[Upper digestive hemorrhage due to aortoesophageal fistula]

We describe the case of a 60-year-old woman who presented with thoracic pain followed by hematemesis. Aortoesophageal fistula was diagnosed. Double aortic and esophageal protheses were placed with good clinical outcome. After 15 days, the patient presented migration of the esophageal prothesis and a further endoscopic examination was performed. A fishbone was visualized in the fistula orifice.

Technique of radiological localisation and endoscopic retrieval of unusual foreign body from urinary bladder

Minimal invasive endoscopic retrieval of an unusual foreign body (Allen key) from urinary bladder in a young female patient is presented. The technique of radiological localisation using plain X-ray, often the only investigation available in small centres, is described.

Aortic Neck Dilation after Endovascular Abdominal Aortic Aneurysm Repair: Should Oversizing Be Blamed?

Long-term durability after endovascular abdominal aortic aneurysm repair (EVAR) is dependent upon the maintenance of an effective seal between the endograft and the proximal landing zone. Continuous neck dilation might lead to the loss of such a seal. This study aims at evaluating the incidence, risk factors, and clinical consequences of post-EVAR aneurysm neck dilation in patients treated with two types of endografts: AneuRx and Ancure. We reviewed data concerning all consecutive patients submitted to primary EVAR using the AneuRx and Ancure devices. Preoperative neck anatomic characteristics (diameter, calcification, and thrombus load) were evaluated, and device oversize percentage was calculated. Postoperative same-level neck diameter was measured on all postoperative computed tomographic (CT) scans. Probabilities of neck dilation (> or = 10% and > or = 15%) relative to preoperative diameter and first postoperative diameter were estimated with the Kaplan-Meier method and compared between patients using both types of endograft. The impact of anatomic characteristics on neck dilation incidence was evaluated using Cox proportional hazards models. Mean neck dilation was compared between patients with and without device migration and proximal type I endoleak. Both groups had similar probabilities of dilating > 10% relative to preoperative diameter and to first postoperative diameter. Proximal necks in AneuRx-treated patients had higher probabilities of dilating > or = 15% relative to preoperative diameter than Ancure-treated patients (45.5% vs. 18.7% at 1.5 years, p = 0.025), but the probability of such dilation relative to the first postoperative diameter was not different between the two groups (12.4% vs. 9.1% at 1.5 years, p = 0.832). None of the preoperative neck characteristics was associated with neck dilation risk. Device oversize percentage was correlated with the percentage of neck dilation at first postoperative CT scan relative to preoperative diameter in both the AneuRx (correlation coefficient = 0.469, p < 0.0001) and the Ancure (correlation coefficient = 0.464, p < 0.011) groups, but it was not correlated with the percentage of neck dilation at 1 or 1.5 years relative to first postoperative CT scan in either group. Patients with and without caudad device migration (> or = 5 mm) had similar percentages of neck dilation at 1.5 years relative to preoperative diameter, but migrators had higher mean percentages of dilation at 1.5 years relative to first postoperative neck diameter (11.4% vs. 5.6, p = 0.012). Two phenomena may be differentiated: an immediate postimplant dilation, strongly correlated with the percentage of oversize and more likely to reach values > or = 15% with an AneuRx device than with an Ancure graft, and a subsequent dilation, relative to the first postoperatively measured diameter, equally probable with either type of device, not correlated with the percentage of oversizing but associated with caudad device migration. Our study does not support any adverse role for the degree of oversize.

Treatment of the young active patient with osteoarthritis of the hip

We compared the five- to seven-year clinical and radiological results of the metal-on-metal Birmingham hip resurfacing with a hybrid total hip arthroplasty in two groups of 54 hips, matched for gender, age, body mass index and activity level.

Function was excellent in both groups, as measured by the Oxford hip score, but the Birmingham hip resurfacings had higher University of California at Los Angeles activity scores and better EuroQol quality of life scores. The total hip arthroplasties had a revision or intention-to-revise rate of 8%, and the Birmingham hip resurfacings of 6%. Both groups demonstrated impending failure on surrogate end-points. Of the total hip arthroplasties, 12% had polyethylene wear and osteolysis under observation, and 8% of Birmingham hip resurfacings showed migration of the femoral component. Polyethylene wear was present in 48% of the hybrid hips without osteolysis. Of the femoral components in the Birmingham hip resurfacing group which had not migrated, 66% had radiological changes of unknown significance.

