Peter Rowlands

Minimally Invasive Retroperitoneal Pancreatic Necrosectomy

Introduction: Open surgery for pancreatic necrosis is associated with considerable morbidity and mortality. We report the results of a recently developed minimally invasive technique that we adopted in 1998. Methods: A descriptive explanation of the approach is given together with the results of a retrospective analysis of patients who underwent a minimally invasive retroperitoneal pancreatic necrosectomy (MIRP) between August 1998 and April 2002. Patients: There were 24 patients with a median (range) age of 61 (29–75) years. The initial median (range) APACHE II score was 8 (2–21). All patients had infected pancreatic necrosis with at least 50% pancreatic necrosis. In three patients it was not possible to complete the first MIRP because of technical reasons. Results: A total of 88 procedures were performed with a median (range) of 4 (0–8) per patient. Twenty-one (88%) patients developed 36 complications during the course of their illness. Five patients required an additional open procedure: 2 for subsequent distant collections, 2 for bleeding and 1 for persisting sepsis and a distant abscess. Six (25%) patients who had MIRP died. The median (range) post-operative hospital stay was 51 (5–200) days. Conclusions: MIRP is a new technique that has shown promising results, and could be preferable to open pancreatic necrosectomy in selected patients. However, unresolved issues remain to be overcome and the exact role of MIRP in the management of pancreatic necrosis has yet to be defined.

Detection of Endoleak with Enhanced Ultrasound Imaging: Comparison with Biphasic Computed Tomography

Purpose: To compare unenhanced and enhanced ultrasound imaging to biphasic computed tomography (CT) in the detection of endoleak after endovascular abdominal aortic aneurysm (AAA) repair. Methods: Fifty-three patients (44 men; mean age 70 years) were examined during 96 follow-up visits after endovascular AAA repair. All patients had color Doppler and power Doppler ultrasound studies performed before and after the administration of an ultrasound contrast agent. Biphasic (arterial and delayed) CT was performed on the same day, and the ultrasound and CT studies were independently scored to record the presence or absence of endoleak and the level of confidence in the observation. Results: The sensitivity of the ultrasound techniques to detect endoleak improved with the use of ultrasound contrast media, ranging from a low of 12% with unenhanced color Doppler to 50% with enhanced power Doppler. However, the enhanced power Doppler failed to detect 9 type II endoleaks identified by CT (86% negative predictive value for endoleak). There were only 2 graft-related endoleaks in the study; one was diagnosed from the ultrasound image, but the other had nondiagnostic ultrasound scans because of poor views. Conclusions: Ultrasound scanning with or without contrast enhancement was not as reliable as CT in diagnosing type II endoleak. CT imaging remains our surveillance modality of choice.

Use of contrast-enhanced ultrasound in follow-up after endovascular aortic aneurysm repair

PURPOSEnTo investigate the use of contrast-enhanced ultrasound in the detection of endoleak after endovascular repair of abdominal aortic aneurysm.nnnMATERIALS AND METHODSnEighteen patients underwent follow-up on 20 occasions after endovascular aortic aneurysm repair by arterial-phase contrast-enhanced spiral computed tomography (CT). All patients had unenhanced color Doppler ultrasound and Levovist-enhanced ultrasound on the same day. The ultrasound examinations were reported in a manner that was blind to the CT results. CT was regarded as the gold standard for the purposes of the study.nnnRESULTSnThere were three endoleaks shown by CT. Unenhanced ultrasound detected only one endoleak (sensitivity, 33%). Levovist-enhanced ultrasound detected all three endoleaks (sensitivity, 100%). Levovist-enhanced ultrasound indicated an additional six endoleaks that were not confirmed by CT (specificity, 67%; positive predictive value, 33%). In one of these six cases, the aneurysm increased in size, which indicates a likelihood of endoleak. Two of the remaining false-positive results occurred in patients known to have a distal implantation leak at completion angiography.nnnCONCLUSIONnIn this small group of patients, contrast-enhanced ultrasound appears to be a reliable screening test for endoleak. The false-positive results with enhanced ultrasound may be due to the failure of CT to detect slow flow collateral pathways. Although the number of patients in this study is small, enhanced ultrasound may be more reliable than CT in detecting endoleak.

