PAPILLARY MICROCARCINOMA OF THE THYROID GLAND - DOES SIZE MATTER?

Introduction: Papillary thyroid microcarcinoma has provoked discussion among the endocrinological community due to the extremely diverse therapeutic methods adopted in international guidelines. From the radical approach of total thyroidectomy with prophylactic central lymphatic dissection to "active monitoring" and opinions such as "papillary microcarcinoma is not carcinoma". Aim: To investigate the factors of invasiveness in papillary microcarcinoma. Material and methods: We included 184 patients with thyroid microcarcinoma, operated in the Department of General Surgery "Kaspela",Plovdiv, for a period of five years. Results: Intra-organ metastases or multifocal growth was identified in 38 of the patients. Positive for micro and macro metastases lymph nodes in the central lymphatic basin are found in 54. In 46 of them we identified metastases in the ipsilateral, and in 21 in the contralateral central neck nodes. The analysis of patients with lateral metastases found 7 unilaterally and 3 bilaterally. Skip metastases were registered in 4 of these 10 patients. Conclusions: The results of our study show that despite the favorable prognosis and non-aggressive behavior of papillary microcarcinoma, factors attesting to the invasive nature of the tumor occur in 44.5% or almost half of patients. This requires careful and individual approach constructing therapeutic strategy for the treatment of patients with papillary microcarcinoma.

Novel insights into transcriptional dysregulation in colorectal cancer.

Colorectal cancer (CRC) is a leading cause of cancer-related mortality worldwide. Although CRC has been comprehensively characterized at the molecular level, the tumor heterogeneity hinders the identification of reliable diagnostic, prognostic and predictive biomarkers. Molecular stratification of CRC is based on prevalent gene mutations and transcription profiles but its significance for clinical practice remains obscure. Indeed, activating mutations in the genes KRAS, NRAS and BRAF are the only predictive biomarkers for anti-EGFR antibody therapy routinely tested the clinic for advanced stages of CRC. Gene expression signatures are important for clarifying the molecular mechanisms of CRC development and progression, but only two such tests for predicting recurrence risk are commercially available. The aim of our study was to propose a diagnostic approach based on mutation and gene expression analysis that can be routinely applied in the clinic for defining the most appropriate treatment strategy for each patient. We used qPCR to determine the presence of KRAS mutations and measure the transcription levels of a panel of 26 genes in 24 CRC patients. Statistical analyses were applied to check for associations between clinico-pathological and molecular parameters. Our results reveal novel data concerning CRC carcinogenesis: almost universal downregulation of EGFR; differential role of the pro-inflammatory cytokines TNF-α and IL-6; overexpression of the vitamin B12 transporter transcobalamin 1; tumor-suppressor function of SETD2, CA7 and GUCA2B. The practical application of these findings has yet to be clarified.

Minimally invasive approach to thyroid gland surgery--indications, methods, first results.

