What is needed to become a good surgeon?

This lecture has been delivered as a part of the RBSS-BAST symposium 'What does it need to become a good surgeon'. The lecture relates to the evolution that has taken place over the last decades in relation to the training in surgery. It also gives some hints to younger colleagues how to make a successful career in surgery.

Prolongation of allogeneic heart graft survival in the rat after implantation on portal vein.

In rats, heart allografts with venous drainage via the portal vein were performed and compared with similar grafts draining into the inferior vena cava. A new technique was developed using the complete thoracic descending aorta and ligation of all its branches. The descending thoracic aorta was anastomosed to the recipient's abdominal aorta below the left renal vein. The pulmonary artery was implanted on the portal vein in an end to side fashion. In two rat strain combinations the allograft survival time was significantly prolonged when compared to that of the control grafts with pulmonary-caval anastomosis. The presumed mechanism for this prolonged graft survival might be the sequestration or degradation of transplantation antigens in the liver during their first passage through this organ. In this way only a small amount of antigen reaches the systemic circulation.

Importance of HLA-DR matching in polytransfused cadaveric kidney transplant recipients. A prospective one-center study.

Since August 1978 prospective HLA-DR typing has been performed in 157 donor-recipient pairs. All recipients received pretransplant blood transfusions. This study shows that HLA-DR matching can significantly improve the survival of cadaveric kidney allografts, even in polytransfused recipients. Patients receiving kidneys with no HLA-DR incompatibilities have a one-year graft survival of 97%, versus 86% for recipients with 1 HLA-DR incompatibility and 73% for recipients with 2 HLA-DR incompatibilities. The cumulative dose of corticosteroids during the first year after transplantation is significantly lower in patients with no DR-incompatibilities. HLA-A and B matching have no additional effect on graft survival.

Immunological and clinical observations in diabetic kidney graft recipients pretreated with total-lymphoid irradiation.

In a feasibility study, twenty patients with end-stage diabetic nephropathy were treated with fractionated total-lymphoid irradiation (TLI, mean dose 25 Gy), before transplantation of a first cadaveric kidney. During radiotherapy, only one patient had a serious side effect (bone marrow depression). After transplantation four patients died (one of a myocardial infarction, one of ketoacidosis, and two of infections occurring during treatment of rejection crises). One graft was lost because of chronic rejection. The other 15 patients have a functioning graft (mean follow-up 24 months) and receive low-dose prednisone alone (less than 10 mg/day, n = 11) or in conjunction with cyclosporine (n = 4) as maintenance immunosuppressive therapy. A favorable clinical outcome after TLI (no, or only one, steroid-sensitive rejection crisis) was significantly correlated with a high pre-TLI helper/suppressor lymphocyte ratio, a short interval between TLI and the time of transplantation, and the occurrence of functional suppressor cells early after TLI. The most striking immunological changes provoked by TLI consisted of a long-term depression of the mixed lymphocyte reaction and of the phytohemagglutinin, and Concanavalin A or pokeweed-mitogen-induced blastogenesis. A rapid and complete recovery of the natural killer cell activity was observed after TLI. A permanent inversion of the OKT4+ (T helper/inducer) over OKT8+ (T suppressor/cytotoxic) lymphocyte ratio was provoked by a decrease of the OTK4+ subpopulation, together with a supranormal recovery of the OKT8+ lymphocytes. A majority of the latter lymphocytes did also express the Leu 7 and the Leu 15 phenotype.

Continuous quantitative monitoring of mural, platelet-dependent, thrombus kinetics in the crushed rat femoral vein.

A new in vivo method to study the size and dynamics of a growing mural thrombus was set up in the rat femoral vein. The method uses a standardized crush injury to induce a thrombus, and a newly developed transilluminator combined with digital analysis of video recordings. Thrombi in this model formed rapidly, reaching a maximum size 391 +/- 35 sec following injury, after which they degraded with a half-life of 197 +/- 31 sec. Histological examination indicated that the thrombi consisted mainly of platelets. The quantitative nature of the transillumination technique was demonstrated by simultaneous measurement of the incorporation of 111In labeled platelets into the thrombus. Thrombus formation, studied at 30 min interval in both femoral veins, showed satisfactory reproducibility overall and within a given animal. With this method we were able to induce a thrombus using a clinically relevant injury and to monitor continuously and reproducibly the kinetics of thrombus formation in a vessel of clinically and surgically relevant size.

