[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.

Diagnostics of liver echinococcosis.

We analyze the clinical data and the possible methods for diagnostics of liver echinococcosis. The most common clinical manifestations are: burden, dull or colic pain in right hypochondrium, hepatomegaly plus. Against this clinical picture available eosinophilia is indicative sign in the diagnostic process; echography is binding method in the study. Establish the possibilities of each diagnostic method individually and in combination. It is recommended that the application of ultrasound in combination with the immunological method, which combined in 9/10 of the patients decided to avoid diagnosis and diagnostic polipragmatic approach. The other, considerably more expensive and radiological overdosing methods must be applied in exceptional cases. In every manifestation of allergy must be investigation to exclude the echinococcosis. We highly recommended the introduction in Bulgaria of screening methods for early detection of disease and timely treatment.

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.

Quality of life aspects in patients operated for low rectal cancer.

Neoplasms of the rectum represent a common therapeutic problem, with plenty of different possible operative decisions for low-situated tumor cases. Some unfavorable consequences of these surgical approaches seriously affect the patient's life. From the surgical point of view, sparing the sphincter can be considered as achievement of the desired result. This seldom matches what the operated people expect before and experience after the treatment. The necessity of critical assessment of the used operative techniques arises with the rectal cancer surgery development. Despite their undeniable attractiveness, sphincter- sparing operations (SSO) are not accompanied with the awaited result in every case. A need of feedback mechanism arises to control vacillation from saving sphincter by all means to the tremendous number of abdominoperineal excisions (APE). With the introduction of the integral psychometric term "Quality of Life" (QoL) a possibility for a dynamic control over the obtained results was created. This control is realized by a set of instruments. These tools help measure objectively the results taken, as well as their practical use aiming to optimize our treatment policy. Recognition of their modifications and principles could be a step forward for the best interpretation.

[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.

[Methodology of quality of life assessment with EORTC questionnaires of operated for rectum carcinoma patients. Prognostic factors].

The integral psychometric term quality of life illustrates the subjective sensation of the received results. The instruments developed by EORTC contribute to its dynamic objectification and optimization, by applying the adequate practice. For patients with rectal carcinoma this marker is expected to have a prediction value, like other markers that determine the progress of the disease.

[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.

[Complications from the liver hydatidosis].

Echinococcosis of the liver is widespread disease in Bulgaria. Frequently there is different complications in its development: allergies, portal hypertension, bille duct pathology, chest or nervous complications. These events frequently lead to misdiagnoses with inadequate treatment. Therefore it is necessary in case of these complains have to involve in the differential diagnosis the hydatid disease and widening indications for ultrasonography of the liver.

[Modification of the transverse coloplasy pouch--experience with this feasible technique in different types of low rectum resections].

The increased number of sphincter-spared patients after low rectal resection requires an up-to-date approach, aiming at better functional results. The authors modify into practice the transverse coloplasy pouch, with a longitudinal seromuscular incision, mucosal liberalization and transverse suture. They describe their experience with this feasible technique in different types of low rectum resections. The conception of the technique is with increased neorectal volume to avoid some unpleasant consequences of this surgery, without changing the oncological effectiveness. The modification with a single-layer suture facilitates the technique, has some advantages and does not worsen the desired effect.

[Retrorectal tumors--15 years experience and literary review].

PURPOSE: Tumors occurring in the retrorectal space are heterogeneous and uncommon. The utility of newer imaging techniques has not been extensively described, and operative approach is variable. This study examined the diagnosis, treatment, and outcome ofretrorectal tumors at a tertiary referral center. METHODS: Patients with primary, extramucosal neoplasms occurring in the retrorectal space were identified using a retropectively maintained, procedural database of all adult colorectal surgical patients (1995-2009). Exclusion criteria included inflammatory processes, locally advanced colorectal cancer, and metastatic malignancy. Medical records, radiology, and pathology reports were reviewed retrospectively. RESULTS: Thirty-eight patients with retrorectal tumors were treated. Malignant tumors comprised 21 percent. Older age, male gender, and pain were predictive of malignancy (P < 0.05). All benign tumors were resected with normal histologic margins and none recurred. Nine patients with malignancy had recurrence/recrudescence of their disease. CONCLUSIONS: Retrorectal tumors remain a diagnostic and therapeutic challenge. Pain, male gender, and advanced age increase the likelihood of malignancy. Various imaging modalities are useful for planning resection but cannot establish a definitive diagnosis. Whereas benign retrorectal tumors can be completely resected, curative resection of malignant retrorectal tumors remains difficult.

[Operative technique for the oesophago-jejunostomy after gastrectomy for the cancer of the stomach].

Author's described operative technique for the oesophagojejunostomy after gastrectomy for the cancer of the smonach. We are making antireflux termino-lateral oesophago-jejunostomy with antiperistaltic including proximal parts of the jejunum and distal parts of the duodenum, and with subcolic dextromesenterial propulsive latero-lateral duodeno-jejunostomy.

[Assessment of the surgical approaches in liver hydatid disease].

Surgery has major role in liver echinococcosis. Different types of operation techniques are being analyzed in the complicated and uncomplicated forms of the disease. The less traumatic closed methods are preferred, as the best results have been the modified operation of Lagro and Coria by bonding the veil with BTG on fibrous plate. In the yeast echinococcosis with best result has been the half-closed method with permanent lavage of the residual cavity. Different complications and behavior have been interpreted. There are offers in the surgery of the uncomplicated echinococcosis to introduced resection of the convex dome with application through pulverization of tissue glue on the remaining fibrosis. Theoretical advantages proved this method.

