Retrograde Migration Research Articles

Early trigeminal nerve involvement in Listeria monocytogenes rhombencephalitis: case series and systematic review.

Listeria monocytogenes is associated with rhombencephalitis. However, the exact mechanisms of brainstem invasion remains poorly understood. Here, we demonstrate clinical and radiological data suggesting that Listeria may invade the brainstem via the trigeminal nerve. Three females (41, 64 and 70years) with culture proven L. monocytogenes bacteremia and rhombencephalitis were investigated in the period of 2014-16. T2-weighted and contrast-enhanced T1-weighted MRI revealed a cerebellopontine abscess in all three patients, including the involvement of the trigeminal nerve root. In two patients, MRI also revealed selective contrast enhancement of the sensory trigeminal tract in the pons and medulla oblongata. Prior to any other neurological symptoms, two patients complained of hypoesthesia and a tingling sensation in the ipsilateral half of the face, consistent with sensory trigeminal nerve dysfunction on that side. In addition, we identified another 120 cases of Listeria rhombencephalitis following a systematic review. Cranial nerves VII, V, IX, and X, respectively, medulla oblongata, cerebellum and pons, were the most frequently involved brain structures. The present clinical and radiological findings corroborate earlier data from animal experiments, indicating that L. monocytogenes may be capable of retrograde intra-axonal migration along the cranial nerves. We suggest that in a subset of patients with rhombencephalitis L. monocytogenes enters the cerebellopontine angle through the trigeminal nerve, invading the brainstem via the sensory trigeminal nuclei.

Transurethral contact ureterolithotripsy in gas (СО2) medium.

Transurethral intracorporeal lithotripsy is the modality of choice for the endoscopic disintegration of large, long-standing, radiolucent or high-density stones. Despite several advantages and proven benefits of contact ureterolithotripsy/ureterolithoextraction (CULT), the application of irrigation carries significant risks of untoward perioperative events including retrograde stone migration and postoperative pyelonephritis. We describe a new technique - endoscopic intracorporeal lithotripsy in the gas (СО2) medium. It is a prospective randomized, single blinded pilot study that included total of (n = 60) patients with urolithiasis who were allocated to either experimental or control group. Out of the total pool of patients, 30 underwent treatment with the new approach (experimental group) and other 30 (control group) had contact ureterolithotripsy in a standard of care 0.9% NaCL medium. We included patients >18 years old, with known symptomatic renal calculi disease who were eligible and scheduled for CULT and free from significant coexisting pathologies of urinary tract. No retrograde migration of the stone fragments into the kidney was reported in the experimental group [complications rate 0%, confidence interval (CI): 0-11.6%]. In the control group, complications were observed in eight cases (complications rate 26.7%, CI: 14.7-42.3%); retrograde migration was in five patients (16.6%), and acute pyelonephritis/exacerbation of chronic pyelonephritis was seen in three (10%) patients. There was not any acute pyelonephritis in the experimental group. Reliability of frequency differences - p = 0.0023 (χ2). The novel method of contact ureterolithotripsy is a safe and promising alternative to the conventional contact ureterolithotripsy in a fluid medium in a carefully selected patient population.

The \u201cGuidewire-Coil\u201d-Technique to prevent retrograde stone migration of ureteric calculi during intracorporeal lithothripsy

BackgroundStone retropulsion represents a challenge for intracorporeal lithotripsy of ureteral calculi. The consequences are an increased duration and cost of surgery as well as decreased stone-free rates. The use of additional tools to prevent proximal stone migration entails further costs and risks for ureteral injuries. We present the simple technique of using a coil of the routinely used guidewire to prevent stone retropulsion.MethodsWe retrospectively evaluated all patients with mid-to-proximal ureteral stones in 2014, which were treated by ureteroscopic lithotripsy (Ho: YAG and/or pneumatic lithotripsy). The preoperative stone burden was routinely assessed using low dose CT scan (if available) and/or intravenous pyelogram.ResultsThe study population consisted of 55 patients with 61 mid-to-proximal calculi. Twentyseven patients underwent semirigid ureterorenoscopy using the “Guidewire-Coil-Technique”, the second group (n = 28) served as control group using the guidewire as usual. There has been a statistically significant reduction of accidental stone retropulsion (2/27 vs. 8/28, p < 0.05) as well as a decreased use of auxiliary procedures (p < 0.05) compared to the control group. No difference was observed in operative time. One ureteral injury in the control group required a prolonged ureteral stenting.ConclusionThe “Guidewire-Coil-Technique” is a simple and safe procedure that may help to prevent proximal calculus migration and therefore may increase stone-free rates without causing additional costs.

