Biomedical subjects
Publications and source records attributed to W Vaneerdeweg.
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.
Congenital diaphragmatic hernia is a rare condition in adulthood. It is even more exceptional when located on the right side. We describe a case of right-sided congenital diaphragmatic hernia in a 74-year old woman. The diagnosis was only made when the patient developed an acute intestinal obstruction after a laparotomy for a gynaecological benign tumour. The treatment of this condition is discussed. In our opinion, in elderly, the advantages of an elective operation in asymptomatic congenital diaphragmatic hernia have to outweigh the risks of the operation. However, if the patient shows symptoms of pulmonary dysfunction or motility disorders of the gut, or even when he has to undergo a laparotomy for a different reason, we advise to repair the hernia in order to prevent complications.
Malignant ascites is often refractory to therapy and rapidly deteriorating the nutritional and physical state of the cancer patient. Nevertheless, ascites does not always implicate preterminal state of the cancer process (e.g. ovarian carcinoma). A short review is made of the pathophysiology of ascites in cirrhosis and in malignancy, and different modes of treatment are discussed. The results of medical therapy of malignant ascites (salt and water restriction, diuretics, intraperitoneal cytostatics or radiocolloids) are not convincing. The immunotherapy with OK-432, as worked out by Katano (16-46) has to prove its value. The best and most hopeful results in cases of massive previously resistant ascites, are obtained with a peritoneojugular shunt, improving immediately the nutritional status and life condition, providing excellent palliation. The superiority of the Denver shunt versus the Le Veen shunt has been assessed recently, especially for malignant ascites. Some technical and perioperative details merit more attention, to limit the high risk ratio. Control of the intrathoracic position of the catheter tip, the maintenance of the bloodflow in the jugular vein, the intramuscular tunnelisation of the peritoneal catheter, the discard of 3 or 5 liters ascitic fluid and the substitution of part of it by physiological fluid, perioperative prophylactic antibiotics and heparinisation, flow-rate control in the postoperative period by changing patients position, respiratory exercises, daily flushing, all those measures limit the risk of fibrinolysis (DIC), shunt occlusion, fluid overload and infection. The fear of metastasis by shunt is unfounded, since the survival of the primary tumor is mostly too short (41). The postoperative follow up in an intensive care unit is necessary during 24-72 hours.
Three children with symptomatic bronchogenic cysts are presented. Because of the variability in clinical presentation and the shortcomings of diagnostic procedures, bronchogenic cysts present a diagnostical problem. In view of the risk of serious complications an aggressive attitude towards all congenital cystic lung lesions is advised, even when they are asymptomatic. Surgical excision assures an excellent outcome in most cases, and is therefore the treatment of choice.
In disseminated nonseminomatous testicular cancer, chemotherapy is the first choice because this treatment can be curative. To illustrate the particular indications for surgical excision of pulmonary metastases from primary nonseminomatous testicular cancer three patients are presented who were operated on during the past two years. Surgery is recommended to ascertain the histologic nature of remaining metastases after chemotherapy, when there is no further response to chemotherapy or a partial response only. Histologic findings range from necrotic pulmonary lesions to benign transformation or viable tumor. These results should guide further therapy, particularly to decide whether chemotherapy should be continued or changed.
Total occlusion of the left common femoral artery occurred after total hip replacement. Presumably the occlusion was caused by polymerization heat produced by the methyl-methacrylate. Only two similar cases have been reported previously. The vascular complications after hip surgery are discussed.
Thrombolytic therapy is an effective, rapid method in treatment of massive lung embolism and major deep venous thrombosis extending to the caval vein. Besides resolution of the thrombus and improving hemodynamics, it prevents evolution to chronic pulmonary hypertension or postphlebitic syndrome. To have a beneficial effect in the early course of acute myocardial infarction, thrombolytic therapy should be instored within about three hours after the onset of pain; a real brief time limit. Intracoronary or systemic fibrinolysis later than the three hours period does not improve cardiac wall motion and hemodynamics and cannot assure infarct size reduction in spite of reestablished coronary flow. In peripheral arterial disease, fibrinolytic therapy of thrombosed grafts or vessels facilitates detection and unmasking of the underlying anatomical lesion permitting definite therapy (graft revision, percutaneous transluminal angioplasty). Selective intraarterial infusion has given encouraging results. Thrombolysis is a reasonably safe therapeutic method, on the condition of respecting all contraindications and avoiding unnecessary punctions. Allergy and hyperthermia are mostly benign and responsive to medical treatment. Cost-effectiveness renders streptokinase the most applicated thrombolytic agent.
