Michael D. Darcy

Laparoscopic Nephrectomy: Initial Case Report

A tumor-bearing right kidney was completely excised from an 85-year-old woman using a laparoscopic approach. A newly devised method for intra-abdominal organ entrapment and a recently developed laparoscopic tissue morcellator made it possible to deliver the 190 gm. kidney through an 11 mm. incision.

Outcomes of neoadjuvant transarterial chemoembolization to downstage hepatocellular carcinoma before liver transplantation.

Purpose:To evaluate outcomes of downstaging patients with advanced (American liver tumor study group stage III/IV) hepatocellular carcinoma (HCC) with transarterial chemoembolization (TACE) to allow eligibility for orthotopic liver transplant (OLT). Methods:From 1999 to 2006, 202 patients with HCC were referred for transplant evaluation. Seventy-six (37.6%) patients with stage III/IV HCC were potential transplant candidates if downstaging was achieved by TACE. OLT was considered based on follow-up imaging findings. The number of patients who were successfully downstaged within the Milan criteria, tumor response using Response Evaluation Criteria in Solid Tumors criteria, findings at explant, and outcomes after transplant were tracked. Results:Eighteen of 76 (23.7%) patients had adequate downstaging to qualify for OLT under the Milan criteria. By Response Evaluation Criteria in Solid Tumors, 27/76 (35.5%) patients had a partial response, 22/76 (29%) had stable disease, and 27/76 (35.5%) had progressive disease. Seventeen of 76 (22.4%) patients who met other qualifications underwent OLT after successful downstaging (13/38 stage III;4/38 stage IV). Explant review demonstrated 28 identifiable tumors in which post-TACE necrosis was greater than 90% in 21 (75%). At a median of 19.6 months (range 3.6–104.7), 16/17 (94.1%) patients who underwent OLT are alive. One patient expired 11 months after OLT secondary to medical comorbidities. One of 17 (6%) OLT patients had recurrent HCC. This patient underwent resection of a pulmonary metastasis and is alive, 63.6 months from OLT. Conclusion:Selected patients with stage III/IV HCC can be downstaged to Milan criteria with TACE. Importantly, patients who are successfully downstaged and transplanted have excellent midterm disease-free and overall survival, similar to stage II HCC.

Lower Extremity Venous Thrombolysis with Adjunctive Mechanical Thrombectomy

PURPOSE To evaluate the use of adjunctive mechanical thrombectomy (MT) with pharmacologic catheter-directed lower extremity venous thrombolysis. MATERIALS AND METHODS Catheter-directed thrombolysis with adjunctive MT was used to treat 28 symptomatic limbs in 20 patients (22 procedures) with lower extremity deep vein thrombosis (DVT) between August 1997 and July 2001. Procedural success, major bleeding, thrombolytic infusion time, and total thrombolytic agent dose were recorded. RESULTS Procedural success was achieved in 23 of 28 limbs (82%). Fifteen patients (18 limbs) received iliac vein stents. Major bleeding was observed after three of 22 procedures (14%) and resulted in transfusion in two patients and endometrial ablation in the third patient. Mean per-limb infusion time was 16.8 hours +/- 12.8. Mean per-limb total doses were lower than those reported in published studies of DVT thrombolysis: 2.67 million U +/- 1.60 urokinase, 18.4 mg +/- 10.7 tissue plasminogen activator, and 13.8 U +/- 6.9 reteplase. Venographic analysis demonstrated minimal thrombus removal (26.0% +/- 24.1) when using MT alone, compared with substantial thrombus removal (62.0% +/- 24.9) when using MT after pharmacologic thrombolytic agents had been administered (P =.006). CONCLUSION The use of adjunctive MT to augment pharmacologic catheter-directed DVT thrombolysis provides comparable procedural success and may reduce the required thrombolytic dose and infusion duration.

Long-Term Outcome After Chemoembolization and Embolization of Hepatic Metastatic Lesions from Neuroendocrine Tumors

