M E D I C A L U N I V E R S I T Y - V A R N A

S C R I P T A

S C I E N T I F I C A

M E D I C A

VOL. XXIX, SUPPLEMENT 2

Varna

1995

MEDICAL UNIVERSITY OF VARNA, BULGARIA

SCRIPTA SCIENTIFICA MEDICA, VOL. XXIX, Supplement 2

Editor-in-Chief: Assoc. Prof. D. Kamburov Supplement Editor: Prof. Dr. sc. Г. Temelkov Editorial Board: Prof Dr. sc. L Koeva, Prof. Dr. sc. H. Tsekov, Assoc. Prof. N Feschieva, Assoc. Prof T. Yankova, Assoc. Prof V. Sirakova, Dr. D. Tomov, Dr. К Bohchelyan (Secretary)

Translated and edited by Dr. D. Tomov

© M e d i c a l U n i v e r s i t y o f V a r n a , Varna, 1995

BULGARIAN SURGICAL S O C I E T Y MEDICAL UNIVERSITY VARNA

International Society of University Colon and Rectal Surgeons Gastrosurgical Club

International College of Surgeons

г-

F O U R T H NATIONAL C O N F E R E N C E ON C O L O - P R O C T O L O G Y

WITH INTERNATIONAL PARTICIPATION

Varna, September 29-30,1995 St. Constantine Resort

Sunny Day Complex, Palace Hotel

S C R I P T A S C I E N T I F I C A M E D I C A , V O L . X X I X , Supplement 2

Editor-in-Chief: Assoc. Prof. D . K a m b u r o v Supplement Editor: Prof. T . T e m e l k o v Translation editor: Dr. D . T o m o v Art editor: C h r . D i a c o v Computer design: C h r . D i a c o v Technical editor: Dr. D . T o m o v Proof-reader: Dr. D . T o m o v

Publ. Lit. group: III-3 Sent to printers: September Print sheets: 4.5 Format: 70/100/16 Approved for printimg: September Total print: 450 Medior and IPS, Dobrich

M e d i c a l U n i v e r s i t y o f V a r n a , 55 Marin Drinov Street, Varna

C O N T E N T S

Т . T e m e l k o v - Preface 13

Colorectal Cancer. Diagnosis and Surgical Treatment

T . T e m e l k o v , K . I v a n o v , E . K i r y a z o v , G . K o b a k o v , V . I g n a t о v - On the Diagnosis and Therapeutic Behaviour in Colorectal Diseases 15 T . T e m e l k o v , M . B o z h k o v , G . K o b a k o v , K . I v a n o v , M . S h t i l i y a n o v - Sphincter Saving Operations in Rectal Carcinoma 16 R . J . S p e n c e r - Conservative Treatment of Selected Rectal Cancers 16 M . T r o m p e t o , G . C . G u a s t i , G . C l e r i c o , A . R e a l i s L u c , P . M i l a n i , F . T i n i v e l l a - The Value of C E A in Bile in Patients Operated for Digestige Neoplasms or for Benign Abdominal Diseases 17 V . D i m i t r o v , Z . D o u d o u n k o v , K . R a l c h e v , P . K o u r t e v - Radically Performed Operations in Patients with Rectal Cancer Who Were Laparotomied and Considered Inoperable in Other Hospitals 18 I . V i y a c h k i , N . Y a r u m o v , K . C h e r n e v a , D . V i y a c h k i -Tumour Markers in Patients with Colorectal Cancer 19 I . V i y a c h k i , D . V i y a c h k i , N . Y a r u m o v - Sphincter Saving Operat-ions as an Alternative in Coloproctology 20 N . Y a r u m o v , I . V i y a c h k i , M . K a r p a r o v , M . M a r i n a , D . V i y a c h k i - New Aspects in the Etiopathogenesis of Colorectal Cancer 20 D . D a m y a n o v , G . S t o y a n o v , N . D a m y a n o v , D . I g n a -t o v , A . A l e x a n d r o v a , P . P u r v a n o v , A . A n g e l o v , L . T a n k o v a , R . L o z a n o v , A . Z h e l y a z k o v - O n Some Aspects of the Diagnosis and Surgical Treatment of Rectal Cancer 21 D . D a m y a n o v , A . A l e x a n d r o v a , G . G e n c h e v , R . L o z a ­n o v , P . Y a n o v s k a , D . N e d i n , S . R o u s k o v a - Colorectal Surgery in Patients at Geriatric Age 22 P K r u s t a n o v , P . K a z a n d z h i e v , T s . P a n o v , I . I l i e v , K . K y o s e v , P . M i t e v - Our Experience in the Surgical Treatment of Colonic and Rectal Neoplasms 23 I D o n k o v , G . G u r b e v , K . V a s i l e v , G . G r i g o r o v , E . B e l o k o n s k i , K . G a b r a k o v , K . V o u k o v - Retrospective Analysis of Causes for Postoperative Lethality on the Occasion of Colorectal Carcinoma 23 I . D o n k o v , G . G r i g o r o v , K . V a s i l e v , E . B e l o k o n s k i , G . G u r b e v , V . D a s k a l o v , K . V o u k o v - Comparative Evaluation of Results from Colonic Anastomoses Done by Automatic Stitcher and Classic Saturation Technique 24

Т . P o z h a r l i e v , A . D e r e d z h y a n , S . T o s h e v - Comparativi Studies in Colorectal Cancer Surgery for the Recent Five Years (1990-1994) 24 T . P o z h a r l i e v , A . D e r e d z h y a n - Our Own Observations of Many Yean on Diagnosis and Surgical Treatment of Colorectal Cancer 25 T . T o d o r o v , G . K o n d a r e v , B . M o s h e v , G . M a r k o v , I . H l e b a . r o v a , V . L y u t z k a n o v - Block Resections in Colorectal Carcinoma 26 P . U c h i k o v , Z . V u z h e v , K . K r u s t e v , K . H e k i m o v , A. U c h i k o v , H . H a t u r - Our Experience with the Surgical Treatment of Colorecti Cancer 26 I . M a n c h e v , C h . A t a n a s o v , V . Z a p r y a n o v , T . T a t s e v , I . I v a n о v - Automatic Staplers in Colorectal Surgery 27 T . T o t e v , A . S t a m o v , A . K y u r k c h i y a n , V . K o l a r o v , R. S a m u n e v , I . K a t s a r o v - Combined Operations in Colorectal Carcinoma 27 T . D e l i y s k i , V . S l i z o v , R . S t o y a n o v , M . B o y k o v , 0 . M u s t a f a - Transanal Excision of Rectal Tumours through Closed Fenestrated Spec­ulum 28

Colorectal Cancer. Preparation, Complications, and Reconstructive Operations

M . T r o m p e t t o , G . C l e r i c o , A . R e a l i s L u c , M . P o z z o -On Table Lavage 28 S . K o r n o v s k i , B . K o r n o v s k i , D . D o b r e v , V . I g n a t o v , N . N i к о 1 о v - Comparative Investigations in Patients with Esophagocolonic and Es­ophagogastric Plastics 29 Z . D o u d o u n k o v , S . I v a n o v , S . K a r a n o v , V . D i m i t r o v -Our Experience with Plastic Esophagus Replacement by a Colonic Part 29 D . L o u l c h e v , H . T s e k o v , S . S t r o u g a r o v , B . K l e i n , G . A n t о v - Disseminated Large Bowel Peritonitis 31 P . S t e f a n o v , E . M i h a y l o v , 0 . C h o l a k o v - Acute Ileus Due to Left Colonic Carcinoma: Surgical Treatment, Results and Prognosis 31 V . S t o y a n o v , G . Z l a t a r s k i , V . H r i s t o v , I . I v a n o v - Rec­onstructive Operations after Urgent Large Bowel Surgery 32 J . S a v о v - Criteria for Large Bowel Biopsy Material Preparation 32 P . K r u s t a n o v , I . I l i e v , V . M u t a f c h i y s k i - Choice of Time and Method for Colostomy Closure 33 N . I v a n o v , P . M i t e v , I . I l i e v - Preoperative Large Bowel Preparation 33 I . N e d e v , P . K i r a d z h i e v , V . I l i e v - Our Experience with the Appl­ication of Multicomponent Endotracheal Anesthesia in Colorectal Carcinoma Patients 34 L . K o v a c h e v , I . P r e s o l s k i , P . F i l i p o v , V . G r o z e v , I . T s v e t k o v , R . K o l e v , S . I l i e v , P . T o n c h e v - Problems with Large Bowel Ileus of Carcinomatous Nature 35 Y u . R a b c h e v , B . B o y a d z h i e v , I . R a c h e v - Internal Sphinct­erotomy as an Alternative of Colostomy in Rectal Anastomosis Insufficiency 36

К I g n a t o v , D . S t o y k o v , В . N i n o v , R . B u r z a k o v a , H . H a r i n o v , Y u . P e t k o v , I . D i m i t r o v a - Urgent Operative Treatment n Colonic Carcinoma Patients on the Occasion of Inflammatory Complications 36

Paraproctitis and Fistulas

A . S h a f i k , Е1 - S . A b d e l - W a h a b , 0 . E l - S i b a i , A . K h a l i l Anorectal Fistulae: Results of Treatment with Cauterization 37

G . F i c h e v , I . P o r o m a n s k i - Rational Operative Accesses in Disseminated Paraproctitis 37 I . P o r o m a n s k i , G . F i c h e v - Surgical Tactics in the Treatment of Admural Pelvic and Ischiorectal Paraproctitis 38 R . P e n c h e v , I . I l i e v , K . K y o s e v , P . M i t e v - Problems of Treatment in Patients with Acute Paraproctitis 39 L . A t a n a s o v , G . K e m a l o v , Z h . Z h e l y a z k o v - Therapeutic Res­ults in Perianal Fistulas 39 N . T s a n k o v , T s . T s a n k o v - Analysis of Pathogenesis and Therapeutic Results in 700 Perianal Fistulas 40 N . T s a n k o v , M . S t o e v a , T s . T s a n k o v - Perianal Abscesses and Fistulas: Diagnosis and Treatment 40

Diagnosis and Functional Disorders of Colorectal Diseases

A . S h a f i k - Electrorectogram under Normal and Pathologic Rectal Conditions 41 A . S h a f i k , K . A b d e l - M o n e i m - Fecoflowmetry: a New Parameter Assessing Rectal Function in Normal and Constipated Subjects 41 A S h a f i k - Hemorrhoidal Venous Plexuses: Anatomy and Clinical Application 42 M . T r o m p e t t o , G . C l e r i c o , A . R e a l i s L u c , M . P o z z o -Daefecography: Limitations and Uses 43 M . T r o m p e t t o , A . R e a l i s L u c , G . C l e r i c o - Milligan-Morgan and Diathermic Haemorrhoidectomy: a Randomised Prospective Trial 44 B . K o r n o v s k i , D . D o b r e v , S h t . S h t e r e v - Anatomic Variations and Intraoperative Control of Arterial Blood Supply of Colonic Transplantant in Esoph-agocolonic Plastics 45 ЩГ N o e v a , P . P e n c h e v , H . K a d i y a n , P . G y u r k o v , E . A t a n a s o v a - Non-Invasive Registration of Electric Colonic Activity (Experimental and Clinical Investigations) 46 I . V i y a c h k i , V M u y k o v , N . Y a r u m o v , D . V i y a c h k i , M . M i t е v a - Functional Sphincter Insufficiency and Epidural Blockade 46

L . K o v a c h e v - O n t h e Problem of Hampered Large Bowel Evacuation Function 4 L . A t a n a s o v , G . G e l o v , V . M u t a f c h i e v - Non-Operative Treat ment of the Anal and Rectal Prolapse in Childhood 48

Ulcerative Colitis. Crohn's Disease

G . K o b a k o v , T . T e m e l k o v , E . K i r y a z o v , K . I v a n o v , M . S h t i l i y a n o v - Intestinal Reservoires in Benign Colorectal Diseases 49 B . K o r n o v s k i , T . T e m e l k o v , G . K o b a k o v , D . D o b r e v , S h t . S h t e r e v - Acute Vascular Failure of the Intestine and Large Bowel: Intra­operative Tactics and Postoperative Results 49 B . M a n e v s k a , I . K r a s n a l i e v , I . D a n e v , M . A t a n a s o v a , V . G l i n k o v a , D . G a n c h e v a , A . A t a n a s o v a , I . S h a l e v , V . Z h e c h e v - Chronic Non-Specific Colitis: Clinico-Morphological Parallelism 50 A . A l e x a n d r o v a , D . D a m y a n o v , D . N e d i n , G . S t o -y a n o v , P . P u r v a n o v - Criteria for the Volume of Surgical Stage Treatment in Severe Ulcerative Colitis Patients 51 A . A l e x a n d r o v a , H . K a d i y a n , A . M i h o v a - Clinico-histomorphologic-al Parallelism and Indications for Operative Treatment of the Severe Ulcerative Colitis 51 T . T o d o r o v , J . T e r z i y s k i - Non-specific Ulcer of Colon Sigmoideum 52 V . D i m i t r o v , P . K o u r t e v , K . R a l c h e v , Z . D o u d o u n k o v - New Method for Colonic Passage Restoration after Total Proctocolectomy by Using an Antiperistaltic Ileum Part 52 M . M o m c h i l o v , M . R a d i o n o v , D . D z h o d z h e v a - Abdominal Actinomycosis with Atypical Localization in the Distal Part of Colon and Rectum: Report of Two Cases 53

Videofilms

M . T r o m p e t t o , G . C l e r i c o , A . R e a l i s L u c - Transanal Endosc­opic Microsurgery: Indications, Technique and Results 54 S . M a r t e l l i , M . T r o m p e t t o , G . C l e r i c o , A . R e a l i s L u c - Well's Laparoscopic Rectopexis 54 M . T r o m p e t t o , A . R e a l i s L u c , G . C l e r i c o - Dolorme's Operation for Complete Rectal Prolapse 55 T . T e m e l k o v , G . K o b a k o v , E . K i r y a z o v , M . S h t i l i y a ­n o v - M. Gracilis Plastics in 150 Patients 55 T . T e m e l k o v , G . K o b a k o v , E . K i r y a z o v , K . I v a n o v -Transsacral Access in Rectal Tumours 56 T . T e m e l k o v , G . K o b a k o v , K . I v a n o v , E . K i r y a z o v , V . I g n a t o v - Ileal Reservoirs: Indications and Operative Technics 56 B . K o r n o v s k i - Esophagocolonic Plastics after Esophagogastrectomy on the Occasion of Corrosive Injury of the Esophagus and Stomach 57

В K o r n o v s k i - Possibilities for Creating the Colonic Anastomoses by Staplers 56 E . K i r y a z o v - The Place of Nd-YAG Laser Therapy in the Treatment of Col­orectal Cancer 58 V . I g n a t o v , E . K i r y a z o v , Y u . S t e f a n o v a - Endoscopic Polypectomy and Nd-YAG Laser Therapy as Prevention of Colonic Precanceroses 58 K . I v a n o v , C h r . D i a c o v - Three-dimensional Endorectal Ultrasound in Patient with Rectal Cancer 59 K . I v a n o v , C h r . D i a c o v - Three-dimensional Computer Atlas of Endorectal Ultrasound 59 V . G l i n k o v a - Prophylaxis and Treatment of Infections in Coloproctology with Dalacin С (Clindamycin) 60 I . D o n k o v , V . D a s k a l o v , G . G r i g o r o v , K . V a s i l e v , E . B e l o k o n s k i , Z . P a r c h e v , G . G u r b e v , K . V o u k o v - Investi­gation of the Diagnosis and Treatment of Rectal Carcinoma 60 T . T o d o r o v - Retrosternal Esophagocolonic Plastics after Two Gastric Operations and after Corrosive Esophagitis-gastritis 61

Poster Presentations

i n к о v - Eviscerations: Prognostic Factors, Treatment, and Prevention 61 M . G o s p o d i n o v a , M . N e n o v a , E . K i r y a z o v , T . G a n c h e v a -Borderline States between Colonic Infectious Diseases and Colorectal Neoplasms 62 I . P 1 а с h к о v -Treatment of Perianal Fistulas and Abscesses 62 H . K a d i y a n , V . B a k a l o v , P . P e n c h e v , L . T a n k o v a , E . P o p h r i s t o v a - Alien Bodies in the Rectum 63 P . P e n c h e v , H . K a d i y a n , E . P o p h r i s t o v a , A . G e g o v a , I T е r z i е v - Endoscopic Loop Polypectomy in Large Bowel Polyps 63 A . U z u n o v a , M . K a r k u m o v , R . K a r a m f i l o v a - Endorectal Echography in Rectal Carcinoma 64 T s . T s a n k o v -On the Problem of the Clinical Findings and Treatment of Perianal Abscesses and Fistulas 65 P A k r a b o v a , D . M a k u l e v a , I . S t a n c h e v - I s Constipation a Risk Factor for Hemorrhoids: a Study of Potential Etiologic Agents? 65 T . D e l i y s k i , G . B a y c h e v , R . S t o y a n o v - Treatment of Perianal Fistulas by Long-lasting Thread Drainage 66 E . M a r k o v a , T . B e t o v a , S . P o p o v s k a , M . B o y k o v - Progn­ostic and Morphologic Study in Patients with Colorectal Carcinoma 66 H p A t a n a s o v , P . A t a n a s o v , D . K o u r t e v - Ileus Due to Malignant Colonic Diseases: Therapeutic Tactics under the Conditions of a Regional Hospital 67

Author's Index 69

PRE FA СЕ

The Fourth National Conference on Coloproctology with International Participation in Vama is a thirsted reality. Coloproctology is a speciality that proves its existence closely linked with polivalency of abilities of and requirements to be met by the surgeon. The localization of the organs in the pelvic space along with the combined mutually influenced functional and organic unity under pathological conditions present an obligatory precondition for interdisciplinary' familiarity with anatomy, function, and disease. That is why the surgeon defending the prestige of coloproctology is obliged to be aware not only of the whole abdominal surgery but also of the operative urology and gynaecology.

