Rare case of enteric type of urachal adenocarcinoma: A case report

Urachal adenocarcinomas, constituting 10 % of bladder adenocarcinomas, pose a significant challenge with limited literature. A 43-year-old male presented with haematuria and abdominal pain, leading to surgical intervention for a 13 cm pelvic tumor. Histopathology identified an intestinal-type primary urachal adenocarcinoma, staged as IIIA, no recurrence on follow-up. Early detection is crucial for improved outcomes in these rare malignancies. While surgery remains the primary treatment, outcomes vary, emphasizing the need for research on standardized protocols. Enhanced awareness and interdisciplinary collaboration are vital for effective management. Comprehensive guidelines are essential for optimizing patient prognoses in urachal adenocarcinomas.

Diagnostic and prognostic role of serum interleukin-6 and carotid ultrasonography to detect subclinical atherosclerosis in patients with RA and ANCA-associated vasculitis

ANCA-associated vasculitis (AAV) can affect multiple organs with severe life-threatening manifestations. Disease monitoring is difficult due to a lack of defined biomarkers. We aimed to assess the diagnostic role of serum interleukin-6 and vascular ultrasonography in AAV and subclinical atherosclerosis. The study included 20 AAV patients and two control groups of 34 patients with rheumatoid arthritis (RA) and 35 healthy controls. The levels of Il-6, carotid intima-media thickness test (CIMT), atherosclerotic plaque, and degree of stenosis were investigated. A GRACE-risk score was calculated for AAV and RA patients. The AAV patients had elevated levels of IL-6 (115 ± 23.96) compared to the RA patients (91.25 ± 42.63) and the healthy controls (15.65 ± 3.30), p < 0.001. IL-6 showed a diagnostic accuracy of 73% in distinguishing AAV from RA patients (AUC = 0.730; 95% CI 0.591 to 0834). In the AAV group, CIMT was 1.09, above the upper reference value of 0.90, p < 0.001. The AAV patients had a higher median GRACE risk score, and 60% of them had a high risk of cardiovascular events as compared to 35% of the RA patients. Sonography of extracranial vessels and serum levels of IL-6 can be used in daily clinical practice to diagnose and monitor patients with AAV.

Estimating reference values of parenchymal stiffness of normal pancreatic parenchyma by means of point shear wave elastography

INTRODUCTION

There are numerous imaging modalities available to describe pancreatic parenchyma. None of the broadly accepted diagnostic methods uses elasticity as an indicator of tissue damage.

Surgical Innovations in Tracheal Reconstruction: A Review on Synthetic Material Fabrication

Background and Objectives: The aim of this review is to explore the recent surgical innovations in tracheal reconstruction by evaluating the uses of synthetic material fabrication when dealing with tracheomalacia or stenotic pathologies, then discussing the challenges holding back these innovations. Materials and Methods: A targeted non-systematic review of published literature relating to tracheal reconstruction was performed within the PubMed database to help identify how synthetic materials are utilised to innovate tracheal reconstruction. Results: The advancements in 3D printing to aid synthetic material fabrication have unveiled promising alternatives to conventional approaches. Achieving successful tracheal reconstruction through this technology demands that the 3D models exhibit biocompatibility with neighbouring tracheal elements by encompassing vasculature, chondral foundation, and immunocompatibility. Tracheal reconstruction has employed grafts and scaffolds, showing a promising beginning in vivo. Concurrently, the integration of resorbable models and stem cell therapy serves to underscore their viability and application in the context of tracheal pathologies. Despite this, certain barriers hinder its advancement in surgery. The intricate tracheal structure has posed a challenge for researchers seeking novel approaches to support its growth and regeneration. Conclusions: The potential of synthetic material fabrication has shown promising outcomes in initial studies involving smaller animals. Yet, to fully realise the applicability of these innovative developments, research must progress toward clinical trials. These trials would ascertain the anatomical and physiological effects on the human body, enabling a thorough evaluation of post-operative outcomes and any potential complications linked to the materials or cells implanted in the trachea.