Comparative study of cemented hemiarthroplasty with or without close suction drain

A drain is device used to prevent collection of fluids in a cavity or closed space, but retropulsive infection can contaminated this clean surgical wound from the drain. The study was conducted between 1stApril 2013 and 31stMarch 2014, in 62 patients who underwent cemented Hemiarthroplasty of hip for fracture neck femur. 12 patients having pre-existing medical/cardiac co morbidities were excluded from the study. The randomization of patients was made by placing even and odd values in a computer-generated table of randomized numbers. We observe Post-operative 3rd day fall in Hematocrit value, Hemoglobin level and infection rate. Analysis of our study showed no significant difference with respect to fall in hemoglobin levels, MCHC levels and infection rate between the patients who had drains after the operation and the ones without drains.-Using drain in cemented Hemiarthroplasty surgeries for neck femur fracture is not showing any statistically significant advantage over not using it, although there is potential risk of retrograde migration of infection.

Reverse transendothelial cell migration in inflammation: to help or to hinder?

The endothelium provides a strong barrier separating circulating blood from tissue. It also provides a significant challenge for immune cells in the bloodstream to access potential sites of infection. To mount an effective immune response, leukocytes traverse the endothelial layer in a process known as transendothelial migration. Decades of work have allowed dissection of the mechanisms through which immune cells gain access into peripheral tissues, and subsequently to inflammatory foci. However, an often under-appreciated or potentially ignored question is whether transmigrated leukocytes can leave these inflammatory sites, and perhaps even return across the endothelium and re-enter circulation. Although evidence has existed to support "reverse" transendothelial migration for a number of years, it is only recently that mechanisms associated with this process have been described. Here we review the evidence that supports both reverse transendothelial migration and reverse interstitial migration within tissues, with particular emphasis on some of the more recent studies that finally hint at potential mechanisms. Additionally, we postulate the biological significance of retrograde migration, and whether it serves as an additional mechanism to limit pathology, or provides a basis for the dissemination of systemic inflammation.

Novel Lumen-Apposing Metal Stent for Treatment of a Benign Gastric Stricture after Caustic Injury

A 69 year old female developed extensive mucosal injury (Zargar Grade 2b) of her esophagus and stomach caused by accidental ingestion of a caustic alkali substance. Eight days after injury, EGD showed esophageal fibrosis with a stricture in the mid-esophagus, diffuse erythema of the stomach and a large ulcer encompassing a large portion of the antrum. The patient underwent a percutaneous endoscopic gastrostomy (PEG) with a 16 French PEG tube confirmed to be 5 cm away from the ulcer. Two weeks after PEG tube placement, the patient reported persistent sialorrhea. Endoscopy revealed worsening of the esophageal stricture and via fluoroscopy, the total length was determined to be 10 cm, with a diameter of 3 mm in the narrowest segment. The patient underwent multiple through-the-scope (TTS) guidewire-assisted endoscopic balloon dilations (EBD) of this esophageal stricture. She then began to have intractable nausea and vomiting after each bolus of tube feeds, and serial measurements of gastric residual volume (GRV) were increasingly elevated. Repeat endoscopy showed a tight prepyloric stricture secondary to the healing antral ulcer, and the PEG tube was replaced with a 16 French PEG tube with jejunal extension (PEG-J). Eleven days after placement, due to retrograde migration of the J-tube, the PEG-J tube was removed. The decision was made to place a novel lumen-apposing self-expandable metal stent (LAMS). A guidewire was inserted into the stomach through the existing gastrostomy tract and was advanced beyond the prepyloric stricture. A 10 mm x 10 mm LAMS (AXIOSTM Stent, Boston Scientific, Marlborough, Massachusetts, USA) was advanced over the guidewire and positioned across the prepyloric stricture with endoscopic and fluoroscopic guidance. This was followed by placement of a 16 French PEG tube into the stomach via the existing gastrostomy tract. During the 12 weeks after stent placement, the area remained patent with no evidence of migration or erosion, and the patient has been able to tolerate tube feedings well with appropriate weight gain. The use of LAMS for treatment of benign strictures can serve as a safe alternative treatment to EBD. Furthermore, the risk of migration, which has been associated with use of traditional fully-covered self-expandable metal stents is potentially lower with LAMS.Figure 1Figure 2

The PEG-Pedi-PEG technique: a novel method for percutaneous endoscopic gastrojejunostomy tubeplacement(with video).

