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The cyst of the Canal of Nuck, or hydrocele, is a rare pathological condition in the female inguinal region. We present a 44-year-old female with a cystic lesion in the right inguinal area, detailing clinical symptoms, differential diagnosis and imaging findings. Surgical intervention involved complete cyst excision, with no recurrence during the follow-up. This case underscores the importance of accurate diagnosis and targeted surgical treatment for favourable outcomes in managing rare anatomical variations like the Canal of Nuck cyst.

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Introduction Multivisceral resections (MVRs) in gastric cancer are potentially curable in selected patients in whom clear resection margins are possible. However, there are still uncertain data on their feasibility and safety considering short- and long-term results. The study compares survival, morbidity, mortality, and other secondary outcomes between standard and MVRs for gastric cancer. Materials and Methods A monocentric retrospective study in patients with gastric adenocarcinoma, covering 2004 to 2020. Of the 336 operable cases, 101 patients underwent MVRs. The remaining 235 underwent standard gastric resections (SGRs), of which 173 patients were in stage T3/T4. To compare survival, a control group of 101 patients with palliative procedures was used-bypass anastomosis or exploration. Results MVR had a lower survival rate than the SGR but significantly higher than the palliative procedures. The predominant gender in MVR was male (72.3%), with a mean age of 61 years. The perioperative mortality was 3.96% ( n = 4), and the overall median survival was 28.1 months. The most frequently resected organs were the spleen (67.3%), followed by the pancreas (32.7%) and the liver (20.8%). In 56.4% of the cases two organs were resected, in 28.7% three organs, and in 13.9% four organs. The main complication was bleeding (9.9%). The major postoperative complications in the MVR were 14.85%, and in the SGR 6.4% ( p < 0.05). Better long-term results were observed in patients who underwent R0 resections compared with R1. Conclusion Multiorgan resections are characterized by poorer survival and a higher complication rate than gastrectomies. On the other hand, they have better long-term outcomes than palliative procedures. However, MVRs are admissible when performed by an experienced surgical team in high-volume centers.

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Background: We present a comparative analysis of survival, complications and major risk factors in patients who underwent surgery for pancreatic head carcinoma. Methods: This is a single-centre retrospective study aimed to evaluate clinical, surgical and pathoanatomical features of 467 patients who underwent radical surgery for pancreatic head carcinoma between September 2004 and October 2019. The series includes 88 patients (18.8%) with venous resections for borderline resectable pancreatic adenocarcinoma. Results: The estimated median survival rates were statistically significant with 19.3 months in pancreatoduodenal venous resections (VR) and 26.9 months in pancreatoduodenal resections (PDR), respectively (p=0.047). On the other hand, one, three, and five-year survival rates of 46.6%, 17.6% and 8.3% in VR, and 53.6%, 20.8%, 14.9% in PDR were not statistically significant (p=0.13, 0.5 and 0.11 respectively). Survival rates comparison in PDR, VR, and palliative procedures (PP) between the three groups showed statistical significance (p 0.05). The clinically relevant postoperative complications in venous resections (13.6%) vs. 14.8% in PDR were not statistically significant (p=0.77). Postoperative bleeding and reoperation (p 0.05) are independent prognostic factors for worse outcomes. There was no statistically significant relationship between survival and presence of vascular invasion (p=0.581). Conclusions: When performed by experienced surgeons at specialized high-volume centres, pancreatoduodenal resections combined with venous resection and reconstruction are reliable and safe surgical procedures.

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Introduction: There are still debatable facts about estimating the risk and severity of coronavirus disease (COVID-19) in liver transplant recipients, as well as assessing the impact of the immunosuppressive therapy on the clinical course and incidence of liver failure. Material and Methods: We present a prospective study of liver transplant recipients with severe acute respiratory syndrome coronavirus (SARS-CoV-2) infection admitted for treatment to the department of First Clinic of Abdominal Surgery, Military Medical Academy, Sofia during 25.11.2020 04.01.2021. The diagnosis is confirmed by a positive reverse transcription polymerase chain reaction (RT-PCR) test for SARS-CoV-2 infection from a naso-pharyngeal swab. COVID-19 severity is estimated as mild (oxygen saturation (SpO2) 94% on room air and no imaging findings of pneumonia), moderate (SpO2 94%, imaging suggestive of pneumonia), and severe (need for high flow oxygen supplementation). Results: Three liver transplant recipients with COVID-19 were admitted and treated in our department during 25.11.2020 04.01.2021. All of them were male, mean age of 51.33 years (47 - 59) and their liver transplantations were performed 13, 5, and 1.5 years before. In each of the three patients a different clinical form of the disease was registered mild (n=1), moderate (n=1), and severe (n=1). Only the patient with severe disease had comorbidities - hypertension, diabetes, and obesity. The patients with mild and moderate disease received dual immunosuppressive therapy with tacrolimus and mycophenolate mofetil while the one with severe disease - tacrolimus only. A dose reduction of tacrolimus was undertaken following serum level evaluation without changing the dose of the mycophenolate mofetil for those on dual therapy. The patient with severe disease died from respiratory failure leading to a case fatality rate of 33.3%. Conclusion: Early diagnosis and hospitalization where possible are essential for the prompt initiation of treatment, prevention of complications and development of severe forms of COVID-19 in liver transplant recipients, especially in patients with comorbidities such as hypertension, diabetes, and obesity. During the course of treatment there may be a dose reduction of the immunosuppressive therapy but not discontinuation, especially of the calcineurin inhibitor in mono- or dual-therapy regimens.