Aortic Side Branch Embolization before Endovascular Aneurysm Repair: Incidence of Type II Endoleak

PURPOSEnTo assess the feasibility of embolization of aortic side branches and its impact on the incidence of type II endoleak after endovascular aneurysm repair.nnnMATERIALS AND METHODSnEndovascular aneurysm repair was performed in 74 patients. Aortic side branch vessels were evaluated on the preoperative angiogram and computed tomography (CT) and, where embolization of lumbar and inferior mesenteric vessels was considered technically possible, this was attempted prior to endovascular repair. Follow-up CT was used to assess the presence of type II endoleak.nnnRESULTSnSeventy-two patients were followed up for longer than 1 month. Embolization was attempted in 25 cases, successfully in 10, with partial success in 11, and failure in four. Twenty patients with successful or partly successful preoperative embolization were discharged and followed-up. Four (20%) had demonstrable type II endoleak during follow-up, with two of these persisting at latest follow-up. Of 43 patients without previous embolization, there were 10 (23.3%) type II endoleaks during the follow-up period, four of these persisting. In cases with type II endoleak, mean sac diameter change was -0.5 mm in the cases with previous embolization and +3.1 mm without. The mean period to onset of type II endoleak was 6.9 months without, and 15.3 months with, previous embolization.nnnCONCLUSIONnAlthough the cohort size is below a level that would confer significance, the trend of these findings is such as to suggest a lack of influence of aortic side branch embolization on the incidence of type II endoleak during the follow-up period.

Increasing age and APACHE II scores are the main determinants of outcome from pancreatic necrosectomy

The aim of this study was to identify factors associated with death after surgery in patients with extensive pancreatic necrosis.

Percutaneous thrombin injection of carotid artery pseudoaneurysm.

Purpose: To report the successful treatment of a carotid artery pseudoaneurysm by percutaneous thrombin injection. Case Report: A 71-year-old man with end-stage renal failure presented with acute left ventricular failure. The right common carotid artery (CCA) was punctured during attempted jugular line insertion, and he developed a large pseudoaneurysm connected to the CCA by a long, narrow neck. Ultrasound-guided compression was unsuccessful, so another technique was attempted. An occlusion balloon was inflated in the CCA at the neck of the aneurysm to avoid distal embolization, and 250 units of human thrombin were injected into the sac percutaneously; thrombosis was instantaneous. There were no procedural complications, and repeat ultrasound at 3 months showed resolution of the hematoma and no residual pseudoaneurysm. There were no neurological complications. Conclusions: Percutaneous thrombin injection may be a new and successful method of treating carotid artery pseudoaneurysms.

Aneurysm neck diameter after endovascular repair of abdominal aortic aneurysms

PURPOSEnTo determine aneurysm neck diameter change after endovascular repair (EVR) of abdominal aortic aneurysm (AAA) and its relationship to stent-graft diameter.nnnMATERIALS AND METHODSnThe cases of 73 patients with AAAs who underwent EVR were reviewed retrospectively: 68 had preoperative imaging available. Neck diameter was reviewed by a single observer (M.F.B.) on preoperative, immediate postoperative, annual, and most recent contrast-enhanced computed tomographic scans. Baseline and follow-up neck diameters were compared with the manufacturers values for unconstrained stent-graft diameters.nnnRESULTSnIntraobserver error was 2 mm. Aneurysm neck diameter increased from 21.8 mm (range, 17-28 mm) at baseline to 22.8 mm (range, 19-30 mm) postoperatively and 25.8 mm (range, 19-31 mm; P <.001) at a mean follow-up of 25.5 months (range, 6.2-60.8 mo). Neck diameter increase was more than 2 mm in 24 patients (33%). Mean change in the first, second, third, and fourth years was +1.63 mm, +0.52 mm, +0.25 mm, and +0.33 mm, respectively. Baseline mean stent-graft oversizing was 2.9 mm (13.7%; range, -1 to +8 mm), which decreased to 0.7 mm (range, -4 to +6 mm) at latest follow-up. Neck diameter exceeded stent-graft diameter (mean, 1.8 mm; range, 1-4 mm) in 21 cases (28%) and by more than 2 mm in five cases (6.8%). When neck diameter change was correlated with change in sac diameter, it was found to be insignificant (P =.24); however, it was significantly correlated with baseline oversizing (P =.01).nnnCONCLUSIONSnAfter EVR, the aneurysm neck dilates, mostly in the first 2 years, by greater than 2 mm in one third of patients. This is possibly related to the presence of the endograft. The associated reduction of stent-graft oversizing warrants continued vigilance for proximal endoleak.

