Balloon Port Research Articles

Five-year experience with optical balloon port for retroperitoneal access in children

Five-year experience with optical balloon port for retroperitoneal access in children

Balloon-assisted Transcatheter arterial embolization using N-butyl cyanoacrylate for iatrogenic arterial bleeding by groin puncture: a new technology

BackgroundBalloon-assisted transcatheter arterial embolization (TAE) using n-butyl cyanoacrylate (NBCA) and lipiodol (Lp) mixture is a new endovascular treatment technique for iatrogenic arterial bleeding by groin puncture. It is less invasive compared to surgical repair, and NBCA migration into the circulation can be prevented by temporary balloon occlusion of the parent artery without ultrasound-guidance. This study aimed to report on the technical aspects and evaluate the efficacy and safety of fluoroscopically guided balloon-assisted transcatheter arterial embolization using NBCA for iatrogenic arterial bleeding by groin puncture.Materials and methodsThe study included five patients (mean age 54.6 years; 3 male and 2 female) with iatrogenic arterial bleeding by groin puncture. We performed transcatheter arterial embolization using NBCA while occluding the responsible artery with a balloon catheter during the embolization to prevent NBCA migration. Two sheaths were inserted into the common femoral artery. A microcatheter was advanced into the pseudoaneurysm or extravasation via the contralateral sheath. A balloon catheter was advanced into the responsible artery until the balloon portion covered the leakage site via another sheath. After balloon inflation, the NBCA and Lip mixture was slowly injected until the pseudoaneurysm, or the extravasation was filled without touching the balloon. The microcatheter was removed immediately after the filling. We assessed technical success, overall success, and complications.ResultsThe injured arteries were the external iliac artery (n = 1), the common femoral artery (n = 2), and the proximal portion of the superficial femoral artery (n = 2). NBCA was injected once in four cases and twice in one case where complete hemostasis could not be achieved with one injection. The technical and overall success rate was 100% with no complications, including distal embolization of NBCA.ConclusionsBalloon-assisted TAE using NBCA is a feasible, effective, and safe treatment for iatrogenic arterial bleeding by groin puncture. It may also be applicable in other arterial bleeding situations where the potential risk of distal embolization can be decreased by applying the balloon-assisted technique.

Precostal top-down extended totally extraperitoneal ventral hernia plasty (eTEP): simplification of a complex technical approach.

Retromuscular mesh augmentation is generally considered to be the ideal technique for repairing ventral hernias and can be performed laparoscopically by 'enhanced view totally extraperitoneal plasty' (eTEP)-a technically complex procedure that requires a high level of surgical expertise. We aimed to develop a simplified technical modification. Thirty-one patients with ventral hernias were operated with a modified precostal, top-down eTEP approach, and prospectively recorded in our hernia registry. We describe this novel standardized precostal access and the bilateral development of both retromuscular compartments with a cylindrical dilating balloon port. Demographic-, hernia-specific-, and perioperative data were analyzed retrospectively. Twenty-two primary and 9 incisional hernias with an average defect size of 34.5cm2 were repaired. An average implant of 420cm2 always completely covered diastasis recti and/or scars from previous midline laparotomies. Average procedure time was 128min. One conversion was required due to peritoneal injury. Postoperatively there was one local infection and one patient suffered an interparietal herniation. There were no recurrences during the average 8-month follow-up period. With technical modification of precostal access and pneumatic balloon dilation of both retro-rectus compartments, the complex procedure can be simplified through time saving and straightforward unidirectional 'top-down' dissection. The better overview facilitates the crossover for connecting both retro-rectus spaces. In addition, the cranial access allows the anterior- and posterior layers to be closed up to the xiphoid.

