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.

Correcting Peripherally Inserted Central Catheter Placement by External Manipulation of the Upper Limb Extremity.

Peripherally inserted central catheters (PICCs) play a critical role in neonatal intensive care units (NICUs), facilitating treatment in premature and critically ill neonates. However, achieving optimal PICC placement can present challenges, requiring meticulous monitoring and adjustment. Here, we describe the case of a 52-day-old, 1.9 kg preterm infant in the NICU requiring a central venous catheter for antibiotics and antifungals. Despite initial insertion into the basilic vein of the right forearm, imaging revealed the catheter's deviation into the right internal jugular vein. Leveraging the influence of arm position on catheter tip depth, external manipulation of the infant's right arm successfully repositioned the catheter tip into the superior vena cava (SVC). This case highlights the significant impact of arm positioning on PICC placement and underscores the efficacy of external extremity manipulation as a simple, non-invasive technique to adjust catheter position. Such innovative strategies offer promising alternatives to invasive interventions, emphasizing the importance of dynamic monitoring and adjustment techniques in neonatal PICC management.

Erector Spinae Plane Block in Post-thoracotomy Pain Management: A Case Series.

Post-thoracotomy pain management remains challenging, with thoracic epidurals traditionally considered the gold standard. Erector spinae plane blocks have emerged as a potential alternative, offering simplicity and a favorable safety profile. This case series presents three patients undergoing a hybrid Ivor Lewis esophagectomy who received erector spinae plane blocks for postoperative analgesia. Ultrasound-guided erector spinae plane catheters were inserted pre-anesthesia, with infusions managed postoperatively based on individual pain scores. All patients achieved effective pain control, enabling early mobilization. This suggests erector spinae plane blocks as a viable option for post-thoracotomy pain management.

The effect of a pushing technique with normal saline on peripheral intravenous catheter placement success in paediatric haematology and oncology: A randomized controlled trial.

PURPOSE: The aim of the present study is to determine the effect of the pushing technique with saline on the success of peripheral IV catheter placement in a paediatric haematology and oncology sample. METHODS: The randomized controlled trial was conducted among 60 paediatric haematology and oncology patients aged between 0 and 17. The participants were randomly assigned to two peripheral intravenous catheter placement groups (intervention group, n:30, control group, n:30). Each patient was evaluated with the Difficult Intravenous Access (DIVA) score before being included in the study. Each patient was assessed using the Personal Information Form for Children and Catheter Registration Form. RESULTS: The average age of the children was 86.4 months (SD = 60.0); 36.7% were female. The pushing technique with saline significantly increased the success of placing a peripheral IV catheter on the first attempt in the intervention group compared to the control group (F = 42.391, p = 0.000). The number of attempts during peripheral IV catheter placement significantly decreased in the intervention group compared with the control group (t = -5.676, p = 0.000). Complications were less in the intervention group compared with the control group (χ2 = 24.438, p = 0.000). The procedure time was significantly shorter in the intervention group compared with the control group (t = -4.026, p = 0.000). CONCLUSION: The pushing technique with saline is an effective method to increase the first attempt success rate, decrease the number of attempts, reduce the procedure time, and reduce the complications during peripheral intravenous catheter placement procedures in paediatric haematology and oncology patients with difficult intravenous access. TRIAL REGISTRATION: This study was registered at ClinicalTrials.gov (NCT05685290 & date of first recruitment: January 3, 2023) https://clinicaltrials.gov/ct2/show/NCT05685290.

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.

Suture passer combined with two-hole laparoscopic peritoneal dialysis catheterization in patients undergoing peritoneal dialysis.

