Sigmoido-Gluteal Fistula—A Rare Complication in Clinically Asymptomatic Chronic Diverticulitis

Chronic colonic diverticulitis may be associated with typical complications such as local abscesses, stenosis, bleeding, intraperitoneal bowel perforations or fistulas to other organs. Most commonly, fistulas exist between the colon and the bladder; nevertheless, they may also extend to the small intestine, other areas of the colon, ureter, uterus, salpinx, vagina, abdominal wall, portal-and mesenterial venous system, pleura, urachus, biliary system and the hip. We report on a patient with chronic colonic diverticulitis having an unusual sigmoido-gluteal fistula along the sacrum, the piriformis muscle and sciatic nerve. The patient presented with sciatic nerve symptoms and recurrent gluteal abscess formation, but no other clinical symptoms leading to an abdominal pathology. Initially, that fact caused an unsuccessful local treatment under the differential diagnosis of a local gluteal abscess for about a year. Finally, a sigmoid colon resection with end-to-end anastomosis and a proximal diverting stoma was performed. The colostomy was closed electively five months later without any complication.     

Does Obesity Affect the Surgical Outcome and Complication Rates of Spinal Surgery? A Meta-analysis

Background

As obesity becomes more prevalent, it becomes more common among patients considering orthopaedic surgery, including spinal surgery. However, there is some controversy regarding whether obesity is associated with complications, failed reconstructions, or reoperations after spinal surgery.

Questions/purposes

We wished to determine, in patients undergoing spine surgery, whether obesity is associated with (1) surgical site infection, (2) mortality and the need for revision surgery after spinal surgery, and (3) increased surgical time and blood loss.

Methods

A systematic literature search was performed to collect comparative or controlled studies that evaluated the influence of obesity on the surgical and postoperative outcomes of spinal surgery. Two reviewers independently selected trials, extracted data, and assessed the methodologic quality and quality of evidence. Pooled odds ratios (OR) and mean differences (MD) with 95% CIs were calculated using the fixed-effects model or random-effects model. Data were analyzed using RevMan 5.1. MOOSE criteria were used to ensure this project’s validity. Thirty-two studies involving 97,326 patients eventually were included.

Results

Surgical site infection (OR, 2.33; 95% CI, 1.94–2.79), venous thromboembolism (OR, 3.15; 95% CI, 1.92–5.17), mortality (OR, 2.6; 95% CI, 1.50–4.49), revision rate (OR, 1.43; 95% CI, 1.05–1.93) operating time (OR, 14.55; 95% CI, 10.03–19.07), and blood loss (MD, 28.89; 95% CI, 14.20–43.58), were all significantly increased in the obese group.

Conclusion

Obesity seemed to be associated with higher risk of surgical site infection and venous thromboembolism, more blood loss, and longer surgical time. Future prospective studies are needed to confirm the relationship between obesity and the outcome of spinal surgery.

     

Syringomyelia – As a Late Complication of Tuberculous Meningitis

Summary  The aim of this paper is to demonstrate the unusual MR features of thoracic syringomyelia following TB meningitis and to discuss the neurosurgical aspect of the treatment of this rare entity. Four years after a TB meningitis episode, a 30 year-old female patient developed a progressive spastic paraparesis. MR studies revealed multiloculated syrinxes throughout the thoracic cord. She had a syringosubarachnoid shunt with a silastic “T” tube inserted. On the first postoperative day, she showed a dramatic neurological improvement, but unfortunately her paraparesis progressed to the preoperative level within a month despite diminished size of the syrinxes on the control MRI examination. Two and a half years after the operation the patient complained of having a burning type of central pain, and further deterioration in neurological function. Thoracic spinal MRI examination demonstrated enlarged syringomyelic cavities. At the second operation syringo-peritoneal shunt insertion was performed via right T_10–11 hemilaminectomy using a “T” tube. At present, 4 months after the second operation, the patient's neurological examination demonstrated decreased spasticity, and improved strength in the legs compared to the preoperative level. MRI is the first choice of investigation in detecting TB related myelopathy as it provides a greater detail of pathological changes within and around the spinal cord such as syrinx formation and arachnoiditis. The MR findings are also helpful in deciding the management and predicting the outcome. Presence of multifocal loculations and arachnoid adhesions is the likely cause of treatment failures and poor prognosis.     

Atlanto Axial Rotatory Dislocation in Adults: A Rare Complication of an Epileptic Seizure—Case Report

Atlanto Axial Rotatory Dislocations (AARDs) are a heterogeneous group of post-traumatic pathologies typical of the pediatric age, and rare in adults. We describe the case of a 34-year-old woman, developing Atlanto Axial Rotatory Fixation (AARF) after a generalized tonic-clonic epileptic seizure, an extremely rare traumatic cause never described in literature. AARF was detected only 1 month after the accident and nonsurgical treatment was attempted at the beginning. The patient underwent surgery only 2 months after the accident. The best treatment should be conservative reduction within 1 month; when it is not possible, it is advisable to perform surgery as soon as possible. C1–C2 fixation with Harm''s technique is the gold standard for fixed luxations. Delay of treatment makes intraoperative reduction more difficult and increase the establishment of the chronic permanent change of neck muscles and ligaments.     