Successful Partial Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in an Octogenarian Trauma Patient

- Background: To demonstrate how to perform successful REBOA/ABO in extreme elderly patient
 - Materials and methods: A case report
 - Results:
 A 86-year old male, he was struck by car and transferred to Level I Trauma center at Siriraj hospital after injury for 30 minutes. Arrival clinical signs were coma and hypotension, lowest SBP was 50 mmHg. Primary survey found unstable pelvic fracture and severe head injury. We did REBOA at Zone I via left common femoral artery which aim to do partial balloon technique by inflation with 15-18 mL and arterial line monitoring for goal SBP around 100-120 mmHg due to his extreme age and associated traumatic brain injury. After CT scan showed no intra-abdominal injury, we did reposition the balloon to zone III under fluoroscopy. Unexpectedly, during deflation the balloon before removal, we found fresh blood through the balloon port, then ruptured balloon was suspected and confirmed with aortography. We immediately converted to remove by open technique due to balloon was failed to shrinkage through 7-Fr sheath. We reviewed the CT scan was shown calcified plaque along aorta and arteries which could be the cause of ruptured balloon. Throughout all procedures to stop bleeding which are pelvic external fixation, preperitoneal pelvic packing and embolization at right internal iliac artery, patient was given PRC only 4 units and no inotropic support to stabilizing patient. Total inflation time was 167 minutes with partial and intermittent REBOA technique. ICU Admission lab showed normal renal and liver function.
 - Conclusion :
 To perform ABO/REBOA in extreme elderly trauma patient, the partial balloon technique with goal SBP to balance between associated injury in polytrauma patient is very essential. The specific concern in this group would be related with reserve function and the changing of vascular access. Techniques for detection and solving the uneventful conditions should be prepared and learnt to successfully save the elderly patient.

Parental home removal of urethral catheters after urological surgery—a prospective benchmarking study

Many urological operations require placement of a urethral Foley catheter. The catheter often needs to remain in situ for a period of time after discharge; and patients subsequently require either a further hospital admission or community nurse review for catheter removal. Parents can easily remove the catheter at home by cutting the balloon port. This disrupts the valve and hence deflates the retaining balloon, thereby facilitating spontaneous passage of the catheter. The authors introduced this practice to their institution. The aim was to assess safety and success of parental home catheter removal. A prospective data study was performed in a large pediatric urology center over a 12-month time period. Patients <16 years after single-stage hypospadias repair or other penile surgery were included on a voluntary basis. Parents of eligible patients were instructed verbally and with an information leaflet, including date for removal. Telephone follow-up after removal was undertaken to assess the outcome. Thirty-eight patients were included over a 12-month time period. Patient age ranged from 9 months to 12 years (median age 2.5 years). The majority (82%) of patients had required a catheter after hypospadias repair. Home catheter removal was successful in 92% cases. Three children required professional support for catheter removal. Median time until catheter passage was 3h (range 0-24h). Considering that cost for day case admission for catheter removal averages at 130£ per patient, home catheter removal saved the NHS 4550£ in the time period. This is the first study to report the safety and feasibility of parental home catheter removal by cutting the balloon port valve in the pediatric population. It offers a number of distinct advantages compared with traditional methods for removal. These include, namely, (i) positive patient experience: catheter removal in a familiar environment by a relative minimizes stressful experiences for the family; (ii) minimal trauma to healing tissues through spontaneous catheter passage; and (iii) health care-related cost savings. This was an initial benchmarking study, so patient numbers were relatively small. Nevertheless, it shows that the method is safeand received positive parental feedback. Parental home removal of a urethral catheter is a feasible and safe alternative to catheter removal by a health-care professional. It minimizes parental anxiety and inconvenience related to the catheter removal appointment and allows for significant cost savings.

Intercostal and Glissonian Pedicle Approach in Laparoscopic Liver Resection for Bilobar Tumors

BackgroundBilobar liver metastasis is challenging for laparoscopic liver resection. Especially, subphrenic liver tumors in S7 or S8 are technically difficult to be resected out because the space is limited and the angle of instruments to lesions cannot be perpendicular.1,2 Major liver lobectomy is also challenging for laparoscopic liver resection. Glissonian pedicle approach has benefit that any variation of vascular and bile duct elements does not need to be considered in the hepatoduodenal ligament under the hilar plate. Glissonian pedicle approach is simpler and faster than individual dissection of hepatoduodenal ligament. MethodsThis video illustrates a hand-assisted laparoscopic left lobectomy and partial liver resection of S8 in a 48-year-old male with metastatic colorectal carcinoma to the liver. He received 6 cycle of FOLFOX as neoadjuvant chemotherapy. The patient was positioned in semi left lateral decubitus so that a lesion in S8 was easily approached. A tumor in S8 was approached after right lobe mobilization. The liver resection was performed by a harmonic scalpel. A 5-mm balloon port was placed in 6th intercostal space to approach the lesion perpendicular. For left hepatectomy, glissonian pedicle approach was applied to control vascular inflow. Dissections was performed at bifurcation on the right glissonian and left glissonian pedicles. Dissection direction to the left side was above hepatogastric ligament. The tunnel was created including all left glissonian sheath, and a vessel loop was taped. An endovascular stapler was inserted and fired with dividing the left glissonian pedicle as en bloc. Hepatic parenchymal dissection was performed by the harmonic scalpel. Left hepatic vein was divided using an endoscopic vascular stapler. The specimens were removed from a hand-port. ResultsThe operative time was 290 min. Blood loss was 250 ml, and no blood transfusion was required. He resumed a regular diet the next day and was discharged on postoperative day 4. ConclusionsIntercostal approach is useful for subphrenic liver tumors, and glissonian pedicle approach is also useful for major lobectomy for laparoscopic liver resection.

