Rajiv N. Srinivasa

Laser Ablation Facilitates Closure of Chronic Enterocutaneous Fistulae

This report describes the use of laser ablation for treatment of chronic enterocutaneous fistulae (ECFs) after failure of conservative therapy. Three patients underwent laser ablation for treatment of 8 ECFs. Mean duration of fistula patency was 28 months with mean fistula output of 134 mL/day. The initial technical success was 100% with no major or minor complications. Three ECFs required repeat treatment. At mean follow-up of 53 days, 7 of the fistulae were occluded. One fistula showed a markedly reduced output of 10 mL/day.

Transjugular Intrahepatic Portosystemic Shunt Reduction Using the GORE VIATORR Controlled Expansion Endoprosthesis: Hemodynamics of Reducing an Established 10-mm TIPS to 8-mm in Diameter

To the Editor, Transjugular intrahepatic portosystemic shunt (TIPS) involves the creation of a shunt between the portal and hepatic veins to treat portal hypertension and its complications, including refractory ascites, hepatic hydrothorax, and variceal bleeding [1]. Complications, however, may result from excessive shunting of portal venous blood to the systemic circulation. 17–46% of patients present with hepatic encephalopathy (HE) following a TIPS [2–4]. Although the majority of patients with TIPS-associated HE may be medically managed, 3–7% of patients develop refractory encephalopathy as a result of this high volume shunting [2, 5–7]. TIPS reduction or occlusion may be effective in decreasing the incidence and severity of hepatic encephalopathy. Complete occlusion of the TIPS returns patients to the baseline risk of variceal bleeding and other portal hypertension complications present prior to TIPS [2, 5]. TIPS reduction has become the preferred method of treatment for excessive portal to systemic shunting of blood that is refractory to first-line medical management. The goal of TIPS reduction is to reduce the volume of shunted blood and divert it back to the intrahepatic portal veins by decreasing the diameter of the existing stent. Ideally, achieving a balance between portal and systemic blood flow to maintain the benefit of TIPS in reducing portal hypertension while concurrently treating the encephalopathy is desired. Numerous TIPS reduction methods using various stents and stent grafts have been previously detailed in the literature [5, 6]. TIPS are commonly reduced to a 6–7 mm residual diameter and usually, but not always, require complicated in vivo or backtable techniques [5, 6]. With the advent of the newly introduced Viatorr Controlled Expansion Endoprosthesis (Gore & Associates, Flagstaff, AZ, USA), there is the potential of a simple single-stent deployment for TIPS reduction leaving a residual TIPS diameter of 8 mm. Two patients with hepatic encephalopathy underwent TIPS reduction using the Viatorr Controlled Expansion Endoprosthesis (Gore) (Fig. 1). Pre and post-reduction pressures and hemodynamics were measured using a pressure transducer and a 6-French ReoCath Retrograde Flow Catheter (Transonic Systems), respectively. Mean increase in portosystemic gradient was 4 mmHg (range 2–6 mmHg) with mean percentage increase of 30.5% (range 18.1–42.8%). Mean reduction in portal vein blood flow was 222.5 mL/min (range 45–400 mL/min) with mean percentage reduction of 16.3% (range 4.6–27.9%). Mean reduction in TIPS blood flow was 187 mL/min (range 87–287 mL/min) with mean percentage reduction of 15.9% (range 12.0–19.7%). No minor or major procedural complications occurred. Mean follow-up was 81 days (range 38–124 days). Both patients showed a 1 grade improvement in HE symptoms using West Haven HE criteria. A 69-year-old male with history of alcoholic cirrhosis and portal hypertension complicated by esophageal varices and ascites had a TIPS placed 1278 days prior to presentation (Fig. 2 and Table 1). Since that time he developed & Ravi N. Srinivasa rnsriniv@med.umich.edu

Transnasal Snare Technique for Retrograde Primary Jejunostomy Placement After Surgical Gastrojejunostomy

PurposeTo report a transnasal snare technique for retrograde primary jejunostomy placement after surgical gastrojejunostomy.Materials and MethodsTwo patients underwent the transnasal snare technique for retrograde primary jejunostomy placement. Patients included two females, age 58 and 62. In both patients, a gooseneck snare was inserted in a transnasal fashion. After insertion of the snare into the jejunum, the location was confirmed with ultrasound. The snare was then targeted using a Chiba needle through which a 0.018-inch wire was advanced and snared through the nose. The wire was exchanged for a 0.035-inch Amplatz wire over which the tract was serially dilated followed by insertion of the jejunostomy catheter through a peel-away sheath. Technical success, complications, and follow-up were recorded.ResultsPrimary jejunostomy placement was technically successful in both patients. No minor or major complications occurred. Both patients received enteral nutrition the day following placement. Follow-up was at 54 and 38xa0days for patients 1 and 2, respectively.ConclusionThe transnasal snare technique provides a novel alternative for primary jejunostomy insertion allowing for targeting of the jejunum with improved procedural success and no complications.

