A new esophageal stent design (Niti-S stent) for the prevention of migration: a prospective study in 42 patients

BACKGROUND

Covered, rather than uncovered, metal stents are used for the palliation of dysphagia from esophageal cancer, but a major drawback is the risk of stent migration, which occurs in up to 20% of patients. To overcome this problem, a double-layered stent, the Niti-S stent (Taewong Medical, Seoul, Korea), has been developed. The Niti-S stent consists of an inner polyurethane layer to prevent tumor ingrowth and an outer uncovered nitinol wire tube to allow the mesh of the stent to embed itself in the esophageal wall.

METHODS

Between June 2003 and May 2004, 42 patients with malignant dysphagia caused by inoperable carcinoma of the esophagus or gastric cardia were treated with a Niti-S stent. Patients were prospectively followed and data collection focused on recurrent dysphagia, functional outcome, complications, and survival.

RESULTS

At 4 weeks, the dysphagia score had significantly improved from a median of 3 (liquids only) to 0 (ability to eat a normal diet). Five of 42 (12%) patients with a Niti-S stent developed recurrent dysphagia, mainly due to tissue overgrowth (2 of 42; 5%) and stent migration (3 of 42; 7%). Major complications (perforation, 1; aspiration pneumonia, 2; hemorrhage, 2) occurred in 5 of 42 (12%) patients. Pain following stent placement was observed in 5 of 42 (12%) patients, and symptomatic gastroesophageal reflux occurred in 2 of 42 (5%) patients.

CONCLUSIONS

The Niti-S stent provides symptomatic relief of malignant dysphagia and effectively reduces recurrent dysphagia. Its double-layered design is probably important in preventing migration. In addition, the complete covering of the Niti-S stent may be a factor in preventing tissue overgrowth at both ends of the stent.

A prospective comparison of cement restrictor migration in primary total hip arthroplasty

Pressurization techniques are used to improve the cement/bone interface at hip arthroplasty. Ultra-high-molecular-weight polyethylene (UHMWPE) cement restrictors leave particulate debris at insertion; biodegradable restrictors may therefore be preferable. We compared the migration behavior of 2 such cement restrictors. A prospective randomized study with 16 patients per group using either a UHMWPE or a biodegradable restrictor was performed. Comparison of intraoperative measurements and postoperative radiographs determined restrictor migration. Mean migration was 3.0 vs 0.5 cm (biodegradable vs UHMWPE, Mann-Whitney U test, P < .002); median, 2.9 vs 0.4; SD, 1.8 vs 0.4; and range, 0.6 to 6.4 vs 0 to 1.2. Our study found that the biodegradable restrictor allowed significantly more migration than the UHMWPE restrictor. Although there are theoretical advantages in avoiding UHMWPE restrictors, the current biodegradable alternative is actually inferior and its use cannot be endorsed.

Silicone intubation with trans-sac fixation to prevent tube dislocation

PURPOSE

To report a new technique for silicone tube fixation, after successful intubation for congenital nasolacrimal duct obstruction, to minimize its lateral dislocation.

METHODS

Thirty patients (40 eyes) aged 20 months to 5 years (median, 28 months) were treated using the Ritleng bicanalicular lacrimal intubation system. After drawing the silicone stent out of the nose, a piece of 7-O Prolene suture was tied securely around one of its limbs. This limb was then pulled up, pulling the tied end of the Prolene suture to the medial canthal area. The same procedure was repeated with the other limb of the stent, pulling up the other Prolene suture end. This suture end was then un-tied. After adjusting the exposed silicone loop, the free end of the Prolene suture was tied securely to the corresponding part of the silicon stent. The nasally drawn two ends of silicone tube were tied in a single square knot. After 2 to 3 months, stents were removed in the medical office for all the patients.

RESULTS

This technique was used successfully for all the patients. Of the 40 tubes in this study, 39 did not displace and one tube was displaced laterally due to loosely tied Prolene suture. On follow-up, the trans-sac suture was well tolerated and no complications were noted.

CONCLUSION

The trans-sac fixation suture prevents lateral displacement of square-knotted silicone tube, which still can be removed easily at the physician's office.