Surgery in Belgium.

To fully understand the present state of surgery in Belgium, it is necessary to know the structure of the Belgian State, the type of education, the statutory health insurance system, and the professional bodies representing surgeons. One of the most important problems is the excessive number of physicians, which recently led to the establishment of limits on the number of candidates receiving medical certification. Surgical training modalities are described and the results of a retrospective study concerning the quality of training are detailed. The continuing medical education and peer-review system (accreditation) is presented.

Primary leiomyosarcoma of the diaphragm.

Primary leiomyosarcoma of the diaphragm is extremely rare and only five cases have so far been reported. In the early stages clinical signs are scarce and diagnosis is difficult. The advent of MR-imaging has helped in detecting the origin of a diaphragmatic tumour and its relationship to the adjacent tissues. The highly malignant character of this tumour accounts for the poor prognosis even when radical surgery is performed.

The sonographic aspects of haemobilia. Clinical and experimental study.

The sonographic aspect of the gallbladder in seven cases of haemobilia is analysed. The changes include a diffuse echogenic gallbladder content during the initial stage. Later, irregular shaped inhomogeneous non shadowing masses are seen in the dependent parts of the lumen. This variable aspect was studied in an experimental model by percutaneous injection of blood in the gallbladder of Guinea pigs. The hyperechoic gallbladder content, seen early after injection is a transitory phenomenon which seems related to red cell aggregation before coagulation occurs. During the later stage the intraluminal masses were shown by histology to represent bloodclots. In a patient the observation of such a rapid evolution from diffuse hyper-reflectivity to less reflective masses is strongly suggestive of haemobilia.

Nerve fiber planimetry in acute and chronic nerve lesions and in nerve lesions in continuity.

The level of resection of damaged nerve tissue in acute and chronic nerve lesions was determined on the basis of the vascular structure, the consistency of the nerve during palpation, the amount of interfascicular connective tissue, and the mushroom formation of the fascicles. Intraoperative electrophysiologic recordings were performed on the cut nerve ends to determine the function of the axons. Postoperative planimetric analyses of cross sections made through the resected nerve stumps were performed to measure axonal and endoneural tube diameters and to correlate these results with the clinical criteria used through the operating microscope. Axons in the proximal nerve ends of acute and chronic nerve lesions displayed a similar mean diameter. Endoneural tubes in chronic nerve lesions shrunk significantly as nerve repair was delayed. In several nerve lesions in continuity, axons remained present across the injured site despite absence of electrical conduction. When comparing the results of axonal or endoneural tube diameters of chronic nerve lesions to the results of other studies or acute nerve lesions, we demonstrated that careful examination through the operating microscope provided valid information about the proper management and resection level of chronic nerve lesions. Electrophysiologic evaluation aided the surgical management but was not useful for the resection of the distal damaged nerve segment. The presence of an evoked potential in the proximal nerve ends guaranteed a nearly normal nerve fiber diameter distribution, while the absence of such a potential in the distal nerve ends indicated an abnormal, absent, or disturbed endoneural tube diameter histogram.

Anal sphincter reconstruction with the gluteus maximus muscle: anatomic and physiologic considerations concerning conventional and dynamic gluteoplasty.

