Acta Chirurgica Belgica最新文献

Background: The diagnosis of acute appendicitis (AA) still represents a considerable problem for surgeons, with a relatively high rate of false positive findings still present. Thus, the aim of our study was to evaluate the diagnostic accuracy of the Alvarado scoring system based on the prospectively included subjects who presented to the emergency department with suspected AA.

Methods: From June 2018 to May 2020, 176 adult patients examined in the Emergency surgical department of University Hospital Sveti Duh with suspicion of AA were prospectively included in the study. The decision on the need for surgery in all patients was made by the same surgeon based only on clinical judgment and remained independent of any diagnostic scoring system.

Results: Fifty-eight (33.0%) of them were operated with negative appendectomy rate of 17.2%. Results showed that the surgeon's decision-making process is superior to the Alvarado scoring system (sensitivity and specificity were 96 and 92.06% vs. 84 and 87.30%, respectively).

Conclusion: The Alvarado scoring system proved to be a worse predictor of the diagnosis of AA compared to the assessment of an experienced surgeon and is not an adequate diagnostic tool for confirming the diagnosis. Only in a narrow group of patients in whom, based on the clinical examination, an indication for surgery has already been established, the Alvarado scoring system can potentially be useful in excluding the diagnosis with considerable caution in terms of close follow-up of the patient.Abbreviations: MSCT: multislice computed tomography; AA: acute appendicitis.

Background: A surgical fellowship allows both additional training as well as maintenance of surgical skills while searching for a steady job. As the presence of fellows usually does not result in a measurably higher productivity, fellowships may be considered a form of disguised unemployment. The aim of this study is to evaluate the career flow of a surgical trainee to a staff position and to determine the number of surgeons working on temporary basis within the general surgery workforce in Flanders.

Methods: All surgeons graduated in Flanders between 2000 and 2022 were invited to fill out a web-based survey concerning their current and past employment. Reminders were sent out after 2 and 4 weeks. Statistical analysis was performed with SPSS version 27.0 (IBM Inc., Chicago, IL).

Results: Response rate was 64% (292/457) with 76% of respondents currently working as surgeons, 14% (38) as fellows and 10% working outside the surgical domain. Eighty-two percent of current fellows graduated in 2019 or later. Thirty-one percent of surgeons graduated in 2019 are still working as fellows. For surgeons graduated in 2020, 2021 and 2022, this is 45%, 80% and 90%, respectively. Compared to staff surgeons, the number of additional training years (2.8 ± 1.0 vs. 2.2 ± 1.3; p = .009) and the number of applications (6.6 ± 5 vs. 3.3 ± 3; p < .001) are significantly higher for current fellows.

Conclusion: This study shows that disguised unemployment is present in the general surgical community in Flanders. The status of 'fellow' should be incorporated in calculations concerning future needs of the surgical workforce in order to prevent open unemployment.

Introduction: Pseudomyxoma peritonei (PMP) is a rare disease characterized by diffuse peritoneal invasion of multifocal mucinous deposits. Gold standard treatment involves cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC). We aimed to compare the outcomes of operated PMP patients in a low-volume center, with those of high-volume centers and using other regimens.

Materials and methods: Retrospective analysis was conducted for PMP patients treated by CRS + HIPEC (using the Elias high-dose Oxaliplatin HIPEC regimen) over a 15-year period (January 2007 - December 2021) at the Jules Bordet Institute - H.U.B.

Results: 32 patients were included. Pathology results were: 21.9% acellular mucin, 34.4% low-grade, and 43.7% high-grade. The median peritoneal cancer index was 24 (range 3-36). The median follow-up was 58 months. The rate of major complications (Clavien-Dindo III/IV) was 41% and postoperative mortality was 3%. Mean disease-free survival (DFS) was estimated at 40 +/- 4 months (standard deviation (SD)) while overall survival (OS) was 122 +/- 9 months (SD). DFS reached a plateau of 44.5% at 5 and 10 years and OS was 92.3% and 76.2% respectively. Statistical analysis showed low-grade PMP to be predictive of better DFS and OS (p = 0.0111 and p = 0.0293 respectively). We also found that female gender was predictive of better DFS (p = 0.0262).

Conclusion: Our postoperative morbidity and mortality rates, DFS, and OS were similar to those reported in the literature for high-volume PMP centers. Our theory is that surgical proficiency can be more attributed to the surgeon's CRS experience, regardless of the nature of the disease.

