Fernando Camúñez

Urgent Transjugular Intrahepatic Portosystemic Shunt for Control of Acute Variceal Bleeding

Objective:Endoscopic sclerotherapy and pharmacological therapy are widely used in the treatment of acute variceal hemorrhage. However, they fail at arresting acute bleeding in 20–30% of bleeding episodes. The efficacy of transjugular intrahepatic portosystemic shunt (TIPS) in the prevention of recurrent variceal bleeding has been proved recently, but the effectiveness and safety of urgent TIPS in the treatment of acute variceal bleeding refractory to conventional therapy are still under evaluation.Methods:Over 4.5 yr, 358 variceal hemorrhage episodes were treated in our hospital. Pharmacological and endoscopic therapy failed to control hemorrhage in 93 episodes. Thirty-two patients died because of uncontrolled massive bleeding. In 56 patients, TIPS (Strecker stent) was performed after temporary control of the episode with balloon tamponade.Results:Eleven of 56 patients with urgent TIPS belonged to Child-Pugh class A, 22 to class B, and 23 to class C. The mean time between indication and insertion was 17 ± 10 h (range 4–24 h). Control of bleeding was achieved in 53 patients (95%). Eight patients had recurrent bleeding at 1 month after TIPS, seven of them during the first week after the procedure. The 1-month actuarial probability of rebleeding was 22%. The main complications of the procedure were massive hemoperitoneum (n = 1), cardiorespiratory arrest (n = 2), cardiac failure (n = 1), acute renal failure-(n = 2), and bacteremia (n = 7). Operative mortality (30 days) was 28%. The actuarial probability of survival at 30 days was significantly lower in Child-Pugh class C than in class A or B (48%vs 90%; p < 0.001). The presence of ascites, hepatic encephalopathy, and serum albumin level before TIPS were independent prognostic factors associated with the risk of operative mortality.Conclusions:Urgent TIPS is an effective alternative for the treatment of acute variceal bleeding refractory to endoscopic and pharmacological therapy, but sometimes is associated with major complications. Because of the high operative mortality rate in patients with severe liver failure, careful selection of patients is required before TIPS.

Stenosis of the inferior vena cava after liver transplantation: Treatment with gianturco expandable metallic stents

AbstractPurpose: Evaluate the efficacy of double Gianturco expandable metallic stents for stenosis of the inferior vena cava (IVC) after orthotopic liver transplantation (OLT). Methods: Three patients developed severe Budd-Chiari syndrome secondary to suprahepatic caval stenosis after OLT. Percutaneous angioplasty (PTA) of the stenoses was unsuccessful. Therefore double Gianturco expandable metallic stents, connected in tandem, were deployed at the site of the stenoses. Results: One double stent was successfully and definitively deployed in patient 1. Partial dislocation of the upper and lower stents comprising the double stent occurred in patient 2. The double stent initially implanted across the stenosis became displaced in patient 3. The Budd-Chiari syndrome resolved in all three patients who remained asymptomatic during follow-up from 3 to 32 months. Conclusions: Double Gianturco stent deployment is a viable option in patients with anastomotic stenosis of the IVC secondary to OLT when initial treatment with PTA fails. Certain modifications of the stents employed are suggested for the purpose of avoiding technical complications.

Randomized controlled trial of aspiration needle versus automated biopsy device for transjugular liver biopsy.

PURPOSE The efficacy and safety of transjugular liver biopsy used to obtain liver specimens in patients with coagulation disorders have been widely proven. However, histopathologic examination is not always possible because of fragmented samples provided by the aspiration technique. Recently, an automated device with a Tru-Cut-type needle was designed. In this randomized controlled trial, the use of this new device is compared with the traditional method in terms of efficacy and safety. METHOD Fifty-six patients were included in the study; 28 were randomized to undergo the aspiration technique and 28 were randomized to undergo the automated biopsy technique. RESULTS Correct positioning of the device was achieved in 93% of patients undergoing the aspiration technique and 96% of patients undergoing the automated biopsy technique (P = NS). Mean duration of the procedure and total number of passes were significantly higher in the aspiration needle group than in the automated device group (22.6 min +/- 12.6 vs 15.5 min +/- 9.4; P = .03, and 3.3 min +/- 1.9 vs 1.5 min +/- 0.63; P < .001, respectively). The number of portal tracts was significantly higher in the automated device group (4.7 +/- 2.5 vs. 2.7 +/- 3.4; P < .05). Adequate specimens for histopathologic evaluation were obtained in 26 patients in the automated device group and 24 patients in the aspiration needle group (92.8% vs 85.7%; P = NS), but a definite histopathologic diagnosis was more frequently obtained with the automated biopsy device (68% vs 43%; P = .05). No significant differences were observed in complication rates (7.14% vs. 10.7%; P = NS). CONCLUSION The automated biopsy device for transjugular liver biopsy is more effective than an aspiration needle in obtaining good samples for a definite histologic diagnosis.

CT demonstration of extension of renal angiomyolipoma into the inferior vena cava in a patient with tuberous sclerosis.

The authors present a case of tumor thrombus in the inferior vena cava produced by angiomyolipoma in a young woman with tuberous sclerosis. Diagnosis was made by computed tomography (CT) by measuring the attenuation values of the tumor thrombus. The values obtained were characteristic of fat, demonstrating that tumoral invasion was the cause of the thrombus. To our knowledge, this is the first description of such an association shown by CT in the literature.

Percutaneous nephrostomy in pyonephrosis.

