Unexpected Complication Research Articles

Spontaneous Liver Rupture After Treatment With Drug-Eluting Beads

Spontaneous rupture of hepatocellular carcinoma (HCC) after transcatheter arterial chemoembolization (TACE) is a rare and life-threatening complication. Pathophysiologic mechanisms are not yet fully known; it is suggested that rupture is preceded by reactive tissue edema and intratumerous bleeding, leading to a rapid expansion of tumour mass with risk of extrahepatic bleeding in the case of subcapsular localisation. This case report discusses a sudden, unexpected lethal complication in a 74year-old male patient treated with TACE using DC Bead loaded with doxorubicin (DEBDOX) in a progressive multifocal HCC.

ABO Discrepancy and Hemolytic Anemia Post Liver Transplant due to Passenger Lymphocyte Syndrome

Patient: 54-year-old male Chief Complaint: High fever, diarrhea, and skin rash History of Present Illness: The patient is blood type group AB, Rh(D) positive with nonalcoholic steatohepatitis (NASH). Due to the advanced nature of his disorder, he received a liver transplant; the donor was group B. The patient received 24 units of blood during and after surgery. Fourteen days post transplant he was discharged. Thirty one days post transplant the patient presented with the current symptoms. Hematology workup revealed pancytopenia with a critically low hemoglobin concentration. The blood bank workup revealed an ABO discrepancy and an apparent auto-anti-E antibody. (Table 1) Past Medical History: The patient has a history of diabetes mellitus. The patient had gastric bypass 25 years prior to the transplant, resulting in a weight loss of 115 pounds. One year ago the patient was diagnosed with NASH. 1. What are the patient’s most striking clinical and laboratory findings? 2. What is the nature of the ABO discrepancy? 3. What is the most likely cause of the intravascular hemolysis? 4. Is hemolytic anemia an unexpected complication of transplants? 5. What is the immunological basis for this condition? 6. What is the appropriate blood component therapy for this patient? 1. The most striking clinical findings of the patient were fever, diarrhea, and skin rash. These are indications of graft versus host disease (GVHD), a complication that is rarely seen after orthotopic liver transplantation.1 Acute GVHD occurs between 1 and 8 weeks after the transplant. Symptoms may include fever, diarrhea, and skin rash. Diarrhea is due to lymphocyte infiltration and destruction of the intestinal mucosa, leading to a loss of absorptive function.1 Pancytopenia is associated with GVHD in many cases. The neutropenia and thrombocytopenia may lead to a life-threatening infection.1 A skin biopsy of this patient was consistent with GVHD. The Hemoglobin …

Book Review: Complications of Urologic Surgery: Prevention and Management, 4th ed

Just as important as surgical outcome are complications after surgery. Complications can not only affect the treatment outcome but also put a mental strain on both the patient and surgeon. However, every surgeon knows that even the perfect patient and flawless procedure can result in an unexpected complication. In this regard, prevention of any complication should be a priority with every operation. This book takes the baton from most textbooks that are usually limited to describing surgical steps and focus on the background behind possible complications and ways to prevent and manage them. Therefore, the reader is also provided with knowledge of preoperative patient risk factors that can aid in patient selection and consultation. In addition, the book includes nonurologic complications such as complication from anesthesia after urologic surgery and complications arising from medical therapies in everyday urologic practice. Furthermore, included topics stem from basics such as patient positioning to the most recent robotic surgery and this makes the book a requisite in every urologist's bookshelf from the training resident to the seasoned surgeon.

