Rapid Development of De Novo Thoracic Aneurysm After Liver Transplant.

The development of aortic aneurysms in post-transplant patients is a rare but potentially lethal problem. De novo aortic aneurysm formation and rapid growth are postulated to result from an imbalance between pro- and anti-inflammatory vascular endothelial factors after transplant. Here, we present a case of de novo thoracic aneurysm formation within 2 months of orthotopic liver transplant. Prompt clinical recognition allowed for successful endovascular repair. Transplant clinicians should be aware of this potentially life-threatening complication and monitor at-risk recipients accordingly.

Immune Reconstitution Syndrome with Initiation of Treatment of HBV/HIV Co-infection: Activity Flare associated with E antigen Seroconversion.

Immune reconstitution syndrome is a recognized complication with initiation of highly active antiretroviral therapy for acquired immune deficiency syndrome patients co-infected with hepatitis B. Hepatitis B flares are seen in 20%-25% of patients after initiation of highly active antiretroviral therapy, an estimated 1%-5% of whom develop clinical hepatitis. We present a case of highly active antiretroviral therapy initiation for HIV that led to a flare of HBV activity despite antiviral therapy directed towards both. Liver biopsy and longitudinal serologic evaluation lend support to the hypothesis that the flare in activity was representative of IRIS. Importantly, we document eAg/eAb seroconversion with the IRIS phenomenon.

Real-Time Ultrasound-Guided Paracentesis by Radiologists: Near Zero Risk of Hemorrhage without Correction of Coagulopathy.

PURPOSE: To evaluate the rate and risk factors for hemorrhage in patients undergoing real-time, ultrasound-guided paracentesis by radiologists without correction of coagulopathy. MATERIALS AND METHODS: This was a retrospective study of all patients who underwent real-time, ultrasound-guided paracentesis at a single institution over a 2-year period. In total, 3116 paracentesis procedures were performed: 757 (24%) inpatients and 2,359 (76%) outpatients. Ninety-five percent of patients had a diagnosis of cirrhosis. Mean patient age was 56.6 years. Mean international normalized ratio (INR) was 1.6; INR was > 2 in 437 (14%) of cases. Mean platelet count was 122 x 103/µL; platelet count was < 50 x 103/µL in 368 (12%) of patients. Seven hundred seven (23%) patients were dialysis dependent. Patients were followed for 2 weeks after paracentesis to assess for hemorrhage requiring transfusion or rescue angiogram/embolization. Univariate analysis was performed to determine risk factors for hemorrhage. Blood product and cost saving analysis were performed. RESULTS: Significant post-paracentesis hemorrhage occurred in 6 (0.19%) patients, and only 1 patient required an angiogram with embolization. No predictors of post-procedure bleeding were found, including INR and platelet count. Transfusion of 1125 units of fresh frozen plasma and 366 units of platelets were avoided, for a transfusion-associated cost savings of $816,000. CONCLUSIONS: Without correction of coagulation abnormalities with prophylactic blood product transfusion, post-procedural hemorrhage is very rare when paracentesis is performed with real-time ultrasound guidance by radiologists.

Race and Gradient Difference Are Associated with Increased Risk of Hepatic Encephalopathy Hospital Admission After Transjugular Intrahepatic Portosystemic Shunt Placement.

BACKGROUND/AIMS: Hepatic encephalopathy (HE) is a well-recognized complication of transjugular intrahepatic portosystemic shunt (TIPS) placement. The aim of this investigation was to evaluate incidence and predictors of post-TIPS HE necessitating hospital admission in a non-clinical trial setting. METHODS: We performed a retrospective cohort study identifying 273 consecutive patients undergoing TIPS from 2010 to 2015 for any indication; 210 met inclusion/exclusion criteria. The primary endpoint was incidence of post-TIPS HE defined as encephalopathy with no other identifiable cause requiring hospitalization within 90 days of TIPS. Clinical demographics and procedural variables were collected and analyzed to determine predictors of readmission for post-TIPS HE. Categorical variables were analyzed using Fisher's exact test; continuous variables were compared using Levene's t-test and student's t-test; P < 0.05, significant. RESULTS: Forty-two of 210 patients (20%) developed post-TIPS HE requiring hospitalization within 90 days. On analysis of cohorts (post-TIPS HE vs. no post-TIPS HE): non-white race (31.0% vs. 17.5%, P = 0.022) and increased hepatic venous pressure gradient (HVPG) difference during TIPS (10.5 vs. 8.9 mmHg, P = 0.030) were associated with an increased incidence of HE requiring readmission within 90 days. CONCLUSIONS: HE remains a common complication of TIPS. Non-Caucasian race is a significant clinical demographic associated with increased risk for readmission. Independent of initial or final HVPG, HVPG difference appears to be a significant modifiable technical risk factor. In the absence of clear preventative strategies for post-TIPS encephalopathy, non-Caucasians with HVPG reductions >9 mmHg may require targeted follow up evaluation to prevent hospital readmission.

