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.

[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.

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.

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.

En bloc laparoscopic sigmoidectomy, left adnexectomy, small bowel loop and piece of urinary bladder resection for advanced sigmoid tumor.

UNLABELLED: The laparoscopic surgery of colon increasingly replaces the conventional surgery of colon on a global and regional scale. Many randomized studies demonstrate the advantages with regard to the shorter postoperative hospital stay, faster recovery, and identical results of the indexes of survival and frequency of relapses. The en bloc resection in cases of locally advanced colon cancer is the most secure method for achieving of R0 resection . The growth of the tumoral mass towards the adjacent structures manifests with histological tumor invasion in approximately 50% of the cases. The cases of laparoscopic en bloc resection for the treatment of colorectal cancer, which are described in the literature, increase. In this report we present a clinical case of substenotic sigmoid colon cancer and perioperative finding of infiltration towards a small intestinal loop and part of the urinary bladder, as well as towards the left uterine tube and the left adnex. In the case of this patient laparoscopic en bloc resection of the tumor formation was performed according to the so called "laparoscopic no touch technique". Approximately 15-20% of the cases of colorectal cancer are still in T4 stage, with involvement of the adjacent organs (1), despite the advance of the examination methods. CLINICAL CASE: A 67 year old female was admitted to the hospital for a substenotic sigmoid colon lesion, syndrome of anemia, resulted adenocarcinoma at colonoscopy. Endoscopy showed an endoluminal tumor at 25 cm from the anal margin and preoperative work-up did not evidence any secondary lesions or invasion of other organs. METHODS: Four abdominal trocars were placed. The laparoscopic exploration of the abdominal cavity showed the presence of a colic mass with suspected invasion of a small bowel loop and part of the urinary bladder, the left uterine tube, and the left ovary. The tumor formation was dissected en bloc with resection of the left uterine tube and ovary, the urinary bladder, and a small bowel loop. Colorectal anastomosis with laparoscopic manual technique was performed. The anastomosis was tested for leak-tightness. The specimen was removed by enlargenemt of the 5 mm. suprapubic trocar. RESULTS: The mean operative time was 285 minutes with blood loss of 300 ml. Patient was discharged on Postoperative Day 5. The histological result verified tumoral invasion towards the urinary bladder, the small bowel, and the ovary. The final staging according to the TNM classification is pT4N0Mx. CONCLUSION: The en bloc laparoscopic resection for the treatment of sigmoid colon cancer, engaging the adjacent organs, is indicated and feasible, with surgical results, comparable with a conventional surgical intervention at the same volume.

[Anal incontinence--new methods of surgical treatment using artificial bowel sphincter and sacral nerve stimulation].

Anal incontinence remains a largely hidden problem, with many patients which are long-term health and mobility problems. Anal incontinence is a symptom or sign rather than a disease, and that there are often multiple contributory factors. Anal incontinence affects both sexes and all age groups. Approximately 2% of the adult population have it on a frequent basis. Treatments include pelvic muscles training, drugs, surgery. Artificial bowel sphincters and sacral nerve stimulation (or neuromodulation) is a relatively new operative techniques for treating anal incontinence and are used in patients with an intact or repaired sphincter complex.

[Genetic counseling, surgical prophylaxis and treatment for familial adenomatous polyposis and hereditary nonpolyposis colorectal cancer].

FAP is an autosomal dominant disorder characterized by the appearance of thousands of adenomatous polyps. FAP is associated with a deletion of chromosome 5q21 (known as the APC gene). Surgical prophylaxis in FAP consists of resection of the entire large bowel, to prevent malignant transformation. Hereditary Nonpolyposis Colorectal Cancer(HNPCC), like FAP, is an autosomal dominant disorder. In contrast to FAP, HNPCC is associated with an unusually high frequency of cancers in the proximal large bowel. If an adenoma or adenocarcinoma of the colon is identified, total abdominal colectomy with an ileorectal anastomosis is recommended.

[Multiple primary carcinomas of the colon and associated extracolonic primary malignant tumors].

