Latest Articles from Folia Medica Latest 100 Articles from Folia Medica https://foliamedica.bg/ Fri, 29 Mar 2024 08:36:05 +0200 Pensoft FeedCreator https://foliamedica.bg/i/logo.jpg Latest Articles from Folia Medica https://foliamedica.bg/ Resection and a rare type of reconstruction of the superior vena cava with the left brachiocephalic vein https://foliamedica.bg/article/102981/ Folia Medica 66(1): 142-146

DOI: 10.3897/folmed.66.e102981

Authors: Georgi Yankov, Magdalena Alexieva, Evgeni Mekov, Rosen Petkov

Abstract: Resection and reconstruction of the superior vena cava (SVC) are required in a selected group of patients with anterior mediastinal tumors and lung neoplasms. We present the case of a 63-year-old woman who underwent invasive type B2 thymoma resection and a rare type of reconstruction of the superior vena cava using a patch of the left brachiocephalic vein (LBV). The various types of reconstruction of the superior vena cava are discussed.

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Case Report Thu, 29 Feb 2024 22:00:20 +0200
Sacral nerve root metastasis in a patient with lung carcinoma resembling neurinoma – a case report and literature review https://foliamedica.bg/article/111619/ Folia Medica 66(1): 136-141

DOI: 10.3897/folmed.66.e111619

Authors: Ivo Kehayov, Atanas Davarski, Polina Angelova, Borislav Kitov

Abstract: Intradural extramedullary metastases from systemic neoplasms are very rare, with an incidence ranging from 2% to 5% of all secondary spinal diseases. We present the case of a 53-year-old man diagnosed with lung adenocarcinoma with symptoms of severe back pain and tibial paresis. The magnetic resonance imaging (MRI) revealed an intradural lesion originating from the right S1 nerve root mimicking neurinoma. Total tumor removal was achieved via posterior midline approach. The histological examination was consistent with lung carcinoma metastasis. Due to the rarity of single nodular nerve root metastases, MRI images may be misinterpreted as nerve sheath tumors, such as schwannomas or neurofibromas. We performed a brief literature review outlining the mainstay of diagnosis, therapeutic approach, and the prognosis of these rare lesions.

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Case Report Thu, 29 Feb 2024 22:00:19 +0200
Paraovarian tumor of borderline malignancy: A case report https://foliamedica.bg/article/116865/ Folia Medica 66(1): 128-131

DOI: 10.3897/folmed.66.e116865

Authors: Dimitrios Bairaktaris, Stefania Tsoplaktsoglou, Efthymia Souka, Konstantinos Kalmantis, Christos Iavazzo

Abstract: Paraovarian tumors of borderline malignancy (PTBM) are exceedingly rare, with only slightly over 60 cases reported worldwide. This report presents the case of a 22-year-old nulliparous patient who incidentally discovered a left paraovarian mass during a routine abdominal ultrasound. Subsequent MRI revealed a 2.5×2.1 cm cystic lesion located in close proximity to, but outside of, the left ovary, with no other pathological findings. A laparoscopic cystectomy was performed with meticulous care to prevent tumor spillage, and the patient experienced an uneventful recovery. Histopathological examination unveiled irregularly shaped tissue measuring 2.2×1.2×1 cm, characterized by fibrous tissue/wall with spindle cell stroma and an epithelium displaying features consistent with a serous borderline tumor. Our multidisciplinary team recommended diligent follow-up. This case contributes to the existing literature on PTBM and highlights the imperative for additional cases to enhance our comprehension of the optimal management of these exceedingly rare tumors.

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Case Report Thu, 29 Feb 2024 22:00:17 +0200
The role of extended resection in locally recurrent colorectal cancer with invasion of the aortoiliac bifurcation: a rare clinical case https://foliamedica.bg/article/107127/ Folia Medica 66(1): 123-127

DOI: 10.3897/folmed.66.e107127

Authors: Vladimir Aleksiev, Boyko Yavorov, Hristo Stoev, Rosen Dimov, Gancho Kostov, Zaprin Vazhev

Abstract: Colorectal carcinoma (CRC) is the third most common cancer and the fourth deadliest. Despite recent advances in screening methods and preoperative imaging techniques, the threat of colorectal cancer remains at an all-time high. Moreover, even after curative treatment, disease recurrence occurs in up to 40% of all cases. However, half of patients with recurrent disease do not register any distant metastases. Therefore, much effort should be expended in identifying and evaluating these patients, as many of them are suitable candidates for en bloc resections with perioperative chemoradiation. In fact, it has recently been found that overall survival benefits greatly from extended resections, provided that free margins are achieved intraoperatively. In this case report, we will present a case of locally advanced recurrent colorectal cancer invading the aortoiliac axis and our approach to achieving a R0 resection.

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Case Report Thu, 29 Feb 2024 22:00:16 +0200
Effects of body mass index on urinary lithogenic factors in urinary system stone patients https://foliamedica.bg/article/114369/ Folia Medica 66(1): 80-87

DOI: 10.3897/folmed.66.e114369

Authors: Yavuz Güler

Abstract: Aim: Obesity and metabolic syndrome are becoming more prevalent these days. In addition, we know that urinary stone disease is also on the rise. In this study, we wanted to examine if body mass index (BMI) had a negative effect on the stone disease by evaluating 24-hour urinalysis in stone patients and recurrence rates in our region. Materials and methods: From January 2017 to December 2019, a total of 193 patients were assessed retrospectively in terms of their 24-hour urine analysis results and blood parathyroid hormone (PTH) values. These patients were divided into 3 groups by their BMI <25, 25-30, and ≥30 (group 1, 2, and 3, respectively). Demographic and 24-hour urine analysis data were compared between the groups. Patients with and without recurrent stones were divided into 2 groups and lithogenic factors were analyzed. Possible lithogenic risk factors for recurrent stone formation were examined in a multivariate logistic regression analysis. Pearson and Spearmen correlation analysis was used for correlation. Results: Groups 1, 2, and 3 had 107, 55, and 31 patients, respectively. There was a statistically significant difference between the groups in their BMI, diabetes mellitus (DM), hypertension (HT), gout, spontaneous stone passage, and extracorporeal shock wave lithotripsy (ESWL) factors. While the mean of BMI was similar for groups 2 and 3, the mean of group 1 was statistically significantly lower. Group 3 exhibited statistically significant higher rates of DM, HT, and gout diseases in comparison to the other groups. ESWL and spontaneous stone removal factors were statistically significantly higher in groups 2 and 3 than in group 1. According to the results of the 24-hour urine analysis, the urinary pH, uric acid, calcium, oxalate, and phosphate values were statistically different in group 1 from other groups. Urinary pH was more acidic and uric acid, calcium, oxalate, and phosphate values were higher in groups 2 and 3. Only BMI was statistically different from the lithogenic factors in the patient groups with and without recurrent stones. Also, in the multifactorial logistic regression analysis, BMI factor was found to be significant in duplicate stone formation. There was a weak but statistically significant correlation between the amount of uric acid and stone volume (r=0.307, p=0.04). Conclusion: Increased BMI negatively affects the lithogenic factors in urine and facilitates the formation of recurrent stones.

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Original Article Thu, 29 Feb 2024 22:00:11 +0200
Initial experience with Bulgarian Arthroplasty Register https://foliamedica.bg/article/117165/ Folia Medica 66(1): 41-45

DOI: 10.3897/folmed.66.e117165

Authors: Atanas Panev, Georgi Lukanov, Georgi Luchev, Slaveyko Dzhambazov, Stoyan Ivanov, Jean-Alain Epinette, Plamen Kinov

Abstract: Introduction: National arthroplasty registries date back to 1975, when the Swedish Knee Arthroplasty Register was founded. This method of database collecting has since been employed for both patient follow-up and the creation of annual statistical reports. In Bulgaria, there is currently no state-approved software that offers these features. Aim: The current study aimed to report on the preliminary findings from our use of the OrthoWave software and the launch of the first Bulgarian registry for arthroplasty. Materials and methods: Using the OrthoWave program, we gathered data on 215 patients who underwent 218 surgical procedures for hip and knee replacement in the Orthopedics and Traumatology Clinic at Tsaritsa Joanna University Hospital, ISUL, between November 2022 and August 2023. Both demographic indicators (sex, age, and BMI) and characteristics of the surgical procedure (intervention execution time, approach used, type and size of prosthesis) were gathered and analyzed. Results: All subjects had a mean BMI of 29.3 kg/m², calculated using OrthoWave’s statistical analysis system. The average weight during surgery was 93 kg, with an average height of 176 cm. The mean age of patients at the time of surgery was 66.11 years. Sex distribution of patients with hip replacement was as follows: 61.38% of them were men and 32.62% were women. Women accounted for 58.9% of all patients with knee endoprostheses, while operated men accounted for 41.1%. Conclusion: In the era of evidence-based medicine, the form of register is crucial for further development of the orthopedic specialty. Our initial experience is promising, and we are looking forward to its development on a national level.

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Original Article Thu, 29 Feb 2024 22:00:06 +0200
Complications after limb salvage surgeries for musculoskeletal malignancies: 10-year experience of the main sarcoma center in Bulgaria https://foliamedica.bg/article/113390/ Folia Medica 66(1): 35-40

DOI: 10.3897/folmed.66.e113390

Authors: Yordan St. Ivanov, Kircho Patrikov

Abstract: Introduction: Limb salvage surgery is currently the most frequently used treatment option in Bulgaria for individuals with musculoskeletal malignancies. Clinical data about complications from these procedures is limited in the country, with only a few studies currently available. Aim: The aim of our study is to analyze complication rates and patterns in Bulgarian patients treated with limb salvage surgery for musculoskeletal malignancies. Materials and methods: Our series consist of a retrospective review of 43 patients with musculoskeletal malignancies, who underwent limb salvage surgeries at Boycho Boychev University Orthopedic Hospital in Sofia, Bulgaria, over a period of 10 years. For staging, we used the AJCC and Enneking’s staging systems for malignant musculoskeletal tumors. Functionality was assessed with the MSTS system. Assessment of complications was done with a modified Clavien-Dindo classification for surgical complications and Henderson’s classification of failure of limb salvage after reconstructive surgery. Results: The mean follow-up time for the series is 40 months (range 12 to 120 months). At the current follow-up, the overall survival rate for the series is 72%. The overall complication rate for the series is 72% and the surgical revision rate is 46.5%. Of the encountered complications, 84% were classified as grade Ⅲb using the Clavien-Dindo classification. Conclusion: Bulgarian patients treated with limb salvage for musculoskeletal malignancies have high complication rates, with no clear prevalence between mechanical and non-mechanical complication patterns. Many of the encountered complications are severe and require additional surgical management.

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Original Article Thu, 29 Feb 2024 22:00:05 +0200
Uterine tumor resembling ovarian sex-cord tumor – a rare gynecological neoplasm https://foliamedica.bg/article/100064/ Folia Medica 65(6): 1020-1024

DOI: 10.3897/folmed.65.e100064

Authors: Georgi D. Prandzhev, Tihomir P. Totev, Svetlana A. Mateva, George Mathew, Grigor A. Gortchev

Abstract: Uterine tumor resembling ovarian sex-cord tumor is a rare group of uterine neoplasms with unknown histogenesis and differentiation towards ovarian sex-cord elements. They are benign in nature with low malignancy potential. Diagnosis is based on immunohistochemistry and morphological features, and the distinction from other more malignant differentials is paramount to correctly individualizing treatment. A 47-year-old patient was admitted to the hospital complaining of abdominal pain and abnormal uterine bleeding. Subsequent detection of multiple uterine fibroids by ultrasound study and CT scans lead to a robot-assisted total hysterectomy. Histological studies revealed that one of the fibroids in the myometrium had a morphology resembling an ovarian sex-cord tumor with low Ki-67 proliferative activity. After 12 months of follow-up, no additional treatment was required, and no signs of recurrence or progression were observed. Uterine tumor resembling ovarian sex-cord tumor is a rare gynecological entity with no established treatment protocol. Differentiation between benign and malignant behavior is based on structural features and immunohistochemical expression assessment. This highlights the importance of immunohistochemical staining and morphological analysis to determine the degree of surgical radicality. Minimally invasive approach is feasible and safe, but more experience is needed for further conclusions.

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Case Report Sun, 31 Dec 2023 19:00:23 +0200
Laparoscopic para-aortic lymphadenectomy for metastatic colon cancer in a patient with left-sided inferior vena cava: a case report https://foliamedica.bg/article/96691/ Folia Medica 65(6): 1015-1019

DOI: 10.3897/folmed.65.e96691

Authors: Efstathios Kotidis, Elissavet Anestiadou, Aikaterini Karamitsou, Georgios Gemousakakis, Orestis Ioannidis, Stefanos Bitsianis, Savvas Symeonidis, Nikolaos Ouzounidis, Odysseas Lomvardeas, Stamatios Aggelopoulos

Abstract: Transposition of inferior vena cava, or, left-sided inferior vena cava (LS-IVC) is a rare clinical entity, in which the inferior vena cava ascends along the left side of the abdominal aorta. Literature contains mainly clinical case reports. Although it is usually not associated with clinical symptomatology, this anomaly should be detected during preoperative planning to avoid iatrogenic injuries intraoperatively. We present a case of left-sided inferior vena cava encountered during laparoscopic lymphadenectomy in a 45-year-old man with previous laparoscopic hemicolectomy due to colon adenocarcinoma. Preoperative CT abdomen revealed the left-sided location of infrarenal IVC and laparoscopic trans-peritoneal aortic lymphadenectomy was decided. Intraoperatively, transposition of inferior vena cava was confirmed in accordance with the CT findings. Resection of lymph node block was conducted with no complications and with minimal blood loss. The postoperative course was uneventful, and the patient was discharged from the hospital the day following surgery. In conclusion, transposition of the inferior vena cava, although rare, constitutes an anatomical variant that should be identified preoperatively to decrease intraoperative risks. Several anatomical variants have been associated with left-sided inferior vena cava.

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Case Report Sun, 31 Dec 2023 19:00:22 +0200
Development of organized pleural empyema as a result of occult foreign body aspiration https://foliamedica.bg/article/91076/ Folia Medica 65(6): 1000-1004

DOI: 10.3897/folmed.65.e91076

Authors: Georgi Yankov, Magdalena Alexieva, Dinko Valev, Evgeni Mekov

Abstract: Foreign body (FB) aspiration is a rare incident in adults. Many patients cannot recall the episode of aspiration and are hospitalized with complications of an endobronchial FB. We present a case with right-sided chronic pleural empyema, ineffectively treated in another hospital with chest drainage, uniportal VATS, and insertion of five chest drains as a result of occult foreign body aspiration. Endoscopic extirpation of a foreign body in the right lower lobar bronchus was performed. Right posterolateral thoracotomy, decortication, and pleurectomy were performed because of a trapped right lung. Preoperative bronchoscopy is recommended in all patients with pleural empyema before surgery. When chest drainage and VATS are unsuccessful in expanding the lung in chronic empyema then thoracotomy, debridement, pleurectomy, and decortication are indicated.

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Case Report Sun, 31 Dec 2023 19:00:19 +0200
The role of postoperative trimetazidine therapy in on-pump coronary artery bypass surgery https://foliamedica.bg/article/102777/ Folia Medica 65(6): 915-921

DOI: 10.3897/folmed.65.e102777

Authors: Kamen Stanev, Antonia Yaneva, Asen Ivanov, Todor Gonovski

Abstract: Introduction: Coronary artery bypass surgery remains the gold standard in the treatment of patients with ischemic heart disease. However, the increased oxidative stress caused by the release of free radicals during the ischemia-reperfusion time is a well-known pathophysiological process during and after coronary revascularization procedures. It may lead to reversible and irreversible myocardial injury. The focus of this prospective single-blinded randomized controlled trial is to investigate and analyze the effectiveness of the drug trimetazidine on reducing postoperative myocardial ischemia-reperfusion injury. Aim: We evaluated the effects of trimetazidine on reactive oxygen species that may arise from myocardial ischemia-reperfusion period or systemic inflammation after coronary artery bypass grafting (CABG) surgery. Materials and methods: The study included 90 patients divided into two groups who underwent elective coronary artery bypass surgery between March 2018 and October 2018. The patients in one of the groups received 35 mg trimetazidine twice daily as soon as they were extubated. The remainder of the pharmaceutical therapy was the same for all participants. Preoperative and postoperative levels of several blood-based biochemical markers including malondialdehyde (MDA), creatinine kinase-MB fraction (CK-MB) and high-sensitivity troponin T (hs-TnT) were measured. The data was classified and analyzed by the timing of sample collection. Results: The results indicate that postoperative trimetazidine medication reduces MDA production, resulting in reduced oxidative stress and improved cardiac cell protection via antioxidant status augmentation. The follow-up was 6 months after the surgery. The Minnesota Living with Heart Failure Questionnaire was used to assess the quality of life of patients, and the results were excellent. Conclusions: Postoperative trimetazidine therapy leads to improvement of the myocardial cell metabolism and thus reduction in post CABG ischemia-reperfusion injury.

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Original Article Sun, 31 Dec 2023 19:00:08 +0200
Laparoscopic vs. open surgical access radical cystectomy with subsequent orthotopic reconstruction in the treatment of invasive urothelial carcinoma of the bladder https://foliamedica.bg/article/101932/ Folia Medica 65(6): 894-901

DOI: 10.3897/folmed.65.e101932

Authors: Dimitar D. Shishkov, Dimitar G. Shishkov, Stefan Todorov, Nikola Mihaylov

Abstract: Introduction: Radical cystectomy combined with extended lymph node dissection is the treatment of choice for muscle-invasive bladder cancer and can be performed using open, laparoscopic, or robot-assisted surgical access. Aim: To compare the outcomes of laparoscopic (LRC) and open-access (ORC) radical cystectomy in terms of surgery, oncology, functional outcomes, and complications. Materials and methods: We conducted a retrospective study of 200 patients who had all undergone cystectomy for muscle-invasive bladder cancer within the last 4 years. All patients were divided into groups according to the surgical access: LRC in 30 patients and ORC in 170 patients. Oncologic outcomes, expressed as perioperative complications and postoperative results, were analyzed. Results: Overall survival rates were most significantly associated with the histological type, as well as the ‘positive’ lymph nodes and positive resection margin. The average duration of the procedure was shorter in ORC than in LRC (245.5 min and 345.3 min, respectively). Hospital stay was on average 9.18 days in LRC and 12.63 days in ORC, and this duration could vary depending on the type of diversion. The average blood loss in LRC (250-320 ml) was lower than that in ORC (200-720 ml). The complications rate was lower with LRC than with ORC; however, with subsequent orthotopic reconstruction, the functional results were better in ORC. Conclusions: LRC is an alternative option to ORC, considering the fewer complications, less amount of blood loss, and greater surgical precision, as well as shorter hospital stay. Orthotopic diversion has better functional outcomes in ORC.

