Outcome and Safety of Unplanned-Start Peritoneal Dialysis according to Break-In Periods: A Systematic Review and Meta-Analysis.

INTRODUCTION: The best timing of peritoneal dialysis (PD) initiation after catheter implantation is still controversial. It is necessary to explore whether there exists a waiting period to minimize the risk of complications. METHODS: A systematic review and meta-analysis were searched in multiple electronic databases published from inception to February 29, 2020, to identify cohort studies for evaluating the outcome and safety of unplanned-start PD (<14 days after catheter insertion). Risks of bias across studies were evaluated using Newcastle-Ottawa Quality Assessment Scale. RESULTS: Fourteen cohort studies with a total of 2,401 patients were enrolled. We found that early-start PD was associated with higher prevalence of leaks (RR: 2.67, 95% CI, 1.55-4.61) and omental wrap (RR: 3.28, 95% CI, 1.14-9.39). Furthermore, patients of unplanned-start PD in APD group have higher risk of leaks, while those in CAPD group have a higher risk of leaks, omental wrap, and catheter malposition. In shorter break-in period (BI) group, the risk of suffering from catheter obstruction and malposition was higher for patients who started dialysis within 7 days after the surgery than for patients within 7-14 days. No significant differences were found in peritonitis (RR: 1.00; 95% CI, 0.78-1.27) and exit-site infections (RR: 1.12; 95% CI, 0.72-1.75). However, shorter BI was associated with higher risk of mortality and transition to hemodialysis (HD) while worsen early technical survival, with pooled RR of 2.14 (95% CI, 1.52-3.02), 1.42 (95% CI, 1.09-1.85) and 0.95 (95% CI, 0.92-0.99), respectively. CONCLUSIONS: Evidence suggests that patients receiving unplanned-start PD may have higher risks of mechanical complications, transition to HD, and even mortality rate while worsening early technical survival, which may not be associated with infectious complications. Rigorous studies are required to be performed.

Extracorporeal Membrane Oxygenation after Heart Transplantation: Impact of Type of Cannulation.

BACKGROUND: Primary graft dysfunction (PGD) is a common cause of early death after heart transplantation (htx). The use of extracorporeal life support (ECLS) after htx has increased during the last years. It is still discussed controversially whether peripheral cannulation is favorable compared to central cannulation. We aimed to compare both cannulation techniques. METHODS: Ninety patients underwent htx in our department between 2010 and 2017. Twenty-five patients were treated with ECLS due to PGD (10 central extracorporeal membrane oxygenator [cECMO] and 15 peripheral extracorporeal membrane oxygenator [pECMO] cannulation). Pre- and intraoperative parameters were comparable between both groups. RESULTS: Thirty-day mortality was comparable between the ECLS-groups (cECMO: 30%; pECMO: 40%, p = 0.691). Survival at 1 year (n = 18) was 40 and 30.8% for cECMO and pECMO, respectively. The incidence of postoperative renal failure, stroke, limb ischemia, and infection was comparable between both groups. We also did not find significant differences in duration of mechanical ventilation, intensive care unit stay, or in-hospital stay. The incidence of bleeding complications was also similar (cECMO: 60%; pECMO: 67%). Potential differences in support duration in pECMO group (10.4 ± 9.3 vs. 5.7 ± 4.7 days, p = 0.110) did not reach statistical significance. CONCLUSIONS: In patients supported for PGD, peripheral and central cannulation strategies are safe and feasible for prolonged venoarterial ECMO support. There was no increase in bleeding after central implantation. With regard to the potential complications of a pECMO, we think that aortic cannulation with tunneling of the cannula and closure of the chest could be a good option in patients with PGD after htx.

Effect of Early Cannulation with Plastic Cannula on Arteriovenous Fistula Patency in Hemodialysis Patients.

