Infected calyceal diverticulum in pregnancy: A rare case.

A calyceal diverticulum is a transitional epithelium-lined outpouching of a renal calyx which communicates with the main collecting system through a narrow infundibulum. There are two types of calyceal diverticula: type I, the most common, communicates with the minor calyx, and type II communicates with the major calyx or renal pelvis. Calyceal diverticula are rare and mostly found incidentally; however, they can cause urinary tract infection symptoms (e.g., hematuria, pain, and fever). Diagnosing an infected calyceal diverticulum during pregnancy is particularly challenging due to overlapping symptoms and the limitations of imaging modalities that avoid ionizing radiation. Prompt diagnosis and treatment are necessary to avoid irreversible renal dysfunction and/or urological surgery. Currently, there are no established treatment guidelines for diagnosing and managing infected calyceal diverticula in pregnant patients. The rarity of this condition and the complexities introduced by pregnancy create challenges in standardizing care and determining the optimal treatment strategy, timing of interventions, and the impact on maternal and fetal outcomes. A 29-year-old primigravid woman presented emergently to the hospital at 15 weeks and 4 days gestation with concerns of severe right-sided flank pain and hematuria. Initial renal ultrasound revealed a complex, hypovascular lesion in the interpolar region of the right kidney measuring 6.9 × 6.8 × 3.7 cm, suspicious for mass versus pyelonephritis with associated phlegmon. Further characterization of the lesion by MRI revealed communication between the lesion and the mid-pole collecting system. Differential diagnoses included infected calyceal diverticulum, hydronephrosis of a duplicated system, renal abscess, and infected urinoma. Through a multidisciplinary approach, including ultrasound-guided placement of a drainage catheter at 16 weeks gestation, and tailored intravenous antibiotic therapy, the patient delivered a 3379 g male at 40 weeks and 0 days gestation. This case highlights the potential for conservative management in the absence of clear guidelines and underscores the importance of collaboration among obstetrics, urology, infectious disease, and interventional radiology teams. The implications of this case extend to increasing awareness of calyceal diverticula as a differential diagnosis in pregnant patients presenting with atypical urinary symptoms. It emphasizes the necessity of a multidisciplinary approach to ensure both maternal and fetal safety and offers valuable insights that could inform future cases, contributing to the development of more concrete guidelines for managing infected calyceal diverticula during pregnancy. Consent was obtained from the patient and IRB approval was not required for this case.

Bilateral abducens and facial nerve palsies following fourth ventriculoperitoneal shunt with laparoscopic-assisted abdominal catheter placement.

Introduction: Hydrocephalus, altering cerebrospinal fluid (CSF) dynamics, affects 175 per 100,000 adults worldwide. Ventriculoperitoneal shunts (VPS) manage symptomatic hydrocephalus, with 125,000 cases annually. Despite efficacy, VPS face complications, necessitating interventions. Research question: "What are the mechanisms and risk factors for bilateral VIth and VIIth lower motor neuron palsies in hydrocephalus patients with a fourth ventriculoperitoneal shunt?" Material and methods: This study details a 36-year-old female with a neonatal meningitis history, multiple shunt replacements, admitted for abdominal pain secondary to pelvic inflammatory disease. An abdominal shunt catheter removal and external ventricular drain placement occurred after consultation with a general surgeon. A cardiac atrial approach and subsequent laparoscopic abdominal approach were performed without complications. Results: After one month, the patient showed neurological complications, including decreased facial expression, gait instability, and bilateral VIth and VIIth lower motor neuron palsies, specifically upgazed and convergence restriction. Discussion: The complication's pathophysiology is discussed, attributing it to potential brainstem herniation from over-drainage of CSF. Literature suggests flexible endoscopic treatments like aqueductoplasty/transaqueductal approaches into the fourth ventricle. Conclusions: This study underscores the need for increased awareness in monitoring neurological outcomes after the fourth ventriculoperitoneal shunt, particularly in cases with laparoscopic-assisted abdominal catheter placement. The rarity of bilateral abducens and facial nerve palsies emphasizes the importance of ongoing research to understand pathophysiology and develop preventive and therapeutic strategies for this unique complication.

The unnecessary application of central venous catheterization in surgical patients / A aplicação desnecessária de cateterização venosa central em pacientes cirúrgicos

Abstract Background and objectives Perioperative physicians occasionally encounter situations where central venous catheters placed preoperatively turn out to be unnecessary. The purpose of this retrospective study is to identify the unnecessary application of central venous catheter placement and determine the factors associated with the unnecessary application of central venous catheter placement. Methods Using data from institutional perioperative central venous catheter surveillance, we analysed data from 1,141 patients who underwent central venous catheter placement. We reviewed the central venous catheter registry and medical charts and allocated registered patients into those with the proper or with unnecessary application of central venous catheter according to standard indications. Multivariate analysis was used to identify factors associated with the unnecessary application of central venous catheter placement. Results In 107 patients, representing 9.38% of the overall population, we identified the unnecessary application of central venous catheter placement. Multivariate analysis identified emergencies at night or on holidays (odds ratio [OR] 2.109, 95% confidence interval [95% CI] 1.021-4.359), low surgical risk (OR = 1.729, 95% CI 1.038-2.881), short duration of anesthesia (OR = 0.961/10 min increase, 95% CI 0.945-0.979), and postoperative care outside of the intensive care unit (OR = 2.197, 95% CI 1.402-3.441) all to be independently associated with the unnecessary application of catheterization. Complications related to central venous catheter placement when the procedure consequently turned out to be unnecessary were frequently observed (9/107) compared with when the procedure was necessary (40/1034) (p = 0.032, OR = 2.282, 95% CI 1.076-4.842). However, the subsequent multivariate logistic model did not hold this significant difference (p = 0.0536, OR = 2.115, 95% CI 0.988-4.526). Conclusions More careful consideration for the application of central venous catheter is required in cases of emergency surgery at night or on holidays, during low risk surgery, with a short duration of anesthesia, or in cases that do not require postoperative intensive care.

