[Sentinel lymph node mapping in patients with colorectal cancer].

UNLABELLED: The colorectal cancer is the most frequent and clinically significant tumor of the gastrointestinal tract. For more than 100 years, radical lymphadenectomy has been the diagnostic and therapeutic gold standard for the management of metastatic nodal disease. More than 50% of patients are initially present with I and II stage of the disease. About 15% to 30% of these patients develop regional or distant metastases within 5 years of diagnosis. This might be because of the pathological understaging, which may occur due to presence of occult micrometastases, smaller than 5 mm. SLN mapping and biopsy is estbilished as tool for accurate nodal staging. The purpose of this study is to present and analyse the data from the expirience in SLN mapping in colorectal cancer, at the same time to be done a description of the applicated method. We used the dye-method with Patent Blue V to patients with verificated colorectal cancer. CONCLUSION: Our study showed that the SLN mapping technique with Patent Blue V is technically simple, quick (usually 5-10 minutes of operating time) and cost effective. It is highly successful (100%), highly sensitive (92%), the SN's status predict the status of the whole regional lymph basein in 67% of the patients. False-negative results are obtained in 8% of the patients. We upstaged the clinical stage of the disease from II to III stage in 4% of the patients, after focused investigation with cytokeratin. We increase the extent of the surgery in 4% of the patients because we found positive SNs beyond the borders of standart resection. SLN mapping and intraoperative detection is an approach, which could increase the possibilities for more accurate nodal staging and it is feasible diagnostic tool in the hands of the surgeon in management of the oncological diseases and colorectal cancer.

[Role of sentinel lymph nodes and lymphatic mapping of colorectal cancer].

The accuracy of staging of colorectal cancer is dependable of number of lymph nodes, colected and investegated from the pathologist. Moreover 50% of newfounded cases with colorectal cancer are diagnosed as I or II stage of the desease. Between 15% and 20% of these patients develop regional or distant metastases around 5 years after the examination, despite of the radical surgery. This may be due to pathological "understaging" (decrease of the stage), becouse of missed micrometastases, which size often is smaller than 5 mm. High accurate and specific pathologoanatomical methods for "ultrastaging" are cost-expensive, therefore their selective application to labeled sentinel lymph nodes has a economical benefit and saves a time. Moreover it is decreasing the understaging effect, assosiated with convectional pathologoanatomical investigaton. In the future, the technical progress will develop the intensive competiton between the sentinel lymph node mapping and the improved imaging diagnostic techniques as flurodeoxyglucose (18FDG), positron emision tomography (PET), or the other molecular imaging techniques. Unfortunately, the limited spatial resolution of these techniques, do not allow to be used for tumor staging as sentinel lymph node techniques. Therefore the sentinel lymphnode mapping become the choice of the lymphnode staging technique.

[Pseudocontinent colostomy - a manometric study]. / Psevdokontinenten protivoestestven anus - manometrichno prouchvane.

The intraluminal pressure in terminal segment of colon has been studied at 42 patients undergone an exterpation of rectum and taken out pseudocontinent colostomy onto a front part of the abdomen. Schmidt's pattern smooth muscle muff, modified in the Clinic Surgery and Coloproctology at MU--Varna, has been transplanted around the colon, taken out as continent colostomy. The intraluminal pressure in the terminal segment of colon has been identified with an index of resistance on the side the smooth muscle muff against the spontaneous evacuation of the colon content. The pressure has been registrated at rest and after the mechanical dillatation of muscle muff. The pressure at the check group of 20 patients with taken out continent colostomy has been investigated manometrically. The basal intraluminal pressure at the patients with a transplanted smooth muscle muff has been 30 +/- 2.9 mmHg at the end of the first postoperative month, as it has been sustained permanent (29.7 +/- 3.0 mmHg) up to the second postoperative jear (0.001). The pressure has been increased up to the mean value of 42 +/- 2.5 mmHg, as it has been sustained at this level for a period of 120 sec. The basal intraluminal pressure at the patients with transplanted smooth muscle muff has been more then four times higher in comparison with the pressure in c. sigmoideum, which has been a prerequisite for stopping of the spontaneous evacuation. A conclusion has been done that the index of resistance in the terminal segment of colon has been depended on a functional potential of the smooth muscle muff directly. The transplanted muff has been an anatomic structure manifested a functional activity in terms of isolation.

[Continent colostomy and colon irrigation]. / Protivoestestven anus i kolonirigatsii.

The authors have studied a functional activity of a continent colostomy at 20 patients, undergone an abdomeno-perineal extirpation of rectum and carried out periodic colonirrigations, during a period of 6 months. A conus type, closed irrigating system has been used. The degree of an incontinency at patients has been compared before and after the beginning of the colonirrigations. The irrigating procedures have reduced spontaneous defications at patients during a week 28 times and have improved the quality of life significantly. The application of colostomy bags has been restricted in 8 (40%) patients. An intraluminal ultrasonographic investigation has been done at 12 (60%) patients at the end of 6 month irrigating period. No changes of the ultrasonographic image of the precolostomic segment of colon has been observed.

[A modified autotransplantation method providing for continence in preternatural anus]. / Modifitsiran avtotransplantatsionen metod za obezpechavane na kontinentnost pri bolni s protivoestestven anus.

