[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.

Clinical and prognostic significance of pathological and inflammatory markers in the surgical treatment of locally advanced colorectal cancer

Background

Locally advanced colorectal cancer (CRC) may vary in its clinical and pathological appearance. It is now accepted that progression of disease in patients with locally advanced CRC is determined not only by local tumor characteristics but also by the immune system and inflammatory response in the body.

Methods

We investigated patients with confirmed CRC who were treated in the surgical clinic at the University Hospital Alexandrovska over a 10-year period and retrospectively evaluated the histological features of the preoperative biopsies and operative specimens removed during radical multivisceral resections. We also collected prospective data for serum C-reactive protein levels and Jass-Klintrup score, Petersen Index score, and Glasgow Prognostic Score in patients with locally advanced CRC.

Results

Of 1,105 patients with CRC, 327 (29.6%) were diagnosed with locally advanced disease. In total, 108 combined multivisceral resections (79 for primary tumors and 29 for recurrent tumors) were performed. Overall survival was 34 months for pR0 cases and 12 months for pR1 cases (P<0.05). Our data confirmed that C-reactive protein is a prognostic marker of overall survival. Data for 48 patients with histologically confirmed locally advanced tumors showed significantly increased survival with a higher Jass-Klintrup score (P=0.037). In patients with node-negative disease, 5-year survival was 49%. However, where there were high-risk pathological characteristics according to the Petersen Index, survival was similar to that for node-positive disease (P=0.702). Our data also showed a significant difference in survival between groups divided according to whether they had a modified Glasgow Prognostic Score of 1 or 2 (P=0.031).

Conclusion

In order to maintain a reasonable balance between an aggressive approach and so-called meaningless “surgical exorbitance”, we should focus on certain histopathological and inflammatory markers that can be identified as additional factors for planning the type and volume of surgical 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.

SINGLE-ACCESS TRANSUMBILICAL LAPAROSCOPIC APPENDECTOMY USING CURVED REUSABLE INSTRUMENTS: AN INITIAL REPORT OF THREE CASES

INTRODUCTION

The continuous evolution of laparoscopic surgery and the ambition of better cosmetic results raise the need for less invasive procedures. The umbilicus represents a natural scar and constitutes a well-healing site of access to the peritoneal cavity. Single-access Transumbilical Laparoscopy (SATL) is gaining popularity and can be an alternative surgical treatment for acute appendicitis. We report three cases of SATL appendectomy using curved reusable instruments.

PATIENTS AND METHODS

Three female patients, wanting minimal scarring (mean age - 30 years) were admitted to our hospital in April 2015 with acute abdominal pain in the right iliac area. A SATL appendectomy was performed using a standard 11-mm reusable trocar for a 10-mm, 30 degrees- angled, rigid scope and curved reusable instruments according to DAPRI (Karl Storz-Endoskope, Tuttlingen, Germany) placed transumbilically.

RESULTS

Neither a conversion to open surgery nor an insertion of extraumbilical trocars was necessary. The mean operative time was 101.6 ± 24.66 minutes and the mean blood loss 6.66 ± 11.54 mL. The mean scar length was 16.66 ± 0.57 mm. No intraoperative complications were registered and the use of minimal pain killers allowed the discharge after 2 or maximum 4 days. After three months of follow-up no late complications occurred and the umbilical scar was not visible.

CONCLUSION

In young and scarless-demanding females with acute appendicitis SATL appendectomy can be performed safely and offers the possibility of surgical treatment without a visible scar.

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.

Optimization of surgical approach and lymph node dissection in patients with gastric cancer

In 2012 there were nearly 1 million new gastric cancer cases (952,000 cases or 6.8% of all cancer cases). That has put the gastric cancer on 5th place in frequency, and on 3th placeas leading cause of death in both sexes in the world--723,000 fatalities or 8.8% of all. According to the data of the World Health Organization, in 2005 Bulgaria was on 23rd place in absolute number of gastric cancer deaths among the men and on 25th place among the women. In 2011, we were on 11th place in absolute number of gastric cancer deaths among the men and on 12th place among the women. According to NCCN (National Comprehensive Cancer Network) there are 2 basic types of surgical interventions that are used for radical gastric cancer treatment- total and subtotal gastrectomy. The scientific society however is still divided on the matter of the volume of lymph dissection. The gastrectomy with D2 lymph dissection is the standard treatment for resectable gastric carcinoma in Asia. In the Western countries, the D2 lymph dissection is considered an advisable, but not mandatory procedure. Despite that, there is a rule that the removal of more than 15 lymph nodes is in favor of the NCCN. Nowadays in Japan the comparative studies between D1 and D2 gastrectomy are considered unethical.

