Subcutaneous Tract Research Articles

Selected best demonstrated practices in peritoneal dialysis access

Many burdensome interventions that adversely affect the utilization of peritoneal dialysis as renal replacement therapy and patient satisfaction with this treatment modality can be avoided by early peritoneal access placement with embedded catheters, implantation techniques that preempt common catheter complications, and the use of access devices that provide flexibility in exit site location. Catheter embedding consists of subcutaneously burying the external limb of the catheter tubing at the time of the insertion procedure. Interval exteriorization of the catheter is performed when dialysis is needed. Earlier commitment by patients to peritoneal dialysis can be achieved by elimination of catheter maintenance until dialysis is necessary. Catheter embedding is a practical strategy to avoid temporary hemodialysis with vascular catheters and reduces stress on operating room access by allowing more efficient scheduling as non-urgent procedures. Laparoscopic catheter placement enables proactive techniques not available to other conventional insertion methods. These techniques include rectus sheath tunneling to prevent catheter tip migration, selective prophylactic omentopexy to prevent omental entrapment, selective resection of epiploic appendages to prevent catheter obstruction, adhesiolysis to eliminate compartmentalization, and diagnosis and simultaneous repair of previously undiagnosed abdominal wall hernias. Both standard and extended 2-piece catheter systems are necessary to customize the peritoneal access to a variety of body configurations. Catheters should be able to produce lower abdominal, mid-abdominal, upper abdominal, and upper chest exit site locations that facilitate management by the patient without sacrificing deep pelvic position of the catheter tip or resulting in excessive tubing stress during passage through the abdominal wall.

Needle Tract Implantation of Follicular Neoplasm After Fine-Needle Aspiration Biopsy: Report of a Case

We herein report a 28-year-old woman with a follicular neoplasm showing subcutaneous needle tract implantation. One month after fine-needle aspiration biopsy (FNAB) for a tumor measuring 2.5 cm, the patient became aware of a subcutaneous nodule measuring about 1 cm at the needle insertion site. FNAB smear of this nodule showed poorly cohesive clusters of follicular cells with nuclear crowding, overlapping and resetting with some microfollicular architecture. Total thyroidectomy and resection of the subcutaneous nodule were performed. Although there was no capsular or vascular invasion of the nodule, the lesion was diagnosed as follicular carcinoma because of the subcutaneous seeding. Ki-67 labeling indices of the thyroid nodule and implanted tumor were higher than 5%. Furthermore, although galectin-3 was completely negative in the thyroid nodule, it was heterogeneously positive in the implanted tumor. It is therefore suggested that high cell proliferating activity as a characteristic of the original nodule and the subsequently obtained invasive characteristic of the implanted tumor contributed to this event. To date, there has not been any recurrence of the implanted lesion. Because implanted follicular carcinoma can be surgically removed, this complication should not impair the usefulness of FNAB.

Bronchocutaneous fistula after chest-tube placement: A rare complication of tube thoracostomy

Bronchocutaneous fistula is a pathologic communication between the bronchus, pleural space, and subcutaneous tissue. It can occur as a complication of positive pressure ventilation and pneumonectomy. Diagnosis is made by imaging studies. Treatment options are endoscopic repair, parietal pleurectomy, and pleurodesis. Our patient is a 53-year-old woman who had a difficult chest-tube placement for complicated parapneumonic effusion. Computed tomography scan revealed a fistulous tract from the bronchus to the skin at the site of the original chest tube, and chest x-ray film revealed a subcutaneous fistulous air tract in the lateral chest. It is usually an acquired condition; congenital bronchocutaneous fistula is rare. We report a case of bronchocutaneous fistula after chest-tube placement.