Myoplasties have acquired an important place in anal sphincter repair. The use of the gluteus maximus muscle for sphincterplasty was reported initially in 1902. However, in 1952, the gracilis sphincterplasty became more popular because of the accessibility of this muscle. Unfortunately, continence rates, especially after graciloplasty, remained unpredictable because of inability to maintain muscle contraction despite training programs. Training should induce a shift in muscle fiber type distribution toward a more fatigue-resistant composition, with predominance of type I fibers. In order to obtain a more pronounced adaptation in the contractile, histochemical, and metabolic properties of muscle fibers, postoperative intermittent long-term stimulation of the graciloplasty was performed. As these results and the results of dynamic cardiomyoplasty with an implantable myostimulator proved to be successful, implantable pulse generators were used after graciloplasty. Subsequently, continence rates after graciloplasties improved significantly. These data encouraged us to perform dynamic gluteoplasties for anal sphincter repair. This paper presents the results in 7 patients treated by conventional and 4 patients treated by dynamic gluteoplasty. Advantages and disadvantages of gluteoplasty were compared with those of graciloplasty. The neurovascular pedicle of the gluteoplasty underwent less traction after transposition compared with the graciloplasty based on cadaver studies. Gluteus muscle transfer far exceeded the amount of muscle tissue of a normal anal sphincter despite muscle atrophy after transposition. This guaranteed a contractile muscle cuff around the anal canal in contrast to the tendinous sling after graciloplasty. Because of the excellent vascularization of the muscle, microperforations of the rectal mucosa caused by submucosal dissection were sealed, and implantation of electrodes and a pulse generator in one surgical intervention was well tolerated. The myoplasty induced a double curvation of the anal canal in contrast to the graciloplasty, which enhanced the natural anorectal angle. Patient evaluation revealed continence for stool in 9 of the 11 patients; 7 of the 11 patients also were continent for liquids, among them all of the patients who had undergone dynamic gluteoplasties. Mean basal pressure after dynamic gluteoplasty was 49 mmHg, which is lower than the reported mean basal pressure (62 mmHg) during stimulation after dynamic graciloplasty. Squeeze pressure after gluteoplasty, with or without stimulation, proved to be similar to or higher than that obtained in dynamic graciloplasty. Comparing our results of conventional gluteoplasty with the results of graciloplasty prior to stimulation, higher pressures were obtained by the gluteoplasty, especially in squeeze pressures. In the last 5 patients intraoperative pressure measurements were used to restore the optimal resting length of the muscle after transposition. An intraluminal pressure of at least 40 mmHg during rest and 80 to 120 mmHg during stimulation should be obtained to guarantee a future continent sphincter.

Scanning electron microscopy of irradiated recipient blood vessels in head and neck free flaps.

Irradiated and control recipient blood vessels in a similar patient population were studied with scanning electron microscopy. The vessels that were biopsied were then anastomosed to a free flap. Irradiated arteries display a significantly greater wall thickness and higher incidence of intimal dehiscence compared with control arteries. Fibrin deposition, microthrombi, and endothelium cell dehiscence are present more frequently in irradiated vessels than in control vessels. Details of the preparation and anastomotic technique for irradiated blood vessels are discussed. Microvascular surgery in irradiated human blood vessels carries with it a higher risk of thrombosis due to preexisting vessel wall damage. This risk can be minimized by experience and attention to detail.

Experience with lymphangioma.

Lymphangioma is a rare and benign tumor, mostly encountered in childhood. Our experience extends to 21 patients, all of which were operated upon. Early radical excision in moderate forms or cervical locations and delayed excision or combined management in complex cervical forms are the more preferable way of treatment.

An unusual case of lymphocele after renal transplantation. Case report.

A patient who developed a lymphocele five years after renal transplantation is presented and discussed.

Lymphedema of the leg associated with rheumatoid arthritis.

A 14-year-old boy with a two year history of seronegative rheumatoid arthritis developed left leg lymphedema and subsequently a severe episode of lymphangitis. The diagnosis of "rheumatoid lymphedema" was confirmed by lymphscintigraphy and conventional lymphography. Treatment consisted of bedrest and antibiotic drugs. When the signs of inflammation had subsided, therapy with corticosteroids was started with improvement of both joint pain and leg swelling. Whereas lymphedema associated with rheumatoid arthritis has been described in the upper limb of adults, to our knowledge this is the first report of the coexistent condition in the lower leg of a child.

Home-going: prognostic factors concerning the major goal in treatment of elderly hip fracture-patients.

Two hundred and forty-one hip fracture patients over 70 years of age still living at home at the moment of the accident were followed prospectively until three months postoperatively. The patients were admitted to the department over a five year period (1978-1983). One hundred and forty-four patients returned home. In order to predict whether an elderly hip fracture patient will be able to return home within three months, the following prognostic factors will have to be taken into account: pre-operative functional status (p = 0.0001), ambulatory capacity at discharge (p = 0.0001), age (p = 0.001), presence of relatives at home to return to (p = 0.02) and general medical postoperative complications (p = 0.0006). In this respect it was noted that sex, fracture type or mechanical complication with possible operation do not significantly influence the home-going rate within three months after surgery (p greater than 0.05).

