Percutaneous Transesophageal Gastrostomy: Procedural Technique and Outcomes.

PURPOSE: To demonstrate the safety and effectiveness of percutaneous transesophageal gastrostomy (PTEG) as a palliative option in patients with malignant bowel obstructions (MBOs), and provide a comprehensive review of PTEG indications, placement technique, and short- and long-term outcomes. MATERIALS AND METHODS: Thirty-eight consecutive patients who underwent a PTEG procedure attempt from 2014 to 2022 were included in this analysis. Clinical indications, method of placement, technical and clinical success, adverse events, including procedure-related mortality, and effectiveness were assessed. Technical success was defined as placement of a PTEG. Clinical success was defined as improvement in clinical symptoms following PTEG placement. RESULTS: Of the 38 patients who underwent PTEG, 19 (50%) were men and 19 (50%) were women (median age, 58 years; range, 21-75 years). Three (8%) PTEG placements were performed with the patients under moderate sedation, whereas the remainder (92%) were performed with the patients under general anesthesia. Technical success was achieved in 35 of the 38 (92%) patients. The mean catheter duration was 61 days (median, 29 days; range, 1-562 days), with 5 of the 35 patients requiring tube exchanges after initial placement. Moreover, 7 of the 35 patients with successful PTEG placement experienced an adverse event, including 1 case of non-procedure-related mortality. All patients with successful PTEG placement experienced improvement in clinical symptoms. CONCLUSIONS: PTEG is an effective and safe option for patients with contraindications to traditional percutaneous gastrostomy tube placement in the setting of MBO. PTEG is an effective means of providing palliation and improving the quality of life.

Dose reduction using digital fluoroscopy versus digital subtraction angiography in endovascular aneurysm repair: A prospective randomized trial.

OBJECTIVE: Endovascular aneurysm repair (EVAR) can result in high radiation dose to patients and operators. This prospective randomized study aimed to assess whether patient radiation dose sustained during EVAR could be decreased by predominantly using digital fluoroscopy (DF) vs the standard technique using digital subtraction angiography (DSA). METHODS: Between February 2011 and June 2017, patients with EVAR of infrarenal abdominal aortic aneurysms were prospectively enrolled and randomly assigned to a standard treatment DSA cohort or a DF cohort in which two or fewer DSA acquisitions were allowed for confirmatory imaging. Primary end points included dose-area product (DAP) and cumulative air kerma. Secondary end points included technical success and conversion to DSA standard treatment (if DF was inadequate for visualization). RESULTS: For all 43 patients enrolled (26 in the DF cohort, 17 in the DSA cohort), technical success was 100%. Of the 26 DF patients, 5 (19%) required conversion to the DSA cohort. In an intention-to-treat analysis, mean DAP was significantly lower in the DF cohort than in the DSA cohort (132 vs 174 Gy·cm2; P = .04). When patients were separated by number of DSA acquisitions (two or fewer vs three or more), mean DAP decreased 41% (109 vs 185 Gy·cm2; P = .005) and cumulative air kerma decreased 40% (578 vs 964 mGy; P = .004). CONCLUSIONS: In most patients (81%), DF or limited DSA was adequate for visualization during EVAR. In both intention-to-treat DF and limited-DSA cohorts, mean DAP was significantly decreased. If image quality allows, a DF-only or limited-DSA approach to EVAR decreases radiation dose.

Paget-Schroetter syndrome: treatment of venous thrombosis and outcomes.

Thoracic outlet syndrome (TOS) is a rare clinical entity with many etiologies. Venous thoracic outlet syndrome (VTOS), also called Paget-Schroetter syndrome (PSS), is a primary "effort" thrombosis. Here we will focus on the pathophysiology, anatomy, clinical presentation, treatments, and outcomes of VTOS. Treatment involves anticoagulation, catheter-directed thrombolysis, and surgical decompression. Early diagnosis and treatment can improve symptoms and quality of life.

Multiple treatment algorithms for successful outcomes in venous thoracic outlet syndrome.

BACKGROUND: We sought to determine the outcomes in patients presenting with venous thoracic outlet syndrome. METHODS: Prospectively collected data from 67 patients between October 2003 and December 2007. The average age was 31 years (range, 16-54); the 37 males and 30 females presented on average 9.2 months (range, 1 month-6 years) after acute thrombosis. Four treatment algorithms were utilized. RESULTS: In group 1, 3 patients presented with acute occlusion and received tissue plasminogen activator (tPA) and immediate first rib resection with scalenectomy (FRRS). One vein rethrombosed and was treated by intravenous tPA postoperatively. In group 2, 39 patients presented with stenotic subclavian veins an average of 22 weeks after their initial thrombosis, all of whom underwent FRRS followed by a venogram 2 weeks postoperatively: 25 had a tight stenosis and underwent venoplasty with anticoagulation; 13 had patent, nonstenotic subclavian veins, and 1 patient required tPA and venoplasty owing to rethrombosis. Two patients had their subclavian vein thrombose after venoplasty and were treated with anticoagulation, tPA, and venoplasty. In group 3, 11 patients presented with intermittent venous obstruction without thrombosis and underwent FRRS; 3 underwent venograms because of concerns of residual stenosis, 2 of whom required venoplasty postoperatively. Finally, in group 4, 14 patients presented with occluded subclavian veins and underwent FRRS with long-term anticoagulation. Eleven have recanalized at an average of 6 months (range, 2-12). CONCLUSION: Overall, 64 of 67 patients have patent subclavian veins after a median follow-up of 10 months, and all patients are asymptomatic for a success rate of 96%. Tailored treatment algorithms including FRRS, postoperative venograms with or without intervention, and the use of long-term anticoagulation seems to be required in this complicated group of young patients to achieve optimal results.