Hepatico-Duodenal Fistula Following Iatrogenic Strasberg Type E4 Bile Duct Injury: A Case Report

INTRODUCTION

Gallstone disease (GSD) is among the most common disorders worldwide. Gallstones are established in up to 15% of the general population. Laparoscopic cholecystectomy (LC) has become the "gold standard" for treatment of GSD but is associated with a higher rate of certain complications, namely, bile duct injury (BDI). Biliary fistulas (BF) are a common presentation of BDI (44.1% of all patients); however, they are mainly external. Post-cholecystectomy internal BF are exceedingly rare.

CASE REPORT

a 33-year Caucasian female was admitted with suspected BDI after LC. Strasberg type E4 BDI was established on endoscopic retrograde cholangiopancreatography (ERCP). Urgent laparotomy established biliary peritonitis. Delayed surgical reconstruction was planned and temporary external biliary drains were positioned in the right and left hepatic ducts. During follow-up, displacement of the drains occurred with subsequent evacuation of bile through the external fistula, which resolved spontaneously, without clinical and biochemical evidence of biliary obstruction or cholangitis. ERCP established bilio-duodenal fistula between the left hepatic duct (LHD) and duodenum, with a stricture at the level of the LHD. Endoscopic management was chosen with staged dilation and stenting of the fistulous tract over 18 months until fistula maturation and stricture resolution. One year after stent extraction, the patient remains symptom free.

DISCUSSION

Management of post-cholecystectomy BDI is challenging. The optimal approach is determined by the level and extent of ductal lesion defined according to different classifications (Strasberg, Bismuth, Hannover). Type E BDI are managed mainly surgically with a delayed surgical approach generally deemed preferable. Only three cases of choledocho-duodenal fistulas following LC BDI currently exist in the literature. Management is controversial, with expectant approach, surgical treatment (biliary reconstruction), or liver transplantation being described. Endoscopic treatment has not been described; however, in the current paper, it proved to be successful. More reports or larger case series are needed to confirm its applicability and effectiveness, especially in the long term.

PAPILLARY MICROCARCINOMA OF THE THYROID GLAND - DOES SIZE MATTER?

Introduction

Papillary thyroid microcarcinoma has provoked discussion among the endocrinological community due to the extremely diverse therapeutic methods adopted in international guidelines. From the radical approach of total thyroidectomy with prophylactic central lymphatic dissection to "active monitoring" and opinions such as "papillary microcarcinoma is not carcinoma".

Aim

To investigate the factors of invasiveness in papillary microcarcinoma.

Material and methods

We included 184 patients with thyroid microcarcinoma, operated in the Department of General Surgery "Kaspela",Plovdiv, for a period of five years.

Results

Intra-organ metastases or multifocal growth was identified in 38 of the patients. Positive for micro and macro metastases lymph nodes in the central lymphatic basin are found in 54. In 46 of them we identified metastases in the ipsilateral, and in 21 in the contralateral central neck nodes. The analysis of patients with lateral metastases found 7 unilaterally and 3 bilaterally. Skip metastases were registered in 4 of these 10 patients.

Conclusions

The results of our study show that despite the favorable prognosis and non-aggressive behavior of papillary microcarcinoma, factors attesting to the invasive nature of the tumor occur in 44.5% or almost half of patients. This requires careful and individual approach constructing therapeutic strategy for the treatment of patients with papillary microcarcinoma.

Clinical Outcomes of EUS-Guided Choledochoduodenostomy for Biliary Drainage in Unresectable Pancreatic Cancer: A Case Series