BACKGROUND: Laparoscopic techniques are being widely applied for peritoneal dialysis (PD) catheter (PDC) placement. The suture passer is a novel fixation tool that aims to reduce catheter migration. We compared the clinical value of the suture passer combined with two-hole laparoscopic PDC placement to open surgical placement by evaluating preoperative and postoperative conditions, as well as the onset of complications in both groups. METHODS: A retrospective study was conducted including 169 patients who underwent PDC placement surgery from January 2021 to May 2023. Based on the method employed, patients were divided into two groups: the suture passer combined with a two-hole laparoscopy group (SLG) and the open surgical group (SG). Comprehensive patient information, including general data, preoperative and postoperative indicators, peritoneal function after surgery, and the incidence rate of complications, were collected and analyzed. RESULTS: The SLG showed a statistically significant decrease in operative time, intraoperative blood loss, and 6-month postoperative drift rate compared to the SG (p < 0.05). No statistically significant differences were observed between the two groups in terms of sex, age, primary disease, hospitalization time, hospitalization costs, preoperative and postoperative examination indicators, peritonitis, and omental wrapping. CONCLUSIONS: Suture passer combined with two-hole laparoscopic PDC placement, characterized by simplicity and facilitating secure catheter fixation, was deemed safe and effective for patients undergoing PD. It reduces the catheter migration rate and improved surgical comfort. Overall, this technique demonstrates favorable outcomes in clinical practice.

A New, Safe, and Effective Technique for Percutaneous Insertion of a Peritoneal Dialysis Catheter.

A properly functioning peritoneal catheter is an essential element of effective peritoneal dialysis (PD). Currently, there are three techniques available for PD catheter placement, which include open surgery, laparoscopic surgery, and percutaneous catheter placement (PCP). Currently, no particular catheter placement approach has been proven with certainty to provide superior outcomes. We present a new modified PCP method with the use of the Veress needle covered with an intravascular catheter (IC) and preliminary clinical results of PD catheter placements with this new technique. The endpoints used in the study were 1-year technical survival of the catheter, and the incidence of early (1 month) mechanical as well as infection complications. The catheter was implanted in 24 patients. The catheter survival rate was 100%; however, in two cases, the catheters were removed due to complications not associated with PD treatment. No early mechanical complications such as bleeding, hematoma, perforations, internal organ damage, exit site leaks, or hernia in the place of insertion were observed. Similarly, no early infectious complications were observed. During the 1-year follow-up, no catheter migration occurred. Our results showed that the new PCP technique is a safe and easy procedure that minimizes the occurrence of both mechanical and infectious complications and ensures good catheter survival.

Comparative Study on Flexible Ureteroscope Guided Peritoneal Dialysis Catheter Placement / 中国微创外科杂志

Objective To explore the feasibility of peritoneal dialysis catheter placement assisted by flexible ureteroscope.Methods A retrospective analysis was conducted on clinical data of 54 cases of end-stage renal disease receiving peritoneal dialysis catheter placement from May 2019 to March 2023.The placement method was chosen by the patient.In the conventional group,23 cases were guided by a metal guide wire for insertion of the peritoneal dialysis catheter,while in the flexible ureteroscope group,31 cases were guided by flexible ureteroscope instead of guide wire for insertion of the peritoneal dialysis catheter.The success rate of catheterization,surgical time,use of postoperative analgesic,complications related to peritoneal dialysis catheter,and postoperative creatinine decrease were compared between the two groups.Results The catheter placement was successfully performed in both groups.The total incidence of complications related to peritoneal dialysis catheter in the flexible ureteroscope group was lower than that in the conventional group[6.5%(2/31)vs.30.4%(7/23),χ2 =3.878,P =0.049].Between the conventional group and the flexible ureteroscope group,there were no statistically significant differences in the surgical time,postoperative analgesic usage,and the decrease of creatinine at 2 weeks after surgery(P>0.05).The median postoperative follow-up period was10 months(range,3-24 months)in the two groups,and there were no complications such as peritoneal leakage,intestinal perforation,or intraperitoneal bleeding.Conclusion The placement of peritoneal dialysis catheter guided by the flexible ureteroscope instead of metal guide wire is a safe,visible,and accurate method,which can reduce complications related to peritoneal dialysis catheter,and detect and manage comorbidities in the abdominal cavity.

A case of perforation of the prostatic abscess into the rectum resulting in a rectoprostatic fistula.

