R. Van Hee

Laparoscopic Treatment of Boerhaave’s Syndrome: a Case Report and Review of the Literature

Abstract Spontaneous rupture of the oesophagus (Boerhaave’s syndrome) is a rare life-threatening disease requiring urgent surgical management. Symptoms can masquerade many other clinical disorders like acute myocardial infarction, dissecting aneurysm or upper gastro-intestinal tract diseases. Without prompt diagnosis and treatment, Boerhaave’s syndrome has a very high mortality rate. We report a case of perforation of the distal oesophagus. A 40-year-old male patient presented at the emergency department with a classic history of acute epigastric pain and dyspnoea after an episode of vomiting. On clinical examination we found a firm, tender abdomen and cervical subcutaneous emphysema. Boerhaave’s syndrome was suspected on a clinical basis and was confirmed by thoraco-abdominal CT scan, showing an apparent pneumomediastinum and fluid at both lung bases. The patient underwent surgical repair of the distal oesophageal tear by laparoscopy. A mediastinal drain was left behind and a feeding gastrostomy was established. After initial improvement, the patient developed fever and dyspnoea. A thoracic CT scan revealed left-sided empyema. A thoracoscopic drainage of pus was performed and antibacterial and antifungal treatment was adapted. The patient recovered well and was discharged from the hospital 34 days after admission.

Assault induced stab injuries: Epidemiology and actual treatment strategy

Abstract Objectives : To investigate and analyse epidemiology, demographics and patterns of presentation of assault induced stab injuries in a main Belgian trauma centre. To evaluate surgical management, complications and postoperative follow-up of the stab wound victims. Methods : One hundred and seventy assaulted patients, hospitalised because of stab injuries from January 2000 to June 2007 are studied retrospectively. Results : Ninety-five percent of the assaults occurred on men and the mean age of the patients was 31.1 ± 9.7 years. Ethnic minorities represent 77% of the patients hospitalised for assaults and 26.5% of all patients proved to be under toxic influence, predominantly from alcohol (21.8%). A decline of admissions of patients with stab injuries during the period 20022004 is recorded. However, the incidence doubled in the next two-year period. A weekend peak and circadian rhythm is apparent with more than 20% of the patients admitted between 4 and 6 am. The trunk is most frequently stabbed (54.5%) resulting in a laparotomy rate of 51%. One third of the patients who underwent thoraco-abdominal surgery revealed diaphragmatic injuries. Seventy-five percent of the patients left the hospital in a good condition while 2.4% had neuromuscular lesions. Two patients had serious vascular complications during follow-up. During the study period, no mortality was recorded. Conclusions : Stab wounds were recorded mainly in young and middle-aged men from ethnic minorities, whereas almost 27% were under the influence of drugs. A conservative approach was generally used resulting in a low laparotomy and thoracotomy rate without affecting mortality. Neuromuscular lesions are important long-term complications of stab injuries.

Pericardiotomy: the first cardiac operation.

Until Harris B. Shumacker in 1989 proposed that cardiac surgery also had to include pericardiac interventions, the German Ludwig Rehn (1849-1930) from Frankfurt had been recognised as the first cardiac surgeon after his successful suture of a laceration of the myocard (). Shumacker stated that the pericard is part of the heart, since the epicard proceeds as the serosal layer of the fibrous pericard. Moreover, the heart is attached to the base of the heart and to the great vessels. For these reasons, Shumacker suggested to recognize Francisco Romero and Dominique Larrey as the first cardiac surgeons (). At the time of his writing, Shumacker could however not yet ascertain that Romero performed the first intervention in 1801, 9 years before Baron Larrey did in 1810 (). The Philadelphian surgeon John Bingham Roberts (1852-1924) in the late 19 century had however already stressed the importance of Romero’s surgery (). In the 20 century this was reiterated by Kilpatrick & Chapman, and by Ruiz Caballero & Quijano Pitman ().

From ants to staples: history and ideas concerning suturing techniques.

think that most of our routinely practiced surgical techniques have been developed in the last 100 years. This idea stems from the knowledge that ether anaesthesia, introduced by the American dentist Morton in 1846, and antisepsis, promoted by Lister in 1860, only decades later allowed ‘greater’ surgical interventions (). However various aspects of surgery have a much longer history. Indeed, surgical practice has for centuries been focussed around three basic steps : dieresis (incision), exeresis (removal) and synthesis (suturing). In this text, the evolution of the last one, namely suturing and its various forms and materials, will be looked at more closely ().