INTRODUCTION: Plastic cannulas have been used to cannulate arteriovenous fistulas (AVFs) for hemodialysis (HD) in Japan for many years. However, the effect of early cannulation with plastic cannulas on AVF patency is not known. OBJECTIVE: We analyzed the relationship between first cannulation time (FCT) and patency rates for AVFs cannulated with plastic cannulas and investigated whether early cannulation with plastic cannulas affects AVF patency. METHODS: In total, 122 patients who underwent primary AVF construction were divided into an early cannulation group (FCT <10 days) and a late cannulation group (FCT ≥10 days). The Kaplan-Meier method and multivariable Cox regression models were used to investigate AVF patency. RESULTS: Median FCT was 6 days. There was no statistically significant between-group difference in primary (p = 0.643) or secondary (p = 0.453) patency rates. Early or late cannulation was not significantly associated with primary patency (hazard ratio [HR] 1.21; 95% CI 0.71-2.05) or secondary patency (HR 0.46; 95% CI 0.08-2.77) after adjustment for age, sex, presence of diabetes mellitus or hypertension, and HD at baseline. CONCLUSIONS: Early AVF cannulation (<10 days from creation) with plastic cannulas does not affect access patency, and it may be possible to cannulate AVFs earlier than 10 days to decrease the need for use of a central venous catheter.

Two-Year Outcomes of Early Cannulation Arteriovenous Grafts for End-Stage Renal Disease.

BACKGROUND: Almost 80% of patients with end-stage renal disease (ESRD) initiate dialysis via a central venous catheter (CVC). CVCs are associated with multiple complications and a high cost of care. The purpose of our project is to determine the impact of early cannulation arteriovenous grafts (ECAVGs) on quality of care and costs. METHODS: The dialysis access modality, complications, secondary interventions, hospital outcomes, and detailed costs were tracked for 397 sequential patients who underwent access creation between July 2014 and October 2018. Complications were grouped into deep vein thrombosis, line infections, sepsis, pneumothorax, and other. Secondary interventions included angioplasty, angioplasty and stent grafting, thrombectomy, surgical revision, and explantation. Hospital outcomes included length of stay, inpatient mortality, 30-day readmission, and discharge disposition. Costs included supplies, medications, laboratory tests, labor, and other direct costs. All variables were measured at the time of the index procedure, 30 days, 90 days, 180 days, 270 days, 1 year, 18 months, and 2 years. RESULTS: There were 131 patients who underwent arteriovenous fistula (AVF) and 266 who received ECAVG for dialysis access. The total cost of care per patient was $17,523 for AVF and $5,894 for ECAVG at 1 year (P < 0.01). Primary-assisted patency for AVF was 49.3% versus 81.4% for ECAVG (P = 0.027), and secondary-assisted patency for AVF was 63.8% versus 85.4% for ECAVG at 1 year (P = 0.011). There was a survival advantage for ECAVGs at 1 year (78.6% for AVF vs 85.0% for ECAVG, P = 0.034). Patients who received ECAVG had fewer CVC days (2.3% vs 19.1% for AVF, P < 0.001), fewer complications (1.6% vs. 21.5% for AVF, P < 0.001), and fewer secondary interventions (17.0% vs 52.5% for AVF, P < 0.001). CONCLUSIONS: This is the first study on patients with ESRD to report detailed outcomes and cost analysis as it relates to AVF versus ECAVG. ECAVGs have an advantage over AVFs due to lower overall cost and better clinical outcomes at 1 year. Implementation of an urgent start dialysis access program centered around ECAVGs may help achieve the national goal of better health care at a lower cost for patients with ESRD.

Effect of first cannulation time and dialysis machine blood flows on survival of arteriovenous fistulas.

Background: To study the effect of cannulation time on arteriovenous fistula (AVF) survival. Methods. Analysis of two prospective databases of access operations and dialysis sessions from 12 January 2002 through 4 January 2015 with follow-up until 4 January 2016. First cannulation time (FCT), defined from operation to first cannulation, was categorized as <2 weeks, 2-4 weeks, 4-8 weeks, 8-16 weeks and ≥16 weeks. Early cannulation was defined as FCT within 4 weeks. AVF survival was defined as the date until the AVF was abandoned. Maximum machine blood flow rate (BFR) for the first 29 dialysis sessions on AVF was analysed. Results: Altogether, 1167 AVF with functional dialysis use were analysed: 667 (57%) radial cephalic AVF, 383 (33%) brachiocephalic AVF and 117 (10%) brachiobasilic AVF. The 631 (54%) AVF created in on-dialysis patients were analysed separately from 536 (46%) AVF created in pre-dialysis patients. AVF survival was similar between cannulation categories for both pre-dialysis patients (P = 0.19) and on-dialysis patients (P = 0.83). Early cannulation was associated with similar AVF survival in both pre-dialysis patients (P = 0.82) and on-dialysis patients (P = 0.17). Six consecutive successful cannulations from the start were associated with improved AVF survival (P = 0.0002). A below-median BFR at the start of dialysis was associated with better AVF survival (P < 0.0001). A below-median increase in BFR in the first 2 months was associated with worse AVF survival (P = 0.007). The type of AVF, diabetes, pre-dialysis state at operation and six successful cannulations from the start were independent predictors for AVF survival. Conclusions: FCT is not associated with AVF survival. Failures to achieve six successful cannulations from the start of dialysis and higher machine BFR in the first week of dialysis are associated with decreased AVF survival.

