Recurrent cholangitis in patients with a non-stenotic hepaticojejunostomy: incidence and risk factors.

BACKGROUND: Cholangitis is a well-known complication after hepaticojejunostomy (HJ), which is mainly caused by a stenotic anastomosis. However, the rate of cholangitis in patients with a non-stenotic (i.e. patent) HJ is unknown. We aimed to evaluate the incidence and risk factors of recurrent cholangitis in patients with a non-stenotic HJ. METHODS: This single-center retrospective cohort study included all consecutive patients who had undergone hepatobiliary or pancreatic (HPB) surgery requiring HJ (2015-2022). Primary outcome was recurrent non-stenotic cholangitis, risk factors for recurrent non-stenotic cholangitis were identified using logistic regression. RESULTS: Overall, 835 patients with a HJ were included of whom 31/698 (4.4%) patients developed recurrent cholangitis with a non-stenotic HJ during a median follow-up of 34 months (IQR 22-50) and 98/796 (12.3%) patients developed a symptomatic HJ stenosis. These 31 patients experienced 205 cholangitis episodes, median 7.0 (IQR 3.8-8.8) per patient, and 71/205 (34.6%) cholangitis episodes required hospitalization. Male sex (aOR 3.17 (95% CI: 1.34-7.49)) and benign disease (aOR 2.97, 95% CI 1.40-6.33) were identified as risk factors for recurrent cholangitis in non-stenotic HJ in both univariate and multivariable analysis. CONCLUSION: This study shows that 4% of patients developed recurrent cholangitis without an underlying HJ stenosis.

Assessment of renal sympathetic control using invasive pressure and flow velocity measurements in humans.

Renal sympathetic innervation is important in the control of renal and systemic hemodynamics and is a target for pharmacological and catheter-based therapies. The effect of a physiological sympathetic stimulus using static handgrip exercise on renal hemodynamics and intraglomerular pressure in humans is unknown. We recorded renal arterial pressure and flow velocity in patients with a clinical indication for coronary or peripheral angiography using a sensor-equipped guidewire during baseline, handgrip, rest, and hyperemia following intrarenal dopamine (30 µg/kg). Changes in perfusion pressure were expressed as the change in mean arterial pressure, and changes in flow were expressed as a percentage with respect to baseline. Intraglomerular pressure was estimated using a Windkessel model. A total of 18 patients (61% male and 39% female) with a median age of 57 yr (range: 27-85 yr) with successful measurements were included. During static handgrip, renal arterial pressure increased by 15.2 mmHg (range: 4.2-53.0 mmHg), whereas flow decreased by 11.2%, but with a large variation between individuals (range: -13.4 to 49.8). Intraglomerular pressure increased by 4.2 mmHg (range: -3.9 to 22.1 mmHg). Flow velocity under resting conditions remained stable, with a median of 100.6% (range: 82.3%-114.6%) compared with baseline. During hyperemia, maximal flow was 180% (range: 111%-281%), whereas intraglomerular pressure decreased by 9.6 mmHg (interquartile range: 4.8 to 13.9 mmHg). Changes in renal pressure and flow during handgrip exercise were significantly correlated (ρ = -0.68, P = 0.002). Measurement of renal arterial pressure and flow velocity during handgrip exercise allows the identification of patients with higher and lower sympathetic control of renal perfusion. This suggests that hemodynamic measurements may be useful to assess the response to therapeutic interventions aimed at altering renal sympathetic control.NEW & NOTEWORTHY Renal sympathetic innervation is important in the homeostasis of systemic and renal hemodynamics. We showed that renal arterial pressure significantly increased and that flow decreased during static handgrip exercise using direct renal arterial pressure and flow measurements in humans, but with a large difference between individuals. These findings may be useful for future studies aimed to assess the effect of interventions that influence renal sympathetic control.

Blood pressure and the risk of rebleeding and delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage.