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BACKGROUND: Tumours involving the supra-renal segment of IVC have dismal prognosis if left untreated. Currently, aggressive surgical management is the only potentially curative treatment but is associated with relatively high morbidity and mortality. This study aims to evaluate perioperative factors, associated with adverse postoperative outcomes, based on the perioperative characteristics and type of IVC reconstruction. METHODS: We identified 44 consecutive patients, who underwent supra-renal IVC resection with a mean age of 57.3 years. Isolated resection of IVC was performed in four patients, concomitant liver resection was performed in 27 patients and other associated resection in 13 patients. Total vascular exclusion was applied in 21 patients, isolated IVC occlusion in 11 patients. Neither venovenous bypass (VVB) nor hypothermic perfusion was used in any of the cases. RESULTS: The mean operative time was 205 min (150-324 min) and the mean estimated blood loss was 755 ml (230-4500 ml). Overall morbidity was 59% and major complications (Dindo-Clavien ≥ III) occurred in 11 patients (25%). The 90-day mortality was 11% (5pts). Intraoperative haemotransfusion was significantly associated with postoperative general complications (p < 0,001). With a mean follow-up of 26.2 months, the actuarial 1-, 3- and 5-year survival is 69%, 34%, and 16%, respectively. CONCLUSIONS: IVC resection and reconstruction in the aspect of aggressive surgical management of malignant disease confers a survival advantage in patients, often considered unresectable. When performed in experienced centres it is associated with acceptable morbidity and mortality.

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BACKGROUNDS/AIMS: Synchronous liver metastases (SLMs) are found in 15-25% of patients at the time of diagnosis with colorectal cancer, which is limited to the liver in 30% of patients. Surgical resection is the most effective and potentially curative therapy for metastatic colorectal carcinoma (CRC) of the liver. The comparison of simultaneous resection of primary CRC and synchronous liver metastases with staged resections is the subject of debate with respect to morbidity. Laparoscopic surgery improves postoperative recovery, diminishes postoperative pain, reduces wound infections, shortens hospitalization, and yields superior cosmetic results, without compromising the oncological outcome. The aim of this study is therefore to evaluate our initial experience with simultaneous laparoscopic resection of primary CRC and SLM. METHODS: Currently, laparoscopic resection of primary CRC is performed in more than 53% of all patients in our surgical department. Twenty-six patients with primary CRC and a clinical diagnosis of SLM underwent combined laparoscopic colorectal and liver surgery. Six of them underwent laparoscopic colorectal resection combined with major laparoscopic liver resection. RESULTS: The surgical approaches were total laparoscopic (25 patients) or hybrid technique (1 patients). The incision created for the extraction of the specimen varied between 5 and 8cm. The median operation time was 223 minutes (100 to 415 min.) with a total blood loss of 180 ml (100-300 ml). Postoperative hospital stay was 6.8 days (6-14 days). Postoperative complications were observed in 6 patients (22.2%). CONCLUSIONS: Simultaneous laparoscopic colorectal and liver resection appears to be safe, feasible, and with satisfying short-term results in selected patients with CRC and SLM.

