Spontaneous Dehiscence Research Articles

Efficacy of the Buried Temporary Suture Tarsorrhaphy: A Novel Technique.

To describe a buried variation of the temporary suture tarsorrhaphy and determine its efficacy period. This retrospective case review includes 11 patients needing corneal protection. Six patients had lagophthalmos from facial nerve palsy, 4 had cicatricial ectropion, and 1 had neurotrophic keratopathy. A total of 14 buried temporary suture tarsorrhaphies (BTSTs) were placed. The duration of the BTST was the main outcome. The corneal status before and throughout the BTST was monitored. The eyelids were examined for any undesired changes from the BTST. The mean duration of the BTST was 97.5 days, with a maximum of 273 days. Aside from one spontaneous dehiscence 5 days after placement, all BTSTs held until intentional removal. Five BTSTs were removed for a more definitive surgical procedure, 6 were removed after resolution of the initial indication, and 2 are still in place as the patient awaits surgery. All cases of keratopathy improved after BTST placement. There were no complications and no undesired eyelid changes. The BTST is a simple, fast, safe, and effective procedure that can be performed in the clinic or inpatient to immediately improve ocular surface coverage. As a minimally invasive procedure that can easily last several months, the BTST is an excellent option for patients who require more intense intervention than medical management alone. It can also securely bridge patients to a permanent solution such as lateral canthal resuspension.

Spontaneous Tegmen Tympani Dehiscence: Causes and Treatment of Conductive Hearing Loss.

Conductive hearing loss (CHL) commonly arises in patients with spontaneous dehiscence of the tegmen of the temporal bone with meningoencephalocele (SME). The aim of this study was to further investigate 1) the potential mechanisms for CHL in this setting; 2) hearing outcomes following surgery to address SME, and 3) the possible causes of persistent CHL following surgery. Retrospective case review. Tertiary referral center. Seven patients (six female; nine ears) who underwent middle cranial fossa repair of SME and were found to have a tegmen tympani dehiscence from October 2010 to September 2014 were included in the study. Pre- and postoperative pure-tone audiometry. Eight of nine ears (89%) had audiometric hearing loss at presentation. Seven ears (78%) had an air bone gap of ≥15 dB; all of these had an encephalocele traversing the tegmen tympani defect, four had a middle ear effusion, and three had a simultaneous superior semicircular canal dehiscence (SSCCD). The CHL resolved postoperatively in four of seven ears. Two of the three ears with persistent CHL had SSCCD. Attic ossicular fixation was identified in the other patient and the CHL resolved after ossiculoplasty. CHL associated with SME can be attributed preoperatively to ossicular chain fixation and synchronous SSCCD as well as the more commonly cited cerebrospinal fluid effusion and prolapse of meningoencephalocele onto the ossicular chain. Persistent postoperative CHL can also occur due to SSCCD and ossicular fixation by adhesions.

Dehiscence of the lamina papyracea

We report the case of a 35 year old patient presenting with acute onset of right periocular pain with palpebral edema due to nose blowing with absence of trauma. Early assessment showed periorbital emphysema without ophthalmological involvement, normal pupillary light reflex and visual acuity. Computerized tomography (CT) scan of facial and orbital bones objectified right pneumo-orbita with orbital fat herniation via a partial agenesis of the lamina papyracea, without muscle incarceration. Emphysema gradually reduced after two weeks by applying pressure dressing associated with broad spectrum antibiotic therapy as well as following the rules for cleanliness (avoiding closed glottis efforts, nose blowing…). Pneumo-orbita is defined by the presence of orbital air. It is mainly caused by a trauma but few cases of spontaneous dehiscence have been reported. The opening of the lamina papyracea, acting as an antireflux valve, prevents air outlet. CT scan is essential to confirm the diagnosis. It most often has a spontaneous resolution but the presence of hyperpression, that can be responsible for ischemic optic neuropathy or occlusion of the central artery of the retina, require a rigorous monitoring in order to implement possible urgent decompressive intervention.