The way to comprehensive and profound knowledge reveals new functional and organic diseases that enlarges the patients' contingent necessitating a competent and complex treatment. The opportunity for combined and organ-matched operations and the enhanced capacities for enlarging the volume of operative reconstructions enable the creativity and surgical initiativeness. By this way these circumstances influence rapidly the forward march of coloproctology as a science and arouse the interest in this discipline of everybody who is being working in the field of large-scale surgery and realizing its significance. The new diagnostic methods prove the opportunity for precise diagnosis of functional, inflammatory and neoplastic diseases. Thus appropriate preconditions for their better treatment can be created.

Making the international contacts enriches the personality and improves by a noble manner the ethic image along with the professional perfectioning. Live and directly communicated information makes up for a knowledge deficiency and gives rise to new interests in science. A tradition forms a school and the school is a warranty for staunchness of interests and ambitions for perfection and progress.

The organization of this traditional meeting is a manifestation of an enthusiasm and willingness for friendship in the name of the surgical community and our national prestige as well.

Prof. Temelko D. Temelkov, MD, PhD, DSc Head, Department of General and Operative Surgery and Clinic of General Surgery with Coloproctology Medical University of Varna Local Organizer and Supplement Editor

Fourth National Conference on Coloproctology with International Participation, Varna'95 Scripta Scientifica Medica, vol. 29, Suppl. 2, J 995 Copyright ©Medical University of Varna

ON THE DIAGNOSIS AND THERAPEUTIC BEHAVIOUR IN C O L O R E C T A L DISEASES

T. Temelkov, K. Ivanov, E. Kiryazov, G. Kobakov, V. Ignatov Clinic of General Surgery with Coloproctology, Department of General and Operative

Surgery, Medical University of Varna, Varna, Bulgaria

The experience gained in the Clinic of General Surgery with Coloproctology, Medical University of Varna, during the recent 15 years with the introduction of modern diagnostic and therapeutic manipulations of colorectal diseases was described. The capacities of echographic endocavital examination of the anus and rectum were demonstrated. During the recent two months the echographic scanning with three-dimensional presentation of the normal and pathological anatomy by a new, computerized variant for image structure demonstration in their exact topographic anatomical space interrelations was also introduced. Visualization enabled the verification of the processses and the performance of puncture diagnostic and therapeutic procedures. This method contributed to the most precise preoperative determination of the stage of the disease in tumour processes.

The technique and results from the application of invasive endoscopic methods for diagnosis and management in 3121 patients during a 7-year period was described. In 358 patients an endoscopic treatment of a carcinoma in situ as well as of malignized polyps and other precancerous states was carried out while in 38 patients a laser photocoagulation and tunnelization of neoplastic processes that obturated the lumen and of postoperative stenoses was performed.

The problem of regional chemotherapy of the liver as well as of the cytostatic introduction into the iliac vessels by means of implantofix in 26 patients was also considered. A total of 32 atypical and 6 typical liver resections in cases with hepatic metastases from a colorectal cancer were done.

The investigation of tumour markers supplemented the diagnostic process during the postoperative period. The problem of pelvic reconstruction after rectum extirpation and in agenesiae in 38 patients as well as of the anal incontinence was paid a particular attention, too. A transposition of m. gracilis was both uni- and bilaterally applied in 150 cases. The creation of pelvic ileal reservoires in 20 patients with ulcerous colitis and diffuse colonic polyposis was introduced, too. Pelvic reservoires of another type were created in 21 patients.

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Fourth National Conference on Coloproctology with International Participation, Varna'95 Scripta Scientifica Medico, vol. 29, Suppl. 2, 1995 Copyright О Medical University of Varna

SPHINCTER SAVING OPERATIONS IN R E C T A L CARCINOMA

T. Temelkov, M. Bozhkov, G. Kobakov, K. Ivanov, M. Shtiliyanov Clinic of General Surgery with Coloproctology, Department of General and Operative

Surgery, Medical University of Varna, Varna, Bulgaria

The authors shared their experience with the application of sphincter saving operations in 1544 patients operated on the occasion of rectal carcinoma. The contingent was divided into two periods. During the first period, from 1970 till 1989, sphincter saving operations were performed in 407 out of a total of 988 patients (41,1 per cent). During the second more recent period, the anus and its function was saved in 443 out of a total of 566 patients operated on (70,9 per cent). The authors suggested a variety of operative methods They had made use of the operations of Parks, Black, Turnbull-Qutait, Mounsell-Wear. Dixon and stapler technique. It was established that best functional results were obtained when the operation after Dixon creating anastomosis with a mechanical stitching, the operation after Mounsell-Wear and Turnbull-Qutait with subsequent operations after Parks and Blackwere used. Each of the aforementioned operations had its own indication in dependence on the anatomical structures, the dissemination of the tumour, and its characteristics according to the TNM system. Both high and low percentages of the application of these operations seemed an extremity. The authors accepted that the opportunities for their usage should be ignored when there existed a risk for development of local relapses. That was why the evaluation of their application required the richest clinical experience when choosing the adequate operative technique.

CONSERVATIVE TREATMENT OF S E L E C T E D R E C T A L CANCERS R. J. Spencer

Mayo Clinic, Scottsdale, AZ 85259, USA

Rectal cancer continues to be a devastating problem. It is an insidous process; however, occasionally a relatively small rectal cancer is encountered and utilization of conservative management for these small lesions should be considered. The justification for conservative treatment of rectal cancer is obvious in those patients with a tumour so near

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Fourth National Conference on Coloproctology with International Participation, Varna'95 Scripta Scientiflca Medica, vol 29, Suppl 2, 1995 Copyright ©Medical University of Varna

the dentate that an abdominal perineal resection is needed - if the tumour is confined local treatment will suffice. The criteria for the selection of cases and the techniques for evaluating these patients will be presented. Techniques for conservative treatment are presented in moderate detail, followed by evaluation of the efficacy of conservative treatment.

THE V A L U E OF C E A IN B I L E IN PATIENTS OPERATED FOR DIGESTIGE NEOPLASMS OR FOR BENIGN

ABDOMINAL DISEASES M. Trompeto, G. C. Guasti, G. Clerico, A. Realis Luc, P. Milani*,

F. Tinivella* Department of Surgery, Coloproctological Service, and ^Laboratory of Microbiological

and Chimico-clinical Analysis, Ivrea Hospital, Ivrea, Italy

Bile contains an unknown quantity of C E A in different pathologies and it should be very important to know, if it is possible and if it exists, its range of normality in this biological liquid. This knowledge could suggest an early chemo- or radiotherapy in patients "radically" operated for colorectal cancer, with normal value of seric C E A but high "pathological" value of this tumoral marker in bile. The aim of this study was to evaluate and compare the value of seric and biliary C E A in benign diseases and digestive malignancies, particularly in patients operated for colorectal cancer. A total of 300 consecutive patients admitted in the Department of Surgery for surgical abdominal procedures for different diseases were investigated. They had a seric and a biliary sample during the surgery. Two hundred of them had a cholelithiasis and bile has been directly taken during the cholecystectomy by emptying of the removed gallbladder. In 37 patients bile could not be sampled because of previous cholecystectomy or possible damage deriving from the procedure. In the rest 63 cases bile was directly taken by puncture of the gallbladder using an insuline syringe during the laparotomies for the different pathologies. Patients with chronic liver diseases or with history or previous operations for cancer were excluded from the study. No complications caused by the procedure occurred. All samples were spin-dried and immediately freezed at -30° С up to the test carried out. C E A was evaluated in the serum as a whole and in the bile prediluted by bovine albumine after an immunometric method with a sandwich technique to a step using two monoclonal specific antibodies and the streptavidine-biotine link as pointing out system.

In the 200 patients with cholelithiasis the mean seric C E A level was 1,7 ng/ml, and the biliary one 16,4 ng/ml. The rest patients were divided in the following groups

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Fourth National Conference on Coloproctology with International Participation, Vamaf95 Scripta Scientific** Medica, vol. 29, Suppl. 2, 1995 Copyright ©Medical University of Varna

according to the pathology: 1)19 cases with colonic cancer (Dukes В and C) had a mean seric C E A value of 3,1 ng/ml and biliary one of 50,6 ng/ml; 2) 14 cases with colonic cancer and hepatic metastases presented a mean seric C E A level of 47,5 ng/ml and biliary one of 522,5 ng/ml; 3) 16 cases with abdominal not colonic carcinomas had a mean seric C E A value of 12 ng/ml and biliary one of 156,7 ng/ml; 4) 14 patients with benign diseases such as IBD, rectal prolapse, and intestinal volvulus had a mean seric C E A value of 4,4 ng/ml and a biliary one of 10,1 ng/ml. One patient with a toxic megacolon presented a very high biliary C E A level of 2135 ng/ml. It was evident that different types of diseases seemed to have comparable values of both seric and biliary C E A although there was no rational explanation up-to-date. The expected higher biliary C E A value was confirmed. It is necessary to examine a greater number of patients in order to establish a normality range of the marker in the bile taking into consideration the big individual differences among single diseases. The elevated biliary C E A levels in IBD and toxic megacolon cannot be explained yet.

R A D I C A L L Y PERFORMED OPERATIONS IN PATIENTS WITH R E C T A L CANCER WHO W E R E LAPAROTOMIED

AND CONSIDERED INOPERABLE IN OTHER HOSPITALS V. Dimitrov, Z. Doudounkov, K. Ralchev, P. Kourtev

Clinic of Coloproctology, National Centre of Oncology, Sofia, Bulgaria

During the period from January 1, 1991 till March 31, 1995, in the Clinic of Coloproctology, the National Centre of Oncology (NCO), Sofia, a total of 16 patients (7 males and 9 females aged between 38 and 72 years) who had been laparotomied and considered inoperable in other hospitals were radically operated for rectal cancer. Three patients (one male and 2 females) with locally advanced tumour in the distal third of the rectum without any evidence of distant metastases were laparotomied and evaluated as inoperable. ТЬец they were admitted to the NCO for radiotherapy. The man underwent rectal extirpation en block together with the whole prostate and seminal vesicles. Both females underwent posterior pelvic evisceration with definite sigmostoma. Echographic evidence of liver metastases was proved 9 months after operation in one female patient who died 1,5 year after the reoperation. Eight patients (3 males and 5 females) with locally advanced tumour in the middle third of the rectum without generalization of the neoplastic process (in the epicrisis of one male and one female patient numerous liver metastases were mentioned which were not seen at reoperation) were considered inoperable and because of ileus phenomena definite sigmostoma was done in 5 of them (one male and

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4 females). The males underwent abdomino-anal rectal resection with sigmostoma closure. Three females underwent posterior pelvic evisceration with coloanal anastomosis and 2 ones - posterior pelvic evisceration with coloanal anastomosis, partial urinary bladder resection and reimplantation of a left ureter. Of this group, seven patients remain still clinically healthy, and one male patient died of liver metastases 2 years after the reoperation. Four patients (2 males and 2 females) with carcinoma in the upper third of the rectum having also infiltrated neighbour organs without any evidence of generalization of the neoplastic process (although in the epicrisis of one female patient numerous liver metastases were mentioned, this was not confirmed at reoperation) were considered inoperable and sigmostoma was created. An anterior rectal resection with partial resection of the urinary bladder in the males and an anterior rectal resection with hysterectomy and ovariectomy in the females were carried out. These patients are still clinically healthy up to present. One male patient with extremely advanced rectal carcinoma with infiltration of the urinary bladder in the area of the triangle only cystostomy was performed in another hospital. The whole abdominal wall around the stoma was affected by the neoplastic process. He underwent pelvic evisceration with coloanal anastomosis. He is clinically healthy 1,3 year after the reoperation.

TUMOUR MARKERS IN PATIENTS WITH C O L O R E C T A L CANCER

I . Viyachki, N. Yarumov, K. Cherneva, D. Viyachki Clinic of Emergency Surgery, Tsaritsa Joanna State University Hospital,

Higher Institute of Medicine, Sofia, Bulgaria

There is a stable tendency towards an incidence rate increase of colorectal cancer in the recent 5 years. Tumour markers play also a significant role in the diagnostics along with roentogenological and endoscopic methods. C E A possesses the highest informative value as tumour-associated antige. CA-19.9 is specific in colorectal cancer. Liver metastases of colorectal carcinoma can be proved by using 23-phetoprotein.

Since 1982 we made use of tumour markers in patients with colorectal cancer. A total of 100 patients aged between 36 and 70 years operated with histologically verified carcinoma of the colon and rectum were followed-up in a time interval of 3 months for a 5-year period. Male-female ratio was 55:45. Patients's serum and imported kit (from Poland and the USA) were used for the radioimmunologic examination. The diagnostic following-up revealed that there were 51 clinically healthy subjects of which 33 tumour marker-negative and 18 tumour marker-positive cases. There were 49 patients with evidence of relapses or metastases of which 40 tumour marker-positive and 9 without enhanced levels

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of the markers. The sensitivity of both markers varies according to literature data available between 37 and 50 %, i. е., it is low. That is why tumour markers are not appropriate for screening investigations.

We conclude that the main application of tumour markers consists in their dynamic postoperative follow-up. The usage of three markers possesses a much higher informative value. That is why they should be applied in any patients with colorectal cancer and particularly postoperatively in a dynamic manner.

SPHINCTER SAVING OPERATIONS AS AN A L T E R N A T I V E IN COLOPROCTOLOGY

I . Viyachki, D. Viyachki, N. Yarumov Clinic of Emergency Surgery, Tsaritsa Joanna State University Hospital,

Higher Institute of Medicine, Sofia, Bulgaria

The performance of sphincter saving operations makes use mainly of several accesses as follows:

1. Abdomino-transanal access - the operations of Babcock-Bacon, the operation of Black, etc.;2. Abdomino-transsacral access - the operation of Kraske; 3. Abdominal access - anterior rectal resection and transrectal operation of Toupe; 4. Transabdominal or transrectal mechanical stitching.

The authors reported a total ot 150 sphincter saving operations of different kind. They were carried out in the Clinic of Emergency Surgery during the period from 1989 till 1994. The advantages and failings of these sphincter saving operations, their strict indications and the results from the operative treatment were analyzed and discussed.

NEW ASPECTS IN THE ETIOPATHOGENESIS OF C O L O R E C T A L CANCER

N. Yarumov, I . Viyachki, M. Karparov, M. Marina, D. Viyachki Clinic of Emergency Surgery, Tsaritsa Joanna State University Hospital,

Higher Institute of Medicine, Sofia, Bulgaria

Colorectal cancer occupies a leading position among neoplastic alimentary tract diseases. In Bulgaria, the incidence rate of colorectal cancer is close to that of stomach cancer tending even to exceed it. Prevalence rate increases from 6,3 up to 26,6 and mortality rate from 4,3 up to 19,5 per 100 000 inhabitants. 20

Fourth National Conference on Coloproctology with International Participation, Varna'95 Scripta Scientifwa Medica, vol 29, Suppl 2, J 995 Copyright ©Medical University of Varna

There exist several etiologic postulates which are important in the etiopathogenesis of colorectal cancer. Dysbacteriosis and resulting fecapentenes exert a mutagenic action. Free bile acids in faeces and their elevated concentration play a crucial role in cancer pathogenesis. Higher intestinal pH is common in most patients with large-bowel carcinoma. Serum cholesterol and ^-lipoproteins show reduced concentrations that is opposite to the enhancement observed with advancing age. Triketosteroid levels are higher among the population with high risk for large-bowel and rectal cancer.

The authors studied 50 patients with histologically verified colorectal cancer operated in the Clinic of Emergency Surgery, Tsaritsa Joanna State University Hospital, Sofia. There was a dependence and etiologic correlation between dysbacteriosis, enhanced levels of bile acids in the faeces and of triketosteroids in the serum and reduced serum cholesterol concentrations. Valvular insufficiency of the gastrointestinal tract played an important role in the etiopathogenesis, too. Insufficient Bauchin's valve was proved in 18 out of 50 patients. However, world science failed to establish a specific reason for colorectal cancer yet. Nevertheless, in the recent 2-3 years, there are new aspects discussed by the authors of crucial importance in proving the pathogenesis of colorectal cancer.