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Original Article Sun, 31 Dec 2023 19:00:05 +0200
Surgical approach to correction of severe knee malalignment in a pediatric population in Tanzania https://foliamedica.bg/article/102090/ Folia Medica 65(6): 885-893

DOI: 10.3897/folmed.65.e102090

Authors: Ilaria Sanzarello, Matteo Nanni, Danilo Leonetti, Domenico Fenga, Francesco Traina, Cesare Faldini

Abstract: Aim: Severe knee malalignment in children usually needs surgery with different options available in surgical approaches. The aim of this study was to report the results of the surgical correction of severe knee malalignment in children treated with femoral and tibial osteotomy, temporarily fixed with percutaneous Kirschner wires, in a low- and middle-income country (LMIC), with limited medical resources. Materials and methods: Thirty children (age range 4–9 years) with severe knee malalignment were observed and surgically treated in a small children hospital located in the Tanzanian rural outback. A total of 53 deformities were treated. Thirty-two knees presented varus deformity and 21 knees presented valgus deformity. In 9 cases, femoral osteotomy alone was performed, tibial osteotomy alone in 28 cases, combined femoral and tibial osteotomy in 16 cases. Fixation was obtained with crossed percutaneous Kirschner wires, and a post-operative long-leg cast immobilization was applied. Results: Mean pre-operative varus passed from 40°±4 to post-operative 5°±6 valgus. Mean pre-operative valgus passed from 39°±4 to post-operative 8°±5 valgus. Complications included delayed healing of the wounds, skin suffering at the outlet of Kirschner wires, knee stiffness, undercorrection and overcorrection of the deformity. Results were considered excellent in 18 cases, good in 21, fair in 11, poor in 3. Conclusions: This technique allowed us to obtain satisfactory correction of severe knee malalignment with less invasive surgery. Inexpensive hardware such as Kirschner wires, combined with cast immobilization, allowed satisfactory fixation of the osteotomy, and reduction of the overall cost of surgery, as it should be desirable in LMICs.

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Original Article Sun, 31 Dec 2023 19:00:04 +0200
Early hip fracture surgery and rehabilitation. How to improve functional quality outcomes. A retrospective study https://foliamedica.bg/article/99513/ Folia Medica 65(6): 879-884

DOI: 10.3897/folmed.65.e99513

Authors: Angelo Alito, Domenico Fenga, Simona Portaro, Giulia Leonardi, Daniele Borzelli, Ilaria Sanzarello, Rocco Salvatore Calabrò, Dario Milone, Adriana Tisano, Danilo Leonetti

Abstract: Introduction: Hip fractures are one of the major disability causes associated with a high morbidity and mortality rate. Early surgery and stable fixation could be associated with better pain control, possibly lower mortality rates, and early recovery of autonomy. Aim: The aim of this study was to analyze a population affected by hip fractures exploring the effects of an early surgery and rehabilitation approach in relation to functional outcomes. Materials and methods: This study included 140 adult patients (mean age 79.35±11.71, range 66-94 years) with hip fractures admitted to the orthopedic unit of the University Hospital of Messina who underwent surgery and a rehabilitation program while hospitalized. Exclusion criteria were patients not surgically treated or discharged with no rehabilitation sessions. Clinical outcomes were evaluated post-surgery and before discharge as follows: pain quantification using the visual analogue scale and functional evaluation using the Barthel Index. A rehabilitation protocol was started within 48 hours after surgery. Results: The study sample resulted in 140 patients. Eighty-seven of them (63.14%) underwent hip replacement surgery, and 53 patients (37.86%) underwent internal fixation surgery. The greater part of the sample (68.42%) had surgery within 48 hours. Patients with more comorbidities had worse clinical outcomes, as shown by the Barthel Index, timing of verticalization and walking, and pain control. Between admission and discharge, the Barthel Index score improved, as did the pain complained of by most patients. Conclusions: A direct connection between orthopedics and the rehabilitation team, even after discharge, should be established and promptly organized to gain the best clinical outcomes. Indeed, we propose the triad early verticalization, pain control, and Barthel Index as a possible tool to define functional quality outcomes in post hip fracture surgery.

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Original Article Sun, 31 Dec 2023 19:00:03 +0200
Guillain-Barré syndrome after elective lateral lumbar interbody fusion https://foliamedica.bg/article/93659/ Folia Medica 65(5): 839-843

DOI: 10.3897/folmed.65.e93659

Authors: Elad Mashiach, Timothy Kravchenko, Christopher E. Talbot, John L. Gillick

Abstract: Complications following lateral retroperitoneal transpsoas lumbar fusion (LLIF) surgery include femoral nerve apraxia, bowel/bladder injury, ureteral injury, and potentially, as illustrated in this case report, Guillain-Barré syndrome. Guillain-Barré syndrome (GBS) is an autoimmune inflammatory condition that typically presents after infection, or, less frequently, post-operatively. We report a case of GBS following elective lumbar fusion through the lateral retroperitoneal transpsoas approach (LLIF). A 56-year-old patient presented with left lower extremity (LLE) weakness on post-operative day 12. EMG showed bilateral upper extremity muscle recruitment, worse distally. Following a treatment with intravenous immunoglobulin (IVIG), the patient gradually improved, and her condition was favorable at 6-month post-operative follow-up. CSF analysis and EMG should be part of the workup for patients presenting with lower extremity neuropathy following LLIF.

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Case Report Tue, 31 Oct 2023 22:00:19 +0200
A rare case of recurrent mediastinal malignant paraganglioma of thyroid origin: a case report https://foliamedica.bg/article/93864/ Folia Medica 65(5): 828-833

DOI: 10.3897/folmed.65.e93864

Authors: Georgi Yankov, Magdalena Alexieva, Silvia Ivanova, Nikolay Yanev

Abstract: Paraganglioma is a neuroendocrine tumor that originates from extraadrenal chromaffin cells. Primary thyroid paraganglioma is an extremely rare neoplasm. In this study, an exceptionally uncommon case of recurrent mediastinal malignant paraganglioma with primary origin from thyroid gland is presented. Median resternotomy, resection of left brachiocephalic vein, and extirpation of the mediastinal tumor were performed successfully. Commonly, it is preoperatively misdiagnosed and has unpredictable biological behavior. Incorrect diagnosis results in disastrous consequences for the patient, and consequently, correct pre- and postoperative diagnoses promise an optimal treatment plan and good prognosis. Long-term follow-up is indicated in all patients due to the risk of recurrence and distant metastases.

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Case Report Tue, 31 Oct 2023 22:00:17 +0200
Cold modified Del Nido cardioplegia in adults undergoing elective cardiac coronary surgery https://foliamedica.bg/article/90286/ Folia Medica 65(5): 760-769

DOI: 10.3897/folmed.65.e90286

Authors: Georgi Stoitsev, Veselin Gavrilov, Valya Goranovska, Georgi Manchev, Vassil Gegouskov

Abstract: Introduction: The cardioplegic solution of Kirklin (Kn) is frequently used in adult cardiosurgical patients. It requires reinfusion at short intervals, which causes further difficulty during surgery and the quality of myocardial protection is often called into question. Aim: To demonstrate whether the modified cardioplegia of del Nido (MDN) with a longer period of cardiac arrest provides sufficiently effective and reliable myocardial protection when compared to the classic cardioplegia of Kirklin we use in our institution. Materials and methods: This ambispective clinical-epidemiological study was conducted in the Department of Heart Surgery at St Anna University Hospital in Sofia between January 2017 and September 2021. Using a random number generator, а hundred and twenty patients were selected and divided into two cohorts of 60 patients each. After further data processing, an additional five patients dropped out of the Kirklin group due to a ‘beating heart’ operative technique. As a result, the groups were divided as follows: 1) intermittent cardioplegia Kirklin (Kn, n=55) used in patients between January 2017 and June 2019, and 2) modified del Nido cardioplegia (MDN, n=60) used from June 2019 to September 2021. Results: In this study, we present our experience with MDN cardioplegia in patients undergoing isolated CABG and compare it with a group of patients who received Kn cardioplegia. The difference in cross-clamp and CPB times is due to the individual qualities and experience of surgeons. When using MDN, the longer intraoperative times not only showed no deterioration in postoperative results, did not increase the need of using an additional dose of cardioplegia, but also did not materialize in a statistically significant difference. The MDN cardioplegia showed significantly less usage of inotropic support (p<0.001) and IABP (p=0.029). Creatinine phosphokinase MB fraction when patients are admitted to intensive care was significantly less in the Kirklin group (p=0.045). Conclusions: Results suggest that the routine use of modified cardioplegic protection of del Nido in adult patients may be safe, leads to comparable clinical outcomes and could accelerate the surgical process. The reduced incidence in intra- and postoperative complications like DC shocks, arrhythmia, myocardial infarction, multiorgan failure and in-hospital mortality should be further studied, as it may imply superiority of myocardial protection with the modified solution.

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Original Article Tue, 31 Oct 2023 22:00:08 +0200
Conventional and digital pleural drainage systems – advantages and disadvantages https://foliamedica.bg/article/97825/ Folia Medica 65(5): 753-759

DOI: 10.3897/folmed.65.e97825

Authors: Nedzhat Yussuf Ali, Petar Uchikov, Angel Uchikov, Lyubomir Paunov, Aleksandra Ilieva, Nikolay Koev, Kiril Atliev

Abstract: Introduction: Pleural cavity drainage is a crucial component of the surgical management of patients with various chest diseases. Digital drainage systems are increasingly used in contemporary thoracic surgical procedure, which is likely a result of their effectiveness in achieving early postoperative ambulation, cutting down on hospital stays and lowering costs. The vast majority of thoracic surgeons worldwide prefer digital drainage systems to traditional ones. The advantages of the former, however, are disputed by some researchers. Aim: The objective of this study was to compare the two types of pleural drainage mechanisms, conventional and digital, in terms of duration of pleural drainage in days, financial cost, and postoperative air leak duration. Materials and methods: The study focused on 80 patients who underwent various thoracic surgical interventions in the Clinic of Thoracic and Abdominal Surgery at St George University Hospital in Plovdiv. They were divided into two groups: group 1 consisted of 42 patients who were postoperatively attached to a conventional non-mobile pleural drainage system, and group 2 consisted of 38 patients in whom a mobile digital pleural drainage system was used. The main analyzed data were duration of pleural drainage, duration of postoperative air leak, hospital stay, and financial costs. Results: The average duration of pleural drainage, regardless of surgery and type of drainage system applied was 4.86±0.8 days. The average duration of pleural drainage in patients attached to the mobile digital drainage system was shorter than that in patients with a conventional pleural non-mobile drainage system, regardless of the type of surgery done. This difference was statistically significant in favor of the digital pleural drainage system. The study also found a statistically significant difference in terms of financial costs in favor of digital draining system. The average cost of a hospital stay for patients attached to a mobile digital drainage system was BGN 119.40±7.15, whereas the average cost of a hospital stay for patients connected to a traditional pleural drainage system (PDS) was BGN 159±10.50. Regarding the duration of postoperative air leak, the difference between the types of pleural drainage mechanism used was not convincing. Conclusions: Digital pleural drainage systems provide clinicians with an opportunity to assess the postoperative air leak more precisely, track its dynamics, shorten hospital stays, reduce postoperative costs, and optimize the time to remove the chest drain. Based on these features, they will undoubtedly continue to enter everyday surgical practice.

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Original Article Tue, 31 Oct 2023 22:00:07 +0200
The role of prophylactic parathyroidectomy during thyroidectomy for MTC in patients with MEN2A syndrome https://foliamedica.bg/article/86749/ Folia Medica 65(5): 720-727

DOI: 10.3897/folmed.65.e86749

Authors: Christos Kavazis, Konstantinos Romanidis, Michail Pitiakoudis, Isaak Kesisoglou, Styliani Laskou, Konstantinos Sapalidis

Abstract: Aim: To define the role of prophylactic parathyroidectomy in the surgical treatment of medullary thyroid carcinoma (MTC) in multiple endocrine neoplasia type IIa (MEN2A) syndrome through a literature review. Materials and methods: The database of PubMed was searched using the terms “parathyroidectomy” and “medullary” in the fields “Title” and “Abstract”, as well as the Google Scholar database. Articles without references to parathyroid management strategies were mainly excluded. Results: Fourteen articles were reviewed as relevant to this study regarding recommendations for the management of parathyroids during prophylactic thyroidectomy in patients with MTC in MEN2A syndrome. Three of them had the same or similar purpose to our work, and the most recent literature review did not clearly support either one of the two management strategies. References to parathyroid management were found in the rest of the articles, but their purpose was not to determine the appropriate management strategy. The majority of the authors support the preservation of macroscopically normal parathyroid glands, while one study favored routine total parathyroidectomy and autografting. Conclusions: Although there does not seem to be a gold standard, the strategy of preserving macroscopically normal parathyroid glands with routine lab testing and surgical exploration for hyperparathyroidism during thyroidectomy seems to be a safe and effective strategy.

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Original Article Tue, 31 Oct 2023 22:00:03 +0200
Trabeculectomy with ExPress – an effective solution to Posner-Schlossman syndrome https://foliamedica.bg/article/84894/ Folia Medica 65(4): 675-680

DOI: 10.3897/folmed.65.e84894

Authors: Vesela Mitkova-Hristova, Nina Stoyanova, Marin Atanassov

Abstract: Posner-Schlossman syndrome (PSS) is a unilateral ocular disease, characterized by recurrent non-granulomatous anterior uveitis and increased intraocular pressure (IOP), leading to chronic secondary glaucoma. In this case report, we present the case of a 46-year-old man with chronic, hypertensive anterior uveitis in the left eye and frequent recurrences over the last two years. The patient suffers from Posner-Schlossman syndrome with chronic secondary glaucoma, unresponsive to medication therapy. After trabeculectomy with ExPress implantation and, later on, cataract surgery with implantation of an intraocular lens in the left eye, the IOP varied between 10 and 12 mmHg over a period longer than a year without any medication therapy. Patients with PSS are at risk of developing secondary glaucoma and irreversible complications. Trabeculectomy with ExPress implantation is a reliable and effective treatment of IOP unresponsive to medication therapy.

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Case Report Thu, 31 Aug 2023 14:00:20 +0300
A metachronous second primary lung cancer after laryngectomy for laryngeal carcinoma https://foliamedica.bg/article/85074/ Folia Medica 65(4): 671-674

DOI: 10.3897/folmed.65.e85074

Authors: Georgi Yankov, Magdalena Alexieva, Stefka Yankova, Evgeni Mekov

Abstract: A combination of laryngeal carcinoma and subsequent primary lung cancer is rare yet important in terms of therapeutic strategy and prognosis. We present a case of primary squamous cell laryngeal carcinoma treated with laryngectomy and chemoradiation therapy. One year later, the patient developed metachronous squamous cell carcinoma of the lung and underwent left pneumonectomy. A second primary lung cancer after laryngeal cancer presents a significant challenge for surgeons, oncologists, and radiotherapists. The differentiation between lung metastasis and primary lung cancer is of paramount importance for the correct therapeutic strategy and prognosis.

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Case Report Thu, 31 Aug 2023 14:00:19 +0300
Lumbar disc herniation in children and elderly patients https://foliamedica.bg/article/97233/ Folia Medica 65(4): 631-637

DOI: 10.3897/folmed.65.e97233

Authors: Mladen E. Ovcharov, Milan N. Mladenovski, Igor N. Mladenovski, Iliya V. Valkov, Stanislava B. Vasilkova

Abstract: Introduction: Lumbar disc herniation is a common pathology of young and middle-aged patients. Fissures and tears in the annulus fibrosus become weak points that facilitate herniation of the nucleus pulposus, especially when extreme forces ‘attack’ the intervertebral disc. A significant biomechanical force applied to a healthy (‘normal’) disc can have the same effect. Disc protrusions and herniations to varying degrees penetrate the spinal canal. Aim: This study aims to present features of lumbar disc herniation in pediatric and elderly patients and evaluate them with respect to data reported in the literature. Materials and methods: Five hundred eighty-nine patients were assessed, 64 of whom were children (0-18 years), and 98 were elderly patients (>60 years). The operated patients were followed up for at least three years. All data were recorded at the regular follow-ups (at 1 and 3 months, and at 1 and 3 years after surgery). We used chi-square tests and directional measures to determine statistically significant data. Operative treatment in children and elderly patients was 28% (162) of our cohort’s total number of patients. Results: Analyzing postoperative MacNaB, our result showed that children have 23.4% excellent and 76.6 good self-assessment, while in elderly patients, on the one hand, MacNaB used to be excellent or good in 78.5%, and on the other hand, 21.5% had fair or poor self-assessment (p<0.05). Conclusions: Long-term postoperative outcomes were worse in elderly patients than in children. This was mainly due to the poor status of the intervertebral discs according to the Phirman scale and the associated pathologies at other levels.

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Original Article Thu, 31 Aug 2023 14:00:13 +0300
The effect of urinary tract infection on overall mortality in elderly male patients https://foliamedica.bg/article/90402/ Folia Medica 65(4): 612-617

DOI: 10.3897/folmed.65.e90402

Authors: Caner Baran, Abdullah Talha Akan, Veysel Sezgin, Ahmet Boylu, Çiğdem Arabaci, Emre Can Polat, Alper Ötünçtemur

Abstract: Introduction: Urinary tract infections are the most common bacterial infections in the older population. Aim: This study aims to determine the impact of the isolated pathogen from urine culture on the estimated survival time of elderly male patients. Materials and methods: We conducted a retrospective cross-sectional study to evaluate the male patients with pathogenic growth in their urine culture tests. We included in the study only male patients aged 80 years or over with positive urine culture tests for pathogenic growth. Urine samples were collected from either first clean-catch midstream urine or from the urinary catheters. Bacterial growth of ≥105 colony-forming units/mL (CFU/mL) in the culture was considered significant. For comparison of the survival time, five groups were created according to the pathogens identified in the urine culture. Results: Between February 2014 and December 2020, there were 1133 patients that met the study criteria. The most common pathogen was Escherichia coli with a rate of 29.5%. The median overall survival time was 4 months. The longest and shortest median overall survival times for the E. coli group and the fungi group were 17.4 months and 0.4 months, respectively (p<0.001). While being in the ICU is the most important risk factor for mortality in this elderly cohort, the statistical analysis showed that being infected with fungi carries a 1.57-fold increased risk of mortality compared with the E. coli infection (p<0.001). Conclusions: The aging of the population requires evaluation of the diseases that are frequently encountered in advanced age. Our study showed that the causative pathogen of the urinary tract infection might have an impact on overall survival time in the senior population.

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Original Article Thu, 31 Aug 2023 14:00:10 +0300
Cholangioscopy-guided lithotripsy in the treatment of difficult bile ducts stones – Bulgarian and Egyptian experience https://foliamedica.bg/article/84828/ Folia Medica 65(4): 582-588

DOI: 10.3897/folmed.65.e84828

Authors: Petko Karagyozov, Kamal El-Atrebi, Irina Boeva, Ivan Tishkov

Abstract: Introduction: Up to 10% of bile duct stones are deemed ‘difficult’ because they cannot be extracted using standard endoscopic techniques. In these situations, cholangioscopy allows for stone fragmentation under direct visual control. Aim: To evaluate the efficacy and safety of a digital single-operator cholangioscopy-guided lithotripsy in cases of difficult stones and to analyze factors related to adverse events and procedure time. Materials and methods: A retrospective review of prospective databases from two tertiary referral centers was performed, which included 38 patients with difficult bile duct stones. All of the patients had previous endoscopic retrograde cholangiopancreatographies and at least one unsuccessful surgery to remove a stone. Following the standard protocol, we performed a digital single-operator cholangioscopy-guided lithotripsy using either electrohydraulic or laser lithotripsy. The main goal was to achieve ductal clearance, which was confirmed by a negative occlusive cholangiogram. We also investigated the occurrence of complications, the factors associated with them, and the variables influencing procedure duration. Results: For the study period, 38 patients were treated with digital single-operator cholangioscopy-guided lithotripsy (33 with laser lithotripsy and 5 with electrohydraulic lithotripsy). Complete ductal clearance was achieved in 92.1% of cases, and in 78.9% of cases, it was accomplished in a single session. The average number of procedures until complete stone removal was 1.22 (1-3). The mean procedure times for electrohydraulic lithotripsy and laser lithotripsy was 83 minutes and 115 minutes, respectively. Complications, which were defined as mild, were observed in four (10.5%) patients. There was no correlation between age, size of stone, duration of the procedure and amount of saline used during lithotripsy and occurrence of complications. The presence of a stricture, barrel shaped or irregular shaped stones was associated with an increased risk of complications (p<0.05). Large stones, multiple lithiases, intrahepatic location, and failed previous EPLBD/ML were related to prolonged procedure time (p<0.05).  Conclusions: A single-operator cholangioscopy-guided lithotripsy is a highly effective and safe procedure. The presence of a distal common bile duct stricture and complex shape of stones is associated with a higher risk of procedure complications.