Ultrasound Evaluation of Peritoneal Catheter Tunnel in Catheter Related Infections in CAPD

In cases of peritonitis and exit site infections it is important to determine the extent of involvement of the subcutaneous catheter tract. The assessment of such involvement by physical examination alone appears to be inadequate and insensitive. We examined the usefulness of ultrasound (US) examination of the catheter tract in delineating catheter related infections, and their relationship to each other and to peritonitis. Patients were examined during clinically defined states of exit-site infection (ESI), clinically defined tunnel infection (TI), peritonitis and in the normal condition. US examinations of the catheter tunnel were performed in 44 CAPD patients. A total of 47 US examinations (examination was repeated in three patients) were performed, divided among 13 episodes of peritonitis, four ESI, and 30 controls. In 12 of 47 US examinations, US-defined TI was demonstrated as a sonolucent pericatheteric fluid collection. These 12 positive US were distributed among seven patients with peritonitis, three with exit-site infections and two control patients. We conclude that peritonitis and ESIs are frequently accompanied by involvement of the catheter tract. It seems that both the internal and external cuffs do not constitute an effective barrier against the spread of infection.

Temporary removal of navel piercing jewelry for surgery and imaging studies.

Navel piercings are becoming increasingly popular among adolescents. Body piercing jewelry must be removed before surgery, because electrical burns can occur with electrocauterization. Also, piercing jewelry creates artifacts during magnetic resonance imaging. Even temporary piercing jewelry removal may lead to closure of the subcutaneous tract; therefore, temporary replacement with a nonmetallic spacer is indicated. This report describes a simple, safe, effective method for perioperative temporary replacement of navel piercing jewelry with a universally available, nonmetallic, sterile, intravenous catheter. The umbilical piercing jewelry of 5 adolescent female patients was removed before surgical or radiologic interventions by using the following technique: 1) disinfecting the piercing and umbilical area with 70% isopropyl alcohol, 2) opening the piercing jewelry by removing the bead from the bar, 3) placing the tip of a tight-fitting intravenous catheter (14 or 16 gauge, without the needle) over the threaded tip of the bar, 4) advancing the intravenous catheter caudally, pushing the piercing out of the skin tract, and 5) removing the jewelry and leaving the intravenous catheter in the subcutaneous skin tract as a spacer. After the intervention, the piercing jewelry was reinserted by following the described steps in reverse order. The patients were evaluated after 1 week, for assessment of any adverse effects, including infection. With this method, piercing jewelry removal and reinsertion required <2 minutes for all patients. No procedural complications were noted. All jewelry was reinserted successfully after the procedure. The intravenous catheter left in situ did not interfere with surgery, and it did not produce any artifacts or adverse effects during magnetic resonance imaging. Follow-up evaluations at 1 week demonstrated no signs of irritation, infection, or other side effects of the procedure for any of the patients. Periprocedural removal of navel piercing jewelry with this new technique proved to be quick, feasible, and safe. Piercings in other locations on the body may be replaced for surgery or imaging studies in the same way, with minor modifications.

Vena cava filter placement using a cutdown of the superficial epigastric vein.

Percutaneous placement of vena cava filters through the femoral vein has been associated with insertion site venous thrombosis. Reported incidence varies from 2% to 41%. In the majority of placements, sequential dilators are used to create the venotomy and subcutaneous tract. This technique disrupts all layers of the vein wall. The injured area may extend as far proximal as the dilator or sheath is placed. The authors present their experience with placement of vena cava filters using a cutdown of the superficial epigastric vein. During a 5-year period, 27 patients underwent placement of the LGM-Vena Tech vena cava filter via a femoral approach. A cutdown of the superficial epigastric vein was performed. The guidewire, dilator, and introducer sheath were inserted under direct fluoroscopic examination. After removal of the dilator, the LGM-Vena Tech filter was placed through the introducer. There were no wound infections and no clinical signs of insertion site venous thrombosis in the postoperative period. Insertion site venous thrombosis is a well-documented complication of percutaneous filter placement. Superficial epigastric vein cutdown is a reasonable alternative technique, which allows gentle atraumatic manipulation of the femoral vein. It is a simple, safe procedure that can be performed without any significant increase in operative time and no additional morbidity.

