Evidence Of Contrast Extravasation Research Articles

Ruptured pial-pial collateral aneurysm associated with left internal carotid artery occlusion: nuances of surgical management. Illustrative case.

Carotid occlusion often leads to the formation of a collateral network. On rare occasions, due to hemodynamic influence, aneurysms can occur. Here, the authors describe a 69-year-old male presenting with intracerebral hemorrhage secondary to a ruptured aneurysm within such a network. The patient presented to the emergency department with an altered level of consciousness. Imaging showed a left temporal lobe hemorrhage extending into the ventricle, subdural hematoma, and evidence of contrast extravasation. Digital subtraction angiography revealed an occluded left internal carotid artery with the left middle cerebral artery territory reconstituted by flow through an external carotid artery-internal carotid artery anastomosis. The latter was formed by the superficial temporal artery-superior orbital artery, as well as pial-pial collaterals from the posterior temporal artery. Notably, a 4-mm aneurysm arising from the pial-pial collateral network was identified. Surgical intervention involved a left temporal craniectomy and aneurysm excision, with special attention paid to preserving the anastomotic flow through the superficial temporal artery. This case underscores the importance of recognizing and preserving collateral vascular pathways in cases of carotid occlusion with an associated aneurysm. It emphasizes the necessary balance between managing aneurysm risk and maintaining cerebral perfusion, highlighting the need for careful preoperative planning and intraoperative caution.

Cannabinoid hyperemesis syndrome complicated by pneumomediastinum: implications for pediatrics

Background. Cannabinoid hyperemesis syndrome / CHS (prolonged and frequent use of high-dose cannabis) in the pediatric population has been increasingly reported over the last decade. CHS can lead to life-threatening complications such as pneumomediastinum, which warrant careful consideration for surgical intervention. Case Presentation. A 17-year-old female with no significant past medical history presented to the emergency department with abdominal, chest and back pain (worse with deep inspiration), nausea, and vomiting for 24 hours. Upon further history, the patient reported a similar episode six months ago, being a cannabis smoker (at least once a day) in the last two years. Chest X-ray revealed a subtle abnormal lucency along the anteroposterior window and anterior mediastinum, consistent with a small amount of pneumomediastinum without any other acute intrathoracic abnormalities. Follow-up chest computed tomography with contrast showed multiple foci of air within the anterior and posterior mediastinum tracking up to the thoracic inlet. There was no evidence of contrast extravasation; however, small esophageal perforation could not be excluded. Given uncomplicated pneumomediastinum (without frank contrast extravasation) the patient was treated medically with piperacillin-tazobactam, metronidazole, and micafungin for microbial prophylaxis; hydromorphone for pain control; as well as with pantoprazole, ondansetron, and promethazine. Nutrition was provided via total parenteral nutrition. The evolution was favorable (no signs of occult esophageal perforation occurred), being advanced to a soft diet on hospital day eight, solid food diet on day nine, at which point antibiotics were discontinued, and the patient was subsequently discharged. Conclusion. CHS in increasingly encountered in the pediatric setting due to rising prevalence of cannabis use. The management of CHS and potentially life-threatening complications such as pneumomediastinum should be given careful consideration. Pneumomediastinum can be a harbinger of esophageal perforation that may warrant urgent surgical intervention.

Bulbar urethrocavernous fistula in setting of inflatable penile prosthesis: a case report

BackgroundUrethral injury or erosion of an inflatable penile prosthetic (IPP) cylinder is a rare complication of IPP placement. It can present with varying symptoms and management can be difficult with risk for future complications.We present a patient with an eroded IPP who developed a secondary contralateral urethrocavernous fistula requiring repeat urethroplasty. We also describe the literature surrounding these complications and strategies to prevent them.Case presentationA 69-year-old man with poorly controlled diabetes presented to our clinic with 6 months of intermittent white urethral discharge first noted after IPP removal and replacement by an outside urologist for device malfunction. Office cystoscopy revealed an eroded right-sided prosthetic cylinder in the bulbar urethra. The patient was taken to the operating room for IPP explantation with closure of right corporal defect, left sided malleable prosthesis placement, and primary excision with anastomosis of his bulbar urethra. A catheter was left in place for two weeks postoperatively, at which time a peri-catheter retrograde urethrogram was performed which showed no evidence of contrast extravasation and his catheter was subsequently removed. Several months later, he presented with recurrent urethral discharge without evidence of recurrent erosion on cystoscopy with development of scrotal abscesses following office cystoscopy, concerning for an unidentified urethral defect. He returned to the operating room for scrotal exploration and was noted on cystoscopy to have a pinpoint fistula between his left corporal body and his bulbar urethra. He underwent left sided malleable prosthetic explant, and non-transecting bulbar urethroplasty. Peri-catheter retrograde urethrogram two weeks later showed no contrast extravasation and he has had no recurrence of urethral discharge or scrotal abscesses since.ConclusionsUrethral erosion and urethrocavernous fistula formation are rare complications of penile prosthesis placement. Risks are elevated in patients with corporal fibrosis, diabetes, those undergoing penile implant revision surgery, and those requiring prolonged urethral catheterization.