ON SOME ASPECTS OF THE DIAGNOSIS AND SURGICAL TREATMENT OF R E C T A L CANCER D. Damyanov, G. Stoyanov, N. Damyanov*, D. Ignatov, A. Alexandrova, P. Purvanov, A. Angelov, L. Tankova,

R. Lozanov, A. Zhelyazkov Clinic of Abdominal Surgery, * Clinical Centre of Gastroenterology, Tsaritsa Joanna

State University Hospital, Higher Institute of Medicine, Sofia, Bulgaria

During the period from 1974 till 1994 a systemic retrospective investigation was carried out in the Clinic of Abdominal Surgery that covered up to present a total of 1443 patients with rectal cancer. Palliative surgical intervention were performed in 464 of them (in 32,2 per cent of the cases). Operations of this nature amounted to 31,5 per cent during the period from 1974 till 1988 while this rate increased up to 35 per cent during the last 5 years (from 1989 till 1994). The diagnostic schedule for both preclinical and clinical examinations did not changed and covered routine clinical and instrumental methods. No progress in the diagnostics of this disease could be registered. Intraluminal ultrasound diagnostics was introduced that enabled the preoperative precise estimation of the stage of the disease and thus the determination of the volume of the surgical intervention. A total of 979 patients (67,8 per cent of the cases) were radically operated on. The relative share of

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sphincter saving operations was 44,1 per cent during the period from 1974 till 1988. It raised up to 55 per cent for the last 5 years. Anterior rectal resections had the greatest relative share. Instrumental stitching of the anastomosis was mainly used in a low localization of the process. The authors paid attention to the improved preoperative preparation and the precise intra- and postoperative prevention leading to reduced morbidity and mortality rates during the recent five years.

C O L O R E C T A L SURGERY IN PATIENTS AT G E R I A T R I C A GE

D. Damyanov, A. Alexandrova, G. Genchev, R. Lozanov, P. Yanovska, Nedin, S. Rouskova

Clinic of Abdominal Surgery, Tsaritsa Joanna State University Hospital, Higher Institute of Medicine, Sofia, Bulgaria

Patients at geriatric age (over 75 years) form a group requiring more specific care when defining the indications for operation and choosinge the surgical method. During a 27-year period (from June 1969 till June 1995), in the Clinic of Abdominal Surgery, Higher Institute of Medicine, Sofia, 143 patients at old age with colorectal cancer were operated on. They amounted to 7,42 per cent of all the patients with this diagnosis operated on. Colonic cancer was proved in 50 cases but rectal one in 93 cases. It was shown that there was no difference in a diagnostic aspect when clarifying the main disease. However, a precise identification of accompanying pathology (cardiovascular, renal, pulmonary and metabolic disturbances and previous diseases as well) was required. This contingent needed a prolonged and comprehensive preoperative preparation. The authors argued for an active surgical behaviour independently of the geriatric age. Only the severely damaged general status along with the combined accompanying pathology was considered a limiting factor concerning the volume of the surgical intervention in favour of the palliative operation mainly as a priority in rectal cancer localization. Radical operations were performed in 54 per cent of the patients with colonic cancer and in 49 per cent of these with rectal one. An active monitoring of the postoperative period with early mobilization and a series of prophylactic measures reducung complications and lethality rate could be recommended.

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OUR E X P E R I E N C E IN THE SURGICAL TREATMENT OF COLONIC AND R E C T A L NEOPLASMS P. Krustanov, P. Kazandzhiev, Ts. Panov, I . Iliev,

K. Kyosev, V. Mitev Clinic of General Surgery, Military Medical Academy, Sofia, Bulgaria

The authors shared their experience in the treatment of 340 patients with malignant diseases of the colon and rectum. Colonic carcinoma was proved in 160 cases and rectal one in the rest 180 cases. The surgical method of treatment was the cardinal one. It provided satisfactory immediate and long-term results. It was emphasized that perfectioning the methods of preoperative preparation and intensive therapy during the postoperative period contributed to an increased operability rate and to a reduced percentage of complications and lower lethality rate. The operative methods applied as well as the indications for their usage in concordance with the localization, stage of development and distribution of the pathological process were described and discussed.

R E T R O S P E C T I V E ANALYSIS OF CAUSES FOR POSTOPERATIVE L E T H A L I T Y ON T H E OCCASION OF

C O L O R E C T A L CARCINOMA I . Donkov, G. Gurbev, K. Vasilev, G. Grigorov,

E. Belokonski, K. Gabrakov, K. Voukov Clinic of Abdominal Surgery and Oncology, Military Medical Academy, Sofia, Bulgaria

The authors analyzed the autopsy material of the Military Medical Academy for a 5-year period. They made an attempt to detect an interrelation between the patients' age, the main disease and the manner of treatment (non-operative, operative, and complex one) as well as to clarify the causes for complications, relaparotomies and lethal outcomes. The place and role of the complications in thanatogenesis were considered. An analysis of a total of 2283 autopsies performed during the period from 1990 till 1994 was carried out. A main attention was paid to deceased patients after abdominal operations. The investigation covered the age composition, the number of the performed reoperations, the different types of complications as well as the postoperative day of the lethal outcome.

There were a total of 601 postoperative autopsy cases. Some 314 patients had died after an abdominal operation. This was the highest percentage of the lethal outcomes after

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surgical interventions (52,24 per cent). Colonic carcinoma was the most common disease causing death after operation. Postoperative peritonitis presented a main complication after abdominal operations. Early diagnosis of the postoperative peritonitis and timely relaparo­tomy were life-saving events for the patient. Multiorgan insufficiency, acute heart failure and myocardial infarction proved to be the immediate cause for death in planned routine operative interventions such as cholecystectomy and herniotomy. The necessity of carefiil preoperative diagnostics and preparation was obvious.

COMPARATIVE EVALUATION OF RESULTS FROM COLONIC ANASTOMOSES DONE BY AUTOMATIC

S T I T C H E R AND CLASSIC SUTURATION TECHNIQUE I . Donkov, G. Grigorov, K. Vasilev, E. Belokonski, G. Gurbev,

V. Daskalov, K. Voukov Clinic of Abdominal Surgery and Oncology, Military Medical Academy, Sofia, Bulgaria

The authors shared their experience with the 4-year long application of the automatic mechanical stitcher of the "Auto Suture" firm, USA. The study covered two groups of patients. The mechanical stapler was used in order to perform low rectal anastomoses in 58 cases. The classic suturation technique was applied in 240 patients during the same period. The authors compared the results obtained in these groups. The patients were classified according to sex, age, histological morphology of the tumour, and the distance from the anorectal line.

Some conclusions concerning the duration of the operative intervention and the postoperative stay as well as concerning the early and late complications were drawn.

COMPARATIVE STUDIES IN C O L O R E C T A L CANCER SURGERY FOR T H E RECENT F I V E Y E A R S (1990-1994)

T. Pozharliev, A. Deredzhyan, S. Toshev Division of Surgery, Dr. Racho Angelov District Clinical Hospital, Sofia, Bulgaria

On the background of their 40-year long experience with colorectal cancer surgery the authors analyzed and compared their observations for the recent 5 years, i . e. during the period from 1990 till 1994. A total of 297 patients were operated on. Of them, 151 patients had rectal cancer and 146 ones had colonic cancer. During the period from 1954 till 1989, i . е., for a total of 35 years, a total of 2628 patients were operated on. Of them, 24

Fourth National Conference on Coloproctology with International Participation, Varna'95 Scripta Scientifica Medica, vol. 29, Suppl 2, 1995 Copyright ©Medical University of Varna

1463 patients had rectal cancer and 1164 ones had colonic cancer. Radical operations were performed in 246 patients and palliative ones in 51 patients the ratio between them being approximately 5:1. The most common localization of the neoplastic process in colonic cancer was sigma-rectum (in 62 cases), caecum-colon ascendens (in 52 cases), colon descendens (in 17 cases), and colon transversum (in 15 cases). Rectum extirpation was carried out in 57 patients but a sphincter saving operation in 63 ones. This fact indicated the tendency of progressively raising number of sphincter saving operations. There were 7 patients operated with double localization of the neoplasm. Twenty-seven operated patients deceased. The cause for death was embolism in 6 cases, insufficiency and subsequent peritonitis in 8 cases, heart failure in 5 cases, and pulmonary complications in 8 cases. The comparison of the results obtained in the previous 35 years and in the recent 5 ones revealed a significant progress in the improvement of the operative technique and absent advances in the early diagnostics of colorectal cancer.

OUR OWN OBSERVATIONS OF MANY Y E A R S ON DIAGNOSIS AND SURGICAL TREATMENT OF

C O L O R E C T A L CANCER T. Pozharliev, A. Deredzhyan

Division of Surgery, Dr. Racho Angelov District Clinical Hospital, Sofia, Bulgaria

The authors shared their 40-year long experience (from 1954 till 1994) with colorectal cancer diagnostics and surgery. A total of 2925 patients were operated on. Of them, 1771 had colonic cancer and 1154 ones had rectal cancer.The issues related with the diagnosis and management of this disease were considered in two time periods. The first period covered the time interval between 1954 and 1983 reflecting the experience gained in the Clinic of Abdominal Surgery at the former Institute for Specialization and Perfecti-oning of the Physicians, Sofia. The second period covered the recent 25 years (from 1970 till 1994) reflecting the experience gained in the Division of Surgery at the Dr. Racho Angelov District Clinical Hospital, Sofia. The authors emphasized that patients with colorectal cancer were still hospitalized and admitted for a surgical treatment at a rather advanced stage of the disease. The rate of inoperability varied permanently between 25 and 35 per cent. This circumstance was still more valid for the patients with rectal carcinoma which diagnosis was most commonly made by a simple manual examination of the rectum. The authors specifi-ed the indications of the sphincter saving operation in rectal cancer as well as the kind of the operative intervention. They rendered an account of the short-term postoperative results and the lethality rate in different operative methods used which varied between 6 and 8 %.

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B L O C K RESECTIONS IN C O L O R E C T A L CARCINOMA T. Todorov, G. Kondarev, B. Moshev, G. Markov, I . Hiebarova,

V. Lyutzkanov Central Clinical Hospital, Research and Applied Institute, Ministry of Internal Affairs,

Sofia, Bulgaria

The authors presented an attempt in the treatment of colorectal carcinoma for the

period from 1985 till 1994. Clinical material covered 338 patients. They were 229 males and 109 females. Thirty-four block resections of colorectal carcinoma locally expanded and infiltrating the neighbour tissues and organs were performed. According to the tumour localization, they were divided into the following groups: in the rectum - 14, sigma - 1 1 , colon transversum - 2, and colon ascendens - 7 neoplasms.

The resections of both colorectal carcinoma and urinary bladder were carried out in 9 patients, of colon and abdominal wall - in 8 patients, of colon and intestine - in 3 patients, of colon, intestine and urinary bladder - in 2 patients, resection of colon and hysterectomy - in 4 patients, of colon and adnexectomy - in 3 patients, of colon and stomach - in one patient, of rectum and vagina - in 2 patients, and of rectum and adnexectomy - in 2 patients. Postoperative lethality rate was 0 per cent. The surveillance of these patients was followed-up. The results showed that it was comparable with that of the operated patients after standard colectomy in a noninfiltrating colorectal carcinoma.

OUR E X P E R I E N C E WITH THE SURGICAL T R E A T M E N T OF C O L O R E C T A L CANCER

P. Uchikov, Z. Vuzhev, K. Krustev, K. Hekimov, A. Uchikov, H. Hatur Clinic of Thoracic and Abdominal Surgery, Higher Institute of Medicine,

Plovdiv, Bulgaria

Based on a retrospective study for a period of the recent 10 years the authors shared their experience with the operative management of colorectal carcinoma. A higher incidence rate of the colorectal cancer during the recent three years was registered. At the same time, the number of organ saving and sphincter saving operations increased, too. All the large-bowel anastomoses and low anterior resections were performed by means of termino-terminal anastomosis at one floor.

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Copyright ©Medical University of Varna

Since 1992, automatic staplers were currently used in the Clinic of Thoracic and Abdominal Surgery. In this communication the authors reported the results from the comparative investigation of the complications such as stenosis, bleeding from the anastomotic line, insufficiency and relapse of the tumour occurred as a consequence of

clonic anastomoses and low anterior resections performed both manually and by using automatic staplers.

AUTOMATIC STAPLERS IN C O L O R E C T A L SURGERY I . Manchev, Ch. Atanasov, V. Zapryanov, T. Tatsev, I . Ivanov

Clinic of General Surgery, Higher Institute of Medicine, Plovdiv, Bulgaria

The authors shared their experience with the application of automatic staplers in >loproctology for the recent 2,5 years. The automatic staplers of the "Auto Suture" firm,

USA, were used in 47 patients. An emphasis was put on the speed, reliability and almost completely absent contamination during the performance of anastomosis in coloproctology. The applcation of automatic staplers in 23 anterior resections of the rectum with tumour localization up to 4 cm from the A R L proved to be of an outlined effectiveness and reliability of the anastomosis. In such cases, manually done sphincter saving operation (i . е., resection) could hardly be performable and the anastomosis should be untrustworthy, indeed. Some other colonic resections were performed in 21 patients as followed: 9 sigmoid resections, 4 left hemicolectomies, 5 right hemicolectomies, and 3 resections of colon transversum. Large bowel restitution was done in other two patients who had preliminarily undergone a Hartmann's operation. All the patients who underwent anterior resections were ultrasonically examined prior to and after operation by using transrectal ultrasound. The postoperative follow-up examination revealed a local relapse in 2 patients and intra-adominal metastases in other two cases. Four patients deceased as the causes for death were not directly related with the main disease.

COMBINED OPERATIONS IN C O L O R E C T A L CARCINOMA T. Totev, A. Stamov, A. Kyurkchiyan, V. Kolarov, R. Samunev,

I . Katsarov Division of Surgery, District Clinical Hospital, Plovdiv, Bulgaria

The authors shared the experience based on their observations on colorectal carcinoma patients during a 5-year period from 1990 till 1994. A total of 316 patients with colorectal carcinoma were operated on during this period. There were 275 planned and 41

Fourth National Conference on Coloproctology with International Participation, Varna'95 Scripta Scientifica Medica, vol. 29, Suppl. 2, 1995 Copyright ©Medical University of Varna

urgent operations. Combined operations were performed in 45 cases. Of them, 40 patient: were treated according to plan but 5 ones under emergency conditions. A total of 5( combined operations were performed in these 45 patients. A double tumour localizator was established in 5 cases. The opportunity for combined operations enabled an enhancec radicalness. However, there were no changes in the effectiveness of the early diagnosis о the disease. That was why the number of emergency cases requiring surgical managemen during the recent years did not decreased, indeed.

TRANSANAL EXCISION OF R E C T A L TUMOURS THROUGH CLOSED FENESTRATED SPECULUM

T. Deliyski, V. Slizov*, R. Stoyanov, M. Boykov, O. Mustafa University Oncological Centre, Pleven, Bulgaria, and *Free University of Berlin,

Berlin, Germany

The authors presented a method for extirpation of non-large tumours of the rectum situated on a broad basis. A fenestrated plexiglass speculum was constructed according to the model of Dewey's glass speculum. It could be introduced into the rectum. Then through a window sized 4 x 4 cm or 4 x 6 cm the tumour could be excised along with the whole rectal wall. The defect was sutured by means of transversal stitches. This method was successfuly used for excisions of tumours in old and damaged patients.

ON T A B L E LAVAGE M. Trompetto, G. Clerico, A. Realis Luc, M. Pozzo

Department of Surgery, Coloproctological Service, Ivrea Hospital, Ivrea, Italy

All we know that a good intestinal preparation is the best prerequisite for the healing of an anastomosis and that anyway an anastomotic leakage is less dangerous if it happens in a prepared bowel. In emergency large bowel surgery this condition is never present and often we must perform for the security of the patient a divering stoma to protect the anastomosis or only as a simple decompressive procedure. The most frequent emergencies in large bowel surgery are obstruction, in particular for cancer, perforated diverticula and diffuse peritonitis and bleeding. The first evenience is in all series the most common and a multicentric study demonstrated that almost 10 per cent of patients only decompressed died before the second stage operation and the mortality and survival between primary resection and complete staged resections were equal. These data urged many surgeons, and we are with them, to use a simple method allowing to perform primary

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s anastomosis in urgency in a situation as equal as possible to an elective operation.This 5 technique seems to have good results in all cases of colonic obstruction or perforation i distally from the splenic flexure; for the more proximal acute pathologies we prefer to i perform an extended right hemicolectomy that offers an adequate removal of the cause for f the obstruction and enables an immediate and safe ileocolic anastomosis. The technique is t very easy to perform: after the adequate resection a big size tubing for anesthesia is tied

into the proximal divided colon with a lace and its distal end passes over the side of the table draining in an appropriate box. Then a little catheter is inserted into the caecum through the appendix if it is still present or through a small caecostomy. This allows an on table antegrade irritation of all the remaining colon, irrigation that must continue until the water arriving in the box is clear. We must after sacrifice a little distal limb of the proximal divided colon, because ruined by the compression of the lace on the tube and then perform the anastomosis in the usual way. Finally, appendicectomy must be performed or caecostomy closed. In our opinion, this technique is very safe, easy and feasible in all operating theatres where the staff is trained for this kind of operation. So we must inform them of the advantages of this technique about mortality, morbidity, duration of hospital stay, and costs.

