Clinic of Gastroenterohepatology--overview of activities.

CThe Clinic of Gastroenterohepatology is a part of the Medical Faculty Skopje and University "St. Cyril and Methodius University, Skopje". It is organized as an educational, scientific and medical care institution. CThere are four diagnostic departments: an out-patients department, endoscopic department, ultrasound department and X-ray department. During Over the last several decades, the Clinic of Gastroenterohepatlogy Clinic has been intensively developed, primarily because of introducing the most recent and modern knowledge in gastroenterology, continuous medical education of the personneal as well education of the doctors and other medical personal from the other medical centrers in Macedonia and neighbouring countries. The hospital part of the Clinic is organized in three divisions, including an intensive care unit. In the department of Ultrasound are performed The most modern diagnostic and therapeutic procedures are performed in the Ultrasound department for: different various liver diseases, benign and malignant liver diseases, bilirye ducts obstructions, pancreas diseases, spleen diseases, and various abdominal and kidney diseases.

Small bowel diverticulosis as a cause of ileus: a case report.

Small bowel diverticulosis (SBD) is a rare condition. In most cases it is asymptomatic, but sometimes it can be manifested with chronic non-specific or acute symptoms. Because of the absence of pathognomonic signs and symptoms and truly reliable diagnostic tests, SBD is hard to diagnose and this is usually done incidentally by radiographic examination or during laparatomy. For uncomplicated patients, those with chronic abdominal pain, syndromes of malabsorption related to jejunoileal diverticulosis, bacterial overgrowth or an episode of intestinal obstruction, as in our case, conservative management is the initial option for treatment. A case of a patient with obstructive symptoms of the gastrointestinal tract due to SBD that was conservatively treated and had a positive outcome is presented.

Choledochal cysts: diagnosis and treatment.

The aim of this study is to show the different diagnostic procedures and treatment in patients diagnosed with congenital choledochal cysts. Choledochal cysts are congenital anomalies of the bile ducts and include cystic dilatation of the extrahepatic and intrahepatic biliary ducts or both. The study shows ten patients diagnosed as having choledochal cysts. Diagnosis was established by clinical and radiographic findings including: ultrasound (US), magnetic resonance cholangiopancreatograpy (MRCP), endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic cholangiography (PTC) and cytological examination of the bile juice. In the study choledochal cysts were classified according to the Todani classification. Most common cysts were type I (six cases); type III (one case), type IVa (one case) and two patients were type V cysts (Caroli disease). The most frequent symptoms were abdominal pain, jaundice and cholangitis. US findings were sensitive for the preliminary diagnosis of choledochal cysts in all the patients. MRCP accurately defined the cyst anatomy and the site of the biliary origin in all the cases with extrahepatic cysts. In three cases ERCP clearly demonstrated the cyst and by PTC smaller cysts were well defined. Cytological examination of the bile juice obtained during the PTC procedure showed malignant cells in one case. Therefore pancreaticoduodenectomy was performed and pathological examination showed associated cholangiocarcinoma. Five years after the operation the patient was well and free of the disease. Five patients underwent surgical treatment with a total cyst excision and Roux-en-Y hepaticojejunostomy while the surgical approach in two patients was partial cyst excision and cystojejunostomy. Patients with Caroli disease were conservatively treated and 3 with interventional endoscopic procedures. Despite US evidence suggesting choledochal cyst diagnosis, other supportive radiographic imaging modalities such as MRCP, ERCP and PTC are required to define the precise cyst anatomy and are essential for the preoperative assessment. Total cyst excision is recommended for reducing cyst-related complications and risk of cholangiocarcinoma.

The role of gastroesophageal reflux disease questionnaire in the Republic of Macedonia.