UNLABELLED: After the introduction of minimally invasive operative techniques in the surgery of organs located in body cavities, extensive work has been done in the last five years with respect to their application in thyroid gland surgery as well. MATERIALS AND METHODS: In 2011, 406 patients underwent thyroid surgery at the Department of Surgery, Kaspela General Hospital for Active Treatment EOOD - Plovdiv. The study involved 48 of these patients, chosen at random and divided into two groups (A-minimally invasive thyroidectomy (MIT) - 26 patients, and B - minimally invasive video-assisted thyroidectomy (MIVAT) - 22 patients). All patients included in the study were selected on the basis of presence of one or more indeterminate nodules (fine needle aspiration biopsy - FNAB) sized up to 3.5 cm, with normal size of the thyroid gland up to 20-25 cm2, detected by preoperative ultrasonography. The study excluded patients with recurrent goitre, malignant disease of the thyroid gland and evidence of preoperative radiation therapy in the area of the head, neck and/or upper mediastinum. The preoperative investigation included history, physical examination, blood indices, echography, gamma camera and FNAB. Sensation of pain was evaluated by the patients according to a visual analogue scale, where lack of pain was evaluated as 0, and the most severe pain was evaluated as 10. RESULTS: The average duration of the hospitalization of patients undergoing MIT was 16 +/- 3.14 hours, whereas the patients undergoing MIVAT had to stay at the hospital for 18 +/- 3.56 hours. No complications were registered regarding the recurrent laryngeal nerves (RLN), as well as the operative wound. It should be noted that in all patients the course of the respective RLN was identified during the operative intervention, visually in most cases, or by electrostimulation. Postoperative hypoparathyroidism, registered by measuring the level of serum calcium, was observed in one visual analogue scale, as well as in the administration of pain-relieving agents during hospitalization. Other complications were not registered for the follow-up period, which covered an average of 6.56 +/- 3.14 months. CONCLUSIONS: The clinical analysis of the patients observed gave us grounds to draw the following conclusions: 1. The minimally invasive approach in patients with thyroid gland pathology is a possible and favourable option in selected patients with size of the gland within certain limits and not suffering from severe concomitant diseases. 2. The results in both groups of patients were comparable and did not show significant difference.

Intraabdominal hypertention--predisposing factor for visceral alterations and abdominal compartment syndrome.

UNLABELLED: Compartment syndrome (CS) is a condition in which increased pressure in a confined anatomical space adversely affects the function and viability of the tissues therein. AIM: The aim of the following research is to detect the influence of the intraabdominal hypertension (IAH) as an often met condition in visceral surgery on the organs in the abdominal cavity and outside it and on musculus rectus abdominis. METHODS: We used adult Wister rats for creating an experimental model of IAH, using our own experimental method with many advantages. RESULTS: We found expressed alterations in the organs of the group with IAH = 25 mmHg. Morphological changes were found in lung, small intestine, large intestine, stomach, liver, kidneys, spleen and in musculus rectus abdominis In the sham group without IAH we did not find any pathomorphological alterations. CONCLUSIONS. IAH, which is considered as a predictor of ACS and MOF, lasting for only 60 min. and level of = 25 mmHg causes heavy visceral alterations within, and also outside the abdominal cavity, and of the abdominal wall.

[Safety and efficacy of modified radical lymph nodes dissection in patients with papillary thyroid cancer (PTC) and clinically manifested lymph metastasis].

INTRODUCTION: Papillary cancer of the thyroid gland is well known as lymphotropic type. In more than 50 percent of cases it metastized in regional lymph nodes. The extent of surgical exploration remains controversial. AIM: The aim of our retrospective study is to evaluate safety and efficacy of modified radical lymph node dissection (MRND) in patients with PTC and regional lymph nodes metastasis. MATERIAL AND METHODS: A retrospective analysis of survival, local recurrences and quality of life on 19 patients operated in Department of General Surgery, Medical University, Plovdiv. All patients were with PTC and regional lymph nodes metastasis. The results were compared with these in patients with the same disease and "berry picking" (BP) lymph nodes dissection. RESULTS: The performed analysis and comparison of data revealed better survival rate and quality of life in patients with (total thyroidectomy) TT and MRND than this one with TT and BP. CONCLUSIONS: MRND is safe and effective procedure for the treatment of patients with PTC and regional lymph nodes metastasis. Exactly performed it assure better survival, quality of life as well as better control of distant metastasis.

[Drainage in thyroid surgery--prospective randomized study].

During the period of 2003-2004 years 100 consecutive thyroid surgeries was done in the clinic. Despite of clinical diagnosis or type of surgery they were separated into two groups. The first one (43) patients with post operative drainage, and the second one (57) with no drains. Patients with neck dissections were excluded from the study. There were no hematoma or seroma in patients without drains. In the other group two of them were reoperated because of drain insertion into the operative wound in post op. The difference in mean hospital stay for the two groups of patients is not statistically significant.

[Acute appendicitis and pregnancy].

