Technical considerations depending on the level of vascular ligation in laparoscopic rectal resection.

AIM: In addition to ischemia there is also anastomotic ends tension proven to be a risk factor for anastomotic leak. HT vascular ligation is accepted as a rule, in attempt to achieve tension-free anastomosis. LT is a preferred option, based on the more accurate preservation of proximal intestinal segment microperfusion and lower risk of damage to the hypogastric plexus. The aim of this study is evaluation of comparative indicators in high tie (HT) and low tie (LT) laparoscopic rectal resections. METHODS: A prospective nonrandomized comparative cohort study of patients in our department with cancer of the rectum in clinical stage I-III, operated on in laparoscopic approach over a 6-years period. RESULTS: For the period 2015-2020, a number of 208 laparoscopic surgeries have been done for rectal cancer. Patients were divided into three groups-group A with HT vascular ligation 116 pts. (69%), group B-53 pts. (25%), underwent low ligation-LT and group C-39pts. (19%) low tie plus lymph node dissection of the apical LN group (LT-appic LND). The distribution was made without randomization, based on the operators' expertise. Anastomotic leaks were 3.8% in group A, 3.0% in group B and 2.9% in group C (p > 0.05) with no significance difference. There is no significant difference in the number of lymph nodes obtained in group A and group B, while in group C the number of the harvested lymph nodes was higher (p < 0.05). The indicators for intestinal / defecation dysfunction, as well as for urinary/sexual dysfunction, according to our data, are significantly more favorable in patients with LT, in contrast to the other two groups. CONCLUSION: HT vascular ligation attempts to achieve tension-free anastomosis and more harvested lymph nodes. However, LT could be a preferred option, based on the lack of significant evidence for a difference in specific oncological survival and due to more accurate preservation of proximal intestinal segment microperfusion to prevent anastomosis dehiscence, also for its lower risk of damage to the hypogastric plexus. Splenic flexure mobilization provides elongation of the proximal intestinal segment, but has no proven effect on anastomotic leakage incidence. It increases surgical duration and is in fact necessary in up to 30% of the cases. At the present moment there is no precise data whether LT has an advantage in terms of prevention of autonomic nervous and urogenital dysfunction. New prospective randomized and highly probative studies are needed to standardize the procedures in specific clinical situations.

Bioluminescent Study of the Distribution of High-Molecular-Weight Protein Fraction of Cellex Daily Preparation in the Brain after Intranasal Administation.

Permeability of the blood-brain barrier for protein fractions 50-100 kDa (PF50-100) of Cellex Daily preparation labeled with fluorescent tracer FITC and non-conjugated FITC were compared after intranasal administration of the preparations to healthy rats. Fluorimetrical analysis of the serum and cerebrospinal fluid samples showed that Cellex Daily PF50-100-FITC administered intranasally penetrated into the blood and cerebrospinal fluid with maximum accumulation in 2 h after administration and persists in the circulation for 24 h probably due to binding with plasma proteins. The differences in the kinetic profile of PF50-100-FITC and free FITC indirectly suggest that the major part of the preparation is not degraded within 24 h and FITC is probably not cleaved from the protein components of the preparation. In vivo fluorescence analysis showed significant fluorescent signal in the olfactory bulbs in 6 h after intranasal administration; hence, the preparation administered via this route can bypass the blood-brain barrier. Scanning laser confocal microscopy of rat brain sections confirmed penetration of the high-molecular weight protein fraction PF50-100-FITC into CNS structures. The most pronounced accumulation of the labeled drug was observed in the olfactory bulb in 6 and 12 h after administration. In contrast to free FITC administered in the control group, significant accumulation of PF50-100-FITC in the olfactory cortex and frontal cortex neurons with functionally active nuclei was observed in 6, 12 and 24 h after intranasal administration.

[Cognitive disorders in stroke patients: the possibilities of pharmacological correction].