Current status of proximal gastric vagotomy, one hundred years after Pavlov: is it finally history?

Abstract One hundred years ago, the role of the vagal nerve in gastric acid production was established. After the second World War, this paradigm served as the basis of treatment of peptic ulcer disease by pharmacological or surgical means. A remarkable parallelism between the developments of both approaches was observed in the 1970s. On the one hand, medication with less side effects became available. On the other hand, vagotomies were becoming more physiologic in nature and produced less postoperative symptoms. The elusive nature of peptic ulcer disease and the inability to cure this by medication were acknowledged. Very few investigators, however, had reported on a possible infectious origin of peptic ulcer disease and those reports were old. After 1984, the role of Helicobacter pylori in the disease was discovered. With this shift in paradigm, the treatment of peptic ulcer disease changed radically, despite attempts in the surgical community to develop simplified operations. This illustrates that neither the most powerful acid reducing drugs on their own, nor the most physiological and least invasive surgical techniques stand the test of time if the underlying paradigm changes. It also illustrates that old ideas should not be overlooked.

Andreas vesalius: his surgical activities and influence on modern surgery

Andreas Vesalius (1514–1564) is best known as ‘father of anatomy’ (Figure 1).[1–5] However, his legacy is not only restricted to anatomy but also includes pathology, physiology, and not the least surgery.[6,7] The surgical activities of the great Flemish anatomist Andries Wijtinck van Wesel or Vesalius have been two-fold:[8,9] first, his 6-year lasting professorship in surgery at the University of Padua between 1537 and 1543, of which possible course notes were published posthumously by Prospero Borgarucci;[10,11] and second, his experiences with victims on the battlefields and patients in his clinical practice. This second aspect of his surgery will here be highlighted.[12] As Vesalius worked at the courts of Emperor Charles V and King Philip II, his patients generally were of high rank and came from either his own country or from abroad. We can obtain information concerning Vesalius’ patients from various sources: in the first place from his own accounts and publications, not the least the Fabrica, where several interventions are mentioned in relation to anatomical observations. Second, from his several letters, as those on Bloodletting and on the Chyna root. Third, there are his Consilia and clinical advices for the treatment of his colleagues, friends, or high officials. On the contrary, also contemporary authors, not the least Dionosio Daza Chacon (ca. 1510–1596?),[13–15] have reported medical advices and operations, performed by Vesalius. And lastly there have been interventions noted by scholars some time or even late after Vesalius’ death. Already during his medical training in Paris and Padua was Vesalius convinced that a correct interpretation and evaluation of a medical diagnosis or surgical treatment could only be obtained by autopsy, once the patient would come to die from his disease. This was in line with the observations made by his predecessors Antonio Benevieni (1443–1502), Alessandro Benedetto (ca. 1445–1525), and Alessandro Achellini (1463–1512). Autopsy confirmation, therefore, was an essential element in Vesalius’ discussion of medical and surgical cases. This was already so in the summer of 1536 when Vesalius had to interrupt his medical studies in Paris and had to come home to Brussels.[16] There the doctors of the duke of Egmond asked him to investigate the cause of death of a young lady of nobility, whose death was obscure, and had been attributed to either poisoning or uterine strangulation. In his letter on the Chyna Root of 1546 (Figure 2), Vesalius described that she did not die from uterine strangulation, but instead probably died from a thoracic compression syndrome, that had produced the so-called ‘constriction of the thoracic organs’, which according to Vesalius had been induced by a too tightened metal corsage. Moreover did Vesalius observe a tear in one of her adrenals.[17] One of the main issues in surgery at the time was bloodletting. Vesalius took the stand of the old Masters, who recommended derivation, in other words bloodletting at the same side of the disease, just as had done the Parisian doctor Pierre Brissot (1478–1522). This led already in Louvain to discussions with his professor of medicine Jerome Thriverius (1504–1554).[18] It is his surgical interest in the location of bloodletting that induced Vesalius to study the venous blood circulation. This is made clear in his Venesection Letter,[19] sent during his stay in Bologna to his previous mentor Nicolas Herco de Florennes.[20] His research on the thoracic venous blood vessels led him to stress the importance of the right sided azygos vein as the reason why bloodletting should be performed at the right arm,

Acute Colonic Pseudo-Obstruction in Vascular Patients (Ogilvie syndrome)

Abstract Two patients with acute colonic pseudo-obstruction are presented. Acute colonic pseudo-obstruction, first described by Ogilvie in 1948, is characterised by signs of colonic obstruction, but without mechanical obstruction to the intestinal flow. The current hypothesis states that it is caused by an imbalance between sacral parasympathetic excitatory nerves and sympathetic inhibitory nerves, thus inducing functional obstruction. It mostly develops in hospitalised patients with a variety of medical and surgical conditions. Two such patients with extensive co-morbidities, developed progressive colon dilatation with signs of acute peritonitis, and were operated on urgently. In both patients, right hemicolectomy and postoperative medical treatment resulted in complete recovery.

