Laparoscopic cholecystectomy: 700 consecutive cases.

From March 1993 till June 1995 700 laparoscopic cholecystectomies have been performed on 590 female and 110 male patients who ranged form 10 to 82 years of age at the Departments of Surgery of County Hospital and Alexander's University Hospital in Sofia. Ninety seven of the patients (13.8%) who have had laparoscopic cholecystectomies (LC) were diagnosed as acute cholecystitis and the rest as chromic calculous cholecystitis. In 16 cases (2.28%) a conversion to standard open cholecystectomy was necessary, the most frequent causes being intraoperative bleeding and unsuspected preoperatively common bile duct stones. Immediate or early postoperative laparotomy was performed in four cases because of biloma (1), small intestine strangulation in the umbilical region (1), perforated duodenal ulcer (1), bleeding (1). One case required laparotomy and removal of a clip misplaced tangentially to the right hepatic duct. There were no cases with lethal outcome following LC. Sixty-five patients have had intraoperative cholangiography and 14 patients underwent concomitant laparoscopic choledochotomy and a common bile duct stones extraction.

[The surgical treatment of extrahepatic bile duct lithiasis]. / Khirurgichnoto lechenie na litiazata na ekstrakhepatalnite zhluchni putishta.

Data concerning operative treatment of 227 patients with lithiasis of the extrahepatic biliary ducts, covering an eleven-year period (1985 to 1995 inclusive), are presented. In all cases diagnosis and operation are done in the Second Surgical Clinic at the Medical University--State University Hospital "Alexandrovska"--Sofia. By type the surgical interventions are distributed as follows: external drainage of hepaticocholedochus--122 cases (53.74 per cent), choledochoduodenostomy 69 (30.39 per cent) and transduodenal papillosphincterotomy 36 (15.85 per cent). Fifteen patients develop postoperative complications (6.60 per cent), and in five patients the outcome is fatal with postoperative lethality amounting to 2.20 per cent. The basic indications for the various types of surgical interventions are established.

[The diagnosis of lithiasis of the extrahepatic biliary tract]. / Diagnoza na litiazata na ekstrakhepatalnite zhluchni putishta.

The diagnostic approach to 227 patients presenting lithiasis of the extrahepatic biliary ducts is discussed. All patients are diagnosed in the second surgical department of the University Aleksandrovska Hospital over an eleven-year period on the ground of complex examinations, including: clinical, laboratory and instrumental (echography, endoscopic retrograde cholangiopancreatography, cholangiography, computerized tomography) study. As shown by the clinical data analysis, the basic symptoms are pain--in 221 cases (97.35%), jaundice--128 (56.38%), accompanied in most of them by dyspeptic complaints, and in a minor part--by cholangitis manifestations. Of the laboratory data, the most commonly met with are the abnormally increased values of serum bilirubin, alkaline phosphatase, liver tests etc. Of the instrumental methods echography is first and foremost used in the preoperative period, supplemented in certain cases with other methods. Intraoperatively, cholangiography is routinely used for concrement detection.

[Lithiasis of the extrahepatic bile ducts--its diagnosis and treatment]. / Litiaza na ekstrakhepatalnite zhluchni putishta--diagnoza i lechenie.

This is a survey paper assaying the relevance of clinical and laboratory data, and other conventional and currently used methods as well, and their precision in detecting concretions in the biliary apparatus, namely: endoscopic echography, magnetic resonance imaging, ERCP, PTH, CT etc. To increase the rate of concrement demonstration the diagnostic process should proceed intraoperatively by resorting to cholangiography, echography, choledochoscopy and the like. Nonoperative and operative methods of treatment are discussed, with the indications for nonoperative ones (endoscopic, extracorporeal lithotripsy, medicamentous and chemical litholysis) being listed, and their superiorities and side effects during practical implementation established. To improve the results of the latter eventually their combination is required. Various types of operative procedures are described, along with the indications for using them, advantages and shortcomings of each individual method, and practicability of their combined application under definite conditions.