How to Reduce the Incidence of Placenta Accreta Spectrum Independently of the Number of Cesarean?

How to Reduce the Incidence of Placenta Accreta Spectrum Independently of the Number of Cesarean?

A Retrospective Review of Vaginal Cuff Dehiscence: Comparing Absorbable and Nonabsorbable Sutures

To compare the rate of spontaneous and complete vaginal cuff dehiscence (VCD) using absorbable versus nonabsorbable sutures for vaginal cuff closure. Retrospective comparative cohort design. Freestanding ambulatory surgery center in suburban Maryland. Women age >18 years old who underwent hysterectomy for benign conditions between October 2013 and April 2018. Laparoscopic retroperitoneal hysterectomy was performed by 2 gynecologic surgical specialists. Transvaginal cuff closure was performed using either absorbable Vicryl (polyglactin 910) sutures (n = 881) or nonabsorbable Ethibond (polyester) sutures (n = 574). The nonabsorbable sutures were surgically removed after 90 days. No statistically significant differences in age, race, weight, body mass index, parity, uterine weight, or number of comorbidities were noted between the nonabsorbable and absorbable suture groups. Spontaneous vaginal cuff dehiscence (VCD) occurred in 3 patients (0.52%) in the nonabsorbable group and in 12 patients (1.4%) in the absorbable group (p = .183). Eleven of the 12 cases of VCD in the absorbable group were precipitated by intercourse and occurred within 90 days of surgery. Our data suggest that use of a nonabsorbable suture may be an effective approach to prevent spontaneous VCD, but the benefits should be weighed against the inherent risk associated with a second procedure to remove sutures.

Prospects of the use of wild relatives for pea breeding

The current global climate change results in shift and shrinkage of ranges of crop cultivation. The potential of crop wild relatives as an important source of genetic diversity for breeding is underestimated. Wild relatives of pea include the species P. fulvum and the subspecies P. sativum subsp. elatius, whereas wild representatives of P. abyssinicum are unknown. Wild peas are characterized by spontaneous dehiscence of pods and ballistic seed dispersal. The cultivated pea represents just a phyletic lineage within P. sativum. Pea crop wild relatives are promising with respect to: (1) resistance to pests and pathogens; (2) resistance to abiotic stress; (3) nutritional value; (4) agrotechnical advantages, e.g. branching, ability of hibernation etc.; (5) symbiotic nitrogen fixation; etc. P. fulvum is resistant to pea weevil, rust, powdery mildew and ascochyta blight. Some P. sativum subsp. elatius are resistant to nematodes, broomrape, powdery mildew, Fusarium wilt, root rot, ascochyta blight and white wilt. P. sativum subsp. elatius responds to weevil oviposition by neoplastic pustules of the pod wall controlled by the locus Np. Some P. sativum subsp. elatius accessions have lowered transpiration rates, and an accession from Italy survives at–20°C. Analyses of quantitative trait loci have been carried out for resistance of P. fulvum to pea weevil, powdery mildew and rust and for resistance of P. sativum subsp. elatius to broomrape, bacterial blight and ascochyta blight. Aryamanesh et al. (2012) obtained five introgression lines with pea weevil resistance transferred from P. fulvum to P. sativum. The practical use of wild peas is hampered by insufficient awareness of their diversity and differences from cultivated peas. Studies of useful traits of wild peas and their natural diversity, which is rapidly vanishing, should be intensified.

A viable childbirth after correction of spontaneous uterine dehiscence

We report a case of uterine dehiscence during pregnancy. Uterine dehiscence and rupture are serious complications of pregnancy. This situation takes place especially in women that prior uterine operation(s). We represent a 30-year-old woman diagnosed uterine dehiscence at 22nd gestation week. Uterine dehiscence treated surgically and then medical treatment was given to prevent preterm labour. At 34th gestation week, the patient was operated because of preterm labour and an alive foetus was born. The result of the pathologic examination of the placenta: Placental adhesion failure was detected. In conclusion women with prior caesarean delivery (one or more), ultrasound measurement should be recommended for measuring the lower uterine segment thickness in order to predict the possibility of uterine dehiscence and rupture.

