Cement leakage during vertebroplasty: an underestimated problem?

Overall, vertebroplasty has a low complication rate. Nevertheless, severe complications can occur. The majority of these are related to cement extrusion. The rate of cement leakage is often obtained by X-ray, with only a single leak registration per vertebra. Detection rate of leaks in comparison with CT and inter-observer reliability for X-ray is, in large parts, unknown. We conducted this study to determine the value of fluoroscopy and X-ray used to detect cement leakage as compared to CT scans. Intraoperative findings in lateral fluoroscopy by the surgeon, and postoperative findings in X-rays by two orthopaedic surgeons, were compared with CT scans for the same study group. Multiple cement leakage was considered, and agreement rate was determined. The detection rate for leaks was 34% for lateral X-ray and 48% for lateral and AP view. Additional AP views only enhanced the detection of leaks in the segmental veins. The agreement rate between fluoroscopy/X-ray and CT scans ranged between 66% and 74%, while inter-observer reliability showed only fair agreement. The rate of cement leaks in vertebroplasty is high if multiple leaks are considered in CT scans. Detection rates using X-rays are low and complicated by only fair inter-observer agreement. Leaks in the basivertebral veins are frequently misinterpreted and can lead to severe complications. Therefore, CT scans should be obtained to calculate the exact leakage rate and to assess persistent or new pain occurring postoperatively.

Migration of the breast biopsy localization wire to the pulmonary hilus

There have been very few reports of severe complications accompanied by wire localization of breast lesions, such as transsection of the wire and wire migration to the extramammary sites. This is a report of wire migration into the pulmonary hilus demanding surgical removal.

Surgical treatment of a dislocated intraocular lens–capsular bag–capsular tension ring complex

We describe a surgical technique for managing late dislocation of an intraocular lens-capsular bag-capsular tension ring (IOL-CB-CTR) complex. Two 10-0 polypropylene sutures are placed transsclerally over and under the CTR through the anterior and posterior capsules to capture the CTR, which then is retracted and sutured through the sclera. The same maneuver is performed 180 degrees away. This simple, easy, effective procedure can be performed with a small corneal incision and does not require extraction of the IOL-CB complex. Although the CTR does not completely prevent IOL-CB dislocation, it provides the possibility of suturing the IOL-CB to the sulcus without replacing the IOL.

Scleral and iris fixation of posterior chamber lenses in the absence of capsular support

PURPOSE OF REVIEW

To review the methods described in the literature in the past year (from August 2003 to date).

RECENT FINDINGS

Techniques for scleral and iris suturing have proven safe and effective to fixate posterior chamber intraocular lenses and avoid the sight-threatening complications of anterior chamber lenses.

SUMMARY

Scleral and iris fixation have both become well-established effective means for stabilizing posterior chamber lenses in the lack of adequate capsular support.

Peritoneal dialysis access-related procedures by nephrologists

Traditionally the placement of a peritoneal dialysis (PD) catheter in a patient with end-stage renal disease (ESRD) has been accomplished by a surgeon and using general anesthesia. This approach often introduces delays in starting PD, incurs additional costs in utilizing an operating room as well as anesthesia services, and introduces the mortality risk associated with general anesthesia. Recent data have emphasized that interventional nephrologists can safely and successfully perform PD access procedures. In this context, operating room facilities and staff and anesthesia services are not required and catheter insertion can be performed in a procedure room using local anesthesia, thereby reducing costs and completely bypassing the mortality risk associated with general anesthesia. When performed by a nephrologist, the catheter insertion can be accomplished swiftly and dialysis therapy initiated in a timely manner. Once begun, the success of PD hinges on reliable and long-term access to the peritoneal cavity. Prospective randomized and nonrandomized studies have shown that PD catheters peritoneoscopically placed by nephrologists have fewer complications (infection, exit site leak) and longer catheter survival rates than those inserted surgically. Although PD offers a variety of advantages, it remains an underutilized form of renal replacement therapy. To counteract PD underutilization, at least two separate centers have demonstrated a positive impact on the growth of the PD population when catheter insertion is performed by nephrologists. This article presents PD access-related procedures currently performed by interventional nephrologists. Furthermore, some of the complicating issues (bowel perforation, catheter migration, prior abdominal surgery) related to PD catheter insertion and management are also discussed.