THE AIM OF THE STUDY: Gastroesophageal reflux disease is a common disease with a multifactorial pathogenesis. Our aim was to analyse the role of the Gastroesophageal Disease Questionnaire in diagnosing reflux disease in the population of the Republic of Macedonia. METHODS: The questionnaire on the severity of the symptoms related to GERD was used. An evaluation of the distal portion of the oesophagus was carried out in all patients with positive questionnaire results. All mucosal injury was classified by the Los Angeles criteria (LA). RESULTS: 642 patients were included. 58.73% females, with an average age of 37.5±8.2. Females had a higher BMI than males 26.8±4.1 vs. 24.9±3.8 p<0.001. Of the total number of examinees (642 patients), in those with erosive reflux disease and also in those with nonerosive reflux disease, as shown respectively in endoscopy, the sensitivity of the RDQ was 100%, and the specifity was 0%. The100 sensitivity means that the questionnaire verified/diagnosed patients with erosive reflux disease with 100% certainty. CONCLUSIONS: RESULTS were found in some studies comparing the positive Reflux Disease Questionnaire and the level of erosive esophagitis (LA classification). This study provides evidence that the RDQ represents a viable instrument for assessing symptom severity and response to treatment in clinical trials of patients with GERD, but in patients with a high score, endoscopic evaluation should not be excluded.

Obstructive jaundice caused by pancreatic head malignancies are there predictive factors for successful endoscopic biliary stenting?

Endoscopic retrograde cholangiopancreatography provides precise imaging of malignant biliopancreatic strictures and allows palliative treatment with endoscopic stenting. Initial successful biliary stenting can be achieved in about 69-100% of patients with pancreatic head malignancies. Preliminary data from our Clinic reported a much lower success rate of endoscopic biliary stenting in obstructive jaundice caused by pancreatic head malignancies. These findings may be because patients are referred at more advanced stages, which could contribute to the lower success rate of biliary stenting. We aimed to determine the success rate of endoscopic biliary stenting prospectively in 50 patients with pancreatic head malignancies and to asses if clinical, laboratory and ultrasound findings can be predictive of success and safety in biliary stenting. Initial successful biliary stenting was achieved in 70% of our patients. No major complications (perforation, severe pancreatitis, massive bleeding, death) were noted. We were able to identify factors predictive of a lower success rate which were associated with a more advanced disease and a longer delay before treatment. Based on our results, we conclude that ERCP should be offered without delay as a primary treatment option for all patients with unresectable pancreatic head malignancy and as a possible treatment option in patients with resectable malignancy who are poor candidates for surgery.

Acute abdominal pain with a spontaneous resolution as a mark to the diagnosis of hereditary angioedema.

Accurate and timely diagnostics of acute abdominal pain, a common emergency, is crucial in decreasing unnecessary surgical interventions. We present the case of a patient, Xh. M. aged 21, transported to emergency after being wakened from sleep by severe, acute abdominal pain. The pain was non-radiating, colic, and associated with flatulence, nausea and vomiting. The family history was negative regarding Angioedema, which decreases but does not exclude the possible appearance of hereditary Angioedema. All laboratory and imaging findings were normal, besides the low levels of C4 complement component were 4.56 mg/dl (normal values 10-40), functional C1-esterase INH was 10.29% (normal values 80-130) C1-estrease inhibitor (protein) 4.58 mg/dl (normal values 16-33), indicating HAE typ I. Regardless of negative medical history in the family of hereditary angioedema, de novo mutation most probably led to her being the first case in the family. The case we have presented confirms the need to include hereditary angioedema as a differential diagnostic possibility in patients with acute abdominal pain, even more so as timely and precise diagnostics enable avoidance of unnecessary surgical interventions.

Iron overload in patients with transfusion dependent myelodisplastic syndrome.

The myelodisplastic syndrome is a heterogeneous group of diseases, characterised by ineffective and dysplastic haematopoesis and pancytopenia in the peripheral blood, followed by progressive disturbance of differentiation of the haematopoetic stem cell, resulting in evolution of the disease towards acute leukaemia. According to the latest WHO classification, the term myelodisplastic syndrome includes diseases with an indolent course, as well as diseases with a fast evolution towards acute leukaemia. Because of this diversity, haematologists base their therapeutic decisions on prognostic scoring systems which incorporate all the significant factors with an influence on survival in this group of patients with myelodisplastic syndrome. Bearing in mind that anaemia is the most frequent form of cytopenia in patients with myelodisplastic syndrome, it is common that at some point of the disease almost every patient with myelodisplastic syndrome is transfusion-dependent. Frequently applied transfusions secure the correction of anaemia in these patients, giving them a good quality of life, but at the same time endangering them with the potential threat of iron overload, when the physiological mechanisms of iron excretion from the organism become insufficient. There is a clear correlation between transfusion dependence and the overall survival in patients with myelodisplastic syndrome. Chelators secure the lowering of the iron surfeit and are indicated in transfusion-dependant patients with myelodisplastic syndrome ( need for two blood units monthly, during one year ), when the ferritin level increases over 1000, in patients who are candidates for transplantation as well as in patients from good prognostic groups with median survival over one year. The therapy with chelators lasts as long as the patient is transfusion-dependant.