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Original Article Thu, 31 Aug 2023 14:00:06 +0300
Success rate and safety of totally implantable access ports placed by the cephalic vein cutdown technique in oncological patients – a single-center study https://foliamedica.bg/article/87401/ Folia Medica 65(4): 577-581

DOI: 10.3897/folmed.65.e87401

Authors: Martin Karamanliev, Tsanko Yotsov, Dobromir Dimitrov

Abstract: Introduction: Totally implantable access ports (TIAPs) are commonly used in oncologic patients undergoing ongoing chemotherapy. The methods of choice for implantation are the subclavian vein puncture approach and the cephalic vein cutdown technique, followed by internal jugular vein access and external jugular vein access. Materials and methods: We analyzed all patients who had a central venous access implanted by a single surgeon at the University Hospital in Pleven between October 2018 and January 2022, with the aim of determining the success rate and safety of the cephalic cutdown technique for placing totally implantable access ports. Results: 135 totally implantable access ports were inserted in the study period. Median age of patients was 69.2 years (range, 35-86 years). There were 71 (52.59%) women and 64 (47.41%) men. In 7 patients, the tip of the catheter was reported to go at the distal part of the subclavian vein and axillary vein on the ipsilateral side after initial placement and was repositioned under real-time fluoroscopic guidance. Successful placement of a totally implantable access port using the cephalic cutdown technique was reported in 127 patients (94.07%). No postoperative pneumothorax, hemothorax, or vessel injury were reported. One case of surgical site infection was seen on postoperative day (POD) 7. Late postoperative complications occurred in 3 patients with catheter-related bacteremia all after POD 30 (81, 95, and 172 days after the procedure). One patient died. Conclusions: Totally implantable access ports placed using the cephalic vein cutdown technique can be used safely and with high success rates in oncological patients.

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Original Article Thu, 31 Aug 2023 14:00:05 +0300
First case of medullary osteogenic sarcoma of the pelvis: 12-year follow-up of reconstruction with hemipelvis allograft after resection https://foliamedica.bg/article/76144/ Folia Medica 65(3): 508-513

DOI: 10.3897/folmed.65.e76144

Authors: Recep Öztürk, Ahmet Fevzi Kekeç, Bedii Şafak Güngör

Abstract: A 45-year-old male patient with low-grade central osteosarcoma (LGCO) in the periacetabular region underwent wide resection, fresh frozen hemipelvis allograft reconstruction, and total hip prosthesis. To the best of our knowledge, this case is the first example of low-grade osteogenic sarcoma in flat bones. Aseptic loosening of the acetabular cup was observed 44 months after the operation, and it was revised with a constrained acetabular cup. Recurrent subluxation due to constraint ring failure and cup malposition was observed at 89 months after the revision surgery. Revision operation was performed with cage + non-constrained cup. Twelve years after the first operation, he is in exceptionally functional and disease-free condition. He can walk unlimited distances without pain. Radiographs show complete union at the junction of the allograft and disease-free bone. In conclusion, fresh frozen hemipelvis allograft is one of the best reconstructive options following hemipelvectomy because of its potential durability and capacity to restore pelvic stability and preserve functionality.

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Case Report Fri, 30 Jun 2023 20:00:22 +0300
Initial experience in target peroral endoscopic submucosal myotomy combined with septotomy for epiphrenic diverticulum https://foliamedica.bg/article/83893/ Folia Medica 65(3): 490-494

DOI: 10.3897/folmed.65.e83893

Authors: Nikola Boyanov, Vladimir Andonov, Katina Shtereva, Katerina Madzharova, Nikolay Stoynov, Desislava Dimitrova, Ivan Yankov

Abstract: The epiphrenic esophageal diverticulum is a rare non-malignant condition that is commonly associated with motility disorders. It would normally be treated surgically, but with the advancement of endoscopy techniques, peroral endoscopic myotomy with septotomy (D-POEM) has shown its benefits in coping with the symptoms. We present a case of a 71-year-old woman with increasing symptoms of dysphagia, weight loss and imaging data showing a large epiphrenic diverticulum. We treated her using peroral endoscopic myotomy combined with septotomy of the diverticular septum. The procedure showed excellent results with reducing the amount of contrast materials retained in it, improving the quality of life of the patient, and increasing her weight. There were minimal adverse events and no perforations or severe adverse effects occurred. D-POEM is a new and rapidly evolving procedure that is proving to be a safe and effective method of treating epiphrenic esophageal diverticulum.

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Case Report Fri, 30 Jun 2023 20:00:19 +0300
Effects of lithotomy and prone positions on hemodynamic parameters, respiratory mechanics, and arterial oxygenation in percutaneous nephrolithotomy performed under general anesthesia https://foliamedica.bg/article/81068/ Folia Medica 65(3): 427-433

DOI: 10.3897/folmed.65.e81068

Authors: Serkan Yucepur, Ali Bestami Kepekci, Akif Erbin, Ecder Ozenc

Abstract: Aim: The position of the body during surgery may affect the patient’s body functions, especially the hemodynamic parameters. We aimed to comparatively analyze the effects of lithotomy and prone position on respiratory mechanics, arterial oxygenation, and hemodynamic parameters in patients who underwent percutaneous nephrolithotomy (PNL). Materials and methods: The study included 40 patients aged 16-63 years who underwent kidney stone surgery. The patients had no history of diabetes or cardiopulmonary disease and had an American Society of Anesthesiology (ASA) score of I–II. The pH, partial arterial oxygen pressure, partial arterial carbon dioxide pressure, HCO3, arterial oxygen saturation, end-tidal carbon dioxide (EtCO2), alveolar oxygen partial pressure, dead space volume/tidal volume ratio, P(A-a)O2, peak inspiratory pressure (PIP), inspiratory plateau airway pressure (PPlt), systolic arterial pressure, diastolic arterial pressure, mean arterial pressure, and heart rate (HR) values were assessed simultaneously throughout the surgery and comparatively analyzed both for lithotomy and prone positions. Results: There was a significant difference between lithotomy and prone positions with regard to pH and HCO3 values, which are among the arterial blood gas parameters measured at 20 minutes (p<0.05 and p<0.001, respectively). There was a significant difference between lithotomy and prone positions with regard to EtCO2, PIP, PPlt, and HR measured at 20 minutes (p<0.05, p<0.001, p<0.001, and p<0.05, respectively). Conclusions: The prone position decreased dynamic and static compliance and increased the PIP and PPlt values in patients undergoing PNL. However, these changes do not have a negative effect on the hemodynamic parameters in low-risk patients.

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Original Article Fri, 30 Jun 2023 20:00:11 +0300
Extrapleural harvesting of the internal thoracic artery – impact on early postoperative results and pulmonary function https://foliamedica.bg/article/83775/ Folia Medica 65(3): 415-419

DOI: 10.3897/folmed.65.e83775

Authors: Dimitar Kyuchukov, Stanislava Stoycheva, Gencho Nachev

Abstract: Introduction: The internal thoracic artery (ITA) has proven to be the best graft for surgical myocardial revascularization, especially in the configuration left ITA (LITA) to the anterior descending branch of left coronary artery (LAD). Its harvesting is usually accompanied by pleurotomy, followed by drainage tube placement into the pleural cavity, using the so called intrapleural method. Extrapleural technique for LITA harvesting is also practiced in many cardiac surgery centers and with this technique the pleura is left intact. Aim: The aim of our study was to investigate the impact of both techniques of LITA harvesting on lung function and incidence of postoperative complications early after operation. Materials and methods: We analyzed retrospectively data of 82 operated patients scheduled for surgical myocardial revascularization and meeting certain inclusion and exclusion criteria. The patients were divided into two groups depending on the way LITA was prepared. Lung parameters and incidence of surgical complications were registered in the early postoperative period until day 30. Results: The patients from both groups had similar preoperative characteristics and risk factors. Those with preserved pleura showed significantly better results of the studied pulmonary parameters and lower complications event rate during early postoperative follow-up. Conclusions: Maintaining the pleura integrity during LITA harvesting is beneficial for lung function and reduces the rate of complications in the early postoperative period.

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Original Article Fri, 30 Jun 2023 20:00:09 +0300
Short-term outcome of treatment of elderly patients with epidural hematomas https://foliamedica.bg/article/82210/ Folia Medica 65(3): 371-377

DOI: 10.3897/folmed.65.e82210

Authors: Polina Angelova, Borislav Kitov, Atanas Davarski, Tanya Kitova, Ivo Kehayov

Abstract: Introduction: There is substantial literature data dedicated to intracranial epidural hematomas affecting young and middle-aged individuals, but studies focusing on their characteristics in elderly patients are scarce, assuming that old age is a poor prognostic factor. Aim: The aim of the current study was to review the typical features of the etiology, clinical presentation, disease course, and outcome in a series of cases with epidural hematomas in elderly patients. Materials and methods: The etiology, clinical presentation, neuroimaging findings, treatment, and outcome in elderly patients operated for traumatic epidural hematomas were investigated in the Clinic of Neurosurgery at St George University Hospital, Plovdiv between January 2015 and December 2020. The study included patients with isolated traumatic epidural hematoma, as well as those with epidural hematoma in combination with other traumatic intracranial lesions (cerebral contusion, subarachnoid hemorrhage, subdural and intracerebral hematoma). Postoperative epidural hematomas were not included in the study. The neurological status of patients at admission was assessed using the Glasgow Coma Scale. The Glasgow Outcome Scale was used to monitor their condition during the first month after discharge. Results: 121 patients with epidural hematomas underwent surgery during the study period in the Clinic of Neurosurgery at St George University Hospital, Plovdiv. Of these patients, 13 (10.7%) were people aged over 65 years (8 women and 5 men, mean age - 69 years). The most common cause of injury was a fall. Twelve patients (92.3%) had associated craniocerebral lesions and only one had an isolated epidural hematoma. Upon admission, 6 patients (46.2%) were neurologically intact. Ten patients were treated surgically, two – conservatively. Good outcome (GOS=4–5) was achieved in 8 patients (61.5%), poor outcome – in one patient, and four patients (30.8%) died. Conclusions: Good outcome in elderly patients with epidural hematoma can be achieved in two-thirds of the cases, despite the negative influence of the age as a prognostic factor.

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Original Article Fri, 30 Jun 2023 20:00:03 +0300
Safety and efficacy of ovarian tissue autotransplantation: A systematic literature review https://foliamedica.bg/article/89198/ Folia Medica 65(3): 362-370

DOI: 10.3897/folmed.65.e89198

Authors: Eirini Giovannopoulou, Maria-Valeria Karakasi, Maria Kouroupi, Alexandra Giatromanolaki, Panagiotis Tsikouras, Pavlos Pavlidis

Abstract: Ovarian tissue autotransplantation is an innovative fertility preservation technique that has provoked ongoing investigations. The purpose of the present study was to assess the safety and reproductive performance of ovarian tissue autotransplantation. This review is conducted according to PRISMA guidelines. Seven studies met the inclusion criteria. A total of 3427 patients underwent ovarian tissue cryopreservation and 205 received an autotransplantation. Tissue retrieval was mainly performed by laparoscopy and only one major complication occurred. Transplantations were predominantly performed by open procedures and data on safety were insufficient. A total of 295 autotransplantations were analyzed, resulting in 104 pregnancies. Sixty-five pregnancies led to live births, while nine were ongoing at that time. A pregnancy rate (PR) of 50.7% and a live-birth rate (LBR) of 32.7% were observed. Natural conception accounted for 46.3% of live births. No birth deficits were recorded. Ovarian tissue autotransplantation seems to be a safe procedure with acceptable pregnancy rates.

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Review Fri, 30 Jun 2023 20:00:02 +0300
Cardiac echinococcosis, a multidisciplinary approach in the diagnosis and treatment of this rare entity: two case reports and literature review https://foliamedica.bg/article/79066/ Folia Medica 65(2): 336-342

DOI: 10.3897/folmed.65.e79066

Authors: Assen Kelchev, Boyan Kunev, Anelia Partenova, Kamelia Genova, Dimitar Nikolov

Abstract: We present two case reports of cardiac echinococcosis. Case 1 was a 33-year-old woman with hepatic and cardiac echinococcosis. The parasitic cyst was located intramyocardially in the free wall of the left ventricle leading to cranial dislocation of the left circumflex coronary artery (LCx). The patient was successfully operated. Case 2 was a 28-year-old woman with hepatic and cardiac echinococcosis. The parasitic cyst was located in the left ventricular myocardium in the area of the apex and manifested clinically as paroxysms of ventricular tachycardia. The ultrasound study showed a 3.2×2.8 cm cyst dislocating the papillary muscles and causing moderate mitral regurgitation. Bulgaria ranks first in the European Union in terms of the number of echinococcosis patients. Although cardiac involvement is uncommon, occurring in only 0.5%–2% of cases, it can cause a wide range of clinical symptoms. Multimodal imaging is a key step in the management of patients with cardiac involvement.

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Case Report Sun, 30 Apr 2023 23:29:26 +0300
Right-sided luxation of the heart caused by blunt traumatic pericardial rupture https://foliamedica.bg/article/78431/ Folia Medica 65(2): 331-335

DOI: 10.3897/folmed.65.e78431

Authors: Ivoslav Ivanov, Dimo Mitev, Rumen Filipov, Plamen Parvanov

Abstract: Cardiac luxation is a rare condition in cases of blunt thoracic trauma, yet it is quite fatal. We present a case of a 28-year-old man, admitted to the emergency room after a motorcycle accident in a hemodynamically unstable condition and radiographic presentation of multiple rib fractures, bilateral pneumothorax, pneumomediastinum, and significant dislocation of the heart to the right. After performing emergency bilateral tube thoracostomy and achieving hemodynamic stability, a CT scan was performed and the patient was diagnosed with pericardial rupture with right-sided luxation of the heart. An emergency sternotomy was performed with repositioning of the heart and pericardial reconstruction. In the postoperative period, suspicion of myocardial infarction was ruled out and the patient was discharged with persistent traumatic monoplegia of the left upper limb and Claude Bernard-Horner syndrome. An analysis of this very rare type of chest trauma has been made and the probable mechanism for its occurrence has been discussed.

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Case Report Sun, 30 Apr 2023 17:52:00 +0300
Anterior chest wall resection and reconstruction due to recurrent chondrosarcoma: a case report https://foliamedica.bg/article/77385/ Folia Medica 65(2): 321-325

DOI: 10.3897/folmed.65.e77385

Authors: Magdalena Alexieva, Georgi Yankov

Abstract: Chest wall chondrosarcoma is a rare malignant tumor with aggressive biological behavior. The only available treatment for primary or recurrent chondrosarcoma consists of radical surgical resection because of its well-known chemo- and radioresistance. Repeated resection for recurrent chondrosarcoma is challenging because of the altered anatomy, scarring, harvested muscles, and close proximity to vital thoracic organs. We present an uncommon case of recurrent chest wall chondrosarcoma resected in the Department of Thoracic Surgery, which we reconstructed with Symbotex mesh and reinforced by omentoplasty. In addition, we created a brief review of the prevalence, diagnostics, surgical treatment, reconstructive options, and prognosis for this condition.

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Case Report Sun, 30 Apr 2023 17:51:00 +0300
Giant inflammatory pseudotumor of the lung: a case report https://foliamedica.bg/article/98342/ Folia Medica 65(2): 316-320

DOI: 10.3897/folmed.65.e98342

Authors: Alexey Shabunin, Dmitry Grekov, Viktor Yakomaskin, Alexander Kuzmenko, Serghei Covantsev

Abstract: The inflammatory myofibroblastic tumor, which was first described in 1939, is a rare neoplasm that accounts for 0.04%–0.7% of all lung neoplasms. These neoplasms occur most often in children, as they are the most common primary lung tumors in children. Preoperative diagnosis of such patients using bronchoscopy with endoluminal biopsy and transthoracic biopsy is not always informative and often the diagnosis can only be established during surgery. The presented case shows that on rare occasions, a giant myofibroblastic tumor of the lung may be encountered in adults, and radical intervention with subsequent rehabilitation can lead to full recovery.

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Case Report Sun, 30 Apr 2023 17:49:00 +0300
Arterial sleeve lobectomy for lung cancer invading chest wall https://foliamedica.bg/article/76253/ Folia Medica 65(2): 311-315

DOI: 10.3897/folmed.65.e76253

Authors: Kajetan Kiełbowski, Piotr Ostrowski, Michał Kubisa, Jarosław Pieróg, Janusz Wójcik, Bartosz Kubisa

Abstract: Lung cancer is a leading cause of cancer-related deaths worldwide. Non-small cell lung cancer (NSCLC) is a predominant subtype and treatment may include immunotherapy, radiotherapy, chemotherapy, and surgery. Tumors of bigger size infiltrating large bronchi and vessels require more invasive resection such as pneumonectomy. To save lung parenchyma, sleeve lobectomy can be performed in certain patients. We report the case of a patient with NSCLC infiltrating the chest wall who underwent arterial sleeve lobectomy with rib resection. Furthermore, we discuss other surgical treatment strategies. A 58-year-old female patient was admitted to the hospital in 2020 with pain in her left posterolateral chest. Radiological imaging revealed a tumor (5.0×3.5×4.8 cm) in the top of the left lung, infiltrating pulmonary artery and ribs. Therefore, left upper sleeve lobectomy together with resection of rib blocks II to V was performed. The surgery was uncomplicated, but a few weeks postoperatively, the patient experienced repeated episodes of consciousness disturbances. Contrast CT revealed a cerebral malformation in the patient who died 3.5 months after surgery. Sleeve lobectomy can be safely performed in patients with lung tumors infiltrating larger bronchi and vessels who would not tolerate pneumonectomy.

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Case Report Sun, 30 Apr 2023 17:44:00 +0300
Giant cell tumor of the patellar tendon sheath in childhood: case report https://foliamedica.bg/article/68256/ Folia Medica 65(2): 301-304

DOI: 10.3897/folmed.65.e68256

Authors: Konstantinos Skarentzos, Dimitra Panteli, Reichan Molla Moustafa, Stylianos Tottas, Ioannis E. Kougioumtzis, Georgios I. Drosos

Abstract: The aim of this study was to report a rare case of a giant cell tumor of the patellar tendon sheath. This indicates the diagnostic procedures and treatment options for giant cell tumors of the patellar tendon. This study reported a case of a 13-year-old male patient with a giant cell tumor of the tendon sheath. In our case, open arthrotomy was performed with complete surgical excision of the lesion. Histopathological examination revealed a giant cell tumor. At the last follow-up, 2 years after surgery, no complications were reported. The giant cell tumor of the patellar tendon sheath is an uncommon benign tumor. It mimics common knee symptoms. A differential diagnosis is definitely a challenge. Available operation approaches have demonstrated similar results, which lead to symptom relief and a low recurrence rate.