Peritoneal dialysis catheter function and survival are not adversely affected by obesity regardless of the operative technique used.

BACKGROUND: Obesity has been considered a relative contraindication to peritoneal dialysis (PD). Surprisingly, PD catheter dysfunction rates and longevity have not been studied in the growing obese ESRD population. The aim of this study was to determine the effect of patient weight on PD catheter survival in the three insertion technique categories of advanced laparoscopy (AL), basic laparoscopy (BL), and open. METHODS: We examine retrospectively collected data on 231 consecutive PD catheter insertions at the NorthShore University HealthSystem between 2004 and 2014. Three cohorts were created based on the catheter insertion technique: open, BL using selective adhesiolysis, and AL using rectus sheath tunnel, selective omentopexy, and adhesiolysis. Primary outcomes included catheter dysfunction and catheter dysfunction-free survival for each cohort by BMI: normal weight (18.5-24.9), overweight (25-29.9), obese (≥30). Nominal variables were compared using Chi-square test, continuous variables using ANOVA or Kruskal-Wallis tests, and catheter survival was assessed using the Kaplan-Meier method with log-rank test. Statistical significance was established at 0.05. RESULTS: For the three BMI categories, there were no statistically significant differences in patient demographics. There were no statistically significant differences in catheter dysfunction or peri-operative complications by BMI category among all patients. This was also true in the AL cohort. Among all patients, similar 2-year dysfunction-free catheter survival was noted for normal weight, overweight, and obese patients (log-rank p = 0.79). This was also true across all insertion techniques: open (log-rank p = 0.87), BL (log-rank p = 0.41), AL (log-rank p = 0.43). In the obese cohort, the 2-year dysfunction-free catheter survival was 91.1% in AL, 83.5% in BL, and 65.7% in open (log-rank p = 0.58). CONCLUSION: Obesity does not increase complications or shorten dysfunction-free PD catheter survival regardless of the operative technique used. Obesity should not be considered as a relative contraindication to PD catheter placement as it confers similar technique success to normal- and overweight individuals.

Weaning adult patients with cardiogenic shock on veno-arterial extracorporeal membrane oxygenation by pump-controlled retrograde trial off.

BACKGROUND: There is a lack of consensus on the timing of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) liberation. VA-ECMO weaning usually consists of serial decrements until an idling flow is achieved, supported by echocardiographic and haemodynamic assessments. Even with minimal idling flow, right ventricular (RV) preload is reduced and, hence, right heart function is not fully tested under adequate loading conditions. Following the use of a novel technique called Pump Controlled Retrograde Trial Off (PCRTO) in neonate VA-ECMO weaning, we report the use of this technique in seven adult patients on VA-ECMO. METHODS: We retrospectively reviewed all adult VA-ECMO patients treated at a tertiary teaching hospital in Hong Kong since 2010. Clinical data, including diagnosis, echocardiography findings, ECMO configuration, PCRTO settings, survival after veno-arterial ECMO (SAVE) score and outcomes, were collected. Mortality and death due to cardiac failure was compared between PCRTO and conventional weaning. RESULTS: Seven patients underwent PCRTO, with a mean SAVE score of -4.4 ± 5.9. All seven patients were successfully decannulated without haemodynamic deterioration. In all cases, no clots or fibrin deposits were found in the circuit after the trial. There was no difference in mean SAVE scores among the seven patients in PCRTO and the 23 patients in the conventional group (-3.6, 95% CI -8.8 to 1.5). The number of deaths due to cardiac failure in the PCRTO group and the conventional group were 0 and 3, respectively (0% vs. 13%, p=0.99). Mortality after decannulation for PCRTO was 42.9% vs. conventional weaning 34.8% (p=0.99). CONCLUSION: Our study suggests that PCRTO is a simple, safe and reversible alternative weaning method. It may have a particular role in the assessment of patients who have marginal recovery and right heart failure. Prospective controlled studies are needed to establish the potential role of PCRTO in the liberation of patients from VA-ECMO support.