OBJECTIVE: To determine the efficacy and safety of cellex in treatment of cognitive disorders in acute ischemic stroke (IS). MATERIAL AND METHODS: The study involved 246 patients with acute IS. Patients were randomly divided into two groups depending on the use of cellex or placebo along with basic treatment during 10 days. The dynamics of neuropsychological status was evaluated. RESULTS AND CONCLUSION: In IS patients, treatment with cellex have led to more rapid and marked reduction of mild and moderate cognitive disorders.

[Inguinal endometriosis: two case reports and literature review].

Endometriosis is a common gynecological disease that is characterized by the presence of endometrial glands and stroma outside the uterus. Ectopic endometrial tissue can be localized in all organs of the human body, but it affects most often organs in the pelvis. The localization in the inguinal canal is extremely rare - 0.3% -0.6% of all cases of endometriosis. We report two cases of inguinal endometriosis in patients with a history of previous surgery in the pelvis. Both patients is formation in the inguinal region of increasing volume, accompanied by severe pain especially in the premenstrual period. The diagnosis was based on an exact medical history and histological examination. The main methods of treatment of inguinal endometriosis is radical surgical excision of the lesion. We recommend hormone therapy as an adjunct to treatment.

[Novelties in the Treatment of Colorectal Diseases - An Echo from the 10-th ESCP Congress].

Treatment of colorectal pathology stands continuous development. One of the promotional leaders of the new therapeutic approaches is the European Society of Coloproctology (ESCP). The annual congress of the organization held in Dublin, Ireland and it unites the elite of European Community countries. The most advanced scientific knowledge of the diseases of the colon and rectum, anal canal and perineum was presented.

PRIMARY RETROPERITONEAL EXTRA-ORGAN TUMORS (PRET) - SURGICAL TACTICS.

INTRODUCTION: Retroperitoneal tumors, in general, are rare tumors which histopathological characteristics and biological behavior can be considered as benign or malignant. They originate from various tissue elements located in the retroperitoneal space. They often cover Anatomical structures of varying importance - mainly retroperitoneal vessels and organs, which determines the type of surgery - radical or palliative. They are composed of adipose tissue, vascular elements, smooth and striated muscle, neural elements germline structures. There are three main types of retroperitoneal tumors: mesodermal, neurogenic and teratosarcomas. As mentioned above each can be either benign and malignant. In most cases there are no specific symptoms except general weakness, heaviness in the abdomen, loss of appetite, progressive weight loss, headache and fever. The pain is most often located in the lumbosacral area. The tumor can also cause disturbances in urination. In patients with advanced stage can be observed significantly symmetrical or asymmetrical tumor growth in the abdominal area. The most commonly used techniques for the diagnosis of the disease are X-ray, CT-scan and MRI. MATERIAL AND METHODS: Retrospective study involving 112 cases operated in the clinic for 14-years period (2000-2014) - 101 patients, 11 of them were operated on twice in a different time interval on the occasion of relapsed malignant process. RESULTS: Out of all operated cases, 42% are males (47 cases) and 58% - women (65 cases). In most cases (72% - 81 cases) tumors are malignant. All patients were treated surgically. There were followed up a total of 89 patients over a period of 3 months to 8 years (96 months) as of the studied malignant cases 3 year survival was observed in 21 patients, and one patient has survived 96 months after total extirpation of fibrosarcoma. Early postoperative mortality (till 20th postoperative day) was registered in 3 patients - 2.67% of all operated cases. DISCUSSION: About 80% of primary retroperitoneal extra-organ tumors are generally malignant. People of all ages are affected equally and no statistically significant difference in the number of men and women is detected. There are many theories about the emergence of retroperitoneal tumors, but currently none of them has not been fully proven. Treatment depends on the type of the lesion. Surgery is the main approach and it should be applied to both benign and malignant lesions. In the case of malignancy other methods than surgical are chemo- and radiotherapy but they are less effective.

Clinical and prognostic significance of pathological and inflammatory markers in the surgical treatment of locally advanced colorectal cancer.