COMPARATIVE INVESTIGATIONS IN PATIENTS WITH ESOPHAGOCOLONIC AND ESOPHAGOGASTRIC

PLASTICS S. Kornovski, B. Kornovski, D. Dobrev, V. Ignatov, N. Nikolov

Clinic of General Surgery with Coloproctology, Department of General and Operative Surgery, Medical University of Varna, Varna, Bulgaria

Two groups of patients with already created neoesophagus with colonic graft and gastric graft (10 cases each) were investigated. Based on a roentgenokinegraphic image providing information about the motility of the transplantant and the presence of duodeno-gastric or gastro-colic reflux, 24-hour pH-metry and endoscopy an attempt was made to evaluate objectively the results obtained when both operative methods were applied.

The 24-hour pH-metry demonstrated that irrespective of the performed vagotomy the functional activity of the stomach interponed into the thorax was restored. No gastro­colic reflux was established in a case of colonic transplantant after the performance of the antireflux cologastric anastomosis. Roentgenological^, gastric graft emptying was by two times more accelerated. Dumping syndrome was observed in two patients in contrast to the colonic graft.

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OUR EXPERIENCE WITH PLASTIC ESOPHAGUS REPLACEMENT BY A COLONIC PART

Z. Doudounkov, S. Ivanov, S. Karanov, V. Dimitrov Clinic of Coloproctology, National Centre of Oncology, Sofia, Bulgaria

The experience gained in the Section of Surgery at the National Centre о Oncology, Sofia, with the management of esophageal cancer in 9 patients and of on benign stenosis as well during the period from 1988 till 1994 was presented. A plastic transposition of a colonic part was used to restore the alimentary tract after esophagea resection or by-pass operation. Operative interventions related to large bowel plastics were performed in two variations. In the first variant, after radical subtotal resection of the esophagus or palliative by-pass the colon already prepared for transposition was proximally connected with the cervical part of the esophagus but distally with the anterioi stomach wall. According to this variant, operations were carried out by a radical manner in two patients and by a palliative manner in 6 ones; one patient was operated with a benign stenosis. In the second variant, after simultaneous subtotal resection of the esophagus and total resection of the stomach the colon already plastically prepared for transposition was transponed through the posterior mediastinum or retrosternally in a neoesophagus by its proximal connection with the esophagus and by its distal connection with the duodenum at the borderline to the pylorus (or with the initial part of the ileum as a modification of this variant). Two patients were operated according to this method. The intervention w a s radical in one patient and palliative in another. The right colon was applied in two cases for transposition in an neoesophagus (isoperistaltically) and the colon transversum - in i cases (antiperistaltically). Very good functional results were obtained in all the patients operated on. Two patients deceased as a consequence of aspiration of intestinal contents due to intestinal reflux. Surveillance of palliativelly operated patients was only between 4-6 months because of tumour progression. That was why a laser recanalization and stent placement was recommended for the treatment of stenosis instead of the labour-consuming and risky operation. Stomach transposition was the method of choice at advanced age as the time for the surgical intervention was considerably shortened. Some patients of interest who presented well the peculiarities of both variants were analyzed. The best result from the plastic esophagus replacement by colon was obtained in benign stenosis of the esophagus by using a colonic by-pass. Because of stomach preservation the colonic transposition in a neoesophagus should be recommended in radically operated younger patients, too.

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DISSEMINATED L A R G E BOWEL PERITONITIS D. Loulchev, H. Tsekov, S. Strougarov, Klein, G. Antov

ection of Emergency Surgery, N. I. Pirogov Research Institute of Emergency Medicine, Sofia, Bulgaria

An analysis of 117 patients with disseminated large bowel peritonitis treated in the Clinics of the Section of Emergency Surgery, N. I . Pirogov Research Institute of Emergency Medicine, Sofia, during the recent 5 years (from 1990 till 1994) was carried out. Of them, 65 patients had malignant neoplasms located in the colon and rectum, 15 patients' peritonitis was not of neoplastic etiology while there was a traumatic large bowel peritonitis in the rest 37 cases. A particular attention was paid to the methods and systems for determination of the severity of peritonitis and the capacities of some point systems such as APACHE-I I and MPI were revised. The surgical tactics and strategy depended on the basic pathological process and its localization. Both intraoperative sanation of peritoneum and pathogenic source elimination were obligatorily incorporated in the management. Recently, the aspiration for primary radical behaviour concerning the malignant causes for the large bowel peritonitis was discussed. A radical resection with primary anastomosis was performed in 13 patients with cancer of the caecum and colon ascendens as well as in two patients with cancer of the sigma. A discontinuing resection was carried out in 45 patients operated on the occasion of left colonic cancer. In the Section of Emergency Surgery, a closed lavage by using drainage systems placed during the first operation was adopted. The abdomen that was left open was considered indicated for relaparotomy. The opportunities of the variations of the primarily left open abdomen and the enlarged indications for the performance of primary anastomosis were discussed. The reasons and possibilities for reducing the mortality rate down from its rather high value of 57 per cent in patients with disseminated large bowel peritonitis were analyzed.

ACUTE ILEUS DUE TO L E F T COLONIC CARCINOMA: SURGICAL TREATMENT, RESULTS AND PROGNOSIS

P. Stefanov, E. Mihaylov, O. Cholakov Section of Emergency Surgery, N. I Pirogov Research Institute of Emergency Medicine,

Sofia, Bulgaria

During the period from 1991 till 1994 in the N. I . Pirogov Research Institute of Emergency Medicine, Sofia, a total of 111 patients with acute ileus caused by left colonic carcinoma were operated on. All the patients were admitted under urgent conditions and operated after a short preoperative preparation. The results from the applied operative

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intervention were demonstrated and discussed. The complications and reasons for them ii| the early postoperative period were also considered. A comparative analysis of the resultsj from one-floor and two-floor operative interventions was carried out.

RECONSTRUCTIVE OPERATIONS A F T E R URGENT LARGE BOWEL SURGERY

V. Stoyanov, G. Zlatarski, V. Hristov, I . Ivanov Section of Emergency Surgery, N. I. Pirogov Research Institute of Emergency Medicine,

Sofia, Bulgaria

The purpose of this study was to analyze the cases with intestinal passage

restoration after resectional large bowel surgery. During the period from 1990 till 1994 in the Section of Emergency Medicine, N. I . Pirogov Research Institute of Emergency Medicine, Sofia, a total of 128 patients were operated on. In these patients, anus praeter naturalis was created as followed: an one-trunk anus in 92 cases and a two-trunk anus in 36 ones. The operation was not carried out on the occasion of a neoplastic process in 8 patients. During the same period 49 reconstructive operations in patients with anus praeter naturalis were performed, too. The mean age of the patients operated on was of 58 years.

The reconstructive operations in patients with neoplastic diseases were carried out at least 6 months after the preceding surgical intervention in case of absent visible metastases. Forty-six patients survived but three patients deceased.

C R I T E R I A FOR L A R G E BOWEL BIOPSY M A T E R I A L PREPARATION

J. Savov Section of Emergency Surgery, N. I. Pirogov Research Institute of Emergency Medicine,

Sofia, Bulgaria

In everyday practice, surgeons resect large bowel parts of different length on the occasion of various diseases and then send these specimens in special containers appropriate for this purpose to the pathomorphological divisions. These specimens are accompnied by an index-card entitled "Request for pathological-histological examination" The operative intervention and surgical finding listed in this index-card underlie the clinical

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Fourth National Conference on Coloproctology with International Participation, Varna'95 Scripta Scientifica Medica, vol 29, Suppi 2, 1995 Copyright ©Medical University of Varna

diagnosis. The final diagnosis of pathologists is based in 90 per cent of the cases on the macroscopic evaluation of the operative material. This determines, therefore, its extraordinarily high value. The comparison of the finding with the clinical diagnosis is also required. In order to enhance its preciseness we present our material concerning the macroscopic evaluation of the speciemens resected from the large bowel. Some guidelines to overcome the diagnostic difficulties are offered based on the exact and highly skilled description of the macroscopic finding, the correct examination of the materials as well as on the practical advices concerning their labelling and the improvement of the organization of biopsy material forwarding procedures.

C H O I C E OF T I M E AND METHOD FOR COLOSTOMY CLOSURE

P. Krustanov, I . Iliev, V. Mutafchiyski Clinic of General Surgery, Military Medical Academy, Sofia, Bulgaria

The authors shared their own experience with the performed reconstructive-restorative operations in 42 patients with colostomies. The analysis of the results demonstrated that the time interval between 4 and 6 months after colostomy creation was the optimal term for the restoration of the intestinal passage. The conclusion was drawn that the choice of method for colostomy closure should be correctly specified in dependence on the nature of the main disease as well as on the type and localization of the stoma. The authors recommended the intraabdominal approach for colostomy closure as a more radical one. Besides this method ensured less postoperative complications.

P R E O P E R A T I V E L A R G E BOWEL PREPARATION N. Ivanov, P. Mitev, I . Iliev

Clinic of General Surgery, Military Medical Academy, Sofia, Bulgaria

In the present report the authors' experience with the preoperative preparation of tients who were due to undergo a large bowel operation was presented. A problem-

focused survey of the world practice in this field was done as the development of the

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Fourth National Conference on Coloproctology with International Participation, Varna'95 Scripta Scientifica Medica, vol. 29, Suppl. 2, 1995 Copyright ©Medical University of Varna

problem was chronilogically followed-up year in, year out. Both priorities and disadvantages of different methods according to the leading teams in large bowel surgery were considered. The analyzed own material covered a total of 340 large bowel operations during a 5-year period (from 1990 till 1994). Of them, 180 operations involved the colon and 160 ones the rectum. During the aforementioned period the authors applied consecutively three different methods for preoperative and intraoperative prevention of the complications in large bowel surgery. The observations of the authors on the effectiveness of every single method were demonstrated. The algorithm that dominated in their practice was also presented.

OUR E X P E R I E N C E WITH THE APPLICATION OF MULTICOMPONENT ENDOTRACHEAL ANESTHESIA

IN C O L O R E C T A L CARCINOMA PATIENTS I . Nedev, P. Kiradzhiev, V. Iliev

Central Clinical Hospital, Research and Applied Institute, Ministry of Internal Affairs, Sofia, Bulgaria

The authors shared the three-year long experience of the Clinic of Anesth­esiology, Reanimation and Intensive Treatment at the Central Clinical Hospital, Research and Applied Institute, Ministry of Internal Affairs, Sofia, with the analgesia of 109 colorectal carcinoma patients. Most common patients' troubles were related with accompanying anaemic, hypoproteinemic and intoxication syndromes as well as with accompanying somatic diseases. This circumstance necessitated a preliminary 4-5-day long preparation with blood, plasma, volume-supersession and substitution solutions as well as an antihypertensive, antiarrhythmic and antidiabetic therapy. With a view to the prevention of infectious complications an intravenously administered antibiotic of the cephalosporine group was intraoperatively incorporated in the therapeutic schedule in 11 patients. Both atropin and phentanyl were used for premedication purposes. The introduction into the anesthesia was performed with 2 ml of phentanyl and in case of high arterial pressure values with 1-2 ml of intravenous droperidol, thiopental in a dose of 2-4 mg/kg, and myorelaxin in a dose of 1-1,5 mg/kg. The necessity for a preoperative preparation, the danger of hypotension on the background of the existing dehydratation and cachexia along

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Fourth National Conference on Coloproctology with International Participation, Varna'95 Scripta Scientifica Medica, vol. 29, Suppl. 2, J 995 Copyright ©Medical University of Varna

with the opportunity for a massive intraoperative haemorrhage imposed the canulation of v. jugularis interna or of v. subclavia. Multicomponent endotracheal anesthesia was carried out by using laughing gas-oxygen in a half-closed system combined with neurolept­analgesia and non-depolarizing muscular relaxative. The mean duration of the operative intervention amounted to 150-240 min and extubation was done 15-20 min after the end of the operation. Intraoperative reanimation consisted in low-molecular and high-molecular volume-substitution solutions, blood and plasma in an amount ensuring a hemodynamic stability and good diuresis. The good results achieved enabled the recommendations of these authors1 principles for guidance of the anesthesia and intraoperative reanimation in colorectal carcinoma patients.

PROBLEMS WITH L A R G E BOWEL ILEUS OF CARCINOMATOUS NATURE

L. Kovachev, I . Presolski, P. Filipov, V. Grozev, I . Tsvetkov, R. Kolev, S. Iliev, P. Tonchev

Apartment of Propedeutics of Surgery, Higher Institute of Medicine, Pleven, Bulgaria

During the period from 1990 till 1994, a total of 44 patients with large bowel ileus determined by a carcinomatous process were admitted to the Department of Propedeutics of Surgery at the Higher Institute of Medicine, Pleven. Radical and palliative operations were performed in one half of the patients each. In the postoperative period three radically operated patients deceased (13,6 per cent) because of anastomosis insufficiency, postoperative pancreatitis and pulmonary embolism, respectively. The mean age of the radically operated patients was 74 years. Postoperative lethality rate in palliatively operated patients was 22,7 per cent (i. е., 5 lethal outcomes). Among the 20 radically operated patients, five-year surveillance amounted to 10 per cent (two patients) and a three-year one - to 35 per cent (7 patients). There were no palliatively operated patients who had survived longer than 2 years. Most of these patients did not survive longer than 6 months. Both age and gender did not influence upon the surveillance rate. However, it correlated with the degree of malignancy and the stage of the neoplastic disease. These results demonstrated that even the patients who had been considered and evaluated as radically operated in case of manifested large bowel ileus presented already an advanced malignant disease.

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Fourth National Conference on Coloproctology with International Participation, Varna'95 Scripta Scientifica Medica, vol. 29, Suppl. 2, 1995 Copyright © Medical University of Varna

INTERNAL SPHINCTEROTOMY AS AN A L T E R N A T I V E OF COLOSTOMY IN R E C T A L ANASTOMOSIS INSUFFICIENCY

Yu. Rabchev, B. Boyadzhiev, I . Rachev Department of Surgery, Higher Institute of Medicine, Pleven, Bulgaria

Extraperitoneal colorectal anastomosis is threatened with insufficiency because of anatomical and physiological preconditions such as absent serous layer of the subperitoneally located rectum and increased tension in it as a result from the normally acting anal sphincter mechanism. Different practices such as anal dilatation, rectal tubing, and colostomy are applied in order to diminish the intraluminal pressure of both gases anc feces. The internal sphincterotomy is suggested as an alternative of the aforementionec techniques. The authors describe two patients with insufficient anastomosis who were favourably influenced after the performance of the internal sphincterotomy. The technique is identical to that applied in case of anal fistula. Postoperative anal continence was satisfactory in both patients. However, this operation has not been done with a prophylactical purpose to avoid the failure of a colorectal anastomosis yet.

URGENT OPERATIVE TREATMENT IN COLONIC CARCINOMA PATIENTS ON THE OCCASION OF

INFLAMMATORY COMPLICATIONS K. Ignatov, D. Stoykov, B. Ninov, R. Burzakova,

H. Marinov, Yu. Petkov, I . Dimitrova Department of Surgery, Higher Institute of Medicine, Pleven, Bulgaria

In the present communication an analysis was made of the clinical features, operative interventions and surgical tactics in 12 patients operated in the First Clinic of Surgery at the Higher Institute of Medicine, Pleven, on the occasion of an "acute abdomen". Intraoperatively, a colonic carcinoma that had induced a severe peritonitis -ileus or a carcinoma at a destruction stage with different clinical forms of peritonitis could be established. The authors considered the clinical peculiarities of the diseases, the reasons for the delayed therapeutic behaviour, and the kinds of operative interventions undertaken in these patients. A special attention was paid to the analysis of the final results. Some conclusions about the most favourable and economically effective surgical tactics in patients with colonic carcinoma were drawn. 36

Fourth National Conference on Coloproctology with International Participation, Varna'95 Scripta Scientific** Medica, vol 29, Suppl 2, 1995 Copyright © Medical University of Varna

ANORECTAL FISTULAE: RESULTS OF T R E A T M E N T WITH CAUTERIZATION

A. Shafik, El-S. Abdel-Wahab**, O. El-Sibai***, A. Khalil* Department of Surgery and ^Department of Pathology, Faculty of Medicine, University of Cairo, Cairo; **Zagazig Hospital, Zagazig, and ***Department of Surgery, Faculty

of Medicine, Menoufta University, Egypt

The results of treatment of anorectal fistulae by electrocauterization in 24 patients were compared with those obtained by laying open operation in another 24 patients. Both groups matched for age, gender, fistula type and follow-up duration. In the cautery group, a fistula cautery probe was introduced into the fistulous track and the electric current was switched on for a few seconds. The laying open operation was done in the classical way.

