TIPS stent migration causing sinus of Valsalva rupture

A man in his 40s presented with haematemesis and melaena and was found to have a massive variceal bleed. Endoscopic procedures were ineffective at controlling the bleed; thus, an emergent transjugular intrahepatic portosystemic shunt (TIPS) procedure was performed. There were no noted complications from the procedure and the patient was eventually discharged home. A month later, a murmur was auscultated on routine physical examination. This prompted an outpatient transthoracic echocardiogram which revealed a TIPS stent in the inferior vena cava (IVC) extending into the right atrium along with a ruptured sinus of Valsalva with left to right shunt.The patient declined surgical intervention. He is currently being followed in the outpatient setting with serial echocardiograms and medical management.

[Intracardiac migration of the ureteral single-J : A case report and removal techniques]

The techniques of derivation of the high urinary tract are indispensable in common practice for the management of ureteral obstructions. Like any surgical gesture, its techniques are not without complications; Among those common are hematuria, urinary incontinence, migration in the bladder and rupture of the probe. However, intracardiac probe migration has rarely been described. We report the case of a 68-year-old patient treated for cervical cancer who benefited from the rise of a bilateral single-J probe, admitted for accidental migration of the left probe into the heart. The diagnosis was made by plain abdominal X-ray and confirmed by thoraco-abdominal CT angiography. The patient benefited, in the catheterization room, from a withdrawal of the probe by endoscopic way and under radioscopic control successfully and without any incident.

Incidence and Risk Factors for Spinal Cord Stimulator Lead Migration With or Without Loss of Efficacy: A Retrospective Review of 91 Consecutive Thoracic Lead Implants

OBJECTIVE

Lead migration after spinal cord stimulator (SCS) implant is a commonly reported complication and the most common reason for revision surgery in cases of loss of efficacy. The primary aims of this study are to describe the incidence and degree of lead migration in the subacute postoperative period after SCS implant and to report potential risk factors for lead migration.

MATERIALS AND METHODS

We performed a retrospective chart review of all patients at a single academic center who received an SCS implant from January 1, 2020, to December 31, 2020. Information on patient (age, sex, weight, and height) and operative factors (device manufacturer, epidural access level and method, and implantable pulse generator location) were extracted from medical records. Intraoperative imaging was compared to subacute follow-up imaging obtained less than 20 days postimplant to measure lead migration distance. Regression models were fitted to determine associations between lead migration distance and potential clinical risk factors.

RESULTS

A total of 91 cases (182 leads) were included in the study. Within 20 days of implantation, 88.5% of leads had migrated (86.3% caudal and 2.2% cephalad). Mean migration distance for leads with caudal migration only was 12.34 ± 12.19 mm based on anteroposterior radiographs and 16.95 ± 15.68 mm on lateral radiographs. There was an association of greater caudal lead migration as patient body mass index increased (β-coefficient 0.07 [95% confidence interval 0.01-0.13], p = 0.031). Within the entire cohort, one patient (1.1%) required lead revision for loss of efficacy.

CONCLUSIONS

In the subacute postoperative period after SCS implant, the majority of SCS leads migrated caudally with an average of two lead contacts. Knowledge of this expected migration and risk factors can better inform implanting physicians intraoperatively when deciding final lead placement location. The finding of high likelihood of caudal lead migration in the subacute postoperative period brings the need for a well-designed prospective study to the forefront of our field. This will allow implanting providers to make well-informed decisions for intraoperative lead placement.

Case of retained guide wires traversing anatomical boundaries with neurological and cardiac morbidity

A 69-year-old woman with a history of multiple hospital attendances for cardiac and neurological symptoms, presented with multifocal cerebral infarcts due to embolisation from retained guide wires and was referred for retrieval of two wires. One was intracardiac and the other had migrated through major vascular structures, breeching anatomical boundaries. Just before surgery, she half-expectorated a 35 cm wire that was removed with a video laryngoscope. Three days later, the second wire had traversed the right ventricular myocardium in an attempt to exteriorise, and a 7 cm wire was removed by emergency left anterior mini-thoracotomy. Her recovery was uneventful.