Adenocarcinoma of the colon is the most common visceral cancer. The incidence of multiple primary colorectal carcinoma varies from 0.6% to 7.6%. A review of 837 cases of colorectal carcinoma showed 32 cases (3.8%) of colorectal multiple primary malignant tumors and 11 cases (1.3%) of colorectal primary malignant tumor associated with extracolonic primary malignant tumor. A total of 78 tumors were involved: 24 in the sigmoid, 12 transverse colon; four in the cecum; 30 in the rectum; 3 in the ascending and 5 in descending colon; 2 each in the bladder, prostate; two each in the breast, cervix, and one each in the skin, nasopharynx, lungs. If synchronous carcinomas are located in the same anatomic region, a conventional resection should be performed. When the carcinomas are widely separated, a subtotal colectomy is the operation of choice. Survival of patients with synchronous carcinomas is not significantly different from survival of patients with same-stage solitary carcinomas.

[Gastrointestinal stromal tumors (GIST) - clinical experience and current therapeutical aspects].

Gastrointestinal stromal tumors (GIST) are specific, generally Kit (CD117) - positive, mesenchymal tumors of the gastrointestinal tract encompassing a majority of tumors previously considered gastrointestinal smooth muscle tumors. They are believed to originate from interstitial cells of Cajal or related stem cells. Diagnosis is based on histological and immunohistochemical examination, and these rare tumors are characterized by c-kit (CD117) staining. We present an analysis of clinical presentation and course, surgical management and pathological features of 11 patients with gastrointestinal stromal tumors treated in our institution from 2002 to 2007. 2 patients with malignant retroperitoneal GIST had disease progression/recurrence and died. They received adjuvant imatinib therapy. 9 patients are disease free on the 3-d year of the follow-up. Our results confirm that in stromal tumors complete surgical resection remains the mainstay of treatment in localized gastrointestinal stromal tumors. Complete removal of the tumor is often curative in localized gastrointestinal stromal tumors and is always recommended. Clinically, their behavior is difficult to predict, and mitotic count and tumor size seem to be the most effective prognostic factors. It is conceivable that treatment and prognosis of metastatic and non - resectable gastrointestinal stromal tumors, as well as the adjuvant treatment of high-risk, radically excised gastrointestinal stromal tumors will be strongly impacted by the c-kit target therapy.

[Pilot study on M2-PK-- a new non-invasive parameter for early diagnosis of colorectal carcinoma].

To determine the level of tumor marker pyruvate kinase dimer (M2-PK) in the feces of patients with colorectal cancer and benign polyps, as well as in individuals with chronic inflammatory bowel diseases. Fecal M2-PK determination could be outlined as a highly reliable non-invasive approach to the diagnosis of colorectal carcinoma. The establishing of elevated values in patients with chronic inflammatory bowel diseases decreases the specificity of M2-PK as a tumor marker. However, this does not compromise its essential clinical significance, because the precise diagnosis in both diseases imposes an obligatory performance of colonoscopy.

[Combined and extended radical operations in colorectal cancer patients].

This is a report on radical operative interventions performed in 513/755 patients presenting complicated colorectal carcinoma, covering the period 2000 through 2007. One hundred and four patients are subjected to combined and extended operations, distributed as follows: 61 combined and 43 extended. In thirty three patients with abdominoperineal extirpation the combined interventions include: hysterectomy (7), ovariectomy (9), resection of vagina (8), prostate gland resection (5) and bladder resection (4). In case of resection of rectum after Hartmann, combined intervention is done in seventeen patients - small intestine resection - 7, ovariectomy - 2, appendectomy - 3 and cyst extirpation from lethality amounts to 12.9 per cent of patients with complicated colorectal carcinoma undergoing combined and extended surgical interventions.

[Obstructive ileus of the large intestine caused by ischemic colitis--literature review and report of 7 cases].