Acute appendicitis remains the most common nonobstetric surgical diagnosis during pregnancy, requiring surgery. It is estimated that its frequency is 1 case per 1500 pregnancies. The delay in the diagnosis correlates with an increase in ruptured appendix and a dramatic elevation in fetal and maternal morbidity and mortality. In the study the authors discuss the clinical presentation, laboratory findings, operative treatment, pathologic diagnosis and the outcome of the disease of 17 cases with acute appendicitis in pregnancy, operated in the Clinic of Thoraco Abdominal Surgery for a ten years period of time. The early surgical treatment plays an important role for the succsessful outcome of the disease and reduces the complications for the mother and the fetus.

[Carcinoid tumors of the gastrointestinal tract--frequency, organ localization, clinical course, treatment (a presentation of 10 cases)].

Carcinoid tumors originate from the argentofile cells found at the bottom of the crypt of Lieberkuhn. In spite of their slow growth and comparatively better prognosis, the carcinoid are malignant tumors, which effective treatment is their surgical resection. We present 10 patients with carcinoid of the gastrointestinal tract (GIT)--3 from small intestine, 3 from large intestine, 2 from appendix, I from rectum and 1 from stomach, operated at our clinic for a 6 year period of time.

[Bouveret' syndrome or secondary duodenal obstruction caused by gallstones. Case report].

Bouveret's Syndrome is obstruction of the duodenum secondary to an impacted gallstone, usually without the presence of pneumobilia With the steadily increasing lie expectancy, greater number of these cases are being seen. Gallstones enter the gastrointestinal tract following fistula formation between the gallbladder and an adjacent hollow viscus and may cause obstruction at any point along the intestinal tract. Duodenal obstruction is the least common and represents only a very small percentage of cases. The presenting signs of nausea vomiting, abdominal cramping, and the absence of abdominal distension should alert the clinician to pathology in the proximal small bowel. The purpose of this report is to heighten the awareness of the primary care physician, emergency room doctors and surgeons to this diagnosis in elderly patients so that it can be included in the differential with the usual cases of gastric outlet obstruction--including ulcer disease, neoplasms, gastric volvulus, and other enteroliths, such as bezoars. Early diagnosis is critical, as these cases require urgent surgical intervention. Early resuscitation. Diagnosis, and treatment are essential for a successful outcome.

[Acute pancreatitis and pregnancy--analysis of a 10 year period of time]. / Ostup pankreatit i bremennost--analiz na 10-godishen period.

Acute pancreatitis during pregnancy is rare and complicates one in 1000 to 5000 pregnancies. The commonest reasons during pregnancy are: biliary disease, congenital or acquired hypertriglyceridemia and very rarely acute pancreatitis is associated with preeclampsia-eclampsia or HELLP syndrome. We presented in the research the clinical course of 14 women who developed acute pancreatitis and were treated at the Clinic of Thoraco-abdominal and Hepato-Biliary Surgery at the University Hospital Plovdiv for a tenth year of a period. The leading etiology was biliary disease. Eleven of 14 patient were successfully treated conservatively during pregnancy; 5 of them underwent surgery after pregnancy. Only one patient underwent operative treatment during pregnancy. Although acute pancreatitis is a rare disease during pregnancy, in order to improve the prognosis and to decrease the maternal and fetal morbidity and mortality, a timely diagnosis and an adequate conservative or surgical treatment is necessary.

[Health-related quality of live in breast cancer patients--actuality and problems]. / Zdravnoopredelenoto kachestvo na zhivot pri patsientki s rak na mlechnata zhleza--aktualnost i problemi.

