Budd-Chiari syndrome and acute portal vein thrombosis: management by a transjugular intrahepatic portosystemic shunt (TIPS) and portal vein interventions via a TIPS.

Acute portal vein thrombosis (PVT) is a devastating complication of Budd-Chiari syndrome (BCS). Conservative approach, anticoagulation, systemic or transarterial thrombolysis, and urgent liver transplantation were applied in this scenario but with poor results. We present and discuss an approach to treat BCS complicated by acute PVT. Two young female patients presented with acute liver failure, rapidly progressive tense ascites, renal- and respiratory failure. The diagnosis of chronic BCS complicated by acute PVT was confirmed with ultrasound Doppler. Initial treatment was supportive. Right portal vein localization was by transarterial portogram or by computed tomography-guided microcoil placement. Transjugular intrahepatic portosystemic shunt (TIPS) was performed and included Wallstents and a Jograft in one case and Viatorr stentgraft that was extended later with a Hemobahn stentgraft in another. Mechanical clot removal from the portal system was performed in the primary procedure and in a revision procedure in the following few days. Stents were placed precisely with no extension into the inferior vena cava or deeply into the main portal vein. Patients were fully anticoagulated and patency was assessed by ultrasound Doppler. The procedures were performed on days 5 and 10 following admission. In both cases, successful thrombectomies were revised and maintained. Partial occlusion of the TIPS and reaccumulation of ascites were reversed with repeated procedure. Both patients were discharged without ascites and normal liver function. In conclusion, urgent TIPS and portal vein thrombectomy via TIPS are emerging therapeutic options that offer a safe and effective treatment to patients with BCS complicated by acute portal vein thrombosis.

Laparoscopic implantation of the Tenckhoff catheter for the treatment of end-stage renal failure and congestive heart failure: experience with the pelvic fixation technique.

BACKGROUND: Peritoneal dialysis is a widely accepted route for renal replacement. With the advent of endoscopy, many surgical techniques for the prevention of catheter failure have been proposed. OBJECTIVES: To evaluate the outcomes of patients undergoing laparoscopic Tenckhoff catheter implantation using the pelvic fixation technique. METHODS: Data analysis was retrospective. All procedures were performed under general anesthesia. A double-cuffed catheter was inserted using two 5 mm trocars and one 10 mm trocar, fixing its internal tip to the dome of the bladder and its inner cuff to the fascia. Catheter failure was defined as persistent peritonitis/exit-site/tunnel infection, severe dialysate leak, migration or outflow obstruction. RESULTS: LTCI was performed in 34 patients. Mean patient age was 65 +/- 17 years. In 12 of the 34 patients the indication for LTCI was end-stage renal failure combined with NYHA class IV congestive heart failure. Operative time was 35 +/- 15 minutes. A previous laparotomy was performed in 9 patients. Hospital stay was 1.5 +/- 0.6 days. The first continuous ambulatory peritoneal dialysis was performed after 20 +/- 12 days. Median follow-up time was 13 months. There were several complications, including 5 (14%) exit-site/tunnel infections, 27 episodes (0.05 per patient-month) of bacterial peritonitis, 3 (9%) incisional hernias, 1 case of fatal intraabdominal bleeding, 2 (5.8%) catheter migrations (functionally significant), and 10 (30%) cases of catheter plugging, 8 of which were treated successfully by instillation of urokinase and 2 surgically. A complication-mandated surgery was performed in 8 patients (23.5%). The 1 year failure-free rate of the catheter was 80.8%. One fatal intraabdominal bleeding was recorded. CONCLUSIONS: LTCI is safe, obviating the need for laparotomy in high risk patients. Catheter fixation to the bladder may prevent common mechanical failures.

Treatment of intra-gastric band migration following laparoscopic banding: safety and feasibility of simultaneous laparoscopic band removal and replacement.

