Endobronchial management of a rare complication associated with pleural catheter

ENTEROCOCCUS FAECALIS EMPYEMA AS A RARE COMPLICATION OF INDWELLING PLEURAL CATHETER USED IN THE MANAGEMENT OF CHRONIC NONMALIGNANT PLEURAL EFFUSION

Objective: The complication associated with percutaneous interventions done on kidneys are usually easily identified and managed with defined protocols. These usually include bleeding, surrounding organ injury, or sepsis. Stripping or knotting of glidewire during these procedures is rare and have no defined management guidelines. There is a paucity in the literature about the management of these complications. A case series is reported on the management of this rare complication. Methods: A case series of 3 patients is presented, with 1 patient experiencing stripping of the glidewire and the other 2 having knotting of glidewire that got stuck during the percutaneous intervention done on the kidney. The guidewires were removed percutaneously with fluoroscopic guidance, thus avoiding the more morbid procedures of open surgery. Results: The stripped and knotted guidewires were removed percutaneously under fluroscopic guidance. we did not report failure or a complication in any of the cases. Conclusion: Stripping or knotting of guidewires is a rare complication occurring during many percutaneous procedures done on kidneys. They can be safely removed percutaneously with fluoroscopic assistance and the use of conventional endoscopic equipment. Lasers play an indispensable role in the management of these complications.

Unilateral exudative pleural effusions have been described as a rare complication of polycystic liver disease. Surgical debridement of the main cyst reduces recurrence of the pleural effusion. We describe the case of an elderly Asian woman with recurrent large right-sided pleural effusion and also a large hepatic cyst under her right hemidiaphragm. She was deemed a poor surgical candidate and was treated with an indwelling pleural catheter (IPC). She was discharged from Sengkang General Hospital with improvement in symptoms. An 88-year-old Asian woman presented twice to Sengkang General Hospital with recurrent right-sided exudative pleural effusion. She had a past medical history of hypertension, type 2 diabetes, hyperlipidemia, ischemic heart disease (left ventricle ejection fraction55%), atrial fibrillation, and chronic kidney disease stage 3 (estimated glomerular filtration rate 53). She denied any family history of polycystic kidney or liver disease. Computer tomography of her chest, abdomen, and pelvis revealed a large right pleural effusion and also a large hepatic cyst. A pleural catheter was inserted and the fluid analysis was consistent with an exudative effusion. The pleural fluid was sterile to culture for bacteria and mycobacterium. The cytology was negative for malignant cells. The pleural effusion recurred quickly despite repeated large-volume drainage from the pleural catheter. Our patient was not suitable for surgical debridement of the hepatic cyst and eventually received an IPC and was discharged. With the advent of IPC, there has been increasing interest in using IPC in the management of non-malignant pleural effusions. While surgical debridement of hepatic cysts is the preferred treatment option in recurrent pleural effusion associated with polycystic liver disease, IPCs now provide another viable and minimally invasive option for clinicians and patients.

Multiple randomized clinical trials have established the advantages of indwelling pleural catheter (IPC) in the management of malignant pleural effusions, resulting in its widespread adoption in clinical practice. Complications can occur with IPC use and must be recognized and managed effectively. This review provides a comprehensive overview of IPC complications and their best care. Pain postinsertion or during drainage of IPC is easily manageable and must be distinguished from tumor-related chest wall pain. IPC-related infections require systemic antibiotics and often intrapleural fibrinolytic/deoxyribonuclease therapy. The removal of IPC for infection is usually unnecessary. Symptomatic loculation usually responds to fibrinolytics but may recur. Catheter tract metastases are common in mesothelioma patients and usually respond to radiotherapy without inducing damages to the IPC. Less common complications include dislodgement, irreversible blockage, and fractures (upon removal) of the catheter. Recommendations on the management of IPC complications by recent consensus statement/guideline are discussed. Expert opinions on management approaches are included in areas where evidence is lacking to guide care.

Pleural pigtail catheter placement is associated with many complications including pneumothorax, hemorrhage, and chest pain. Air embolism is a known but rare complication of pleural pigtail catheter insertion and has a high risk of occurrence with positive pressure ventilation. In this case report, we present a 50-year-old male with bilateral pneumonia who developed a pneumothorax while on mechanical ventilation with continuous positive airway pressure mode. During the placement of the pleural pigtail catheter to correct the pneumothorax, the patient developed a sudden left sided body weakness and became unresponsive. An air embolism was identified in the right main cerebral artery, which was fatal.

The purpose of this case report is to describe an occurrence of a rare complication of lead extrusion, which was observed 10months after spinal cord stimulator (SCS) implantation. A patient with low back pain and failed back surgery syndrome underwent implantation of a SCS without complications. Ten months after implantation, one SCS lead extruded from her lower back leading to surgical removal of the leads. After identifying the complication of a SCS lead extruding from the patient's back, a surgical revision was performed to remove the SCS leads but retain the implantable pulse generator (IPG) in the gluteal region. During the surgery, it was noted that the anchors were in the appropriate position, sutured and fibrosed to a deep fascial layer. There were no complications from the surgical revision and no infectious process was observed. We report the occurrence and management of a rare complication of SCS lead extrusion after SCS implantation for failed back surgery syndrome. After recognition, removal of the leads with retention of the IPG was able to effectively resolve the complication. The revising procedure was well tolerated but resulted in the recurrence of the patient's previous low back pain. We believe that knowledge of this case and its management will aid future physicians in the recognition and management of this rare complication of SCS implantation. Furthermore, as there is a paucity of literature discussing the management of lead extrusion after SCS implantation, we hope that this case report will spur additional research on the management of this complication.

