Alain Rosière

Management of oesophageal perforation after delayed diagnosis: the merit of tissue flap reinforcement.

Abstract Oesophageal perforation remains a life-threatening situation and its management represents a challenge for the surgeon, especially if diagnosis has been delayed. In most cases, a surgical approach is indicated. Simple primary repair often result in leakage. In order to avoid leakage, the primary repair should be buttressed with some kind of tissue flap. We here report our experience with 15 esophageal perforations and 10 tissue flap reinforcements performed during the last decade. The different types of tissue flap are illustrated and their results are compared with more aggressive alternatives such as oesophagectomy, T-tube drainage and oesophageal exclusion.

From laparoscopic training on an animal model to retroperitoneoscopic or coelioscopic adrenal and renal surgery in human

So far, laparoscopic approaches to kidney and adrenal have been limited because of their retroperitoneal location. We here report eight renal and adrenal endoscopic procedures performed in seven patients: two adrenalectomies for hyperaldosteronism, one adrenalectomy for isolated metastasis from an adenocarcinoma of the lung; two nephrectomies for end-stage infected hydronephrosis, two partial nephrectomies for small circumscribed lesions of the kidney, and one endoscopic resection for pain relief of a voluminous cyst at the kidney. The approach was transperitoneal in two cases and retroperitoneal in five cases using the retropneumoperitoneum insufflation technique. One patient was operated by a combined approach using the retro- and transperitoneal routes. All procedures were successfully completed endoscopically. The retroperitoneoscopic approach of the kidney is safe and does not interfere with the peritoneal organs. Its working space is tenuous, but allows a direct access on the kidney with good exposure of its pedicle. For adrenal surgery, the retroperitoneoscopic dissection is more difficult, because movements of instruments are often impaired by the closeness of the costal margin and the iliac crest. However, in case of difficulties we found it very convenient to switch from a retroperitoneal endoscopic approach to a combined coelioscopic and retroperitoneoscopic operation. Far from excluding each other, both approaches are complementary, particularly for difficult situations (i.e., previous peritoneal or retroperitoneal surgery).

Occurrence of thyroid papillary carcinoma in young patients. A Chernobyl connection

The risk of thyroid papillary carcinoma is increased by external radiation particularly in children under 15 years of age as shown by a marked increase in those exposed to radiation after Chernobyl. We were recently confronted in Belgium over a short period with four patients (3 F, 1 M) with papillary thyroid carcinoma who were aged 10 years, 2 months, 2 years and 6 years when the Chernobyl accident occurred. We thus raise the question of a possible relationship. The patients were aged 17, 11, 10, 19 years at presentation. They all presented fortuitously over 3 years which was a very unusual increase in our extensive experience in thyroid surgery (62 cases of thyroid cancer among 1014 thyroidectomies in adults vs 4 cases in 18 children since the Chernobyl accident in 1986). Two out of the four patients had psammoma bodies (identifiable on CT scanning and ultrasound) and thyroglobulin autoantibodies (TgAb). The first patient had positive lymph nodes at the time of surgery. The incidence of thyroid cancers in Belarus and Ukraine rose just 4 years after the Chernobyl disaster; because radioactive clouds passed over Belgium, we wonder whether the occurrence of thyroid cancer in our patients could be related to this irradiation. The mechanism of increased incidence of radiation-induced thyroid cancer is thought to be due to rearrangement of the tyrosine kinase domains of the RET and TTK genes. The other important similarities in our patients are the presence of psammoma bodies that can be visualized on radiological examination and the presence of TgAb that are more frequent in differentiated thyroid cancers. Whether or not these cases reflect an increased incidence in the population as a whole, clinicians must remain vigilant for this rare but curable cancer in young patients, especially if suggestive radiological features or TgAb are present.