[Lithiasis of the extrahepatic bile ducts]. / Litiaza na ekstrakhepatalnite zhluchni putishta.

This is a literature survey on issues relating to average incidence rate of choledocholithiasis for the last few years, basic mechanisms and factors underlying the formation of biliary calculi, as well as form and location of the concrements, with a special reference to the impact of the latter on the course run by the disease. Choledocholithiasis is divided in two forms--primary and secondary: in the former the underlying causes and criteria for the occurrence of calculi are described, and in the latter--the factors and conditions promoting migration of the concrements towards the bile ducts, with emphasis on the importance of the division suggested in choledocholithiasis treatment. The clinical picture with its characteristic symptoms, and the pathogenesis of the latter are also discussed. Evolution of the disease left without adequate intervention has unfavourable prognosis. A description is submitted of the various complications and their characteristic manifestations observed. Differential diagnosis is made both often and rarely met with diseases presenting similar symptomatology.

[The pneumodynamic barium x-ray study of small intestine adhesions (a preliminary report)]. / Pnevmodinamichno barievo rentgenovo izsledvane na tunkochrevnite adkhezii (predvaritelno suobshtenie).

Small-intestinal adhesions are not very rare, but on conventional X-ray examination are frequently missed because of their poor semiotics. By the method of pneumodynamic-barium X-ray examination, which allows to obtain high-quality double-contrast image, in addition to the better visualized classical symptoms--exostotic rebounds, diverticulum-like deformities, peristaltic spasms, spastic contractions etc, one may evince also the following new criteria: when inflated the intestines do not freely increase their volume, as is normal, are not unplaited along the entire abdomen, but remain amassed in a definite zone (usually in the left half); On external pressure the inflated loops do not move, as do the ones without adhesions, but remain fixed, so that their structure remains unchanged. The intestinal loops are crooked with acute angles; when in a normally inflated state, they are not crooked, but long. A frequent finding in small intestinal adhesions are the V-shaped figures in whose bottom there is barium meal over which air passes. A study of the small-intestinal cannon contraction reveals insufficiency in the hydrodynamics of the intestinal passage, marked by delayed evacuation, in spite of the strong peristalsis. This method allows a more precise elucidation than the conventional X-ray examination of the abdominal status in small-intestinal adhesions and better orientates the surgeon to choose conservative or operative treatment.

[Peritoneovenous shunt in ascites]. / Peritoneovenozen shunt pri astsit.

For a two-year period (1987-1988) 14 peritoneal-venous shunts with Le Veen's valve were performed in patients with cirrhosis of the liver and ascites. Immediate effect, manifested by decrease in the abdominal circumference and diminution or even complete disappearance of ascites with increased diuresis, was observed in 12 patients. Two patients died during the early postoperative period. The indications, postoperative preparation, operative technique, complications and postoperative care in this type of operative intervention are discussed. Inference is made that the good postoperative results depend on the need patients with refractory ascites to report early enough for operative treatment.

[Diagnosis and treatment of primary retroperitoneal extra-organic tumors]. / Diagnoza i lechenie na p'rvichni retroperitonealni izv'norganni tumori.

Primary retroperitoneal extra-organ tumors (PRET) are a relatively rare group of diverse neoplasms. They are classified in three main groups according to their histogenesis: PRET from mesodermal origin, from ectodermal origin and from embryonic remnants. Most of PRET are malignant, a the most frequent malignant PRET are soft tissue sarcomas. Because of their specific localization PRETs grow silently for a relatively long period and are often considerably large at the time of diagnosis. These tumors usually have no specific symptoms. Computerized tomography and magnetic resonance imaging are the most useful methods in the diagnosis of PRET. Surgery is the only effective treatment of PRET with exclusion of some histologic types as lymphoma and malignant germ cell tumors. One of the most specific characters of PRET is their great tendency to recur locally, which is explained not only by their biological characteristics but the difficulties of accomplishing a radical resection. For the malignant PRET, especially the retroperitoneal soft tissue sarcomas, no adjuvant therapy has proved to be beneficial on survival.

