Volume 13 (2020): Issue 1 (September 2020)

Total mesorectal excision (TME) has become the golden standard for treating rectal cancer since Heald introduced it [1]. Transanal total mesorectal excision (taTME) is an innovative surgical method for rectal cancer. A nonsystematic literature review on the articles on taTME in the PubMed and Scopus database was performed. ‘TaTME’ and ‘transanal total mesorectal excision’ keywords were used. The search was restricted to articles in English on more than 25 patients analyzed and followed-up. Fourteen articles were identified, most of them from Europe and China. Of these, eight were original studies, and six were systematic reviews and meta-analyses. TaTME is safe and efficient in experienced hands. It could be superior to laparoscopic total mesorectal excision (laTME) concerning perioperative complications. Its advantages in oncological outcomes over laTME are to be proven in structured randomized clinical trials (RCTs).

Alzheimer’s disease (AD) is an age-related neurodegenerative disorder clinically characterized by memory impairment, disorientation, cognitive deficits, and behavioral disturbances. The neuropathological features are amyloid plaques containing aggregated amyloid-beta (Aβ) peptide, neurofibrillary tangles composed of the hyperphosphorylated form of the microtubule protein tau (HP-tau), and loss of neurons and synapses in the brain.

There are no effective strategies for the prevention or treatment of the disease, leading to an increased need for AD biomarkers to improve early detection, accurate diagnosis, and accelerate drug development in this field. Recently, increasing attention has been dedicated to neuropeptides in searching for new drug targets in the treatment of nervous system disorders. Available data suggest that many neuropeptides may be associated with the pathophysiology and potential therapy of AD because of their wide distribution in brain areas responsible for learning and memory processes and their predominately neuroprotective actions. This short review aimed to briefly describe the neuropathology of AD and summarize the data related to one of its recently proposed biomarker - kyotorphin (KTP) neuropeptide. Our previous experiments showed moderate and selective protective effects of KTP against the late consequences of the intracerebroventricular streptozotocin-induced AD model.

Introduction: Bariatric surgery has amply demonstrated its benefit in the treatment of morbidly obese patients. After surgery, there is a progressive and significant decrease in weight in a high percentage of patients. Most comorbidities resolve, improving quality of life and increasing life expectancy.

Methods and Objective: The literature review is based on a 10-year or longer follow-up of patients who underwent various bariatric surgery procedures. The long-term weight loss results and the clinical impact were evaluated.

Results: The applied surgical techniques, including Rouxen-Y gastric Bypass (RYBG), Biliopancreatic Diversion, Scopinaro type (BPD), and Duodenal Switch (DS), have contributed to achieving very satisfactory long-term and sustainable weight loss results. According to the reviewed literature, the percentage of excessive BMI Loss (%EBMIL) for the various techniques was 67.9%, 70.7%, and 71.5% for RYGB, BPD, and DS, respectively. Patients undergoing BGYR have lost much more weight than non-surgical patients and can maintain long-term weight loss, reaching a Percentage of Excessive Weight Loss (%EWL) as high as 56.4% in 10 years. Patients who underwent Adjustable Gastric Band (AGB) presented with a %EWL of 45.9% in 10 years, but with very high re-operation rate range (8-78%). There are few studies in the literature on Laparoscopic Sleeve Gastrectomy, reporting weight loss results over ten years. According to the study carried out by Arman G. A., Himpens J., et al. isolated Laparoscopic Sleeve Gastrectomy (LGS) produced a satisfactory weight loss over ten years, reachingEBMIL of 62.5%. Amending LSG with a new surgical design with malabsorbtive component (in 25% of patients) increased the weight loss, achieving %EBMIL of 81.7%.The Vertical Band Gastroplasty technique resulted in EWL of 38.1 ± 28.8%, as shown by a mean follow-up of 17.3 years, with a high rate of re-operations and conversions.

