Site Of Previous Surgery Research Articles

Penicillin G-induced hemorrhagic cystitis: a case and review of the literature

Penicillin G-induced hemorrhagic cystitis: a case and review of the literature

Strictureplasty and intestinal resection: different options in complicated pediatric-onset Crohn disease

Background/PurposeSurgical resection or strictureplasty (SP) are different options for intestinal Crohn disease (CD) strictures. The aim of this article is evaluation of long-term outcome of SP and resection. MethodsFrom 1996 to 2011, 39 patients (23 male, 16 female) with symptomatic ileal and ileocolonic CD strictures resistant to medical/nutritional therapy and treated with surgery in 2 different surgical units were reviewed. The mean age at diagnosis was 11.82 years (range, 4-17 years). Mean age at surgery was 15.94 years (range, 4-24 years). Mean follow-up was 6.88 years (range, 0.5-15 years). Patients underwent resection (group A) or different SP techniques (group B). ResultsTwenty patients underwent intestinal resection (ileal or ileocolonic resection), and 19 patients underwent SP (jejunal, ileal, or ileocolic). Early postsurgical complications were observed in 2 patients of group A. Follow-up of group A patients revealed that 1 patient needed emergency treatment after 8 months surgery because of adhesions and 1 patient developed recurrence treated with medical therapy. In the follow-up group B, 3 patients experienced disease recurrence, 2 of them at the site of previous surgery. ConclusionsAt long-term follow-up, no significant difference in relapsing rate was observed between the 2 groups. Strictureplasty and resection represent an effective treatment of pediatric CD strictures. Strictureplasty could represent the first option for intestinal preservation.

Nerve root herniation into a calcified pseudomeningocele after lumbar laminectomy

A 63-year old man with a prior history of an L4‐L5 laminectomy 5 years back presented with weakness of the right foot, sensory loss in the S1 dermatome, and sciatica. Magnetic resonance imaging revealed spinal canal stenosis at the L3‐L4 level and a pseudomeningocele at the previous operative site (Fig. 1). An L3‐L4 laminectomy and exploration of the pseudomeningocelewas performed. The calcified wall of the pseudomeningocelewas enlarged with a rongeur. A loop of inflamed nerve root prolapsed and was found adherent to the inner wall of the pseudomeningocele (Fig. 2). The herniated nerve root was separated from the pseudomeningocele and repositioned into the dural sac, and the dural defect was repaired. Postoperatively, the patient reported good resolution of his symptoms. A postoperative pseudomeningocele results from a dural tear and is a well-known complication after lumbar laminectomy. Nerve root herniations into a pseudomeningocele are rare and generally undiagnosed on magnetic resonance imaging [1,2].

Gossypiboma in the scrotum with unusual cutaneous manifestations

Background: Gossypiboma is retained cotton gauze in a patient after a surgical procedure. It is generally rare with incidence ranging between 1 per 1000 and 1500. Retained gauze in the scrotum is even rarer. Gossypiboma has occurred in virtually every surgical procedure despite taking adequate precautions and performing routine gauze count. The use of radio-opaque markers and radiofrequency tags on gauze is hoped to prevent the occurrence and aid in its detection. Case Report: A 65-year-old man presented with scrotal swelling, scrotal and groin skin nodular lesions 9 months after bilateral hydrocelectomy for vaginal hydrocele. Clinical evaluation revealed bilateral hemiscrotal swellings with a thickened hyperkeratotic skin, and multiple, firm, non-tender, nodular growths on the scrotum, groin, and mons-pubis. The enlarged scrotum contained a firm non-tender mass. The phallus was edematous and tortuous. He was also found to have metastatic carcinoma of the prostate. Scrotal ultrasound scan showed bilaterally enlarged testes with distorted echo pattern and a few abscess cavities. Multiple biopsies of the groin and scrotal nodular lesions showed non-specific chronic inflammation with no evidence of malignancy. The cause of the scrotal and groin lesions could not be determined before surgery. He had orchidectomy and scrotoplasty during which gauze was found in the scrotum. Conclusion: Retained gauze in the scrotum is uncommon. Our patient presented with unusual cutaneous lesions, making the diagnosis very difficult. Foreign body reaction should be considered as a possible cause of unusual skin lesions when seen around a site of previous surgery.