BACKGROUND: Locally advanced colorectal cancer (CRC) may vary in its clinical and pathological appearance. It is now accepted that progression of disease in patients with locally advanced CRC is determined not only by local tumor characteristics but also by the immune system and inflammatory response in the body. METHODS: We investigated patients with confirmed CRC who were treated in the surgical clinic at the University Hospital Alexandrovska over a 10-year period and retrospectively evaluated the histological features of the preoperative biopsies and operative specimens removed during radical multivisceral resections. We also collected prospective data for serum C-reactive protein levels and Jass-Klintrup score, Petersen Index score, and Glasgow Prognostic Score in patients with locally advanced CRC. RESULTS: Of 1,105 patients with CRC, 327 (29.6%) were diagnosed with locally advanced disease. In total, 108 combined multivisceral resections (79 for primary tumors and 29 for recurrent tumors) were performed. Overall survival was 34 months for pR0 cases and 12 months for pR1 cases (P<0.05). Our data confirmed that C-reactive protein is a prognostic marker of overall survival. Data for 48 patients with histologically confirmed locally advanced tumors showed significantly increased survival with a higher Jass-Klintrup score (P=0.037). In patients with node-negative disease, 5-year survival was 49%. However, where there were high-risk pathological characteristics according to the Petersen Index, survival was similar to that for node-positive disease (P=0.702). Our data also showed a significant difference in survival between groups divided according to whether they had a modified Glasgow Prognostic Score of 1 or 2 (P=0.031). CONCLUSION: In order to maintain a reasonable balance between an aggressive approach and so-called meaningless "surgical exorbitance", we should focus on certain histopathological and inflammatory markers that can be identified as additional factors for planning the type and volume of surgical treatment.

[Differentiation of mesenchymal stem cells of adipose tissue].

Experimental investigation were conducted with the objective to determine a stem cells, capacity to differentiate in adipogenic direction, if they were obtained from adipose tissue. The investigation results have witnessed, that the cells, obtained from adipose tissue, are capable for a tissue-speciphic differentiation in osteogenic, chondrogenic, and, principally--in adipogenic direction, what confirms a multypotent nature of mesenchymal stem cells of adipose tissue. Adipose tissue constitutes an alternative to the bone marrow, as a source of multipotent mesenchymal stem cells, which may be applied in further investigations, concerning determination of their defense possibility for the transplanted autologous adipose tissue from the tissue resorption, made in a lipophiling way.

Peutz-Jeghers syndrome--a rare case and a literature review.

The Peutz-Jeghers syndrome is inherited condition, characterized by hamartomatous gastrointestinal polyposis and with mucocutaneous pigmentation. We have experienced a case with typical clinical features, diagnosed before complication's development. In order to prevent cancer setting it is recommended to perform aggressive screening and high-technological procedures.

[Cellex in the treatment of patients with acute disturbance of cerebral blood circulation: results of a multicenter comparative open clinical trial].

OBJECTIVE: To evaluate efficacy and tolerability of cellex in the treatment of patients with acute disturbance of cerebral blood circulation (ADCBC) used in the clinical practice in the Russian Federation. MATERIAL AND METHODS: A trial included 178 patients with ADCBC from 6 Russian clinical centers, 146 (82%) patients were diagnosed with ischemic stroke and 32 (18%) with hemorrhagic stroke in the age of 35-80 years. RESULTS: One hundred and sixty-six patients have completed the trial. The better outcome with the decrease of motor, visual, speech and sensory disorders was found after 4-week treatment. CONCLUSION: Cellex may be recommended for treatment in acute and early rehabilitation stages of ADCBC.

Postoperative complications after Nissen fundoplication.

Anti-reflux laparoscopic operations replaced conventional surgery and are now widely available, because of the advantages of this type of surgery. One of the main reasons for the high complications rate in this type of operations is the lack of experience of the surgeons, although recently in the reports of most leading authors complications and increased mortality rate is due to the older patients undergoing this type of surgery. The main causes of death were gastrointestinal hemorrhage, necrosis with perforation of the esophagus or stomach, cardiac arrest, respiratory and inflammatory complications, and pulmonary thromboembolism.

Per magna-ovarian metastases from primary locally advanced colorectal cancer--a review of the literature with a description of three clinical cases.

