Acta Chirurgica Belgica最新文献

Background: Tibial fractures, with an annual incidence of 51.7 per 100.000 adults, often result in complications like non-union and infection, particularly in open fractures. Non-union rates after intramedullary nailing are 9.7%. Hypertrophic non-union stems from unstable fracture sites, while atrophic non-union arises from inadequate biological environments. Treatment involves rigid bone fixation for hypertrophic non-union and combining biological tissue supply with mechanical stability for atrophic non-unions. This case report outlines a complex tibial non-union post-high-impact injury, detailing the surgical technique and TRUMATCH^TM Graft Cage-Long Bone usage. In addition, we outlined the current literature on this topic.

Case report: A male patient suffered a traumatic Gustilo II comminuted tibia and fibula fracture, Lisfranc injury and a Schatzker I tibial plateau fracture of the right leg. During follow-up the patient developed an aseptic non-union with eight-centimeter anterolateral bone defect after primary surgery. Surgical intervention was performed using the three-dimensional printed TRUMATCH^TM Graft Cage-Long Bone. At one year follow-up, clinical and radiological consolidation of the right tibia was seen.

Conclusion: This case report describes a challenging case of aseptic traumatic non-union of the tibia with a critical-sized defect treated with a novel patient-specific implant in a one-stage procedure. The application of the TRUMATCH^TM Graft Cage-Long Bone is promising and warrants further investigation in larger, more controlled studies to substantiate our findings.

Introduction: About five billion people worldwide lack access to safe surgery and multispecialty surgical volunteerism missions (SVMs) offer a plausible solution to this problem. This study aimed to evaluate the outcomes of elderly patients operated on over 13 surgical missions between 2006 and 2019 from 'Operation Giving Back Bohol' (OGBB) Tagbilaran, Philippines.

Patients and methods: This was a retrospective analysis of prospectively collected data on all patients treated during SVM over 13 years (2006-2019). Non-elderly (age 16-64 years) were compared with the elderly (age ≥ 65 years) for pre-, intra-, and postoperative variables. Multivariable logistic regression was utilized to identify independent predictors of postoperative complications.

Results: Of 1184 patients, the majority (1030) was in the non-elderly group and 154 in the elderly. The mean age was 36 ± 13.6 and 68.3 ± 3.8 years in the non-elderly and elderly groups, respectively. Comorbidities, type of surgery, type of anesthesia, operating time, estimated blood loss, estimated blood loss, need for blood transfusion, postoperative complication rates, comprehensive complication index, length of hospital, ICU requirement, and mortality rates stay did not significantly differ between the groups. Multivariable logistic regression found pelvic surgery (OR (95%CI)=3.7 (1.3-10.8); p=.01), hypertension (OR (95%CI)=8.4 (2.2-32.9); p<.01), and intraoperative blood loss (OR (95%CI) = 1.007 (1.005-1.009); p<.01) to be independent predictors of postoperative complications.

Conclusions: Elderly patients may safely undergo general surgery procedures in surgical volunteer missions, and age alone should not preclude them.

Introduction: Reversal of Roux-en-Y gastric bypass (RYGB) may be indicated for possible side effects such as malnutrition, intolerance, dumping syndrome, or late dumping. Reversal can however induce significant gastro-esophageal reflux disease (GERD).

Method: We report the case of a 55 years old Caucasian woman, who had undergone conversion of Nissen fundoplication performed for GERD (Grade B) into RYGB because of recurrent reflux, though Grade A esophagitis and increasing obesity (37.5 kg/m² BMI). She developed invalidating symptoms of late dumping syndrome and severe diarrhea. Pre- and postoperative evaluation an eso-gastroscopy with esophagitis grade evaluation. Treatment consisted of physiologic reversal of the RYGB, by reimplantation of the alimentary limb into the remnant stomach.