Management of gunshot wound to the lumbosacral spine in a 17-year-old girl without neurological impairment

We report the case of a young girl (17-year-old) wounded by an accidental gunshot. The bullet entered through the skin midline over the navel area, passed through the stomach perforating the vena cava and, by breaking the right pedicle of L4, moved inside the vertebral canal (bridging the cauda equina) stopping just in front of the body of S2. Because of the sudden onset of acute abdomen due to a massive retroperitoneal hematoma, the patient underwent emergency explorative laparotomy with the evacuation of the hematoma and the suture of the perforated cava vein, the peritoneum, and the stomach. No neurological deficits were observed after the gunshot. Two weeks later, the patient underwent spinal surgery to remove the bullet from the spinal canal, which was performed successfully without any instrumentation and with no onset of new neurological signs and symptoms or surgery-related complications. Patient was discharged on day 9 after surgery in good general conditions.

Superior Vena Cava Stent Migration Into the Right Atrium

Possible stent migration was suspected in this case and confirmed on transesophageal echocardiography. The patient underwent successful stent removal with snaring, as well as subsequent placement of another stent in the superior vena cava without further complications.

Transvenous extraction of 3-year-old Seldinger guide wire lost in venous system and causing superior vena cava syndrome - rare complication of implantable cardioverter-defibrillator implantation

A 65-year-old male patient underwent left-sided placement of implantable cardioverter-defibrillator. At three years after implantation he emerged complaining on left upper limb and left-sided neck edema. Left brachicephalic vein thrombosis due to device leads was recognized. The attending cardiologist referred the patient to university radiology department for venous angioplasty but the patient was admitted to cardiology department. Coronary angiography was performed due to suspicion of ischemic heart disease. However, it showed the presence of foreign body in cardiovascular system - completely intravascular round-tipped guide wire used in Seldinger technique for insertion of the endocardial lead abandoned in left subclavian vein and reaching to superior vena cava. Patient was transferred to third-degree reference lead extraction center. The procedure was performed under general anesthesia in hybrid operating room. Via femoral vein access we introduced Needle's Eye Snare and grasped the guide wire. Then, using polytetrafluoroethylene sheath the tissue adhesions were dissected and the complete guide wire was retrieved.

Intrauterine device in the rectal cavity

We report a case of a 51-year- old woman who had an intrauterine contraceptive device, which migrated to the rectum and it was seen in a videocolonoscopy.

Retrograde bullet migration from inferior vena cava into right common iliac vein following gunshot: A case report

Bullet embolization cases are rare and even rarer are its retrograde migration in the veins. We report the case of a 14 year old male with a gunshot wound to the left side of his chest. CT scan revealed bilateral haemothorax and foreign body in the right common iliac vein. The patient was immediately taken to the operating theatre and median sternotomy performed. Bullet entry tear was found in the inferior vena cava however, the bullet was found lodged in the right common iliac vein and slipped down against the flow of blood. The bullet was left in situ and after the necessary repair the chest was closed and the patient shifted to the CICU and discharged after 4 days in stable condition. Patient was followed after 1 week and reassured and advised for one year follow-up.

Positional Ventricular Tachycardia from a Fractured Mediport Catheter with Right Ventricular Migration

The totally implantable catheter system has gained popularity as venous access when prolonged treatment is needed. Despite its frequent use, intravascular fracture and embolization of catheter fragments from implantable venous port-catheter systems present a rare but potentially life-threatening complication. Any implanted catheters should therefore be removed after completion of the treatment or the system's integrity should be monitored on a regular basis. This report illustrates such a case, which presented with ventricular tachycardia triggered by changes in body position from a fractured Mediport catheter with cardiac migration. A 34-year-old woman had a venous port catheter (Mediport) implanted into the right subclavian vein for neoadjuvant radio-chemotherapy for Hodgkin’s lymphoma. Owing to the patient's difficult venous access the catheter was left in situ after treatment. Three years after insertion of the Mediport she presented with shortness of breath and palpitations when lying in the left lateral position. Physical examination revealed no abnormalities. An electrocardiogram was within normal rhythm. An outpatient Holter monitor revealed multiple episodes of nonsustained and sustained ventricular tachycardia triggered by lying in the left lateral position. A chest radiograph showed a normal location of the port-system, but the distal fragment of the catheter had embolized into the right ventricle. The embolized fragment was extracted with a gooseneck snare technique and the reservoir of the system was removed under local anesthesia without any complications. The patient was free of symptoms at 7 seven months follow-up.