Krukenberg tumor is defined as metastatic lesions of gastrointestinal cancers. Several specific immunohistochemical methods can identify the main focus of malignant neoplasm. Ovarian metastases from colorectal cancer are rarely seen phenomenon. The authors examine in detail the literature on this issue and describe three own clinical cases of metachronous ovarian meta lesions in women undergoing surgery for locally advanced colorectal cancer--two of these metastases are unilateral, while one--bilateral established in a short time interval despite the casuistic nature of the pathology. One of the patients died in the early postoperative period of co-morbid complications unrelated to the underlying disease, and the other two monitoring continues during the adjuvant. Krukenberg-metastases from colorectal cancer occur in the blood-vascular pattern in time without damage to the left or right ovary. Metachronous development and operative treatment of ovarian metastases is far better prognosis of the cases with and operated simultaneously established metastases in the ovaries.

Surgical approach in locally advanced colorectal cancer--combined, extended and compound surgery.

UNLABELLED: Cancer of the colon and rectum (colorectal cancer - CRC) is ranked second in prevalence--the men he is after lung cancer, and for women--after breast cancer. There is a steady trend to annual increase in incidence in the country. Definition of locally advanced disease is necessary in order to achieve practical and theoretical clarity regarding not a small percentage of patients with colorectal cancer presenting for treatment to the surgeon. As for the primary and the recurrent locally advanced tumors, postoperative long-term survival is achievable, but only after complete R0-resection. AIM: The objective of the presented literature review is to analyze data from a number of internationally published studies looking multifactorial variety of problems in the primary and recurrent locally advanced colorectal cancer (LAKRK) capable of optimizing behavior in surgical patients with this frequently encountered oncological and social significant pathology. Aim The objective of the presented literature review is to analyze data from a number of internationally published studies looking multifactor variety of problems in the primary and recurrent locally advanced colorectal cancer (LACRC) capable of optimizing behavior in surgical patients with this frequently encountered oncologic and social significant pathology. MATERIAL AND METHODS: A retrospective, critical and comparatively examined published in the world literature review papers, case reports and clinical studies dealing with locally advanced primary and recurrent cancer that goes beyond the colon and rectum involving the surrounding structures and organs with the requirements for individualized "Team" approach of preoperative and intraoperative staging, planning and execution of multivisceral "en-block" resection with typical technical difficulties, complications and results. RESULTS: As "locally advanced" tumors represent 5-22% of all colorectal carcinomas. According to the analyzed data in patients with tumor stage IIB, which extend through the intestinal wall and infiltrated the surrounding structures without lymph node metastases (T4 N0 M0) have a worse chance of survival than those with tumors in stage III, which remain within the intestinal wall, but had spread to the lymph nodes (T1 - 2 N1 - 2). Recent studies confirm that T4 stage is an important independent predictor of disease-free interval and overall survival. Discussed are the terms " combined", "extended" and "compound" surgery. Describe the importance of dissection in lymphnodes in LACRC through related analogue of total mesorectal excision in rectal cancer excision in complete mesocolic excision location in the colon. Discussed are ways of locally advanced primary tumors and recurrences with different types of loco - regional involvement of surrounding structures and organs. Describe in detail the operational- tactical and technical aspects of the block R0- resection in primary and recurrent LAKRK with type and severity of any complications and treatment outcomes. Concerns the importance of an integrated approach with neoadjuvant and adjuvant chemotherapy and radiotherapy. CONCLUSION: Justified the opinion of the adequate, in particular disease, reasonably aggressive pattern to LACRC securing the most favorable long-term survival prognosis.

[The mechanoreceptor tactile diagnostics of thoracic diseases].

The novel system of tactile analysis was used in the mechanoreceptor device. The local pressure measurement is carried out in in cameras, divided by the elastic membrane from the analyzed organ. The devise allows fast and adequate real-time measurement of tissue density and elasticity. The results, acquired with the use of the mechanoreceptor device were checked microscopically. The study showed high compatibility and adequacy of the novel mechanoreceptor.

[Complicated colorectal cancer--aspects of surgical tactics].