Automated pressure-controlled cerebrospinal fluid drainage during open thoracoabdominal aortic aneurysm repair.

OBJECTIVE: Perioperative cerebrospinal fluid (CSF) drainage is a well-established technique for spinal cord protection during thoracoabdominal aortic aneurysm (TAAA) open repair and is usually performed using dripping chamber-based systems. A new automated device for controlled and continuous CSF drainage, designed to maintain CSF pressure around the desired set values, thus avoiding unnecessary drainage, is currently available. The aim of our study was to determine whether the use of the new LiquoGuard automated device (Möller Medical GmbH, Fulda, Germany) during TAAA open repair was safe and effective in maintaining the desired CSF pressure values and whether the incidence of complications was reduced compared with a standard catheter connected to a dripping chamber. METHODS: Data of patients who underwent surgical TAAA open repair using perioperative CSF drainage at our institution between October 2012 and October 2014 were recorded. The difference in CSF pressure values between patients who underwent CSF drainage with a conventional dripping chamber-based system (manual group) and patients who underwent CSF drainage with the LiquoGuard (automated group) was measured at the beginning of the intervention (T1), 15 minutes after aortic cross-clamping (T2), just before unclamping (T3), at the end of surgery (T4), and 4 hours after the end of surgery (T5). The choice of the draining systems was randomly alternated with one-to-one rate until the last six patients consecutively treated with LiquoGuard were enrolled. Primary outcomes were occurrence of spinal cord ischemia, intracranial hemorrhage, postdural puncture headache, and in-hospital mortality. RESULTS: The study included 152 patients who underwent open surgical TAAA repair during the study period: 73 patients underwent CSF drainage with the traditional system and 79 with LiquoGuard. The CSF pressure values at T1 and T5 were not considerably different in the two groups. By repeated-measures analysis of variance, a significant upward trend of perioperative CSF pressure was observed in the automated group at T2, T3, and T4 (group × time interaction = F3,66; P < .001). No difference was reported in the occurrence of spinal cord ischemia, intracranial hemorrhage, or mortality. The LiquoGuard group reported significantly reduced postdural puncture headache (3.3% vs 16.9%; P = .01). CONCLUSIONS: Perioperative use of LiquoGuard during TAAA open repair was safe and effective. Despite slightly higher intraoperative CSF pressures, the rate of spinal cord ischemia did not increase in the LiquoGuard group, and postdural puncture headache significantly decreased.

Mortality Following Catheter Drainage Versus Thoracentesis in Cirrhotic Patients with Pleural Effusion.

BACKGROUND: Pleural effusion is an abnormal collection of body fluids that may cause related morbidity or mortality in cirrhotic patients. There are insufficient data to determine the optimal method of drainage, for symptomatic relief in cirrhotic patients with pleural effusion. AIMS: In this study, we compare the mortality outcomes of catheter drainage versus thoracentesis in cirrhotic patients. METHODS: The National Health Insurance Database, derived from the Taiwan National Health Insurance Program, was used to identify cirrhotic patients with pleural effusion requiring drainage between January 1, 2007, and December 31, 2010. In all, 2556 cirrhotic patients with pleural effusion were selected for the study and divided into the two groups (n = 1278/group) after propensity score matching. RESULTS: The mean age was 61.0 ± 14.3 years, and 68.9% (1761/2556) were men. The overall 30-day mortality was 21.0% (538/2556) and was higher in patients treated with catheter drainage than those treated with thoracentesis (23.5 vs. 18.6%, respectively, P < 0.001 by log-rank test). After Cox proportional hazard regression analysis adjusted by patient sex, age, and comorbid disorders, the risk of 30-day mortality was significantly higher in cirrhotic patients who accepted catheter drainage compared to thoracentesis (hazard ratio 1.30, 95% confidence interval 1.10-1.54, P = 0.003). Old age, hepatic encephalopathy, bleeding esophageal varices, hepatocellular carcinoma, ascites, and pneumonia were associated with higher risks for 30-day mortality. CONCLUSION: In cirrhotic patients with pleural effusion requiring drainage, catheter drainage is associated with higher mortality compared to thoracentesis.