Liver abscess secondary to duodenal perforation by fishbone: Report of a case

Liver abscesses usually arise from amoebian or bacterial origin, being rarely secondary to foreign bodies (1-3). We report the case of a 72-years-old female complaining from abdominal pain located in epoigastrium and right hypochondrium during the last 48 hours. Laboratory data revealed leukocytosis with neutrophilia and pain located in the mentioned locations at physical examination. Ultrasonography showed a liver abscess involving segments 2 and 3. CT scan revealed that the abscess was secondary to a fishbone perforating the duodenum and inlaid in the liver (Figure 1). The fishbone was surgically extracted from the hepatic lobe with hemostasia and a duodenal suture with epiploplastia was performed. Antibiotic was added to the treatment. The patient presented an uneventful postoperative course. The intake of foreign bodies is a frequent event, representing bones and fishbones the most frequent foreing bodies in the adults. Sometimes, the diagnosis may be difficult because the symptoms are not specific. Imaging test are very usefol for the diagnosis, as in the case we present.

Obstructive jaundice secondary to endoclip migration into common bile duct after laparoscopic cholecystectomy

Obstructive jaundice is a rare condition due to foreign body in common bile. In this article we report a 69 year-old man who was diagnosed obstructive jaundice secondary to the endoscopic clip migration. The patient had been performed laparoscopic cholecystectomy 5 years ago and had recovered without any complications. He presented with abdominal pain and jaundice. The magnetic resonance cholangiopancreatography (MRCP) revealed filling defect in choledoch consistent with a bile duct stone. The endoscopic retrograde cholangiopancreatography (ERCP) exhibited an endoclip migration into the common bile duct which caused bile duct stone. Endoclips can migrate into bile duct and cause obstructive jaundice. ERCP is the first option for its treatment.

Vertebral-subclavian bifurcation treatment. "The wedding ring technique" for a vertebral in-stent restenosis associated with stent fracture

This report describes a solution for a restenosis and for the fracture of a stent in the vertebral artery in a patient suffering from vertebrobasilar symptoms. Angiography demonstrates restenosis of a vertebral stent as well as its fracture and migration into the subclavian artery. This complication was managed percutaneously by passing a guide wire through the fractured stent. Pre-dilatation and kissing balloon techniques were applied in both the vertebral and subclavian arteries to modify the stent's dimensions and shape it into the form of a "ring." Postprocedural angiography demonstrated an excellent final result with the assistance of StentBoost visualization. Control angiography at six months also utilized StentBoost imaging and confirmed the patency of the bifurcation and that the stent was not displaced.

A rare complication of Epistats

We report a 53-year-old man who sustained severe facial and base of skull fractures. At the scene of his accident he had Epistats (Medtronic Sofamor Danek, Memphis, TN, USA) placed for control of his severe nasal haemorrhage, subsequently resulting in the migration of one Epistat into the anterior cranial fossa. There are numerous reports of inadvertent intracranial placement of medical equipment, predominantly in association with complex facial and skull trauma. Other factors that can predispose to aberrant location include previous anterior cranial base surgery and lesions affecting structures in that area.

Fractured inferior vena cava filter strut presenting with ST-segment elevation and cardiac tamponade

The fracture of an inferior vena cava filter strut and its migration to the heart is a rare sequela of implanted inferior vena cava filters. Perforation through the right ventricle into the pericardium with resultant cardiopulmonary compromise is even less frequent. We report the case of a 53-year-old man who presented with chest pain and hypotension consequent to cardiac tamponade. A fractured inferior vena cava filter strut had migrated and perforated his right ventricle. The fractured strut was successfully removed by means of cardiac surgery. Inferior vena cava filters should be placed when necessary to minimize the risk of pulmonary embolism, and regular radiologic monitoring should be performed; however, the eventual extraction of retrievable filters should be considered. In addition to discussing the patient's case, we briefly review the relevant medical literature.

Palliation of esophageal cancer with a double-layered covered nitinol stent: long-term outcomes and predictors of stent migration and patient survival

PURPOSE

To evaluate the long-term clinical outcomes and the negative predictors after the deployment of double-layered stents in malignant esophageal strictures.

