Degree of obesity is not associated with more than one intubation attempt: a large centre experience.

BACKGROUND: The role of obesity as a risk factor for difficult intubation remains controversial. We primarily assessed the association between body mass index (BMI) and difficult tracheal intubation. METHODS: We analysed electronic records of more than 67 000 adults having elective non-cardiac surgery requiring tracheal intubation at the Cleveland Clinic between 2011 and 2015. The association between BMI and difficult intubation, defined as more than one intubation attempt, was assessed using multivariable logistic regression adjusting for pre-specified confounders. RESULTS: Amongst 40 183 patients with BMI <30 kg m-2 and 27 519 with BMI ≥30 kg m-2, 9% required more than one intubation attempt. Increasing BMI up to 30 kg m-2 was significantly associated with increased odds of more than one intubation attempt [odds ratio (OR): 1.03; 97.5% confidence interval (CI): 1.02, 1.04] per unit increase in BMI, P < 0.001. However, the odds of difficult intubation remained unchanged once BMI exceeded 30 kg m-2 (P = 0.08). The results were similar when analysis was restricted to patients without history of airway abnormalities in whom intubation was attempted using a standard direct laryngoscope (OR: 1.03; 99.4% CI: 1.01, 1.04) per kg m-2 increase in BMI <30 kg m-2). CONCLUSIONS: Increasing BMI was associated with increasing odds of difficult intubation in the lean range. At higher BMI, the odds of difficult intubation remain elevated, but there is no additional increase in odds with further increase in BMI. Obese patients were thus harder to intubate than lean ones, but difficult intubation was no more likely in morbidly obese patients than in those who were only slightly obese.

AIDS-related cholangiopancreatographic changes.

The cholangiographic and pancreatographic appearances of the acquired immunodeficiency syndrome (AIDS) associated cholangitis were evaluated in 26 patients. Twenty-four patients were diagnosed by retrograde cholangiography or endoscopic cholangiopancreatography (ERC or ERCP). One patient was diagnosed by T-tube cholangiography and another patient by transhepatic cholangiography. The radiographic findings ranged from intrahepatic ductal abnormalities with or without involvement of the extrahepatic biliary tree (eight patients) to irregularities and strictures involving the ampulla of Vater or the intrapancreatic portion of the common bile duct (CBD) with proximal dilatation (18 patients). Significant strictures involving the juxta-ampullary pancreatic duct were identified in six of 12 patients. Twenty-one of the 26 patients had associated infections which included: Cryptosporidium (CS), Mycobacterium avium intracellulare (MAI), cytomegalovirus (CMV), Microsporidium (MSP), and Isospora (ISP). Three patients were operated upon for acute acalculous cholecystitis. In each instance, organisms were identified in both the bile duct and the inflamed gallbladder.

Hepatobiliary complications of polyarteritis nodosa.

Although polyarteritis nodosa (PAN) may result in thrombosis or aneurysm formation in any organ in the body, hepatobiliary complications are unusual. We reviewed seven cases that demonstrated the diagnostic difficulties and therapeutic options available in the management of hepatobiliary PAN. No consistent sign that indicated the severity of hepatobiliary PAN could be identified. In cases of thrombotic PAN, acalculus cholecystitis usually could be diagnosed preoperatively. Early tissue diagnosis and aggressive intervention are required for appropriate patient treatment. If the diagnosis is unclear, a preoperative muscle or skin biopsy specimen is often helpful in establishing a tissue diagnosis of PAN, even if no obvious pathologic condition is evident. Patients who undergo celiotomy for acalculus cholecystitis or peritoneal signs of an unclear origin should have tissue specimens (gallbladder wall, liver, or omentum) submitted for pathologic study. Angiography may be diagnostic preoperatively or when results of biopsies are equivocal. In addition, early angiography can define the extent of visceral involvement and permit control by embolization of hemorrhage secondary to aneurysm rupture. Awareness of the possibilities of thrombotic, ischemic, or bleeding complications from PAN allows more aggressive and rapid management of abdominal complaints, especially in patients who are receiving immunosuppressant therapy.

Colonic diverticulitis in young patients with chronic renal failure and transplantation.