Sinking Skin Flap Syndrome after Craniectomy in a Patient Who Previously Underwent Ventriculoperitoneal Shunt

Sinking skin flap syndrome, resulting from decompressive craniectomy, is defined as a series of neurologic symptoms with skin depression at the site of cranial defect. A 61-year-old male was hospitalized with high fever and operative site swelling. He underwent decompressive craniectomy on his left side for treatment for acute subdural hematoma and traumatic intrace- rebral hematoma 5 years ago. Four months later, a ventriculoperitoneal shunt was performed for treatment for hydrocepha- lus and cranioplasty was also performed. We suspected infection at the previous operative site and proceeded with craniec- tomy and epidural abscess removal. Following the procedure, the depression of the sinking flap became significant, and he has suffered from right hemiparesis. We performed a shunt catheter tie at the level of the right clavicle under local anesthesia, and the patient recovered his health to his baseline. We present a patient who was successfully managed with a tie of the shunt cath- eter for sinking skin flap syndrome. (Korean J Neurotrauma 2012;8:149-152)

Early Reherniation of Disk Material in Eleven Dogs with Surgically Treated Thoracolumbar Intervertebral Disk Extrusion

To report findings and outcomes of dogs with reherniation of nuclear material within 7 days of hemilaminectomy for acute thoracolumbar (TL) intervertebral disk extrusion. Retrospective case series. Chondrodystrophic dogs (n = 11). Dogs with acute neurologic decline within 1 week of surgical decompression for TL disk extrusion were identified. Advanced imaging was used to document extradural spinal cord compression at the previous surgery site. Ten dogs had a 2nd decompressive surgery to remove extruded nuclear material. All dogs had acute neurologic deterioration (average, 2 neurologic grades) 2-7 days after initial hemilaminectomy. Computed tomography (CT; n = 10) or myelography (n = 1) documented extradural spinal cord compression compatible with extruded disk material at the previous hemilaminectomy site. Dogs that had a 2nd surgical decompression improved neurologically within 24 hours and were paraparetic at discharge. The single dog that did not have decompressive surgery did not regain deep nociception during 185-day follow-up. Early reherniation at the site of previous hemilaminectomy can produce acute deterioration of neurologic function and should be investigated with diagnostic imaging. Repeat decompressive surgery can lead to functional recovery.

Canadian Optically-guided approach for Oral Lesions Surgical (COOLS) trial: study protocol for a randomized controlled trial

BackgroundOral cancer is a major health problem worldwide. The 5-year survival rate ranges from 30-60%, and has remained unchanged in the past few decades. This is mainly due to late diagnosis and high recurrence of the disease. Of the patients who receive treatment, up to one third suffer from a recurrence or a second primary tumor. It is apparent that one major cause of disease recurrence is clinically unrecognized field changes which extend beyond the visible tumor boundary. We have previously developed an approach using fluorescence visualization (FV) technology to improve the recognition of the field at risk surrounding a visible oral cancer that needs to be removed and preliminary results have shown a significant reduction in recurrence rates.Method/DesignThis paper describes the study design of a randomized, multi-centre, double blind, controlled surgical trial, the COOLS trial. Nine institutions across Canada will recruit a total of 400 patients with oral severe dysplasia or carcinoma in situ (N = 160) and invasive squamous cell carcinoma (N = 240). Patients will be stratified by participating institution and histology grade and randomized equally into FV-guided surgery (experimental arm) or white light-guided surgery (control arm). The primary endpoint is a composite of recurrence at or 1 cm within the previous surgery site with 1) the same or higher grade histology compared to the initial diagnosis (i.e., the diagnosis used for randomization); or 2) further treatment due to the presence of severe dysplasia or higher degree of change at follow-up. This is the first randomized, multi-centre trial to validate the effectiveness of the FV-guided surgery.DiscussionIn this paper we described the strategies, novelty, and challenges of this unique trial involving a surgical approach guided by the FV technology. The success of the trial requires training, coordination, and quality assurance across multiple sites within Canada. The COOLS trial, an example of translational research, may result in reduced recurrence rates following surgical treatment of early-stage oral cancer with significant impacts on survival, morbidity, patients' quality of life and the cost to the health care system.Trial RegistrationClinicaltrials.gov NCT01039298