Over the period 2000-2011 (6th m) a total of 856 patients with complicated colorectal cancer are subjected to treatment in the Clinic of surgical diseases--Department of Surgery in University Hospital "Alexandrovska", Sofia. Obturation is the commonest form of complication--47 per cent, perforation within the tumor or diastasis noted in 74 cases (8.6 %), paratumor abscesses and infiltrates--in 7.6 per cent and rectohemorrhage--in 4.2 per cent. The therapeutic and operative approach, and the scope of surgery are dependent on a multitude of factors which should be given due consideration by the surgeon. In each patient presenting complicated colorectal carcinoma it is mandatory to make a precise and individual choice of the extent of operative intervention, consistent with the patient's general condition and contributing to eliminate the life-endangering underlying cause. Postoperative mortality in patients with complicated colorectal cancer is 17.1% whereas in radical operated patients without complicated cancer mortality is only 6.8%.

[Lymph nodes metastases in differentiated thyroid cancer--prognostic value and syrgical results with 430 patients for 30 years period (1980-2010)].

In this we review 430 differentiated thyroid cancer patients underwent surgery for 30 years period since 1980 to December 2009. The stage of disease was T1-3.Na-b.Mo(TNM). Papillary thyroid cancer patients were 77.2% and folicular thyroid cancer--22.8%. The regional lymph nodes metastases distribution were analyzed according to the age, sex, of the patients and tumor histology. Preoperatively,clinically involved were neck nodes in 35 patients 8.3%--26 patients with PTC and in 9 patients with FTC. Surgical procedures for low-risk group of patients were variable from lobectomy and istmusectomy to near total thyroidectomy and modified radical lymph node dissections of the neck and patients in high risk group underwent total thyroidectomy and radiojodine therapy. The level of regional recurrences was 1.7 folds higher in patients treated by total thyroidectomy and radiotherapy J131.

Lymph nodes metastases in differentiated thyroid cancer--prognostic value and surgical results with 430 patients for 30 years period (1980-2010).

The papillary cancer and the follicular cancer are the most common forms of thyroid malignitet. Based on 30-year follow up of 430 patients, who underwent differentiated thyroid cancer surgery, the incidence of the lymph nodes metastases and the rate of postoperative recurrence of the disease was studied and the performance criteria of modified radical lymph node dissection of the neck were specified. Papillary cancer patients were 77.2% (332 people) and follicular cancer patients were 22.8% (98%). At the time of the diagnosis 8.2% (35 people) of the patients had palpable lymph nodes metastases. All patients with lymph nodes metastases, which developed after the surgery, underwent successful treatment with a modified lymph node dissection of the neck. In none of the cases the lymph node metastases led to a fatal outcome.

Case of classic Kaposi sarcoma.

A rare case of 66-year-old man with Classic Kaposi sarcoma and a few month histoty of asymptomatic purple lesion located on right foot. A surgical excision was performed. The histological examination was confirmed the diagnosis. Case report and literature review.

[Surgical treatment of the perianal and rectovaginal fistulas by means of Surgisis AFP anal fistula plug].

Symptoms of painful and uncomfortably occurred in patients with anal and rectovaginal fistulas witch worsened their quality of life. The introduce of Biodesign Fistula Plug is called "dramatic jump in surgery of the fistulas". We can avoid from the traditionally and technicaly difficult treatment of perianal and rectovaginal fistulas through this advice. Therefore like this surgeons can avert frequently complications of the anal sphyncteric apparatus like incontinence or stenosis. We have only two cases like attempt for now but with excellent result followed up about 31 and 33 months.

[Malignant melanoma of the anus and rectum].

There is approximately 300 cases of malignant melanoma written in the world literature. We write up 13 operated from us for 15 years cases of melanoma of the anus and rectum. The neoplastic localization is usually at linea dentate area. The patients complains are foreign-body filling and rectohaemorrhagy. This formation considers like haemorrhoid frequently. The pain is not common symptom but ulceration occurs in many percent. The metastasing is in the inguinal lymph nodes. The tumor colour is between light-brown to red-purple in 50% of the cases. The colouring matter is absent in the other half of the cases and these tumors consider like nonpigmentous melanoes. Despite the complex treatment--surgical, chemotherapy etc. the prognosis is at large poor.