Intercostal and glissonian pedicle Approach in laparoscopic liver resection for bilobar tumors

Bilobar liver metastasis is challenging for laparoscopic liver resection. Especially, subphrenic liver tumors in S7 or S8 are technically difficult to be resected out because the space is limited and the angle of instruments to lesions cannot be perpendicular.1,2 Major liver lobectomy is also challenging for laparoscopic liver resection. Glissonian pedicle approach has benefit that any variation of vascular and bile duct elements does not need to be considered in the hepatoduodenal ligament under the hilar plate. Glissonian pedicle approach is simpler and faster than individual dissection of hepatoduodenal ligament. This video illustrates a hand-assisted laparoscopic left lobectomy and partial liver resection of S8 in a 48-year-old male with metastatic colorectal carcinoma to the liver. He received 6 cycle of FOLFOX as neoadjuvant chemotherapy. The patient was positioned in semi left lateral decubitus so that a lesion in S8 was easily approached. A tumor in S8 was approached after right lobe mobilization. The liver resection was performed by a harmonic scalpel. A 5-mm balloon port was placed in 6th intercostal space to approach the lesion perpendicular. For left hepatectomy, glissonian pedicle approach was applied to control vascular inflow. Dissections was performed at bifurcation on the right glissonian and left glissonian pedicles. Dissection direction to the left side was above hepatogastric ligament. The tunnel was created including all left glissonian sheath, and a vessel loop was taped. An endovascular stapler was inserted and fired with dividing the left glissonian pedicle as en bloc. Hepatic parenchymal dissection was performed by the harmonic scalpel. Left hepatic vein was divided using an endoscopic vascular stapler. The specimens were removed from a hand-port. The operative time was 290 min. Blood loss was 250 ml, and no blood transfusion was required. He resumed a regular diet the next day and was discharged on postoperative day 4. Intercostal approach is useful for subphrenic liver tumors, and glissonian pedicle approach is also useful for major lobectomy for laparoscopic liver resection.

Efficacy of freeze-dried amnion graft following hysteroscopic adhesiolysis of severe intrauterine adhesions.

To evaluate the efficacy of freeze-dried amnion graft for prevention of intrauterine adhesion (IUA) reformation after hysteroscopic adhesiolysis. A prospective randomized controlled trial was conducted among 88 women with severe IUAs who underwent hysteroscopic adhesiolysis at Beijing Obstetrics and Gynecology Hospital between July 15, 2015, and July 1, 2016. All participants had a balloon inserted into the uterine cavity for 1week. Sterilized freeze-dried amnion graft covered the balloon portion of the Foley catheter among patients allocated to the amnion group (n=44), whereas patients in the control group (n=44) did not receive the graft. Follow-up hysteroscopy was performed 3months after surgery. Preoperative and postoperative IUA scores, menstruation scores, and pregnancy rates were assessed. Both groups exhibited reductions in IUA scores and improvements in menstruation scores following treatment (P<0.001 for each measure). Compared with the control group, the amnion group had a lower IUA score (P=0.032) and a higher menstruation score (P<0.001) at follow-up. By contrast, the rates of IUA reformation and pregnancy were not significantly different between the two groups. Use of freeze-dried amnion graft was effective in reducing IUA reformation and improving menstruation (according to pictorial blood-loss assessment chart) following hysteroscopic adhesiolysis of severe IUAs. ClinicalTrials.gov: (NCT02496052).