METHODS

This is a single-center study of patients who received a double-layered covered stent for the palliation of dysphagia due to malignant esophageal strictures in a 3-year period. 56 patients fulfilled the inclusion criteria. The study's primary end points were technical success, dysphagia improvement, stent migration, and complication rates; secondary end points were the stent's primary patency and overall survival. Cox regression analysis was used to adjust for confounding variables and to identify predictors of survival outcomes.

RESULTS

Technical success was 95%. Median dysphagia score improved significantly after stenting (p < 0.0001). Stent migration rate was 7.1% and occurred exclusively in the group of patients who received chemoradiotherapy (p < 0.01). The median stent patency was 87 days (range 5-444 days). Dysphagia reoccurred in 39.3% and was successfully managed with restenting in 98.2%. The median survival was 127 days (range 15-1480 days). Chemoradiotherapy and baseline histology did not influence survival outcomes. Survival was adversely affected by metastases (p = 0.005) and poor oral intake (p = 0.048). Patient survival was improved by repeat stenting in case of tissue overgrowth (p = 0.06).

CONCLUSION

The device is safe and effective for the treatment of patients with dysphagia due to esophageal cancer. Migration rate is zero for patients who do not receive chemoradiotherapy. Reintervention when required is a positive survival predictor.

Transmural gastric migration of dual-sided PTFE/ePTFEE mesh after laparoscopic surgery for a recurrent hiatal hernia with dysphagia: case report

Several series have shown that laparoscopic fundoplication is feasible and safe for the treatment of hiatal hernia, although a high recurrence rate of 42% has been published. The use of mesh repair in these hernias has shown fewer recurrences than primary suture with small number of complications reported.Some of these are severe fibrosis within the hiatus, mesh erosion of the intestinal wall, esophageal strictures, mesh migration into the upper gastrointestinal tract and esophageal perforations. We present a case with late erosion and complete transmural gastric migration of the mesh after surgery. In these cases, the patients may require complex surgical intervention.That was not the case in our patient, who did not require further surgery because the mesh migrated completely. It is therefore advisable to use a mesh very selectively for the laparoscopic repair of hiatal hernias, taking into account the surgeon's experience, the anatomy of the hiatus and the symptoms of the patient.

[An intravesical foreign body by migration of remnant gauze into the bladder: a case report]

A 35-year-old female, who had undergone Caesarean sections in 2000 and 2001, presented with repeated candida vaginitis and cystitis. She reported that a piece of gauze was excreted through the urethra in 2005. The patient visited an outpatient clinic, but no foreign body was identified by cystoscopy. She again visited the clinic in 2012 complaining of miction pain, and a calcified mass was identified in the bladder. The patient was then referred to our hospital. During a transurethral operation, crushed stones, which included the gauze, were removed from the bladder. We concluded that remnant gauze left in the abdominal cavity during the previous pelvic surgery, had migrated into the bladder and formed a calcified mass.

Endoscopic ultrasound (EUS)-guided fiducial placement allows localization of small neuroendocrine tumors during parenchymal-sparing pancreatic surgery

BACKGROUND

Parenchymal-sparing pancreatic surgery is ideal for lesions such as small pancreatic neuroendocrine tumors (PanNET). However, precise localization of these small tumors at surgery can be difficult. The placement of fiducials under endoscopic ultrasound (EUS) guidance (EUS-F) has been used to direct stereotactic radiation therapy for pancreatic adenocarcinoma. This report describes two cases in which placement of fiducials was used to guide surgical resection. This study aimed to assess the feasibility, safety, and efficacy of using EUS-F for intraoperative localization of small PanNETs.

METHODS

A retrospective study analyzed two consecutive patients with small PanNETs who underwent EUS-F followed by enucleation in a tertiary-care referral hospital. The following features were examined: technical success and complication rates of EUS-F, visibility of the fiducial at the time of surgery, and fiducial migration.

RESULTS

In the study, EUS-F was performed for two female patients with a 7-mm and a 9-mm PanNET respectively in the uncinate process and neck of the pancreas. In both patients, EUS-F was feasible with two Visicoil fiducials (Core Oncology, Santa Barbara, CA, USA) placed either within or adjacent to the tumors using a 22-gauge Cook Echotip needle. At surgery, the fiducials were clearly visible on intraoperative ultrasound, and both the tumor and the fiducials were successfully enucleated in both cases. No complications were associated with EUS-F, and no evidence of pancreatitis was shown either clinically or on surgical pathology. This investigation had the limitations of a small single-center study.