When PEG tube feeding is complicated by anatomic obstruction, dysmotility, or aspiration, a need arises for feeding beyond the pylorus. The currently available percutaneous gastrojejunostomy (PEG-J) kits have issues with the jejunal extension portion migrating back into the stomach. The aim of this study was to evaluate the feasibility and safety of a novel technique that creates PEG-J tubes by combining an adult percutaneous gastrostomy (PEG) tube with a pediatric PEG tube, the PEG-Pedi-PEG procedure. This was a retrospective study at a single tertiary care center. The main outcome measures were success of placement, rate of retrograde tube migration, early (<24 h after procedure was performed) and late (>24 h after procedure was performed) adverse events. Seventeen patients underwent PEG-Pedi-PEG procedures during the study period. Technical success was achieved in all patients (100%). The retrograde migration rate of the jejunal extension tube was 0%. Early adverse events included peristomal pain in 1 patient. Late adverse events included inadvertent tube removal (3 patients), diarrhea (1 patient), prolonged ileus/gastroparesis (1 patient), and tube occlusion (1 patient). Mean follow-up was 290 days. The PEG-Pedi-PEG procedure is a novel endoscopic technique to facilitate post-pyloric feeding because the pediatric PEG bumper may act like a sail in the small bowel, with peristalsis pushing the bumper distally and thus decreasing the possibility of migration back into the stomach. This study demonstrated excellent technical success, no retrograde migration, and a low rate of adverse events.

OC-076 Endoscopic Placement of Fully Covered Self Expanding Metal Stents (FC-SEMS) into the Pancreatic Duct of Patients With Painful Chronic Pancreatitis

Introduction Endoscopic placement of plastic stents into the pancreatic duct (PD) has achieved disappointing outcomes in the treatment of painful chronic pancreatitis (CP), when compared to surgery. However, pancreatic bypass surgery or resection is associated with significant morbidity. Recently, FC-SEMS have proven more effective than plastic stents in the management of strictures of the bile duct. We aimed to assess feasibility, safety and efficacity of PD FC-SEMS in the management of painful CP. Methods Patients were recruited at a single tertiary UK pancreatobiliary centre. Patients were considered for PD FC-SEMS after demonstration of i) CT/MR imaging criteria of chronic pancreatitis including dilatation of the main PD and ii) characteristic pancreatic pain resistant to analgesia. Patients’ treatment plans were all determined in a MDT meeting. All patients gave informed consent. Visual analogue pain scores and analgesia requirements were documented prior to intervention and at each follow up appointment. At ERCP, PD cannulation was attempted from the major papilla in all cases. In cases of pancreas divisum, or where PD cannulation via the major papilla failed, cannulation of the minor papilla was attempted. On cannulation of the PD, a pancreatic sphincterotomy was performed before deployment of a 60 mm by 8 mm FC-SEMS. Stent removal was scheduled between 10 and 14 weeks after placement. Results 35 patients (22 M) had FC-SEMS placed into the PD. The median age at time of stent placement was 55 y (range 21–71). In 24 cases the stent was placed via the major papilla, 11 were placed via the minor papilla. The median interval between stent placement and removal was 86 days (13–252) with median follow up of 22 months (3–33). One patient developed a Santorini duct abscess, which precipitated early stent removal but was otherwise managed conservatively. One instance of retrograde stent migration was noted and was managed endoscopically. 20 (57%) patients reported a complete resolution of pancreatic pain, 10 (29%) a partial response and 5 (14%) no response. A concomitant cessation or decline in the use of opiate analgesia was demonstrated. Of the five non- responders, three proceeded to lateral pancreatojejunostomy – two of whom reported a full symptomatic response. Conclusion Placement of FC-SEMS into the pancreatic duct of patients with painful chronic pancreatitis appears to be feasible and safe and does not preclude subsequent surgical intervention. The lengthy follow up data presented suggests that this endoscopic approach may be more effective than would be expected from historical studies of the use of plastic pancreatic duct stents. A controlled trial is warranted. Disclosure of Interest None Declared

Bacterial Biofilm in Salivary Gland Stones: Cause or Consequence?