Over the period 1996 through 1998, a series of 58 patients undergo operation in the clinic of coloproctology--Medical University, Varna and in the clinic of surgery at the Naval Hospital--Varna, for continent preternatural anus formation on the anterior abdominal wall. A personal modification of Schmidt's (1978) method is used where a smooth-muscle cuff exerting pressure on the terminal segment of the large bowel, brought out as an artificial anus, is created. The operative procedure is combined with periodic colon irrigations in the postoperative period for the purpose of stimulating controlled intestinal content evacuation. The degree of continence is evaluated clinically and manometrically in all cases at termination of the first postoperative month, and in 31 of them--at the end of the second postoperative year. The early and late results are good.

[Pseudocontinent colostomy - comparative experimental study]. / Psevdokontinentni kolostomi - sravnitelno eksperimentalno prouchvane.

The possibilities of smoothmuscle sphincteroplastic have been researched experimentally at 29 mongrel dogs. Six types smoothmuscle plastics have been studied--a method of Feodorov and Odariuc, a method of Musiani, a pylor as a sphincter, an own operative method in three versions. A comparatively research upon a functional fitness of the offered plastics and Schmidt's method has been done. The level of intraluminal pressure into the precolostomy segment of colon and a functional status of the taken out colostomy have been compared. The reliable lower level of intraluminal compression has been established (p < 0.05), using longitudinal muscle as a plastic material. The intraluminal pressure into the end segment of colon has been sustained raised, permanently, due to the tonus of circular muscle in to the transplant's wall. The degree of intraluminal compression seems to be directly proportional to the volume of stretching of smoothmuscle transplant (p < 0.001). There has been done a conclusion, that the smoothmuscle plastic gives operative-technical possibilities for raising of intraluminal pressure by changing the volume of stretching of the transplant.

[Continent preternatural anus--histomorphological and functional aspects]. / Kontinenten protivoestestven anus--khistomorfologichni i funktsionalni aspekti.

Transplantation of a free smooth-muscular cuff around a terminal large-intestinal segment, brought out as preternatural anus, secures high-degree continence and controlled evacuatory rhythm of the intestinal content. The preserved structure of the muscular layers in the cuff wall and the myogenic nature of smooth muscle tone are preconditions for functional activity manifestation in conditions of denervation, isolation and even after block of neurons and intramural ganglia. Five preparations comprising the smooth muscle cuff and recipient large-intestinal segment undergo histomorphologic and electromyographic study within a year of transplantation. In a series of 31 patients with drawn out continent preternatural anus the thickness of the abdominal wall together with the smooth muscle cuff graft is echographically registered at the end of the first postoperative year. The echographically documented abdominal wall thickness is compared with the histomorphologically established values of the indicator under study. Analysis of the functional activity of the smooth-muscle-cuff transplant is also done.

[Endorectal ultrasonography]. / Endorektalna ultrasonografiia.

Endorectal ultrasound examination is a valuable method for detection and monitoring of pelvic diseases. The authors record their clinical experience in endorectal ultrasonography with Bruel & Kjaer ultrasound scanner. One hundred patients with diseases of the pelvic organs were examined, mainly before and after operation of ano-rectal cancer. There were 59 patients with rectal cancer, 8 patients with relapse after rectal resection, 3 patients with anal cancer, 2 patients with insufficiency of the anastomoses after rectal resection with formation of pelvic abscesses, 2 patients with metastases of bladder cancer, 2 patients with rectal cancer invading the prostate gland, 1 patient with vaginal cancer invading the rectum, 1 patient with rectal cancer invading the bladder and both ureters leading to bilateral hydronephrosis and 2 patients with extrauterine pregnancy. Another group of 20 patients was examined for detecting early postoperative recurrences. EU is an obligatory method of diagnosis of rectal cancer. It is part of the complex approach to the choice of operative method and helps to make short- and long-term prognosis after the operation. The method is also essential for the diagnosis of inflammatory processes in the pelvis and in-lying organs.

[Oblique terminal-lateral gastroduodenoanastomosis in surgery of stomach ulcer]. / Kosoi terminolateral'nyi gastroduodenoanastomoz v khirurgii iazvennoi bolezni zheludka.

The authors analyse the results of surgical treatment of 316 patients with peptic ulcer after gastric resection completed by the formation of terminolateral gastroduodenoanastomosis after the Haberer-Finney techniques. In 189 patients vagotomy was carried out in addition to the operation. The postoperative mortality rate was 0.3% (due to incompetence of the sutures of the anastomosis). The incidence of nonfatal complications was 9.4%. The late-term results were good (according to Visick's grading) in 98.65% of patients.

[Plastic and reconstructive operations on the anal sphincter]. / Plasticheskie i rekonstruktivnye operatsii na anal'nom sfinkternom apparate.

The results of surgical management of anal incompetence in 96 patients are analysed. The author elaborated his own techniques of plastic surgery with the use of the gracilis muscle of the thigh. The results were excellent in 81.8% of patients. Indications for various types of operations and their results are discussed.

[A case of leiomyosarcoma of the stomach in which diagnosis echotomographic study made a contribution]. / Vurkhu edin sluchai ot leiomiosarkom na stomakh, za diagnosti-tsiraneto na koito doprinese mnogo i ekhotomografskoto izsledvane.

The authors describe a case of leiomyosarcoma of the stomach, progressing clinically with manifested pains in almost all joints, febrile-septic state and repeated enterorrhagias - hematemesis and melena. The case was diagnosed prior to the operation, with the ehcotomographic study of the stomach contributing greatly.