Clinical case of neuroendocrine malignant tumor with unusual localization in the adrenal cortex.

The authors present unusual clinical case with atypical diagnostic work-up and histological result of adrenal neuroendocrine carcinoma.

EPIDEMIOLOGICAL REGISTRY OF NEUROENDOCRINE TUMORS IN BULGARIA--A PILOT SURVEY.

The National registry of patients with neuroendocrine tumors (NET) in Bulgaria was established in 2013 as a joint initiative of the Bulgarian Surgical Society and the Institute for Rare Diseases. The register aims to explore the epidemiology of NET in Bulgaria, as well as the different diagnostic and treatment approaches for the disease throughout the country. This the first of its kind retrospective study of NET in the country is covering the period January 2012 - January 2013. A total of 127 patients with NET were identified. At the time of the survey the average age of patients with NET was 58.61 ± 15.59 years. The data show almost equal distribution between the genders with a slight predominance of women. The largest relative part of NET is those of NET located in the gastrointestinal tract (54.10 ± 4.51%), followed by those located in the pancreas (12.30 ± 2.97%) and in the lungs (10.66 ± 2.79%). In 72.44 ± 3.96% of the patients a immunohistochemical diagnosis was performed. The study confirmed the leading role of the surgery method of the NET management. In 65.83 ± 4.33% of the patients a radical removal of the tumor was conducted, while the relative part of the undertaken partial resection was 7.50 ± 2.40%. A statistically significant association between the type of surgical treatment and during the follow-up of patients was found. An update of the information in the register will allow a more precise determining of the distribution and management of NET in Bulgaria.

[Sepsis--current aspects].

Sepsis is defined as a clinical syndrome of systemic response to infections. With progression of the disease develop organ failure (i.e. severe sepsis) and hypotension (i.e. septic shock) and mortality increases significantly. Sepsis is an interdisciplinary problem, cause significant morbidity and mortality and higher hospital costs. Deepening ofinflammation, immunity distortions, coagulation and oxygen perfusion have a major role in organ dysfunction and death. Proper diagnosis of sepsis requires an understanding of risk factors, a high index of suspicion and anatomic approach to the localization of the infectious focus. Early detection of septic patients is crucial for the outcome of disease in the application of reasoned therapy. Future treatment of sepsis associated with a better understanding of the molecular bases of pathological process.

[Contemporary surgical treatment for unresectable periampullary tumors. Double or tripple by-pass surgery].

BACKGROUND/AIM: Pancreatic neoplasms continues to be a highly lethal disease with poor prognosis. This single-institution experience reviews the palliative surgical techniques used in a group of patients with periampullary tumors accenting to a technique of pancreato-wirsungo-jejunostomy, protesed with "perdue"-drain and combined with gastroenterostomy. MATERIALS AND METHODS: For the period of 01.01.2006-31.12.2007 in the Clinic of General and Liver-Pancreatic Surgery of University Hospital "Alexandrovska" are operated 162 patients with pancreatic cancer. 113 of them are with periampullary localization of the tumor, 49 are with localization at the body or at the tail of pancreatic gland. In 97 of the cases a different palliative procedures was performed. In two cases the technique of pancreato-wirsungo-jejunostomy, protesed with "perdue"-drain and combined with gastroenterostomy was performed. RESULTS: The levels of the postoperative mortality and morbidity in patients with palliative surgical procedures are 6.2%, respectively 39.2%. The level of early pastoperative morbidity and mortality in cases with pancreato-wirsungo-jejunostomy, protesed with "perdue"-drain and combined with gastroenterostomy is 0%. CONCLUSION: For patients with advanced periampullary malignacies, the prevention and alleviation of suffering due to obstructive jaundice, gastric outlet obstruction, cancer-related pain and pancreatic exocrine insufficiency is of primary importance. We think that the operative technique is represented by us useful often at patients with chronic pancreatitits, but the tehnique will be useful in given conditions for patients with unresectable periampullar pancreatic neoplasms.

[Analysis of microbial flora during operation for cholangitis and other inflammatory deseases of the hepato-billiary system].