Selective Penile Arterial Embolization Preserves Long-Term Erectile Function in Patients with Nonischemic Priapism: An 18-Year Experience

OBJECTIVEnTo report long term outcomes of selective arterial embolization for nonischemic priapism on erectile function utilizing validated outcome questionnaires after selective arterial embolization.nnnMATERIALS AND METHODSnTwenty men, mean age of 36 years (range: 8-58 years), underwent selective penile embolization for nonischemic priapism between December 1997 and February 2016 (218 months). Each identified case of nonischemic priapism was embolized using gelatin sponge, autologous blood clot, platinum microcoils, polyvinyl alcohol particles, or a combination of these. A variety of procedural details, immediate complications, recurrence of nonischemic priapism, post-procedure performance on Sexual Health Inventory for Men and International Index of Erectile Function Questionnaires, and follow-up duration were recorded.nnnRESULTSnMean time from development of symptoms until treatment was 117 days (range: 1-1,042 days). After selective arterial embolization, nonischemic priapism resolved in 18 (90%) patients. No patients with successful treatment of their nonischemic priapism developed a recurrence of nonischemic priapism during the study period following the initial treatment. Eight (40%) patients experienced ischemic priapism following embolization with 4 (50%) resolving after treatment. Mean post-procedure Sexual Health Inventory for Men score was 22.1 (range: 16-25). Mean post-embolization erectile function, orgasmic function, sexual desire, intercourse satisfaction, and overall satisfaction domains on the International Index of Erectile Function were 25.8 (range: 16-30), 7.8 (range: 6-10), 7.4 (range: 5-10), 10.9 (range: 6-14), and 7.9 (range: 6-10), respectively. Mean follow-up was 4,601 days (range: 970-6,711 days).nnnCONCLUSIONnResolution of nonischemic priapism following selective arterial embolization occurred in 90% of the patients. Two validated questionnaires showed no erectile dysfunction following treatment. Mild orgasmic dysfunction, sexual desire dysfunction, intercourse dissatisfaction, and overall satisfaction dysfunction were noted following treatment.

Erratum: Pediatric Portal Interventions

[This corrects the article DOI: 10.1055/s-0038-1642043.].

Balloon tract dilatation facilitates fluoroscopically guided removal of deeply penetrating foreign bodies

Previous reports describe removal of foreign bodies using image guidance with serial tract dilation or blunt and sharp dissection techniques. This report describes a novel technique utilizing balloon tract dilatation to facilitate the removal of retained radiopaque soft tissue foreign bodies under fluoroscopic guidance. This technique offers a minimally invasive approach for rapid retrieval of deeply penetrating foreign bodies, obviating the need for a large incision or surgical cut down.

Bleeding diverticulum of the colon treated with CT-guided percutaneous injection of epinephrine and cyanoacrylate

Hematochezia may be a result of anatomic, vascular, inflammatory, infectious, or neoplastic diseases. Colonoscopic evaluation and therapy may be limited because of intermittent bleeding in the setting of numerous diverticula. This report describes a patient with diverticulosis who presented with hematochezia and hemodynamic instability with failed colonoscopic and arteriographic evaluations, and was treated with percutaneous transcolonic diverticular cyanoacrylate and epinephrine injection.