Introduction: A rectoprostatic fistula complicating a prostatic abscess is extremely rare, and there are many uncertainties regarding its treatment and prognosis. Case presentation: We present the case of a 68-year-old male who presented with rectal bleeding. Computed tomography reveals a prostatic abscess in contact with the rectum. As conservative treatment with antibiotics resulted in the aggravation of symptoms, we placed a transperineal catheter placement in the prostate, followed by drainage of the abscess through the catheter. The abscess communicated with the rectum, forming a rectoprostatic fistula. Subsequently, a transverse colostomy was performed. The abscess resolved, and no recurrence was observed even after 6 months of drainage. However, the rectal ulceration that resulted in the formation of the fistula persisted, and stoma closure was not achieved. Conclusion: In cases of prostatic abscess complicated by rectoprostatic fistula, drainage of the abscess along with colostomy seems essential for a curative approach.

A multi-institutional, observational study of outcomes after catheter placement for peritoneal dialysis in Japan.

BACKGROUND: This multi-institutional, observational study examined whether the outcomes after peritoneal dialysis (PD) catheter placement in Japan meet the audit criteria of the International Society for Peritoneal Dialysis (ISPD) guideline and identified factors affecting technique survival and perioperative complications. METHODS: Adult patients who underwent first PD catheter placement for end-stage kidney disease between April 2019 and March 2021 were followed until PD withdrawal, kidney transplantation, transfer to other facilities, death, 1 year after PD start or March 2022, whichever came first. Primary outcomes were time to catheter patency failure and technique failure, and perioperative infectious complications within 30 days of catheter placement. Secondary outcomes were perioperative complications. Appropriate statistical analyses were performed to identify factors associated with the outcomes of interest. RESULTS: Of the total 409 patients, 8 who underwent the embedded catheter technique did not have externalised catheters. Of the 401 remaining patients, catheter patency failure occurred in 25 (6.2%). Technical failure at 12 months after PD catheter placement calculated from cumulative incidence function was 15.3%. On Cox proportional hazards model analysis, serum albumin (hazard ratio (HR) 0.44; 95% confidence interval (CI) 0.27-0.70) and straight type catheter (HR 2.14; 95% CI 1.24-3.69) were the independent risk factors for technique failure. On logistic regression analysis, diabetes mellitus was the only independent risk factor for perioperative infectious complications (odds ratio 2.70, 95% CI 1.30-5.58). The occurrence rate of perioperative complications generally met the audit criteria of the ISPD guidelines. CONCLUSION: PD catheter placement in Japan was proven to be safe and appropriate.

Impact of Radial Arterial Location on Catheter Lifetime in ICU Surgical Intensive Care.

The use of arterial catheters is frequent in intensive care for hemodynamic monitoring of patients and for blood sampling, but they are often removed because of dysfunction. The primary objective is to compare the prevalence of radial arterial catheter dysfunction according to location in relation to the radiocarpal joint in intensive care patients. DESIGN: Prospective randomized, controlled, single-center study. SETTING: The surgical ICU of the university hospital of Poitiers in France. PATIENTS: From January 2016 to April 2017, all patients over 18 years old admitted to the surgical ICU and requiring an arterial catheter were included. INTERVENTIONS: Randomization into two groups: catheter placed near the wrist (within 4 cm of the radiocarpal joint) and catheter placed away the wrist. The primary endpoint was the prevalence of dysfunction. We also compared the prevalence of infection and colonization. MEASUREMENTS AND MAIN RESULTS: One hundred seven catheters were analyzed (14 failed placements with no difference between the two groups, and 16 catheters excluded for missing data), with 58 catheters in near the wrist group and 49 in away the wrist group. We did not find any significant difference in the number of catheter dysfunctions between the two groups (p = 0.56). The prevalence density of catheter dysfunction was 30.5 of 1,000 catheter days for near the wrist group versus 26.7 of 1,000 catheter days for away the wrist group. However, we observed a significant difference in terms of catheter-related infection in favor of away the wrist group (p = 0.04). In addition, distal positioning of the catheter was judged easier by the physicians. CONCLUSIONS: The distal or proximal position of the arterial catheter in the radial position has no influence on the occurrence of dysfunction. However, there may be an association with the prevalence of infections.

Effects of ultrasound with an automatic vessel detection system using artificial intelligence on the selection of puncture points among ultrasound beginner clinical nurses.

