Subject(s)
Aortic Dissection , Pulmonary Artery , Humans , Aortic Dissection/complications , Aortic Dissection/diagnostic imaging , Aortic Dissection/diagnosis , Pulmonary Artery/diagnostic imaging , Pulmonary Artery/abnormalities , Male , Aortic Aneurysm, Thoracic/complications , Aortic Aneurysm, Thoracic/diagnostic imaging , Aortic Aneurysm, Thoracic/diagnosis , Aortic Aneurysm/diagnostic imaging , Aortic Aneurysm/complications , Tomography, X-Ray Computed , Middle AgedABSTRACT
INTRODUCTION: Historically, the gold standard management of esophageal perforations, leaks, and fistulae has been traditional open surgery, but it is associated with significant morbidity and mortality. Minimally invasive approaches offer alternatives to surgery in treating hemodynamically stable patients with such defects. In this review article, we will discuss the recent advancements in the minimally invasive management of esophageal perforations, leaks, and fistulas. AREAS COVERED: This review includes information from case reports, case series, and clinical trials on minimally invasive management of esophageal perforations, leaks, and fistulas. The focus is on the devices, outcomes, and application of the technology. EXPERT COMMENTARY: Minimally invasive treatment represents significant progress in the management of esophageal perforations, leaks, and fistulas. Based on current evidence, it seems safe and effective but it is evolving and more studies are needed to help draw definitive conclusions.
Subject(s)
Esophageal Fistula/surgery , Esophageal Perforation/surgery , Endoscopy , Esophageal Perforation/diagnosis , Humans , Minimally Invasive Surgical Procedures , Treatment OutcomeABSTRACT
The goal of the study is to characterize the relationship between portal vein thrombosis (PVT) and hepatic atrophy in patients without cirrhosis and the effect of various types of surgical shunts on liver regeneration and splenomegaly. Patients without cirrhosis with PVT suffer from presinusoidal portal hypertension, and often hepatic atrophy is a topic that has received little attention. We hypothesized that patients with PVT have decreased liver volumes, and shunts that preserve intrahepatic portal flow enhance liver regeneration. Sixty-four adult and pediatric patients with PVT who underwent surgical shunt placement between 1998 and 2011 were included in a retrospective study. Baseline liver volumes from adult patients were compared with standard liver volume (SLV) as well as a group of healthy controls undergoing evaluation for liver donation. Clinical assessment, liver function tests, and liver and spleen volumes from cross-sectional imaging were compared before and after surgery. A total of 40 patients received portal flow-preserving shunts (32 mesoportal and 8 selective splenorenal), whereas 24 received portal flow-diverting shunts (16 nonselective splenorenal and 8 mesocaval). Baseline adult liver volumes were 26% smaller than SLV (1248 versus 1624 cm3 ; P = 0.02) and 20% smaller than the control volumes (1248 versus 1552 cm3 ; P = 0.02). Baseline adult spleen volumes were larger compared with controls (1258 versus 229 cm3 ; P < 0.001). Preserving shunts were associated with significant increase in liver volumes (886 versus 1131 cm3 ; P = 0.01), whereas diverting shunts were not. Diverting shunts significantly improved splenomegaly. In conclusion, we have demonstrated that patients without cirrhosis with PVT have significant liver atrophy and splenomegaly. Significant liver regeneration was achieved after portal flow-preserving shunts. Liver Transplantation 24 881-887 2018 AASLD.
Subject(s)
Hypertension, Portal/surgery , Liver Regeneration , Liver/pathology , Portal Vein/pathology , Portasystemic Shunt, Surgical/methods , Adolescent , Adult , Atrophy/surgery , Child , Female , Humans , Hypertension, Portal/etiology , Hypertension, Portal/pathology , Liver/blood supply , Liver/diagnostic imaging , Magnetic Resonance Imaging , Male , Middle Aged , Organ Size , Portal Vein/surgery , Retrospective Studies , Splenomegaly/diagnostic imaging , Splenomegaly/pathology , Splenomegaly/surgery , Tomography, X-Ray Computed , Treatment Outcome , Venous Thrombosis/complications , Venous Thrombosis/pathology , Young AdultABSTRACT
BACKGROUND: Renal insufficiency (RI) is common after liver transplantation (LT) and may worsen due to calcineurin inhibitor (CNI) use. We compared LT outcomes using basiliximab induction and delayed CNI initiation to controls with a standard CNI regimen in patients with peri-LT RI. METHODS: All adults transplanted January 2004 to December 2007 with peri-LT RI (hemodialysis or creatinine ≥1.5 within 1 week of LT) were included in a retrospective nonrandomized cohort. Outcomes including 30-day and 1-year patient and graft survival and renal function were compared between basiliximab and control groups. RESULTS: Two hundred twenty-nine patients (102 basiliximab, 127 controls) were analyzed, mean age 54 years, 72% men, 54% with hepatitis C virus. Mean model for end-stage liver disease (28.2 vs. 20.0; P<0.001) and creatinine (1.9 vs. 1.6; P=0.001) were higher and more patients were on hemodialysis at LT (29% vs. 6%; P<0.001) in the basiliximab group. 30-day patient (99% vs. 97%; P=0.26) and graft survival (98% vs. 95%; P=0.17), 1-year patient (87% vs. 87%; P=0.89) and graft survival (86% vs. 82%; P=0.37), mean creatinine at 1-year (1.5 vs. 1.5 mg/dL; P=0.82), and treated acute rejection (6% vs. 6%; P=0.90) were similar between basiliximab and control groups, respectively. In multivariable logistic regression, basiliximab was not significantly associated with 30-day (odds ratio, 0.10; P=0.11) or 1-year (odds ratio, 0.97; P=0.94) survival, controlling for age, previous LT, model for end-stage liver disease, and hepatitis C virus. CONCLUSIONS: Basiliximab induction resulted in 30-day and 1-year patient, graft and renal outcomes comparable with a control group receiving standard CNI-based immunosuppression. Antibody induction with delayed CNI should be further studied prospectively.
