2006 - UZ Leuven

CYRURGIE2006

Tot stand gekomen dank zijde financiële steun vanNavona BuildingCulliganlaan 1 c1831 DiegemTel. 02/710 54 73Fax: 02/710 54 09Verantw. Uitg. : Raad van HeelkundeRedactie: Elvire Helsemans, Diane PardonK.U.Leuven – U.Z. LeuvenHerestraat 49 – 3000 Leuven

Heelmeesters allerhande, verenig u!Als heelmeesters hebben we ervoor gekozen met onze handen, maarook volgens onze gegronde medische overtuiging onze patiënten tebehandelen.We hebben veelal een lange, soms moeizame opleiding doorlopen, ineen tijd dat de Wet Colla nog niet bestond.Uiteindelijk hopen we een beroep te kunnen uitoefenen dat ons eenmenswaardig bestaan verzekert en dat bij de bevolking toch nog hetaanzien krijgt dat het verdient.De laatste decennia zijn we er evenwel niet op vooruitgegaan: heelwat collega’s worden in hun ziekenhuis gereduceerd tot technischeuitvoerders van elders genomen medische beslissingen, bij velendreigen de financiële inkomsten zelfs te verminderen, de frequenteklachten van patiënten zijn geen bewijs van een grote waardering …We kunnen ons hier in eerste instantie tegen verzetten doorgeneeskunde van een hoge kwaliteit te bedrijven, dit is een conditiosine qua non, maar ook door in gesloten slagorde naar buiten te tredenversterken we onze positie.Het feit dat een boekje zoals “Cyrurgie” elk jaar een reeks behoorlijkewetenschappelijke prestaties van heelmeesters uit het Leuvensenetwerk bundelt, is en blijft een bewijs van een samenhorigheid ingunstige zin.Als voorzitter van de Raad Heelkunde van de UZ Leuven mag ik mijgelukkig prijzen met de eendrachtigheid die binnen onze disciplinesheerst. Dit werd recent nog maar eens bewezen. Maar we moetenverder gaan.Initiatieven die verschillende chirurgen, universitairen van welke almamater ook, en andere beroepsmensen behorende tot verschillendedeelgebieden, zowel vanuit het vlaams- als franstalig landsgedeelte,samenbrengen zal ik volmondig steunen.

Hopelijk leidt dit tot een orgaan dat door overheid, pers, politiek enmedische sector als representatief voor ons allen wordt ervaren.Vertrouwen en overleg tussen de verschillende collega’s zal binneneen constructief debat dikwijls tot een brede consensus leiden,resulterend in guidelines voor “good practices”.Dit alles zal niet alleen bijdragen tot het bevorderen van dewetenschappelijke waarde van ons medisch handelen, maarongetwijfeld ook onze beroepsbelangen ten goede komen!Tot slot, laten we niet vergeten dat het goed opleiden van onze ASO’songetwijfeld één van onze hoofdtaken is. Zij zijn ook nu reeds onzecollega’s, zij zijn onze toekomstige medewerkers. Hun belangen, hunmoeilijkheden zijn grotendeels ook de onze.Laat ons bewijzen dat samenhorigheid onze levens- enarbeidsvoorwaarden verbetert en uiteindelijk opleiding enpatiëntenzorg ten goede komt!Paul BroosJuli 2007

INHOUDSOPGAVEAbdominale Heelkunde 1Abdominale Transplantatiechirurgie 12Artikels uit het Leuvense Net 22Cardiale Heelkunde 25Multidisciplinair Borstcentrum 36Neurochirurgie 39Oncologische Heelkunde 44Orthopedie 49Plastische, Reconstructieve en Esthetische Heelkunde 72Thoraxheelkunde 94Traumatologische Heelkunde 118Urologie 127Vaatheelkunde 161

ABDOMINALE HEELKUNDEBRANNINGAN A.E., DE BUCK S., SUETENS P., PENNINCKX F.,D’HOORE A.: Intracorporal rectal stapling following laparoscopic totalmesorectal excision. Surg. Endosc., 2006; 20: 952-955.Background: Division of the rectum following total mesorectal excision(TME) using intracorporeal stapling devices is technically difficult dueto their width and limited roticulation. More than one cartridge is oftenrequired and resultant wedging of the stump may be associated withan appreciable leak rate.Methods: Three-dimensional reconstruction was performed of CT andMRI images from the lower abdomen of six patients undergoinglaparoscopic TME using the Amira software environment. The staplingdevice was virtually reconstructed by in-house developed software,superimposed over the point of division of the rectum and the site ofskin entry identified.Results: The 45 degrees angulation of available roticulating staplingdevices precludes perpendicular division of the rectum followinglaparoscopic TME. The optimal angulation for transverse rectalstapling varied between 62 and 68 degrees .Conclusion: A roticulating stapler with minimum angulation of 65degrees would achieve transverse division of the rectum followinglaparoscopic TME.BUDIHARTO T., HAUSTERMANS K., TOPAL B., VAN CUTSEM E.:(Neo)adjuvante behandeling bij het maagcarcinoom. Tijdschr. voorGeneeskunde, 2006; 62(19): 1393-1401.Maagkanker heeft een slechte prognose. Chirurgie is debehandelingsoptie bij voorkeur aangezien ze de therapie is met degrootste kans op genezing. Het recidiefpercentage ligt ook na radicaleheelkunde hoog, en de 5-jaarsoverleving na chirurgie alleen is laag.De rol van adjuvante chemotherapie bij maagkanker blijftcontroversieel door het ontbreken van een significanteoverlevingswinst in gerandomiseerde studies. Een recente studie (theMAGIC trial) in het Verenigd Koninkrijk heeft wel een voordeel inoverleving voor perioperatieve chemotherapie op heelkunde alleenaangetoond, waardoor deze behandeling daar nu de zorgstandaard isgeworden.1

De resultaten van een grote Noord-Amerikaanse studie (IntergroupTrial INT-0116) tonen aan dat postoperatieve chemoradiotherapiezorgt voor een overlevingsvoordeel in vergelijking met chirurgiealleen, waardoor deze therapie overgenomen werd als zorgstandaardin Amerika.Tevens blijft controverse bestaan over de uitgebreidheid van deheelkunde en over de plaats van nieuwe cytostatica, waarvan deeffectiviteit reeds bewezen werd bij gemetastaseerde maagkanker.Ook dient moderne conformele radiotherapie geïmplementeerd teworden om het toxiciteitsrisico te verminderen.In dit artikel wordt de huidige status van de (neo)adjuvantebehandeling bij maagkanker overlopen. Er zijn in ieder gevalbijkomende gerandomiseerde klinische studies nodig om dezorgenstandaard voor deze ziekte nauwkeuriger te kunnen bepalen.DELAERE P., HIERNER R., GOELEVEN A., D’HOORE A.: Reconstructionfor postcricoid pharyngeal stenosis after organ preservation protocols.Laryngoscope, 2006; 116(3): 504-506.Postcricoid hypopharyngeal stenosis is a devastating complication oforgan-sparing chemoradiation therapy for head and neck cancer. Thecombination of chemotherapy and radiation may improve the localcontrol and survival rate because of the additive or synergistic effect ofchemoradiation. However, the radiosensitization effect ofchemotherapy may also lead to increased acute toxicity and latecomplications. Little is known or understood about the pathogenesis ofchemoradiation-induced hypopharyngeal stenosis. It seems thatchemoradiation-induced mucositis results in ulceration of opposingsurfaces of redundant postcricoid mucosa. Healing of these opposingsurfaces occurs by secondary intention, leading to circumferentialcicatrix and subsequent postcricoid stenosis. It is a rare complicationthat occurs between 2 and 120 months after the termination ofradiation and correlates with progressive obliterative endarteritis andischemia. The addition of chemotherapy, hyperfractionated, andconcomitant boost radiation will result in higher toxicity and higher riskof stenosis. Partial or complete stenosis of the postcricoidhypopharynx leads to an inability to swallow resulting in aspiration andgastrostomy tube dependence. Patients with partial stenosis can bemanaged successfully with anterograde dilatation.Patients with complete postcricoid hypopharyngeal stenosis havepreviously remained gastric tube dependent. Bypassing of thepostcricoid area by using reconstructive tissue with the larynx in situ istechnically challenging. We have developed a reconstructiontechnique for complete postcricoid stenosis. The technique uses avariation of the “classical” free jejunal graft interposition technique.2

D’HOORE A., PENNINCKX F.: Laparoscopic ventral recto(colo)pexy forrectal prolapse: surgical technique and outcome for 109 patients. Surg.Endosc., 2006; 20: 1919-1923.The authors propose a new laparoscopic technique for correction ofrectal prolapse. The unique feature of this technique is that it avoidsany posterolateral dissection of the rectum. The mesh is sutured tothe anterior aspect of the rectum to inhibit intussusception. Thetechnique was applied in 109 consecutive patients to correct totalrectal prolapse. Conversion was needed for four patients. Nopostoperative mortality or major morbidity occurred. Minor morbiditywas noted for 7% of the patients, and a recurrence rate of 3.66% wasobserved. Because this technique limited the dissection and thesubsequent risk of autonomic nerve damage, a cure comparable withthat resulting from classical mesh rectopexy can be anticipated.DRIESSEN A., LANDUYT W., PASTOREKOVA S., MOONS J., GOETHALSL., HAUSTERMANS K., NAFTEUX P., PENNINCKX F., GEBOES K.,LERUT T., ECTORS N.: Expression of carbonic anhydrase IX (CA IX), ahypoxia-related protein, rather than vascular-endothelial growth factor(VEGF), a pro-angiogenic factor, correlates with an extremely poorprognosis in esophageal and gastric adenocarcinomas. Ann. Surg.,2006; 243(3): 334-340.Objective: To evaluate the expression of carbonic anhydrase IX (CAIX) and vascular-endothelial growth factor (VEGF) in esophageal andgastric adenocarcinomas and in turn with the histologic subtype.Summary Background Data: Tumor hypoxia is an important factor intherapy resistance. A low oxygen concentration in tumors stimulatesa.o. the expression of CA IX, a marker of hypoxia, and VEGF, a proangiogenicfactor.Methods: We evaluated the immunohistochemical expression of CA IXand VEGF on paraffin-embedded material of 154 resectionspecimens: 39 esophageal, 73 cardiac, and 42 distal gastricadenocarcinomas (UICC classification). The adenocarcinomas weresubtyped according to the Lauren classification (intestinal- and diffusetype).Statistical analysis: chi test, Kaplan-Meier survival analysis, log-ranktest, and Cox proportional hazards model.Results: CA IX and VEGF expression were independent of thelocalization of the tumor. However, intestinal-type adenocarcinomasshowed a significantly higher expression of CA IX as well as VEGFthan diffuse-type tumors. VEGF expression was associated with ahigh microvessel density. Although survival analysis showed that CAIX expression (P = 0.008) as well as the coexpression of CA IX and3

VEGF (P = 0.008) correlate with a poor outcome, only CA IXexpression is an independent prognostic factor for overall survival andmetastasis-free survival.Conclusion: The difference in expression of CA IX and VEGF betweenintestinal- and diffuse-type adenocarcinomas may possibly explain thedifferent clinical behavior of these tumors. CA IX expression, ratherthan VEGF positivity in tumors, enables the identification of asubpopulation, characterized by a more aggressive behavior and apoorer prognosis.FA-SI-OEN P., VAN DE GENDER P., PUTTER H., ECTORS N., D’HOOREA., TOPAL B., PENNINCKX F.: The effect of polyethylene glycol andbutyrate on anastomotic healing in the rat colon. Tech. Coloproctol.,2006; 10(4): 308-311.Background: The use of mechanical bowel preparation is muchdebated.Methods: We evaluated the effects of polyethylene glycol (PEG), withor without a single dose of 3.0 mmol butyrate (BUT), on the burstingpressure (BP) of an intact colon segment and a colon anastomosis inrats. Also, histopathologic damage was studied.Results: In rats without colectomy, the mean BP was 159.2 mmHg(SD=18.9) after PEG treatment and 116.7 mmHg (SD=27.5) incontrols (p=0.001). In rats with colectomy, the mean BP was 90.4mmHg (SD=45.9) in the PEG group, 108.0 mmHg (SD=31.9) in theBUT group, and 102.7 mmHg (SD=44.7) in controls (p=0.44). Nosignificant differences in histopathologic scores were observedbetween rats treated with PEG and controls.Conclusions: PEG does not interfere with anastomotic healing in ratsas measured by BP. No benefit of a single dose of butyrate wasobserved.FERRANTE M., DE HERTOGH G., HLAVATY T., D’HAENS G.,PENNINCKX F., D’HOORE A., VERMEIRE S., RUTGEERTS P., GEBOESK., VAN ASSCHE G.: The value of myenteric plexitis to predict earlypostoperative Crohn’s disease recurrence. Gastroenterology, 2006;130(6): 1595-1606.Background & Aims: Early ileocolonoscopy allows detection ofrecurrence after surgically induced remission of Crohn's disease (CD).Unequivocal histologic markers predicting recurrence have not beenidentified. We assessed the predictive value of neural lesions for earlyendoscopic CD recurrence and long-term reintervention risk.4

Methods: Ileocolonic resection specimens from 59 patients with CDand 21 control patients were histologically scored for typicalinflammatory bowel disease lesions, neural hypertrophy, andpresence and severity of inflamed ganglia and nerve bundles.Endoscopic recurrence was determined at 3 months in all patients andat 1 year in 32 patients as part of 2 prospective clinical trials.Results: Myenteric plexitis of the proximal resection margin waspresent in 32 patients with CD (54%) in absence of surroundinginflammation. Patients with this feature had a higher endoscopicrecurrence (Rutgeerts score >/=2) at 3 months (75% vs 41%; oddsratio, 4.36; 95% confidence interval, 1.44-13.23; P = .008) and at 1year (93% vs 59%; odds ratio, 9.80; 95% confidence interval, 1.04-92.70; P = .041) and had a trend toward an earlier reintervention(mean, 7.00 vs 5.30 years; P = .174). The severity of myentericplexitis in the proximal resection margin correlated with the severity ofendoscopic recurrence at 3 months (r = 0.334, P = .010) and 1 year (r= 0.560, P = .001). Myenteric plexitis was the only consistent predictorof endoscopic recurrence.Conclusions: The presence of myenteric plexitis in proximal marginsof ileocolonic resection specimens is predictive of early endoscopicCD recurrence.FERRANTE M., DE HERTOGH G., PENNINCKX F., VAN ASSCHE G.:Protein-losing enteropathy in Crohn’s disease. Clin. Gastroenterol.Hepatol., 2006; 3(6): A 25.A 21-year-old man presented with pitting edema at both ankles,persisting hypoproteinemia, and iron-deficiency anemia, for which hehad been treated in another hospital with regular infusions of humanalbumin and iron sucrose. For the past 4 years, Crohn’s disease hadaffected his entire gastrointestinal tract and had been treated withaminosalicylates, prednisolone, oral budesonide, azathioprine,methotrexate, and, after exclusion of tuberculosis, infliximab. Atpresentation, he was on oral budesonide and he had nogastrointestinal symptoms. Blood analysis showed lymphopenia,hypoproteinemia with hypoalbuminemia, hypochromic anemia withpossible iron deficiency, and normal liver and kidney function withoutproteinuria on a urine sample.A stool collection after administration of 51 Cr-chloride-radiolabeledalbumin intravenously was used to confirm our hypothesis of proteinlosingenteropathy 1 ; 49% of the administered dose was found in a 4-day stool collection, suggestive of major protein loss in thegastrointestinal tract (normally < 1%). Magnetic resonanceangiography showed no large-vessel vasculitis. A radiologic bariumfollow-through performed 1 year earlier was reviewed and showed5

severe ulcerative ileitis and jejunitis, without strictures or boweldilatation. We continued oral budesonide and supportive treatmentwith iron sucrose and human albumin monthly.FERRANTE M., PENNINCKX F., DE HERTOGH G., GEBOES K.,D’HOORE A., NOMAN M., VERMEIRE S., RUTGEERTS P., VAN ASSCHEG.: Protein-losing enteropathy in Crohn’s disease. Acta Gastroenterol.Belg., 2006; 69(4): 384-389.Protein-losing enteropathy (PLE) is a rare but severe complication ofCrohn’s disease (CD) and hypoalbuminemia can be one of thepresenting symptoms of this illness. The diagnosis of PLE can only bemade after exclusion of malnutrition and liver or kidney failure.Significant intestinal leakage can be caused by mucosal injury,increased lymphatic pressure or dilated lymphatics and has beenreported in a large number of diseases. The protein-losing can bediagnosed by assessing the excretion of different radiolabeledmacromolecules in the faeces or by the clearance of alpha-1-antitrypsine in stools. The primary approach should be theoptimization of the nutritional status. Medical treatment of theunderlying disease is primordial. In other cases surgical resection ofthe most affected areas is inevitable.We report a case of a 21-year-old male with a 4 year history of CD,who developed significant hypoproteinemia with pitting oedema,initially in the absence of any other sign of severe disease activity. A51 Cr-chloride albumin excretion confirmed our hypothesis of proteinlosingenteropathy. Because of sub-obstruction signs some monthslater, a laparotomy was performed which revealed a severely affectedloop with dilatation of the proximal jejunum. Interestingly, multiplelarge lymph nodes and dilated lymphatics were seen. A partial jejunalresection was performed for stricturing Crohn’s Disease. Histologyshowed severe mesenteric granulomatosis, dilated lymph vessels andgranulomatous vasculitis. After the resection our patient improvedwithout further albumin infusions and the oedema resolved.GOETHALS L., DEBUCQUOU A., PERNEEL C., GEBOES K., ECTORS N.,DE SCHUTTER H., PENNINCKX F., McBRIDE W., BEGG A.C.,HAUSTERMANS K.M.: Hypoxia in human colorectal adenocarcinoma:comparison between extrinsic and potential intrinsic hypoxia markers.Int. J. Radiation Oncology BIol. Phys., 2006; 65(1): 246-254.Purpose: To detect and quantify hypoxia in colorectaladenocarcinomas by use of pimonidazole and iododeoxyuridine6

(IdUrd) as extrinsic markers and carbonic anhydrase IX (CA IX),microvessel density (MVD), epidermal growth-factor receptor (EGFR),and vascular endothelial growth factor (VEGF) as intrinsic markers ofhypoxia.Methods and Material: Twenty patients with an adenocarcinoma of theleft colon and rectum treated by primary surgery were injected withpimonidazole and IdUrd. Serial sections of tumor biopsies were singlestained for VEGF, EGFR, Ki67, and double stained for blood vesselsin combination with either pimonidazole, IdUrd, or CA IX. Percentageof expression was scored as well as colocalization of pimonidazolewith CA IX.Results: The median percentage of hypoxia, as judged bypimonidazole staining, was 16.7% (range, 0-52.4%). The expressionof pimonidazole correlated inversely with the total MVD andendothelial cord MVD (R = -0.55, p = 0.01; R = -0.47, p = 0.04). Goodcolocalization was found between pimonidazole and CA IX in only30% of tumors, with no correlation overall between pimonidazole andCA IX, VEGF, or EGFR or between the different intrinsic markers.Cells around some vessels (0.08-11%) were negative for IdUrd butpositive for Ki 67, which indicated their lack of perfusion at the time ofinjection.Conclusion: Chronic and acute hypoxic regions are present incolorectal tumors, as shown by pimonidazole and IdUrd staining. Onlyin a minority of tumors did an association exist between the areasstained by pimonidazole and those positive for CA IX. Pimonidazolealso did not correlate with expression of other putative intrinsichypoxia markers (VEGF, EGFR).MISPELAERE B., FERRANTE M., AERTS R., OP DE BEECK K.,VANBECKEVOORT D., LIBBRECHT L., ROSKAMS T., VANSTEENBERGEN W., VERSLYPE C.: Een jonge man met dyspepsie enicterus. Tijdschr. voor Geneeskunde, 2006; 62(5): 390-398.Bij een 20-jarige man met dyspepsieklachten en icterus wordt dediagnose van alveolaire echinokokkose gesteld. Dit is een zeldzameparasitaire infectie, veroorzaakt door larven van de Echinococcusmultilocularis. Na ingestie van de larven ontwikkelt de volwassenworm zich in de dunne darm van zijn gastheer. De parasietvervolledigt zijn levenscyclus via intermediaire gastheren zoalsvossen, honden en katten.Een E. Multilocularis-infectie veroorzaakt traaggroeiende cystischemassa’s met tumorachtige aantasting van verschillende organen.Meestal is de lever aangetast. De symptomen kunnen zeer aspecifiekzijn en ontwikkelen zich meestal laattijdig door compressieuitgeoefend door de cystische massa’s. Specifieke radiologische7

tekens op CT en/of MRI kunnen een belangrijke bijdrage leveren tothet stellen van de juiste diagnose. Bijkomende serologische tests zijnbeschikbaar die niet alleen zinvol zijn bij diagnose, maar ook een rolspelen in de follow-up.Onbehandeld is de afloop van alveolaire echinokokkose slecht.Resectie van het aangetaste weefsel lijkt de beste behandeling.Indien resectie onmogelijk blijkt, is het opstarten van een therapie metbenzimidazolen gedurende weken, maanden of zelfs jarenaangewezen. Bij belangrijke leverdestructie kan levertransplantatieworden overwogen.PENNINCKX F., DANSE E. on behalf of the PROCARE Workgroup. On therole of radiologists in the Belgian project on cancer of the rectum,Procare. JBR-BTR, 2006; 89(1): 19.-22.Radiologists are involved at all stages of the treatment of patients withrectum cancer: in the preoperative staging, in the diagnosis ofpostoperative complications, in the detection of recurrent or metastaticdisease during follow-up, in the monitoring of the therapeutic effect ofpalliative therapy. PROCARE is a Belgian national project to improveoutcome in all patients with rectum cancer. Guidelines were made bya multidisciplinary workgroup and are available on the web.Decentralised implementation of guidelines is organised by thescientific and professional organisations. It is planned that a centralreview committee of radiologists, delegated by the Royal BelgianSociety of Radiology, will survey the quality of preoperative staging.Overall quality of care will be assured by registration in a specificnational database starting in 2006. Participating teams will receiveannual feedback. Radiologists should provide data on cTNM stagingand cCRM. Differentiation between cT2 and cT3, cN0 and cN+, andmeasurement of the cCRM in mm are crucial as they have a relevantimpact on treatment strategy. While spiral abdominal CT is adequatefor cM staging, high-resolution MRI is highly recommended and, infact, a necessity for locoregional staging because its adequacy issuperior to that of CT-scan and EUS. However, EUS is mandatorywhen local excision is considered, i.e. for cT1N0 lesions.PENNINCKX F., VAN EYCKEN L., MICHIELS G., MERTENS R.,BERTRAND C., DE CONINCK D., HAUSTERMANS K., JOURET A.,KARTHEUSER A., TINTON N. on behalf of the PROCARE working group.Survival of rectal cancer patients in Belgium 1997-1998 and thepotential benefit of a national project. Acta Chir. Belg., 2006; 106: 149-157.8

Background: PROCARE, a Belgian multidisciplinary project on rectalcancer (RC), will be launched in 2006. Guidelines have beendeveloped, but remain to be implemented.Aim: A population-based study on RC treatment and outcome inBelgium and comparison with recent international benchmarks inorder to better define targets that should be reached.Patients and methods: Anonymous data of 3079 patients with rectalcancer registered in the National Cancer Registry in 1997 and 1998were analysed. Observed (OS) and relative survival (RS) werecompared with figures from nation-wide projects and multi-centrestudies.Results: The 5-yr OS and RS were 46.6% and 58.5%, respectively.For patients with stage I-III tumours 5-yr OS was 57.1% and 5-yr RS70.1%. Adjuvant or neo-adjuvant treatment was given in 54.8% stageII-III patients who were < 70 years old. There were markeddifferences between the provinces in the use of radiotherapy for stateII-III patients and in 5-yr RS for all stages. In stage IV, the median OSwas 13 months and the 2-yr OS was 28%. Comparison with recentmulti-centre trials indicates significant potential benefits from thePROCARE project: an absolute increase of the 5-yr OS by 10 to 20%after chemoradiotherapy and TME in stage II-III patients 75 years oldor less, a 7-month increase of the median OS and an absolute 15%increase of the 2-yr OS in unresectable stage IV patients withcombined chemotherapy.Conclusion: Significant improvement seems to be achievable.Implementation of the PROCARE guidelines with quality assurancethrough prospective registration in a specific database, however, is acrucial prerequisite for credible audit of performance and feedback toindividual teams.ROBIJN J., SEBRECHTS E., MISEREZ M.: Management of incidentallyfound Meckel’s diverticulum. A new approach: resection based on arisk score. Acta Chir. Belg., 2006; 106: 467-470.The management of incidentally found Meckel’s diverticulum (MD)remains unclear. The risk for future complications of a non-resectedMD must be weighed against the risk of complications for a resectedMD in order to justify a prophylactic resection. Morbidity-rates afterresection of incidentally found MD are much lower than those afterresection of symptomatic MD. Several risk factors which increase therisk for future complications of an asymptomatic MD have beendescribed in the literature. We suggest that an asymptomatic MDshould be removed in cases where there is a higher risk of itbecoming symptomatic in the future, on condition that the resectioncan be done with presumed low morbidity. Based on the literature9

data we propose a scoring system in order to base the decision forsurgery on more objective grounds and weighted criteria. The RiskScore is based on 4 risk factors: male sex, patients younger than 45years, diverticula longer than 2 cm and the presence of a fibrousband. We suggest resection of an asymptomatic MD with a Risk Score≥ 6 points. A transverse diverticulectomy is preferable in most cases.In short, broad MD, or in the case of a palpable mass at the base, awedge-shaped excision is the best alternative.ROELS S., DUTHOY W., HAUSTERMANS K., PENNINCKX F.,VANDECAVEYE V., BOTERBERG T., DE NEVE W.: Definition anddelineation of the clinical target volume for rectal cancer. Int. J.Radiation Oncology Biol. Phys., 2006; 65(4): 1129-1142.Purpose: Optimization of radiation techniques to maximize local tumorcontrol and to minimize small bowel toxicity in locally advanced rectalcancer requires proper definition and delineation guidelines for theclinical target volume (CTV). The purpose of this investigation was toanalyze reported data on the predominant locations and frequency oflocal recurrences and lymph node involvement in rectal cancer, topropose a definition of the CTV for rectal cancer and guidelines for itsdelineation.Methods and Materials: Seven reports were analyzed to assess theincidence and predominant location of local recurrences in rectalcancer. The distribution of lymphatic spread was analyzed in another10 reports to record the relative frequency and location of metastaticlymph nodes in rectal cancer, according to the stage and level of theprimary tumor.Results: The mesorectal, posterior, and inferior pelvic subsites aremost at risk for local recurrences, whereas lymphatic tumor spreadoccurs mainly in three directions: upward into the inferior mesentericnodes; lateral into the internal iliac lymph nodes; and, in a few cases,downward into the external iliac and inguinal lymph nodes. The risk forrecurrence or lymph node involvement is related to the stage and thelevel of the primary lesion.Conclusion: Based on a review of articles reporting on the incidenceand predominant location of local recurrences and the distribution oflymphatic spread in rectal cancer, we defined guidelines for CTVdelineation including the pelvic subsites and lymph node groups atrisk for microscopic involvement. We propose to include the primarytumor, the mesorectal subsite, and the posterior pelvic subsite in theCTV in all patients. Moreover, the lateral lymph nodes are at high riskfor microscopic involvement and should also be added in the CTV.10

STAS Ph., D’HOORE A., VAN ASSCHE G., GEBOES K., STEENKISTE E.,PENNINCKX F., RUTGEERTS P., VERMEIRE S.: Miliary tuberculosisfollowing infliximab therapy for Crohn disease: A case report andreview of the literature. Acta Gastroenterol. Belg., 2006; 69(2): 217-220.We present a cased of miliary tuberculosis diagnosed 15 months afterinfliximab treatment despite negative screening for previous exposureto Mycobacteria on skin PPD and chest X-ray. This case shows that –although screening for TB with a skin PPD and a chest X-ray shouldbe performed in all patients – this is not 100% effective and may be aproblem in patients on concomitant immunosuppression. The clinicalcourse of this patient further shows that in a patient treated with anti-TNF antibodies who’s condition does not improve one should alwaysbe aware of the possibility of a tuberculosis infection. Even thoughtuberculosis is usually not rapidly fatal, the disease may show afulminant course in immunocompromised patients.TOPAL B.: Multidisciplinair management van het maagcarcinoom.Heelkundige stagering en behandeling. Tijdschr. voor Geneeskunde,2006; 62(19): 1387-1392.Heelkundige resectie is de enige potentieel curatieve behandelingvoor patiënten met een maagcarcinoom. De postoperatieve morbiditeiten mortaliteit zijn het laagst in ziekenhuizen met een hoog volume,alsook in ziekenhuizen met een laag volume met ervarenmultidisciplinaire teams. De lokalisatie van een maagcarcinoom enzijn metastaseringspatroon naar de lymfeklieren bepalen deuitgebreidheid van de heelkundige resectie. Een uitgebreide of D2-lymfeklierdissectie kan beschouwd worden als de standaardprocedurewaarbij minstens 15 lymfeklieren microscopisch dienen onderzocht teworden. De rol van de laparoscopie is voorlopig gevestigd in destagering, terwijl laparoscopische resecties best uitgevoerd worden ingespecialiseerde centra.11

ABDOMINALETRANSPLANTATIECHIRURGIECASSIMAN D., ROELANTS M., VANDENPLAS G., VAN DER MERWES.W., MERTENS A., LIBBRECHT L., VERSLYPE C., FEVERY J., AERTSR., PIRENNE J., MULS E., NEVENS F.: Orlistat treatment is safe inoverweight and obese liver transplant recipients: a prospective, openlabel trial. Transplant Int., 2006; 19(12): 1000-1005.Obesity is a frequent complication following liver transplantation and isinsufficiently responsive to dietary and life style advice. We studiedthe safety of orlistat treatment in obese and overweight liver transplantrecipients (n = 15) on a stable tacrolimus-based immunosuppressiveregimen. For safety reasons, the treatment period was restricted (6months 120 mg t.i.d., 3 months 120 mg daily). Three patients droppedout, tacrolimus dose was adjusted in six of 12 remaining patients(dose reduction in 4, increase in 2, P = N.S.). All dose adjustmentsoccurred during the 6 months of orlistat 120 mg t.i.d. therapy. No drugintolerance, adverse events or episodes of rejection occurred duringthe study. Efficacy of orlistat treatment in this population could not beshown, because a formal control population was not included in thissafety trial. Moreover, only a significant decrease of waistcircumference (P < 0.01 versus start of the study), but not of weight orbody mass index, was achieved in the treated group. Orlistattreatment is well tolerated in liver transplant recipients and can bestarted safely, provided immunosuppressive drug levels and dietaryadherence are closely monitored.DECAESTECKER J., VERSLYPE C., WILMER A., PIRENNE J., NEVENSF.: Acuut leverfalen: nieuwe bevindingen. Tijdschr. voor Geneeskunde,2006. 62(1): 1-6.Acuut of fulminant levervalen is een klinisch syndroom met een plotseen ernstige daling van de leverfunctie in afwezigheid van voorafbestaand leverlijden, gekenmerkt door encefalopathie en ernstigestollingsstoornissen (PT < 40%). De belangrijkste oorzaken in dewesterse wereld zijn intoxicaties en virale hepatitis.De mortaliteit van acuut leverfalen is zeer hoog. Vaak is eenlevertransplantatie de enige oplossing, maar hierbij is het afwegen12

van de risico’s van een onnodige transplantatie tegenover deze vaneen te late indicatiestelling voor transplantatie zeer moeilijk.De belangrijkste prognostische criteria blijven voorlopig de King’sCollege-criteria en in mindere mate de Clichy-criteria. Op dit ogenblikis er nog onvoldoende evidentie voor het gebruik van artificiëleleverondersteuning als brug tot dringende transplantatie.DURNEZ A., VERSLYPE C., NEVENS F., FEVERY J., AERTS R.,PIRENNE J., LESAFFRE E., LIBBRECHT L., DESMET V., ROSKAMS T.:The clinicopathological and prognostic relevance of cytokeratin 7 and19 expression in hepatocellular carcinoma. A possible progenitor cellorigin. Histopathology, 2006; 49(2): 138-151.Aims: Cytokeratin (CK) 7 and CK19 expression, present in hepaticprogenitor cells (HPCs) and in cholangiocytes but not in normalhepatocytes, has been reported in some hepatocellular carcinomas(HCCs); however, the incidence and relevance of this expression inHCC in Caucasians is not known. Therefore, our aim was to study theoccurrence and clinicopathological characteristics of HCC expressingCK7 and/or CK19 in 109 Caucasian patients.Methods and Results: The expression of hepatocellular differentiationmarkers (Hepar, canalicular polyclonal carcinoembryonic antigen),biliary/progenitor cell markers (CK7, CK19), alpha-fetoprotein (AFP),p53 and beta-catenin in HCC was semiquantitatively assessed byimmunohistochemistry. Of 109 HCCs, 78 were CK7-/CK19- (72%), 13CK7+/CK19- (12%), seven CK7-/CK19+ (6%), 11 CK7+/CK19+(10%). CK19 expression was significantly associated with elevatedserum AFP (400 ng/ml) (P = 0.023), tumour AFP expression (P 2 mg/dl) (P = 0.0005) andless nuclear beta-catenin expression (P = 0.003). HCC expressingCK19 had a higher rate of recurrence (P = 0.009, hazard ratio 12.5, n= 31) after liver transplantation compared with CK19- tumours.Conclusions: In our series, 28% of HCCs contained cells expressingCK7 and/or CK19. They potentially derive from HPCs. The higherrecurrence rate of CK19+ HCC after transplantation suggests a worseprognosis for these HCCs compared with CK19- HCC.13

DYCKMANS K., LERUT E., GILLARD P., LANNOO M., ECTORS N.,HOORENS A., MATHIEU C., COOSEMANS W., VANRENTERGHEM Y.,KUYPERS D.: Post-transplant lymphoma of the pancreatic allograft in akidney-pancreas transplant recipient: a misleading presentation.Neprhol. Dial. Transplant, 2006; 21: 3306-3310.A 37-year-old male patient underwent combined kidney-pancreastransplantation with an immuno-suppressive treatment consisting oftacrolimus, mycophenolate mofetil and steroids, after inductiontherapy with anti-thymocyte globulin. The pancreas graft had intestinaldrainage. Twenty-seven days post transplantation, the patientdeveloped an episode of acute graft pancreatitis, which respondedwell to conservative measures (i.v. fluids, nil per orally, histamine-2receptor blockade). On day 45, renal function was stable with a serumcreatinine of 1.28 mg/dl, corresponding to a measured creatinineclearance of 57 ml/min. Because of persistent postprandialhyperglycaemia, the addition of low-dose insulin therapy wasnecessary for a period of 6 weeks after transplantation.Two months post transplantation, the patient was admitted because ofdiarrhoea and a rise in serum creatinine to 2.49 mg/dl. A renal biopsyshowed acute cellular rejection grade Ib according to the revised Banff2001 criteria. The patient was treated with corticosteroids, resulting ina good clinical and biochemical response. However, renewed insulintherapy was temporally required during this rejection episode and wasdiscontinued during further follow-up. Stool cultures at that timerevealed Campylobacter jejuni, for which doxycylin was administeredfor 10 days.GOEGEBUER A., PIRENNE J., AERTS R., NEVENS F.:Levertransplantatie via levende donatie bij volwassenen: eenliteratuuroverzicht. Tijdschr. voor Geneeskunde, 2006; 62(5): 368-374.Levertransplantatie is de levensreddende behandeling vooronomkeerbaar leverfalen. Door de exponentiële toename van detransplantatiekandidaten is er de laatste jaren een toegenomen tekortaan kadaverlevers opgetreden. Een alternatief is levende donatie.Aangezien bij een dergelijke ingreep kleinere levervolumes wordengebruikt, zijn de beste kandidaat-receptoren de patiënten die nog eengoede leversynthesecapaciteit hebben, zoals patiënten met cirroseverwikkeld met een hepatocellulair carcinoom. De huidige overlevingop korte termijn voor levertransplantatie door middel van levendedonatie is vergelijkbaar met deze van kadaverlevers. Bij de ingreeptreden bij de acceptor echter meer biliaire en vasculaireverwikkelingen op. De voornaamste zorg blijft het risico van morbiditeit14

van de gezonde donor met een gerapporteerd mortaliteitsrisico van0,5%.KATOONIZADEH A., NEVENS F., VERSLYPE C., PIRENNE J., ROSKAMST.: Liver regeneration in acute severe liver impairment: aclinicopathological correlation study. Liver International, 2006; 26(10):1225-1233.Background: Although normally quiescent, the adult mammalian liverpossesses a great capacity to regenerate after different types ofinjury. Major players in the regeneration process are mature residualcells, including hepatocytes, cholangiocytes and stromal cells.However, if the regenerative capacity of mature cells is impaired,hepatic progenitor cells (HPCs) are activated and expand into theliver parenchyma. Upon transit amplification, the progenitor cellsgenerate new hepatocytes and biliary cells to restore liverhomeostasis.Aims/Methods: To study the relationship between differenthistopathological parameters as well as their correlations with clinicalparameters and outcome, we examined liver specimens from 74patients with acute or subacute severe liver impairment byimmunohistochemistry for CK7/CK19 (evaluation of HPCsactivation/differentiation), Mib1(Ki 67)/P21 (evaluation of proliferativeactivity/proliferation arrest of hepatocytes) and hematoxylin andeosin (evaluation of hepatocyte loss).Results: Of the 74 patients, 32% survived without transplantation,14% died without transplantation and 54% were transplanted. Ourresults show that a threshold of 50% loss of hepatocytes, associatedwith significant decrease in the proliferative activity of remainingmature hepatocytes, is needed for extensive hepatic progenitor cellactivation. Such activation is a sign of disease severity and occursearly (within 1 week) in the disease course. However, developmentof intermediate hepatocytes, suggesting HPCs differentiationtowards mature hepatocytes, takes at least 1 week's time. We founda positive correlation between histopathological parameters(percentage hepatocyte loss, number of proliferating hepatocytesand number of HPCs) and clinical parameters of liver impairmentsuch as model for end stage liver diseases (MELD). Survivingpatients compared with those who either died or were transplantedhad significantly less hepatocyte loss, less HPCs activation andmore mature hepatocyte proliferative activity. Hepatocyteproliferative activity and degree of hepatocyte loss were the mostimportant independent histopathological parameters in predictingoutcome. Conclusion: Liver biopsy can provide important additionalinformation in a patient with severe acute liver impairment.15

LERUT J., ORLANDO G., ADAM R., SABBA C., PFITZMANN R.,KLEMPNAUER J., BELGHITI J., PIRENNE J., THEVENOT T., HILLERT C.,BROWN C.M., GONZE D., KARAM V., BOILLOT O.: Liver transplantationfor hereditary hemorrhagic telangiectasia. Report of the European LiverTransplant Registry. Ann. Surg., 2006; 244(6): 854-864.Background: Hereditary hemorrhagic telangiectasia (HHT) or Rendu-Osler-Weber disease is a rare disease characterized by the presenceof arteriovenous malformations. Hepatic involvement can lead to lifethreateningconditions.Material and Methods: Forty patients, reported to the European LiverTransplant Registry, were analyzed to define the role of livertransplantation in the treatment of the hepatic disease form.Indications for transplantation were classified according to Garcia-Tsao: cardiac failure (14 patients), biliary necrosis causing hepaticfailure (12 patients), severe portal hypertension (5 patients), cardiacfailure and biliary necrosis (6 patients), cardiac failure and portalhypertension (2 patients), and cardiac failure associated with biliarynecrosis and portal hypertension (1 patient). Eighteen (81%) of 22patients had pulmonary artery hypertension. Twelve (30%) patientshad pretransplant hepatic interventions. Follow-up was complete forall patients with a mean of 69 months (range, 0-230 months).Results: One-, 5- and 10-year actuarial patient and graft survival ratesare 82.5%. Six of the 7 pretransplant procedures performed on thehepatic artery were severely complicated. Cardiovascular functiondocumented in 24 patients improved in 18 patients and remainedstable in 5 patients; 1 patient died perioperatively of acute heartfailure. Twenty-four (60%) patients had post-transplant complications,all but one occurring within the first 4 posttransplant months. Seven(17.5%) patients died perioperatively, 6 of them due to bleeding and 1due to cardiac failure; 1 (2.5%) patient died late due to chronicrejection. There were 2 possible recurrences. Quality of life markedlyimproved in all 32 surviving patients.Conclusion: The results of the largest reported transplant series in thetreatment of hepatic-based HHT are excellent. Elimination ofhepatobiliary sepsis and reversal of cardiopulmonary changesdramatically improve quality of life of the recipients. LT should beproposed earlier in the course of symptomatic hepatic HHT presentingwith life-threatening conditions. Palliative interventions, especially onthe hepatic artery, should be avoided in view of their high (infectious)complication rate.16