Polytrauma in patients of 65 and over. Injury patterns and outcome.

In a consecutive series of 416 patients with multiple injuries, 49 were aged 65 years or older (mean age 72.1). This group of "old" patients was compared with the remaining 367 "young" patients (mean age 31.3). In the old patients group, survivors and non-survivors were profiled. In general the injured old patient was a pedestrian hit by a car or a motorbike or someone who had simply fallen at home. Despite the fact that the mean Injury Severity Score (ISS) was significantly lower in the old patients' group (33.2 versus 42.1) (p less than 0.001), the mortality rate was significantly higher (18% versus 7.6%) (p less than 0.05). We found that in the elderly injured the ISS and preexisting diseases were not predictive of survival. However, brain injury with unconsciousness and the need for early intubation followed by long-term assisted ventilation were predictive of survival (p less than 0.001). Seventy-six per cent of the survivors were able to return home again within six months. As the final outcome in the elderly is no worse after polytrauma than after other important emergency procedures, an aggressive treatment including urgent operative fixation of major fractures is in our opinion justified.

Hip fractures in the elderly. Mortality, functional results and social readaptation.

Six-hundred and fourteen aged over 70 and presenting hip fractures have been studied prospectively. The results were compared with the literature. The overall mortality rate within three months was 24%. This mortality was significantly influenced by the general health condition of the patient at the time of the injury, his living conditions and the possibility of walking again after the operation (p less than 0.001). For 38% of the survivors, the fracture means a considerable loss of functional independence. The adjacent impairment was in close relationship with patient's age and fracture-type (p less than 0.05). Sixty per cent of the patients were able to return home. In predicting the probability of returning home, the functional status before injury and the possibility of walking at the moment of discharge were particularly important (p less than 0.001).

Traumatic rupture of the diaphragm. Review of 62 successive cases.

From 1970 to 1987, 62 patients, suffering from traumatic rupture of the diaphragm, have been treated. In more than 75% of the cases, other severe post-traumatic associated lesions were noticed. In 54 cases these concerned blunt trauma, most of which were due to road accidents. There were 53 lesions of the left hemidiaphragm. Early diagnostics were made 40 times (i.e. within 24 hours after the accident). This is why it is all-important to correctly interpret the simple X-ray of thorax and abdomen, possibly after inserting a nasogastric tube. In general, exploration by laparotomy was preferred. Thoracolaparotomy or sternolaparotomy was only used in cases of thoracic or thoraco-abdominal injuries associated with important lesions at the lungs or the mediastinal organs; or in the case of long-standing ruptures accompanied by herniation of different organs. The total mortality rate was 21%. Death was due to hypovolemia, serious brain injuries or multiple organ failure (MOF) due to sepsis.

[Transposition of the gluteus maximus muscle for sphincter replacement in anal incontinence]. / Transposition des Musculus glutaeus maximus zum Sphincterersatz bei analer Inkontinenz.

The replacement of the external anal sphincter by gluteus muscle in fecal incontinence is described in 4 cases. All patients, three children and one adult, had been operated on previously because of different types of anal atresia and suffered from fecal incontinence grade IV. They all showed a congenital defect of the somatic sphincter. The absent external and sphincter muscle was repaired by transposing innervated and vascularized gluteus muscle. In all cases active anal continence was achieved proven by clinical and electromanometric measures. The results, compared to other techniques, are discussed.

Current concepts of inhalation injury in burn victims.

Twenty patients with bronchoscopic diagnosis of inhalation injury were reviewed. The history of a burn in a closed space was present in 90% of the patients in our study and evidence of orofacial burns in 100%. In four of these patients serum concentrations of human placental alkaline phosphatate (hPLAP) were determined. This protein can be detected in serum with hPLAP specific monoclonal antibody and increased serum levels of hPLAP are found when there is damage of pneumocyt I cells.