Spontaneous rupture of the lens capsule in hypermature cataract: presentations and outcomes

AimTo describe the occurrence of spontaneous rupture of the lens capsule in patients with hypermature cataract.Study designConsecutive case series.MethodsThe records of patients with hypermature cataract and spontaneous capsular dehiscence seen...

Uterine Dehiscence During Initiation of Spinal Anesthesia for Cesarean Delivery

Uterine dehiscence is a known but uncommon complication during pregnancy. The symptoms of uterine dehiscence can be subclinical and usually occur during prolonged augmented labor in women who had previous cesarean delivery and/or are carrying a macrosomic baby. It can be associated with maternal and fetal hemodynamic compromise and complications. However, to our knowledge, spontaneous uterine dehiscence during performance of spinal anesthesia for an elective cesarean delivery has not been reported in obstetric anesthesia practice. Here, we report a case of uterine dehiscence while subarachnoid block was being performed.

Merkmale von traumatischen und spontanen Wunddehiszenzen nach perforierender Keratoplastik

After penetrating keratoplasty (PK) patients remain at risk for wound dehiscence at the graft-host junction even years after surgery. The aim of our study was, firstly, to assess the site-specific characteristics between traumatic and spontaneous wound dehiscence at the graft-host junction and, secondly, to determine the incidence of traumatic and spontaneous wound dehiscence. The medical records of all 243 patients who underwent a penetrating keratoplasty from 1 March 1996 to 1 March 2012 were retrospectively reviewed. During a 16-year period 9 eyes showed signs of open wound dehiscence after blunt ocular trauma and 7 eyes spontaneously after suture removal. Over the 16-year period, the incidence of traumatic wound dehiscence was 3.7 % (9 of patients), whereas the incidence of spontaneous wound dehiscence after suture removal was 2.9 % (7 of 243 patients). In traumatic cases the graft dehiscence occurred in 88.9 % (8 of 9 patients) in the nasal part, predominantly in the inferior nasal part. In one case (11.1 %), only the temporal part was affected. The average extent of wound dehiscence for traumatic cases was 96° of the total wound circumference in the nasal part, and only 30° of the circumference in the temporal part. Spontaneous dehiscence after suture removal mainly occurred at temporal site in 71.4 % (5 of 7 eyes), mostly temporal inferior. Only in one case was the nasal part affected (14.3 %). The average extent of wound dehiscence in spontaneous cases was 54° of the total circumference in the temporal part and 21° in the nasal part. The total average extent of dehiscence was significantly larger in traumatic cases, 126° (one third) for traumatic and 75° (one fifth) of the wound circumference for spontaneous cases. All of the re-sutured grafts retained clarity, except for 3 eyes among the traumatic cases. The difference between both groups was significant regarding the localisation, the extent and the clarity of the re-sutured grafts. The nasal inferior part was the most affected area in traumatic cases probably as a result of indirect, contrecoup injuries, and the temporal part in spontaneous wound dehiscence probably due to direct minor forces.

