CLAN Congress in Review and the History and Future of Neurosurgery in Latin America: A Colombian Perspective
XXXVIII CLAN Congress in Bolivia
Bolivian neurosurgeons were proud to welcome the 38th Congress of Latin American Neurosurgery to Santa Cruz de la Sierra, Bolivia, Nov. 9–14, 2018. This was the first time that Bolivia hosted the Congress of the Federación Latinoamericana de Sociedades de Neurocirugía (FLANC), the Latin American continental society. It was also the first time that the Congress featured a meeting of women in neurosurgery.
The American Association of Neurological Surgeon (AANS) participated in the meeting under the leadership of AANS President, Shelly D. Timmons, MD, PhD, FAANS, FACS, and Jacques J. Morcos, MD, FAANS. For his contributions to neurosurgery in Latin America, AANS member Raymond Sawaya, MD, FAANS, was presented with the FLANC Medal of Honor by then FLANC President José Marcus Rotta, MD..
Attendees were welcomed to Santa Cruz by Bolivian neurosurgeon and Congress president, Gueidar Salas Ferrufino, MD, who successfully orchestrated the nearly week-long meeting. The meeting concluded with the transition of leadership to Claudio G. Yampolsky, MD, IFAANS, from Buenos Aires, Argentina, who succeeds Dr. Rotta as 2018-2020 FLANC President.
FLANC has hosted congresses in Latin America since 1945. The next CLAN Congress, Nov. 15-19, 2020, will be held in Guayaquil, Ecuador can celebrates the Congress’s 75 year. It will be closely followed by the World Federation of Neurological Societies (WFNS) Congress, where Colombia and all of Latin America will welcome neurosurgeons from around the world to Bogota, Colombia, Aug. 29–Sept. 3, 2021, for the XVII WFNS World Congress.
There is much to look forward to in Latin America in the next couple of years. History and Future of Colombian Neurosurgery
Birth of Columbian Neurosurgery
The birth of Colombian neurosurgery began with a a partially successful operation on a patient that most likely had a glioma. Doctor Tomás Quevedo Restrepo performed the surgical intervention at the beginning of 1894 in Medellín. The patient was a 35-year-old male suffering from seizures. Borax had been prescribed, as was customary at the time “nevertheless, the illness continued its course, causing progressive hemiparesis and aphasia”.
Dr. Quevedo examined the patient and unequivocally diagnosed a “left cerebral tumor, in all probability a glioma”, so he recommended surgery. However, as a result of the differing opinions among his colleagues and the indecision of the family, the patient’s symptoms progressed to complete hemiplegia and an altered mental status. In the end, due to the patient’s decline as predicted by Dr. Quevedo, the recommendation of surgical intervention was accepted. Dr. Quevedo performed the surgery with the collaboration of Dr. Londono and Dr. A. Pelaez “under rigorous aseptic technique and following modern methods.”
This procedure was the first craniotomy with immediate success,resulting in an improvement in extremity weakness and aphasia. Despite this intervention, the patient died several days later. During the autopsy, an infiltrating glioma affecting the left motor and speech area was discovered. According to the autopsy records “a significant mass effect by the tumor was present as well.” Dr. Quevedo’s accuracy in regard to both the topography of the brain lesion and the seriousness of the disease was remarkable. It should be noted that Dr. Quevedo completed his studies in 1871 in Paris under the direction of Dr. Charcot, who advocated for use of ophthalmoscope to help diagnose intracranial hypertension.
By many accounts, the excision of the left frontal glioma by Dr. Quevedo is regarded to be the first neurosurgical intervention conceived and carried out successfully in Colombia. Three fundamental principles were applied:
- A meticulous examination resulting in an accurate clinical diagnosis that indicated the precise localization of the lesion in the brain prior to the surgical intervention. As mentioned above, the only ancillary equipment available at that time was the ophthalmoscope and a reflex hammer. Besides those two tools, the diagnosis was based on signs and symptoms as seen within the framework of physician’s knowledge of physiopathology and anatomy.
- Surgical intervention confirming the tumor diagnosis and resulting in partial tumor removal.
- Partial and temporary improvement of the patient’s symptoms as a result of the surgery.
The fact that the patient died within days of the operation doesn’t negate this surgical intervention as a milestone in Colombian neurosurgery. The excellent physiopathological and clinical understanding of the patient’s neurosurgical condition at such an early time in history is remarkable.
This successful brain tumor removal is also believed to be the first of its kind in Latin America. It should be noted that during the same year in Bogotá, Professor Julio Z. Torres removed a brain tumor resulting in an “immediate cure”, although, the patient did eventually die due to the recurrence of the tumor.
