Intragastric erosion of laparoscopic adjustable silicone gastric band.

Intragastric erosion of the adjustable silicone gastric band (ASGB) is a rare but severe complication of gastric banding, often leading to reoperation. We describe our experience with 4 cases referred to us. The best timing of removal and the choice of another bariatric procedure is still controversial. We advise to wait until migration of the band into the lumen is complete. With removal of the ASGB if another weight reduction procedure is advisable, conversion to a biliopancreatic diversion is possible.

Isolated lung perfusion with melphalan and tumor necrosis factor for metastatic pulmonary adenocarcinoma.

BACKGROUND: Isolated left lung perfusion with melphalan and human tumor necrosis factor-alpha for pulmonary metastatic adenocarcinoma in the WAG/Rij rat was studied. METHODS: Survival was determined for melphalan, human tumor necrosis-alpha. Lung, pulmonary effluent, and serum melphalan were analyzed by chromatography after isolated lung perfusion or intravenous injection. On day 0, rats were injected with 2.0 x 10(6) CC531S cells intravenously. On day 7, rats underwent sham thoracotomy, received melphalan intravenously, or underwent isolated left lung perfusion with saline, melphalan, tumor necrosis factor, and a combination of the latter two. On day 14, tumor nodules were counted. RESULTS: For the doses of 400 microg tumor necrosis factor, 1,000 microg tumor necrosis factor, or both melphalan and tumor necrosis factor (2 mg + 200 microg), survival rates after contralateral pneumonectomy were 33%, 17%, and 80%, respectively. Survival in all other groups was 100%. Left lung melphalan level was significantly higher after isolated lung perfusion compared to intravenous administration. Significantly fewer left lung nodules were found for 0.5 mg isolated lung perfusion with melphalan (28+/-17) compared to isolated administration (200+/-0) (p = 0.001), and for 1.0 mg intravenous lung perfusion with melphalan (16+/-10) compared to controls (171+/-65) (p = 0.00047). Tumor necrosis factor showed no significant effect. CONCLUSIONS: Isolated lung perfusion with melphalan is an effective treatment for pulmonary metastases from adenocarcinoma in the rat.

Neutrophils and acute ischemia-reperfusion injury.

Leukocyte infiltration in response to I/R injury is a well-known but poorly understood phenomenon. The contribution of neutrophils in this process is still controversial. Despite numerous data, little is known about exact numbers of infiltrating neutrophils. The role of monocytes/macrophages in this process is even more unclear. The role neutrophils in the kidney and other organs was reviewed. The variability in models and methods for neutrophil quantification were examined, along with carrying out a critical overview of depletion and anti-adhesion approaches. Nevertheless, the exact role attributed to neutrophils in the I/R process remains unclear.

Repeat mediastinoscopy in the staging of lung cancer.

OBJECTIVE: Despite technical difficulties due to mediastinal fibrosis, repeat mediastinoscopy can be a valuable tool in the restaging of lung cancer. It provides essential pathological information on mediastinal invasion when selecting patients for surgical resection after induction chemotherapy in stage IIIa disease. The aim of our study was to evaluate the feasibility, sensitivity and accuracy of repeat mediastinoscopy. METHODS: From 1994 to 1997 we performed a repeat mediastinoscopy in 15 patients (13 men, two women) with bronchogenic carcinoma. Their age ranged from 49 to 75 years. (mean 64.7). Seven patients had induction chemotherapy for a non-small cell bronchogenic carcinoma with positive N2 nodes on mediastinoscopy. Four patients had a second primary contralateral lung cancer, one had a locoregional recurrence of bronchogenic carcinoma. The other three had a first mediastinoscopy for other reasons than lung cancer, repeat mediastinoscopy being performed for staging of malignant disease. RESULTS: In all 15 patients it was possible to perform a complete repeat mediastinoscopy. In one patient repeat mediastinoscopy turned out to be false negative, so, in our series, sensitivity was 87.5%, specificity 100% and accuracy 93.7%. CONCLUSION: Previous mediastinoscopy is no contraindication for a repeat one. Repeat mediastinoscopy offers valuable pathological information in restaging of lung cancer.

Nodular sclerosing Hodgkin's disease of the thymus gland.

An asymptomatic anterior mediastinal mass in a 22-year-old man proved to be nodular sclerosing Hodgkin's disease of the thymus gland. Complete excision was possible via a left posterolateral thoracotomy. Postoperative chemotherapy was given. Follow-up after 1 year showed no residual disease. Nodular sclerosing Hodgkin's disease is an uncommon tumor of the thymus gland and should be incorporated in the differential diagnosis of anterior mediastinal tumors. Multimodality treatment is advocated.

Superficial thrombophlebitis of pubic collateral veins after gynecological surgery: a case report.

Superficial pubic collateral veins are the result of iliac vein occlusion due to previous thrombosis. They can be accompanied by deep crossover veins. We present a patient with thrombophlebitis of superficial pubic collateral veins after a hysteroscopic procedure.