Myometrial Cystic Formation after Local Methotrexate Application into Cornual Gestational Sac: A Case Report of an Unexpected Complication

Cornual pregnancy is a rare type of ectopic pregnancy, and diverse therapeutic options exist for the management. Medical treatment despite high initial beta HCG values is not thought to be safe. We reported a 39-year-old woman with an initial beta HCG value of 22000 mIU/mL and diagnosed of a cornual pregnancy. Patient was managed successfully with the administration of combined systemic and ultrasonographically guided local injection of methotrexate into the gestational sac. During followup with serial beta hcg measurements, 27 × 20 mm cystic area in myometrium has been detected. Beta hcg <1 mIU/mL value was reached three months later, and this cystic area resolved spontaneously. Systemic methotrexate administration combined with ultrasound-guided local methotrexate injection into the gestational sac might be considered as the first-line treatment in the management of hemodynamically stable patients having cornual pregnancy even with high beta HCG values and risk of myometrial cystic formation.

Severe Parkinsonism Following Endoscopic Third Ventriculostomy for Non-communicating Hydrocephalus -Case Report-

A 23-year-old male with non-communicating hydrocephalus caused by intraventricular hemorrhage from an arteriovenous malformation was treated by endoscopic third ventriculostomy (ETV) after repeated ventricular cerebrospinal fluid drainage and removal of ventriculoperitoneal shunt due to infection. Postoperatively, the patient developed robust rigidity and akinesia with mutism, suggesting secondary parkinsonism. These symptoms showed marked improvement after administration of levodopa, and were not aggravated after discontinuation. The pathophysiology of this case might involve dysfunction of the dopaminergic system caused by repeated compression and release of the paraventricular white matter. Careful perioperative management not leading to excessive dilation of the the ventricles should be considered for ETV for non-communicating hydrocephalus to avoid this unexpected complication.

Complication respiratoire inattendue après le traitement chirurgical d’une scoliose chez un adolescent

We report the case of an unexpected respiratory complication after a surgical treatment of scoliosis during postoperative period in an adolescent patient. This complication results of a vascular compression of the left main bronchus between the aorta and the pulmonary artery, which induces severe atelectasis of left lower lobe. Prolonged non-invasive ventilation with high level of positive end-expiratory pressure prevents aorto-pulmonary compression, allows a pulmonary recruitment associated with a favorable prognostic for the adolescent.

Haemorrhagic shock induced by subcutaneous insulin injection.

Sir—A number of chronic kidney disease patients with diabetes receive intensive insulin therapy nowadays, and many of them are also treated for several comorbidities. The combination of insulin therapy and other comorbidities could result in an unexpected complication.

Transient Paraplegia due to Accidental Intrathecal Bupivacaine Infiltration Following Pre-Emptive Analgesia in a Patient With Missed Sacral Dural Ectasia

A case report with review of the literature. To highlight the need for careful magnetic resonance imaging evaluation for the presence of incidental lumbosacral dural anomalies before attempting caudal epidural interventions. Pre-emptive analgesia through the caudal epidural route provides good postoperative pain relief in spine surgeries. Several precautions have been advised in the literature. Presence of sacral-dural ectasia should be considered a relative contraindication for this procedure. A 50-year old woman underwent posterior instrumented spinal fusion for L4-L5 spondylolisthesis under general anesthesia. She received single shot caudal epidural analgesia at the start of the procedure. After complete emergence from anesthesia, she had complete motor and sensory loss below the T12 spinal level, which reversed to normal neurology in 6 hours. Retrospective evaluation of the patient's magnetic resonance imaging showed an ectatic, low lying lumbosacral dural sac which had been overlooked in the initial evaluation. The drugs given by the caudal route have been accidentally administered into the thecal sac causing a brief period of neurologic deficit. This unexpected complication has been reported only in the pediatric literature before. It is important to look for the presence of lumbosacral dural anomalies before planning caudal epidural injections in adults also. Sacral dural ectasia and other lumbosacral anomalies must be recognized as contraindications for caudal epidural pre-emptive analgesia for spine surgery. Other modes of postoperative pain relief should be tried in these patients.