Technical success and outcomes in pediatric patients undergoing transjugular intrahepatic portosystemic shunt placement: a 20-year experience

BackgroundTransjugular intrahepatic portosystemic shunt (TIPS) placement has been extensively studied in adults. The experience with TIPS placement in pediatric patients, however, is limited.ObjectiveThe purpose of this study was to report technical success and clinical outcomes in pediatric patients undergoing TIPS placement.Materials and methodsTwenty-one children — 12 (57%) boys and 9 (43%) girls, mean age 12.1xa0years (range, 2–17xa0years) — underwent TIPS placement from January 1997 to January 2017. Etiologies of hepatic dysfunction included biliary atresia (n=5; 24%), cryptogenic cirrhosis (n=4; 19%), portal or hepatic vein thrombosis (n=4, 14%), autosomal-recessive polycystic kidney disease (n=3; 14%), primary sclerosing cholangitis (n=2; 10%) and others (n=3, 14%). Indications for TIPS placement included variceal hemorrhage (n=20; 95%) and refractory ascites (n=1; 5%). Technical success, manometry findings, stent type, hemodynamic success, complications, liver enzymes, and clinical outcomes were recorded.ResultsTIPS placement was technically successful in 20 of 21 (95%) children, with no immediate complications. Mean pre- and post-TIPS portosystemic gradient was 18.5±10.7xa0mmHg and 7.1±3.9xa0mmHg, respectively. Twenty-two total stents were successfully placed in 20 children. Stents used included: Viatorr (n=9; 41%), Wallstent (n=7; 32%), Express (n=5; 23%), and iCAST (n=1; 5%). All children had resolution of variceal bleeding or ascites. TIPS revision was required in 9 (45%) children, with a mean of 2.2 revisions. Hepatic encephalopathy developed in 10 children (48%), at a mean of 223.7 days following TIPS placement. During the study, 6 (29%) children underwent liver transplantation.ConclusionTIPS placement in pediatric patients has high technical success with excellent resolution of variceal hemorrhage and ascites. TIPS revision was required in nearly half of the cohort, with hepatic encephalopathy common after shunt placement.

Transinguinal interstitial (intranodal) lymphatic embolization to treat high-output postoperative lymphocele

Postoperative lymphoceles may occur after abdominal or pelvic surgery secondary to disruption of lymphatic channels. First-line therapy includes conservative therapy with medical management and dietary restriction. Despite these measures, some patients may have persistent high-output lymphoceles requiring percutaneous aspiration, drainage, or sclerosis. Rarely, surgical evacuation is required. Management of intrathoracic chyle leak by thoracic duct embolization has been well described. Recently, interstitial (intranodal) lymphatic embolization for the treatment of plastic bronchitis has been performed. This case report describes interstitial (intranodal) lymphatic embolization as a novel therapy for high-output postoperative pelvic lymphocele.

Vascular and lymphatic complications after thoracic duct cannulation

OBJECTIVEnThe objective of this study was to determine the incidence of vascular and lymphatic complications after attempted transabdominal thoracic duct cannulation.nnnMETHODSnThere were 58 patients who underwent attempted thoracic duct cannulation. Patients presented with chylexa0leak in the chest (nxa0= 40), abdomen (nxa0= 9), neck (nxa0= 8), and pelvis (nxa0= 1). Vertebral body level and geographic access, needle gauge, additional access for treatment, technical success, intervention performed, immediate and delayed complications, and follow-up duration were recorded. Imaging and electronic medical records were reviewed at follow-up for complications and treatment success.nnnRESULTSnAccess into the lymphatic system was obtained at L1 (nxa0= 21), T12 (nxa0= 17), L2 (nxa0= 14), L3 (nxa0= 3), T11 (nxa0= 1), L4 (nxa0= 1), and L5 (nxa0= 1). Lymphatic access was achieved in the center (nxa0= 28), on the right (nxa0= 16), or on the left (nxa0= 14) of the vertebral body; 21-, 22-, and 25-gauge needles were used in 45 patients, 12 patients, and 1 patient, respectively. Arm venous and percutaneous supraclavicular access was successful in 15 patients and eight patients, respectively. Cannulation of the thoracic duct was achieved in 52 (89.7%) patients. Embolization, disruption, and stenting were performed in 41 (70.7%), 12 (20.7%), and 2 (3.4%) patients; 3 (5.2%) patients had normal thoracic ducts after successful cannulation. Immediate complications consisted of shearing of the access wire in two (3.4%) patients. Retrospective analysis of initial follow-up imaging in 49 (84.5%) patients revealed the following late complications: inferior vena cava and right renal vein thrombosis and one perinephric lymphatic collection.nnnCONCLUSIONSnOf 58 patients who had attempted thoracic duct cannulation, successful access was achieved in 90% of patients. Early and delayed complications occurred in 3.4% and 4% of patients, respectively. Thoracic duct cannulation represents a highly successful technique that aids in the treatment of chyle leaks in medically complex patients.