Functional outcome and quality of life after restorative proctocolectomy and ileal pouch-anal anastomosis.

Restorative proctocolectomy with ileal pouch-anal anastomosis is the surgical treatment of choice for patients with medically refractory ulcerative colitis, ulcerative colitis with dysplasia or cancer, or familial adenomatous polyposis (FAP). The aim of this study is to report our 6-year experience of restorative proctocolectomy and IPAA at a tertiary referral centre. Chart review was performed for 7 patients undergoing IPAA from 2006 to 2010. Preoperative histopathological diagnoses were ulcerative colitis (n=5), FAP (n=1) and other (n=1). We collected data regarding patient demographics, type and du-ration of the disease, previous operations and indications for surgery. We analysed the operative protocols and postoperative pathological diagnoses. Early (within 30 days after surgery) and late complications were noted. Follow-up was conducted upon annual function and a quality of life questionnaire, physical examination and endoscopic evaluation of the pouch. Postoperative histopathological diagnoses were: ulcerative colitis (n=3), indeterminate colitis (n=2), FAP (n=1) and colonic necrosis and gangrene (n=1). The average age of the operated patients was 48, with a female predomination of 71%. The mean duration of the follow-up was 4 years. We report 2 cases of steroid use prior to operation as well as 2 cases of extraintestinal manifestations. We report no septic complications and 3 cases of pouchitis. Functional results and quality of life were good to excellent in all 7 cases of IPAA. Restorative proctocolectomy with IPAA is a safe procedure with a low morbidity rate. Functional results are generally good and patient satisfaction is high.

Prevalence of thyroid dysfunction and autoimmunity in pregnant women with gestational diabetes and diabetes type 1.

OBJECTIVE: The aim of the present study was to determine the prevalence of abnormal thyroid function and antithyroid antibodies during pregnancy in women with diabetes type 1 and gestational diabetes mellitus (GDM). METHODS: The study group included 83 pregnant women who attended the Outpatient Department of the Endocrinology, Diabetes and Metabolic Disorders Clinic in the period from 05.2009 to 11.2009. The one hundred-g. oral glucose tolerance test (OGTT) was conducted on the pregnant women except for women with diabetes type 1. Thyroid functions were evaluated in all the pregnant women. After routine screening for GDM, thirty of the pregnant women were healthy and GDM was diagnosed in forty of them. The rest, thirteen women, had diabetes type 1. RESULTS: The women who developed GDM showed a mean free thyroxin concentration (fT4) significantly lower than that observed in the healthy pregnant women and women with diabetes type 1. Among the pregnant women with GDM, 10 women or 25% had fT4 concentrations below the lower cut-off with normal thyroid-stimulating hormone concentrations (TSH). A statistically significant difference was found in the prevalence of antithyroid antibodies (anti-TPO) between the (30%) women with diabetes type 1 and (10%) healthy pregnant women (p<0.05). In the women positive for anti-TPO, TSH was significantly higher (p<0.05). CONCLUSION: The significantly higher prevalence of hypothyroxinemia in GDM pregnancies and anti-TPO titres in pregnancies with diabetes type 1, than in healthy pregnant women warrants routine screening for thyroid abnormalities in these groups of pregnant women.

Dyslipidaemia and hypertension in patients with subclinical hypothyroidism.