Late in-the-bag intraocular lens dislocation: Incidence, prevention, and management

Dislocation of an intraocular lens (IOL) with the capsular bag is a late complication of cataract surgery, reported with increasing frequency in recent years. Pseudoexfoliation, uveitis, myopia, and other diseases associated with progressive zonular weakening and capsular contraction are the predisposing conditions. Capsular tension rings probably help but do not prevent this complication. Management includes IOL exchange, replacement with an anterior or a sutured posterior chamber IOL, or suturing the IOL through the bag to the iris or the sclera.

Minilaparoscopic extraperitoneal tunneling with omentopexy: a new technique for CAPD catheter placement

BACKGROUND

Continuous ambulatory peritoneal dialysis (CAPD) is an effective form of treatment for patients with end-stage renal disease. Open insertion of peritoneal dialysis (PD) catheters is the standard surgical technique, but it is associated with a relatively high incidence of catheter-related problems. To overcome these problems, different laparoscopic techniques have been presented, being preferable to the open and percutaneous methods.

OBJECTIVE

To introduce and evaluate the efficiency of laparoscopic omental fixation and extraperitoneal placement of the cuff-coil part (the straight portion) of the catheter to prevent catheter tip migration, pericatheter leakage, severe abdominal pain, and the obstruction caused by omental wrapping.

SETTING

The study was carried out in the General Surgery Department, Akdeniz University Medical School, in Turkey.

PATIENTS AND METHODS

Between November 2001 and March 2005, the technique was applied in 44 consecutive patients (mean age 51.6 years, range 18 - 67 years) with end-stage renal disease. During this laparoscopic technique, the omentum was first fixed onto the parietal peritoneum, and then the catheter was introduced through the subumbilical trocar site into the posterior rectus compartment and advanced toward the symphysis pubis. The catheter was then inserted into the abdominal cavity, passing the peritoneal opening, which was prepared before catheter insertion. The straight portion of the catheter was located into the extraperitoneal area of the anterior abdominal wall. The curled end, which contains the side-holes of the catheter, was placed into the true pelvis. Catheter position and patency were verified under direct vision using a 2 mm telescope.

RESULTS

All procedures were completed laparoscopically. Operating time ranged between 40 and 100 minutes (median 52 minutes). There was no intraoperative complication or surgical mortality. Peritoneal dialysis was initiated within 15 - 24 hours after catheter implantation. After a median follow-up period of 17.4 months (range 1 - 38 months), early exit-site infection occurred in 1 of 44 patients. All catheters functioned well postoperatively. There was no pain during CAPD.

CONCLUSION

This new laparoscopic technique using an extraperitoneal approach with omentopexy for PD catheter placement could prove extremely useful for preventing catheter malfunction caused by catheter tip migration, pericatheter leakage, omental wrapping, and periodic catheter movement that causes abdominal pain in CAPD.

Laparoscopic-assisted rectal foreign body removal: report of a case

PURPOSE

Rectal foreign bodies are not an uncommon presentation to the emergency department. Frequently they can be removed in the department through the transanal approach. However, this often is not well tolerated by the patient or can force the foreign body more proximal. We present a case of a difficult rectal foreign body in an obese patient that was successfully removed transanally in the operating room with laparoscopic assistance.

METHODS

Under general anesthesia, with the patient in Trendelenburg position, laparoscopy was used to push the rectal foreign body from above while it was removed transanally from below. This was performed with one 10-mm and two 5-mm incisions.

RESULTS

The foreign body was successfully removed transanally with laparoscopic assistance, and the patient was discharged within 12 hours from the operation.

CONCLUSIONS

The laparoscopic approach to assist in rectal foreign body removal is a good treatment choice for difficult cases. It allows for easy removal, detection of rectal injury, and early discharge.

Ventricular catheter tack-down suture: technical note

Tubing migration accounts for a significant number of shunt complications. In an attempt to reduce the likelihood of disconnection and tubing migration, we have developed a technique to rigidly fix the proximal catheter to the skull. The method involves the placement of a small twist drill hole adjacent to the catheter burr hole through which a suture is passed. The suture is then used to rigidly bind the proximal shunt tubing and valve to the skull. This approach provides an efficient and effective means for reducing complications related to shunt tubing migration.

