Advanced portal venous access techniques for transjugular intrahepatic portosystemic shunt placement.

INTRODUCTION: Transjugular intrahepatic portosystemic shunt (TIPS) placement is a well-established but technically challenging procedure for the management of sequelae of end-stage liver disease. Performed essentially blindly, traditional fluoroscopically guided TIPS placement requires multiple needle passes and prolonged radiation exposure to achieve successful portal venous access, thus increasing procedure time and the risk of periprocedural complications. Several advanced image-guided portal access techniques, including intracardiac echocardiography (ICE)-guided access, cone-beam CT (CBCT)-guided access and wire-targeting access techniques, can serve as alternatives to traditional CO2 portography-based TIPS creation. METHODS: A literature search was performed on the electronic databases including MEDLINE and Embase, from 2000 to the present to identify all relevant studies. The reference list also included studies identified manually, and studies referenced for other purposes. FINDINGS: The main benefit of these advanced access techniques is that they allow the operator to avoid essentially blind portal punctures, and the ability to visualise the target, thus reducing the number of required needle passes. Research has shown that ICE-guided access can decrease the radiation exposure, procedure time and complication rate in patients undergoing TIPS placement. This technique is particularly useful in patients with challenging portal venous anatomy. However, ICE-guided access requires additional equipment and possibly a second operator. Other studies have shown that CBCT-guided access, when compared with traditional fluoroscopy-guided access, provides superior visualisation of the anatomy with similar amount of radiation exposure and procedure time. The wire-targeting technique, on the other hand, appears to offer reductions in procedure time and radiation exposure by enabling real-time guidance. However, this technique necessitates percutaneous injury to the liver parenchyma in order to place the target wire. CONCLUSION: Advanced portal access techniques have certain advantages over the traditional fluoroscopically guided TIPS access. To date, few studies have compared these advanced guided access options, and further research is required.

Combined Robot-assisted Kidney Transplantation and Sleeve Gastrectomy in a Morbidly Obese Recipient.

BACKGROUND: Kidney transplantation confers a well-documented survival advantage for patients with end-stage renal disease (ESRD) over dialysis, regardless of body mass index (BMI). However, obese patients with ESRD have limited access to kidney transplantation. In most transplant centers, a patient with a BMI above 35 to 40 kg/m is either completely excluded from transplantation or is required to lose weight before being considered for transplantation. MATERIALS AND METHODS: Herein, we present the first case of a 35-year-old woman with a BMI of 42 kg/m (96.8 kg) and ESRD, who underwent combined robot-assisted kidney transplant and sleeve gastrectomy. RESULTS: The total operative time was 318 minutes with an estimated blood loss of 125 mL. At 24 months after transplantation, the patient's weight, BMI, creatinine, and estimated glomerular filtration rate were 81.9 kg, 35.1 kg/m, 0.79 mg/dL, and 81.2 mL/min per 1.73 m, respectively. CONCLUSIONS: Combined robot-assisted kidney transplant and sleeve gastrectomy is feasible in morbidly obese patients and adds little additional operative time.