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AIM: To evaluate the results of an aggressive surgical approach of resection and reconstruction of the inferior vena cava (IVC). METHODS: The approach to caval resection depends on the extent and location of tumor involvement. The supra- and infra-hepatic portion of the IVC was dissected and taped. Left and right renal veins were also taped to control the bleeding. In 12 of the cases with partial tangential resection of the IVC, the flow was reduced to less than 40% so that the vein was primarily closed with a running suture. In 3 of the cases, the lumen of the vein was significantly reduced, requiring the use of a polytetrafluoroethylene (PTFE) patch. In 2 of the cases with segmental resection of the IVC, a PTFE prosthesis was used and in 1 case, the IVC was resected without reconstruction due to shunting the blood through the azygos and hemiazygos veins. RESULTS: The mean operation time was 266 min (230-310 min) with an average intraoperative blood loss of 300 mL (200-2000 mL). The patients stayed in intensive care unit for 1.8 d (1-3 d). Mean hospital stay was 9 d (7-15 d). Twelve patients (66.7%) had no complications and 6 patients (33.3%) had the following complications: acute bleeding in 2 patients; bile leak in 2 patients; intra abdominal abscess in 1 patient; pulmonary embolism in 2 patients; and partial thrombosis of the patch in 1 patient. General complications such as pneumonia, pleural effusion and cardiac arrest were observed in the same group of patients. In all but 1 case, the complications were transient and successfully controlled. The mortality rate was 11.1% (n = 2). One patient died due to cardiac arrest and pulmonary embolism in the operation room and the second one died 2 d after surgery due to coagulopathy. With a median follow-up of 24 mo, 5 (27.8%) patients died of tumor recurrence and 11 (61.1%) are still alive, but three of them have a recurrence on computed tomography. CONCLUSION: There are a variety of options for reconstruction after resection of the IVC that offers a higher resectable rate and better prognosis in selected cases.

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BACKGROUND/AIMS: The purpose of this study was to analyze the influence of aggressive surgery regarding resection of liver metastases (LM) from colorectal cancer (CRC) on morbidity, mortality and survival rates and to establish utility of multimodal strategies increasing resectability rates of liver metastases. METHODOLOGY: Two hundred twenty eight consecutive patients with CRC LMs operated from January 2004 to October 2009 were presented. They underwent 137 curative liver resections. We have used extended criteria for respectability including the possibility to spare 2 adjacent liver segments. Multimodal approaches meaning transformation of primary unresectable LMs to resectable ones were used in 46 cases. During the final decision intraoperative ultrasonography took an important part. RESULTS: The resectability in presented series was 46% for synchronous LM and 76% for metachronous. Aggressive surgical approach was applied in 75 patients. The average rate of intraoperative hemorrhage was 300mL. Postoperative complications occurred in 25.5% of patients. Two patients died postoperatively. CONCLUSIONS: Rational surgical behavior in context of multimodal approach to LMs of CRC can increase chances of resectability and long-term survival without influencing morbidity and mortality.

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BACKGROUND/AIMS: The incidence of pancreatic cancer is rising in all developed countries. The aim of this study is to define the surgical options in the treatment protocols for this disease and to evaluate the effect of radical resections. METHODOLOGY: One hundred ninety six consecutive patients with pancreatic cancer, operated in our department in a 4-year period, were evaluated. Among them, 106 were radically operated and the rest underwent palliative procedures. RESULTS: Twenty-eight of the presented patients underwent pancreatic resection with simultaneous vessle resection, venous in 26 cases and arterial in 2 cases. Seventeen extended resections were made. The rate of postoperative morbidity of the radically operated was 36.8% (39 patients). Early bleeding (10 cases) and pancreatic fistula (10 cases) were the most common major complications. The 3-year survival rate of the radically operated patients was 21.5% vs. 0% in these with palliative procedures. The data analysis revealed no statistically significant difference in the survival of patients with modifications of pancreaticoduodenectomy, Whipple and PPPD (p=0.065). CONCLUSIONS: The radical surgery ensures better long-term results. We recommend this type of surgery to be concentrated in highly specialized centers in order to improve the outcome.

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In the past decades considerable improvements in diagnostic imaging procedures, surgical technique and perioperative intensive care treatment have lead to a significant decrease in perioperative mortality and morbidity after pancreatic resection. This lead to an expansion of the indications for pancreatoduodenectomy. Little data exist in the literature on emergency pancreatoduodenectomy in non-trauma patients. We present a 43-year-old woman with extensive bleeding from papilla of Vater after endoscopic retrograde cholangiopancreatography (ERCP) with papillosphincterotomy. During the surgical exploration a tumor mass on the head of the pancreas was observed and a pancreatoduodenectomy was performed. On day 7 after the operation pancreatic leakage was observed and conservative therapy was administrated. Two weeks later the patient was released from the hospital in good health. Emergency pancreatoduodenectomy may be considered in institutions with extensive experience in these procedures, where cooperation of the invasive gastroenterologists and the abdominal surgeons, long experience of the surgeon and intensive reanimation care are present.

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