S1908 Use of Biliary Stent in Premature Infant With Severe Esophageal Anastomotic Stricture After Esophageal Atresia Repair

INTRODUCTION: Anastomotic strictures following surgical repair of esophageal atresia is common. Symptomatic strictures may require periodic dilation or, in refractory cases, surgery. Placement of an endoscopic metal stent is a less invasive alternative to surgical revision. Few cases describe an early, proactive approach to stent placement in premature infants who have increased risk for complications. CASE DESCRIPTION/METHODS: A 31 week-old 1.3 kg female presented with hypoxia after birth. Type C esophageal atresia was identified and tracheoesophageal fistula division was completed but anastomosis was deferred for ∼3.5 weeks given proximal-distal esophageal gap. GJ tube placed for feeds. Patient had ongoing, episodic hypoxic episodes requiring HFNC. Bronchoscopy and laryngoscopy were largely unremarkable. Attempt at EGD was unsuccessful, and gastroscope was unable to be advanced secondary to esophageal stenosis. Esophagram revealed severe anastomotic stenosis. Attempt at wire guided dilation via radiology was unsuccessful. Therefore, combined anterograde-retrograde EGD was attempted and luminal continuity was achieved via guidewire using transillumination. The tract was sequentially dilated to 9 Fr and a fully covered 8 mm metal biliary stent was placed. Within one week, the patient discharged, tolerating feeds without apnea. On repeat EGD, four weeks later, the lumen was patent and the stent was exchanged for another fully covered 8 mm biliary stent to assist with further healing. No further dilation was required. Six weeks from initial EGD, the biliary stent was removed with a widely patent lumen. Repeat esophagram revealed no stricture, leak or fistula. DISCUSSION: Stent placement for anastomotic stricture in pediatrics is traditionally reserved for patients who fail serial balloon dilations or surgical revision. Although balloon dilation therapy has good safety and efficacy profiles, the vast majority of patients require serial dilations and 20% of patients experience ineffective symptom relief. In this patient, in consideration of young age and risk for repeated procedures, it was opted for early intervention via esophageal stent. Lumen patency was achieved within 6 weeks and therapy for oral ingestion could take place. This case represents an important clinical scenario where esophageal stenting should be considered initially and is one of the earliest successful uses of biliary stent in the management of severe esophageal stricture after esophageal atresia repair.Figure 1.: A series of endoscopic images revealing successful guidewire placement through severe anastomotic stricture (Image 1) followed by metal biliary stent placement (Image 2) using combined anterograde-retrograde endoscopy. On repeat endoscopy six weeks later, the metal biliary stent (Image 3) was removed revealing a widely patent lumen (Image 4) and resolution of the esophageal stricture.Figure 2.: Left image: Initial esophagram revealing a patulous proximal esophageal pouch with no obvious luminal continuity with the distal esophagus. Right image: Esophagram after esophageal stent removal revealing mild proximal esophageal dilation and no evidence of contrast extravasation or residual tracheoesophageal fistula.

S1997 Spontaneous Pneumomediastinum Secondary to Cannabinoid Hyperemesis Syndrome

INTRODUCTION: Marijuana use has been infrequently identified as a potential risk factor for the development of spontaneous pneumomediastinum, a rare condition characterized by free air in the mediastinum not preceded by medical or surgical trauma. We present the case of cannabinoid hyperemesis syndrome causing spontaneous pneumomediastinum. CASE DESCRIPTION/METHODS: A 23-year-old female with a history of cannabinoid hyperemesis syndrome presented to the emergency room with a 3-day history of chest pain associated with nausea and multiple episodes of vomiting. She confirmed a three-year history of daily inhaled marijuana use. A CT Chest revealed extensive pneumomediastinum with air tracking along the left hilum/bronchovascular sheath of an unclear source with no radiographic evidence of chest trauma. The patient was admitted to the intensive care unit for continued management. Subsequent water-soluble contrast esophageal revealed findings consistent with pneumomediastinum and no evidence of esophageal perforation, hence Boerhaave’s syndrome was excluded. Given her recurring cyclic vomiting in the setting of cannabis the patient was diagnosed with cannabinoid hyperemesis syndrome (CHS) with spontaneous pneumomediastinum. The patient was managed conservatively, with complete recovery and extensively counseled on cannabis cessation. DISCUSSION: Inhaled marijuana use has been infrequently identified as a potential risk factor for the development of spontaneous pneumomediastinum. Spontaneous pneumomediastinum is a rare clinical entity defined as the presence of free air within the mediastinal structures in the absence of thoracic trauma, surgery, or medical procedure. It is a self-limiting condition resulting from alveolar rupture secondary to an acute increase in intrathoracic pressure subsequently leading to dissection of air along the bronchovascular sheath towards the mediastinum. The hypothesized pathophysiology of marijuana related pneumomediastinum is barotrauma occurring during breathing movements. SPM is managed conservatively with analgesia and treatment of the underlying etiology. Long term prognosis depends on the etiology of the SPM and involves lifestyle modification especially in the setting CHS. Diagnosis of a SPM can often be overlooked as its presenting symptoms remains non-specific. A comprehensive history should be obtained including a detailed history of tobacco and cannabinoid use in patients with intractable nausea and vomiting with a low threshold for chest imaging.Image 1.: Air within the mediastinal structures with no evidence of perforation.Image 2.: Water-soluble contrast esophagram with no evidence of contrast extravasation into the mediastinum.