It is also important to mention the surgeries performed by Dr. Pompilio Martínez and Dr. R. Posada as “Psychosurgery pioneers.” Dr. Martínez successfully operated on a number of patients suffering from Jacksonian Epilepsy. He completed 12 craniotomies for different diseases between 1900 and 1906, 10 of them with satisfactory results. Overall, many similar operations took place in Medellín, Bogotá and Manizales as well as in Barranquilla where patients were treated for trauma, epilepsy, infections and brain tumors. Overall, the bulk of these procedures were traumatic or infectious in nature. This type of surgery continued in Colombia until the end of World War II.
Dr. Juan Bautista Montoya who was a disciple of Doyen in Paris performed the first periarterial sympathectomy in Colombia in 1925. This procedure, created by Jabowlai in 1900 and popularized by Leriche, was designed for pain control and epilepsy treatment. One of Dr. Montoya’s disciples Dr. Alberto Saldarriaga Velez, was one of the strongest advocates of this surgical intervention in Colombia. Additionally, Dr. Montoya performed several trigeminal rhizotomies. These procedures were reported by Dr. Bonilla Naar in 1923 in his thesis.
Dr. Alfonso Castro and Dr. Toro Echeverry performed the first spinal laminectomy in Medellín in 1920. The operation succeeded in the decompression of a bullet resulting in spinal cord compression. They are also credited with having performed the first cubital nerve neurorrhaphy in Colombia.
In 1903, Dr. Avelino Saldarriaga reported that two patients were operated on for congenital spinal lesions and recovered from motor deficits; however, their bladder dysfunction remained.
Dr. Montoya y Flórez brought the first x-ray unit to Medellín only six years after its invention by Roentgen. Nevertheless, according to the first reports in 1929, it was only used in Antioquia to study cranial trauma. In 1919, Walter Dandy introduced the pneumoencephalography, which was very useful for localizing intracranial lesions. Shortly afterwards contrast media was introduced. In 1922, Sicard and Forestier used iodized oils in order to observe the subarachnoid spaces and the ventricular system (myelography); however, the visualization of the ventricular system was felt to be suboptimal.
In 1927, Dr. Manual Balado of Argentina injected contrast material [(lipiodol) directly into the ventricles allowing a better imaging resolution. In fact, lesions or deformations of the ventricles, including the sylvian aqueduct, were easily discernible.
In 1947, Dr. Ernesto Bustamante Zuleta, one of the modern Colombian neurosurgery pioneers, presented his thesis entitled Iodoventriculography in the Diagnosis of Intracranial Tumors (Yodoventriculografia en el diagnostico de tumors intracraneanos) for his medical degree at the University of Antioquia. Professor Gil J. Gil was a member of the thesis committee. This interesting work demonstrated the use of this technique in 13 patients with “infectious tumorous lesions” and was instrumental for the diagnosis of cysticercosis at that time.
III. Beginning of the North American Influence and Establishment of Neurosurgery as a Specialty
By the end of World War I, the North American leadership in the medical field was uncontested. Colombian physicians were very interested in receiving training in the U.S.. The first Colombian neurosurgeon trained in the U.S. was Dr. Álvaro Fajardo Pinzón who was trained by Stokey and Scarf at the Neurological Institute of New York and at the Mayo Clinic in Rochester with Adson and Craye. He returned to Bogotá in 1941 and worked for the San José and San Juan de Dios hospitals, performing the first pneumoencephalography and several neurosurgical procedures.
Later, Dr. Mario Camacho Pinto, who was trained in New York, returned to Bogotá in 1945 and was appointed “neurosurgeon” at the Hospital San Juan de Dios. In 1951, he was appointed Professor of Neurosurgery at the Universidad Nacional. That same year he performed the first Colombian cerebral angiogram. Dr. Camacho carried out a variety of neurosurgical interventions, including the first frontal lobectomy performed in 1942. In 1961, Dr. Camacho Pinto was a founding member and the first president of the Colombian Neurological Society, which brought together all of the specialists in neurological sciences.
First Neurosurgery Departments
4.1. City of Bogotá
In 1950, upon the arrival of Professor Alejandro J. Jiménez Arango, the Universidad Nacional Neurosurgery Department, at the Hospital San Juan de Dios Universidad Nacional was created. He had been trained under Dr. Asenjo in Santiago de Chile and with Penfield in Montreal. Additionally, he completed a neurology fellowship at Mass General Hospital in Boston. It is noteworthy that in addition to the general neurosurgery room available at the Hospital San Juan de Dios, an operative room devoted to epilepsy surgery and equipped with intraoperative corticography was available.