Cannulation Technique and Arteriovenous Fistula Survival in Older Adult Patients on Hemodialysis.

Cannulation technique has the potential to impact arteriovenous fistula (AVF) function. The aim of this research was to determine the impact of cannulation technique on the length of the functioning AVFs in older adult patients on hemodialysis. The study included 110 participants with fistula thrombosis who had used area technique or rope ladder technique. Biochemical parameters, gender, demographic, and clinical variables were determined. Patients who used the area cannulation technique differed significantly from patients using the rope ladder technique with regard to duration of hemodialysis (p < 0.001), outcome of the AVF revision (p = 0.045), and positioning of the anastomosis (p = 0.013). The group that used the area cannulation technique had a longer duration of hemodialysis, proximal anastomoses, and more successful revisions of AVFs.

Conservative treatment and percutaneous catheter drainage improve outcome of necrotizing pancreatitis.

BACKGROUND/AIMS: To investigate the clinical effects of the maximum conservative treatment algorithm with percutaneous catheter drainage (PCD) as the first choice for necrotizing pancreatitis (NP). METHODOLOGY: Retrospectively analyzed NP patients who had fine needle aspiration (FNA) for proven infection of necrosis which was considered an indication for surgery (n=22, group 1) compared to patients subjected to maximum conservative treatment with PCD in NP patients (n=30, group 2). RESULTS: On admission, most baseline data did not show any statistical difference between the two groups, In group 2, all patients were implemented maximum conservative treatment, 25 of 30 patients were cured by PCD (83.3%), open necrosectomy were needed for 3 patients (10.0%) and 2 dead during hospitalization (6.7%). Whereas, in group 1, surgical operation rate was 45.6% and hospital mortality 31.8%, both of the ratios differed significantly compared with group 2 (45.6% vs. 10%, P=0.004; 31.8% vs. 6.7%, P=0.046 respectively). Furthemore, Hospital stay were significantly higher in group 1 compared with group 2 (90±18.5 vs. 39±13.4; P=0.033). CONCLUSIONS: A conservative approach with PCD as the first choice to treatment NP might decrease the rate of surgical operation and mortality, and improve the outcome of NP.

Investigation of treatment methods in obstructive colorectal cancer.

PURPOSE: The aim of this study was to explore the treatment strategies for patients with obstructive colorectal cancer at different sites. METHODS: Treatment strategies were adopted according to the location of colorectal cancer and the condition of the patients when they were admitted to the hospital. Among a total of 134 patients, 29 patients were subjected to stent placement to relieve the obstruction before undergoing colorectal resection, 15 patients underwent per anum ileus catheterization to alleviate the symptoms of obstruction and waited for removal of the tumor within a limited time; 39 underwent intraoperative colonic lavage and colon resection with anastomosis and the remaining 51 patients were subjected to emergency surgery due to strangulation of the bowel, perforation, septic shock or other conditions before surgery. RESULTS: Stent placement was successfully performed on 23 patients, with a success rate of 79%. Ninety-five of 134 patients (71% had stage I anastomosis and only one case had anastomotic fistula. Infection of incision happened in 9 (7%) cases and 2 (1.5%) patients died of infection. CONCLUSIONS: Individualized treatment for patients with obstructive colorectal cancer can lead to tumor resection and stage I anastomosis, thereby avoiding the suffering of second-stage surgery or colostomy.

Fluoroscopic versus laparoscopic implantation of peritoneal dialysis catheters: a retrospective cohort study.

