Suture Granuloma Research Articles

Mersilene mesh: long-term results in oculoplastic surgery

We evaluated the long-term results of Mersilene mesh application in 72 patients with various ophthalmic disorders. Mersilene mesh was used as a cover material for primary and secondary orbital implantation, as a sling material for the upper and lower lids, and as a spacer material for lid retraction. The postoperative follow-up period ranged from 15 to 62 months (average 43.21±12.8). Orbital implant exposure developed in 10 of 35 cases who had undergone enucleation and primary orbital implantation. Sphere exposure developed in one of 18 cases who had undergone secondary orbital implantation. We used Mersilene mesh as a frontalis sling material in 19 ptotic lids of 15 cases. Suture granuloma developed in 3 cases, and in 2 cases we observed Mersilene mesh extrusion associated with chronic discharge near the free edge of the lid. When used as a spacer material in lid retraction surgery, Mersilene mesh extruded through the conjunctiva of both lower lids in one of three cases. These long-term results indicate that Mersilene mesh is not an ideal material and further studies should be carried out in order to find new alternatives.

Dermal fatty tissue transplant as primary and secondary orbital implant. Complications and results

In this retrospective study we report the indications, complications and functional and cosmetic results after dermofat grafting into anophthalmic orbits. The method consists of implantation of autogenous dermis with attached subcutaneous fat from the gluteal region into the orbit. Twenty-four primary and 4 secondary grafts were implanted in 28 patients aged 12 to 49 years. In the explantation site one patient showed delayed healing. All implants became integrated, none were lost because of infection or extrusion. Eleven patients developed minor complications like central ulceration in the dermis, hair growth on the dermis or suture granuloma. In the primary implant group the functional and cosmetic outcome was evaluated by measurements of the lid structures, exophthalmometry (Hertel) and measuring the prosthesis motility (Kestenbaum). Three patients showed fair results; all the others had good or very good results. In one case of a secondary implant marked graft atrophy was observed. Despite the more extensive surgery and some minor complications the safety of this method with good functional and cosmetic results makes dermofat grafting an excellent alternative to heterogeneous orbital implants.

Foreign material in postoperative adhesions.

The authors determined the prevalence of foreign body granulomas in intra-abdominal adhesions in patients with a history of abdominal surgery. In a cross-sectional, multicenter, multinational study, adult patients with a history of one or more previous abdominal operations and scheduled for laparotomy between 1991 and 1993 were examined during surgery. Patients in whom adhesions were present were selected for study. Quantity, distribution, and quality of adhesions were scored, and adhesion samples were taken for histologic examination. In 448 studied patients, the adhesions were most frequently attached to the omentum (68%) and the small bowel (67%). The amount of adhesions was significantly smaller in patients with a history of only one minor operation or one major operation, compared with those with multiple laparotomies (p < 0.001). Significantly more adhesions were found in patients with a history of adhesions at previous laparotomy (p < 0.001), with presence of abdominal abscess, hematoma, and intestinal leakage as complications after former surgery (p = 0.01, p = 0.002, and p < 0.001, respectively), and with a history of an unoperated inflammatory process (p = 0.04). Granulomas were found in 26% of all patients. Suture granulomas were found in 25% of the patients. Starch granulomas were present in 5% of the operated patients whose surgeons wore starch-containing gloves. When suture granulomas were present, the median interval between the present and the most recent previous laparotomy was 13 months. When suture granulomas were absent, this interval was significantly longer--i.e., 30 months (p = 0.002). The percentage of patients with suture granulomas decreased gradually from 37% if the previous laparotomy had occurred up to 6 months before the present operation, to 18% if the previous laparotomy had occurred more than 2 years ago (p < 0.001). The number of adhesions found at laparotomy was significantly larger in patients with a history of multiple laparotomies, unoperated intra-abdominal inflammatory disease, and previous postoperative intra-abdominal complications, and when adhesions were already present at previous laparotomy. In recent adhesions, suture granulomas occurred in a large percentage. This suggests that the intra-abdominal presence of foreign material is an important cause of adhesion formation. Therefore intra-abdominal contamination with foreign material should be minimized.

Cytology of suture granulomas in post‐hysterectomy vaginal smears

In histologic sections, foreign body giant cells are often associated with a granulomatous reaction to embedded suture material. However, this finding is unusual in exfoliative cytology samples. We describe the cytologic findings associated with suture granulomas in nine vaginal smears obtained from four women, ages 53 to 72. The patients had undergone hysterectomy for endometrial adenocarcinoma (three patients) and cervical carcinoma in situ (one patient). Smears taken 6 to 34 mo after surgery showed a moderate to severe acute inflammatory reaction, foreign body giant cells, and polarizable suture material. A vaginal cuff biopsy from one patient confirmed the diagnosis. Although multinucleated giant cells in postmenopausal vaginal smears are usually a non-specific finding, phagocytosed refractile material observed post hysterectomy may reflect a chronic tissue reaction to suture material. The presence of an acute inflammatory reaction, foreign body type giant cells, and the appropriate past surgical history, should prompt the pathologist to rapidly screen the slide under polarized light to evaluate the possibility of suture granulomas.