The pathogenesis of salivary calculi is not yet clear; however, 2 theories have been formulated: (1) "the classic theory," based on calcium microdeposits in serous and ductal acinous cells, successively discharged into the ducts; (2) "the retrograde theory," based on a retrograde migration of food, bacteria, and so on from the oral cavity to the salivary duct. The aim of the present study is to highlight the role of bacteria and biofilm in stone formation. Case series without comparison. Laboratory of the Department of Anatomical Pathology. Traditional optic microscopy and scanning electron microscopy were carried out on 15 salivary gland calculi that were collected from 12 patients. A qPCR (quantitative real-time polymerase chain reaction) assay was performed to highlight the presence of bacterial DNA on each stone. Optic microscopy showed formations that-due to their size, shape, and Gram and Giemsa staining-seemed to be Gram-positive bacterial cells. PAS- (periodic acid-Schiff) and alcian-PAS-positive staining matrix was present around them. The ultrastructural observation of the material processed for scanning electron microscopy showed the presence of structures resembling bacterial cells in the middle of the stones, surrounded by soft, amorphous material. Results of qPCR showed the presence of bacterial DNA in the internal part of the tissue sample. The presence of bacteria and/or bacterial products resembling biofilm in salivary gland stones supports the "retrograde theory." This evidence may support the hypothesis that biofilm could be the causative effect of lithiasic formations.

Intra Detrusor Botulinum Toxin and Lower Limbs Motor Deficit: About 2 Clinical Cases

Objective: To demonstrate how a single intra detrusor botulinum toxin injection could be responsible for lower limbs proximal motor deficit. Results: Two women-37 and 38 years old-presenting with secondary progressive multiple sclerosis, having received intra detrusor botulinum toxin injections (400 BOTOX® U and 750 DYSPORT® U) due to major neurogenic detrusor over activity with high-pressure and risks of uro-nephrologic complications despite an efficient-dose anticholinergic bi-therapy (DITROPAN®/CERIS®). Few days in post-injection they present heavy tiredness, instability of the pelvis, and a major reduction of the walking distance. Those symptoms last for several months. During the emergency neurology consultation set up in the event of a new relapse, an aggravation of the paraparesis at the proximal level is observed. This deficit accounts for the realization of a corticosteroids bolus, the effectiveness of which is questioned by the patient. A cerebral and medullary MRI is performed in order to certify the appearance of new lesions. The MRI doesn’t objectify any new lesions or any pathological contrast enhancement. Discussion: Ramirez-Castaneda et al. describe three means of dissemination of the BoNT: migration by systemic or neuronal transport, propagation/spread and diffusion. Conclusion: The retrograde migration of the botulinum toxin via hypo-gastric nerves seems to prevail. It could be followed by axonal anterograde transport causing a deficit on the hip flexors via the L2 nerve root.

Complete guidewire retention after femoral vein catheterization

Central venous catheters (CVCs) are often used for various purposes in the emergency departments (ED). The main uses of CVCs in the EDs are emergent hemodialysis, in situations where peripheral vein catheterization cannot be achieved, and continuous invasive hemodynamic monitoring. The complications related to CVC insertion are usually mechanical and observed in the near term after the procedure. Retained CVC guidewire after catheterization is a rare complication in the published reports and usually related with intra- or postoperative settings and jugular or subclavian vein. The present study reported a young female patient who underwent left femoral vein catheterization 6 months earlier in an intensive care unit of another hospital and was diagnosed with complete guidewire retention in the ED. To the best of the authors’ knowledge, this is the first case in published reports with a diagnosis of retained CVC guidewire with retrograde migration into the femoral vein. Surprisingly, the patient developed no thrombotic or embolic complication during this 6-month period.

