-
Frontiers in Surgery 2022Intracranial hypotension (IH) is usually associated with cerebrospinal fluid (CSF) leakage and/or CSF hypotension, and epidural blood patch (EBP) therapy has been proven...
BACKGROUND
Intracranial hypotension (IH) is usually associated with cerebrospinal fluid (CSF) leakage and/or CSF hypotension, and epidural blood patch (EBP) therapy has been proven to be effective for treating spontaneous IH and post-dural puncture headaches. Tarlov cysts (TCs) are common lesions of the sacral spine. They have rarely been reported in thoracic locations and are even less common in the posterior mediastinum, which can lead to their misdiagnosis as neurogenic tumors.
CASE PRESENTATION
Here, we report the case of a 60-year-old woman who developed an orthostatic headache after the thoracoscopic resection of a TC in the posterior mediastinum that was presumed to be a schwannoma preoperatively. The patient was finally diagnosed with IH caused by a subarachnoid-pleural fistula (SPF) and was cured by targeted EBP treatment.
CONCLUSION
This is a case to show that a single targeted EBP treatment is effective for a patient with IH caused by an SPF after thoracoscopic resection of a TC. This case reminds us to be vigilant that a TC may be masquerading as a posterior mediastinal neurogenic tumor, and a detailed examination should be performed to identify it before deciding on a surgical procedure. In addition, postural headache after thoracoscopic spinal surgery should be alert to the possibility of IH induced by an SPF. Once it occurs, early treatment is necessary, and targeted EBP treatment can serve as a safe and effective alternative when conservative treatment fails.
PubMed: 36238858
DOI: 10.3389/fsurg.2022.936949 -
Radiology Case Reports Dec 2022Caudal regression syndrome (CRS) is a rare congenital disorder characterized by arrest of caudal spinal growth and associated with wide spectrum multisystemic anomalies....
Caudal regression syndrome (CRS) is a rare congenital disorder characterized by arrest of caudal spinal growth and associated with wide spectrum multisystemic anomalies. Herein, we presented a case of a newborn baby who did not pass meconium due to imperforated anus and was referred to the pediatric surgeon for urgent diverting loop colostomy. The conventional X-ray, abdominal ultrasound and abdominal pelvic magnetic resonance imaging (1.5 T) at 2-month-old age revealed right kidney agenesis, sacrococcygeal agenesis, vertebral bodies dysraphism and the spinal cord ends at D12-L1 with anterior and posterior bands of the terminating filaments. The diagnosis of CRS was confirmed. Through this case report, we hope to draw attention to this rare syndrome and the wide range of associated anomalies, also to consider this syndrome on the top of differential diagnosis list once the newborn has anorectal malformation mainly imperforated anus.
PubMed: 36204402
DOI: 10.1016/j.radcr.2022.09.037 -
The Neuroradiology Journal Jun 2023Spinal filum terminale pial arteriovenous fistulas (FT PAVFs) are uncommon. Most FT PAVFs are located in the lumbar region; far fewer are located in the sacral region....
Spinal filum terminale pial arteriovenous fistulas (FT PAVFs) are uncommon. Most FT PAVFs are located in the lumbar region; far fewer are located in the sacral region. Due to the rarity of sacral FT PAVFs, the precise surgical dissection and removal of these lesions are challenging. Here, we report an FT PAVF in the sacral region. The patient was a 45-year-old male who suffered from progressive weakness and numbness of the bilateral lower limbs; his symptoms gradually worsened. Digital subtraction angiography (DSA) showed an AVF at the sacral canal at the S3-4 level. Microsurgical treatment with intraoperative DSA was performed, and the FT PAVF was resected. After the operation, the patient gradually recovered. Follow-up magnetic resonance imaging revealed a recession in the dilation of the spinal cord venous plexuses. A literature review was also performed, and a total of 14 FT PAVFs of the sacral region were identified. The patients identified in the literature review had an average age of 58.9 ± 12.9 years, and 92.9% of the patients were male. Spinal cord edema was present in 85.7% of the FT PAVF patients. Regarding treatment, 64.3% of the FT PAVF patients underwent microsurgical resection, 28.6% patients underwent endovascular treatment, and 7.1% patients underwent a hybrid operation; good outcomes were achieved with all three methods. Therefore, FT PAVF of the sacral region is a unique lesion whose angioarchitecture needs to be identified carefully; prompt treatment is necessary, and microsurgery can yield good outcomes.