S2764 A Novel Cause of Odynophagia From Unintentional Foreign Body Introduction During EGD With Dilation

INTRODUCTION: Esophageal dilation is a valuable treatment option for multiple symptoms including dysphagia. Like all procedures, dilation carries its own unique risks including iatrogenic injury. We present a patient who underwent dilation and suffered a medical error when a sterilization indicator strip was inadvertently placed and left in her esophagus. CASE DESCRIPTION/METHODS: An 88-year-old female presented to a referring hospital with suspected food bolus impaction. The week prior, she had undergone an esophageal dilation for solid food dysphagia. The day after the procedure, she developed intermittent, spasm-like substernal chest pain. Her symptoms worsened to include dysphagia, hematemesis, regurgitation, and inability to tolerate her saliva which prompted her to return to the hospital. On arrival, her vitals, labs, EKG, and CXR were within normal limits and without acute findings. A CT scan of the chest demonstrated a dilated esophagus with intraluminal contents at the upper thoracic inlet. Upon transfer to our facility, GI recommended a trail of glucagon. She continued to have symptoms, which prompted an evaluation with EGD. This revealed a stiff, plastic-like foreign body in the upper esophagus. The distal edge was embedded within the esophageal mucosa causing ulceration and raising concern for impending perforation (Figure 1). Attempts were made to remove the object using a raptor grasper. Eventually, the object was removed with a jumbo oval snare. There were no deep mucosal tears or active bleeding noted after removal (Figure 2). The object was identified as a sterilization indicator strip which was almost certainly introduced at her dilation the week prior (Figure 3). An esophagram revealed moderate esophageal dysmotility without stricture, mass, or evidence of contrast extravasation. She was ultimately discharged home on a PPI with outpatient GI follow-up. DISCUSSION: In the patient presented, we do not know the type of dilator used or if any complications were encountered during dilation. We suspect the indicator strip was introduced either through a pre-dilation EGD or stuck to the dilator itself. Indicator strips can take a concave shape which allows them to adhere to round equipment reprocessed for GI procedures. Given the reduced lighting during these procedures, careful inspection of equipment is necessary to avoid missing these objects. Perhaps by standardizing a post-dilation EGD to evaluate for complications, this could have been addressed sooner.Figure 1.: Foreign Body Located in the Proximal Esophagus.Figure 2.: Esophagus following Foreign Body Removal.Figure 3.: Foreign Body after Removal from the Esophagus.

The abdominal CTA shows aneurysmal dilatation of the descending thoracic aorta, surrounded by massive amount of blood products and evidence of contrast extravasation in the posterior aspect. Findings c/w aortic rupture

The abdominal CTA shows aneurysmal dilatation of the descending thoracic aorta, surrounded by massive amount of blood products and evidence of contrast extravasation in the posterior aspect. Findings c/w aortic rupture

Bi-layer silk fibroin grafts support functional tissue regeneration in a porcine model of onlay esophagoplasty.

Partial circumferential, full thickness defects of the esophagus can occur as a result of organ perforation or tumour resection, or during surgical reconstruction of strictured segments. Complications associated with autologous tissue flaps conventionally utilized for defect repair necessitate the development of new graft options. In this study, bi-layer silk fibroin (BLSF) scaffolds were investigated for their potential to support functional restoration of partial circumferential defects in a porcine model of esophageal repair. Onlay thoracic esophagoplasty with BLSF matrices (~3 x 1.5 cm) was performed in adult swine (N = 6) for 3 months of implantation. All animals receiving BLSF grafts survived with no complications and were capable of solid food consumption. Radiographic esophagrams revealed preservation of organ continuity with no evidence of contrast extravasation or strictures. Fluoroscopic analysis demonstrated peristaltic contractions. Ex vivo tissue bath studies displayed contractile responses to carbachol, electric field stimulation, and KCl while isoproterenol produced tissue relaxation. Histological and immunohistochemical evaluations of neotissues showed a stratified, squamous epithelium, a muscularis mucosa composed of smooth muscle bundles, and a muscularis externa organized into circular and longitudinal layers, with a mix of striated skeletal muscle fascicles interspersed with smooth muscle. De novo innervation and vascularization were observed throughout the graft sites and consisted of synaptophysin-positive neuronal boutons and vessels lined with CD31-positive endothelial cells. The results of this study demonstrate that BLSF scaffolds can facilitate constructive remodeling of partial circumferential, full thickness esophageal defects in a large animal model. Copyright © 2017 John Wiley & Sons, Ltd.