BACKGROUNDPeritoneal dialysis (PD) is an important renal replacement therapy for patients with end-stage renal disease. PD-related hydrothorax is a rare but serious complication in PD patients, produced by the movement of peritoneal dialysate through pleuroperitoneal fistulas. In previous reports, patients with hydrothorax secondary to PD were usually recommended to discontinue PD and transfer to hemodialysis (HD). Herein, we describe another method of managing this complication—with an adjusted PD prescription and continuous drainage of pleural effusion, patients could continue PD without recurrence of hydrothorax.CASE SUMMARYIn this report, we present the medical records of 2 patients with hydrothorax secondary to PD. We recommended intermittent PD with continuous drainage of pleural effusion. A type 18Ga soft catheter was placed to drain pleural effusion. Ultrasound-guided thoracentesis was performed, and the soft catheter was placed in the pleural cavity for a long period (3 mo and 2 mo, respectively). The pleural catheter was removed when no fluid was drained from the pleural cavity. After several months, pleuroperitoneal fistulas were closed in both patients and PD was continued. These patients did not transfer to HD, had no recurrence of hydrothorax and were still treated with PD after 1 year.CONCLUSIONThese 2 case reports show that continuous drainage of pleural effusion with an 18Ga soft catheter is a useful method for hydrothorax secondary to PD.

S269 – Anterior Cerebral Artery Syndrome: A Silent Killer in ESS

This review discusses long-term complications from immunosuppressants after liver transplantation and the management of these complications. Common complications of calcineurin inhibitors include nephrotoxicity and metabolic diseases. Nephrotoxicity can be managed by targeting a lower drug level and/or adding an immunosuppressant of a different class. Metabolic disorders can be managed by treating the underlying condition and targeting a lower drug level. Gastrointestinal adverse effects and myelosuppression are common complications of antimetabolites that are initially managed with dose reduction or discontinuation if adverse events persist. Mammalian targets of rapamycin inhibitors are associated with myelosuppression, proteinuria, impaired wound healing, and stomatitis, which may require dose reduction or discontinuation. Induction agents and agents used for steroid-refractory rejection or antibody-mediated rejection are reviewed. Other rare complications of immunosuppressants are discussed as well.

Autologous free tissue transfer is a safe and effective option for breast reconstruction. It is an increasingly utilized technique with well-demonstrated improved patient satisfaction and quality of life. Microvascular thrombosis is a rare but significant complication of microsurgical breast reconstruction, often resulting in flap failure. Proper diagnosis and timely management of this complication are essential to free flap salvage. While microvascular thrombosis poses a threat to flap survival, several methods may be employed to mitigate its more devastating effects. Here, we present a comprehensive review of arterial and venous thrombotic complications in both the intraoperative and postoperative settings. We discuss preoperative risk assessment, methods for flap monitoring, and operative and medical management of thrombotic complications. We present an updated algorithm for the intraoperative management of microvascular thrombosis adapted to reflect the most recent literature and our novel algorithm for the postoperative management of microvascular thrombosis.

The Frequency, Risk Factors, and Management of Complications From Pleural Procedures

A Case of Small Bowel Obstruction Following Appendectomy

Complications of ERCP

In the prethrombolytic era, ventricular septal rupture (VSR) complicated 1%–3% of all acute myocardial infarctions (AMIs). However, since the introduction of reperfusion therapy, the incidence of VSR has decreased, complicating 0.17%–0.31% of AMIs. Despite a reduction in incidence, mortality of patients with VSR remains high (41%–80%). It is important to identify this rare, but lethal complication at the earliest, as it is associated with high morbidity and mortality. Even with early diagnosis, the survival rate is not good. The management of this fatal complication is also a topic of debate. Even after much research, the management of this fatal complication is not standardized. Here, we present a case series of nine patients who developed VSR as a postmyocardial infarction complication and discuss management options for this rare lethal complication. Cases: We present 9 cases of VSR as a postmyocardial infarction complication. Among these nine patients with VSR, three patients underwent surgical repair, whereas 6 were treated conservatively for various reasons. These cases illustrate the challenges confronted in the diagnosis and management of postmyocardial infarction VSR as one of the rare but lethal complications of myocardial infarction. VSR is a rare but fatal complication of myocardial infraction that poses a challenge in diagnosis and management due to its varying presentation. Therefore, increased awareness of key diagnostic features is crucial for the early recognition of this complication and its effective management.

Proximal Extracapsular Tunneling: A Simple Technique for the Management of Impending Cylinder Erosion and Complications Related to Corporal Dilation