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PURPOSE: To report antegrade transvenous obliteration, with or without concurrent portosystemic shunt creation, for the treatment of hemorrhagic rectal varices. MATERIALS AND METHODS: Eight patients, including five (62.5%) females and three (37.5%) males, with mean age of 55.8 ± 13.8 years (range: 30-70 years), underwent transjugular-approach antegrade transvenous obliteration of rectal varices, with or without portosystemic shunt creation. Demographic data, procedural details, technical success of variceal obliteration, clinical success, adverse events, and follow-up outcomes were retrospectively recorded. Clinical success was defined as resolution of rectal hemorrhage. RESULTS: Portal venous access was achieved via a transjugular intrahepatic approach in all patients. The inferior mesenteric vein was selected, and foamy sclerosant (1:2:3 mixture by volume of ethiodized oil: sodium tetradecyl sulfate: air) was injected into the rectal varices with antegrade balloon occlusion in seven (87.5%) and without balloon occlusion in one (12.5%). Five of eight (62.5%) patients underwent concomitant transjugular intrahepatic portosystemic shunt (TIPS) creation (mean diameter 8.4 ± 0.9-mm) immediately following transvenous obliteration. Technical success of variceal obliteration was achieved in all patients. There were no immediate post-procedural adverse events. There were no reported occurrences of rectal ischemia, perforation, or stricture following obliteration. Two (40%) of the patients who underwent concomitant TIPS creation developed hepatic encephalopathy within 30 days of the procedure, which was medically managed. Clinical resolution of hemorrhage was achieved in all patients with no recurrent rectal variceal hemorrhage during mean follow-up of 666 ± 396 days (range: 14 - 1,224 days). CONCLUSION: Transvenous obliteration, with or without concurrent TIPS creation, is feasible with promising results for the management of rectal variceal hemorrhage.
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Backgrounds/Aims: Biliary surgery in patients with extrahepatic portal vein obstruction with portal cavernoma (PC) is technically challenging, and associated with the risk of bleeding. Therefore, prior portal vein decompression is usually recommended before definitive biliary surgery. Only a few studies have so far reported the safety of isolated laparoscopic cholecystectomy. We aimed to evaluate our experience of laparoscopic cholecystectomy in patients with PC without prior portal decompression. Methods: Prospectively maintained data for patients with PC who underwent laparoscopic cholecystectomy for symptomatic gallstone disease without portal decompression were analyzed. Clinical features, imaging, intraoperative factors, conversion rate, complications of surgery, and long-term outcomes were assessed. Results: Sixteen patients underwent cholecystectomy without portal decompression from 2012 to 2021, of which interventions 14 were laparoscopic cholecystectomies. One patient required conversion (7.1%) to open surgery. Jaundice was present in 5 patients (35.7%), and underwent endoscopic stone clearance before surgery. Median intraoperative blood loss, operative time, and hospital stay were 100 mL (20-400 mL), 105 min (60-220 min), and 2 days (1-7 days), respectively. Blood transfusion was required in two patients (14.2%). Prior endoscopic or percutaneous intervention was associated with significant blood loss and prolonged intraoperative time. Conclusions: In centers with experience, prior portal decompression can be avoided in patients with PC requiring isolated cholecystectomy to treat gallstones or their complications. Laparoscopic surgery is safe and feasible for these patients, and gives excellent outcomes in the selected group.
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BACKGROUND: Presentation of degenerative facet cysts (FC) as radicular pain in patients is well established. The traditional treatment of FCs has been decompressive laminectomy with a medial facetectomy and cyst excision. A major disadvantage of open procedures with medial facetectomy is predisposition to further instability. OBJECTIVE: To describe a contralateral bi-portal endoscopic excision of FC along with minimizing facet joint resection. METHODS: Thirteen patients between March 2016 and December 2017 were evaluated retrospectively for clinical, radiological, and morphometric outcomes. Patients with complaints of unilateral radiculopathy with associated neurogenic claudication from degenerative lumbar FC were included. Clinical evaluation was by NRS leg pain and ODI scores, radiological evaluation was by MRI. For morphometric analysis, cross-sectional area of facet joint (CSA-FJ) was measured on MRI in square millimeters. RESULTS: Thirteen FCs were decompressed (no adverse events) NRS leg pain and ODI improved from 6.85 ± 0.69 and 65.08 ± 7.95 preoperatively to 1 ± 0.91 and 13.46 ± 5.19 at 1-yr follow-up, respectively. CSA-FJ remained relatively well preserved from 212.83 ± 58.05 to 189.77 ± 62.93 post decompression (statistically insignificant, P = .3412). CONCLUSION: Bi-portal endoscopic decompression of FC can be performed with good clinical and radiological outcomes. This surgical technique may be recommended for further evaluation as an addition in the armamentarium of a spine surgeon for treatment of degenerative lumbar FC.
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Quistes , Articulación Cigapofisaria , Descompresión Quirúrgica , Estudios de Factibilidad , Humanos , Vértebras Lumbares/diagnóstico por imagen , Vértebras Lumbares/cirugía , Estudios Retrospectivos , Articulación Cigapofisaria/diagnóstico por imagen , Articulación Cigapofisaria/cirugíaRESUMEN
PURPOSE: The aim of this study was to assess national trends in utilization, demographics, hospital characteristics, and outcomes of patients undergoing surgical or percutaneous portal decompression since the introduction of transjugular intrahepatic portosystemic shunts (TIPS). METHODS: A retrospective analysis of patients undergoing surgical portal decompression and TIPS procedures was conducted using Medicare Physician/Supplier Procedure Summary Master Files from January 2003 through December 2013 and National (Nationwide) Inpatient Sample data from 1993, 2003, and 2012. Utilization rates normalized to the annual number of Medicare enrollees, estimated means, and 95% confidence intervals were calculated. RESULTS: The Medicare total annual utilization rate per million for all portosystemic decompression procedures decreased by 6.5% during the study period, from 15.3 in 2003 to 14.3 in 2013. TIPS utilization increased by 19.4% (from 10.3 to 12.3 per million), whereas open surgical shunt utilization decreased by 60.0% (from 5.0 to 2.0 per million). TIPS procedures represented 86% of all procedures in 2013. From 1993 to 2012, mean age increased slightly (from 53.0 to 55.5 years, P < .05). The percentage of procedures performed at teaching hospitals increased, whereas in-hospital mortality and length of stay decreased by 42% (P < .05) and 20% (P < .05), respectively. Of factors evaluated, the performance of procedures on an elective basis was the most influential on in-hospital mortality (P < .01, all years studied) and length of stay (P < .0001, all years studied). CONCLUSIONS: Approximately two decades after the introduction of TIPS, the utilization of all portal decompression procedures has remained relatively stable. The TIPS procedure represents the dominant portal decompression technique. In-hospital mortality and mean length of stay after decompression have decreased, partially because of the performance of procedures during elective admissions.