In the electrocauterization group, recurrence occurred in 3 patients (12,5 per cent). The procedure was done under local anesthesia as an outpatient procedure. Mild analgesic was given to 8 patients. No antibiotics were administered. Continence was not affected. In the laying open operation, relapses occurred in 4 patients (16,7 per cent). The procedure was performed under general anesthesia with a mean hospital stay of 2,2 days. Analgesics and antibiotics were given to all the patients. Temporary continent disorders occurred in 3 patients; one patient remained incontinent for flatus and fluid stools. In conclusion, electrocauterization for anorectal fistulae is a simple, easy, safe and effective procedure. Moreover it is less costy and can be performed on an outpatient basis.

RATIONAL OPERATIVE ACCESSES IN DISSEMINATED PARAPROCTITIS

G. Fichev, I . Poromanski inic of Purulent and Septic Surgery, N. I. Pirogov Research Institute of Emergency

Medicine, Sofa, Bulgaria

The arch-like and radial sections widely used in the surgical practice do not satisfactorily meet the requirements in cases of disseminated paraproctitis. In the recent 10 years, looking for rational operative accesses, we introduced in the Clinic of Purulent and Septic Surgery, N . I . Pirogov Research Institute of Emergency Medicine, Sofia, the "T",

J ' \ and "V"-shape sections as well as the combinations of them. However, the combinations of sections often created areas of poorly drained or even open zones thus

37

Clin.

Fourth National Conference on Coloproctology with International Participation, Varna'95 Scripta Scientifwa Medica, vol 29, Suppl 2, 1995 Copyright О Medical University of Varna

resulting in soft-tissue defects which were rather irregular and difficult to close. That was why in the recent ten years we applied in the treatment of disseminated paraproctitis the following modifications called "omega" because of the considerable similarity with that character as well as "the combined sections". In the latter variant, the section continued on raphe perinei, then on raphe scroti and passed into exploratio scroti. In the opposite direction, the section could without any troubles continue and then reach the sacral area if necessary. These sections were applied in more than 250 patients during the period of the recent ten years. The clinical practice and the nonparametric analysis carried out that accepted a significance level concerning the final result the state of a healed patient or of! chronified one allowed us to accept that these sections had essentially contributed to the favourable therapeutic results.

SURGICAL TACTICS IN THE TREATMENT OF ADMURAL P E L V I C AND ISCHIORECTAL PARAPROCTITIS

I . Poromanski, G. Fichev Clinic of Purulent and Septic Surgery, N. I. Pirogov Research Institute of Emergency

Medicine, Sofia, Bulgaria

During the period from 1965 till 1988 in the Clinic of Purulent and Septic Surgery, N . I . Pirogov Research Institute of Emergency Medicine, Sofia, a total of 110 patients with high pelviorectal and ischiorectal abscesses located immediatelly to the wall of the rectum were treated. The patients were operated according to the method of transrectal incision and introduction of a Redon's drainage approved in the Clinic. How­ever, we came upon the fact that a relapse of the disease was established in almost all the patients in a period of ten years after operation. This circumstance as well as the changed knowledge about the origin and dissemination of the acute paraproctitis gave us reason to replace the operative tactics and to pass to the external operative access by using an arch-shaped or "T"-shaped section in dependence on the depth of the process. In the early postoperative period a revision of the wound and the "entrance orifice" i f present was performed. We operated 98 patients after this new method. Relapses were found out in 3 patients only (3,06 per cent). This enabled us to accept as an operative behaviour the external access thus completely excluding the transrectal resection and Redon's drainage because of the extraordinarily high percentage of relapses with the aforementioned operation type.

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PROBLEMS OF TREATMENT IN PATIENTS WITH A C U T E PARAPROCTITIS

R. Penchev, I . Iliev, K. Kyosev, P. Mitev Clinic of General Surgery, Military Medical Academy, Sofia, Bulgaria

The authors analyzed the results of the treatment of 92 patients with acute paraproctitis. The complex method of treatment of such patients which was elaborated and adopted in the Clinic of General Surgery, Military Medical Academy, Sofia, was described. This method was based on the radical operative intervention with subsequent restoration therapy. It was emphasized that the choice of an optimal volume of the operative intervention in case of acute paraproctitis was of crucial importance for the prevention of both relapses and fistulae. Surgical methods used in the different kinds of acute paraproctitis were also demonstrated in the present communication. Antibacterial and disintoxication treatment along with immunotherapy occupied an important place within the complex management of this disease. The application of this complex method of treatment allowed to achieve positive results in 92 per cent of the patients.

T H E R A P E U T I C RESULTS IN PERIANAL FISTULAS L. Atanasov, G. Kemalov, Zh. Zhelyazkov

Division of Surgery, Regional Hospital, Haskovo, Bulgaria

During the period from 1990 till 1994 in the Division of Surgery, the Regional Hospital, Haskovo, a total of 37 patients with perianal fistulas were diagnosed and treated. The following diagnostic methods were used: clinical examination and rectal finger examination (in 37 patients or 100 per cent each); fistulography (in 28 patients or 75,68 per cent); rectoromanoscopy (in 7 patients or 18,92 per cent); sphincterotonometry (in 3 patients or 8,11 per cent), and irrigography (in 5 patients or 13,51 per cent of the cases). There were 13 patients (35,14 per cent) with intrasphincterically located fistulas, 15 ones (40,54 per cent) with transsphincterically located fistulas, and 9 ones (24,32 per cent) with extrasphincterically located fistulas. Complete fistulas were established in 29 patients (78,38 per cent) but incomplete ones with orifice from the inside outwards in the rest 8 patients (21,62 per cent). There was a preceding paraproctitis in all 37 patients. The fistula was formed during the first 6 months after the paraproctitis in 28 patients (75,68 per cent) and until the end of the first year after the paraproctitic in the rest 9 patients (24,32 per cent). The following operative methods were applied: total fistula extirpation after W.

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Fourth National Conference on Coloproctology with International Participation, Varna'95 j Scripta Scientifica Medica, vol 29, Suppl 2, 1995 Copyright ©Medical University of Varna

Gabriel - in 11 patients (29,74 per cent), ligature method after Jonnesco - in 18 patients (48,64 per cent), elastic ligature method - in 4 patients (10,81 per cent), extirpation with Whitehead's operation - in 3 patients (8,11 per cent), and anus praeter naturalis of the sigma - in one patient (2,70 per cent of the cases). There were relapses in 5 patients only (13,51 per cent of the cases).

ANALYSIS OF PATHOGENESIS AND T H E R A P E U T I C RESULTS IN 700 P E R I A N A L FISTULAS

N. Tsankov, Ts. Tsankov Division of Surgery, Municipality Hospital, Botevgrad, Bulgaria

According to authors' material, abscesses, mucosal rhagades and haemorrhoides as well as states after anorectal surgery presented the main causes for perianal fistulas. Fistulography, tubing and injection of dye substance possessed the greatest diagnostic value when clarifying the kind of the fistular canal The analysis of the patient contingent of the Division of Surgery revealed that the internal fistular orifice could not be detected in approximately 8 per cent of the cases. Perianal fistulas were more common in males than in females. The treatment of perianal fistulas is difficult, prolonged and requires endurance from both physician and patient. Four operative methods were mainly applied in the treatment of the perianal fistulas as followed: ligature, excision with drainage, extirpation, and closed suture. The authors preferred the ligature method as its usage proved the best postoperative results.

PERIANAL ABSCESSES AND FISTULAS: DIAGNOSIS AND T R E A T M E N T N. Tsankov, M. Stoeva, Ts. Tsankov

Division of Surgery, Municipality Hospital, Botevgrad, Bulgaria

In general, diagnosis of perianal abscesses and fistulas is relatively easy while treatment is much more difficult and long-lasting often accompanied by relapses. The authors shared their own experience with the treatment of a total of 350 perianal abscesses and fistulas. In these patients, the ratio between primary and recurrent cases was 5:1. Males were more commonly affected. In most cases, perianal fistulas were complete. The ligature method was preferred as its application resulted in less relapses and a definite healing could be achieved.

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Fourth National Conference on Coloproctology with International Participation, Varna'95 Scripta Scientifwa Medica, vol. 29, Suppl. 2, 1995 Copyright О Medical University of Varna

E L E C T R O R E C T O G R A M UNDER NORMAL AND PATHOLOGIC R E C T A L CONDITIONS

(r- scqi A. Shafik

Department of Surgery, Faculty of Medicine, University of Cairo, Cairo, Egypt

The rectal electric activity recorded by electrorectogram (ERG) was studied in 23 healthy volunteers, 22 chronically constipated subjects, 18 patients with chronic proctitis and 14 patients with Hirschsprung's disease. The recordings were done using a silver-silver chloride electrode situated 1 cm from tip of a 6 f catheter which was applied to rectal mucosa by suction. At least 4 recording sessions of 120 min each were performed for every individual. In normal subjects, regular and reproducible pacesetter potentials (PP) were recorded with a mean frequency of 2,6 ± 0,4 cycle/min (cpm), amplitude of 1,9 ± 0,6 mV and velocity of 4,2 ± 0,9 cm/sec. They were randomly followed by action potentials (AP). In patients with inertia constipation, PP were so infrequent that in the majority of cases half an hour would have elapsed without PP recording; mean frequency was 2,4 ± 0,2 cycle/60 min, amplitude was 0,92 ± 0,02 mV and velocity was 4,1± 0,6 cm/sec. AP were recorded only in 4 out of 14 patients during the recording time, in 2 patients they were occasional. In obstructive constipation regular and reproducible PP recorded higher frequency (p < 0,01) and velocity (p < 0,05) than normal. Two E R G patterns were thus identified in chronic constipation: bradyrectia in inertia constipation and tachyrectia in obstructive constipation. In the proctitis patients, the PP frequency was higher (mean 8,2 ± 1,6 SD cpm in bilharziasis and 8,9 ±2,1 SD cpm in ulcerative proctitis) (p < 0,001) while the amplitude and velocity were lower than normal (p < 0,05 and p < 0,01, respectively). AP had higher frequency and amplitude. In Hirschsprung's disease, neither PP, nor AP were recorded and a "silent" E R G was reproducible. In conclusion, E R G is a technique by which rectal electric activity is recorded. It is non-invasive and non-radiologic. Therefore, it could be included as an investigative tool in rectal detrusor disorders.

F E C O F L O W M E T R Y : A NEW PARAMETER ASSESSING R E C T A L FUNCTION IN NORMAL AND CONSTIPATED

SUBJECTS A. Shafik, K. Abdel-Moneim*

Department of Surgery, Faculty of Medicine, University of Cairo, and *Sahel Teaching Hospital, Cairo, Egypt

Fecoflowmetry is a new technique by which the fecal flow rate (FFR) is studied through recorded curves representing the changes occurring in the rate against time. F F R is

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Fourth National Conference on Coloproctology with International Participation, Varna'95 Scripta Scientifwa Medica, vol. 29, Suppl. 2, 1995 Copyright ©Medical University of Varna

the product of rectal detrusor action against outlet resistance. The technique was performed on 36 normal volunteers and 88 chronically constipated patients. An one-litre enema was given to the individual. Upon feeling the desire to defecate, she/he was placed on the commode of a fecoflowmeter and was asked to defecate. Evaluation of the obtain­ed defecation flow curve comprised reporting on the defecated volume, flow time, maximum and mean F F R and the shape of the curve. Developed to simulate natural defecation, the technique assessed all objective parameters in one test. It provided quantitative and qualitative data concerning the act of defecation.

In the 88 constipated patients, two fecoflowmetric patterns were recognized: non­obstructive (inertia) and obstructive. They differed from each other in parameters and curve configuration. The evacuated volume and maximum and mean F F R were smaller in outlet obstruction than in the inertia type, whereas flow time and time to maximal flow were more prolonged. The ascending limb in the obstructive type curve rose less steep than that in inertia. The curve had a long plateau and the descending limb sloped more gradually. To conclude, fecoflowmetric studies could differentiate between defecation of normal and constipated subjects, and in the latter between the obstructive and the inertia type of constipation. The procedure was simple, non-invasive and useful in screening defecation and rectal disorders.

HEMORRHOIDAL VENOUS PLEXUSES: ANATOMY AND C L I N I C A L APPLICATION

A. Shafik Department of Surgery, Faculty of Medicine, University of Cairo, Cairo, Egypt

A study (Shafik, 1985) of the hemorrhoidal venous plexuses by radiographic and plastic injection has demonstrated 2 plexuses: submucosal and adventitial. Two to six "hemorrhoidogenital veins" were identified to connect the hemorrhoidal plexus with the prostatic or vaginal one. The study refutes the theory of venous congestion in the hemorrhoidal plexus as being primary event in hemorrhoidogenesis. When contrast medium is injected in anal submucosa, urinary bladder is opacified (Shafik, 1984). Hemorrhoids are believed to play a role in recurrent bacteriuria. Rectal flora reaches the congested genitourinary organs through the hemorrhoidogenital veins (Shafik, 1985). Further studies by Shafik et al. (1985) have proved that anal route administration provided adequate channel required for Misonidazole, a radiation sensitizer, to promote radiation responsiveness in bladder carcinoma. Another study (Shafik, 1984) has shown that hemorrhoids are a "disease" caused by a fibrous tube called "anorectal band" in the lower rectal neck. The constricting effect of the anorectal band on the rectal neck resulted in elevation of its pressure, straining at defecation and prolapse of rectal mucosa. Division of 42

Fourth National Conference on Coloproctology with International Participation, Varna'95 Scripta Scientifica Medica, vol 29, Suppl 2, 1995 Copyright ©Medical University of Varna

the anorectal band (bandotomy) with hemorrhoid ligation was pract-iced in 502 patients with hemorrhoids. The results obtained were satisfactory and the complications were considered negligible.

DAEFECOGRAPHY: LIMITATIONS AND USES M. Trompetto, G. Clerico, A. Realis Luc, M. Pozzo

Department of Surgery, Coloproctological Service, Ivrea Hospital, Ivrea, Italy

Functional disorders of the defecation are a new diagnostic and therapeutic field for surgeons. So coloproctologists became not only surgeons but little by little changed into researchers in physiology and mechanisms of defecation with the aim of choosing the best treatment for the single patient. A series of new investigations were carried out that confirmed some diagnosis based on an accurate history of the patients and carefiil clinical examination. Anyway some centres, also very important ones consider the forefinger examination the best instrument for coloproctologists to study recto-anal physiology.

Daefecography is helpful in numerous frequent pathologies such as rectal intussusception, rectal prolapse, rectocele, many combinations between them, paradoxal puborectalis syndrome, perineal descent syndrome, incontinence and solitary rectal ulcer syndrome. In these disorders of defecation daefecography allows to confirm clinical diagnosis, to enhance manometric, EMGgraphic and bioptic results, to quantify the problem and to control therapeutic results. Rectal prolapse in its different degrees and rectocele are the most common eveniences in which the utility of daefecography always performed only with a view to a surgical approach is evident. The coloproctologist must remember that he always operates on the patient and not on the x-ray. Similarly to E M G , daefecography is very helpful in the diagnosis of the paradoxal puborectalis syndrome treatable successfully by biofeedback and in selected more severe cases by surgical methods. In case of incontinence the complete etiopathogenetic picture can be provided only if all the physiological examinations have been done. Daefecography can confirm the diagnosis of the perineal descent syndrome caused by the excessive and prolonged straining with stretching and damage of pudendal nerves with consequent weakness of the pelvic floor. Finally, daefecography is complementary but useful to confirm the diagnosis, first of all clinically, endoscopically and bioptically, of the solitary rectal ulcer syndrome. We can conclude that this method is very important for the coloproctologist. However, it is not miraculous investigation but only a good help for some diagnosis of functional rectoanal disturbances. The significance of daefecography was confirmed lately by the members of Ле Coloproctological Section of the Royal Society of Medicine and of the American Society of Colon and Rectal Surgeons who gave their positive opinion about this mvestigation for the "availability, use and perceived helpfulness for the evolution of the

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Fourth National Conference on Coloproctology with International Participation, Varna'95 Scripta Scientifwa Medica, vol 29, Suppl 2, 1995 Copyright ©Medical University of Varna

physiology of the rectum and anus". In our opinion, daefecography must be considered with caution and common sense given the wide range of normal variation in the control population and in the patients, too. The radiologist should be very interested and trained enough. He should undoubtedly closely collaborate with the coloproctologist when interpreting the results from the daefecographic investigation .

MILLIGAN-MORGAN AND DIATHERMIC HAEMORRHOIDECTOMY: A RANDOMISED

PROSPECTIVE T R I A L M. Trompetto, A. Realis Luc, G. Clerico

Department of Surgery, Coloproctological Service, Ivrea Hospital, Ivrea, Italy

Today we have many techniques to operate haemorrhoids and the choice of the operation depends on many factors the personal ideas of the surgeon coming not last. I f we consider all kinds of haemorrhoids, 70-80 per cent of them are treated as out-patient. However, sometimes because of severe disease or patient's preferention a conventional surgical approach has to be used. All the techniques have both advantages and dis­advantages that requires a personal choice having in mind some factors such as post­operative pain, bleeding, time for healing, hospital stay duration, work incapacity duration, etc. We have always performed the Milligan-Morgan's operation with the classical steps: local infiltration with Adrenalin 1:200 000, dissection of the haemorrhoids by scissors, high ligature of the pedicle, and haemostasis.