Introduction. Pancreatic ductal adenocarcinoma (PDA) is associated with poor prognosis and 98% loss-of-life expectancy. 80% of patients with PDA are unfit for radical surgery. In those cases, emphasis is set on management of cancer-related symptoms, among which obstructive jaundice is most common. Endoscopic ultrasound-guided biliary drainage (EUS-BD) emerges as a valid alternative to the well-accepted methods for treatment of biliary obstruction. Patient Selection. Five consecutive patients with unresectable pancreatic malignancy, were subjected to EUS-BD, particularly EUS-guided choledochoduodenostomy (EUS-CDS). Ethics. Oral and written informed consent was obtained in all cases prior procedure. Technique. EUS-guided puncture of the common bile duct was performed, followed by advancement of a guidewire to the intrahepatic bile ducts. After dilation of the fistulous tract with a cystotome, a fully covered self-expandable metal stent was inserted below the hepatic confluence and extending at least 3 cm in the duodenum. Technical and clinical success was achieved in four patients without adverse events. In one patient procedure failed due to dislocation of the guidewire, with consequent biliary leakage requiring urgent surgery. Recovery was uneventful with no further clinical sequelae and there was no mortality associated with procedure. Discussion. Introduced in 2001, EUS-guided biliary drainage has become an accepted option for treatment of obstructive jaundice. According to recent guidelines published by European Society of Gastrointestinal Endoscopy (ESGE) in 2022, EUS-CDS is a preferred modality to percutaneous transhepatic biliary drainage (PTBD) and surgery in patients with failed ERCP, with comparable efficiency and better safety profile, which is supported by our experience with the procedure. Conclusions. Our case series suggests that EUS-CDS is an excellent option for palliative management of malignant distal biliary obstruction, emphasizes on the importance of adequate technique and experience for the technical success, and urges the need for future research on establishing the best choice for guidewire and dilation device.

Evaluation of Liver Stiffness Measurement by Means of 2D-SWE for the Diagnosis of Esophageal Varices

Portal hypertension (PH) and esophageal varices (EVs) are a matter of extensive research. According to current Baveno VII guidelines, in patients with compensated advanced chronic liver disease (cACLD), liver stiffness measurement (LSM) < 15 kPa and PLT count > 150 × 10⁹/L, upper endoscopy (UE) is not mandatory, and the emphasis should be set on non-invasive methods for evaluation of clinically significant portal hypertension (CSPH). The aim of this study is to establish whether liver stiffness (LS) measured by 2D-SWE could be used as a predictor for the presence and severity of EVs in cirrhotic patients. In total, 86 patients of whom 32 with compensated liver cirrhosis (cLC) and 54 with decompensated liver cirrhosis (dLC) were examined in the Gastroenterology clinic of University hospital "Kaspela", Plovdiv, Bulgaria. Each patient underwent LS assessment by 2D-SWE and EVs grading by UE. EVs were detected in 47 (54.7%) patients, 23 (49%) of them were stage 4-high-risk EVs (HREV). The cut-off value for LS that differentiates HREV from the rest was set at 2.49 m/s with 100% sensitivity and 100% specificity (AUC 1.000, CI 0.925). Conclusions: 2D-SWE can be used as a non-invasive method in the assessment of only high-grade esophageal varices. For the other grades, upper endoscopy remains the method of choice.

Comparison of short term results following robotic and laparoscopic total gastrectomy and D2 lymph node dissection

INTRODUCTION

In the last decade, there has been a progressive shift from open to mini-invasive operative techniques for surgical resection of gastric cancer. Advanced equipment of surgical robots, with its 3D visualization, steady camera view, flexible instrument tips, attracts more and more practitioners in performing robotic gastrectomy with D2 dissection in gastric cancer patients. Thus, the comparison of some basic oncological as well as some surgical variables related to laparoscopic and robotic gastrectomy and D2 lymphadenectomy is necessary.

Surgical Management of Liver Metastases from Colorectal Cancer: A Single-Surgeon Preliminary Findings Report

Introduction: Colorectal cancer is a significant medical and social problem. Approximately half of the patients with colorectal carcinoma develop liver metastasis. Most commonly, they are identified during the diagnostic process or the initial surgery. After the diagnostics, only 15% of the cases are referred to receive radical surgery. Liver resection in patients with hepatic metastases is the only way to improve their survival. Objective: To introduce a surgical strategy used for the treatment of colorectal liver metastases. Materials and Methods: The study included 539 patients who underwent surgery for colorectal carcinoma in the Department of Surgery at University Hospital "Kaspela" during the period 2014–2020. This data was collected from the patients' disease history. Results: Of the 539 patients with colorectal carcinoma, 74 (13.7%) were diagnosed with synchronous liver metastases. In 38 (51.3%) of the cases, the metastases were solitary, of which 21 were removed simultaneously and 17 at the follow-up stage. In 8 (10.8%) cases, more than one (2 to 3) solitary metastasis was established near the edges. They were also removed simultaneously. In 6 patients (8.1%), bi-lobar and peripherally localized solitary lesions were found, which were removed instantly and chemotherapy was administered. In 22 (29.7%) of the patients with multiple bi-lobar metastases, only a biopsy was performed, and surgery was carried out only in those affected by chemotherapy. Conclusion: The possibilities of simultaneous and stepwise liver resections were expanded by focusing on individual approach preferences and improving diagnostic methods, liver surgery techniques, and modern chemotherapy. This increased the survival rate of patients with colorectal liver metastases.