BACKGROUND: Intra-gastric band migration (band erosion) following laparoscopic adjustable gastric banding (LAGB) is a known complication requiring revisional surgery. Management has most often involved band removal and suturing of the stomach wall, followed by delayed replacement at a third operation. We report our experience with simultaneous band removal and replacement. METHODS: Between May 2001 and December 2003, we performed 754 laparoscopic operations using the Lap-Band (R). Patients developing band erosion were treated by laparoscopic band removal and immediate replacement of a new band following gastric wall repair. RESULTS: 16 patients (2.1%) developed band erosion after a mean of 23 months following surgery (range 11-40 months). Patients presented with epigastric pain (6), port-site bulge (3) or were asymptomatic (7), band erosion being suspected during fluoroscopy for band adjustment and confirmed by gastroscopy. Postoperatively, 11 patients developed fever that responded to antibiotics. No patient suffered from intra-abdominal infection, wound infection, pneumonia or pulmonary embolism. Mean hospital stay was 4 days (range 1-8 days). CONCLUSION: Band erosion following LAGB can be treated safely with simultaneous laparoscopic band removal, gastric wall suturing and immediate replacement of the band, thereby preventing weight gain, the appearance of co-morbidities and the need for additional surgery.

The yield of flexible fiberoptic bronchoscopy in pediatric intensive care patients.

STUDY OBJECTIVE: To evaluate the contribution of flexible fiberoptic bronchoscopy (FFB) and BAL to the clinical management of patients in a pediatric ICU (PICU). SETTING AND DESIGN: A retrospective study based on medical records in a six-bed pediatric ICU of a tertiary care children's hospital serving as a referral center for airway surgery. PATIENTS AND PARTICIPANTS: One hundred consecutive infants and children hospitalized in a PICU, who underwent FFB with or without BAL. MEASUREMENTS AND RESULTS: One hundred fifty-five procedures were performed, for the following causes: search for airways anatomic pathologies (114 of 155 procedures, 74%), including 55 procedures during the perioperative period of airway surgery; treatment of atelectasis (35 of 155 procedures, 22.5%); and BAL (30 of 155 procedures, 19%). Thirty-five percent of procedures had more than one cause. Airway pathology was observed in 79 of 114 procedures (69%). Management changed from conservative to surgical in 44 of 114 procedures (39%). In airway surgery cases, reoperation subsequent to postoperative FFB took place in 35%. BAL results changed antimicrobial treatment in 15 of 30 cases, with clinical improvement in 10 of 30 cases (33%). Treatment of atelectasis was successful in 26 of 35 cases (74.3%). No procedure-related mortality, life-threatening complications, or significant changes in patient status occurred. CONCLUSIONS: FFB is an important and safe procedure in very sick infants and children with a variety of respiratory diseases, and significantly contributes to their management. FFB should be considered to be a PICU staff expertise.

The effect of Ras inhibition on the proliferation, apoptosis and matrix metalloproteases activity in rat hepatic stellate cells.

In vivo inhibition of Ras by its antagonist farnesylthiosalicylic acid (FTS) prevents and reverses liver fibrosis in a rat model. In this study we showed the in vitro effects of Ras inhibition in a rat hepatic stellate cell line, HSC-T6. The IC(50) of FTS that inhibited PDGF-induced proliferation was 15 microM. FTS, by itself or in combination with PDGF, induced a three- to fivefold increase in the number of apoptotic stellate cells but did not induce apoptosis in cells cultured with TGFbeta1. We observed increased activity of MMP-9 and MMP-2 induced by FTS in combination with PDGF or TGFbeta. FTS, alone or in the presence of PDGF and TGFbeta, reduced collagen I mRNA expression. In conclusion, the in vivo amelioration of liver fibrosis by FTS may be explained by its ability to inhibit hepatic stellate cell proliferation, induce apoptosis and MMP-2 and MMP-9 activity, and decrease collagen I expression.

Usage of blood products in multiple-casualty incidents: the experience of a level I trauma center in Israel.