The association of colonic diverticulitis with chronic renal failure is well known. In those patients with "adult" autosomal dominant polycystic kidney disease, colonic diverticulitis is an especially common complication. We present two young patients (one teenager and one mid-twenties) who developed intra-abdominal abscess several years after renal transplantation. Neither patient had autosomal dominant polycystic disease nor a known history of gastrointestinal problems but both proved to have underlying, previously unsuspected colonic diverticular disease with abscess formation.

Obstruction of the Roux limb after portoenterostomy for biliary atresia: a delayed complication.

We report the case of a 5-year-old girl who underwent a Kasai portoenterostomy for extrahepatic biliary atresia. The conduit was exteriorized until 11 months of age. She was doing well, with stable portal hypertension until she suddenly developed jaundice, acholic stools, and bacteremia not responsive to a course of steroids and intravenous antibiotics. Suspecting obstruction at the site of the previously exteriorized anastomosis, a percutaneous cannulation of the conduit was performed. Catheterization of the conduit obstruction unkinked it and reestablished bile flow. She has remained anicteric with stable liver function.

Gianturco-Rosch biliary stents: preliminary experience.

Results of long-term follow-up are reported for nine patients who underwent placement of Gianturco-Rosch expandable metallic stents. Seven patients had malignant disease. The average duration of patency was 7 months. In one patient with inactive primary sclerosing cholangitis (PSC), the stents remained patent at 22 months, but recurrent stent closure was seen in a second patient with PSC. In the patient population studied, no advantages were seen with use of the stents; however, they may have an application in certain patients with benign disease.

Total occlusions of the femoropopliteal artery: high technical success rate of conventional balloon angioplasty.

Seventy patients 48-93 years of age underwent standard percutaneous transluminal angioplasty (PTA) for femoropopliteal artery occlusions 1-10 cm long. PTA was accomplished through an antegrade puncture of the common femoral artery. The angiographic criterion for technical success was restoration of the vessel lumen with no significant residual stenosis. The authors report technical success in 64 (91%) of their patients, an improvement over a technical success rate of 74% in their previous series of 46 other PTA patients with occlusions 1-20 cm long. In this series, no complications related to PTA necessitated emergency surgical intervention. Refinements in PTA can be attributed to changes in patient selection and medication, improvements in balloon catheters and guide wires, and greater proficiency on the part of angiographers. This update reflects currently achievable results with standard angioplasty techniques, and it is against such results that all new vascular recanalization techniques, including laser-assisted PTA, should be compared.

Percutaneous transjejunal approaches to the biliary system.

The authors report 10 cases in which various retrograde manipulations in the biliary tract were performed via percutaneous access from the jejunum in patients who had previously undergone Roux-Y biliary surgery. The first cases involved attempted retrograde cholangiography through the jejunal limb in children who had undergone Roux-Y portoenterostomies, followed by cases of percutaneous placement of U tubes and an attempt at percutaneous creation of an hepaticojejunostomy. When a limb from the Roux-Y has been brought to the skin and marked with clips, jejunal puncture is easily performed, is well tolerated by patients, and may be repeated frequently. It also appears that after Roux-Y choledochojejunostomy, the Roux-Y limb is fixed and may be punctured with relative safety. Since access from below is more favorable for intrabiliary manipulations, the transjejunal approach expands the armamentarium of the interventional radiologist in the combined radiologic and surgical management of complex biliary disease.

Percutaneous drainage of intra-abdominal abscesses following abdominal trauma.

Between January 1, 1984, and June 30, 1987, we performed percutaneous catheter drainage (PCD) of 28 intra-abdominal abscesses in 21 postoperative trauma patients. During this period only three patients had abdominal re-exploration for drainage of abdominal abscess. The PCD patients were predominantly young men who had sustained penetrating abdominal injuries (81% GSW or SW; 19% MVA). Seventeen (81%) patients had multiple abdominal organ injuries with the colon being the most frequently injured (57%). Multiple abscesses were identified in 33% of the patients. All 21 patients had successful treatment of their abscesses by PCD alone. There was one complication (4.8%) from PCD (pneumothorax) and no deaths in this group. Our data suggest that in most cases, PCD can be safe, effective, and definitive treatment for postoperative intra-abdominal abscesses following abdominal trauma. We recommend PCD in all postoperative trauma patients who develop accessible abdominal abscesses before resorting to re-exploration.