A series of 76 pyonephrotic kidneys in 73 patients were drained by percutaneous nephrostomy (PN) tube and examined to evaluate the contribution of this technique to the treatment of pyonephrosis. In 71 patients, clinical symptoms disappeared 24–48 h after the procedure. Two patients died from sepsis subsequent to anuria and underlying malignancy.Once the acute phase had remitted, interventional procedures were carried out in 39 cases, and constituted the definitive therapy in 36. In 32 cases, elective surgery was the definitive therapy, including the 3 cases not resolved after interventional procedures. Three patients in whom the obstruction cleared spontaneously following PN needed no additional treatment. Major complications included 6 cases of sepsis, all of which resolved satisfactorily with proper medical therapy.

Percutaneous treatment of benign portal vein stenosis after liver transplantation.

O SCVIR, 1996 PORTAL vein stenosis at the site of anastomosis is a relatively uncommon complication following liver transplantation (1). Although such complications have traditionally been managed surgically, percutaneous transluminal angioplasty (PTA) and placement of vascular endoprostheses have increasingly been used as therapeutic alternatives in selected patients (2,3). We present two cases of anastomotic stenosis of the portal vein in liver transplant recipients. One patient was treated with PTA and the other was managed with balloon dilation and subsequent implantation of a vascular stent.

Ultrasound diagnosis of ruptured hydatid cyst of the liver with biliary obstruction

Communication between a hydatid cyst of the liver and biliary tract results in a clinical picture of obstructive jaundice because of occupation of the extrahepatic biliary tract by intracystic material. Five cases of this complication are presented. Ultrasound criteria for diagnosis are analyzed, based on previous publications as well as our own experience.

Value of Superficial Cultures for Prediction of Catheter-Related Bloodstream Infection in Long-Term Catheters: a Prospective Study

ABSTRACT Cultures taken from the skin and from the hubs of short-term central venous catheters can help us to predict catheter-related bloodstream infections (C-RBSIs). The value of these cultures for such predictions has not been assessed in long-term catheters. Our objective was to assess the value of superficial cultures for the prediction of C-RBSI among patients with long-term catheters. Over a 2-year period, we prospectively obtained cultures from the skin overlying reservoir ports (group A) and from the skin insertion site and hubs of all tunneled catheters (group B). This routine was performed by vascular and interventional radiologists immediately before catheter removal (irrespective of the reason for withdrawal). Swabs were processed semiquantitatively. Catheter tips from both groups were cultured using Makis semiquantitative technique and sonication. We also performed cultures of the reservoir ports at different sites. C-RBSI was defined as the isolation of the same species of microorganism(s) both in the colonized catheter and in at least 1 peripheral blood culture. We included 372 catheters (group A, 223; group B, 149) during the study period. The catheter colonization rate was 23.4% (87/372), and 28 patients had C-RBSI. Validity index values for the capacity of surface cultures to predict C-RBSI in groups A and B were, respectively, as follows: sensitivity, 23.5% and 45.5%; specificity, 59.7% and 63.0%; positive predictive value, 4.6% and 8.9%; and negative predictive value, 90.4% and 93.5%. Superficial cultures of patients with long-term catheters could help us to rule out the catheter as the portal of entry of bloodstream infections. Superficial cultures (from skin and hubs) proved to be a useful conservative diagnostic tool for ruling out C-RBSI among patients with long-term tunneled catheters and totally implantable venous access ports.

How Should Long-Term Tunneled Central Venous Catheters Be Managed in Microbiology Laboratories in Order to Provide an Accurate Diagnosis of Colonization?

ABSTRACT Guidelines recommend the roll-plate technique for short-term central venous catheter (CVC) tip cultures. However, the issue of whether the roll-plate technique is better than the sonication method for long-term CVCs remains unresolved. In addition, no data are available for predicting the value of direct Gram staining in anticipating catheter colonization or catheter-related bloodstream infection (CRBSI) in these long-term CVCs. Our objectives were to compare the roll-plate technique and the sonication method and to define the validity values of Gram staining for the prediction of colonization and CRBSI in patients with long-term tunneled CVCs. During the study period, all tunneled CVCs removed at our institution were prospectively and routinely sent to the microbiology laboratory for Gram staining (first) and tip culture (the Maki technique and sonication, in a random order). We received 149 tunneled CVCs, 39 (26.2%) of which were colonized and 11 (7.4%) of which were associated with CRBSI. Overall, the roll-plate method detected 94.9% of the colonized catheters, whereas sonication detected only 43.6% (P < 0.001). The validity values of Gram staining for the detection of colonization and CRBSI were as follows: a sensitivity of 35.9% to 60.0%, a specificity of 100% to 94.2%, a positive predictive value of 100% to 42.9%, and a negative predictive value of 81.5% to 97.0%. The roll-plate technique proved to be better than sonication for the detection of bacteria in long-term tunneled CVCs. Gram staining of the tips of tunneled CVCs can anticipate a positive culture and rule out CRBSI. In our opinion, direct Gram staining should be incorporated into routine microbiological assessments of long-term catheter tips.

Diagnosis of venous access port colonization requires cultures from multiple sites: should guidelines be amended?

Data on microbiological management of withdrawn venous access ports (VAPs) are scarce. The aim of our study was to assess the validity of Gram stain and culture performed on VAPs to detect colonization and VAP-related bloodstream infection (VAP-RBSI). We prospectively performed cultures of the following: catheter tip (roll-plate and sonication), port content aspirate before and after sonication, port sonication fluid (PSF), and port internal surface biofilm (ISB). The gold standard of VAP colonization was positivity of at least 1 of the cultures mentioned above. We collected 223 VAPs in which no single culture had validity values reliable enough to predict colonization and VAP-RBSI. The best validity values were those obtained when cultures of catheter tip (roll-plate), PSF, and port ISB were combined. Cultures from several areas on the VAP are necessary to ensure suitable assessment of colonization and VAP-RBSI.