OBJECTIVE: To predict how much blood will be needed based on the number of injured patients arriving after a multiple-casualty incident. DESIGN: A retrospective study evaluating data collected in 18 consecutive terrorist attacks in the city of Tel Aviv between January 1997 and February 2005. SETTING: A large, urban trauma center. PATIENTS: A total of 986 patients in 18 events. MAIN OUTCOME MEASURES: Number of packed red blood cell (PRBC) units transfused per patient. RESULTS: A total of 332 U of PRBCs were transfused. Half of the PRBC units were administered as massive transfusions to 4.7% of the patients. The number of PRBC units transfused per patient index (PPI) was related to incident size (mean [SD], 0.70 [1.60] to 1.50 [1.60]). The most frequent major blood group transfused was type O (50%). Half of the units of PRBCs were supplied during the first 2 hours. CONCLUSIONS: One unit of blood per evacuated victim is sufficient in a small multiple-casualty incident and 2 U is sufficient in a large multiple-casualty incident. Half of the PRBC units should be blood group O.

Soluble CD14 as a predictor of subsequent development of recurrent wheezing in hospitalized young children with respiratory syncytial virus-induced bronchiolitis.

BACKGROUND: Respiratory syncytial virus (RSV) infection in infancy that causes severe bronchiolitis had been implicated as potentially responsible for the subsequent development of asthma. The CD14 receptor responds to the microbial burden in the environment and modulates the development of the allergic phenotype. OBJECTIVE: To investigate the relationship between the serum level of soluble CD14 (sCD14) in children hospitalized because of RSV-induced bronchiolitis and the subsequent development of recurrent wheezing. METHODS: Serum levels of sCD14 were measured in 21 children younger than 14 months who were hospitalized because of RSV-induced bronchiolitis. The diagnosis of significant wheezing was evaluated by recurrent episodes of coughing, wheezing, and respiratory distress, which were relieved by inhalation of beta-agonists and corticosteroids. RESULTS: Of the 21 children, 19 were followed up for 12 months. The mean sCD14 serum level of 14,521 +/- 1,773 pg/mL in the group of 6 children who did not exhibit recurrent wheezing was significantly higher than the level of 11,243 +/- 3,264 pg/mL in the group of 13 children who exhibited significant recurrent wheezing (P < .05). The subsequent development of recurrent wheezing was not influenced by positive family history of asthma, number of siblings, sex, or breast-feeding. CONCLUSION: A follow-up period of 12 months in this small pilot group showed that high serum levels of sCD14 modulate the influence of RSV on subsequent recurrent episodes of wheezing.

Diagnosing cystic fibrosis--asthma and failure to thrive as indications for a sweat test.

Children with asthma or failure to thrive (FTT) are frequently referred for the quantitative pilocarpine iontophoresis sweat test (QPIT) for diagnosing cystic fibrosis (CF). The aim of our study was to compare the prevalences of asthma and FTT among patients with a confirmed diagnosis of CF. Two-hundred and fifty-five children, who were referred for QPIT between 1991-1996 in order to rule out CF were studied retrospectively. All sweat samples had been obtained and analyzed according to the National Committee For Clinical Laboratory Standards. Asthma was defined as 24 episodes of wheezing, treated successfully by inhaled bronchodilators. Failure to thrive was was defined by either a weight below the 5th precentile or crossing of 2 major precentiles in 1 year. The prevalence of asthma was significantly higher than that of FTT among the cohort study (28.6% vs. 7.1% as a single indication, and 36.5% vs. 7.9% when combined with other indications). The prevalence of CF among patients with FTT was higher than among asthmatic patients (5.2% vs. 3%, p = 0.06). Not one patient diagnosed as having CF was referred to a sweat test only because of asthma. As a single presentation, the diagnostic yield of asthma seems to be poor, compared to FTT. However, further, larger-scale studies should be conducted on this issue.