Refractory Hepatic Encephalopathy After Elective Transjugular Intrahepatic Portosystemic Shunt: Risk Factors and Outcomes with Revision.

BACKGROUND AND AIMS: Hepatic encephalopathy (HE) is a common complication of elective transjugular intrahepatic portosystemic shunt (TIPS) placement and is often successfully medically managed. Risk factors for refractory hepatic encephalopathy (RHE) necessitating revision of TIPS are not well defined. We evaluated the incidence, predictors, and outcomes of post-TIPS RHE necessitating TIPS revision. METHODS: In a retrospective cohort study of 174 consecutive patients undergoing elective TIPS placement (2010-2015), we evaluated the incidence of post-TIPS RHE. Clinical demographics and procedural variables were collected. 1-year outcomes after revision were collected. RESULTS: Ten of 174 patients (5.7%) developed post-TIPS RHE requiring revision. Significant differences between RHE and non-refractory groups were shunt size > 8 versus ≤ 8 mm (18.5 vs. 3.4%, p = 0.001), history of HE (14 vs. 2%, p = 0.007), and serum albumin levels ≤ 2.5 versus > 2.5 g/dL (13.1 vs. 3.1%, p = 0.020). On multivariate analysis, shunt size > 8 mm (p = 0.001), history of HE prior to TIPS (p = 0.006), and low serum albumin (≤ 2.5 g/dL) (p = 0.022) remained independent predictors of RHE, controlling for age and Model for End-Stage Liver Disease score. RHE improved in 8 of 10 patients but survival at 1 year without liver transplantation (LT) was only 10%. CONCLUSION: While TIPS revision successfully improves RHE in most cases, 1-year mortality rates are high, limiting the value of revision in non-LT candidates. Patients with previous history of HE and low serum albumin levels prior to TIPS may benefit most from the use of shunt sizes < 8 mm to mitigate the risk of RHE. LEVEL OF EVIDENCE: Level 4, case series.

Simple cystectomy: outcomes of a new operative technique.

OBJECTIVE: To present an efficient technique for simple cystectomy. Urinary diversion for benign indications is a relatively rare procedure. However, diversion alone without accompanying cystectomy results in a significant risk of complications, such as pyocystis, hematuria, pain, and secondary carcinoma. METHODS: We retrospectively reviewed our institutional experience with this simple cystectomy technique, which included 23 patients from 2007-2010 performed by 3 surgeons. There were 14 females and 9 males. All patients had exhausted all other possible conservative therapies. Indication for the procedure included neurogenic bladder and resulting complications in 9 patients, complications from prostate radiation therapy in 5 patients, refractory interstitial cystitis in 5 patients, and refractory incontinence in 4 patients. RESULTS: The average patient was 63.3 years old and had undergone 2.7 prior abdominal or pelvic surgeries and 3.6 prior urinary operations. The average operative time was 27.5 minutes for the simple cystectomy portion of the case (recorded in 19 cases) and average blood loss was 46.7 mL (recorded in 12 cases). For the entire procedure, including diversion with bowel segment, the average blood loss was 231.5 mL. The mean entire operative time was 318.5 minutes. There were no complications noted intraoperatively or postoperatively specifically attributed to the cystectomy portion. All pathology specimens revealed no evidence of malignancy. Mean follow-up was 8 months (range 1-33). CONCLUSION: This simple cystectomy technique, in most cases of urinary diversion for benign indications, can be performed quickly with minimal blood loss and complications.

Risk factors for conversion to hand assisted laparoscopy or open surgery during laparoscopic renal surgery.