The Lurking Catastrophic Complication of an Equally Catastrophic Disease

Abstract BACKGROUND Medullary-bridging vein dural arteriovenous fistula (DAVF) is an uncommon type of DAVF with an aggressive clinical course due to direct fistulous shunting into medullary and brainstem veins. Important considerations need to be given to retrograde embolic migration or perforator involvement while treating these fistulas endovascularly with a liquid embolic agent. We report a lateral spinal artery feeding the DAVF, the recognition of which is important to avoid potential catastrophic complications during definitive therapy, and which has not been described before. OBJECTIVE To discuss the anatomy of the lateral spinal artery (LSA) and its communications with pial arteries such as the posterior inferior cerebellar artery (PICA) that may have important implications in the management of neurovascular diseases in and around the foramen magnum. METHODS A retrospective analysis of cerebral angiograms and 3-dimensional rotational angiograms of a patient with medullary-bridging vein DAVF treated by transarterial embolization under balloon protection was performed after the patient developed lateral medullary syndrome in the postoperative period. RESULTS Detailed analysis revealed a dural branch from the LSA feeding the DAVF which anastomosed with rudimentary PICA. CONCLUSION LSA has important anastomoses with perforating arteries of the medulla and cervical cord and, hence, it is important to recognize and identify LSA prospectively in the vascular pathologies of the foramen magnum to avoid fatal neurological complications during endovascular therapy. This is especially important while treating neurovascular pathologies using liquid embolic agents such as Onyx or SQUID, because they can percolate retrogradely through the anastomoses into PICA or other vertebrobasilar perforators.

Botulinum toxin spread after intra detrusor injection. About two cases

It's in the wake of Brigitte Schurch's work that the indication of Botulinum Toxin (BoNT) developed in the treatment of Detrusor Hyperactivity (DH). DH treatment by BoNT injection is considered to be well tolerated. However, in two patients treated with intradetrusor BoNT injections, a motor deficit located at the root of lower limbs was noticed. That observation raises questions about its diffusion beyond the injection site. They are two women with Secondary Progressive Multiple Sclerosis (SPMS) receiving BoNT as a treatment for DH. On several occasions in post injection, an aggravation of the proximal motor deficit on the hip flexors was observed, which justified the realization of a SOLUMEDROL bolus in the event of relapses. Ramirez-Castaneda et al. [1] describe three means of dissemination of the BoNT: migration by systemic or neuronal transport, propagation and diffusion. Migration by systemic transport: it has been established by electromyography (EMG) analysis. These subclinical manifestations are not correlated by EMG [2] . This mechanism can’t account for an isolated motor deficit. Animal experiments confirm the axonal transport of BoNT. On human subjects, Marchand-Pauvert et al. suggest its existence: reduction of the reciprocal inhibition exercised by Renshaw cells after BoNT injections [3] . In the absence of direct connection between the iliopsoas and the bladder, this hypothesis looks compromised. A retrograde migration of BoNT via hypogastric nerves seems to prevail. It could be followed by axonal anterograde transport causing a deficit on the hip flexors via the L2 nerve root.

The ciliary transition zone functions in cell adhesion but is dispensable for axoneme assembly in C. elegans.

Cilia are cellular projections that perform sensory and motile functions. A key ciliary subdomain is the transition zone, which lies between basal body and axoneme. Previous work in Caenorhabditis elegans identified two ciliopathy-associated protein complexes or modules that direct assembly of transition zone Y-links. Here, we identify C. elegans CEP290 as a component of a third module required to form an inner scaffolding structure called the central cylinder. Co-inhibition of all three modules completely disrupted transition zone structure. Surprisingly, axoneme assembly was only mildly perturbed. However, dendrite extension by retrograde migration was strongly impaired, revealing an unexpected role for the transition zone in cell adhesion.

Induction of post-menstrual regeneration by ovarian steroid withdrawal in the functionalis of xenografted human endometrium.