EComment. Vacuum-assisted closure therapy for deep sternal wound infections

We read with great interest the article by Steingrimsson et al. regarding the efficiency of vacuum-assisted closure (VAC) therapy for deep sternal wound infections (DSWI) in cardiac surgery [1]. The definition of DSWI as documented by the US Centers for Disease Control is an ‘infection involving fascia or deeper with at least one of the following: evidence of infection seen at re-operation or spontaneous dehiscence, positive culture of mediastinal fluid and/or positive blood culture and/or chest pain with sternal instability and temperature higher than 38°C [2].’ VAC therapy has now become a standard method of treatment for DSWI. In a prospective randomized trial by Moues and colleagues in 2004, a significant reduction in the wound surface area was noted in the VAC group compared to the conventional moist gauze therapy [3.8 ± 0.5 percent/day (mean ± SEM) vs 1.7 ± 0.6 percent/day respectively; p < 0.05]. However, the superiority of VAC therapy could not be explained by a significant reduction in the bacterial load [3]. In the retrospective cohort study by Gdalevitch and colleagues, the predictive factors identified for VAC treatment failure were the positive blood cultures (most sensitive predictor), wound depth of more than 4 cm (most specific predictor) and a high degree of sternal exposure and instability. Furthermore, the authors have suggested that these patients might be better managed by a surgical approach [4]. Luckraz and colleagues, in 2003, suggested that VAC therapy used alone or combined with other surgical modalities can offer acceptable results for the treatment of DSWI in cardiac surgery. In addition, the total cost for the hospitalization and treatment for patients in the VAC group was $16 400 per patient, compared with $20 000 per patient in the sternal rewiring and closed irrigation treatment group [5]. In conclusion, VAC therapy is an acceptable method for the treatment of DSWI. Patients with these devastating and potentially life-threatening complications can be assessed on an individual basis by an experienced team of cardiothoracic surgeons. Conflict of interest: none declared.

Traumatic rupture of the deltoid muscle during a pull-up: a case report

Rupture of the deltoid is a rare injury and has been reported most frequently in the elderly. It has been well recognized in association with acute or chronic massive rotator cuff tears. Spontaneous dehiscence of a deltoid repair following open cuff repairs is also well documented. A traumatic rupture of this muscle in the elderly has been attributed to weakening of this muscle from aging. Repeated steroid injections for rotator cuff tendinitis may also predispose one to atraumatic deltoid tears. A traumatic rupture of the deltoid has been reported to be caused by a seatbelt during a road traffic accident in a middle-aged patient. This injury is rare in the young. It has been described in a 31-year-old bowler where the deltoid was detached from the posterolateral corner of the acromion. We report a young male who sustained an anterior deltoid tear after a pull-up during military training.

ビスフォスフォネート関連顎骨壊死とメトトレキサート関連リンパ増殖性疾患を併発した関節リウマチ患者の1例

We report a case of rheumatoid arthritis associated with bisphosphonate-related osteonecrosis of the jaw （BRONJ） and methotrexate-associated lymphoproliferative disorder （MTX-LPD）. A 60-year-old woman had spontaneous pain, swelling, and dehiscence of the right mandibular gingiva after the placement of dental implants. The patient was given MTX, steroids, and bisphosphonates to treat rheumatoid arthritis. BRONJ was diagnosed, and anti-inflammatory therapy was administered. On the day of admission, she had a high fever, pancytopenia, liver dysfunction, and hemostatic disorder. MTX-LPD was diagnosed on the basis of the results of a bone marrow biopsy and symptoms. MTX was withdrawn, and chemotherapy was begun. Three months after the start of chemotherapy, FDG-PET scanning showed uptake of FDG in the liver. The patient died 10 months after initial treatment despite intensive care, including several aggressive courses of chemotherapy.

Nonselective matrix metalloproteinase but not tumor necrosis factor-α inhibition effectively preserves the early critical colon anastomotic integrity

Increased matrix metalloproteinase (MMP) activity has been implicated in the pathogenesis of colorectal anastomotic leakage. Tumor necrosis factor-α (TNF-α) induces MMPs and may influence anastomosis repair. We assessed the efficacies of the nonselective hydroxamate MMP inhibitor GM6001, the selective hydroxamate MMP inhibitor AG3340 and a TNF-α antagonist with respect to anastomotic breaking strength of left-sided colon anastomoses in male Sprague-Dawley rats. Systemic GM6001 treatment effectively blocked MMP activity and maintained the initial breaking strength day 0 of the anastomoses when administered subcutaneously as daily depositions (100 mg/kg) or continuously (10 mg/kg/day). In contrast, the anastomotic biomechanic strength was lowered by 55% (p < 0.001) in vehicle-treated rats on postoperative day 3. GM6001 treatment increased breaking strength by 88% (p < 0.0005) compared with vehicle-treated rats day 3 and reduced (p = 0.003) the occurrence of spontaneous anastomotic dehiscence. Histologically, the anastomotic wound was narrower (p < 0.05) in the longitudinal direction in GM6001-treated animals whereas GM6001 had no significant effect on inflammatory cell infiltration or epithelialization. AG3340 (10 mg/kg) increased (p < 0.012) breaking strength by 47% compared with vehicle on day 3 but did not significantly prevent the reduction of the initial breaking strength on day 0. Although the increased TNF-α levels in the wound were attenuated, the anastomotic breaking strength was not improved (p = 0.62) by the TNF-α (10 mg/kg) inhibitor given systemically. Pharmacological nonselective MMP inhibition ought to be explored as a prophylactic regimen to reduce anastomotic complications following colorectal resection. The involvement of TNF-α was insignificant in anastomotic wound healing in an experimental model.