PURPOSE: Risk factors for conversion to hand assisted laparoscopic or open surgery during laparoscopic renal surgery are incompletely defined. MATERIALS AND METHODS: We reviewed our institutional database of 759 standard laparoscopic and 833 hand assisted laparoscopic radical, simple, donor and partial nephrectomies, pyeloplasties and nephroureterectomies from June 1996 to February 2009, representing a total of 1,592 cases. We identified the incidence of and indications for conversion to hand assisted laparoscopic and open surgery, and determined risk factors for conversion. RESULTS: Of all 1,592 procedures 20 (1.3%) required conversion to open surgery. Of 759 standard laparoscopic procedures 21 (2.8%) were converted to hand assisted laparoscopic surgery and 1.7% were converted to open surgery for an overall standard laparoscopy conversion rate of 4.6%. Only 0.7% of hand assisted laparoscopic procedures were converted to open surgery. The rate of conversion to open surgery ranged from 0.3% for laparoscopic partial to 2.5% for laparoscopic simple nephrectomy. The rate of conversion to hand assisted laparoscopic surgery ranged from 0% for laparoscopic pyeloplasty to 6.5% for laparoscopic partial nephrectomy. Conversion to open surgery was most likely due to hemorrhage (50% of cases) or failure to progress (40%) while conversion to hand assisted laparoscopic surgery was most likely due to failure to progress (76%) and tumor anatomy (19%). Multivariate analysis revealed that the only significant risk factor for conversion to open surgery was greater American Society of Anesthesiologists score. Conversion to hand assisted laparoscopic surgery was associated with greater body mass index, American Society of Anesthesiologists score and partial nephrectomy. CONCLUSIONS: Conversion during laparoscopic renal surgery to open or hand assisted laparoscopic surgery is a rare but important event in laparoscopic surgery. The risk is influenced by the nature of the procedure and overall patient health.

The University of Michigan experience with percutaneous nephrostolithotomy for urinary matrix calculi.

OBJECTIVES: To evaluate commonalities in presentation and long-term efficacy of treatment by percutaneous nephrostolithotomy of matrix stones, a rare form of urinary calculi. METHODS: The clinical data of 9 consecutive patients with urinary matrix calculi in 11 kidneys treated at our institution between 1995 and 2007 were retrospectively reviewed. RESULTS: The matrix component in all 11 kidneys was successfully treated with percutaneous nephrostolithotomy, with few complications. Among 8 patients (9 kidneys) with follow-up, none has had recurrence of matrix stones after a mean follow-up of 3.8 years. Along with previously known risk factors for matrix stones, such as urinary tract infections and renal insufficiency, we identified smoking as another possible risk factor. Long-term antimicrobial prophylaxis was used in only 1 patient and thus does not seem necessary for prevention of recurrence. CONCLUSIONS: Matrix stone treatment with percutaneous nephrostolithotomy is durable and should remain the treatment modality of choice.

G-protein signaling participates in the development of diabetic cardiomyopathy.

Diabetic patients develop a cardiomyopathy that consists of ventricular hypertrophy and diastolic dysfunction. Although the pathogenesis of this condition is poorly understood, previous studies implicated abnormal G-protein activation. In this work, mice with cardiac overexpression of the transcription factor peroxisome proliferator-activated receptor-alpha (PPAR-alpha) were examined as a model of diabetic cardiomyopathy. PPAR-alpha transgenic mice develop spontaneous cardiac hypertrophy, contractile dysfunction, and "fetal" gene induction. We examined the role of abnormal G-protein activation in the pathogenesis of cardiac dysfunction by crossing PPAR-alpha mice with transgenic mice with cardiac-specific overexpression of regulator of G-protein signaling subtype 4 (RGS4), a GTPase activating protein for Gq and Gi. Generation of compound transgenic mice demonstrated that cardiac RGS4 overexpression ameliorated the cardiomyopathic phenotype that occurred as a result of PPAR-alpha overexpression without affecting the metabolic abnormalities seen in these hearts. Next, transgenic mice with increased or decreased cardiac Gq signaling were made diabetic by injection with streptozotocin (STZ). RGS4 transgenic mice were resistant to STZ-induced cardiac fetal gene induction. Transgenic mice with cardiac-specific expression of mutant Galphaq, Galphaq-G188S, that is resistant to RGS protein action were sensitized to the development of STZ-induced cardiac fetal gene induction and bradycardia. These results establish that Gq-mediated signaling plays a critical role in the pathogenesis of diabetic cardiomyopathy.