[Complex results of investigating the quality of life after rectal surgery].

INTRODUCTION: The recent development of rectal surgery is related to the possibility of avoiding permanent stoma formation, which is presumably believed to be the main factor that decreases quality of life. Despite the modern views of the disease, the adequacy of complex treatment and the technical improvements, low anastomoses often result in poor bowel function. The subjective perception of health is changed for these patients. There arises the question of adequacy of operative approach. The aim of our investigation was analysis of the present QoL data of patients treated in the Specialized Oncology Hospital of Veliko Tarnovo. MATERIALS AND METHODS: The quality of life of 173 patients was examined with the help of EORTC questionnaires QLQ C30 and QLQ C38. The comparison is between a group with high anterior resection (N1 = 50-28.9%), a group with low sphincter-sparing operation (N2 = 59-34.3%) and primary extirpated patients (N3 = 53-30.8%). They were questioned preoperatively, in an early and late aspect, as well as before prophylactic stoma closure. RESULTS: The high resected patients present the best QoL values. Performing the extirpation leads to significant preoperative drop and a good adaptation afterwards. Their indexes are not much different from anterior resection group. Compared with the low technique group considerable improvement as regards the scales social functioning and global health status (P < 0.05) was observed. This group has high values of general and specific symptomology (pain, constipation, diarrhea, dyspnoea, financial difficulties, defecational problems and sexual dysfunction) generating low QoL. Their recovery is prolongated in relation with the drop of the modules before the prophylactic stoma closure. CONCLUSION: The best health perception available after treating the rectum carcinoma is for high located tumors. We recon that for patients with extirpation techniques and primary stoma formation there is no objective data of QoL decrease. In comparison, the group with low rectal resections had to undergo another operative intervention, and there were some specific complications and following poor function reducing quality of life. The requirement for very precise selection of patients must be fulfilled.

[Enzymology of the liver in hydatidosis].

A research has been conducted studying the enzyme system of the liver using biopsy material of the organ taken during the operation from patients with echinococcosis and an experiment with infantile white mice. It is proved reduction of the activity of the alkaline and acid phosphatase as well as of the glycogen along with their progressive reduction during the disease progression. Compared with the other researches--histological and by electronic microscope, etc.--there are proved great hepatic damages due to the echinococcosis that have caused change of the treatment tactics: large preoperative period, including reconstructions of the glycogenic depot in the organ, gentle to the liver anesthesia, exact postoperative reanimation. Very good results have been obtained concerning the postoperative complications and operative mortality: observing the developed acute liver insufficiency--in the past the mortality has been 27.60% throughout 2.49% of the operated patients; after those measures the acute liver insufficiency after this kind of operation is seen just once (0.40% of the patients) and the mortality is 0.

[10 years experience in treatment of rectovaginal fistulas].

We presented our experience in treating 109 patients with acquired rectovaginal fistula operating in the Clinic of Surgery ?? 2001-2009. In 56 patients the modified method used by Gabriel, at 20 a modified method by Gabriel with sphincterolevatorplasty, in 3 abdomino-anal resection with the fall of the sigma in demucosal anal canal, in 13 definitive anus preter and in 17 out temporary anus preter subsequent expression in Gabriel. To allow a conclusion that despite the small number of cases, our results of treatment of rectovaginal fistula are encouraging with good technical and operational performance is a reliable treatment.

[Combined surgical treatment for liver echinococcosis].

Liver echinococcosis is a disease which is often seen in combination with echinococcosis in other organs, as well as with other medical conditions and is the reason for many complications that require surgical treatment. Most commonly echinococcosis manifests with abdominal echinococcosis and/or complications concerning the biliary system. Careful assessment by both the surgical and anesthesiological team, followed by extended surgical intervention via combined manners is thought to be a reasonable action. When dealing with echinococcosis in the spleen it is accepted to be performed organ-spearing intervention, having in mind the important role of the spleen in the immunogenesis. If a stenotic process in the distal bile duct is present, endoscopic papillosphincterotomy simultaneously with echinococcectomy might give an advantage for the combined operations.

[Surgical treatment of esophageal achalasia--20 years experience].

Achalasia comes from a Greek word that means "failure to relax." Cardiospasm and achalasia refer to the same condition. This report addresses esophageal achalasia--its history, diagnosis, pathophysiology, and treatment options. We report our experience in treating this disorder surgically using modified Heller myotomy combined or not with partial gastric fundoplication. 47 patients with achalasia surgically operated in 20-years period are reported by authors. These features make it reasonable to reasses the relative indications for surgery and nonsurgical therapy in achalasia of the esophagus.

[Clinical "maskas" of liver echinococcosis].

The Hydatid desease of the liver is without exactly pointed pathological syndrome. Frequently this disease is promoting with some kinds of masks: allergies, hyperpirexis without suppuration of the cyst bile duct pathological motilities, portal hypertension, icterus, abdominal mass, neuroses than all of those make medic difficulted at the diagnostic process. Some cases of diagnostic lapse are note rare or correct discover getting just on the surgical table. Because of this it is very imported to recognize those masks and always look for hydatid disease. Disappearing or keeping of this symptoms is exciting clinical sign about grading of healing processes in the liver after the operation and this radicality.