INTRODUCTION AND OBJECTIVE: Blood pressure is presumably related to rebleeding and delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (aSAH) and could serve as a target to improve outcome. We assessed the associations between blood pressure and rebleeding or DCI in aSAH-patients. MATERIALS AND METHODS: In this observational study in 1167 aSAH-patients admitted to the intensive care unit (ICU), adjusted hazard ratio's (aHR) were calculated for the time-dependent association of blood pressure and rebleeding or DCI. The aHRs were presented graphically, relative to a reference mean arterial pressure (MAP) of 100 mmHg and systolic blood pressure (sBP) of 150 mmHg. RESULTS: A MAP below 100 mmHg in the 6, 3 and 1 h before each moment in time was associated with a decreased risk of rebleeding (e.g. within 6 h preceding rebleeding: MAP = 80 mmHg: aHR 0.30 (95% confidence interval (CI) 0.11-0.80)). A MAP below 60 mmHg in the 24 h before each moment in time was associated with an increased risk of DCI (e.g. MAP = 50 mmHg: aHR 2.59 (95% CI 1.12-5.96)). CONCLUSIONS: Our results suggest that a MAP below 100 mmHg is associated with decreased risk of rebleeding, and a MAP below 60 mmHg with increased risk of DCI.

Pregnancy in women with an inferior vena cava filter: a tertiary center experience and overview of the literature.

Patients with an inferior vena cava (IVC) filter that remains in situ encounter a lifelong increased risk of deep vein thrombosis and IVC filter complications including fracture, perforation, and IVC filter thrombotic occlusion. Data on the safety of becoming pregnant with an in situ IVC filter are scarce. The objective was to evaluate the risk of complications of in situ IVC filters during pregnancy. We performed a retrospective cohort study of pregnant patients with an in situ IVC filter from a tertiary center between 2000 and 2020. We collected data on complications of IVC filters and pregnancy outcomes. Additionally, we performed a systematic literature search in MEDLINE, Embase, and gray literature. We identified 7 pregnancies in 4 patients with in situ IVC filters with a mean time since IVC filter insertion of 3 years (range, 1-8). No complications of IVC filter occurred during pregnancy. Review of literature yielded five studies including 13 pregnancies in 9 patients. In 1 pregnancy a pre-existent, until then asymptomatic, chronic perforation of the vena cava wall by the IVC filter caused major bleeding and uterine trauma with fetal loss. Overall, the complication rate was 5%. It seems safe to become pregnant with an indwelling IVC filter that is intact and does not show signs of perforation, but because of the low number of cases, no firm conclusions about safety of in situ IVC filters during pregnancy can be drawn. We suggest imaging before pregnancy to reveal asymptomatic IVC filter complications.

Treatment of symptomatic postoperative pelvic lymphoceles: A systematic review.

PURPOSE: A broad range of therapeutic options exists for symptomatic postoperative lymphoceles. However, no consensus exists on what is the optimal therapy. In this study, we aimed to compare the efficacy of currently available radiologic interventions in terms of number of successful interventions, number of recurrences, and number of complications. METHODS: A systematic review was conducted with a pre-defined search strategy for PubMed, EMBASE, and Cochrane databases from inception until September 2019. Quality assessment was performed using the 'Risk Of Bias In Non-randomized Studies - of Interventions' tool. Statistical heterogeneity was assessed using the I2 and χ2 test and a meta-analysis was considered for studies reporting on multiple interventions. RESULTS: 37 eligible studies including 732 lymphoceles were identified. Proportions of successful interventions for percutaneous fine needle aspiration, percutaneous catheter drainage, percutaneous catheter drainage with delayed or instantaneous addition of sclerotherapy, and embolization were as follows: 0.341 (95% confidence interval [CI]: 0.185-0.542), 0.612 (95% CI: 0.490-0.722), 0.890 (95% CI: 0.781-0.948), 0.872 (95% CI: 0.710-0.949), 0.922 (95% CI: 0.731-0.981). Random-effects meta-analysis of seven studies revealed a pooled relative risk for percutaneous catheter drainage with delayed addition of sclerotherapy of 1.57 (95% CI: 1.17-2.10) when compared to percutaneous catheter drainage alone. The risk of bias in this study was severe. CONCLUSIONS: This systematic review demonstrates that the success rates of percutaneous catheter drainage with sclerotherapy are more favorable when compared to percutaneous catheter drainage alone in the treatment of postoperative pelvic lymphoceles. Overall, percutaneous catheter drainage with delayed addition of sclerotherapy, and embolization showed the best outcomes.

High-Dose Nadroparin Following Endovascular Aneurysm Treatment Benefits Outcome After Aneurysmal Subarachnoid Hemorrhage.