Balloon-Inflated Catheters for Enteral Feeding: a Word of Caution.

Catheters with inflatable balloons such as a Foley catheter may be used for feeding gastrostomy/jejunostomy. The incorrect or improper use of these catheters can have serious consequences. We report 13 cases of feeding jejunostomy with balloon-inflated catheter's malfunction, some referred to our centre and others operated here over a period of 8years. The most dramatic consequence of such improper use led to rupture of the small intestine due to inadvertent over-inflation (over 100ml) of the balloon of the catheter during a contrast study. The patient required a laparotomy with resection and anastomosis of the bowel. Three other patients had similar over-inflation of the balloon leading to severe pain and discomfort. In all three patients, timely deflation of the balloon was sufficient to relieve the symptoms. One patient had intussusception with the inflated balloon acting as a lead point. The patient underwent resection of the small bowel with end jejunostomy and distal mucous fistula. All other patients presented with abdominal pain and distension and intestinal obstruction and were managed non-operatively with deflation of balloon either by aspiration, cutting the balloon port or ultrasound-guided puncture of balloon. Healthcare personnel dealing with patients with indwelling catheters must be educated to suspect, detect and manage such problems. The best measure for such unusual complications of otherwise safe devices would be prevention by training and generation of awareness.

Yes or no? Pretesting indwelling urinary catheter balloons

Insertion of an indwelling (retention) urinary catheter is a frequently performed procedure in the acute care setting, with approximately 25% of patients having a urinary catheter placed at some point during hospitalization (see Reasons to place an indwelling urinary catheter). Indwelling catheters are associated with increased incidence of urinary tract infections and can impact patient comfort and safety (see Potential risks of indwelling urinary catheter placement). Historically, indwelling catheter balloons were pretested by nurses before insertion to prevent the use of a defective catheter. However, some manufacturers pretest their indwelling catheter balloons before sterilization and packaging as a quality control measure and specifically instruct healthcare professionals not to do so. How does this translate into practice? Evidence says... Evidence-based practice (EBP) recommendations don't support pretesting indwelling catheter balloons by putting the prefilled sterile water syringe into the balloon port before insertion. The rationale underscoring this clinical decision is that pretesting the balloon may stretch and actually distort the catheter, resulting in damage that can lead to increased trauma on insertion. Previously, pretesting of indwelling catheter balloons was done as a way to prevent insertion of a catheter with a defective balloon. However, pretesting doesn't guarantee that the balloon won't be defective once the catheter is in the bladder. In addition, pretesting silicone catheter balloons isn't recommended; the silicone can develop a cuff or crease at the balloon area that may result in trauma to the urethra during catheter insertion and removal. The sterile kit will generally have clear instructions indicating the status of balloon pretesting; the recent consensus is to nix pretesting entirely. Recommendations for catheter selection and insertion should be followed so that the catheter doesn't cause harm to your patient. Furthermore, review your facility's guidelines and apply its policy regarding pretesting of indwelling catheter balloons. Nurses entering the workforce are usually not taught to pretest indwelling catheter balloons because several nursing text manuals recommend against it. CDC guidelines advise that hospital personnel and individuals who participate in catheter care should be given regular in-service training that emphasizes use of the correct technique, as well as the possible complications of urinary catheterization, such as catheter-associated urinary tract infections and urosepsis. Keeping current and safe As nurses, we're responsible for keeping up with EBP recommendations and knowing the risks and benefits of any procedure we're performing. Review your facility's current policies and advocate for changes when necessary. It's vital that we translate evidence into practice to improve patient safety and optimize outcomes. Further research will be beneficial to fully elucidate the implications for nurse-driven protocols and develop consistency in standardized practices. Reasons to place an indwelling urinary catheter Acute urinary retention or bladder outlet obstruction Accurate intake and output measurements in critically ill patients Selected surgical procedures (genitourinary surgery/colorectal surgery) Intraoperative monitoring of urinary output during surgery or diuretic therapy Continuous or intermittent bladder irrigations Healing of open sacral/perineal wounds in incontinent patients Prolonged immobilization (such as in multiple traumatic injuries) Comfort for end-of-life care Potential risks of indwelling urinary catheter placement Urethral trauma Urethral or perineal irritation Catheter encrustation Compromised mobility

Port Placement and Docking for Robotic Surgery: The University of Southern California Approach.