OBJECTIVE: The aim of this study was to assess whether subclinical hypothyroidism (SCH) is associated with dyslipidaemia and arterial hypertension. METHODS: At the Department of Endocrinology, Diabetes and Metabolic Disorders, Skopje, R. Macedonia, we examined 24 consecutive patients with SCH and 13 healthy controls in a period of 6 months. SCH was defined as an elevated thyrotropin (TSH) (> 4.2 mU/l) and normal free thyroxine (fT4) level (10.3-24.45 pmol/l). None of the patients had been previously treated with thyroxine. In all participants we determined blood pressure, body mass index (BMI), TSH, fT4, antibodies to thyroid peroxidise (TPOabs), total lipids (TL), total cholesterol (TH), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), and triglycerides. RESULTS: Mean diastolic blood pressure increased in SCH patients vis-a-vis controls (85 vs. 74 mmHg; p < 0.05). Mean values of TL, TH, HDL-C, LDL-C, triglycerides, TC/HDL-C, and LDL-C/HDL-C were no different in patients with SCH compared with controls. Individual analysis revealed that the percentages of patients with SCH having arterial hypertension (29%), hypertriglyceridaemia (34.78%), elevated LDL-C (41.66%), elevated TC/HDL-C (21.7%), and LDL-C/HDL-C (21.74%) ratios were higher than the percentages in controls. No significant correlation between TSH and biochemical parameters was detected. CONCLUSION: Our study revealed that SCH patients have a greater prevalence of dyslipidaemia and arterial hypertension, and, as well, a greater value of mean diastolic pressure vs. control patients.

Association between foetal growth and different maternal metabolic characteristics in women with gestational diabetes mellitus.

OBJECTIVE: The aim of the study was to investigate the association between foetal growth and different maternal metabolic characteristics in women with gestational diabetes mellitus (GDM). METHODS: The study group included 200 consecutive pregnant women who attended the Endocrinology, Diabetes and Metabolic Disorders Outpatient Department in the period from 02.2006 to 02.2009 with singleton pregnancy and GDM diagnosed following ADA criteria. The following parameters were studied: pre-pregnancy maternal body mass index (BMI), 3-hours 100g oral glucose tolerance test (OGTT) results, glycosylated haemoglobin (HbA1c), total lipids (TL), total cholesterol (TH), triglycerides (TG), HDL- and LDL-cholesterol levels at admission. Neonatal birth weight and the prevalence of being large for gestational age (LGA) was an end-point. RESULTS: We found a significant association between birth weight and pre-pregnancy BMI, HDL-C and birth weight of a large child born previously. Birth weight of a large child born previously was the strongest independent predictor for LGA. The prevalence of LGA (from 27% to 80%) was related to a number of altered maternal characteristics. CONCLUSION: Pre-pregnancy BMI, HDL-C and birth weight of a large child born previously are the independent predictors for LGA, but results of glucose levels during OGTT are not useful in the prediction of LGA in GDM pregnancies. Probably more factors and other maternal metabolic parameters than glucose levels during OGTT are responsible for the risk of LGA.

Gestational Diabetes Mellitus - the impact of maternal body mass index and glycaemic control on baby's birth weight.

OBJECTIVES: To asses the influence of the maternal BMI and glycaemic control in women with GDM on the baby's birth weight (BW). MATERIAL AND METHODS: We analysed 180 women with GDM. Macrosomia has been defined as BW > 4000 gm, small for gestational age < 2700 gm and appropriate for gestational age between both. According to the baby s BW the pregnant women were divided into three groups: group 1 (G1) with BW < 2700 gm (n = 26); group 2 (G2) with BW between 2700 to 4000 gm (n = 117), and group 3 (G3) with BW > 4000 gm (n = 37). We also analysed BMI (kg/m2), HbA1c (%), PPG (mmol/L) and time of delivery (WG). RESULTS: Comparisons between G1 and G2 showed: BMI (30.7 +/- 5 & 31 +/- 5.2; p < 0.7), HbA1c (6.4 +/- 0.8 & 5.1 +/- 0.8, p < 0.002), PPG (8.2 +/- 1.7 & 6.9 +/- 1.5, p < 0.02), time of delivery (35.2 +/- 3.8 & 38.6 +/- 1.5, p < 0.0001) and BW (2289 +/- 504 & 3474 +/- 334, p < 0.0001). Comparisons between G2 and G3 showed: BMI (31 +/- 5. 2 & 33.4 +/- 6.1; p < 0.02), HbA1c (5.2 +/- 1.1 & 6.4 +/- 2.3, p < 0.02), PPG (6.9 +/- 1.5 & 8.2 +/- 1.9, p < 0.02), time of delivery (38.6 +/- 1.5 & 39.3 +/- 1.4, p < 0.01) and BW (3474 +/- 334 & 4431 +/- 302, p < 0.0001). Comparisons between G1 and G3 showed the difference at delivery time and the baby's BW (p < 0.0001). CONCLUSIONS: Maternal obesity and PPG contribute to macrosomia and also PPG to SGE.