The rationale for performing MR imaging before surgery for primary hyperparathyroidism

Abstract Objective : The purpose of this study was to evaluate prospectively Magnetic Resonance Imaging (MRI) for the preoperative localization of hyperfunctioning parathyroid glands. Design : Prospective study of 58 consecutive patients with biochemically confirmed primary hyperparathyroidism who underwent preoperative MRI. Setting : The setting is a referral centre. Patients : Fifty-six of the 58 consecutive patients (41 women, 17men) were studied by both preoperative MRI and 99mTC MIBI scintigraphy, and two by MRI alone. The same surgeon, using the information from both MRI and 99mTC MIBI, performed surgery in 58 patients, including 19 with a history of neck surgery. Initial interpretation of each MR study was done independently by one radiologist and the surgeon and then results were compared. At surgery, the operative duration, the precise anatomical location, weight, and dimensions as well as complete histopathological evaluations of all excised glands were recorded. Main outcome measure : In addition to the prospective assessment of MRI, this study compared performance of MRI with double-phase 99mTC MIBI scintigraphy for preoperative localization of hyperfunctioning parathyroid glands. Results : All patients became normocalcaemic after surgery. MRI and 99mTC MIBI imaging revealed 53 of 58 (91%) and 47 of 56 (84%) of abnormal glands, respectively. Sensitivities of MRI and 99mTC MIBI were respectively 94.3 and 88.0. Positive predictive values were 96.15 and 93.60. When MRI and 99mTC MIBI were interpreted together, the sensitivity and positive predictive values both raised to 98.10. Median operative duration was 30 minutes (ranges 20–300 minutes, mean 65). Conclusion : MRI has better sensitivity and positive predictive value than 99mTC MIBI scintigraphy for the detection of hyperfunctioning parathyroid glands. The combination of the two studies provides an additional increase in sensitivity and positive predictive value leading to a more precise anatomical localization of the abnormal parathyroid glands reducing both the extent of the surgical dissection and the operative duration.

Intraoperative gamma probe detection of insulinoma in an elderly patient with pancreatic cystic lesions.

Insulinoma is a rare endocrine tumour in the elderly. We report the case of an 81‐year‐old woman suffering from grand mal seizures. Insulinoma was suspected because plasma glucose and insulin levels were 1·5 mmol/l and 80·4 pmol/l, respectively. A pancreatic computerized tomography (CT) scan, magnetic resonance imaging (MRI) and arteriography were normal but 111In‐DTPA‐octreotide scintigraphy detected a hotspot in the pancreatic tail. Intraoperative pancreatic ultrasonography and palpation were non‐contributory due to multiple pancreatic cysts and nodular lesions. However, a gamma‐detecting probe localized a small tumour, labelled preoperatively with 111In‐DTPA‐octreotide. Intraoperative insulin measurements in portal venous blood confirmed the successful removal of an insulinoma that was 6 mm in diameter histologically. Pancreatic cystic lesions increase with age and make the intraoperative localization of the insulinoma difficult. Intraoperative gamma probe detection of the tumour labelled with 111In‐DTPA‐octreotide might therefore constitute a useful surgical tool.

Spiral computed tomography with three-dimensional reconstructions for severe blunt abdominal traumas: a useful complementary tool?

Spiral computed tomography (CT) has proved to be a valuable tool by providing three-dimensional (3D) images of the studied structures. We hypothesized that a more realistic depiction of lesions by 3D CT could be of interest for surgeons who are treating blunt abdominal traumas and lead to less inappropriate triage. A good working relationship between surgeons and radiologists allowed us to perform a 3D CT examination in six patients. In the first patient, the 3D CT accurately demonstrated spleen fragmentation without devascularized fragment. The second patient had complete devascularization of the spleen upper pole. Conservative treatment was pursued for both patients. For the third patient, 3D CT helped us to differentiate peritoneal-perisplenic fluid from subcapsular fluid. The fourth patient had minor spleen injury associated with severe lacerations of the left kidney. 3D CT showed a complete separation of the kidney lower pole. A delayed partial lower nephrectomy was performed. The fifth patient presented a fragmented spleen and transient massive haematuria related to a well-contained laceration of the kidney upper pole that were amenable to nonoperative management. The sixth patient was emergency operated for active bleeding from a fragmented spleen. 3D CT performed 2 months after spleen repair allowed the assessment of the amount of devascularized tissue, as well as the status of the upper abdomen arteries. For haemodynamically stable patients, 3D CT could be a helpful addition to conventional axial CT for quantifying blunt abdominal traumas, for making the choice between nonoperative and operative treatment, but also between emergency and delayed surgical strategy.