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Case Report Sun, 30 Apr 2023 17:41:00 +0300
Smoker pseudo-paradox in ST-segment elevation myocardial infarction patients https://foliamedica.bg/article/80189/ Folia Medica 65(2): 243-250

DOI: 10.3897/folmed.65.e80189

Authors: Parisa Janjani, Nahid Salehi, Atiyeh Asadmobini, Soraya Siabani, Mahdi Nalini

Abstract: Introduction: Cigarette smoking is a preventable cause of cardiovascular morbidity and mortality. Despite the adverse effects of smoking, some studies have reported the term “smoker’s paradox’, meaning better outcomes in smokers following acute myocardial infarction. Aim: The aim of the present study was to evaluate the relationship between smoking status and one-year mortality in patients with ST-segment elevation myocardial infarction (STEMI). Materials and methods: This was a registry-based cohort study of STEMI patients from Imam-Ali hospital, Kermanshah, Iran. Consecutive STEMI patients (July 2016-October 2018) were stratified by smoking status and followed for one year. Cox proportional models were used to estimate crude, age-adjusted, and full-adjusted hazard ratios with 95% confidence intervals (HR, 95%CI). Results: Of 1975 patients (mean age 60.1 years, 76.6% male) included in the study, 48.1% (n=951) were smokers (mean age 57.7 years, 94.7% male). Crude and age-adjusted HR (95% CI) for the associations of smoking and mortality were 0.67 (0.50-0.92) and 0.89 (0.65-1.22), respectively. After adjusting for age, sex, hypertension, diabetes, body-mass index, anterior wall myocardial infarction, creatine kinase-MB, glomerular filtration rate, left ventricular ejection fraction, low-density lipoprotein cholesterol, and hemoglobin, smoking was associated with increased risk of mortality: HR (95% CI: 1.56 (1.04-2.35). Conclusions: In our study, smoking was associated with an increased risk of mortality. Although the smokers had a better outcome, this would be reversed after controlling for age and the other STEMI associated factors.

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Original Article Sun, 30 Apr 2023 11:20:00 +0300
The role of retrograde intrarenal surgery in kidney stones of upper urinary system anomalies https://foliamedica.bg/article/77728/ Folia Medica 65(2): 226-234

DOI: 10.3897/folmed.65.e77728

Authors: Gokhun Ozmerdiven, Yavuz Güler, Cagatay Cicek, Kadir Omur Gunseren, Hakan Kilicarslan

Abstract: Introduction: Fusion, pelvic, and duplicated urinary tract anomalies of the kidney are rarely seen. There might be some difficulties in the stone treatment, in the administration of extracorporeal shockwave lithotripsy (ESWL), retrograde intrarenal surgery (RIRS), percutaneous nephrolithotomy (PCNL), and laparoscopic pyelolithotomy procedures in these patients due to the anatomical variations in kidneys with anomalies. Aim: To evaluate RIRS results on patients with upper urinary tract anomalies. Materials and methods: Data of 35 patients with horseshoe kidney, pelvic ectopic kidney, and double urinary system in two referral centers were reviewed retrospectively. Demographic data, stone characteristics, and postoperative characteristics of the patients were evaluated. Results: The mean age of patients (n=35, 6 women and 29 men) was 50 years. Thirty-nine stones were detected. The total mean stone surface area in all anomaly groups was found to be 140 mm2, and the mean operative time was 54.7±24.7 minutes. The rate of using ureteral access sheath (UAS) was very low (5/35). Eight patients needed auxiliary treatment after the operation. The residual rate, which was 33.3% in the first 15 days, decreased to 22.6% in the third month follow-ups. Four patients had minor complications. In patients with horseshoe kidney and duplicated ureteral systems, it was observed that the risk factor increasing the presence of residual stones was the total stone volume. Conclusions: RIRS for kidneys with low and medium stone volume anomalies is an effective treatment method with high stone-free and low complication rates.

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Original Article Sun, 30 Apr 2023 11:17:00 +0300
Modified tension band wiring technique by safely inserting K-wires in olecranon fracture osteosynthesis https://foliamedica.bg/article/78264/ Folia Medica 65(2): 221-225

DOI: 10.3897/folmed.65.e78264

Authors: Athanasios P. Fortis, Vasileios Dedes, Nikolaos Vergados, Georgios I. Panoutsopoulos

Abstract: Aim: The present study presents the results of a modified tension band technique by surgically inserting K-wires to treat olecranon fractures. Materials and methods: The modification includes inserting the K-wires from the olecranon’s upper tip and directing them to the ulna’s dorsal surface. Twelve patients (three males and nine females) from 35 to 87 years of age were operated for olecranon fracture. After the standard approach, the olecranon was reduced and fixed with two K-wires from the tip to the dorsal ulnar cortex. Then the standard tension band technique was carried out. Results: The average operating time was 17.25±3.08 min. No image intensifier was used since the wires’ discharge was either visible, penetrating the dorsal cortex, or palpable through this area’s skin. The time needed for the bone union was six weeks. In one female patient, the wires were cut out. This patient showed a satisfactory painless range of motion (ROM) of the elbow but did not achieve full ROM. However, this particular patient had a previous removal of the radial head, and she spent some time in the ICU intubated. The modified technique used here is as stable as the classic operation, and it is safe since there is no risk of injuring the nerves and vessels of the olecranon fossa. There is less or no need for an image intensifier. Conclusion: The outcomes of the present study are entirely satisfactory. However, many patients and randomized studies are needed to establish this modified tension band wiring technique.

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Original Article Sun, 30 Apr 2023 11:15:00 +0300
Surgical management of tension pneumomediastinum in mechanically ventilated coronavirus disease 2019 patients https://foliamedica.bg/article/76658/ Folia Medica 65(2): 215-220

DOI: 10.3897/folmed.65.e76658

Authors: Ivoslav A. Ivanov, Dimo B. Mitev, Rumen A. Filipov

Abstract: Introduction: Tension pneumomediastinum is an increasingly common condition since the COVID-19 pandemic’s onset. It is a life-threatening complication with severe hemodynamic instability that is refractory to catecholamines. Surgical decompression with drainage is the key point of treatment. Various surgical procedures are reported in the literature, but no cohesive approach has yet been developed. Aim: The aim was to present the available options for surgical treatment of tension pneumomediastinum, as well as the post-interventional results. Materials and methods: Nine cervical mediastinotomies were performed on intensive-care unit (ICU) patients who developed a tension pneumomediastinum during mechanical ventilation. The age and sex of patients, surgical complications, pre- and post-intervention basic hemodynamic parameters, as well as oxygen saturation levels, were recorded and analyzed. Results: The mean age of patients was 62±16 years (6 males and 3 females). No postoperative surgical complications were recorded. The average preoperative systolic blood pressure was 91±12 mmHg, the heart rate was 104±8 bpm, and the oxygen saturation level was 89±6%, while the short-term postoperative values changed to 105±6 mmHg, 101±4 bpm, and 94±5%, respectively. There was no long-term survival benefit, with a mortality rate of 100%. Conclusions: Cervical mediastinotomy is the operative method of choice in the presence of tension pneumomediastinum allowing an effective decompression of the mediastinal structures and improving the condition of the affected patients without improving the survival rate.

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Original Article Sun, 30 Apr 2023 11:13:00 +0300
Prophylaxis of postoperative hypoparathyroidism in thyroid surgery https://foliamedica.bg/article/75427/ Folia Medica 65(2): 207-214

DOI: 10.3897/folmed.65.e75427

Authors: David Dolidze, Аlexey Shabunin, Arshak Vardanyan, Kirill Melnik, Serghei Covantsev

Abstract: Introduction: There are a number of thyroid gland diseases that require surgical treatment. Therefore, it is important to improve the surgical approaches and treatment tactics in patients that need such surgery. Aim: To provide an algorithm to prevent parathyroid gland damage during surgery. Materials and methods: This work was based on treatment results of 226 patients with different thyroid diseases. All patients received extrafascial surgical interventions using modern methodological approaches. For prevention of postoperative hypoparathyroidism, we used the “stress-test”, 5-aminolevulenic acid, and a method of double visual-instrumental registration of photosensitizer-induced fluorescence of parathyroid glands. Results: Transient hypoparathyroidism was registered in four (1.8%) cases after surgery. Permanent hypocalcemia in patients was not recorded. Autotransplantation of parathyroid gland was required only in one case (0.44%). A deficiency or low level of vitamin D was detected in 35% of the cases, and in the majority of those cases, it was due to secondary hyperparathyroidism. The deficiency was corrected with the administration of vitamin D in all cases. In 10.17% (23 patients) of cases, there was no proper visual glow effect after administration of 5-aminolevulinic acid (5-ALA), which required proceeding to the second part of the proposed method (a helium-neon laser and registration of fluorescence using a laser spectrum analyzer). Conclusions: The proposed methodological approach allows prevention of persistent hypoparathyroidism and reduces the frequency of transient hypoparathyroidism and other complications in surgical treatment of patients with various thyroid gland diseases.

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Original Article Sun, 30 Apr 2023 11:12:00 +0300
Ileal bypass for pruritus relief in a 3-year-old boy with advanced progressive familial intrahepatic cholestasis: how effective is it? https://foliamedica.bg/article/73628/ Folia Medica 65(1): 183-185

DOI: 10.3897/folmed.65.e73628

Authors: Anastasia Dimopoulou, Dimitra Dimopoulou, Nikolaos Zavras, Eleni Kontaki, George Vaos, Smaragdi Fessatou

Abstract: Progressive familial intrahepatic cholestasis (PFIC) is a group of liver disorders that manifest in early childhood with cholestasis and pruritus resulting progressively in liver failure. We present a case of a 3-year-old boy with advanced PFIC from refractory pruritus. In order to offer an effective treatment of pruritus, our patient underwent ileal bypass and after a 2-month period free of symptoms, unexpectedly relapsed after a Rota viral infection. Finally, the child underwent orthotopic liver transplantation. Patients with advanced PFIC do not seem to benefit from nontransplant invasive interventions regarding the relief of pruritus.

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Case Report Tue, 28 Feb 2023 20:00:26 +0200
Gallbladder injury in a catatrauma patient: a clinical case https://foliamedica.bg/article/89642/ Folia Medica 65(1): 171-176

DOI: 10.3897/folmed.65.e89642

Authors: Alexey Shabunin, David Dolidze, Natalia Pichugina, Yuriy Barinov, Tatiana Sheviakova, Nataliya Ivanova, Yury Marchenkov, Serghei Covantsev

Abstract: Gallbladder trauma is a rare medical emergency in abdominal surgery because of its anatomic location. Gallbladder injury occurs in only 1.9%-2.1% of cases with abdominal traumas, with an isolated injury being ten times rarer. Despite the different mechanisms of injury, intravesical hypertension is the most important factor contributing to gallbladder rupture. A fall from a height is a rare cause of gallbladder injury, with only a few cases described in the literature. Laparoscopic cholecystectomy is the most common primary treatment. In the present case report, we present the diagnosis and management of a patient with a rare combined trauma. The patient was polytraumatized but had an isolated gallbladder injury in the absence of other abdominal injuries. Modern diagnostic methods, primarily ultrasound, can be critical in determining the best treatment strategy.

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Case Report Tue, 28 Feb 2023 20:00:24 +0200
Free-gliding screw fixation in slipped capital femoral epiphysis: potentially growing implants for symptomatic and prophylactic pinning https://foliamedica.bg/article/77257/ Folia Medica 65(1): 93-98

DOI: 10.3897/folmed.65.e77257

Authors: Stefan Tserovski, Venelin Alexiev, Raytcho Kehayov

Abstract: Introduction: In situ fixation is the gold standard for mild and moderate slipped capital femoral epiphysis (SCFE) cases. The condition is associated with a low percentage of avascular necrosis and chondrolysis.[1] The present study examines the postoperative femoral neck remodelling and implant elongation in cases of therapeutic and prophylactic in situ fixation using the free-gliding screw system. Aim: The aim of our study was to assess the postoperative femoral neck growth and evaluate the biomechanical evolution and complication’s rate for 19 therapeutic and 11 prophylactic in situ fixations with a free-gliding screw. Materials and methods: We measured the preoperative and postoperative articulo-trochanteric distance (ATD), alpha angle (α angle) and screw elongation in symptomatic hips and in contralateral hips with prophylactic fixation. We compared the radiographic parameters of 30 hips. Results: ATD remains approximately the same for symptomatic cases, whereas it increases for prophylactic fixated hip. Screw elongates in both group with statistically higher value for the prophylactic group. The alpha angle remains pathological in these cases with a mean value of 67.12±4.62°, but decreases for group II. Screw elongates by a mean value of 3.14±2.74 mm for group I and 6.78±8.81 mm for group II. Conclusions: Prophylactic in situ fixation with free-gliding screws does not affect the proximal femoral growth (ATD), and does not decrease the alpha angle significantly. Screw elongates statistically in both groups, but more significantly for group II. For symptomatic hips, the in situ fixation allows the femoral neck to grow with ATD preserved, but significantly less than in group II. The alpha angle decreases but remains pathological.

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Original Article Tue, 28 Feb 2023 20:00:13 +0200
Functional results after reconstruction with modular tumor endoprostheses in patients with malignant bone tumors https://foliamedica.bg/article/75380/ Folia Medica 65(1): 80-86

DOI: 10.3897/folmed.65.e75380

Authors: Yordan S. Ivanov, Tsvetan Tsenkov

Abstract: Introduction: The functional outcome in patients after limb salvage surgery, and in particular reconstructions with modular tumor endoprostheses, has been the subject of many international series, but only a few publications mention the functionality in a Bulgarian patient group. Aim: The aim of the present study was to analyze the functional outcome in a Bulgarian group of patients with malignant bone tumors that underwent resection and reconstruction with modular tumor endoprostheses. Materials and methods: Our series consists of 14 patients with malignant bone tumors who underwent limb salvage surgery and reconstruction with modular tumor endoprostheses between February 2012 and January 2021. Staging was done using the AJCC staging system for bone sarcoma. The MSTS score system was used to evaluate the functional results. Results: The mean follow-up time was 38.5 months (range, 8 to 96). The mean MSTS score for our series was 70%. Distant metastases were found in 4 (28%) patients. Local recurrence occurred in 3 (21%) patients. The most severe late complication was a mechanical failure of the expanding mechanism in 1 patient. Conclusions: Reconstruction with modular tumor endoprostheses offer superb functionality and improved life quality in patients with primary malignant bone tumors.

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Original Article Tue, 28 Feb 2023 20:00:11 +0200
Can we predict death using scoring systems in patients with local peritonitis ? A retrospective study https://foliamedica.bg/article/76709/ Folia Medica 65(1): 73-79

DOI: 10.3897/folmed.65.e76709

Authors: Evgeni N. Dimitrov, Georgi A. Minkov, Emil T. Enchev, Krasimira S. Halacheva, Yovcho P. Yovtchev

Abstract: Introduction: Prognostic scores in patients with local peritonitis (LP) have not yet been studied exhaustively. Aim: We, therefore, aimed in this study to evaluate the ability of several scoring systems to predict death in LP. Materials and methods: A retrospective analysis including 68 patients with LP was conducted at Prof. Dr. Stoyan Kirkovich University Hospital in Stara Zagora from January 2017 to August 2021. Clinical and laboratory data needed for calculating the scoring systems were collected at admission or postoperatively. We compared the prognostic performance of WSES SSS, MPI, SIRS, and qSOFA using area under the receiver operation characteristics (AUROC) curves and bivariate correlation analysis. Results: The observed mortality rate was 8.8%. Among all scores, MPI showed the best prognostic performance (AUROC=0.805, 95% CI 0.660–0.950). A threshold MPI >25 points permitted prediction of adverse outcome with a sensitivity of 66.7% and a specificity of 80.6%. The only significant correlation was found between outcome and MPI (p=0.012, r=0.302). Conclusions: The MPI has the ability to prognosticate mortality in patients with LP unlike WSES SSS, qSOFA and SIRS.

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Original Article Tue, 28 Feb 2023 20:00:10 +0200
Is it possible to predict postoperative blood loss in surgery for idiopathic scoliosis? https://foliamedica.bg/article/75163/ Folia Medica 65(1): 66-72

DOI: 10.3897/folmed.65.e75163

Authors: Maya Lebedeva, Anastasia Ivanova, Mikhail Mikhaylovskiy, Vyacheslav Novikov, Vitaliy Lukinov, Aleksandr Vasyura

Abstract: Introduction: Postoperative drain loss can exceed intraoperative blood loss and affect the severity of the patient’s condition. Aim: The objective of the study was to find significant predictors of postoperative blood loss in surgery for idiopathic scoliosis. Materials and methods: We analyzed the data of 140 patients with idiopathic scoliosis. One hundred three patients (group 1) underwent Smith-Petersen osteotomy as part of the multilevel pedicle screw fixation; 37 patients (group 2) required no spinal osteotomy. Correlation and regression analysis of the data was performed. Results: There were significant differences between the groups in the number of fixed segments (p<0.001), the volume of intraoperative blood loss (p<0.001), drain loss (p=0.010), and perioperative blood loss (p<0.001). The study showed that spinal osteotomy had no effect on the volume of postoperative blood loss. A univariate regression analysis revealed the following predictors: patient’s body weight −0.3 [−0.4; −0.2] (p<0.001) and intraoperative blood loss expressed as a percentage of circulating blood volume 0.3 [0.2; 0.5] (p<0.001). The predictors established in univariate regression analysis were significant also in the multivariate analysis. Conclusions: The study established the most significant predictors determining the volume of postoperative blood loss in surgery for idiopathic scoliosis: body weight and intraoperative blood loss expressed in percentages of circulating blood volume. A model for predicting the volume of postoperative blood loss was created based on the identified parameters. This model will optimize support for the treatment associated with transfusion during the perioperative period.

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Original Article Tue, 28 Feb 2023 20:00:09 +0200
Custom anterior segment optical coherence tomography indices for detection of corneal ectasia https://foliamedica.bg/article/74326/ Folia Medica 65(1): 60-65

DOI: 10.3897/folmed.65.e74326

Authors: Angel Atanassov, Marieta Konareva-Kostianeva, Marin Atanasov

Abstract: Introduction: Corneal thinning and changes in the corneal thickness profile are major symptoms of corneal ectasia. The anterior segment optical coherence tomography is currently widely used, and the development of additional indices may lead to improvements in the diagnostics of keratoconus. Aim: To determine the diagnostic value of newly developed custom anterior segment OCT indices in diagnosing corneal ectasia. Patients and methods: Two sets of patients were included in the current study - healthy controls in the first and patients with corneal ectasia in the second, 80 eyes per group of 43 patients each. The groups were age- and sex-matched. Each patient underwent a standard ophthalmological examination (visual acuity, tonometry, slit lamp examination, fundus biomicroscopy), a corneal topography with OCULUS Keratograph 5M, and an anterior segment optical coherence tomography with RTVue-100. Besides the indices automatically generated by the software of the device, we measured the following custom parameters: partial corneal area (PCA), partial chamber area (PCA), and an index that reflects the relation between the two (CpC). All measurements were performed in two axial pachymetric scans, one vertical and one horizontal using the built-in software. Results: A statistically significant difference was found between the two groups (p<0.001, confidence Interval 95%) for all the proposed indices in both the vertical and the horizontal scans. The ROC analysis showed promising results for differentiation between the groups with the area under the curve (AUC) in the range from 0.892 for the vertical partial anterior chamber area to 0.984 for the vertical CpC index. Conclusions: The proposed indices can be used to differentiate between normal and ectatic corneas.

