Giant cell tumor of the eleventh thoracic vertebra in a pediatric patient: an interesting case report and comprehensive literature review.

INTRODUCTION: Giant cell tumors of the mobile spinal column are very rare tumors, especially in the pediatric age group. Although they are benign tumors, they have locally aggressive growth pattern and high risk of recurrence. CASE PRESENTATION: We report a 15-year-old female patient with thoracic giant cell tumor who underwent percutaneous vertebroplasty and had cement extravasation into the spinal canal. Because of the deterioration of the patient's neurological condition, total enbloc spondylectomy and cement excision were performed. She underwent instrumentation and fusion procedures in order to prevent spinal instability. CONCLUSION: The main purpose of the treatment is gross total resection of the giant cell tumor. However, adjuvant methods such as denosumab should be added to the treatment protocol in patients who are older than 2 years old and can not undergo gross total resection due to tumor size and anatomic localization.

Management of Intravenous Infiltration Injuries.

BACKGROUND: Intravenous (IV) lines are ubiquitous in hospital settings. These lines can malfunction, leaking noxious contents into subcutaneous tissue. Existing literature describes invasive intervention and complex treatment protocols. These persist despite significant changes in the composition and administration of IV agents. The purpose of this study is to examine the consequences of IV infiltrations at a tertiary medical center to update protocols and treatment algorithms. MATERIALS AND METHODS: This study is an observational, retrospective chart review performed at a tertiary care medical center. All inpatient plastic surgery consultations for IV infiltration were reviewed from 2011 to 2017. Patients were included if IV infiltration was suspected or documented. Data were collected for each injury regarding patient demographics, substance, and intervention. RESULTS: The plastic surgery service evaluated 381 IV infiltration injuries from 2011 to 2017, with 363 meeting the criteria. Injuries per year progressively increased, with 32 consultations in 2011 and 102 consultations in 2017. The vast majority of injuries identified (91%) were treated with only elevation and observation. The minority consisted of wound care (7%) performed by nursing or any form of incision, aspiration, or antidote injection (2%) performed by the physician. Of the 363 injuries, the most common infiltrates were noncytotoxic (35%), radiographic contrast (27%), and known vesicants (18%). Interestingly, a large portion of consultations were requested by other surgical services (32%). CONCLUSIONS: Although there is an increase in expert involvement for cases of IV infiltration injuries, the vast majority of these injuries are managed with minimal intervention. This is most likely owing to recent changes that have decreased the potential for harmful infiltration. Contrary to existing literature, invasive intervention is almost never indicated.

Computed tomography contrast media extravasation: treatment algorithm and immediate treatment by squeezing with multiple slit incisions.

In our hospital, an adverse event reporting system was initiated that alerts the plastic surgery department immediately after suspecting contrast media extravasation injury. This system is particularly important for a large volume of extravasation during power injector use. Between March 2011 and May 2015, a retrospective chart review was performed on all patients experiencing contrast media extravasation while being treated at our hospital. Immediate treatment by squeezing with multiple slit incisions was conducted for a portion of these patients. Eighty cases of extravasation were reported from approximately 218 000 computed tomography scans. The expected extravasation volume was larger than 50 ml, or severe pressure was felt on the affected limb in 23 patients. They were treated with multiple slit incisions followed by squeezing. Oedema of the affected limb disappeared after 1-2 hours after treatment, and the skin incisions healed within a week. We propose a set of guidelines for the initial management of contrast media extravasation injuries for a timely intervention. For large-volume extravasation cases, immediate management with multiple slit incisions is safe and effective in reducing the swelling quickly, preventing patient discomfort and decreasing skin and soft tissue problems.

Treatment of benign biliary leaks with transhepatic placement of coated self-expanding metallic stents. / Tratamiento de fugas biliares mediante colocación transparietohepática de endoprótesis metálicas recubiertas.