Post-Chernobyl incidence of papillary thyroid cancer among Belgian children less than 15 years of age in April 1986: a 30-year surgical experience

Abstract Objective: We raised the question of a possible relationship in Belgium between the occurrence of papillary thyroid carcinoma (PTC) and age of children (<15 years) at the time of the Chernobyl nuclear plant accident in April 1986. Setting: Referral university centre for endocrine surgery. Material and methods: Thirty-year prospective study of the experience of a surgical team with PTC since the Chernobyl accident, taken out of 2349 patients operated on for any thyroid lesions from April 1986 to April 2015, comparing the incidence of PTC by age groups. Main outcome measurement: Comparison of PTC incidence in patients >15 years (group A) and children <15 years (group B) in April 1986. Results: Out of a total of 2349 patients having undergone thyroid surgery for all types of lesions during 30 year after Chernobyl and born before April 1986, 2164 were >15 years of age at the time of the nuclear accident (group A) and 175 developed PTC (8.1%) compared to 36 PTC (19.5%) that occurred in 185 children <15 years of age (group B) in April 1986 (p < 0.001). Conclusions: Radiation exposure affected residents of countries (including Belgium) well beyond Ukraine and Belarus. This was demonstrated by a 1990 meteorological report. Over 30 years, there has been a persistent higher incidence of PTC among Belgian children below the age of 15 years at the time of the Chernobyl accident. This relationship with age has even been strengthened by the implementation of more sophisticated immunohistochemical biomarkers diagnostic technology since April 2011.

Localisation cæcale d’un sarcome myéloïde a-leucémique : un diagnostic difficile

Myeloid sarcoma is a malignant neoplasia composed of abnormal myeloid or monocytic cells, often localized in bones, but also rarely in extra-medullary sites such as lymph nodes, skin and soft tissue. We report a case of caecal myeloid sarcoma, diagnosed in a 60 year old woman who complained from abdominal pain and weight loss, in absence of any medullary disorder. Initially misdiagnosed as a B lymphoma because of a weak positivity for CD79a, the diagnosis of primitive caecal myeloid sarcoma was eventually established after further investigations showing a positivity for lysozyme and myeloperoxidase. This report of such a rare clinical and pathological presentation of a myeloid sarcoma underlines a difficult differential diagnosis for which adequate immunohistochemistry, including lysozyme and myeloperoxydase is mandatory.

Making Surgical Care Safer: A Survey on the Implementation of the Checklist by Belgian Surgeons.

Abstract Background : The operating theatre (OT) is a complex environment. The purpose of this survey was to evaluate the implementation of the surgical checklist (SC) at individual level by Belgian Surgeons. Methods : A Surgical Checklist Questionnaire (SCQ) related to the use of the SC by individual surgeons was attached to the registration website for the 2015 Belgian Surgical Week. It was a one page long, user friendly document, easy to be filled voluntarily and anonymously. Results : Among the 206 surgeons who registered, 81 (39%) filled in the SCQ. The SC template proposed by the WHO “Safe Surgery Saves Lives” initiative was used by 91% of the respondents. However, 89% adapted the SC to their local hospital environment, and 87.5% use it personally for their patients. Since implementation, the SC was never adapted in 46%. According to 21% of respondents, an adverse event was avoided thanks to the SC. Amazingly, SC was considered as an administrative burden by 83% despite the same percentage recognized that patients benefited from the SC. Only 28% of respondents got feedback from the use of the SC. Conclusions : In this survey, the number of adverse event avoided thanks to the use of the SC demonstrates that SC represents a simple strategy for addressing surgical patient safety in OT. Nevertheless, SC is still considered by many surgeons as an additional administrative burden and/or as just another gimmick. Further studies are needed to understand why some surgeons are still not willing to adapt to a changing safety culture.