DXA is a gold-standard method for assessing bone mineral density (BMD) to diagnose osteopenia and osteoporosis. Osteoporosis and degenerative lumbar scoliosis are well-known diseases in adults, which are most often coexistent. This study aimed to assess the prevalence of osteopenia and osteoporosis in 1019 women aged ≥40 years divided into different groups according to the Cobb angle measured from DXA scan images with DICOM software. We found that the incidence of osteoporosis of the lumbar spine and total hip, as well as the incidence of osteopenia of the total hip, increased in the groups according to the Cobb angle. The group with a Cobb angle >10^◦ showed the highest prevalence of osteoporosis. According to the Cobb angle, the incidence of osteopenia of the lumbar spine remained similar in the different groups. The results of the current study show that scoliosis has an essential impact on the interpretation of DXA scans. The BMD’s false elevation, respectively, of the T-score of some vertebrae, could lead to an incorrect final diagnosis. In this case, additional assessment of the hip BMD could be useful for a more accurate interpretation of the results based on the lumbar spine BMD.

Morbidity and mortality rate for stroke and ischemic stroke (IS), in particular, have ranked Bulgaria at a top place in the European Union. In the acute recovery stage of the disease, patients need continuous and personalized health care. The assessment of individual needs and adequate planning for nursing interventions, known as nursing process stages, are the basis of effective care management for patients, surviving ischemic stroke (PSIS). Therefore, the study and application of the nursing process in practice have proved to be an objective prerequisite for improving the quality and development of nursing care for PSIS. The objective of the study was to analyze the opinion of nurses working in clinics/departments of Neurology and Physiotherapy and Rehabilitation in three towns in Northern Bulgaria, on health care (HC) planning for PSIS and the required documentation. A direct anonymous inquiry was carried out, using specially designed questions to investigate the opinion of the respondents on the problems studied. Of the 81 individuals approached, 75 (93%) responded. Of these, 52 (69%) were familiar with the main points of the nursing plan concept, and 34 (65%) had heard about the concept during their basic training in the speciality. According to 67 (89%) of the respondents, a care plan was necessary to increase the health care (HC) efficiency in IS patients. Our results showed that healthcare professionals considered care planning an important tool to ensure continuity, evaluation and control of the care provided. According to the respondents, documenting health care and evaluating the activities performed will contribute to improve the quality of nursing care and promote research into nursing care.

Unsatisfactory results from lumbar disc herniation (LDH) conservative treatment suggest referral of patients for neurosurgical treatment. The time required for such a decision is considered to be about 4-6 weeks. In most cases, surgery quickly relieves pain symptoms, all along with the restoration of patient functions. The optimal surgical technique for LDH is theoretically controversial. We consider two discectomy methods as quite effective in our clinic: standard open discectomy (SD) and microdiscectomy (MD). Many retrospective studies have demonstrated the superiority of one of these techniques. Most studies describe microdiscectomy as a golden standard for surgical treatment of symptomatic disc herniation. We focused on the clinical aspects and correlations in the surgical treatment of LDH, as presented in the literature.

The patients we present were divided by type of surgical procedure (SD or MD), and other parameters: sex, age, duration of symptoms, blood loss, duration of the operation, reoperation rate, Visual Analogue Scale (VAS), and Oswestry Disability Index (ODI). We used chi-square tests (ANOVA analysis) and directional measures to determine statistically significant data. Five hundred eighty-nine single-level lumbar discectomies were performed for five years (2012-2017), and all the patients presented with classical signs of the condition, i.e., vertebral and radicular syndromes. SD was performed on 498 patients, and MD – on 91 patients. Analyses of the parameters mean VAS values of lumbar and leg pain postoperatively, and within one month after surgery demonstrated statistically significant differences between standard and microdiscectomy (p<0.05). LDH surgical techniques have become more and more sophisticated over the last 40 years, but without substantial improvement in the functional and clinical results. Appropriate patient selection is a crucial factor for the postoperative outcome. Neurosurgeons should fully master the chosen technique for satisfactory postoperative results.