To describe our approach for port placement and robot docking for pelvic and kidney surgery (KS). We use a four-arm robotic approach and a 5 to 6 port placement consisting of: One 12-mm camera port, three 8-mm robotic ports, and one to two assistant ports. For radical prostatectomy, the working robotic ports run parallel below the level of the umbilicus. Radical cystectomy ports are more cephalad and above the level of the umbilicus. For transperitoneal KS, two bariatric robotic ports are used, aiming for an equilateral triangle configuration. With retroperitoneal (RN) KS, a balloon dilator and balloon port create the RN space; bariatric ports comprise the most anterior and posterior ports. This technique has been used since 2010 on more than 2370 robotic urologic cases. To date, no procedure has needed patient or robot positioning while maintaining fourth arm functionality with minimal robotic arm clashing. Our approach of port placement and robot docking is reproducible and feasible for pelvic surgical procedures and KS.

Successful Obliteration of a Pseudoaneurysm from Post-CEA Repair Secondary to a Pruitt-Inahara Shunt Using a Stent Graft

Pseudoaneurysms of the carotid artery are very uncommon complications following carotid endarterectomy. Pseudoaneurysms are usually caused by any kind of blunt injury or trauma during carotid artery surgery. CEA has become an increasingly more common vascular surgery performed in the United States. The standard of treatment for a carotid PA has been open surgical repair with excision of the defect and then a graft reconstruction of the artery. Advancements in endovascular intervention have helped to make it a more popular choice in treatment because of the positive results and less invasive approach. This case report describes the successful obliteration of a large post-CEA PA using a stent graft. The PA was likely secondary to the use of a Pruitt-lnahara Shunt because it was found to be distal to the endarterectomized area of the carotid artery which means that the defect was likely caused by the balloon portion of the shunt. This case demonstrates the feasibility of using endovascular interventional techniques to treat a PA using a stent graft.

Endovascular Treatment of Shunt-Induced Carotid Pseudoaneurysm: Less Invasive but Still a Big Risk

Objective: Carotid artery pseudoaneurysm (PSA) is a challenging complication of carotid endarterectomy (CEA). We present a case and literature review of post-CEA PSAs successfully treated percutaneously with a covered stent. Methods: A 57-year-old woman underwent a CEA of the left internal carotid artery using patch closure and selective shunting using a Pruitt-Inahara shunt. She was found to have a 3-cm incidental carotid artery PSA 3 months later distal to the endarterectomized portion of the artery, the injury likely resulting from the clamp or the balloon portion of the shunt. A percutaneous 5-mm 25-mm Viabhan (Gore, Flagstaff, Ariz) covered stent was deployed to successfully exclude the PSA. The patient suffered no complications. Follow-up duplex imaging at 3 and 6 months and at 1 year confirmed PSA sealing and patency of the internal carotid artery. Results: A PubMed search of the topic found 15 patients (Table) with post-CEA PSA treated with a covered stent. The results revealed the procedure is technically feasible with acceptable patency rates, the longest being 9 years. The procedure, however, caries a significant rate of periprocedural complications: one (7%) bleeding complication, four strokes (26%) and two deaths (13%). Conclusions: Endovascular repair of carotid PSA with a covered stent can be successfully performed; however, high complication rates should be considered before undertaking the procedure. Review of literature on results of endovascular treatment of postoperative carotid artery pseudoaneurysm using covered stents

Use of a New Double-Lumen Balloon Catheter for Single-Catheter Balloon-Assisted Coil Embolization of Intracranial Aneurysms: Technical Note

The prevalence of intracranial aneurysms is approximately 2% with an annual rupture rate of 0.7%. We describe our initial feasibility experience using a new double-lumen balloon catheter for single-catheter balloon-assisted coil embolization of wide-neck intracranial aneurysms. Two patients with large wide-neck intracranial aneurysms were referred for endovascular therapy. Endovascular treatment in the form of coil embolization alone was not feasible given the angioarchitecture of the aneurysms. Balloon-assisted coil embolization was planned. The patients underwent balloon-assisted coil embolization using the Ascent double-lumen balloon catheter (Micrus, San Jose, California). The balloon portion of the catheter was placed into the proximal neck of the aneurysm. The balloon was inflated and coil embolization performed through the inner lumen of the catheter. There were no procedural complications. Both aneurysms were successfully coiled by using the Ascent balloon occlusion catheter. The single-catheter balloon-assisted coil embolization technique can be performed safely and effectively with the Ascent double-lumen balloon catheter.