Robotic Repair of Access-Related Aortic Injuries: Unexpected Complication of Robot-Assisted Prostatectomy

Robot-assisted surgery is becoming more widespread, but despite adoption by most academic institutions, curricula for training residents in robotics have yet to be developed fully. Even after teaching surgeons have mastered robotic techniques, an inherent risk of avoidable injuries may persist as they seek to impart their knowledge of this relatively new surgical modality to trainees. Two cases of aortic injury during access for robot-assisted prostatectomy are described along with their successful robotic repair with root-cause analysis of the events. Robotic surgeons who are involved in training programs should be prepared to handle even major potential complications of robot-assisted surgery regardless of their own expertise or experience.

Iatrogenic Parasitic Myomas: A New Complication of Laparoscopic Morcellation

Study Objective: To describe our experience in diagnosing and managing parasitic myomas arising as an unexpected late complication of laparoscopic morcellation. Design: Observational study (Canadian Task Force classification II-3). Setting: Large University hospital with tertiary care facilities. Patients: Retrospective chart review of all patients found to have parasitic myomas developed after previous morcellation. Intervention: Laparoscopic morcellation. Laparoscopic images of iatrogenic parasitic myomas. Review of the recent literature correlated with clinical, surgical and pathologic features of our cases. Measurements and Main Results: We encountered 4 patients presenting with heterogeneous pelvic masses after morcellation. Symptoms appeared between 2 and 16 years after primary surgery in 3 cases. One patient was asymptomatic and was referred for the finding of a suspicious pelvic mass. Vaginal examination revealed painful pelvic masses in the pouch of Douglas in 2 cases and painless masses, fixed to the vaginal vault and anterior vaginal wall in the other two. Laparoscopic evaluation confirmed the presence of parasitic masses in 3 cases. In one case the mass was excided vaginally. Histologic examination confirmed leiomyoma fragments in all cases. A well-differentiated endometrial carcinoma was incidentally found in one patient after hysterectomy. Conclusion: These masses probably resulted from the growth of missed fragments of uterine tissue after previous morcellation, culminating in the development of symptomatic iatrogenic parasitic myomas. If morcellation is anticipated or required, exclusion of malignancy is mandatory. Meticulous inspection of the abdominal cavity is necessary after morcellation. In patients with history of morcellation presenting with pelvic masses, iatrogenic parasitic myomas should be considered as part of the differential diagnosis.

Iatrogenic Sacroiliac Joint Syndrome After Percutaneous Pedicle Screw Fixation at the L5-S1 Level

This article reports an unexpected complication of percutaneous pedicle screw fixation at the L5-S1 level. We describe a 66-year-old man who underwent anterior lumbar interbody fusion followed by percutaneous pedicle screw fixation at the L5-S1 level. The Sextant pedicle screw system was used. The patient experienced postoperative sacroiliac joint syndrome caused by the screw head and rod tip. In the immediate postoperative period, the preoperative right-side leg pain improved, but the patient complained of left-side buttock and leg pain. The left-side screws were removed, and after revision surgery, the left-side pain disappeared. However, at that time, right-side pain recurred. We found that the screw head and rod had violated the iliac crest and the sacroiliac joint, causing referred pain rather than radicular pain. After the screw head was repositioned and the rod was replaced with a new shorter rod with a blunt end, the patient's symptom was relieved. Surgeons should be aware of this unprecedented adverse effect when planning percutaneous pedicle screw fixation at the L5-S1 level. An android pelvis with a narrow and high iliac crest can be a risk factor. Careful preoperative evaluation and more accurate surgical technique are needed to prevent this type of complication.

Correction to “Scintillation Screen Investigations for High-Current Ion Beams” [Jun 10 1414-1419

In the above titled paper (ibid., vol. 57, no. 3, pp. 1414-1419, Jun. 10), due to an unexpected complication during the calibration of the spectrometer for Figs. 10 and 11, some corrections have been made to Figs. 10 and 11, The revised figures are presented here.