OBJECTIVES: To analyze the safety and efficacy of percutaneous placement of coated self-expanding metallic stents (SEMS) in patients with biliary leaks. MATERIAL AND METHODS: This ethics committee at our center approved this study. We retrospectively reviewed all coated SEMS placed between October 2008 and September 2015. We analyzed patient-related factors such as the primary underlying disease, prior hepatic procedures, and clinical outcome. We evaluated the location, the number and type of leak (anastomotic or non-anastomotic), and the characteristics of the interventional procedure (number of stents deployed, location of the stents, technical success, and primary functionality). We recorded the complications registered. RESULTS: We studied 14 patients (11 men and 3 women). The mean follow-up period was 375.5 days (range 15-1920 days). Leaks were postsurgical in 12 patients. One patient developed an arteriobilioportal fistula. In another, the biliary leak occurred secondary to the rupture of the common bile duct after ERCP. A total of 23 coated SEMS were placed, including 21 Fluency® stents (Bard, Tempe, AZ, USA) and 2 Wallflex® stents (Boston Scientific, Galway, Republic of Ireland). The technical success of the procedure was considered total in 11 (78.6%) patients, partial in 2 (14.3%) patients, and null in 1 (7.2%) patient. The clinical outcome was good in 13 of the 14 patients. The mean period of primary functionality of the coated SEMS was 331 days (range 15-1920 days). No major complications were observed in 11 (78.6%) patients. CONCLUSIONS: Percutaneous placement of coated SEMS for the treatment of benign biliary leaks is safe and efficacious, with a high rate of technical and clinical success and a moderate rate of complications.

Breast necrosis secondary to vasopressor extravasation: management using indocyanine green angiography and omental flap closure.

Extravasation is a rare but serious complication of vasopressor administration. A 60-year-old female who underwent ascending and hemiarch repair of the aorta along with aortic valve replacement developed extensive right breast and chest wall necrosis after vasopressor extravasation from an internal jugular vein central line. The patient underwent a total mastectomy due to deep tissue necrosis detected by laser-assisted indocyanine green dye angiography, and eventually required omental flap reconstruction to obtain adequate sternal coverage. This case represents a previously unreported complication of internal jugular central line extravasation of vasopressors with resultant breast and chest wall necrosis, and highlights the utility of the omentum in chest wall reconstruction.

[Development of compartment syndrome after intravenous administration of an X-ray contrast medium. Recommendations on acute therapy regimens]. / Kompartmentsyndrom nach paravasaler Applikation von Röntgenkontrastmittel. Empfehlung zum akuten Therapieregime.

The incidence of extravasation of contrast medium is reported in the literature to be between 0.2 % and 0.9 %. A rare consequence of this could be compartment syndrome of the affected limb which requires immediate treatment.We report the case of a patient who developed acute compartment syndrome of the forearm after intravenous injection of radiographic contrast medium in a radiovolar vein during a computed tomography (CT) scan for multiple trauma. The clinical symptoms with pain, loss of range of motion and sensitivity functions, measurement of compartment pressure and radiological images confirmed the diagnosis. After emergency dermatofasciotomy of the forearm the full range of motion and sensitivity functions could be restored.

[Surgical treatment of extravasation injuries]. / Chirurgische Behandlung von Paravasaten.

OBJECTIVE: Extravasations account for most iatrogenic injuries. The aim of the study was to analyse the results of surgery in patients with extravasations and to draw conclusions for future treatment. MATERIALS AND METHODS: 24 patients with soft-tissue defects after extravasations were treated between 1999 and 2009 in our hospital. The cases were analysed retrospectively. We looked at the drugs causing tissue necrosis and the localisation in relation to the number of interventions and reconstruction complexity. RESULTS: In 83 % (n = 20) of cases tissue necrosis was caused by chemotherapeutic agents, in 8 % (n = 2) by contrast mediums and in 4 % (n = 1) by antibiotics and insulin. 70 % of the cases involved the upper extremity, in 30 % the thoracic wall was affected. 38 % of the extravasations occurred over venous access ports. In mean 2 ±â€Š1.5 interventions were necessary for defect coverage. Two patients died as a direct result of the extravasations, one due to sepsis originating from an infected necrosis area and one due to right-heart failure with prior pulmonary damage. CONCLUSION: Most extravasations can be treated without surgery. In cases of toxic extravasations or pressure-caused ischaemia rapid surgical intervention is necessary to prevent the necrosis progressing to deeper tissue layers.

[Clinical manifestation of extravasation caused by infusion and its therapeutic management]. / Klinische Manifestationen infusionsbedingter Extravasate und ihr therapeutisches Management.