Does the endometrial functionalis have the potential to undergo self-renewal after menstruation and how is this process controlled by ovarian steroids? Endometrial xenografts subjected to withdrawal of estradiol and progesterone shrink but also show signs of proliferation and tissue repair; new estradiol supply prevents atrophy but is not sufficient to increase graft volume. Menstruation, i.e. cyclic proteolysis of the extracellular matrix of endometrial functionalis, is induced by a fall in estrogen and progesterone concentration and is followed by tissue regeneration. However, there is debate about whether regenerating cells must originate from the basalis or from stem cells and whether new estrogen supply is required for the early repair concomitant with menstruation. Fragments from human endometrial functionalis (from 24 hysterectomy specimens) were xenografted in ovariectomized SCID mice and submitted to a 4-day estradiol and progesterone withdrawal (to mimic menstruation) followed by re-exposure to estradiol (to mimic the proliferative phase). We measured signs of proliferation and changes in graft volume. Endometrium was collected from spontaneously cycling women. Cell proliferation was examined by immunolabeling Ki-67, cyclin D1 and phosphorylated-histone H3. Xenograft volume was measured by magnetic resonance imaging. Xenograft histomorphometry was performed to determine how the different tissue compartments contributed to volume change. Hormone withdrawal induced a rapid decrease in graft volume mainly attributable to stroma condensation and breakdown, concomitant with an increase of proliferation markers. Reinsertion of estradiol pellets after induced menstruation blocked volume decrease and stimulated epithelial and stromal growth, but, surprisingly, did not induce graft enlargement. Reinsertion of both estradiol and progesterone pellets blocked apoptosis. Mechanisms of endometrial remodeling are different in women and mice and the contribution of circulating inflammatory cells in both species remains to be clarified. Moreover, during human menstruation, endometrial fragments resulting from tissue proteolysis can be expelled by the menstrual flow, unlike in this model. Menstruation is a multifocal event within the functionalis. This is the first evidence that endometrial fragments that are not shed after menstrual tissue breakdown can support endometrial regeneration. Endometriosis is commonly thought to result from the retrograde migration of menstrual fragments of the degraded functionalis into the peritoneal cavity. Our study supports their potential to regenerate as ectopic endometrium. This work was supported by the Fonds de la Recherche Scientifique Médicale, Concerted Research Actions, Communauté Française de Belgique, Région wallonne, Région bruxelloise and Loterie nationale. P.H. and B.F.J. are research associates of the Belgian Fonds de la Recherche Scientifique (F.R.S.-F.N.R.S.). E.M. is Associate Editor at Human Reproduction. There is no conflict of interest to declare.

Ventricular migration of shunt: Chhabra shunt complication

We report a rare complication of Intraventricular migration of whole shunt and discuss the causes of this complication. A 9-month-old child presented in OPD with enlarging head and vomiting. The patient had undergone VP shunt twice before due to congenital hydrocephalus. Imaging was done which suggested of Intraventricular migration of complete shunt. The patient was posted for surgery and the shunt was removed from the lateral ventricle. Patient recovered well and has been followed up for 1 year till the writing of this report. After careful review of literature we found twenty reported cases of intra cranial migration of VP shunts. The probable causes of retrograde migration include technical issues like large burr hole and wide opening of Dura. An increasing number of reported cases are from Indian subcontinent and mostly the Chhabra shunt is implicated in this complication. The probable reasons for migration are: 1) Malnourished infant with thin cortical mantle, large ventricles having reduced pressure and raised intraabdominal pressure due to excess amount of CSF not absorbed in peritoneum. 2) Poor anchorage of shunt chamber along with indiscriminate pressing of cylindrical Chhabra shunt reservoir. To prevent it special care must be taken in neonates and infants in making smaller burr holes, smaller chamber area and stronger anchorage of shunt chamber to periosteum. Further instead of using the cylindrical Chhabra chambers which can easily migrate to ventricles, larger spherical chambers may be used.

Recruitment of skeletal muscle progenitors to secondary sites: a role for CXCR4/SDF-1 signalling in skeletal muscle development.

During embryonic development, myogenesis occurs in different functional muscle groups at different time points depending on the availability of their final destinations. Primary trunk muscle consists of the intrinsic dorsal (M. erector spinae) and ventral (cervical, thoracic, abdominal) muscles. In contrast, secondary trunk muscles are established from progenitor cells that have migrated initially from the somites into the limb buds and thereafter returned to the trunk. Furthermore, craniofacial muscle constitutes a group that originates from four different sources and employs a different set of regulatory molecules. Development of muscle groups at a distance from their origins involves the maintenance of a pool of progenitor cells capable of proliferation and directed cell migration. We review here the data concerning somite-derived progenitor cell migration to the limbs and subsequent retrograde migration in the establishment of secondary trunk muscle in chicken and mouse. We review the function of SDF-1 and CXCR4 in the control of this process referring to our previous work in shoulder muscle and cloacal/perineal muscle development. Some human anatomical variations and malformations of secondary trunk muscles are discussed.