“Iatrogenic” Parasitic Myomas: Unusual Late Complication of Laparoscopic Morcellation Procedures

Study Objective To describe our experience in diagnosing and managing parasitic myomas developing as an unexpected late complication of laparoscopic morcellation. Design Observational study (Canadian Task Force classification II-3). Setting University hospital. Patients Retrospective chart review of all patients found to have parasitic myomas that developed after previous morcellation. Intervention Laparoscopic morcellation. Review of the recent literature correlated with clinical, surgical, and pathologic features of our cases. Measurements and Main Results Four patients had heterogeneous pelvic masses after morcellation. In 3 patients, symptoms developed between 2 and 16 years after the primary surgery. One patient had no symptoms, and was referred because of a suspect pelvic mass. Vaginal examination revealed painful pelvic masses in the pouch of Douglas in 2 patients, and painless masses fixed to the vaginal vault and anterior vaginal wall, respectively, in the other 2 patients. Laparoscopic examination confirmed the presence of parasitic masses in 3 patients. In 1 patient, the mass was excised vaginally. Histologic analysis confirmed leiomyoma fragments in all patients. A well-differentiated endometrial carcinoma was incidentally found in 1 patient after hysterectomy. Conclusion These masses probably resulted from growth of missed fragments of uterine tissue after previous morcellation, culminating in development of symptomatic iatrogenic parasitic myomas. If morcellation is anticipated or required, exclusion of malignancy is mandatory. Meticulous inspection of the abdominal cavity is necessary after morcellation. In patients with a history of morcellation who have pelvic masses, iatrogenic parasitic myomas should be considered in the differential diagnosis.

Unusual complication after laparoscopic left nephrectomy for renal tumour: a case report

In splenic rupture after blunt trauma, iatrogenic spleen injury or non-traumatic cases it is essential that the surgeon makes correct decisions. Conservative treatment must include continual monitoring and repeated, stringent evaluation of the splenic injury (the American Association for the Surgery of Trauma – AAST) in order to avoid any delay in diagnosis of delayed spleen rupture and the high mortality it causes. We present the case of an unexpected complication after radical nephrectomy performed for renal cell carcinoma. A 61-year old man sought medical help for acute abdominal pain. He presented with some cardiovascular risk factors (diabetes mellitus, smoker of 30 cigarettes per day) and moderate alcohol use. In the Emergency Unit, computed tomography scan revealed an incidental tumour of the left kidney. Nephrectomy via the laparoscopic approach was done without any iatrogenic complications, with less than 500 cc of blood loss. Firm adhesions between the spleen and abdominal wall, which caused some minor traction that resulted in a small subcapsular haematoma, were the only surprising intraoperative finding. Within the first 6 h, the patient presented with haemodynamic instability, while the drain evacuated less than 50 cc of discharge. However, CT scan showed that subcapsular haematoma had increased to the size of 10 × 10 cm without free peritoneal fluid present. Unfortunately, 6 h later emergency surgery had to be performed due to rupture of the subcapsular splenic haematoma. Massive haemoperitoneum was evacuated and the splenic capsule was the only remnant of the spleen that could be found on re-intervention. So far, it is the first case describing an increasing subcapsular haematoma of the spleen, most likely caused by the traction of firm adhesions to the organ. We discuss means to avoid such a complication: with liberation of the adhesions, placement of a perisplenic mesh, embolization of the splenic artery or subcapsular nephrectomy. An acute splenic rupture or delayed one demands from the surgeon practical knowledge of how to prevent subcapsular haematoma and how to treat splenic rupture.