Pre-operative staging of gastric carcinoma.

This study is a prospective clinical investigation that includes 195 patients (pts), of whom 64 were diagnosed with gastric cancer and endosonographically determined operability. Endosonography is not used in the primary detection and diagnosis of gastric cancer, but as a supplementary method that, besides the basic detection of the presence or absence of a tumour, gives additional information about the extent of the neoplasm. For this investigation the patients were divided into 3 groups. The first group of 58 pts (30%) were those with benign gastric lesions, 18 pts with polyps and 40pts with gastric ulcers respectively. The second groups of 64 pts (32.5%) consisted of those with gastric cancer. According to the endosonographic findings this group consisted of 2 subgroups: 45 operable patients and 19 inoperable patients with gastric cancers. The third group consisted of 73 pts (37.5%) who were without any changes in the gastric wall. The endosonographic findings in the first subgroup that underwent surgery were correlated with the final intraoperative stage and pathohistology, and in the second subgroup they were compared with the operative finding during the palliation procedure and the final diagnosis of the additional investigation. All these qualities make this method useful for the diagnosis, control and follow-up of the findings in all of the stadiums of the disease including the post-operative period.

Clinical importance of insulin resistance after renal transplantation in patients on triple immunosuppressive therapy with cyclosporine, corticosteroids and mycophenolate mofetil.

INTRODUCTION: Post-transplant diabetes mellitus and impaired glucose tolerance are confirmed complications after solid organ transplantation associated with the use of glucocorticoids and calcinuerin inhibitors in maintenance immunosuppression. Insulin resistance (IR) is also an independent factor for cardiovascular morbidity and mortality among renal allograft patients. The aim of our work was to investigate the clinical importance of elevated IR in renal transplant recipients on standard triple-drug immunosuppression in correlation with immunosuppressive therapy and certain independent factors such as body mass index (BMI), time after transplantation, lipid disorders, etc. METHODS: 36 allograft pts with different periods after transplantation without previous glucose disorders were included in the study. An oral glucose tolerance test (OGTT) was made to distinguish pts with or without glucose disorders. The basal values of glucose (G) and insulin (I) were used to calculate indexes of IR and beta-cell function according to the homeostasis equations. Impaired fasting glucose (IFG), impairred glucose tolerance (IGT), impaired post prandial hyperglycemia (IPPH) and diabetes mellitus (DM) were also analysed. RESULTS: The mean value of the IR index was 2.57 +/- 1.20. It was elevated in 31 pts (86%) The IR showed a positive correlation with: I0 (p < 0.01), I2 (p < 0.05), beta cell function (p < 0.05) and CsA (p < 0.01). The fasting I, G, and BMI were shown as independent risk factors for IR (p < 0.01, p < 0.01, and p < 0.05 respectively). There were 12 pts with different glucose disorders (IFG, IGT, DM) and 24 pts without. The pts with glucose disorders showed an elevated IR index (91%) more frequently compared with (41.67%) decreased beta-cell function. CONCLUSION: IR is frequent among renal recipients with and without glucose disorders. IR is an independent risk factor for atherogenesis. Higher CsA trough levels are assotiated with higher Insulin values and indexes of IR. The defect in insulin action is more a prominent mechanism in post-transplant glucose disorders than the impaired insulin secretion.

Hip reduction in cerebral palsy with soft tissue operative procedures.