Pseudoaneurysms of the superficial temporal artery secondary to placement of external ventricular drainage catheters

BACKGROUND Pseudoaneurysms of the superficial temporal artery have been described following trauma and various surgical procedures. There are no reports in the literature of these lesions following the placement of external ventricular drainage catheters. This article describes two patients and their successful treatment, and reviews diagnostic and treatment strategies. CASE DESCRIPTION Two patients developed tender, nonpulsatile masses in the scalp along the former subcutaneous tract of an EVD catheter. Both lesions were successfully excised in the operating room and found to be thrombosed pseudoaneurysms of the superficial temporal artery. CONCLUSION Pseudoaneurysms of the parietal branch of the STA may occur secondary to incision of the skin for twist drill hole placement or the use of a sharp trocar for subcutaneous tunneling of catheters. Use of a blunt-tipped trocar may reduce the risk of developing pseudoaneurysms secondary to EVD placement. Knowledge of the possibility of developing these lesions from catheter placement may aid the neurosurgeon in proper diagnosis and treatment.

Commentary

BACKGROUNDPseudoaneurysms of the superficial temporal artery have been described following trauma and various surgical procedures. There are no reports in the literature of these lesions following the placement of external ventricular drainage catheters. This article describes two patients and their successful treatment, and reviews diagnostic and treatment strategies.CASE DESCRIPTIONTwo patients developed tender, nonpulsatile masses in the scalp along the former subcutaneous tract of an EVD catheter. Both lesions were successfully excised in the operating room and found to be thrombosed pseudoaneurysms of the superficial temporal artery.CONCLUSIONPseudoaneurysms of the parietal branch of the STA may occur secondary to incision of the skin for twist drill hole placement or the use of a sharp trocar for subcutaneous tunneling of catheters. Use of a blunt-tipped trocar may reduce the risk of developing pseudoaneurysms secondary to EVD placement. Knowledge of the possibility of developing these lesions from catheter placement may aid the neurosurgeon in proper diagnosis and treatment.

A new abdominal drain insertion technique after a cirrhotic liver resection to prevent ascitic leakage.

A simple technique for inserting an abdominal drain is reported to prevent the leakage of ascitic fluid at the abdominal drainage site after a cirrhotic liver resection. This technique consists of inserting the abdominal drain through a subcutaneous tract. When the drain is then removed during the postoperative period, the pressure of the ascitic fluid that has built up in the peritoneal cavity causes pressure which thus obliterates the subcutaneous tract and thereby prevents leakage. This technique was found to be easy to perform, safe, and effective.

Common iliac artery access during endovascular thoracic aortic repair facilitated by a transabdominal wall tunnel.

To describe a technique for common iliac artery (CIA) access during endovascular aortic aneurysm repair when unfavorable angulation between the CIA and the delivery sheath precludes direct arterial access. After retroperitoneal exposure of the CIA, a puncture site is chosen inferolateral to the surgical incision, and an 18-G trocar/cannula is advanced in alignment with the CIA through the anterior abdominal wall or skin of the upper thigh into the retroperitoneal space. Serial dilatation is performed over a guidewire placed through the cannula to create the subcutaneous tract. The trocar/cannula is replaced over the wire, and the CIA is punctured under direct vision. The guidewire is then advanced into the proximal aorta. A CIA arteriotomy is performed and the delivery system introduced over the guidewire through the tunnel into the iliac artery. Retroperitoneal exposure of the CIA with tunneled transabdominal wall delivery of the stent-graft avoids both external iliac artery injury and creation of a temporary access conduit in patients with iliac tortuosity and/or occlusive disease.

Utilización de la vía subcutánea para el control de síntomas en un centro de salud

To describe the use of the subcutaneous tract for symptoms control in patients those are in phase of palliative treatment of their illness. Observational study. Primary care. Patients seen in a health center, in phase of palliative treatment of their illness, that needed for symptoms control the subcutaneous administration of drugs. Most of the patients were in terminal phase (19), the fundamental cause (17 cases) that justified the use of the subcutaneous tract was the difficulty to take drugs by oral tract in the last days of life, attention on death throes. The infusion continuous through injector type travenol, at an infusion speed of 2 ml/h, it was the most common way of drug administration (19 patients). The drugs and initial average dose most used were: morphine 19 patients dose 100 mg/24 h, hyoscine butylbromide (Buscapina), 13 patients, 60 mg/24 h, haloperidol 12 patients, 4 mg/24 h. The patients death was the main cause that justified the retirement of the continuous infusion (17 people sick), happening in its own home. Symptoms control was good or very good in the most of patients (14). The experience on using the subcutaneous tract for symptoms control in our health center is positive, being the fundamental cause for its use symptoms control in the last days of the patients life. The continuous subcutaneous infusion should be used in primary attention, as an usual technique for the symptoms control in patients that are in phase of palliative treatment of their illness.