Genome-wide gene expression profiles of ovarian carcinoma: Identification of molecular targets for the treatment of ovarian carcinoma

This study aimed to clarify the molecular mechanisms involved in ovarian carcinogenesis, and to identify candidate molecular targets for its diagnosis and treatment. The genome-wide gene expression profiles of 22 epithelial ovarian carcinomas were analyzed with a microarray representing 38,500 genes, in combination with laser microbeam microdissection. A total of 273 commonly up-regulated transcripts and 387 down-regulated transcripts were identified in the ovarian carcinoma samples. Of the 273 up-regulated transcripts, only 87 (31.9%) were previously reported as up-regulated in microarray studies using bulk cancer tissues and normal ovarian tissues for analysis. CHMP4C (chromatin-modifying protein 4C) was frequently overexpressed in ovarian carcinoma tissue, but not expressed in the normal human tissues used as a control. Our data should contribute to an improved understanding of tumorigenesis in ovarian cancer, and aid in the development of diagnostic tumor markers and molecular-targeting therapy for patients with the disease.

[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.

[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.

[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.

[Obstructive syndrome caused by primary colon-rectal cancer]

This is a report on 311 patients presenting colorectal carcinoma with complication assuming the form of occlusive ileus, observed over the period 2005 through 2009. Obturation is the commonest complication of colonic carcinoma (48.9%) with the left colon being more often involved (58.3%). During the same period of time, occlusive ileus against the background of carcinoma of the rectum is diagnosed in 61 cases, representing 37 per cent of complicated forms of this malignant neoplasm. The scope of operative management and the procedure used are largely determined by the location of primary malignancy. The timing of undertaking one or another operative intervention depends on the efficacy of preoperative preparation, degree of occlusive ileus progress, patientr's age, concomitant diseases and the like. Failing to comply with or overlooking some of the aforementioned factors invariably exerts an unfavourable effect on the final outcome of treatment. In each patient presenting colorectal-carcinoma-induced occlusive ileus it is mandatory to precisely specify the scope of surgery, consistent with the patient's general condition, and eliminate the underlying cause jeopardizing his life.

[Gastric cancer--Japanese Classification, sentinel lymph nodes and lymph dissection]

The aim of Japanese Classification is to provide a common language for the clinical and pathological description of gastric cancer and thereby contribute to continued research and improvements in treatment and diagnosis. Lymph-node dissection has been regarded as an effective surgical treatment for gastric cancer in Japan. It reduces local recurrences and improves survival rate. Japanese-style systematic D2 lymphadenectomy is now being introduced in western countries for treatment of gastric cancer. This surgical procedure, however, is not simple and shoul be performed by experienced surgeons. And it is too early to apply sentinel node biopsy for reducing extent of lymphadenectomy because of so complicated lymphatic streams from the stomach and frequent skip- and micrometastases.

[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.

[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.

[Diverticulosis of the colon end its complications under the mask of emergency surgical abdomen--10 years experience]

OBJECTIVES

estimating the prevalence of colonic diverticulosis and its complications studied at the clinic for 10-years period as well as the approaches for its operative treatment and analysis of the subsequent results. CASES AND APPROACHES: During the period 1998-2008 56 patients were hospitalized (31 women and 25 men) at the Surgical department of the University hospital "Alexandrovska". They had different forms of colonic diverticulosis. The average age of the patients was 66.7. The retrospective analysis divides the patients into three clinical groups: 1st group--peritonitis and pericolic abscess caused by diverticulosis--present in 49 patients. 2nd group--chronic non-specific inflammatory infiltrate and fistula--present in 5 patients. 3rd group--severe haemorrhage and anaemic syndrome--present in 2 patients

RESULTS

Mortality-rate is 12.5% (7 patients). 10 patients with complications were registered--5 with suppuration of the surgical wound and 5 with pneumonia and pleural effusion.

CONCLUSION

Colonic diverticulosis is a disease of great surgical interest because of its complicated forms requiring conventional or surgical treatment. Various forms of peritonitis which are part of the emergency surgical abdomen domain are relatively frequent complication of the gastrointestinal (in particular of the colon) diverticulosis. They are difficult to diagnose in the pre-operative period and its not easy to take a decision about the particular operative approach. All that is related with the relatively high morbidity and mortality.