Hip reduction in cerebral palsy patients with a soft tissue procedure was analysed during operative procedure. Eleven patients with unilateral dislocation of the hip and a quadriplegic form of cerebral palsy underwent soft tissue operation on the hips. Tenotomy of the adductor and flexor muscles of the hip was performed. The contralateral hip sustained only tenotomy of the adductor muscles. The average age of the patient study group was 8.5 and the follow-up period was 4 years. In all patients, repositionings of the hip were achieved and stabilization was maintained postoperatively at the regular outpatient follow-up. The range of extension and abduction motion were increased postoperatively compared to the preoperative range of motion. Retention of the hip was maintained within 20 degrees of abduction. Tenotomy of the adductor and flexor muscles enables hip reduction without opening the joint capsule in quadriplegic cerebral palsy patients. The hip became painless and the improvement in the hygiene was evident.

JAK2V617F mutations in myeloid malignancies: single center experience.

Recently, V617F mutation in JAK2 tyrosine kinase gene was established as a marker of myeloproliferation, useful for proving clonality and securing diagnosis in a considerable proportion of the myeloproliferative neoplasms (MPN) The discovery presents a major breakthrough in the understanding of the pathogenesis of the MPN. Moreover, some studies suggest a possible role of the JAK2V617F mutation in the pathogenesis of some specific acute myeloid leukemia (AML) subtypes. To further improve the understanding of the role of JAK2V617F mutations in the pathogenesis and the clinical course of the myeloid malignancies we screened 192 patients with various MPN and AML for the mutations and analyzed the possible association between JAK2V617F mutations and the clinical features of MPNs patients. The frequency of V617F JAK2 mutation was analyzed by theallele-specific PCR assay. Out of 153 cases with known or suspected diagnoses of MPNs, 100 (65.3%) were positive for the JAK2V617F mutation and 53 (34.7%) were negative. In 39 AML cases the mutant allele V617F was not expressed. Correlations of the clinical features at diagnosis and long-term prognosis between the two JAK2-V617F different MPNs groups revealed comparability regarding all tested parameters except for the incidence of thrombotic history. Patients with the mutation had significantly higher incidence of thrombotic complication (38.5%), compared to the group without the mutation (19.2%) (P < 0.005). Our results confirmed the diagnostic significance of JAK2V617F mutation in MPNs and supported the notion that patients with the mutation should be classified in a new entity of MPNs.

Helicobacter pylori and gastric carcinoma.

The aim of the study was to evaluate the relation of Helicobacter pylori (HP) infection and gastric cancer and a possible relation with a certain histopathological type of gastric cancer and localization within the stomach. A cross-section study was conducted on 60 consecutive patients (45 men and 15 women) with an established histological diagnosis of gastric cancer. The patients were divided into 2 groups (HP positive and HP negative) and additionally, depending on histopathological type, into intestinal, diffuse and cardia cancer, and localization as cardia carcinoma, proximal and distal carcinoma. HP was detected with a rapid ureasa endoscopic test and a serologic immune essay. Forty-two out of 60 patients 42 (70%) were HP positive. There were 36 intestinal type of gastric cancer, 34 (94.4%) HP positive (statistically significant), 19 patients with diffuse type, and 8 (42.1%) HP positive. The remaining 5 were carcinoma of cardia and all were HP negative. Thirty-seven (61.7%) were distal carcinomas, up to (76.2%) in the HP positive group, there were 18 (30%) proximal carcinomas and 5 (8.3%) localized on the cardia. This study confirmed the high incidence of HP infection in patients with gastric carcinoma, particularly in those with an intestinal type of cancer. Carcinomas were predominantly localized in the distal part of the stomach, especially in the HP positive group of intestinal type. Carcinomas of cardia were negatively associated with HP infection.

Imaging diagnosis of musculoskeletal hydatid disease.