Acute compartment syndrome following fibula flap harvest for mandibular reconstruction

Donor site morbidity for free fibula osteofasciocutaneous flaps has rarely been reported in the literature. We report on a case of acute compartment syndrome (ACS) in a 22-year-old male, following fibula flap harvest for mandibular reconstruction and arising after post-ischemic reperfusion damage. Dissection during this patient’s surgery was unusually difficult. The skin defect was covered with a loose dressing while waiting for secondary grafting. Intracompartmental pressures measured by the Wick catheter technique confirmed the diagnosis of ACS. ACS is an unexpected complication after fibula flap harvest since the three compartments of the leg are opened during surgery. Only four cases of ACS have been reported in the literature. Analysis of this serious complication might lead to changes in the routine use of the pneumatic tourniquet in some selected cases. New automatic tourniquet systems might also be advantageous in such cases.

Fat embolism – An update

Summary Fat embolism syndrome is an unexpected and alarming complication that is difficult to actively prevent, hard to diagnose with confidence and has limitations in effective treatment modalities. The syndrome is a melange of respiratory, haematological, neurological and cutaneous symptoms and signs associated with trauma and other disparate surgical and medical conditions. The pathogenesis is still debated. It is clear that fat emboli are quite common yet the clinical syndrome is rare. Diagnosis is by pattern recognition as befits a syndrome, but the recently defined features on MRI could now be used to increase the probability of the diagnosis. Various therapeutic options have been tried and failed. At present steroids have a single meta-analysis suggesting benefit but it is in the trauma population where they may be contra indicated for other reasons, i.e. infection, so their place is ill defined. Supportive treatment is the mainstay.

Inhibitors that activate

Inhibitors of RAF enzymes can suppress or activate the same signalling pathway. The details of how this happens provide a cautionary note for those targeting the pathway for anticancer drug discovery. Abnormal activation of the RAS-RAF-MEK-ERK signalling pathway is a feature of many human cancers, making it an attractive target for antitumour therapy. Several RAF and MEK inhibitors are in clinical trials, but an unexpected complication has emerged. Although selective BRAF inhibitors are effective in treating mutant BRAF melanoma, in which they potently suppress RAF-MEK-ERK signalling, the same inhibitors are ineffective against tumours that carry an oncogenic mutation in the KRAS gene. Two groups now report that the reason for this dramatic difference is that RAF 'inhibitors' have dual activity, functioning as either inhibitors or activators of RAF, depending on the cellular context and mutational status of RAF. In News & Views, Karen Cichowski and Pasi Jänne discuss the mechanistic and clinical implications of these findings and similar work reported in Cell.

The Dragon Strikes: Lessons from the Wenchuan Earthquake

The Dragon Strikes: Lessons from the Wenchuan Earthquake

Unilateral Isolated Abducens Nerve Paralysis

Although paranasal sinus mucoceles are benign lesions, they are important because of the destruction they form in the bone structure in sinus wall. They are observed most frequently in frontal sinus; especially at this location, they may cause serious pathologic lesions in the neighboring structures as the orbit and cranium. Paranasal sinus mucoceles can be treated with open or closed endoscopic surgical methods. In this article, we present an unexpected complication of frontal mucocele, abducens nerve paralysis, and its treatment.

Short communication articles published in BJOMS during 2008–2009—an analysis of types of submission and subject material

The British Journal of Oral and Maxillofacial Surgery (BJOMS) accepts many types of papers that include leading articles, reviews, full length articles, and short communications. Many of the latter are isolated case reports of rare or interesting pathology, or personal experience of a difficult or unexpected complication. Case reports are considered to have a relatively low value in the advancement of medical knowledge, and with increasing pressure for space in paper publications, many journals now limit them to online publication only. We evaluated all 142 short communications published in BJOMS during 2008/2009. Most (87%) were single case reports, and they covered virtually the whole remit of the specialty. There were also 14 formal studies that included two laboratory-based research projects; these were excluded from the analysis. We used established criteria to assess the possible educational value of each publication, and found that 61/128 papers (48%), while interesting and informative, probably added little to existing knowledge. The remaining papers described new or unreported cases, rare or unexpected outcomes, and adverse effects or complications of treatment. We discuss the possible implications of this study for readers of BJOMS and for the journal itself.