INTRODUCTION: Extravasal application of chemo-therapeutic agents may cause necrosis of surrounding tissue. Often tendons, nerves and muscles are destroyed. In some cases a surgical excision with an additional coverage is indicated. PATIENTS AND METHODS: In the last ten years we have treated 44  patients with necrosis after extravasation. The defects were mostly localised at the hand or distal forearm, but the cubital fossa and the thorax were affected, too. Excision of the infiltrated tissue was performed and the defect covered with local or free flaps, split skin graft or primary closure. RESULTS: In nearly all cases a stable coverage was achieved. An amputation of the hand was never necessary. Patients with immunosuppression or comorbidity sometimes had wound-healing difficulties that in some cases necessitated further operations. Serious complications were in one case a flap necrosis and another patient died 2  days after the operation because of his nephrotic syndrome. CONCLUSION: Chemotherapy extravasation is an important oncological complication that may cause permanent functional disability of the anatomic region. A variety of free and local flaps with tolerable donor site morbidity can be used for -coverage. We prefer a two-step procedure with radical resection of the area and conditioning of the wound with vacuum therapy or temporary wound coverage and in the next step the definitive wound closure. Conservative treatment is -often followed by a high rate of complications. Early radical debridement and coverage with an adequate flap offers a cure with good functional results.

Reconstruction of cubital fossa skin necrosis with radial collateral artery perforator-based propeller flap (RCAP).

In recent years, perforator flaps have become an indispensable tool for the reconstruction process. Most recently, "propeller" perforator flaps allow each perforator vessels to become a flap donor site. Once the perforator of interest is identified by acoustic Doppler, the cutaneous or fascio-cutaneous island is designed and then customized according to the principle of "perforasome". So, the flap can be rotated such a propeller, up to 180°. Ideally the donor site is self-closing, otherwise it can be grafted at the same time. Through a skin necrosis secondary to a contrast medium extravasation of the cubital fossa in a 47-year-old man, we describe the use of propeller perforator flap based on a perforator of the radial collateral artery (RCAP). The perforator was identified preoperatively by acoustic Doppler then the flap was adapted bespoke to cover the loss of substance. Ultimately, the result was very satisfying. Well experienced for lower-extremity reconstruction, perforator-based propeller flap are still few reported for upper limb. It is likely that in the future, propeller flap supersede in many indication not only free flaps and locoregional flaps but also, leaving no room for uncertainties of the vascular network, the classic random flaps.

A large forearm subcutaneous hematoma after contrast extravasation requires surgical managements: A case report.

RATIONALE: Large extremity hematoma can rarely happen after contrast extravasation during a contrast-enhanced computed tomography scan. Some hematomas need prompt surgical managements. PATIENT CONCERNS: A 77-year-old man had acute ischemic stroke and received the thrombolytic and antiplatelet therapies. He had a contrast extravasation during the computed tomography scan and developed a large hematoma in the right forearm, despite without evidence of compartment syndrome. DIAGNOSIS: Right forearm hematoma, status post contrast extravasation. INTERVENTIONS: The patient responded poorly to the routine care with arm elevation, cold pack, and wet dressing, and was finally treated by the surgical debridement, vacuum sealing drainage, fascioplasty, and skin flap repair. OUTCOMES: Right forearm wound healed with a scar. LESSONS: Large extremity hematoma can happen after contrast extravasation during computed tomography scan, which may require surgical treatments. Careful preparation, close monitor, and prompt managements should be applied in high-risk patients.

Idiopathic left ventricular rupture in the absence of coronary artery disease.

Idiopathic cardiac rupture in the absence of coronary artery disease is rare. We describe a case of idiopathic left ventricular free wall rupture with successful surgical repair.

Mucus extravasation into the orbit during frontal sinus irrigation.

During minitrephination and irrigation of the frontal sinus, mucus extravasated into the orbit through a defect in the sinus floor. The mucus incited a foreign body reaction and became encapsulated within the orbit necessitating excision via an anterior orbitotomy.

Extravasation injuries: current medical and surgical treatment.

BACKGROUND: Extravasation is a devastating complication of intravenous therapy that develops when a drug infiltrates the interstitial tissue surrounding the vein. Due to the uncertain and possibly dramatic outcome, early recognition and adequate treatment with the aid of a standardized protocol are needed. METHODS: A pubmed literature search was conducted and all relevant articles were reviewed for the development of an extravasation treatment protocol. RESULTS: An overview of current treatment guidelines and clinical experience is provided. The extravasation treatment protocol was implied during 1 year in this university hospital with satisfactory outcome. CONCLUSION: Treatment starts with prevention. In case of an established extravasation injury, early recognition, assessment of severity, and treatment with medical and/or surgical therapies are recommended.