Visual Diagnosis: A Family That Has an Itchy Rash

1. Tamar Stricker, MD* 2. Felix H. Sennhauser, MD* 1. 2. *University Childres’s Hospital, Zurich, Switzerland. A brother and sister are brought to the clinic for evaluation of an itchy rash of 4 months’ duration. The 4-year-old girl and 8-month-old boy each have a red, raised, and scaly rash extending over their trunk and extremities. In the previous week, they had developed inflamed, cracked bumps on their feet that intermittently bled and had a yellow discharge. Both parents also have an itchy rash. There is no history of recent illness or use of any topical agents. The family had been living in crowded conditions in Switzerland for 6 months, having emigrated from eastern Europe as refugees. Both children had received their primary immunizations for diphtheria, tetanus, pertussis, polio, Haemophilus influenzae type b, and hepatitis B upon arrival in Switzerland. The girl also had received immunization against mumps, measles, and rubella. On physical examination, the girl is afebrile and appears well. Her height and weight are normal (75th to 90th percentile and 50th to 75th percentile, respectively). Dry, abraded skin lesions with occasional thickening and crusting are present over the scalp, nape of the neck, trunk, buttocks, and extremities. The lesions are more pronounced in the axillae and flexor surfaces of the legs and have an annular configuration (Fig. 1⇓ ). Honey-colored crusts with surrounding erythema cover the lower legs and feet. Results of the remainder of the physical examination are normal. Figure 1. Annular, dry, abraded lesions on lower leg. The 8-month-old boy, also afebrile and well-appearing, has …

Exchange of poorly functioning tunneled permanent hemodialysis catheters.

The usefulness of exchanging poorly functioning tunneled permanent hemodialysis catheters in patients with end-stage renal disease was evaluated. We retrospectively reviewed case histories of 51 consecutive patients who underwent 88 catheter exchanges because of poor flow rates. All hemodialysis catheters were initially placed by the radiology service using image guidance. Catheter exchanges were performed through the existing subcutaneous tract over two stiff hydrophilic guidewires and without additional interventions such as fibrin sheath stripping or venoplasty. Life table analysis was performed to evaluate catheter patency rates after initial placement (primary patency) and after multiple exchanges (secondary patency). The technical success rate for hemodialysis catheter exchange was 100%. Primary catheter patency was 42% at 60 days and 16% at 120 days. Secondary patency was 92% at 60 days and 82% at 120 days. The cumulative infection rate was 1.1 per 1000 catheter days. No complications from the procedure occurred. Catheter exchange is an effective means of prolonging catheter patency in patients with end-stage renal disease and limited central venous access.

Subcutaneous feather tract denervation does not alter feather retention force ante- and postmortem in broilers

To determine whether feather retention force (FRF) in 6-wk-old commercial broilers was influenced by the presence or absence of cutaneous innervation, nerve trunks for the pectoral and sternal feather tracts were severed unilaterally (left side) in Trial 1. In Trial 2, the sternal subcutaneous nerve trunk was severed either unilaterally (left or right side) or bilaterally. Four days postdenervation, FRF was determined bilaterally either antemortem (immediately prior to stunning) or 2 min after stunning and bleeding (postmortem). In Trial 1, the pectoral feather tract ante- and postmortem FRF values did not differ significantly for innervated or denervated tracts. In this trial, the sternal feather tract ante- and postmortem FRF values were 13% higher (44 g) for the denervated (left side) than for the innervated (right side) treatments. Partitioning this difference into the effects of sample side or innervation could not be attained because only the left side was denervated (left-denervation or right-innervated) in Trial 1. In Trial 2, both the left and right sternal feather tracts were represented in equal numbers for the innervated and denervated treatments, and there were no significant differences in FRF related to innervation, left and right side, or ante- and postmortem sample times. The presence or absence of cutaneous nerve innervation does not appear to influence FRF ante- or postmortem. This finding indicates that treatments disabling the central nervous system antemortem may lower FRF indirectly by altering cutaneous metabolism and therefore have been consistently unsuccessful in substantially altering postmortem FRF.