LIBBRECHT L., CASSIMAN D., VERSLYPE C., MALEUX G., VAN HEESD., PIRENNE J., NEVENS F., ROSKAMS T.: Clinicopathological featuresof focal nodular hyperplasia-like nodules in 130 cirrhotic explant livers.Am. J. Gastroenterol., 2006; 101(10): 2341-2346.Objectives: Focal nodular hyperplasia-like nodules (FNH-like nodules)are focal lesions occurring in liver cirrhosis and are morphologicallyvery similar to classical FNH in an otherwise normal liver. They aresometimes misdiagnosed as hepatocellular carcinoma (HCC) onimaging because both types of lesions show arterial-phaseenhancement. Although the morphological, immunohistochemical, andimaging features of FNH-like nodules are well-known, theirpathogenesis and role in hepatocarcinogenesis have not been studiedin detail. Therefore, we performed a detailed pathological evaluationof 130 cirrhotic explant livers and correlated these data with theclinical features of the patients.Methods: All cirrhotic explant livers were uniformly sliced at 5-mmintervals and all detected focal lesions were microscopically classifiedaccording to internationally accepted criteria. The obtained dataregarding FNH-like nodules were then correlated with otherpathological findings and with clinical data obtained duringpretransplant evaluation and recorded in a database.Results: FNH-like nodules were present in 15% of patients and theirsmall size (75% of cases < 1 cm) appears to preclude detection byimaging in almost all cases. The presence of esophageal varices andpretransplant treatment with chemoembolization were independentlyand significantly associated with the presence of FNH-like nodules.There were no associations between FNH-like nodules on the onehand and low-grade dysplastic nodules, high-grade dysplasticnodules, and HCCs on the other hand.Conclusions: The clinicopathological features of FNH-like nodulessupport the hypothesis that vascular alterations in liver cirrhosis playan important role in their pathogenesis and that FNH-like nodules donot have an increased risk of malignant transformation.LIBBRECHT L., SEVERI T., CASSIMAN D., VANDER BORGHT S.,PIRENNE J., NEVENS F., VERSLYPE C., VAN PELT J., ROSKAMS T.:Glypican-3 expression distinguishes small hepatocellular carcinomasfrom cirrhosis, dysplastic nodules, and focal nodular hyperplasia-likenodules. Am. J. Surg. Pathol., 2006; 30(11): 1404-1411.Distinguishing small hepatocellular carcinoma (HCC) from other typesof small focal lesions that occur in a cirrhotic liver can be difficult onthe basis of morphologic features alone. We investigated whether theexpression of glypican-3 (GPC3) could be an ancillary tool in the17

histopathologic diagnostic process. We performedimmunohistochemistry for GPC3 on 16 low-grade dysplastic nodules,33 high-grade dysplastic nodules, 13 focal nodular hyperplasia-likenodules, and 59 HCCs with a diameter less or equal to 3 cm presentin the cirrhotic liver of 66 patients. Both resected lesions and lesionsbiopsied by needle were included and nonlesional cirrhoticparenchyma was also stained. In a subset of cases (23 samples ofcirrhosis, 4 low-grade dysplastic nodules, 5 high-grade dysplasticnodules, 2 focal nodular hyperplasia-like nodules, and 18 HCCs), realtime reverse transcriptase-polymerase chain reaction for GPC3 wasperformed. GPC3 expression was, both on immunohistochemistry andby real time reverse transcriptase-polymerase chain reaction, muchhigher in small HCCs than in cirrhosis and other types of small focallesions, indicating that the transition from premalignant lesions tosmall HCC is associated with a sharp increase of GPC3 expression ina majority of cases. The sensitivity and specificity of a positive GPC3-staining for the diagnosis of HCC in small focal lesions was 0.77 and0.96, respectively, in resected cases, and 0.83 and 1, respectively, forneedle biopsies. Because the result of the staining was easilyinterpretable, immunohistochemistry for GPC3 is valuable ancillarytool in the histopathologic diagnosis of small focal lesions in cirrhosis.PIRENNE J., HOFFMAN I., MISEREZ M., COOSEMANS W., AERTS R.,MONBALIU D., FERDINANDE P., HIELE M., VAN ASSCHE G.,RUTGEERTS P., JANSSENS J., TACK J., VLASSELAERS D., DESMET L.,NEVENS F., VEEREMAN G., FEVERY J., LOMBAERTS R.: Selectioncriteria and outcome of patients referred to intestinal transplantation:an European center experience. Transplantation Proceedings, 2006.38(6): 1671-1672.Until 1998, intestinal transplantation (SBT) had not been performed inour region of Flanders, Belgium. Potential SBT activity was not knownand selection criteria had not been validated. A multidisciplinary SBTprogram was launched in 1998. We analyzed requests for SBT andoutcomes in these patients whether with or without SBT. Listing forSBT was only considered for patients with irreversible short bowelsyndrome who had developed life-threatening complications of totalparenteral nutrition, but whose general condition was still thoughtcompatible with surgery and immunosuppression. During the studyperiod 1998 to 2004, one third of the requests for SBT (10/31) weredeemed suitable. SBT in this group was lifesaving (100% survival)when performed in time. Mortality in this group without SBT was high(67%). Two thirds of the patients (21/31) did not fulfill the SBTinclusion criteria, either because they were "too moribund" to toleratetransplantation or because they were "too well". This preliminary study18

emphasized the importance of (1) early referral of potential SBTcandidates, (2) adherence to strict criteria for listing patients for SBT,and (3) referral of intestinal donors to procurement organizations.PIRENNE J., KAWAI M.: The protective effect of the liver: does it applyto the bowel too? Transplantation, 2006; 81(7): 978-979.Calne and Kamada demonstrated that the liver is an“immunoprivileged” organ. Indeed, in some rodent and porcine strains,the liver is accepted without or with minimal immunosuppression. Livertransplant patients usually need less immunosuppression thanrecipients of other organs. In contrast with other organs, acuterejection of the liver has less impact on long-term graft survival.Histologically-proven episodes of liver acute rejection can sometimesbe self-limiting. Finally, chronic rejection of the liver is rare: 2% versus20% after transplantation of other solid organs.Mechanisms behind the “liver effect” are not completely elucidated butinclude both deletional and nondeletional pathways. Soluble MHCmolecules released by the liver allograft act as blocking factor. Morerecently, it was shown that liver-derived donor cells induce peripheralclonal exhaustion and deletion through activation-induced cell death(AICD). Among nondeletional pathways,various mechanisms havebeen hypothesized, including anergy, Th2 deviation, and morerecently the generation of regulatory cells.PIRENNE J., KAWAI M.: Tolerogenic protocol for intestinaltransplantation. Transplantation Proceedings, 2006; 38(6): 1664-1667.Transplantation is standard therapy for many patients suffering fromkidney, liver, or heart failure. In contrast, transplantation of theintestine remains a high-risk procedure, which is performed in aminority of patients with short bowel syndrome. The difficulty is thestrong alloimmune response caused by intestinal grafts and thecomplications of the profound immunosuppression. We tested a newclinical immunomodulatory protocol using donor-specific bloodtransfusion, a strategy that was popular before the introduction ofcyclosporine and was recently shown to promote development ofregulatory cells. Low-dose steroids and low-dose tacrolimus wereadministered based on previous observations that tolerance requiresan intact immune system, that over-immunosuppression iscounterproductive, and that high doses of calcineurin inhibitors blockdevelopment of regulatory cells whereas low doses promote it. Finally,inflammation within the intestinal graft was minimized to reduce the19

additional stimulants that the innate immunity of the transplantedintestine exert on the adaptive immune response. Under this protocol,freedom from rejection was achieved in four consecutive intestinaltransplant recipients using extremely low immunosuppression.SCHAFER-KELLER P., LYON S., VAN GELDER F., DE GEEST S.: Apractical approach to promoting adherence to immunosuppressivemedication after renal transplantation. Curr. Opin. Nephrol. Hypertens.,2006; 15 (Clinical update): S1-S6.Renal transplant recipients are expected to adhere to a lifelongtherapeutic regimen designed to preserve long-term graft function andto reduce the risk of complications. Adherence to immunosuppressionis a critical component of this regimen, but studies using electronicmonitoring, the most sensitive tool currently available, have foundnon-adherence rates of 20-26% in adult patients, whereas a meanprevalence of 32% has been reported among adolescent renaltransplant recipients. Non-adherence after renal transplantation is animportant clinical problem because even comparatively low rates ofnon-adherence are associated with increased risks of acute rejection,graft loss, reduced quality of life, and mortality. All members of thetransplant team including hospital-based and communitynephrologists, surgeons, nurses and therapists, should be aware ofthe possibility of non-adherence and be prepared to intervene.Promoting adherence is not straightforward, because risk factors fornon-adherence are multifactorial and individual to each patient. As aresult, intervention is more likely to promote lasting adherence if it islong term and takes place within the context of a chronic-illnessmanagement model that integrates behavioural, psychosocial andmedical aspects of care appropriate to the unique needs of theindividual patient.SMETS S., OYEN R., COOSEMANS W., KUYPERS D.R.J.: An unusualcause of ureteral obstruction in a renal allograft. Nephrol. Dial.Transplant, 2006; 21(12): 3593-3594.We describe a 66-year-old patient, on haemodialysis since 2002because of chronic renal failure due to chronic glomerulonephritis ofuncertain origin (supposedly IgA nephropathy). In March 2006, heunderwent cadaveric donor kidney transplantation. The allograft hadone polar artery, with the anastomosis made on the right internal iliacartery, the main renal artery was anastomosed to the right commoniliac artery. The immunosuppressive regime consisted of steroids,20

tacrolimus and mycophenolate mofetil. The immediate post-operativephase was unremarkable until day 10, when a mild rise in plasmacreatinine concentrations was noted (from 1.65 to 1.74 mg/dl) despitestable urine output. An ultrasound was performed, showing severehydronephrosis of the graft without enlargement of the ureter. Anephrostomy was promptly placed. The plasma creatinine level fellover the next day to its previous value (1.65 mg/dl on day 12). Anantegrade percutaneous pyelography study revealed an importantdilation of the pyelocalyceal system, stenosis of the ureteropelvicjunction (UPJ) and a normal diameter of the ureter.VAN GELDER F., VAN HEES D., DE ROEY J., MONBALIU D., AERTS R.,COOSEMANS W., DAENEN W., PIRENNE J.: Implementation of anintervention plan designed to optimize donor referral in a donorhospital network. Progress in Transplantation, 2006; 16(1): 46-51.Context: The shortage of donor organs remains the most importantfactor of waiting list mortality in organ transplantation worldwide.Donor detection is influenced by the legal system, family refusal, andunderreporting caused by erroneous knowledge of donation criteriaand lack of familiarity with the procedure.Objective: To identify possible key factors of donor referral patternswithin an existing cooperation with donor hospitals and donor unitsacross the Dutch-speaking part of Belgium, an area of approximately3 million inhabitants. An intervention plan to optimize the cooperationand procedure quality and efficiency was designed.Design: The intervention plan was based on 3 essential principles indonor referral by donor reporters, information on donor criteria,facilitation of the donor procedure, and communication between donorreporters and the transplant center. The interventions were structuredto optimize all 3 of these principles. Two successive periods of 4 yearswere retrospectively compared.Participants: Data were collected retrospectively on donor referralbehavior from a total of 37 donor hospitals and donor units over an 8-year period.Main outcome measures: The referrals were reviewed for potentialdonors, effective donors, percentage of effective donors, refusal rateof relatives, number of tissue donors, impact on local and nationaltransplant programs, and national donor numbers.Results: Data showed a significant positive impact on donor referralsand donor referral behavior (+27% potential donors, +30% effectivedonors, +172.7% tissue donors, -7% family refusals rates, +9.63%national donors). The results stress the importance of reducedworkload and optimization of communication and informationavailability in an existing donor hospital network.21

ARTIKELS UIT HETLEUVENSE NETCREVITS J.H., BRUGMAN E., CEUPPENS H., FRIBERG J., SEYNAEVEP.: Catheter perforation of the superior vena cava. Belg. Tijdschr. Radiol.,2006; 89: 122-123.Background: A 43-year-old woman with metastatic breast cancer hada Port-A-Cath (PAC) implanted on her anterior chest wall forchemotherapy purposes. The outlet catheter was inserted into the leftcephalic vein. Antero-posterior fluoroscopy showed the catheter tipreaching the right atrium via the subclavian vein and the superior venacava (SVC). A few hours after every session of chemotherapy, thepatient complained of severe right-sided subclavicular pain irradiatingto the right arm. The patient’s symptoms persisted.DE BRAUWER J., MASEREEL B., VISSER R., GEYSKENS P.:Pneumatosis intestinalis caused by ischaemic bowel: report of threecases. Acta Chir. Belg., 2006; 106: 592-595.Pneumatosis intestinalis is a rare condition in which gas is found inthe bowel wall. It exists in a primary form or can be secondary to anunderlying pathology. We present three cases of patients in whompneumatosis intestinalis was caused by ischaemic bowel. In all threecases, the diagnosis was made using CT scan. A partial bowelresection with ileocolic anastomosis was performed in every case. Allpatients fully recovered after surgery.DE RAET J., VANDEKERKHOF J., BAEYENS I.: Ruptured femoralpseudo-aneurysm through the skin: a rare vexing complicationfollowing aortobifemoral reconstruction. Acta Chir. Belg., 2006; 106: 420-422.A man, aged 73, presented with a pulsatile mass in his left groin areaafter an aortobifemoral reconstruction 24 years ago. This caseshowed a femoral pseudo-aneurysm that evolved very quickly torupture through the skin requiring emergency operative repair.22

D’HONDT M., VANSTEENKISTE F., VAN ROOY F., DEVRIENDT D.:Gastrogastric fistula after gastric bypass. Is surgery always needed?Obesity Surgery, 2006; 16(11): 1548-1551.Because of regain of weight to BMI 37.1 kg/m(2) 6 years after a VBG,a 41-year-old female now underwent revision to divided Roux-en-Ygastric bypass, performed laparoscopically. 12 days postoperatively,she started bleeding from the main stomach, and CT scan revealedthat the bypassed stomach was distended with clot. She was treatedconservatively and stopped bleeding. Upper GI series 2 weekspostoperatively revealed a large gastrogastric fistula between the tinypouch and the bypassed stomach. We initially planned to close thefistula. However, upper GI series 2 months and 4 monthspostoperatively showed no sign of gastrogastric fistula, and protonpump inhibitors were stopped. At 1 year after gastric bypass, ourpatient has had good weight loss.MALEUX G., THIJS M., HEYE S., VANDEKERKHOF J.: Cannulated screwfor proximal tibial fracture complicated by iatrogenic poplitealpseudoaneurysm: definitive treatment by ultrasound-guided thrombininjection. J. Trauma, 2006; 61(5): 1261-1263.Vascular complications associated with placement of cannulatedscrews for fractures are very rare and estimated to occur in less than1% of cases using external fixation. These vascular iatrogenic lesionsare mostly arterial thromboses associated with distal ischemia andpseudoaneurysms with potential to embolize, to compress theadjacent vein, or to rupture. Therefore, treatment is mandatory andclassically consists of surgical reconstruction of the injured vessel.Recently, some minimally invasive, image-guided techniques aredeveloped to treat definitively iatrogenic vascular injury, in particulariatrogenic, arterial pseudoaneurysms.In this article we describe a case of a giant, iatrogenic poplitealpseudoaneurysm developed after placement of a screw to treat aproximal open tibial bone fracture. Because of recent bone surgeryand the residual, inflammatory changes in the popliteal fossa, weopted for a minimally invasive treatment consisting of an ultrasoundguidedembolization of the pseudoaneurysm by direct injection ofhuman thrombin. Control ultrasound after 1 month, 1 year, and 2years, demonstrates a successful and durable thrombosis of thepseudoaneurysm and a progressive shrinkage of its volume over time.23

PRUYT M., DEVRIENDT D., VANNESTE A.: Malignant melanoma andadenocarcinoma of a Barrett Oesophagus. Acta Chir. Belg., 2006; 106(5):616-618.An adenocarcinoma with a malignant melanoma in a Barrettoesophagus is extremely rare. We did not find any other cases in theEnglish literature. The diagnosis of a malignant melanoma can bedifficult but can be made by tissue examination with a specialimmunoreaction with several markers to see it expresses S-100, butlacks activity for KER and EMA. S-100 is relatively non-specific as asingle immunodeterminant in the diagnosis separation of melanomaand anaplastic carcinoma, but very sensitive. Immunohistochemically,these tumours react to S-100 protein, neuron-specific enolase andHMB-45 antibody (less sensitive than S-100), but not to cytokeratin orCEA. In our case it was obvious that there were two different tumoursbecause the MM was negative for cytokeratin, but theadenocarcinoma was positive for cytokeratin.WOLTHUIS A.M., WATKINSON A.F., KINSELLA D.C., THOMPSON J.F.:Complex iliac and bilateral common femoral artery aneurysms: a novelhybrid procedure. Surgeon, 2006; 4(2): 111-113.A 74-year-old man presented with a right common iliac arteryaneurysm and bilateral common femoral artery aneurysms. Theseaneurysms were repaired by a hybrid procedure. A one-stageapproach was chosen including an endovascular stent-graft andfemoro-iliaco-femoral Y-bypass grafting. The authors describe a novelcombined open and endovascular approach to repair these complexaneurysms.24

CARDIALE HEELKUNDEBAKIR I., VAN TRICHT I., VERDONCK R., MEYNS B.: In vitro set-up ofmodified Blalock Taussig shunt: vascular resistance-flow relationship.Int. J. Artif. Organs., 2006; 29(3): 308-317.Background: A modified Blalock-Taussig (mBT) shunt is ananastomosis created between the systemic and pulmonary arterialtree in order to improve pulmonary blood flow in neonates andchildren with congenital heart disease. The aim of this study was toassess vascular resistance-flow relationship in an in vitro set-up of amodified Blalock Taussig shunt.Methods: A shunt set-up was constructed with the vessels of a sheep.A modified BT shunt was anastomosed between an innominate(brachiocephalic) and a right pulmonary artery. A Medos pump(ventricular assist device) was used to create pulsatile flow. Threedifferent mean pulmonary artery flow rates (Q PA ) were applied.Once mean pulmonary and mean aortic flows (Q AO ) were fixed,shunt flow rates for twelve different pulmonary vascular resistances (Rp ) were investigated.Results: For all three pulmonary flow rates, the shunt flow decreasedwith increasing pulmonary resistance. In addition, systemic flowdecreased compared to pulmonary flow. When pulmonary flow ratewas set at 800 ml/min and aorta flow rate at 900 ml/min, thedistribution of flow between pulmonary and systemic organs flow ratesranged between 69% - 70% and 30% - 31% respectively. Similarly,when both pulmonary and aorta flow rates were set at 900 ml/min,pulmonary and systemic organ flows ranged between 73% - 77% and23% - 27% respectively. For pulmonary and aorta flow rates of 1000ml/min and 900 ml/min, respectively, the distribution of flow betweenpulmonary and systemic organ flow rates varied between 79% - 83%and 17% - 21% respectively.Conclusion: Knowledge of the relationship between vascularresistances and flow in this surgically created in vitro mBT shunt setupmay be helpful in the clinical management of the patients whosesurvival is crucially dependent on the blood flow distribution betweenthe pulmonary and systemic circulation.25

BOSHOFF D., BUDTS W., MERTENS L., EYSKENS B., DELHAAS T.,MEYNS B., DAENEN W., GEWILLIG M.H.: Stenting of hypoplastic aorticsegments with mild pressure gradients and arterial hypertension.Heart, 2006; 92(11): 1661-1666.Objective: To determine the safety, feasibility and effectiveness ofstent expansion of hypoplastic aortic segments with pressuregradients in patients with arterial hypertension. DESIGN: Nonrandomisedprospective clinical trial.Setting: Tertiary referral centre, congenital cardiac unit. Patientselection: 20 consecutive patients (median age 14.5 years, range11.6-38.8 years) with arterial hypertension and a hypoplastic segmentof the aorta. Seventeen patients had successful previous archinterventions in a coarctation site.Interventions: Stent deployment in hypoplastic arch segments.Main outcome measures: Gradient across the aortic arch;complications early and during follow up; residual hypertension.Results: 23 stents were deployed: 13 in the cross and 10 in theisthmus. The mean gradient across the aortic arch decreased from 16(SD 6) (median 17) to 3 (4) (median 1) mm Hg (p < 0.001). In a fewpatients a mild gradient persisted just distal to the left carotid arterydue to residual orificial narrowing or acute angulation. Nocomplications occurred during or after the procedure. During follow upof 2.2 years (range 0.2-4.8 years) arterial hypertension resolved in 10patients and 10 required residual drug treatment with better control ofblood pressures.Conclusions: Pressure loss due to residual hypoplastic aorticsegments can be treated effectively and safely with stent expansion.Some patients remain mildly hypertensive and require additional drugtreatment.ECTOR B., WILLEMS R., HEIDBUCHEL H., GEWILLIG M., MERTENS L.,MEYNS B., DAENEN W., ECTOR H.: Epicardial Pacing: a single-centrestudy on 321 leads in 138 patients. Acta Cardiol., 2006. 61(3): 343-351.Objective: This study presents the long-term outcome of 321epicardial leads in 138 patients.Methods and results: All leads were Medtronic CapsureEpi model4965 steroid eluting leads. The 1-, 3-, and 5-year patient survival was91%, 83% and 77%, respectively.Twenty-seven patients died. In25/27 deaths a pacing-related death could be excluded. Strangulationof the heart by an abandoned epicardial lead was the cause of deathin one child. One other patient died suddenly at the age of 3 years.Failures occurred in 57 of 321 epicardial leads (18%). For all 321leads, the 1-, 3- and 5-year freedom from failure was 91%, 85% and26

71%, respectively.The cumulative proportion of patients without anylead defect was 85% after I year, 76% after 3 years and 62% after 5years. The percentage of patients without serious adverse events at 1,3, and 5 years was 97%, 91%, 85%, respectively. Lead fracture wasthe cause of failure in 15 leads of 9 patients. An important increase inpacing threshold occurred in 35 leads of 30 patients. Other failureswere: diaphragmatic stimulation, infection, excessive traction andstrangulation. Eighteen failures were repaired by 11 surgicalinterventions in 9 patients.Thirty-nine defects were corrected noninvasivelyin 31 patients.Conclusions: The use of steroid-eluting epicardial leads has proven tobe an adequate option. In paediatric cardiology, the epicardialapproach remains an indispensable tool for achieving a life-longpacing.ELLGER B., DEBAVEYE Y., VANHOREBEEK I., LANGOUCHE L.,GIULIETTI A., VAN ETTEN E., HERIJGERS P., MATHIEU C., VAN DENBERGHE G.: Survival benefits of intensive insulin therapy in criticalillness: impact of maintaining normoglycemia versus glycemiaindependentactions of insulin. Diabetes, 2006; 55(4): 1096-1105.Tight blood glucose control with insulin reduces morbidity andmortality of critically ill patients. However, the relative impact ofmaintaining normoglycemia and of glycemia-independent actions ofinsulin remains unknown. We therefore independently manipulatedblood glucose and plasma insulin levels in burn-injured, parentally fedrabbits over 7 days to obtain four study groups: two normoglycemicgroups with either normal or elevated insulin levels and twohyperglycemic groups with either normal or elevated insulin levels. Westudied the relative impact of glycemia and glycemia-independenteffects of insulin on survival; myocardial contractility in an open chestpreparation; endothelial function in isolated aortic rings; and liver,kidney, and leukocyte function in a rabbit model of critical illness.Mortality was significantly lower in the two normoglycemic groupsindependent of insulin levels. Maintaining normoglycemia,independent of insulin levels, prevented endothelial dysfunction aswell as liver and kidney injury. To increase myocardial systolicfunction, elevated insulin levels and prevention of hyperglycemia wererequired concomitantly. Leukocyte dysfunction was present in the twohyperglycemic groups, which could in part be rescued by insulin. Theresults suggest that the observed benefits of intensive insulin therapyrequired mainly maintenance of normoglycemia; whereas glycemiaindependentactions of insulin exerted only minor, organ-specificimpact.27

FLAMENG W., MEURIS B., HERIJGERS P., HERREGODS M.C.:Prosthesis-patient mismatch is not clinically relevant in aortic valvereplacement using the Carpentier-Edwards Perimount valve. Ann.Thorac. Surg., 2006; 82(2): 530-536.Background: Previous studies have shown that prosthesis-patientmismatch (PPM) results in higher early and late mortality afterbioprosthetic aortic valve replacement. Careful selection of stentedbioprostheses was recommended to avoid inadequate effective orificearea. We studied the incidence of PPM and its potential effects onclinical outcome in patients undergoing aortic valve replacement usingthe Carpentier-Edwards Perimount bioprosthesis.Methods: Independent predictors of early and late mortality andhospital readmission for cardiac reasons were defined in 506 patients(mean age, 73 years; range, 57 to 87 years) by multivariate analysis.Mean follow-up was 6.1 +/- 4.8 years; maximum follow-up was 18.6years.Results: The incidence of severe PPM (effective orifice area index 0.65 and < 0.85) was 20%. Multivariate analysis revealed thatmoderate PPM was not an independent predictor of early mortality,late mortality, or hospital readmission for cardiac reasons. Reductionof septal hypertrophy was similar in patients with and withoutmoderate PPM.Conclusions: The incidence of severe PPM is virtually nonexistentafter aortic valve replacement using the Carpentier-EdwardsPerimount valve. Moderate PPM is found in 20% of cases and isclinically irrelevant in this population.FLAMENG W., MEURIS B., YPERMAN J., DE VISSCHER G., HERIJGERSP., VERBEKEN E.: Factors influencing calcification of cardiacbioprotheses in adolescent sheep. J. Thorac. Cardiovasc. Surg., 2006;132(1): 89-98.Objective: We determined the possible effects of age,antimineralization treatments, circulatory implant conditions,prosthesis design, and valve-related structural aspects on valvecalcification in adolescent sheep.Methods: Calcium content was measured by means of atomicabsorption spectrometry in bioprostheses implanted in 120 sheep(age

pericardial, wall portion or cusp), and antimineralization treatment areindependent factors influencing calcification; implant duration beyond3 months was not. In juvenile sheep (age 5 months) the wall portion,as well as the cusps of the prosthesis, calcified significantly more thanin adolescent sheep (age 11 months). Irrespective of age, the cuspsof valves implanted in the mitral position calcified more than those inthe pulmonary position. The wall portion of stentless valves calcifiedmore than that of stented valves, and pericardial valves calcified lessthan porcine valves. The surfactant (Tween 80, No-React, and alphaamino-oleicacid) and alcohol (ethanol and octanediol) treatmentsignificantly reduced cusp calcification; sodium dodecylsulfate did not.None of the anticalcification treatments was able to prevent wallcalcification in stentless porcine valves.Conclusion: These findings suggest that tissue valve calcification isdetermined by many independent factors, which can be identified byusing adolescent sheep as a preclinical in vivo model.HILL E.E., HERIJGERS P., HERREGODS M.C., PEETERMANS W.E.:Infective endocarditis treated with linezolid: case report and literaturereview. Eur. J. Clin. Microbiol. Infect. Dis., 2006; 25(3): 202-204.Infective endocarditis (IE) remains a serious disease with mortalityrates of 20–25% after 1 year [1]. Antibiotic resistance may limit thetherapeutic options and compromise the outcome of infectiveendocarditis. Linezolid belongs to the oxazolidinone class ofantimicrobial agents. It has activity against multidrug-resistant grampositiveorganisms, including coagulase-negative staphylococci(CNS), methicillin-resistant Staphylococcus aureus (MRSA),glycopeptide intermediate S. aureus and vancomycin- resistantEnterococcus [2]. Linezolid has 100% bioavailability, allowingcontinuation of treatment via the oral route, an elimination half-life of5–7 h, and good tissue penetration. Linezolid has no cross-resistancewith other classes of antibiotics. Due to non-enzymatic oxidation of themorpholine ring, its clearance is not dependent on renal function orhepatic enzyme action. The most common adverse effects aregastrointestinal disturbances, and rarer complications are associatedwith prolonged linezolid therapy, such as reversible myelosuppressionwith anemia and thrombocytopenia, and peripheral and opticalneuropathy. The oxazolidinones are reversible non-selectivemonoamine oxidase inhibitors. Therefore, caution is required whenprescribing them with adrenergic or serotonergic agents such aspseudoephedrine, phenylpropanolamine, and selective serotonergicreuptake inhibitors [2, 3]. Successes and failures have been reportedfor IE cases treated with linezolid. We report the case of a patient with29

prosthetic valve endocarditis who was successfully treated withlinezolid.HILL E.E., HERIJGERS P., HERREGODS M.C., PEETERMANS W.E.:Evolving trends in infective endocarditis. Clin. Microbiol. Infect., 2006;12(7): 698-699.Infective endocarditis is a microbial infection of the endocardialsurface and, despite improvements in diagnostic accuracy, medicaltherapy and surgical techniques, mortality remains high. This reviewfocuses on changes in epidemiology, microbiology and diagnosis, aswell as changes in medical and surgical management of infectiveendocarditis affecting native and prosthetic valves in adults, that haveevolved during the past two decades. Significant changes haveincluded an increasing involvement of prosthetic valves andnosocomially-acquired disease, an increased involvement ofstaphylococci as the causative agents, and a recognition that elderlyindividuals with degenerative valvular disease are the most vulnerablepopulation. Topics still requiring study include whether and whenvalve replacement should be performed, and how to predictperivalvular complications or embolisation based on echocardiographyfindings. Optimisation of antimicrobial treatment schemes (choice ofthe antibiotic, dose and duration) also requires further investigation.MEURIS B., GEWILLIG M., MEYNS B.: Extreme levels of alphafetoproteinin newborn with a benign intrapericardial teratoma. Cardiol.Young., 2006; 16(1): 76-77.We report a neonate presenting with an intrapericardial benignteratoma and an exceptionally high level of alpha-fetoprotein. Suchsevere elevation of alpha-fetoprotein in a neonate with a teratoma isusually associated with the presence of immature or malignantelements, compromising the prognosis. The tumour in our patient,however, proved to be completely benign. We discuss recent findingswith regard to normal levels of alpha-fetoprotein levels in preterminfants, and in children with neonatal teratomas.MEYNS B., VERBEKEN E., KERKHOFFS W., BETHUYNE N., BAKIR I.,MARSEILLE O., SCHUMACHER O.: Partial support for chronic heartfailure with a subcutaneous pump. J. Heart Lung Transplant, 2006; 25(2):123-124.30

Background: A small axial flow pump (Circulite ®) can be insertedsubcutaneously to support the failing heart with 2 to 3 L/min. Theconcept consists of 1) an inflow from the left atrium, 2) an outflow graftto the subclavian artery and 3) a small rotary pump implanted in apacemaker pocket. We sought to investigate the hemodynamic in- andoutflow conditions of such an approach.Methods: Pumps were implanted in seven sheep (mean 75 ± 6 kg).The pump itself was positioned subcutaneously and the inflowcannula was inserted in the left atrium through a small thoracotomy.The outflow graft was sutured to the left carotic artery as a substitutefor the human subclavian artery. Flow and pressure distribution wasmeasured at implantation and on termination of the experiments (5weeks). Pumps were operated on lowest flow conditions for worsecase testing (2000 rpm). No anticoagulants or any other drugs wereadministered. Animals were euthanized and an autopsy wasperformed to investigate local histological effects and peripheralemboli.Results: At implantation, mean pump flow as 2.6 ± 1L/min and 68 ±0.1% of flow was directed toward the body. The blood pressuregradient between the left carotid artery and the rest of the body was18 ± 4 mmHg in systole and 27.6 ± 7 mmHg in diastole. Attermination, 85 ± 2% of pump flow was directed towards the body. Theblood pressure gradient decreased to 5 ± 8 mmHg in systole and 8 ± 8mmHg diastole. Autopsies showed no specific cardiac findings orperipheral emboli. The carotid artery showed preserved anatomy andendothelium at the level of and proximal to the outflow.Conclusion: Partial support with inflow from the left atrium and outflowto a peripheral vessel is feasible. Vascular adaptation and complianceallow the flow to be more directed toward the body than toward thedistal outflow of the vessel. This approach allows a minimal invasivesupport for patients in chronic heart failure.Disclosure: Circulite paid the cost of the research to investigate thehemodynamic performance of this device.MULLENS W., DE KEYSER J., VAN DORPE A., MEURIS B., FLAMENGW., HERREGODS M.C., VAN DE WERF F.: Migration of two venousstents into the right ventricle in a patient with May-Thurner syndrome.Int. J. Cardiol., 2006; 110(1): 114-115.May-Thurner syndrome is an uncommon process in which the rightcommon iliac artery compresses the left common iliac vein, possiblyresulting in pain, severe edema of the left leg or in left iliofemoral deepvein thrombosis Corrective surgical treatment requires extensivedissection. Therefore, endovascular venous stenting is currently used31

in these patients We present a case of migration of two iliacal veinstents into the right ventricle in a patient with May-Thurner syndrome.REGA F.R., NEVELSTEEN A., PEETERMANS W.E., HERREGODS M.C.,FLAMENG W., HERIJGERS P.: Simultaneous valve replacement andvenous patch repair of superior mesenteric artery aneurysm due toinfective endocarditis: a case report. Heart Surg. Forum, 2006; 9(5):E741-743.Background: Peripheral mycotic aneurysm development is a raresystemic complication of infective endocarditis.Case Report: We report on a case of a mycotic aneurysm of thesuperior mesenteric artery in a 66-year-old man with infectiveendocarditis of the mitral valve. After the mitral valve was replaced bya mechanical valve, a laparotomy was performed. The mycoticaneurysm was excised and the vessel was repaired by sewing anautologous venous patch at the neck of the aneurysm. Five yearsafter the operation, the patient is doing fine, with a normal morphologyand patency of the superior mesenteric artery.Conclusion: Our case demonstrates that simultaneous valve surgeryand repair of a superior mesenteric artery mycotic aneurysm bysewing a vein patch in the neck of the artery is a viable treatmentoption.VANDENBERGH A., FLAMENG W., HERIJGERS P.: Type II diabetic miceexhibit contractile dysfunction but maintain cardiac output byfavourable loading conditions. Eur. J. Heart Fail., 2006; 8(8): 777-783.Background: Cardiomyopathy in type II diabetes is incompletelyunderstood. The leptin receptor-deficient (db/db) mouse is a wellacceptedmodel of type II diabetes. To date, left ventricularcontractility has not been studied in animal models of type II diabeteswith in vivo load-independent parameters.Aim: To determine cardiac function in db/db mice in vivo.Methods: Cardiac function in 12- and 24-week-old db/db and wild-typemice was assessed using a microtip-pressure-conductance catheter.Results: Left ventricular contractile dysfunction, measured by loadindependentparameters (preload recruitable stroke work, end-systolicelastance, dP/dt-V(ed)), is present in diabetic mice from age 24 weeksonwards. Despite this contractile dysfunction, the conventionalparameters cardiac output, ejection fraction and dP/dt(max) weremaintained, which was due to an increased preload and decreased32

afterload. Ventriculo-arterial coupling was increased and mechanicalefficiency significantly reduced in db/db mice.Conclusion: Our results demonstrate that, despite impaired cardiaccontractility and mechanical efficiency, cardiac output is maintained indb/db mice by favourable loading conditions and that in vivo loadindependentmeasurements are necessary to fully characterizecardiac performance in animal models of pathophysiological states.VANDENBERGHE S., SEGERS P., STEENDIJK P., MEYNS B., ROBERTD.A.E., ANTAKI J.F., VERDONCK P.: Modeling ventricular functionduring cardiac assist: does time-varying elestance work? ASAIOJournal, 2006; 52(1): 4-8.The time-varying elastance theory of Suga et al. is widely used tosimulate left ventricular function in mathematical models and incontemporary in vitro models. We investigated the validity of thistheory in the presence of a left ventricular assist device. Leftventricular pressure and volume data are presented that demonstratethe heart-device interaction for a positive-displacement pump(Novacor) and a rotary blood pump (Medos). The Novacor wasimplanted in a calf and used in fixed-rate mode (85 BPM), whereasthe Medos was used at several flow levels (0-3l/min) in seven healthysheep. The Novacor data display high beat-to-beat variations in theamplitude of the elastance curve, and the normalized curves deviatestrongly from the typical bovine curve. The Medos data show how themaximum elastance depends on the pump flow level. We concludethat the original time-varying elastance theory insufficiently models thecomplex hemodynamic behavior of a left ventricle that is mechanicallyassisted, and that there is need for an updated ventricular model tosimulate the heart-device interaction.VANGHELUWE P., TJWA M., VAN DEN BERGH A., LOUCH W.E.,BEULLENS M., DODE L., CARMELIET P., KRANIAS E., HERIJGERS P.,SPIDIO K.R., RAEYMAEKERS L., WUYTACK F.: A SERCA2 pump with anincreased Ca2+ affinity can lead to severe cardiac hypertrophy, stressintolerance and reduced life span. J. Mol. Cell. Cardiol., 2006; 41(2): 308-317.Abnormal Ca(2+) cycling in the failing heart might be corrected byenhancing the activity of the cardiac Ca(2+) pump, thesarco(endo)plasmic reticulum Ca(2+)-ATPase 2a (SERCA2a) isoform.This can be obtained by increasing the pump's affinity for Ca(2+) bysuppressing phospholamban (PLB) activity, the in vivo inhibitor of33

SERCA2a. In SKO mice, gene-targeted replacement of SERCA2a bySERCA2b, a pump with a higher Ca(2+) affinity, results in cardiachypertrophy and dysfunction. The stronger PLB inhibition on cardiacmorphology and performance observed in SKO was investigated herein DKO mice, which were obtained by crossing SKO with PLB(-/-)mice. The affinity for Ca(2+) of SERCA2 was found to be furtherincreased in these DKO mice. Relative to wild-type and SKO mice,DKO mice were much less spontaneously active and showed areduced life span. The DKO mice also displayed a severe cardiacphenotype characterized by a more pronounced concentrichypertrophy, diastolic dysfunction and increased ventricular stiffness.Strikingly, beta-adrenergic or forced exercise stress induced acuteheart failure and death in DKO mice. Therefore, the increased PLBinhibition represents a compensation for the imposed high Ca(2+)-affinity of SERCA2b in the SKO heart. Limiting SERCA2's affinity forCa(2+) is physiologically important for normal cardiac function. Animproved Ca(2+) transport in the sarcoplasmic reticulum may correctCa(2+) mishandling in heart failure, but a SERCA pump with a muchhigher Ca(2+) affinity may be detrimental.VLASSELAERS D., DESMET M., DESMET L., MEYNS B., DENS J.:Ventricular unloading with a miniature axial flow pump in combinationwith extracorporeal membrane oxygenation. Intensive Care Med., 2006;32(2): 329-333.Objective: ECMO for acute cardiorespiratory failure is an establishedtherapeutic option. Persistent insufficient unloading of the left ventricle(LV) can compromise recovery of ventricular function. We decided toinsert a miniature rotary blood pump (Impella) for decompression ofthe LV. In contrast to previous experience with this new device, whereit was generally used for postcardiotomy heart failure or cardiogenicshock and inserted in the operating room or the catheter laboratory,this is the first report describing the potential of this technology in theintensive care unit, in a patient on ECMO and the value ofechocardiography guidance.Patient: A 13-year-old boy with a history of congenital heart diseasewas admitted to the ICU with acute cardio-respiratory failure.Interventions: On day 2 venoarterial ECMO was instituted because ofworsening cardiorespiratory insufficiency refractory to conventionaltreatment. On day 5 a percutaneous rotary blood pump was insertedto decompress the LV.Conclusions: A percutaneous miniature rotary blood pump can be analternative to decompress a failing LV in the setting of VA-ECMO.Echocardiography can avoid the use of fluoroscopy and the transportto a catheter laboratory to insert the rotary pump.34

WUYTS W.A., HERIJGERS P., BUDTS W., DE WEVER W., DELCROIX W.:Extensive dissection of the pulmonary artery treated with combinedheart-lung transplantation. J. Thorac. Cardiovasc. Surg., 2006; 132(1):205-206.A case of extensive dissection of the pulmonary artery was seen in awoman with pulmonary arterial hypertension (PAH) with severeinterscapular pain. The diagnosis was made on computedtomographic (CT) scan of the chest. This case report shows that in apatient with PAH with thoracic pain, dissection of the pulmonary arteryneeds to be excluded. The pathogenesis of pulmonary arterydissection is discussed, as well as diagnosis and therapeuticinterventions.35

MULTIDISCIPLINAIRBORSTCENTRUMMORALES L., PANS S., PARIDAENS R., WESTHOVENS R., TIMMERMAND., VERHAEGHE J., WILDIERS H., LEUNEN K., AMANT F., BERTELOOTP., SMEETS A., VAN LIMBERGEN E., WELTENS C., VAN DEN BOGAERTW., DE SMET L., VERGOTE I., CHRISTIAENS M.R., NEVEN P.:Debilitating muscoloskeletal pain and stiffness with letrozole andexemestane: associated tenosynovial changes on magnetic resonanceimaging. Breast Cancer Res. Treat., 2006; (Epub Springer Science +Business Media 24 october 2006).Objective: Arthralgia, skeletal and muscle pain have been reported inpostmenopausal women under treatment with third generationaromatase inhibitors (AIs). However, the pathogenesis and anatomiccorrelate of musculoskeletal pains have not been thoroughlyevaluated. Moreover, the impact of AI-induced musculoskeletalsymptoms on normal daily functioning needs to be further explored.Patients and methods: We examined 12 consecutive non-metastaticbreast cancer patients who reported severe musculoskeletal painunder a third generation AI; 11 were on letrozole and 1 onexemestane. Clinical rheumatological examination and serumbiochemistry were performed. Radiological evaluation of thehand/wrist joints were performed using ultrasound (US) and/ormagnetic resonance imaging (MRI).Results: The most common reported symptom was severe earlymorning stiffness and hand/wrist pain causing impaired ability tocompletely close/stretch the hand/fingers and to perform dailyactivities and work-related skills. Six patients had to discontinuetreatment due to severe symptoms. Trigger finger and carpal tunnelsyndrome were the most frequently reported clinical signs. USshowed fluid in the tendon sheath surrounding the digital flexortendons. On MRI, an enhancement and thickening of the tendonsheath was a constant finding in all 12 patients.Conclusions: Musculoskeletal pains in breast cancer patients underthird generation AIs can be severe, debilitating, and can limitcompliance. Characteristic tenosynovial, and in some patients jointchanges on US and MRI were observed in this series and have notbeen reported before.36

NEVEN P., PARIDAENS R., AMANT F., WILDIERS H., BERTELOOT P.,LEUNEN K., SMEETS A., WELTENS C., VAN DEN BOGAERT W., VANLIMBERGEN E., CHRISTIAENS M.R., VERGOTE I.: Adjuvant therapy forpostmenopausal ER-positive breast cancer. Why tamoxifen still has afuture? The Leuven point of view. Int. J. Gynecol. Cancer, 2006; 16(2):505-510.Currently, the value of predictive markers when choosing between anAI and tamoxifen such as levels of steroid receptors, an absent PR,HER-2 overexpression, gene profiles, molecular markers, andCYP2D6 polymorphisms have not prospectively been tested in largeclinical trials. Therefore, the choice between an AI and tamoxifen cancurrently only be based on “good old prognostic markers” as tumorgrade, size, and lymph node status. Retrospective analysis doessuggest a potential role for an absent PR when choosing betweentamoxifen and an AI, but data are inconsistent.Based on available results from published/presented trials, all threeAIs show great promise over tamoxifen in further increasing diseasefreesurvival from breast cancer whether they substitute for tamoxifenor whether they are given for 2-3 years after completion of tamoxifenfor 2-3 years. High-risk groups seem to benefit the most. However,survival differences of AIs over 5 years tamoxifen are unclear.Tamoxifen for 5 years therefore continues to play an important role inlow-risk patients with an endocrine-responsive tumor (PR present,HER-2 absent). Long-term serious side effects to tamoxifen likeendometrial cancer and thrombo-embolic events are rare andprobably preventable (clean uterus at baseline and there are riskfactors for deep vein thrombosis). Efficacy of AIs over tamoxifenshould be balanced against the tolerability profile of AIs, osteoporoticfractures, and cardiovascular risk. Bearing QOL data in mind, patientpreference for treatment should also be considered when choosingbetween efficacy and side effects to obtain the highest compliancepossible.RISHA A., SMEETS A., CHRISTIAENS M.R.: Aspergilloma of the breastin a lung transplantation patient: a case report. Acta Chir. Belg., 2006;106(6): 730-731.Discussion: Aspergillus is an ubiquitous saprophyte fungus found innature, commonly isolated from soil, plant debris and indoor airenvironment. Immune suppression is the major factor predisposing toopportunistic infections in man. The fungus affects essentially the lungof immune depressed patients. Extrapulmonary involvement is veryrare though almost any organ or system in the human body can beinvolved. Infections of the breast are mostly described in patients with37

east implant. Only two other cases of aspergilloma of the breastwere reported in the literature. In both cases the aspergilloma wastreated by surgical excision. In our patient, primary surgery wouldhave caused considerable cosmetic damage due to the size of thelump and the subcutaneous fistulae: furthermore the patient was veryreluctant to undergo surgery. The usual presentation is a painless noninflamed lump in the breast that could be easily mistaken for a breastcarcinoma. As in all breast lumps, correct imaging and ultrasoundguided biopsy should be performed. In immune suppressed patients aculture of the aspirate is advisable. The clinical response to acombination of voriconazole, amphotericine B and capsofungin wassuboptimal. With pozaconazole, the mass disappeared and totalclinical and MRI regression was obtained after almost one year. MRIhas proven to be an additional tool in evaluating the response to themedication.38

NEUROCHIRURGIECEYSSENS S., VAN LAERE K., DE GROOT T., GOFFIN J., BORMANS G.,MORTELMANS L.: [ 11 C] Methionine PET, histopathology and survival inprimary brain tumors and recurrence. AJNR, 2006; 27(7): 1432-1437.Background and purpose: [(11)C]Methionine (MET) PET imaging is asensitive technique for visualizing primary brain tumors andrecurrence/progression after therapy. The aim of this study was toevaluate the relationship between the uptake of MET andhistopathologic grading and to investigate the prognostic value of thetracer, in both settings.Methods: Cerebral uptake of MET was determined in 52 patients: in26 patients for primary staging (group A) and 26 patients withsuspected brain tumor recurrence/progression after therapy (group B).Semiquantitative methionine uptake indices (UI) defined by the tumor(maximum)-to-background ratio was correlated with tumor grade andfinal outcome.Results: Overall median survival was 34.9 months. MET showedpathologically increased uptake in 41 of 52 scans. Although a weaklinear correlation between MET uptake and grading was observed (R= 0.38, P = .028), analysis of variance showed no significantdifferences in MET UI between tumor grades for either group A or B.Benign and grade I lesions showed significant difference in METuptake in comparison with higher grade lesions (P = .006). UsingKaplan-Meier survival analysis, no thresholds could be found at whichMET was predictive for survival. Proportional hazard regressionshowed that only WHO grading class (low versus high) was predictiveof survival (P = .015).Conclusion: Interindividual MET uptake variability does not allownoninvasive grading on an individual patient basis. Moreover, there isno significant prognostic value in studying maximal methionine UI inbrain tumors. The clinical use of MET should therefore be primarilyfocused on questions such as detection of recurrence, biopsyguidance, and radiation therapy target volume delineation.DEPREITERE B., VAN LIERDE C., VANDER SLOTEN J., VANAUDEKERCKE R., VAN DER PERRE G., PLETS C., GOFFIN J. :Mechanics of acute subdural hematomas resulting from bridging veinrupture. J. Neurosurg., 2006. 104(6): 950-956.39

Object: Based on data from primate experiments it is known thatrotational acceleration in the sagittal plane and in a forward directionis most likely to produce acute subdural hematomas due to bridgingvein rupture. For protection against these lesions, knowledge ofrotational acceleration tolerance levels in humans is required. In thepresent study the authors analyze human tolerance levels for bridgingvein rupture by performing head impact tests in cadavers.Methods: Ten unembalmed cadavers were subjected to 18 occipitalimpacts producing head rotation in the sagittal plane with varyingrotational acceleration magnitudes and pulse durations. Rotationalacceleration was calculated from the linear acceleration historiesrecorded by three uniaxial accelerometers mounted on the side of thehead. Bridging vein ruptures were detected by injecting contrast dyeinto the superior sagittal sinus under fluoroscopy and by autopsyprocedures. Bridging vein ruptures were produced in six head impacttests: one test with a pulse duration of 5.2 msec and a peak rotationalacceleration of 13,411 rad/second2; three tests with a pulse durationbetween 7 and 8 msec and a peak rotational acceleration of 12,558,10,607, and 8567 rad/second2; and two tests with a pulse durationlonger than 10 msec and a peak rotational acceleration as low as5267 rad/second2.Conclusions: This is the only cadaveric study of bridging vein rupturefocused on short pulse durations, which are usually associated withfalls. The data suggest a tolerance level of approximately 10,000rad/second2 for pulse durations shorter than 10 msec, which seems todecrease for longer pulse durations.DE VLEESCHOUWER S., RAPP M., SORG R.V., STEIGER H.J.,STUMMER W., VAN GOOL S., SABEL M.: Dendritic cell vaccination inpatients with malignant gliomas: actual status and future directions.Neurosurgery, 2006; 59(5): 988-1000.Objective: Despite recent advances in neurosurgical resectiontechniques, radiation therapy, and chemotherapy, malignant gliomascontinue to have a dismal prognosis because relapses areunavoidable.Methods: Dendritic cell vaccination has recently emerged as apromising type of active immunotherapy that aims to induce ratherthan transfer specific antitumor immune responses in patients. Activeimmunotherapy is the only type of immunotherapy able to induceimmunological memory.Results: Although an increasing number of small clinical trials showsafety, feasibility, and immunological and clinical responses, thistechnology requires further clarification of some critical basic andclinical issues before its presumed place in the treatment of malignant40

gliomas can be specified. This article addresses the basic and clinicalpitfalls that, more than with conventional therapies, may interfere withthe potential benefits of this approach.Conclusion: Considering the particular mechanisms involved in theimmune modulation of tumor biology using dendritic cell-basedvaccinations, the authors summarize the arguments in favor of afurther, appropriate assessment of this technology.DUPONT P., VAN PAESSCHEN W., PALMINI A., AMBAYI R., VAN LOONJ., GOFFIN J., WECKHUYSEN S., SUNAERT S., THOMAS B., DEMAERELP., SCIOT R., BECKER A., VANBILLOEN H., MORTELMANS L., VANLAERE K.: Ictal perfusion patterns associated with single MRI-visiblefocal dysplastic lesions: implications for the non-invasive delineationof the epileptogenic zone. Epilepsia, 2006; 47(9): 1550-1557.Background: Invasive electroencephalogram (EEG) studies are oftenconsidered necessary to localize the epileptogenic zone in partialepilepsies associated with focal dysplastic lesions (FDL). Our aim wasto evaluate the relationships between subtraction ictal SPECTcoregistered with magnetic resonance imaging (MRI) (SISCOM)hyperperfusion clusters and MRI-visible FDL, and to establish apreliminary algorithm for a noninvasive presurgical evaluation protocolfor MRI-visible FDLs in patients with refractory epilepsy.Methods: Fifteen consecutive patients with refractory partial epilepsyand a single MRI-visible FDL underwent a noninvasive presurgicalevaluation including SISCOM. Each hyperperfusion cluster wasvisually analyzed, automatically quantitated, and its distance form thelesion as outlined on the MRI was measured. In patients whounderwent surgery, the volumes of resected brain tissue containingthe FDL, the SISCOM hyperperfusion cluster, and surrounding regionswere assessed on postoperative MRI and correlated with surgicaloutcome.Results: Fourteen of the 15 patients (93%) showed SISCOMhyperperfusion overlapping with the FDL. The FDL was detected onlyafter reevaluation of the MRI guided by the ictal SPECT in 7 of the 15patients (47%). Four distinct hyperperfusion patterns were observed,representing different degrees of seizure propagation. Nine patientshave been operated on. Five have been seizure-free since surgeryand one since a reoperation. The degree of resection of the MRIvisibleFDL was the major determinant of surgical outcome. Fullresection of the SISCOM hyperperfusion cluster was not required torender a patient seizure-free.Conclusion: Detailed analysis of SISCOM hyperperfusion patterns is apromising tool to detect subtle FDL on MRI and to establish theepileptic nature of these lesions noninvasively. Overlap between the41