CONCLUSIONS

For patients undergoing enucleation, EUS-F is technically feasible and safe and aids intraoperative localization of small PanNETs.

Are concerns about EVAR durability relevant with modern devices?

Endovascular aneurysm repair (EVAR) is now universally adopted as first-line therapy for the management of large abdominal aortic aneurysms (AAA). The applicability has broadened such that up to 80% of patients are morphologically suitable for EVAR. In-spite of the evidence base demonstrating improved early outcomes following EVAR compared to open surgery, and informed patients' preference, EVAR-sceptics remain. The doubters voice anxieties regarding the durability of an endovascular repair and cite evidence of graft failures from the EVAR-1 trial results. Historically, graft migration and endoleak development have been the Achilles heel of EVAR. However, EVAR is an evolving technology that over the last 10 years has seen significant development from industry, and greater experience among clinicians. This has combined with centralisation of expertise in larger vascular units, with increased case-volume, leading to more appropriate periprocedural and long-term care. Current devices offer a durable repair for patients with infra-renal aortic aneurysms. The risk of graft migration is minimised by devices with secure fixation systems, potentially limiting de-novo type 1 and 3 endoleaks. Appropriate surveillance and timely endovascular re-interventions are perhaps the most important factors to ensure robust long-term outcomes from endovascular repair, even when native vessel morphology changes. Industry registry evidence and large single unit case series are now generating a healthy evidence base of EVAR durability in contemporary endovascular practice, that affirms its role as first-line therapy in the majority of morphologically suitable patients.

Whereabouts of an internal short stent placed across the pancreaticojejunostomy following pancreatoduodenectomy

BACKGROUND/PURPOSE

It is generally thought that an internal short stent placed across the pancreaticojejunostomy (PJ) following pancreatoduodenectomy (PD) usually passes spontaneously through the rectum thereafter; however, we experienced some patients who presented with pancreatitis and cholangitis owing to delayed defecation of the stent. The purpose of this study was to clarify when the stent eventually became detached from the PJ and how it passed through the body until it was finally defecated. In addition, we also investigated the factors that may prevent such detachment and defecation.

METHODS

This study retrospectively analyzed 57 patients who had had internal short stents placed across the PJ following PD. Defecation from the body, detachment from the PJ, and distal migration of the stent was confirmed by X-ray or computed tomography (CT) during the postoperative course. The cumulative rates of defecation and detachment of the stents, complications in relation to delayed defecation of the stents, and factors predictive of the delayed defecation, delayed detachment, and distal migration of the stents were analyzed.

RESULTS

Defecation of the stent was confirmed in 35 patients. The median time to defecation after PD and the cumulative defecation rate at 1 year were 454 days and 41 %, respectively. Acute pancreatitis occurred in 2 patients with the stent remaining in the pancreatic duct. One patient experienced acute cholangitis owing to migration of the stent to the bile duct. Multivariate analysis showed that ≥5 stitches in the duct-to-mucosa anastomosis, stent size of ≥5 Fr, and pancreatic fistula classified as either Grade B or C were independent predictive factors for delayed defecation of the stent. Five or more stitches in the duct-to-mucosa anastomosis was an independent predictive factor for delayed detachment of the stent. A stent size of ≥5 Fr was a risk factor for distal migration of the stent.

CONCLUSION

In more than half of the study patients, internal short stents were not defecated within 1 year. Retrieval of the stent should be considered following the migration of an internal short stent. A stent size of ≥5 Fr was an independent predictive factor for delayed defecation and distal migration of a stent. Five or more stitches in the duct-to-mucosa anastomosis was an independent predictive factor for delayed defecation and detachment of a stent.

First perforator vein cement occlusion following total hip arthroplasty

Cement intravasation of the venous system is a rare complication of total hip arthroplasty. This is a case report of a 54-year-old female who sustained cement occlusion of the first perforator vein of the femur after hybrid total hip arthroplasty. However, she was asymptomatic and attained excellent clinical outcome. Differential diagnoses for the radiographic appearance are discussed as well as possible reasons for this occurrence.