Subcutaneous Ureteral Replacement: A Canine Model

There are several clinical situations in which extrinsic or intrinsic ureteral diseases necessitate extensive reconstructive surgery. Unfortunately, not all patients are candidates for such surgery (e.g., those with retroperitoneal metastatic disease). Ureteral replacement is indicated in this selected group of patients. A viable option is to establish a ureteral replacement using subcutaneous tubes. Among the problems associated with this method of urine diversion are selecting the proper material for the tubes, the timing of tube replacement, encrustation and occlusion, urine reflux, and renal function. There is an obvious need for an animal model to address these issues. The aim of this study was to establish a reproducible canine model for subcutaneous ureteral replacement, by using a combination of nephrostomy and cystostomy tubes joined together under the skin. The animal study was conducted in 6 dogs. A pigtail nephrostomy and a cystostomy were inserted through a midline abdominal incision and stab wounds in the abdominal wall. A subcutaneous tract was bluntly made toward the nephrostomy incision starting from the cystostomy incision. The nephrostomy was grasped with the clamp and brought through the subcutaneous tunnel to the cystostomy incision. Upon emerging through the cystostomy incision, the tubes were joined and buried under the skin. Intravenous urography at 4-6 weeks postoperatively in 4 dogs showed no deterioration of renal function, but some hydronephrosis was present. Using the technique described in this paper, it is possible to establish a subcutaneous ureteral replacement using nephrostomy and cystostomy tubes in dogs. This model may serve for further research of the various questions associated with subcutaneous ureteral replacement in humans.

Liver Resection: To Drain or not to Drain?

Purpose: A prospective, randomized trial was performed to determine if intra-abdominal drainage catheters are necessary after elective liver resection.Patients and Methods: Between April 1992 and April 1994, 120 patients subjected to liver resection, stratified by extent of resection and by surgeon, were randomized to receive or not receive operative closed-suction drainage. Operative blood loss was not an exclusion criteria, and no patient who consented to the study was excluded. Results: Eighty-seven patients (73%) had resection of one hepatic lobe or more (27 lobectomies, 54 trisegmentectomies, and 6 bilobar atypical resections) and 33 had less than a lobectomy (8 wedge resections or enucleations, 9 segmentectomies, and 16 bisegmentectomies). Eighty-four patients (70%) had metastatic cancer and 36 patients (30%) had primary liver pathology. There were no differences in outcome, including length of hospital stay (no drain, 13.4 ± 0.9 days; drain, 13.1 ± 0.8 days; P not significant [NS]), mortality (no drain, 3.3%; drain, 3.3%), complication rate (no drain, 43%; drain, 48%; n= NS), or requirement for subsequent percutaneous drainage (no drain, 18%; drain, 8%; P= NS). All infected collections (n= 3) occured in operatively drained patients. Two other complications were directly related to the operatively placed drains. One patient developed a subcutaneous abscess at the drain site, and a second developed a subcutaneous drain tract tumor recurrence as the only current site of recurrence. Conclusion: In the first 50 consecutive resections performed since the conclusion of this trial, only 4 patients (8%) have required subsequent percutaneous drainage. We conclude that abdominal drainage is unnecessary after elective liver resection,

A technique for inserting inadvertently removed tunneled hemodialysis catheters using existing subcutaneous tracts.

A technique for inserting inadvertently removed tunneled hemodialysis catheters using existing subcutaneous tracts.

P-1-12 - External ventricular drainage in patients with subarachnoid hemorrhage due to aneurysm rupture

BACKGROUNDPseudoaneurysms of the superficial temporal artery have been described following trauma and various surgical procedures. There are no reports in the literature of these lesions following the placement of external ventricular drainage catheters. This article describes two patients and their successful treatment, and reviews diagnostic and treatment strategies.CASE DESCRIPTIONTwo patients developed tender, nonpulsatile masses in the scalp along the former subcutaneous tract of an EVD catheter. Both lesions were successfully excised in the operating room and found to be thrombosed pseudoaneurysms of the superficial temporal artery.CONCLUSIONPseudoaneurysms of the parietal branch of the STA may occur secondary to incision of the skin for twist drill hole placement or the use of a sharp trocar for subcutaneous tunneling of catheters. Use of a blunt-tipped trocar may reduce the risk of developing pseudoaneurysms secondary to EVD placement. Knowledge of the possibility of developing these lesions from catheter placement may aid the neurosurgeon in proper diagnosis and treatment.