Result: Pre-reversal endoscopy showed Grade A esophagitis. Oral glucose test demonstrated severe hypoglycemia persisting till 120 min post-ingestion and clinical symptoms of hypoglycemia (Whipple triad) (40 to 53 mg/dl). Three months after reversal the diagnostic tests had significantly improved, both in terms of glucose metabolism and GERD symptoms. At 22 months after surgery, the patient still did not suffer from diarrhea anymore, her glycemic profile was stable under antidiabetic medications and her BMI raised to 29 kg/m².

Discussion and conclusion: Reversal of Roux-en-Y gastric bypass by incorporation of the alimentary limb between the gastric pouch and the gastric remnant seems to successfully address the dual issue of post-RYGB late dumping and preventing GERD, the different mechanisms involved will be explained latter in this paper.

Introduction: Giant dedifferentiated liposarcomas of the spermatic cord are a rare and aggressive entity. Both large size and dedifferentiated liposarcoma histology implicate a poorer prognosis with a high risk of recurrence and metastasis.

Methods: This is a retrospective case report. We describe a 58-year-old patient who presented with a hemodynamic collapse, caused by a high gastro-intestinal bleeding. A giant inguinoscrotal mass challenged the diagnostic path.

Results: A combined abdominal and scrotal approach was used to remove the giant mass (26 × 15 × 11 cm, 1.617 kg) en bloc with the right testicle and spermatic cord. Pathological examination showed a giant dedifferentiated liposarcoma (FNCLCC grade 2), with a microscopically complete resection. Follow-up at 24 months showed no locoregional recurrence or distant metastasis.

Conclusion: Radical surgery remains the cornerstone of treatment for retroperitoneal liposarcoma. Microscopically complete resection is an important positive prognostic indicator for risk of recurrence. Rigorous follow up is necessary, considering the high risk for recurrence. This patient illustrates the challenge of not allowing the giant inguinoscrotal mass to draw away all attention from a life-threatening high gastro-intestinal bleeding.

Background: Access to surgical care is a global health burden. A broad spectrum of surgical competences is required in the humanitarian context whereas current occidental surgical training is oriented towards subspecialties. We proposed to design a course addressing the specificities of surgery in the humanitarian setting and austere environment.

Method: The novelty of the course lies in the implication of academic medical doctors alongside surgeons working for humanitarian non-governmental organizations (NGO). The medical component of the National Defense participated regarding particular topics of war surgery. The course is aimed at trained surgeons and senior residents interested in participating in humanitarian missions.

Results: The program includes theoretical teaching on surgical knowledge and skills applied to the austere context. The course also covers non-medical aspects of humanitarian action such as international humanitarian law, logistics, disaster management and psychological support. It comprises a large-scale mass casualty exercise and a practical skills lab on surgical techniques, ultrasonography and resuscitation. Attendance to the four teaching modules, ATLS certification and succeeding final examinations provide an interuniversity certificate. Thirty participants originating from 11 different countries joined the course. Various surgical backgrounds, training levels as well as humanitarian experience were represented. Feedback from the participants was solicited after each teaching module and remarks were applied to the following session. Overall participant evaluations of the first-course session are presented.

Conclusion: Teaching humanitarian surgery joining academic and field actors seem to allow filling the gap between high-income country surgical practice and the needs of the humanitarian context.

Introduction: The onset of the COVID-19 pandemic has forced a rapid and extensive change in the need of intensive care beds. Therefore, we decided early in the pandemic to suspend all elective cases of cardiac surgery and closed the ambulatory clinic. The effect of this strategy on the mental well-being of the non-COVID-19 patients is unknown. The aim of this study is to assess whether planned or operated patients suffered from either anxiety or depression by their altered medical care trajectory and if their score influenced decision-making. The findings intend to anticipate individual needs during subsequent waves of the COVID-19 pandemic.

Methods: The patient population consisted of two groups. The first group included planned patients whose operation date was delayed; in the second group, the postoperative control visit was postponed. Both groups received a twofold questionnaire. Part one was the Hospital Anxiety and Depression scale, part two a series of questions on the influence of the COVID-19 pandemic on cardiac surgical care from a patient's perspective.