[Application of levonorgestrel-releasing intrauterine system in early pregnancy: a case report]

Intrauterine device is a popular cost-effective method of contraception known worldwide. It is extremely effective, with pregnancy rates comparable to tubal ligation (5-year cumulative rate varying from 0.5 to 1.1). LNG-IUS increases in popularity and may be used as the method of choice for adults because it offers non-contraceptive benefits: slight menstrual bleeding, decreased number of incidents of dysmenorrhea, and reduced pain associated with endometriosis. The levonorgestrel-releasing intrauterine system (LNG-IUS) provides a release rate of 20 microg/24 h of levonorgestrel. The hormone released from the intrauterine device causes some systemic changes, however local effects, such as glandular atrophy and stromal decidualization, in addition to foreign body reaction, are dominant. According to the Food and Drug Administration regulations, category X was assigned to LNG. The use of the product is contraindicated in women who are or may become pregnant. We report a case of a 30-year old woman who has already been pregnant before the insertion of a levonorgestrel -releasing intrauterine system (LNG-IUS). The patient was lactating after the previous pregnancy the first menstruation had not appeared yet. The patient planned to have the IUD inserted but she missed her appointed visits twice. The third visit took place 8 weeks postpartum. During that visit, the doctor asked her about the possibility of being pregnant, but the patient denied. The gynecologist inserted the intrauterine device and performed transvaginal ultrasound examination. The location of LNG-IUS was proper and there was no gestation sac in the uterine cavity. After the next six weeks, transvaginal ultrasonography and manual examination showed an intrauterine pregnancy at 8 weeks of gestation. The intrauterine device was not detectable in the uterine cavity by ultrasound, and the IUD strings were not visualized in the vagina. It was impossible to remove the device without causing miscarriage. Other risks during pregnancy were connected with potential masculinisation of the fetus by levonorgestrel, premature delivery and preterm rupture of the membranes. The pregnancy progressed normally and the delivery was uncomplicated. A female infant was born without congenital abnormalities. The pediatrician did not find any indices of infection. The IUD was found in fetal membranes. The postpartum recovery was uneventful. This case report demonstrates that a healthy infant can be delivered at term with an IUS in situ, probably without causing any abnormalities. Due to that fact that adverse effects of fetal exposure to the LNG-IUS have not been yet established, the exclusion of pregnancy before IUD insertion is strictly indicated.

Groin abscess due to a forgotten midurethral sling connector

Midurethral slings (MUS) have been used for female stress urinary incontinence throughout the past decade on a worldwide scale. Although this minimally invasive treatment has high success rates, formation of groin abscesses, as well as vaginal and urethral erosions, can occur after the procedure. We report a patient presenting with groin abscess and sinus tract formation after a transobturator tape procedure. The patient exhibited a swollen sinus tract, which drained the abscess at the site of the tape entry to the obturator foramen within her inner left groin. She was referred to our department after unsuccessful medical and surgical treatments. Surgical exploration revealed a forgotten MUS connector located between the mesh and hook within the skin incision. To the best of our knowledge, this is the first report of such a case.

Cephalad lead migration following spinal cord stimulation implantation

Lead migration (LM) is the most common complication after spinal cord stimulation (SCS). Although multiple reports of caudad LM have been described, cephalad LM has not been reported. Here we describe a case in which a stimulator lead migrates in the cephalad direction. A 60-year-old male with failed back surgery syndrome underwent SCS lead implantation via a dual lead approach to the top of vertebral body (VB) T9. A standard strain relief loop was used for each lead in the paramedian pocket. Postoperative testing revealed 100% paresthesia coverage of the painful areas. For the first 4 days, the patient continued to have excellent coverage; however, by the seventh day, the paresthesias ascended to above the nipple line. At the 2-week follow-up, cephalad migration of the left lead to the top of VB T1 was confirmed on fluoroscopy. The patient underwent successful lead revision in which a single paramedian incision technique was used to place extra sutures and a "figure-of-eight" strain relief loop. We provide the first case report of significant cephalad LM following SCS lead implantation. This migration can occur despite the use of current standard anchoring techniques. Additional investigation into the mechanism of such LM and lead-securing techniques is warranted.

