Percutaneous Isolated Hepatic Perfusion: Hemodynamic Monitoring and Goal-Directed Anesthetic Management: A Case Report.

The percutaneous isolated hepatic perfusion utilizes a venovenous bypass to administer high-dose chemotherapy exclusively in the liver, getting depurated through a hemofilter before returning to the systemic circulation. The hepatic perfusion is managed under general anesthesia and invasive monitoring as a result of very abrupt changes in venous return and vascular resistances because of the isolation of the hepatic territory and absorption of circulating catecholamines by the hemofilter. We report a case in which we describe the technique, physiologic implications, anesthetic, and goal-directed hemodynamic management for this procedure.

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Data on microbiological management of withdrawn venous access ports (VAPs) are scarce.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.

Comparison of transjugular intrahepatic portosystemic shunt dysfunction in PTFE-covered stent-grafts versus bare stents.

PURPOSE: The aim was to compare the clinical and hemodynamic outcome between polytetrafluoroethylene (PTFE)-coated stent-grafts and bare stents in patients who required both elective and emergency transjugular intrahepatic portosystemic shunt (TIPS) placement due to portal hypertension related complications. MATERIALS AND METHODS: Retrospective analysis of all seventy patients with portal hypertension related complications who required TIPS placement in a referral hospital from September 1998 to May 2002 was done. Follow-up was extended until May 2003. PTFE-covered stent-grafts were used in the latter 20. Demographic variables, cirrhosis etiology and Child-Pugh class, indication of TIPS placement and clinical outcome were recorded. The following TIPS-related outcomes were registered: recurrent variceal bleeding and/or ascites, hepatic encephalopathy and mortality. RESULTS: Baseline characteristics, portacaval gradient (PCG) after TIPS placement and at 1 month angiographic revision were similar in both groups. At 6 month follow-up, PCG was significantly lower in patients with stent-grafts (14.2 mmHg (5.6 mmHg) versus 7 mmHg (1 mmHg), p<0.001). Overall, there were no cases of clinically relevant TIPS dysfunction in the coated stent group while 22% of patients in the bare stent group had recurrence of portal hypertension related complications (p=0.085). Actuarial probability of TIPS dysfunction in bare stents was 82% at 12 months compared to no episode in covered stent-grafts (p=0.03). Mean increase in total serum bilirubin was higher in the PTFE-coated stent group (6.7 mg/dl (14.4 mg/dl) versus 0.5 mg/dl (2.4 mg/dl), p=0.01) without differences in encephalopathy nor mortality rate. CONCLUSION: One year shunt patency rate is improved with placement of ePTFE-covered stent-grafts without a higher rate of encephalopathy. Further prospective trials are required.

Patients with cirrhosis and bare-stent TIPS may have increased risk of hepatocellular carcinoma.

A trend toward a higher incidence of hepatocelullar carcinoma (HCC) in patients with cirrhosis treated with bare-stent transjugular intrahepatic portosystemic shunt (TIPS) has been observed in previous studies. To assess the influence of TIPS as a risk factor for developing HCC, we have compared the incidence of HCC in two retrospective cohorts of patients. The TIPS cohort (n = 138) included patients with cirrhosis who underwent TIPS placement for the treatment of portal hypertension-related complications; the non-TIPS cohort was composed of patients admitted at the hospital at the same time of TIPS insertion who were individually matched 1:1 according to age, sex, Child-Turcotte-Pugh class, and cause of cirrhosis. A stratified Cox model was used to assess risk of HCC development. The median time of follow-up was similar in TIPS and non-TIPS cohorts (30.3 [range, 7.8-119.5] and 31.4 [range, 7.8-110.8] months, respectively). The cumulative probability of developing HCC at 1, 3, and 5 years was 3%, 24%, and 34% for the TIPS cohort and 1%, 6%, and 25%, for the non-TIPS cohort, respectively (Breslow test = 5.23, P = .022). The adjusted hazard ratio was 1.52 (95% confidence interval, 1.06-2.19; P = .02). Hepatitis C virus infection and age were independent predictors of HCC development in patients without TIPS. In conclusion, patients with cirrhosis who are treated with TIPS may have a higher incidence of HCC. This observation suggests the need for a strict HCC surveillance program for these patients, especially if they are not expected to undergo a short- or medium-term liver transplantation.

Comparison of transcatheter arterial embolization and surgery for treatment of bleeding peptic ulcer after endoscopic treatment failure.

PURPOSE: To compare the outcomes of embolotherapy and surgery as salvage therapy after therapeutic endoscopy failure in the treatment of upper gastrointestinal peptic ulcer bleeding. MATERIALS AND METHODS: Retrospective analysis of 70 cases of refractory peptic upper gastrointestinal hemorrhage was performed. Thirty-one cases were managed with embolotherapy and 39 were managed surgically. Demographic variables, underlying conditions, clinical findings, endoscopic treatment, transfusion requirements before and after alternative therapeutic approach, length of hospital stay, and outcomes including recurrent bleeding, need for surgery after initial alternative treatment, and in-hospital death were recorded. RESULTS: Patients who received embolotherapy were older (75.2 years +/- 10.9 vs 63.3 years +/- 14.5; P <.001) and had greater incidences of heart disease (67.7% vs 20.5%; P <.001) and previous anticoagulation treatment (25.8% vs 5.1%; P =.018). There were no differences in the rest of the pretreatment variables. No differences were found between the embolotherapy and surgery groups in the incidence of recurrent bleeding (29% vs 23.1%), need for additional surgery (16.1% vs 30.8%), or death (25.8% vs 20.5). CONCLUSIONS: The lack of differences between these two treatment alternatives, despite the more advanced age and greater prevalence of heart disease in the embolotherapy group, provides support for future prospective randomized studies aimed to evaluate the role of embolotherapy in the management of refractory peptic ulcer bleeding.

TIPS versus drug therapy in preventing variceal rebleeding in advanced cirrhosis: a randomized controlled trial.

Prevention of variceal rebleeding is mandatory in cirrhotic patients. We compared the efficacy, safety, and cost of transjugular intrahepatic portosystemic shunt (TIPS) versus pharmacologic therapy in preventing variceal rebleeding in patients with advanced cirrhosis. A total of 91 Child-Pugh class B/C cirrhotic patients surviving their first episode of variceal bleeding were randomized to receive TIPS (n = 47) or drug therapy (propranolol + isosorbide-5-mononitrate) (n = 44) to prevent variceal rebleeding. Mean follow-up was 15 months. Rebleeding occurred in 6 (13%) TIPS-treated patients versus 17 (39%) drug-treated patients (P =.007). The 2-year rebleeding probability was 13% versus 49% (P =.01). A similar number of reinterventions were required in the 2 groups; these were mainly angioplasty +/- restenting in the TIPS group (90 of 98) and endoscopic therapy for rebleeding in the medical group (45 of 62) (not significant). Encephalopathy was more frequent in TIPS than in drug-treated patients (38% vs. 14%, P =.007). Child-Pugh class improved more frequently in drug-treated than in TIPS-treated patients (72% vs. 45%; P =.04). The 2-year survival probability was identical (72%). The identified cost of therapy was double for TIPS-treated patients. In summary, medical therapy was less effective than TIPS in preventing rebleeding. However, it caused less encephalopathy, identical survival, and more frequent improvement in Child-Pugh class with lower costs than TIPS in high-risk cirrhotic patients. This suggests that TIPS should not be used as a first-line treatment, but as a rescue for failures of medical/endoscopic treatments (first-option therapies).