PURPOSE: A previous clinical trial showed that radiologic insertion of first peritoneal dialysis (PD) catheters by modified Seldinger technique is noninferior to laparoscopic surgery in patients at low risk in a clinical trial setting. The present cohort study was performed to confirm clinical effectiveness of radiologic insertion in everyday practice, including insertion in patients with expanded eligibility criteria and by fellows in training. MATERIALS AND METHODS: Between 2004 and 2009, 286 PD catheters were inserted in 249 patients, 133 with fluoroscopic guidance in the radiology department and 153 by laparoscopic surgery. Survival analyses were performed with the primary outcome of complication-free catheter survival and secondary outcomes of overall catheter survival and patient survival. Outcomes were assessed at last follow-up, as long as 365 days after PD catheter insertion. RESULTS: In the radiologic group, unadjusted 365-day complication-free catheter, overall catheter, and patient survival rates were 22.6%, 81.2%, and 82.7%, respectively, compared with 22.9% (P = .52), 76.5% (P = .4), and 92.8% (P = .01), respectively, in the laparoscopic group. Frequencies of individual complications were similar between groups. Adjusting for patient age, comorbidity, and previous PD catheter, the hazard ratio (HR) for catheter complications by radiologic versus laparoscopic insertion is 0.90 (95% confidence interval [CI], 0.62-1.31); the HR for overall catheter survival is 1.25 (95% CI, 0.59-2.65); and that for death is 2.47 (95% CI, 0.84-7.3). CONCLUSIONS: Radiologic PD catheter insertion is a clinically effective alternative to laparoscopic surgery, although there was poorer long-term survival with radiologic catheter placement, possibly because of preferential selection of radiologic insertion for more frail patients.

Fatal surgical or procedure-related complications: a Finnish registry-based study.

INTRODUCTION: In Finland, all healthcare personnel must be insured against causing patient injury. The Patient Insurance Centre (PIC) pays compensation in all cases of malpractice and in some cases of infection or other surgical complications. This study aimed to analyze all complaints relating to fatal surgical or other procedure-related errors in Finland during 2006-2010. MATERIALS AND METHODS: In total, 126 patients fulfilled the inclusion criteria. Details of patient care and decisions made by the PIC were reviewed, and the total national number of surgical procedures for the study period was obtained from the National Hospital Discharge Registry. RESULTS: Of the 94 patients who underwent surgery, most fatal surgical complications involved orthopedic or gastrointestinal surgery. Non-surgical procedures with fatal complications included deliveries (N = 10), upper gastrointestinal endoscopy or nasogastric tube insertion (N = 8), suprapubic catheter insertion (N = 4), lower intestinal endoscopy (N = 5), coronary angiogram (N = 1), pacemaker fitting (N = 1), percutaneous drainage of a hepatic abscess (N = 1), and chest tube insertion (N = 2). In 42 (33.3 %) cases, patient injury resulted from errors made during the procedure, including 24 technical errors and 15 errors of judgment. There were 19 (15.2 %) cases of inappropriate pre-operative assessment, 28 (22.4 %) errors made in postoperative follow-up, 23 (18.4 %) cases of fatal infection, and 11 (8.8 %) fatal complications not linked to treatment errors. CONCLUSION: Fatal surgical and procedure-related complications are rare in Finland. Complications are usually the result of errors of judgment, technical errors, and infections.

Characterizing cardiopulmonary arrest during interventional radiology procedures.

PURPOSE: Careful case selection and preparation can prevent most cardiopulmonary arrest (CPA) in the interventional radiology (IR) suite. A series of CPAs was analyzed to provide insight into risk factors for these events. MATERIALS AND METHODS: A single-institution CPA database was used to identify all code team activations from January 1, 2005, to May 30, 2011, in the IR department. Medical records were searched for medical history, American Society of Anesthesiologists (ASA) classification, moderate sedation, and outcomes. Procedural data and procedure classification was acquired from the HI-IQ database. RESULTS: There were 36,489 procedures and 23 CPAs during the study period. Of the 23 patients with CPAs, 12 (52%) were male and 11 (48%) female, and average age was 57 years ± 19 (standard deviation). Risk factors included a 56% incidence of diabetes mellitus, 48% incidence of hypertension, and 78% incidence of renal failure. Of the patients with kidney disease, 56% were chronically dialysis-dependent, and an additional 9% were undergoing central venous catheter placement for new hemodialysis. Seventy-eight percent had ASA status of III or greater, and 57% underwent moderate sedation during the procedure. Relative risk of a CPA during dialysis shunt interventions versus arterial interventions was 3.6 (95% confidence interval, 1.0-11.3; P = .045). Eight of 23 (35%) died: one (12%) during resuscitation and seven (88%) after resuscitation (P = .070). CONCLUSIONS: The most common comorbidity of patients with CPA in IR was kidney disease, and the most patients who had CPA underwent dialysis access-related procedures.