SISCOM hyperperfusion cluster and MRI-visible FDL in a noninvasivepresurgical evaluation with concordant data may suffice to proceed toepilepsy surgery aimed at removing the MRI-visible FDL and the partof the hyperperfusion cluster within and immediately surrounding theFDL.GOFFIN J.: Complications of cervical disc arthroplasty. Semin. SpineSurg., 2006; 18: 87-98.To date, reported complications with cervical disc replacement havenot been numerous. However, the clinical experience is still limitedboth from the perspective of number of cases and duration of followup.As a consequence, likely failure is also contemplated in this article.There are a number of absolute and relative contra-indications forartificial disc surgery in the cervical spine. The intraoperative risks arenot terribly different from those known from anterior discectomy andfusion. Malpositioning of the prosthesis may be due to procedurerelatedor surgeon-related problems and might lead to short-term orlong-term failures. Early postoperative displacement may be avoidedby initial bone-interplant interface stability. Besides other factors,intermediate term postoperative loss of motion may be due to thedevelopment of paravertebral ossification, an issue that still needsmore investigation. From a theoretical viewpoint, long term weardebris formation might lead to loosening of the prosthesis; however,no corresponding case reports have been reported yet.HEYE S., MALEUX G., VAN LOON J., WILMS G.: Symptomatic stenosisof the carvernous portion of the internal carotid artery due to anirresectable medial sphenoid wing meningioma: treatment byendovascular stent placement. AJNR, 2006; 27(7): 1532-1534.A 48-year-old woman, with right-sided proptosis and decreased visualacuity, presented with acute left sensorimotor deficit. Recent ischemiain the right posterior watershed area was found on CT and MRimaging, as well as a right-sided medial sphenoid wing meningiomacausing high-grade stenotic encasement of the cavernous portion ofthe right internal carotid artery. Because the patient was symptomaticand complete resection of the meningioma was impossible, thestenosis was successfully treated with a balloon-expanding stent.42

MAAS A., MURRAY G., HENNEY III H., KASSEM N., LEGRAND V.,MANGELUS M., MUIZELAAR J.P., STOCCHETTI N., KNOLLER N.:Efficacy and safety of dexanabinol in severe traumatic brain injury:results of a phase III randomised, placebo-controlled, clinical trial.Lancet Neurol., 2006; 5: 38-45.Background: Traumatic brain injury is a major cause of death anddisability. We sought to assess the safety and efficacy of dexanabinol,a synthetic cannabinoid analogue devoid of psychotropic activity, insevere traumatic brain injury.Methods: 861 patients with severe traumatic brain injury admitted to86 specialist centres from 15 countries were included in a multi-centre,placebo-controlled, phase III trial. Patients were randomised to receivea single intravenous 150 mg dose of dexanabinol or placebo within 6h of injury. The primary outcome was the extended Glasgow outcomescale assessed at 6 months, with the point of dichotomisation intounfavourable versus favourable outcome differentiated by baselineprognostic risk. Prespecified subgroup analyses were defined by injuryseverity, recruitment rate, and time to dosing. Secondary analysisincluded control of intracranial pressure and quality of life. Analysiswere prespecified in the protocol and the statistical analysis plan. Thisstudy is registered with ClinicalTrials.gov, number NCT00129857.Findings: 846 patients were included in the efficacy analysis. Theextended Glasgow outcome scale at 6 months did not differ betweengroups; 215 (50%) patients in the dexanabinol group and 214 (51%)patients in the placebo group had an unfavourable outcome (oddsratio for a favourable response 1.04; 95% CI 0.79-1.36).Improvements in the control of intracranial pressure or quality of lifewere not recorded and subgroup analysis showed no indication ofdifferential treatment effects. Dexanabinol was not associated withhepatic, renal, or cardiac toxic effects.Interpretation: Dexanabinol is safe, but is not efficacious in thetreatment of traumatic brain injury.43

ONCOLOGISCHEHEELKUNDEBROUNS F., SCHUERMANS A., VERHAEGEN J., DE WEVER I., STAS M.:Infection assessment of totally implanted long-term venous accessdevices. J. Vasc. Access, 2006; 7: 24-28.Aim: Comparison of catheter tip versus port content culture techniquesto assess infection in totally implanted vascular access devices(TIVAD).Materials and methods: Comparison of pocket swab, catheter-tip andport content cultures after removing the silicon puncture septum in aprospectively collected consecutive series of 102 TIVAD removed forclinical suspicion of infection, between May 2000 and March 2003.Results: 102 totally implanted port-catheters in 98 patients, ageranging from 1 to 90 years (median 53 years), were removed 7 to2616 days after insertion (median 210 days). Infection of the pocketsurrounding the port was found in 21 cases, all proven by a positiveculture of the pocket swab. Out of the remaining 81 cases withoutpocket infection, 32 had only a positive catheter tip culture, whereas56 had a positive port content culture (p=0.0002). Always the samemicroorganism was isolated in the 32 patients with positive catheter tipand port content cultures. The main organisms identified with TIVADwere Coagulase Negative Staphylococcus (CNS) (41 cases) andCandida sp (15 cases). Eight out of the 21 pocket infections werecaused by Staphylococcus aureus.Conclusion: In the presence of local signs of infection, taking culturesof the pocket surrounding the port is sufficient for diagnostic purposes.When infection is localized within the device only, port content culturestaken after removal of the silicon septum are more often positive thancultures of the catheter tip, and constitute therefore a more reliabletool for the assessment of TIVAD infection.DE RAEDT T., COOLS J., DEBIEC-RYCHTER M., BREMS H., MENTENSN., SCIOT R., HIMPENS J., DE WEVER I., SCHOFFSKI P., MARYNEN P.,LEGIUS P.: Intestinal neurofibromatosis is a subtype of familial GISTand results from a dominant activating mutation in PDGFRA.Gastroenterology, 2006; 131(6): 1907-1912.44

Background & aims: Intestinal neurofibromatosis (Online Mendelianinheritance in Man database number 162220) is an alternate form ofneurofibromatosis. Patients present with neurofibromas limited to theintestine in the absence of any other typical features of NF1 and NF2.At present, the molecular basis of intestinal neurofibromatosis remainselusive. The aim of the present study was to find the gene responsiblefor intestinal neurofibromatosis and to characterize functionally themutation.Methods: Three candidate genes (NF1, KIT, and PDGFRA) werescreened for mutations in 3 sisters diagnosed with intestinalneurofibromatosis. Five tumors were available for pathologicexamination. Activation (phosphorylation) of PDGFRalpha wassubsequently tested by Western blot analysis on a transfected 293Tand Ba/F3 cell line.Results: We found an inherited mutation (Y555C) in thejuxtamembrane domain of PDGFRA in the affected individuals. TheY555C mutation leads to autophosphorylation and thus activation ofPDGFRalpha. These observations confirm that PDGFRalpha(Y555C)is an oncogenic kinase. The clinical phenotype in the reported familyresembles the syndrome of familial gastrointestinal stromal tumors(familial GIST). Somatic activating mutations in KIT and PDGFRA arefrequent in sporadic GISTs, and mutations in both genes have alsobeen described in familial GISTs. The tumors in the reported familyare morphologically identical to intestinal neurofibromas, but,immunohistochemically, they do not express S100 or any of theknown GIST markers.Conclusions: The inherited PDGFRA mutation in the reported familyshows that intestinal neurofibromatosis is allelic to familial GISTcaused by PDGRA mutations. We therefore propose that thesetumors be classified as familial KIT-negative gastrointestinal stromaltumors.DERAEDT K., VANDER POORTEN V., VAN GEET C., RENARD M., DEWEVER I., SCIOT R.: Multifocal kaposiform haemangioendothelioma.Virchows Arch 2006; 448: 843-846.Kaposiform haemangioendothelioma (KHE) is a rare, locallyaggressive vascular spindle cell proliferation, with resemblance toKaposi's sarcoma. This tumour usually occurs in skin andretroperitoneum of infants and young children and is oftencomplicated by the Kasabach-Merritt phenomenon (KMP). A 3-yearoldboy presented with a right submandibular swelling due tolymphadenopathies, a violaceous skin lesion at the left commissure ofthe lips and an ill-defined lesion in the right thyroid lobe. There weresome signs of KMP. Histological examination revealed a typical45

infiltrative multilobular spindle cell proliferation with slit-like vascularspaces in these three localisations. Immunohistochemical stainsshowed positivity for CD34 and CD31 and many alpha-smooth muscleactin-positive spindle cells around the vascular spaces. There was noHerpes virus type 8 expression. The presented case is unique in twoways. First, thyroid involvement of KHE has never been described inthe literature until now. Secondly, and most remarkably, the multifocalpresentation in three anatomically distinct and separated localisationsis extremely unusual.GUETENS G., PRENEN H., DE BOECK G., HIGHLEY M., DE WEVER I.,VAN OOSTEROM A.T., DE BRUIJN E.A.: Imatinib (Gleevec ® , Glivec ® )tumour tissue analysis by measurement of sediment and by liquidchromatography tandem mass spectrometry. J. Sep. Sci, 2006; 29(3):453-459.The analysis of the signal transduction inhibitor imatinib in patienttumour tissue using LC and MS/MS is described. The anticanceragent is eluted over RP-C18 within 2 mm together with its internalstandard STI571-d8. Calibration curves were prepared in red bloodcells (RBC). For quantitative isolation of the RBC, measurement ofsediment was applied. There were no indications of signalsuppression by substances originating in the biological matrix. Thelimit of determination in tumour tissue was in the range of thoserecorded for RBC and plasma. The assay is selective and sensitive,with its robustness favouring the experimental application in clinicaloncology and its routine use in animal experiments. The LOD was 4.5ng per gram in tumour tissue.MAERTENS O., PRENEN H., DEBIEC-RYCHTER M., WOZNIAK A., SCIOTR., PAUWELS P., DE WEVER I., VERMEERSCH J., DE RAEDT T., DEPAEPE A., SPELEMAN F., VAN OOSTEROM A., MESSIAEN L., LEGIUSE.: Molecular pathogenesis of multiple gastrointestinal stromal tumorsin NF1 patients. Human Molecular Genetics, 2006; 15(6): 1015-1023.Gastrointestinal stromal tumors (GISTs) are the most commonmesenchymal tumors of the gastrointestinal tract. KIT and PDGFRAactivating mutations are the oncogenic mechanisms in most sporadicGISTs. In addition to sporadic occurrences, GISTs are increasinglybeing recognized in association with neurofibromatosis type 1 (NF1),yet the underlying pathogenic mechanism remains elusive. To gain aninsight into the mechanisms underlying GIST formation in NF1patients, we studied seven GISTs from three NF1 patients with a46

combination of different techniques: mutation analysis (KIT, PDGFRAand NF1), western blotting, array CGH and ex vivo imatinib responseexperiments. We demonstrate that (i) the NF1-related GISTs do nothave KIT or PDGFRA mutations, (ii) the molecular event underlyingGIST development in this patient group is a somatic inactivation of thewild-type NF1 allele in the tumor and (iii) inactivation of neurofibrominis an alternate mechanism to (hyper) activate the MAP-kinasepathway, while the JAK-STAT3 and PI3K-AKT pathways are lessactivated in NF1-related GIST compared with sporadic GISTs. Inconclusion, we report for the first time the molecular pathogenesis ofGISTs in NF1 individuals and demonstrate that this type of tumorclearly belongs to the spectrum of clinical symptoms in NF1.WINNEPENNINCKX V., LAZAR V., MICHIELS S., DESSEN P., STAS M.,ALONSO S.R., AVRIL M.F., ORTIZ ROMERO P.L., ROBERT T.,BALACESCU O., EGGERMONT A.M.M., LENOIR G., SARASIN A., TURSZT., VAN DEN OORD J.J., SPATZ A.: Gene expression profiling ofprimary cutaneous melanoma and clinical outcome. J. Natl. Cancer Inst.,2006; 98(7): 472-482.Background: Gene expression profiling data for human primarycutaneous melanomas are scarce because of the lack of retrospectivecollections of frozen tumors. To identify differentially expressed genesthat may be involved in melanoma progression and prognosis, weinvestigated the relationship between gene expression profiles andclinical outcome in a cohort of patients with primary melanoma.Methods: Labeled complementary RNA (cRNA) from each tissuesample was hybridized to a pangenomic 44K 60-mer oligonucleotidemicroarray. Class comparison and class prediction analyses wereperformed to identify genes whose expression in primary melanomaswas associated with 4-year distant metastasis-free survival among 58patients with at least 4 years of follow-up, distant metastasis, or death.Results were validated immunohistochemically at the protein level in176 independent primary melanomas from patients with a medianclinical follow-up of 8.5 years. Survival was analyzed with a Coxmultivariable model and stratified log-rank test. All statistical testswere two-sided.Results: We identified 254 genes that were associated with distantmetastasis-free survival of patients with primary melanoma. These254 genes include genes involved in activating DNA replicationorigins, such as minichromosome maintenance genes and geminin.Twenty-three of these genes were studied at the protein level;expression of five (MCM4, P = .002; MCM3, P = .030; MCM6, P =.004; KPNA2, P = .021; and geminin, P = .004) was statisticallysignificantly associated with overall survival in the validation set. In a47

multivariable Cox model adjusted for tumor thickness, ulceration, age,and sex, expression of MCM4 (hazard ratio [HR] of death = 4.04, 95%confidence interval [CI] = 1.39 to 11.76; P = .010) and MCM6 (HR ofdeath = 7.42, 95% CI = 1.99 to 27.64; P = .003) proteins was stillstatistically significantly associated with overall survival.Conclusion: We identified 254 genes whose expression wasassociated with metastatic dissemination of cutaneous melanomas.These genes may shed light on the molecular mechanisms underlyingpoor prognosis in melanoma patients.48

ORTHOPEDIEBELLEMANS J.: Comment obtenir une amplitude de flexion maximumaprès une PTG. Maitresse Orthopédique, 2006; 153: 6-9.En dépit des récents progres réalisés dans le domaine del’arthroplastie totale de genou, la limitation de l’amplitude de flexionreste un sujet de frustration pour de nombreux chirurgiens du genouet de nombreux patients.La faute est généralement rejetée sur le kinésithérapeute, le patient,ou les ingénieurs qui ont conçu la prothèse. Mais l’expérience nous amontré que le plus souvent, la limitation de l’amplitude de flexionaprès une PTG tient à des facteurs liés à la technique opératoire..BELLEMANS J., D’HOOGHE P., VANDENNEUCKER H., VAN DAMME G.:Soft tissue balance in total knee arthroplasty. Clinical Orthopaedics andrelated research, 2006; 452: 49-52.The restoration of correct soft tissue tension is key to achieving asuccessful total knee arthroplasty. However, it remains unclearwhether the status achieved immediately after the operation willpersist over time. Some surgeons believe soft tissue stress relaxationoccurs and therefore the knee loosens somewhat after the procedure.It was the aim of this study to investigate this hypothesis. Weanalyzed 25 in vivo total knee implantations using contemporarycomputer navigation technology to assess and quantify perioperativesoft tissue relaxation. Mediolateral joint laxity and maximal passiveextension were analyzed immediately intraoperatively and 30 minuteslater under the same conditions. Stress relaxation occurred in allcases, leading to increased mediolateral laxity by an average of 1 mmon the medial and lateral sides. Maximal passive extension increasedby an average of 3 degrees . This data confirms the hypothesis theknee becomes looser in the early phase after total knee arthroplasty.BELLEMANS J., VANDENNEUCKER H., VICTOR J., VANLAUWE J.:Flexion contracture in total knee arthroplasty. Clinical Orthopaedics andRelated Research, 2006; 452: 78-82.49

We retrospectively evaluated a surgical algorithm for treating flexioncontracture in total knee arthroplasty using a prospectively collecteddatabase of 2898 knees. We asked how many steps were required toobtain correction with increasing severity of the flexion contracture.We further wanted to know whether correction was maintained at twoyears after surgery, and which complications occurred in relation tothe algorithm. Our algorithm consisted of four steps executed until fullextension was achieved: (1) medio-lateral ligament balancing withresection of all osteophytes and overresection of the distal femur by 2mm; (2) progressive posterior capsular release and gastrocnemiusrelease; (3) additional resection of the distal femur up to a maximumof 4 mm; (4) hamstring tenotomy. A flexion contracture between 5°and 15° occurred in 794 cases, between 15° and 30° in 95 cases, andgreater than 30° in 35 cases. The data suggest 98,6% of the caseswith flexion contracture less than 30° could be corrected with Steps 1and 2. Even in the 35 flexion contractures greater than 30°, additionalresection of the distal femur and hamstring tenotomy was performedin only 28,6% and 22,9% of cases, respectively.BOLLARS P.N.J., VAN STEIJN M.J.A., DECKERS P., BELLEMANS J.:Computergestuurde versus conventionele implantatie van een totaleknieprothese. Nederlands Tijdschrift voor Orthopedie, 2006; 13: 85-91.Een totale knieprothese is een gevestigde behandelmethode voor debehandeling van ernstige gonartrose. Om te zorgen voor een groterenauwkeurigheid bij het plaatsen van de prothesen zijn ernavigatiesystemen ontwikkeld die de chirurg tijdens de operatiekunnen assisteren. De toegenomen precisie in protheseplaatsing metdergelijke systemen werd inmiddels aangetoond in verscheidenepublicaties, maar er is tot op heden weinig of geen informatievoorhanden wat betreft andere voor- of nadelen in vergelijking met deconventionele techniek. In deze studie werd dit in kaart gebracht, metname wat betreft het aantal complicaties, opnameduur, operatieduuren bloedverlies. Hiertoe hebben we de resultaten van operaties van77 genavigeerde patiënten vergeleken met die van 134 conventionelepatiënten. Afgezien de kans op een stressfractuur, waarvan zich eréén voordeed in de computergestuurde groep, zijn er geensignificante verschillen wat betreft het optreden van complicatiestussen beide technieken. De duur van de operatie is 31 minutenlanger met de computergestuurde techniek, de opnameduur is voorbeide technieken hetzelfde. Echter, het totale bloedverlies tijdens deoperatie is met de computergestuurde navigatie techniek 100 mlminder dan bij de conventionele techniek.50

BONNEUX I.M.F., BELLEMANS J., FABRY G.: Evaluation of woundhealing after total knee arthroplasty in a randomized prospective trialcomparing fonsaparinx with enoxaparin. The Knee, 2006; 13: 118-121.Background: Fondaparinux, a new synthetic pentasaccharide hasproven to be a more potent thromboprophylactic drug compared toenoxaparin after major orthopaedic surgery. However, the safety offondaparinux regarding wound healing has not yet been investigated.Methods: We performed a single-centre prospective clinical trial, inwhich patients undergoing total knee arthroplasty or revision of atleast one of the components of a previous knee arthroplasty wererandomly assigned to thromboprohylaxis with fondaparinux orenoxaprin. The trial included 109 patients and wound discharge wascompared. Secondary outcome measures were the amount of bloodin the suction drain, postoperative transfusion rate, change inhaemoglobin levels, haematocrit, intervention rate, time to regainflexion and rate of symptomatic thromboembolic events.BOONEN A., MATRICALI G., VERDUYCKT J., TAELMAN V.,VERSCHUEREN P., SILEGHEM A., CORLUY L., WESTHOVENS R.:Orthopaedic surgery in patients with rheumatoid arthritis: a shifttowards more frequent and earlier non-joint-sacrificing surgery. Ann.Rheum. Dis., 2006; 65: 694-695.Medical treatment of rheumatoid arthritis (RA) aims at controllingsynovitis and arresting erosive disease. Orthopaedic surgery dealswith joint destruction, reflecting the severity of damage, but also dealswith local persistent synovitis and tenosynovitis. Along with alteringmedical treatment strategies, rheumatologists and surgeons feel theyhave changed the type and timing of surgery in recent years. Weperformed a cross sectional study on the use of orthopaedic surgeryin RA, to provide data on types of procedures and evolution of timingand type of surgery.DEBEER P., PLASSCHAERT H., STUYCK J.: Resection arthroplasty ofthe infected shoulder: a salvage procedure for the elderly patient. ActaOrthop. Belg., 2006; 72: 126-130.Infection of the shoulder joint is a challenging problem for theorthopaedic surgeon. Several treatment options have been proposed.Here, we evaluate the results achieved following resectionarthroplasty of the shoulder in seven patients.51

We performed resection arthroplasty in seven cases to treat a chronicuncontrollable infection of the shoulder. Three patients had aninfected shoulder arthroplasty, one had an infected non-unitedarthrodesis, one was treated for an infected osteosynthesis, one hadan infected rotator cuff repair and one patient had a septic arthritis ofthe shoulder joint. All patients ware reviewed after a mean of 252days. The functional outcome was evaluated using the Constant andDASH score. C-Reactive Protein levels were determined to evaluatethe presence of residual infection.Except for one doubtful result, all our patients remained free ofinfection and there was excellent pain relief after the resection.Nevertheless, the functional outcome was poor: the mean Constantscore was 25.7 and the mean DASH score was 69.3.Resection arthroplasty of the shoulder is a valuable treatment optionfor infection of the shoulder, especially in older patients with a poormental and physical condition who suffer intolerable pain.DEGREEF I., DEBEER P.: Heterotopic ossification of the supraspinatustendon after rotator cuff repair: case report. Clin. Rheumatol., 2006; 25:251-253.Heterotopic ossifications of the shoulder are uncommon. Rarely, theseossifications are seen after open or even arthroscopic shouldersurgical procedures. Here, we report a patient who underwent arotator cuff repair, complicated with an axillary nerve paralysis.Postoperatively he developed substantial ossification of thesupraspinatus tendon. A review of the literature was done. To ourknowledge no other cases similar to this have been reported.DEGREEF I., DE SMET L.: Predictors of outcome in surgical treatmentfor basal joint osteoarthritis of the thumb. Clin. Rheumatol., 2006: 140-142.In this series, several preoperative factors influencing the outcome insurgically treated patients with carpometacarpal osteoarthritis of thethumb were analyzed. Thirty-six patients were studied. Handdominance, interphalangeal joint motion, radiographic stage, andsurgical procedure did not reach significance. In contrast, age, firstweb retraction, and hyperextension of the metacarpophalangeal jointwere considered valuable in predicting the ultimate outcome.52

DEGREEF I., DE SMET L.: Accessory extensor pollicis longus: a casereport. Eur. J. Plast. Surg., 2006; 28: 532-533.A rare case is reported in which the accessory extensor pollicis longuswas discovered during dorsal wrist surgery. The morphology of thistendon corresponds with four previously reported cases.DEGREEF I., DE SMET L.: Complications following resection of theolecranon bursa. Acta Orthop. Belg., 2006; 72(4): 400-403.We retrospectively reviewed 37 cases of resection of the olecranonbursa and noted wound healing problems in 10 (27%) and recurrencein 8 (22%). A lateral arm flap was necessary in one patient.Conservative treatment remains the treatment of choice for olecranonbursitis. Differentiation between septic and non-septic cases ischallenging. The risk of wound healing problems and recurrenceshould be taken into account when planning surgical resection.DEGREEF I., DE SMET L.: Vanishing finger in psoriatic arthritis: a casereport. Clin. Rheumatol., 2006; Sep 14.Dactylitis is a typical phenomenin in psoriatic arthritis, presenting as a“sausage-shaped” finger. Although classically the distalinterphalangeal joints are affected, proximal interphalangeal joints andmetacarpophalangeal joints are frequently involved. We present apatient who presented with severe psoriatic arthritis of the proximalinterphalangeal joint, leading to subtotal disappearance of thephalangeal bones and important shortening of the fourth finger after10 years of evolution.DELPORT H.P., BANKS S.A., DE SCHEPPER J., BELLEMANS J.: Akinematic comparison of fixed-and mobile-bearing knee replacements.J. Bone & Joint Surg., 2006; 88B: 1016-1021.Mobile-bearing posterior-stabilised knee replacements have beendeveloped as an alternative to the standard fixed- and mobile-bearingdesigns. However, little is known about the in vivo kinematics of thisnew group of implants. We investigated 31 patients who hadundergone a total knee replacement with a similar prosthetic designbut with three different options: fixed-bearing posterior cruciateligament-retaining, fixed-bearing posterior-stabilised and mobile-53

earing posterior-stabilised. To do this we used a three-dimensional totwo-dimensional model registration technique. Both the fixed- andmobile-bearing posterior-stabilised configurations used the samefemoral component. We found that fixed-bearing posterior stabilisedand mobile-bearing posterior-stabilised knee replacementsdemonstrated similar kinematic patterns, with consistent femoral rollbackduring flexion. Mobile-bearing posterior-stabilised kneereplacements demonstrated greater and more natural internal rotationof the tibia during flexion than fixed-bearing posterior-stabiliseddesigns. Such rotation occurred at the interface between the insertand tibial tray for mobile-bearing posterior-stabilised designs.However, for fixed-bearing posterior-stabilised designs, rotationoccurred at the proximal surface of the bearing. Posterior cruciateligament-retaining knee replacements demonstrated paradoxicalsliding forward of the femur. We conclude that mobile-bearingposterior-stabilised knee replacements reproduce internal rotation ofthe tibia more closely during flexion than fixed-bearing posteriorstabiliseddesigns. Furthermore, mobile-bearing posterior-stabilisedknee replacements demonstrate a unidirectional movement whichoccurs at the upper and lower sides of the mobile insert. The femurmoves in an anteroposterior direction on the upper surface of theinsert, whereas the movement at the lower surface is pure rotation.Such unidirectional movement may lead to less wear when comparedwith the multidirectional movement seen in fixed-bearing posteriorstabilisedknee replacements, and should be associated with moreevenly applied cam-post stresses.DESCHAMPS K., CALLEWAERT B., BIRCH I., MC INNES J.,DESLOOVERE K., MATRICALI G.: What is the inter- and intra-observerreliability of landmark placement (in a hallux valgus group) withinplantar pressure measurements. Gait and Posture 24S, 2006: S98-S289.Using a method based upon 2D coordinates calculations made itpossible to estimate the inter- and intra-observer reliability of landmarkplacements within plantar pressure measurements. Results of thisinvestigation showed that landmark placement (of small size) is not areliable method to analyze plantar pressures in the forefoot. Resultsagreed well with other reliability studies: the intra-observer reliabilitycan be considered as sufficient, but the inter-observer reliability ispoor.54

DE SMET L.: Carpale tunnel syndroom: is er iets nieuws? U.Z.Gezondheidsbrief, 2006; 173: 1-3.Het carpale tunnelsyndroom is een veel voorkomende oorzaak vangevoelsstoornissen en pijn in de hand. Sommige mensen menen datvooral computerwerk er de oorzaak van is, maar het syndroombestond al lang voor er van computers sprake was. De meestemensen kunnen goed geholpen worden.DE SMET L.: Anterior interosseous nerve transfer to the motor branchof the ulnar nerve: a case report. Eur. J. Plast. Surg., 2006; 28: 523-524.High ulnar nerve lesions have a poor outcome: usually there is someprotective sensation and some recuperation of the forearm musclesbut none of the intrinsic muscles. We report a case with a high ulnarnerve lesion and failed recovery, in which we transferred the anteriorinterosseous nerve (particularly the motor branche to the pronatorquadratus muscle) to the motor branch of the ulnar nerve; this resultedin an excellent outcome.DE SMET L.: The distal radioulnar joint in rheumatoid arthritis.International Congress Series, 2006; 1295: 63-68.DE SMET L.: The distal radioulnar joint in rheumatoid arthritis. ActaOrthop. Belg., 2006; 72: 381-386.Rheumatoid arthritis (RA) often-up to 80%-involves the wrist; even upto 95% of the patients after 12 years of disease have signs of wristarthritis. The distal radioulnar joint (DRUJ) is involved in 31% of thesepatients in early rheumatoid arthritis and in 75% in late presentations.It is often the first compartment of the wrist involved. Only a fewpapers discuss the DRUJ problem in RA separately; usually, thewhole wrist complex is discussed or described. The latter are right: itis practically impossible to distinguish the DRUJ problem from otherarthritic changes in other compartments of the wrist or to ignoreassociated tendon involvement.DE SMET L., DECRAMER A.: Key pinch force in children. J. Ped. Orthop.B, 2006; 15: 426-427.The key pinch force in a group of 262 healthy children between 5 and12 years was measured. A clear correlation was observed between55

age and key pinch strength. The differences between the left and righthand grips and between girls and boys were not significant.DE SMET L., DEGREEF I., ROBIJNS F., TRUYEN J., DEPREZ P.: Salvageprocedures for degenerative osteoarthritis of the wrist due to advancedcarpal collapse. Acta Orthop. Belg., 2006. 72: 535-540.Arthrodesis of the wrist has been considered as the gold standard forosteoarthritis of the wrist. In 1984 Watson and Ballet identified aspecific pattern of carpal collapse (scapholunate advanced collapse =SLAC) with progressive osteoarthritis. In order to preserve somemotion, other alternative procedures have been proposed: proximalrow carpectomy (PRC) and scaphoidectomy combined with a fourcorner arthrodesis (4CA). In this cohort of 63 patients, three types ofsurgical treatment were performed (arthrodesis in 19, PRC in 26 andscaphoidectomy with 4Ca in 18. The DASH questionnaire was used toevaluate the residual disability. PRC had a significantly better outcome(DASH = 16), while there were no significant differences between fullarthrodesis (DASH = 39). In PRC and in four corner arthrodesis afunctional range of motion could be preserved (respectively 44° and52° flexion/extension arc). Gripping force remained inferior to the nonoperated side. There was a significant increase in gripping force in thePRC group, but not in the others. The final gripping force was notsignificantly different in the three treatment regimes.DE SMET L., ROBIJNS F., DEGREEF I.: Outcome of proximal rowcarpectomy. Scan. J. Plast. Reconstr. Surg. Hand Surg., 2006; 40: 302-306.Fifty-one patients who had had proximal row carpectomy between1992 and 2002 with a minimum follow-up of one year were followedup clinically and radiologically retrospectively. Their diagnosis includedKienböck disease (n=21), avascular necrosis of the scaphoid (n=4),non-union of the scaphoid with osteoarthritis (n=9), and scapholunateadvanced collapse (n=17). The mean follow-up was 5 years, 8months. The mean “disabilities of the arm, shoulder and hand”(DASH) score was 18. The mean patient-rated wrist evaluation(PRWE) score list was 25% of maximum disability for the function andpain score. Thirty-four patients (87%) were able to return to work amean of six months after operation (range 3 weeks-35 months). Ninepatients (11%) required arthrodesis of the wrist and are considered asfailures. Mean flexion of the wrist was 66%, extension 73%, radialdeviation 74%, ulnar deviation 76%, and grip force 70% of the56

opposite side. Excision of the proximal row provided predictable anddurable pain relief, restored functional movement and grip strength,and allowed returned to gainful employment in most of the patients.D’HOOGHE P., BELLEMANS J., FABRY G., MANZOTTI A.: Ligamentbalancing in navigation-assisted total knee arthroplasty: the effect ofstress relaxation. J. Bone & Joint Surg., 2006; 88-B-S1: 87.As total knee arthroplasties (TKA) have become the gold standardprocedure fore severe gonarthrosis, greater interest in postoperativetibiofemoral instability has developed. Emphasizing the correlationbetween evaluation of symptoms and findings, offers an opportunity toelucidate the specifics of the instability. Mandatory is the joint gapmeasurement during surgery to assess the effect of specific cuts orreleases of the anatomic portion of the joint gap. By performingnavigation-assisted total knee arthroplasties, we are capable ofmeasuring the joint gap in a highly reliable way. During the ligamentbalancing in navigation-assisted TKA, we performed a data collectionof the joint gap in 0-30 and 90 of flexion in 100 patients. Themeasurements were repeated after 10 and 20 minutes in extension.The result offers us an opportunity to assess the interesting effect ofligament-stress relaxation in TKA and to gain more insights in thefurther release-necessity and choice of insert during the TKAprocedure.D’HOOGHE P., DEFOORT K., LAMMENS J., STUYCK J.: Management ofa large post-traumatic skin and bone defect using an Ilizarov frame.Acta Orthop. Belg., 2006; 72: 214-218.The authors report the case of a 28-year old male who presented witha compound diaphyseal fracture of the tibia, which was treated withintramedullary nailing. Postoperatively he required an extensivefasciotomy for an acute compartment syndrome. The fracture evolvedtowards post-traumatic osteomyelitis, growing methicillin-resistantStaphylococcus aureus (MRSA), combined with a large overlying softtissue gap. An Ilizarov frame was used to treat both the bone and theskin defect. The infected fracture was treated by resection andlongitudinal bone transport. Meanwhile, the skin was gradually closedusing extra rods on the frame, allowing for a transverse 'skintransport'. Both the bone and the soft tissues healed without furthercomplications.57

FABRY K., LAMMENS J., DELHEY P., STUYCK J.: Ilizarov’s method: asolution for infected bone loss. Eur. J. Orthop. Surg. Traumatol., 2006;16: 103-109.We report the results of 22 infected nonunions treated by radicalresection and bone transport technique according to Ilizarov with aminimal follow-up period of 2 years. This series involves four fracturesof the femur diaphysis, ten at tibial level, four defects of the knee andfour of the upper limb. The mean length of the bone defect was 7.7cm. The mean time from the transport procedure to frame removalwas 14.5 months. In 15 cases the docking site was reviewed torefresh the bone ends at the end of the transport procedure, of whicheight had a bone graft performed. Five refractures were noticed at thedocking site in the nonrevised group and one in the other group. Twoof them were treated conservatively and four with a new externalfixator. Consolidation was achieved in all but two nonunions at theknee level, which means a success rate of 91%. The infection couldbe eradicated in all 22 patients. A revision of the docking side at theend of the bone transport procedure with or without bone grafting isrecommended.FRANCOIS J., LAUWERYNS P., FABRY G.: Monosegmentaireposterieure lumbale “interbody”-fusie. Tijdschrift voor Geneeskunde,2006; 62(10): 733-745.De heelkundige behandeling van degeneratieve afwijkingen van delumbale wervelkolom is in de eerste plaats gericht op het bekomenvan een solide arthrodese van een bewegingssegment en een goededecompressie van de neurologische structuren. De posterieurelumbale “interbody”-fusie (PLIF) is een erg krachtige maarveeleisende techniek en verwikkelingen komen vaak voor. Bovendienblijft het wegnemen van mobiliteit een veelbesproken nadeel,waarover eensgezindheid ontbreekt in de literatuur.In deze retrospectieve studie werden de postoperatieve resultaten van44 monosegmentaire PLIF-procedures opgevolgd gedurendegemiddeld 5 jaar. De verwikkelingen beperkten zich tot één scheur inde dura mater, één oppervlakkige wondinfectie en één geval vantransiënte dropvoet. De subjectieve tevredenheid bedroeg 80% na 13maanden en 75% na 5 jaar. Dit werd ook bevestigd aan de hand vanenkele gevalideerde scoresystemen. Deze klinische resultaten blekenglobaal stabiel te zijn na verloop van tijd. Rokers vertoonden na éénjaar meer neiging tot een slechter klinisch resultaat, maar dit verschilwas verdwenen na 5 jaar.In de groep van lumbosacrale fusies werd een significante verbeteringvastgesteld na verloop van tijd. Radiografische controle na 1358

maanden toonde een fusiepercentage van 91%. Er bleek geenverband tussen de radiografische en de klinische resultaten.Gezien de lage incidentie van verwikkelingen, de goede subjectievetevredenheid en de stabiele resultaten na een follow-up van 5 jaar,kan besloten worden dat monosegmentaire PLIF een waardevolle enveilige techniek is in de heelkundige behandeling van lage rugpijn.Symptomatische degeneratie van de aangrenzende lumbale niveausblijkt op deze termijn klinisch niet relevant te zijn.GOVAERS K., MEERMANS G., STUYCK J., DEPREZ P., BORTIER H.,ROELS J.: Endoscopy for cement removal in revision arthroplasty ofthe hip. J. Bone Joint Surg. (Am), 2006; 88(4): 101-109.One of the primary steps in revision hip arthroplasty is the extraction ofretained components and cement before surgical reconstruction. Inrevision hip arthroplasty, the removal of well-fixed cement can beextremely demanding, time-consuming, and damaging to theremaining host bone. A number of studies have shown the usefulnessof endoscopy of the medullary canal to facilitate cement removalwithout performing a trochanteric osteotomy. Various endoscopysystems have been designed to visualize the endosteal surface of thebone. Here we report on a multicenter prospective study on cementremoval with standard available endoscopy equipment in both infectedand uninfected hips undergoing revision arthroplasty. The aims of ourstudy were (1) to define the usefulness of and the quality of the viewprovided by standard available laparoscopic equipment, (2) to reporton intraoperative complications during medulloscopy-assisted cementremoval, (3) to define the risk factors for femoral perforation andintraoperative fracture, (4) to define the indications for and limitationsof medulloscopy for cement removal, and (5) to perform a criticalanalysis of the completeness of cement removal, especially inrevisions done in infected hips.HARDEMAN F., VANDENNEUCKER H., VANLAUWE J., BELLEMANS J.:Cementless total knee arthroplasty with Profix: a 8- to 10- year followupstudy. The Knee, 2006; 13: 419-421.A consecutive series of 115 cementless Profix (Smith and Nephew,Memphis, USA) Total Knee Arthroplasties performed in 113 patientswere followed in order to determine the functional results andsurvivorship at 8 to 10 years. All patients were included in aprospective database and were reviewed annually until final followup.Patients overall satisfaction was excellent or good in 91,3% of59

cases. The mean Knee Society’s knee and function scores increasedrespectively from 49.3 and 36.7 preoperatively to 93.1 and 82.2postoperatively. The Kaplan-Meier estimate of implant survival at 10years was 97.1%. Two patients underwent revision and wereconsidered as failures. One patient had a fracture of the medialcondyle at 4 days post-surgery, and the other was revised for asepticloosening of the tibial component at 6 years post-surgery. On thebasis of this long-term follow-up study, we can conclude that the ProfixTotal Knee System is effective and safe.HELLEMANS J., DEBEER P., WRIGHT M., JANECKE A., KJAER K.W.,VERDONK P.C.M., SAVARIRAYAN R., BASEL L., MOSS C., ROTH J.,DAVID A., DE PAEPE A., COUCKE P., MORTIER G.R.: Germline LEMD3mutations are rare in sporadic patients with isolated melorheostotis.Human Mutation, 2006; 27(3): 290.To further explore the allelic heterogeneity within the group of LEMD3-related disorders, we have screened a larger series of patientsincluding 5 probands with osteopoikilosis or Buschke-Ollendorffsyndrome (BOS), 2 families with the co-occurrence of melorheostosisand BOS, and 12 unrelated patients with isolated melorheostosis.Seven novel LEMD3 mutations were identified, all predicted to resultin loss-of-function of the protein. We confirm that loss-of-functionmutations in the LEMD3 gene can result in either osteopoikilosis orBOS. However, LEMD3 germline mutations were only found in twomelorheostosis patients belonging to a different BOS family and onesporadic patient with melorheostosis. The additional presence ofosteopoikilosis lesions in these patients seemed to distinguish themfrom the group of sporadic melorheostosis patients where no germlineLEMD3 mutation was identified. Somatic mosaicism for a LEMD3mutation in the latter group was also not observed, and therefore wemust conclude that the genetic defect in the majority of sporadic andisolated melorheostosis remains unknown.HORSNELL K., ALI M., MALIK S., WILSON L., HALL C., DEBEER P.,CROW Y.: Clinical phenotype associated with homozygosity for aHOXD13 7-residue polyalanine tract expansion. Eur. J. Med. Genet.,2006; 49(5): 396-401.Synpolydactyly (SPD) is an autosomal dominant malformation of thedistal limbs caused by mutations in the homeobox gene HOXD13located on chromosome 2q31. We detail the clinical findings in aconsanguineous Pakistani family segregating a HOXD13 7-residue60

polyalanine tract expansion. Three members of this pedigree wereheterozygotes with features typical of SPD. Two further membersdemonstrate a more severe phenotype consistent with homozygosityfor the familial mutation. We also report a child from aconsanguineous Somali family homozygous for the same molecularlesion. Characteristic changes include a complex central polydactyly inthe hands, abnormal modeling of the metacarpals and metatarsals, anincreased number of carpal bones with abnormal shapes, hypoplasiaor absence of the fifth digital rays in the feet, hypoplasia of the middlephalanges and abnormally long proximal phalanges in hands and feet.These cases illustrate the distinct phenotype associated withhomozygosity for a HOXD13 mutation and also highlight theimportance of considering homozygosity for a dominant mutation inconsanguineous pedigrees.JACOBS R., DEBEER P.: Calcifying tendonitis of the rotator cuff.Functional outcome after arthroscopic treatment. Acta Orthop. Belg.,2006; 72: 369-374.In this study, we assessed the functional results after arthroscopicexcision of rotator cuff calcifications. Sixty-one shoulders in 57patients with chronic calcifying tendinitis of the rotator cuff weretreated with arthroscopic excision, subacromial bursa debridementand shaving. In patients with fraying or roughness of thecoracoacromial ligament, an acromioplasty was also performed.Patients were evaluated after a mean follow-up of 15 months. Themodified Constant score and DASH score significantly improved from33,4 to 66,8 and from 49,7 to 17,3 respectively. Performing anacromionplasty did not influence the final outcome. Frozen shoulderwas a frequent complication (18%) without significant effect on thefinal DASH or Constant score. The presence of residual calcificationsafter arthroscopic needling did not influence the final outcome. Wetherefore believe that the presence of residual calcifications can beaccepted if this is deemed necessary to preserve the integrity of thetendon.LAUWERYNS P.: Role of conservative treatment of cervical spineinjuries. Book of abstracts, XIIIth Brussels International Spine Symposium“Fractures of the spine, tumors in the spine. November 2006.Surgical fixation of fractures in general, has gained popularity.Improved imaging techniques together with more reliable surgicaltools have lowered the threshold for surgery, offering the patient a61

short-term solution for his fracture. Conservative measures, i.e.nonsurgical tools, still have a role to play, either in the initial stage,either later on as an adjunct to surgery, or as the definitive treatment.Skeletal skull traction certainly still has a role to play in the initialphase, and is mainly indicated in cases of facet subluxation ordislocation, and in burst-type fractures, to stabilise and realign thecervical spine. Gardner-Wells tongs are advocated because of theirease of use, whereas a halo ring can be preferred in those caseswhere a halo-vest is considered ad definitive treatment. The timing ofcranial traction is still controversial. Early application and attempt atreduction is advocated in patient with a spinal cord injury. Controversymainly exists in those cases of a neurologically intact or cognitivelyimpaired patient, recent literature supporting the safety of earlyreduction before MRI investigation. The application of Gardner-Wellstongs is discussed, together with the technique of realignment andreduction of subluxations or dislocations. Although long-term skulltraction has a poor tolerance for the patient and is associated withmorbidity, it can be part of a treatment plan to avoid fusion in complexfractures, considering conversion to a halo-vest after a 6-week to 3-month period. Cervical braces of different designs have been used.Rigid collars like a Philadelphia collar, have their application in thetreatment of stable fractures, or after surgical treatment.Cervicothoracic orthoses are mainly used for lower cervical spineinjuries, cervicothoracic injuries, or after surgical treatment withuncertain stability. Cervical orthoses offer very poor control of motionin the cervical spine. Because of this, orthotic devices only have alimited role to play in the immobilisation of the cervical spine. The bestchoice for external immobilisation is provided by a halo-vest, whichcan be applied in the treatment of unstable fractures. The applicationof a halo-vest continues to play a role in the definitive management ofcervical fractures, and also as an adjunct to surgery. If offers a bettercontrol of lateral bending and rotation compared to other externalimmobilization devices, and provides a more rigid fixation of the uppercervical spine. Indications, limitations, contraindications and alsocomplications of its use are being discussed. Nonsurgical means oftreating cervical spine trauma can therefore be the treatment strategyby itself, or be prior to, or complementary to surgical fixation.LAUWERYNS P.: Design and surgical technique of the flexicore lumbarartificial disc. In: Non-fusion technologies in spine surgery. Editors:Szpalski M., Gunzburg R., 2006, Chapter 22: 191-200.The FlexiCore Intervertebral Disc is comprised of four components,which are assembled by the manufacturer and provided to thesurgeon as a single unit. The four components are as follows:62