BACKGROUND: Ultrasound guidance increases the success rate of peripheral intravenous catheter placement. However, the longer time required to obtain ultrasound-guided access poses difficulties for ultrasound beginners. Notably, interpretation of ultrasonographic images is considered as one of the main reasons of difficulty in using ultrasound for catheter placement. Therefore, an automatic vessel detection system (AVDS) using artificial intelligence was developed. This study aimed to investigate the effectiveness of AVDS for ultrasound beginners in selecting puncture points and determine suitable users for this system. METHODS: In this crossover experiment involving the use of ultrasound with and without AVDS, we enrolled 10 clinical nurses, including 5 with some experience in peripheral intravenous catheterization using ultrasound-aided methods (categorized as ultrasound beginners) and 5 with no experience in ultrasound and less experience in peripheral intravenous catheterization using conventional methods (categorized as inexperienced). These participants chose two puncture points (those with the largest and second largest diameter) as ideal in each forearm of a healthy volunteer. The results of this study were the time required for the selection of puncture points and the vein diameter of the selected points. RESULTS: Among ultrasound beginners, the time required for puncture point selection in the right forearm second candidate vein with a small diameter (<3 mm) was significantly shorter when using ultrasound with AVDS than when using it without AVDS (mean, 87 vs 247 s). Among inexperienced nurses, no significant difference in the time required for all puncture point selections was found between the use of ultrasound with and without AVDS. In the vein diameter, significant difference was shown only in the absolute difference at left second candidate among inexperienced participants. CONCLUSION: Ultrasonography beginners needed less time to select the puncture points in a small diameter vein using ultrasound with AVDS than without AVDS.

Modified minimally invasive laparoscopic peritoneal dialysis catheter insertion with internal fixation.

BACKGROUND: Laparoscopic technique is widely used in peritoneal dialysis (PD) catheter placement. We developed a modified minimally invasive laparoscopic PD catheter (PDC) insertion with internal fixation and evaluated the early results by observing the intraoperative and postoperative conditions of the novel technique with those of conventional open surgery. METHODS: Retrospective research was performed on 59 patients who underwent PDC insertion from June 2019 to January 2022, including 23 patients who received open surgery and 36 patients who received modified minimally invasive laparoscopic surgery. Information such as preoperative conditions, operation time, incision length, incidence of intraoperative complications, time from operation to starting PD, time from operation to discharge, and incidence of catheter-related complications were collected and analyzed. RESULTS: The incision length, intraoperative blood loss, catheter migration rates and the total incidence of complications 6 months after operation in the laparoscopic group were lower than those in the conventional group. There were no statistically significant differences between the two groups in operation time, time from operation to starting PD, time from operation to discharge and the incidence of catheter blockage, leakage, exit-site infection, peritoneal dialysis associated peritonitis and hernia. CONCLUSIONS: Modified minimally invasive laparoscopic PDC insertion and internal fixation method achieved direct vision and reliable fixation of the catheter, significantly reduced incision length and blood loss. The incidence of catheter migration was significantly lower than that of open surgery. Our primary findings reveal that modified minimally invasive laparoscopic PDC insertion with internal fixation is safe, effective and beneficial for PD patients.

Effectiveness of ultrasonography for peripheral catheter insertion and catheter failure prevention in visible and palpable veins.

BACKGROUND: The increase in the success rate of peripheral intravenous catheterization against a difficult intravenous access (DIVA) using ultrasonography is reported; however, reports related to the effectiveness of using ultrasonography in increasing the success rate for visible and palpable veins is limited. Furthermore, according to a previous study, first attempt success in catheterization contributes to low catheter failure incidence. Thus, we developed a catheterization method using ultrasonography for peripheral veins including visible and palpable veins. This study investigates the effectiveness of ultrasonography use in improving the success rate of catheterization and preventing the catheter failure for peripheral veins including visible and palpable veins. METHODS: Adult inpatients were recruited. Trained nurses inserted intravenous catheters using ultrasonography. Ultrasonography was used for all vein assessment, target vein selection, and puncturing (i.e. target point selection and/or needle guidance), regardless of the target vein's visibility or palpability. Catheters with over a 24-h dwelling time were followed for catheter failure incidence. RESULTS: Thirty-one patients were recruited, and they required 34 catheterizations. Total number of catheterization attempts were 39. Of the peripheral veins, 51.3% (20/39) were visible and palpable, 48.7% (19/39) were DIVA. The rate of successful intravenous cannulation was 29 of 34 (85.3%) after one attempt and 4 of 34 (total 97.0%) after two attempts. The catheterization failure incidence was 3.2% (1/31) in the catheter that had an over 24-h dwelling time. CONCLUSIONS: Using ultrasonography to all target veins might have contributed to higher success rates of catheterization and extremely low incidence of catheter failure based on objective findings. Selecting the vein with larger diameters and healthy tissue as puncture point and showing center of vessel lumen clearly using ultrasonography might have been contributed the results.