Current management of thoracic outlet syndrome.

Thoracic outlet syndrome (TOS) is a condition caused by compression of the neurovascular structures leading to the arm passing through the thoracic outlet. There are three distinct types of TOS: neurogenic (95%), venous (4%-5%), and arterial (1%). Treatment algorithms depend on the type of TOS. Although statistically the most common type, neurogenic TOS can often be the most difficult to diagnose and treat. We have good follow-up data indicating that appropriately selected patients benefit from surgical intervention. Arterial and venous TOS often present more urgently with arterial or venous thrombosis. The thrombosis is typically recognized expeditiously by thorough history taking and physical examination, augmented by duplex ultrasonography. The restoration of blood flow, be it venous or arterial, often can be accomplished readily by thrombolysis. The key, however, comes in diagnosing the underlying structural component involved in the development of symptoms. To prevent recurrence, patients must undergo first rib resection and anterior scalenectomy, as well as resection of any rudimentary or cervical ribs. In the case of arterial TOS, the subclavian artery often requires reconstruction as well. Regardless of the type of TOS encountered, proper treatment requires a multidisciplinary approach.

Surgical intervention for thoracic outlet syndrome improves patient's quality of life.

OBJECTIVE: To assess long-term quality of life outcomes in patients following transaxillary first-rib resection and scalenectomy for thoracic outlet syndrome (TOS). METHODS: This was a prospective observational study using the Short-Form 12 (SF-12) and Disability of Arm, Hand, and Shoulder (DASH) instruments between February 2005 and March 2008 in patients with TOS presenting to an academic medical center for preoperative surgical evaluation after failing physical therapy protocol. Surveys were conducted preoperatively and then again at 3, 6, 12, 18, and 24 months after surgery. Longitudinal data analysis was performed with population-averaged models using generalized estimating equations (GEE) method for average rate of recovery. Kaplan-Meier method was used to analyze time to return to work. RESULTS: A total of 70 out of 105 eligible patients (66.7%) completed the study protocol (44 neurogenic; 26 venous), returning 243 valid SF-12 surveys (162 neurogenic; 81 venous) and 188 valid DASH surveys (124 neurogenic; 64 venous). Half (50%) of the neurogenic patients and 77% of the venous patients returned to full-time work or activity within the study follow-up, with half of them doing so by 4 months and 75% of them by 5 months. There was no statistically significant difference in return to work between the neurogenic or venous patients. Neurogenic patients had baseline SF-12 Physical Component Scores (PCS) similar to chronic heart failure patients and were significantly worse than venous patients (33.8 vs 43.6, P < .001). In contrast, no difference existed in Mental Component Scores (MCS) (44.5 vs 43.5, P = .78). In follow-up, on average, PCS scores for neurogenic patients improved 0.24 points (P < .001) and MCS scores improved 0.15 points per month (P = .01); while PCS scores for venous patients improved 0.40 points (P = .004) and MCS scores improved 0.55 points per month (P < .001). Additionally, neurogenic patients had baseline DASH scores that were similar to patients with rotator cuff tears, and they were also significantly worse than venous patients (50.2 vs 25.0, P < .001). DASH scores, on average, also improved 0.85 points (P < .001) for neurogenic patients and 0.81 points (P < .001) for venous patients per month. CONCLUSION: The use of the SF-12 and DASH instruments in patients with TOS demonstrated significant improvement in patients postoperatively. Venous TOS patients typically improved both physical and mental scores in shorter periods of time than their neurogenic counterparts. Neurogenic and venous TOS patients returned to full-time work/activity within the same length of time postoperatively. However, neurogenic patients required more secondary interventions. We conclude that in appropriately selected patients with either neurogenic or venous TOS, surgical intervention can improve their quality of life over time.

Seroma development following body contouring surgery for massive weight loss: patient risk factors and treatment strategies.

BACKGROUND: The most common complications following body contouring surgery for massive weight loss include delayed wound healing and seroma. The authors investigated risk factors for seroma in this patient population and describe treatment strategies. METHODS: A retrospective review of 222 patients who underwent body contouring surgery for massive weight loss from March of 1997 to December of 2005 was performed. Risk factors assessed included age, sex, medical conditions, tobacco use, body mass index, weight of skin excised, and surgery performed. RESULTS: Within this group, there were 187 women and 35 men, with a mean age of 42 years. Weight loss was achieved by open (n = 167) or laparoscopic (n = 35) gastric bypass surgery, or diet (n = 20). Average body mass index at contouring was 33, ranging from 20 to 69. Surgical areas addressed alone or in combination included the abdomen (n = 205), thigh (n = 71), arm (n = 69), back (n = 59), and chest (n = 57). Average weight of skin excised at surgery was 9.6 lb, ranging up to 49 lb. Seroma occurred in 31 patients, placing the risk at 14 percent in this series. Seroma risk in abdominal panniculectomy was 12 percent; in circumferential belt lipectomy, the risk was 18 percent; and in thigh lift, the risk was 4 percent. On multivariate statistical analysis, the major risk factor for seroma formation was weight of skin excised, with seroma risk increasing 9 percent for each additional pound of skin excised. CONCLUSIONS: The most important risk factor for seroma is weight of skin excised at the time of surgery. Treatment strategies include aspiration, drain placement, sclerosis, and surgery.