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Original Article Tue, 28 Feb 2023 20:00:08 +0200
Association between pain, arthropathy and health-related quality of life in patients suffering from acromegaly. A cross-sectional study https://foliamedica.bg/article/68278/ Folia Medica 65(1): 37-45

DOI: 10.3897/folmed.65.e68278

Authors: Angelo Alito, Giorgio Carmelo Basile, Daniele Bruschetta, Gina Lacramioara Berescu, Filippo Cavallaro, Aurelio Daniele Postorino, Eliseo Scarcella, Marta Ragonese, Salvatore Cannavò, Adriana Tisano

Abstract: Introduction: Despite successful therapy, acromegalic patients have reduced health-related quality of life (HRQoL) compared to healthy controls. Finding predictors of poor HRQoL can be crucial to improving these patients’ global health state. Aim: The primary objective of the study was to find out predictors of HRQoL. Secondary objectives were: (I) to determine correlations with AcroQoL subscales, and (II) to identify predictors for subscales. Materials and methods: In this cross-sectional study conducted in 2019 at the Messina Policlinic Hospital, 45 acromegalic patients were assessed at the Physical and Rehabilitative Medicine Ambulatory. During routine outpatient clinic attendances, the following questionnaires were administered: Acromegaly Quality of Life Questionnaire (AcroQoL), Patient-Assessed Acromegaly Symptom Questionnaire (PASQ), and Western Ontario and McMaster Universities Arthritis Index (WOMAC). We furthermore included the following variables obtained by medical record review: age, BMI, disease duration, previous surgery (Yes/No), previous radiotherapy (Yes/No), use of GH lowering medications (Yes/No), hypertension (Yes/No), diabetes mellitus (Yes/No), and biochemical control of the disease (Yes/No): immunoradiometric assays were employed to serum GH and IGF-1 measurements to identify biochemical control of the disease. Correlation between outcome measures and AcroQoL has been performed. Pearson’s r was calculated for continuous data following normal distribution (AcroQoL, PASQ, AcroQoL-B, AcroQoL-R, WOMAC-P), while Spearman’s rank order correlation was calculated for non-normally distributed data (WOMAC, WOMAC-F, WOMAC-S, AcroQoL-P) and point-biserial correlation for binary variables (biochemically controlled disease, use of GH lowering medications, radiotherapy, surgery). The same correlation analysis was performed for the AcroQoL subscales. Multiple linear regression with backwards, stepwise analysis was used to assess the influence on AcroQoL of correlated variables. Results: AcroQoL was strongly negatively correlated with PASQ (r=−0.700, p<0.001) and negatively correlated with WOMAC [rs (43)=−0.530, p<0.001] and among WOMAC subscales with WOMAC-Physical fitness [rs (43)=−0.518, p<0.001] WOMAC-Pain [r (43)=−0.428, p=0.003], WOMAC-Stiffness [rs (43)=−0.393, p=0.007], and radiotherapy [r (43) =−0.314, p=0.035]. After univariate stepwise regression, PASQ was the strongest independent predictor of AcroQoL, with R2 of 0.392 [F (1,43)=27.695, p<0.001]. Conclusions: This study shows that the severity of painful symptoms is the most important predictor of HRQoL in patients with acromegaly; at the same time, acromegalic arthropathy leads to pain and to a variable amount of functional impairment, exerting great impact on the patient’s perception of his health status. Measure of the progression of arthropathy and symptomatic management could lead to a great HRQoL benefit.

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Original Article Tue, 28 Feb 2023 20:00:05 +0200
The effects of thiopental on cold ischemic injury in renal transplantation https://foliamedica.bg/article/71368/ Folia Medica 65(1): 30-36

DOI: 10.3897/folmed.65.e71368

Authors: Başak Büyük, Yasemen Adali, Ebru Karakoç, Hüseyin Avni Eroğlu, Cemre Aydeğer

Abstract: Introduction: One of the most important factors influencing post-transplant success in kidney transplantation is preserving the viability of the organ from removal to transfer into the recipient. Aim: This study aimed to reduce the energy requirement with thiopental doses administered before organ transplantation, and to increase the organ viability by minimizing the tissue damage during the cold ischemia process. Materials and methods: Twenty female Wistar albino rats were divided into two groups: control group (group C), and thiopental group (group T). In group C, a midline incision was performed, and the renal artery was isolated under ketamine and xylazine anesthesia. A standard organ storage solution (cooled to +4°C) was used for kidney perfusion. Nephrectomy was applied, and the removed kidneys were placed into +4°C standard organ storage solution and stored at +4°C for 12 hours. Animals in group T were subjected to the procedures explained above under 85 mg/kg thiopental sodium anesthesia. After 12-hour storage, samples from the kidney tissues were fixed in 10% neutral buffered formalin. Histopathological evaluation and apoptosis detection via TUNEL method were performed. Results: Tubular necrosis was more extensive in group C compared with that in group T and this difference was statistically significant. Similarly, vacuolization was widely observed in group C, and this increase was also statistically significant. For the ‘dilatation of Bowman’s space’ parameter, a significant decrease was observed in group T compared with group C. When the apoptotic index values of both groups were examined, it was seen that they were lower in group T than those in group C. This result was statistically significant. Conclusions: These data suggest that thiopental provides protection to the kidney tissue during the cold storage process. Thiopental has been shown to decrease the number of apoptotic cells in the kidney tissue when administered to the donor before organ transplantation, increasing the organ viability.

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Original Article Tue, 28 Feb 2023 20:00:04 +0200
Intraoperative ultrasound for nonpalpable breast lesions – experience and operative time https://foliamedica.bg/article/76193/ Folia Medica 65(1): 16-19

DOI: 10.3897/folmed.65.e76193

Authors: Valentin Ivanov, Rossen Dimov, Blagoi Marinov, Valentin Ivanov, Desislava Tashkova

Abstract: Introduction: The essential tools doctors need to diagnose breast cancer tumors at the early stages and with no clinical presentation are screening mammography and ultrasonography. Nonpalpable breast lesions are a current problem nowadays and there are various types of navigation techniques that are utilized in order to achieve cancer cell-free resection margins in the first place. Intraoperative ultrasound has been proven to be a safe and effective way to excise this type of breast tumors. Aim: To study the correlation between the experience we obtained while using intraoperative ultrasound for excision of nonpalpable breast lesions, and the duration of surgery. Materials and methods: Twenty-five women with nonpalpable breast lesions underwent breast-conserving surgery using ultrasound navigation. Nominal and ordinal data were presented using numbers and percentages. Spearman’s rank-order correlation was used to assess the effect of experience gained on the duration of surgery. Results: The tumor distribution was 72% malignant tumors and 28% benign. A 100% identification rate in the effective surgical excisions was reported. In the process of gaining experience using the method, the duration of surgery shortened by 30%. No tumor cells on ink were found in all specimens and there was no need for secondary surgeries. Conclusions: Our results demonstrate a relatively short learning curve, and we believe that breast surgeons should be helped and encouraged to gather adequate expertise to ensure patient safety and gain confidence.

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Original Article Tue, 28 Feb 2023 20:00:02 +0200
Revascularization methods in patients with carotid stenosis and concomitant coronary heart disease https://foliamedica.bg/article/69913/ Folia Medica 65(1): 7-15

DOI: 10.3897/folmed.65.e69913

Authors: Georgi Goranov, Petar Nikolov, Mariya Tokmakova

Abstract: A major feature of the atherosclerotic process is its systemic and progressive character. The plaque pathogenetic mechanisms, morphology, evolution, and predilection site (bifurcation zones) determine the frequent coincidence of carotid and coronary atherosclerosis in the same patient. The present overview chronologically traces the history, effectiveness, and benefit of surgical and continuously improving interventional carotid revascularization. It thereby analyzes the indications, results, and complications based on a number of randomized clinical trials, industry-sponsored registries, and large single-center series in the last 3 decades. Carotid endarterectomy (CEA) and percutaneous carotid angioplasty (CAS) have evolved from ‘dubious’ procedures to a modern strategy resulting in a significantly lower incidence of stroke and death compared to medical treatment only. Although almost every second patient with carotid stenosis and indications for CAS has coronary atherosclerosis, studies on therapeutic modeling in such a combination are few, showing controversial results. Having both CHD and CS doubles the risk of myocardial infarction, stroke, HF, and death. An isolated revascularization approach compromises the results of therapeutic strategies and worsens patient survival. The high risk associated with coronary heart disease in CAS and CEA is a fact and minimization requires both an individualized and uniform stepwise revascularization strategy.

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Review Tue, 28 Feb 2023 20:00:01 +0200
Priapism in an otherwise healthy man with SARS-CoV-2: case report and literature review https://foliamedica.bg/article/71053/ Folia Medica 64(6): 1016-1019

DOI: 10.3897/folmed.64.e71053

Authors: Emil Dorosiev, Boris Mladenov, Ivan Stoev, Dimiter Velev, Simeon Georgiev

Abstract: COVID-19 disease causes acute respiratory infection – pneumonia. It is associated with an increased risk of complications such as hypercoagulopathy, which leads to thromboses. We present a case of a young man presenting with typical SARS-CoV-2 symptoms (fever, cough, fatigue, and dyspnea), who experienced ischemic priapism, most probably due to thrombosis of penile vessels caused by the novel coronavirus infection. After prompt treatment of the priapism with punctures and irrigation, lasting penile detumescence was achieved. However, despite younger age, lack of serious comorbidities and administration of anticoagulants, priapism was followed by a fatal pulmonary embolism some days later.

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Case Report Sat, 31 Dec 2022 12:00:00 +0200
Combination of cardiac and carotid glomus tumour: a rare case report https://foliamedica.bg/article/67448/ Folia Medica 64(6): 1012-1015

DOI: 10.3897/folmed.64.e67448

Authors: Feridoun Sabzi, Aghigh Heydari, Mohammad Rouzbahani, Reza Heidari Moghaddam, Atefeh Asadmobini

Abstract: The most common tumour of the heart is myxoma but paraganglioma (also called glomus tumour in extracardiac sites) in the cardiac position is the rarest of them. While this tumour accounts for 0.8% of all primary benign tumours, the combination of both neoplasms is an exceedingly rare occurrence. Herein, we present a case of combined carotid glomus tumour and left atrial paraganglioma tumour in which respiratory distress was the presenting symptom of cardiac type but carotid tumour was asymptomatic. The case underwent a two-step resection of the neck and cardiac mass with an uncomplicated postoperative course and in the 1year follow-up, no recurrence of tumour in both sites was found on physical exam and imaging studies.

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Case Report Sat, 31 Dec 2022 12:00:00 +0200
Paraganglioma in the spinal cord histologically mimicking ependymoma – a case report https://foliamedica.bg/article/71407/ Folia Medica 64(6): 1007-1011

DOI: 10.3897/folmed.64.e71407

Authors: Nadezhda Stefanova, Yavor Enchev, Deyan Dzhenkov, Antoniya Hachmeryan

Abstract: Paraganglioma is a tumour lesion of neuroectodermal origin that occurs at various places in the human body, but is rarely observed in the spinal cord. Usually, it presents in the lumbar region (cauda equine and filum terminal) as a slow-growing painless tumour mass that causes local compression. We present a 53-year-old man with chronic low back pain, difficulty in walking, and impotence. The magnetic resonance study showed a tumour lesion suspicious for ependymoma. Surgical excision was performed and the result from the intraoperative frozen section was also ependymoma due to the presence of pseudorosettes structures. After the surgery, a thorough histological examination of the specimen revealed an encapsulated formation composed of ovoid and spindle-shaped cells with eosinophilic to light cytoplasm, with rounded nuclei with finely dispersed chromatin. An arrangement of cells in the form of pseudorosettes – ependymoma-like features was found in a large area of the tumour. Immunohistochemically, it was proved that the tumour was paraganglioma, not ependymoma. Paraganglioma is a rare tumour in the spinal cord and it should be distinguished from other tumours normally observed in this area like ependymomas by using immunohistochemical stains.

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Case Report Sat, 31 Dec 2022 12:00:00 +0200
Endobronchial localization - arena of two tumors: a case report https://foliamedica.bg/article/71252/ Folia Medica 64(6): 1003-1006

DOI: 10.3897/folmed.64.e71252

Authors: Spasimir Shopov

Abstract: The lung is a common arena for metastases of tumors with different localization, but endobronchial localization of metastases is very rare. The most common tumors with endobronchial localization of metastasis are renal, breast, and colorectal cancer. We report a man presenting with cough and hemoptysis. Endobronchial biopsy showed renal cell carcinoma and micro-invasive bronchogenic squamous cell carcinoma. Endobronchial metastases from renal cell carcinoma are rare. The squamous cell lung cancer is one of the most common cancers in men, but the combination of renal cell carcinoma and micro-invasive squamous cell carcinoma with endobronchial localization is a casuistic case.

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Case Report Sat, 31 Dec 2022 12:00:00 +0200
Neonatal urinoma associated with ascites in a newborn with a solitary kidney https://foliamedica.bg/article/69787/ Folia Medica 64(6): 998-1002

DOI: 10.3897/folmed.64.e69787

Authors: Emil Dorosiev, Gabriela Minova, Boris Mladenov, Teofil Pelov, Stoyan Peev

Abstract: Fetal urinomas are often diagnosed in prenatal ultrasonography. The etiology is usually an obstructive uropathy leading to hydronephrosis and increased intrarenal pressure putting future kidney function at risk. Rupture of pyelocaliceal system in such cases may lead to retroperitoneal urinoma or urinary ascites, sepsis, uraemia, and acute renal failure. On the other hand, this may serve as “pop-off valve” mechanism decreasing intrarenal pressure and protecting from definitive kidney function loss. We present a case of a newborn girl with a retroperitoneal urinoma, ascites, uraemia, and obstruction of a solitary right kidney, which was successfully treated minimally invasively through peritoneal and retroperitoneal drainage and intubation of the right ureter with a DJ stent shortly after birth.

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Case Report Sat, 31 Dec 2022 12:00:00 +0200
Antenatal anticoagulant therapy and neonatal hemorrhagic syndrome. Case report https://foliamedica.bg/article/68688/ Folia Medica 64(6): 991-997

DOI: 10.3897/folmed.64.e68688

Authors: Irina Sagaidac, Dorina Rotaru, Olga Cernetchi

Abstract: Neonatal hemorrhagic syndrome, which affects several principal organs during the early neonatal period, denotes a deficiency of vitamin K and coagulation factors. This article presents the case of a patient who gave birth at term, had congenital heart disease and required several prior surgical interventions including corrected transposition of the great vessels via ventricular septal defect (VSD) repair, atrial septal defect (in childhood) and tricuspid valve replacement (6 years ago), mitral regurgitation (MR), grade I pulmonary regurgitation (PR), grade II mitral and tricuspid valve regurgitation, and grade II heart failure based on the New York Health Association (NYHA) classification. Throughout the pregnancy, the patient received large doses of anticoagulant, specifically acenocumarolum, until the moment she gave birth. The vaginal delivery was spontaneous, contrary to the recommendations given to the pregnant woman in a secondary healthcare institution. At birth, the newborn was in satisfactory condition, with 8/9 on the Apgar score. However, the newborn’s condition worsened over time, suspected of having neonatal hemorrhagic syndrome caused by medications received by the mother. Forty-eight hours after birth, the newborn died. Anticoagulant therapy cannot be regarded as 100 percent risk-free during pregnancy due to the potential for hemodynamic disorders to develop in both the mother and the unborn child. Considering the high incidence of perinatal mortality in such cases (10-30%), it is advised that a multidisciplinary team work together to inform the mother about potential complications, collaboratively determine the length of treatment with vitamin K antagonists (VKAs), develop a plan for monitoring the pregnancy, and determine which institution the mother and newborn would benefit from receiving qualified medical assistance.

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Case Report Sat, 31 Dec 2022 12:00:00 +0200
Initial experience with peroral endoscopic myotomy in Bulgaria: case series https://foliamedica.bg/article/90599/ Folia Medica 64(6): 982-984

DOI: 10.3897/folmed.64.e90599

Authors: Nikola Boyanov, Katina Shtereva, Katerina Madzharova, Vladimir Andonov, Neno Shopov, Petko Dimov

Abstract: Achalasia is a rare motility disorder with unknown etiology that results in failure of relaxation of the lower esophageal sphincter (LES). As there is no etiological treatment, different pharmacological agents and invasive techniques have been used for relieving the symptoms. For the past decade, peroral endoscopic myotomy (POEM) has proven to have excellent results. We present a retrospective study of five patients that underwent POEM for primary achalasia. We used anterior approach for the submucosal tunneling. The procedure showed immediate results and no severe short- or long-term adverse events. We have been following the patients up for more than 3 years now. Since its invention more than ten years ago, the POEM procedure and its advantages and disadvantages compared to the pneumatic dilatation and the Heller myotomy have been extensively studied. There is still no universal opinion on which procedure should be the first line treatment.

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Case Report Sat, 31 Dec 2022 12:00:00 +0200
Comparison of short term results following robotic and laparoscopic total gastrectomy and D2 lymph node dissection https://foliamedica.bg/article/89545/ Folia Medica 64(6): 889-895

DOI: 10.3897/folmed.64.e89545

Authors: Gancho Kostov, Rossen Dimov, Mladen Doykov

Abstract: 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. Aim: The aim of the study was to compare our initial short-term results after robotic and laparoscopic gastrectomy. Materials and methods: A retrospective cohort study was performed. For a period of four years between January 2018 and August 2022, a total number of 110 patients with total gastrectomy and D2 lymphadenectomy due to gastric cancer operated in Department of General Surgery, Kaspela University Hospital, Plovdiv, were included into the study. They were separated in two groups: thirty-eight patients with robotic surgery and 72 with laparoscopic assisted procedure. Results: The oncological variables such as location of tumor, nodal status, number of lymph nodes removed, and pathological tumor showed no statistically significant differences between robotic and laparoscopic group. The demographic variables as age, sex, BMI, as well as ASA score also demonstrated no remarkable difference in both groups (p>0.05). The overall complication rate were similar (p=0.983). Conclusion: We found no significant advantages of robotic over laparoscopic gastric surgery in our patients. However, we think that robotic surgery is effective, safe, and promising approach to the treatment of gastric cancer capable of correcting some of the disadvantages of laparoscopy.

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Original Article Sat, 31 Dec 2022 12:00:00 +0200
Robotic gastrointestinal stromal tumors surgery - initial results https://foliamedica.bg/article/91448/ Folia Medica 64(6): 884-888

DOI: 10.3897/folmed.64.e91448

Authors: Valentin Ivanov, Luboslav Dimov, Strahil Strashilov, Denis Milkov, Nikolai Dzalov, Lyubomir Chervenkov

Abstract: Introduction: Gastrointestinal stromal tumors (GISTs) usually present as an exophytic mass localized in stomach. Years ago, conventional surgery was the only option. Laparoscopic and robotic procedures have risen to prominence in recent decades as technology and surgical techniques have advanced. Aim: The aim of this study was to evaluate the safety and feasibility of robotic surgery of GIST. Materials and methods: All patients who underwent robotic surgery for a GIST in the University Hospital Kaspela-Plovdiv between November 2021 and April 2022 were included. Post-operative course and short oncological outcomes were analyzed. Results: Four patients with gastric GIST, median size 50 mm [40–70 mm], underwent robotic surgery. Conversion to open surgery not occurred. We have two cases with localization in corpus, one in antrum and one in the fundus. We have registered one complications- anastomotic leakage after proximal resection treated conservatively. In others, the post-operative period was uneventful. The average hospital stay was 8.2 (4-11) days. The median operating time was 255 min (220–320 min). Conclusions: On basis of this initial results, we can conclude that robotic gastrointestinal tumors surgery is safe, feasible, and oncological sustained. Of course, one of the weakest sides of this surgery is prolonged operative time and increased expenses.