Ischemic colitis is the most common form of intestinal ischemia. The damage produces ulcers in the lining of the large intestine. Ischemic colitis affects primarily people who are 50 or older. The disease was first described by Boley and associates [1] as a "reversible vascular occlusion" of the colon, and Marston and colleagues [2] went on to detail the gangrenous, stricturing, and transient forms. Two mechanisms may cause bowel ischemia: The first and most common is diminished bowel perfusion due to low cardiac output often seen with in patients with cardiac disease or in prolonged shock of any etiology. The second mechanism is occlusive disease of the vascular supply of bowel due to atheroma, thrombosis, or embolism in which the collateral circulation is not adequate to maintain bowel integrity.

[Tactics and approach to the treatment of choledocholithiasis--7-year follow up study].

Laparoscopic surgery approved itself as "golden standard" in treatment of cholelithiasis. However, in cases with common bile duct stones (CBDS), still there are several methods of management: 1.) Preoperative Endoscopic Retrograde Cholangio-pancreato graphy (ERCP), endoscopic papiloshpyncterothomy (EPS) and stone extraction, followed by Laparoscopic cholecystectomy (LC). 2.) LH with intraoperative common bile duct exploration and stone extraction. 3.) LH, followed by EPS and CBDS extraction. CBDS are present in about 10-15 % of patients, treated by laparoscopic cholecystectomy. In most cases choledocholithiasis is suspected. In small percentage it is unsuspected and it's found during the operation. In present days still there is no clear conclusion about treatment of CBDS. In our clinic we use a multidiscipline method - ES with stone extraction on first stage and LC on second stage. In small percentage of patients we use LC with intraoperative common bile duct exploration and stone extraction, and LH, followed by ES and CBDS extraction. Our aim is to represent a prospective study of our results.

[Economical and social effectiveness of one day surgical treatment in patients with hernial defects of anterior abdominal wall - results of 7 year study].

A hernia is a protrusion of a tissue, structure or part of a organ through the muscular tissue or the membrane by which it is normally contained. Most frequently hernial deffect is seen in anterior abdominal wall. Usually contents of hernial sac are abdominal organs or portion of organs. Hernia is classified according to the operating methods combining with type and grading of hernia. Recent surgical treatment of hernia can be divided in to 3 major groups: 1) Hernioplasty with double breasting techniques ( Bassini, McVay, Schouldice, Halsted). 2) Hernioplasty using tension free techniques (Lichtenstein, Gilbert-Rutkow). 3) Laparoscopic hernioplasty. One day surgery is a diagnostic and operative procedure in hospitalized patients in a single day, without night stay in hospital.

[Clinical experience and current aspects of treatment of abdominal actinomycosis].

Actinomycosis is an uncommocn inflammatory entity caused by the universally distributed anaerobic bacterium, Actinomyces Israeli. The most common sites of the abdominal form of the disease are the transverse colon and the cecum with the appendix. Actinomycosis can mimic other abdominal diseases as diverticulitis, abscesses, inflammatory bowel disease and malignant tumors, presenting a diagnostic challenge. In most cases surgical intervention is performed. Antibiotic administration should be a part of the complex treatment of the disease.

[Hartmann's operation--urgent operative technique in complicated colorectal cancer].

In 1923 the French surgeon Henri Hartmann described an operation for resection of a cancer in the distal sigmoid and upper rectum, resulting in a permanent sigmoid colostomy. In the subsequent years, the indications for performing the Hartmann procedure have broadened to include complicated diverticulitis, ischemic bowel, iatrogenic perforations, volvulus, and colitis. Hartmann's procedure is recognised by most colorectal surgeons to be a blunt but effective method of dealing with left-sided colonic emergencies. Hartmann procedure is a safe and efficacious option for the surgeon confronted with the complex pathology of the rectosigmoid area, with acceptable morbidity and mortality.

[A case of dermatofibrosarcoma in 27 year old patient]. / Sluchai na dermatofibrosarkoma pri 27-godishna patsientka.

A case of dermatofibrosarcoma protuberans of the trunk involving the underlying soft tissue and muscle fascia, in early stage of development in 27 year old patient, operated by taking safety margin of 3 cm and the underlying muscle fascia, is being reported. Modality of treatment has been discussed.