[Ectopic splenic tissue mimicking a retroperitoneal tumor. A case report and literature review]. / Ektopichna lienala t'kan, imitirashta retroperitonealen tumor. Edin sluchai i pregled na literaturata.

Ectopic splenic tissue can be found as congenital or acquired condition. It is occasionally symptomatic and very rarely can simulate a neoplastic disease, especially when it locates in the retroperitoneal space. A case of ectopic splenic tissue simulating a retroperitoneal tumor is reported. A 32-years-old female was admitted in the clinic for a tumor in the left retroperitoneal space, discovered by ultrasound and computed tomography. 9 years before, an operation for a pheochromocytoma with similar localization was performed as the tumor was removed together with the spleen. At this admission, the tumor was considered a local recurrence of the pheochromocytoma and was resected. The result of the histopathological examination showed a splenic tissue.

[Rectal prolapse]. / Prolaps na rektuma.

A variety of pathogenetic mechanisms underly rectal prolapse. Treatment is predominantly operative. Some of the basic surgical techniques are reviewed. The modification of posterior rectopexy with ampoxen, implicated at the Department of Surgery of the Medical Academy in Sofia, is presented. After exposure of the rectum at the side of the sacrum, the intestine is fixed to the presacral fascia. The aim is to create adhesions. Septic complications are avoided, which otherwise, with applications of other synthetic implants are quite common. Experience is recorded with the application of the method in three patients, who were followed up over a period of 2 years.

[One-step breast reconstruction]. / Ednomomentna mamarna rekonstruktsiia.

The mental trauma induced by removal of the mammary gland for cancer may be overcome by reconstruction of the breast. One-step reconstruction applied on 4 patients showed considerable advantages over a postponed reconstruction: technically it is easier to perform; a single stay of the patient in hospital makes it cheaper. It is no obstacle to perform pre- and postoperative radio- and chemotherapy. According to available data in the literature, implanted prosthesis or transposed flap do not veil a local relapse.

[Relaparotomy in early postoperative complications in the abdominal cavity]. / Relaparotomiiata pri rannite sledoperativni uslozhneniia v koremnata kukhina.

A series of 138 (1.3 per cent) re-laparotomies, performed for diverse complications subsequent to abdominal interventions, are reviewed. The lethality rate is rather high. Eighty-five patients died which makes 61.5 per cent those undergoing re-operation. Complications demanding re-laparotomy are divided up into five groups. Group I includes hemorrhage a/ in the lumen of the digestive canal and b/ in the abdominal cavity. Group II - postoperative peritonitis. It includes perforative, circumscribed and diffuse peritonitis without perforations, and due to suture insufficiency, as well as to necrosis of the pancreas and biliary peritonites. Group III - postoperative ileus conditions: mechanical and paralytic. Group IV - operative wound dehiscence. Group V - seventeen patients where re-laparotomy is justified by miscellaneous complications omitted in the listed above four basic groups.

[A case of somatostatinoma of the pancreas]. / Vurkhu edin sluchai sus somatostatinom na pankreasa.

A case of a 36-year-old man with pancreatic somatostatinoma is reported. Such cases are very rare. The following signs were found; quick ESR, increased alpha 2- and beta-globulins, shortened Weltmann's coagulation band, increased serum bilirubin level, especially of the conjugated fraction, enzyme constellation of cholestasis and moderate liver cytolysis. Ultrasound examination of the abdomen, retrograde cholangiopancreatography and percutaneous liver cholangiography were performed in order to prove the diagnosis. They demonstrated an obstruction in Vater's papilla region and a bulky process in the head of the pancreas. The patient was operated. The microscopic, electron microscopic and immunohistochemical examinations proved a somatostatinoma of the pancreas. The positive immunohistochemical tests for somatostatin and carcinoembryonal antigen in the tumor cels are especially indicative.