OBJECTIVE Hepatic artery chemoembolization and hepatic artery embolization (HAE) are accepted treatments of patients with hepatic metastasis from neuroendocrine tumors. Long-term outcome data are limited. We present our experience in the use of hepatic artery chemoembolization in the treatment of patients with hepatic metastasis from neuroendocrine tumors. MATERIALS AND METHODS Forty-six patients with carcinoid (n = 31) or islet cell (n = 15) tumors were treated. Overall and progression-free survival times starting with the first treatment were calculated. Potential factors affecting survival, including presence of extrahepatic disease and resection of the primary lesion, were analyzed. Relief of symptoms was subjectively determined for tumors with hormonal secretion. RESULTS The 46 patients underwent 93 hepatic artery chemoembolization or HAE sessions. The mean overall survival time for the entire group was 1,273 +/- 185 days. The mean overall survival times for the carcinoid (1,255 +/- 163 days) and islet cell tumor (1,311 +/- 403 days) subgroups were similar (p = 0.66). The progression-free survival times for the carcinoid (602 +/- 144 days) and islet cell (501 +/- 107 days) tumor subgroups also were similar (p = 0.72). The survival time of patients without known extrahepatic metastasis (n = 18; 1,571 +/- 291 days) trended toward significance compared with that of patients with known extrahepatic disease (n = 26; 770 +/- 112 days; p = 0.08). Resection of the primary tumor in 19 of 46 patients did not affect survival (resection survival, 1,558 +/- 400 days; nonresection survival, 1,000 +/- 179 days; p = 0.44). Twenty of 25 patients with hormonally active tumors had relief of symptoms after one cycle of treatment. The 30-day mortality was 4.3%. CONCLUSION The overall survival time after hepatic artery chemoembolization or HAE among patients with neuroendocrine tumors is approximately 3.5 years. The progression-free survival time approaches 1.5 years. The presence of extrahepatic metastasis or an unresected primary tumor should not limit the use of hepatic artery chemoembolization or HAE.

Hepatic arterial chemoembolization for hepatocellular carcinoma: comparison of survival rates with different embolic agents.

PURPOSE The optimal embolic agent for transhepatic arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) has not been identified. This study reports outcomes of TACE for HCC with Gelfoam powder and polyvinyl alcohol (PVA). MATERIALS AND METHODS Eighty-one patients underwent 152 TACE sessions with Gelfoam powder (n = 41) or polyvinyl alcohol (PVA) and Ethiodol (n = 40) as the embolic agent. Chemotherapeutic drugs were the same for all patients (50 mg cisplatin, 20 mg doxorubicin, 10 mg mitomycin-c). The groups were compared based on number of TACE sessions, maximum tumor size, bilirubin level, aspartate and alanine aminotransferase levels, Child-Pugh score, Model for End-stage Liver Disease score, and hepatitis B or C virus positivity. The number of cases of each Child class in each group was also evaluated. Survival starting from the first TACE session was calculated according to Kaplan-Meier analysis. Forty-eight patients died during the study period, 19 received transplants, and 14 were alive at the end of the study period. RESULTS The groups were statistically similar in all categories regarding liver function, Child-Pugh score, tumor size, hepatitis status, and percentage of patients with Child class A, B, and C disease. The number of TACE sessions was significantly greater for the Gelfoam powder group (mean, 2.2) versus the PVA group (mean, 1.6; P = .01). Overall survival was similar between groups whether patients who received transplants were included in the analysis (mean, 659 days +/- 83 with Gelfoam powder vs 565 days +/- 71 with PVA; P = .42) or were excluded (mean, 519 days +/- 80 with Gelfoam powder vs 511 days +/- 75 with PVA; P = .93). CONCLUSION In similar patient groups, survival after treatment of HCC with TACE with Gelfoam powder or PVA and Ethiodol was similar.

Safety and efficacy of transjugular intrahepatic portosystemic shunt creation for the treatment of hepatic hydrothorax.

PURPOSE To evaluate safety and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) creation for hepatic hydrothorax (HHyd). MATERIALS AND METHODS Twenty-one patients underwent TIPS creation for HHyd. A prospective TIPS database and medical records were reviewed. Clinical and radiographic outcomes were recorded as complete (symptom/effusion resolution), partial (improved symptoms/effusion), or none. Data patterns were examined with chi(2) tests and Kaplan-Meier analysis. RESULTS Patients included 12 women and nine men, with a mean age of 56 years, all with Child class B (n = 7) or C (n = 14) disease. The technical success rate was 100%. Mean follow-up was 223 days. Twenty-nine percent (six of 21) died within 30 days of TIPS creation, 10% (two of 21) underwent transplantation within 30 days, and 62% (13 of 21) survived beyond 30 days. Data were incomplete in two patients. Clinical response was classified as complete in 63% (12 of 19), partial in 11% (two of 19), and none in 26% (five of 19). Radiographic response was classified as complete in 30% (six of 20), partial in 50% (10 of 20), and none in 20% (four of 20). Nonresponders had multisystem organ failure, and all but one died within 30 days. However, of the 13 patients surviving longer than 30 days, 10 (77%) had a complete clinical response. CONCLUSION TIPS is a relatively safe and effective method of controlling HHyd. The majority of patients experienced improvement or resolution of clinical symptoms with a variable reduction in the quantity of pleural fluid. There was a tendency among nonresponders to die within 30 days.