MP79-07 INDICATIONS FOR NOVEL INTERPOSITION MYOCUTANEOUS FLAP FOR THE REPAIR OF RECTO-URINARY FISTULA

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: External Genitalia Reconstruction and Urotrauma (including transgender surgery) I1 Apr 2017MP79-07 INDICATIONS FOR NOVEL INTERPOSITION MYOCUTANEOUS FLAP FOR THE REPAIR OF RECTO-URINARY FISTULA Alyssa Greiman, Lawrence Dagrosa, Nima Baradaran, Eric Rovner, and Harry Clarke Alyssa GreimanAlyssa Greiman More articles by this author , Lawrence DagrosaLawrence Dagrosa More articles by this author , Nima BaradaranNima Baradaran More articles by this author , Eric RovnerEric Rovner More articles by this author , and Harry ClarkeHarry Clarke More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.2491AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Recto-urinary fistula (RUF) is a rare complication following pelvic surgery, radiation or trauma. We report our experience using a perineal approach with a cremasteric myocutaneous interposition flap (CIF) for the treatment of symptomatic RUF and sought to compare their outcomes with patients undergoing repair with other interpositions. METHODS We identified all patients undergoing RUF repair at a single institution from January 2001 to June 2014. Demographics, fistula etiology, surgical approach and outcomes were reviewed. Successful RUF repair was defined based on a post-operative voiding cystourethrogram without evidence of contrast extravasation. RESULTS 26 patients underwent RUF repair by a single surgeon at our institution. All patients underwent colonic diversion prior to repair. Initial repair was performed at the median age of 63 (21-83) years using a cremasteric interposition flap (CIF) in 12 patients, gracilis interposition flap (GIF) in 13 and a rectus myocutaneos flap (RMF) in one. Median follow-up was 8.8 (1-44) months. Fistulas were categorized as complex where radiation therapy, salvage cryoablation or APR was performed (69.2%), and simple when they occurred in the setting of radical prostatectomy, hemorrhoidectomy or trauma (30.8%). Pre-repair hyperbaric oxygen was performed in 57.7% of patients and was not associated with improved success in initial closure for either complex or simple fistulas (p=0.16, 0.69). In the CIF group, 9 (75%) patients failed the initial repair with 2 subsequently undergoing successful second CIF, 4 with successful subsequent GIF and 2 lost to follow-up. One patient failed a repeat CIF. The majority of patients (88%) who failed initial repair with CIF had radiation-induced fistulas, whereas only 33% of patients with a successful initial repair had prior radiation exposure (p=0.12). In the GIF group, 11(84.6%) had successful repair with initial surgery. Initial repair of simple fistulas was more successful than complex fistulas (p=0.04). The use of GIF or rectus myocutaneous flap resulted in improved success in complex fistula repair as compared to CIF (p=0.004). There was no difference seen in success of simple fistula repair when comparing GIF and CIF (p=0.17). CONCLUSIONS Perineal repair of RUF using CIF is a novel approach with potentially less morbidity than larger muscle interposition flaps. However, the CIF is less effective in complex fistulas and thus should only be considered in patients with simple fistulas. For complex fistulas, a more vascularized flap such as GIF or rectus myocutaneous flap is effective. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e1075 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Alyssa Greiman More articles by this author Lawrence Dagrosa More articles by this author Nima Baradaran More articles by this author Eric Rovner More articles by this author Harry Clarke More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Pituitary gland adenoma with hyperprolactinemia and male erectile dysfunction – A case report

Pituitary gland adenoma with hyperprolactinemia and male erectile dysfunction – A case report

Is CT cystography an accurate study in the evaluation of spontaneous perforation of augmented bladder in children and adolescents?