- A highly polished semi-spherical head.- A superior baseplate having a domed upper surface and acylindrical stem extending from the lower surface and into thehead.- An inferior baseplate having a domed lower surface and asemispherical recess formed in the upper surface toaccommodate the head.- A shield seated around the head and press fit to the upper surfaceof the inferior baseplate.LOWYCK H., DE SMET L.: Recurrence rate of giant cell tumors of thetendon sheath. Eur. J. Plast. Surg., 2006; 28: 385-388.Recurrence of giant cell tumors of the tendon sheath in the hand hascontinued to be a problem since it was first described. Authors havetried to identify factors to predict the chance of recurrence and havefound several. This paper reports our experience with resection ofGCTTS in the hand, and the predisposing factors of recurrence werestudied. The recurrence rate of 16 % is similar to that of earlierpublished results. The predisposing factors for recurrence such aspressure erosion on X-ray and presence of degenerative changescould not be confirmed.MATHIJSSEN I.B., COSSEY V., FRYNS J.P., DE SMET L., DEVRIENDT K.:Unilateral symbrachydactyly of the foot. Genetic Counseling, 2006; 17(1):77-80.Symbrachydactyly is a congenital abnormality, characterized byunilateral limb anomalies consisting of brachydactyly, cutaneoussyndactyly and global hypoplasia of the hand or foot. It commonlyaffects the hands but rarely the feet. Only a few articles have beenpublished about patients with isolated symbrachydactyly of the foot.MATRICALI G.A., BOONEN A., VERDUYCKT J., TAELMAN V.,VERSCHUEREN P., SILEGHEM A., CORLUY L., WESTHOVENS R.: Thepresence of forefoot problems and the role of surgery in patients withrheumatoid arthritis. Ann. Rheum. Dis., 2006; 65(9): 1254-1255.Foot problems constitute a major problem in up to 90% of patientswith rheumatoid arthritis, causing pain and functional limitations.Forefoot deformities are often complicated by ulcers, which can infect63

the foot and result in major septic complications. Although no data areavailable on the effect of foot problems on function and quality of lifein patients with rheumatoid arthritis, in patients with diabetes mellitusthese scores drop substantially.MATRICALI G.A., DEREYMAEKER G.P.E., LUYTEN F.: Theposteromedial rim of the talar dome as the site for harvesting cartilagein the ankle: an anatomic study. Arthroscopy, 2006; 22(11): 1241-1245.Purpose: The goal of this study was to determine whether a biopsyspecimen of a fixed size can be harvested reliably and consistently byarthroscopy at the posteromedial rim of the talar dome.Methods: A cartilage biopsy specimen was taken post mortemarthroscopically from the posteromedial rim of the talar dome in 20ankles. We aimed to take a full-thickness biopsy specimen of 10 x 5mm in size. The shape, length, width, position, and depth of thecreated defect were determined. Subsequently, 2 observers analyzedthe biopsy sites twice. The same set of parameters and the surfacearea of the lesion were determined. Differences between aimed andobserved sizes were studied.Results: In all ankles the aimed biopsy site could be seen andreached. The observed mean size of the biopsy specimens, whencompared with the aimed size, was only significantly different for themediolateral size. A wide variation of surface area was found. Nearlyall biopsy specimens started exactly at the posterior border of thedome, but they were somewhat more lateral than intended. In onlyhalf of the biopsy specimens was the shape linear or oval, the othersbeing rounded or irregular. In case a pre-existing posteromedialcartilage lesion was present, its position did not coincide with that ofthe biopsy specimen.Conclusions: A limited cartilage biopsy specimen could be harvestedreliably and consistently by arthroscopy at the posteromedial rim ofthe talar dome, although the size tended to be somewhat larger thanwe intended. Containment of a pre-existing posteromedial lesion wasnever jeopardized.Clinical relevance: A safe biopsy site for cartilage in the ankleeliminates donor-site morbidity in the knee and may improve thesuitability and biology of the obtained chondrocytes for successfulrepair of symptomatic joint surface defects of the ankle.64

MATRICALI G., DEREYMAEKER G., MULS E., FLOUR M., MATHIEU C.:Economic aspects of diabetic foot care in a multidisciplinary setting: areview. Diabetes/metabolism Research and Reviews, 2006, publishedonline 14.11.1006.Background: To evaluate the economic aspects of diabetic foot care ina multidisciplinary setting.Method: A review of the English language literature, published from1966 to November 2005.Results: The results of available studies on the cost-of-illness ofdiabetic foot problems are difficult to compare. Nevertheless trendsconcerning excess of costs, protraction in time of costs, positivecorrelation to severity of ulcer and/or peripheral vascular disease,contribution of in-hospital stay and length of stay, and the patient'sown contribution to total costs, are obvious. Only a few costeffectivenessand cost-utility studies are available. Most use a Markovbased model to predict outcome and show an acceptable result onlong-term.Conclusions: Diabetic foot problems are frequent and are associatedwith high costs. A multidisciplinary approach to diabetic foot problemshas proved to be cost saving with regard to cost of treatment itself.Nevertheless, it remained unclear if these savings could offset theoverall costs involved in implementing this kind of approach. The fewstudies that address this issue specifically all show an acceptablecost-effectiveness, but often the profit will be evident after some yearsonly, because long-term costs are involved. Based on these data,policymakers should foresee sufficient reimbursement for preventiveand early curative measures, and not only for 'salvage manoeuvres'.MOLENAERS G., DESLOOVERE K., FABRY G., DE COCK P.: The effectsof quantitative gait assessment and botulinium toxin A onmuscoloskeletal surgery in children with cerebral palsy. J. Bone & JointSurg., 2006; 88(1): 161-170.Background: The limits of nonoperative treatment for children withcerebral palsy, including physical therapy and orthotics, commonlylead to orthopaedic surgical intervention. The purpose of the presentstudy was to evaluate the influence of gait analysis and botulinumtoxin type-A injections on the timing, prevalence, and frequency oforthopaedic surgery.Methods: We performed a retrospective review of 424 children withcerebral palsy who had been born between 1976 and 1994. Thechildren were divided into three groups: Group 1 comprised 122patients who were managed throughout the entire study periodaccording to best-practice guidelines in orthopaedics, Group 265

SAEGEMAN V., LISMONT D., VERDUYCKT B., ECTORS N., STUYCK J.,VERHAEGEN J.: Antimicrobial susceptibility of coagulase-negativestaphylococci on tissue allografts and isolates from orthopedicpatients. J. Orthop. Res., 2006; 25(4): 501-507.Allograft infection occurs at a rate not different from that of similarprocedures with large allografts or sterilized prosthetic devices and isusually caused by coagulase-negative staphylococci (CNS). CNS arefeared for their limited antimicrobial susceptibility. We aimed atinvestigating this risk. CNS were isolated from 260 of 1461 allografttissue grafts and compared with 384 consecutive clinical isolates froma general orthopedic population (258 patients). The CNS wereidentified and examined for their susceptibility to nine antibiotics usedin routine practice. Staphylococcus epidermidis was the mostcommonly identified (35%) and the most resistant species of theallograft isolates. Comparing the overall antibiotic susceptibilitypatterns, clinical pathogens were significantly more resistant to six ofthe nine antibiotics (p < 0.01), namely penicillin, oxacillin,erythromycin, clindamycin, ofloxacin, and gentamicin. In conclusion,massive allograft infection is a well-known life-threatening surgicalrisk. However, we did demonstrate that allograft-related in contrast toorthopedic clinics-related CNS, are susceptible to commonly used firstand second line antibiotics.THIENPONT E., SCHMALZRIED T., BELLEMANS J.: Ankylosis due toheterotopic ossification following primary total knee arthroplasty. ActaOrthop. Belg., 2006. 72(4): 502-506.We present a case of ankylosis of the knee after knee arthroplastydue to heterotopic ossification in the ligaments. Treatment withresection of the collateral ligaments, reconstruction with a hingedimplant and radiotherapy was successful.VAN CAMPENHOUT A., MOENS P., FABRY G.: Serial bone scintigraphyin Legg-Calvé-Perthes disease: correlation with the Catterall andHerring classification. J. Ped. Orthop., 2006; 15: 6-10.Radiographic classifications in Legg-Calvé-Perthes disease aredifficult to use in the early stage of the disease. Changes on bonescintigraphy (revascularization versus recanalization pathway)precede the radiographic changes. Our purpose was to study thecorrelation between serial bone scintigraphy and radiographicclassifications in Legg-Calvé-Perthes disease. In 86 patients, 95 hips67

that presented with Legg-CalvéPerthes disease in the early stagewere followed with serial bone scintigraphy and radiographs. Fortyfourhips showed recanalization: pathway A on bone scintigraphy. Ofthese hips 96% were classified as Herring A or B and 66% as Catterall2. Thirty-five hips showed revascularization: pathway B on bonescintigraphy. Of this group 82.8% were classified as Herring C and17.1% as Herring B. All pathway B hips have Catterall 3 or 4. Sixteenhips showed pathway C: regression from pathway A to pathway B.They presented in 56% of cases with Herring B, 44% with Herring C,and in 81% with Catterall 3 or 4 classifications. We can conclude thatthere is a significant correlation between the vascularization patternand the radiographic classification of Herring and Catterall.VAN DEN BEKEROM M.P.J., STUYCK J.: The value of pre-operativeaspiration in the diagnosis of an infected prosthetic knee: aretrospective study and review of literature. Acta Orthop. Belg., 2006; 72:441-447.The purpose of this study was to compare the results of cultures ofpreoperative aspiration samples with those of swabs taken intraoperatively.The records of 70 revision arthroplasties of the knee from69 patients, 49 females and 20 males, were reviewed. The mean ageof the patients at time of revision arthroplasty was 67 years (range: 34to 89). Sixty-eight knees from 67 patients were included. There were32 true positives, 17 true negatives, 6 false positives and 13 falsenegatives. This led to a specificity, sensitivity and accuracy of 57%,84% and 72%, respectively. Based on these findings, pre-operativeaspiration has a positive predictive value of 71% and a negativepredictive value of 74%. When the aspiration sample yields a positiveculture, the chances are high that the prosthetic knee is infected.When aspiration is negative, infection cannot be ruled out. Our studysuggests that, in such cases, a coagulase negative Staphylococcus(CNS) infection has to be considered.VAN ESCH H., AGARWAL A.K., DEBEER P., FRYNS J.P. and GARG A.: Ahomozygous mutation in the lamin A/C gene associated with a novelsyndrome of arthropathy, tendinous calcinosis, and progeroid features.J. Clin. Endocrinol. Metab., 2006; 91(2): 517-521.Context: Mutations in the lamin A/C (LMNA) gene have been reportedin a wide variety of disorders, including lipodystrophies,cardiomyopathy, muscular dystrophies, neuropathy, mandibuloacraldysplasia, restrictive dermopathy, and progeria.68

Objective: The objective of this study was to carry out mutationalanalysis of LMNA in a patient with a novel syndrome of arthropathy,tendinous calcinosis, and progeroid features.Design: The study design was a descriptive case report.Setting: The study was performed at a referral center.Patient: A 44-yr-old male of European descent with an autosomalrecessive arthropathy syndrome affecting predominantly the distalfemora and proximal tibia in the knee with tendinous calcifications wasstudied. He also had progeroid features, such as pinched nose andmicrognathia, cataract, alopecia, generalized lipodystrophy, andsclerodermatous skin.Main outcome measures: The main outcome measures weremutational analysis of lamin A/C (LMNA) and its processing enzyme,zinc metalloproteinase (ZMPSTE24), as candidate genes.Results: We found a homozygous nucleotide substitution, 1718C>T, inexon 11 of the LMNA gene, resulting in substitution of a wellconservedresidue serine at position 573 with leucine (S573L). Thismissense mutation only affects lamin A, not lamin C, because thealternative splicing site is located in exon 10. Immunofluorescencestaining of the nuclei from his skin fibroblasts showed occasionalmisshapen morphology.Conclusions: The S573L homozygous LMNA mutation is associatedwith a novel phenotype of arthropathy, tendinous calcifications, andprogeroid features distinct from the acroosteolysis previously reportedin patients with mandibuloacral dysplasia caused by LMNA orZMPSTE24 mutations. Thus, arthropathy with tendinous calcificationscan be added to the growing list of disorders associated with LMNAmutations.VAN GIFFEN N., DEGREEF I., DE SMET L.: Dupuytren’s disease:Outcome of the proximal interphalangeal joint in isolated fifth rayinvolvement. Acta Orthop. Belg., 2006; 72: 671-677.In this study of 38 patients, we assessed the clinical result followingsurgical treatment of Dupuytren’s disease with isolated fifth rayinvolvement, particularly with respect to the proximal interphalangealjoint. Three surgical techniques were used: limited fasciectomy,segmental fasciectomy and dermofasciectomy. At a mean follow-uptime of 53.6 months, there were no residual deformities norrecurrences in the metacarpophalangeal joint. At the proximalinterphalangeal joint, there was an overall improvement of 45° inmovement with a residual flexion deformity avering 30°. Therecurrence rate in this series was 39%. There was no significantdifference in residual deformity or recurrence rate between the varioussurgical techniques used.69

Fifth ray involvement in Dupuytren’s disease remains a surgicalchallenge, especially at the proximal interphalangeal joint. Residualdeformity and recurrence rate remain high, irrespective of the surgicaltechnique used.VAN LOON P., DE MUNNYNCK B., BELLEMANS J.: Periprostheticfracture of the tibial plateau after unicompartmental knee arthroplasty.Acta Orthop. Belg., 2006; 72: 369-374.The authors report three cases of unicompartimental knee arthroplasty(UKA), complicated with peri-operative periprosthetic fracture of thetibial plateau. The surgical technique was held responsible in allcases. The initial treatment was different in every case; all patientsultimately underwent revision total knee arthroplasty with a goodfunctional outcome.The authors emphasise the importance of careful preparation of thetibial plateau during UKA, adequate sizing of the tibial component andcaution when using a hammer during implantation of the tibialcomponent. When a tibial plateau fracture occurs, the treatment ofchoice should be immediate revision total knee arthroplasty.VAN TONGEL A., FABRY G.: Epiphysiodesis of the greater trochanter inLegg-Calvé-Perthes disease: The importance of timing. Acta Orthop.Belg., 2006; 72: 309-313.Patients with Legg-Calvé-Perthes disease (LCP) often exhibit relativeovergrowth of the greater trochanter and shortening of the femoralneck. Biomechanically, this corresponds to a shorter lever arm and adecreased muscle tension which may result in a Trendelenburg gaitand pelvic instability. This is a retrospective study of 31 patients (32hips) with LCP disease and relative overgrowth of the greatertrochanter who were treated with an epiphyseodesis. The averageage at operation was 10 years and 6 months. We evaluated thepatients clinically with the Trendelenburg sign and analysed onradiographs the growth of the greater trochanter and the neck-shaftangle of the normal hip and the pre- and postoperative growth andangle of the involved hip. We did not find any significant differencesbetween the pre-and postoperative values. After a mean follow-up of 4years and 2 months, however, 27 patients presented with a negativeTrendelenburg sign (versus 14 patients preoperatively).70

VICTOR J., BELLEMANS J.: Physiologic Kinematics as a concept forbetter flexion in TKA. Clin. Orthop. Relat. Res., 2006; 452: 53-58.Functional outcome after total knee arthroplasty is determined bystrength, stability and range of motion. Flexion in the replaced knee issuboptimal for many patients and kinematics after total kneearthroplasty is abnormal. The relation between kinematics of thereplaced knee and postoperative flexion is analyzed and compared tonormal knee kinematics. Specific characteristics that relate to betterflexion are defined: posterior condylar offset, femoral roll-back andfemoral external rotation. The rationale for a guided motion kneearthroplasty is developed and positioned within the current state of theart knowledge on total knee arthroplasty.71

PLASTISCHE,RECONSTRUCTIEVE ENESTHETISCHE CHIRURGIEDELAERE P., HIERNER R., GOELEVEN A., D’HOORE A.: Reconstructionfor postcricoid pharyngeal stenosis after organ preservation protocols.The Laryngoscope, 2006; 116(3): 1-3.In cases of tracheal stenosis of less than 5 cm, standard surgicaltreatment is resection of the stenosed segment and end-to-endanastomosis or slide tracheoplasty. However in cases of longerstenosis this is unfeasible and augmentation is required. The idealtissue for tracheal grafting should closely resemble the native trachealtissue – well vascularised with a respiratory epithelium-lined mucousmembrane and cartilaginous support. Tracheal allografts or autograftsare not clinically available. We present a novel augmentationapproach, illustrating this by two patients with post-intubation longsegment tracheal stenosis and permanent Montgomery tubes.Definitive treatment was carried out by a multidisciplinary surgicalteam with otolaryngology, thoracic, and plastic surgery specialists.DICKENS S., VERMEULEN P., VRANCKX J.J.: Multi-lineage potential ofadult mesenchymal stem cells for tissue repair, familiar challenges.Novel strategies. J. Plast. Reconstr. Aesth. Surg., 2006; 59: S8.The future in off-the-shelf tissue equivalents requires enormousadvances in the fields of regenerative and extra cellular matrixbiology. The fabrication of the ideal construct requires that we furtherunravel the complex concerted process of extra cellular matrixassembly and fully understand the macro and micro architecture ofhuman tissues. Even more complex will be the anticipation of impactand integration of tissue-engineered scaffolds utilized in aberranthealing conditions when vascularization parameters are bad, anabolictendencies diminished due to cytostatica, corticosteroids or whenchronic inflammation exists. Therefore, the development of materialsthat can specifically and molecularly interact with cells in the defecthas become an emerging field in research. For example the more a72

skin construct displays authentic full thickness skin with its epidermaland dermal extracellular matrix elements, the more accurate thisconstruct will integrate into the wound environment and will elicit therequired cell signaling pathways that will lead to permanent healingand regeneration. However, unlike the extracellular matrix thatrepresents a millenary natural evolution, artificial biomaterials do nothave such a complex structure and chemical composition. Inconsequence, the pay off to large-scale producibility andstandardization of these ‘man-made devices’ is the very low bioinformationcontent and the scarce quantity of signals they transmit tocells. The development of materials that can specifically andmolecularly interact with cells in the defect has become an emergingfield in research. In our research efforts we focus on an integratedconcept of “smart autologous tissue engineering”. Using the plasticityand growing potential of adult progenitor cells and the guidance andstructural capacities of smart biomaterials, we add intelligence byintroducing selected proteins by ex vivo gene transfer technologies.Due to high availability we currently purify lipoaspirate derived adultprogenitor cells as susbtrate and carriers for growth factor release intofull thickness defects.DICKENS S., VERMEULEN P., VRANCKX J.J.: Transfection with atetracyclin inducible VEGF 165 plasmid results in transient regulablehigh expression of VEGF165 in vitro and in vivo. ETRS Bulletin, 2006;13: 59.Background: Pathofysiology of non-healing skin wounds is oftenrelated to an altered GF profile. Ex vivo Gene Transfer of GrowthFactors (GF) shows great promise for gene delivery into tissue in apathological state. Vascular Endothelial Growth Factor (VEGF)promotes neovascularization of granulation tissue in skin wounds andtherefore seems a good candidate for gene therapy. However,controlled release of VEGF is obligatory to prevent hazardous sideeffects.Methods: A hVEGF165 plasmid was ligated into a pcDNA4/TOvector using EcoR1 and EcoR5 restriction sites. This results inhVEGF165 expression under the control of a CMV-promotor and 2Tetracycline operator2 sites (TeTO2). Porcine Keratinocytes (KC)were transfected with pcDNA4/TO.VEGF (1,5 to 3μg) andpcDNA6/TR (repression molecule; 9-18μg) by means of lipofectinin a DNA:lipofectin ratio of 1:4. For in vitro studies, KC culturesupernatans was collected at timepoints 0, 24, 36 and 48 hours afteraddition of 0-5 μg/ml Tetracyclin (TC). For in vivo studies, VEGFtransfected KC are seeded in Full Thickness Wounds (FTW) in a73

porcine model. Subsequently, wound fluid is collected at 2, 12, 24, 48and 72 hours after addition of 2μg/ml TC. Saline treated wounds areused as negative control. Expression of VEGF165 is assessed withELISA. Biopsies are taken to assess neovascularization with lectinand anti-CD144 antibodies.Results: A transient VEGF165 expression is observed in vitro after TCaddition. Peak level is 25,700 pg/ml at 48 hours. When no TC isadded to the medium, VEGF levels remain below 200 pg/ml. In vivo,VEGF concentration is doubled at t12, 24 and 48 (3464 pg/ml) in theTC treated wounds. VEGF levels of FTW without TC and salinetreated wounds remain lower (1673 pg/ml). At t72, VEGF levels of allFTW equal around 6000 pg/ml. An increase in endothelial cells isobserved in wounds with high VEGF expression compared to controlwounds (P

Bewertung des Spenderdefektes ergab 13 x gut, 6 x befriedigend und2x schlecht.Schlussfolgerungen: Die A. Interossea posterior-Lappenplastik stelltaufgrund ihrer konstanten anatomischen Verhältnisse, einfachenPräparation und geringen funktionellen Spenderdefektes die Therapieder ersten Wahl bei Hautdefekten im Bereich der 1. Kommissur unddes Handrückens dar. Aufgrund der Knochenqualität und des grossenSpenderdefektes hat sich die osteo-kutane Variante in unsererErfahrung nicht bewährt. Aufgrund des grossen Spenderdefektes indistalen Unterarmbereich hat sich die A. interossea anteriorLappenplastik in unseren Händen nicht bewährt. Die M. pronatorquadratus-Lappenplastik stellt eine elegante Methode zur Bedeckungdes N. medianus im distalen Unterarmbereich bis zur Rascetta dar.Das distal gestielte vaskularisierte myo-ossäre Transplantat stellt eineAusnahmeindikation zur Behandlung therapieresistenter,atrophischer Frakturen im Karpalbereich dar. Wegen der feinenVaskularisation erscheinen die distal-gestielten Lappenplastiken ausdem Interossea-Strohmgebiet nach Verletzungen im distalenUnterarmbereich riskant, und bei fehlendem eindeutigemDopplersignal kontraindiziert.HIERNER R., BERGER A.: Subtotal and total degloving injuries at thehand. Chirurgica, 2006; 101: 32.Background: Total or subtotal skin loss at the hand presents one ofthe most severe functional impairment.Patients and methods: In a retrospective clinical study 11 patients whounderwent reconstruction for subtotal or total skin loss were reviewed.All patients were males and manual workers.The age ranged from 18– 53 years. Primary treatment consisted of a pocket graft according toMarino in 8 patients and primary skin grafting followed by early (within6 months after injury) microsurgical toe transfer in 3 patients. Studycriterias were 1) functional result (perfusion, sensibility, active andpassive ROM), 2) donor site morbidity, and 3) complications.Results: There was protective sensibility in all patients. In the patientswith the pocket graft active ROM of the MP II – V joints was Ex/Flex:0-15-60° and there was significantly reduced thumb mobility becauseof first web space contracture. In the patients with early microsurgicalreconstruction active ROM of the MP II – V joints was Ex/Flex: 0-0-70° and there was no first web space contracture. Static 2PD aftermodified wrap-around transfer showed 6 mm. Regardless the conceptchosen, 4 – 6 operations were needed in every patient in order toreconstruct a „basic-hand“ according to ENTIN. Patients with free toetransfer showed better results at the Moberg pick-up test. Inspite ofthe hugh donor site defect at the abdomen, all patients would prefere75

econstruction to amputation and prosthesis. Two patient do wear anesthetic prosthetis of PILLET for social events.Conclusion: The following principles of treatment should be applied forthe reconstruction of subtotal or total degloving injuries: 1) The thumbis best reconstructed with free toe transfer, 2) If P3 are still present,they should be amputated at the day of injury as almost all of them arelost later on, 3) Joint capsule tissue should be preserved as it providessome useful protective sensibility at the finger stumps.HIERNER R., BERGER A.: Long-term results after macroreplantation atthe upper limb. J. Hand Surg., 2006; 31B: 17.Background: Emergency management of a total or subtotal upper limbamputation poses a complex problem for the therapy team (surgeon,anesthesiologist, nurses, physiotherapist, social service, family doctor)and the patient. With today`s therapeutic and technological advances,the surgeon has the ability to salvage viability in most severe upperlimb injuries (1). Nowadays restoration of viability alone is notsufficient to fulfil the criteria of a successful replantation.Patients and methods: Using our personal series of 65 patientsoperated between 1981 and 1993 (upper arm: n = 18, proximal andmiddle forearm: n = 32, distal forearm and wrist level: n = 15) and theresults of an extensive literature review the following criterias wereevaluated; 1) survival rate, 2) possible individual motor and sensoryfunctions of the extremity, 3) global upper extremity function judgedaccording to Chen`s classification, and 4) socioeconomic aspects, and5) number and nature of local and/or systemic complication andsubjective judgment by the patient.Results: The survival rate of upper limb replantation, which onlymeans perfect restoration of viability is about 76 to 92,3%. With theamputation level going distally there is an increase of individual motorand sensory functions of the "functional chain upper extremity". Takinggrade I and II results together a „functional extremity“ can bereconstructed at the upper arm level in 22 to 34%, proximal forearmlevel 30 to 41% and distal forearm level 56 to 80%. All patientsneeded at least 2 secondary operative procedures. 5 of 65 patientswere re-amputated because of postoperative complications.Conclusion: As the functional results after replantation are at leastequal (proximal level) or even far superior (distal level), someprotective sensibility at the hand can be expected even at the mostproximal levels, and the missing psychological impairment cause bymissing body integrity, reconstruction should be carried out if possible,reasonable with regard to the expected function, estimated of low riskfor the patient and desired.76

HIERNER R., BERGER A.: Options and results of neurotization of themusculocutaneous nerve in posttraumatical brachial plexus lesions ofthe adult. J. Hand Surg., 2006; 31B: 27.Background: If active elbow flexion must be reconstructed in brachialplexus lesions the option of nerval reconstruction should always beconsidered first. Depending on the etiology there are severalpossibilities of reneurotization of the musculocutaneous nerve, suchas intraplexuel reconstruction from C6 root, or extraplexualreconstruction from the accessory nerve, phrenic nerve, intercostalnerves, ulnar nerve, pectoral nerve, and contralateral C7 root.Patients and methods: In 100 patients with a minimum follow-up of 3years the results of nerval reconstruction of active elbow flexion usingC6+ 3 nerve grafts (n = 50), ½ accessory nerve + nerve graft (n = 12),phrenic nerve (direct coaptation on anterolateral aspect of the uppertrunc; n = 3), 3 intercostal nerves (direct coaptation; n = 20), 3intercostal nerves + nerve graft (n = 10), ulnar nerve (FCU; n = 3) anddorsal root of contralateral C7 + vasc. ulnar nerve gaft (n = 2) wereevaluated. Criterias used are muscle power (MRC classification) andtime for recovery. Successful elbow flexion is achieved if musclepower > M3.Results: A successful elbow flexion, i.e. muscle power > M3 wasachieved after intraplexual neurotization from C6 root in 45/50patients. After extraplexual neurotization from the acessory nerve9/12, from the phrenic nerve 3/3 from the intercostals directly onto theMC nerve 15 /20, from the intercostals + nerve grafts 6/10, the FCUpart of the ulnar nerve 3/3 and the contralateral C7 root 2/2 patients.The distal extraplexual neurotization using part of the ulnar nerveshowed the fastest, the intercostal transfer the slowest recovery rate.Conclusion: Provided adequate muscle organ function active elbowflexion can be reconstructed in 60 - 90% of patient. If possible MCnerve should be grafted from the C6 root. However in case of bad rootquality or avulsion distal neurotization, especially from the phrenic andparts of the ulnar nerve proved to be of great value. Because of thelow donor site morbidity the ulnar nerve should be considered moreoften.HIERNER R., BERGER A.: Results after partial contralateral C7-transferin posttraumatic brachial plexus lesions of the adult. J. Hand Surg.,2006; 31(1): 28.77

Background: Within the last decade contralateral C7-Transfer hasbecome a new source of axon donor in complete brachial plexuslesions.Patients and methods: Between 1995 and 2001 10 adult patient weretreated. If possible the vascularized ulnar nerve graft or if not availabletwo sural nerves were used. Neurotization of the musculocutaneous(MC) nerve was carried out in six patients and in four patients of themedian nerve. There were six patients in the MC group and fourpatients in the median nerve group with more than 3 years of followup.Criteria for evaluation were, donor site morbidity, classification,time for recovery, time for autonomization, and functional result.Successful elbow flexion is achieved if muscle power > M3, successfulmedian nerve motor function is achieved if a primitive power grippattern is achieved.Results: All patients were complaining of temporary paresthesia in thedorsal part of P2 of the thumb and P3 of index and middle finger.There was complete sensory recovery at the 3 month postoperatively.There was no clinical evident motor loss at the donor extremity. Asuccessful elbow flexion, i.e. muscle power > M3 was achieved in allsix patients after 9 to 15 months. Four of six patients are able to usethis function individually. In the other two patients a start commandmust be given volontarily from the contralateral side (contraction of thecontralateral latissimus dorsi muscle). A functional primitive grippattern could be achieved in one out of four patients after 18 months.In three patients although there was movement this movement had tobe judged “academic” at the present state.Conclusion: The C7-transfer proved to be a save transfer if at the timeof operation no fascicles innervating wrist and finger extension aretaken. Adequate biceps muscle function was provided with activeelbow flexion in most patienst. However for median nervereinnervation motor results are moderate up to now.HIERNER R., BERGER A.: Free functional muscle transfer inposttraumatic brachial plexus lesions: is it worthwhile? J. Hand Surg.,2006; 31B: 29.Background: Free functional muscle transfer is indicated in brachialplexus lesions for reconstruction of basic functions at the elbow andhand level, if the neural reconstruction and eventual secondaryprocedures did not lead to a satisfactory result.Patients and method: In a retrospective clinical study 29 patients witha free functional muscle transfer after brachial plexus lesion with afollow-up of more than 3 years were examined. In 8 patients elbowflexion (direct intercostal transfer to gracilis (n = 4) or latissimus dorsi(n = 4)), in 16 patients wrist and finger flexion (intercostal transfer to78

vascularized ulnar nerve graft and secondary free latissimus dorsitransfer), in 4 patients elbow/wrist and finger flexion (direct intercostaltransfer to latissimus dorsi) and in 1 patient wrist and finger extension(intercostal transfer to latissimus dorsi) were reconstructed. Criteria forevaluation were the MRC-scale for power and active range of motion.Results: Functional elbow flexion (> 90°, M³) could be reconstructed in75 % of patients especially if residual but inadequate muscle functionis present (augmentation indication). Functional wrist and fingerflexion could be reconstructed only in 6% of cases. Reconstruction ofelbow, wrist and finger flexion with one transfer does not provide anyacceptable functional result.Conclusion: Especially in complete brachial plexus lesions freefunctional muscle transfer often is the only treatment option. By goodpatient selection satisfactory results can be achieved for elbow flexion.Up till now reconstruction at the forearm and hand level givesdisappointing results. A higher number of axon, as provided by thecontralateral C7 transfer, may lead to better results. This is the topic ofan ongoing study.HIERNER R., BETZ A., REYNDERS P., BERGER A.: Major limbreplantation at the lower extremity – still a worthwhile technique ?Chirurgica 2006; 101: 22.Introduction: As a result of modern therapeutic and technologicaladvances, the surgeon has the ability to salvage even the mostseverely injured lower limbs. However, the success of replantationnowadays is no longer evaluated simply on the basis of restoring theviability but also on 1) the risk for the patient during and afterreplantation, and 2) the functional and aesthetic outcome, and 3) timeof unfit of work and social reintegration.Material and method: Patient selection is based on an algorithmdeveloped upon personal experience and an extensive literaturereview. 14 patients presenting a total unilateral (n = 4), total bilateral(n = 2) and subtotal unilateral (n = 8) lower leg amputation underwentreplantation in our institution. The patient`s age ranged from 9 to 55years (average: 30,2). There was 1 child (male), 4 female and 9 malepatients. In one of the bilateral injuries bilateral normotopicreplantation was done. In the second case only unilateral normotopicreplantation was possible.Results: All replanted lower legs survived. Using CHEN`sclassification the functional results can be given as follows: Stage I66,6%, Stage II 25% (thus a "functional extremity" could bereconstructed in 91,6%), stage III 8,4% and stage IV 0%. Socialreintegration was achieved within 8 to 10 months after replantation. 4to 7 secondary operations were carried out in every patient in order to79

improve the result. Total duration of therapy took 28 to 48 months.There were no secondary re-amputation.Conclusion: Using the new algorithm, on the one hand there is asignificant decrease in replantation frequency (30% of all tranferredcases in our replantation center), on the other hand those casesreplanted show better functional and aesthetic results and a significantlower replantation risk. Our results show that lower leg replantation isstill worthwhile contrary what is believed by an increasing number oforthopaedic and trauma surgeons.HIERNER R., FLOUR M., NOTEBAERT M., TOMBEUR M., KIEKENS C.,DEGREEF H., VECKMAN L., VANDERMEERSCH E., JOOSTEN E.:Richtlinien für das globale Decubitusmanagement unter besondererBerücksichtigung plastisch-chirurgischer Therapieansätze. Chir.Gastroenterologie, 2006; 22: 155-168.Pressure sores are a serious medical and surgical problem, despitegrowing knowledge on pathophysiology, diagnosis, prevention andtreatment. Pressure ulcer occurs in several groups of patients,including elderly patients, patients with central nervous systemdisease and paralysis, chronically ill, debilitated, patients with longoperation (in hypothermia) and bedridden patients. Efficientmanagement of pressure sores is based on a multidisciplinary teamapproach, a “common language” for diagnosis and documentation andan integrated treatment concept. Prevention remains the cornerstoneof management of pressure sores. Treatment of pressure sore aimson systemic and local factors. The conservative treatment is the basisof local wound care. Operative treatment can be understood asadjunct to a no more efficient conservative treatment. Using plasticsurgical techniques and principles, even large defects can besuccessfully reconstructed. Simple wound closure nowadays is notsufficient, the defect must stay closed after resuming normal lifeactivities. This requirement especially applies for the young patientage group. The postoperative care is as important as the operationitself.HIERNER R., GOFFIN J., VAN LOON J., VAN CALENBERGH F.: Freelatissimus dorsi flap transfer for scalp and cranium reconstruction.Chirurgica, 2006; 101: 16.Introduction: Free tissue transfer for scalp and cranium reconstructionis indicated in large defects with exposed brain tissue, deperiosted80

cranial bone and dura which cannot be reconstructed with local flapsor skin grafts.Material and method: Free latissimus dorsi transfer was carried out in6 patients with subtotal and total scalp defects ( 4x reconstruction aftertumor removal, 1x tissue break down after irradiation, 1x defectreconstruction after high voltage injury). There were 2 male and 4female patients. The age ranged from 36 to 72 years. Reconstructionwas carried out with a muscle flap (1x) or a myo-cutaneous flap (5x)in combination with a split thickness skin mesh (1:1,5) graft, done in asingle-stage procedure. In a retrospective clinical study the followingcriteria were evaluated: 1) flap healing, 2) aesthetic result, and 3)complications.Results: All flaps healed primarily, and all wounds remained closedwithout any signs of infection. Complete wound healing was achievedafter 4 to 8 weeks, depending on the “take” of the skin grafts.Secondary skin grafting was necessary in 2 patients, revision of thedonor site in 1 patient. From an aesthetic point of view 4 patientscomplained about the appearance of the retroauricular skin island.After removal of the skin island 6 months after the initial operation, allpatient judged the result as good or acceptable.Conclusion: Free LD transfer is the only option for coverage ofsubtotal or total scalp defects. Contrary to most authors, our preferreddonor vessels are maxillary artery and the external jugular vein. Inorder to avoid any vascular compression we are using a myocutaneousflap. The skin island must be removed secondarily.HIERNER R., NIJS S. BERGER A.: Vascularized joint transfer for fingerjoint reconstruction: - currrent indications an long-term results. J. HandSurg., 2006; 31B: 37.Background: Vascularized complete joint transfer offers the uniquepossibility to reconstruct a joint defect at the thumb or fingers usingautologous tissue, which fully preserves its growth potential.Patients and methods: In a retrospective clinical study 14 vascularizedjoint transfers to the hand with an average follow-up of 8,2 (3 – 15)years were evaluated. The joint defect was caused by trauma in 11patients and infection, tumour and congenital deformity in 1 patienteach. There were 12 men and 2 women. The mean age range was 26(2 – 42) years. In 4 cases a partial vascularized joint transfer, and in10 patients a complete vascularized joint transfer was carried out. Thefollowing criteria were evaluated: active range of motion (Neutral-0-Method), postoperative arthritis, growth and complications.Results: Active range of motion of the transplanted joint was for partialPIP-joint transfer Ex/Flex 0/20°/65°, partial MP-joint transfer0/20°/30°, DIP-to PIP-joint transposition 0/20°/60°, PIP-to-PIP81

transposition 0/30°/60°, PIP-to-MP-transposition 0/20°/80° and MP-to-MP-transposition 0/20°/57°. The results after microvascular PIP-jointtransfer from the 2 nd toe for PIP-joint reconstruction were 0/25°/58° forPIP-joint reconstruction and 0/15°/70° for MP-joint reconstruction.Arthritic changes could be seen in 3 out of 4 patients with partialvascularized joint transfer. In all complete joint transfers there was noclinical and radiological evidence of arthritis even after 15 years. In thetwo skeletal immature patients at the time of transfer, normal growthcompared to the contralateral donor site could be seen. In 8 out of 14patients complications occurred.Conclusions: Indications for vascularized joint transfer at the finger inchildren is set because of lack of therapy option offering normalgrowth potential. In adults vascularized joint transfer is indicated incase of contraindication for prosthetic joint replacement or arthrodesis.HIERNER R., NIJS S., VAN DEN KERCKHOVE E.: Possibilities andresults of defect coverage at the elbow. J. Hand Surg., 2006; 31B: 88.Background: Large defects at the elbow region often lead tosignificant impairment of function.Patients and methods: In a retrospective clinical study 151 patients(82 male, 59 female) who underwent flap surgery for defectreconstruction at the elbow were reviewed. The age ranged from 7 –82 (average 39,4) years. The defect was located in 49 cases at thefossa cubitalis, in 15 cases at the medial epicondyle region, in 29cases at the lateral epicondyle region and in the remaining 61 casesat the dorsal region or involved multiple regions. Etiology of defectwas trauma (n = 95), impaired wound healing and infections (n= 27),extravasation injuries (n = 12), unstable scare after multiple previoussurgeries (n = 8) and revision after ulnar nerve decompression at theelbow. Defect coverage was done using local flaps (n = 71), pedicledflaps (n = 41) and free microvascular flaps (n = 39). Study criteriaswere successful defect coverage and active and passive ROM preandpostoperatively.Results: Successful primary reconstruction could be achieved in 142cases (93,6%). There were 2 complete and 4 partial flap necrosis afterlocal flap transfer. And 3 after free microvascular transfer. There wereno changes in ROM depending on the flap reconstruction unless ascar release had been carried out.Conclusion: Reconstruction of large defects at the elbow do require amultidisciplinary approach. For the treatment of large soft tissuedefects we are using a standardized diagnostic and therapeuticschedule. We distinguish 4 functional units (fossa cubitalis, lateralepicondyle unit, dorsal unit (regio olecrani) and medial epicondyleunit, thus defects can be classified into monoregional and polyregional82

defects.Adequate debridement, early soft tissue coverage, and adequatepostoperative care are necessary to achieve a good result. Bycombining different orthopaedic and plastic surgical techniques incombination with a adequate postoperative care, will lead to asignificant improvement of results and diminish the number ofamputations.HIERNER R., REYNDERS P., MATRICALI G.: Results of microsurgicalreconstruction at the heel. Chirurgica, 2006; 101: 19.Introduction: Soft tissue defects alone or in combination withunderlying bone defects at the heel lead to significant functionalimpairment of the foot. For reconstruction purpose, two differentfunctional subunits can be described at the heel such as, 1) dorsalheel subunit, and 2) the plantar heel subunit.Material and Methods: In a retrospective clinical study 18 patients withheel defects were examined. There were 11 male and 5 femalepatients. The age ranged from 4 – 79 years. Etiology of defect wastrauma (14), tumor (2) and pressure sore (2). Follow-up was at least 1year. The following criteria were examined: 1) type of treatment, 2)primary wound healing, and 3) complications.Results: In 2 patients with pressure sore at the heel treatmentconsisted of partial calcanectomy and secondary wound healing. In 16patient treatment was carried out using a pedicled (5 x plantarismedialis, 1x suralis) or a free (6 x Radial forearm flap, 2 x Scapulaflap, 2x latissimus dorsi muscle flap + skin graft) flap. Primary woundhealing was achieved in 13 patients with flap coverage. There wasone partial necrosis at the distal part of a suralis flap, which ultimatelywas treated by lower leg amputation. In two patients there wasincomplete fullthickness skin graft take at the donor site of an instepflap.Discussion: If ever possible the plantar subunit of the heel should bereconstructed with a sensible flap. The plantaris medialis flap turnedout of extreme value. For the dorsal subunit of the heel the pedicledsuralis flap offers an elegant treatment option. To improve hisreliability a delay procedure can be added. If no local flaps areavailable, the following points principles should be taken into account:Protective sensibility is coming from skin, aponeurosis plantaris, jointcapsules and periosteum; the larger the defect the more important ispostoperative physiotherapy and adequate orthopaedic shoeproviding. Fasciocutaneous flaps are indicated in partial defect,complete heel defects are best treated by a muscle flap coved bysplitthickness skin graft. Secondary operation are always necessary toimprove the functional and/or aesthetic result or to treat secondary83

tissue break down. In case of limited operability, partial calcanectomyfollowed by guided secondary wound healing should be considered.HIERNER R., REYNDERS P., MATRICALI G.: Microsurgicalreconstruction for defects at the sole of the foot. Chirurgica, 2006; 101:21.Introduction: Defect at the sole of the foot often lead to significantinpairment of function and thus in a large number of those cases endin (partial) foot amputation. Provides adequate patient selection plasticsurgical techniques can be used sucesfully to reconstruct the sole ofthe foot.Material and Methods: In a retrospective clinical study 26 patients whounderwent flap surgery for defect at the sole of the foot werereviewed. There were 14 partial and 12 complete defects of the sole ofthe foot. The patient were 4 – 72 years old.Discussion: If ever possible in partial defects local plantar tissueshould be used to cover the functionally most important places(metatarsal I and V and heel). If no local tissue transfer is possible thefollowing requirements have to be discussed. Protective sensibility atthe sole of the foot may come from the skin or the periosteum. Thelarger the defect the more important become secondary surgery andpostoperative physiotherapy and special orthopedic shoe treatment.Fasciocutaneous flap do have the theoretical possibility ofresensibilisation, a highly discussed issue. However there is higherrisk of „floating flap“ („savonnage“). Muscle flaps covered with skingraft are the golden standard for complete plantar resurfacing.Conclusion: Reconstruction of large defects of the sole of the foot dorequire a multidisciplinary approach. By combining differentorthopedic and plastic surgical techniques in combination with aadequate postoperative care amputation can be sucessfully preventedin a large number of patients.HIERNER R. VAN DEN KERCKHOVE E., NIJS S.: The ulno-dorsal fasciaflap for treatment of recurrent carpal tunnel syndrome. J. Hand Surg.,2006; 31B: 66.Background: Multiple revisions because of persistant complaints aftercarpal tunnel release are leading to an increasing fibrosis at the levelof the median nerve and the surrounding tissue. Inspite of technicalaedequate microsurgical intrafascicular release, hyperesthesia at thepalmar wrist level may persist.84

Patients and Methods: Between 1995 – 2002 5 patients with recurrentcompression complaints of the median nerve at the wrist level weretreated with a microsurgical intrafascicular neurolysis according toMILLESI in combination with a pedicled fat-fascia flap according toBECKER/GILBERT. There were 4 female and 1 male patient. Theirage ranged from 36 to 55 years. In all patients a minimum of 4 (4-7)previous operations had been performed. All patients had anadequate pain treatment. In a retrospektive clinical study the followingcriterias were evaluated: 1) pain (analog scale 1 – 10), 2) sensibility(static 2PD), 3) active and passive ROM (neutral-0-method), 4) powerand pinchgrip (JAMAR, PINCHMETER), and 5) subjektive jugdementof the flap donor site by the patient (excellent, acceptable, fair). Theminimum follow-up was 18 months.Results: In all patients reduction of pain from an average of 7/10(heavy permanent pain under pain medication) to 4/10 (intermittentpain without permanent pain medication) occurred. There was nochange in sensibility after operation. However there was an increasein power grip from an average from 14 kg to 20 in average. The flapdonor site was judged acceptable by all patients.Conclusion: Combination of microsurgical interfascicular neurolysiswith the ulno-dorsal fascia flap will lead to better vascularization at thepalmar wrist region, better vascularization at the median nerve andadditional „padding“ of the neurolysed nerve. This leads to asignificant ameloration but not to a complete pain free status of thepatient.HIERNER R., VAN LOON J., VAN CALENBERGH F., GOFFIN J.: Freelatissismus dorsi flap transfer for subtotal scalp and cranium defectReconstruction. Eur. J. Plast. Surg., 2006; 29: 181-185.The purpose of this paper is to review the results of free latissimusdorsi transfer for scalp and cranial reconstruction in the case of largedefects with exposed brain tissue, cranial bone without periostealcover, and dura, which cannot be reconstructed with local flaps or skingrafts. Free latissimus dorsi transfer was carried out in seven patientswith subtotal and total scalp defects (two reconstruction after tumorremoval, two reconstructions after long-standing osteitis, two tissuebreakdown after irradiation, one defect reconstruction after highvoltage injury). There were three male and four female patients. Theage ranged from 36 to 72 years. Reconstruction was performed with amuscle flap or a myocutaneous flap in combination with a splitthicknessskin mesh (1:1.5) graft in a single-stage procedure. In aretrospective clinical study, the following criteria were evaluated: (1)flap healing, (2) aesthetic result and (3) complications. All flaps healedprimarily, and all wounds remained closed without any signs of85

infection. Complete wound healing was achieved after 4 to 8 weeks,depending on the “take” of the skin grafts. Secondary skin graftingwas necessary in two patients, while revision of the donor site wasnecessary in two patients. From an aesthetic point of view, fourpatients complained about the appearance of the retroauricular skinisland. After removal of the skin island 6 months after the initialoperation, all patients judged the result as good or acceptable.Besides the free omentum flap, the free latissimus dorsi transfer is theonly option for cover of subtotal or total scalp defects. Compared tothe omentum flap, the latissimus dorsi offers more tissue, has lessdonor site morbidity, and secondary surgery such as cranial bonereconstruction is possible. Contrary to most authors, our preferreddonor vessels are maxillary artery and the external jugular vein. Toavoid any vascular compression, we use a myocutaneous flap. Theskin island must be removed secondarily. In patients where no bonereconstruction is possible or planned, the de-epithelialized skin paddlecan be used for correction of a contour defect.HIERNER R. WILHELM K.: Callotaxis lengthening of the capitate afterresection of the lunate for the treatment of stage III lunate necrosis – a10 year follow-up. J. Hand Surg., 2006; 31B: 35.Background: In order to reduce the risk of iatrogenic devascularizationof the capitate in the conventional GRANER-II technique, thecallotaxis lengthening techique of ILIZAROV has been used aftercapitate osteotomy between the middle and distal third of the capitate.Patients and methods: Since november 1993 the callotaxislengthening technique has been used to gradually lengthen thecapitate after resection of the lunate in stage IIIa NECROSIS in 23patients.Results: Results of 10 patients with a follow-up of more than five yearsshowed rapid and sufficient callus formation in every patientregardless of age.Conclusion: The callotaxis lengthening modification of the Graner-IIoperation provides all advantages, and avoids the major inconvenientof the traditional Graner-II-operation. There was no increased rate ofdisturbed fracture healing. Results of the DTPA-Gadullinium MRIstudydid not show any significant impairment of vascularization withinthe region of the capitate bone. With the "intrinsic bone formation",contrary to every other intercarpal arthrodesis at the wrist, there is noneed of an additional bone graft.86