Women with early breast cancer have three surgical options fir this current moment: conservative treatment (lumpectomy, quadrantectomy); mastectomy alone and mastectomy plus reconstruction (immediate or delayed). When randomized trials showed oncological safety of breast--conservative treatment compared with mastectomy, the question of cosmetic results assessment become actual, because of its impact on quality of live. The current state of the art permits achievement of good oncological results and good cosmetics ones. There are some technical factors affecting cosmetic results after breast--conservative treatment: orientation of resection; the breast / resection ratio; tumor localization; orientation of axillary dissection. Combination of extended resection (quadrantectomy) plus axillary dissection through the same incision results in cosmetic failure. After operation there is a remarkable breast asymmetry, retraction of the mammilla and inferior contour distortion. The main reasons for cosmetic failures are: volume of resection (lumpectomy, quadrant-ectomy), postoperative radiotherapy, deviation from normal breast morphology and tumor location. There are a lot of questionnaires for quality of live assessment. For Bulgarian population N. Mashonov created and adopted original questionnaire. The author investigated quality of live among patients with hard failure during recovery period.

A case of melanoma metastatic to the gallbladder and the common bile duct with clinical presentation of obstructive jaundice and bilirubinemia.

Cutaneous melanoma is known to have the capacity to metastasize to virtually any organ. Because melanoma metastases to the gallbladder and the extrahepatic bile ducts are usually clinically asymptomatic, there are only few reports on this topic in living patients. We describe a case of melanoma metastatic to the gallbladder and the common bile duct presenting with obstructive jaundice and bilirubinemia.

[Clinical and microbiological characteristics of nosocomial infections according to material of the IIIrd Surgical Clinic, UMBAL "St. George"--Plovdiv, over a 10-year period]. / Klinichna i bakteriologichna kharakteristika na nozokomialnite infektsii po materiali na III-ta Khirurgichna Klinika pri UMBAL "Sv. Georgi"--Plovdiv, za period ot 10 godini.

UNLABELLED: As a nosocomial (NI) infection we describe this one acquired in hospital due to proper conditions for spreading of virulent microbes. This is old problem with new vision in the field of use of powerful antibiotics and fast growth microbial resistance. AIM OF THE STUDY: To make an retrospective clinical investigation about the rate, type and etiology of NI as well as duration and outcome of treatment in our clinic and to compare the data with these quoted in literature. MATERIAL AND METHODS: We use hospital charts about the period of 1990-1999. Distribution of NI types was according to CDC criteria. RESULTS: For the period were operated on 14 932 patients. In 918 (6.15%) of them a NI was diagnosed. Sex ratio was 56% (514) man and 44% (404) women with a mean age of 56 years. After the treatment of patients with NI 86.48% (805) of them got better. 13.52% (102) were with unsuccessful treatment and got lethal exit. In 78 (76.47%) of death patients a pneumonia NI was developed. 633 antibiograms were received with 63.03% monoinfections and 22.59% polyinfections. In 91 cases smears were sterile. CONCLUSIONS: NI are one of the reasons for prolonged hospital stay and death of patients although fast development of pharmacy and new antimicrobial agents. It was centered on their prophylaxis.

[Papillary carcinoma in thyroglossal duct cyst]. / Papilaren kartsinom v kisti na duktus tireoglusus.

OBJECTIVE: To report the management and outcome of three cases of papillary carcinoma (PC) in thyroglossal duct cysts (TGCs). MATERIAL AND METHODS: We present case reports of one male and two female patients between the ages of 30 and 38 years who had DTR cyst. In addition, we discuss the theories about the pathogenesis of DTR carcinoma (de novo versus metastatic lesions). RESULTS: In all three patients, we found a DTR that contained a vegetating mass. Subsequent pathologic examination revealed the presence of a PC. All patients underwent total thyroidectomy, and two of them concurrently had PC in the thyroid gland. Besides the PC in the TGC, the first patient had a "cold" scintigraphic thyroid nodule that was also a PC, whereas the second patient had a thyroid microcarcinoma that had not been detected before surgical intervention. The third patient did not have carcinoma of the thyroid. The patients received postoperative I131 and suppressive therapy with levothyroxine. During a follow-up period of 1 to 2.5 years (mean--1.75), we found no recurrence of the disease, and serum thyroglobulin remained undetectable in all cases. CONCLUSION: Although use of total thyroidectomy followed by radioiodine therapy and suppressive treatment with levothyroxine is a matter of debate in patients with PC in TGCs, we conclude that this approach yields a favorable outcome in most cases, especially when the thyroid is also involved by the PC, and allows a better postoperative follow-up.