Management of anastomotic complications after sleeve lobectomy for lung cancer

One hundred twelve patients (102 male and 10 female) underwent sleeve lobectomy for lung oncer from January 1969 to December 1991. Bronchopleural fistula occurred in 6 (5.6%), bronchovascular fistula in 2 (1.6%), pulmonary aiterial occlusion in 2 (1.9%), anastomotic stricture or stenosis in 7 (6.3%), and local recurrence in 7 patients (6.3%). Early repair of bronchopleural fistula combined with an omentopexy achieved permanent closure of the fistula. Two patients who underwent a completion pneumonectomy for a pnlmonary arterial occlusion died of respiratory failure. Two patients experienced uncontrollable bleeding into the bronchial tree through a bronchovascular fistula and sudden death. Completion pneumonectomy is indicated for a stricture due to scar formation. If pneumonectomy is precluded by poor pulmonary reserve, endoscopic excision using biopsy forceps is an alternative. Endcscopic resection is the treatent of choice for suture granulomas. Complications associated with bronchial or vascular anastomoses are serious and frequently fatal.

Esophageal Suture Granuloma as a Complication of a Fundoplication

Esophageal Suture Granuloma as a Complication of a Fundoplication

Esophageal Suture Granuloma as a Complication of a Fundoplication

Esophageal Suture Granuloma as a Complication of a Fundoplication

Pyogenic Granuloma After Transconjunctival Blepharoplasty

This is the first known report of a relatively large postoperative pyogenic granuloma developing after a nonsutured transconjunctival blepharoplasty. Inflammation and separation or malapposition of the conjunctival wound edges probably permitted the lesion to proliferate in the inferior fornix. No foreign material could be implicated because no suture was used to close this incision. Additionally, Polydek suture material (braided polyester fiber) was associated with the complication of a suture tract and granuloma when used for a tarsal suspension procedure for ectropion repair in this patient.

Stone Granuloma: A Cause of Ureteral Stricture

Ureteral stricture is a recognized complication of ureteroscopy and ureteral stone fragmentation. Although most strictures are either asymptomatic or easily dilated, there are some strictures that result in progressive ureteral obstruction, do not respond to ureteral dilation and require operative intervention. A review of 125 percutaneous nephrostolithotomies for staghorn stone disease and 652 ureteroscopic stone fragmentations revealed 5 cases in which refractory ureteral strictures developed, requiring operative intervention. In 4 patients a “stone granuloma,” embedded particles of calcium oxalate associated with macrophages and foreign body giant cells, was found with surrounding fibrosis and ureteral obstruction. In the remaining patient a suture granuloma from a recent ureterolithotomy was the source of the stricture. In each instance of stone granuloma the particles of calcium oxalate had become embedded in the wall as a consequence of ureteroscopic stone fragmentation and partial ureteral wall disruption.During ureteroscopy and intracorporeal lithotripsy every effort should be made to prevent calcium oxalate particles from becoming embedded in the ureteral wall. They are not inert and may cause irreversible stricture formation. To our knowledge, stone granuloma is a previously undescribed phenomenon and should be suspected when ureteral strictures that occur following ureteroscopy do not respond to endourological methods of management.

Perforation of the Augmented Bladder

In 12 of 264 children treated with enterocystoplasty 15 spontaneous perforations occurred. Of the 12 children 9 had myelodysplasia. All segments of the gastrointestinal tract were used for the augmentation and most were detubularized. Surgery to increase bladder outlet resistance was done in 8 cases. At the time of each perforation 9 children had sterile cultures, however, 3 died of overwhelming sepsis. Presenting signs included abdominal pain in 8 cases, septic shock in 4 cases and shoulder pain in 4 older myelodysplastic children with diaphragmatic irritation from escaping urine. Cystography demonstrated a leak in 10 of 11 cases. Urodynamic studies revealed good compliance with low maximum filling pressure in 8 of 10 children. Hyperreflexia was noted in only 5 cases and outlet resistance greater than 85cm. water was demonstrated in 5. Histological analysis showed changes in the bowel wall consistent with ischemia but suture granulomas were present in areas adjacent to the perforation site or thinned areas in biopsy or autopsy specimens. In addition to the theory that overdistention may cause enterocystoplasty perforation, current detubularization techniques may produce areas of relative ischemia, which become accentuated when the augmented bladder is distended beyond a reasonable volume.