Diffuse Large B-Cell Lymphoma Associated with Chronic Inflammation Manifested as a Soft Tissue Mass: Incidental Discovery on Histological Examination

We report an extraordinary case of diffuse large B-cell lymphoma arising in a cystic necrotic mass in a 35-year-old man who presented with a soft tissue mass at the site of previous surgery. A benign mass was surgically removed 17 years ago, after which a cystic lesion gradually developed at the same site. The resected mass appeared as a thick-walled cyst filled with brown necrotic and hemorrhagic material. On microscopic examination, the cyst wall was primarily necrotic tissue with some aggregates of large atypical lymphoid cells. These atypical cells were diffusely positive for CD20 and showed a high proliferation index, Epstein-Barr virus positivity, and clonal rearrangement of the immunoglobulin gene. His present condition was diagnosed as Epstein-Barr virus-associated diffuse large B-cell lymphoma arising from chronic inflammation. It is important to be aware of the clinical manifestations and histological features of this rare disease in light of diagnosis and treatment.

Superficial Palmar Arch Aneurysm after Carpal Tunnel Decompression, a Rare Complication: A Case Report

False aneurysms of the palmar arteries are rare. They are usually associated with traumatic injuries to the hand vasculature. We present a case of superficial palmar arch aneurysm (SPAA), complicating carpal tunnel decompression which presented as a pulsatile mass at the site of previous surgery. Initial diagnosis was made on clinical examination and confirmed on doppler ultrasound (US) and computed tomographic angiography (CTA). The feeding vessel of the aneurysm was subsequently occluded using coil embolization.

An Unusual Case of Post-Operative Spondylitis Caused byMycobacterium Intracellularein an Immunosuppressed Patient

There are few reported cases of post-operative spondylitis caused by Mycobacterium intracellulare. A 75-year-old female presented to our hospital with low back pain and paraparesis after a fall. The radiologic examination revealed compression fractures of L1, L3 and L4 and an epidural hematoma compressing the spinal cord. The dark-red epidural hematoma was urgently evacuated. Four weeks post-operatively, neurologic deficits recurred with fever. On magnetic resonance image, an epidural abscess and osteomyelitis were detected in the previous operative site. Five weeks post-operatively, revision was performed with multiple biopsies. The specimen were positive for acid-fast bacilli and traditional anti-tuberculous medications were started. Because the Polymerase Chain Reaction for non-tuberculous mycobacterium (NTM) was positive, the anti-tuberculous medications were changed to anti-NTM drugs. However, the neurologic deficits did not improve and persistent elevation of erythrocyte sedimentation rate and C-reactive protein were noted. Eight weeks after the revision, Mycobacterium intracellulare was detected in the specimen cultures. Despite supportive care with medication, the patient died due to multiple organ failure.

Desmoid Tumor Arising in the Site of Previous Surgery in the Left Lower Quadrant of the Abdomen

A desmoid tumor is a fibroblastic proliferation arising in musculoaponeurotic structures. The pathogenesis is still not clear. A 79-year-old woman who developed a desmoid tumor in the left lower abdomen after surgical resection of an abdominal lipoma seven years previously is presented. Preoperative computed tomography showed a large left lower abdominal mass. Pathology showed the spindle fibroblastic cell pattern typical of desmoids.