To reduce the residual risk of transfusion-transmitted infections, nucleic acid amplification testing (NAT) of donated blood with higher sensitivity for HBV, HCV, and HIV 1/2 was implemented in Bulgaria at the end of 2019. This study aimed to assess the clinical sensitivity of HBsAg testing and NAT testing of donated blood to detect all forms of HBV infection. A total of 9498 consecutive blood donations collected for six months, from February 10 to July 17, 2020, from first-time and repeat donors at the Regional Center of Transfusion Hematology Pleven, Bulgaria, were screened for HBsAg and HBV DNA. The detection of HBsAg was performed by enzyme-linked immunoassay and chemiluminescent immunoassay. Detection of HBV DNA was performed using the HIV1/2 /HCV / HBV multiplex Procleix Ultrio Elite assay in a fully automated and integrated Procleix Panther System. The overall HBsAg prevalence was 0.05%. HBV DNA was detected in 25 blood units (0.26%), but only 12 (0.13%) were found positive after repeat testing and were confirmed by a discriminatory test. The other 13 units were false positive, with the initial reactive result and negative results after repeat testing. HBV DNA’s overall incidence was significantly higher in HBsAg-positive donors than the HBsAg- negative (Fisher exact p=0.0063). In our study, blood donations were not tested for anti-HBc and anti-HBs, so it is difficult to determine whether HBV DNA-positive/HBsAg-negative results were associated with the early phase of infection or persistent occult infection. There was no statistical difference in the incidence of HBV DNA between repeat-donors (0.16%) and first-time donors (0.06%) (Fisher exact test p=0.239 NS), and also between the incidence in female donors (0.12%) and male donors (0.13%) (Fisher exact test p=1.0 NS). The results of this study showed a low rate of detection of the hepatitis B virus in donated blood. NAT testing demonstrates higher sensitivity for the detection of HBV, as compare to HBsAg screening.

Acute appendicitis (AA) is the most common non-traumatic abdominal emergency. Despite the improved knowledge, experience, and technological advance, its diagnosis remains a challenge. Herein we report an example of a difficult diagnosis of acute appendicitis and comment on the possible pitfalls in the differential diagnosis and surgical tactics. We present the case of a 41-year-old man who had been admitted to another hospital with an initial diagnosis of acute appendicitis and changed to Crohn’s disease (CD). Because of a pelvic abscess, percutaneous drainage had been performed. Thrombosis of the right femoral vein had been diagnosed and treated accordingly. In an improved condition, he was referred for elective operation with a final diagnosis of neuroendocrine tumour based on cytology. At laparotomy, the appendix was found densely adherent to the right external iliac vein with a well-demarcated tumour (1 cm) at the base. Appendectomy with partial resection of the caecum with a linear stapler was performed. The histological examination revealed acute to chronic appendicitis with lymphoid follicle hyperplasia at the base. The case illustrates the necessity for broad differential diagnosis in AA and the possibility of severe vascular complications in complicated AA. Taking a detailed history and CT are of paramount importance for an accurate preoperative diagnosis, especially of CD. All emergency surgeons should also be familiar with the scenario of unexpected findings at laparotomy, especially with the management of CD and the algorithms for treatment of appendiceal malignancies. The mini-invasive drainage of right iliac fossa abscess allows for optimizing the patient’s condition and may help to avoid unnecessary extensive resections.