[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.

[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.

[A 10-years experience in the treatment of the acute peritonitis]

The contemporary classification of the acute peritonitis, the etiology, the special features of the pathogenesis, the difficulties of the diagnostics with some of the kinds and the contemporary aspects of the healing tactics related to the clinical experience of the treatment of that severely and life-threatening disease are included in the present report for 10 years period. 341 laparotomies because of various kinds of peritonitis with patients aged 11-89 years old were performed at the Department of Surgery, University Hospital "Aleksandrovska" -Sofia for the period of 1996-2006. A diffusous fibrino-purulented peritonitis was founded out in most of the cases (41.6%) and the perforations constituted the most common etiologic cause. Total mortality is 25.8% (88 cases). The cause of death was not directly connected to the surgical suffering in 2.34% (8 cases). The death rate is high as expected with the groups of pregressed widespread peritonitis, the 3rd group by Mannheim peritonitis Index (MPI), the postoperative peritonitis, accompanied usually by atypical clinical features, for the elderly patients and patients with worsening the prognosis with premorbid pathology. A complex approach was applied not only for the peritonitis but also for the pathologic processes caused life-threatening complications. The applied treatment depends on the contemporary methods. The results are in accordance with those of the international experience.

[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.

[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.

[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.

[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.

[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.

[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.

[Retroperitoneal endoscopic adrenalectomy for cavernous adrenal hemangioma]

Adrenal cavernous hemangiomas are rare non-functional tumors. This article describes the case of a patient with a cavernous adrenal hemangioma. Prior to surgery, the mass was diagnosed as an incidentaloma. It was successfully removed by means of endoscopic retroperitoneal adrenalectomy without any intraoperative, nor postoperative complications and histologycally verified as "adrenal cavernous hemangioma".

[Acute upper gastrointestinal tract haemorrhage: tactics and treatment]

Haemorrhage due to upper digestive tract diseases is one of the major complications and is relatively common. The cause for haemorrhage depend on the main disease and in many cases has complicated mechanism. The frequency is 100 cases over 100 000 people. There is no proven alternative to the surgical treatment. The issue with second time haemorrhage is controversial. The goal of every surgeon, when dealing with haemorrhage from upper digestive tract, especially with patient with bleeding ulcer, is surgical treatment, when conservative and endoscope treatment have failed. Every patient with bleeding stomach or duodenal ulcer should undergo FGS for Forrest haemorrhage demonstration, endoscope haemostasis and HP examination. Eradication should be applied to every HP positive patient for haemorrhage prevention.

[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.

[Pseudomyxoma peritonei--a case report]

Pseudomyxoma peritonei is a rare condition consisting of mucinous ascites, most commonly arising from mucinous tumors of the appendix and occasionally from the ovary. Ronnett et al. have suggested a classification based on tumor pathology where they place all pseudomyxoma peritonei in three groups in order of decreasing prognosis: disseminated peritoneal adenomucinosis (DPAM), peritoneal mucinous carcinoma with intermediate or discordant features (PMCA) and peritoneal mucinous carcinoma (PMCA). Treatments are now standardized as a combination of cytoreductive surgery and perioperative intraperitoneal chemotherapy.

[The volume of the surgical treatment and follow-up of patients with malignant ovarian tumors in the first stages]

From 1987 till 1997 110 patients with stage-I ovarian malignant tumors were treated and follow-up at the Department of Gynaecological Oncology, National Oncological Center. Papillifery-adenocarcinoma were in 40 cases, serous carcinoma were in 26 cases, mucinous carcinoma were in 15 cases, malignant granulosa cell tumor were in 14 cases, endometrioid carcinoma were in 6 cases, dysgerminoma were in 6 cases, Teilum's tumour were in 2 cases, and 1 case of ovary sarcoma were detected. Radical operated on the first operation were 69 patients (62.8%), and in 37 cases (33.6%) second operation for radicality were performed. In 4 cases only adnexectomy were done. In all cases post operative adjuvant chemotherapy were used. The patients were follow-up by tumour markers, sonography and CT. Follow-up period is from 5 months till 11 years. Alive were 80 patients (73%), and 30 patients (27%) were died. The patients with stage Ic and those nonradical operated in the first operation have worst prognosis then patients with stage Ia and stage Ib. The patients with ovarian tumours must be operated only in the hospitals with possibility of urgent hystological diagnosis for better prognosis in the cases of stage-I malignant ovarian tumours.