Retrospective review of angiography before cannulation of newly created vascular accesses in hemodialysis patients.

PURPOSE: To investigate vascular access status before first cannulation and the clinical implications of angiography performed before cannulation. MATERIALS AND METHODS: A retrospective review of 300 consecutive patients who underwent angiography after vascular access surgery and before cannulation between August 2004 and April 2010 was performed. Angiography was performed 4-6 weeks after the surgery but before the first cannulation. RESULTS: Angiography revealed 94 (31.3%) cases of severe stenosis (≥ 50% luminal narrowing) that required percutaneous transluminal angioplasty (PTA) or a second operation. No stenosis was observed in 122 (40.7%) cases, and mild stenosis (< 50% luminal narrowing) was observed in 84 (28%) cases. For the 94 cases with severe stenosis, PTA was performed in 66, and a second operation was performed in 16. In the other cases (n = 12), HD was maintained by a permanent catheter, or the patients were transferred to another institution. PTA was an immediate success in all patients who underwent the procedure except two. Of 84 patients with mild stenosis, 70 were followed for 1 year; vascular access dysfunction occurred in 15, and 11 of these underwent successful PTA. Of the 122 patients with normal angiographic findings, 102 were followed for 1 year, and vascular access dysfunction did not occur in any of these patients. CONCLUSIONS: Early postoperative angiography before the first hemodialysis is helpful for the early detection and treatment of vascular access dysfunction.

Balloon dilatation of anastomotic strictures secondary to surgical repair of oesophageal atresia: a systematic review.

Surgical repair of oesophageal atresia may result in anastomotic strictures. These strictures are often treated by balloon dilatation (BD) and currently balloon dilatation (fluoroscopic or endoscopic) is the preferred primary treatment method. Here we review the current evidence of the outcomes of balloon dilatation of anastomotic strictures secondary to surgical repair of oesophageal atresia. We searched the standard databases (January, 1960-May, 2012) to identify all studies that reported outcomes of balloon dilatation of anastomotic strictures secondary to surgical repair of oesophageal atresia in children. Data, reported as median (range), were analysed and compared. Outcomes were success of BD, number of BD sessions, number of oesophageal perforations, need for other surgical interventions and mortality. Five studies were found to be relevant (n = 139; 81 [58%] male children). The total number of dilatation sessions was 401 (2.9 dilatations per child patient). General anaesthesia was used in two (40%) studies; sedation in a further two (40%) studies and one (20%) study used a combination of both. The size of balloon catheter ranged from 4 mm to 22 mm. Seven perforations were reported (1.8% per dilatation session), of which only one (14%) required surgery. No deaths were recorded. Balloon dilatation for anastomotic strictures post-EA repair is safe, and associated with a low perforation and mortality rates. Most perforations are amenable to conservative management.

Direct innominate artery cannulation in surgery for annuloaortic ectasia.

INTRODUCTION: The selection of the ideal cannulation site is still one of the major concerns in ascending aortic surgery. In the last decade, many surgeons have chosen to utilize antegrade cerebral perfusion in hypothermic circulatory arrest. In this study, we aimed to evaluate arterial cannulation techniques in patients who underwent root replacement for annuloaortic ectasia. MATERIALS AND METHODS: Between 2005 and 2012, a total of 69 patients with a diagnosis of annuloaortic ectasia underwent aortic root replacement with femoral artery, axillary artery, and direct innominate artery cannulation (IAC). Patients demographic, operative, and postoperative data were collected prospectively and analyzed. RESULTS: A total of 69 patients were investigated. Their ages varied from 13 to 78 (mean age was 54.25 ± 15.69) and 48 patients were male (69.5%). Mean aortic diameter was 5.65 ± 1.58 cm (min: 4.5 cm to max: 7.8 cm) by computerized tomography. The procedures included modified Bentall operation in 61 patients, and Cabrol operation in eight patients. In hospital, the mortality rate was 1.85%, and a 30-day mortality rate was 3.7% in the IAC group and 6.6% in patients who underwent femoral and axillary artery cannulation. Temporary cognitive dysfunction and stroke rate were similar between groups. CONCLUSION: Innominate cannulation is associated with low morbidity and mortality in patients who underwent ascending aorta surgery.