MASSAGE P., VANDENHOF B., VRANCKX J.J.: Full face resurfacing of3rd degree burns with artificial dermis: barriers & opportunities. J.Plast. Reconstr. & Aesth. Surg., 2006; 59: S7.The face is a visiting card for every individual human being, playing amajor role in his social and professional life. Scar formation in theface, its prevention and its reconstructive treatment has always been amajor concern for all surgeons. In this search for solutions cliniciansand research team up. At the extreme of the scope of facial scarring isthe deep dermal complete facial burn. We show the results obtainedwith a tissue engineered skin substitute in 2 immediate and 2 latemajor facial reconstructions. These results encourage the furthersearch for the ideal skin substitute and raise questions about the ideaof considering facial transplantation for treatment of facial burnsequellae.PEETERS W., HIERNER R., NIJS S., VAN DENKERCKHOVE E.: Cost ofreplantation injuries at the hand: replantation versus stump providing.J. Hand Surg., 2006. 31B: 53.Background: With increasing financial pressure in the health caresector the question arises if the costs of replantation do outweight thebenefit ?Patients and Methods: The financial costs for reconstruction andstump providing are calculated and compaired in case of a: 1) singlelong finger amputation, 2) thumb amputation, and 3) multiple fingeramputation involving the thumb. Financial costs are calculated for a 25year old and a 50 year old manual worker.Criterias for calculation are:medical costs (for primary and secondary surgery), costs for unfit ofwork, and costs for disability.Results: Costs of single finger replantation for a 25 year old manualworker are equal for reconstruction and primary amputation. From apure financial point of view reconstruction of a subtotal or total singlefinger amputation in a 50 year old manual worker is not justified. Forthumb amputation in a 25 year old manual worker, there is a cleardifference in costs in favour reconstruction, thus justifyingreplantation/revascularization in every case possible and reasonable.From a pure financial point of view reconstruction of a subtotal or totalthumb amputation even in a 50 year old manual worker is justified. Inmultiple finger amputation there is a clear difference in cost in favourof reconstruction for the 25 and 50 year old manual worker.Conclusion: From a pure financial point of view all replantations arejustified except for the single long finger replantation in a 50 year oldmanual worker. Although in each group the major part of costs iscreated by costs for disability, there is no worldwide accepted87

classification for judging the persistent impairment after replantation,like there is for amputation. The advantage of low costs for medicaltreatment in case of stump providing will be lost over time due to costsarising for continuing disability which have to be paid until retirement.PEETERS W., HIERNER R., REYNDERS P.: Simultaneous free flapcoverage in total knee joint replacement: - indications and results.Chirurgica, 2006: 101: 20Objective: Insufficient soft tissue prior to prosthetic implantation is oneof the most important reasons for postoperative soft tissuecomplications and/or joint stiffness.Methods: In a retrospective clinical study 10 patients who underwentfree latissimus dorsi flap together with total knee prosthesis arereviewed. Follow-up ranges between 6 to 30 (average: 23) months.Study criteria were primary wound healing, complications and activerange of motion.Results: Primary wound healing could be achieved in all patients. In 2patients skin necrosis occurred at the recipient site making a secondoperation (1 skin graft, 1 fasciocutaneous flap) necessary. In 2patients with preexisting osteomyelitis infection occurred, and had tobe treated with serial debridements. However no prosthesis had to beremoved. Active range of motion after combined prosthesisimplantation and flap transfer showed on average Ex/Flex 0-10-70°.Conclusions: Free flap transfer together with total knee jointreplacement in an exceptional indication. Simultaneous flap transfer incase of insufficient soft tissues can successfully prevent postoperativestiffness. In case of postoperative tissue breakdown, the pedicledmedial gastrocnemius muscle flap is the treatment of choice, and willlead to reliable results, if done early. In case with tissue breakdownand prosthetic show, removal of prosthesis is only indicated in case ofprosthetic loosening and persisting deep infection. After adequatedebridement, and especially a complete synovialectomy the defectcan be covered by well vascularized muscle tissue in a single-stageprocedure. Alternatively a VAC can be placed after debridement andflap coverage can be done 3 – 7 days later; after reevaluation of(systemic and local) infection parameters.PEETERS W., HIERNER R. VAN DEN KERCKHOVE E.: High pressureinjection injuries of the hand: a case report of an industrial painter.Chirurgica, 2006; 101: 41.88

Background: High pressure injuries of the hand are characterized byvery small visible defect on clinical examination by admission, but veryextensive lesions of the inside.Patients and methods: A case report of a 33 year old industrial painterwill be presented. He injected an amount of paint in his right hand byaccident and was referred to our hospital. On admission only a smallentry port at the level of the index finger was seen. On X-ray of thehand there was a big amount of radioopac material from the entry portuntil the carpal tunnel level. By checking the injected substance anacute danger of systemic intoxication was ruled out. The patient wasimmediately taken to the OR and an extensive debridement includinga complete synovialectomy a microsurgical neurolysis and arteriolysison the palmar side was carried out. On intraoperative fluoroscopicexam, a dorsally placed amount of paint was seen. Therefore astraight dorsal approach starting from P1 and going up to the MP levelwas carried out. A suction drain was placed and definitive wound wasdone. Antibiotics were started for 5 days. The hand was placed on apalmar splint in intrinsic + position. Postoperative healing wasuneventfully. An extensive physiotherapy program was started 3weeks after surgery and continued until 6 months post-OP. One yearafter the injury the patient was reevaluated with special regards tovascularization, sensibility, active and passive range of motion andsocial reintegration.Results: Vascularisation of the hand showed no complaints at rest andat work, however paling of the skin occurs by cold exposure. Thestatic 2PD for N1 to N10 is at 4 mm. There are soft scars on thepalmar side and a slightly hypertrophic scar on the dorsal side. Thereis full active and passive range of motion. The patient is reintegratedin his previous job.Conclusion: High pressure injuries are often underestimated injuries.To avoid systemic intoxication the nature of the substance injectedmust be known. If treated adequately acceptable to good results canbe obtained. Adequate treatment means a multidisciplinary approachwith close communication with physiotherapy. However if treatedlately secondarly damage will lead to important sequellae with anultimately impaired hand function or stiff hand.VAN DEN KERCKHOVE E., HIERNER R., BOECKX W., MASSAGE P.:Clinical parameters, assessment and treatment of burn scarring. J.Plast. Reconstr. Aesth. Surg., 2006; 59(9): S3.In this presentation some of the basic principles in hypertrophic scarhealing will be briefly summarised. More specially, the clinicalparameters (as thickness, erythema and pigmentation, pliability) thatspecify this type of aberrant wound healing are discussed.89

Furthermore, subjective (questionnaires) and objective tools(colourimeters, elastometers, ultrasound, etc.) to assess theseparameters will be critically analysed with regard to their scientifical oradded value in a possible test battery for scar assessment. Finally,based on evidence based articles a short overview will be given of alldifferent conservative therapeutical strategies. Also own research inthe field of the use of pressure on burn related is shown. Although theworking mechanism is still questionable both pressure therapy andsilicone contact media seem to have the best scientifical evidence forefficacy in the conservative treatment on prevention of hypertrophic(burn) scars.VAN DEN KERCKHOVE E., HIERNER R., DEGREEF H., GYSKENS J.:Possibilities and results of scar and compression treatment after freeflap surgery. Chirurgica, 2006; 101: 27.Introduction: The aesthetic result is an important part of a successfulreconstruction. Possibilities to influence the aesthetic result areadequate flap planning (colour, texture), recipient site dissection(aesthetic units), insetting of the flap (intradermal stitches) andpostoperative treatment (conservative and/or operative).Material and Methods: 20 Patients with free flap transfer to the lowerleg after trauma and tumor removal were treated according astandarized protocol in our multidisciplinary “scar clinic”. Aftercomplete wound healing scar massage (3-5x/d) is started andcontinued up to 6 months post-op. In case of hypertrophic scars weare adding a silicon sheat (cica care/R). Compression is started 3weeks after surgery using soft compression (Tubigrip/R) and after 6weeks compression stocking. This crescendo treatment is carried outfor at least 6 months, but best until the scar turned from red to white.In a retrospective study the following criteria were evaluated: 1)patient’s compliance, 2) patients judgment (excellent, good, moderate,fair), 3) reviewer judgment (excellent, good, moderate; fair).Results: All patients followed the treatment at least for 6 months.Patient judged their lower leg reconstruction as excellent (5), good(11), moderate (3), fair (2). The reviewer judged the results asexcellent (3), good (9), moderate (6), fair (2).Summary: Using a standarized program the aesthetic result after flapsugery can be improved with regard to the scar formation and colourchanges and the shape of the flap. We highly recommend such atreatment for the upper limb, lower limb and face.90

VERMEULEN P., DICKENS S., VRANCKX J.J.: Expansion ofhematopoetic stem cells as a model for vascularized tissue constructs:the facts, the myths, the promises. J. Plast. Reconstr. & Aesth. Surg.,2006; 59: S5.In order to maintain bulk and function of tissue engineered constructs,vascular networks are essential for delivery of oxygen and nutrients.Different strategies are studied thus far to achieve this goal. 1) Theuse of angiogenic growth factors (VEGF, bFGF, PDGF, HGF,Angiopoietin) releasing polymers. These gels create a microenvironmentwhere cytokines promote the in situ formation of capillarbeds. 2) Prevascularization allows vascular ingrowth into an in vivoimplanted (biodegradable) matrix and seeding of cells of choiceafterwards. The peritoneal cavity is mostly used for this purpose. 3)Genetic modifcation of the in vivo environment or ex vivo expandedcells with an angiogenic growth factor. 4) Transplantation of“angiogenic stem cells” like endothelial progenitor cells (EPCs) orhematopoietic stem cells (HSCs) which can sprout from alreadyformed vessel walls (angiogenesis) or create tubular conduits withendothelial lining (vasculogenesis). Recent insights in the last decadehave shown that the biological behavior of bone marrow derivedendothelial progenitor cells (EPCs) and (HSCs) is complex andintertweened. These cells have the possibility to integrate intodamaged endothelium (smoking, atherosclerosis, trauma…) or createcollateral blood vessels in vivo. From their release out off the bonemarrow sinsoids to the final homing and differentiation, they undergo adynamic functional and morphological profiling. Culture of EPCsallows to expand and purify these CD34+/KDR+/AC133+ cells ex vivoand apply them to morphological defects, ischemic tissue or use themas cellular components for ex vivo tissue engineering. We present ourstrategy for understanding the behavior and integration of ex vivoexpanded EPCs in a pathological wound healing model. The coreelements of this strategy are 1) ex vivo expansion of EPCs ; 2)Tetracyclin regulated expression of VEGF165 by means of lipofectinmediated transfection; 3) establishment of a diabetic porcine fullthickness wound healing model.VRANCKX J.J., STEINSTRAESSER L., MOHAMMADI-TABRISI A.,JACOBSEN F., MITTLER D., LEHNHARDT M., LANGER S., STEINAUH.U., ERIKSSON E.: A novel titanium wound chamber for the study ofwound infections in pigs. Comp. Med., 2006; 56: 279-285.In the face of emerging multidrug-resistant microbes, reliable animalmodels are needed to study potential new therapies in infectedwounds. To this end, we implanted screw-top titanium chambers91

subdermally in full-thickness wounds on both flanks (n = 6 per flank) of2 Goettinger minipigs. After 1 wk, chambers were inoculated withStaphylococcus aureus, Pseudomonas aeruginosa, or vehicle only.Throughout the study, wound fluid was harvested for quantitativebacterial cultures to monitor infection. Animals were followed for 4 wk,after which tissue biopsies were taken for histologic analysis andquantitative bacterial counts. The implanted titanium chambers werewell tolerated by the pigs throughout the study. After inoculation of thechambers, wound infection was established and maintained for 14 d.Despite infection, no systemic effects were noted. Crosscontaminationwas negligible, compared with the vehicle-only control.After tissue ingrowth, each chamber creates a closed system thatallows harvest of exudate or application of substances without loss ofmaterial from the chamber. Because 12 chambers are implanted ineach pig, researchers have the opportunity to compare multipletreatment options (for example, antibiotics, antimicrobial peptides,gene therapy) in the same animal, with no interindividual variation. Weconclude that the use of titanium chambers in pigs provides a reliableand reproducible in vivo model to investigate wound healing, woundinfection, and treatment options.VRANCKX J.J., VERMEULEN P., DICKENS S., MASSAGE P.: Smartautologous skin engineering: science and fiction. J. Plast. Reconstr. &Aesth. Surg., 2006; 59: S7.The ultimate tissue engineering construct for tissue repair should beautologous to optimally integrate without rejection, three-dimensionalto bridge deep defects, porous to allow cell migration; bio-inductive forcells to proliferate and to topically produce extra cellular matrixcomponents, bio-inductive and supportive for angio and arteriogenesisand chemotactic for cells that infiltrate from the wound surroundingsand that will orchestrate, stimulate and regulate these processes.Proliferative cells with stem cell properties should be part of theconstruct in order to obtain an optimal degree of integration with theintrinsic capacity to respond to a changing microenvironment. Suchconstructs should also be part of the construct in order to obtain anoptimal degree of integration with the intrinsic capacity to respond to achanging microenvironment. Such constructs should also beapplicable to defects present under (or even induced by) anunfavorable healing environment and in systemic diseases such asdiabetes or cardiovascular and under treatment with corticosteoirds orcytostatica. These constructs may be spiked with recombinant DNAplasmids or populated with transgene cells transfected or transducedwith plasmids expressing wound-healing proteins that are deficient orlacking in the particular morbidity state or, conversely, with proteinase92

inhibitors that neutralize the impairing effects of proteinases presentabundantly in chronic defects. Tissue engineering skin equivalentsheralds promising clinical appliances in restoration of skin continuityafter burns, tumor removal and in congenital skin disease. Tissueengineering produces the elementary building blocks required torestore large defects while gene therapy delivers supplementaryintelligence to the wound healing niche by production of coordinatingand directing regeneration factors. Hence, cell proliferation, geneoverexpression and protein production in vivo should be tightlyregulated to fine-tune or finalize protein expression and proteinexpression once the wound healed or the tissue regenerated in orderto avoid cancerogenesis. With tissue engineering and gene therapy ofelementary proteins we target the cultivation of a smart autologousskin equivalent, available on-the-shelf for immediate use in extensivedeep full thickness skin defects such as in third degree burns,congenital skin deformities such as epidermolysis bullosa or after theremoval of large skin tumors. In order to be in skin “equivalent”, ourengineering strategies should be biocompatible, mimicking theauthentic repair and healing processes as accurately as possible.93

THORAXHEELKUNDECOOSEMANS W., DECKER G., DE LEYN P., NAFTEUX P., VANRAEMDONCK D., LERUT T.: Achalasie: laparoscopische myotomie enfundoplicatie. Tijdschr. voor Geneeskunde, 2006; 62(7): 541-548.Achalasie is een functionele slokdarmaandoening die zich kenmerktdoor een verhoogde rustdruk en een onvolledige relaxatie van degastro-oesofagale sfincter, samen met een afwezige peristaltiek vanhet slokdarmlichaam.Dysfagie is het meest voorkomende symptoom bij alle patiënten.Door de ontwikkeling van de videoscopische chirurgie heeft delaparoscopische Heller-myotomie een belangrijke plaats in debehandeling, niet alleen na voorafgaande dilataties en/of botulineinjecties,maar zelfs als primaire behandeling.Om iatrogene gastro-oesofagale reflux te voorkomen, wordt meestaleen additionele anterieure partiële Dor-fundoplicatie toegevoegd.In de periode van januari 1996 tot en met mei 2004 werden in dedienst Thoraxheelkunde van de Universitaire Ziekenhuizen Leuven 49patiënten op die wijze chirurgisch behandeld met 85,1% uitstekendetot zeer goede resultaten.DEKETELAERE A., KELCHTERMANS G., STRUYF E., DE LEYN P.:Disentangling clinical learning experiences: an exploratory study onthe dynamic tensions in internship. Med. Educ., 2006; 40(9): 908-915.Clinical practice is an essential component of medical training, but notall internships yield the appropriate and expected learning results. Wereport on an exploratory study of the learning process duringinternship in undergraduate medical education. We hypothesised thatlearning experiences in clinical practice are determined bycharacteristics of the interns, characteristics of the training setting andthe meaningful interactions between them. As the study focused onthe perceptions and interpretations of both interns and theirsupervisors of interns' experiences in practical training, qualitativeresearch methods were used for data collection and analysis. Thisconsisted of student shadowing, complemented by informal andsemistructured interviews with both interns and supervisors. Analysisrevealed 5 components that constitute learning experiences in clinical94

internship. These components represent dynamics in the clinicalenvironment that constantly require students to (re-)define and (re-)position themselves: the agenda of the internship (working versuslearning); the attitude of the supervisor (evaluator versus coach); theculture of the training setting (work-orientated versus trainingorientated);the intern's learning attitude (passive versus proactive),and the nature of the learning process (informal versus formal). Themodel of components and tensions offers a conceptual framework toanalyse and understand students' learning during internship. It notonly contributes to a grounded theoretical conceptualisation of clinicallearning, but may also be used in efforts to improve the quality oflearning during internship, as well as the level of support andsupervision.DE LEYN P., STROOBANTS S., DE WEVER W., LERUT T., COOSEMANSW., DECKER G., NAFTEUX P., VAN RAEMDONCK D., MORTELMANS L.,NACKAERTS K., VANSTEENKISTE J.: Prospective comparative study ofintegrated positron emission tomography-computed tomography scancompared with remediastinoscopy in the assessment of residualmediastinal lymph node disease after induction chemotherapy formediastinoscopy-proven stage IIIA-N2 non-small-cell lung cancer: aLeuven cancer group study. J. Clin. Oncol., 2006; 24(1): 3333-3339.Purpose: Mediastinal restaging after induction therapy for non-smallcelllung cancer remains a difficult and controversial issue. The goal ofthis prospective study was to compare the performance of integratedpositron emission tomography (PET)-computed tomography (CT) andremediastinoscopy in the evaluation of mediastinal lymph nodemetastasis after induction chemotherapy.Patients and methods: Thirty consecutive stage IIIA-N2 non-small-celllung cancer patients surgically treated at our institution were enteredonto this prospective study. N2 disease was proven by cervicalmediastinoscopy, at which a mean number of 3.8 lymph node levelswere biopsied. After completion of induction chemotherapy, themediastinum was reassessed by integrated PET-CT andremediastinoscopy. All patients underwent thoracotomy withattempted complete resection and systematic nodal dissection.Results PET-CT showed no evidence of nodal disease (N0) in 13patients, Hilar nodal disease (N1) disease in three patients, andresidual mediastinal disease (N2) in 14 patients. Remediastinoscopywas positive in only five patients. The preinduction involved lymphnode level could be accurately re-evaluated in 18 patients. This wasnot the case in the other 12 because of extensive fibrosis andadhesions. In 17 patients, persistent N2 disease was found atthoracotomy. The sensitivity, specificity, and accuracy of PET-CT95

were 77%, 92%, and 83%, respectively. These parameters forremediastinoscopy were 29%, 100%, and 60%, respectively.Sensitivity (P < .0001) and accuracy (P = .012) were significantlybetter for PET-CT.Conclusion: After a thorough staging mediastinoscopy, postinductionremediastinoscopy had a disappointing sensitivity because ofadhesions and fibrosis. Integrated PET-CT yielded a better result thanthat obtained in previous studies with side-by-side PET and CTimages.DE LEYN P., VANSTEENKISTE J., NACKAERTS K., LORENT N., LIEVENSY., NAFTEUX P., VAN RAEMDONCK D., COOSEMANS W., DECKER G.,LERUT T.: Inductietherapie voor lokaal gevorderd niet-kleincelligbronchuscarcinoom: ervaring van de Leuven lung cancer group.Tijdschr. voor Geneeskunde, 2006; 62(7): 509-515.Bij het lokaal uitgebreide niet-kleincellige bronchuscarcinoom(wanneer er aantasting is van mediastinale lymfeklieren of bij zeercentraal gelegen tumoren of tumoren van de sulcus superior) zijn deresultaten van primaire heelkunde niet bemoedigend. Zowel de kansop complete resectie als de verwachte 5-jaarsoverleving zijn laag.Inductietherapie, bij middel van hetzij chemotherapie, hetzijchemoradiotherapie, biedt hier nieuwe perspectieven. In de groep vanpatiënten met aangetaste mediastinale klieren (N2-aantasting) die eenresectie ondergingen, bedroeg de 2-jaars en de 5-jaars overleving nainductietherapie respectievelijk 68 en 33%. Vooral patiënten metrespons in de mediastinale lymfeklieren hebben de beste prognose.PET-scan lijkt veelbelovend te zijn om deze respons te meten. BijPancoasttumoren is inductieradiochemotherapie gevolgd doorresectie de nieuwe standaardbehandeling.In dit kort artikel rapporteren we de ervaring vaninductiechemotherapie en inductiechemotherapie met radiotherapievan de Leuven Lung Cancer Group.DRIESSEN A., LANDUYT W., PASTOREKOVA S., MOONS J., GOETHALSL., HAUSTERMANS K., NAFTEUX P., PENNINCKX F., GEBOES K.,LERUT T., ECTORS N.: Expression of carbonic anhydrase IX (CA IX), ahypoxia-related protein, rather than vascular-endothelial growth factor(VEGF), a pro-angiogenic factor, correlates with an extemely poorprognosis in esophageal and gastric adenocarcinomas. Ann. Surg.,2006; 243(3): 334-340.96

Objective: To evaluate the expression of carbonic anhydrase IX (CAIX) and vascular-endothelial growth factor (VEGF) in esophageal andgastric adenocarcinomas and in turn with the histologic subtype.Summary background data: Tumor hypoxia is an important factor intherapy resistance. A low oxygen concentration in tumors stimulatesa.o. the expression of CA IX, a marker of hypoxia, and VEGF, a proangiogenicfactor.Methods: We evaluated the immunohistochemical expression of CA IXand VEGF on paraffin-embedded material of 154 resectionspecimens: 39 esophageal, 73 cardiac, and 42 distal gastricadenocarcinomas (UICC classification). The adenocarcinomas weresubtyped according to the Lauren classification (intestinal- and diffusetype).Statistical analysis: chi test, Kaplan-Meier survival analysis, log-ranktest, and Cox proportional hazards model.Results: CA IX and VEGF expression were independent of thelocalization of the tumor. However, intestinal-type adenocarcinomasshowed a significantly higher expression of CA IX as well as VEGFthan diffuse-type tumors. VEGF expression was associated with ahigh microvessel density. Although survival analysis showed that CAIX expression (P = 0.008) as well as the coexpression of CA IX andVEGF (P = 0.008) correlate with a poor outcome, only CA IXexpression is an independent prognostic factor for overall survival andmetastasis-free survival.Conclusion: The difference in expression of CA IX and VEGF betweenintestinal- and diffuse-type adenocarcinomas may possibly explain thedifferent clinical behavior of these tumors. CA IX expression, ratherthan VEGF positivity in tumors, enables the identification of asubpopulation, characterized by a more aggressive behavior and apoorer prognosis.DUPONT L.J., BLONDEAU K., SIFROM D., VAN RAEMDONCK D.M.,VERLEDEN G.M.: Is gastro-oesophageal reflux more frequent in lungtransplant patients with chronic rejection? J. Heart Lung Transplant.,2006; 25: S84(117).Chronic allograft dysfunction predisposes to poor long-term survivalafter lung transplantation (LTx). It has been suggested that gastrooesophagealreflux (GOR) contributes to non-alloimmune lung injuryand the development of BOS. A cross-sectional study was performedto determine the prevalence of GOR in a cohort of lung transplantrecipients by means of combined oesophageal 24-hr pH andimpedance testing. This allowed accurate detection of all GOR events(acid and nonacid) while acid suppression therapy (omeprazole 20 mgor ranitidine 300 mg)- was continued. Thirty-six patients were included97

(5 HL/22SS/9SLTx), with initial diagnosis of emphysema (n=16),CF/bronchiectasis (n=7), fibrosis (n=6), PPH (n=5) and Eisenmengersyndrome (n=2). They were subdivided in 3 subgroups according tothe BOS stage: no BOS (n=11), BOS stage 0p (n=13) and BOS stage≥ 1 (n=12: stage 1 (n=7), stage 2 (n=4), stage 3 (n=1)). GORparameters are shown in the table. Mean oesophageal acid exposurewas normal and similar in the 3 groups. Only 2 subjects (1 withoutBOS and 1 with BOS 1) had increased acid exposure. There was nosignificant difference in mean number of total, acid or nonacid GORevents between the patients with or without BOS. Patients withCF/bronchiectasis had a slightly higher number of acid GOR events,regardless of the presence of BOS, when compared to otherdiagnoses (p=0.07). There was no correlation between FEVI (% ofpostTx best) at time of pH/impedance testing and the oesophagealacid exposure time or the number of GOR events.Prevalence of Reflux Events(mean + SEM)acid exposure timetotal # reflux events# acid reflux events# nonacid reflux eventsNo BOS(n = 11)2.4 ± 0.8%35 ± 613 ± 423 ± 4BOS stage 0p(n = 13)1.7 ± 0.5%27 ± 79 ± 318 ± 4BOS stage ≥ 1(n = 12)0.8 ± 0.2%28 ± 410 ± 318 ± 5These data show that LTX patients treated with anti-acid medicationmaintain a low oesophageal acidity and controlled nonacid reflux,irrespective of having BOS and argue against a role of GOR inpathogenesis of BOS.DUPONT L.J., DEWANDELEER Y., VANAUDENAERDE B.M., VANRAEMDONCK D.E., VERLEDEN G.M.: The pH of exhaled breathcondensate of patients with allograft rejection after lungtransplantation. Am. J. Transpl., 2006; 6: 1486-1492.Endogenous airway acidification, as assessed by the condensate pH,has been implicated in the pathophysiology of inflammatory airwaydiseases such as cystic fibrosis and asthma. The aim of this studywas to investigate the pH of condensate in patients after lungtransplantation (LTX). From the cohort of transplanted patients at ourcenter, 83 patients (9 heart-lung transplantation, 48 double-lungtransplantation, 26 single-lung transplantation) were recruited andanalyzed in a cross-sectional manner: 26 patients were diagnosedwith chronic rejection or bronchiolitis obliterans syndrome (BOS), 798

patients were diagnosed with acute rejection (AR) while 50 patientshad no evidence of rejection according to the International Society forHeart and Lung Transplantation criteria. The condensate pH wassignificantly reduced in patients with BOS and AR when compared topatients without rejection and control subjects (5.8 +/- 0.5 and 6.2 +/-0.4 versus 6.6 +/- 0.4 and 6.5 +/- 0 .4, respectively; p < 0.05).Moreover, there was a significant correlation between condensate pHlevels and the BOS grade (r =-0.62; p < 0.01), the FEV(1) (r = 0.39; p< 0.01) and the total cell and neutrophil count in bronchoalveolarlavage fluid (r =-0.39 and r =-0.56, respectively; p < 0.01). Airwayacidification occurs in BOS and may directly or indirectly reflect airwayinflammation in patients with allograft rejection after LTX. Measuringcondensate pH might thus be a new tool for the evaluation of rejectionin lung transplant patients.DUPONT L.J., LAGROU K., COLPAERT K., BOSSUYT X., VANRAEMDONCK D.E.: Levels of specific anti-pseudomonas aeruginosaIGG antibodies in cystic fibrosis patients before and after lungtransplantation. J. Heart Lung Transpl., 2006; 25: S174 (380).The level of specific anti-Pseudomonas aeruginosa (PA) IgGantibodies in CF patients has been associated with severePseudomonas lung infection leading to inflammation and lung tissuedestruction. PA is frequently isolated from sputum or BAL of lungallograft (LTx) recipients and especially those with chronic allograftdysfunction (BOS).In the present study the level of specific anti-PA IgG was measured(by means of ELISA) in serum samples of CE patients obtained atleast 4 months after lung transplantation and was compared to levelsin serum samples collected just before transplantation in these samepatients.Eighteen CF-patients were recruited (9 female, mean age 27±7 yearsat time of LTx). Specific anti-PA IgG levels were measured at a meanof 1165±735 days post LTx.The mean anti-PA IgG pre LTX was 63 ± 44 U, the mean PA IgGlevel post LTx was 16 ± 9 U (p < 0.001; control level in non PAcolonizedCF patients is < 13 U). The mean anti-PA IgG level postLTx was significantly higher in those patients with persistentcolonization of the airways with PA, than those with negative cultureresults for PA post LTX (16 ± 6 U, n = 13 versus 2 ± 2 U, n = 5;respectively; p < 0.001). Four patients were identified with BOS stage≥ 1. PA positivity in BAL and sputum was found in 3 of these 4patients, while 10/14 patients without BOS had persistent chroniccolonization of the airways with PA post LTX (p = NS, chi-square).The mean anti-PA IgG level was not significantly different between the99

patients with BOS as compared to those without BOS (16 ± 10 Uversus 10 ± 10 U, respectively, p = NS). There was no correlationbetween the anti-PA IgG level and the number of days post LTX, northe FEVI (% of best post LTx) in these patients.Specific serum anti-PA IgG levels in CF patients decline significantlyafter lung transplantation but remain elevated in those patients withchronic colonization of the airways with PA, irrespective of thepresence of BOS.GEUDENS N., VANAUDENAERDE B.M., NEYRINCK A.P., VAN DEWAUWER C., REGA F.R., VERLEDEN G.M., VERBEKEN E., LERUT T.E.,VAN RAEMDONCK D.E.M.: Impact of warm ischemia on differentleukocytes in bronchoalveolar lavage from mouse lung: possible newtargets to condition the polmonary graft from the non-heart-beatingdonor. J. Heart Lung Transplant., 2006; 25(7): 839-846.Background: The use of non-heart-beating donors (NHBDs) for lungtransplantation is a possible alternative for increasing the number oforgans available. The warm ischemic period after circulatory arrestmay contribute to a higher degree of primary graft dysfunction,resulting from ischemia-reperfusion injury (IRI). A betterunderstanding of the role of inflammatory cells during the warmischemic interval may be useful for developing new therapeuticstrategies against IRI.Methods: Mice were divided in 7 groups (n = 6/group). In 3 groups,ischemia was induced by clamping the hilum of the left lung for 30, 60or 90 minutes (Groups [30I], [60I] or [90I], respectively). In 3 moregroups, the lung was reperfused for 4 hours after identical ischemicintervals (Groups [30I+R], [60I+R] or [90I+R], respectively). Surgicalimpact was evaluated in a sham group ([sham]). Total and differentialcell counts and interleukin-1beta (IL-1beta) protein levels inbronchoalveolar lavage (BAL) were determined and their correlationswere investigated.Results: Total cell, macrophage and lymphocyte numbers and IL-1beta protein levels increased progressively with longer ischemicintervals. A significant rise in BAL macrophages and lymphocytes wasobserved between [60I] and [90I] (p < 0.01 and p < 0.001,respectively). BAL neutrophils only increased after reperfusion withlonger ischemic intervals. A positive correlation was found in theischemic groups between IL-1beta levels and the number ofmacrophages (r = 0.62; p = 0.0012) and the number of lymphocytes (r= 0.68; p = 0.0002). A positive correlation was found in the reperfusiongroups between IL-1beta levels and the number of neutrophils (r =0.48; p = 0.044).100

Conclusions: This study demonstrates for the first time that BALmacrophages and lymphocytes increase significantly during warmischemia and correlate with IL-1beta levels.GEUDENS N., VANAUDENAERDE B., NEYRINCK A., REGA F., VAN DEWAUWER C., VERLEDEN G., VERBEKEN E., VAN RAEMDONCK D.: N-Acetyl cysteine reduces inflammatory triggers in bal from mice lungfollowing warm ischemia and reperfusion. J. Heart Lung Transplant.,2006; 25: S 163 (347).Purpose: The warm ischemic period prior to cold preservation of nonheart-beatingdonor (NHBD) pulmonary grafts may increase the risk ofischemia reperfusion injury (IRI). Leukocytes and IL-1β are importanttriggers in the development of IRI. N-Acetyl Cysteine (NAC) is knownto be a potent anti-oxidant. We investigated the impact of NAC oninflammatory events in Broncho-Alveolar Lavage (BAL) in a mousemodel of in situ warm ischemia and reperfusion.Methods: Female SWISS mice were divided in 5 groups (n=6/group).After thoracotomy, the hilum of the left lung was clamped to inducewarm ischemia (I) for 90 minutes in all groups, except in SHAM, andfurther unclamped in 2 study groups for 4 hours of reperfusion (I + R).NAC (10mg/kg, 50µl) or Saline (50µl) were instilled endotracheally 15minutes before the onset of ischemia. After sacrifice, cell count and IL-1β levels were analyzed in BAL from the left lung.Results: (mean ±SD) are listed in Table. There was a positivecorrelation between IL-1β levels and the number of macrophages(r=0,73; p < 0.0001) as well as lymphocytes (r=0.63; p < 0.0001).GroupTotal cells Macrophages Lymphocytes Neutrophils IL-1β(n=6/group) (*10 4 /ml) (*10 4 /ml) (*10 4 /ml)(*10 4 /ml)SHAMSaline+INAC+ISaline + I + RNAC + I + R40.0 ± 7.2195.3 ± 25.1*46.5 ± 7.6*166.0 ±27.764.0 ±22.6 SS 35.7 ± 6.7151.6 ± 20.3*39.3 ±7.1 #119.5 ± 19.953.4 ± 20.0 SS 4.2 ±0.842.6 ± 11.3*7.0 ±1.8 #23.3 ± 7.07.9 ± 1.8 SS 0.4 ± 0.50.9 ±1.40.2 ±0.323.2 ± 9.43.2 ± 3.2 SS 58.6 ± 26.6208.9 ± 37.9*64.4 ± 13.4 #203.2 ± 48.499.0 ±20.5 S* p< 0.001 versus SHAM; # p < 0.001 vs Saline +I; S < 0.01 and SS p < 0.01 vs Saline + I + RConclusion: Administration of NAC attenuated the lymphocyticincrease during ischemia and the rise in neutrophils after reperfusion.Whether there is a biochemical trigger between lymphocytes andneutrophils needs to be further investigated. Preharvest treatment withNAC could be a promising tool to reduce IRI in NHBD lungtransplantation.101

GEUDENS N., VAN DE WOUWER M., VANAUDENAERDE B.M.,NEYRINCK A.P., REGA F.R., VAN DE WAUXER C., LERUT T.,VERBEKEN E., VERLEDEN G.M., CONWAY Ed., VAN RAEMDONCKD.E.M.: The lecitin-like domain of thrombomodulin supressesleukocytose lung infiltration in a murine ischemia-reperfusion injurymodel. Eur. Resp. Journal, 2006; 28(50): p. 779s.Background: Thrombomodulin (TM) is a vascular endothelial cellreceptor that is a cofactor for thrombin-mediated activation of the anticoagulantand anti-inflammatory properties. In this study weinvestigated the role of this domain on lung ischemia-reperfusioninjury, which remains an important risk factor for the early survival oflung transplant recipients. The use of wild-type (TM wt/wt ) andtransgenic (TM LeD/LeD ) mice, the latter which lack the N-terminal lectinlikedomain of TM, could give us a better insight on proteins importantin leukocyte infiltration in the lung.Methods: In female TM LeD/LeD and TM wt/wt mice (n=6/group), the hilumof the left lung was clamped to induce warm in situ ischemia for 90minutes, followed by 4 hours of reperfusion. After sacrifice, BAL wasobtained by instillation of saline in the left lung for cell count.Results: (mean±SD) are listed in TableBALCells(x10 4 /ml)Macrophages(x10 4 /ml)Lymphocytes(x10 4 /ml)Neutrophils(x10 4 /ml)TM wt/wt mice 96.0 ± 22.0 72.8 ± 17.6 16.9 ± 6.1 6.2 ± 3.4TM LeD/LeD 139.3 ± 16.5** 101.8 ± 19.9* 17.2 ± 4.7 20.4 ± 5.0******: p < 0.001; **: p < 0.01 and * p < 0.05 versus TM wt/wt miceConclusion: The lack of the N-terminal lectin-like domain of TMdampens the inflammatory cellular respons after ischemia andreperfusions in the mouse lung. This domain could be an interestingtarget to modulate the inflammatory status following lungtransplantation.JACQUEMIN M., NEYRINCK A., HERMANNS M.I., LAVEND’HOMME R.,REGA F., SAINT-REMY J.M., PEERLINCK K., VAN RAEMDONCK D.,KIRKPATRICK C.J.: FVIII production by human lung microvascularendothelial cells. Blood, 2006; 108(2): 515-517.While extrahepatic factor VIII (FVIII) synthesis suffices for hemostasis,the extrahepatic production sites are not well defined. We thereforeinvestigated the ability of the human lungs to produce FVIII. Lungsfrom heart-beating donors who were declined for transplantation wereperfused and ventilated in an isolated reperfusion model for 2 hours. A102

progressive accumulation of FVIII and von Willebrand factor (VWF)was recorded in the perfusion medium in 3 of 4 experiments. Bycontrast, factor V, fibrinogen, and immunoglobulin G (IgG) levelsremained constant during the perfusion period, indicating that theaccumulation of FVIII and VWF was not due to diffusion from theintercellular medium into the vascular system. Purified human lungmicrovascular endothelial cells produced FVIII during at least 2passages in vitro. Altogether, these data identify the lung endothelialcells as a FVIII production site in humans.JANSSENS V., HOFFMAN I., LERUT A., EGGERMONT E.: Achalasie bijkinderen: casuïstiek en literatuuroverzicht. Tijdschr. voor Geneeskunde,2006; 62(7): 561-568.Achalasie is bij kinderen een zeldzame motiliteitsstoornis van deslokdarm, die zich kenmerkt door een gestoorde slokdarmperistaltieken disfunctie van de onderste slokdarmsfincter, wat leidt tot klachtenvan dysfagie en regurgitatie. Hoewel de exacte oorzaak nog nietgekend is, beschrijft men een inflammatoire degeneratie van destikstof (NO)-producerende neuronen in de plexus myentericus, dieverantwoordelijk zijn voor relaxatie.Bij kinderen is de achalasie leeftijdsafhankelijk. Radiografie engastroscopie zijn richtinggevend voor de diagnosestelling, dochmanometrie is nodig voor de zekerheidsdiagnose.De behandeling bij kinderen beoogt resultaten op lange termijn. Devoorkeur gaat uit naar een chirurgische myotomie gecombineerd meteen antirefluxprocedure. Een laparoscopische benadering verkort hetpostoperatieve herstel.JANSSENS W., VAN RAEMDONCK D., DUPONT L., VERLEDEN G.M.:Listeria pleuritis 1 week after lung transplantation. J. Heart LungTransplant., 2006; 25(6): 734-737.Listeria monocytogenes is an important bacterial pathogen inimmunocompromised patients, the elderly, pregnant women andtransplant patients, but until now it has not been reported in lungtransplants. We report the first case of listeriosis in a lung transplantrecipient who presented with a pleural effusion 8 days aftertransplantation. After the introduction of a thorax drain and theadministration of intravenous antibiotics during 3 weeks, the patientrecovered completely. This case highlights the increased risk foruncommon respiratory infections in lung transplant patients andexamines the specific management of listeria pleuritis.103

LARDINOIS D., DE LEYN P., VAN SCHIL P., PORTA R.R., WALLER D.,PASSLICK B., ZIELINSKI M., LERUT T., WEDER W.: ESTS guidelines forintraoperative lymph node staging in non-small cell lung cancer. Eur. J.Cardiothorac. Surg., 2006; 30(5): 787-792.The European Society of Thoracic Surgeons (ESTS) organized aworkshop dealing with lymph node staging in non-small cell lungcancer. The objective of this workshop was to develop guidelines fordefinitions and the surgical procedures of intraoperative lymph nodestaging, and the pathologic evaluation of resected lymph nodes inpatients with non-small cell lung cancer (NSCLC). Relevant peerreviewedpublications on the subjects, the experience of theparticipants, and the opinion of the ESTS members contributing online, were used to reach a consensus. Systematic nodal dissection isrecommended in all cases to ensure complete resection. Lobespecificsystematic nodal dissection is acceptable for peripheralsquamous T1 tumors, if hilar and interlobar nodes are negative onfrozen section studies; it implies removal of, at least, three hilar andinterlobar nodes and three mediastinal nodes from three stations inwhich the subcarinal is always included. Selected lymph nodebiopsies and sampling are justified to prove nodal involvement whenresection is not possible. Pathologic evaluation includes all lymphnodes resected separately and those remaining in the lung specimen.Sections are done at the site of gross abnormalities. If macroscopicinspection does not detect any abnormal site, 2-mm slices of thenodes in the longitudinal plane are recommended. Routine search formicrometastases or isolated tumor cells in hematoxylin-eosin negativenodes would be desirable. Randomized controlled trials to evaluateadjuvant therapies for patients with these conditions arerecommended. The adherence to these guidelines will standardize theintraoperative lymph node staging and pathologic evaluation, andimprove pathologic staging, which will help decide on the bestadjuvant therapy.LERUT T., COOSEMANS W., DECKER G., DE LEYN P., NAFTEUX F.,VAN RAEMDONCK D.: Pathophysiology and treatment of Zenker’sdiverticulum. In: Surgery of the alimentary tract, volume 1, Sixth edition.Editors: Ch. Yeo, D. Dempsey, A. Klein, J. Pemberton, J. Peters. Uitgeverij:Saunders-Elsevier, Chapter 27, p. 391-404.Pharyngoesophageal diverticulum was described for the first time as apathologic entity by Ludlow in 1769. However, it was Zenker who gave104

his name to this condition through a publication in 1877 in which hereported a series of 27 patients. Already at that time Zenker presumedthat the pouch is the consequence of “forces within the lumen actingagainst a restriction”, a hypothesis that is indeed close to the modernunderstanding of its pathogenesis and remarkable because bothendoscopy and radiology had yet to be invented. However, themechanistic compression theory as a cause of symptoms wouldprevail until far into the 20 th century, thanks to new developments inimaging, endoscopy, manometry, and manofluorography, has betterinsight into the pathogenesis of Zenker’s diverticulum (ZD) emergedand led to fundamental changes in the therapeutic strategy (myotomyof the cricopharyngeal muscle).LERUT T., COOSEMANS W., DECKER G., DE LEYN P., MOONS J.,NAFTEUX P., VAN RAEMDONCK D.: Diagnosis and therapy in advancedcancer of the esophagus and the gastroesophageal junction. Curr.Opin. Gastroenterol., 2006; 22(4): 437-441.Purpose of review: The aim of this article is to discuss recentdevelopments in the diagnosis and treatment with curative option ofadvanced cancer of the esophagus and gastroesophageal junction.Recent findings: Recent data indicate improvement of clinical stagingaccuracy by multi-slice computer tomography, endoscopic ultrasoundwith fine needle aspiration and positron emission tomography, thelatter gaining growing impact as a prognostic indicator. Whencombined with extended lymphadenectomy primary surgery offers 5-year survivals between 25 and 35% for stage III disease. Results ofinduction therapy remain conflicting. While the most recent metaanalysisfavored induction chemoradiotherapy, a subsequentrandomized trial failed to confirm this conclusion. A growing interest inadjuvant chemoradiotherapy is stimulated by promising results from arecent pilot study. Trials investigating definitive chemoradiotherapyindicate a high incidence of locoregional recurrence. The emergingunderstanding of the molecular pathways that govern neoplasticevents are under intense investigation. Results of pilot clinical studieson targeted therapy are expected shortly.Summary: Refinements in staging offer incremental increase ofaccuracy, the impact of positron emission tomography becomingincreasingly important. In locally advanced disease, the debate on theadded value of multimodality therapy remains unsolved as primarysurgery combined with extended lymphadenectomy offers equalresults. New drugs in particular in combination with targeted therapymay offer better perspectives in the near future.105