Fungal Infection but Not Type of Bacterial Infection Is Associated with a High Mortality in Primary and Secondary Infected Pancreatic Necrosis

Introduction: Knowledge of microbiology in the prognosis of patients with necrotizing pancreatitis is incomplete. Aim: This study compared outcomes based on primary and secondary infection after surgery for pancreatic necrosis. Method: From a limited prospective database of pancreatic necrosectomy, a retrospective case note review was performed (October 1996 to April 2003). Results: 55 of 73 patients had infected pancreatic necrosis at the first necrosectomy. 25 of 47 patients had resistant bacteria to prophylactic antibiotics (n = 21) or did not receive prophylactic antibiotics (n = 4), but this was not associated with a higher mortality (9 of 25) compared to those with sensitive organisms (4 of 22). Patients with fungal infection (n = 6) had a higher initial median (95% CI) APACHE II score compared to those without (11 (9–13) verus 8.5 (7–10), p = 0.027). Five of six patients with fungal infection died compared to 13 of 47 who did not (p = 0.014). With the inclusion of secondary infections 21 (32%) of 66 patients had fungal infection with 10 (48%) deaths compared to 11 (24%) of 45 patients without fungal infection (p = 0.047). Conclusion: Whether associated with primary or secondary infected pancreatic necrosis, fungal but not bacterial infection was associated with a high mortality.

Percutaneous Untying of a Knot in a Retained Swan-Ganz Catheter

A patient was referred to us with a tightly knotted Swan-Ganz catheter. The catheter could not be removed by conventional simple methods. We describe a minimally invasive means of removal of the catheter using an Amplatz gooseneck snare and an angioplasty balloon. This allowed the Catheter to be removed without trauma.

Retrievable inferior vena cava filter for thrombolic disease in pregnancy

Sir, We read the case-report of Neill et al. (Vol 104, December 1997)’ with interest, having recently been involved in a similar case, where an inferior vena cava filter was used in a 20 year old woman at 25 weeks gestation in her first pregnancy. Our patient presented with pain and discolouration of her left leg. Doppler ultrasound confirmed a left ilio-femoral thrombosis, with extensive fresh unstable clot in the distal iliac vein, while the inferior vena cava (IVC) was patent. In view of her high risk of pulmonary embolism, a Gunther tulip vena cava filter (William Cook Europe, Bjaeversikov, Denmark) was inserted, using a standard technique via the right internal jugular vein under low-dose pulsed fluoroscopic imaging. The filter was placed with its upper end below the right renal vein, rather than in the suprarenal position recommended by Neill et ul. I because of the potential risk of renal vein thrombosis. The Gunther tulip filter was selected in our patient because of the possibility of retrieval for up to 10 days after insertion. Unfortunately, extensive thrombus was still present in the left ilio-femoral vein after nine days, despite full heparin anticoagulation. In view of this, a decision was taken to leave the filter in situ. The patient continued her pregnancy with heparin anticoagulation until 37 weeks gestation, when labour was induced and she had a normal delivery of a live infant. She was anticoagulated with warfarin for three months after delivery. Subsequent thrombophilia investigations demonstrated the presence of a Leiden V mutation. We are concerned about the likely long term effects of a permanent IVC filter in such a young woman. We carried out a review of the literature, and came across several disturbing reports of complications resulting from migration of all or part of the filter, including intra-cardiac migration2. We feel that the use of the term ‘retrievable’ is somewhat misleading when applied to these devices In pregnancy, unless the thrombo-embolic event occurs in a patient after fetal lung maturity has been achieved, it is likely that the filter will need to remain in situ for longer than 10 days, in order to reduce the risk of embolism in the remainder of the pregnancy and the postnatal period. It is unclear from the literature whether the presence of the filter itself is an indication for long-term anticoagulant treatment, although one report suggested that there was no benefit from anticoagulation after placement of the filtes. We agree with Neill et al. that follow up of young patients with IVC filters is necessary to identify the long-term risks of these devices Inferior vena cava filters will continue to have a role in patients at high risk of pulmonary embolism and those who have heparin hypersensitivity; however, we would caution against their widespread use in young women until more is known about their long term complications.