Assessment of the Utility of Multiparametric Magnetic Resonance Imaging for Initial Detection of Prostate Cancer

BACKGROUND: An accurate diagnosis is essential for the effective treatment of prostate cancer (PCa) and for the patients’ well-being. AIM: Thе main purpose of this study was to assess the utility of multiparametric magnetic resonance imaging (mp-MRI) for initial detection of PCa among the Bulgarian population of men with prostate diseases. MATERIALS AND METHODS: Fifty-three patients, aged 44 to 82 years, were evaluated for clinically significant PCa. Assessment methods included prostate-specific antigen (PSA) serum levels, transrectal ultrasonography (TRUS), GE Discovery 3T MRI, and 12-core TRUS biopsy. RESULTS: mp-MRI showed 83.20% concordance with TRUS biopsy: sensitivity of 91.43% (76.90–98.20), specificity of 75.00% (34.90–96.80), positive predictive values 94.10% (82.80–98.20) and negative predictive values 66.70% (38.70–86.40). Of the patients classified in prostate imaging–reporting and data system (PI-RADS) levels 4 and 5, 94.12% had positive TRUS biopsy, as well as 44.40% of PI-RADS had level 3. Irrespective of the patients’ age and PSA, PI-RADS was found to be a significant predictor of a positive TRUS biopsy (p = 0.009). PSA serum levels showed a low concordance with TRUS biopsy (area under the curve = 0.539; 95% confidence interval [CI]: 0.363–0.712) and a low, although significant, correlation with PI-RADS (rs = 0.416; 95% CI: 0.164–0.617). CONCLUSION: According to our findings, mp-MRI and TRUS biopsy have a high level of concordance for the initial detection of PCa. The incorporation of mp-MRI into the diagnostic pathway for PCa can significantly reduce the number of incorrect diagnoses based on PSA serum levels and/or suspicious physical and digital examinations.

Robotic-assisted colorectal surgery - initial results

INTRODUCTION

The mini invasive procedure in colorectal surgery is gaining ground as an alternative to conventional surgery. Colorectal surgery has significantly evolved since the advent of the automatic stapler devices and subsequently with the minimally invasive approach. The next logical step - the robotic assisted surgery was developed to satisfy surgeons' needs to the area of colorectal surgery and to offer a new and safer method to patients. The evidence for benefits of its use in this area appears to be promising.

Diverting ileostomy in low anterior resection: single center retrospective analysis

<b> Introduction:</b> Low anterior resection (LAR) is the standard procedure for distal rectal cancer allowing anal sphincter preservation. Anastomotic leakage remains one of the most dangerous complications following LAR and its management is difficult. </br></br> <b>Aim:</b> This study reviews our experience of LAR with and without protective ileostomy (PI). </br></br> <b> Methods:</b> One hundred ninety-nine patients undergoing LAR resection for low rectal cancer in this centre during the period 2015–2019 were divided retrospectively into two groups. Group A underwent rectal resection and coloanal/rectal anastomosis with diverting ileostomy and group B without ileostomy. </br></br> <b> Results:</b> Among our patients, 20 had a covering ileostomy (stoma group);179 did not (control group). The stoma group comprised 14 men and 6 women ranging in age from 36 to 89 years (mean, 64.2 ± 10.5 years). Conventional v. minimally invasive surgery was 6/14. Anastomotic leakage occurred in 16/179 (8.93%) patients without a PI, and in 6/20 (30%) with a stoma (Tab. I.). Of the 16 patients experiencing an anastomotic leak, 3 (18.75%) from Group A and 5 (83.33%) from Group B were classified as Grade B leakage and were treated conservatively. As many as 13/16 (81.25%) in Group A and 1/6 (16.77%) in Group B were classified as Grade C leakage and required emergency surgery. </br></br> <b>Conclusion:</b> These results do not show a preventive effect on the occurrence of anastomotic leakage in low anterior resection, but may significantly reduce the need for further surgery due to septic complications in the early postoperative period. Selection of patients for protective ileostomy requires great care as its creation and closure are associated with severe complications.