Spinal Epidural Arteriovenous Fistula: A Unique Pathway into the Perimedullary Vein

Spinal dural arteriovenous fistulas (AVFs) are rare vascular malformations in the spinal dura, fed by dural branches of the radicular arteries, and drain primarily into intradural venous plexuses. They may cause elevated medullary venous pressure and produce a progressive myelopathy. We describe a case of AVF in the epidural space of the previous surgery site of L3 and it showed a unique complex venous pathway into the perimedullary vein, leading to classic clinical symptoms of venous congestion in the spinal cord. The shunt was draining into bilateral epidural venous plexus and then to the paravertebral veins at the level of L2. The venous outflow entered to the epidural space again and finally refluxed into the intradural perimedullary vein.

Guidelines for Safe Surgery in Patients with Systemic Mastocytosis

Systemic mastocytosis (SM) is a rare disorder with important perioperative implications. The physiological stress of operative procedures and a variety of anesthetic and analgesic medications can be triggers of acute exacerbation of this condition. We present two patients with systemic mastocytosis. One underwent open left inguinal hernia and umbilical hernia repair and the other laparoscopic ventral hernia repair. The literature for perioperative management of patients with SM is extensively reviewed. Both patients were treated preoperatively with intravenous antihistamines and steroids to minimize SM reactions. The first patient underwent uneventful open left inguinal hernia repair and umbilical hernia repair under spinal anesthesia. The second patient underwent general anesthesia. A composite mesh was used to repair a 9 x 12-cm Swiss cheese incisional hernia at the site of previous surgery. After the administration of neostigmine and glycopyrrolate, she developed a generalized rash without any hemodynamic instability. The patient was treated with intravenous Solu-Medrol and Benadryl and was extubated successfully and had an unremarkable postoperative course. Patients with SM require careful perioperative management for surgery under spinal and general anesthesia. These patients can undergo surgical procedures safely and effectively without compromising the standard of care.

Spontaneous appendico-cutaneous fistula, after drainage of a right loin abscess – A case report

A young male patient presented with right lower abdominal pain and fever. He had tenderness in the right lumbar region, with no palpable lump. Subsequently he developed a tender fluctuant lump in the right loin. Abdominal ultrasonography showed heterogenous collection in the right lumber region near the posterior abdominal wall. Making a diagnosis of right-sided perinephric abscess, drainage was done. The patient was discharged. Eight months after his discharge, he developed fever and painful swelling in the previous operation site followed by spontaneous discharge of pus. Sinogram showed the contrast passed through the sinus tract into the large bowel and into the terminal ileum. Laparotomy, fistula tract was found communicating with the appendix. Appendicectomy and curettage of the fistula tract was followed by complete cure.

Laparoscopic repair of recurrent childhood inguinal hernias after open herniotomy

Open repair of recurrent paediatric inguinal hernias (IH) is difficult and there is definite risk of damaging the vas deferens and testicular vessels during dissection of the previous open herniotomy field. Laparoscopic repair (LR) has the benefit of avoiding the previous operative site. Records of patients with recurrent IH that had LR after open repair were reviewed and evaluated retrospectively. The results were compared with data from cases in which the LR method was used in the initial IH repair. From September 2002 to October 2005, four boys and one girl (mean age 58.8 months) were treated in our institution for recurrent IH after open repair. Operative time, success rate and complications did not show any statistically significant difference when compared with our previous prospectively collected data for primary repairs. Laparoscopic repair is the preferred operation for recurrent childhood IH after open repair.