Stimulation electromyography as a method of intraoperative identification of the recurrent laryngeal nerve in thyroid surgery.

INTRODUCTION: The iatrogenic injury of the recurrent laryngeal nerve during thyroid surgery still represents a major problem because of the great physiologic and psychologic trauma to the patients. The incidence of this complication ranges between 1% and 15% depending on the thyroid pathology and type of surgery. AIM: To evaluate the potential of stimulation electromyography as a method of intraoperative prophylaxis of iatrogenic injuries of the recurrent laryngeal nerve. MATERIAL AND METHODS: Intraoperative monitoring of the recurrent laryngeal nerve based on stimulation electromyography, which was introduced in the Clinics of Surgery and Otorhinolaryngology at the Higher Medical Institute in Plovdiv, was applied in thyroid surgery using Neurosign 100 (Magstim Company Ltd., Wales, UK) apparatus. The study involved 5 experimental dogs and 73 recurrent laryngeal nerves in 47 patients treated in the clinics from November 1, 1999 to February 15, 2000. RESULTS: In all experimental animals and patients the electrical stimulation was successful triggering an "M" response of the laryngeal muscles (the vocal muscle). A stable contact was achieved between the recording (needle) electrodes and the vocal folds. None of the patients had signs of laryngeal palsy or complaints other from the usual in endotracheal intubation. CONCLUSION: The results suggest that the intraoperative stimulation electromyography of the recurrent laryngeal nerve is a safe and effective method for evaluation of the nerve integrity during and at the end of the operation.

Intraoperative identification of recurrent laryngeal nerves in thyroid surgery by electrical stimulation.

INTRODUCTION: Iatrogenic injury of the recurrent laryngeal nerve and its prevention is one of the controversial issues in thyroid surgery. The incidence of this operative complication ranges from 0.4% to 3.9%. PATIENTS AND METHODS: The authors analysed the results of the identification of 114 nerves in 60 patients who underwent thyroid surgery between July 9, 1999 and December 19, 2000 in the 3rd Surgical Clinic at the Department of Clinical Surgery and in the Department of Ear Nose and Throat Diseases of the Medical University in Plovdiv, Bulgaria. Nerve integrity monitor Neurosign 100 and specially designed EMG electrodes (Magstim Company Ltd., Wales, UK) were used. The patients were examined pre- and postoperatively for vocal cord paralysis by otolarygologist. RESULTS: In all patients electrical stimulation of the recurrent laryngeal nerve was successfully used for identification of the nerve and evaluation of its integrity during and at the end of the operation. No postoperative recurrent laryngeal nerve deficit was detected clinically. CONCLUSIONS: The results indicate that the identification of the recurrent laryngeal nerve by electromyography is a safe, effective and simple method for electrophysiologic monitoring during thyroid surgery. This method allows assessment of the neural integrity at the end of the procedure.

Method of anaesthesia in thyroid surgery with intraoperative monitoring of the recurrent laryngeal nerves.