Retrieval of inflatable penile prosthesis reservoir from the bladder

We report a rare complication of a penile prosthesis reservoir removed from the urinary bladder in a patient with a history of radiation therapy and previous abdominal surgery. The reservoir was retrieved by open cystotomy 13 years after original placement.

Management of polypropylene mesh erosion after intravaginal midurethral sling operation for female stress urinary incontinence

The intravaginal midurethral sling operations have become a trend to treat female stress urinary incontinence. Cases of complications requiring surgical revision are rarely reported. We report on seven patients with complications necessitating surgery. Six patients with vaginal erosion were treated with transvaginal excision of migrated tape and fibrotic tissues around the vaginal wall, and one patient with bladder erosion was treated with suprapubic minimal laparotomy and transvaginal partial excision of the tension-free vaginal tape (TVT). The incidence of polypropylene mesh erosion was 1.1% in this study. All patients recovered well from our surgical intervention, except the bladder erosion patient who needed anticholinergic medication to treat postoperative urgency and urge incontinence.

[Broken part of IOL haptic as a cause of bullous keratopathy. Case report]

Presentation of the case of the patient in whom 1 year after penetrating keratoplasty a broken, free moving haptic part of the IOL within anterior chamber was found. In accordance to increases of pain and high likelihood of donor corneal flap damage decision about surgical removal of free haptic was undertaken. Finding of the broken part of IOL throw light on the cause of bullous keratopathy in this case.

Case: unusual migration of osteosynthetic material

The authors present a rare and unusual case of complication, migration of osteosynthetic material for stabilization, titanium rod, which was used for stabilization of comminutive fracture of the first lumbar vertebra. This rod migrated from the retroperitoneal space to the pleural cavity. The removal of this rod was carried out by videothoracoscopy.

Coronary embolization of a gauze fragment: A cautionary case report

A 44-year-old woman underwent fractional flow reserve (FFR) assessment of a stenosis of the left circumflex coronary artery. The FFR was within normal limits, however, shortly after leaving the catheterization laboratory the patient developed refractory angina. Repeat angiography demonstrated a new filling defect in the mid left anterior descending coronary artery. Aspiration thrombectomy was performed, and analysis of the effluent revealed a strand of gauze material with adherent thrombus. The gauze fiber was likely unknowingly injected with flush solution during FFR measurement. This previously unreported but potentially dangerous phenomenon underscores the importance of not using a single receptacle to hold moist gauze and saline flush solution, as is the practice in some catheterization laboratories.

[Capsule contraction as a cause of in-the-bag intraocular lens subluxation and simplified technique of IOL reposition]

Presentation of the case of the pseudophakic patient in whom 3 months after uncomplicated phacoemulsification severe capsule contraction syndrome, followed by equatorial capsule fibrosis, 240 degree zonular dialysis, and spontaneous in-the-bag intraocular lens subluxation, were observed. Consecutive surgical intervention consisting of simplified transscleral "free haptic" through the capsule fixation and additional plastic of phimotic capsulorrhexis allowed to restore the best corrected visual acuity to 20/25.

Late intestinal fistula formation after incisional hernia using intraperitoneal mesh

Enteric fistulas are a rare but serious complication following the repair of an incisional hernia using a prosthesis. We report the case of a 52-year-old man who developed an enterocolocutaneus fistula after incisional hernia repair with intra-abdominal polyester mesh. This case shows that one may want to avoid placing the parietal prostheses in direct contact with intestinal loops.

[Subhepatic abscess as a late complication of missed intraperitoneal gallstone after laparoscopic cholecystectomy]

Laparoscopic cholecystectomy is the treatment of choice in symptomatic cholelithiasis. Despite its many advantages over the conventional laparotomic approach, accidental perforation of the gallbladder with spilled stones and bile leakage is frequent during this procedure. Complications from missed gallstones are uncommon, although they can sometimes lead to severe consequences. Great effort must be made to achieve laparoscopic retrieval of all the gallstones missed into the peritoneal cavity and conversion to an open procedure should be used only in selected cases. We report a case of subhepatic abscess as a late complication of a missed gallstone during a previous laparoscopic cholecystectomy.