[The silicone spleen (description of a clinical case)]

The paper describes a rare case of verified foreign body (silicone) migration into the spleen. The specific feature of this clinical case is a rare clinical finding through histological study and the use of inductively coupled plasma-mass spectrometry for the determination of silicone in splenic tissues.

Delayed intra-articular migration of the IntraFix outer sheath after anterior cruciate ligament reconstruction: a case report

We describe a case of foreign body synovitis caused by delayed intra-articular migration of the outer sheath 5 months after anterior cruciate ligament (ACL) reconstruction with a quadrupled tibialis allograft tendon using the IntraFix device for tibial fixation. The postoperative course was unremarkable. At 5 months after surgery, the patient experienced a sudden catching sensation and a slight pain without any obvious twisting or trauma. At 6 months after surgery, extension deficit was 20°. At arthroscopy, intra-articular migration of the outer sheath from the tibial tunnel and reactive synovitis were observed. The outer sheath in the joint and the inner screw in the tibial tunnel were removed successfully. The ACL graft was well incorporated under good tension. Patient was able to return to her previous level of all daily activities with no further episodes of swelling. To our knowledge, described here is the only case of foreign body synovitis due to intra-articular migration of the unbroken sheath.

Spontaneous mesh evacuation per rectum after incisional ventral hernia repair

We present a case of a 58-year-old man who was admitted to our hospital because of abdominal pain. He underwent incisional ventral hernia repair with intraabdominal mesh (ePTFE). On the day of admission, physical examination included the discovery of a foreign body in the rectum. There were no signs of acute abdomen. We induced stool, and the mesh came out with it. His further course was uneventful. Gastrografin series showed persisting fistula between the small intestine and colon, but without extralumination into the peritoneal cavity. The patient was discharged in good health and without signs of incisional ventral hernia.

[Intravesical migration of intrauterine contraceptive device (IUCD) with stone formation]

Migration of an intrauterine contraceptive device (IUCD) into the bladder and secondary stone formation are uncommon complications associated with the insertion of IUCD. To our knowledge, there have been no such reported cases in Japan. In the present report, we describe the case of a 59-year-old woman who underwent an operation for the removal of an IUCD from the bladder, which had been inserted 30 years ago. The patient was referred to our facility because of hematuria and recurrent urinary tract infections. A plain film revealed a calcified mass in the pelvis, and cystoscopy revealed a fully mobile calculus in the bladder. During a transurethral cystolithotripsy, the IUCD was found within the calculus and removed transurethrally. No fistulae or defects were found in the bladder wall.

Medial displacement of T-tubes: case report

Medial displacement of T-tubes is rare and only 6 cases have been reported in literature. We report a case of a medial displacement of a T-tube in the middle ear behind an intact tympanic membrane with normal mobility. No treatment was undergone as the patient was asymptomatic and no hearing problems were detected. A brief overview of this unusual complication of tympanostomy tubes is presented and the management strategy is discussed.

Recurrent implantable cardioverter-defibrillator replacement is associated with an increasing risk of pocket-related complications

BACKGROUND

Despite beneficial effects of implantable cardioverter-defibrillator (ICD) therapy, limited service life results in replacement within the majority of patients. Data concerning the effect of replacement procedures on the occurrence of pocket-related adverse events are scarce. In this study, the requirement for pocket-related surgical re-interventions following ICD treatment and the effect of device replacement were evaluated.

METHODS

From 1992 to 2008, 2,415 patients receiving an ICD at the Leiden University Medical Center were analyzed. Pocket-related complications requiring surgical re-intervention following ICD implantation or replacement were noted. Elective device replacement, lead failure, and device malfunction were not considered pocket-related complications.

RESULTS

A total of 3,161 ICDs were included in the analysis. In total, 145 surgical re-interventions were required in 122 (3.9%) ICDs implanted in 114 (4.7%) unique patients. Three-year cumulative incidence for first surgical re-intervention in all ICDs was 4.7% (95% confidence interval [CI] 3.9-5.5%). Replacement ICDs exhibited a doubled requirement for surgical re-intervention (rate ratio 2.2, 95% CI 1.5-3.0). Compared to first implanted ICDs, the occurrence of surgical re-intervention in replacements was 2.5 (95% CI 1.6-3.7) times higher for infectious and 1.7 (95% CI 0.9-3.0) for noninfectious causes. Subdivision by the number of ICD replacements showed an increase in the annual risk for surgical re-intervention, ranging from 1.5% (95% CI 1.2-1.9%) for the first, to 8.1% (95% CI 1.7-18.3%) for the fourth implanted ICD.

