.13 %, surgical site infection 48.3 %. The mean five-year overall survival for R0 - resection is 32%, for R1 - and R2 - resection is 12% and for the palliative operations - 0%. The mean overall survival for R0-resection is 37 months, for R1 - and R2 - resection is 19 months and for the palliative operations 7 months. CONCLUSIONS: Radically extended surgical resection for hilar cholangiocarcinoma is necessary to obtain improved patient survival.

[Pancreatic cancer--multidisciplinary approach and possibilities for surgical treatment].

Pancreatic cancer is one of the most serious and severe diseases and takes a significant part of malignant diseases in Bulgaria, during the last years. The fast progression of this disease requires complex treatment and is still a considerable challenge for the conservative and the surgical approaches. We present a series of 196 consecutive patients operated in our clinic for the period September 2003-February 2008. 106 radical pancreatic resections and 90 palliative procedures were performed. All of the patients were assessed before operation by multimodality team using standard protocols. The criteria for respectability are absence of distant metastasis as well as absence of data for infiltration of celiac trunk and superior mesenteric artery. In the presented series the percent of respectability is 54.1%. 35 Whipple procedures. 49--Traverso-Longmire (PPPD--resections), 15-distal pancreatectomies and 7 papillectomies were performed. In 28 cases the pancreatic resection was combined with vessel resection. 17 patients underwent extended resections. The average postoperative stay for the patients with radical operations is 16.1 days. 39 patients (36.8%) had complications. Six patients among the radically operated died (5.6%). The average survival rate for the patients with radical surgical interventions is 16.2 months. The surgical resection is the only method of choice for radical treatment of pancreatic cancer and periampular tumors. The indications for pancreato-duodenal resections have expended thanks to the development of the surgical technique and reanimation care during the last ten years. In order to achieve better results it's recommended that type of surgery to be concentrated in highly specialized centers.