Evaluation of Ultrasound-Based Point Shear Wave Elastography for Differential Diagnosis of Pancreatic Diseases

Introduction: A variety of imaging techniques exists for the diagnosis of pancreatic disorders. None of the broadly applied diagnostic methods utilizes elasticity as an indicator of tissue damage. A well-known fact is that both chronic pancreatitis (CP) and pancreatic ductal adenocarcinoma (PDA) are associated with the development of prominent fibrosis (increased tissue stiffness). Purpose: To prospectively assess the accuracy of point shear wave elastography (pSWE) in differentiating between benign and malignant pancreatic diseases, establish a cut-off value for the diagnosis of PDA, and evaluate the influence of certain variables on the obtained results. Materials and methods: The present study included 78 patients who were admitted at the Department of Gastroenterology at the university hospital “Kaspela” between December 2017 and August 2021 for diagnosis and/or treatment of pancreatic disorders. Based on the clinical criteria, diagnostic imaging, and histological findings, patients were divided into the CP and PDA group. The ultrasound based pSWE technique was applied and shear wave velocity (SWV) was measured. The depth of region of interest (ROI) and successful measurement rate were also recorded. Results: The mean ± SD SWV values established through pSWE were 1.75 ± 0.34 m/s and 2.93 ± 0.91 m/s for the CP and PDA, respectively. With a cut-off value of 2.09 m/s, we calculated the sensitivity (Se), specificity (Sp), and accuracy for differentiating between CP and PDA of 89.47%, 91.20%, and 88.60%, respectively. Of the examined variables, BMI and depth of ROI in the CP group and sex in the PDA group showed a statistically significant influence on the obtained results. Conclusions: pSWE may be utilized as a differential diagnostic modality in patients with suspected CP or PDA.

Factors Affecting Residual Stone Rate, Operative Duration, and Complications in Patients Undergoing Minimally Invasive Percutaneous Nephrolithotomy

Background and objectives: Although minimally invasive percutaneous nephrolithotomy (MPCNL) has demonstrated its efficacy, complete stone clearance was not always achieved, necessitating a second procedure. The purpose of this study was to evaluate factors associated with residual stone rate, operative duration, complications, and hospital stay, in order to develop algorithms for pre-operative prognosis and planning. Materials and Methods: This retrospective study involved 163 Bulgarian patients who underwent MPCNL with Holmium: YAG lithotripsy for the treatment of kidney stones. Patients were considered stone-free if no visible fragments (<3 mm) were found on nephroscopy at the end of the procedure, as well as on postoperative X-ray and abdominal ultrasound on the first postoperative day. Results: Immediate postoperative stone-free outcome was attained for 83.43% of the patients (136/163). Residuals were associated with staghorn stones (OR = 72.48, 95% CI: 5.76 to 91.81); stones in two locations (OR = 21.91, 95% CI: 4.15 to 137.56); larger stone size (OR = 1.12, 95% CI: 1.006 to 1.25); and higher density (OR = 1.03, 95% CI:1.005 to 1.06). The overall categorization accuracy for these factors was 93.80%, AUC = 0.971 (95% CI: 0.932 to 0.991), 89.71% sensitivity, and 96.30% specificity. Predictors of prolonged operative duration were staghorn stones and volume, R-square (adj.) = 39.00%, p < 0.001. Longer hospitalization was predicted for patients with hydronephrosis and staghorn stones, R-square (adj.) = 6.82%, p = 0.003. Post-operative complications were rare, predominantly of Clavien-Dindo Grade 1, and were more frequent in patients with hydronephrosis. We did not find a link between their occurrence and the outcome of MPCNL. Conclusions: Staghorn stones and stones in more than one location showed the strongest association with residual stone rate. Staghorn stones and larger volume were linked with a longer operative duration. Hydronephrosis increased the risk of complications and longer hospitalization.