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Original Article Sat, 31 Dec 2022 12:00:00 +0200
Acute retinal necrosis: pathophysiological aspects, diagnosis, and treatment https://foliamedica.bg/article/68036/ Folia Medica 64(6): 871-877

DOI: 10.3897/folmed.64.e68036

Authors: Vesela Mitkova-Hristova, Nina S. Stoyanova

Abstract: Acute retinal necrosis (ARN) is a devastating viral infection commonly associated with varicella zoster virus (VZV) and herpes simplex virus types 1 and 2 (HSV-1, HSV-2). Typically, ARN affects individuals without immune status disorders between the ages of 50-70. In two-thirds of the cases, one-eye involvement is observed and the inflammation can be presented as panuveitis. The most characteristic clinical manifestations are vitreitis, occlusion of the retinal arterioles, and peripheral necrotizing retinitis. Retinitis presents with the appearance of deep, multifocal, yellowish-white foci, typically localized in the peripheral retina. Systemic antivirals are the first treatment of choice for ARN. The goal of the therapy is to stop the viral replication and disease progression in the affected eye, as well as to prevent involvement of the healthy eye. The other eye can be attacked in an interval of 5 days to 30 years. The visual prognosis after illness is poor. Early diagnosis and timely initiation of treatment play an important role in maintaining visual acuity and preventing the other eye from being affected.

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Review Sat, 31 Dec 2022 12:00:00 +0200
Duodenal diverticulum perforation: a case report and review of the literature https://foliamedica.bg/article/66425/ Folia Medica 64(5): 849-852

DOI: 10.3897/folmed.64.e66425

Authors: Paraskeuas Mitragkas, Eirini Synekidou, Konstantinos Hatzimisios

Abstract: Duodenum is the second most common site for diverticula formation. Duodenal diverticula (DD) are asymptomatic incidental findings and their complications are rare. The rarest and most severe complication is DD perforation. Until 2012, only 162 cases of DD perforation were reported in the world literature. A woman presented with acute abdomen and peritonitis. CT scan revealed hydropneumoretroperitoneum suggestive of duodenal perforation. The patient underwent an exploratory laparotomy and the diagnosis of a DD perforation was made. A diverticulectomy with tube duodenostomy was performed, without complication. A duodenal diverticulum perforation can be treated either surgically or conventionally. Only selected patients can be treated conventionally. Surgical treatment remains the standard option. Treatment must be individualized.

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Case Report Mon, 31 Oct 2022 20:00:00 +0200
Incidental finding of unilateral complete duplication of ureter in a patient with large ureteric calculus obstructing both left limbs https://foliamedica.bg/article/68429/ Folia Medica 64(5): 844-848

DOI: 10.3897/folmed.64.e68429

Authors: Ioannis Tsikopoulos, Dileara Cuziurova, Konstantinos Galanoulis, Dimitrios Kalogiannis, Konstantinos Skriapas

Abstract: Duplication of the ureter is a common congenital malformation, which unfortunately may be accompanied by unpleasant and challenging pathologies. Hereby, a rare case of a patient with obstructive urolithiasis secondary to undiagnosed complete ureteral duplication is presented. A single large calculus in the vesicoureteral junction was obstructing both duplicated ureters. The aim of this article was to discuss both the challenges arising from this clinical entity and the diagnostic approaches. In such complicated cases combined with suspected pyelonephritis or severe hydronephrosis, the option of an urgent lithotripsy should be considered. The obstructed orifices are often inflammatory, hindering their stenting. Asymptomatic and undiagnosed patients with completely duplicated ureters are prone to severe complications. Thus, early screening of these patients is an imperative need for the clinician.

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Case Report Mon, 31 Oct 2022 20:00:00 +0200
A rare case of Watson syndrome https://foliamedica.bg/article/63559/ Folia Medica 64(4): 672-675

DOI: 10.3897/folmed.64.e63559

Authors: Feridoun Sabzi, Aghigh Heydari, Reza Heidari Moghaddam, Mohammad Rouzbahani, Atefeh Asadmobini

Abstract: Watson for the first time reported a case series of children in a family that presented with pulmonary valve stenosis, mental retardation, short stature, and small brown color skin lesions that are known as cafe-au-lait spots. We present a rare new variant of the syndrome in an adult patient with severe pulmonary valve stenosis, main, left, and right pulmonary artery aneurysm, short stature, mental retardation, coronary artery disease, and skin lesions. The patient underwent open cardiac surgery with pulmonary valvotomy and aneurysmorrhaphy of the main pulmonary artery and its right and left branches. The postoperative course was uneventful and the six-month follow-up with transthoracic echocardiography revealed no recurrence of aneurysm of repairing pulmonary arteries and good clinical outcome of the patient. Our patient had a unique characteristic of aneurysm of the main pulmonary artery and its both branches that has rarely been reported previously in the medical literature.

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Case Report Wed, 31 Aug 2022 17:30:00 +0300
Analysis of characteristics and surgical outcome of intradural extramedullary tumors – a retrospective cohort study of 52 patients https://foliamedica.bg/article/64273/ Folia Medica 64(4): 609-616

DOI: 10.3897/folmed.64.e64273

Authors: Borislav Kitov, Georgi Apostolov, Atanas Davarski, Ivo Kehayov, Kristina Kilova

Abstract: Introduction: Although intradural extramedullary tumors (IET) are relatively well studied, research on the typical epidemiological, demographic, and clinical characteristics of these malignancies is scanty. Aim: The aim of this study was to investigate retrospectively the epidemiology, demographics, clinical presentation, imaging data, type of surgery, and the outcome of treatment of IETs. Materials and methods: We performed retrospective chart review of medical history, clinical presentation, paraclinical and imaging data, and operative protocols of operated patients with IETs from January 2011 to August 2020. Special attention was paid to the onset of symptoms, clinical presentation at admission, imaging data, localization, type of surgery, histology, and outcome of the disease. The degree of neurological deficit and disability of the patients at admission, discharge, and follow-up was assessed by the Modified McCormick Scale and the Modified Rankin Scale, respectively. The follow-up period varied from 1 to 105 months (mean 43 months). Results: Fifty-two patients (mean age 58 years, range 14-78 years) with IETs were surgically treated for the study period. At admission to the clinic, 48 patients (92.3%) had vertebralgia, 34 (65.4%) had concurrent radicular pain, 42 (80.8%) had motor deficit, and 18 (34.6%) had sphincter disorders. Total tumor removal was achieved in 47 patients (90.4%). Favourable outcome was registered in 43 patients (82.7%). The degree of disability (mRS) at admission (p=0.0001), the McCormick grade at admission (p=0.0001), gender (p=0.042), and age (p=0.047) of patients were significantly correlated with the functional status assessed by McCormick scale at discharge. Conclusions: Most of the IETs can be successfully removed via a standard posterior or posterolateral surgical access. Favourable outcome of treatment depends on early diagnosis and total tumor resection.

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Original Article Wed, 31 Aug 2022 17:30:00 +0300
Gastric trichobezoar in the absence of psychosocial stressors: a report of two cases https://foliamedica.bg/article/62464/ Folia Medica 64(3): 537-542

DOI: 10.3897/folmed.64.e62464

Authors: Ivan Yankov, Vasil Tashev, Pavlin Kozev, Rayna Shentova, Danail Mitkovski, Nikola Boyanov

Abstract: Abstract Bezoars are accumulations in the gastrointestinal tract caused by intentional or unintentional consumption of indigestible materials. After food and mucus impaction they become solid masses with different sizes, presenting with various non-specific symptoms. Current treatment options for bezoars include enzymatic dissolution, endoscopic fragmentation and removal, and surgical removal. Herein, we report two cases with an abdominal trichobezoar due to trichophagia presenting with mild atypical symptoms and requiring surgical removal. The patients had no underlying psychological and behavioral deviations, psychiatric disorders, stressful or traumatic live events that may trigger the condition. We present our approach to making the diagnosis, the challenges we met, and our treatment strategy. Trichobezoar should not be forgotten as part of the differential diagnosis of abdominal pain and abdominal mass in children and adolescent.

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Case Report Thu, 30 Jun 2022 20:00:23 +0300
An extremely rare clinical manifestation of acute appendicitis in a nonagenarian patient: lessons still to be learned https://foliamedica.bg/article/62008/ Folia Medica 64(3): 527-531

DOI: 10.3897/folmed.64.e62008

Authors: Anargyros Bakopoulos, Nikolaos Koliakos, Ioannis Katsaros, Natasha Hasemaki, Dimitrios Tsapralis, Diamantis I. Tsilimigras, Dimitrios Moris, Dimitrios Schizas

Abstract: Abstract Acute appendicitis is associated with a relatively high mortality rate among elderly patients due to the unusual clinical presentation that often leads to misdiagnosis and, in turn, severe complications. This report describes an extremely uncommon clinical manifestation of acute appendicitis in an elderly patient - a subcutaneous abdominal wall abscess initially treated as cellulitis. Despite the initial misdiagnosis, contrast-enhanced computed tomography revealed a circumscribed inflammatory process of the appendix that was in close proximity to the abdominal wall. The patient underwent a surgical drainage of the abscess, received broad-spectrum antibiotics, and was discharged on day 12 following an uneventful course. Diagnosis of acute appendicitis in elderly patients is challenging due to the atypical clinical presentation and co-existing comorbidities that can be misleading. Early application of high-resolution imaging techniques is necessary to identify the cause of acute abdomen in the elderly population.

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Case Report Thu, 30 Jun 2022 20:00:20 +0300
Evaluation of the quality of life after implantation of light or standard polypropylene hernia meshes https://foliamedica.bg/article/65709/ Folia Medica 64(3): 459-466

DOI: 10.3897/folmed.64.e65709

Authors: Miglena Doneva, Maria Kamusheva, Guenka Petrova, Stoyan Sopotensky, Nikolay Gerasimov

Abstract: Abstract Introduction: The present pilot study evaluates the quality of life of Bulgarian patients after a conventional hernia operation in which light or standard polypropylene hernia meshes were used. Materials and methods: Sixty-eight patients planned for recovery of primary or recurrent open hernia with implanted standard or lightweight polypropylene meshes were included in the study. Patients’ data were collected prospectively for a 5-month period (October 2017 - February 2018) on the basis of the case histories. The patients were interviewed using the EQ5D questionnaire and a visual analogue scale. Follow-up of each patient’s results was performed up to a year after surgery. Results: Three months after the operation, the patients reported only the presence of pain. On average, 24.5% of patients experienced mild pain and 20.3% - severe pain. In the standard mesh group, on average, the mild pain was 7.69%, swelling 3.84%, and foreign body sensation - 15.38% one year after the surgery. In the light mesh group the reported mild pain was 6.69%, pulling without pain - 13.33%, and foreign body sensation - 6.69%. There was no statistically significant difference in the pain level according to the used mesh, but in the group with implanted standard meshes, the reported problems prevailed. At the end of the survey period, the average score was 84.39±13.67. Conclusions: Hernia operation reduces pain 1 year after the procedure. The intensity of chronic pain one year after the surgery is relatively similar for both light and standard meshes in conventional inguinal hernia repair. The differences in the overall quality of life are insignificant in the long run. An individualized choice, based on the patients’ characteristics and safety of meshes, should be done by the healthcare specialists.

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Original Article Thu, 30 Jun 2022 20:00:13 +0300
Prophylactic central lymph node dissection in differentiated thyroid cancer – benefits and risk https://foliamedica.bg/article/64030/ Folia Medica 64(3): 430-436

DOI: 10.3897/folmed.64.e64030

Authors: Gancho G. Kostov, Rossen S. Dimov, Mladen I. Doykov

Abstract: Introduction: Papillary thyroid cancer is the most common thyroid malignancy. Lymph nodes involvement is common in differentiated thyroid cancer, and cervical lymph node micrometastases are observed in up to 85% of patients with papillary thyroid cancer during surgery. While the therapeutic central lymph node dissection has been accepted, the debate on the prophylactic in differentiated thyroid carcinoma (DTC) continues. Aim: To evaluate the benefits and risk of prophylactic central lymph node dissection in differentiated thyroid cancer. Materials and methods: Between January 2014 and December 2018, 223 total thyroidectomies due to papillary thyroid cancer were performed in the Kaspela University Hospital in Plovdiv. The patients were allocated into two groups: group A consisting of 36 patients with total thyroidectomy alone, and group B - 178 patients with total thyroidectomy and prophylactic central lymph node dissection. Results: In 36 (21.6%) patients, we found metastases only in ipsilateral side. In 24 (13.4%) of them we found metastatic spread in both ipsilateral and contralateral lymph nodes. In 7 (3.9%) patients, the metastasis was found only in the contralateral nodes. A pre-laryngeal lymph node was found and removed in 79 patients. Metastases were found in 12 of these 79 nodes. Analysis of complications showed no significant differences in its rate in patients with TT+ PCLND vs. patients with TT alone. Conclusions: The present study suggests that the realization of total thyroidectomy with prophylactic central lymph node dissection in papillary thyroid cancer patients has neither substantial advantages nor significant complications for the short period of observation.

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Original Article Thu, 30 Jun 2022 20:00:09 +0300
An outbreak of postoperative rapidly developing and multidrug-resistant Klebsiella pneumoniae urosepsis due to a contaminated ureteroscope https://foliamedica.bg/article/62365/ Folia Medica 64(3): 401-407

DOI: 10.3897/folmed.64.e62365

Authors: Yavuz Güler, Akif Erbin, Tahsin Gozdas

Abstract: Introduction: Outbreaks caused by microorganisms contaminating the inside of rigid ureteroscopes are extremely rare. Some of these outbreaks, especially those caused by multidrug-resistant (MDR) infections, can cause serious problems, even death. Among these serious infections, we have no data about Klebsiella pneumoniae outbreaks caused by rigid ureteroscopes and their management and consequences. Aim: We aimed to report the outcomes of an outbreak of rapidly developing MDR K. pneumoniae urosepsis linked to rigid ureteroscopy (URS). Materials and methods: Data for 68 patients who had ureteroscopic lithotripsy (URS-L) operations using the same ureteroscope were retrospectively reviewed. Among them, 17 patients with postoperatively developing urosepsis were included in the study. Samples were taken from the operating room, camera heads, endoscopes, and ancillary instruments for culture workup. K. pneumoniae was produced in a swab culture obtained from the water inlet channel of the ureteroscope. Results: All patients had sepsis signs that developed within hours (2-7 hours). MDR K. pneumoniae was detected in the urine cultures of all patients. It was sensitive only to amikacin, tigecycline, colistin, and netilmicin. All patients were treated with tigecycline (100 mg intravenous daily). It was observed that K. pneumoniae growth continued without any symptoms in the first and fourth weeks of follow-up in 4 patients. These patients were accepted as colonization; no additional treatment was given. Conclusions: In the case of rapidly developing urosepsis after the URS procedure in a patient, instruments, devices, and endoscopes should be immediately checked for contamination to prevent the emergence of an outbreak.

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Original Article Thu, 30 Jun 2022 20:00:05 +0300
Robotic-assisted colorectal surgery – initial results https://foliamedica.bg/article/70942/ Folia Medica 64(3): 388-392

DOI: 10.3897/folmed.64.e70942

Authors: Gancho Kostov, Mladen Doykov, Rossen Dimov

Abstract: 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. Aim: The aim of this study was to analyse and share our initial results in robotic colorectal surgery and compare them with literature data. Materials and methods: A retrospective study was conducted in order to review seven patients with colorectal cancers operated by the robotic-assisted technique over three months in the initial phase of the learning curve. Gender, age, diagnosis, and surgical indication, type of surgery performed, surgical time, conversion, bleeding, post-operative complications, and hospital stay, were analysed and described. A literature review was performed on the role of robotic surgery in colorectal cancer. Results: Seven patients were operated, 5 males and 2 females with a mean age of 68.2 years. The following procedures were performed: left hemicolectomy with primary anastomosis, low anterior resection, left hemicolectomy, sigmoid resection. The mean surgery time for the seven patients was 4 h 06 min, with a time on the console of 2 h and 50 min, and mean bleeding of 192 cc. None of the patients required conversion and the hospital stay was 7 days. Conclusions: Despite the reduced case series, the initial results of our learning curve in colorectal robotic surgery are among the parameters imposed by the medical literature.

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Original Article Thu, 30 Jun 2022 20:00:03 +0300
Two distinct episodes of life-threatening hemobilia due to a lesion of common bile duct and delayed intrapancreatic arteriobiliary fistula managed by emergency pancreatoduodenal resection https://foliamedica.bg/article/62513/ Folia Medica 64(2): 359-364

DOI: 10.3897/folmed.64.e62513

Authors: Georgi Popivanov, Nicola Vladov, Dimitar Penchev, Marina Konaktchieva, Boriana Ilcheva, Radoslav Kostadinov, Vladimir Nikolov, Daniel Stefanov, Ventsislav Mutafchiyski

Abstract: Hemobilia is an extremely rare cause of upper gastrointestinal bleeding. It often has intermittent manifestation, which may lead to significant diagnostic delay. In 65% of the cases, the causes are iatrogenic, in 7% the cause is malignancy, in 5% - gallstones, in 8% it is inflammation (cholecystitis, parasites, reflux cholangitis), vascular abnormality is the cause in 7% (most commonly pseudoaneurysm of the hepatic artery), and pancreatic pseudocyst causes hemobilia in 1%. In almost all cases, the bleeding originates from intrahepatic or extrahepatic bile ducts, and rarely from the pancreas. PUBMED search with keywords “hemobilia” and “arteriobiliary fistula” found a total of 44 papers. No case with intrapancreatic arterio-biliary fistula was found. To the best of our knowledge, we present a unique case of delayed life-threatening hemobilia caused by intrapancreatic arterio-biliary fistula. It was diagnosed at the fourth admission and managed successfully by emergency Traverso-Longmire pancreatoduodenal resection. We briefly discuss the keys to a timely diagnosis and the cornerstones of the treatment. The timely diagnosis of hemobilia depends on a high index of suspicion and careful interpretation of the symptoms. Hemodynamic stability has a crucial role in the decision-making process. Angioembolization is the cornerstone of the treatment, whereas surgery is reserved only for cases with an unstable hemodynamic or unsuccessful embolization. Surgical approach depends on the bleeding site. Although an emergency pancreatic head resection is a procedure of last resort, it can be life-saving in cases with intractable bleeding due to intrapancreatic arteriobiliary fistula.

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Case Report Sat, 30 Apr 2022 14:15:00 +0300
Metastatic malignant melanoma of the breast: report of a case and review of the literature https://foliamedica.bg/article/62755/ Folia Medica 64(2): 354-358

DOI: 10.3897/folmed.64.e62755

Authors: Aikaterini Mastoraki, Anastasia Gkiala, George Theodoroleas, Ero Mouchtouri, Alexios Strimpakos, Despoina Papagiannopoulou, Dimitrios Schizas

Abstract: Melanoma is the most rapidly increasing cancer in the world. Associated morbidity and mortality are mainly related to metastatic potential. Metastases to the breast from malignant melanoma are rare and represent only 1.3%–2.7% of reported cases. The aim of this study was to present a rare case of metastatic malignant melanoma to the breast. A 51-year-old woman was admitted for management of a palpable mass of the left breast. The past medical history referred to a sizable nodular melanoma that was removed from her back. Classification of the breast lesion was BI-RADS 5. Core needle biopsy was compatible with the diagnosis of malignant melanoma. Immunohistochemical evaluation was positive for Mart1 and Ki67. Subsequent staging was indicative of multiple secondary foci in the liver and bones. The patient was administered a combination of PD L1 inhibitor nivolumab with the anti-CTLA4 inhibitor ipilimumab followed by additional targeted therapy with the BRAF inhibitor vemurafenib. Metastasis to the breast from malignant melanoma is extremely rare. Nevertheless, breast metastases must be suspected in patients with a history of malignant melanoma. Moreover, recent breakthroughs in the Braf and MEK inhibitors and immune checkpoint inhibition therapies have impressively improved prognosis in patients affected by melanoma.