Current Trends and Challenges in Nephrology Fellowship Training: Expansion of Education in Home Dialysis, Palliative Care, and Point-of-Care Ultrasound.

Nephrology education has changed significantly since the first nephrology fellowship programs were established in the United States in the 1950s and 1960s. The past several years have seen increased opportunities for subspecialization in areas such as interventional nephrology, onconephrology, and glomerular disease. Notable trends in fellowship curricula include the expansion of education in home dialysis and palliative care, driven by policy changes and focus on patient-centered care. In addition, point-of-care ultrasound has garnered significant interest due to its potential to provide diagnostic information that improves patient care. An important area that remains largely unaddressed appears to be education about the business and administrative aspects of nephrology. Meanwhile, the importance of training in hemodialysis catheter placement and kidney biopsy has come into question due to the small proportion of nephrologists performing these procedures today. Nephrology fellowship programs should strive to tailor their curriculum to meet the interests and needs of individual fellows.

Foley catheter for cervical preparation prior to second trimester dilation and evacuation: A supply-based alternative for surgical abortion: A case series.

Objective: To document the use of Foley catheter as an alternative to osmotic dilators for cervical preparation before second trimester dilation and evacuation at a tertiary setting in Ethiopia. Methods: This is a retrospective case series conducted at St. Paul's Hospital Millennium Medical College (Ethiopia) from April 1, 2021 to August 30, 2021. Forty-three cases of dilation and evacuation (D&E) in which overnight intra-cervical Foley catheter placement was used to prepare the cervix were reviewed. Data were analysed using SPSS version 23 and simple descriptive statistics were applied to analyze the clinical characteristics of study subjects and procedure outcomes. Percentages and frequencies were used to present the findings. Results: The calculated median gestational age was 21.4(17-24.2) weeks. Around 40%(17/43) of cases had cervical dilation of 3 to 4 cm, with another 33% (14/43) achieving cervical dilation of 1.5 to 2.5 cm. Additional dilation during the procedure was required only in 12 cases (28%) prior to D&E procedure. In 36 cases (84%), the procedure was attended by family planning fellow. Conclusion: Cervical preparation using overnight Foley catheter before second-trimester D&E resulted in majority of the cases requiring no additional dilation immediately prior to D&E procedure. Where osmotic dilators are not available, Foley catheter can be an alternative method to prepare the cervix prior to D&E procedures. Implications: In the absence of osmotic dilators, Foley catheter can be used as an alternate, and readily available means of cervical preparation for second trimester D&E procedures.

Right thyrocervical trunk rupture after right internal jugular vein puncture: a case report and systematic review of the literature.

BACKGROUND: Thyrocervical trunk rupture is an unusual, but critical, complication associated with central venous catheter (CVC) placement. The management of this complication has not been fully determined because it is rare. CASE PRESENTATION: A 53-year-old Japanese woman with anorexia nervosa developed refractory ventricular fibrillation. After returning spontaneous circulation, a CVC was successfully placed at the initial attempt in the right internal jugular vein using real-time ultrasound guidance. Immediately after CVC placement, she developed enlarging swelling around the neck. Contrast-enhanced computed tomography showed massive contrast media extravasation around the neck and mediastinum. Brachiocephalic artery angiography showed a "blush" appearance of the ruptured right thyrocervical trunk. After selective arterial embolization with 33% N-butyl-2-cyanoacrylate, the extravasation completely disappeared and hemostasis was achieved. CONCLUSION: Our findings suggest that severe vascular complications arising from CVC placement can occur in patients with a fragile physiological state. Endovascular embolization is an effective treatment for such complications.