Transanal division of the anorectal junction followed by laparoscopic low anterior resection and coloanal pouch anastomosis: A technique facilitated by a balloon port

We performed a laparoscopic ultra low anterior resection in two patients with low rectal cancers (3 cm from dentate line). A transanal division and continuous suture closure of anorectal junction was performed first followed by laparoscopic low anterior resection. A handsewn anastomosis between colonic pouch/transverse coloplasty and anal canal was facilitated by use of a transanal balloon port.

Laparoscopic Hernia Repair: a Two-Port Technique

Various ventral and incisional hernia repair techniques exist and have largely replaced the open ones. The purpose of this study was to document the 2-port technique and demonstrate that it is feasible, efficient, and safe. To our knowledge, this is the largest report on this topic to date in the English-language literature. Forty patients with ventral hernias (VH) or incisional hernias (IH) underwent laparoscopic repair with a 2-port technique. The technique involves insertion of one 10-mm to 12-mm balloon port and one 5-mm port, usually on the left side as laterally as possible. A mesh is inserted through the balloon port site and secured to the abdominal wall by using either 4 peripheral or 1 central Prolene suture. Helical fasteners are used to attach the mesh to the abdominal wall. Forty patients with 47 hernias underwent repair. Operating time ranged from 15 minutes to 70 minutes. Early complications were seen in 5 patients and included 1 small bowel enterotomy, 2 small bowel obstructions (SBO) with bowel adhering to the visceral side of the mesh, 1 wound infection, and 1 seroma. Late postoperative complications occurred in 8 patients (20%) who experienced persistent abdominal pain that resolved without any treatment. There was one recurrence during a mean follow-up of 23.5 months. Laparoscopic herniorrhaphy with the 2-port technique offers an efficient, safe, and effective repair for ventral and incisional hernias.

The role of dose escalation with intracavitary brachytherapy in the treatment of localized CNS malignancies: Outcomes and toxicities of a prospective study

Purpose This single-institution prospective study was designed to investigate the feasibility and safety of dose escalation with GliaSite (Proxima Therapeutics Inc., Alpharetta, GA) brachytherapy for the treatment of patients with newly diagnosed and recurrent central nervous system (CNS) tumors after neurosurgical resection. We now report mature results of this trial, its outcomes, and a toxicity profile. Methods and Materials Ten adult consecutive patients with recurrent and newly diagnosed CNS malignancies underwent GliaSite brachytherapy after maximally safe neurosurgical resection between 2004 and 2007. GliaSite balloon was placed intraoperatively, and the size was selected so as to conform to the surgical cavity. Low-dose-rate radiation was delivered with an aqueous solution of organically bound 125I (Iotrex: sodium 3-( 125I)-iodo-4-hydroxybenzenesulfonate; Proxima Therapeutics Inc.), introduced into the balloon portion of the device via a subcutaneous port. Two to 3 weeks later, the device was filled with Iotrex for a median dwell time of 94.3 hours (range, 68.0–120.5 hours), after which the balloon was explanted. A commercial 3-D planning system was used for a detailed analysis of dosimetry. Median dose of 52.0 Gy (range, 45.0–60.0 Gy) was prescribed 0.5–1.0 cm from the balloon surface. Radiation Therapy Oncology Group (RTOG) criteria were used to assess acute and long-term toxicities associated with this technique. Followup was assessed with MRI scans and was available on all enrolled patients. Results Median followup for surviving patients was 38 months (range, 18–57 months). Mean size of GliaSite balloon was 3.4 cm (range, 2.0–4.0 cm). Mean volume of filling was 19.0 cc (range, 4.0–35.0 cc). Median activity of Iotrex was 301.6 mCi (range, 95.0–515.4 mCi). Median survival was 14.0 months for the entire cohort after the treatment with the GliaSite device. Of our cohort, 6/10 (60%) patients sustained recurrence (20% local and 40% distant). Median time to recurrence after treatment with GliaSite was 8.0 months, and median time to death after recurrence was 7.5 months. There were no RTOG Grade 3 or 4 acute or late toxicities. Followup MRI imaging did not identify any evidence of radiation necrosis. Conclusions Our data indicate that treatment with GliaSite balloon brachytherapy is feasible and safe, while rendering acceptable local control and minimal acute and long-term toxicities for newly diagnosed and recurrent CNS malignancies. These encouraging results compel us to embark on testing larger numbers of patients with this treatment modality.