Successful Removal of Bovine Pericardium by Bronchoscope After Lung Volume Reduction Surgery

We report on a patient in whom, 10 months after lung volume reduction surgery, bovine material visibly migrated to the bronchial lumen. In this particular case, bronchoscopic treatment was successful. The patient remained well 12 months after such treatment. The report also suggests that the alternative use of absorbable material will reduce later postoperative complications.

Late problems at the proximal aortic neck: Migration and dilation

Migration is a late-term complication of endovascular aneurysm repair (EVAR) evidenced by downward slippage of the endograft. The etiology of migration may be inherent to problems with endograft fixation, although aortic neck dilation may also play a role. Devices with active fixation (ie, hooks and barbs) possess an additional mechanism of fixation and may better resist migration. Aortic neck dilation after EVAR is significant in a subset of patients and may be related to neck degeneration. Excessive oversizing of endografts may contribute to dilation and migration and is, therefore, not recommended. Migration should be treated when the overlap between the endograft and aortic neck is less than 10 mm or when associated with clinically significant events such as type I endoleak or aneurysm expansion. Failure to treat migration could lead to repressurization and subsequent rupture of the aneurysm.

Spontaneous dislocation of a phakic refractive lens into the vitreous cavity

A 36-year-old woman with high myopia had uneventful implantation of a phakic refractive lens (PRL) bilaterally. Two months postoperatively, the best corrected visual acuity (BCVA) in the right eye decreased to the preoperative level and the posterior chamber PRL disappeared from the anterior segment and was found lying in the vitreous cavity inferiorly. After lensectomy and pars plana vitrectomy, the PRL was removed through the initial clear corneal incision, improving the BCVA to 1.0. A zonular defect associated with high myopia, previously forgotten and unrecognized ocular trauma, or intraoperative manipulations may have resulted in the spontaneous dislocation of the PRL.

Management of porous polyethylene implant exposure in patients with retinoblastoma following enucleation

BACKGROUND AND OBJECTIVE

To report the features and the management of porous polyethylene implant exposure in patients with retinoblastoma following enucleation.

PATIENTS AND METHODS

The medical records of 33 patients (33 sockets) following enucleation and porous polyethylene implantation for retinoblastoma were reviewed.

RESULTS

The mean age at enucleation was 24 months (range, 2 to 85 months). The exposure rate was 33% (11 cases), and the mean time from enucleation to exposure was 15 months (range, 7 to 29 months). One case was resolved only by supportive management, and the remaining 10 were successfully treated with a scleral patch graft and maintained well during a mean follow-up of 15 months after surgical repair. There was no statistical evidence that age, gender, implant size, or chemotherapy had an effect on implant exposure.

CONCLUSIONS

Porous polyethylene implant exposure does not seem to be resolved by conservative management. We recommend early surgical management, such as scleral patch graft, as opposed to supportive management.

Silicone Posterior Chamber Phakic Intraocular Lens Dislocated into the Vitreous Cavity

PURPOSE

To report two highly myopic patients with silicone posterior chamber phakic intraocular lenses (Phakic Refractive Lens; CIBA Vision, Duluth, Ga) that luxated into the vitreous cavity without history of ocular trauma.

METHODS

Two patients with posterior chamber phakic intraocular lenses (PIOLs) that luxated into the vitreous cavity of the right eye were examined. Each eye underwent pars plana vitrectomy and removal of the posterior chamber PIOL under retrobulbar anesthesia.

RESULTS

Both patients were treated successfully. In the first patient, the posterior chamber PIOL luxated into the anterior vitreous cavity whereas in the second patient, the posterior chamber PIOL lay on the posterior pole. No ocular complications developed postoperatively.

CONCLUSION

Luxation into the vitreous cavity is a rare, but potentially severe complication of posterior chamber PIOL refractive surgery in highly myopic eyes. Successful management includes pars plana vitrectomy and removal of the posterior chamber PIOL.