Topics: Aged; Female; Humans; Male; Middle Aged; Arteriovenous Fistula; Cauda Equina; Magnetic Resonance Imaging; Sacrococcygeal Region; Spinal Cord Diseases
PubMed: 36086815
DOI: 10.1177/19714009221126017 -
Journal of Pediatric Gastroenterology... Jun 2022The present study aimed to assess long-term functional outcomes of children with anorectal malformations (ARMs) across a network of expert centers in France.
OBJECTIVES
The present study aimed to assess long-term functional outcomes of children with anorectal malformations (ARMs) across a network of expert centers in France.
METHODS
Retrospective cross-sectional study of patients ages 6-30 years that had been surgically treated for ARM. Patient and ARM characteristics (eg, level, surgical approach) and functional outcomes were assessed in the different age groups.
RESULTS
Among 367 patients, there were 155 females (42.2%) and 212 males (57.8%), 188 (51.2%) cases with, and 179 (48.8%) higher forms without, perineal fistula. Univariate and multivariate statistical analyses with logistic regression showed correlation between the level of the rectal blind pouch and voluntary bowel movements (odds ratio [OR] = 1.84 [1.31-2.57], P < 0.001), or soiling (OR = 1.72 [1.31-2.25], P < 0.001), which was also associated with the inability to discriminate between stool and gas (OR = 2.45 [1.28-4.67], P = 0.007) and the presence of constipation (OR = 2.97 [1.74-5.08], P < 0.001). Risk factors for constipation were sacral abnormalities [OR = 2.26 [1.23-4.25], P = 0.01) and surgical procedures without an abdominal approach (OR = 2.98 [1.29-6.87], P = 0.01). Only the holding of voluntary bowel movements and soiling rates improved with age.
CONCLUSION
This cross-sectional study confirms a strong association between anatomical status and functional outcomes in patients surgically treated for ARM. It specifically highlights the need for long-term follow-up of all patients to help them with supportive care.
Topics: Adolescent; Adult; Anal Canal; Anorectal Malformations; Child; Constipation; Cross-Sectional Studies; Defecation; Female; Humans; Male; Rectum; Retrospective Studies; Young Adult
PubMed: 35849503
DOI: 10.1097/MPG.0000000000003447 -
Surgical Neurology International 2022Filum terminale arteriovenous fistulas (FTAVFs) are rare and usually classified as intradural ventral AVFs or Type IVa perimedullary fistulas, located on the pia surface...
BACKGROUND
Filum terminale arteriovenous fistulas (FTAVFs) are rare and usually classified as intradural ventral AVFs or Type IVa perimedullary fistulas, located on the pia surface along the course of filum terminale internum (FTI). We report an extremely rare case of sacral dural arteriovenous fistula of the FT. We also review the occurrence of FTAVFs in the sacral region.
CASE DESCRIPTION
A 64-year-old man presented with progressive weakness of the lower extremities for 3 months and bowel/bladder dysfunction following long history of back pain radiating to both legs. Magnetic resonance imaging of the lumbosacral and thoracic spine showed spinal cord congestion, extending from the conus medullaris to the level of T3, and partial thrombosis within the abnormal tortuous and dilated flow void, running from the sacral area to conus medullaris. Further findings were compression fracture of L2 vertebra, Grade I degenerative spondylolisthesis at the level of L2-3, and L3-4, and spinal stenosis at L2-3, L3-4, and L4-5. Spinal angiography, maximum intensity projection reformatted image of angiographic computerized tomography, and three-dimensional reconstructed image clearly demonstrated dural AVF of the FT at the level of S2 supplied by bilateral lateral sacral and middle sacral arteries with cranial drainage to perimedullary vein through the enlarged vein of the filum. The patient was indirectly treated by transection of the filum terminale and the draining vein at the level of L5 rostral to the fistula.
CONCLUSION
Sacral DAVFs of the FT are extremely rare. In our case, the formation of fistula may cause by venous hypertension secondary to partial thrombosis within the filum vein, probably resulting from long-standing spinal canal stenosis. Sacral FTAVFs may be found on the pia surface of the terminal FTI, dural component at the area of dural sac termination, or dural extension covering the filum terminale externum.
PubMed: 35399884
DOI: 10.25259/SNI_980_2021 -
Journal of Pediatric Surgery Sep 2022Outcome of patients operated for anorectal malformation (ARM) type rectovestibular fistula (RVF) is generally considered to be good. However, large multi-center studies...