Autologous vein–covered stent for the endovascular management of an iliac artery–ureteral fistula: Case report and review of the literature

Iliac artery-ureteral fistula is a rare entity that is being reported with increasing frequency. Patients with iliac artery-ureteral fistulas can be divided into two distinct groups on the basis of the factors that predispose them to having these fistulas. In group I the fistula is associated with degenerative iliac artery disease or previous arterial reconstructive surgery. Patients in group II have undergone some combination of the following procedures: pelvic extirpative surgery for malignancy, urinary diversion, radiation therapy, and ureteral stenting. The diagnosis of an iliac artery-ureteral fistula can be elusive even with the use of multiple imaging methods. Direct operative repair is technically demanding and is associated with high mortality rates. In recent years, treatment has shifted toward percutaneous embolization of the iliac artery and extraanatomic lower extremity vascular reconstruction for group II patients. In this report, the 24 group II patients with iliac artery-ureteral fistulas who previously have been described are reviewed, and a new endovascular treatment for this entity that uses a stented vein graft is detailed.

Treatment of lower gastrointestinal bleeding: vasopressin infusion versus embolization.

Traditionally, embolization has been reserved for treatment of upper gastrointestinal bleeding whereas lower gastrointestinal (LGI) bleeding has been controlled with vasopressin infusion. This is based on findings in older literature in which infarction frequently complicated LGI embolization. With modern embolization techniques, clinically significant bowel ischemia has become an uncommon complication. Although the efficacies of vasopressin and embolization are fairly comparable, embolotherapy has advantages in terms of quicker completion of therapy and decreased likelihood of systemic complications. Although vasopressin is still probably preferable for diffuse lesions and cases in which superselective catheterization is not technically possible, embolization should be considered a primary option for treating LGI bleeding.

Comparison of MELD and Child-Pugh Scores to Predict Survival after Chemoembolization for Hepatocellular Carcinoma

PURPOSE To compare the value of the Child-Pugh and Model for End-stage Liver Disease (MELD) scores to predict patient survival rates after transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC). MATERIALS AND METHODS Eighty-seven patients underwent 169 TACE sessions. Child-Pugh and MELD values were calculated before initial treatment. Survival length was tracked from the date of the first TACE procedure. Transplant recipients were censored from the study at the time of surgery. Child-Pugh and MELD scores as well as bilirubin and albumin levels and International Normalized Ratio were placed in high and low categories defined by their respective medians. Patient survival was compared at 3 months, 6 months, 12 months, and 24 months, and patterns were tested with chi2 or Fisher exact tests. Survival over the entire period was examined with Kaplan-Meier analysis and differences were tested with log-rank tests. RESULTS Mean and median survival times for all patients were 24 and 17 months, respectively. Sixteen patients were censored for transplantation at a mean of 12.9 months. MELD and Child-Pugh scores correlated well with each other (r = 0.68). Child-Pugh score (r = -0.35, P = .04) correlated more strongly with 12-month survival than did MELD score (r = -0.26, P = .12). After high/low score category division, a significantly greater survival difference was predicted by Child-Pugh score (27.2 months vs 10.3 months; P = .03) versus MELD score (27.5 months vs 15.8 months; P = .19). An albumin level greater than 3.4 g/dL was also associated with significantly improved survival (29.3 months vs 10.1 months; P = .0032). Survival differences between high-risk and low-risk groups at the 3-, 6-, 12-, and 24-month intervals were significant for low Child-Pugh scores and for albumin levels greater than 3.4 g/dL. Statistical significance was not approached at any of the time lengths with MELD scores. CONCLUSIONS Child-Pugh score correlates better than MELD score to overall patient survival and is a better predictor than MELD score of survival at specific time points. Of the components of the Child-Pugh and MELD systems, albumin level is the most useful predictor of survival.

Combined Percutaneous And Retrograde Approach To Staghorn Calculi With Application Of The Ureteral Access Sheath To Facilitate Percutaneous Nephrolithotomy

PURPOSE We describe our technique and clinical experience with application of the ureteral access sheath for single access ablation of staghorn and partial staghorn calculi. MATERIALS AND METHODS We retrospectively reviewed our experience with 9 patients who underwent percutaneous nephrolithotomy for staghorn (6) or partial staghorn (3) renal calculi using a combined antegrade and retrograde approach. Patient data, operative parameters, efficacy of stone ablation and convalescence parameters were reviewed. RESULTS Mean operative time for the primary procedure was 3.1 hours with a mean estimated blood loss of 290 ml. Postoperatively, the mean analgesic requirement was 33.2 mg. MSO(4) equivalents. Hospital stay was 3.2 days. There were no major and 4 minor (44%) complications. No patient required transfusion. Complete stone clearance was achieved in 7 of the 9 cases (78%) using a single percutaneous nephrostomy tract. CONCLUSIONS Our preliminary clinical experience using the ureteral access sheath during percutaneous nephrolithotomy for simultaneous antegrade and retrograde stone treatment has been favorable. A large renal stone burden can be successfully managed with a single percutaneous access and limited blood loss.