Resumo Justificativa e objetivo No perioperatório, os médicos ocasionalmente encontram situações nas quais um cateter venoso central colocado pré-operativamente se revela desnecessário. O objetivo deste estudo retrospectivo foi identificar a colocação desnecessária de um cateter venoso central e determinar os fatores associados à colocação desnecessária de cateter venoso central. Métodos Com os dados da vigilância institucional de cateter venoso central no período perioperatório, analisamos 1.141 pacientes submetidos à colocação de cateter venoso central. Revisamos o registro de cateter venoso central e os prontuários médicos e alocamos os pacientes registrados entre aqueles com colocação adequada ou desnecessária de cateter venoso central, de acordo com as indicações padronizadas. Uma análise multivariada foi usada para identificar os fatores associados à colocação desnecessária de cateter venoso central. Resultados Em 107 pacientes, que representaram 9,38% da população global, identificamos a colocação desnecessária de cateter venoso central. A análise multivariada identificou emergências à noite ou em feriados (razão de chances [OR] 2,109; 95% de intervalo de confiança [IC 95%] 1,021-4,359), baixo risco cirúrgico (OR = 1,729; IC 95%: 1,038-2,881), curta duração da anestesia (OR = 0,961/10 min de aumento; IC 95%: 0,945-0,979) e assistência pós-operatória fora da unidade de terapia intensiva (OR = 2,197; IC 95%: 1,402-3,441), todos independentemente associados à aplicação desnecessária de cateterização. Complicações relacionadas à colocação de cateter venoso central, quando esse procedimento revelou-se desnecessário, foram frequentemente observadas (9/107), em comparação com a necessidade da execução desse procedimento (40/1.034) (p = 0,032, OR = 2,282; IC 95%: 1,076-4,842). Porém, o modelo logístico multivariável subsequente não manteve essa diferença significativa (p = 0,0536, OR = 2,1515; IC 95%: 0,988-4,526). Conclusão É preciso que uma análise mais cuidadosa seja feita sobre a colocação de cateter venoso central em casos de cirurgia de emergência à noite ou em feriados, durante cirurgia de baixo risco, em anestesia de curta duração ou em casos que não requeiram terapia intensiva no pós-operatório.

[The unnecessary application of central venous catheterization in surgical patients]. / A aplicação desnecessária de cateterização venosa central em pacientes cirúrgicos.

BACKGROUND AND OBJECTIVES: Perioperative physicians occasionally encounter situations where central venous catheters placed preoperatively turn out to be unnecessary. The purpose of this retrospective study is to identify the unnecessary application of central venous catheter placement and determine the factors associated with the unnecessary application of central venous catheter placement. METHODS: Using data from institutional perioperative central venous catheter surveillance, we analysed data from 1,141 patients who underwent central venous catheter placement. We reviewed the central venous catheter registry and medical charts and allocated registered patients into those with the proper or with unnecessary application of central venous catheter according to standard indications. Multivariate analysis was used to identify factors associated with the unnecessary application of central venous catheter placement. RESULTS: In 107 patients, representing 9.38% of the overall population, we identified the unnecessary application of central venous catheter placement. Multivariate analysis identified emergencies at night or on holidays (odds ratio [OR] 2.109, 95% confidence interval [95% CI] 1.021-4.359), low surgical risk (OR=1.729, 95% CI 1.038-2.881), short duration of anesthesia (OR=0.961/10min increase, 95% CI 0.945-0.979), and postoperative care outside of the intensive care unit (OR=2.197, 95% CI 1.402-3.441) all to be independently associated with the unnecessary application of catheterization. Complications related to central venous catheter placement when the procedure consequently turned out to be unnecessary were frequently observed (9/107) compared with when the procedure was necessary (40/1034) (p=0.032, OR=2.282, 95% CI 1.076-4.842). However, the subsequent multivariate logistic model did not hold this significant difference (p=0.0536, OR=2.115, 95% CI 0.988-4.526). CONCLUSIONS: More careful consideration for the application of central venous catheter is required in cases of emergency surgery at night or on holidays, during low risk surgery, with a short duration of anesthesia, or in cases that do not require postoperative intensive care.

The surgery of the long-term central venous accesses in oncology.

The implantation of Long-Term Central Venous Catheters (LTCVC) in cancer patients has been essential to conduct the oncological treatments of today. The complexity of the protocols requires accuracy on the management of such devices in order to keep them long-functioning. The article focuses on such subject from an oncological perspective, pointing out threats of the disease to the central venous system (CVS) and the ways to face them successfully. The most salient points related to surgical techniques and the insights to follow-up long-term inserted catheters are discussed. An anatomical classification is suggested to help understand occurrence of malpositions and to north the necessary maneuvers of repositioning. Such matters are based on 3000 LTCVC-placements performed by the author at the Brazilian National Cancer Institute (INCA) between 1999 and 2011. As nearly 30% of the patients presented some sort of anatomical disorder at the moment of the surgery, it was judged worthy to address such experience to those young surgical oncologists willing to tackle LTCVCs in Cancer Units.