BACKGROUND: Inflammatory deseases of the billiary system are common in the hepato-billiary surgery. Most serious is the cholangitis. Treatment is based on individual approach of choice of moment of correct surgical intervention and corresponding adequate antibiotic therapy. AIM: Retrospective analysis of the experience of our clinic of the positive biliocultures and their antibiograms. MATERIALS AND METHODS: 152 positive biliocultures taken intraoperativly, for 10 years period. 48 of them are from patients with cholangitis. RESULTS: Analysis of count and species microbiological agents and their sensitivity to antibiogram antibiotics in table format. The data of the literature reviewed and discussed. CONCLUSIONS: Most common microbiological agents are E. coli 60%, Klebsiella 31%, Pseudomonas 24%. In 40% theres are more then one agent. Most common agents have big sensivity to Cefalosporines II-III generation, Amikacin, Ciprofloxacin and Carbapenems.

[Postoperative entero-cutaneus fistulas--a study of 24 cases].

AIM: To perform a retrospective study on the experience of the Clinic of General, Liver, Biliary and Pancreatic Surgery, Alexandrovska Hospital in the diagnosis and treatment of patients with acquired entero-cutaneus fistulas and to analyse the early postoperative results. MATERIAL AND METHODS: We treated 24 patients with postoperative entero-cutaneous fistulas in the period Jan., 2000 - Aug., 2004. The male sex and the age above 50 were dominent. The primary disease was of oncological origin in 22 cases (91.66%). Anemia, hypoprotenemia and hypoalbuminemia were predisposing and risk factors in 19 cases (79.17%). Fistulography was routinely used for establishing the diagnosis. Surgical treatment was received by all the 6 patients (100%) with small bowel fistulas and by 15 from the 18 patients with large bowel fistulas (83.33%). EARLY POSTOPERATIVE RESULTS: The mortality rate was 4.54% (1 fatal outcome from 22 operated patients). The morbidity rate was 36,36% (8 cases) but none of the complications needed a reoperation. CONCLUSIONS: 1. The most frequent causal factor for entero-cutaneus fistulas in our material was an anastomotic leakige after bowel resection (95.83%); 2. The risk for such a coplication is higher in cancer patients with other predisposing pathological factors; 3. From the pahtological and clinical point of view the entero-cutaneus fistulas caused significant disturbances in base-alkaline and electrolyte balance, malnutrition and cahexia; 4. The clinical signs and the fistulography prooved to be reliable diagnostic methods; 5. The preoperative substitution and nutritional therapy had a significant benefit on the postoperative results, especially in cases of small bowel fistulas; 6. The open surgery was the main therapeutical method in the complex treatment of those patients.

[Acquierd entero-cutaneous fistulas--diagnostic and therapeutic approach].

The acquired entero-cutaneous fistulas are a current problem in the field of abdominal surgery. Most of them are postoperative--after an intestinal resection and/or anastomosis. Crohn's disease and coplicated colonic diverticulosis rank second as causal factors. The risk factors for the development of an entero-cutaneous fistula and for the poor prognosis at the same time are the next: (1) Most of the patients suffer of severe main and co-exhisting diseases; (2) The presence of previous laparotomies, radion and chemotherapy, significant disturbances in the base-acid and water-electrolyte balance; (3) The fistula itself worsens these disturbances and may doom to fail the substitutional and nutritional therapy. The diagnostics of a fistula, including its location is comparatively easy. The surgical treatment plays an important role in the therapeutic scheme, especially in cases of high-output fistulas of the small intestin. At the same time the adequate total parenteral nutrition and correction of the base-acid and water-electrolyte disbalance is also very important. Recently there are some new diagnostic methods and alternatives of the basic surgical procedures, some of them quite contraversial.

[Internal biliary fistulas--diagnostic and therapeutic problems].

BACKGROUND: Internal biliary fistula (IBF) is still a challenging condition. The preoperative diagnosis is established in less than 50% of cases. Treatment is based on individual approach but postoperative morbidity and mortality rates are high. AIM: To study the experince of our clinic in the diagnosis and treatment of IBF's and to make a review of the literature. MATERIAL AND METHODS: a retrospective analysis of the data of 7 patients with IBF (0,53% of all surgical interventions on the biliary system during a 4-years period). The preoperative diagnosis was correct in only 2 cases. All the 7 patients were treated surgically. RESULTS: The early postoperative mortality and morbidity rates were 0% and 42,86% respectively. The data of literature are reviewed and discussed. CONCLUSION: IBS is a rare condition affecting more often women above 65 yrs suffering of gallstones. There are no typival clinical and laboratory data but US, CT-scan, ERCP and MRI might be a 100% informative. Open surgery remains the basic method of treatment.