The prognosis of patients operated on for gastric cancer in relation to the percentage of lymph nodes invaded by tumour.

Abstract Introduction : In evaluating the type of gastrectomy and lymphadenectomy for gastric cancer, adequate prognosis has been dependant on the retrieval of at least 15 lymph nodes. We propose an alternative method in which the prognostic value is evaluated, according to whether or not more than 20% of the retrieved lymph nodes are invaded by tumour. Materials & Methods : Sixty-five patients (36 men, 29 women) with a median age of 69 years (mean age 68.9 ± 12.1 years) were evaluated, who were operated upon between 1985 and 1999 for gastric cancer by gastrectomy with either D1 or D2 lymphadenectomy. Results : The average number of retrieved lymph nodes was 10.4 ± 8.6. In 51 patients (78.5%) less than 15 and in 14 patients (21.5%) 15 or more lymph nodes were retrieved, according to the TNM guidelines. In our study, there is a statistically significant difference in prognosis between patients with less than 20% and those with more than 20% of the retrieved lymph nodes invaded by tumour, irrespective of the total number of lymph nodes resected. Conclusion : Gastric cancer patients in whom less than 20% of the retrieved lymph nodes are invaded, have a significantly better prognosis compared with patients in whom 20% or more of the lymph nodes retrieved are invaded by tumour, irrespective of the total number of retrieved lymph nodes.

Re-operation for recurrent lymph node metastasis of medullary thyroid cancer--is it useful?

Abstract Recurrent disease in medullary thyroid cancer (MTC) occurs frequently. Repeated measurements of calcitonin levels as well as imaging techniques may help detect such recurrence or metastatic disease. Re-operative tumour excision may be a good therapeutic option to treat patients with recurrence and is believed to substantially lengthen life expectancy. However, it only leads to cure in 50% of patients. Two repeatedly operated patients with recurrent MTC are presented and the literature is discussed.

Surgery during world war I : a great breakthrough of techniques.

Surgery experienced an enormous breakthrough during the four years of World War I. This proved to be the case in practically all fields of so-called general surgery. We will restrict ourselves in this article to the surgery of the soft tissues. Of course new developments did not just start in 1914, nor were the breakthroughs only devoted to surgical techniques (1). Surgery greatly benefited from different new discoveries in other technical fields. So did the introduction of the light bulb and thus of electricity in 1879 by Thomas Edison (1847-1931) revolutionize the method and use of cauterisation during surgical operations (2). Equally did the introduction of X-ray technology in 1895 by Wilhelm Conrad Röntgen (1845-1923) (3) add enormous possibilities not only to fracture treatment but equally to the treatment of lung and other soft tissue pathologies. So did also the introduction of the first useful apparatus for blood pressure measurement in 1896 by Scipione Riva-Rocci (1863-1937) make the evaluation of the medical condition of sick but especially of traumatized patients enormously more adequate. Equally did the introduction in 1903 of the electrocardiograph by Willem Einthoven (1860-1927) allow cardiac monitoring during surgical procedures (4). It induced many researchers to investigate the clinical condition of patients with serious haemorrhage, with burns or with extensive loss of fluids. It was particularly the American scientist George Crile (1864-1943) (5) who in 1912 discovered the principles of shock and its relation to blood pressure (6). Crile, who later during WW I worked in one of the French military hospitals (Fig. 1), pointed out that two causes of shock were possible : either the real volume of blood could become insufficient as a result of haemorrhage, or the content of the cardiovascular bed could change as a result of dilatation of the vessels and consequently induce a relative blood deficiency. Crile suggested that this process of vasodilatation was based on a nervous reflex mechanism, which was operated by a vasomotor centre in the brain (7). Both types of shock however induced the same low blood pressure, that had now become measurable. Acta Chir Belg, 2014, 114, 292-298