Bowel function and associated risk factors at preschool and early childhood age in children with anorectal malformation type rectovestibular fistula: An ARM-Net consortium study.
BACKGROUND
Outcome of patients operated for anorectal malformation (ARM) type rectovestibular fistula (RVF) is generally considered to be good. However, large multi-center studies are scarce, mostly describing pooled outcome of different ARM-types, in adult patients. Therefore, counseling parents concerning the bowel function at early age is challenging. Aim of this study was to evaluate bowel function of RVF-patients at preschool/early childhood age and determine risk factors for poor functional outcome.
METHODS
A multi-center cohort study was performed. Patient characteristics, associated anomalies, sacral ratio, surgical procedures, post-reconstructive complications, one-year constipation, and Bowel Function Score (BFS) at 4-7 years of follow-up were registered. Groups with below normal (BFS < 17; subgroups 'poor' ≤ 11, and 'fair' 11 < BFS < 17) and good outcome (BFS ≥ 17) were formed. Univariable analyses were performed to detect risk factors for outcome.
RESULTS
The study included 111 RVF-patients. Median BFS was 16 (range 6-20). The 'below normal' group consisted of 61 patients (55.0%). Overall, we reported soiling, fecal accidents, and constipation in 64.9%, 35.1% and 70.3%, respectively. Bowel management was performed in 23.4% of patients. Risk factors for poor outcome were tethered cord and low sacral ratio, while sacral anomalies, low sacral ratio, prior enterostomy, post-reconstructive complications, and one-year constipation were for being on bowel management.
CONCLUSIONS
Although median BFS at 4-7 year follow-up is nearly normal, the majority of patients suffers from some degree of soiling and constipation, and almost 25% needs bowel management. Several factors were associated with poor bowel function outcome and bowel management.
LEVEL OF EVIDENCE
Level III.
Topics: Adult; Anal Canal; Anorectal Malformations; Child; Child, Preschool; Cohort Studies; Constipation; Follow-Up Studies; Humans; Rectal Fistula; Rectum; Retrospective Studies; Risk Factors; Treatment Outcome
PubMed: 35317943
DOI: 10.1016/j.jpedsurg.2022.02.015 -
Annals of Indian Academy of Neurology 2021
PubMed: 35002153
DOI: 10.4103/aian.AIAN_1245_20 -
International Journal of Surgery Case... Dec 2021Melioidosis is a rare infectious tropical disease caused by Burkholderia pseudomallei (B. pseudomallei), an environmental saprophyte usually habitating on soils of...
INTRODUCTION
Melioidosis is a rare infectious tropical disease caused by Burkholderia pseudomallei (B. pseudomallei), an environmental saprophyte usually habitating on soils of Southeast Asian fields. Most of the reported cases present with pneumonia and intra-abdominal abscess. Diagnosis is established by culture studies from the blood, sputum or abscess drainage. Management relies on culture-guided antibiotic treatment, with good prognosis. Surgical intervention is required in cases not responsive to medical management.
PRESENTATION OF CASE
We are presenting a case of Melioidosis in a 72 year old Filipino who presented with Pneumonia, Femoral and Sacral Osteomyelitis, Splenic Abscess and High Rectal Fistula. He was successfully managed with systemic antibiotic treatment and surgery. The splenic abscess was managed by splenectomy and a transverse loop colostomy was used for fecal diversion to address the rectal fistula.
DISCUSSION
Melioidosis varies in its presentation and thus management should be individualized, depending on the organs involved. Our patient presented with multiple foci of infection which rendered the treatment more complicated as compared to those reported previously in published literature. The pneumonia and the osteomyelitis were managed with aggressive systemic antibiotics but the other sites of infection required drainage and surgery.
CONCLUSION
Melioidosis is a rare infection caused by an environmental saprophyte Burkholderia pseudomallei. An accurate diagnosis using culture studies is essential to institute appropriate treatment. Antibiotic treatment complemented by surgery for specific organ involvement is essential for cure.
PubMed: 34775325
DOI: 10.1016/j.ijscr.2021.106588 -
Frontiers in Pediatrics 2021Sacral ratio (SR) is currently the only measurement to quantitatively evaluate sacral development in patients with anorectal malformations (ARM). This study proposes...