Spontaneous bladder perforation (SBP) is a potentially fatal complication of augmented bladder. Imaging is often used for diagnosis. In this study we present our experience with CT cystography (CTC) in the diagnosis of SBP. To determine CTC accuracy in the evaluation of SBP in children with an augmented bladder. The institutional review board approved this HIPAA-compliant study; informed consent was waived. All patients under 20 years old, who underwent CTC for SBP evaluation from 2003 to 2013, were identified. Two radiologists independently reviewed CTC studies for contrast extravasation, ascites, and pneumoperitoneum. Ascites was graded: small - confined to the rectovesical pouch (RVP); moderate - beyond the RVP; large - beyond the pelvis. Eighty-nine patients (47 males, age 4.2-19.8 years) had 132 CTCs. SBP was diagnosed in 14% (19/132). Both radiologists found contrast extravasation in 74% (14/19) of patients with SBP; two patients had only pneumoperitoneum, and three had only ascites (large = 2, moderate = 1) (Fig.). SBP was found in 1% of CTCs with no ascites or small ascites (1 of 98 and 92; radiologists 1 and 2, respectively). Findings of extraluminal extravasation, unexplained pneumoperitoneum, or large ascites, yielded a detection rate of 95% for SBP by each radiologist. In eight patients, small bowel obstruction was diagnosed. Contrast extravasation was detected in only 74% of patients with SBP. The use of indirect signs of perforation (unexplained pneumoperitoneum and large ascites) in addition to contrast extravasation, increased the detection rate of SBP to 95%. US screening for SBP and selection of patients with moderate or large ascites for CTC, may eliminate the need for most CT scans. In the absence of SBP, other abdominal abnormalities should be evaluated. Bowel obstruction was the most common non-urological emergency detected in this series. The main limitations of the study are: the small number of SBP cases; the diagnosis of SBP not based on surgical findings in three patients; and inability to completely exclude occult SBP in patients not explored surgically. Extraluminal contrast was seen on CTC in most cases of SBP, but some patients with sealed bladder perforation had only pneumoperitoneum or moderate/large ascites. Therefore, SBP should be suspected in any patient with moderate/large volumes of pelvic fluid or unexplained pneumoperitoneum, even when there is no evidence of contrast extravasation. Patients with no ascites, or small volumes, are unlikely to have SBP; therefore, US can be used to screen low risk patients.

Acellular Bi-Layer Silk Fibroin Scaffolds Support Tissue Regeneration in a Rabbit Model of Onlay Urethroplasty

Acellular scaffolds derived from Bombyx mori silk fibroin were investigated for their ability to support functional tissue regeneration in a rabbit model of urethra repair. A bi-layer silk fibroin matrix was fabricated by a solvent-casting/salt leaching process in combination with silk fibroin film casting to generate porous foams buttressed by homogeneous silk fibroin films. Ventral onlay urethroplasty was performed with silk fibroin grafts (Group 1, N = 4) (Width×Length, 1×2 cm2) in adult male rabbits for 3 m of implantation. Parallel control groups consisted of animals receiving small intestinal submucosa (SIS) implants (Group 2, N = 4) or urethrotomy alone (Group 3, N = 3). Animals in all groups exhibited 100% survival prior to scheduled euthanasia and achieved voluntary voiding following 7 d of initial catheterization. Retrograde urethrography of each implant group at 3 m post-op revealed wide urethral calibers and preservation of organ continuity similar to pre-operative and urethrotomy controls with no evidence of contrast extravasation, strictures, fistulas, or stone formation. Histological (hematoxylin and eosin and Masson's trichrome), immunohistochemical, and histomorphometric analyses demonstrated that both silk fibroin and SIS scaffolds promoted similar extents of smooth muscle and epithelial tissue regeneration throughout the original defect sites with prominent contractile protein (α-smooth muscle actin and SM22α) and cytokeratin expression, respectively. De novo innervation and vascularization were also evident in all regenerated tissues indicated by synaptophysin-positive neuronal cells and vessels lined with CD31 expressing endothelial cells. Following 3 m post-op, minimal acute inflammatory reactions were elicited by silk fibroin scaffolds characterized by the presence of eosinophil granulocytes while SIS matrices promoted chronic inflammatory responses indicated by mobilization of mononuclear cell infiltrates. The results of this study demonstrate that bi-layer silk fibroin scaffolds represent promising biomaterials for onlay urethroplasty, capable of promoting similar degrees of tissue regeneration in comparison to conventional SIS scaffolds, but with reduced immunogenicity.