Spontaneous Anterior Lens Capsular Dehiscence Causing Lens Particle Glaucoma

To report acute onset lens particle glaucoma associated with a spontaneous anterior capsular dehiscence. A 66-year-old man presented with spontaneous anterior lens capsule dehiscence with an acute onset of right eye pain that was associated with white particles in the anterior chamber angle and intraocular pressure (IOP) of 55 mmHg. No trauma or other inflammatory antecedents were reported. A hypermature cataract was observed at slit lamp exam. After medical treatment without IOP control, we performed extracapsular cataract extraction and anterior vitrectomy. Anterior chamber aspirate confirmed the presence of macrophages. The postoperative IOP at one month was 16 mmHg OD without medication. Spontaneous dehiscence of the anterior lens capsule in a patient with a hypermature cataract may release lens cortical material, resulting in lens particle glaucoma. Prompt surgical removal of the lens material usually controls the high IOP, and the need for additional glaucoma surgery is not common.

"Spontaneous scar dehiscence of a repaired bladder rupture in a 5 yr old girl – a case study"

Spontaneous scar dehiscence of a previous repaired urinary bladder rupture is described in a 5 yr old girl approximately 4 yrs after the original repair, she presented at the hospital with the chief complain of pain and distension of the abdomen. No underlying aetiology could be related to the event, her blood urea and creatinine levels were found to be raised. A diagnostic peritoneal tap showed non bloody straw colour urine in the peritoneal cavity. Emergent laparotomy was carried out and the site of scar dehiscence was closed in layers.

Proposition d’un algorithme de prise en charge médico-dentaire pour les patients traités par bisphosphonates

Bisphophonates (BP) were first named diphosphonates. They are potent inhibitors of osteoclastic activity and so reduce bone remodeling. Additionally they have anti-angiogenic properties and contribute to progressive disappearance of bony micro-vascular blood supply. Administrated orally, BP are generally used to prevent and treat osteoporosis. Injectable BP are used in patients with multiple myeloma and metastatic solid tumors. Scientific evidence dealing with a potentially devastating side effect of BP, osteochemonecrosis of the jaws, is growing rapidly. Clinical signs and symptoms include absent or delayed soft tissue healing with bony exposure following dental extraction or spontaneous gum dehiscence. Patients are usually asymptomatic but may develop pain if the bone becomes secondarily infected. At the beginning, no radiographic manifestations are seen, but in some cases a vast zone of necrotic bone can be seen on MRI, larger than what could be expected. Surgical debridements, bone curettage, local irrigation and or hyperbaric oxygen therapy have proven to be unsuccessful. Up to now, no definitive treatment strategy has been published to manage those patients leaving the dentist or the stomatologist resourceless. This article proposes recommendations for general practitioners, dentists, oral surgeons and designed for three types of patients: 1. patients to be treated with BP; 2. patients treated with BP without bisphosphonate-associated osteonecrosis; 3. patients with bisphosphonate-associated osteonecrosis. The proposed guidelines are not definitive and practitioners remain free to choose their treatment. Of upmost importance is to recognize the risks of oral complications before, during and after surgery in patients treated with BP and to inform them of such risks.