CONCLUSIONS

ICD replacement is associated with a doubled risk for pocket-related surgical re-interventions. Furthermore, the need for re-intervention increases with every consecutive replacement.

CooperSurgical Colpotomizer Koh Cups are being left in patients after uterine surgery

The Koh cup--a component of the CooperSurgical Koh Colpotomizer system, which is used in some surgeries of the uterus-may detach during removal of the system from the patient, presenting the risk that it will be retained in the patient following surgery. Users should confirm that the system is intact when it is removed from the patient.

Insertion of tantalum beads in RSA of the hipVariations in incidence of extra-osseous beads with insertion site

Radiostereometric analysis (RSA) is a technique that can be used to measure the in-vivo micro-motion of the components of hip arthroplasty. It requires the insertion of tantalum beads into the bone permitting analysis of the radiographs. Extra-osseous beads reduce the usable bead pattern and previous studies have reported their incidence in the proximal femur as between 11% and 13% of all inserted beads. We reviewed the relative incidence of extra-osseous beads by examining 1038 radiographs of 97 patients who were part of an ongoing RSA hip study. Extra-osseous beads were seen in 44% of our patients with most having a single extra-osseous bead. The relative incidence of extra-osseous beads was 2% and 6% in the femur and pelvis, respectively. We observed a reduction in the incidence of the femoral beads with time, but not of the pelvis, which suggests that experience in the insertion technique improves the insertion rates at least of the femur. Our findings indicate that the incidence of extra-osseous beads is lower than previously reported. However, care should be taken in the design of studies to ensure that an adequate number of beads are placed in locations which are both surgically achievable and technically useful.

Hip revision using the Exeter stem, impacted morselized allograft bone and cementA consecutive 5-year radiostereometric and radiographic study in 15 hips

BACKGROUND

Impaction grafting in hip revision surgery is widely used but studies with mid- and long-term follow-up are scarce.

PATIENTS, METHODS AND RESULTS

A 5-year radiostereometric (RSA) follow-up of 15 hip revisions with the Exeter stem, morselized impacted allograft bone and cement revealed that 3 stems had not migrated between 2 and 5 years after revision, 11 stems had migrated to a minor degree in at least 1 direction, and 1 stem was loose according to RSA but without any radiographic signs of loosening or pain. The pain score was comparable to primary arthroplasties.

INTERPRETATION

From a 5-year perspective, first-time hip revisions for aseptic loosening with impacted morselized allograft bone and cement appear to yield good clinical results, although stem migration continues to a minor degree 2 years after revision.

A single-centre experience of over one thousand lead extractions

AIMS

The aim of the study was to present a single-centre experience of pacemaker and implantable cardioverter defibrillator (ICD) lead extraction using different methods, mainly laser-assisted extraction.

METHODS AND RESULTS

Data from 1032 leads and 647 procedures were gathered. A step-by-step approach using different techniques while performing an ongoing risk-benefit analysis was used. The most common indications were local infection, systemic infection, non-functional lead, elective lead replacement, and J-wire fracture. Mean implantation time for all leads was 69 months and for laser-extracted leads 91 months. Laser technique was used to extract 60% of the leads, 29% were manually extracted, 6% extracted with mechanical tools, 4% were surgically removed, and 0.6% extracted by a femoral approach. Failure rate was 0.7%, and major complication rate was 0.9%. No extraction-related mortality occurred. Median time for laser extraction was 2 min. Long implantation time was not a risk factor for failure or for complication.

CONCLUSION

Pacing and ICD leads can safely, successfully, and effectively be extracted. Leads can often be extracted by a superior transvenous approach; however, open-chest and femoral extractions are still required. Laser-assisted lead extraction proved to be a useful technique to extract leads that could not be removed by manual traction. The results indicate that the paradigm of abandoning redundant leads, instead of removing them, may have to be reconsidered.