Laser angioplasty with a pulsed NdYAG laser: Early clinical experience

Since December 1986, 40 laser angioplasty procedures have been performed using the energy from a pulsed NdYAG laser, delivering near infrared light (1064 nm) in 100-microseconds pulses of approximately 300 mJ per pulse, directly through a transparent sapphire tipped device. All patients had total occlusion of the superficial femoral artery and symptoms severe enough to warrant surgery, with ulceration or gangrene in eight, rest pain in 14 and severe claudication interfering with life-style in the others. The device was introduced through an antegrade puncture of the superficial or common femoral artery and laser recanalization was followed by attempted balloon angioplasty in all cases. Occlusions were a median length of 15 cm (range 2-35 cm); ten patients had previously undergone failed attempts at conventional balloon angioplasty and four had occluded femoropopliteal grafts. Thirty-seven legs of 34 patients were treated with an average of 60 J (range 10-235 J) with successful recanalization in 27 and immediate reocclusion in seven. The 20 successful recanalizations have been followed up for up to 24 months (median 7 months) with only one late occlusion at 5 months. Failed recanalization was due to poor transmission by the delivery device in the early part of the series (five cases), repeated passage of the device down a collateral branch (four cases), dissection at the site of previous surgery (two cases) or no apparent reason (two cases). Immediate reocclusion was due to very poor run off in patients with severely ischaemic limbs (three cases) or technical difficulties with balloon dilatation (two cases). Complete symptomatic relief was obtained in all the cases of radiologically successful laser angioplasty. Early surgery was required in one case following reocclusion of the artery when an angioplasty balloon failed to deflate, and one patient suffered a skin reaction thought to be due to inadequate removal of the sterilizing solution. A different sterilizing procedure is now followed. Laser angioplasty can reduce the number of patients requiring bypass surgery and improvements in the device and access methods may reduce the number of untreatable cases.

MR peritoneography in complications of continuous ambulatory peritoneal dialysis

We evaluated the usefulness of magnetic resonance (MR) peritoneography for the examination of complications from continuous ambulatory peritoneal dialysis (CAPD). MR peritoneography was performed in 20 patients who had suspected CAPD-related complications. Patients who had active peritonitis were not included in the study. Before MR imaging, a mixture of 2000 mL of peritoneal dialysis solution and 20 mL of gadopentetate dimeglumine was instilled into the peritoneal cavity. MR imaging was performed on a 1.0-Tesla system using a body coil. Axial, coronal, and sagittal fat-saturated fast spoiled gradient echo (repetition/echo times, 100/6.3 ms; flip angle, 90 degrees), axial fat-saturated T2-weighted fast spin echo (repetition/echo times, 6000/107 ms), and coronal fat-saturated T2-weighted fast spin echo (repetition/echo times, 3000/96.2 ms) images of the abdomen and the pelvis were obtained. After drain-age, triplanar fat-saturated fast spoiled gradient echo images were repeated with the same parameters. Homogeneous distribution of the dialysate in the peritoneal cavity was detected in 18 patients (90%). In 12 patients (60%), fluid leaks were discovered peripheral to the exit site, tunnel, and site of peritoneal entrance of the catheter. Fluid leaks through the abdominal wall in five patients (25%), retroperitoneum in one patient (5%), and a previous operation site in one patient (5%) were demonstrated. No abnormal finding was detected in three patients (15%) who had clinically suspected complications, whereas a dialysate leak was found in two patients (10%) who had no significant finding at physical examination. MR peritoneography provides detailed information about the anatomic distribution of dialysate leaks in patients treated with CAPD and poses no risks associated with ionizing radiation and nephrotoxic contrast medium.

Plaque incision and grafting as a salvage after a failed Nesbit procedure for Peyronie's disease.