Complication of a Percutaneous Endoscopic Gastrostomy Tube Causing Duodenal Ischemia

A 33-year-old woman with a percutaneous endoscopic gastrostomy tube was admitted with bilious vomiting, 1 month after her feeding tube was replaced by a temporary Foley catheter. A computed tomography scan of her abdomen revealed a 4.5 cm by 7.5 cm fluid-filled structure in the distal duodenum surrounding the Foley feeding tube. Approximately 100 mL of fluid was aspirated from the Foley's balloon port. We hypothesized that the Foley catheter was flushed inappropriately through the balloon port, causing an iatrogenic ischemic duodenal injury. Conservative management was successful in the intensive care unit. This case highlights an unusual complication of percutaneous endoscopic gastrostomy tubes. In addition, it emphasizes the temporary nature of Foley catheters as replacement gastrostomy tubes, and the importance of training in the handling of feeding tubes.

An inflatable balloon catheter and liquid 125I radiation source (GliaSite Radiation Therapy System) for treatment of recurrent malignant glioma: multicenter safety and feasibility trial.

In this study the authors evaluated the safety and performance of the GliaSite Radiation Therapy System (RTS) in patients with recurrent malignant brain tumors who were undergoing tumor resection. The GliaSite is an inflatable balloon catheter that is placed in the resection cavity at the time of tumor debulking. Low-dose-rate radiation is delivered with an aqueous solution of organically bound iodine-125 (lotrex [sodium 3-(125I)-iodo-4-hydroxybenzenesulfonate]), which are temporarily introduced into the balloon portion of the device via a subcutaneous port. Adults with recurrent malignant glioma underwent resection and GliaSite implantation. One to 2 weeks later, the device was filled with Iotrex for 3 to 6 days, following which the device was explanted. Twenty-one patients with recurrent high-grade astrocytomas were enrolled in the study and received radiation therapy. There were two end points: 1) successful implantation and delivery of brachytherapy; and 2) safety of the device. Implantation of the device, delivery of radiation, and the explantation procedure were well tolerated. At least 40 to 60 Gy was delivered to all tissues within the target volume. There were no serious adverse device-related events during brachytherapy. One patient had a pseudomeningocele, one patient had a wound infection, and three patients had meningitis (one bacterial, one chemical, and one aseptic). No symptomatic radiation necrosis was identified during 21.8 patient-years of follow up. The median survival of previously treated patients was 12.7 months (95% confidence interval 6.9-15.3 months). The GliaSite RTS performs safely and efficiently. It delivers a readily quantifiable dose of radiation to tissue at the highest risk for tumor recurrence.

Early Recognition of Air Leakage from the Balloon of Pulmonary Artery Catheter during Its Advancement by Transesophageal Echocardiography

Transesophageal echocardiography (TEE) in addition to the conventional pressure tracing method may enhance a proper insertion of pulmonary artery (PA) catheter by providing information about the real-time location of catheter. We report a case of abrupt air leakage from the balloon of PA catheter during its advancement that was immediately diagnosed by TEE in 54-year-old male with moderate tricuspid regurgitation for elective CABG. Introducer and sheath of PA catheter were inserted in right internal jugular vein. After checking balloon function, connecting distal port to a previously zeroed transducer and confirming the location in right atrium, PA catheter was advanced under direct the visual surveillance by TEE images as well as pressure tracing. During the third trial of catheter advancement through tricuspid valve, multiple air shadows, which convincing balloon leakage, were appeared in right atrium in the view of TEE after inflation of air. We withdrew catheter immediately without any further effort of balloon inflation or advancement, then, balloon leakage and the incapability of balloon expansion were confirmed by saline injection, instead of air, into the balloon port. We replaced the injured PA catheter to new one, and advanced it successfully to the wedged position by the aid of TEE and pressure tracing. We assumed that TEE image might be a beneficial aid to enhancing PA catheter placement in a proper position and preventing possible complications or side effects produced by advancing it with unawareness or delayed recognition of its dysfunction.