LERUT T., COOSEMANS W., DECKER G., DE LEYN P., NAFTEUX F.,VAN RAEMDONCK D.: Kanker van de slokdarm en gastro-oesofagealejunctie. Patient Care, 2006; (maart-april): 5-11.Slokdarmkanker heeft een slechte reputatie, vooral omdat dediagnose gewoonlijk pas laat wordt gesteld. Onderzoek wijst uit dateen agressieve chirurgische aanpak – niet zelden in combinatie metbestraling en chemotherapie – de beste overleving biedt. Daarnaastblijft het een uitdaging om een goede palliatie van de symptomen, metname de dysfagie, te verzekeren.Kanker van de slokdarm en cardia blijft – ten gevolge van eenlaattijdige diagnose – veelal een dodelijke aandoening. Het aantalgevallen van adenocarcinoma neemt de laatste decennia overigenstoe. Dysfagie is vaak de eerste klacht en ontwikkelt zich bijslokdarmkanker geleidelijk, zodat patiënten pas laat consulteren.MEEKERS F., NAFTEUX P., COOSEMANS W., DECKER G., DE LEYN P.,VANRAEMDONCK D., LERUT T.: Chirurgische resectie van hetslokdarmleiomyoom. Ervaringen in de Universitaire ZiekenhuizenLeuven met een minimaal invasieve benadering. Tijdschr. voorGeneeskunde, 2006; 62(24): 1724-1732.Een leiomyoom is veruit de meest voorkomende goedaardigeslokdarmtumor. De indicaties voor heelkunde zijn symptomatischeletsels, tumoren groter dan 4 cm, evolutieve letsels en het uitsluitenvan maligniteit. De klassieke behandeling omvat enucleatie viathoracotomie. Binnen de algemene evolutie naar minimaal invasievechirurgie hebben thoracoscopie en iets later ook laparoscopie echtersterk aan interesse gewonnen.Tussen 1993 en 2004 ondergingen in onze dienst 17 patiënten eenchirurgische behandeling voor een leiomyoom van de slokdarm. Sinds1993 genoot een minimaal invasieve benadering waar mogelijk steedsde voorkeur. Uiteindelijk werden 10 patiënten via een minimaalinvasieve manier behandeld en zeven patiënten via klassieke openchirurgie, met inbegrip van een conversie wegens dense pleuraleadhesies en twee slokdarmresecties wegens erg uitgebreide letsels.In geen van beide groepen traden belangrijke verwikkelingen op.Zoals verwacht, konden patiënten na minimaal invasieve chirurgiedoor een beter comfort sneller gemobiliseerd en ontslagen wordendan de patiënten na thoracotmie (hospitalisatieduur gemiddeld 6,6 vs.9,1).In onze ervaring is thoracoscopische en laparoscopische enucleatievan een slokdarmleiomyoom technisch uitvoerbaar en veilig. Hoewelde thoracotomie nog steeds een plaats heeft in geselecteerde106

gevallen, beschouwen wij de minimaal invasieve benadering als dekeuzebehandeling in centra met ervaring in minimaal invasieveabdominale en thoracale chirurgie.NAFTEUX P., COOSEMANS W., DECKER G., DE LEYN P., VANRAEMDONCK D., LERUT T.: Gastro-oesofagale reflux en de Nissenantirefluxprocedure:past het schoentje voor iedereen? Tijdschr. voorGeneeskunde, 2006; 62(7): 554-560.Mits een goede indicatiestelling op basis van zowel anatomische alsfunctionele evaluatie levert de antirefluxchirurgie – meestal onder devorm van de laparoscopische Nissen-fundoplicatie – uitstekenderesultaten. Deze ingreep is evenwel niet vrij van bijwerkingen, m.n.vooral dysfagie, evenals “gas bloating” en flatulentie. Ook dienenbepaalde pathologische situaties, bv. brachyoesofagus envolumineuze paraoesofagale hernia, op een andere manier benaderdworden. Hiertoe beschikt de chirurg over een brede waaier vanoperaties. Kunnen bepalen welke ingreep bij een welbepaalde patiënttot het beste resultaat zal leiden, is nochtans niet altijd even evidentomdat de resultaten van de beschikbare studies niet eenduidig zijn.Dit artikel is, via analyse van de literatuur en van onze eigen ervaring,een pleidooi voor een behandeling op maat, die gebaseerd is op eengrondige klinische evaluatie vóór de operatie en op de ervaring van dechirurgie die deze operatie zal uitvoeren.NAFTEUX P., LIEVENS Y., NACKAERTS K., COOSEMANS W., DE LEYNP., VAN RAEMDONCK D., LERUT T.: Malignant pleural mesothelioma: amultidisciplinary approach. Acta Chir. Belg., 2006; 106 (suppl.): 66.Purpose: We propose a multidisciplinary treatment of malignantpleural mesothelioma combining induction chemotherapy(Pemetrexed-cisplatinum), followed by extrapleural pneumonectomie(EPP) and radical hemichest radiotherapy.Patients: Prospective study of 26 consecutive MPM patients proposedfor multidisciplinary treatment between march 2003 and may 2005.Inclusion criteria’s were age not more than 65 years, physiologicalcharacteristics making completion of treatment possible and withoncological staging for the epithelial type T2N2M0 or less and for allother types T2N1M0 or less.Results: 22 patients presented epithelial type, 2 patients desmoplastictype, 1 patient sarcoma type and 1 mixed type, 9 patients wereexcluded based on mediastinoscopy (n=7) or laparoscopy (n=2)findings, 2 more patients presenting progressive disease after107

termination of induction chemotherapy were refused for surgery. 13patients underwent an EPP, 2 patients were irresecable due to chestwall invasion. Post op mortality of EPP was 7.7% (n=1). Post surgicalcomplications were re-thoracotomy for bleeding (n=1), atrial fibrillation(n=7), ARDS (n=2), DVT (n=1). 3 patients couldn’t finish theradiotherapy course due to tumour recurrence and 1 patient diedshortly after the radiotherapy due to BOOP. Survival of resectedpatients (n=13) was 17 months and of patients who completed the fullmultidisciplinary treatment (n=0) was 22 months after diagnosis.Conclusion: This study shows the feasibility of this multidisciplinaryapproach showing a benefit for patients able to complete the alltreatment. Careful selection is mandatory to define potential targetgroups.NEYRINCK A.P., REGA F.R., VAN DE WAUWER C., GEUDENS N.,VERLEDEN G.M., WOUTERS P., LERUT T.E., VAN RAEMDONCK D.:Lungs from HBD have an increased inflammatory status and impairedperformance compared to NHBD. J. Heart Lung Transplant, 2006; 25:S67(70).Aim: Non-heart-beating donors (NHBD) have been advocated toovercome organ shortage in lung transplantation. Brain death (BD) inthe heart-beating donor (HBD) may be an underestimated risk factorfor donor lung injury. We postulated that 1 h of warm ischemia inNHBD is less detrimental to the donor lung than BD in HBD.Methods: Pigs were divided in 3 groups (n=10/group). In group I(HBD), BD was induced by intracranial balloon inflation. In group II(CONT) the balloon was not inflated. In group III (NHBD) cardiacarrest was induced by myocardial fibrillation. After 5 h of mechanicalventilation, lungs in HBD and CONT were flushed. Unflushed grafts inNHBD were explanted after 1 h of warm ischemia and 4 h of topicalcooling. Graft performance (pulmonary vascular resistance (PVR) andplateau airway pressure (PlatAwP)) of the left lung was evaluatedduring 1 h in an isolated ventilation and reperfusion model. Rightlungs were not perfused. Pro-inflammatory cytokines (IL-8 and IL-1β)were measured in broncho-alveolar lavage fluid from both lungs.Results: A cushing response occured in HBD. Results are listed inTable I and 2 (mean ± SEM). (table 2)†, p < 0.05 HBD compared toNHBD; *: p < 0.05 HBD compared to CONT.108

Table 1Reperfusion time(min)PVR(dynesxsecxcm-5)PlatAwP(cmH2O)HBDCONTNHBDHBDCONTNHBD45 602600 ± 364*†1705 ± 1091291 ± 9616 ± 1*12 ± 114 ± 12634 ±371*†1894 ± 1371268 ± 11117 ± 1*12 ± 114 ± 1Table 2IL-8(pg.ml)IL-1β(pg/ml)HBDCONTNHBDHBDCONTNHBDRight (beforereperfusion)1138 ± 517*†272 ± 13325 ± 14196 ± 38*106 ± 12110 ± 12Left (afterreperfusion)2200 ± 533*†745 ± 337500 ± 111135 ± 2490 ± 995 ± 13Conclusion:1-h warm ischemic lungs are less susceptible to graftinjury than lungs retrieved 5 h after BD. This study further supports theclinical use of lungs from NHBD.NEYRINCK A.P., VAN DE WAUWER C., GEUDENS N., REGA F.R.,VERLEDEN G.M., WOUTERS P., LERUT T.E., VAN RAEMDONCK D.E.M.:Comparative study of donor lung injuriy in heart-beating versus nonheartbeating donors. Eur. J. Cardiothorac. Surg., 2006; 30: 628-636.Objective: The use of non-heart-beating donors (NHBD) has beenadvocated as an alternative to overcome the critical organ shortage inlung transplantation despite the warm ischemic period that may resultin primary graft dysfunction. On the contrary, brain death in the heartbeatingdonor (HBD) may be an underestimated risk factor for donorlung injury. We postulated that 60 min of warm ischemia in the NHBDis less detrimental to the lung than the pathophysiological changesafter brain death in the HBD. In this study we compared the quality oflungs from HBD versus NHBD in an isolated reperfusion model.Methods: Pigs (n=10 per group) were divided into three groups. Ingroup I (HBD), brain death was induced by acute inflation of anintracranial epidural balloon catheter. In group II (CONTROL), theballoon was not inflated. In group III (NHBD), cardiac arrest wasinduced by myocardial fibrillation. After 5 h of in situ mechanical109

ventilation, lungs in HBD and CONTROL were preserved with a coldantegrade flush. In NHBD, unflushed grafts were explanted after 1 hof warm ischemia and 4 h of topical cooling in the cadaver. Graftperformance was evaluated during 1 h in an isolated ventilation andreperfusion model. Extravascular lung water content (EVLW) wascalculated. All data are reported as mean+/-SEM.Results: A significant autonomic storm was observed in HBD followingballoon inflation. During ex vivo assessment, pulmonary vascularresistance (PVR) at 60 min in HBD (2634+/-371 dynes cm(-5)) wassignificantly higher as compared with that of CONTROL and NHBD(1894+/-137 dynes s cm(-5) and 1268+/-111 dynes s cm(-5),respectively; p

transplantation; dehiscence (n = 25), stenosis (n = 6) and fistula (n =5). Four patients exsanguinated as a result of AC (mortality 1.7%) and217 patients survived the first 6 weeks after LTx (344 airwayanastomoses). In an univariate analysis, recipient male gender(32/344 (M) versus 4/344 (F); p = 0.0011), recipient length (177 ± 1.8cm versus 167.9 ± 0.5 cm; p < 0.0001), younger donor age (30.5 ± 2years versus 36.5 ±0.8 years; p = 0.019) and shorter mechanicalventilation in the donor (42.2 ± 3.5 hours versus 57.1 ± 2.5 hours; p =0.015) were significant predictors of AC. In the multivariate analysis,recipient length, no use of CPB, younger donor age and shortermechanical ventilation in the donor where individual predictors for AC.Conclusion: Airway complications after lung transplantation remain achallenging problem. Special surgical attention is needed in tallpatients who unlikely need bypass (emphysema). This may be relatedto the longer circumference of the airway anastomosis in this patientgroup.VAN DE WAUWER C., DUPONT L., DE LEYN P., COOSEMANS W.,NAFTEUX P., DECKER G., LERUT T., VERLEDEN G.M., VANRAEMDONCK D.: Airway complications after isolated lungtransplantation: a review of 362 bronchial anastomoses in 232 patients.Acta Chir. Belg., 2006; 106(Suppl.): 136 (362).Objective: Lung transplantation (LTx) is a valuable therapeutic optionfor selected patients with end-stage pulmonary disease. Thistreatment has enjoyed increasing success with better early and latesurvival. Nevertheless, airway anastomotic complications are still apotential cause of morbidity and mortality. The purpose of this studywas to review the results of bronchial healing in our LTx populationover the past 13 years.Methods: Between July 1991 and December 2004, 232 consecutivesingle (n=102) and bilateral (n=130) lung transplantations wereperformed. There were 142 male patients and 90 female patients witha mean age of 48 years (range 15 – 66 years). The indications for LTxwere emphysema (n=113), pulmonary fibrosis (n=45), cystic fibrosis(n=35), pulmonary hypertension (n=10), sarcoidosis (n=7) and otherindications (n=22). Bronchial anastomoses (n=362) were performedusing a telescoping (T, n=23), an interrrupted end-to-end (IE, n=309)or a continuous end-to-end (CE, n=30) technique. Complications werecategorized as stenosis, dehiscence, malacia or fistula.Results: Fifty-seven complications occurred in 362 airwayanastomoses (15.7%): dehiscence (n=29), stenosis (n=15), malacia(n=5) and fistula (n=8). Six patients (2.6%) died directly from anairway complication: massive bleeding (n=4) and brain death (n=2).Complications occurred more often in bilateral lung transplantation111

compared to single lung transplantation (45/260 anastomoses [17.3%]versus 12/102 anastomoses [11.8%]). The use of IE or CE wereassociated with less complications (45/309 [14.6%] and 5/30 [16.7%];respectively compared to T (7/23 [30.4%] (p

upon reperfusion results from a reduced number of residualmicrothrombi in the pulmonary vasculature.Table 1ReperfusiontimePVR(dynes*seccm -5PO 2/FiO 2(mmHg)Plat AwP(cmH 2O)Compi(ml/cmH 2 O)NFAFRFNFAFRFNFAFRFNFAFRF40’ 45’ 50’ 55’ 60’1482 ± 611528 ±1701387 ± 85610 ±24619 ±32697 ± 2814 ± 114 ± 013 ±117 ± 116 ±120 ± 21418 ± 761581 ±1111225 ± 54°607 ± 20640 ± 31686 ± 3414 ± 114 ± 013 ± 118 ± 216 ± 121 ± 31351 ± 871565 ± 1001249 ± 57°618 ± 25632 ±31658 ± 3313 ± 114 ± 113 ± 118 ± 117 ± 222 ±31448 ± 821571 ± 1041186 ± 69°♦627 ± 22630 ± 32662 ± 4314 ± 114 ± 113 ± 118 ± 117 ± 220 ± 31435 ± 951560 ±1231145 ± 56°♦621 ± 25636 ± 35673 ± 4214 ± 114 ± 013 ± 117 ± 218 ± 124 ± 3VAN DE WAUWER C., NEYRINCK A., GEUDENS N., REGA F.,VERLEDEN G.M., LERUT T. VAN RAEMDONCK D.: Modification of thearterial anastomotic technique improves survival in a porcine singlelung transplant model. Acta Chir. Belg., 2006; 106: 450-457.Background: Lung transplantation is a valuable therapeutic option forselected patients with end-stage pulmonary disease. However, thistreatment is complicated by ischaemia-reperfusion injury (IRI) of thelung in 10-20% of the recipients. We developed an unilateral porcinelung transplant model to study IRI and describe our experience withtwo different arterial anastomotic techniques.Material and methods: Twenty four domestic pigs (n=6x(donor +recipient)/group) were used in this study. Donor lungs were harvestedusing an antegrade flush with cold Perfadex ® and stored in the samesolution for ± 8 hours. Recipient animals underwent a leftthoracotomy. After native pneumonectomy, the left donor lung wastransplanted in the following order: 1. left arterial cuff; 2. bronchus; 3.pulmonary artery. 2 The outcome in recipients from historical groupsdiffering in anastomotic technique was compared. An end-to-endanastomosis on the left pulmonary artery was performed in group Iversus a patch anastomosis on the main pulmonary artery in group II.One hour after reperfusion, the right pulmonary artery and mainbronchus were ligated forcing the recipient to survive on thetransplanted lung only. The animals were further observed for 6 hours.Results: Survival 6 hours after exclusion of the right lung was 33%(2/6) in group I versus 83% (5/6) in group II. Animals in group I died of113

ight heart failure manifested by acute dilation of the right ventriclefollowing ligation of the hilum of the right lung.Conclusion: Single lung transplantation with exclusion of thecontralateral native lung is a critical model. Arterial end-to-endanastomosis resulted in an increased right ventricular afterload. Theuse of a patch technique improved the compliance of the arterialanastomosis and decreased early mortality. This transplant model iscurrently used in our laboratory to assess new methods for pulmonarypreservation.VAN DE WAUWER A., NEYRINCK A., GEUDENS N., REGA F.,VERLEDEN G.M., LERUT T., VAN RAEMDONCK D.E.M.: Retrogradeflush after topical cooling in the non-heart-beating donor results inimproved pulmonary graft function. Interactive Cardiovasc. Thor. Surg.,2006; 5(2): S218 (134-0).Objectives: The use of non-heart beating donors (HNBD) has beenpropagated as an alternative to overcome the scarcity of pulmonarygrafts. However, formation of microthrombi after circulatory arrest isstill a concern for the development of reperfusion injury. We looked atthe effect and the best route of pulmonary flush after topical cooling.Methods: Non-heparinised pigs were sacrificed by ventricularfibrillation and divided in 3 groups (n=6/group). After 1 h of in situwarm ischaemia and 2.5 h of topical cooling, lungs in group I wereretrieved unflushed (NF). In group II, lungs were explanted followingan antegrade flush (AF) through the pulmonary artery with 50 ml/kgPerfadex ® . Finally, in group III, lungs were explanted after an identicalbut retrograde flush (RF) via the left atrium. Flush effluent wassampled at intervals to measure haemoglobin concentration.Performance of the left lung was assessed during 60 min in our exvivoreperfusion model.Results: Haemoglobin concentration (g/dl) was initially higher after RFvs. AF (3,4 ± 1.1 vs. 0.6 ± 0.1) (P < 0.05). Pulmonary vascularresistance (dynes*sec*cm -5 ) was 975 ± 85 (RF) vs. 1567 ± 98 (AF)and 1576 ± 88 (NF) at 60 min of reperfusion (P < 0.001). Oxygenation(mmHg) and compliance (ml/cmH 2 O) were higher and plateau airwaypressure (cmH 2 O) was lower after FR vs. AF and NF (491 ± 44 vs.472 ± 61 and 430 ± 33 (NS); 22 ± 3 vs. 19 ± 3 and 14 ± 1 (NS); 11 ± 1vs. 13 ± 1 and 13 ± 1 (NS), respectively. No differences in W/D wereobserved after reperfusion.Conclusions: Retrograde flush in the non-heart-beating donor resultsin a more effective flush-out and subsequent reduced pulmonaryvascular resistance upon reperfusion.114

VAN DE WAUWER C., VAN RAEMDONCK D.E.M., VERLEDEN G.M.,DUPONT L., DE LEYN P., COOSEMANS W., NAFTEUX P., LERUT T.:Risk factors for airway complications within the first year after lungtransplantation. Interactive Cardiovasc. Thor. Surg., 2006; 5(2): S 218(132-0).Objectives: Lung transplantation (LTx) has enjoyed increasing succeswith better survival in recent years. Nevertheless, airway anastomoticcomplications (AC) are still a potential cause of early morbidity andmortality. In this retrospective study we looked at possible predictorsof AC within the first year after LTx.Methods: Between July 1991 and December 2004, 232 consecutivesingle (n=102) and bilateral (n=130) LTx were performed (142 malesand 90 females; mean age, 48 years (range 15-66 years)). Indicationsfor LTx were emphysema (n = 113), pulmonary fibrosis (n = 45), cysticfibrosis (n = 35), pulmonary hypertension (n = 10), sarcoidosis (n = 7)and miscellaneous (n = 22). Donor (age, PaO 2 /Fi0 2 , mechanicalventilation, ischaemic time) and recipient (age, diagnosis, length,gender, preop steroids, smoking, CMV matching, LTx type,anastomotic type, wrapping and bypass) variables were evaluated in aunivariate and multivariate model.Results: Fifty-seven complications occurred in 362 airwayanastomoses (15.7%) of which 55 (15.2%) within the first year aftertransplantation. Six patients died as a result of AC (mortality 2.6%)and 191 patients survived the first year after LTx (321 airwayanastomoses). In a univariate analysis, anastomotic type (7/17(telescoping) vs. 48/304 (end-to-end); P = 0.011), recipient length (P =0.0012), donor ventilation (> 50-70 h; P = 0.0015) and recipient malegender (43/191 (M) vs. 12/130 (F); P = 0.0092) were significantpredictors of AC. Three factors remained significant predictors in themultivariate analysis: telescoping (OR: 3.121; P = 0.0495), recipientlength (OR: 1.065; P = 0.0029) and donor ventilation (OR = 0.999; P =0.0029).Conclusions: Airway complications after lung transplantation remain asignificant problem. Special surgical attention is needed in tallrecipients and in those receiving lungs from donors with prolongedventilation.VAN RAEMDONCK D., VERLEDEN G.M., DUPONT L., DELCROIX M.,DAENEN W., VANHAECKE J., COOSEMANS W., DECKER G., DE LEYNP., NAFTEUX P., LERUT T. en de Leuvense Longtransplantatiegroep.Longtransplantaties in de U.Z. Leuven. Deel I: Klinisch programma:ervaring met 260 (hart-)longtransplantaties. Tijdschr. voor Geneeskunde,2006; 62(7): 516-524.115

Voor sommige patiënten met terminaal (cardio)pulmonaal falen is een(hart-)longtransplantatie de enige uitweg. In dit artikel wordt een kortoverzicht gegeven van de indicaties en resultaten bij 260transplantaties uitgevoerd in de Universitaire Ziekenhuizen Leuventussen juli 1991 en oktober 2004.Er werd een sterke stijging vastgesteld van het aantal transplantatiesop jaarbasis, enerzijds door het groter aantal verwijzingen enanderzijds door de minder strenge selectie van beschikbarelongdonoren. Door grotere ervaring zijn de vroegtijdige verwikkelingenaanzienlijk gedaald (huidig hospitaalmortaliteit < 5%) en zijn deoverlevingskansen na de transplantatie duidelijk gestegen(momenteel 89% na 1 jaar en 76% na 5 jaar).VAN RAEMDONCK D., REGA F., NEYRINCK A., VAN DE WAUWER C.,GEUDENS N., COOSEMANS W., DECKER G., DE LEYN P., NAFTEUX P.,VERLEDEN G.M., LERUT T.: Longtransplantaties in de U.Z. Leuven.Deel II: Experimenteel programma: een zoektocht naar alternatievelongdonoren. Tijdschr. voor Geneeskunde, 2006; 62(7): 524-531.Het kritieke tekort aan geschikte donororganen blijft de meestbeperkende factor voor de verdere uitbreiding van het klinischelontransplantatieprogramma aan de Universitaire ZiekenhuizenLeuven. Dit resulteert in lange wachttijden voor patiënten die leidenaan terminaal longfalen, met soms vroegtijdig overlijden nog voor eengeschikte donor wordt gevonden.Wereldwijd wordt onderzoek verricht naar methoden om het aantallongdonoren uit te breiden.In dit artikel wordt een overzicht gegeven van het onderzoek dat deafgelopen 10 jaar heeft plaatsgevonden in de EenheidThoraxheelkunde binnen het Centrum voor Experimentele Heelkundeen Anesthesiologie aan de K.U.Leuven. Het onderzoek spitst zichvoornamelijk toe op het gebruik van longen afkomstig vanzogenaamde “non-heart-beating” donoren. Daarnaast besteden weaandacht aan de mogelijkheid om de kwaliteit te verbeteren vanafgewezen longen afkomstig van marginale donoren.VERLEDEN G.M., DUPONT L.J., VANAUDENAERDE B.M., VANRAEMDONCK D.E.: Which factors predict the beneficial effect ofAzithromycin in patients with bronchiolitis obliterans syndrome afterlung transplantation. J. Heart Lung Transplant, 2006; 25: S82(112).116

Bronchiolitis obliterans syndrome (BOS) remains the most importantcause of late mortality after lung transplantation (LTx). Treatment isdifficult, although recently azithromycin (azi) has been shown to havea beneficial effect in about 45% of patients. It is not known at thepresent time which patients have the most chance to benefit from thistreatment. Therefore, in this study we investigated the characteristicsof patients with BOS before starting treatment with azi and comparedthese parameters between responders (> 10% increase in FEVI) andnon-responders (no increase in FEVI). Fourteen patients wereincluded, with a mean age of 47 (13) y at the time of Ltx. There initialBOS stages were: 0-p(3), 1 (10), 2 (1). After 3 months of azi the meanFEVI (SD) increased from 2.40 (0.82) to 2.67 (0.85) (p=0.014). Therewere 6 responders (R) and 8 non-responders (NR). The FEVI in groupR increased from 2.11 (0.54)L to 2.75 (0.74)L (p = 0.016), whereas inthe NR group there was no change. The characteristics of both groupsat inclusion are summarized in the table. In conclusion: the onlysignificant different parameter discriminating between the R and NRgroup seems to be the % neutrophils in the BAL fluid. In fact, a BALneutrophilia of > 15% has a positive predictive value of 85% for asignificant FEVI response to azi, whereas a BAL neutrophilia of < 15%confers no effect at all (negative predictive value 100%).Characteristics at inclusionAgeSex (M/F)Type of LtxFK/CyAPOD azi startPre azi FEV1Pre Ltx diseaseBAL Pseudomonas% BAL neutrophiliaResponders(n = 6)48.8 (15)4/24SS/2SLtx5/1438 (493)2.20 (0.56)L2E/3F/1CF269.6 (24.3)Non-responders(n = 8)46.3 (12.5)5/36SS/1S/IHLTx8/01309 (942)2.50 (1.03) L4E/1F/2CF/1PPH29.2 (12.4)p-valueNSNSNSNS0.06NSNSNS0.0013117

TRAUMATOLOGISCHEHEELKUNDEBEVERNAGE C., GEUSENS E., NIJS S.: Case report: a gossypiboma inthe shoulder. Emerg. Radiol., 2006; 12(5): 231-233.We present the case of a 15-year-old boy who underwent shouldersurgery for repair of a Bankart lesion after dislocation of his rightshoulder. A compress was left in the surgical wound. This case ispresented to highlight an important pitfall in the diagnosis ofgossypiboma (foreign body reaction): when the wires of a compressare visualized on X-ray, beware of the fact that it is possibly locatedinside the body. The diagnosis of an abscess was made byultrasound. The compress wires were visualized on radiographs.BOL L., BROOS P.: De gevolgen van osteoporose enosteoporosegerelateerde heupfracturen. Tijdschr. voor Geneeskunde,2006; 62(17): 1171-1181.Hoewel osteoporose aanvankelijk een asymptomatische aandoeningbetreft, gaat ze in een laattijdig stadium gepaard met een belangrijkemortaliteit en morbiditeit. Osteoporose is gekend als onderliggendeoorzaak van verschillende factoren bij ouderen, waarbij deheupfracturen als de meest ernstige worden beschouwd. Aangeziener wereldwijd sprake is van een vergrijzing van de populatie, vormtosteoporose een steeds grotere uitdaging voor de gezondheidszorg,zowel wat het voldoen aan de stijgende behoefte aan medische zorgals het dragen van de daaraan verbonden kosten betreft.De impact van een heupfractuur bij ouderen is enorm. Naast eendaling van de levensverwachting betekent een heupfractuur dikwijlseen ernstige aanslag op de fysieke integriteit en de kwaliteit van hetleven. De lichamelijke conditie komt vaak niet meer terug op het oudeniveau en tot 20% van de patiënten dient blijvend te wordenopgenomen in een verpleeginstelling. Hierdoor overschrijden de totalekosten van een heupfractuur ruim de kosten van de directehospitalisatie.Nu de naoorlogse generaties ouder worden, is er een dringendebehoefte aan effectieve preventiemethoden. Hiervoor is het118

noodzakelijk een beter inzicht te verkrijgen in de gevolgen van deosteoporose en osteoporosegerelateerde heupfracturen.BROOS P.: Unstable trochanteric fractures: are there better implantsthan DHS? Eur. J. Trauma, 2006; 32: 171(Abstract).Introduction: Since the eighties, the Dynamic Hip Screw (DHS)became the gold standard in the treatment of pertrochantericfractures. Nevertheless, there is a mechanical failure rate of 15% inunstable fractures. The results can be improved by using in addition aTrochanteric Stabilizing Plate (TSP). The concept of the lag screw canalso be replaced by a nail with Twin Hooks. On the other hand, manyauthors prefer to treat these lesions with an endomedullary nail-screwimplant (PFN, PFNA, ...).Methods: We performed two different meta-analysis of paperspublished on these items. Between 2000 and 2003, we made aprospective randomized trial on 412 patients using a DHS with TSP ora PFN. Also the results of 54 patients treated with the Twin Hookpinciple and 76 patients treated with the PFNA were analysed andcompared with “the gold standard”. We also paid attention to theindication for primary prosthetic replacement.Results: More and more authors are using endomedullary implants,because of the shorter operating time and the limited blood loss. Ourown results confirm the statistically significant difference in operatingtime and blood loss in favour of the endomedullary implant. Therewere no differences in the mechanical complication rate and the needfor reintervention.Conclusion:1. Endomedullar fixation using a PFN for unstable pertrochantericfractures seems to be a more easy procedure than DHStechnique.Until now, there is however no significant difference incomplication rate and final functional results.2. The Twin Hook and the PFNA have some particular advantages.3. Primary prosthetic replacement in non-arthrotic hip is onlyindicated in octogenarians in good functional condition with a veryunstable fracture.CORTEN K.: Periprosthetic fractures in the elderly: plate or revisionstem? European Journal Trauma, 2006; 32: 111 (Abstract).Periprosthetic fractures of the femur are a more and more commoncomplication of the long term use of total hip replacement. Thesefractures are difficult to deal with and are a real surgical challenge in119

hip surgery. We evaluated our experience in results and complicationsof 56 periprosthetic femoral fractures in 54 patients with an averageage of 78 years at time of revision. The vast majority of these fractureswere Vancouver type B2 or B3 fractures. From December 1995 toDecember 2004, all these fractures were treated operatively withORIF (n=30), Wagner prosthesis (n=14) or a cementless tapered stem(n=6). The decision which strategy would be used, was not onlyinfluenced by the type of fracture but as well by the medical comorbiditiesof the patient. All these patients could be followed upprospectively for at least 1 year. We evaluated the radiographic signsof bone remodelling, prosthetic alignment and the rate of subsidence.The functional status and the complications related to the procedurewere evaluated as well. Our conclusion is that although most of thesepatients do have significant co-morbidities and these operations aretechnically highly demanding, the mortality rate and peri-operativecomplication rate are not as high as one would expect. In general, thefinal results are radiographically well-remodelled fractures at the 1year follow-up period with a functional painless mobility in which nowalking aid is required. Based on these results, we believe that ORIFin Vancouver type B1 and B2 fractures is a reliable option.DE TROYER B., NIJS S., GEUSENS E., DAENENS K., BROOS P.: Radialartery thrombosis by a single blunt trauma: a case report. Eur. J.Trauma, 2006; 32(3): 301-303.Acute thrombosis of the radial artery in the absence of arteriosclerosisis a rare event. We report on an acute thrombosis after a single blunt(carting) trauma. Since there were only local symptoms and no signsof digital ischemia, a conservative approach was preferred. Wedescribe the clinical presentation and review the literature concerningnon-atherosclerotic acute thrombosis of the radial artery.FIERENS J., BROOS P.L.O.: Quality of life after hip fracture surgery inthe elderly. Acta Chir. Belg., 2006; 106: 393-396.As the world population ages, the prevalence of osteoporosis and theincidence of hip fractures will increase dramatically, being responsiblefor an increase of the health expenditure. On the other hand, there isthe inescapable fact of scarcity creating the necessity of makingdifficult choices with regard to the allocation of human resources. Sothe question remains: should we carry on investing an important partof our health expenditure for the treatment of hip fractures in elderlypeople? To answer this statement, we compared 384 hip fracture120

patients of 70 years and older treated in our department between1978 and 1983 with 1102 patients treated between 1998 and 2003.Both groups had a prospective follow-up of at least one year. Therewere no statistically significant differences: mortality rate 24% vs.23%; good functional outcome 82% vs. 73%; and home going rate60% vs. 66%. The factors influencing these results were studied. Sowe can conclude: - the number of hip fractures treated nowadaysincreased compared with twenty years ago; - there is no significantimprovement in mortality, nor in quality of life; - age is not acontraindication for hip fracture surgery.JOCHMANS I., NIJS S., DE BONNAIRE G., SERMON A., BROOS P.: Howsafe is proximal humeral nailing? Eur. J. Trauma, 2006; 32: 580(Abstract).Introduction: Proximal humeral fractures are frequently treated usingantegrade nailing. To secure the head fragment multiple locking boltsor spiral blades are used. Little evidence is available about the safetyof proximal humeral nailing. Theoretically these locking bolts canendanger several structures around the shoulder, among others: theaxillary nerve, the long head of the biceps tendon, the anteriorcircumflex humeral artery and its ascending branch.Materials and methods: We did implant the Synthes PHN and C-PHN,the Strycker T2-PHN, the Smith & Nephew Trigen PHN, the Braun-Aesculap Targon nail and the Zimmer Sirus nail in 30 cadavers. Usinga digital calippometer the distance between the locking bolts and theabove-mentioned structures has been recorded. Each measurementhas been repeated 3 times to minimize measurement errors.Furthermore the distance between the acromions lateral edge and theaxillary nerve has been recorded dorsally and ventrally as the width ofthe axillary nerve in order to be able to describe the variability of thecourse of the axillary nerve and to comparative plot the results of thedifferent implantations.Results: There was wide variability in distance of the bolts to both tothe axillary nerve and the ascending branch of the anterior circumflexhumeral artery. The mean minimal distance between a bolt an theaxillary nerve was 6,85 mm. However this distance is very variablebetween the different nail types ranging from a mean of 13,5 mm forthe Targon nail to 1 mm for the Sirus nail. The mean distance betweenthe antero-posterior locking screw in the three nail types offering thislocking possibility and the ascending arterial branch is 7,3 mm.Conclusion: Proximal humeral nailing is a widespread technique.However the safety both regarding the axillary nerve as the ascendingbranch of the anterior circumflex humeral artery is limited. There is awide variability in safety between the different nail designs. As121

anteroposterior locking can endanger the humeral headsvascularisation the benefit of this locking option critically has to beevaluated.KUPPERS M., NIJS S., BROOS P.: Tubercle fixation and healing inshoulder fracture prosthesis. Eur. J. Trauma, 2006; 32: 779 (Abstract).Introduction: Previous studies clearly demonstrated a correlationbetween functional outcome after shoulder fracture prosthesis andfunctional outcome. In a previous multicenter study of our workinggroup tubercle healing was associated with a mean absolute Constantscore of 77, where in the non-healed group only a score of 48 wasobserved. Multiple studies however did demonstrate the only, at best,half of the refixated tubercles do heal. We do believe that stability offixation in one of the main determinants whether a tubercle will heal ornot.Material and methods: In a separate biomechanical study we diddemonstrate that fixation of tubercles on the Articula (Mathys Betlach)shoulder prosthesis using a circular 2 mm steel cable is significantlymore stable than fixation using nr. 5 fibrewire. Between December2004 and June 2005 we did use the above mentioned steel cablefixation in 23 patients treated for acute four part fracture of theproximal humerus. Mean age was 73. 18 patients were available forradiographic re-evaluation 6 months after surgery. Standard true APand Scapular Y X-rays have been used to judge tubercle healing.Results: 15/18 patients tubercle healing has been observed. In 10/15we did observe anatomical healing. In 5/15 we did observe tuberclemalposition. In 3/15 no healing and secondary loss of tubercles hasbeen documented. Compared to our own historical results using nr. 2fibrewire (Arthrex) fixation these results are significantly better as theyare compared to the best series found in literature.Conclusion: Stable tubercle fixation using steel cables in proximalhumeral fracture prosthesis results in significant better healing oftubercles than standard fixation techniques.LERUT F., NIJS S., BROOS P.: The non-reconstructable proximalfracture: reversed or anatomical prosthesis. Eur. J. Trauma, 2006; 32:732 (Abstract).Introduction: The treatment of proximal humeral fractures remains achallenge. When confronted with a non reconstructable fracture, thesurgeon has to distinguish whether the patients would benefit from aprosthesis or not. The results of fracture prostheses remain an issue122

of debate. A good pain relief can be predicted but function is notalways a success. A good pain relief can be predicted but function isnot always a success. Because of the good functional results in a cuffdeficient shoulder and the ease of rehabilitation some people doadvocate to use a reversed shoulder prosthesis as primary fracturetreatment.Materials and methods: We did compare a prospective series ofreversed shoulder prosthesis (Delta III Depuy Warshaw) used aprimary shoulder fracture prosthesis to a historical series ofanatomical shoulder prosthesis (Articula Mathys Betlach). 15 patients,matched for sex and age have been included in both groups. Patientshave been scored functionally using the ASES shoulder index and theConstant score. Complications have been documented.Results: Both using the ASES index as the Constant score theAnatomical shoulder prosthesis did score significantly better than thereversed shoulder prosthesis. The number of complications washigher in the reversed shoulder prosthesis group.Conclusion: For the treatment of complex proximal humeral fracturesan anatomical shoulder fracture prosthesis seems to be the treatmentof choice as compared to a reversed shoulder prosthesis. We believethat the fact that there are no cuff remnants attached to the reversedshoulder prosthesis does yield in a poorer outcome as for reversedshoulder prostheses used for rotator cuff arthropathy.NIJS S., HIERNER R., CLAES M., BROOS P.: Defect fractures withsevere soft tissue defect in the polytraumatized. Eur. J. Trauma, 2006;32; 195 (Abstract).Introduction: Complex fractures of the elbow are difficult to treat.When bone defects are combined with severe soft tissue damagetherapeutic options are limited. We describe our treatment results in 7patients with combined bone loss and severe soft tissue defect.Material and methods: Between August 2001 and May 2005 we didtreat 7 patients because of combined articular bone loss of the elbowand severe soft tissue defect. All patients were polytraumatized. Thereare 4 female and 3 male patients. Mean age is 30 years. In 6 patientsa total elbow arthroplasty has been performed. In 3 of them thearthroplasty has been augmented with the use of an allograft. In the7 th patient we did reconstruct the joint using an allograft alone. Tocover the soft tissue defects we did use in every patient a latissimusdorsi muscle flap. In two patients vascular reconstruction of thebrachial artery was necessary. In 4 patients nerve reconstructionshave been performed.Results: Every patient obtained a functional elbow joint. 5 of the sevenpatients were professionally active at the time of injury. 4 of them were123

able to return to their previous job. One did change occupation but isfully active. The two remaining patients are students. The mean HSSelbow score is 75,8% and the mean Morrey score is 72%. We did seeheterotopic ossifications in two patients, necessitating an arthrolysis.In two patients a dislocation of the elbow occurred. There was onepost-operative infection, which could be cured by repeated irrigationand antibiotics. All patients do score their results subjectively as goodor satisfying.Conclusion: Defect fractures of the elbow with severe soft tissuedamage remain challenging to treat. With a patient tailored,multidisciplinary approach however, acceptable functional results canbe obtained, avoiding arthrodesis or even amputation.SERMON A., BROOS P., REYNDERS P.: Twin hook: preliminary resultsin the treatment of intertrochanteric fractures. Eur. J. Trauma, 2006; 32:169.Introduction: A new method for the stabilisation of intertrochantericfractures will be presented in this study. The operative techniqueconsists of an alternative for the traditional lag screw. The cephalicimplant is a cannulated nail with two oppositely directed apical hooksand is used in combination with a sliding plate.Aims: The aim of this study is to give a description of the implantcharacteristics and operative technique and to give an overview of thepreliminary results of the use of the Twin Hook in the department ofTraumatology of the University Hospitals Gasthuisberg in Leuven,Belgium.Materials and methods: 19 patients with 20 intertrochanteric fractureswere enrolled in the study between June 2004 and October 2005. Allof the fractures were treated with a Twin Hook and a four hole plate.Radiological and clinical follow-up was performed at 3 weeks, at 2, 4and 6 months and at one year.Results: Follow-up could be obtained up to one year in 16 patients. In15 patients, consolidation occurred within the first six months. Therewas one case of delayed union due to extensive impaction of thefracture. There was one peroperative complication: due to theeccentrical position of the twin hook the hooks could not be openedcompletely. There was one postoperative complication: a woundhematoma occurring in a patient receiving anticoagulation for cardiacvalve replacement.Conclusions: We think the Twin Hook is a feasible alternative for theDHS in the treatment of intertrochanteric fractures and offers theadvantage of minimal invasive placement.124

VAN GESTEL L., NIJS S., BROOS P.: Tubercle fixation in proximalhumeral fractures: biomechanical evaluation. Eur. J. Trauma, 2006; 32:780 (Abstract).Introduction: Previous studies clearly demonstrated a correlationbetween functional outcome after shoulder fracture prosthesis andfunctional outcome. In a previous multicenter study of our workinggroup tubercle healing was associated with a mean absolute Constantscore of 77, where in the non-healed group only a score of 48 wasobserved. Multiple studies however did demonstrate that only, at best,half of the refixated tubercles do heal. We do believe that stability offixation is one of the main determinants whether a tubercle will heal ornot.Material and methods: We did create a standardized four partproximal humeral fracture in 8 cadaveric proximal humeri with intactrotator cuff attached to the bone. In all humeri an Articula fractureshoulder prosthesis (Mathys Betlach) has been implanted. In fourhumeri the tuberculae were fixed upon the prosthesis using nr. 2Fibrewire. In four other humeri the fixation was achieved using acircular 2 mm metal cable (Dall-Miles Howmedica). Using an highspeed camera setup interfragmentary dislocation was measured afterputting an alternated load on the subscapuaris, supraspinatus andinfraspinatus tendons.Results: The construct using the cable was significantly more stable inall directions as the construct using Fibrewire.Conclusions: As interfragmentary stability is an condition for fracturehealing we believe a construct using metal woven cable isbiomechanically preferable over a fibre wire refixation construct.VAN ROY B., NIJS S., BROOS P.: Proximal humeral nailing: 4 systemscompared. Eur. J. Trauma, 2006; 32: 122 (Abstract).Introduction: Proximal humeral fractures are endemic. Two and threepart fractures often have been treated conservatively. It nowadaysbecomes clear that an anatomical reconstruction and stable fixation ofthese fractures, allowing early active mobilization, results in betterfunctional outcome. A minimal invasive approach to the proximalhumerus avoiding the risks of adhesion formation and reducing therisk of avascular necrosis is beneficial for the patient, at least when astable fixation can be achieved. To achieve this stability was difficultusing non angular stable systems. The advent of angular stablefixation systems should solve this problem of implant loosening in theosteoporotic, metaphyseal bone. Different systems of achieving thisstability have been proposed.125

Material and methods: We want to evaluate the clinical outcome andease of surgical procedure of four different commercially availablenailing systems for the proximal humerus. The systems evaluated are:Synthes PHN, Braun Targon, Zimmer Sirus and Strycker T2. We didinclude 40 patients in the study. Patients were randomly allocated toone of the implant groups and all per- and post-operative data havebeen collected prospectively. Functional outcome is scored using theConstant score, DASH and ASES shoulder index. Radiographically,helaing, loosening and implant related complications are scored.Results: Peroperatively the duration of surgery was significantly lowerin the Synthes PHN-group. Between the other groups there were nodifferences. Intra-operative complications were significantly higher forthe Strycker T2-group. Post-operative complications and implantrelated complaints were significantly higher for the Strycker and theZimmer groups. Functional scoring was significantly better for theSynthes and the Braun group.Conclusions: 2 and 3 part fractures of the proximal humerus can betreated using intramedullary implants. In our hands the Synthes andthe Brain nail did score significantly better, both in functional as inradiographycal evaluations.VAN SEYMORTIER P., STOFFELEN D., FORTEMS Y., REYNDERS P.:The reverse shoulder prosthesis (Delta III) in acute shoulder fractures:technical considerations with respect to stability. Acta Orthop. Belg.,2006; 72(4): 474-477.The reverse shoulder prosthesis reverses the relationship between thescapular and humeral component, resulting in a mechanicaladvantage as the deltoid muscle is able to compensate for the rotatorcuff deficiency. Based on this mechanical advantage, the reverseshoulder prosthesis has become an accepted alternative for thetreatment of complex proximal humeral fractures. The purpose of thisarticle is to discuss technical considerations related to stability in theuse of the reverse shoulder prosthesis in acute shoulder fractures,based on clinical experience.126