Forty consecutive patients were randomized in two groups by closed envelopes. Group A - 20 patients with Milligan-Morgan's procedure, and group В - 20 patients with diathermic haemorrhoidectomy without peduncle ligature. No significant difference for sex (p = 0,72) and age (p = 0,89) in these groups was noted. All the patients had third or fourth degree haemorrhoids. Any possible concomitant colonic disorders were excluded along with indications for out-patient therapies. The patients were admitted the day before the operation and had a glycerine suppository in the evening prior to operation. Only after the exposition of the haemorrhoids on the operatory table and their local infiltration with Adrenalin we opened the envelope and could choose the technique. Discharge from hospital was done after the first bowel movement. Patients visited the clinic 7 days after the operation and then every two weeks until the complete healing of the wounds. Eventual disorders of miction and defecation were also registered. Pain was evaluated following an analogous linear scale at three levels: slight, moderate, and severe. Postoperative treatment consisted in Agiolax for 4 weeks. Noramidopyrine and Ketoralac were used as analgetic

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Fourth National Conference on Coloproctology with International Participation, Varna'95 Scripta Scientifica Medica, vol. 29, Suppi 2, 1995 Copyright © Medical University of Varna

agents. In the group-А patients the normal Milligan-Morgan procedure with dissection of the haemorrhoids by scissors and high ligature of the vascular pedicle with Vycril 3-0 was carried out. The group-B patients had their haemorrhoids dissected using only the diathermy and they had no ligature of the vascular peduncle. Mean hospital stay duration was 3,35 days for the group В and 4,3 days for the group A (p = 0,0002). There were no significant differences between the two groups regarding intensity of pain (p = 0,399) and its duration (p = 0,915), as well as concerning the time of the first defecation and urinary function. One patient of the group A had a bleeding from the ligated peduncle and another patient from the group В had a bleeding from a subcutaneous vessel. Complete healing of the wounds occurred in a month.

Diathermic haemorrhoidectomy is easy to perform, not longer than the normal Milligan-Morgan's procedure and intraoperative bleeding is insignificant. The latter can allow a considerable reduction of the hospital stay of the patients without interfering with the results. Later we performed up-to-date a total of 172 haemorrhoidectomies by this technique and we can confirm the simplicity of the procedure and its good results.

ANATOMIC VARIATIONS AND INTRAOPERATIVE CONTROL OF A R T E R I A L BLOOD SUPPLY OF COLONIC TRANSPLANTANT IN ESOPHAGOCOLONIC PLASTICS

B. Kornovski, D. Dobrev, Sht. Shterev Clinic of General Surgery with Coloproctology, Department of General and Operative

Surgery, Medical University of Varna, Varna, Bulgaria

During a ten-year period in the Clinic of General Surgery with Coloproctology a total of 56 esophagocolonic plastics in esophageal stenosis after corrosive esophagitis were performed. A nutrient vessel was presented by a. colica media in 30 patients, by a. colica dextra in 8 patients, by a. colica sinistra in 12 patients while blood supply was provided by both a. colica media and a. colica sinistra in 6 patients. Although the transplantant was antiperistaltically placed in 14 patients this location did not influence unfavourably upon the vitality of the transplantant. There was no case with graft necrosis. However, a neck fistula was established in 10 patients (17,6 per cent) which spontaneously closed within 10 days after operation. With a view to the assessment of the esophageal end of the transplantant a Doppler control was intraoperatively performed until the appearance of an adequate blood flow. After the adoption of this method we did not establish neck fistulas in 8 consecutive patients operated on any more.

Fourth National Conference on Coloproctology with International Participation, Varna'95 Scripta Scientifica Medica, vol 29, Suppl 2, 1995 Copyright О Medical University of Varna

NON-INVASIVE REGISTRATION OF E L E C T R I C COLONIC A C T I V I T Y (EXPERIMENTAL AND C L I N I C A L

INVESTIGATIONS) A. Noeva, P. Penchev*, H. Kadiyan*, P. Gyurkov, E. Atanasova

Institute of Physiology, Bulgarian Academy of Sciences and ^Department of Gastroenterology, Tsaritsa Joanna State University Hospital, Higher Institute of

Medicine, Sofia, Bulgaria

An electric activity leading of the muscular wall of dog colon simultaneously with implanted (EColMG) and skin (EColG) electrodes was performed. A correlation between the appearance of groups of spike potentials and oscillations in the EColMG along with EColG wave amplitude increasing was registered. This corresponded to the active periods of the myoelectric activity of the colon in contrast to the that in the periods of relative rest when low-amplitude waves were registered. Therefore, this method enabled the evaluation of the functional state of the colon. EColG-recordings of healthy volunteers using skin electrodes by means of an original electrogastrograph were carried out. A coincidence between the nature of the electric activity of the colon of healthy volunteers and that of experimental animals was established, i . е., low-amplitude waves outlined the periods of relative rest while high-amplitude ones reflected the periods of activity. The authors worked on the elaboration of criteria for the normal electric activity of the colon when registered non-invasively. They investigated patients with functional diseases and idiopathic inflammatory diseases of the colon.

FUNCTIONAL SPHINCTER INSUFFICIENCY AND EPIDURAL BLOCKADE

I . Viyachki, V. Muykov, N. Yarumov, D. Viyachki, M. Miteva Clinic of Emergency Surgery, Tsaritsa Joanna State University Hospital,

Higher Institute of Medicine, Sofia, Bulgaria

According to literature data available, anal sphincter insufficiency is mainly due to three reasons as follows: an injury (in 75 per cent), anorectal anomalies (in 10 per cent) and functional disorders (in 15 per cent of the cases). Functional failure of the anal sphincter is characterized by neuroreflectory disturbances, reduced or increased sensitivity of the distal parts of the rectum and more rarely by reduced contractile capacities of the 46

Fourth National Conference on Coloproctology with International Participation, Varna'95 Scripta Scientifica Medica, vol. 29, Suppl. 2, 1995 Copyright О Medical University of Varna

anal sphincter. The decreased sensitivity hampers the control of continence of colonic contents while the enhanced one leads to often evacuation of feces even if there are insignificant quantities in the rectum. This causes a disturbed motor function of the colon.

In the Clinic of Emergency Surgery, Tsaritsa Joanna State University Hospital, Higher Institute of Medicine, Sofia, nine children (eight boys and one girl) aged between 9 and 16 years with a mean age of 10,7 years were observed and treated. In a sitting position, at the level of L3_4 an epidural catheter of No 18 was placed. Continuous epidural blockade was realized by local anesthetics in a strictly individualized dosage until a sympathetic blockade was achieved without any essential hemodynamic effects. The treatment aimed at blocking the sympathetic innervation and obtaining the prevalence of parasympathic stimulation of gastrointestinal and urinary tract motility with a subsequent complete emptying the pelvic reservoires. The authors reported very good results obtained from the application of the epidural blockade in cases with functional anal sphincter insufficiency.

ON T H E PROBLEM OF HAMPERED L A R G E BOWEL EVACUATION FUNCTION

L. Kovachev Department of Propedeutics of Surgery, Higher Institute of Medicine, Pleven, Bulgaria

Incapacity to defecate or achieving it only by means of digital evacuation has never been accepted well neither by the patients, nor by the physicians. Three patients with such severe evacuation disorders were operatively treated. They were two males with subtotal colectomy and one female with left hemicolectomy after a previous resection of the transverse colon on the same occasion. The histomorphological examinations of the nerve fibres in the operative preparations demonstrated a feature of degenerative alter­ations. The patients with subtotal colectomy restored their normal defecations between one and two times daily while, however, the female patient with a preserved right half of the colon did not achieve any improvement at all. On the other hand, there were also data about dyscoordination of the evacuation capacity of a distal (anal) type in the female patient.

Fourth National Conference on Coloproctology with International Participation, Varna'95 Scripta Scientifica Medica, vol 29, Suppl 2, 1995 Copyright ©Medical University of Varna

NON-OPERATIVE TREATMENT OF T H E ANAL AND R E C T A L PROLAPSE IN CHILDHOOD

L. Atanasov, G. Gelov, V. Mutafchiev Division of Surgery, Regional Hospital, Haskovo, Bulgaria

In the Division of Surgery, Regional Hospital, Haskovo, during the period from I 1974 till 1994 a total of 237 children with prolapse of the anus and rectum were diagnosed and treated. The diagnosis was based on: clinical examination and rectal touche (in all the patients), rectoromanoscopy (in 53 patients or 22,36 per cent), electromyotonometry (in 23 patients or 9,70 per cent), and irrigography (in 9 patients or 3,07 per cent of the cases). There were 53 children (22,36 per cent) aged up to one year; 162 children (68,35 per cent) aged between one and three years, and 22 children (9,28 per cent) aged over than three years. This disease was preceded in 113 children (47,68 per cent) by some other disorders such as constipation (in 73 patients or 30,80 per cent), pertussis (in 14 patients or 5,90 per cent), and long-lasting diarrhoea (in 26 patients or 10,97 per cent). According to the severity of the disease, these children were divided into the following groups: a) with anal prolapse - 153 or 64,56 per cent; b) with rectal prolapse of degree one - 67 or 27,27 per cent, and c) with rectal prolapse of degree two - 17 or 7,17 per cent of the cases.

The conservative method of treatment was the main approach used including nutrition regimen, regimen and manner of emptying the rectum from fecal masses, and iontophoresis with Nivalin of the anal area. This therapeutic method was applied in 112 children under out-patient conditions and in 125 ones (52,74 per cent) in the Division of Surgery of the hospital. Single therapeutic procedures were performed in 203 children (85,65 per cent), twofold ones - in 25 (10,55 per cent), threefold ones - in 6 (2,53 per cent), and fourfold - in 4 (1,69 per cent) consisting in iontophoresis with Nivalin every second month. A surgical treatment was carried out in 7 children with rectal prolapse (2,95 per cent) after failed conservative measures. Sclerozing therapy after Mesenev combined with iontophoresis with Nivalin was applied in 5 children and Tirsch's operation was done in 2 children. Catamnestic following-up the children up to one year after the treatment did not reveal any signs of relapses of the disease.

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INTESTINAL RESERVOIRES IN BENIGN C O L O R E C T A L DISEASES

G. Kobakov, T. Temelkov, E. Kiryazov, K. Ivanov, M. Shtiliyanov Clinic of General Surgery with Coloproctology, Department of General and Operative

Surgery, Medical University of Varna, Varna, Bulgaria

The results from proctocolectomies in patients with various diseases and 41 intestinal reservoires constructed in one or two-stage operations were presented. Twenty-six of them were ileal with ileoanal or ileorectal anastomosis and 15 were coecoanal. In 5 cases ileal reservoires by Kock were formed, in 3 ones - 'T'-type by Utsunomiya, in 2 ones "W"-type by Nicholls, and in 16 "S"-type shaped reservoires by Parks. In 9 cases a protective ileostoma was performed, in 3 cases - a two-stage operation was done while in the rest patients the operation was of one stage. During the recent years our ambition was to carry out an one-stage operation without a protective stoma. In some rare cases of fulminant form of the disease performance of a two-stage operation, in our opinion, seemed obligatory.

Best results were obtained in patients with intact anal canal. Besides it was possible to reduce the number of cases requiring an ileal reservoire by Kock. The indications and the results of the functional examination were discussed. It was concluded that the different functional activity and resorptive abilities of the digestve tract necessitated an individualized treatment.

A C U T E VASCULAR F AIL URE OF T H E INTESTINE AND L A R G E BOWEL: INTRAOPERATIVE T A C T I C S AND

POSTOPERATIVE RESULTS B. Kornovski, T. Temelkov, G. Kobakov, D. Dobrev, Sht. Shterev

]inic of General Surgery with Coloproctology, Department of General and Operative Surgery, Medical University of Varna, Varna, Bulgaria

During the period of 5 years in the Clinic of General Surgery with Coloproctology, epartment of General and Operative Surgery, Medical University of Varna, Varna, a

total of 30 patients (22 males and 8 females) with acute mesenteric insufficiency were treated. The operative intervention consisted in explorative laparotomy in order to establish a diffuse peritonitis because of the occurred necrosis of the intestinal tract and of the

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Fourth National Conference on Coloproctology with International Participation, Varna'95 Scripta Scientifica Medica, vol 29, Suppl 2, 1995 Copyright ©Medical University of Varna

proximal colon in 12 patients. A resection of the necrotic intestinal tract was performed in 13 patients as in 5 of them the proximal colon was included in the resection, too. A thrombectomy could be carried out in 3 patients being combined with a resection of the intestinal tract in two of them because of a necrosis found out at the repeated inspection 24 hours later on. In one female patient the thrombectomy was a single independent operative intervention which efficiency was established at the secondary inspection after 12 hours. In 11 out of 13 patients with a resection of the intestine a primary anastomosis was created which was then insufficient in 2 ones (18,1 per cent) as revealed at the secondary inspection of the abdomen. A secondary abdominal inspection after the operation was done in 9 patients as followed: in the form of laparoscopy (in 3 cases), of "Zip" laparotomy (in 2 patients), and relaparotomy (in 4 patients). Some 13 operated patients (43,22 per cent) deceased.

CHRONIC NON-SPECIFIC COLITIS: CLINICO-MORPHOLOGICAL P A R A L L E L I S M

B. Manevska, I . Krasnaliev, I . Danev*, M. Atanasova*, V. Glinkova, D. Gancheva*, A. Atanasova*, I . Shalev*, V. Zhechev*

Deapertment of General and Special Pathology, and * Clinic of Gastroenterology, Department of Endocrinology, Gastroenterology and Metabolic Diseases, Medical

University of Varna, Varna, Bulgaria

An analysis of 81 patients with unspecific complaints of the colon (of them, 68 with data about a chronic colitis and 18 ones with an "irritable colon") was carried out. These patients were endoscopically examined and biopsy specimens of them were taken in the Clinic of Gastroenterology, Medical University of Varna, Varna, during the period from 1993 till 1995. Biopsy examination of the colonic mucosa demonstrated that in patients with clinical evidence of colitis the diagnosis was confirmed in 47 cases, an ulcerous colitis was found out in 5 cases, tumours were seen in 4 cases, and the mucous membrane was normal in 7 cases. Morphologically, in patients with "irritable colon" the normal colonic mucosa dominated (11 cases) followed by chronic non-specific colitis (6 cases) and a tumour process (one case). Despite of their inspecificity, the pecularities of the morphological findings allowed the suggestion of the role of certain etiologic factors such as yersiniosis.The analysis showed that the morphological examination determined to a great extent the final diagnosis. That was why it should be an obligatory component of the endoscopic investigation.

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C R I T E R I A FOR THE VOLUME OF SURGICAL STAGE TREATMENT IN S E V E R E U L C E R A T I V E C O L I T I S

PATIENTS if Alexandrova, Damyanov, D. Nedin, G. Stoyanov, P. Purvanov

Clinic of Abdominal Surgery, Tsaritsa Joanna State University Hospital, Higher Institute of Medicine, Sofia, Bulgaria

During a 30-year period (from 1958 till 1988) a total of 96 patients with ulcerative colitis were operated on. The retrospective analysis of 42 of them presented as a severe ulcerative colitis and its complications with a lethality rate of 42,85 per cent where ileostomy dominated at the first stage of the surgical treatment (in 80,95 per cent of the cases) provoked a more active behaviour. During the period from 1989 till 1995, 15 patients with severe ulcerative colitis were operated on. There were 5 urgent cases because of haemorrhage, perforation, and toxic megacolon. The rest 10 patients had a severe persistent activity of the inflammatory process. In 4 of them an ileostomy as a first step of the treatment with subsequent colectomy was done. In 6 patients a colectomy with ileostomy at the first stage was performed. The results from the radical interventions in complicated forms were better than those after exteriorizing and debarassing stomae. This was to a greater extent valid for the patients with severe persistent activity. Ileostomy as a first step should be used in patients with severe preoperative non-surgical complications and decompensated incorrectable parameters of haemostasis. After the stablization of the patient's state colectomy seemed possible. The last stage consisting in proctectomy and ileoanastomosis was commonly delayed by the patients due to their adaptation to the stoma.

CLINICO-HISTOMORPHOLOGICAL P A R A L L E L I S M AND INDICATIONS FOR OPERATIVE TREATMENT

OF T H E S E V E R E U L C E R A T I V E C O L I T I S A. Alexandrova, H. Kadiyan, A. Mihova

Clinic of Abdominal Surgery, Tsaritsa Joanna State University Hospital, Higher Institute of Medicine, Sofia, Bulgaria

During the period from 1989 till 1995 a total of 15 severe ulcerative colitis patients were operated on. There were 5 urgent cases because of haemorrhage, perforation, and toxic megacolon. The rest 10 patients had a severe persistent activity of the inflammatory process. While the indication for operation in these 5 urgent cases were

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Fourth National Conference on Coloproctology with International Participation, Varna'95 Scripta Scientific** Medico, vol. 29, Suppl. 2, 1995 Copyright ©Medical University of Varna

rather explicit, until recently, the persistent and therapeutically resistant activity of the inflammatory process in the rest 10 patients remained a disputable indication for surgical treatment in Bulgaria. This decision could not be based on preoperatibe biopsy findings as they only confirmed the clinical data of an active inflammatory process that was proved in all the cases with exacerbations. Retrospectively, after the radical operations the macroscopic alterations and the much more detailed floor histomorphological investigations manifesting an outlined inflammatory infiltration, crypt-abscesses, severe fibrosis, mucosal atrophy, and pseudopolyps categorically warranted the surgical intervention.