Bronchopleural fistulas remain a severe complication of pulmonary surgery and pulmonary disease. Treatment often requires multiple surgical interventions. The etiology, the methods for diagnosis and the different possible therapeutic procedures are discussed.
Forty-seven cases treated for atherosclerotic occlusion of the abdominal aorta are reported. The classical trans-abdominal approach used in all our cases is compared with alternative approaches. The reasons for this preference are discussed.
Although it is not uncommon to encounter a Mecklel's diverticulum in a patient with Crohn's disease, the involvement of this diverticulum by Crohn's disease is less common. A well performed radiological small intestinal study strongly suggests the diagnosis, which is definite after histologic examination of the reported.
The surgical indications of a benign multinodular euthyroid struma are: compression of trachea and oesophagus or a possible malignity of the lesion. The operation of choice is a bilateral subtotal lobectomy. To avoid postoperative vocal cord paralysis or hypocalcemia due to damage of the parathyroid glands, it is important to demonstrate systematically the recurrent nerve and spare the inferior thyroid artery.
Although vertical banded gastroplasty is considered as a safe and efficient bariatric procedure, reoperation rates either because of failure, or the induction of unacceptable side effects are important. In this study we evaluated 54 obese subjects with a history of vertical banded gastroplasty. One patient (2%) died postoperatively due to pulmonary embolism. Seven patients (13%) underwent a reoperation. A new vertical banded gastroplasty because of dilatation of the pouch with weight regain resulted in a loss of 26% of the initial weight after 3 years (1 patient). The vertical staple line disrupted in 4 patients: restapling failed after 1.5 year (1 patient), conversion into a gastric bypass resulted in a loss of only 12% of the initial weight after 3 years (1 patient), conversion into a biliopancreatic diversion resulted in a loss of 43 and 32% of body weight after 18 and 6 months, respectively (2 patients). In 2 cases a Nissen fundoplication was performed with good result for reflux oesophagitis. Since regastroplasty was not entirely successful in our hands, we consider biliopancreatic diversion as the method of choice for failed vertical banded gastroplasty.
A major problem in the surgical treatment of diffuse peritonitis is to obtain a complete clearance of septic foci in the peritoneal cavity which may lead to persistence of sepsis and multiple organ failure. We describe our experience with staged abdominal re-explorations using a Zipper system in 23 patients with a mean APACHE II score of 20.3 (s.e.m: 1.5). A total of 91 lavages were done in these patients. Overall mortality was 39%. None of the patients having an APACHE II score between 10 and 20 died whereas the predicted mortality was 15%-45%. After successful treatment, primary closure was possible in 8 of the 14 surviving patients. Large incisional hernias developed in 6 patients. One patient eviscerated two years after complete granulation of his laparostoma. Staged abdominal re-explorations using a Zipper system is an useful tool in the treatment of diffuse peritonitis.
In the treatment of diffuse peritonitis, planned relaparotomies with peritoneal lavages using a zipper system (EthiZip Ethicon) are sometimes necessary to obtain a complete eradication of the infectious focus. While most reported series are dealing with an adult population, this review focuses on the treatment of peritonitis using a zipper system in a paediatric age group. In a period of 3 years, insertion of a zipper device and peritoneal lavages were considered necessary to control intraabdominal sepsis in 7 children (age varying from 5 days to 13 years). They consequently underwent planned relaparotomies with peritoneal lavages every 24 to 48 hours. The peritonitis was caused by necrotizing enterocolitis (3 patients), postoperative complications (3 patients) and long existing perforated appendicitis (1 patient). Physical status, assessed by the Acute Physiologic Score (A.P.S.), varied from 12 to 22 (mean 17.7). Usually more than one lavage was necessary (1 to 3, mean 1.9) before the abdomen was considered clean and the zipper could be removed. Closure of the abdominal cavity could be achieved primarily in all cases. All patients survived. Although no statistically significant conclusions can be drawn from this small series and although it is unclear whether these children would not have survived without the zipper, this review shows that planned relaparotomies with peritoneal lavages using a zipper system can be performed safely even in very small children.