Introduction and importance A totally implantable venous access device (TIVAD), also referred to as ‘chemoport’, is frequently used for oncology patients. Chemoport insertion via the subclavian vein access may compress the catheter between the first rib and the clavicle, resulting in pinch-off syndrome (POS). The sequela includes catheter transection and subsequent embolization. It is a rare complication with incidence reported to be 1.1–5.0% and can lead to a devastating outcomes . Case presentation 50-year-old male had his chemoport inserted for adjuvant chemotherapy 3 years ago. During the removal, remaining half of the distal catheter was not found. There was no difficulties during the removal. Chest xray revealed that the fractured catheter had embolized to the right ventricle. Further history taking, he did experienced occasional palpitation and chest discomfort for the past six months. Electrocardiogram and cardiac enzymes were normal. Urgent removal of the fractured catheter via the percutaneous endovascular approach, under fluoroscopic guidance by an experience interventional radiologist was done. The procedure was successful without any complication. Patient made an uneventful recovery. He was discharged the following day, and was well during his 3 rd month follow up. Conclusion Early detection and preventive measures can be done to prevent pinch-off syndrome. Unrecognized POS can result in fatal complications such as cardiac arrhythmia and septic embolization. Retrieval via the percutaneous endovascular approach provide excellent outcome in the case of embolized fractured catheter.
BackgroundIngestion of foreign bodies leading to impaction at the pharynx and oesophagus have been extensively described in English literatures. However, impactions at the gastrointestinal tract distal to the oesophagus are less commonly encountered due to the more capacious luminal diameter as it approaches the stomach. While intentional foreign body ingestions impacted distal to the oesophagus are often more complicated, literatures on the management of these distal oesophageal impactions are scarce. Case presentationWe present five cases of foreign body impaction at varying sites of gastrointestinal tract beyond the oesophagus, contrasting management approach comparing the role of endoscopy, open surgery and conservative management. Cases presented include patients aged 40 to 70 with intentional foreign bodies ingestion. The first case described a cerebral palsy patient with pica who had to undergo difficult evacuation under anaesthesia followed by colonoscopy; the second and third cases presented two different schizophrenic patients with two differing management approach. The second case was managed with multiple operations due to complications and died eventually, making the only mortality in our case series; whereas the third case was managed conservatively with acceptable outcome after multiple laparotomies prior. Fourth and fifth cases described two body packers who swallowed tobacco and two phones, respectively; the former was uneventfully managed conservatively, the latter, had to undergo surgical extraction. Individualized approach to these distal impactions of ingested foreign bodies are described with a review of available literatures which are tabulated and discussed in this case series. ConclusionEndoscopy, surgery, conservative management and sometimes a combination of approaches are utilised for the management of foreign bodies impacted distal to the oesophagus, especially in complex and recurrent cases. Decision, timing and approach of extraction must be individualised with consideration of risk weighed against the benefit of each intervention over the other.
Purpose: Numerous guidelines have been proposed in managing surgical emergencies during COVID-19 pandemic. Literature on the implications of these adjustments during this pandemic remained limited. This review aims to examine the implications of these critical adjustments with focus on appendicitis management. Method: This is a single-centre retrospective observational study in a Malaysian tertiary state surgical centre and review of recent guidelines and literature. Patients with appendicitis from March to May 2020 were included and medical records were reviewed and analysed. Results: Of the 173 appendicitis patients, 117 (67.6%) were operated and 56 (32.4%) were conservatively treated. Those screened for SARS-CoV-2 pre-operatively showed longer wait for operation (3.0 vs 2.0 days, p=0.001) and a longer hospital stay (4.5 vs 4.0 days, p=0.005). One-third of patients screened (36.6%) were expedited for surgery on clinical suspicion of complicated appendicitis and 42.1% progressed from acute to complicated appendicitis while waiting for screening result. All patients screened were COVID-19 negative. Delay due to SARS-CoV-2 screening did not result in worse outcome for appendicitis patients. Conclusion: With the increase in incidence and rise of COVID-19 cases, routine screening by questionnaire, physical examination and naso-oropharyngeal swab may be considered to detect asymptomatic carrier, especially in regions with high infection. Regular reassessment with low threshold to expedite the surgery is necessary, to ensure satisfactory surgical outcome.
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