Reoperation After Cholecystectomy. TheRole of the Cystic Duct Stump

The so-called “Postcholecystectomy Syndrome” may be due to various pathological biliary causes. The aim of this study was to evaluate the significance of the cystic duct stump syndrome and if so, how often a long (>1.5 cm) cystic duct stump was an indication for reoperation on the bile ducts after cholecystectomy in our patients. Three hundred and twenty two patients underwent a second operation on the bile ducts after cholecystectomy in the last ten years. In 35 patients (10.8%) a striking finding was a long cystic duct stump (>1.5 cm). In 24 of these patients, a pathological finding, in addition to the long cystic duct stump, was found on exploration. Out of these 24 patients there were 14 with common bile duct stones; 6 with stenosis of the sphincter of Oddi; 3 with chronic pancreatitis and in one patient hepatitis was the cause of the symptoms. From the remaining 11 patients 8 had a stone in a partial gall bladder or cystic duct stump. One patient had a fistula between the cystic duct stump and duodenum and one a suture granuloma. There was only one patient where a 1.5 cm long cystic duct stump remnant was the only pathological finding. Four years after reoperation this patient is still suffering from the same intermittent gastrointestinal symptoms. We conclude that the cystic duct stump is hardly ever a cause for recurrent symptoms in itself. Total excision of the cystic duct does not eliminate the existence of postcholecystectomy symptoms.

The Transconjunctival Approach to the Orbital Floor and Orbital Fat A Prospective Study

The transconjunctival approach to the inferior orbit and orbital fat offers the potential advantage of avoidance of scar creation in the lower eyelid skin and anterior lamellae. Complications of this approach, including conjunctival fornix shortening and eyelid margin malposition, have been occasionally reported. We prospectively observed 25 patients undergoing transconjunctival blepharoplasty and orbital floor surgery. Fornix depth, eyelid margin position, and the presence or absence of eyelid retraction were measured preoperatively and at each postoperative visit. No significant permanent change in these parameters was observed. Temporary entropion was observed in two patients; this resolved with conservative treatment. On self-limited suture granuloma was observed. In a subgroup of six patients, the conjunctival incision was closed on one side and left unclosed on the other. No adverse healing was noted on the unclosed side. We conclude that the transconjunctival approach is associated with a low incidence of complications, and that it does not significantly alter the fornix depth or eyelid margin position. A skin incision is avoided. The inferior orbital septum is not violated, greatly reducing the risk of development of lower eyelid retraction.

Suture granuloma masquerading as malignancy of the biliary tract

Eighteen years after having a duodenal leiomyosarcoma resected, a patient presented with weight loss, pruritus, and abdominal pain. ERCP was consistent with a cholangiocarcinoma with proximal hepatic duct stricture and nonfilling of the cystic duct. CAT scan revealed no extrinsic masses compressing the gallbladder or biliary tract. At surgical exploration, the patient was found to have a suture granuloma with surrounding fibrosis within the common bile duct. There was no evidence of malignancy.

Cutaneous metaplastic synovial cyst

Metaplastic synovial cyst, a recently described entity, is histologically characterized by a cystic cavity lined by metaplastic synovial tissue that is often hyperplastic and protrudes into its lumen as villous structures. Clinically, these lesions resemble suture granuloma and develop at the site of previous surgical trauma. We have studied 4 cases of this unusual entity and have investigated the immunohistochemical profile in an effort to determine the nature and derivation of their lining tissue. One of our cases is unique since the lesion was associated with a basal cell carcinoma. A history of previous surgery was noted in one, and history of trauma in 2 of the 4 cases. Our immunohistochemical observations confirmed a mesenchymal derivation for the "synovial like villous structures" but non-availability of a specific "synovial" marker does not permit us to conclude with certainty the synovial nature of the metaplastic tissue. Cutaneous metaplastic synovial cysts are unique lesions which deserve attention and should be included in the differential diagnosis of cutaneous cysts.

Anastomotic Suture Granuloma Following Radical Retropubic Prostatectomy

We report 2 cases of symptomatic suture granuloma formation after erosion of the silk suture (used to ligate the dorsal venous complex) into the urethrovesical anastomosis. Irritative or obstructive voiding complaints, sterile pyuria or hematuria found after radical retropubic prostatectomy mandates urological evaluation, including cystoscopy to rule out anastomotic suture granuloma formation. Although erosion appears to be a rare occurrence, we recommend use of absorbable suture to control the dorsal venous complex and avoid this possible complication.