Hydatid disease has a worldwide distribution and causes health problems in endemic countries. Musculoskeletal hydatid disease may be a difficult differential diagnosis. The aim of this retrospective study is to present some different imaging features of musculoskeletal hydatid disease. We evaluated imaging findings of 15 patients with musculoskeletal hydatid disease over a 15-year period. Ten (67%) were men and 5 (33%) women, ages ranging between 12 and 69 years. All underwent radiographic evaluation. CT was done in 9 patients and MRI in 3 patients with soft tissue involvement. All underwent surgery, followed by histological examination. Bone involvement occurred in 11 patients and soft-tissue involvement in 4 patients respectively. Bone lesions in the spine were found in 4 (36%), in the pelvis 2 (18%), in the proximal femur 2 (18%), in the tibia 2 (18%) and 1 (9%) in the first metatarsal. On plain film we identified three different patterns of presentation of bone HD, defined as "typical" osteolytic lesion (33%), "tumour-like" features (41.6%) and lesions resembling infection (25%). Soft-tissue hydatidosis was localized on the distal part of the thigh, paravertebral and deltoid muscle. MR imaging showed a cystic mass, containing multiple vesicles, and in one of them the pathognomonic for hydatid disease, the "water lily" sign, was present. We present three cases of primary musculoskeletal hydatid disease localized on metatarsal bone, proximal femur and deltoid muscle. Musculoskeletal hydatid disease, presenting with a variety of patterns, may resemble a tumour or an inflammatory process. Because of the rare presentation of the disease it should be kept in mind in the diagnostic work-up of musculoskeletal tumours.

Endosonographic diagnosis in submucosal tumours of the stomach.

This study is a prospective clinical investigation that includes 158 patients (pts.), of whom 64 were diagnosed with gastric cancer by EUS in which operability was determinate, and 94 pts. with gastric submucosal tumours. Endoscopy and pathohistological examination were used in the primary detection and diagnosis of the gastric cancer, and EUS was a supplementary method that revealed additional information about the extent of the neoplasms. According to the findings of the EUS, the patients were divided into 2 groups. The first group consisted of 94 pts (59.5%) with gastric submucosal lesions, and 64 pts (40.5%) with gastric cancer respectively. The first group consisted of 94 pts. with submucosal tumours of the stomach. There were 71 pts with Leiomyoma, 11 pts with Leiomyosarcoma, 7 with an aberrant pancreas, 3 with submucosal cysts, one lipoma and one varix at fundus. The second group consisted of 64 pts (40.5%) with gastric cancer. According to the EUS findings this group was divided into two subgroups: 45 operable patients and 19 inoperable patients with gastric cancer. EUS proved a useful method for the diagnosis and follow-up of the patients with gastric cancer, as well as the staging of the tumour and follow-up during the post-operative period, and with submucosal tumours.

Preservation of the vegetative pelvic nerves and local reccurence in the operative treatment of rectal cancer.

Life quality of the patients operated from rectal cancer is a serious problem. Despite the curing as a primary objective in the treatment of the rectal cancer, special attention is paid to the life quality upon the performed operation on the subjected patients. The analyzed series consists of 29 patients with rectal cancer, operated on at the Digestive Surgery Clinic within the framework of the Clinical Centre in Skopje, in the period between 2001-2006. Our series involves patients from the T2 and T3 stage of the illness, where it possible to preserve the vegetative pelvic nerves, that are characterized by a relatively long-lasting symptomatology and relatively high percentage of lymphatic metastases. The standardization of the operative intervention resulted in an increase in the number of patients with continuous operations and preservation of the neuro-vegetative plexus without influencing the radicalism of the intervention. The application of the Stapler and Double Stapler technique brought about an increase in the number of continuous operations characterized by a termino-terminal colorectal anastomosis. On the other hand the preventive creation of LOOP ileostomies in the case of the ultra low resections resulted in a decrease in the level of dehiscence of this type as one of the most common and most difficult complications. The preservation of the pelvic neuro-vegetative plexus prolongs the operation time by 30 to 60 minutes, depending on the case and the patient. We assume that the procedure does not have a particular influence on the frequency of the complications, and at the same time it positively affects the revival of the urinal and sexual function. Taking into consideration the fact that the lymphatic dissection increases the possibility of removal of the malignant tissue and enables an adequate "staging" and on the other hand the preservation of the pelvic plexus improves the quality of life, both in terms of the sexual function and the function of the urinary bladder, it is recommended that this way of treatment becomes an integral part in the surgical treatment of the rectal cancer.