BACKGROUND: Delayed cerebral ischemia (DCI) is one of the major causes of delayed morbidity and mortality in patients with aneurysmal subarachnoid hemorrhage (aSAH). OBJECTIVE: To evaluate the effect of high-dose nadroparin treatment following endovascular aneurysm treatment on the occurrence of DCI and clinical outcome. METHODS: Medical records of 158 adult patients with an aSAH were retrospectively analyzed. Those patients treated endovascularly for their ruptured aneurysm were included in this study. They received either high-dose (twice daily 5700 AxaIE) or low-dose (once daily 2850 AxaIE) nadroparin treatment after occlusion of the aneurysm. Medical charts were reviewed and imaging was scored by 2 independent neuroradiologists. Data with respect to in-hospital complications, peri-procedural complications, discharge location, and mortality were collected. RESULTS: Ninety-three patients had received high-dose nadroparin, and 65 patients prophylactic low-dose nadroparin. There was no significant difference in clinical DCI occurrence between patients treated with high-dose (34%) and low-dose (31%) nadroparin. More patients were discharged to home in patients who received high-dose nadroparin (40%) compared to low-dose (17%; odds ratio [OR] 3.13, 95% confidence interval [95% CI]: 1.36-7.24). Furthermore, mortality was lower in the high-dose group (5%) compared to the low-dose group (23%; OR 0.19, 95% CI: 0.07-0.55), also after adjusting for neurological status on admission (OR 0.21, 95% CI: 0.07-0.63). CONCLUSION: Patients who were treated with high-dose nadroparin after endovascular treatment for aneurysmal SAH were more often discharged to home and showed lower mortality. High-dose nadroparin did not, however, show a decrease in the occurrence of clinical DCI after aSAH. A randomized controlled trial seems warranted.

Predicting the need for abdominal hemorrhage control in major pelvic fracture patients: the importance of quantifying the amount of free fluid.

BACKGROUND: In our institution, the computed tomographic (CT) scan has largely replaced the ultrasound for the rapid detection of intraperitoneal free fluid (FF) and abdominal injuries in severely injured patients.We hypothesized that in major pelvic fracture patients, quantifying the size of FF on CT improves the predictive value for the need for abdominal hemorrhage control (AHC). METHODS: The CT scans of major pelvic fracture (pelvic ring disruption) patients (January 1, 2004, to June 31, 2012) were reviewed for the presence of FF (small, moderate, or large amount) and abdominal injuries. AHC was defined as requiring a surgical intervention for active abdominal bleeding or angiographic embolization for an abdominal arterial injury.Positive predictive value (PPV) and negative predictive value (NPV) (95% confidence interval [CI]) were calculated for all patients and in a subgroup of patients with a high risk for significant hemorrhage (base deficit ≥ 6 mEq/L). RESULTS: Overall, 160 patients were included in the study. Of the 62 FF patients, 26 required AHC (PPV, 42%, 95% CI, 30-55%). Of the 98 patients without FF, none required AHC (NPV, 100%; 95% CI, 95-100%). For a moderate-to-large amount of FF, the PPV and NPV in all patients were 81% (95% CI, 60-93%) and 96% (95% CI, 91-99%), respectively.In the subgroup of 49 high-risk patients (31%), 17 of 26 FF patients required AHC (PPV, 65%; 95% CI, 44-82%), and none of the 23 patients without FF required AHC (NPV, 100%; 95% CI, 82-100%). For a moderate-to-large amount, the PPV and NPV in high-risk patients were 93% (95% CI, 64-100%) and 89% (95% CI, 72-96%), respectively. CONCLUSION: In major pelvic fracture patients, the predictive value of FF on CT for the need for AHC is closely related to the amount present. A moderate-to-large amount of FF is highly predictive for the presence of abdominal bleeding that requires hemorrhage control. LEVEL OF EVIDENCE: Therapeutic study, level IV; prognostic study, level III.

Management of pelvic ring fracture patients with a pelvic "blush" on early computed tomography.