Endoscope-assisted transscleral suture fixation to reduce the incidence of intraocular lens dislocation

PURPOSE

To examine the surgical complications of transscleral sulcus suture of posterior chamber intraocular lenses (IOLs) and to compare the rates of surgical complications between patients in the nonendoscope-assisted and endoscope-assisted groups.

SETTING

Kyoto University Hospital, Kyoto, Japan.

METHODS

This retrospective nonrandomized study comprised 121 eyes of 115 patients who had transscleral sulcus suture fixation of an IOL by the ab externo method. Typical 3-port vitrectomy was performed in 26 eyes in which the needle entry site and the haptic location were controlled using an endoscope.

RESULTS

During follow-up of at least 3 months, surgical complications in the nonendoscope-assisted group (95 eyes) included IOL dislocation in 22 eyes (23%), high astigmatism in 12 eyes (13%), transient ocular hypertension in 10 eyes (11%), vitreous hemorrhage in 5 eyes (5.3%), retinal detachment in 4 eyes (4.2%), and cystoid macular edema in 2 eyes (2.0%). In the endoscope-assisted group (26 eyes), the same complications were markedly decreased: there were no cases of IOL dislocation, high astigmatism, vitreous hemorrhage, retinal detachment, or cystoid macular edema; transient ocular hypertension occurred in 1 eye (3.8%). There was a statistically significant difference in the incidence of IOL dislocation between the 2 groups (P<.01).

CONCLUSION

Using an endoscope for transscleral sulcus suturing of an IOL can be an effective technique to reduce surgical complications, especially postoperative IOL dislocation.

Fixation of total knee arthroplasty improved by mobile-bearing design

We examined the in vivo displacement of mobile-bearing polyethylene and its effect on prosthesis-bone fixation. Thirty-five patients with the Interax ISA mobile platform total knee arthroplasties were examined by roentgen stereophotogrammetric analysis. Our protocol included weightbearing to measure the range of motion of the mobile platform in relation to the tibial component. We also studied the micromotions of the tibial component in relation to the tibia during a 2-year followup. The analysis of micromotion (maximum total motion mean, 0.5 mm; subsidence mean, 0.15 mm) showed this mobile platform design is stable and improves fixation at the prosthesis-bone interface. Longitudinal rotations of the mobile platform occurred in all patients and followed a homogeneous pattern of motion, depending on the examination. However, anteroposterior translations did not show any patterns with specific examination. This suggests the meniscal movement adapts itself to different weightbearing conditions. We measured the in vivo mobile-bearing displacement under static loading conditions. We also observed improved fixation at the bone-prosthesis interface.

Reduction in Slippage with 11-cm Lap-Band® and Change of Gastric Banding Technique

BACKGROUND

Slippage occurs after 2-18% of gastric bandings performed by the perigastric technique (PGT). We investigated the slippage-rate before and after the introduction of the pars flaccida technique (PFT) and the 11-cm Lap-Band, and the long-term results of the re-operated patients.

METHODS

Between Dec 1996 and Feb 2004, 360 patients with a mean BMI of 44 kg/m2 were operated. The PGT (n=168) and PFT9.75 (n=15) groups received the 9.75-cm Lap-Band, and the PFT11 group (n=177) received the new 11-cm Lap-Band. Follow-up rate was 99%.

RESULTS

Slippage occurred in a total of 31 patients from all groups (PGT, n=28, or 17%; PFT9.75, n=1, or 7%; PFT11, n=2, or 1%). Average yearly re-operation rate for slippage in the first 3 years postoperatively was 3.8%, 2.2% and 0.9%, respectively. Laparoscopic re-banding was necessary for posterior (n=19) or lateral (n=12) slippage. The late postoperative course after re-banding was: uneventful 58%, weight regain 35% and/or esophageal motility disorder 23%, secondary band intolerance 20%, and one persistent posterior slippage. 8 patients (26%) needed biliopancreatic diversion.

CONCLUSION

Since the introduction of the PFT and the 11-cm Lap-Band, we observed a significant reduction in slippage rate and no posterior slippage. Re-banding had a less favorable long-term result than did first-procedure banding.

Placing the Molteno implant in a long scleral tunnel to prevent postoperative tube exposure

PURPOSE

The purpose of this study was to retrospectively evaluate whether it is possible to decrease the risk of Molteno tube erosion through the conjunctiva by using a new technique where the silicone tube is inserted into a scleral tunnel instead of being covered only by the conjunctiva.