In 1961, Dr. José Mora Rubio, who trained in Stockholm under Dr. Olivecrona, became the new chair after Dr. Alejandro Jiménez stepped down. Under Dr. Mora Rubio’s leadership, the neurosurgery department at the Universidad of Colombia became a neurosurgical center of excellence. Dr. Mora Rubio’s trainees went on to become neurosurgical leaders within the different regions of Colombian. In fact, Dr. Salomon Hakim, one of the faculty members at that time described and published on the Normal Pressure Hydrocephalus syndrome (NPH), based on the observation of three patients at the Hospital San Juan de Dios. In 1965, the results of Dr. Hakim’s seminal work were published in association with Raymond Adams in the Journal of Neurological Sciences. Subsequently, Dr. Hakim along with his son the engineer Carlos Hakim designed their world-renown programmable valve for the treatment of hydrocephalus.
4.2. City of Medellín
As in the Colombian capital Bogotá, the second most important city Medellín became another Colombian neurosurgery center of excellence under Dr. Ernesto Bustamante Zuleta’s leadership. Dr. Bustamante was trained in neurosurgery under Dr. Alfonso Asenjo in Santiago de Chile. He returned to Colombia between 1948-1949. Upon his return he created and conducted the neurology and neurosurgery service at the Hospital San Vicente de Paul in Medellín.
Dr. Bustamante performed the first of several neurosurgical procedures in Colombia such as the first aneurysm clipping in 1949, the first temporal lobectomy in 1953, the first hemispherectomy in 1954 and the first comisurotomy in 1966. . In 1969, Dr. Bustamante introduced the use of the microscope for neurosurgical interventions. Several generations of outstanding neurosurgeons trained under him.
Dr. Bustamante is undoubtedly an icon and pioneer for Colombian neurosurgeons. In addition to his unquestionable surgical skills, he is a hardcore clinician with a depth of knowledge in basic sciences. Dr. Bustamante has been an innovative, avant-garde neurosurgeon all his life.
4.3. Neurological Institute of Colombia
The Neurological Institute of Colombia was created in 1966. It was founded and directed by Dr. Jaime Gómez González in the city of Bogotá and associated with the Universidad Javeriana. This institute opened its doors in 1973 and gave a great boost to Colombian neurology and neurosurgery. The first CT and the first MRI performed in Colombia took place in this institution in 1977 and 1989 respectively. Unfortunately, it closed in 1996.
Colombian Neurosurgery Today
The current population of Colombia is 45.5 million and is served by approximately 500 neurosurgeons. There are 11 neurosurgery programs that graduate 19 neurosurgeons every year. Training consists of five years of post-graduate education. Six of these programs are offered through private institutions and five through public universities. In addition, these neurosurgery programs are concentrated in four major cities: Bogotá, Medellín, Cali and Cartagena.
The Executive Board of the WFNS chose the Asociación Colombiana de Neurocirugía to host the XVII World Congress of Neurosurgery in Bogotá, Colombia in 2021. In collaboration with recognized experts around the world, the association has been working tirelessly to organize an unforgettable neurosurgical meeting. The format of the meeting has been changed in order to be more interactive and inclusive. Main meeting sessions featuring the world’s leading neurosurgeons, scientists, writers and artists presenting the latest advances will be formatted in both morning and afternoon conferences. Participants will be able to vote and express their opinions during these discussions. Additionally, sessions with topics outside of neurosurgery have been added in order to make this a holistic international meeting.
To top it all off, attendees will enjoy incomparable fellowship amidst the varied and rich textures of Colombian music, art and gastronomy. The host city Bogotá is a thriving cosmopolitan area located in the heart of the Americas. It is home to the largest and most important gold museum in the world along with many other beautiful sights to see in and around the city. Moreore than 700 international destinations can access Bogotá and more than 96 countries do not require a visa to enter the country.
Please save the dates from Aug. 29-Sept. 3, 2021, and consider taking a few extra days of vacation to really experience all the country has to offer, from the UNESCO World Heritage Site in the old city of Cartagena to the Amazon jungle. Colombia is waiting for you.We look forward to seeing you in Bogotá, Colombia, in August of 2021.
Kranzler Chicago Review Course in Neurosurgery
Jan. 24-31, 2020; Chicago
46th Annual Richard Lende Winter Neurosurgery Conference
Jan. 31-Feb. 3, 2020; Snowbird, Utah
Third Annual Cedars Sinai Intracranial Hypotension Symposium
Feb. 8, 2020; Los Angeles
2020 Managing Coding and Reimbursement Challenges
Feb. 14-16, 2020; Las Vegas
13th Annual International Symposium on Stereotactic Body Radiation Therapy and Stereotactic Radiosurgery
Feb. 21-23, 2020; Lake Buena Vista, Fla.
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