BACKGROUND: The sliding computed tomographic (CT) scanner in our trauma resuscitation room can be used early in the assessment of pelvic ring fracture patients. We determined the association between the presence of a pelvic blush on CT scan and the need for pelvic hemorrhage control (PHC). We hypothesized that many pelvic blushes found early in the resuscitation phase can be safely managed without intervention. METHODS: Contrast-enhanced CT scans of pelvic ring fracture (pelvic ring disruption) patients admitted from January 1, 2004, to June 31, 2012, were reviewed for the presence of a pelvic blush. PHC was defined as requiring a surgical or radiologic intervention for pelvic bleeding. A subanalysis was performed in "isolated" pelvic fracture/ blush patients (absence of a major nonpelvic bleeding source). RESULTS: Overall, 68 (42%) of 162 pelvic ring fracture patients and 53 (40%) of 134 isolated pelvic fracture patients had a pelvic blush. Of those 32 (47%) and 27 (51%) patients, respectively, required PHC. In the absence of a pelvic blush, 87 (93%) of 94 of all and 77 (95%) of 81 of isolated pelvic fracture patients did not require PHC. Of all patients with a pelvic blush and of isolated pelvic blush, those with PHC had a higher Injury Severity Score (ISS) (p = 0.01 and p = 0.05), base deficit (p = 0.03 and p = 0.01), as well as 24-hour and any packed red blood cells requirement (p <0.001 and p = 0.05; p <0.001 and p = 0.02). In isolated pelvic blush patients, there was a trend toward a higher hospital and hemorrhage-related mortality in patients with PHC (p = 0.06 and p = 0.06). CONCLUSION: In pelvic ring fracture patients, a pelvic blush on early contrast-enhanced CT is a frequent finding. Many patients with (particularly isolated) pelvic blushes have stable vital signs and can be managed without surgical or radiologic PHC. The need for an intervention for a pelvic blush seems to be determined by the presence of clinical signs of ongoing bleeding. LEVEL OF EVIDENCE: Therapeutic study, level IV. Prognostic/epidemiologic study, level III.

The utility of FAST for initial abdominal screening of major pelvic fracture patients.

BACKGROUND: Focused Assessment with Sonography for Trauma (FAST) is widely used in pelvic fracture patients. We examined the performance of FAST for detecting hemoperitoneum and predicting the need for intra-abdominal hemorrhage control in major pelvic fracture patients. METHODS: A 5-year retrospective study of major pelvic fracture patients was performed. The presence of hemoperitoneum was confirmed on CT or at laparotomy. The need for hemorrhage control was defined as requiring a surgical or radiological intervention for intra-abdominal bleeding. Hemorrhagic shock (HS) patients had a systolic blood pressure ≤ 90 mmHg or base deficit of ≥ 6 mEq/L on admission. RESULTS: A total of 120 patients were included, 42 (35 %) of which had any hemoperitoneum and 21 (18 %) had a moderate-large amount. The sensitivity, specificity, and positive and negative predictive values of FAST for any hemoperitoneum were 64, 94, 84, and 83 % and for a moderate-large amount they were 86, 86, 56, and 97 %. In HS patients the indices were 68, 93, 88, and 78 % for any hemoperitoneum and 79, 83, 65, and 91 % for a moderate-large amount. For the need for hemorrhage control, FAST had a positive predictive value of 50 % (16/32) in all and 71 % (12/17) in HS patients. The negative predictive value was 99 % (87/88) in all and 97 % (31/32) in HS patients. CONCLUSION: FAST had a good to excellent diagnostic accuracy, depending on the size of hemoperitoneum. A positive FAST result (even in HS patients) does not reliably predict the need for immediate intra-abdominal hemorrhage control but a negative FAST result renders the need for an intervention highly unlikely.

Acute pulmonary embolism: effect of a computer-assisted detection prototype on diagnosis--an observer study.

PURPOSE: To assess the effect of a computer-assisted detection (CAD) prototype on observer performance for detection of acute pulmonary embolism (PE) with computed tomographic (CT) pulmonary angiography. MATERIALS AND METHODS: In this institutional review board-approved retrospective study, six observers with varying experience evaluated 158 PE-negative and 51 PE-positive CT pulmonary angiographic studies (mean age, 57 years; 111 women, 98 men) obtained consecutively during nights and weekends. Observers were asked to determine the presence of PE and to rank their diagnostic confidence without CAD and subsequently with CAD within a single reading session. Reading time was separately measured for both readings. Reader data were compared with an independent standard established by two readers, with a third in case of discordant results. Statistical evaluation was performed on a per-patient basis by using logistic regression for repeated measurements and Pearson correlation. RESULTS: With CAD, there was a significant increase in readers' sensitivity (P = .014) without loss of specificity (P = .853) on a per-patient basis. CAD assisted the readers in correcting an initial false-negative diagnosis in 15 cases, with the most proximal embolus at the segmental level in four cases and at the subsegmental level in 11 cases. In eight cases, readers accepted false-positive CAD candidate lesions on scans negative for PE, and in one case, a reader dismissed a true-positive finding. Reading time was extended by a mean of 22 seconds with the use of CAD. CONCLUSION: At the expense of increased reading time, CAD has the potential to increase reader sensitivity for detecting segmental and subsegmental PE without significant loss of specificity.