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Treatment of necrotic pancreatitis patients is still disputable, posing serious problems and a real challenge to surgeons. The surgeon's approach to the problem ranges from strictly conservative to extremely aggressive. In this paper are discussed the indications, timing and operative technique used in the treatment of necrotic pancreatitis (NP), with special attention focused on the method suggested by the authors--necrotomy and closed continuous lavage of the retroperitoneum. An algorithm of the therapeutic approach to patients presenting acute pancreatitis is likewise presented. All patients with necrotic pancreatitis are routinely referred for treatment in the intensive care unit (ICU), and mandatorily subjected to antibiotherapy. Only one-third of the cases developing infected pancreatic necrosis (IPN) within 3 weeks of admission undergo operation. Lethality among those operated on is reduced to 13 per cent, and among NP patients--4 per cent. The new concept for therapeutic approach to necrotic pancreatitis patients according to which only cases presenting evidence of infected pancreatic necrosis are liable to surgery, whereas those with SPN should be treated conservatively, is strongly supported.

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In ten healthy volunteers and ten patients with diseases involving the upper section of the gastrointestinal tract (chronic cholecystitis, chronic gastritis) the electrical activity of the colon is registered noninvasively using skin electrodes to the projection site of sigmoid and colon descendens. Recordings are taken with original gastrograph. Apart from the electrocolograms (EColG), the changes in intracolonic pressure in the group of 10 patients are also registered. Pressure recordings (mechanogram--MG) are done in physioscript "Hellige". Two types of EColG waves are identified depending on their frequency: 1) type A waves with frequency 5.86 +/- 0.59 cpm, and 2) type B waves with frequency 2.35 +/- 0.25 cpm. Type A are low-amplitude waves and correspond to the type A waves seen in the EColG of dogs (described by the authors elsewhere), characterizing the calm period of colonic motility. When A waves appear in the EColG no changes in the mechanograms are registered. Type B are high-amplitude waves, corresponding to the B waves in dogs (described elsewhere); as shown by the mechanograms, the appearance of B waves in the EColG is followed by the appearance of high-amplitude waves--the active period of colonic motility. There is a significant difference between the frequencies of either type of EColG waves and the frequency of waves in the electrogastrograms (EGG) registered synchronously with EColG.

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The authors retrospectively analyzed 523 patients with large bowel obstruction (LBO): 126 (24.09%) right-sided (RSLBO) and 397 (75.91%) left-sided (LSLBO), treated at the Emergency Medicine Institute "N. I. Pirogov" in Sofia. For the period 1988-1997, a trend toward more radical and aggressive surgery is shown: compared to a previous period (1964-1983) the one-time operations (partial, subtotal and total colectomy with primary anastomoses) are becoming standard operations in RSLBO as well as in LSLBO. A classification based on objective clinical, X-ray and intraoperative findings is considered in the diagnostic and therapeutic algorithm of the LSLBO.

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Thoracic and associated injuries pose problems demanding enormous interdisciplinary efforts regardless of the improved organizational, diagnostic and treatment potentialities. As shown by the experience of the Emergency Surgery Section at the Pirogov Institute, rendering medical services to patients presenting chest and associated injuries require coordinated integration of specialists from various profiles along with specification of the priorities and hierarchy of the emergency measures undertaken. Over a 12-year period (1985 through 1996), a total of 6983 patients with chest, abdominal and multiple trauma are admitted. They are distributed as follows: chest trauma casualties--3286, abdominal trauma--679, and multiply injured--3018. Chest injuries are divided in close and open injuries--2843 and 444, respectively; the latter include 29 gunshot and 415 penetrating-incise wounds. The abdominal trauma group includes 679 cases, distributed as follows: spleen rupture--341, disruption of liver and mesenterium--151, and lesion to a hollow abdominal organ--187.

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A contingent of patients presenting closed chest injuries, sustained over a 12-year period (1985-1996), are analyzed. Of the total of 6938 traumas, chest injuries amount to 3286 (47.06 per cent) of which 2842 (40.7 per cent)-closed. Of the latter 2248 (79.09 per cent) are located in the left thoracic half, 420 (14.77 per cent)-in the right thoracic half, and in 174 (6.12 per cent) it is a matter of bilateral involvement. At the point of heaviest impact, involving 5th to 9th rib segment, left side injury is recorded in 2034 cases (71.56 per cent), right side--408 (14.35 per cent), and bilateral--in 155 (5.45 per cent). There are 28 fractures of the sternum (0.85 per cent). Of the latter 14 are located in the manubrium sterni region, twelve--in the middle portion, and two in the distal part of the sternum. Over the last 5 years (1991 through 1995), of 63 casualties with flail chest 16 are with indications for stabilization osteosynthesis, and accordingly subjected to operation. A Schimelmann plate is used in 13 cases, artificial rib type "Ampar"--in three, and sternal stabilization--in one.

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In closed thoracoabdominal trauma the diagnosis rupture of the diaphragm is usually made in 5 per cent of the casualties. Over a 12-year period (1985 through 1996), in the Pirogov Institute are admitted 3018 cases presenting polytrauma. Among the contingent of closed thoracoabdominal trauma lesions to the diaphragm are registered in 151 cases, and among those with open injuries--in 21 cases. There are 71 closed injuries in PTP, and 80 closed thoracoabdominal injuries caused by high falls. Open injuries associated with lesion to the diaphragm are due to gunshot wounds in two cases, and inflicted by knife and other pointed objects in nineteen. In closed trauma there is 2:1 male-to-female ratio, and in open injuries--5:1.

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In vitro experiments were performed on smooth-muscle strips cut out in longitudinal and circular direction from the colon of Hirschsprung's patients who underwent an operation and from patients operated on for tumors of the sigmoid colon and rectum, serving as controls. The changes in the contractile activity of the smooth-muscle strips after carbachol applied cumulatively were examined and dose-response curves were plotted. The EC50 values for the circular strips from the aganglionic part of the colon were 6 x 10(-7) M in Hirschsprung's patients and 3.7 x 10(-8) M in control patients: the pD2 values were 6.23 and 7.43, respectively. This showed that the affinity of cholinoreceptors in the aganglionic part of the colon for carbachol was 16 times lower in Hirschsprung's patients as compared to control patients. The EC50 values for longitudinal strips from the ganglionic part of the colon were 2.6 x 10(-7) M in Hirschsprung's patients and 4 x 10(-8) M in control patients; pD2 values were 6.6 and 7.4, respectively. The affinity of cholinoreceptors in the smooth muscle of the ganglionic part of the colon for carbachol was also decreased (nearly 6.5 times) in Hirschsprung's patients as compared to controls.

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