NON-SPECIFIC U L C E R OF COLON SIGMOIDEUM T. Todorov, J. Terziyski

Central Clinical Hospital, Research and Applied Institute, Ministry of Internal Affairs, Sofia, Bulgaria

Non-specific colonic ulcer is a rare disease with unclarified etiology. There are approximately 250 case reports in the world literature available. The following terms are used to define this lesion: "solitary", "simple", "benign", "idiopathic" or non-specific ulcer.

A case report of a non-specific colonic ulcer in a 58-year old female patient was presented. The woman was admitted to hospital with the clinical feature of a carcinoma of colon sigmoideum complicated by bleeding. The clinical diagnosis was confirmed by fibrocolonoscopy and irrigography. The patient underwent a resection of the sigma with an operative diagnosis of carcinoma of the colon sigmoideum. Histologically, the initial diagnosis was denied because of explicit macroscopic and microscopic evidence of a non­specific colonic ulcer. The patient was discharged healthy. A literature survey was elaborated on the occasion of this case report, too.

NEW METHOD FOR COLONIC PASSAGE RESTORATION A F T E R TOTAL PROCTOCOLECTOMY BY USING

AN ANTIPERISTALTIC I L E U M PART V. Dimitrov, P. Kourtev, K. Ralchev, Z. Doudounkov

Clinic of Coloproctology, National Centre of Oncology, Sofia, Bulgaria

The method was applied in 8 patients (after total proctocolectomy in generalized polyposis in 6 and after total prococolectomy in chronic ulcerohaemorrhagic colitis in 2 cases). After the total proctocolectomy the rectal residual below the levator muscles was

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Fourth National Conference on Coloproctology with International Participation, Varnav95 Scripta Scientifica Medica, vol. 29, Suppl. 2, 1995

У right О Medical University of Varna Co,

demucosed and the intact a. v. colica was preserved. Ileum was closed immediately over the Bauchin's valve. Proximally, about 35-40 cm from its distal part the ileum was disconnected together with its vascular arch. This ileal part which blood supply was entirely on the account of a. ileocolica was antiperistaltically transposed to the demucosed rectal area. Then a termino-terminal anastomosis after A. Parks' method was performed. The superior ileal loop was placed parallelly to the antiperistaltically situated distal loop. A 20-25 cm long latero-lateral anastomosis between both loops was created to form a reservoir. Distally from this reservoir the antiperistaltic loop was at the average 10-15 cm long. A gas tube was placed which orifices were 10-15 cm over the intestinal reservoir. This tube performed the function of a provisory ileostoma as it unburdened the reservoir and excluded completely the intestinal passage from the ileoanal anastomosis. A prophylactic ileostoma was not created in 5 patients. The postoperative period was without any troubles in these cases. The number of defecations was at the abverage 2 to 5 daily as anal continence was completely preserved. A prophylactic ileostaoma was created in 3 patients. One female patient had also a rectal cancer. Because of early occurring liver metastases she deceased prior to ileostoma closure. The complications after ileostoma closure in the other two patients necessitated its leading away.

ABDOMINAL ACTINOMYCOSIS WITH A T Y P I C A L LOCALIZATION IN THE DISTAL PART OF COLON

AND R E C T U M : REPORT OF TWO CASES M. Momchilov, M. Radionov, D. Dzhodzheva

Clinic of Surgery, St. Ana State Institute Hospital, Sofa, Bulgaria

According to data reported by Bulgarian and foreign authors, abdominal ctinomycosis is the most rare form of this chronic specific infection. This disease creates

serious diagnostic difficulties. Certain obligatory preconditions for the origin of the infection are emphasized such as inflammatory and ischemic changes in the tissues, destroyed intactness of the mucosa, reduced defence capacities of the organism, and microbial associations. We have revealed 4 publications in the Bulgarian periodicals for the period from 1982 till 1994 while in the foreign literature a total of 23 papers have been detected for the time interval from 1988 till 1993.Concerning our first case reported here the process is localized in colon sigmoideum and it infiltrates the anterial abdominal wall. There is an undoubted evidence based on the clinical and instrumental investigations of a neopl-astic process. An operation after Hartmann is performed and a diagnosis of actinomycosis is histopathologically verified. A course of antibiotic therapy results then in passage restitution. In the second patient a neoplastic process of colon sigmoideum and

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Fourth National Conference on Coloproctology with International Participation, Varna'95 Scripta Scientifica Medica, vol. 29, Suppl. 2, 1995 Copyright ©Medical University of Varna

rectum has been bioptically proved. One year ago he has been operated on the occasion of an acute and subsequently fistulized paraproctitis. An anterior resection is carried out and on the histological preparation actinomyces within the tumour are established. A long-lasting postoperative antibiotic therapy is carried out with this patient, too. In our opinion, these cases present an interest with a view to the precise preoperative differential diagnosis in patients with neoplasms along with hardly curable relapsing inflammatory processes in the distal parts of the gastrointestinal tract.

TRANSANAL ENDOSCOPIC MICROSURGERY: INDICATIONS, TECHNIQUE AND RESULTS

M. Trompetto, G. Clerico, A. Realis Luc Department of Surgery, Coloproctological Service, Ivrea Hospital, Ivrea, Italy

Transanal endoscopic surgery is a quite new technique to remove sessile polyps of cancers T J ( T 2 ? ) located in the middle-upper rectum. It allows to avoid a major surgery as an anterior resection of a Miles' procedure in cases of neoplasms located 8-20 cm far from the anal verge. Patients must be carefully selected and preoperatively evaluated. A good training of the surgeon is mandatory in order to achieve satisfactory results. We present our experience with the procedure and a video about one operation with this technique.

W E L L f S LAPAROSCOPIC R E C T O P E X I S S. Martelli, M. Trompetto*, G. Clerico*, A. Realis Luc*

Martini Hospital, Turin, and ^Department of Surgery, Coloproctological Service, Ivrea Hospital, Ivrea, Italy

Abdominal rectopexis is a common operation for patients with rectal prolapse of intussusception. Results are not always satisfying, especially regarding on the long-time functional evolution of the disease. Many variants of the classical operations have been presented. However, numerous factors up-to-date not liable to be correctly quantified can influence upon the results. As some patients present a rectal prolapse or intussusception at the young age a laparoscopic approach can be also considered. We present a video about one of our cases with this technique.

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Fourth National Conference on Coloproctology with International Participation, Varna'95 Scripta Scientifica Medica, vol 29, Suppl 2, 1995 Copyright О Medical University of Varna

DELORME'S OPERATION FOR C O M P L E T E R E C T A L PROLAPSE

M. Trompetto, A. Realis Luc, G. Clerico Department of Surgery, Coloproctological Service, Ivrea Hospital, Ivrea, Italy

Perineal procedures for complete rectal prolapse have been well considered for a long time and then abandoned for many years because of the high rate of relapses confirmed by a lot of authors. In the recent years, the results from these operations improved thus in many centres the perineal approach is now considered the method of choice in the majority of patients with rectal prolapse. In fact, the simplicity of the procedure, the possibility of avoiding a laparotomy with all the consequences of possible deriving complications such as adhesions, nerve destructions, etc. and the feasibility also in very old patients put this approach in an advantageous position when compared to the abdominal operations. We present a video about one of our cases of Delorme's procedure for complete rectal prolapse.

M. G R A C I L I S PLASTICS IN 150 PATIENTS T. Temelkov, G. Kobakov, E. Kiryazov, M. Shtiliyanov

Clinic of General Surgery with Coloproctology, Department of General and Operative Surgery, Medical University of Varna, Varna, Bulgaria

The opportunities for uni- and bilateral application of M. Gracilis in the anal region in 150 donors were presented. An operative technique for restoration after traumatic lesion of the anal sphincter group and transposition of M. Gracilis for anatomical unification of damaged muscles was demonstrated. After the extirpation of both rectum and anus on the occasion of anal cancer a neosphincter with bilateral application was created. By means of endocavity transrectal trandsucer of the echograph the anatomical structure was visualized and its functional fitness after the usage of these M. Gracilis was shown.

The perfectioned operative technique along with the personal author's experience gained during a 14-year period supported the necessity and reliability when applying more widely the operations of this kind in the coloproctological practice.

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Fourth National Conference on Coloproctology with International Participation, Varna'95 Scripta Scientifica Medica, vol. 29, Suppl. 2, 1995 Copyright ©Medical University of Varna

TRANSSACRAL ACCESS IN R E C T A L TUMOURS T. Temelkov, G. Kobakov, E. Kiryazov, K. Ivanov

Clinic of General Surgery with Coloproctology, Department of General and Operative Surgery, Medical University of Varna, Varna, Bulgaria

The videofilm demonstrates the operative technique of sacral accesses by a visualization in detail of the anatomical structures of the anorectum. A differentiation is made of the disection and restoration of the muscular groups of the sphincter region. Work on rectum is done by preserving the sphincters or by using a posterior sagittal transection after Masson. The indications and possibilities for removing the tumours which can not be eliminated by the transanal way are demonstrated. The opportunities for partial resection of the rectal wall with subsequent restitution of the anatomical integrity of this organ are also presented.

I L E A L RESERVOIRS: INDICATIONS AND O P E R A T I V E TECHNICS

T. Temelkov, G. Kobakov, K. Ivanov, E. Kiryazov, V. Ignatov Clinic of General Surgery with Coloproctology, Department of General and Operative

Surgery, Medical University of Varna, Varna, Bulgaria

During the period from January, 1983 till August, 1995, in the Clinic of General Surgery with Coloproctology, Department of General and Operative Surgery, Medical University of Varna, an ileal intestinal reservoir was created in 20 proctocolectomized patients. This intervention was on the occasion of a mucous ulcerative colitis in 17 patients and of a familial diffuse polyposis in the rest 3 ones. A planned operation was done in 15 patients of the first group. A pseudopolyposis of both colon and rectum was fibrocolon-oscopically and bioptically proved in these cases as a malignant degeneration was also present in one patient. Two patients were urgently operated because of a bleeding from the colon and rectum resistant to conservative treatment. Two-stage intervention was carried out in the urgent cases and in two patients operated according to plan. A " J " - reservoir was constructed in 4 cases, a flWf,-reservoir in one, and a flSM-reservoir in the rest 15 patients. Postoperatively, 13 patients were clinically, endoscopically, roentgenologically, and bioptically followed-up for different time intervals. We present our own modification of performing the ileoanal anastomosis in 2 patients as well as the short and long-term results and complications. At present, these methods are a positive solution as an alternative of the abdominal ileostoma.

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opyright ©Medical University of Varna

ESOPHAGOCOLONIC PLASTICS A F T E R ESOPHAGOGASTRECTOMY ON T H E OCCASION OF

>RROSIVE INJURY OF THE ESOPHAGUS AND STOMACH B. Kornovski

Clinic of General Surgery with Coloproctology, Department of General and Operative Surgery, Medical University of Varna, Varna, Bulgaria

During a 5-year period in the Clinic of General Surgery with Coloproctology, jpartment of General and Operative Surgery, Medical University of Varna, 68 patients

| p corrosive injury of the esophagus and stomach were treated. In the course of conservative treatment and clinical observation 12 patients underwent an urgent operative intervention consisting in esophagogastrectomy because of necrosis, development of an acute purulent mediastinitis and peritonitis. The surgical intervention terminated with esophagostoma and nutrient jejunostoma. Ten operated patients deceased until the 30th day while two patients underwent an esophagocolonic plastics with formation of an intestinal reservoir after the second month. Esophagus was removed by a transhiatal and cervical access and at the second stage the colonic transplantant was placed retrosternally. The technique of the operative intervention was demonstrated and the opportunities for evaluation of the optimal term of esophagogastrectomy by means of modern laparoscopy and echography were discussed.

POSSIBILITIES FOR CREATING THE COLONIC ANASTOMOSES BY STAPLERS

B. Kornovski Clinic of General Surgery with Coloproctology, Department of General and Operative

Surgery, Medical University of Varna, Varna, Bulgaria

The author has used Soviet staplers since 25 years and American circular stitchers since 5 years to optimize the technique for creating the anastomoses in large bowel surgery. Circular stitchers were applied to perform termino-terminal anastomoses in rectal resections. The usage of the SITU-28,32 Soviet staplers necessitated obligatorily a serous-muscular suture as a second floor which was not required when the E E A American stitcher was used. Folio catheter for baloon dilatation could be applied when a colonic lumen dilatation was required. A termino-lateral anastomosis was created in ileotransversal anastomoses. A technique for creating the anastomoses by using an UO-40 and tfO-60

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linear stapler was elaborated. The suturing endings were termino-terminally juxtaposed and with both apparatuses an inverting posterior and an everting anterior wall of the anastomosis was formed.

T H E P L A C E OF Nd-YAG LASER THERAPY IN T H E TREATMENT OF C O L O R E C T A L CANCER

E. Kiryazov Clinic of General Surgery with Coloproctology, Department of General and Operative

Surgery, Medical University of Varna, Varna, Bulgaria

The experience gained with Nd-YAG laser destruction in 38 colorectal cancer patients during the period from March, 1991 till June, 1995 was shared. There were the following indications for this laser therapy: a) local growth of the process or dissemination hampering the performance of the radical operation; b) patient's refusal of operation; c) state of an acute ileus as a preparation for planned one-stage operation; d) state of stenosis of the anastomosis from the previous resection. This method aimed at ensuring a satisfactory ileal passability or at overcoming the ileus if presented. A laser energy of 4000-13000 J per seance was used. The course icluded 1 till 9 seances. A non-contact approach in an endoscopic way with rigid proctoscope or fibrosigmoscope was applied. There were excellent results in 28 and very good results in 9 patients. One case presented with a complication consisting in colon sigmoideum perforation and ileus. The prompt operation prevented a peritonitis and the final result was very good, too.

ENDOSCOPIC POLYPECTOMY AND Nd-YAG LASER THERAPY AS PREVENTION OF COLONIC

PRECANCEROSES V. Ignatov, E. Kiryazov, Yu. Stefanova

Clinic of General Surgery with Coloproctology, Department of General and Operative Surgery, Medical University of Varna, Varna, Bulgaria

During a 7-year period in the Centre of Endoscopy at the Clinic of General Surgery with Coloproctology, Department of General and Operative Surgery, Medical University of Varna, a total of 3121 recto- and sigmocolonoscopies were carried out. Rectal and colonic polyps were detected in 358 cases (11,06 per cent). Endoscopic polypectomy was applied in all the patients. Since 1991, the pedicle residual was treated with Nd-YAG laser photocoagulation. This technique was used after a preliminary

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histological examination in polyps on a moderately wide and wide basis which were inappropriate for loop polyp-ectomy. Any patients were due to be dynamically endoscopically controlled after 3 and 6 months, as well as at least once every year for 5 years.

I THREE-DIMENSIONAL COMPUTER ATLAS OF ENDORECTAL ULTRASOUND

K. Ivanov, Chr. Diacov Clinic of General Surgery with Coloproctology, Department of General and Operative

Surgery, Medical University of Varna, Varna, Bulgaria

Endorectal ultrasound (US) is one of the basic methods for the diagnostics of the diseases of rectum and anal canal. The US scanners provide planar (2D) images, sometimes unable to represent the complex spatial relations of pelvic structures. In this study we present a fxill three-dimensional (3D) reconstruction of the normal human pelvic anatomy. The visualized structures are: inner rectal surface, prostatic gland, seminal vesicles, internal and external sphincter and levator ani muscles. Precise knowledge of the normal US anatomy of this region ensures correct diagnostic and treatment planning of the diseases of rectum and anal canal.

THREE-DIMENSIONAL ENDORECTAL ULTRASOUND IN PATIENT WITH R E C T A L CANCER

K. Ivanov, Chr. Diacov Clinic of General Surgery with Coloproctology, Department of General and Operative

Surgery, Medical University of Varna, Varna, Bulgaria

Endorectal ultrasound (US) is a valuable method for staging rectal cancer. Many of the structures, visualized by this technique have three-dimensional (3D) features, difficult to estimate by the standard planar imaging. In order to overcome this draw-back of the method we introduce 3D endorectal US. Using US scanner and our ChrisSoft ImageSTAR! PC-based system for 3D medical imaging, we separate the tumour tissue and rectal wall and perform full 3D visualization. This new technique significantly improves the role of endorectal US in the preoperative staging and postoperative follow-up. This is a new stage in the diagnostics, allowing US-guided surgical treatment of rectal cancer.