Bronchial migration of a systemic-pulmonary shunt conduit

Using an expanded polytetrafluoroethylene conduit, a subclavian artery-to-pulmonary artery shunt was created in an infant with tetralogy of Fallot. The postoperative course was complicated by sepsis, shunt occlusion, and pneumonia. Four years later, an obstructive mass was found in the right main bronchus on fluoroscopy and was retrieved on rigid endoscopy, which turned out to be the migrated conduit. This case implies that a vascular conduit anastomosed to a systemic artery can migrate into the airway without bleeding, pseudoaneurysm formation, or host artery occlusion.

Unilateral transforaminal lumbar interbody fusion and bilateral anterior-column fixation with two Brantigan I/F cages per level: clinical outcomes during a minimum 2-year follow-up period

OBJECT

There are no published reports of unilateral transforaminal lumbar interbody fusion (TLIF) in which two Brantigan I/F cages were placed per level through a single portal to achieve bilateral anterior-column support. The authors describe such a surgical technique and evaluate the clinical outcomes of this procedure.

METHODS

Data obtained in 86 (93.5%) of the first 92 consecutive patients who underwent the procedure were retrospectively reviewed; the minimum follow-up duration was 2 years. The clinical outcomes were evaluated using the Japanese Orthopaedic Association (JOA) scoring system. Disc height, disc angle, cage positioning in the axial plane, and fusion status were radiographically evaluated. The mean follow-up period was 33.8 months. The mean improvement in the JOA score was 77.2%. Fusion was successful in 93% of the cases. According to the Farfan method, the mean anterior and posterior disc heights increased from 20.2 and 16.9% preoperatively to 35.9 and 22.7% at follow up, respectively (p < 0.01). The mean disc angle increased from 4.8degrees preoperatively to 7.5degrees at last follow-up examination (p < 0.01). Two cages were correctly placed to achieve bilateral anterior-column support in greater than 85% of the cases. The following complications occurred: hardware migration in two patients and deep infection cured by intravenous antibiotic therapy in one patient.

CONCLUSIONS

Unilateral TLIF involving the placement of two Brantigan cages per level led to good clinical results. Two Brantigan cages were adequately placed via a single portal, and reliable bilateral anterior-column support was achieved. Although the less invasive unilateral approach was used, the outcomes were as good as those in many reported series of posterior lumbar interbody fusion in which the Brantigan cages were placed via the bilateral approach.

Resorbable clip migration in the collecting system after laparoscopic partial nephrectomy

A complication is reported in which Lapra-Ty absorbable suture clips (Ethicon EndoSurgery) migrated from a laparoscopic partial nephrectomy bed into the collecting system, causing renal colic. During surgery performed with hilar occlusion, visual inspection did not reveal collecting system entry. Transected vessels were oversewn with absorbable suture secured with Lapra-Tys. Absorbable bolsters were placed in the parenchymal bed, and compression sutures secured with Lapra-Tys were placed through the renal capsule. Six weeks postoperatively, the patient developed ipsilateral renal colic, and computed tomography demonstrated several 3-mm opacities within the ureter. After 2 weeks of conservative management, he spontaneously passed several Lapra-Ty clips.

Migration of prostate brachytherapy seeds to the vertebral venous plexus

PURPOSE

We report two cases of seed migration to the vertebral venous plexus after iodine-125 (I-125) transperineal interstitial permanent prostate brachytherapy.