Replacement of Accidentally Removed Tunneled Venous Catheters Through Existing Subcutaneous Tracts

The authors describe their experience with reinsertion of accidentally removed tunneled venous catheters using existing subcutaneous tracts. Replacement of 13 dislodged tunneled venous catheters was attempted a median of 12 hours (range, 3 hours to 5 days) after accidental removal. The catheters were needed for hemodialysis (n = 11), plasmapheresis (n = 1), or antibiotic therapy (n = 1). The tunnel exit was probed in the same fashion as for a dislodged nephrostomy tube, and new catheters were reinserted once a guide wire was advanced into the central veins. The medical record was reviewed to determine materials used and occurrence of complications, if any. Replacement was successful in 12 of 13 patients. The remaining patient had a new catheter placed through a fresh puncture during the same visit. There were no infections associated with re-use of existing tunnels. In five patients, after probing the tract with a guide wire, new catheters were simply advanced into the desired position. Seven other successes required additional manipulations with use of dilators and peel-away sheaths. Tunneled catheters that "fall out" can be readily replace even when reinsertion is attempted up to 5 days later. This represents an important contribution that radiologists can offer in the management of venous access cases.

Frequent involvement of the internal cuff segment in CAPD peritonitis and exit-site infection--an ultrasound study

The extent of involvement of the subcutaneous Tenckhoff catheter tract in CAPD peritonitis and catheter-related infections is of major therapeutic importance. By definition, both peritonitis and exit-site infections do not involve the catheter tract. However, diagnosis of these infections as well as the more sinister tunnel infection is based mainly on clinical signs. We examined the usefulness of ultrasound examination (US) of the catheter tract in delineating catheter-related (exit-site and tunnel) infections, and their relationship to each other and to peritonitis. CAPD patients with no evidence of peritonitis or catheter-related infections for 6 months prior to examination served as controls. US were performed by one of two experienced radiologists using the Acuson 128XP/10 scanner with a 7-MHz linear transducer. A positive US was defined as an area of hypoechogenicity (indicative of fluid collection) >2 mm in width along any portion of the catheter tract. Findings were localized into segments(S) as follows: S1, limited to external cuff; S2, intercuff segment adjacent to the external cuff; S3, intercuff segment adjacent to the internal cuff; S4, limited to the internal cuff; and S5, involvement extending throughout the catheter tract. Between March 1993 and January 1995, 39 CAPD patients, all with a double-cuff straight Tenckhoff catheter with the exit site situated above the point of entry into the peritoneum were studied. A total of 56 US were performed divided among 26 episodes of peritonitis, four tunnel infections, 13 exit-site infections,and 13 controls. There were 30 positive US distributed among 16 peritonitis, four tunnel, eight exit site infections and two control patients. The two positive controls went on to develop peritonitis within 1 month of the US. The majority of the US findings (13/16 in episodes of peritonitis and 5/8 exit site infections were localized to segment 4, that is, to the internal cuff region. Apart from a significant increase in width in all infected segments versus a normal tunnel, no differences in size were seen between peritonitis, exit-site, or tunnel infections, nor were there any differences in size and localization in these infections when comparing the offending organism (Gram-positive, negative, or culture negative). We conclude that peritonitis and exit-site infections are frequently accompanied by involvement of the catheter tract. The localization of infection to the internal cuff region in cases of exit-site infection probably occurred as a result of downward migration along the catheter tract. This supports the notion that ideally the exit site should be pointing caudally or that the peritoneal catheter have a swan-neck configuration. With regard to peritonitis, infection within the peritoneal cavity appears to extend and involve the internal cuff region. Thus both the internal and external cuffs do not seem to pose an effective barrier against the spread of infection.. Based on our data, we recommend that US be performed as a routine investigation in all cases of exit-site infection and in cases of refractory or relapsing peritonitis.