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Case Report Sat, 30 Apr 2022 14:13:00 +0300
Uterine angiolipoleiomyoma. A case report and systematic literature review https://foliamedica.bg/article/60937/ Folia Medica 64(2): 341-347

DOI: 10.3897/folmed.64.e60937

Authors: Victoria Psomiadou, Christos Iavazzo, Eirini Geramani, Alexandros Fotiou, Loukas Karelis, Christos Valavanis, Sofia Lekka, Kalliopi Kokkali, George Vorgias

Abstract: Uterine angiolipoleiomyomas are rare, benign mixed mesenchymal lesions. A manifestation in the gynecological region is quite uncommon, with few cases described in the literature so far. We present an interesting case of a 59-year-old woman diagnosed with uterine angiolipoleiomyoma, and the results of the conducted systematic review of the literature. The patient presented with a pelvic mass masquerading as a leiomyoma on the ultrasound and postmenopausal vaginal bleeding. At laparotomy, a large uterus was noticed and the histopathology set the diagnosis of angiolipoleiomyoma. Immunohistochemistry revealed negativity for Melan-A and HMB-45 melanoma-specific antibodies and positivity for Van Gieson and orcein histochemical stains. We systematically reviewed the literature. The eligible articles were those written in English, excluding animal studies and studies reporting angiolipoleiomyomas in other regions beside the uterus. The present case is one of the 10 cases of uterine angiolipoleiomyoma reported in the literature. In 8 out of 11 (72.7%) cases, uterine angiolipoleiomyomas arose from the corpus of the uterus, while in 2 (18.1%) cases they were located at the cervix, and in one case (9%) angiolipoleiomyoma was located in the broad ligament. Concerning symptoms, four of the patients (36.4%) presented with abdominal and pelvic pain, two (18.1%) with postmenopausal vaginal bleeding, one with menometrorrhagia (9%), and one with uterine prolapse and cystocele (9%). Immunohistochemical staining of uterine angiolipoleiomyomas was positive for SMA in 4 patients (36.4%), positive for desmin in 3 cases (27.3%), positive for anti-S-100 protein antibody in 2 patients (18.1%), while in one case (9%) immunopositivity was observed for CD31. Only our case (9%) was also tested for CD34, Van Gieson and orcein, the first of these being negative and the other two positive (at the blood vessels in a specialized pattern). Three of the patients (27.3%) were also tested for HMB-45 and all three were immunonegative. In order to establish the diagnosis of uterine angiolipoleiomyomas, ultrasonography and additional MRI may help the preoperative prediction of a benign mass. Immunohistochemistry will show strong positivity of alpha-smooth muscle actin and desmin. Complete abdominal hysterectomy is the preferable treatment.

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Case Report Sat, 30 Apr 2022 14:02:00 +0300
Acute systemic complications of intravitreal bevacizumab and triamcinolone injections – a comparative study https://foliamedica.bg/article/61424/ Folia Medica 64(2): 240-247

DOI: 10.3897/folmed.64.e61424

Authors: Mohammad Karim Johari, Malihe Askari, Abdulrahim Amini, Masoud Yasemi

Abstract: Introduction: Macular edema is a common visual threatening complication in patients with diabetic retinopathy and retinal vein occlusion. The injection of intravitreal drugs, such as anti-vascular endothelial growth factor (anti-VEGF) and corticosteroids, revolutionized the treatment of these diseases. Aim: To compare and assess the acute systemic complications of intravitreal bevacizumab and triamcinolone injections in patients with diabetic retinopathy and retinal vein occlusion. Materials and methods: The study population included 211 patients with diabetic retinopathy and retinal vein occlusion who required intravitreal injections of bevacizumab and triamcinolone. In this study, 118 patients had generally received intravitreal injections with bevacizumab and the rest (93 patients) injections with triamcinolone. Experimental data, including demographic information, number of injections, the history of comorbidities, intraocular pressure, and systemic hypertension before and after injections, were recorded on specific forms following groups’ classification. In addition, the incidence of various complications was investigated during one month after the intravitreal injections. Results: In the present study, we included 211 patients (mean age 62.41±11.34 years, median - 63 years). The results showed that there was no significant correlation between the injectable drug and changes in increased intraocular pressure (IOP) (p=0.66). No significant difference was detected for systemic hypertension in any of the studied groups. On the other hand, the incidence of complications of blood sugar, facial skin redness, neurological problems of TIA and CVA, myocardial infarction, vascular problems after injection, and ocular complications were estimated to be zero, 1.4, 0, 0.8, 0, and 6.1%, respectively. Conclusions: Overall, the results indicated a prevalence of 1.4% for systemic complications and a prevalence of 6.1% for ocular complications. Accordingly, it seems that intravitreal injections of both drugs studied in the present study are placed in the group of low complication medications.

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Original Article Sat, 30 Apr 2022 13:09:00 +0300
Treatment approach in malignant left-bowel obstruction using self-expandable metallic stent: a case series https://foliamedica.bg/article/67124/ Folia Medica 64(1): 143-147

DOI: 10.3897/folmed.64.e67124

Authors: Nikola B. Boyanov, Katina T. Shtereva, Sergey K. Sergeev, Katerina I. Madzharova, Nikolay A. Stoynov, Desislava D. Dimitrova-Yurukova

Abstract: Endoscopic self-expandable metallic stent (SEMS) decompression in patients with bowel obstruction due to colon carcinoma has been practiced for over two decades now, both in potentially curable cases and metastatic cancer. Using this case series, we aim to review the literature on the subject and to present our initial experience with using this technique as a bridge to single stage surgery, thus minimizing colostomy creation. We retrospectively reviewed seven cases of bowel obstruction due to left-sided colonic cancer, between March 2020 and March 2021. All patients received SEMS prior to being treated, 7 to 13 days later, using either laparoscopic surgical techniques or open surgery methods. All seven patients underwent single stage surgery, eliminating the need for placing a temporary or permanent stoma, therefore minimizing the hospital stay and increasing the quality of life of the individual. We concluded that treatment with SEMSs for bowel obstruction in colorectal cancer was safe and well tolerated, resulting in primary anastomosis and restoration of the intestinal passage and low short-term morbidity.

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Case Report Mon, 28 Feb 2022 10:19:00 +0200
Advantages and disadvantages of laparoscopic inguinal hernia repair (hernioplasty) https://foliamedica.bg/article/65965/ Folia Medica 64(1): 61-66

DOI: 10.3897/folmed.64.e65965

Authors: Nikola Trokovski, Petar Uchikov, Emanuil Yordanov, Kiril Atliev

Abstract: Aim: The aim of this study was to explore the advantages and disadvantages of laparoscopic hernioplasty by comparing them with conventional surgeries. Materials and methods: The study included 376 patients (344 men and 32 women) who underwent inguinal hernia repair in inpatient settings over a 3-year period (2017–2020). The patients were divided into two groups: patients with conventional hernioplasty (CH) - 312 patients (291 men and 32 women, mean age 55±15 years, range 18–93) and 64 patients with laparoscopic hernioplasty (LH), all of them middle-aged men at mean age 45±15 years (range 24–69). Results: Thirty-eight patients (59.38%) with LH were ASA class 1 patients while the CH patients were stratified in ASA classes 1 to 4. The LH group consisted of 39 patients who had transabdominal preperitoneal (TAPP) surgery and 25 who received total extraperitoneal (TEP) repair. The average operating time was 12 minutes (range 90–200 min) for TAPP and 50 minutes (range 20-125 min) for TEP. The mean intensity of pain score measured by VAS (0-10) was 4 (2-5) for CH patients and 3 (2-4) for LH patients. The duration of pain was 3 days (2-4) for CH patients and 2 days (1-3) for the LH group. Ninety-five percent (61/64) of LH patients defined their quality of life as “better”. Conclusions: The following factors are of particular importance for the choice of hernioplastic technique: operating time, possible intraoperative complications, the level of postoperative pain and potential postoperative analgesics, possible complications, patient recovery, length of hospital stay, cost, quality of life, and long-term results of the treatment.

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Original Article Mon, 28 Feb 2022 09:56:00 +0200
Does biopsy before excision have contribution to clinical results in patients with schwannoma? A single-center prospective observational study https://foliamedica.bg/article/59138/ Folia Medica 64(1): 55-60

DOI: 10.3897/folmed.64.e59138

Authors: Recep Öztürk, Emin Kürşat Bulut, Bedii Şafak Güngör

Abstract: Introduction: This study aimed to investigate whether tru-cut biopsy before excision contributes to clinical outcomes in patients diagnosed with limb schwannoma. Materials and methods: Tru-cut biopsy was performed before excision in patients diagnosed with schwannoma of the extremity in clinical and radiological evaluations. All patients underwent total excision with microsurgical methods. Demographic data, complications of tru-cut biopsy, treatments, and clinical results were analyzed. Results: Data for 17 patients (9 males and 8 females) were analyzed. The mean age was 49.8 years. No complications related to tru-cut biopsy were observed. The mean preoperative and postoperative VAS scores were 4.3 and 0.4, respectively. One patient developed postoperative neurological complications. No recurrence was observed in any patient. Conclusions: In schwannomas of the extremities, tru-cut biopsy before excision is an applicable and reliable option. The preoperative diagnosis is ascertained as schwannoma, and the outcomes of making the excision with microsurgical techniques are quite good.

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Original Article Mon, 28 Feb 2022 09:56:00 +0200
Crohn’s Disease of the Vulva: a Case Report https://foliamedica.bg/article/58002/ Folia Medica 63(6): 990-993

DOI: 10.3897/folmed.63.e58002

Authors: Kalliopi Kokkali, Christos Iavazzo, Efthimia Souka, Sofia Lekka, Alexandros Fotiou, Eirini Geramani, Victoria Psomiadou, George Vorgias

Abstract: Crohn’s disease is a multi-systemic chronic inflammatory disease that can affect various organs besides the gastrointestinal tract such as joints, uvea, and the skin. Vulvar Crohn’s disease is a rare entity occurring with vulvar lesions that show typical Crohn’s disease granulomatous inflammation but are not contiguous with the gastrointestinal involvement. Vulvar Crohn’s disease can be easily confused with other granulomatous diseases and awareness that such involvement may precede gastrointestinal symptoms must be raised. Few cases of vulvar Crohn’s disease have been reported in the literature to date. Here, we report a case of a 43-year-old woman with a 6-month history of a vulvar lesion; the patient was diagnosed with Crohn’s disease of the large bowel just over a year ago.

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Case Report Fri, 31 Dec 2021 10:30:00 +0200
A Rare Location of Pseudoaneurysm in Subaortic Ring after Bentall Operation https://foliamedica.bg/article/57294/ Folia Medica 63(6): 981-984

DOI: 10.3897/folmed.63.e57294

Authors: Feridoun Sabzi, Aghigh Heydari, Reza Heidari Moghaddam, Atefeh Asadmobini

Abstract: Bentall operation is considered a gold standard of surgery in the treatment of ascending aortic aneurysm. This operation with en-bloc resection of ascending aorta and aortic valve requires aortic valve with two coronary bottoms re-replacements in a prepared composite graft. The four important locations for the pseudoaneurysm include proximal and distal composite graft anastomosis and two coronary bottom sites. However, many complications have been reported with this technique but the most serious complication associated with this operation is defined as pseudoaneurysm. We report an exceedingly rare case of subaortic ring pseudoaneurysm in retro composite graft position enclosed by infected surgical that was used to control bleeding in this location. Dehiscence occurred between the aortic ring and the underlying left ventricular muscle. The aortic ring was separated from the underlying muscle by the high tensile strength of sewing ring sutures. The pseudoaneurysm compressing the left atrium without communicating with any cardiac chamber and presenting with high fever (39°C), chills, a few months after Bentall operation. The patient underwent redo operation and repair of the dehiscence’s site. The 6-month follow-up revealed no recurrence of a pseudoaneurysm. The uniqueness of this case report is related to the site of pseudoaneurysm between the aortic ring and underlying left ventricular muscle that have not been reported in the medical literature so far.

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Case Report Fri, 31 Dec 2021 10:30:00 +0200
Intraductal Papillary Mucinous Neoplasm of the Pancreas: Need for a Tailored Approach to a Rare Entity https://foliamedica.bg/article/63071/ Folia Medica 63(6): 970-976

DOI: 10.3897/folmed.63.e63071

Authors: Marina Konaktchieva, Dimitar Penchev, Georgi Popivanov, Lilia Vladova, Roberto Cirocchi, Marin Penkov, Petko Karagyozov, Ventsislav Mutafchiyski

Abstract: Intraductal papillary mucinous neoplasm (IPMN) of the pancreas is a relatively new entity that has gained increased attention because of its unique features – presence of different subtypes with different malignant potential, biological behavior, and prognosis, higher rates of recurrences and concomitant or metachronous pancreatic duct cancer. It is rare with an incidence of 4 to 5 cases per 100 000. The relative lack of experience significantly hampers decision making for surgery (pancreatic head resection, distal pancreatectomy or enucleation) or follow-up.Herein we present two cases managed by diametrically different tactic according to the risk stratification – distal pancreatectomy with splenectomy and observation, respectively. An up-to-date literature review on the key points in diagnostics, indications for surgery, the extent of surgery, follow-up, and prognosis is provided.The tailored approach based on risk stratification is the cornerstone of management. Absolute indications for surgery are the lesions with high-risk stigmata, whereas the worrisome features should be evaluated by endoscopic ultrasound and fine-needle aspiration. Main duct and mixed type are usually referred to surgery, whereas the management of a branch type is more conservative due to the lower rate of invasive cancer. Strict postoperative follow-up is mandatory even in negative resection margins due to a high risk for recurrences and metachronous lesions.Despite the guidelines, the intraductal papillary mucinous neoplasm remains a major challenge for clinicians and surgeons in the balance the risk/benefit of observation versus resection. Risk stratification plays a key role in decision-making. Future trials need to determine the optimal period of surveillance and the most reliable predictive factors for concomitant pancreatic duct cancer.

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Case Report Fri, 31 Dec 2021 10:30:00 +0200
The Role of Mesenchymal Stem Cells in Regulating PDGF and VEGF during Pancreatic Islet Cells Regeneration in Diabetic Animal Model https://foliamedica.bg/article/57636/ Folia Medica 63(6): 875-883

DOI: 10.3897/folmed.63.e57636

Authors: Agung Putra, Zakariya Hadi Suwiryo, Adi Muradi Muhar, Agus Widyatmoko, Fifin Luthfia Rahmi

Abstract: Introduction: Diabetes is a heterogeneous group of metabolic diseases characterized by elevated blood glucose due to autoimmune disorder or a combination of insulin resistance and insulin deficiency. VEGF and PDGF are the main actors in the regeneration of damaged pancreatic tissue. However, the prolonged release of these molecules may induce fibrosis formation. Mesenchymal stem cells (MSCs) have a high potential to regenerate damaged pancreatic tissue by releasing PDGF and VEGF.Aim: This study aimed to investigate the effect of MSCs on the levels of PDGF and VEGF on days 2 and 44 in diabetic mice and determine the number of pancreatic islet cells and blood glucose levels.Materials and methods: This study used a post-control group design with animals divided into five groups: sham, control, and three treatment groups (P) which were given MSCs at doses of 1.5×105, 3×105, and 6×105 cells. The levels of PDGF, VEGF, and blood glucose were measured by enzyme-linked immunosorbent assay (ELISA), while the number of pancreatic islet cells was analyzed using H&E staining.Results: This study showed a significant increase of VEGF and PDGF levels on day 2 and a significant increase in islet cell percentages on day 44 in line with the decreased blood glucose level. However, there was no difference between VEGF and PDGF levels on day 44.Conclusions: MSCs regulate PDGF and VEGF levels in wound healing phases and remodel pancreatic islet β-cells regeneration to control blood glucose in diabetic model mice.

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Original Article Fri, 31 Dec 2021 10:30:00 +0200
Acute Management of Deep Facial Burns https://foliamedica.bg/article/57073/ Folia Medica 63(6): 847-857

DOI: 10.3897/folmed.63.e57073

Authors: Katia I. Kalinova, Ralitsa D. Raycheva, Neli Petrova, Petar A. Uchikov

Abstract: Introduction: Management of deep facial burns is a serious challenge for many reasons: a considerable anatomic and functional diversity is concentrated in a small space, a uniform treatment does not exist, late sequelae are frequent and may be severe, and the literature on the subject is ambiguous.Aim: To analyse management of deep facial burns.Patients and methods: A retrospective medical chart review was conducted for 569 patients with deep facial burns hospitalized between January 2005 and January 2015. Demographic data, type, depth and size of burns, chronology and type of surgical treatment, length of hospital stay, and type and incidence of late sequelae were analysed and compared.Results: Over 10 years, 596 patients with deep facial burns, 216 (36.24%) females and 380 (63.76%) males, aged from 5 months to 95 years (mean 39.5±26 years) were treated. The most common burn agents were hot liquids and flames. The mean total body surface area (TBSA) burned was 17±13.3%. Concomitant eye injury was detected in 63 (10.6%) patients. Priority was given to the early, meticulous, staged surgical approach aimed at sparing the survived tissues and rapid wound closure. Follow-up ranged from 3 months to 5 years. Late functional sequelae were documented for 50 (8.38%) patients and ocular sequelae - for 33 (5.54%) of them. There was no incidence of secondary corneal perforation or definitive loss of vision.Conclusions: Adequate and up-to-date acute management of deep facial burns based on early, judicious, surgical approach could limit initial damage and reduce late sequelae.

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Original Article Fri, 31 Dec 2021 10:30:00 +0200
Renal abnormalities associated with Mayer-Rokitansky-Küster-Hauser syndrome https://foliamedica.bg/article/63325/ Folia Medica 63(5): 815-818

DOI: 10.3897/folmed.63.e63325

Authors: Emil Dorosiev, Galya Muzikadzhieva, Boris Mladenov, Ivan Stoev, Dimiter Velev

Abstract: Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is a rare congenital disorder affecting female reproductive system (agenesis of uterus and upper part of vagina) alone (type 1), or associated with abnormalities of other organs and systems (type 2). We report a case of a 21-year-old woman diagnosed with MRKH due to primary amenorrhea during puberty and operated for formation of neovagina. She was admitted to the Department of Urology with abdominal pain and oligoanuria, where the physical examination and imaging studies revealed a malformation of the upper urinary tract: a solitary dystopia of kidney in the pelvis with stenosis of ureteropelvic junction and hydronephrosis. After initial desobstruction with a DJ stent, a pyeloplasty was performed. Females with primary amenorrhea are often delayed with the diagnosis of potential MRKH syndrome, and those diagnosed with the syndrome should undergo detailed examination to exclude concomitant urinary abnormalities.

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Case Report Sun, 31 Oct 2021 17:00:24 +0200
Use of Foley catheter in control of internal carotid hemorrhage during endoscopic endonasal surgery https://foliamedica.bg/article/56461/ Folia Medica 63(5): 809-814

DOI: 10.3897/folmed.63.e56461

Authors: Matteo Alicandri-Ciufelli, Francesco Maccarrone, Cecilia Botti, Giacomo Pavesi, Livio Presutti

Abstract: Internal carotid artery (ICA) injuries during endoscopic endonasal surgery (EES) are rare life-threatening events. We describe a technique to manage ICA injuries based on the use of Foley catheters.A 26-year-old female underwent endoscopic transnasal trans-sphenoidal removal of pituitary adenoma. Cerebrospinal fluid leak occurred 4 days postoperatively. During repair procedure, accidental injury of ICA occurred. Emergency nasal packing through positioning of four Foley urologic catheters was successfully performed to stop bleeding. The patient did not report neurologic deficits.In author’s opinion, Foley catheters are suitable to obtain immediate bleeding control since they are rapidly available and easily usable.