METHODS AND MATERIALS

Case 1: A 67-year-old Japanese man underwent percutaneous transperineal interstitial permanent prostate brachytherapy at our institution. Three months after brachytherapy, routine followup kidney-urinary bladder (KUB) radiography showed two seeds that had migrated to the pelvic area and were overlapped by sacral bone. It was very difficult to detect the seeds by visceral CT, because seeds were in contact with to vertebral bone, and seeds and bone were of the same CT value in visceral CT. But bone CT could distinguish seeds and bone, and it showed seed migration to the vertebral venous plexus in the sacral vertebral canal. Case 2: A 75-year-old Japanese man underwent percutaneous transperineal interstitial permanent prostate brachytherapy at our institution. The day after seed implantation, routine followup KUB radiography showed that a seed had migrated to the pelvic area and was overlapped by sacral bone. Bone CT clearly showed seed migration to the vertebral venous plexus in the vertebral canal in comparison with visceral CT.

RESULTS

Seeds that have migrated to the vertebral venous plexus are difficult to be detected by visceral CT or KUB radiography. In visceral CT, it is difficult to distinguish seed and bone, especially when they are touching each other because they have the same CT value in visceral CT. It is therefore necessary to perform bone CT to detect such migrating seeds.

CONCLUSIONS

To our knowledge, this is the first report of seed migration to the vertebral venous plexus after prostate brachytherapy. We thought that seeds migrate to the vertebral plexus via the pelvic venous pathway. If seed migration to the pelvic area and the overlapped sacral bone area is found after brachytherapy, bone CT should be performed, especially when it is difficult to detect the seed in visceral CT.

The KTP laser: an emerging tool in pediatric otolaryngology

PURPOSE

To report the frequency and spectrum of use of the potassium titanyl phosphate (KTP) laser in a tertiary referral pediatric otolaryngology practice and to focus on a novel use for the KTP laser which has not previously been described in the literature.

DESIGN

A retrospective chart review of the operative log database of a pediatric otolaryngologist in a tertiary referral setting over a seven year period.

RESULTS

Out of 2886 cases, a total of 49 (1.7%) involved the use of the KTP laser. These included 7 otologic cases, 3 laryngeal cases, 31 subglottic/tracheal cases, 1 esophageal case and 7 nasal cases. One of these cases involved a previously unreported use of the KTP laser, closure of a tracheo-esophageal fistula (TEF).

CONCLUSION

The KTP laser is an important operative tool in pediatric otolaryngology and new uses for this laser continue to emerge. One of these, KTP closure of a TEF offers pediatric otolaryngologists the potential for significant changes in management of this congenital problem with reduced surgical morbidity. Familiarity with the KTP laser and expertise in its use and applications is essential in providing state-of-the-art care to pediatric otolaryngology patients in a tertiary referral center.

Rare complication of multiple revision surgeries of penile prosthesis

INTRODUCTION

Migration of the penile prosthesis reservoir into the bladder is rare.

METHODS

A 67-year-old male was found with painful gross hematuria after two revision surgeries of the penile prosthesis.

RESULTS

The inflatable penile prosthesis reservoir migrated into the bladder. A new reservoir was repositioned on the contralateral side to the erosion site with salvage surgery.

CONCLUSIONS

Erosion of penile prosthesis reservoir into the bladder due to shortened tubing by multiple revision surgeries is rare. In selected cases, reposition of a new reservoir on the contralateral side to the erosion site can be used as salvage surgery.

Candida peritonitis: a rare complication following early dislodgement of percutaneous endoscopic gastrostomy tube

Candida peritonitis is a rare but potentially fatal complication of early dislodgement of percutaneous endoscopic gastrostomy (PEG) feeding tube. We report the case of 12-year-old boy who developed Candida peritonitis subsequent to early dislodgement of PEG tube. PEG tubes may be prone to accidental dislodgement or removal by patients or carers. This complication has to be recognized early in order to avoid the risk of peritonitis. In our case the patient initially developed coliform peritonitis followed by peritoneal and systemic candidiasis. The patient needed ventilatory support, inotropic support, broad-spectrum antibiotics, total parenteral nutrition and antifungal agents liposomal amphotericin and flucytosine.

CONCLUSION

Early dislodged PEG tubes should be recognized early in order to avoid the risk of peritonitis and managed by endoscopic or surgical replacement rather than blind replacement by the appropriately skilled personnel.