Blunt trauma induced splenic blushes are not created equal

BackgroundCurrently, evidence of contrast extravasation on computed tomography (CT) scan is regarded as an indication for intervention in splenic injuries. In our experience, patients transferred from other institutions for angioembolization have often resolved the blush upon repeat imaging at our hospital. We hypothesized that not all splenic blushes require intervention.MethodsDuring a 10-year period, we reviewed all patients transferred with blunt splenic injuries and contrast extravasation on initial postinjury CT scan.ResultsDuring the study period, 241 patients were referred for splenic injuries, of whom 16 had a contrast blush on initial CT imaging (88% men, mean age 35 ± 5, mean ISS 26 ± 3). Eight (50%) patients were managed without angioembolization or operation. Comparing patients with and without intervention, there was a significant difference in admission heart rate (106 ± 9 vs 83 ± 6) and decline in hematocrit following transfer (5.3 ± 2.0 vs 1.0 ± 0.3), but not in injury grade (3.9 ± 0.2 vs 3.5 ± 0.3), systolic blood pressure (125 ± 10 vs 115 ± 6), or age (38.5 ± 8.2 vs 30.9 ± 4.7). Of the 8 observed patients, 3 underwent repeat imaging immediately upon arrival with resolution of the blush. In the intervention group, 4 patients had ongoing extravasation on repeat imaging, 2 patients underwent empiric embolization, and 2 patients underwent splenectomy for physiologic indications.ConclusionsFor blunt splenic trauma, evidence of contrast extravasation on initial CT imaging is not an absolute indication for intervention. A period of observation with repeat imaging could avoid costly, invasive interventions and their associated sequelae.

Aggressive intervention to treat a young woman with intracranial hemorrhage following unsuccessful intravenous thrombolysis for left middle cerebral artery occlusion

Stroke patients whose condition does not improve after intravenous administration of tissue plasminogen activator (tPA) may be candidates for endovascular intervention. Patients with new intracerebral hemorrhage noted during such interventions pose a difficult challenge to neurointerventionists and are often sequestered as treatment failures and deemed inappropriate for intraarterial recanalization efforts. The authors present a case in which aggressive intervention was performed despite evidence of contrast extravasation on preintervention angiography. This 37-year-old woman presented with an occlusion of the M(1) segment of the left middle cerebral artery and a National Institutes of Health Stroke Scale score of 24. She received intravenous tPA without improvement. Angiography revealed M(1) thrombus as well as active contrast extravasation without arterial displacement. Thromboaspiration was performed in light of her known hemorrhage with excellent recanalization. Immediate postprocedure imaging demonstrated a large insular hematoma and emergent craniectomy and hematoma evacuation were performed. At 4 months' follow-up, the patient was living at home, was ambulating, and had excellent comprehension with mild expressive aphasia. There is little peer-reviewed data in the literature to aid in the decision-making process when contrast extravasation is recognized at the time of preinterevention angiography. Continuation of mechanical endovascular stroke intervention, in light of active contrast extravasation, may be warranted in young patients with major deficits and absence of arterial displacement or delayed global filling. Further thrombolytics are not advised. In select stroke patients, continuation of a planned attempt at mechanical recanalization without the further use of thrombolytics may be warranted in light of known intracerebral hemorrhage.

Variability in pediatric splenic injury care: results of a national survey of general surgeons.

Although nonoperative management is the standard of care for hemodynamically stable children with blunt splenic trauma, significant variation in practice exists. Little attention has been given to physician factors associated with management differences. Nationally representative mail survey conducted in June 2008. United States. Ten percent random sample of active, dues-paying fellows in the American College of Surgeons. Knowledge, attitudes, and beliefs toward pediatric splenic injury management, including the role of clinical practice guidelines. Almost all of the 375 responding surgeons (97.4%) agreed that surgical intervention is not immediately necessary for hemodynamically stable children. However, surgeons reported significant disagreement regarding whether blood should be administered before operative intervention for hemodynamically unstable children and whether explorative surgery is needed for stable patients with evidence of contrast extravasation on computed tomography. Only 18.7% of surgeons reported being very familiar with the clinical practice guidelines for the management of pediatric blunt splenic trauma from either the Eastern Association for the Surgery of Trauma or the American Pediatric Surgical Association. Surgeons who were very familiar with either guideline were significantly more likely to rate the guidelines as beneficial (90.0% vs 72.8%, P = .002). General surgeons reported varying degrees of familiarity with and use of clinical practice guidelines for pediatric splenic injury management. Limited pediatric experience and lack of pediatric hospital resources may limit more widespread adoption of nonoperative management. Targeted educational interventions may help increase surgeon knowledge of guidelines and best practices.