INTRODUCTION: The incidence of injury of the recurrent laryngeal nerve (RLN) in various types of surgery is reported to be as high as 12%. By monitoring the recurrent laryngeal nerve intraoperatively we can identify it and preserve it even in atypical positions or in operations for processes involving the nerve. These types of surgery give rise to some specific problems facing the anaesthesiologist and the method of anaesthesia used. AIM: The aim of the study was to assess the efficacy and relevance of an anesthetic method in thyroid surgery with intraoperative monitoring of the RLN. Tasks: 1. To determine the level of myorelaxation in anaesthetic patients by intraoperative neurostimulation of the ulnar nerve. 2. By careful dosing of the non-depolarizing myorelaxants to create a "window" in the myorelaxation immediately before identification of the RLN that is detected by a neurostimulator. MATERIAL AND METHODS: Forty eight patients subjected to different types of thyroid surgery were given inhalational anaesthesia with supplementation of non-depolarizing myorelaxants. The level of relaxation was constantly monitored by neurostimulation of the left ulnar nerve. This peripheral stimulation allows creating a "window" in the myorelaxation just before the identification of the recurrent laryngeal nerve. RESULTS: There were no perioperative complications in all patients as to both surgery and anesthesia; postoperative comfort was achieved. The recurrent laryngeal nerve was readily identified and its function was preserved in the postoperative period. CONCLUSIONS: The authors consider as a method of choice the general inhalational anaesthesia supplemented with non-depolarizing myorelaxants and permanent intraoperative monitoring of the level of relaxation in surgery with intraoperative monitoring of the cranial nerve and recurrent laryngeal nerve.

Stimulation electromyography as a method of intraoperative localization and identification of the facial nerve during parotidectomy: review of 15 consecutive parotid surgeries.

INTRODUCTION: It has been widely recognized that one of the major hazards during operation of the parotid gland, mainly in tumor resection, is the injury of the facial nerve. Facial nerve monitoring has achieved wide application in otologic and neurotologic procedures to help localization and protection of the facal nerve in the temporal bone. MATERIAL AND METHODS: The authors analyze localization and identification of 15 nerves in 15 patients who underwent parotid gland surgery in the Department of Ear Nose and Throat Diseases of the Medical University in Plovdiv from September 15, 2000 to December 15, 2000. Nerve integrity monitor Neurosign 100 and specially designed electromyographic electrodes were used. RESULTS: In all patients stimulation electromyography of the facial nerve was successfully used to locate, identify and evaluate the integrity of the facial nerve during and at the end of the operation. No postoperative facial nerve injury was detected clinically. In two patients with parotid gland cancer the inferior division of the facial nerve was found infiltrated by the cancer growth. CONCLUSION: The results indicate that identification of the facial nerve by electromyography is a safe, effective and simple method of electrophysiologic monitoring during parotid gland surgery. This method allows assessment of the nerve integrity at the end of the operation.

Surgical complications in hematological malignancies.

Surgical complications in oncohematological practice appear a primary problem for their high incidence, diagnostic and therapeutic difficulties and unfavourable prognosis. The authors present data from a retrospective study of 93 patients from the Clinic of Hematology and Surgical Clinic of the Higher Medical Institute in Plovdiv for the period from 1990 to 1997. Surgical complications occurred in 9.9% of the patients treated for hematological malignancies. Most frequent and hazardous were the cases of acute abdomen, followed by soft tissue purulent infections. The authors suggest that high risk of surgical complications exists in patients undergoing vigorous chemotherapy. Patients are particularly vulnerable in the neutropenic period after chemotherapy when the abdominal and anorectal complications may be fatal.

A comparative analysis of the postoperative complications of thyroid cancer surgery related to surgical approach.

A retrospective study of the postoperative complications in 129 patients treated for thyroid cancer in the clinics of surgery of the Higher Medical Institute for a period of 9 years (1988-1996) was performed. The majority of the patients (90) were treated by total thyroidectomy. Subtotal thyroidectomy was performed in 21 and thyroid lobectomy in 15 patients. Postoperative complications occurred in 56 of the operated patients. Of these 5 had permanent and 51 transient complications. Most of the complications (80.35 +/- 3.56%) ensued from total thyroidectomy. The variety of the complications included permanent hypoparathyroidism in 3 patients, transient hypocalcemia in 37 patients, injury of the recurrent laryngeal nerves in 11 patients, esophageal damage in 1 patient, hematoma within the operation field in 1 patient and suppuration of the operative wound in 1 patient. Four of the patients with injury of the recurrent laryngeal nerve suffered from obstruction of the airways which required temporary tracheostoma to be performed. No lethal postoperative outcome was observed. The data of the study are discussed in relation with the literature data.