To analyse the outcome of plaque incision and grafting in patients who have a residual penile deformity after a Nesbit procedure for Peyronie's disease, as a further Nesbit procedure may present difficulties in dissection at the previous operative site, and may result in further penile shortening. Over a 5-year period, 15 patients (mean age 58 years, range 34-66) presented with a residual penile deformity after a Nesbit procedure. All the patients had painless and stable Peyronie's disease. All patients had the Peyronie's plaque incised and grafted with either saphenous vein (12) or modified human fascia lata (three). The outcome was assessed using criteria which recorded the degree of penile shortening, quality of erections and penile angulation. Before surgery the mean (range) angle of deformity was 56 (40-90) degrees ; at a mean follow-up of 10 (3-16) months 11 patients had a straight penis, three a residual angle of 10-30 degrees and one had no change in angle. Two patients reported penile shortening and one a new onset of erectile dysfunction. Overall, 14 patients reported either an excellent or satisfactory result. These results indicate that plaque incision and grafting is an effective salvage operation to correct a residual penile deformity after a failed Nesbit procedure in patients with Peyronie's disease.

Surgical workload and cost of postoperative adhesion-related intestinal obstruction: importance of previous surgery.

Postoperative intraabdominal adhesions cause morbidity of varying degree. Intestinal obstruction is the most severe complication of adhesions. This study examined the importance of previous surgery on clinical and economic workloads caused by intestinal obstruction due to postoperative intraabdominal adhesions. All emergency hospitalizations due to adhesion-related intestinal obstruction from January 1, 1999 to December 31, 1999 in a hospital district serving roughly 450,000 inhabitants was reviewed retrospectively. The patient population was divided into six groups according to the site of previous surgery, and the total as well as group-related surgical workload and direct costs of inpatient care were analyzed. There were 123 hospitalizations due to postoperative adhesion-related intestinal obstruction during the study period. A total of 101 patients had experienced 176 operations. The most prevalent operations were colorectal (with or without other operations), upper abdominal, and female reproductive system procedures. Colorectal surgery preceded 40% and 38% of inpatient episodes and inpatient days, respectively. Altogether, 40 operations were performed because of adhesion-related intestinal obstruction. No differences between groups were seen in terms of the mean operating or theater time. Total annual inpatient costs due to emergency hospitalizations for intestinal adhesion-related obstruction related to colorectal surgery in a hospital district serving roughly 450,000 inhabitants was 72,520.60 (U.S. dollars) which accounted for 35.3% of all annual costs caused by postoperative adhesion-related intestinal obstructions. There were no significant differences between groups regarding the total mean inpatient episode costs. Intestinal obstruction due to postoperative adhesions poses substantial costs for the society. Colorectal operations are the most important procedures preceding adhesion-related intestinal obstruction, accounting for 35.3% to 46.8% of the total clinical workload or costs attributable to postoperative adhesion-related obstruction.

The MR imaging appearances and natural history of seromas following excision of soft tissue tumours

Fluid collections (seromas) may accumulate at the site of surgery following excision of musculoskeletal soft tissue tumours. The aim of this retrospective study was to review the magnetic resonance (MR) imaging features of postoperative seromas identifying changes over time on follow-up scans. A total of 170 MR scans from 80 patients were reviewed showing one or more seromas. All patients had undergone previous surgery for a musculoskeletal soft tissue tumour. The typical MR appearances of a seroma were shown to be a well-defined oval or rounded (54%) soft tissue mass, arising at the site of previous surgery, with a thin, dark pseudocapsule, surrounding soft tissue oedema (80%), homogeneous contents that are hypointense (relative to adjacent muscle) on T1-weighted images (74%) and hyperintense on T2-weighted and STIR images (79%). Approximately one-quarter of cases revealed atypical features including hyperintense contents on T1-weighted (26%) and/or heterogeneous contents on T2-weighted images (21%), reflecting the breakdown of blood products and organization of the fluid collection. A distinctive fine feathery pattern arising from the inner surface of the seroma or from septations was identified in 10% of cases. In those patients who underwent one or more follow-up scans, the volume of the seromas decreased in 66% cases, remained unchanged in 15% and increased in 19%. Seromas are not an uncommon finding (<10% of cases) following surgery for a soft tissue tumour. The majority of cases show the typical MR features of a fluid collection. The pitfalls in differentiating an atypical seroma from a recurrent soft tissue sarcoma are discussed.