Sacral ratio (SR) is currently the only measurement to quantitatively evaluate sacral development in patients with anorectal malformations (ARM). This study proposes sacral curvature (SC) as a new indicator to qualitatively assess the sacrum and hypothesizes that sacral development, both quantitatively and qualitatively, can be an indicator to predict the type of ARM. The study aims to investigate the difference of SR and SC between ARM types and the association with the type of ARM. This study was retrospectively conducted between August 2008 and April 2019. Male patients with ARMs were enrolled and divided into three groups based on the types of ARM: (1) rectoperineal fistulae, (2) rectourethral-bulbar fistulae, and (3) rectourethral-prostatic or rectobladder-neck fistulae. SC was measured in the sagittal views of an MRI or a lateral radiograph of the sacrum. Included in the study were 316 male patients with ARMs. SRs were 0.73 ± 0.12, 0.65 ± 0.12, and 0.57 ± 0.12 in perineal, bulbar, and prostatic/bladderneck fistula, respectively ( < 0.01). The SCs in perineal fistulae and bulbar fistulae were significantly higher than that in prostatic/bladderneck fistulae (0.25 ± 0.04, 0.22 ± 0.14, and 0.14 ± 0.18, < 0.01). When SR ≥ 0.779, there was an 89.9% of possibility that the child has a perineal fistula. When SR ≤ 0.490 and SC ≤ 0, the possibilities of the child having prostatic/bladderneck fistulae were 91.6 and 89.5%, respectively. SC < 0 was also noted in 27 (27.8%), 19 (10.5%), and no (0%) patients of prostatic/bladderneck, bulbar, and perineal fistulae ( < 0.01), respectively. Sacral defect was noted in 63% of patients with SC ≤ 0, compared to none with SC > 0 ( < 0.01). The higher the rectal level is in an ARM, the lower are the objective measurements of the sacrum. SC ≤ 0 is associated with sacral defects and implies a high likelihood of prostatic/bladderneck fistulae.
PubMed: 34660489
DOI: 10.3389/fped.2021.732524 -
Acta Obstetricia Et Gynecologica... Dec 2021Although live surgeries are routinely included in surgical congress programs, they are the subject of an ongoing debate in terms of patient safety and teaching value....
INTRODUCTION
Although live surgeries are routinely included in surgical congress programs, they are the subject of an ongoing debate in terms of patient safety and teaching value. The goal of our study was to assess the risk of postoperative complications related to live surgery broadcast from the surgeon's routine theater, in patients managed for deep endometriosis infiltrating the digestive tract.
MATERIAL AND METHODS
We report a retrospective comparative study, enrolling women managed for colorectal endometriosis by a gynecologic surgeon, from September 2013 to March 2020 in two referral centers. We compared the rate of postoperative bowel fistula in women managed during live surgery in the routine operating theater, with that observed in women for whom surgery was not broadcast.
RESULTS
Among 813 women, 33 (4.1% of cases) underwent surgical procedures transmitted live to various conference rooms located outside the hospital and were compared with 780 patients who underwent non-broadcast surgery. Women's age, body mass index, past surgical and obstetrical history, and major preoperative complaints were comparable. Cases presented with impaired constipation score, more frequent sciatic pain, and infiltration of the vagina, whereas overall revised American Fertility Society classification scores were more severe in controls. The rate of rectal nodules over 3 cm in size was comparable between the two groups (72.7% in cases vs. 72.1% in controls). Operative time was also comparable (153 ± 52 minutes vs. 148 ± 79 minutes). Cases were more frequently managed by disk excision of rectal nodules (63.7% vs. 30.3%), and more frequently involved the sacral plexus (18.2% vs. 7.3%). Postoperative complications were comparable between the two groups, in terms of bowel fistula (3% in the live surgery group vs. 4.1% in controls), pelvic abscess requiring secondary laparoscopy (3% vs. 4.9%), or bladder dysfunction requiring self-catheterization after discharge (6.1% vs. 5.3%).
CONCLUSIONS
Performing laparoscopic management of colorectal endometriosis with live transmission of surgery from a surgeon's routine operating theater, is not related to a higher risk of major postoperative complications.
Topics: Adult; Colorectal Neoplasms; Endometriosis; Female; Humans; Laparoscopy; Patient Safety; Postoperative Complications; Practice Patterns, Physicians'; Retrospective Studies; Treatment Outcome
PubMed: 34546562
DOI: 10.1111/aogs.14264