Results: The study population was composed of 46 patients (63% men). Most of them (82.6%) would like the surgery to be performed as fast as possible, even before the end of the first wave of COVID-19-related hospitalizations. Of all patients 30.4% have avoided to consult a physician because of fear and 34.8% consulted a physician by phone call. When they physically consulted a physician, there was a prominent role for the general practitioner (41.3% went to the GP vs 19.6% to the specialist). Most (58.7%) of the patients would have liked a (tele)consultation with the cardiac surgeon.

Conclusions: Regardless of the HADS, one can state that a closer follow-up using telemedicine during the pandemic is expected by all patients. All patients prefer their surgery to take place even during a pandemic.

A 33-year-old patient was managed in the emergency room. After right thoracic drainage for a pneumothorax, intubation for hypoxemia, and extraction of wooden foreign bodies from his mouth, a full-body scan identified a 6 mm diameter tubular-shaped structure extending from the nasopharynx to the retroperitoneum, passing through the mediastinum, in between major cardiovascular structures and organs. Cardiothoracic surgeons performed a sternotomy to remove the foreign body, which was identified as a long tree branch, without finding any major collateral anatomical damage. The cause of this ingestion was attributed to psychiatric delirium. Post-operative care included prolonged antibiotic therapy, one drainage surgery, and intensive rehabilitation, ultimately leading to a slow and progressive recovery. This unique case of tree branch ingestion crossing the mediastinum in an adult is astounding as the patient survived remarkably this life-threatening self-inflicted trauma. Furthermore, this case highlights the critical role of multidisciplinary management, the importance of imaging, and the emphasis on coordinated medical efforts to achieve positive outcomes in similar self-inflicted multiple site injuries cases.

Background: Surgery is one of the most important branches of medical science. The importance of using surgical tools in applying various surgical methods is clear. With the development of surgical instruments, the science of surgery made significant progress. At the beginning of the era of Islamic civilization (tenth century A.D.), The book entitled Al-Tasrif Leman Ujza an Al-Talif was written by Zahrawi, an Andalusian physician, which became world famous due to its section on surgery and surgical instruments. The original of this book was in Arabic and was translated into Latin by Gerald of Cremona. After that, he made his way to Europe and taught in European medical universities for many years. In this study, the possible source used by Zahrawi in writing this part of his book is discussed.

Methods: This study was done by library and Internet research method. Reference books and relevant articles from reliable databases such as ISI, Scopus, PubMed and search engines such as Google Scholar, and also some archeological websites were used for gathering data. The date was analyzed.

Results: Zahrawi has introduced more than 200 surgical tools in an illustrated form and described their use in the 30th chapter of the 3rd part of Al-Tasrif book. Also, there are some images of surgical instruments carved on a stone inscription on the wall of the Kom Ombo temple in Egypt, dating back to 305-30 BC, which are very similar to Al-Tasrif's.

Discussion: The similarity between the images of these two mentioned documents, releaves a potential of Zahrawi's exposure to the Egyptian Kom Ombo and the use of that source in the compilation of al-Tasrif.

Introduction: We present a case of a patient with resectable perihilar cholangiocarcinoma (pCCA) who underwent primary metal stenting above the ampulla, followed by a successful surgical resection. Biliary drainage is a crucial step in the preoperative management of pCCA, yet there is no consensus on the optimal approach. Traditional drainage methods involve passing through the ampulla and/or the skin barrier, thereby increasing the risk of bacterial contamination of the biliary tree and secondary cholangitis.

Method: A novel drainage technique was utilised in this case. A metal stent was percutaneously placed across the malignant hilar stenosis without external biliary drainage. During the procedure, both guidewires and stents were meticulously prevented from passing through the ampulla. Additionally, percutaneous access to the biliary tree was removed during the index procedure to minimise the risk of biliary colonisation and cholangitis.

Results: Following the drainage, bilirubin levels rapidly normalised, and no clinical or biochemical signs of cholangitis were observed. This allowed for rapid and uncomplicated surgical resection.

Conclusion: This case illustrates the potential of a novel biliary drainage technique in patients with pCCA. By minimising the risk of biliary colonisation and cholangitis, this approach could potentially improve surgical outcomes.