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Case Report Sun, 31 Oct 2021 17:00:23 +0200
Surgical treatment of pneumothorax in patients with COVID-19 – results and management https://foliamedica.bg/article/69003/ Folia Medica 63(5): 663-669

DOI: 10.3897/folmed.63.e69003

Authors: Angel Uchikov, Lyubomir Paunov, Atanas Batashki, Emanuil Yordanov, Kiril Atliev, Chavdar Stefanov, Milena Sandeva, Peter Uchikov

Abstract: Introduction: The new coronavirus, SARS-CoV-2, provokes infection with different clinical presentation. It involves an asymptomatic condition, mild variants with fever and dry cough to severe pneumonia, adynamia and respiratory failure with lethal outcome. The fibrotic lung tissue after the inflammatory process is a background for development of a secondary pneumothorax. Although it rarely causes lethal outcomes in COVID-19 patients, pneumothorax requires early diagnosis and adequate treatment to prevent any complications and decrease mortality rate.Aim: The aim of this study was to analyse the results of surgical treatment of hospitalized COVID-19 patients with pneumothorax in terms of demographic data, concomitant diseases, complications, and outcome.Materials and methods: Longitudinal prospective study was carried out with 26 patients with pneumothorax as a result of SARS-CoV-2 infection. They were treated at the Intensive Care Unit of the Infectious Disease Clinic and at the Second Clinic of Surgery, St George University Hospital in Plovdiv over a 6-month period from September 2020 to February 2021.Results: Seventeen of the patients were men and nine – women. Twenty-four of all patients underwent thoracentesis and two of them had a video-assisted thoracoscopy. The mean age of the studied patients with pneumothorax and COVID-19 was 66.77±12.61 years, which shows that it is the patients of advanced age with concomitant diseases that are at a higher risk of serious complications and adverse outcome. Of the hospitalized 1245 patients with COVID-19, 385 (30.92%) passed away. Of all hospitalized patients with SARS-CoV-2, 26 (2.08%) developed pneumothorax. Sixteen of them (62%) passed away. The possibility of a lethal outcome for intubated patients increased more than twice.Conclusions: The pneumothorax as a complication of COVID-19 carries high mortality and severely worsens the prognosis for these patients.

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Original Article Sun, 31 Oct 2021 17:00:05 +0200
Effect of video games playing on surgical simulation training: a systematic review. https://foliamedica.bg/article/67296/ Folia Medica 63(5): 647-656

DOI: 10.3897/folmed.63.e67296

Authors: Petar Dimov, Jennie Hurtig, Konstantinos Georgiou, Dimitrios Theodorou, Blagoi Marinov, Lars Enochsson

Abstract: Introduction: Video games have a positive impact on the skills required for laparoscopic surgery. Several studies have assessed the impact of video games on laparoscopic skills.Aim: This study aims to systematically review the existing evidence.Materials and methods: A search strategy was implemented to retrieve relevant articles from MEDLINE and SCOPUS databases. The retrieved articles were reviewed for further evaluation according to the predetermined inclusion/exclusion criteria.Results: Twenty-six studies were included in this systematic review. These included prospective (n=9), retrospective (n=5) and interventional (n=12). Other review papers were cited in the discussion section. Studies with positive outcomes significantly outweighed the negative ones (21 vs. 5, respectively).Conclusions: Although there is some evidence that video game experience could give some advantage in laparoscopy no firm conclusions could be drawn yet. The reasons for that lay in the various aims, approaches and results of different study reports. Gaming could be used as a daily warm-up or as a tool to speed-up mastering new skills. A standardized protocol is needed for answering the different questions regarding the impact of video game exposure to laparoscopic skills development and progression.

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Review Sun, 31 Oct 2021 17:00:03 +0200
Sternal reconstruction and omentoplasty after mediastinitis https://foliamedica.bg/article/53706/ Folia Medica 63(4): 618-622

DOI: 10.3897/folmed.63.e53706

Authors: Hristo Stoev

Abstract: Deep sternal infections are serious complications after open heart surgery. We present a case of a 59-year-old female with uncontrolled diabetes who underwent aortocoronary bypass surgery in another cardiac surgery department. After the surgical intervention sternal dehiscence and wound infection occurred, which was followed by two unsuccessful attempts for sternal refixation. Two months after the initial procedure the patient was admitted to our institution with severe dyspnea and paradoxical movement of the thorax. Computed tomography revealed a huge defect of the sternum and metal osteosynthesis with a titanium plate and omentoplasty was performed. The patient was followed-up for one year with excellent postoperative result.

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Case Report Tue, 31 Aug 2021 18:00:00 +0300
Massive subgaleal hematoma in a 62-year-old man treated with apixaban as a consequence of mild head trauma https://foliamedica.bg/article/58872/ Folia Medica 63(4): 613-617

DOI: 10.3897/folmed.63.e58872

Authors: Diamantoula Pagkou, Theodosios Papavramidis, Xanthippi Mavropoulou, Moysis Moysidis, Ioannis Patsalas

Abstract: Subgaleal hematoma, accumulation of blood in the loose areolar tissue of the subgaleal space of the skull, is considered the most catastrophic complication of instrumental delivery. It is a rare finding in older ages, usually associated with coagulation disorders, severe head trauma leading to skull base fractures and accidental or abusive hair pulling. Complications include periorbital necrotising fasciitis, permanent blindness, infections and, in extreme rare cases, airway obstruction. Most cases of subgaleal hematoma resolve spontaneously, without the need of aspiration or drainage.We present here the case of a 62-year-old male on anticoagulant therapy with apixaban for chronic atrial fibrillation, who came to the emergency department after a car accident suffering from mild head trauma. The patient was complaining of a diffuse headache and physical examination showed a large ecchymosis and edema on the frontal area of the head. His neurological examination was unremarkable. Full-body computed tomography (CT) revealed a fracture of the third right rib. Twelve hours after admission, due to an excessive decrease of hematocrit, a second CT was performed. Although the images didn’t show intracranial hemorrhage or skull base fractures, a large and diffuse hematoma of the subaponeurotic space was observed and the diagnosis of subgaleal hematoma was confirmed.Massive subgaleal hematoma after mild head trauma is rather infrequent. Early diagnosis improves outcomes and can avert serious complications. Therapeutic strategy should be based on the severity of each case. In our case, conservative treatment appeared to be a valid alternative to surgery, as hematoma resolved spontaneously within 10 days. It is noteworthy that the use of anticoagulation is the only evident factor that could have been the precipitating factor for the development of the hematoma in our patient.

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Case Report Tue, 31 Aug 2021 18:00:00 +0300
Closed posterolateral elbow dislocation without fracture leading to complete brachial artery rupture https://foliamedica.bg/article/55771/ Folia Medica 63(4): 595-600

DOI: 10.3897/folmed.63.e55771

Authors: Athanasios N. Ververidis, Ioannis E. Kougioumtzis, Christos Chatzipapas, Christos Argyriou, Stylianos Tottas, Konstantinos Tilkeridis, George S. Georgiadis

Abstract: Traumatic vascular injury of the brachial artery by closed posterolateral complete elbow dislocation, without fracture is an unusual injury. Based on clinical and radiological evidence, emergency treatment is necessary.We present a case of complete brachial artery rupture, with a clot resulting from a closed posterolateral elbow dislocation, without fracture. We report the early assessment and operative treatment.A brachial artery injury due to a closed elbow dislocation, without fracture is uncommon. The diagnosis poses a dilemma and the operation is a challenge. It is addressed by Orthopaedic and Vascular team.

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Case Report Tue, 31 Aug 2021 18:00:00 +0300
Primary renal echinococcosis – a rare location of hydatid disease https://foliamedica.bg/article/65684/ Folia Medica 63(4): 591-594

DOI: 10.3897/folmed.63.e65684

Authors: Boris Mladenov, Emil Dorosiev

Abstract: Hydatid disease is a condition affecting mainly the liver or, to a lesser extent, the lungs. We present an uncommon case of a primary renal echinococcosis in a young man complaining of intermittent hematuria, dull flank pain, and palpable mass in the left lumbar and lateral abdominal area which increases its size over time. After initial self-treatment with painkillers and antibiotics, the patient was referred to a urological clinic, where the physical examination revealed a large tumour mass in the left kidney. Ultrasound showed a large multilocular renal cyst, with a CT highly suspicious for renal echinococcosis (15×12.8×24.2 cm). Serological tests confirmed presence of IgG against Echinococcus. The patient was operated using the lumbar approach and nephrectomy was performed. The man recovered completely after surgery without the need for further treatment.

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Case Report Tue, 31 Aug 2021 18:00:00 +0300
Correlation between keratometry and corneal incision before and after phaco surgery https://foliamedica.bg/article/55396/ Folia Medica 63(4): 527-532

DOI: 10.3897/folmed.63.e55396

Authors: Akbar Derakhshan, Shahram Bamdad, Hosssein Kheiri, Masoud Yasemi

Abstract: Introduction: Cataract is a common cause of vision loss and blindness in humans. After surgical management of cataract, all efforts should be focused on reducing postoperative astigmatism thus providing an excellent vision to patients.Aim: To determine the relationship between corneal incision and refraction changes before and after phacoemulsification surgery in 300 patients undergoing cataract surgery in Khatam hospital in Mashhad, Iran from January 2017 to April 2018.Materials and methods: Three hundred patients (144 women and 156 men) with cataract undergoing phacoemulsification surgery were recruited in this cross-sectional study. Refraction, keratometry and visual acuity measurement were performed before surgery. Then, a steep-based incision in the cornea was made without stitches. A 3.2 mm corneal incision was made at two supratemporal and temporal sites. The patients were followed-up for one and six months, and one year after surgery monitoring their vision and refraction, and performing keratometric measurements.Results: The mean age of the patients was 65.7±9.54 years (age range, 42–84 years). No major complications were observed. The greatest mean of changes in corneal power was in the supratemporal incision (1.28±0.6). Keratometry had a significant relation with the incision (p<0.04).Conclusions: An incision made along the steepest meridian leads to flatness of this meridian, this effect being more pronounced at the supratemporal incision. A temporal incision is recommended in cases where there is little difference in the keratometry of the two axes.

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Original Article Tue, 31 Aug 2021 18:00:00 +0300
High-sensitivity CRP levels in women with gestational hypertension, preeclampsia and in normotensive pregnant women and its correlations https://foliamedica.bg/article/56489/ Folia Medica 63(4): 511-518

DOI: 10.3897/folmed.63.e56489

Authors: Dolina G. Gencheva, Fedya P. Nikolov, Ekaterina H. Uchikova, Rosen D. Mihaylov, Blagovesta G. Pencheva, Katerina I. Ivanova

Abstract: Introduction: Gestational hypertension is a less investigated hypertensive disorder of pregnancy than preeclampsia, but evidence exists of an unfavourable cardiovascular profile for women after such a pregnancy.Aim: To determine serum high-sensitivity C-reactive protein (hs-CRP) levels in women with preeclampsia, gestational hypertension, and in normotensive pregnancy in order to assess the cardiovascular implications and to examine its correlations with some characteristics of women.Materials and methods: Thirty-six women with gestational hypertension, thirty-seven with preeclampsia, and fifty maternal and gestational age-matched controls were included in a single-center prospective clinical-epidemiological study. Serum hs-CRP levels were determined using ELISA method.Results: Significantly higher hs-CRP levels were found in the gestational hypertension group than in the controls (p=0.043), but not in the preeclampsia group (p=0.445). The levels between the two pathological groups did not differ significantly (p=0.247). Odds ratio for hs-CRP levels higher than the provided cut-off was 3.31 (95% CI 1.32–8.29) for the presence of gestational hypertension. In the normotensive pregnant women, the hs-CRP levels had a positive correlation with BSA, pre-pregnancy and current BMI, but such correlations were absent in the hypertensive groups. There were no correlations with the maternal or gestational age, current weight gain in any of the groups or with the highest detected blood pressure in the pathological groups. These levels did not differ according to gravidity, smoking status and smoking during pregnancy.Conclusions: Elevation of hs-CRP was more pronounced in women with gestational hypertension than in women with preeclampsia, which could indicate a different pathophysiological mechanism and a higher cardiovascular risk for those women.

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Original Article Tue, 31 Aug 2021 18:00:00 +0300
Surgical treatment of urethral stricture disease – the earlier, the better https://foliamedica.bg/article/57517/ Folia Medica 63(4): 481-487

DOI: 10.3897/folmed.63.e57517

Authors: Valeri Mariyanovski, Emil Dorosiev, Boris Mladenov

Abstract: Introduction: Surgical treatment of urethral strictures is a constantly evolving process. There are various treatment options like internal urethrotomy (IUT) and open surgery. A variety of techniques for urethral reconstruction are available (grafts, flaps, and excision-reanastomosis). Functional results of urethral reconstructive surgery are very satisfying and with low rate of complications.Aim: We assessed the early open surgical reconstruction in comparison with the continuation with the endourological treatment – IUTs.Materials and methods: The study included 129 patients with urethral strictures referred to our center. At that time point, they had received two unsuccessful IUTs and were divided into two groups – consecutive IUT and surgical repair, which included excision and reanastomosis or augmented urethroplasty. These patients were evaluated at 12 months using urethrography and uroflowmetry. Sexual function was evaluated using the international index of erectile function questionnaire 5-IIEF. Chi-squared test for statistical analysis was used.Results: Successful outcomes (urethrography presented equal caliber and Qmax was >15 ml/sec 12 months after the procedure) were achieved in 59 (88%) of the patients using reconstructive surgery versus 26 (41.9%) of the patients with consecutive IUT (p<0.001). Mild sexual dysfunction was reported by 12 (17.9%) patients from the group with open surgery and 7 (11.3%) from the group with continuous IUT (p=0.289).Conclusions: Early open surgery seems a reasonable solution to the problem of urethral strictures as there are only a few complications from this surgery and the functional results are satisfactory. The success rate using open surgery was found to be significantly greater than that in the consecutive IUT group, whereas no differences in the complication rates regarding sexual function were observed.

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Original Article Tue, 31 Aug 2021 18:00:00 +0300
Cardiocutaneous fistula secondary to left ventricular pseudo-aneurysm rupture https://foliamedica.bg/article/55544/ Folia Medica 63(3): 457-459

DOI: 10.3897/folmed.63.e55544

Authors: Feridoun Sabzi, Atefeh Asadmobini, Neda Raofi, Mohammad Javad Kademi

Abstract: Cardiocutaneous fistula (CF) is a potentially serious and catastrophic complication. Infection the suture line after left ventricular aneurysm repair, presenting with the CF. We present an unusual case of CF due to staphylococcus infection 6 months after repair of a myocardial rupture secondary to dehiscence repair.

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Case Report Wed, 30 Jun 2021 21:00:22 +0300
L3 rootlet recurrent melanocytic schwannoma – case report and literature review https://foliamedica.bg/article/55295/ Folia Medica 63(3): 448-456

DOI: 10.3897/folmed.63.e55295

Authors: Georgi K. Georgiev, Ivan V. Todorov, Todor P. Shamov, Ivan V. Krushovenski, Albena D. Fakirova, Boryana N. Ilcheva, Iliyan T. Georgiev, Nikolai D. Georgiev, Vladimir S. Prandjev, Tihomir N. Eftimov

Abstract: First described by Miller in 1932, melanocytic schwannoma (MS) (melanotic schwannoma, pigmented schwannoma) is a rare variation of peripheral nerve sheet tumours with ectodermal origin occurring predominantly in somatic, but also in the autonomic peripheral system with around two hundred cases in the literature. Predominantly benign tumours, MS are still imaging and pathological challenge and can be easily misdiagnosed with more aggressive peripheral nerve tumours.We report a case of melanocytic schwannoma on L3 sensory rootlet with systematic literature review of nearly 200 cases presented in intracranial, paraspinal region, thoracic, abdominal or pelvic cavities and skin. Two-thirds of cases are part of Carney complex.We present a case of a 61-year-old male with a 3-month history of low back pain, progressive numbness and stiffness in the right thigh, shin and knee, tibial and peroneal paresis causing gait disturbance and neurological claudication. MRI findings present “sand clock” type intradural extramedullary tumour formation with extension to the L3 rootlet through right L3-L4 foramen, hypointense on T2 and hyperintense on T1. Pathological diagnosis of sporadic type melanocytic schwannoma was made via immunohistological and ultrastructural analysis. Thirteen months after total resection there was clinical and MRI evidence of recurrence of the tumour. Total resection and radiosurgery was performed with a recurrence free period of 14 months.A gold standard for melanocytic schwannoma treatment is gross total surgical resection. Despite being considered benign tumours, MS have a local or metastatic recurrence of around 13%. MRI imaging in most of the cases is insufficient and only exhaustive pathological and immunohistological examination is the key to diagnosis. Need of postoperative radiation therapy is still controversial. For the first time, a criterion for postoperative adjuvant therapy was established.

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Case Report Wed, 30 Jun 2021 21:00:21 +0300
A rare case of primary adrenal lymphoma https://foliamedica.bg/article/55651/ Folia Medica 63(3): 443-447

DOI: 10.3897/folmed.63.e55651

Authors: Alexey V. Shabunin, Dmitry N. Grekov, Ivan N. Lebedinsky, Andrey I. Evsikov, Serghei Covantev, Varvara A. Afanaseva

Abstract: Adrenal gland incidentaloma (incidental – sudden, accidental) is a mass of the adrenal gland(s), accidentally detected by an instru-mental examination conducted for other reasons. The frequency of detection of this pathology based on computer tomography of the abdominal organs is 0.5%–2%. In most cases, the mass is represented by adrenocortical adenomas without hormonal secretion. It is an extremely rare case (less than 1% of all cases) when the adrenal incidentaloma is a primary adrenal lymphoma, which accounts for 1% of all non-Hodgkin lymphomas and 3% of all extranodal lymphomas with a few cases reported in the literature. In our article, we present a case of left adrenal incidentaloma of the adrenal gland, which, during further observation and examination, increased in size, which was the reason for performing laparoscopic adrenalectomy. According to the results of the histological examination, the mass turned out to be diffuse large B-cell lymphoma.

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Case Report Wed, 30 Jun 2021 21:00:20 +0300
Rupture of a mature cystic teratoma in a young girl caused by a car accident: an extremely rare case and review of the literature https://foliamedica.bg/article/55388/ Folia Medica 63(3): 438-442

DOI: 10.3897/folmed.63.e55388

Authors: Dimitrios Tsapralis, Anastasia Prodromidou, Georgios Vasiliadis, Chrysovalantis Vergadis, Nikolaos Machairas, Athanasios Syllaios, Evangelos Misiakos, Dimitrios Schizas

Abstract: Mature cystic teratomas (MCT) of the ovary or dermoid cysts are commonly encountered benign ovarian lesions accounting for approximately 70% of benign tumors and originating from germ cells. A rare case of peritonitis in a 17-year-old female patient caused by traumatic rupture of an MCT of the right ovary is herein presented. A meticulous search of the literature has also been performed. Due to deterioration of patient’s clinical condition, she was urgently led to surgery and intraoperative investigation of the peritoneal cavity revealed an inflamed ruptured ovarian cyst along with extensive peritoneal adhesions and purulent peritoneal fluid. A cyst resec-tion was performed with preservation of the ovary followed by adhesiolysis and meticulous abdominal washing and the patient had an uneventful recovery. Despite its rarity, traumatic rupture of ovarian cyst should be considered at evaluation of trauma patients with special attention to cases with a discovered or known presence of ovarian cyst.

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Case Report Wed, 30 Jun 2021 21:00:19 +0300