Der Einflu\ der Fibrinklebung und ihrer wichtigsten Komponenten auf die Fibrosierung von Nervenanastomosen

The fibrinous adhesion, although generally adopted and more and more successfully applied in many sectors of surgery, is not yet fully established in the anastomosis of separated nerves. Initially, the adhesion was expected to offer some essential advantages in this domain, especially in the prevention of suture granulomas. However, the blood clots dissolved too early, and this resulted in the formation of dehiscences. So antifibrinolytic substances had to be added to the adhesive, and this led to a frequent appearance of fibroses. The adhesion of nerves is still hampered by this fact. Now we have examined the fibrosis-inducing effect of different factors of the adhesive system. We found that aprotinin and the fibrin clot as an obstacle to supply had no additional fibrotic effect, whereas thrombin, factor XIII and fibronectin promoted the formation of fibroses.

The influence of fibronectin on the fibrosing of a nerve anastomosis in the rat

Although the fibrin adhesion enjoys increasing success in many areas of surgery, it has not, however, become fully established in nerve anastomosis. It was in this area particularly that significant advantages were expected, especially by the avoidance of suture granulomas. As the fibrin clot dissolved prematurely, however, and dehiscences ensued, antifibrinolytic substances had to be added to the adhesive. Fibroses occurred frequently as a result, which to date encumber nerve adhesive. We examined fibronectin for its fibrosis-inducing effect, comparing both presently available fibrin adhesive systems, because one contained up to 5 times more fibronectin per milliliter than the other. On the basis of a test grouping using 100 and 1000 KIU aprotinin/ml, we were able to establish that fibronectin in fibrin adhesives possesses a fibrosis-promoting effect.

Pitfalls of autogenous lipodermal implantation to the orbit.

Autogenous kinetic lipodermal implantation in the orbit is an effective postenucleation procedure that gives optimal socket volume, motility, and cosmesis. The major complication of autogenous lipodermal implantation is graft atrophy. Other minor complications are infection, hair retention, conjunctival cysts, wound dehiscence, and suture granuloma. We presented a systematic description of the technique emphasizing prevention of complications by proper selection of patients, meticulously performed surgery, and appropriate postoperative management. In particular, attention should be paid to atraumatic dissection of the socket-respecting surgical anatomy, hemostasis, identification and placement of sutures in the extraocular muscles, atraumatic and aseptic manipulation of the graft, and proper anastomosis of the graft to the recipient bed.

A 20-Year Experience with Vasovasostomy

A total of 624 of 699 vasovasostomy patients was followed during the last 20 years. Better results were obtained when there was shorter duration of obstruction, bilateral straight vas-to-straight vas anastomosis and bilateral presence of sperm in the vas fluid during vasovasostomy. Results of end-to-end and side-to-side macrosurgical anastomosis, as well as of 1-layer and 2-layer microsurgical anastomosis were similar. Macrosurgical success rates were 84 per cent for patency and 35 per cent for pregnancy in the 300 cases. Microsurgical success rates were 90 per cent for patency and 51 per cent for pregnancy in 324 cases. Failure of patency was caused mainly by anastomotic scar formation with sperm and suture granulomas. Failure of pregnancy was owing mainly to inadequate postoperative semen quality.

Living related kidney donors. A 14-year experience.

Living related donor (LRD) nephrectomies are controversial due to the risks to the donor and improved cadaveric graft survival using cyclosporine A. Between December 22, 1970, and December 31, 1984, 1096 renal transplants were performed at a single institution, 314 (28.6%) from LRD. The average age was 34.3 years (range: 18-67); none had preoperative hypertension. All nephrectomies were performed transabdominally. Major perioperative complications occurred in 22 (7.0%). These include wound infections (3.5%), pancreatitis (1.0%), injuries to spleen (1.0%) or adrenal gland (0.3%) requiring removal, pneumonitis (0.6%), ulnar nerve palsy (0.6%), femoral artery thrombosis after arteriogram (0.3%), pulmonary embolus (0.3%), and upper pole infarct of contralateral kidney (0.3%). There are six known deaths in this series, none of which were related to the operation. Major late complications were seen in 50 (20.0%) of 250 patients followed for 6 to 175 months (mean 53.1 months). These included definite hypertension (5.6%), suture granuloma (4.4%), incisional hernia (3.6%), proteinuria (2.4%), bowel obstruction (2.0%), nephrolithiasis (1.2%), wound infection (0.4%), scrotal hydrocele (0.4%), and chronic pancreatitis (0.4%). While the risk of hypertension appears to increase as the interval from donation increases, no cases of renal failure after donation have been noted, and negligible proteinuria among those followed long-term has been seen in this series. It is felt that living related kidney donation is justified when the relative is sincerely motivated and well informed prior to donation.