Maintaining quality of life after palliative diversion for malignant ureteral obstruction.

The records of 71 consecutive patients who underwent percutaneous nephrostomy for malignant ureteral obstruction were reviewed. The average post-nephrostomy survival time was seven months, of which 25% was spent in the hospital. When comparing these figures to older studies of open nephrostomy, the percutaneous procedure is associated with less morbidity and an increased percentage of time spent at home (75% compared to 36%). Long-term survival, however, is still poor, with only 25% of patients alive at one year. We suggest that the criteria previously adopted for open nephrostomy generally remain appropriate for patients being considered for percutaneous urinary diversion.

Percutaneous creation of a hepaticojejunostomy.

A procedure is described whereby a direct anastomosis may be created percutaneously between the biliary system and a Roux-en-Y limb; in effect a percutaneous hepaticojejunostomy. Although it will have limited applications, it represents a further extension of percutaneous techniques in the biliary system for complex problems.

Hepatic neurofibromatosis, malignant schwannoma, and angiosarcoma in von Recklinghausen's disease.

Liver involvement by neurofibromatosis is rare. This report describes a young man with von Recklinghausen's disease and hepatic neurofibromas who developed a large right hepatic lobe malignancy and died of massive intratumor hemorrhage. Postmortem examination showed the tumor to be composed of both malignant schwannoma and angiosarcoma and to have arisen from contiguous neurofibromas in portal tracts. Widespread pulmonary metastases consisted of the angiosarcomatous elements alone. The expression of malignant schwannoma and angiosarcoma phenotypes in this tumor may be related to a common histogenesis from cells of the neural crest.

Cystic duct occlusion and transcatheter sclerosis of the gallbladder in the rabbit.

We have identified a reliable sclerosant of the gallbladder in rabbits. After ligating the cystic ducts with a silk ligature in 24 rabbits and aspirating the bile from the gallbladder, we instilled a mixture of 95% ethanol and either 2 M% trifluoroacetic acid (TFA) or 5 M% TFA into the gallbladder. The animals were killed after 6 or 8 weeks. Ethanol with TFA resulted in replacement of gallbladder lumen with fibrous tissue in 22 rabbits. The two sclerosants were equally reliable and produced quantitatively similar fibrosis in the rabbits. The tendency for normal biliary mucosa to repopulate a sclerosed gallbladder can be obviated by complete occlusion of the cystic duct. The parameters for successful transcatheter sclerosis of the gallbladder have now been defined in an animal model.

Percutaneous removal of large gallstones.

Two patients are described in whom large gallstones, up to 4 cm in diameter, were removed percutaneously. The technique has some relevance to high risk patients with surgical cholecystotomies in whom elective cholecystectomy may be deferred if all the calculi can be removed. It may also be relevant if "percutaneous cholecystectomy" is ever developed clinically.

Transcatheter sclerosis of the gallbladder in rabbits. A preliminary study.

Catheter sclerosis of 56 rabbit gallbladders was attempted at laparotomy. The proximal cystic duct was occluded with a hemoclip and transcatheter administration of six different sclerosing agents and a saline control was performed. Eight animals were used for each agent, three being sacrificed after two weeks and the remainder after six weeks. Hot contrast and sotradecol were comparable with saline in their lack of effect on gallbladder mucosa. Alcohol alone, tetracycline, methylcyanoacrylate and alcohol plus trifluoroacetic acid were successful at two weeks in denuding the gallbladder epithelium and promoting fibrosis of the gallbladder wall. After six weeks, evidence of mucosal regeneration was present with all agents, and the epithelium appeared to have grown back from the occluded cystic duct. Late regeneration has not been previously reported and its significance when considering the application of the technique to the human gallbladder is discussed.

Percutaneous management of benign biliary disease.

Thirty-two patients had percutaneous drainage for benign disease of the biliary system, and in 81% of the patients the catheter could be removed. The patients' conditions were of 3 types: choledocholithiasis, biliary strictures, and primary sclerosing cholangitis. Fourteen patients had balloon dilatation of strictures in the biliary tract. As in malignant disease, many patients may be managed entirely by percutaneous methods and surgery avoided, but the results with percutaneous drainage are more gratifying.