Ventriculomammary shunt: An unusual ventriculoperitoneal shunt complication

Ventriculoperitoneal (VP) shunt malfunctions are common and can result in significant consequences for patients. Despite the prevalence of breast augmentation surgery and breast surgery for other pathologies, few breast related VP shunt complications have been reported. A 54-year-old woman with hydrocephalus post-subarachnoid hemorrhage returned 1 month after VP shunt placement complaining of painful unilateral breast enlargement. After investigation, it was determined that the distal VP shunt catheter had migrated from the peritoneal cavity into the breast and wrapped around her breast implant. The breast enlargement was the result of cerebrospinal fluid retention. We detail this unusual case and review all breast related VP shunt complications reported in the literature. To avoid breast related complications related to VP shunt procedures, it is important to illicit pre-procedural history regarding breast implants, evade indwelling implants during catheter tunneling and carefully securing the abdominal catheter to prevent retrograde catheter migration to the breast.

Outcome in primary cemented total knee arthroplasty with or without drain: A prospective comparative study.

Background:Suction drain insertion is a common practice in orthopedic surgery, especially after joint arthroplasty to prevent the formation of a hematoma. Theoretically the use of a drain should diminish the volume of hematoma; however the literature has conflicting data. Some authors state that drainage evacuates fluid from a limited area only and can be a cause of infection due to retrograde migration of bacteria. It can also impair the early postoperative rehabilitation. The aim of this study was to evaluate the clinical outcome (especially postoperative pain) and intake of analgesics in patients who had undergone primary cemented total knee arthroplasty (TKA) with or without a postoperative drain.Materials and Methods:A prospective comparative study of 108 consecutive patients (121 knees) was conducted. They were divided into two groups: A study group, with no drainage and a control group with drain inserted at the end of surgery. A total of 121 patients were recruited into two groups. A study group consisted of 59 knees, in which we did not use drainage after TKA and a control group with 62 knees, in which drain was inserted post surgery. Both groups were comparable in terms of preoperative characteristics. The indication for TKA was osteoarthritis (n = 105) and rheumatoid arthritis (n = 16).Results:In patients without drainage we observed lower need for opioids, higher blood loss on the 1st postoperative day and a lower need for change of dressings. There were no statistically significant differences in terms of total blood loss, hidden blood loss, transfusion rate, range of motion, length of hospital stay or incidence of complications between the two groups. In 1 year observation there were no differences in clinical outcome between the two groups.Conclusions:The present study conclude that there is no rationale for the use of drain after primary TKA. There are benefits in terms of lower opioid intake, lower blood loss on the first postoperative day and lower need for dressing reinforcement during hospitalization.

Foreign body induced sialolithiasis treated by sialoendoscopic intervention.

The study aims to identify the impact of sialolith formation by reviewing the foreign body induced sialolithiasis treated by sialoendoscopic intervention. The study group included 13 patients whose sialolithiasis was induced by foreign body. After the routine radiographic examination, sialoendoscopic procedures were performed. Then, the treatment protocol was designed. The occupations of the 13 patients included 5 fishermen, 3 office workers, 2 workers, 1 teacher, 1 farmer, and 1 retired police officer. All patients had a unique diet habit-seafood. Eleven patients had a remembered incident of implanted fish bone and the following symptoms, with either obstructions or infections. Only 2 of the 13 had no memory of such an injury. All the stones were in the ducts of submandibular glands. In 10 procedures, there was 1 solitary stone, whereas 2 stones were encountered in 3 procedures. After being removed, 16 stones were crushed to expose the fish bone nidus of the stone. There was relief of symptoms after the procedures. This study supported the possibility that some sialoliths resulted from a retrograde migration within the salivary ducts. In our study, the occupations (fisherman), the diet habit (seafood), and the injury history (a remembered incident of implanted fish bone and the following symptoms) were obviously related to the stone formation that was induced by the fish bone.