Migration of implants: a problem with injectable polyacrylamide gel in aesthetic plastic surgery

Polyacrylamide gel (PAAG) has been used as a soft tissue filler material for cosmetic purposes in Europe and China since 1997. The various complications of PAAG have been reported. A total of 15 patients who received PAAG injections at other institutions were treated for gel migration in the authors' hospitals. During treatment, the authors found that the injected PAAG had not formed capsules within the muscle and was encapsulated only by thin fibrous tissue in skin and mammary glands. Consequently, the filler material migrated easily because of muscular activity or the influence of gravity, especially when the capsule was broken by incorrect massage or incidental force. It is suggested that PAAG should not be injected into muscular tissue or subcutaneous areas with active movement, such as joints and muscles involved in facial expression with thin skin. After years of gel implantation, the thinned capsule may result in an increasing incidence of this complication. Management and some clinical findings in relation to the complication also are discussed.

Locoregional silicone spread after high cohesive gel silicone implant rupture

A 45-year-old patient had routine cosmetic bilateral breast augmentation 6 years previously using cohesive gel implants. She presented 4 years later with a breast lump and multiple axillary lymph nodes. Exploration revealed that the breast implant had a large tear at the posterior wall of the shell with intra-capsular leakage of silicone. The axilla had eight enlarged lymph node--all were removed. Histology showed silicone granuloma in the capsule and silicone lymphadenitis. High cohesive gel implants may not be as safe as is commonly believed and all implant ruptures, irrespective of the cohesiveness of the silicone gel, should be investigated thoroughly.

Complications with cervical arthroplasty

Object

Spinal arthroplasty is becoming more widely performed in the treatment of degenerative cervical disc disease. Although this new technology may offer benefits over arthrodesis, it also requires that the surgeon acquire new operative techniques, and new potential complications are introduced. To determine the incidence and distribution of perioperative complications, the authors analyzed their early data obtained in a series of patients treated with the Bryan Cervical Disc prosthesis.

Methods

The authors prospectively recorded operative data, complications, and clinical and radiographic outcome data in all patients treated with Bryan prosthesis–based arthroplasty at two tertiary care centers since 2001. Patients underwent standard anterior cervical discectomy followed by one- to three-level arthroplasty.

Ninety-six discs were implanted in 74 patients. The perioperative complication rate was 6.2% per treated level. In one patient a retropharyngeal hematoma developed, requiring evacuation. Neurological worsening occurred in three patients. Intraoperative migration of the prosthesis was observed in one two-level case, whereas delayed migration occurred in one patient with postoperative segmental kyphosis. In another patient with severe postoperative segmental kyphosis, revision was required with a customized lordotic prosthesis. Heterotopic ossification and spontaneous fusion occurred in two cases; motion was preserved in the remaining 94 prostheses. Partial dislocation of the prosthesis in extension occurred in one patient with preoperative segmental hypermobility, the first reported failure of a Bryan prosthesis. Twenty-five percent of patients reported neck and shoulder pain during the late follow-up period. There was a trend toward increased kyphosis of the C2–7 curvature postoperatively.

Conclusions

The Bryan prosthesis was effective in maintaining spinal motion. Major perioperative and device-related complications were infrequent.

TrapEase™ Vena Cava Filter: A Case of Filter Migration and Pulmonary Embolism After Placement

Inferior vena cava filters provide an alternative method of protection against pulmonary embolism in situations where anticoagulation either fails or is contraindicated. These filters are easily placed, with a relatively minor risk of complications. Currently, we know of only one reported case of filter migration using the TrapEase filter. We present a case report of a migrating TrapEase filter, as well as pulmonary embolism after TrapEase filter placement. This complication developed in a 31-year-old trauma patient who developed bilateral popliteal deep vein thromboses and an initial pulmonary embolus while on low molecular weight heparin.

Retracted:Loss of the Guide Wire

A case of a lost guide wire extending from the vena cava to the back of the neck after central venous catheterization is presented. A trainee inserted a central venous catheter via the left subclavian vein in a 40-year-old male patient after surgery, but did not notice that a guide wire was completely inserted in the vein. After 6 months, the lost guide wire was seen extending from the saphenous vein through the vena cava, right atrium, right ventricle, pulmonary artery and lung tissue to the back of neck. Although percutaneous catheterization of central veins is a routine technique, it is a procedure requiring advanced surgical skills, expert supervision, and attention to detail in order to prevent adverse effects. The present case is not only a technological problem, but also one of responsibility. The operator must hold onto the guide wire at all times until removal from the vessel, and a supervisor must make sure that trainees are aware of all possible complications.