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Fourth National Conference on Coloproctology with International Participation, Varna'95 Scripta Scientifica Medica, vol. 29, Suppl 2, 1995 Copyright ©Medical University of Varna

PROPHYLAXIS AND TREATMENT OF INFECTIONS IN C O L O P R O C T O L O G Y WITHDALACIN С (CLINDAMYCIN)

V. Glinkova Clinic of Gastroenterology, Department of Endocrinology, Gastroenterology and

Metabolic Diseases, Medical University of Varna, Varna, Bulgaria

Abdominal infections and particularly these in colorectal surgery are of complex nature and caused by a broad range of aerobic and anaerobic microorganisms. The follow­ing anaerobic microorganism are the most common etiologic agents of intraabdominal infections: B. fragilis, B. tetanotaomicron, B. ovatus, B. melaninogenicus, other Bacte-roides spp., Fusobacterium spp., Peptostreptococcus spp., anaerobic Gram-positive non-sporeforming bacteries, and Clostridium spp. Dalacin С (Clindamycin) is one of the main preparations for the treatment of infections caused by the aforementioned microorganisms because of its effectiveness against a series of aerobic, anaerobic Gram-positive and Gram-negative microorganisms. The combination between Clindamycin and aminoglycoside is a golden standard in both prevention and treatment of intraabdominal infections against which any new therapeutic schedules are assessed. The polyetiologic nature of these infections determines the necessity for these schedules to cover a broad range of microorganisms.

INVESTIGATION OF THE DIAGNOSIS AND T R E A T M E N T OF R E C T A L CARCINOMA

I . Donkov, V. Daskalov, G. Grigorov, K. Vasilev, E. Belokonski, Z. Parchev, G. Gurbev, K. Voutov

Clinic of Abdominal Surgery and Oncology, Military Medical Academy, Sofia, Bulgaria

The authors analyze 265 cases of rectal cancer patients hospitalized in the Clinic of Abdominal Surgery and Oncology, Military Medical Academy, Sofia, during a 5-year period (1990-1994). Patients' distributions are made according to gender, age and stage of disease. The manner of defining the diagnosis and the stage of the disease are analyzed. The therapeutic methods used in these patients as well as the radical and palliative operations are considered in detail. A particular attention is paid to the laparoscopic method for creating the two-orifice sigmostomy in senile patients with severe accompanying diseases and inoperable carcinoma leading to ileus. This method enables the minimization of postop-erative complications and lethality rate.

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Fourth National Conference on Coloproctology with International Participation, Varnaf95 Scripta Scientifica Medica, vol 29, Suppl 2, 1995

pyright ©Medical University of Varna

ITROSTERNAL ESOPHAGOCOLONIC PLASTICS A F T E R TWO GASTRIC OPERATIONS AND A F T E R CORROSIVE

ESOPHAGITIS-GASTRITIS T. Todorov

ntral Clinical Hospital, Research and Applied Institute, Ministry of Internal Affairs, Sofia, Bulgaria

This videofilm shows an operation of a patient who has engulfed an amount of nitric acid after two stomach operations in the past, i . е., vagotomy and pyloroplasties, and then Bilroth I I stomach resection. Despite the conservative treatment for a one-year period an esophageal stricture and deformation of the gastric residual has occurred. The present operation consists in the preparation of a new esophagus from the half of the colon that is retrosternally transposed by an one-moment esophagocolonic anastomosis. The videofilm visualizes the main stages of the operation, its atypical moments and the final result that is excellent as both clinically and roentgenological^ documented.

EVISCERATIONS: PROGNOSTIC FACTORS, TREATMENT, AND PREVENTION

S. Glinkov Clinic of General Surgery with Coloproctology, Department of General and Operative

Surgery, Medical University of Varna, Varna, Bulgaria

During a 5-year period, from 1988 till 1993, in the Surgical Clinics of the Departments of Surgery, Medical University of Varna, 24 patients (18 males and 6 females) with a mean age of 47 years developed evisceration after the operation. Of them, there were 15 urgent cases and 9 patients were operated according to plan. Single eviscerations were established in 20 patients, twofold ones - in one and threefold ones in 3 patients. An analysis of the possible prognostic factors aiming at reducing the risk of evisceration was attempted. The correlation between the eviscerations and the age, anatomic peculiarities, accompanying diseases, and hemodynamic disorders was followed-up. The effectiveness of the operative treatment as well as the volume and severity of the operations themselves in patients with evisceration was assessed. Some preventive measures in patients with a supposed enhanced risk for evisceration were recommended. The significant role of certain factors such as persistent hypoalbuminemia, wound infection

lung diseases was emphasized.

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Fourth National Conference on Coloproctology with International Participation, Varnaf95 Scripta Scientific** Medica, vol. 29, Suppl. 2, 1995 Copyright О Medical University of Varna

BORDERLINE STATES BETWEEN COLONIC INFECTIOUS DISEASES AND C O L O R E C T A L NEOPLASMS

M. Gospodinova, M. Nenova, E. Kiryazov*, T. Gancheva Department of Infectious Diseases and Epidemiology, *Clinic of General Surgery

with Coloproctology, Medical University of Varna, Varna, Bulgaria

Diseases with enterocolitis syndrome belong to the most common pathologic states. In the Infectious Clinic, Medical University of Varna, between 550 and 1000 patients with enterocolitis or colitis (colic-like pains and tenesmus, mucous-bloody diarrhoea) syndrome, respectively, are annually treated. Their hospitalization is assessed according to clinical, epidemiologic and psycho-social factors. This communication presents the clinical manifestations, biochemical parameters and the microbiological and instrumental examinations in 10 patients (5 males and 5 females) aged between 44 and 65 years and treated in the Second Infectious Clinic admitted from the out-patient network as cases suspected for dysenteria. Sh. flexneri lb and infiltrating colonic adenocarcinoma is proved in two patients, Salmonella enteritidis and infiltrating rectosigmoid carcinoma in one case while no pathogenic bacterial flora but other neoplastic colorectal diseases in the rest patients are found out. There are two lethal outcomes. Some conclusions about the exact indications for hospitalization of patients with acute enterocolitis syndrome, the incidence rate of mixed forms of intestinal infections and the necessity of rapid endoscopic diagnosis are drawn.

T R E A T M E N T OF PERIANAL FISTULAS ANDABSCESSES I . Plachkov

Naval Hospital, Varna, Bulgaria

The experience with the treatment of 288 patients with perianal fistulas and abscesses during a 4-year period was shared. The author considered the perianal fistulas and abscesses two stages of one and the same disease of the pararectal connective tissue. A complete healing was achieved in 190 out of 195 patients (in 97,4 per cent of the cases) when the elastic ligature method enabling a slow section, granulation and epithelization of the tissues in extra- and transsphincteric fistulas was applied. The relapses were due either to incorrect detection of the internal fistular orifice in old fistulas or to rapid tightening-up for a earlier section of the sphincter muscle. The elastic ligature method was recommended as an effective means for treatment of the perianal fistulas and abscesses.

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Fourth National Conference on Coloproctology with International Participation, Varna'95 Scripta Scientifica Medica, vol. 29, Suppl 2, 1995 Copyright ©Medical University of Varna

A L I E N BODIES IN THE R E C T U M H. Kadiyan, V. Bakalov, P. Penchev, N. Penkov,

L. Tankova*, E. Pophristova* Clinic of Gastroenterology and Emergency Surgery and ^Section of Pathology, Tsaritsa

Joanna State University Hospital, Higher Institute of Medicine, Sofia, Bulgaria

Alien bodies can be established in the rectum by means of rectoscopy in cases of: a present disease within and out of the large bowel; 1.1. Catgut with hypergranulation of

"alien body" type in the area of anastomosis after resection. Differential diagnosis with rel­apse of a malignant process requires endorectal echography, histomorphological examinat­ion and following-up the healing process after catgut extirpation. 1.2. Bile calculi in cholel­ithiasis with biliary ileus. The main disease has been masked by a "bleeding duodenal ulcer 1 and "appendicitis". Bile calculi have been manually removed after dilatation of the anal sphincter and the zones of perforation have proved at autopsy. 2. Occasional finding: 2.1. Device adapters; 3. Introduction by perverse patients: 3.1. spoons; 3.2. metal bottle caps; 3.3. wooden pestle.

ENDOSCOPIC LOOP POLYPECTOMY IN L A R G E BOWEL POLYPS

P. Penchev, H. Kadiyan, E. Pophristova*, A. Gegova*, I . Terziev Clinic of Gastroenterology and ^Section of Pathology, Tsaritsa Joanna State

University Hospital, Higher Institute of Medicine, Sofia, Bulgaria

During the period from March, 1992 till May, 1995, in the Clinic of Gastroenterology,Tsaritsa Joanna State University Hospital, Sofia, loop polypectomies wereperformed in 124 polyps from 87 patients aged between 18 and 92 years. The polyps were located as followed: in cecum and colon ascendens (6,45 per cent), in colon transversum (12,09 per cent), colon descendens (13,7 per cent), sigma (21,1 per cent), rectum/sigma (9,68 per cent), and rectum (less than 15 cm) - in 36,29 per cent of the cases.They were sized between 0,5 and 4,5 cm in diameter. The pediculized polyps were 53,2 percent, widely-based ones - 16,2 per cent, and polyps on intermediate and short pedicle 30,6 per cent. Histomorphologically, 23,3 per cent were tubular, 48,4 per cent tubulovillous, 4,03 per cent villous, 4,8 per cent juvenile, and 4,03 percent hyperplastic.

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Fourth National Conference on Coloproctology with International Participation, Varna'95 Scripta Scientifwa Medica, vol. 29, Suppl. 2, 7995 Copyright ©Medical University of Varna

Morphological examination of 16 polyps (12,9 per cent) was not carried out. "Carcinoma in situ" was proved in 3 cases (4,03 per cent). Catamnestic following-up every 3 months did not detect any relapse or invasive cancer during a 25-month period. An invasive cancer was found in 3 polypectomized patients timely admitted to radical therapy. The following-up was performed in all the polypectomized patients on the 45th day, 26 per cent - on the 3rd month, 63 per cent on the 6th month, and 88 per cent on the 12th month and after one year. Control endoscopy revealed residual particles/relapses on the 45th day in 3 cases, a relapse of one villous adenoma on the 6th month, and a relapse of a tubulovillous adenoma on the 15th month. Metachronous polyps were established in 4,6 per cent of the cases. The complications consisted of immediate bleedings in 2 cases (1,6 per cent) and a so-called postpolypectomic postcoagulation syndrome in one case (0,8 per cent) which were successfully treated by conservative means.

ENDORECTAL ECHOGRAPHY IN R E C T A L CARCINOMA A. Uzunova, M. Karkumov, R. Karamfilova

Department of Gastroenterology and Abdominal Surgery, Military Medical Academy, Sofia, Bulgaria

Endoscopic sonography of the alimentary tract enables the precise examination of gastrointestinal walls. This method is related, on the one hand, with absent common obstacles for ultrasound, and the application of high frequencies, on the other hand. Morbidity and mortality rates of rectosigmoidal carcinoma increase. At present, only 45 per cent of the patients operated on the occasion of colorectal carcinoma survive longer than 5 years. Endoscopic examination with histological confirmation remains the main diagnostic method of these neoplasms. Endorectal echography provides information about the tumour invasion. An usage has been made of Dukes classification when assessing the results in order to define a correct therapeutic behaviour in these patients. The aim of the present study is to introduce the endorectal echography for evaluation of the tumour process in the practice. A total of 38 patients with histologically proved and distally located rectal cancer were examined. Adenocarcinoma was verified in all the patients. Stage В of rectal cancer after Dukes classification was seen in 25 patients and stage С in the rest 13 ones. The examination was singly done in order to determine the volume of the operative intervention.

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Mirth National Conference on Coloproctology with International Participation, Varna'95 :ripta Scientifica Medica, vol 29, Suppl 2, 1995 opyright ©Medical University of Varna

ON T H E P R O B L E M OF THE C L I N I C A L FINDINGS AND T R E A T M E N T OF PERIANAL ABSCESSES AND FISTULAS

Ts. Tsankov Clinic of Surgery, Transport Medical Institute, Sofia, Bulgaria

While the diagnosis of perianal abscesses and fistulas is easy the etiology is rather icult to reveal. Like the most authors we also consider fissurae, external and internal lorrhoids and anal glands along with their complications the main reasons for perianal

)scesses and fistulas. We differentiate between complete and incomplete perianal fistulas. We make mainly diagnostic use of fistulography, tubing of the fistular canal and injection of a dye substance. We apply the ligature method, the excision with drainage, the extirpation-drainage with partial and complete suture in the treatment of perianal abscesses and fistulas. In some patients we use the ligature already at opening the abscess with subsequent out-patient treatment and preserved patient's work capacity.

IS CONSTIPATION A RISK FACTOR FOR HEMORRHOIDS: A STUDY OF POTENTIAL E T I O L O G I C AGENTS ?

P. Akrabova, D. Makuleva, I . Stanchev Clinic of GastroenterologyHigher Institute of Medicine, Plovdiv, Bulgaria

It is well-known that constipation plays an important role in the origin of hemorrhoids. Our aim was to study the association of hemorrhoids with constipation and other potential risk factors in our patients' contingent. A retrospective investigation of 256 rectosigmoidoscopies performed in the Clinic of Gastroenterology, Higher Institute of Medicine, Plovdiv, from January, 1992 till June, 1995, was carried out. An individual patient's index-card was filled-in in all the cases examined reflecting the age, accompanying diseases and the presence of some of complaints such as constipation, diarrhoea, tenesmus, meteorismus, pains, and pathological excretions. Hemorrhoids were found out in 123 patients and the rest 133 ones served as controls. There was no statistically significant correlation between constipation and hemorrhoids although it was the most common symptom. However, its incidence rate did not differ from that of the control group. Second came diarrhoea followed by the alternating periods of constipation and diarrhoea. Our analysis showed that diarrhoea presented a significant risk factor for the hemorrhoids.

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Fourth National Conference on Coloproctology with International Participation, Varna'95 Scripta Scientifica Medica, vol. 29, Suppl. 2, 1995 Copyright © Medical University of Varna

TREATMENT OF PERIANAL FISTULAS BY LONG-LASTING THREAD DRAINAGE T. Deliyski, G. Baychev, R. Stoyanov University Oncologic Centre, Pleven, Bulgaria

The authors presented a method of treatment of perianal fistulas by long-lasting thread drainage and results obtained. Throughthe perianal fistula a thread was introduced and ligated to form a loose loop. During a several month-long period the thread crawled to complete dropping-out or to hanging on a small skin bridge easy to incise under out-patient conditions. Twenty-ne patients were prospectively followed-up. The duration of treatment was between 5 and 18 months. The thread dropped out independently in 8 patients while the rest 13 required small skin incisions. No relapses during the observation period of 1-6 years were reported. A conclusion was drawn that by this method a healing of the perianal fistula could be achieved with a minimal surgical intervention and short loss of work capacity.

PROGNOSTIC AND MORPHOLOGIC STUDY IN PATIENTS WITH C O L O R E C T A L CARCINOMA

E. Markova, T. Betova, S. Popovska, M. Boykov* Department of Pathological Anatomy, Medical University, and

*Clinic of Surgery, University Oncologic Centre, Pleven, Bulgaria

The exact prognosis in colorectal cancer patients depends on numerous pathologic factors. Traditional classifications possess their own restrictions. The authors attempted a multifactorial analysis of several parameters related to patients' surveillance rate. A total of 343 patients with primary carcinoma of colon and rectum registered during a 3-year period in the Oncologic Dispensary, Pleven, were analyzed. Of them, 90 had deceased. A morphologic-prognostic code-card consisting of 30 parameters was elaborated. Along with generally accepted signs such as size, macroscopic shape, stages, degree of differentiation, metastases, volume of the surgical intervention, chemo- and x-ray therapy certain histologic and histochemical patterns such as mucous secretion, mucus composition, type of histological structure, angioinvasive growth, mitotic activity, desmoplastic, stromal, and 66

ourth National Conference on Coloproctology with International Participation, Varna'95 Scripta Scientifica Medica, vol. 29, Suppl. 2, 1995

opyright ©Medical University of Varna

ammatory reaction in tumour periphery were incorporated. Data were statistically processed. The following factors were identified to be related to the unfavourable course of the disease: mucus production, low degree of differentiation, angioinvasive growth, as well as stromal and inflammatory reaction in tumour periphery.

I L E U S DUE T O MALIGNANT COLONIC DISEASES: T H E R A P E U T I C TACTICS UNDER T H E CONDITIONS

O F A REGIONAL HOSPITAL L. Atanasov, P. Atanasov, D. Kourtev

Division of Surgery, Regional Hospital, Haskovo, Bulgaria

The study covered 101 cases with histologically proved colorectal cancer ospitalized during a 3-year period (1992-1994) in the Division of Surgery, Regional

Hospital, Haskovo. Complications were found out in 62 patients (61,39 per cent). Most tients (43 or 69,35 per cent) were in the group with large bowel lumen obturation llowed by colonic ileus. Bleeding per rectum was seen in 8 cases (12,90 per cent);

eritumour inflammatory reaction - in 5 cases (8,64 per cent), and tumour perforation with subsequent diffuse peritonitis - in 3 cases (4,84 per cent). More than a single complication,

g., bleeding and perforation, and peritubular inflammatory process and complete turation, could be observed in one and in two patients, respectively. The surgical terventions used in dependence on the localization of the process, its complications, the erability of the neoplasm, patient's age and general status prior to operation were monstrated.

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