Ruptured Pseudoaneurysm of the Lateral Plantar Artery After Tibiotalocalcaneal Fusion With Retrograde Nail—A Rare Complication

We report a rare presentation of a ruptured pseudoaneurysm of the lateral plantar artery following tibiotalocalcaneal fusion with a retrograde nail at 1 month after the index surgery. Although case reports of pseudoaneurysms of larger arteries such as the anterior tibial artery and posterior tibial artery after ankle surgery (e.g., ankle arthroscopy, implant removal, Ilizarov application) have been reported, we report a rare complication of a pseudoaneurysm of the lateral plantar artery. We discuss the anatomic considerations of the lateral plantar artery in the foot and the entry point of the retrograde nail to avoid this unusual complication.     

Pyoderma Gangrenosum in a Patient with Bruton's X-linked Agammaglobulinemia: Shared Pathogenesis of Altered Tumor Necrosis Factor Alpha?

Individuals with Bruton's X-linked agammaglobulinemia (XLA) inherit a defect in the Btk gene, critical for B-cell differentiation. As a result, there is an absence of mature B-cells in the peripheral circulation with a marked reduction in serum levels of all immunoglobulin subtypes, predisposing patients with XLA to recurrent bacterial infections. Btk also functions in myeloid and dendritic cells, specifically in Toll-like receptor (TLR) signaling. TLRs are important in the recognition of foreign pathogens and elaboration of cytokines, such as tumor necrosis factor alpha (TNF-α). This suggests that the pathophysiology of XLA involves additional and unexplored immune dysregulation. The coexistence of pyoderma gangrenosum (PG) in a patient with Bruton's XLA has been rarely reported. PG is an uncommon, ulcerating, neutrophilic dermatosis. Although its etiology is unknown, it is noninfectious and thought to involve abnormal immune and neutrophil responses. Anti-TNF agents have been effective in treating some patients with PG, suggesting TNF-α may play a role in the pathogenesis of PG. Here we report the association of PG and Bruton's XLA, and demonstrate the presence of TNF-α within the lesion of PG.     

Inflammatory Myofibroblastic Tumor After Lung Transplant—A Rare and Aggressive Complication: A Case Report

IntroductionMalignant diseases are well-known complications after lung transplantation (LT). Among these, inflammatory myofibroblastic tumor (IMT) is a rare neoplasm with a not well-known and often aggressive biological behavior.Material and MethodsWe hereby describe 2 cases of cystic fibrosis patients who underwent bilateral sequential LT (BSLT) complicated by IMT.ResultsA 26-year-old man presented a right endobronchial lesion 6 months after BSLT. Two consecutive fiber bronchoscopic biopsies showed granulation tissue. For the persistent lesion growth, the patient underwent a transthoracic biopsy showing histologic diagnosis of IMT. Therefore, he underwent to right pneumonectomy that was unfortunately complicated after 6 months with a late bronchopleural fistula and empyema with exitus 6 months later. A 31-year-old woman 1 year after BSLT presented with a left voluminous pleural-parenchymal lesion; the histologic examination after biopsy revealed an IMT. She underwent a removal of the lesion with a macroscopic R0 resection. Histologic, immunophenotypic, and cytogenetic examinations showed a strong overexpression of anaplastic lymphoma kinase requiring biological adjuvant therapies; however, the patient refused it. Four years later, she presented a recurrence treated with debulking procedure and adjuvant radiotherapy. At last follow-up, the patient was alive with stable disease and optimal graft function.ConclusionsAlthough IMT is a rare complication after lung transplant, to obtain a careful diagnosis, an early and aggressive treatment is mandatory.     

Titanium Mini-Plate for Securing Septal Cartilage – A Case of High-Impact Nasal Trauma

A technique is presented of securing the cartilaginous nasal septum using titanium mini-plates in the repair of a complex open comminuted type I nasoethmoid fracture, with internal impaction of the external cartilaginous nose. This technique allows primary skin closure and obviates the need for external metal-work and the attendant potential complications.     

Surgical treatment of adult idiopathic scoliosis – comparison of two instrumentations

In this study, 22 women patients with adult idiopathic scoliosis treated surgically with Cotrel-Dubousset instrumentation (CDI) or Texas Scottish Rite Hospital instrumentation (TSRHI) were followed up for 56.2+/-4.0 months. The overall immediate and final corrections were respectively 21.5+/-40 (58%) and 26.6+/-2.90 (48%), giving a loss of correction of 5.1+/-1.00 (10%). No significant differences were found in these two parameters between the two groups. The functional outcomes were good in 21 patients. There was no difference between CDI and TSRHI in deformity correction.