Mobile vs. fixed meniscal bearing in total knee replacement: a randomised radiostereometric study

52 knees scheduled for a total knee arthroplasty were randomised to either a fixed or a mobile polyethylene bearing. The design was identical in all parts. The knee systems used were the Rotaglide Total Knee System (RTK) and the Nuffield Total Knee System (NTK), both from the same manufacturer (Corin Medical Ltd., UK). All knees implanted were uncemented. The patients were followed for 2 years clinically and with radiostereometric analyses to assess migration over time and inducible displacement of the tibial component. Separate analysis of the mobility of the tibial insert in the knees with a mobile bearing was also made. The migration measured with RSA between the 1st and 2nd year expressed as maximum total point motion (MTPM) might predict the risk of loosening of the implant. There were no differences between the groups regarding clinical outcome (HSS Knee score), migration or inducible displacement during the 2 years follow-up. The movement between the tibial tray and the mobile meniscal insert expressed as maximum total point motion (MTPM) was 6.8+/-3.3 mm at the 1st year follow-up.

Implanon® : difficultés d'insertion et de retrait, échecs contraceptifs

OBJECTIVE

Analysis of the results of a national pharmacovigilance study on Implanon, a contraceptive implant containing 68 mg of etonogestrel.

PATIENTS AND METHODS

This survey concerns cases of pregnancies (contraception failures), of migrations and of insertion or removal problems with Implanon reported to French Regional Drug Pharmacovigilance Centres and to Organon SA between May 2001 and September 2002.

RESULTS

In France, 39 unintended pregnancies were reported over 17 months. The pregnancies were in 77% of cases (N = 30) due to an insertion technique error (implant not found when pregnancy has been diagnosed). For 3 patients (7,6%), pregnancy was due to a failure of etonogestrel contraceptive effect, explained twice by its association with an enzymatic inductor drug. For 4 patients (10%), pregnancy was due to an untimely insertion (insertion after day 5 of menstrual cycle or woman already pregnant). For two patients, no information was available. The incidence of reported pregnancies in France is estimated at 0.359 / 10(3) implants [0.246-0.482], in accordance with a typical Pearl Index of 0.06 [0.04-0.08]. Twenty-eight suspected migrations (N = 11), problems or failures in removal of the implant (N = 11) and insertion difficulties (N = 6) were notified, corresponding to an incidence of 0.257/10(3) implants [0.162-0.363].

DISCUSSION AND CONCLUSION

Occurrence of pregnancy is possible with Implanon, due to errors in the insertion technique (device not really inserted) or to a non-respect of the SPC recommendations (drug-drug interaction or untimely insertion). Insertion problems can lead to localisation problems (implant not visible by X-ray) then needing further tests and even harmful practice (removal under general anaesthesia). That is why a real and strict training is highly recommended to physicians.

Nitinol stents in the treatment of benign proximal tracheal stenosis or tracheomalacia

Nitinol stents have been used in the treatment of benign tracheal stenosis. A retrospective review of five patients treated at Stobhill Hospital over the last six and a half years is presented. Age at presentation ranged from 17 to 76 years. The minimum follow-up period was 23 months and the maximum was 78 months. All our patients were successfully decannulated, with none requiring recannulation. Four patients developed granulation tissue related to the stent at intervals ranging from three weeks to 41 months post stenting. Topical mitomycin C application has been useful after resection of granulations using the carbon dioxide (CO2) laser. Stent migration occurred in one patient three weeks after insertion. Nitinol stents are easy to insert and effective in the treatment of tracheal stenosis, but can have associated morbidity. Their use should be considered carefully, as insertion should be regarded as permanent. Publications reporting experience and outcome with the use of Nitinol stents in the trachea are reviewed.