Evaluation of the frequency and factors predictive of hernia incarceration following transjugular intrahepatic portosystemic shunt placement.

AIM: To examine the frequency and predictive factors for bowel incarceration following transjugular intrahepatic portosystemic shunts (TIPS) placement to treat refractory cirrhosis-induced ascites. MATERIALS AND METHODS: Ninety-nine patients with known hernias at the time of TIPS placement were identified. Their electronic medical records were reviewed and pertinent pre-procedural, procedural, and outcome variables were recorded. Patients were divided between those that suffered incarceration (study group) and a control group of those with a hernia who did not suffer incarceration. RESULTS: Twelve of the 99 patients (12.1%) suffered hernia incarceration, of which seven (7.1%) suffered incarceration in the first 90 days. One patient who suffered incarceration ultimately died from complications of the incarceration. When comparing all patients who suffered incarceration to controls, incarceration patients were found to have significantly higher albumin levels (mean 3.13 versus 2.73, p=0.02). When just considering those who had incarcerations in the first 90 days to controls, incarceration patients were less likely to have improvement in their ascites (p=0.04). CONCLUSIONS: Incarcerated hernias occur frequently after TIPS placement and can lead to significant morbidity and mortality. Clinicians should be aware of this complication and counsel patients on presenting symptoms prior to placement.

Transjugular intrahepatic portosystemic shunt (TIPS) placement: A comparison of outcomes between patients with hepatic hydrothorax and patients with refractory ascites.

PURPOSE: To compare the outcomes in patients who had transjugular intrahepatic portosystemic shunts (TIPS) placed for hepatic hydrothorax with those who had it placed for refractory ascites. MATERIALS AND METHODS: One hundred and forty-seven patients who underwent TIPS placement for refractory fluid accumulation were included. There were 97 men and 50 women with a mean age of 56.1±9.7 (SD) years (range: 25-81 years). Of those, 32 patients (32/147; 21.8%) had refractory hepatic hydrothorax and 115 (115/147; 78.2%) had refractory ascites. Electronic medical records were reviewed for all patients to determine demographic, procedural related, and outcomes data. Both traditional analysis and a propensity score matching analysis were performed, to account for differences in baseline laboratory values, etiology of cirrhosis, age, and average number of paracenteses/thoracenteses per week. Survival analysis was also performed to compare post-TIPS survival by indication. RESULTS: Differences in response rates, in terms of fluid accumulation reductions, at 1, 3, and 6 months were not significant (P=0.19, P=0.33, and P=0.28, respectively). A successful propensity score matching was made between 24 hepatic hydrothorax and 46 ascites patients. After propensity score matching the response rates at 1, 3, and 6 months remained non-significant (P=0.3, P=0.71, and P=0.78 respectively). No differences in mean overall survival were found between hepatic hydrothorax patients (672 days) and ascites patients (1224 days) (P=0.15). CONCLUSION: The clinically relevant outcomes of improvement in fluid accumulation and overall survival do not appear to be significantly different in patients who have TIPS placed for refractory hepatic hydrothorax or and those who have TIPS placed for ascites.

Small hepatocellular carcinomas displayed as a ring enhancing mass on arterial phase MRI in the chronically diseased liver.

AIM: To assess the prevalence of arterial phase (AP) ring-enhancing small hepatocellular carcinomas (HCC) on magnetic resonance imaging (MRI); detail additional MRI features that enable HCC diagnosis; and examine arterial timing as one possible cause of this appearance. MATERIALS AND METHODS: Patients undergoing HCC screening with both computed tomography (CT) and MRI within 40 days were examined at a single institution over a 7- year time period ending in 2013. From this initial group, small (1-3 cm), (AP) ring-enhancing HCC on MRI were studied. RESULTS: From the initial group of 64 patients with 129 HCC, 20 patients with 78 HCCs had a small diameter with 32 (41%) having an AP ring at MRI. The mean age of this latter group was 63-years old, with the average tumour diameter of 1.9 cm. Histopathology and secondary imaging supported a diagnosis of HCC in 20 (100%) patients and 31 (97%) lesions. Most of the ringed lesions had early AP timing. CONCLUSION: This study revealed a high prevalence (41%) of small, AP ring HCC with MRI. The use of other MRI sequences adds support in making the proper diagnosis with this appearance. Early AP timing may help create this pattern.

Long-term outcomes (>5-year follow-up) with porcine acellular dermal matrix (Permacol) in incisional hernias at risk for infection.

PURPOSE: We reviewed retrospectively all patients undergoing abdominal wall reconstruction using porcine acellular dermal matrix (PADM) from 2004 to 2008 with follow-up assessment in 2012. Technique, short-term (infection, seroma, wound dehiscence), and long-term (mesh infection, recurrence) complications, and hernia recurrences were evaluated by physician examination ≥5 years postoperatively. RESULTS: 56 patients at high risk for infection had elective operation; nine had non-elective operation for complications of prior incisional hernia/hernia repair. Operations were clean, clean-contaminated, contaminated, or grossly infected in 49, 32, 12, and 6%, respectively. Techniques of repair included 10 onlay (six reinforced primary closures, four bridging patches), 47 sublay (20 reinforced primary closures, 27 bridging patches), six inlay, and two sandwich (sublay and onlay). Early complications (≤30 days postoperatively) occurred in 19 of the 65 patients (29%), including two prosthetic dehiscences from fascial attachment, 13 wound infections, and 4 seromas. After a mean follow-up of ≥5 years in 59 of 65 patients, physician-reported incidences of infection requiring removal of mesh or hernia recurrence were 25 and 66%, respectively. Hernia recurrence occurred in 12 of 26 (46%) patients with a reinforced repair and 27 of 33 (82%) with patched repairs. Mesh infection occurred in 7 of 24 patients with sublay patch and in 4 of 19 sublay reinforcement. The greatest recurrence rate was in contaminated (71%) and grossly infected wounds (100%), while recurrence rate was 63% in clean and 63% in clean-contaminated wounds. CONCLUSIONS: At ≥5 years of follow-up, use of PADM as a bioprosthesis in ventral hernia in high-risk patients is unreliable as a definitive repair in the majority of patients, but may provide satisfactory outcomes in some patients.

Posttransplant lymphoproliferative disorder following pancreas transplantation.

The incidence, risk factors and impact on patient and graft survival were evaluated for posttransplant lymphoproliferative disorder (PTLD) among 212 pancreas transplant recipients. Thirteen (6.1%) developed PTLD during 71 +/- 27 months follow-up. Cumulative incidences of PTLD at 1, 3, 5 and 10 years posttransplant were 4.2%, 5.3%, 6.0% and 7.0%, respectively. Incidence of PTLD was lower for recipients of simultaneous pancreas kidney compared to pancreas after kidney transplant or pancreas transplant alone, though not significantly so. Recipient Epstein-Barr virus (EBV) seronegativity and number of doses of depleting antibody therapy administered at transplant were associated with increased risk of PTLD, while recipient age, gender, transplant type, cytomegalovirus mismatch maintenance immunosuppression type and treated acute rejection were not. All 13 cases underwent immunosuppression reduction, and 10 received anti-CD20 monoclonal antibody. During follow-up, 10/13 (77%) responded to treatment with complete remission, while 3 (23%) died as a result of PTLD. Patient and graft survivals did not differ for recipients with and without PTLD. The strong association of PTLD with EBV-seronegativity requires considering this risk factor when evaluating and monitoring pancreas transplant recipients. With reduction of immunosuppression and anti-CD20 therapy, survival for pancreas transplant recipients with PTLD was substantially better than previously reported.