Cystadenocarcinoma of the pancreas: characteristics and surgical strategy.

When a cystic lesion of the pancreas is encountered, the first priority is to differentiate whether it is an inflammatory or neoplastic cyst. Failure to recognize the true nature of a neoplastic cyst will lead to an incorrect treatment strategy. This was dramatically proven in one of our patients. Nevertheless, because of the slow growth of this type of tumor, its tendency not to infiltrate adjacent structures and the relatively low likelihood of metastasis, operative resection should be attempted in all patients, even in more advanced stages.

Lamellar bone formation in an atherosclerotic plaque of the carotid artery, with a review of histogenesis--a case report.

Longer existing atherosclerotic lesions may contain calcifications; lamellar bone rarely develops within them. A 59-year-old man was referred with a progressive stroke. A high-grade stenosis of the left common carotid artery, formed by an ulcerating atherosclerotic plaque with a free-floating thrombus, was detected on angiography. An urgent endarterectomy was performed. Surprisingly this plaque contained pieces of lamellar bone, proved by histologic examination.

Intussusception in infants: an emergency in diagnosis and treatment.

Intussusception is an important cause of intestinal obstruction and bowel necrosis in infants under 2 years. Most frequently the ileocaecal junction is involved. Various aetiologic factors, such as Meckel's diverticulum and lymphoid hyperplasia have been identified. Hydrostatic reduction of the intussusception should be attempted, but delay in diagnosis frequently leads to surgical intervention, because of failing reduction. We report a case of a 4-month-old boy whose ileocaecal junction was intussuscepted into the rectum, and therefore could be palpated by rectal examination. Unsuccessful hydrostatic reduction and bowel necrosis because of delay in diagnosis, made surgical intervention necessary. A terminal ileostomy was performed. A second case report considers a 10-month-old boy whose ileocaecal junction was intussuscepted into the colon sigmoideum. Because there was no delay in diagnosis, this intussusception could be reduced hydrostatically. The procedure however was difficult because of a dolichosigmoideum. Recent literature is also reviewed.

[Viscerosynthesis: the realization of an old dream. A look at the 150-year development of surgical suture techniques]. / Viscerosynthese: de verwezenlijking van een oude droom. Een kijk op 150 jaar evolutie van de heelkundige hechtingstechnieken.

In analogy with osteosynthesis in bone surgery, viscerosynthesis has been introduced as a term for intestinal tissue fixation by staplers. As a result of continuous research, the development of mechanical suture instruments started early in the 19th century. At that time the base of manual suture technique was described by A. Lembert (1826), which is still applicable today. Simultaneously F. Denans introduced a device for intestinal anastomosis. An impressive variety of instruments was developed since then, which resulted in 1893 in the construction of the successful J. Murphy anastomotic button. Derived from it several more elaborate instruments were constructed until recently for oesophageal and rectal anastomoses as well. Entirely new of conception was the stapler apparatus by H. Hültl in 1906, succeeded shortly after by von Petz' stapler clamp. Inspired by them the Russians developed since World War II a tremendous instrumentarium. From 1959 the Americans took over and delivered highly specialized and technologically outstanding stapler instruments which currently dominate the market. Referring to the preceding generations of surgeons, one might say that with the advent of those instruments an old dream has been realized.

Improved ventilatory function after combined operation for pulmonary emphysema and lung cancer.

BACKGROUND: Smoking is the leading cause of both lung cancer and emphysema. Therefore, some patients with stage I and II disease will present with contra-indications to resection including a predicted postoperative FEV1 of less than 0.81 or a VO2max of less than 10 ml/kg/min. Recently, lung volume reduction surgery (LVRS) has re-emerged in the management of emphysema with excellent results. METHODS AND PATIENTS: 2 patients are reported with lung cancer in the left lower lobe and emphysematous destruction in both upper lobes. They, respectively, had a predicted postoperative FEV1 of 0.9211 and 0.6851. No metastases were present. Pre-operatively, a COPD index of 0.9 and 0.7 was calculated. A left lower lobectomy together with volume reduction of the left upper lobe was performed through a standard posterolateral thoracotomy. RESULTS: Pathological examination showed, respectively, stage IIb and stage Ib disease. The postoperative course was uneventful and 3 months later a FEV1 of 1.441 for patient 1 and 1.041 for patient 2 were recorded. CONCLUSION: These findings suggest that pulmonary function criteria for pulmonary resection have to be revised when patients can undergo simultaneous lung cancer resection and LVRS. The pre-operatively calculated COPD index can be used to predict which patients may not have a decrease in ventilatory function.

[Giant fibrovascular polyp of the esophagus]. / Reusachtige fibrovasculaire poliep van de slokdarm.

The observation of a giant fibrovascular polyp of the esophagus is presented. Diagnostic and therapeutic implications of this rare affection are discussed.

Ethics in actual surgery. The surgeon and HIV seropositive and AIDS patients.