Atypical facial pain related to apical fenestration and overfilling.

AIM: To report a case of apical fenestration and overfilling in which unusual pain characteristics made differential diagnosis challenging. SUMMARY: A 32-year-old woman with diffuse, spontaneous, moderate pain in the maxillary left posterior sector, exacerbated by masticatory and facial muscle movement, with intense sporadic electric-shooting pain, underwent clinical examination and 3D cone beam computed tomography (CBCT). Apical fenestration with protrusion of the mesial root of tooth 26 beyond the buccal cortical plate, extrusion of canal filling material into the soft tissues and a periosteal reaction were detected. Surgery was performed under the operating microscope. The filling material and surrounding fibrous tissue were located, dissected from healthy soft tissues and removed. The mesiobuccal root apex was resected with a bur to within the bony crypt. A root end was prepared and filled with Tech Biosealer RootEnd™ (Isasan, Como, Italy). At the 2-week recall, the patient had complete resolution of the symptoms and good soft-tissue healing. The 1-year recall examination and intra-oral radiography confirmed complete resolution of the symptoms and health of periradicular tissues. KEY LEARNING POINTS: Apical fenestration may occur in 9% of cases and may be considered an anatomic predisposing factor for persistent pain after root canal treatment. This complication provides a considerable differential diagnostic challenge and is often misdiagnosed and mistreated. When correctly diagnosed through an accurate, multidisciplinary approach, it may be managed with a simple surgical procedure in which the endodontist should play a key role. Misdiagnosis and over treatment of apical fenestration, through the surgical management of chronic facial pain conditions, could lead to severe exacerbation of chronic pain, which may potentially become persistent or, indeed, intractable.

[Unusual presentation of sigmoid diverticulitis. Sigmoid-vesical fistula in sigmoid diverticulitis]. / Ungewöhnliche Präsentation einer Sigmadivertikulitis. Sigmavesikale Fistel auf dem Boden einer Sigmadivertikulitis

A 68-year-old male patient presented with mild tenderness in the suprasymphyseal region, hematuria and dysuria. In this case typical symptoms of a sigmoid-vesical fistula were initially absent. Because of hematuria and the findings provided by urethrocystoscopy, the radiological diagnosis was a bladder tumor. Contrast-enhanced computed tomography with rectal contrast administration provided the decisive information. In addition to sigmoid diverticulitis (fat stranding/centipede sign) in the urographic phase, contrast media was well traceable intraluminally from the bladder through the bladder wall abscess and subsequently in the sigmoid colon.

Indications for surgical endodontics and findings of an audit into referrals.

UNLABELLED: Peri-radicular surgery is a valuable treatment modality allowing thorough treatment of chronic infection of the peri-radicular tissues. It is important that this treatment option is prescribed appropriately and steps are taken to help improve outcomes of surgery. We discuss the indications for peri-radicular surgery, considerations when planning treatment for teeth where orthograde endodontics has failed and present the findings of an audit into the appropriateness of referrals for peri-radicular surgery to the Department of Oral and Maxillofacial Surgery at a District General Hospital. CLINICAL RELEVANCE: This article highlights the indications and contra-indications for peri-radicular surgery to general dental practitioners.

[Introduction of a clinical protocol for extravasation at the National Institute of Oncology, Budapest, Hungary]. / Extravazációs protokoll bevezetése az Országos Onkológiai Intézetben.

Extravasation of cytostatics occurs when an infusion containing a cytotoxic drug leaks into the surrounding perivascular and subcutaneous tissues. Incidence of cytostatic extravasation is found to be 0.1-6% according to the literature. Depending on the severity of complications, pain, loss of function in the extremities, or in extreme cases tissue necrosis necessitating an amputation may develop, drawing consequences like delay or interruption of the chemotherapy. Extent of complications is greatly influenced by the type of medication administered, general condition of the patient, and professional preparedness of staff providing the oncological health service. The protocol recently implemented in the National Institute of Oncology is a short, compact guidance for physicians and nurses providing oncological care, so by quick and adequate management of extravasation cases, severe complications could be prevented. More complex practical guidelines including algorithms could be created as a result of a wider collaboration, with the help of which oncological health professionals could easily cope with this rare problem. The authors describe in their review the implementation of the use of dry warm and cold packs, dymethylsulfoxide and hyaluronidase and their function within the algorithm of extravasation treatment.