Г Григоров

Ingested foreign bodies (FBs) present a common clinical problem. As the incidence of FBs requiring operative removal varies from 1% to 14%, it was decided to perform this study and compare the data with those from the world literature, as well as to outline an algorithm for management, including indications for surgery. We reviewed all patients with FB ingestion from 1973 to 1993. There were 542 patients with 1203 ingestions, aged 15 to 82 years. Among them, 69. 9% (n = 379) were jail inmates at the time of ingestion, 22.9% (n = 124) had a history of psychosis, and 7.2% (n = 39) were alcoholics or denture-wearing elderly subjects. Most foreign bodies passed spontaneously (75.6%; n = 410). Endoscopic removal was possible in 19. 5% (n = 106) and was not associated with any morbidity. Only 4.8% (n = 26) required surgery. Of the latter, 30.8% (n = 8) had long gastric FBs with no tendency for distal passage and were removed via gastrotomy; 15.4% (n = 4) had thin, sharp FBs, causing perforation; and 53.8% (n = 14) had FBs impacted in the ileocecal region, which were removed via appendicostomy. Conservative approach to FB ingestion is justified, although early endoscopic removal from the stomach is recommended. In cases of failure, surgical removal for gastric FBs longer than 7.0 cm is wise. Thin, sharp FBs require a high index of suspicion because they carry a higher risk for perforation. The ileocecal region is the most common site of impaction. Removal of the FB via appendicostomy is the safest option and should not be delayed more than 48 hours.

Helical tomotherapy (HT) is a novel treatment approach where the ring gantry irradiation geometry of a helical CT scanner is combined with an intensity-modulated megavoltage x-ray fan beam. An inverse treatment planning system (TomoTherapy Inc., Madison) was used to optimize the treatment plans for ten randomly selected prostate patients. Five different sets of margins (2, 5, 7.5 and 10 mm uniform 3D margins and a non-uniform margin of 5 to 10 mm) were employed for the prostate (GTV2) and seminal vesicles (GTV1). The dose distribution was evaluated in targets, rectum, bladder and femoral heads. HT plans are characterized by a rapid dose fall off around the target in all directions resulting in low doses (less than 30% of the dose at ICRU reference point) to the femurs in all cases. Up to a margin of 5 mm for target structures, it was always possible to satisfy the requirements for dose delivery set by RTOG protocol P-0126. Using a 'class solution', HT plans require minimal operator interaction and result in excellent sparing of normal structures in prostate radiotherapy.

MATERIALS AND METHODS: Over a period of 25 years, 35 patients with acquired benign esophago-airway fistulas were treated. Only two of them were female. The etiology of the communications was corrosive burns, penetrating wounds, postoperative and endoscopic lesions, esophageal diverticula, prolonged ventilatory assistance, pleural empyema and foreign bodies. Radical operative treatment was performed in 31 cases. In four of these the procedure was palliative, because of poor general condition and lung complications. The operative approach was chosen after precise endoscopic and contrast X-ray examinations. A cervical approach with partial median sternotomy to the third intercostal space was performed in 19 patients. In the rest of the patients a thoracotomy was performed. Simple excision of the fistula, longitudinal suture of the trachea and horizontal suture of the esophagus was the method of choice in nine patients. A flap from the left sternocleidomastoid was additionally interposed in front of the esophagus in 12 patients. In six cases circular resection, reconstruction of the trachea and plastic suture of the esophagus were performed. Esophagectomy with ensuing colon substitution was necessary in four patients. RESULTS: Excellent or good results were obtained in 29 of the 31 patients operated on. We had two deaths in the early postoperative period (6.8%) due to lung complications in patients with chemical burns of the esophagus. The operated patients were followed up for period ranging from 3 to 20 years. CONCLUSION: Acquired esophago-respiratory fistulas require emergency surgical treatment. The proper choice of operative approach is largely dependent on the precise diagnosis. Preoperative intensive care and metabolic balance are important factors in this report. Radical operative treatment depends on the basic disease, local inflammation and lung complications.

The routine use of mesh for repair of inguinal hernia has been popularized by Lichtenstein and coworkers. We adopted this technique and performed it widely using a mesh unknown in the Western world. Ampoxen [multifilamented polycaproamide, impregnated with 5-Nitro-8-Hydroxyquinolinum (Nitroxolinum, DCI), MEDICA, SA, Sandanski, Bulgaria] was discovered in 1975 and proved to be an excellent prosthetic material for replacement of attenuated or destroyed abdominal wall; furthermore, this mesh is very cheap and became widely applicable in our country. This report describes our experience with the first 846 adult inguinal hernia repairs under local anesthesia using Ampoxen. All 846 patients had excellent results, without recurrence. There were nine wound infections (1.1%), 16 testicular oedemas (1.9%), no seromata and no deaths. In no patient was the prosthetic mesh removed. There were no complications related to the use of Ampoxen; this mesh is permanent, has a great degree of fibrous tissue reaction, and wide spectrum antimicrobic activity. We advocate the Lichtenstein technique using irresorbable mesh (particularly Ampoxen) for all adult groin hernias except Types 1 and 2 (according to Nyhus' classification), and for all adult recurrent groin hernias.

PURPOSE: We sought to evaluate a new technique for creation of a continent perineal colostomy following abdominoperineal resection (APR) of the rectum for low rectal cancer. METHODS: Nine selected patients with low rectal cancer (two males; median age, 55.6 years; classified as Dukes A, 6 patients and as Dukes B, 3 patients) underwent APR. Following this, the original Lazaro da Silva technique was used as follows: 1) for performance of three circular myotomies in the distal sigmoid with a distance between each couple of no more than 8 cm; 2) repair of the myotomies, thus creating three circular colonic valves, the most distal of which remained extraperitoneally; 3) for construction of a perineal colostomy lying flush with the perineal skin; 4) after the patient starts consuming a regular diet, enemas through the perineal stoma are done, usually twice per week, to achieve defecation. Functional outcome was assessed by evaluation of bowel movements and neoanal continence. RESULTS: There were no deaths. From January 1994 until October 1995, no tumor recurrence has occurred, and fecal continence has been good. Four of the patients were able to defecate without enemas (2-4 times per week), and in five patients the self-administration of enemas (2-4 times a week) were necessary to accomplish defecation. CONCLUSION: Initial results with the Lazaro da Silva technique have been encouraging.