Catarata polar anterior piramidal deslocada para a câmara anterior causando edema de córnea: relato de caso

Cataratas polares anteriores piramidais são opacidades cônicas que se projetam para a câmara anterior a partir da cápsula anterior do cristalino. Na grande maioria dos pacientes a opacidade permanece aderida e estável durante toda a vida. O objetivo deste trabalho é documentar uma manifestação incomum desse tipo de catarata: a deiscência espontânea das pirâmides para a câmara anterior causando descompensação endotelial e edema corneal bilateral. Relatamos o caso de uma paciente feminina, de 66 anos, branca, que apresentava edema corneal localizado inferiormente no olho direito associado à lesão nodular branco-esclerótica compatível com a pirâmide anterior da catarata polar. O olho esquerdo apresentava edema corneal difuso intenso e presença de uma catarata polar anterior com a região piramidal deslocada para a câmara anterior. Sabe-se que a pirâmide anterior pode permanecer inabsorvida na câmara anterior por longo período, pois é composta de tecido colágeno denso. Isto causa perda endotelial progressiva e edema corneal e deve ser considerada indicação de remoção cirúrgica da catarata polar anterior e de seu fragmento. Ressalta-se, também, a importância do bom senso no julgamento das cataratas polares anteriores, considerando-se tamanho da opacidade, simetria das opacidades e componente cortical associado, na tentativa de se evitar ambliopia.

Dehiscence of the bony roof of the superior semicircular canal in the middle cranial fossa.

Spontaneous dehiscence of the superior semicircular canal (SSC) in the middle cranial fossa is rare and may cause clinical problems. This dehiscence was investigated in cadaveric and dried temporal bone specimens. One cadaveric specimen showed a spontaneous defect: the dehiscence was a symmetrical, elongated ellipse with smooth margins. Four of 244 dry bone specimens showed bony defects in the roof of the SSC, however, only one specimen was thought to have a spontaneous defect. Based on computer-simulation models, we hypothesized that spontaneous defects of the SSC may arise during the fetal period. Although rare, this defect may cause problems in middle cranial fossa surgery and may relate to certain vertiginous disorders.

Spontaneous wound dehiscence after removal of single continuous penetrating keratoplasty suture

Purpose To determine the incidence and complications of spontaneous wound dehiscence after removal of a single continuous penetrating keratoplasty (PK) suture. Design Retrospective consecutive, noncomparative interventional case series. Methods Retrospective review of 324 consecutive continuous suture PKs performed between 1992 and 1999. Results Sixty-nine (21.3%) of 324 PKs reviewed had the continuous suture removed. The average interval for suture removal after PK was 24.5 ± 15 months (range, 2.8–63.3 months). Five of the 69 eyes (7.2%) developed spontaneous wound dehiscence without direct eye trauma. In the five eyes that developed wound dehiscence, the continuous suture was removed at 24.6 ± 10.3 months (range, 14–42 months). Dehiscence occurred at 11.6 ± 6.5 (range, 3–18) days after suture removal. Significant history associated with wound dehiscence included coughing, yawning, falling without trauma to the eye, and spontaneous wound separation. The reasons for suture removal were astigmatism in four of five (80%) patients and a broken suture in one of the five patients. In four of five (80%) patients, the location of wound dehiscence correlated with the steep axis of corneal keratometry before suture removal. Surgical intervention preserved the presuture removal best-corrected visual acuity in four of the five eyes. No eyes with an intact suture spontaneously dehisced. Conclusions The rate of spontaneous wound dehiscence after removal of a continuous suture in our series was 7.2%. All spontaneous dehiscences occurred within 2 weeks after suture removal. Older patients, who had PK for corneal edema with postoperative astigmatism and have been using corticosteroids drops for prolonged periods of time, are at higher risk of wound dehiscence. Patients should be monitored closely during the first 2 weeks after removal of a continuous suture for signs of wound separation, especially when suture removal is performed for astigmatism. Patients should be cautioned about the risk and symptoms of wound dehiscence before suture removal to facilitate early recognition and intervention for preservation of best visual potential.