UROLOGIEALBERSEN M., JONIAU S., VAN POPPEL H.: Identification of predictorsof functional outcome of open nerve-sparing radical prostatectomy. J.Sex Med., 2006: 17.Objective: To report functional outcome of open nerve-sparing radicalretropubic prostatectomy (NS RRP), and to identify predictors ofpostoperative erectile function, ability to achieve orgasm andcontinence.Methods: Between January 2001 and November 2004, 272 patientsunderwent uni- or bilateral NS RRP at our institution. At a minimum of18 months post-surgery, patients received a questionnaire on erectilefunction, ability to achieve orgasm, and continence. Patients reportingerectile dysfunction pre-operatively, and patients who receivedadjuvant therapy (radiotherapy and/or hormone treatment) wereexcluded.Results: The response rate was 71.7% (n=195). A further 34 patientswere excluded, leaving 161 patients for the final analysis. Mean agewas 59.44 years (range 45-75). 55% underwent bilateral, 45%unilateral or partial bilateral nerve sparing surgery. Overall fullrecovery rate of potency using single-item assessment (erections firmenough for penetration) was 36.1. Postoperatively, 29.3% of patientsreported anorgasmia, where pre-operatively none of the patients hadanorgasmia. One patient (0.6%) suffered from incontinence grade 3,indicating pad use of more than one pad per day.Conclusion: Because of an increased detection of organ confinedprostate cancer, the demand for nerve-sparing surgery is rising. In ourgroup, recovery of potency, continence and orgasm were mainlycorrelated with age and blood loss. The single factors that can beinfluenced are blood loss and quality of nerve-sparing, which stressesthe importance of proper anatomical surgical technique.ALBERSEN M., JONIAU S., VAN POPPEL H.: The use of the IIEF-5questionnaire for evaluation of erectile dysfunction following nervesparing.J. Sex Med., 2006: 19.Objective: Because of an increased detection of organ confinedprostate cancer, the demand for nerve-sparing surgery is rising. In thevast majority of studies concerning erectile dysfunction following127

nerve-sparing radical prostatectomy (NS RRP), single itemassessment is used for reporting of ED post-surgery. However,potency rates differ widely between various groups. We thereforeaimed to investigate the use of the IIEF-5 for the reporting of EDfollowing NS RRP. Objectives: To study the results of the use of theIIEF-5 questionnaire for evaluation of post-NS RRP erectiledysfunction.Methods: At a minimum of 18 months post-surgery, patients receiveda questionnaire on erectile function including single item assessmentand IIEF-5. Ninety-one patients who reported on having no erectiledysfunction pre-operatively, who stated to be sexually active, who didnot receive adjuvant therapy were included.Results: 50 patients (55%) underwent bilateral NS RRP, 41 patients(45%) underwent unilateral or partial bilateral nerve sparing surgery.When using the IIEF-5 questionnaire, we found that a mean of 25.5%had no ED (IIEF-5 score of 22-25). However, with single-itemassessment we saw a far higher potency rate.Conclusion: We studied the effect of the use of the validated IIEF-5questionnaire on reporting of erectile dysfunction following nervesparingsurgery, and found that it results in a significantly lowerpercentage of men classified as having no ED. However, it isexpected to have a higher level of validity, accuracy, and reliability,and seems more stable than the single-item assessment. Wetherefore think it is an excellent instrument for the reporting of EDfollowing RRP.BOGAERT G.A.: Congenital neuropathic bladder dysfynction:diagnostics and prevention of complications. In: Pediatric neurogenicbladder dysfunction. Eds. C. Esposito, J.M.Guys, D. Gough, A. Savanelli.Springer, 2006; 45: 343-355.Being born with myelomeningocele is a life-long crusade for the childand for the parents and siblings, who are often forgotten. It is a neverendingresponsibility and impairment of quality of life. In addiction, themedical care of patients with spinal dysraphism is a multidisciplinaryspecialized challenge and is not a simple and straightforward issue;however, there is more than just medical care: as much as possible,information to the family or caretakers is essential and, as soon aspossible, to the children. Lack of adequate information and the abilityto choose treatment options results often in lack of compliance oftreatment. Doctors sometimes think they know what is best for thepatient, but in reality it is only the patient who knows what is best forhim. Medical caretakers must also try to achieve independence of thepatient as much as possible. It is a wrong perspective that “others”can take better care of the child with spina bifida. As soon as other128

children achieve bladder and bowel control, the goal of medicalcaretakers should be to make these children also dry for bladder andbowel control, so that they can be socially integrated. If they are ableto join normal school it has been shown that these children arehappier and perform much better socially than if they would grow up inan environment with only physically or mentally disabled patients.Renal failure and complications are still the most common cause ofdeath in all age categories. Early intervention, regular diagnosticexamination, and patient education are most likely to lead to the mostsuccessful outcome. From a pediatric urological point of view, it is veryimportant to introduce intermittent catheterization as soon as possibleto familiarize the patient and caretakers with this technique. Inaddition, the pediatric urologist must also treat the impaired bowelfunction and must be one of the first to bring up the subject of sexualidentity and development. Of course, there is more, and only togetherwith a multidisciplinary team consisting of pediatricians, socialworkers, urotherapists or nurses, neurosurgeons, orthopedicsurgeons, physiotherapists, and all those wanting to devote time andcare to these children and their families, can the team make adifference. Working as a team, the impaired quality of life of a childborn with spina bifida can be decreased, and one can significantlycontribute to make these children and their families happy in society.CLAERHOUT F., COOREMANS G., DE RIDDER D., DEPREST J.:Anatomical and functional outcome after laparoscopic sacralcolpopexy: a prospective long-term follow up of 222 patients. Ing. J.Urogynaecol., 2006, 17S (Abstract 029).Objectives: Evaluation of the anatomical and functional outcome overlong term in a series of 222 patients undergoing laparoscopicsacrocolpopexy (LS) for vaginal vault prolapse.Materials and methods: Preoperative and postoperative evaluationconsisted of a structured interview by a standard questionnaire toassess prolapse symptoms, bladder, bowel and sexual function,clinical examination according to the Baden Walker vaginal profile andthe POPQ-score, a multichannel urodynamic investigation and RXcolpocystodefaecography. The primary approach was laparoscopy,unless if the latter was judged to be inappropriate (10%).Postoperative reviews performed at 6 w, 6 m and annually after by athird person.Results: 222 patients underwent 224 sacral colpopexies between May1996 and October 2005. Ninety-five percent of the patients werefollowed-up for a mean of 37.8 ±29.1 months (range 3-115). Thirtyonepercent underwent a concomitant procedure (7.1% subtotalhysterectomy, 11.1% rectopexy, 4.5% anti-incontinence surgery).129

Eighty-four percent of all sacropexies were completed by laparoscopy;6% were converted to laparotomy and 10% underwent primarylaparotomy. There were 2% intraoperative complications (one bladdertrauma, one ureteral trauma, two bleeding of epigastric artery). Majorpostoperative complications included one postoperative bleedingrequiring reintervention, two pulmonary embolism and two small bowelstrangulations both requiring laparotomy. Subjective total cure rate ofprolapse symptoms was 87.8% and another 8.5% improved. Of thepatients not undergoing incontinence surgery, preoperative stressincontinence (35.3%) and urge incontinence (35%) improvedpostoperatively in respectively 51% and 56%. Fifteen % of patientsdeveloped de novo stress incontinence and 7% underwent asecondary procedure because of urinary incontinence. Preoperativeconstipation (50%) improved in one third, worsened in 15% and 23%developed de novo constipation. In sexually active patients (45%),sexual function improved in 27%; 15% had worsening or de novodyspareunia. The objective failure (≥ Stage II prolapse) in anterior,middle and posterior compartment was respectively 7%, 3.7% and9.3%; total reoperation rate because of prolapse was 4%. The vaginalmesh erosion rate was 2.6%. The Prolaps quality of life questionnairesdemonstrated limited postoperative quality of life impairment (6w, IY)or a significant improvement of the quality of life.Conclusion: Sacrocolpopexy has a high objective and subjective curerate of prolapse symptoms and limited intraoperative andpostoperative complications. The majority of cases can be done bylaparoscopy. Reoperation rate because of prolapse was 4%.CLAERHOUT F., COOREMANS G., DE RIDDER D., DEPREST J.:Sacrocolpopexy with collagen materials: less mesh erosions atexpense of more recurrences? Int. J. Urogynaecol., 2006; 17S (Abstract248).Objectives: The purpose of this study was to evaluate the use ofbiomaterials and collagen coated materials performing sacralcolpopexy and compare them with the standard, polypropylene.Materials and methods: In consecutive series, 149 patients underwentsacral colpopexy with one of the 4 study materials: lightweightpolypropylene (Gynemesh, Johnsson&Johnsson), cross-linked dermalcollagen (Pelvicol, Bard), small intestinal submucosa (SIS, Cook) orcollagen coated polypropylene (Pelvitex, Bard). Primary outcomesincluded subjective cure, defined as absence of prolapse symptoms,objective cure, defined as absence of vaginal prolapse ≥ Stage II atany compartment and local: mesh complications (erosion, infection,pain). Secondary outcomes included bowel, bladder and sexualfunction, and quality of life.130

Results: Ninety-five percent of the patients were followed-up for 24 ±16.9 months (range 3-115). The subjective cure rate was significantlylower in the Pelvicol operated patients. The objective cure rate wassignificantly lower for patients operated with SIS. There were 6% localmesh complications. The mesh erosion rate was 2.6% for theGynemesh group, 5% for the Pelvitex group, 2.1% for the Pevicolgroup and 0% for the SIS group. There were 5.1% partial meshexcisions in the Gynemesh group and 2.5% in the Pelvitex groupbecause of pain related to a folded mesh. SIS was associated with8.3% mesh infections successfully treated with antibiotics and vaginaldrainage in one patient.Material N Subjectivecure (%)Objectivecure (%)Postoperative < Stage IIfor each compartment (%)Ant Middle PostReoperationrate forprolapse (%)Local meshcomplications(%)Gynaemes h 39 95 90 100 97 95 0 7.8Pelvicol 46 73° 84 89 95 84 6.5 2.1SIS 24 87.5 72* 91 86 82 0 8.3Pelvitex 40 95 89 94 97 97 0 7.5*p < 0.05 Pelvicol vs Gynaemesh, SIS, Pelvitex; *p < 0.05 SIS vsGynaemesh, PevitexConclusion: Biological materials are associated with a lower subjectiveand objective cure rate. Although biological materials have beenintroduced to avoid local side effects associated with synthetic nonabsorbablemeshes, local mesh complications may occur. Collagenmesh coating does not decrease the rate of mesh complicationscompared to uncoated polypropylene meshes.CLAERHOUT F., COOREMANS G., DE RIDDER D., DEPREST J.:Prospective study of the learning process in adopting laparoscopicsacrocolpopexy. Int. J. Urogynaecol., 2006: 17S (Abstract 339).Objectives: Laparoscopy may reduce the morbidity of sacrocolpopexyby open surgery but requires advanced operative laparoscopic skills.The aim of this study is to analyse the learning process for performinglaparoscopic sacrocolpopexy (LS) by a surgeon familiar with advancelaparoscopy but not with LS (trainee) with operation time as a firstoutcome measure.Materials and methods: Prior to the study the trainee primed hissuturing skills by 15 hours of practicing endoscopic suturing on anendotrainer. LS was empirically divided in 3 parts: (1) dissection of thepromontory, (2) of the paracolic gutter and vagina and (3) fixation of131

the implant to the vault and sacrum. The operation time, peri-operativecomplication rate and performance (on a Visual Analogous Scale: 0-10) for each step were registered, analysed and compared to those ofthe surgeon experienced in performing LS (> 200 LS) referred to asteacher. In the first 30 procedures the trainee only performed step 1and 2. The trainee performed suturing and stapling (step 3) in the next20; the study is ongoing.Results: Between November 2003 and March 2006 50 patients wereincluded. The dissection of the promontory by the trainee took 14.8 ±8.6 min which was no different from that of the teacher (12.4 ± 9.7min; ns). The mean time to dissect the vaginal vault was 42.4 ± 16.7min, significantly longer than that by the teacher (25 ± 18.4 min, p

esistant to degradation, but at 365d half of the implants demonstratedsigns of degradation, the other half remaining intact. We wanted tofollow up the latter process in a 2-year follow up study in the rabbitmodel.Material and methods: Four 2.5 x 2.5 cm full thickness abdominal walldefects were created in 8 New Zealand rabbits, resulting in 32 implantsites. In a random fashion the defects were primarily closed with oneeither Prolene (Ethicon), SIS or Pelvicol. At 545 and 720 days fourrabbits were sacrificed providing minimally 5 implants for eachmaterial and for each time group. The macroscopic appearance of theimplant was noted and freshly harvested explant strips (1 cm wide)were tested by tensiometry (Instron). Microscopic evaluation consistedof quantification of polymorphonuclear cells, mononuclear cells(MNC), foreign body giant cells and newly formed vessels onHematoxylin and Eosin (H&E) and Movat stained parafin sections.Results: Three of the 8 rabbits, all from the 545 group, died fromunknown reasons, before sacrifice could take place. Macroscopically80% of all Pelvicol implants remained nearly intact except that thematerial showed 3 to 4 bursts spread over the implant area and half ofthem. These implants felt hard, rigid and stiff. The remaining 20%Pelvicol implants had a moth-eaten aspect with 90% of the meshsurface remaining intact. SIS implants were macroscopically notrecognisable anymore and replaced by a connective tissue scar. Ontensiometry all biopsies were tearing at the interface with nosignificant difference in strength between the different materials. Therewere two clinical herniation sites at sacrifice, one in the SIS (545d)and Pelvicol (545d) group. Pelvicol explants showed a strong chronicinflammatory infiltrate (100 MNC/hpf), limited to the interface. Theconnective tissue deposition was parelleling the implant(encapsulation), except from rare small islands of connective tissueinvading the implant. SIS was entirely replaced by slightly organisedconnective tissue consisting of collagen, fat and muscle tissue withalmost no inflammatory cells (5MNC/hpf). Prolene explants had amilder chronic inflammatory cell infiltrate (10MNC/hpf) and fibrosiswith an intermediately dens collagen deposition.Conclusion: Pelvicol implants remain virtually intact up to two yearsafter implantation. They are encapsulated by the host but become stiffand non compliant. SIS is entirely replaced by a mix of connectivetissue.CLAES H., VAN POPPEL H.: Thoughts and views on erectiledysfunction in the 50+ population in Belgium. Eur. Urol. Suppl., 2006;5(2): 102 (320).133

Introduction & Objectives: In order to provide further insight into thesexual ecology of the 50+ population in Belgium, we developedseparate questionnaires for men and women, which were distributedduring a convention for the 50+ population.Material & Methods: During the 2004 convention, 947 men (45,1%)and 1151 women (54,9%) spontaneously completed the questionnaire(N = 2098). To guarantee anonymity, each subject was asked to puttheir questionnaire into a limited access container. Subjects: meanage was 61.3 years (47,7% were between 56 and 65 years). 92,7%(1944) declared they were in a stable relationship (77,7% for morethan 10 years). 74,3% declared it was their first marriage. 64.2% wereretired.Results: For men and women, penetration came 14.8 minutes(median 12 minutes) from the beginning of the foreplay. Thiscorresponded with the finding that 86% of them would be satisfiedwith a drug that worked within 30 minutes. 71,2% of subjects reportedminimum 1 sexual problem. ED was reported in 49% and this ED preexistedfor 4.3 years (median 2 years). Age, stress, psychologicalproblems and medication were considered as the most importantcauses by this population which may explain why only 53% of theseED cases consulted a physician for their ED. From this consultationmedication was prescribed in no more than 63% of cases. Moreover,only 54% of the patients did take the medication (14% at eachintercourse and 41% from time to time).Conclusions: The cohort of the retired people is not aware of theimportant influence of organic factors as smoking, alcohol and beingoverweight on ED. If medication was prescribed, they would besatisfied with a drug that worked within 30 minutes. There still exists ahigh reluctance in patients as well as in doctors to treat ED.DARRAS J., JONIAU S., VAN POPPEL H.: Salvage radical prostatectomyfor radiorecurrent prostate cancer: Indications and results. Eur. J. Surg.Oncol., 2006; 32: 964-969.Aims: A rise in the incidence of radiorecurrent prostate cancer is to beexpected, since approximately one third of early prostate cancercases are nowadays treated with a radiotherapy modality. Onepossibility in treating radiorecurrent prostate cancer is salvageprostatectomy. Our objective was to look into our own experience withsalvage radical prostatectomy and to analyse outcome and morbidity.Methods: A computer search through our hospital database identified11 patients who underwent a salvage radical prostatectomy forradiorecurrent cancer over the last 15 years. All data wereretrospectively analysed and confronted with the literature.134

Results: Although the surgery was mostly difficult, there were nointraoperative complications. Bladder neck stricture is the mostcommon postoperative complication (18%). Continence rates areworse than in classical radical prostatectomy. All patients lost potency,since no attempt was made to spare the neurovascular bundles. Witha mean follow-up of 6.9 years, biochemical disease-free survival rateswas 55%, while overall and cancer-specific survival was 91%.Conclusion: While most patients with radiorecurrent prostate cancerwill be treated by many experts with hormonal therapy, a salvageradical prostatectomy can give a second chance for cure in carefullyselected patients.DEPREST J., CLAERHOUT F., ROOVERS J.P., SPELZINI F., ROMMENSH., SCHREURS A., VERGUTS J., DE RIDDER D.: Sacropexie: kan hetook laparoscopisch? Nederlands Tijdschrift voor Obstetrie &Gynaecologie, 2006; 119: 82-84.Vaginatopprolaps is een zeldzame complicatie van hysterectomie.Zeker bij jonge, seksueel actieve patiënten dient gewaakt te wordenover behoud van de vaginale capaciteit en een langdurend functioneelherstel als doel vooropgesteld te worden. Sacropexie heeft een hogesubjectieve en objectieve ‘cure rate’, met weinig recidief in hetmiddelste compartiment, ook in onze handen. Laparoscopischemodificatie lijkt het succes noch de complicaties negatief tebeïnvloeden, hoewel we dit niet in een vergelijkende studie hebbenonderzocht. LSP is een technisch complexe operatie, die lang duurtondanks ruime ervaring met laparoscopie in onze maatschappij. Opbasis van onze ervaring is de ingreep vrijwel altijd laparoscopischuitvoerbaar: leeftijds- of gewichtslimieten die we ons eerder oplegdenspelen inmiddels geen rol meer. De intra- en postoperatievecomplicaties zijn beperkt, maar kunnen ernstig zijn. LSP kanaangeleerd worden aan een chirurg met uitgebreide laparoscopischeervaring. Na dertig operaties blijft de operatie echter nog steedssignificant langer duren dan in ervaren handen, waar het op zichzelf aleen tijdsrovende ingreep is. Deze langdurige ingreep blijkt in depraktijk wel te resulteren in een aanzienlijk kortere opname enherstelperiode. Gezien het zeldzaam karakter van vaginatopprolaps,de lange operatietijd en langdurige leercurve concluderen wij dat dezeelectieve ingreep best in hoogvolumecentra, en door een beperktaantal handen, zal worden uitgevoerd.135

DEPREST J., ZHENG F., KONSTANTINOVIC M., SPELZINI F.,CLAERHOUT F., STEENSMA A., OZOG Y., DE RIDDER D.: The biologybehind fascial defects and the use of implants in pelvic organ prolapserepair. Int. Urogynecol. J., 2006; 17: S16-S25.Implant materials are increasingly being used in an effort to reducerecurrence after prolapse repair with native tissues. Surgeons shouldbe aware of the biology behind both the disease as well as the hostresponse to various implants. We will discuss insights into the biologybehind hernia and abdominal fascial defects. Those lessons from“herniology” will, wherever possible, be applied to pelvic organprolapse (POP) problems. Then we will deal with available animalmodels, for both the underlying disease and surgical repair. Then wewill go over the features of implants and describe how the hostresponds to implantation. Methodology of such experiments will bebriefly explained for the clinician not involved in experimentation. Aswe discuss the different materials available on the market, we willsummarize some results of recent experiments by our group.DE RIDDER D.: Antimuscarinics and cognitive function. Eur. Urol., 2006;50: 211-212.In recent years antimuscarinics have been studied extensively afterdecades of silence. For many years oxybutynin formed thecornerstone of the treatment for overactive bladder (OAB). Currently,trospium chloride, tolterodine, solifenacin, and darifenacin have madeit to the market. Despite many studies the clinician might wonderwhere the differences among these products lie. One aspect, namely,the antimuscarinic side-effects on cognitive function, has beenneglected by urologists.A close relationship exists between central cholinergic activity andinformation processing in the brain. Studies on vigilance, memory,problem solving, stimulus processing, and response processing haveshown the importance of the cholinergic system. Acetylcholinesteraseinhibitors are being prescribed in the treatment of dementia andcognitive impairment in an attempt to improve the cholinergictransmission.136

DE RIDDER D.: Conservatieve aanpak van blaasproblemen bijgevorderde multiple sclerose. Urobel Magazine, 2006; 3(1): 20-21.Bij patiënten met minimale aantasting ten gevolge van multiplesclerose staat de behandeling van blaasklachten relatief goedbeschreven. Het opstarten van blaasrelaxerende medicijnen ofanticholinergica eventueel samen met intermittente zelfsondagevormen hier de gouden standaard. Bij gevorderde MS (EDSS > 7) isde behandeling minder duidelijk. In vele gevallen worden permanentekatheters gebruikt. Deze brengen hun eigen problemen met zich meezoals het verstoppen van de katheter, urineverlies naast de katheter,chronische infectie, steenvorming of bloedverlies in de urine. Anderefactoren kunnen tevens een goed management van de blaasbemoeilijken. Moeilijke transfers, moeilijk bereikbare toiletten,bijwerkingen van medicaties, spasticiteit en cognitieve problemenkunnen roet in het eten strooien. Veel artsen minimaliseren dezeproblematiek of zijn hier onvoldoende mee vertrouwd zodat vele vandeze problemen eigenlijk moeten opgevangen worden door deverpleegkundigen. Binnen de SUBDIMS (Sexual Urological BowelDysfunction in MS – een studiegroep van Rehabilitation in MultipleSclerosis) werden hieromtrent een paar consensus meetingsgeorganiseerd. Enerzijds werd er een literatuur onderzoek uitgevoerd.Anderzijds werd er ook een vragenlijst verstuurd naar 45 EuropeseMS centra met vragen omtrent hun dagelijkse praktijkvoering.DIRIX P., HAUSTERMANS K., JUNIUS S., WITHERS R., OYEN R., VANPOPPEL H.: The role of whole pelvic radiotherapy in locally advancedprostate cancer. Radiother. Oncol., 2006; 79(1): 1-14.Routine PSA testing has led to diagnosis and treatment of prostatecancer at earlier stages than previously. Earlier and technicallyimprovedtreatment, together with escalation of dose has enhancedcure rates. Although, the incidence of nodal metastases is now lowerthan in pre-PSA days, more extended pelvic lymphadenectomies haveshown the actual rate of lymph node involvement to be higher thanhad been determined from standard radical prostate surgery. As incancers in other sites, especially in their earlier stages, lymph nodemetastases may exist in the absence of haematogenousdissemination. This, together with the improved rates of control of theprimary prostate tumour, suggests that elective irradiation of earlystagelymph nodes from prostate cancer should enhance survival in amanner analogous to improvements seen with this approach in othercancers. Although, the absolute incidence of positive nodes in locally137

advanced prostate cancer warrants elective radiotherapy, it isrelatively low and the modest improvements to be expected may beundetected in the results of a small trial.GANN P.H., AKAZA H., HABIB F., KIRBY R., VALDES MENDOZA A.,THOMPSON I., VAN POPPEL H.: Prostate cancer prevention. In: ProstateCancer. Editors: J. McConnell, L. Denis, H. Akaza, S. Khoury, J. Schalken.Edition, 2006: 249-274.This report critically evaluates our current state of knowledgeregarding strategies for the primary prevention of prostate cancer.Prostate cancer is a good candidate for prevention, since it is arelatively common cancer with a generally slow rate of growth andprogression. Moreover, the costs of screening and treatment – bothterms of financial costs and morbidity – are extremely high. In thisdiscussion, pharmacological approaches to prevention areemphasized since they predominate in the literature; however, we alsodiscuss non-pharmacological approaches such as alterations in diet orphysical activity patterns. Chemoprevention has been defined as “theuse of pharmacological agents to impede, arrest, or reversecarcinogenesis at its earliest stages. Since they normally will beapplied in large populations that are cancer-free, preventiveinterventions are held to more stringent standards regarding cost andsafety than therapeutic interventions. In reality, most people who usea preventive agent are not expected to derive any benefit, and areexpected to take the agent for a long period or indefinitely.GEVAERT T., VANDEPITTE J., VRIENS J., NILIUS B., DE RIDDER D.:TRPVI acts as a local stretch-sensing molecule in rat bladder. Eur. Urol.Suppl., 2006; 5: 799 (49).Introduction and objectives: Is has been demonstrated thatintravesical volume load increases amplitude and frequency ofautonomous bladder contractions. Thus local afferent-efferentreflexes, free from spinal and central neuronal pathways, seem to beinvolved in stretch-contractile responses in bladder. However themechanism underlying these stretch-evoked reflexes are still poorlyunderstood. In the present study we looked at the role of the vanilloidtransient receptor potential channel subtype-1 (TRPV1) in localstretch-evoked rat bladder contractility.Materials and methods: Wistar rat bladders were used. Each bladderwas excised, a pressure catheter was inserted and the bladderpreparation was placed in a heated organ bath, where intravesical138

pressures were measured. The effects on autonomous bladdercontractility of intravesical volume load (Krebs solution, 20µl/min, 15min) and of the TRPV1 agonist piperine (PIP, 10 µM) were studied.The effects of extravesical pre-treatment with TRP-antagonistruthenium red (RR, 10µM) and TRPVI-antagonist capsazepine (CZP,10µM) on the stretch-contractile response were studied. Thesecontractile responses were compared with data from untreatedbladders.Results: Intravesical volume load induced an increase in amplitudeand frequency of autonomous bladder contractions. The TRPVIagonistPIP provoked similar effects, which were effectivelyantagonized by CZP. CZP and RR induced a decreased rise inamplitude of contractions after intravesical volume load, comparedwith the control group (p < 0.05). Intravesical volume load provokedan increase in duration of contractions in CZP-treated bladders (p

cell types include papillary, chromophobe, and Bellini duct (collectingduct) tumors. A number of RCC are hereditary types including vonHippel-Landau syndrome, and are associated with different cell types.GHYSEL C., JONIAU S., VAN POPPEL H.: The role of metastasectomy inrenal cell carcinoma. Eur. Urol. Suppl., 2006; 5(2): 221 (794).Introduction & Objectives: More than 60% of patients diagnosed withrenal cell carcinoma (RCC) have synchronous or metachronousmetastases in the course of their disease. In the absence of effectivenon-surgical therapy, surgical management in selected patients withmetastatic RCC should be considered. The selection criteria forpatients to undergo aggressive surgical management are not welldefined. The current study aimed to determine predictive factors forlong-term survival after metastasectomy.Material & Methods: We retrospectively reviewed the records of 59patients who underwent one or multiple metastasectomies formetastatic RCC between 1984 and 2003. The population included 37male and 22 female patients. Clinical and pathologic data werereviewed in order to determine whether outcome after metastasectoywas affected by the age of the patient, the site of metastasis, diseasefree interval (DFI) from nephrectomy to the diagnosis of metastasis,tumour-stage, or history of prior metastasectomy.Results: The population consisted of 59 patients. In all patients ,primary nephrectomy was performed. Synchronous metastases werefound in 16 cases and metachronous metastases in 43 cases. Overall,74 metastasectomies with curative intent were performed. 46 patientsunderwent a single metastasectomy, 11 and 2 patients hadmetastases resected 2 and 3 times respectively. The median age atfirst metastasectomy was 60 years (range 25-79). Metastasectomieswere performed at different locations: lung n = 14, adrenal n = 14,bone n = 12, bowel n = 9, liver n = 7, retroperitoneum n = 5, thyroid n= 4, contralateral kidney n = 3, bladder n = 2, other n = 8. Minorcomplications occurred shortly after metastasectomy (cardiac arrest,pulmonary embolism). 5-year overall survival was 58%. UnivariateCox regression analysis identified location of metastases at the lung.DFI > 2 years, initial tumour stage T1 and age at first metastasectomy< 60 years as significant predictors for better disease-specific survival.Overall survival in repeated metastasectomy was equal to singlemetastasectomy.Conclusions: In a selected patient group, metastasectomy withcurative intent can provide an overall 5-year survival of 58%. Ageyounger than 60 and location of metastases in the lung are relatedwith an even longer survival.140

GOEMAN L., JONIAU S., OYEN R., VAN POPPEL H.: Percutaneousultrasound-guided radiofrequency ablation of recurrent renal cellcarcinoma in renal allograft after partial nephrectomy. Urology, 2006;67(1): 199.Percutaneous thermal ablation is increasingly being studied in thetreatment of renal tumors. Because radiofrequency ablation is aminimally invasive and nephron-sparing procedure, it is ideally suitedfor patients with a single kidney, multiple tumors, or contraindicationsto conventional surgery. We report on a patient with recurrent renalcell carcinoma in a transplanted kidney that was successfully treatedwith percutaneous ultrasound-guided radiofrequency ablation.HSU C.Y., JONIAU S., OYEN R., ROSKAMS T., VAN POPPEL H.: Stagingof unilateral clinical T3A prostate cancer: digital rectal examination ortransrectal ultrasound? Eur. Urol. Suppl., 2006; 5(2): 206 (735).Introduction & Objectives: The long-term outcome of surgicaltreatment for locally advanced prostate cancer (ct3a) is very good andsurpasses radiotherapy outcomes. It is anticipated that surgicalmanagement for cT3a disease will gain importance. Stagingmodalities for cT3a disease are not well studied. The purpose of thisretrospective study is to assess the sensitivity (SENS), specificity(SPEC), positive predictive value (PPV) and negative predictive value(NPV) of digital rectal examination (DRE), transrectal ultrasound(TRUS) and the combination of both in unilateral cT3a prostatecancer.Material & Methods: Between 1990 and 2004, 267 patients werestaged as unilateral cT3a prostate cancer either by DRE and/orTRUS. All patients underwent radical prostatectomy and bilateralpelvic lymphadenectomy. Final histopathology was compared withDRE and TRUS. SENS, SPEC, PPV and NPV for DRE, TRUS andcombination of both were calculated.SENS SPEC PPV NPVDRE 90,9% 15,8% 47,2% 67,7%TRUS 80,2% 25,3% 47,1% 60,7%Combination 71,1% 41,1% 50,0% 63,2%Although the SENS is lower in the combination group, it has thehighest SPEC (41,1%) and PPV (50,0%). Combination of DRE and141

TRUS can detect T3a prostate cancer more accurately than eithermethod alone.Conclusions: Until data on staging modalities like magnetic resonanceimaging become available, combination of DRE and TRUS isadvisable in the selection of cT3a patients for primary radicalprostatectomy.HSU C.Y., JONIAU S., OYEN R., ROSKAMS T., VAN POPPEL H.:Outcome for clinical unilateral T3A prostate cancer: a single-institutionexperience. Eur. Urol. Suppl., 2006; 5(2): 213 (763).Introduction and objectives: An estimated 12-25% of prostate cancersare clinical stage T3 (cT3). The management of cT3 disease is stillmatter or debate. The purpose of this study is to present 10-yearoutcomes of radical prostatectomy (RP) in unilateral cT3a prostatecancer.Material and methods: Between 1987 and 2004, two hundred patientswith unilateral cT3a prostate cancer underwent RP and bilateral pelviclymphadenectomy. Mean follow-up was 70.6 months (range 7 to 177).The mean serum PSA was 14.88 ng/ml (range 1.0 to 127.0). Mediansurgical Gleason score was 7 (range 4 to 9). The pathological stageswere recorded according to the 2002 TNM classification. Kaplan-Meiersurvival analysis was used to calculate the overall survival (OS),cancer specific survival (CSS), biochemical progression free survival(BPFS) and clinical progression free survival (CPFS) rate. MultivariateCox proportional hazard analysis was used to determine independentprognostic indicators of cancer progression.Results: Forty-seven patients (23,5%) were confirmed with organconfined disease (pT2); 145 (72.5%) were pT3 including 113 (56,5%)with extraprostatic extension only (pT3a) and 32 (16%) with seminalvesicle invasion (pt3b): 8 (4%) had adjacent structure invasion (pT4).Seventeen patients (8.5%) had lymph node involvement. Sixty-sevenpatients (33.5%) were found with positive surgical margin. Onehundred and twelve (56%) patients received adjuvant or salvagetherapy. This OS, CSS, BPFS and CPFS et 5 and 10 years were:5 years 10 yearsOverall survival 95.9% 77.0%Cancer specific survival 98.7% 91.6%Biochemical progression free survival 59.5% 51.1%Clinical progression free survival 95.9% 85.4%Margin status and preoperative PSA were identified as strongindependent factors predicting BPFS. Surgical Gleason score and142

pelvic lymph node status were not withheld as independent factors inpredicting CCS, BPFS and CPFS. Pathological stage was a significantindependent predictor in CSS. There were no significant differencesbetween pT2 and pT3a-b in CSS, BPFS and CPFS.Conclusions: RP is a valuable treatment option in unilateral cT3aprostate cancer, yielding very high 10-year overall and cancer specificoutcomes. More than half of the patients might need adjuvant orsalvage treatment.JONIAU S., ALBERSEN M., VAN POPPEL H.: Combined reporting offunctional and oncological results following open radicalprostatectomy using the ‘Salomon-score’. J. Sex Med., 2006: 64.Objective: Since functional outcome becomes more important to(increasingly younger) patients, we think combined oncologic andfunctional reporting is valuable in the comparison of outcome of RRPbetween various centres. In 2003, Salomon et al. proposed a scoringsystem to jointly report cancer control and functional results followingRRP. We aimed to evaluate the use of this scoring system in our ownexperience.Methods: Between January 2001 and November 2004, 272 patientsunderwent nerve-sparing (NS) RRP at our institution; 45% unilateral orpartial-bilateral, and 55% bilateral nerve-sparing. Each patient wasattributed 0 or 4 points for the presence or absence of biochemicalprogression (PSA > 0.2 ng/ml), 0 or 2 points for the presence orabsence of urinary incontinence (any use of pads) and 0 or 1 point forthe presence or absence of impotence (no erections firm enough forpenetration). The sum of these points provides the Salomon-score.We compared the scores of our own institution to those published bySalomon et al.Results: The response rate was 71.7%. Patients reportingpreoperative ED or incontinence were excluded; leaving 176 patientsin the final analysis. Mean age was 59.45 years. At a minimum of 18months postoperatively, 41% of patients were potent, 87% of patientsreported no pad use. Seven patients experienced biochemicalprogression. Salomon-scores are shown in the table.Conclusion: This study is the first to evaluate the Salomon-score inreporting combined oncological and functional outcome after RRP. Itprovides an excellent way to present outcome of NS-RRP andfacilitates comparison of outcomes between various centres.143

JONIAU S., VAN BAELEN A., HSU C.Y., OYEN R., ROSKAMS T., VANPOPPEL H.: Treatment of clinical stage T3 prostate cancer: a surgicaldisease?. Eur. Urol. Suppl., 2006; 5(2): 213 (761).Introduction & Objectives: The value of surgery as monotherapy inclinical stage T3 prostate cancer (cT3 PCa) is still subject to debate.The aim of this study was to examine the technical feasibility of radicalprostatectomy for cT3 PCa.Material & Methods: We reviewed the records of 139 patients whounderwent a radical retropubic prostatectomy (RRP) with pelviclymphadenectomy for cT3 PCa from January 1997 to December 2003.The files were critically reviewed and all data related to surgical andperi-operative complications were collected. Additionally, continenceand erectile function were assessed at 12 months postoperatively.Data were compared to series of RRP in patients with clinicallylocalised disease.Results: There was no peri-operative mortality. No ureteral or largevessel injury occurred. Rectal injury and injury of the obturator nerveoccurred both in 0.7% of cases. No serious in-hospital complicationswere noted and no reintervention was needed. Lymphorrhea wasnoted in 2,2% of patients and 1,4% experienced prolonged drainageof urine. In 7.2%, wound related problems occurred. Anastomoticstricture occurred in 2,9%. At 12 months, complete continence was87,8%. Erectile function fully recovered in 6% of patients whounderwent a non-nerve-sparing procedure and in 10% of patients whounderwent a unilateral nerve-sparing procedure. Positive surgicalmargin rate was only 13,7%.Conclusions: In cT3 PCa, RRP is technically feasible with morbiditycomparable to RRP in clinically localised PCa. Prospectiverandomised trials are needed to clearly define the place of surgery inthe treatment of cT3 PCa.JONIAU S., VANDER EECKT K., VAN POPPEL H.: The indications forpartial nephrectomy in the treatment of renal cell carcinoma. NatureClin. Practice Urol., 2006; 3(4): 198-205.Partial nephrectomy is performed more frequently for small,incidentally discovered, low-stage renal tumors. Importantly, oneshould distinguish the imperative indications for such surgery from therelative and elective indications, while taking contraindications tonephron-sparing surgery into account. The main advantage of partialnephrectomy over radical nephrectomy is the avoidance of renalinsufficiency; the major disadvantages include the possibility of localrecurrence and perioperative complications. In this article, the144

literature on nephron-sparing surgery was reviewed in order to put themanagement of renal cancer into a modern perspective.JONIAU S., VAN POPPEL H.: Nephron-sparing surgery: experience in159 consecutive cases. Eur. Urol. Suppl., 2006; 5(2): 182 (640).Introduction & Objectives: As a result of the widespread use ofultrasound, CAT scan and MRI, the majority of Renal Cell Cancer(RCC) is nowadays detected at an early stage. Nephron springsurgery has become an accepted treatment for small RCC. We reviewour experience in nephron sparing surgery for T1 and T2 lesions overthe last 5 years. The aim is to evaluate the feasibility and the safety ofthe technique and to assess oncological control.Material & Methods: Between July 1998 and July 2003, 159consecutive patients underwent nephron sparing surgery for T1 andT2 lesions at our institution. Mean age was 59 (2-82) years, meantumour volume was 4 (1-11) cm, mean follow-up 32 (5-65) months.Clinical stage was T1a in 77n4%, T1b in 19,5% and T2 3,1%. 69%had a normal contralateral kidney, 23% a solitary kidney and 8% hadbilateral tumours. Mean operating time was 91 minutes, 23% a solitarykidney and 8% had bilateral tumours. Mean operating time was 91minutes, mean blood loss 342 ml. Clamping was performed in 32,7%with a mean duration of 15 minutes. In 5% renal cooling wasperformed. There was an endorenal growth in 10,7%, a combinedgrowth in 43,4%, and an exorenal growth in 45,9%. Resection wasperformed in 30,2%, enucleoresection in 49,7% and enucleation in20,1%.Results: At histopathology, RCC was found in 76,7% and 23,3% werebenign lesions. Cancer free survival was 98,1%. Local tumourrecurrence occurred in 1,3% and metastasis in 0,6%. Intra-operativecomplications were seen in 2 patients (1,2%). In one patient, asplenectomy was necessary for bleeding and in another patient, aradical nephrectomy was done for arterial bleeding.In 15,1%, an early (< 1 month) postoperative complication occurred: apostoperative haematoma was found in 5,7%, acute renal failure in1,9%, wound problems in 1,3% and hematuria and urine leakage in 1patient (0,6%). 5 patients (3,9%) developed pneumonia and 3 patientshad cardiac problems. Late (> 1 month) postoperative complicationsoccurred in 6,3%. Chronic renal failure occurred in 2,5% andwoundherniation in 1,9%. One patient developed an arterial-venousfistula for which a super selective embolisation was performed. Localrecurrence occurred in two patients (1,3%). One patient had arecurrence at the resection site, another patient had a kidneyrecurrence.145

Conclusions: We believe that nephron sparing surgery for T1 and T2lesions is safe and reproducible with good oncological control atintermediate term follow-up.KIRBY M., ARTIBANI W., CARDOZO L., CHAPPLE C., DIAZ D.C., DERIDDER D., ESPUNA-PONS MP., HAAB F., KELLEHER C., MILSOM I.,VAN KERREBROECK P., VIERHOUT M., WAGG A.: Overactive bladder:the importance of new guidance. Int. J. Clin. Pract., 2006; 60(10): 1263-1271.Overactive bladder (OAB) affects an estimated 49 million people inEurope, but only a minority receive appropriate treatment. Others arebothered by unacceptable levels of symptoms that severely impairtheir quality of life and represent a significant financial burden tothemselves and to their healthcare providers. Recently updatedguidelines from the International Consultation on Incontinence (ICI)and the European Association of Urology (EAU) take account ofimportant new developments in the management of bladder problemsin both primary and secondary care. However, local implementation ofprevious guidance has been variable, with many patients with OABand other bladder problems failing to gain full benefit from currentclinical and scientific understanding of these conditions. The recentexpansion of the range of treatments available for OAB and stressurinary incontinence makes it especially important that physiciansbecome aware of the differential diagnosis of these conditions - thequestions they need to ask, and the investigations which will helpdetermine the most appropriate course of action.KLAVER S., JONIAU S., GOETHUYS H., SUY R., VAN POPPEL H.: Renalcell carcinoma with venous tumour thrombus: prognostic significanceof the level of the tumour thrombus and of associated metastases onlong-term survival. Eur. Urol. Suppl., 2006; 5(2): 258 (942).Introduction & Objectives: To evaluate the significance of venoustumour thrombus (TT) on the long-term outcome in patients withunilateral renal cell carcinoma (RCC) and to what extent the presenceof associated metastases influences survival.Material & Methods: Between January 1990 and June 2003, 87patients with RCC and associated TT were treated at our institution.All patients underwent a radical nephrectomy with resection of TT.The correlation between tumour characteristics (tumour grade andsize, associated metastases) and the level of TT was analysed.Furthermore, the impact of the level of TT and associated metastases146

on overall survival was studied. Survival was calculated using theKaplan-Meier method.Results: Tumour grade (p = 0,200), tumour size (p = 0.057) andpresence of associated metastases (p = 0.1491) were not significantlypredictive for TT level. However, in the group with no apparentmetastases, we found a significantly better 5-year overall survival of55% in patients with TT confined to the renal vein compared to 20% inpatients with TT extending into the IVC (p = 0.0016). We were unableto determine to what extent the level of TT in the IVC influences longtermsurvival due to small sample sizes. Finally, the presence ofassociated metastases clearly impacted survival in the total group,with a 5-year survival of 55% in the group without metastasiscompared to 10% in the group with metastasis (p < 0.0001).Conclusions: The level of TT is not significantly associated withtumour characteristics (grade, size and metastasis). Our data confirmthat non-metastatic RCC with TT is potentially curable condition, witha 5-year overall survival of 55%. However, survival is significantlydifferent for patients with TT extending into the renal vein compared toTT extending into the IVC. In this respect, it might be interesting to reevaluatethe 2002 TNM staging system which combines these twogroups (except IVD involvement extending above the diaphragm)equally as T3b. Radical nephrectomy in patients with TT andassociated metastatic spread yields poor results, with only 10%surviving more than 5 years.KONSTANTINOVIC M.L., PILLE E., MALINOWSKA M., VERBEKEN E., DERIDDER D., DEPREST J.: Tensile strength and host response towardsdifferent polypropylene implant materials used for augmentation offascial repair in a rat model. Int. Urogynecol. J., 2006; oct. 10; (Epubahead of print).We compared inflammatory response, fibrosis and biomechanicalproperties of different polypropylene materials from one manufacturer(Tyco Healthcare) in a rat model for primary fascial repair. Fullthicknessabdominal wall defects were primarily repaired using'overlay' technique. Multifilament implants were Surgipro SPM andSPMW, the latter a wider-weave type of the former. MonofilamentSPMM implants and polypropylene suture repair (Surgipro II) servedas controls. Explants were evaluated macroscopically and changes inthickness, shrinkage and tensile strength were measured.Inflammatory and connective tissue response was assessed onhaematoxylin-eosin and Movat stains. Immunohistochemistry wasdone to localise rat macrophages/monocytes. Multifilament materialsinduced a shorter acute inflammatory response and more pronouncedchronic inflammatory reaction compared to monofilament implants.147

Macrophages could be found deep in interstices 7.5 by 12.5 mum. Nodifference in collagen deposition and neovascularisation wasobserved. At 90 days time point, explants reconstructed with tighterwoven multifilament SPM were weaker than sutured or SPMMcontrols. Overall shrinkage of 10% was comparable for all groups.KONSTANTINOVIC M.L., POTTIER C., GUELINCKX I., SPELZINI F.,VERBEKEN E., DE RIDDER D., DE PREST J.: Reconstruction of thefascia with synthetic and biologic implant materials used inurogynecology. Int. J. Urogynaecol., 2006; 17S (Abstract 001).Objectives: To compare inflammatory response, fibrosis process andbiomechanical properties of different materials already in use orproposed for augmentation of fascial repairs for genital prolapse.Materials and Methods: We experimentally compared two porcinecross-linked dermal collagen and two synthetic polypropylenecontaining implants: Pelvicol TM and Pelvisoft TM (Bard, Haasrode,Belgium), the latter a modification with large longitudinal slits;Pelvitex TM (Bard) as a novel collagen-coated monofilamentpolypropylene implant and Vypro II ® (Johnson and Johnson MedicalNV, Dilbeek, Belgium) lightweight mesh which is composed ofresorbable multifilament polyglactin 910 and synthetic monofilamentpolypropylene. The dermal collagen matrices are believed to induce amilder inflammatory response without compromising tensile strength.Implants were used to primarily repair a full thickness abdominal walldefect in 96 Wistar rats. Animals were sacrificed on day 7, 14, 30 and90 after implantation. At sacrifice the explant (implant and surroundinghost tissue) was evaluated for the presence of herniation, infection,erosion, adhesion formation and changes in size. Tensile strength wasassessed both on implants and explants. Histopathology wasperformed to evaluate collagen deposition and inflammatoryresponse. ED-1 antibody was used to identify rat macrophages.Results: While no herniations occurred, two clinical and two additionalpathololgy confirmed infections were observed, one in Pelvisoft andthree in the Pelvicol group. Pelvitex induced the least adhesion. At 90days Vypro II shrunk by 19% while the other materials did not shrink.At 90 d all materials could resist tensile forces of 16 N/cm (Pelvisoft),or higher (Pelvicol, Pelvitex and Vypro II; range 25-27 H/cm).Pelvisoft, with its open macroporous construct, had a lowertensiometric strength than Pelvico in the early postoperative phase at14 days. The acute inflammatory response was most pronounced inVypro II. The chronic inflammatory response and foreign body reactionwas comparable in both polypropylene containing materials but morepronounced compared to dermal matrices. Collagen deposition at theinterface between muscle and material was comparable for all148

materials, although it was architecturally more organised in thecollagen products.Conclusion: Pelvisoft has a lesser tensiometric resistance thanPelvicol on the short term, but not at 90 d, at what time all materialswere equally strong. Pelvitex has a slightly more attenuated acuteinflammatory reaction, with fewer adhesions than Vypro II. It didneither shrink. Vypro II induces most adhesions, shrinks by one fifthand induces the strongest acute inflammation.LERUT E., ROSKAMS T., JONIAU S., OYEN R., ACHTEN R., VANPOPPEL H., DEBIEC-RYCHTER M.: Metanephric adenoma duringpregnancy: clinical presentation, histology, and cytogenetics. HumanPathol., 2006; 37(9): 1227-1232.Metanephric adenoma is a rare benign tumor of the kidney. It isconsidered to be derived from embryonic renal tissue and to be thebenign counterpart of the Wilms tumor. Although its imaging findingsand immunohistochemistry are nonspecific, it has a typicalmicroscopic morphology. We describe a case of a 24-year-oldprimigravida who presented in the 28th week of pregnancy with lowerback pain, fever, malaise, and anemia. At renal ultrasonography andmagnetic resonance imaging, a hemorrhagic tumor of 10 cm indiameter originating from the right kidney was seen. Based on theimaging findings, the diagnosis of a cystic renal cell carcinoma withrecent hemorrhage was suggested, and a radical nephrectomy wasperformed. Pathologic examination concluded to a metanephricadenoma. The further pregnancy went on well. The karyotype of thetumor was 46,XX,t(1;22)(q22;q13),t(15;16)(q21;p13). To ourknowledge, this is the first report on these chromosomal abnormalitiesin metanephric adenoma.MALKOWICZ S.B., VAN POPPEL H., MICKISCH G., PANSADORA V.,THOROFF J., SOLOWAY M., CHANG S., BENSON M., FUKUI I.: Muscleinvasiveurothelial carcinoma of the bladder. In: Bladder Tumors. Editors:Soloway M., Carmack A., Khoury S., 2006: 221-237.Urothelial (transitional cell) carcinoma of the bladder is a significantneoplasm with over 55.000 new cases and 12.000 cancer-relateddeaths per year in the United States. It is the 5 th most common cancerin the USA and the 4 th leading cause of cancer deaths. The majority ofthese deaths are due to the effects of muscle-invasive disease, whichaccount for approximately one-third of the novo cases and are derivedfrom about 10% to 15% of preexisting cases of superficial disease.149