Esophagogastroduodenoscopy-associated gastrointestinal perforations: A single-center experience

Esophagogastroduodenoscopy (EGD) is commonly used in the diagnosis and treatment of gastrointestinal (GI) disorders. Our aim was to define the risk of perforation associated with EGD and identify patients who required operative intervention. We retrospectively reviewed 72 patients from our institution plus 5 transferred patients who sustained EGD-associated perforations from January 1996 through July 2008. Percutaneous endoscopic gastrostomy, endoscopic ultrasonography, endoscopic retrograde cholangiopancreatography, transthoracic echocardiography, and concurrent colonoscopy procedures were excluded. Perforations in 72 of 217,507 EGD procedures were identified (incidence, 0.033%); 124,844 EGDs included an interventional procedure and 92,663 were examination only. The incidence of perforation was similar whether an interventional procedure was performed or not (0.040% vs 0.029%; P = .181). The esophagus was injured most commonly (51%), followed by the duodenum (32%), jejunum (6%), stomach (3%), and common bile duct (3%). Overall mortality after perforation was 17% with a morbidity rate of 40%. Thirty-eight patients (49%) were initially treated nonoperatively, 7 of whom (18%) failed nonoperative management. The only factors we could determine that were associated with failure were free fluid or contrast extravasation on computed tomography (75% vs 23% [P < .005] and 33% vs 0% [P = .047], respectively). The morbidity of failures was equivalent to those who underwent initial operative management (63% vs 61%; P = .917), with mortality seeming to be greater (43% vs 21%; P = .09). EGD is safe in the majority of patients; however, iatrogenic perforation is associated with considerable morbidity and mortality. Nonoperative management of GI perforation can be successful if there is no evidence of contrast extravasation or free fluid on radiographic studies. If nonoperative management fails, the outcomes may be worse than those treated initially with operative repair.

Endovascular repair of a ruptured, mycotic popliteal aneurysm

In 1985 Osler used the expression; ‘mycotic aneurysm’ in relation to aneurysms of septic aetiology. In his reported case the infective embolic source was septic endocarditis.1 Currently the term mycotic aneurysm is used in a broad sense; it covers all aneurysms of infective aetiology, both bacterial and fungal in nature. According to recent data the most frequent infective organisms are Staphylococcus and Salmonella.2,3 The femoral artery and the abdominal aorta are the most common locations of septic aneurysms, the popliteal artery has rarely been implicated.3,4 Primary vascular surgical repair of mycotic aneurysms is often impossible or contraindicated in an infected operating field on a seriously ill patient. Patients may end up with ligation of a major artery, for example, superficial femoral or popliteal artery as an emergency procedure.3 Extra-anatomical vascular reconstruction or endovascular repair remain the other treatment alternatives. Elective endovascular repair of popliteal aneurysms has gained momentum in recent years. Tielliu et al. presented 76% 5-year patency rate after elective endograft insertion in a series of 73 patients.5 Endovascular treatment of a ruptured, non-infected, popliteal aneurysm was reported by Ihlberg.6 Our case report demonstrates successful endovascular management of a ruptured mycotic popliteal aneurysm. A previously well 80-year-old man presented in the Emergency Department with few days history of increasing back pain, abdominal discomfort, fever and malaise. An MRI examination of the thoracolumbar spine was suggestive of osteomyelitis of the 10th thoracic vertebra as the most likely primary focus of a blood-born infection. Blood cultures confirmed staphylococcus aureus sepsis (Methicillin sensitive) which was treated with intravenous Flucloxacillin. A subsequent echocardiography demonstrated thickened aortic and mitral valve leaflets, raising the suspicion of endocarditis. A week after hospital admission sudden onset of left-leg swelling was noted and subsequently the patient developed a large painful pulsatile mass in the popliteal fossa extending up to the medial and posterior aspects of the thigh. A CT scan examination revealed the aneurysmal popliteal artery and large periarterial haematoma formation. X-ray contrast appeared in the haematoma indicating the rupture and contrast communication with the pulsating haematoma (Fig. 1). The haematoma extended proximally on the posterior aspect of the thigh (Fig. 2). Ruptured mycotic popliteal aneurysm (CT angiography). Periarterial haematoma extending up to mid thigh level (computed tomography). The patient was transferred to the operating theatre where under local anaesthesia and sedation percutaneous, antegrade femoral puncture was made and an 8mm × 10 cm Viabahn endoprosthesis (Viabahn, WL Gore, Flagstaff, Az, USA) was deployed in the popliteal artery. The post-procedural angiography and the subsequent CT angiography showed excellent flow through the endograft. The endograft successfully sealed the popliteal artery rupture, there was no further evidence of contrast extravasation (Fig. 3). Patent endograft 1 week and 6 months after graft placement. No evidence of endoleak (CT angiography). The postoperative period was uneventful. Early ambulation was commenced. He stayed on antibiotics for another 6 weeks. All the inflammatory markers normalized. Two months after the procedure the thigh haematoma decreased significantly in size. At 6 months the duplex scan examination and CT angiography confirmed the patent endograft without evidence of endoleak (Fig. 3). Endovascular surgery under local anesthesia was our preferred option in a severly ill patient under emergency circumstances. The popliteal artery was anatomically suitable for the procedure and a fast satisfactory outcome was achieved. By providing long-term, adequate antibiotic cover the risk of endograft sepsis was minimized and the infection was eradicated. Recently published papers analyse the value of endovascular treatment in the management of mycotic aortic and iliac aneurysms.7,8 There have been no data to date on endovascular management of ruptured mycotic popliteal aneurysms. The recommendations and calls for caution by certain authors7,8 can be extended to the management of popliteal aneurysms. Before deciding the best intervention one has to weigh the risk of implanting a synthetic graft material in the infected popliteal artery against the burden of major surgery that also carries the risk of ischaemic and further septic complications. We were encouraged by the reported satisfactory longer term patency rates following elective endovascular repair of popliteal aneurysms5 and the emergency situation also shifted our decision making towards endovascular treatment. Our case report indicates that endovascular treatment may be a useful alternative to conventional surgery in this special group of patients.