METHODS

We reviewed Molteno implants carried out at the University Hospital of Oulu, in 332 patients who underwent traditional Molteno implantation between October 1986 and October 1998 and 92 patients who underwent surgery with the new technique between November 1998 and April 2001.

RESULTS

With our former technique, conjunctival erosions occurred in 15 eyes of 15 patients (4.5%) after a median follow-up of 3.5 months (range 1-72 months); no conjunctival complications were discovered in patients who underwent surgery using the new technique during a median follow-up of 22 months (range 10-39 months). (p = 0.038, two-sample test of proportions).

CONCLUSION

Inserting the Molteno tube into a scleral tunnel prevents tube extrusion through the conjunctiva in eyes with Molteno implants. The technique for making the scleral tunnel is described.

Fixation of silicone stents in the subglottic trachea: preventing stent migration using a fixation apparatus

Silicone stents are widely used to treat benign or malignant airway stenosis. However, since straight silicone stents placed into the subglottic trachea to treat stenosis display a high risk of migration, novel approaches are required. The present report outlines our method of external fixation for silicone stents in the subglottic trachea. This technique utilizes a fixation apparatus, is readily performed, and may help to overcome the hesitation seen in placing silicone stents for subglottic tracheal stenosis.

Free Orbital Fat Graft to Prevent Porous Polyethylene Orbital Implant Exposure in Patients with Retinoblastoma

PURPOSE

To determine if porous polyethylene orbital implant (Medpor) exposure can be prevented in retinoblastoma patients when the implant is placed in combination with a free orbital fat graft over the anterior surface of the implant.

METHODS

Free orbital fat grafts were performed after enucleation and Medpor implantation, and results were compared with patients who underwent conventional enucleation and Medpor implantation without an orbital fat graft.

RESULTS

Although implant exposure occurred in 13 of 39 eyes (33.3%) that had conventional enucleation and Medpor implantation, exposure did not develop in any of the 38 eyes that had the combined procedure with a free orbital fat graft.

CONCLUSIONS

These findings suggest that a free orbital fat graft is a simple, effective way to prevent orbital implant exposure in patients requiring enucleation and Medpor implantation.

Late dislocation of scleral-sutured posterior chamber intraocular lenses

PURPOSE

To examine a recent series of late scleral-sutured posterior chamber intraocular lens (PCIOL) dislocations to identify possible causes and preventive measures.

SETTING

Price Vision Group, Indianapolis, Indiana, USA.

METHODS

In this retrospective non-comparative interventional case series, 5 consecutive patients received treatment for dislocated scleral-sutured PCIOLs between July 2002 and March 2004. Dislocated lenses were resutured or replaced with another scleral-sutured PCIOL.

RESULTS

Dislocation of scleral-sutured PCIOLs occurred 7 to 14 years after implantation. Four dislocations were spontaneous, and 1 was precipitated by trauma. In each case, the suture affixing 1 or both haptics failed. There was no evidence that the suture had eroded through the tissue or that the knot had untied. Microscopic analysis of an explanted IOL with remnants of the suture attached showed localized degradation and cracking of the polypropylene suture material where it had been embedded in the scleral tissue.

CONCLUSION

Suture-fixated PCIOLs can dislocate due to degradation of the suture material over time. The use of larger diameter (9-0 instead of 10-0) polypropylene suture material and placement of the haptic and sutures in the ciliary sulcus to promote attachment of scar tissue may enhance the long-term stability of scleral-fixated PCIOLs.

Superior sealing effect of hydroxyapatite in porous-coated implants: experimental studies on the migration of polyethylene particles around stable and unstable implants in dogs

BACKGROUND

Migration of wear debris to the periprosthetic bone is a major cause of osteolysis and implant failure. Both closed-pore porous coatings and hydroxyapatite (HA) coatings have been claimed to prevent the migration of wear debris. We investigated whether HA could augment the sealing effect of a porous coating under both stable and unstable conditions.