Surgeons feel threatened by the risk of contamination when operating on HIV-seropositive or AIDS patients. Observations on the likelihood of contamination in literature are most divergent due to variables in seropositive prevalence, in frequency of contamination risk and in distinction between HIV seropositive and AIDS patients. Except in emergency the surgeon may refuse to treat a patient. Screening seropositively for selection is hampered by the inconsistency of false positives and false negatives depending on the method used and on costs appropriate to large scale controls. Exclusion of patients from treatment is unethical. Referring them to other colleagues on ground of contamination risk is ethically unjustified. Denial of care to a HIV infected patient may be justified when the operative risk is considered too high and the expected benefit too low because of the precarious condition of the patient and his shortened life expectancy. However the surgeon and his team need not to expose themselves to even a limited but real risk of contamination. Therefore the surgeons have to reconsider their surgical strategy and technique in order to keep chances of contamination as low as possible. A search for safer working methods for all operations and without any discrimination with regard to the patient is needed and should be taught to the surgical team.

Ethics in actual surgery. Ethics and organ transplantation.

Actual organ transplantation evokes more and more ethical questions. There is scarcity of donor organs. The waiting lists of potential recipients for organ transplantation are steadily growing as is the number of dead among the waiting patients. In Belgium the mortality rate of traffic victims during the first thirty days of hospital admission has been reduced by half. Among this group the number of potential cadaveric donor candidates is further reduced following complications of sustained intensive care. Shortage of cadaveric organs prompts some to select candidates for transplantation with exclusion of those considered responsible for their illness. Some centres incline to reconsider the definition of cerebral death by extending this notion to the irreversibly unconscious and therefore socially dead. Organ donation by living donors opens the way to commercialism specially in case of unrelated living donation. Living donors are often insufficiently informed about their risks and the final outcome of these transplantations. The use of implantable artificial organs should be the solution to many ethical problems. But some experience with the Jarvik heart as a temporary implant increases so far the shortage of donor heart supply and the number of patients on the waiting lists as well. It also excludes patients who became unsuitable for transplantation after complication of the Jarvik implantation. Xenotransplantation is largely under investigation. However, it is out of question that primates, which are threatened already with extinction should act as organ suppliers for mankind. Xenograft organs should be found in animals for food consumption, sufficient in number and more easily accepted as organ donors on ethical ground.

[The meaning of hepatic artery ligation in surgery (author's transl)]. / De betekenis van het afbinden der arteria hepatica in de chirurgie

On the occasion of a traumatic rupture of the hepatic artery in a 10 year old boy, successfully treated by ligation of the left branch, the meaning of arterial suppression to the liver was studied. Follow-up of 58 cases reported in the literature are reviewed; so is the role of collateral arterial circulation and of portal circulation as compensatory mechanism. A number of provisions tending towards optimal oxygenization of the patient and towards upholding of portal circulation are proposed as treatments against surgical interruption of the hepatic artery.

[Volvulus of the stomach]. / Volvulus van de maag.

Volvulus of the stomach. On occasion of three observations the volvulus of the stomach is studied in the light of recent advances of the literature. Different types of gastric volvulus are defined by etiopathogenic analysis. Symptomatology and diagnosis are examined and possibilities of treatment are emphasized. The therapeutic behaviour which is required towards this rare affection is discussed.

[Abscess of the liver (author's transl)]. / Het pyogene leverabces.

A case of liver abscess is analysed in the light of recent data from the literature. The attention is drawn on the increase in frequency of this disease over the last 10 years. The diagnosis is difficult to set on clinical and biological grounds but can be established with certainty by means of scintigraphy and hepatic angiography. Identification of the micro-organism is difficult and impossible in more than half of the cases. Treatment which is essentially surgical, in association with antibiotherapy specific of the anaerobic and gram negative micro-organisms, can reduce total mortality to 10%.

Rectovaginal fistulas.

The treatment of rectovaginal fistulas is controversial. The choice of the technique used for repair depends on many factors. Therefore the classification, etiology and treatment are discussed, in order to help decision making in the management of this troublesome disease.

[Formation of a phytobezoar following surgery of the stomach. Review of the literature]. / Fytobezoar vorming na heelkunde op de maag. Overzicht van de literatuur.

Phytobezoar after partial gastrectomy. An observation on phytobezoar formation after partial gastrectomy, attended by an intestinal obstruction is presented. According to a review of the literature bezoar formation following gastric surgery seems to develop in the stomach after vagotomy, and rather in the small intestine after partial gastrectomy. The etiopathogenesis of this phenomenon is analysed, and the physiopathology, the clinical manifestation, the diagnosis and therapeutic possibilities of this affection are discussed.

[A gallbladder filled with barium sulfate: an enigma]. / Een galblaas gevuld met bariumsulfaat: een raadsel.

We report an unusual observation in a 60-year-old patient with a Ba-sulfate filled gallbladder. A thorough search of the literature failed to disclose a similar case. Several hypotheses are proposed. We could not find a satisfactory explanation for this phenomenon.