Spontaneous bladder rupture in a chronic hemodialysis patient

Spontaneous bladder rupture is very rare. A 67-year-old woman who was nearly anuric and had been on chronic hemodialysis therapy for diabetic end-stage renal disease for 6 years complained of severe low abdominal pain and fever for 2 days. Abdominal computerized tomography and retrograde cystography revealed the extraperitoneal leakage of contrast medium, confirming bladder perforation. Partial cystectomy around the perforation site and repair of the bladder rupture were performed. Microscopic examination of the excised bladder tissue revealed that the bladder mucosa was ulcerated. Severe suppurative inflammation was observed throughout the bladder wall. Antibiotic treatment was continued for 3 weeks postoperatively, and repeated retrograde cystography showed no evidence of contrast extravasation. She was discharged, with no other complications.

Complete Endoscopic Closure of Gastrotomy After Natural Orifice Translumenal Endoscopic Surgery Using the NDO Plicator

The NDO Plicator is a device developed for endoscopic treatment of gastroesophageal reflux disease (GERD) by approximation of tissues together with a double-pledgeted U-stitch. It was theorized that this device may facilitate transgastric natural orifice translumenal endoscopic surgery (NOTES) because closure of the transgastric defect remains a key component for advancement of this new technology. A standardized 12-mm gastrotomy was created endoscopically in four pigs using a combination of needle-knife cautery and balloon dilation. As the endoscope was removed, a Savary soft-tipped wire was introduced into the stomach, and the NDO Plicator was subsequently advanced over the wire. Each defect was identified, and the device was positioned. If necessary, the Plicator's tissue grasper was used to hold the superior aspect of the gastrotomy and bring the opposed borders of the defect within the jaws of the device. The device was fired three times, leaving three pledgeted suture bundles to close the gastric defect. After closure, each animal was explored, and the integrity of the closure was assessed. The animals underwent in vivo contrast fluoroscopy and ex vivo burst pressure testing studies for assessment of leakage at the closure site. The first animal was used to test feasibility, refine techniques, and develop a standard procedure. All of the next three animals studied showed complete sealing of the gastrotomy site without evidence of contrast extravasation on multiplanar fluoroscopic imaging. Each stomach was excised, submerged in water, and subjected to a pressurized air leak test. No leaks were noted until pressures exceeded 55 mmHg. This study supports the use of the NDO Plicator for closure of standardized gastric defects in a porcine model. In addition to closing NOTES gastrotomies, the NDO Plicator may be a particularly useful tool for obtaining complete closure of gastric perforations and anastomotic leaks, and for performing stomal reduction after gastric bypass procedures. The mechanical properties of a closure are not the only factor determining whether a leak will develop. Tissue opposition, ischemia, and tension are important factors that are not easily or reliably measured. The physiologic relevance of gastric bursting pressure is not known. Therefore, corollary animal studies with longer-term evaluation are necessary before research proceeds to clinical trials.

Angiography in poor-risk patients with massive nonvariceal upper gastrointestinal bleeding

The purpose of this retrospective study was to determine the diagnostic and therapeutic usefulness of gut angiography in patients with massive upper gastrointestinal bleeding from a nonvariceal source. All patients (n = 64) in this category who underwent a gut angiogram between 1980 and 1986 were studied. Pre-angiogram endoscopy was attempted in all patients and was nondiagnostic in 14 (22%). Contrast extravasation at angiography was seen in 25 of 64 patients (39%), and in over half of these patients endoscopy was nondiagnostic (n = 11) or wrong (n = 3). Attempts to control bleeding in this group by selective arterial embolization (n = 14) or intra-arterial vasopressin (n = 11) successfully averted operation in 13 of 25 patients (52%) and was associated with a 50% reduction in mortality (83% versus 38%). Selective embolization of vessels thought to be bleeding on clinical grounds without evidence of contrast extravasation (i.e., "blind" embolization) was not helpful in controlling hemorrhage. Urgent gut angiography in patients with massive upper gastrointestinal bleeding of arteriocapillary source is a useful diagnostic and therapeutic maneuver and warrants continued application in this group of poor-risk patients.