The disease occurs predominantly in men yet is increasing inincidence in women in a manner that cannot be entirely explained byincreased tobacco use.SCHOFFSKI P., DUMEZ H., CLEMENT P., HOEBEN A., PRENEN H.,WOLTER P., JONIAU S., ROSKAMS T., VAN POPPEL H.: Emerging roleof tyrosine kinase inhibitors in the treatment of advanced renal cellcancer: a review. Annals of Oncology, 2006; 17(8): 1185-1186.Advanced and metastatic renal cell cancer (RCC) is resistant toconventional chemotherapy. Only a very small number of patientssurvive long term after immunotherapy. However, any effect ofinterleukin-2 (IL-2) and/or interferon on median overall survival issmall, and treatment-associated toxicities may be severe. The diseaseis therefore an area of high unmet medical need. Activation of theVEGF and EGF/RAS/RAF/MAP kinase pathways is frequent in solidtumours such as RCC. Such activation is implicated in tumourangiogenesis and proliferation. VEGF and EGF receptors andmolecules (such as RAF kinase) involved in downstream signallingare therefore potential appropriate targets for drug therapy. Severalantibodies and low molecular weight tyrosine kinase inhibitors (TKIs)have completed phase II clinical trials. Phase II studies ofmultitargeted agents, which include inhibition of VEGFR tyrosinekinase in their repertoire (sorafenib, sunitinib and AG 013736), showclear second-line activity in metastatic RCC. The same is true of theanti-VEGF antibody, bevacizumab. In a randomised phase IIIcomparison against placebo in pretreated patients, sorafenib doubledmedian progression free survival (24 versus 12 weeks). Studies nowin progress will determine whether benefits seen second-line will alsobe evident first-line, and whether the activity of novel agents can beincreased by combining them with each other, with cytokines, or withchemotherapy.SIEMER S., VAN POPPEL H., MACHTENS S., STROHMAIER W.L.,WECHSEL H.W., GOEBELL P.J., SCHMELLER N., OBERNEDER R.,STOLZENBURG J.U., TETENS V.: Prospektiv randomisiertemultizentrische Studie zur Effektivität von TachoSil ® als Hämostypikumnach Nierenteilresektion (NT). Der Urologe Suppl.1, 2006; S107: V.8.9.Ziel: Zur Hämostase nach NT stehen heute unterschiedlicheBehandlungsmodalitäten zur Verfügung. Ziel der verliegenden Studiewar es, die Effektivität von TachoSil gegenuber der Standard-Behandlung (ST-B; Kapselnaht) zu untersuchen.150

Material und Methoden: Von 13 Zentren konnten 185 Pat. mit einemNierentumor nach NT von Sept. 2002 bis Okt. 2004 eingeschlossenwerden. Das Alter lag im Mittel bei 63 Jahren, der BMI bei 27,6 kg/m²,64% Männer und 36% Frauen. Nach Tumorresektion wurden größereGefäßstümpfe legiert (primäre Hämostase). Dann erfolgte eineRandomisierung (1:1) TachoSil (Kollagenflies mit Fibrinogen undThrombin beschichtet) oder ST-B als sekundäre Hämostase. PrimärerEndpunkt: Zeitpunt der kompletten Hämostase (log-rank Test).Sekundäre Endpunkte: Patienten mit einer Hämostase ≤ 10 Min. undHämatomgröße (Sonographie am 2. post-Op-Tag), die mittelsCochran-Mantel-Haenszel bzw. Mann-Whitney Test bestimmt wurden.Ergebnisse: TachoSil war der St-B hinsichtlich der Zeit bis zurHämostase significant überlegen (mean 5,3 resp. 9,5; p < 0.0001). DieHämostase konnte bei 92% der Pat. Mit TachoSil ≤ 10 Min. undlediglich bei 67% nach St.-B erreicht werden (p < 0.001). Die mittlereResektionsfläche war mit 8,2 resp. 8,1 cm² vergleichbar. Es wurdenkeine signifikanten Unterschiede hinsichtlich der Hämatombildung, derpostoperativen Drainagenflüssigkeit und der Blut/Flüssigkeits-Substitution festgestellt. Es ziegten sich keine Unterschiedehinsichtlich der Adverse Events.Zusammenfassung: Mit TachoSil konnte eine signifikant effektivereHämostase im Vergleich zur Standard-Kapselnaht erreicht werden.TachoSil was gut verträglich und sicher bei der Anwendung. TachoSilkann somit bei der Nierenteilresektion als Hämostyptikumuneingeschränkt empfohlen werden.SPELZINI F., KONSTANTINOVIC M., GUELINCKX I., VERBEKEN E., DERIDDER D., DEPREST J.: A comparison of mesh characteristicsbetween two silk-based implants and a polypropylene implant in ananimal model for the fascial defect repair. Int. J. Urogynaecol., 2006; 17S(Abstract 201).Objective: A fast growing range of implants is used in pelvic floorsurgery. Silk, although used for decades, was never studied as meshmaterial. We present the data from a comparison of meshcharacteristics between two silk constructs and a polypropylene mesh.Materials and methods: The tested materials were two macroporousconstructs of silk with different densities (respectively 0.000135 and0.0002 g/mm², manufactured by BARD and not available on themarket) and a standard monofilament type I polypropylene mesh(Surgipro SPMM TM , TycoHealthcare). A rat model for abdominal fasciawall repair was used. This was done by creating full thicknessabdominal wall defects in 72 male Wistar rats and repairing thesedefects with the tested meshes. Animals were sacrificed on day 7, 14,30 and 90 after implantation. At sacrifice the explants were evaluated151

macroscopically for infections, herniations and adhesions,mechanically for tensile strength, and histopathologically, to evaluatecollagen deposition and inflammatory response.Results: None of the animals developed herniation or infection, andseromata were present only at day 7 around the silk implants. Amountand density of peritoneal adhesions, initially higher with the silk,progressively decreased over the time to be comparable for allmaterials at 90 days. The tensile strength of the explants showed agradual and similar increase for silks and SPMM at all time points. Allimplants uniformly shrank around one fifth by day 90. In the silkimplants the inflammatory reaction showed a remarkable highernumber of foreign body giant cells that characteristically spread fromthe periphery to the central part of the mesh. Collagen deposition wascomparable in amount, composition and organisation for all testedmaterials. In both of the two silk materials a higher grade ofneovascularisation was observed.Conclusion: The two tested silk constructs induced a similar level ofintraperitoneal adhesions after surgery when compared to a standardmacroporous polypropylene mesh. Tensile strength of the explantswas also comparable over the three months observation period.Microscopically this coincided with a strong foreign body reaction andintense fibrosis process, that took place deeply between individual silkfilaments, with obvious architectural degradation of the initialconstruct, a phenomenon not observed in polypropylene explants.Density of the silk material did not appear to affect the meshcharacteristics.SPELZINI F., KONSTANTINOVIC M., GUELINCKX I., VERBIST G.,VERBEKEN E., DE RIDDER D., DEPREST J.: Tensile strength and hostresponse towards silk and type I polypropylene implants used foraugmentation of fascial repair in a rat model. Gynecol. Obstet. Invest.,2006; 63: 155-162.Objective: We compared host response, architectural integration andtensile strength of two different macroporous silk constructs to apolypropylene type I implant in a rat model for augmentation ofprimary fascial defect repair.Materials and Methods: Animals were sacrificed on days 7, 14, 30 and90 after implantation. The explants were evaluated macroscopicallyfor infections, herniations and adhesions, mechanically for tensilestrength, and histopathologically, to evaluate collagen deposition andinflammatory response.Results: The tensile strength of the explants showed a gradualincrease for all materials. All implants uniformly shrank around onefifth by 90 days. In the silk implants, the inflammatory reaction showed152

a remarkable higher number of foreign body giant cells thatcharacteristically spread from the periphery into implants. Collagendeposition was comparable for all the materials. In silk a higher gradeof neovascularisation was observed.Conclusion: Silk explants expressed high tensiometric strength, whichwas associated with a marked fibrotic process. The silk implantsinduced a strong foreign body reaction accompanied by microscopicsigns of architectural degradation at 90 days. Polypropylene explantsshowed a more moderate foreign body reaction without architecturaldisturbance.TANG H.W., VAN BRUSSEL H., VANDER SLOTEN J., REYNAERTS D.,DE WIN G., VAN CLEYNENBREUGEL B., KONINCKX P.R.: Evaluation ofan intuitive writing interface in robot-aided laser laparoscopic surgery.Computer Aided Surgery, 2006; 11(1): 21-30.Objective: The feasibility of the conceptual Intuitive Writing Interface(IWI) in robot-aided laser laparoscopic surgery has beendemonstrated previously. This paper investigates the potentialimprovement of IWI by comparing conventional manipulation (CM)and IWI manipulation (IM) and conducting an animal experiment.Materials and methods: Three tasks were designed that wereconsidered to be representative of laser laparoscopic surgicalprocedures. All test participants used both CM and IM in all tasks.Completion time and error level of each task were taken ascomparative indices and were integrated into a self-defined Index ofTime and Error (ITE). Six sequential in vitro trials were carried out toinvestigate learning curves. In addition, nephrectomy was performedon a rabbit by employing IWI in robot-aided laser laparoscopicsurgery.Results: The results showed significant advantages for IM, withshorter completion time, more successful shots, and smaller errorlength in the three tasks, as compared to CM. The learning curveshowed a promising trend for IM. More than half of the participantsperformed better with IM. The animal model experiment demonstratedthe clinical feasibility of IM, but at the same time revealed somelimitations.Conclusions: The new IWI interface definitely improved laserlaparoscopic procedures by taking advantage of familiar writing skills.With its flexibility of implementation and ease of use, IWI has clearpotential for use in laser laparoscopic procedures.153

TOMBAL B., IVERSEN P., VAN POPPEL H., TAMMELA T.L., DE LAROSETTE J.J., JOHANSSON J.E., PERSSON B.E., JENSEN J.K.,OLESEN T.K.: Determining the dose of degarelix for effective therapy ofprostate cancer patients as investigated by the degarelix study groups.Annals of Oncology, 2006; Volume 17, Suppl.9: (461P).Introduction: Degarelix is a gonadotropin-releasing hormone (GnRH)blocker with an immediate onset of action that produces fast, profoundand sustained suppression of serum testosterone (T) levels, without Tsurge.Objective: International, multicentre, phase II studies were performedto determine the initiation dose (studies 1 and 2) and maintenancedose (study 2) of degarelix for hormonal therapy of prostate cancer(CaP).Methods: Both studies involved patients with histologically confirmedCaP, PSA levels ≥ 2ng/mL, and who were candidates for hormonaltherapy. In study 1, patients (n=172) were randomised to receivedegarelix as a single dose of 120-360 mg. In study 2, following aninitiation dose of 200 or 240 mg, patients (n=187) received monthlymaintenance doses of 80, 120 or 160 mg. Response was defined aspercentage of patients with T ≤ 0.5 mg/mL.Results: In study 1, all doses produced fast (by day 3) and profoundsuppression of T levels to ≤ 0.5 mg/mL and suppression wassustained up to at least day 28. Responses at both time-points (days3 and 28) were dose dependent. No T surge was observed. At a doseof 240 mg, 96% of patients achieved T suppression to ≤ 0.5 mg/mL atday 28 and PSA decreased to 25% of the baseline level at this timepoint.In study 2, 95% (240 mg group) of patients achieved Tsuppression to ≤ 0.5 mg/mL at day 28. For patients with T ≤ 0.5mg/mL at day 28 (n = 168) response rates at one year increased withmaintenance dose from 92% (80 mg), to 96% (120 mg) and 100%(160 mg). Median percentage reductions in PSA levels for theresponders were similar for all three maintenance doses and were ≥95% from week 12 onwards.Conclusion: Degarelix at an initiation dose of 240 mg induced fast andprofound T suppression to ≤ 0.5 mg/mL in 96% of patients within 3days of administration, without T surge. Monthly maintenance therapywith 160 mg produced sustained T suppression in 100% of patients.Degarelix induced fast, profound and sustained reduction of PSA andwas well tolerated. This dose regimen has been referred to a phase IIIprogram.154

VAN CALSTEREN K., VAN MENSEL K., JONIAU S., OYEN R., HANSSENSM., AMANT F., VAN POPPEL H.: Urachal carcinoma during pregnancy.Urology, 2006; 67: 1290-1291.We report a case of Stage T4aN2M0 urachal carcinoma that wasdiagnosed early in pregnancy. Because positive pelvic lymph nodesand uterine involvement were present, surgical resection, includinghysterectomy with termination of the pregnancy, and postoperativeradiotherapy were performed. The treatment options, which largelydepend on the duration of the pregnancy, the tumor stage, and thepatient’s desire to continue the pregnancy, are discussed.VAN DER KWAST T., BOLLA M., VAN POPPEL H., VEKEMANS K., VANCANGH P., SCHRODER F., DE REIJKE T., DAPOZZA L., BOSSET J.F.,COLLETTE L.: Impact of pathological review of radical prostatectomyspecimens on prognosis and predicted benefit from immediatepostoperative irradiation for high-risk patients (EORTC 22911). Eur.Urol. Suppl., 2006; 5(2): 205 (729).Introduction & Objectives: Patients with prostate cancer extending intosurgical margins and/or extension beyond the capsule have anincreased risk of local failure. As a part of EORTC trial 2911 apathological review of prostatectomy specimens was performed toassess predictors of biochemical recurrence.Material & Methods: After radical prostatectomy 503 patients wererandomly assigned to a control arm and 502 to immediatepostoperative radiotherapy. All eligible patients had pN0M0 diseaseand local pathology showed pT3a/b disease and/or positive surgicalmargins. A total of 552 prostatectomy specimens (280 control arm,272 test arm) of 12 major centres was reviewed and the localpathology in relation to biochemical recurrence by treatment arm wasassessed by logrank test for heterogeneity (α=0.05).Results: Agreement of local pathologists and review pathologist washigh (Kappa 0.83) for seminal vesicle involvement, but low forextracapsular extension and margin status (kappa 0.33 and 0.45respectively). The overall agreement for extracapsular extension andmargin status was 57.5 and 69.4% respectively. More tumours wereconsidered organ confined by the reviewer and causes fordiscrepancies were e.g. the automatic assignment by localpathologists of surgical margin positive cases of pT3 category. Reviewpathology of surgical margins was a stronger predictor of biochemicalrecurrence than local pathology (HR=2.16, P=0.0002 versus HR=1.08p>0.1). A multivariate prognosis model in the control arm showed thatGleason sum, margin positivity assessed by the review pathologistand post operative PSA value (> 2 ng/ml vs.

three strongest predictors of biochemical PFS. A prognosticclassification could be derived from the model, that was predictive oftreatment benefit (P = 0.04) and suggested that patients with Gleasonscore > 7, positive margins and positive post-operative PSA benefitmost from post-operative irradiation.Conclusions: Review of radical prostatectomy specimen shows aremarkably low agreement for extracapsular extension and for marginstatus. Gleason score (after review), margin status (after review), andpost-operative PSA are the strongest predictors of outcome andradiotherapy benefit after radical prostatectomy.VAN DER KWAST T., COLLETTE L., VAN POPPEL H., VAN CANGH P.,VEKEMANS K., DAPOZZO L., BOSSET J.F., KURTH K.H., SCHRODERF.H., BOLLA M.: Impact of pathology review of stage and margin statusof radical prostatectomy specimens (EORTC trial 22911). VirchowsArch, 2006; 449(4): 428-434.Pathological staging and surgical margin status of radicalprostatectomy specimens are next to grading the most importantprognosticators for recurrence. A central review of pathological stageand surgical margin status was performed on a series of 552 radicalprostatectomy specimens of patients, participating in the EuropeanOrganisation for Research and Treatment of Cancer trial 22911.Inclusion criteria of the trial were pathological stage pT3 and/orpositive surgical margin at local pathology. All specimens were totallyembedded. Data of the central review were compared with those oflocal pathologists and related to clinical follow-up. Although a highconcordance between review pathology and local pathologists existedfor seminal vesicle invasion (94%, K =0.83), agreement was much lessfor extraprostatic extension (57.5%, K =0.33) and for surgical marginstatus (69.4%, K=0.45). Review pathology of surgical margin statuswas a stronger predictor of biochemical progression-free survival inunivariate analysis [hazard ratio (HR) = 2.16 and p = 0.0002] thanlocal pathology (HR=1.08 and p > 0.1). The review pathologydemonstrated a significant difference between those with and withoutextraprostatic extension (HR = 1.83 and p = 0.0017), while localpathology failed to do so (HR = 1.05 and p > 0.8). The observationssuggest that review of pathological stage and surgical margin ofradical prostatectomy strongly improves their prognostic impact inmultiinstitutional studies or trials.156

VANDE WALLE J.G.J., BOGAERT G.A., MATTSSON S., SCHURMANS T.,HOEBEKE P., DEBOE V., NORGAARD J.P.: A new fast-melting oralformulation of desmopressin: a pharmacodynamic study in childrenwith primary nocturnal enuresis. BJU International, 2006; 97(3): 603-609.Objective: To determine the pharmacodynamic properties of a neworal lyophilisate formulation of desmopressin (in single doses of 30,60, 120, 240, 360 or 480 microg) in children with known primarynocturnal enuresis (PNE) and thus identify those dosages that couldprovide a duration of action corresponding to a typical length of nighttimesleep in children with PNE; additional objectives were todetermine the safety and tolerability of desmopressin in thispopulation.Patients and methods: Children with PNE (mean three or more wetnights/week), aged 6-12 years, were randomized into a double-blind,placebo-controlled study. An overhydration technique was usedbefore dosing to suppress endogenous vasopressin production andthereby ensure that any antidiuresis could be attributed to treatment.Dosing with desmopressin or placebo occurred when urinaryproduction was >0.13 mL/min/kg. Urinary volume, osmolality andduration of urinary-concentrating action (above three threshold levels:125, 200 and 400 mOsm/kg) were determined as endpoints.Results: All 72 participants receiving desmopressin had apharmacodynamic response to the drug, while there was no change inurinary output in the 12 placebo-treated patients. There was a clearrelationship between desmopressin dose and duration of action andosmolality during action, although the three highest-dose groups hadsimilar results. The mean duration of action of desmopressin at thelowest osmolality threshold level was 3.6-10.6 h, according to dose;for the highest threshold, the values were 1.3-8.6 h.Conclusion: Desmopressin, as the oral lyophilisate, causes a markeddecrease in urinary output in hydrated children with PNE. A smalldose range (120-240 microg) is likely to control diuresis for a periodcorresponding to a night's sleep (7-11 h) in most children with PNE.However, some patients might require a higher dose to obtainantidiuresis for the complete night.VAN POPPEL H.: Management of the urethra in the cystectomy patient.In: Textbook of bladder cancer. Edited by: S.P.Lerner, M.P. Schoenberg,C.N. Sternberg, 2006; 515-524.Over the past 10 years, the indications for urethrectomy at the time ofcystectomy have undergone substantial modification. While years ago157

a prophylactic urethrectomy was performed in many patients withcutaneous diversions, it has become clear that only patients withinvasion from transitional cell carcinoma (TCC) at the level of theprostatic urethra or bladder neck have a substantial risk of developingsubsequent urethral recurrence. Since the introduction of bladderreplacement procedures, the indications for prophylactic urethrectomyhave become more and more restricted. The pre- or intraoperativeassessment of the prostatic urethra in males and of the bladder neckin females is the most important issue determining appropriatemanagement of the urethra in patients with bladder cancer.VAN POPPEL H.: La cistectomía en el tratamiento del cáncer superficialde vejiga. In: Tumores vesicales superficiales. Editors: J. Vicente, R.G.Chechile, J. Salvador, 2006; 191-200.VAN POPPEL H., JONIAU S., BOGAERT G.: Prophylaktischepräpubische Urethrektomie. In: Standardoperationen in der Urologie.Herausgegeben von Peter Albers, Axel Heidenreich, Unter Mitarbeit vonHerbert Leyh, Georg Thieme Verlag, 2006, 290-296.Die prophylaktische Urethrektomie wird im Rahmen der radikalenZystoprostatektomie bei muskelinfiltrativem Harnblasenkarzinom oderCarcinima in situ und Beteiligung der prostatische Urethra zurVermeidung eines lokoregionären Harnröhrenrezidives durchgeführt.In der überwiegenden Zahl der Fälle wird von den Operateuren derperineal Zugang favorisiert, der einde Steinschnittlage mit zusätzlicherperinealer Schnittführung notwendig macht. Der Nachteil dieserOperationstechnik ist nicht nur in einer Verlängerung des ohnehinzeitintensiven operativen Eingriffes zu sehen, sondern vor allenDingen in den signifikanten postoperativen Schmerzen, die denPatienten von einer frühzeitigen Mobilisation abhalten können unddamit das Risiko thromboembolischer Komplikationen deutlicherhöhen. Bereits 1998 wurde die hier beschrieben Technik derweniger zeitintensiven und komplikationsarmen Urethrektomiebeschrieben.VAN POPPEL H., SIEMER S., LAHME S., ALTZIEBLER S., MACHTENS S.,STROHMAIER W., WECHSEL H.W., GOEBELL P., SCHMELLER N.,OBERNEDER R., STOLZENBURG J.U., BECKER H., LUFTENEGGER W.,TETENS V., JONIAU S.: Kidney tumour resection with use of tachosil ashaemostatic treatment. Eur. Urol. Suppl., 2006; 5(2): 180 (630).158

Introduction & Objectives: Control of haemorrhage during andfollowing nephron sparing surgery remains a challenge, despite theavailability of several treatment modalities. The objective of thepresent study was to evaluate a new ready to use and a traumaticagent, TachoSil*, as haemostatic adjunct treatment in kidney surgery.Material & Methods: 185 patients scheduled for resection of smallkidney tumours were included at 13 centres between Sept. 2002 andOct. 2004. All patients were Caucasian with a mean age of 63 years,mean BMI of 27,6 kg/m², 64% male and 36% female. Tumourresection was followed by primary haemostatis of major vessels bysuturing and ligation. The patients were then randomised (1:1) toeither TachoSil* or standard suturing for secondary haemostasis.TachoSil* is a fixed combination of fibrinogen and thrombin on acollagen sponge patch. The primary endpoint, time to haemostasis,was analysed by a log-rank test. The secondary endpoints, proportionof patients with haemostasis, was analysed by a log-rank test. Thesecondary endpoints, proportion of patients with haemostasis ≤ 10min and haematoma detected by ultrasonography 2 days aftersurgery, were analysed by the Cochran-Mantel-Haenszel and theMann-Whitney test, respectively. The surgeons rated the usefulnessof trial treatments by 5 point scales.Results: TachoSil* was significantly superior to standard suturing witha mean (median) time to haemostasis of 5.3 (3.0) and 9.5 (8.0) min,respectively (p

VAN POPPEL H., VEKEMANS K., DA POZZO L., BONO A., KLIMENT J.,MONTIRONI R., DEBOIS M., COLLETTE L.: Radical prostatectomy forlocally advanced prostate cancer: results of feasibility study (EORTC30001). Eur. J. Cancer, 2006, 42(8): 1062-1067.The aim of this open, non-randomised, 2-stage feasibility study was todetermine whether radical prostatectomy (RP) was safe and couldprovide cure for good prognosis patients with clinical T3 prostatecancer, in a multicentre setting. Cure was defined as a 3 months postoperativeof undetectable serum PSA in combination with thepresence of pathologically negative margins in the surgical specimen.Forty patients were enrolled of whom 38 were eligible. Six patients (5pN+ and 1 pNx) did not meet the inclusion criteria and were excludedleaving 32 evaluable pN0 patients of whom 19 (59.4%, SE=4.26)achieved a complete response (CR) and in whom only two serioustoxic events (STEs) were observed. The results of the first phase ofthe study passed the toxicity criteria (

VAATHEELKUNDEBLADT O., MALEUX G., HEYE S., VANBECKEVOORT D., NEVELSTEENA.: Progressive growth of a pelvic collection five years afterendovascular aneurysm repair: an atypical presentation of anasymptomatic contained rupture. J. Vasc. Surg., 2006; 43(1): 172-176.We report a case of an unusual and late presentation of anasymptomatic contained rupture after modular stent-graft implantationto treat an aortobiiliac aneurysm. Follow-up computed tomography(CT) scans 4 and 5 years after endovascular aneurysm repair showeda homogeneous, nonenhancing, but clearly growing, pelvic collection.CT-guided drainage of the collection was performed, and cultures ofthe evacuated brown fluid were negative for any infection. Control CTscan after drainage showed a complete collapse of both the collectionand the previously excluded iliac aneurysms. A direct communicationbetween the sterile pelvic collection and the excluded iliac aneurysmwas suggested on this CT imaging and confirmed afterwards bysurgery. From these imaging and surgical findings, this pelviccollection can be considered as an atypical presentation of anasymptomatic contained rupture of the excluded aneurysm.BONNEFOY A., DAENENS K., FEYS H.B., DE VOS R., VANDERVOORTP., VERMYLEN J., LAWLER J., HOYLAERTS M.F.: Thrombospondin-1controls vascular platelet recruitment and thrombus adherence in miceby protecting (sub)endothelial VWF from cleavage by ADAMTS-13.Blood, 2006; 107(3): 955-964.The function of thrombospondin-1 (TSP-1) in hemostasis wasinvestigated in wild-type (WT) and Tsp1-/- mice, via dynamic plateletinteraction studies with A23187-stimulated mesenteric endotheliumand with photochemically injured cecum subendothelium. Injectedcalcein-labeled WT platelets tethered or firmly adhered to almost allA23187-stimulated blood vessels of WT mice, but Tsp1-/- plateletstethered to 45% and adhered to 25.8% of stimulated Tsp1-/- vesselsonly. Stimulation generated temporary endothelium-associatedultralarge von Willebrand factor (VWF) multimers, triggering plateletstring formation in 48% of WT versus 20% of Tsp1-/- vessels. Injectionof human TSP-1 or thrombotic thrombocytopenic purpura (TTP)patient-derived neutralizing anti-ADAMTS13 antibodies corrected the161

defective platelet recruitment in Tsp1-/- mice, while having a moderateeffect in WT mice. Photochemical injury of intestinal blood vesselsinduced thrombotic occlusions with longer occlusion times in Tsp1-/-venules (1027 +/- 377 seconds) and arterioles (858 +/- 289 seconds)than in WT vessels (559 +/- 241 seconds, P < .001; 443 +/- 413seconds, P < .003) due to defective thrombus adherence, resulting inembolization of complete thrombi, a defect restored by both humanTSP-1 and anti-ADAMTS13 antibodies. We conclude that in a shearfield, soluble or local platelet-released TSP-1 can protect unfoldedendothelium-bound and subendothelial VWF from degradation byplasma ADAMTS13, thus securing platelet tethering and thrombusadherence to inflamed and injured endothelium, respectively.DANNEELS M.I.L., VERHAGEN H.J.M., TEIJINK J.A.W., CUYPERS P.,NEVELSTEEN A., VERMASSEN F.E.G.: Endovascular repair for aortoentericfistula: a bridge too far or a bridge to surgery? Eur. J. Vasc.Endovasc. Surg., 2006; 32(1): 27-33.Purpose: To review our experience of endovascular treatment ofaorto-enteric fistula (AEF).Methods: Between March 1999 and March 2005, 15 patients in fiveuniversity and teaching hospitals in Belgium and The Netherlandswere treated for AEF by endovascular repair. Twelve (80%) weremale. The mean age was 67 years. Thirteen (87%) had had previousaortic or iliac surgery, 1.7-307 months before. All patients showedclinical or biochemical signs of bleeding. Eight (53%) were in shock,five (33%) had systemic signs of infection. Eight (53%) patients weretreated in an emergency setting. Ten (67%) were treated with anaortouniiliac device, three (20%) with an aortobiiliac device, one with atube graft and one with occluders only. All patients received antibioticspostoperatively for a prolonged period of time.Results: All AEF were successfully sealed, the 30-days mortality wasnil. Mean hospital stay was 20 (2-81) days. One patient died 2.7months later of postoperative complications, one died of lung cancer.Until now, there are no signs of reinfection in four (27%) patients(mean follow-up 15.7 (1-44) months). However, reinfection orrecurrent AEF occurred in nine (60%) patients after 9.5 (0.61-31)months. Seven patients were reoperated successfully, two patientsdied after reintervention.Conclusion: Endovascular sealing of AEF is a promising technique,which provides time to treat shock, local and systemic infection, andco-morbidity. This creates a better situation to perform open repair inthe future with possibly better outcome. Danger of reinfection remainshigh. Endovascular sealing of AEF should, therefore, be seen as abridge to open surgery when possible.162

FOURNEAU I., SABBE T., DAENENS K., NEVELSTEEN A.: Hand-assistedlaparoscopy versus conventional median laparotomy foraortobifemoral bypass for severe aorto-iliac occlusive disease: aprospective randomised study. Eur. J. Vasc. Endovasc. Surg., 2006; 32:645-650.Objectives: To demonstrate that hand-assisted laparoscopy foraortofemoral bypass for severe aorto-iliac occlusive disease reducesmorbidity with earlier recovery of bowel function and shorter inhospitalstay.Design: Randomised controlled trial.Materials and methods: Thirty-six consecutive patients with severeaorto-iliac occlusive disease (TASK C/D) without history of majorabdominal surgery necessitating an aortobifemoral bypass wererandomised between a hand-assisted laparoscopic (HALS) approachand a conventional medial laparotomy. Operative data, early recoverydata, quality of life and vascular outcome were analysed.Results: No significant differences in operative data were found. Fluidand solid diet were resumed earlier (28.8 hrs vs. 76.9 hrs; p=0.016)(45.6 hrs vs. 105.6 hrs; p=0.02) and in-hospital stay was shorter (7.5vs. 8.9 days; p=0.005) in the HALS group. Six weeks post-operativelysocial functioning measured by the SF-36 survey score was better inpatients randomised to HALS (p=0.023).Conclusions: HALS is a less invasive approach for aortofemoralbypass.GODDEERIS K., DAENENS K., MOULIN-ROMSEE G., BLOCKMANS D.:Chronic-contained rupture of an infected aneurysm of the abdominalaorta due to Listerio monocytogenes. Nederlands J. Med., 2006; 64(3):85-87.We report a case of chronic-contained rupture of an infectedaneurysm of the abdominal aorta, from which Listeria monocytogeneswas cultured. The diagnosis of rupture and retroperitoneal mass wasmade by computed tomography, whereas FDG -PET diagnosedvessel wall inflammation. The infectious nature only became apparentat surgery.HASSEN-KHODJA R., FEUGIER P., FAVRE J.P., NEVELSTEEN A.,FERREIRA J.: Outcome of common iliac arteries after straight aortictube-graft placement during elective repair of infrarenal abdominalaortic aneurysms. J. Vasc. Surg., 2006; 44(5): 943-948.163

Purpose: To determine the relative rates of common iliac artery (CIA)expansion after elective straight aortic tube-graft replacement ofinfrarenal abdominal aortic aneurysms (AAA).Methods: Five participating centers in this 2004 study entered patientsthey had managed by an aortoaortic tube graft for elective AAA repair.The procedures took place between January 1995 and December2003. Postoperative computed tomography (CT) scans were obtainedfor all patients in 2004 to assess changes in CIA diameter.Measurements on preoperative and postoperative CT scans were allmade at the same level using the same technique.Results: Entered in the study were 147 patients (138 men, 9 women)with a mean age of 68 years. Mean follow-up from aortic surgery toverification of CIA diameter on the postoperative CT scan was 4.8years. Mean preoperative CIA diameter was 13.6 mm vs 15.2 mmpostoperatively. No patient developed occlusive iliac artery diseaseduring follow-up. Three patients (2%) required repeat surgery duringfollow-up for a CIA aneurysm. The 147 patients were divided intothree groups based on preoperative CIA diameter shown in CT scan:group A (n = 59, 40.1%), both CIA were of normal diameter; group B(n = 53, 36.1%), ectasia (diameter between 12 and 18 mm) of at leastone CIA; group C (n = 35, 23.8%), an aneurysm (diameter >18 mm) ofat least one CIA. CIA diameter increased by a mean of 1 mm (9.4%)over 5.5 years in group A vs 1.7 mm (12.1%) over 4.3 years in groupB and 2.3 mm (12.7%) over 4.2 years in group C. The three patientswho required repeat surgery for a CIA aneurysm during follow-upwere all in group C. Four variables were associated with aneurysmalchange in CIA: initial CIA diameter, celiac aorta diameter on thepreoperative CT scan, a coexisting aneurysm site, and the follow-upduration.Conclusions: Tube-graft placement during AAA surgery is justifiedeven for moderate CIA dilatation ( or =25 mm enlarge more rapidly and warrantinsertion of a bifurcated graft during the same surgical session as AAArepair. The evolutive potential of CIA between 18 mm and 25 mm indiameter justifies a bifurcated graft when the celiac aorta diameter is>25 mm or the patient's life expectancy is > or =8 years.HEYE S., DAENENS K., MALEUX G., NEVELSTEEN A.: Stent-graft repairof a mycotic ascending aortic pseudoaneurysm. J. Vasc. Interv. Radiol.,2006; 17(11): 1821-1825.A 75-year-old woman with a history of coronary artery bypass surgerycomplicated by mediastinitis presented with hemoptysis and fever. Anenlarging pseudoaneurysm of the ascending aorta was found on164

computed tomography (CT) and magnetic resonance imaging. After abypass graft procedure for cerebral and cardiac protection, twoendoprosthetic cuffs, which are normally used for proximal abdominalaortic stent-graft extension, were positioned over thepseudoaneurysm neck via right carotid artery access. Blood culturesrevealed methicillin-sensitive Staphylococcus aureus, and antibiotictherapy was continued for 6 weeks. Follow-up CT imagesdemonstrated exclusion of the pseudoaneurysm with decrease in sizeover time. Endovascular stent-graft placement combined withantibiotic therapy may offer an alternative to surgery for themanagement of mycotic ascending aortic pseudoaneurysm.HILL M.D., MORRISH W., SOULEZ G., NEVELSTEEN A., MALEUX G.,ROGERS C., HAUPTMANN K.E., BONAFE A., BEYAR R., GRUBERG L.,SCHOFER J. for the MAVErlC International Investigators: Multicenterevaluation of a self-expanding carotid stent system with distalprotection in the treatment of carotid stenosis. Am. J. Neuroradiol., 2006;27(4): 759-765.Purpose Carotid artery stent placement may be limited by theembolization of atheromatous material. We evaluated the safety andfeasibility of the Medtronic Self-Expanding Carotid Stent (Exponent) incombination with the Medtronic Interceptor Carotid Filter System forthe treatment of carotid stenosis among patients at high risk for carotidendarterectomy.Methods: Patients at high risk for carotid endarterectomy butamenable to percutaneous treatment with stent placement wereenrolled. Clinical follow-up was performed at 30 days and 6 and 12months postprocedure. The National Institutes of Health Stroke Scalewas assessed before and within 3 days postprocedure and at 30 daysand 6 months postprocedure. Angiography was performed pre- andpostprocedure, and carotid duplex scans were performed at baselineand at 30 days and 6 months.Results: Fifty-two carotid procedures were performed in 51 patients(mean age, 69 years; 84% of patients were men). The major adverseevent (MAE) rate (death, stroke, and myocardial infarction [MI]) at 30days was 5.9%: 2 strokes and a single death from periprocedural MI.MAE rates after 6 and 12 months were 5.9% and 11.8%, respectively.The delivery success rate was 94.2% (49/52) for the Interceptor FilterSystem and 95.9% (47/49) for the Exponent Stent. The meandiameter stenosis of the target lesion was reduced from 62.4%preprocedure to 21.2% postprocedure.Conclusion: High delivery success rates were achieved with a low rateof MAE (death, stroke, or MI) in a high-risk population. Treatment ofcarotid artery disease with the Exponent Carotid Stent combined with165

distal protection from the Interceptor Filter System is effective andsafe.MALEUX G., DEMAEREL P., VERBEKEN E., DAENENS K., HEYE S., VANSONHOVEN F., NEVELSTEEN A., WILMS G.: Cerebral ischemia afterfilter-protected carotid artery stenting is common and cannot bepredicted by the presence of substantial amount of debris captured bythe filter device. Am. J. Neuroradiol., 2006; 27(9): 1830-1833.Purpose: Protected carotid artery stent placement is currently underclinical evaluation as a potential alternative to carotid endarterectomy.The current study was undertaken to determine the incidence of newischemic lesions found on diffusion-weighted MR imaging (DWI) innonselected patients after protected carotid artery stent placementusing a filter device and to determine the potential relationshipbetween these new ischemic lesions and the presence or absence ofa clear amount of debris captured by the neuroprotection filter device.Materials and methods: A nonrandomized cohort of 52 patients (40men, 12 women) presenting with carotid occlusive disease underwentprotected carotid artery stent placement using a filter device. DWIobtained 1 day before stent placement was compared with thatobtained 1 day after stent placement. In addition, the macroscopic andmicroscopic analysis of debris captured by the filter device during thecarotid stent placement procedure was assessed.Results: Neuroprotected carotid stent placement was technicallysuccessful in all 53 procedures but was complicated by a transientischemic attack in 3 patients (5.6%). In 22 patients (41.5%), newischemic lesions were found on DWI, and in 21 filter devices (39.6%),a substantial amount of atheromatous plaque and/or fibrin was found.No clear relationship between the presence of debris captured by thefilter device and new lesions detected by DWI was found (P = .087;odds ratio 3.067).Conclusion: Neuroprotected carotid artery stent placement will notavoid silent cerebral ischemia. Systematic microscopic analysis ofdebris captured by the filter device has no predictive value forpotential cerebral ischemia after carotid artery stent placement.MEESTER D.J., VAN MUISWINKEL K.W., AMEYE F., FRANSEN H.,STOCKX L., MERCKX L., NEVELSTEEN A.: Endovascular treatment of aureteroiliac fistula associated with ureteral double J-stenting and anaortic-bifemoral stent graft for an inflammatory abdominal aorticaneurysm. Ann. Vasc. Surg., 2006; 20: 408-410.166

We report an unusual case of a ureteroiliac fistula due to prolongedureteral stenting for hydronephrosis combined with an aortic-bifemoralstent graft in an inflammatory abdominal aortic aneurysm (AAA),treated with an endovascular stent graft. In a 77-year-old man ureteralJ-stents were placed for bilateral hydronephrosis due toretroperitoneal fibrosis caused by an inflammatory AAA. Theaneurysm was treated with an endovascular aortic-bifemoral stentgraft. Three months later, the patient suffered from severehypovolemic shock. Emergency angiography showed a fistulabetween the right ureter and the right common iliac artery just distal tothe right leg of the stent graft. The ureteroiliac fistula was treated witha wall graft (10F). The patient recovered well and remainedasymptomatic. Ureteroiliac fistula remains a rare complication ofureteral stenting. Several risk factors have been described before.This case emphazes the increased risk of an arterial-ureteral fistuladue to an indwelling ureteral stent and an inflammatory AAA,especially in combination with an additional stent graft for thisinflammatory AAA.NEVELSTEEN A.: The role of TASC classification in managing patientswith aorto-iliac disease. In: Vascular Surgery Highlights 2005-2006, Editor:Alun H. Davies, Health Press, 2006:pp. 57-64.In 2000, the TransAtlantic Inter-Society Consensus (TASC) WorkingGroup published a historical document on the treatment of peripheralarterial disease (PAD). This classified aorto-iliac disease into fourcategories based on severity, and recommended that minor lesions(TASC A) should be treated by endovascular means, and extensivelesions (TASC D) by open surgery. No consensus was reached on thetreatment of “intermediate lesions” (TASC B and C); more evidencewas needed in order to recommend either endovascular techniques oropen surgery for these. Over the last 5 years, great developments inboth open surgery and, particularly, endovascular treatment havemeant that the TASC document might be reconsidered. This issuewas discussed at length in a multidisciplinary session betweensurgeons, interventionalists and radiologists at the Charing CrossMeeting in May 2005.NEVELSTEEN A., DAENENS K., FOURNEAU I.: Trauma of the thoracicaorta. In: European Manual of Medicine. Vascular Surgery. Eds.: LiapisC.D., Balzer K., Benedetti-Valentini F., Fernandes e Fernandes J., Springer,2006: 299-314.167

Introduction: Thoracic aortic trauma is a relatively rare but catastrophicevent. It may be secondary to several mechanisms: it can be seenafter penetrating or iatrogenic trauma. The most frequent causehowever is blunt trauma and this chapter will focus on this specificaetiological mechanism. Most of the patients have sufferedautomobile-related trauma and the associated mortality remainsenormous. Therefore, thoracic aortic trauma is identified in theadvanced trauma life support (ATLS) franchise as one of the eight“life-threatening chest injuries” in the so-called secondary survey.Diagnosis is based on clinical suspicion and technical examinationssuch as spiral computed tomography, angiography andtransoesopagheal echocardiography. Classic treatment consists ofopen surgery, but endovascular stent-grafting is becoming more andmore popular.NEVELSTEEN A., DAENENS K., FOURNEAU I.: Inflammatory aneurysmsof the abdominal aorta. . In: European Manual of Medicine. VascularSurgery. Eds.: Liapis C.D., Balzer K., Benedetti-Valentini F., Fernandes eFernandes J., Springer, 2006: 331-342.Introduction: The indications of abdominal aortic aneurysm repair havebeen well defined in the UK Small Aneurysm Trial. Electivereconstruction can be offered with an acceptable morbidity andmortality rate. Occasionally however, the vascular surgeon isconfronted with certain pathological or anatomical variants, which mayincrease the risk of the operation. In this chapter a distinct pathologicaland anatomical entity is described, namely the inflammatory aneurysmof the abdominal aorta, which is characterized by a very thick wall anda dense fibrotic reaction enveloping the aneurysm and thesurrounding structures, leading to ureteral and even caval veinobstruction in a significant percentage of the cases.OURY C., DAENENS K., HU H., TOTH-ZSAMBOKI E., BRYCKAERT M.,HOYLAERTS M.F.: ERK2 activation in arteriolar and venular murinethrombosis: platelet receptor GBlb vs. P2X 1 . J. Thromb. Haemost., 2006;4(2): 443-452.The functional significance of extracellular signal-regulated kinase 2(ERK2) activation was investigated during shear induced humanplatelet aggregation (SIPA) in vitro and during shear controlledthrombosis in vivo in intestinal arterioles and venules of wild type (WT)and transgenic (TG) mice with platelet-specific overexpression ofhuman P2X(1) (TG). In SIPA, ERK2 was rapidly phosphorylated168

during GPIb stimulation, its activation contributing to SIPA for 50%,independently of P2X(1) regulation. Thrombotic occlusion of injuredarterioles occurred considerably faster in TG (4.3 +/- 2.3 min) than inWT (38 +/- 8 min) arterioles, but occlusion times in TG (19 +/- 12) andWT (48 +/- 4.5 min) venules differed less. Both the alphabeta-meATPtriggered desensitization of platelet P2X(1), as well as P2X(1)antagonism by NF279 or NF449 prolonged mean occlusion to about75 min in WT and 65 min in TG arterioles, but venular occlusion timeswere less affected. Preventing ERK2 activation by U0126 prolongedocclusion times in TG (41 +/- 10 min) and WT (51 +/- 17) arteriolesmore than in TG (46 +/- 5 min) and WT (56 +/- 6 min) venules,uncovering a role for ERK2 in shear controlled thrombosis.Antagonism of GPIb by a recombinant murine von Willebrand factor(VWF)-A1 fragment prolonged occlusion times to comparable values,ranging from 55 to 58 min, both in TG and WT arterioles and venules.Further inhibition strategies, combining VWF-A1, U0126 and NF449 inWT and TG mice and resulting in occlusion in various time windows,identified that inhibition by VWF-A1 largely abrogated the ERK2contribution to thrombosis. In conclusion, P2X 1 and ERK2 bothparticipate in shear stress controlled thrombosis, but ERK2 activationis initiated predominantly via GPIb-VWF interactions.169