Juvenile pilocytic astrocytoma (JPA) is a low-grade glioma, a most common astrocytoma in young patients. It is a tumor with relatively well-defined margins. Pilocytic astrocytomas (PA) comprise approximately 5-6% of all gliomas. Gross total resection ensures a radical cure of patients and long-time survival. In the literature, the data on the survival rate of more than 20 years is scarce. A 5.5-year old boy with a history of 3-month complaints of headache, dizziness, and vomiting was diagnosed after CT to harbour a hypodense cerebellar tumor mass, situated in the midline-right hemisphere. The compression of the fourth ventricle resulted in rostral hydrocephalus with transependymal resorption. Within a week, a VP shunt was applied, followed by a radical Nafziger-Town operation. Gross total resection of the tumor was achieved. Profound clinical improvement was observed immediately after the operation. Postoperative CT scans, including the ones 22 years after the operation, remained practically normal. The patient is now 28-year old and is a perspective economist now. He leads a healthy working life. In general, the prognosis is excellent. If the tumor is completely removed by surgery, the chances of being “cured” are very high. Pilocytic astrocytoma has a five-year survival rate in over 96 percent in children and young adults, which is one of the highest survival rates of any brain tumor. However, there is even a small percent possibility for malignant transformation (1-4%).

Chronic lymphocytic leukemia is one of the most common types of leukemia affecting adults over 65 years of age [1]. The disease is a part of the so-called indolent lymphomas and has a variable clinical course, defined by many factors. In recent years, knowing better the pathogenetic mechanisms of the disease, significant advances in the treatment have been made [2]. Monoclonal antibodies, immunomodulators, tyrosine kinase inhibitors, anti-apoptotic Bcl-2 protein inhibitors have been approved for clinical practice. Nevertheless, the development of tumor resistance and recurrence of the disease remains a challenge for hematologists, biologists, and pharmacists. We present two clinical cases of patients of both age groups (young adults and adults), in whom treatment was started with a Bruton’s tyrosine kinase (BTK) inhibitor, after inadequate response to immunochemotherapy (CIT).

Retroperitoneal soft tissue sarcomas comprise a relatively rare entity with incidence rates of less than 1% of all malignancies. The surgical treatment of these tumors is challenging. We present a case of a 70-year-old patient who underwent radical surgery at the Department of Surgical Oncology at the University Hospital in Pleven for giant dedifferentiated liposarcoma. The patient presented with cachexia, anemia, dull abdominal pain, and a huge abdominal mass. After ultrasound and CT, the tumor was assessed as resectable. The removed tumor mass weighed 5.7 kg. Nowadays, complete resection of such tumors remains the most important predictive factor for local recurrence and overall survival.

The term meningeal melanocytoma was first introduced by Limas and Tio in 1972 to figure out lesions of the central nervous system that, under light microscope view, have meningioma characteristics, and ultrastructural characteristics of melanocyte neoplasm, respectively. Meningeal melanocytomas (MM) represent 0.06-0.1% of brain tumors. The annual incidence is about 1 per 10 million. This type of neoplasm is rarely seen in clinical practice. A few cases have been reported in the literature. A 62-year-old man was admitted, complaining of trigeminal pain in the area of the I and II branches of CN V on the left of his face. He underwent two surgeries in a row. First, malignant melanoma, and then meningeal melanocytoma were histologically verified. Neurological examination demonstrated hyperpigmented left iris, neuralgic pain in I and II branches of CN V, latent central hemiparesis and hemihypesthesia for the right extremities, positive Babinski reflex on the right, positive axial pathological reflexes, and partial motor aphasia.

Primary intracranial meningeal melanocytoma is difficult to diagnose preoperatively because of the tumor’s non-specific clinical and neuroradiological characteristics. So electron microscopy and immunohistochemical additional diagnostic confirmation are mandatory. Immunohistochemical findings - the presence of S-100 protein, vimentin, and antimelanocyte antigen HMB-45, no reaction for EMA and ultrastructural (melanosomes in different maturation, contacts type zonula adherens) are all in favour of the histopathological diagnosis of MM. Meningeal melanocytoma is a slow-growing tumor, biologically benign, and attempts for surgical radicalism are recommended. It is not entirely clear whether a malignant transformation of these tumors is possible. The role of chemotherapy also remains questionable and has not been documented as effective.