Early percutaneous mitral commissurotomy vs. conventional management in asymptomatic moderate mitral stenosis.

AIMS: The optimal timing of percutaneous mitral commissurotomy (PMC) remains controversial in asymptomatic patients with moderate mitral stenosis (MS). We sought to compare the long-term outcomes of early preemptive PMC and a conventional treatment strategy. METHODS AND RESULTS: From 1997 to 2007, we prospectively enrolled 244 consecutive asymptomatic patients (191 women, age 51 ± 11 years) with moderate rheumatic MS who were potential candidates for early PMC. The treatment groups were not randomly assigned and the choice of early PMC or conventional treatment for each patient was at the discretion of the attending physician. The primary endpoint was defined as the composite of cardiovascular mortality, cerebral infarction, systemic embolic events, and PMC-related complications. In the PMC group, there were no procedure-related deaths and mitral valve area was increased from 1.26 ± 0.11 to 2.07 ± 0.28 cm(2) immediately after PMC (P < 0.001). During a median follow-up of 8.3 years, there were 3 cardiovascular deaths and 5 cerebral infarctions in the PMC group (n= 106) compared with 16 cardiovascular deaths, 12 cerebral infarctions, and 7 systemic embolic events in the CONV group (n = 138). The estimated actuarial 11-year event-free survival rate was 89 ± 4% in the PMC group and 69 ± 5% in the CONV group (P < 0.001) but not significantly different in those without atrial fibrillation and previous embolism (86 ± 5% in the PMC group and 79 ± 6% in the CONV group at 11 years, P = 0.28). For the 62 propensity score-matched pairs, the risk of cardiovascular endpoint was significantly lower in the PMC than in the CONV group (hazard ratio: 0.327; 95% CI: 0.112-0.954; P = 0.041). CONCLUSION: In asymptomatic patients with moderate MS and favourable valve morphology, the clinical benefits of early PMC may outweigh the risks associated with early intervention, but prospective randomized trials are required to confirm the efficacy of early PMC.

A conservative and minimally invasive approach to necrotizing pancreatitis improves outcome.

BACKGROUND & AIMS: Treatment of patients with necrotizing pancreatitis has become more conservative and less invasive, but there are few data from prospective studies to support the efficacy of this change. We performed a prospective multicenter study of treatment outcomes among patients with necrotizing pancreatitis. METHODS: We collected data from 639 consecutive patients with necrotizing pancreatitis, from 2004 to 2008, treated at 21 Dutch hospitals. Data were analyzed for disease severity, interventions (radiologic, endoscopic, surgical), and outcome. RESULTS: Overall mortality was 15% (n=93). Organ failure occurred in 240 patients (38%), with 35% mortality. Treatment was conservative in 397 patients (62%), with 7% mortality. An intervention was performed in 242 patients (38%), with 27% mortality; this included early emergency laparotomy in 32 patients (5%), with 78% mortality. Patients with longer times between admission and intervention had lower mortality: 0 to 14 days, 56%; 14 to 29 days, 26%; and >29 days, 15% (P<.001). A total of 208 patients (33%) received interventions for infected necrosis, with 19% mortality. Catheter drainage was most often performed as the first intervention (63% of cases), without additional necrosectomy in 35% of patients. Primary catheter drainage had fewer complications than primary necrosectomy (42% vs 64%, P=.003). Patients with pancreatic parenchymal necrosis (n=324), compared with patients with only peripancreatic necrosis (n=315), had a higher risk of organ failure (50% vs 24%, P<.001) and mortality (20% vs 9%, P<.001). CONCLUSIONS: Approximately 62% of patients with necrotizing pancreatitis can be treated without an intervention and with low mortality. In patients with infected necrosis, delayed intervention and catheter drainage as first treatment improves outcome.