Introduction: High-grade pancreatic neuroendocrine tumors are rare, and most of them are well differentiated. Management of this type of tumor is not yet well established.

Methods: A 28-year-old woman was referred to our hospital for a well-differentiated grade-3 pancreatic neuroendocrine tumor with multiple liver metastases. The patient received neoadjuvant therapy consisting of combination of Capecitabine/Temozolomide chemotherapy and somatostatin analogue.

Results: An excellent regression was observed on both pancreatic and hepatic lesions, and therefore, an aggressive surgical management could be performed with a two-step scheme. Adjuvant hormono-chemotherapy was administered between the two surgeries. The patient achieved six years of disease-free survival following the last therapy.

Discussion and conclusion: We highlight the difference between well and poorly differentiated high-grade neuroendocrine neoplasia and report that aggressive surgery is a valid option even in metastatic presentation at diagnosis.

Objective: Adrenal cortical carcinoma (ACC) is a rare and aggressive endocrine malignancy. Clinical symptoms are mainly related to excess hormone secretion. Hypercortisolism and virilisation are among the most common presentations.

Methods: We report a case series of five patients with ACC, three of which presented as adrenal incidentalomas. Additionally, a literature review on current diagnosis and management of ACC was performed.

Results: ACCs are often incidentally detected because of the liberal use of medical imaging. Management of ACC remains challenging, and the poor prognosis makes early diagnosis of crucial importance to increase chances of a better outcome. Biochemical evaluation should be performed to diagnose hormonally active tumours.

Conclusion: Surgery is the main and only potentially curative treatment option. Adjuvant treatment with mitotane may improve survival and is indicated for patients with a perceived high risk of recurrence. Aggressive cytotoxic therapy should be given to patients with an unfavourable prognosis.

Purpose: To compare the mid-term primary and assisted-primary patency results of plain balloon angioplasty (PBA) versus drug-eluting balloon angioplasty (DEB) with non-thrombotic arteriovenous fistula (AVF) stenosis in hemodialysis (HD) patients.

Subject and methods: A total of 128 consecutive HD patients, who underwent endovascular treatment with DEB or PBA between October 2015 and December 2021, were investigated in this retrospective study. Color Doppler examination was performed for follow-up after 1, 3, 6, 12, 18, 24, and 36 months. Survival curves for primary and assisted primary vein patencies of the PTA and DEB group were generated with Kaplan-Meier survival analysis and were compared with the log-rank test.

Results: 78 patients (60.9%) underwent PBA (45 men, 33 women; mean age: 64.2 ± 13.9, range: 29-82 years) and 50 (39%) patients underwent DEB (36 men, 14 women; mean age: 65.6 ± 12.8, range: 28-87 years). The estimated primary patency rates at 6, 12,18, 24, and 36 months for the DEB group (95.5%, 92.8%, 88.6%, 77.1% and 54.0%, respectively) were significantly higher than those in the PBA group (84.5%, 76.9%, 73.9%, 66.4% and 59.0%, respectively) (p = .048). Assisted primary patency rates at 6, 12, 18, 24, and 36 months were higher in the DEB group (97.9%, 95.4%, 90.2%, 87.3% and 75.5%, respectively) than PBA group (94.7%, 86.9%, 85.0%, 78.0%, and 66.9%, respectively) but they were not statistically significant (p = .187).

Conclusion: Our study confirms DEB is a safe and effective treatment of dysfunctional AVF. We demonstrate higher primary patency rates in DEB than PBA at 6, 12, 18, 24 and 36 months. However, no statistically significant were detected between the two groups in mid-term follow-up.

Background: Aortogastric-tube fistula is a rare but fatal complication of esophagectomy, most commonly induced by anastomotic leakage and peptic ulcer formation.

Methods: We report a rare case of a 55-year-old male patient presenting with an aortogastric-tube fistula located in the gastric conduit due to a recurrence of esophageal carcinoma.

Results: The patient was treated successfully with Thoracic Endovascular Aortic Repair (TEVAR) followed by esophageal stent placement to relieve dysphagia.

Conclusion: Although aortogastric-tube fistula is an extremely rare entity, the advent of esophageal cancer surgery, has led to the recognition of aortogastric-tube fistula with increasing frequency in the literature. Herein, we provide a comprehensive review of the literature, focusing on the pathophysiology, time interval between surgery and presentation, type of treatment and survival of reported cases with post-esophagectomy aortogastric-tube fistula.

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.

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.