METHODS

We inserted porous-surfaced knee implants, with and without HA coating, in 16 dogs, according to a paired, randomized study design. 8 dogs had 2 implants inserted into each knee using a stable implant device and 8 dogs received 1 implant in each knee using a micromotion (500 microm) implant device. Implants had a peri-implant gap of 0.75 mm. We then injected polyethylene (PE) particles or a control solution into the knee joints on a weekly basis.

RESULTS

After 16 weeks, the rating of particles around stable implants was reduced by the HA coating froma median value of 2 (1-4) to 1 (0-1) (p = 0.01) and during micromotion from 3 (2-4) to 1 (0-3) (p = 0.002). HA-coated implants had superior bone ongrowth during stable and unstable conditions. We found no difference in bone ongrowth between PE-exposed and vehicle-exposed implants.

INTERPRETATION

Compared to a pure plasma-sprayed porous coating, a layer of HA coating provides bettter bone ongrowth and protects the bone-implant interface against the migration of wear debris under both stable and unstable conditions.

A Novel Approach to Prevent Repeated Catheter Migration in a Patient With a Baclofen Pump: A Case Report

We report a novel solution to a problem of repeated catheter migration that may aid others caring for patients with catheter migration problems. Catheter migration is a frequently reported complication of intrathecal drug delivery systems. We report on an ambulatory patient with a baclofen pump for control of spasticity due to cerebral palsy and dystonia; the patient suffered repeated episodes of catheter migration. The ultimate solution to the migrations was to place a pediatric pump in the lower thoracic, paraspinal region with the catheter entering the thoracic spine directly adjacent to the pump, thereby minimizing the differential motion between the pump and the spine, which was thought to be the cause of the repeated migration. This solution has not been previously described. Paraspinal pump placement may eliminate repeated catheter migration for patients with intrathecal drug pumps.

Interim results of the United States investigational device study of the Ophtec capsular tension ring

PURPOSE

To evaluate the safety and efficacy of the Ophtec capsular tension ring (CTR) in providing capsular support during and/or after cataract extraction in cases of a weak or partially broken ciliary zonule.

DESIGN

Phase III multicenter, nonrandomized, investigational device study.

PARTICIPANTS

Twelve investigators at 9 sites enrolled 224 subjects and placed 255 CTRs.

METHODS

Capsular tension rings were placed in patients who were found to have a weakened or partially broken ciliary zonule comprising <34% of the circumference of the lens capsule. Two CTR models were evaluated, with noncompressed diameters of 12 mm and 13 mm. Patients were examined preoperatively, intraoperatively, and postoperatively at day 1 and months 1, 3, 6, and 12.

MAIN OUTCOME MEASURES

Rate of successful stabilization of the capsular bag and intraocular lens (IOL) centration, complications, and adverse events.

RESULTS

Interim results from this ongoing study indicate that immediately after surgery 98.8% of IOLs were centered and 1.2% of the IOLs implanted (3/251) were not centered. Subsequently, the prevalence of decentered IOLs was 1.7% (4/236) 3 months after surgery, 3.8% (8/211) 6 months after surgery, and 2.3% (4/172) 12 months after surgery. The primary complication was posterior capsular opacification, which is unlikely to be a complication of CTR insertion. Neodymium:yttrium-aluminum-garnet laser capsulotomies have been performed in 12.8% of eyes by 12 months (22/172).

CONCLUSIONS

Ophtec CTR models 275 and 276 safely provided capsular support during and after cataract surgery in cases where the zonule was weak or partially broken.

Variables affecting initial stability of impaction grafting for hip revision

Impaction grafting allows restoration of bone stock in hip revision, but there are reports of massive early subsidence. The aim of this study was to determine prognostic factors for stem and cup migration in a group of 56 consecutive patients followed up from 1 to 5 years. Cup and stem migration was correlated with 13 predictors including stem design, stem positioning, femoral anatomy, patient characteristics, and bone graft density. All migration occurred mainly during the first 3 months after surgery. Stem alignment changed by an average of 4.8 degrees . Fifty percent of the change in stem alignment was explained by four variables: age, femoral diameter, stem design, and density of the graft at the tip of the stem. Stem subsidence averaged 2.7 mm, and cup migration averaged 3.0 mm. None of the predictors explained the wide variation of migration of the cup or distal migration of the stem. It may be necessary to determine implant stability at the time of surgery.