ABSTRACT
A proximally migrated ureteral stent into the renal pelvis is an uncommon problem that poses a difficult technical challenge. A 32-year-old woman had her ureteral stent inadvertently dislodged into the renal pelvis at the time of stent exchange. The stent was successfully retrieved and repositioned transurethrally with a snare fed through the left ureter and into the renal pelvis. This is a relatively noninvasive method of retrograde retrieval of a proximally dislodged ureteral stent.
Subject(s)
Endoscopy/methods , Foreign-Body Migration , Stents/adverse effects , Ureter , Urinary Catheterization , Urologic Surgical Procedures/methods , Adult , Female , HumansABSTRACT
We report herein the results of extended follow-up of an expanded randomized clinical trial comparing transjugular intrahepatic portosystemic shunt (TIPS) to 8 mm prosthetic H-graft portacaval shunt as definitive treatment for variceal bleeding due to portal hypertension. Beginning in 1993, through this trial, both shunts were undertaken as definitive therapy, never as a "bridge to transplantation." All patients had bleeding esophageal/gastric varices and failed or could not undergo sclerotherapy/banding. Patients were excluded from randomization if the portal vein was occluded or if survival was hopeless. Failure of shunting was defined as inability to shunt, irreversible shunt occlusion, major variceal rehemorrhage, hepatic transplantation, or death. Median follow-up after each shunt was 4 years; minimum follow-up was 1 year. Patients undergoing placement of either shunt were very similar in terms of age, sex, cause of cirrhosis, Child's class, and circumstances of shunting. Both shunts provided partial portal decompression, although the portal vein-inferior vena cava pressure gradient was lower after H-graft portacaval shunt (P < 0.01). TIPS could not be placed in two patients. Shunt stenosis/occlusion was more frequent after TIPS. After TIPS, 42 patients failed (64%), whereas after H-graft portacaval shunt 23 failed (35%) (P < 0.01). Major variceal rehemorrhage, hepatic transplantation, and late death were significantly more frequent after TIPS (P < 0.01). Both TIPS and H-graft portacaval shunt achieve partial portal decompression. TIPS requires more interventions and leads to more major rehemorrhage, irreversible occlusion, transplantation, and death. Despite vigilance in monitoring shunt patency, TIPS provides less optimal outcomes than H-graft portacaval shunt for patients with portal hypertension and variceal bleeding.
Subject(s)
Esophageal and Gastric Varices/surgery , Gastrointestinal Hemorrhage/surgery , Portacaval Shunt, Surgical/methods , Portasystemic Shunt, Transjugular Intrahepatic/methods , Adult , Aged , Esophageal and Gastric Varices/complications , Esophageal and Gastric Varices/diagnosis , Female , Follow-Up Studies , Gastrointestinal Hemorrhage/complications , Gastrointestinal Hemorrhage/diagnosis , Humans , Hypertension, Portal/complications , Hypertension, Portal/diagnosis , Liver Cirrhosis/complications , Liver Cirrhosis/diagnosis , Liver Transplantation/statistics & numerical data , Male , Middle Aged , Portacaval Shunt, Surgical/mortality , Portasystemic Shunt, Transjugular Intrahepatic/mortality , Probability , Prospective Studies , Reoperation , Sensitivity and Specificity , Survival Rate , Treatment OutcomeABSTRACT
BACKGROUND: Transjugular intrahepatic portosystemic shunt (TIPS) is popular in treating portal hypertension because of its perceived efficacy and cost benefits, although it has never been compared with surgical shunting in a cost-benefit analysis. This study was undertaken to determine the cost benefit of TIPS versus small-diameter prosthetic H-graft portacaval shunt (HGPCS). METHODS: Cost of care was determined in 80 patients prospectively randomized to receive TIPS or HGPCS as definitive treatment for bleeding varices, beginning with shunt placement and including subsequent admissions for complications or follow-up related to shunting. RESULTS: Patients were similar in age, gender, severity of illness/liver dysfunction, and urgency of shunting. After TIPS or HGPCS, variceal rehemorrhage (8 versus O, respectively; p = 0.03), shunt occlusion (13 versus 4; p = 0.03), shunt revision (16 versus 4; p < 0.005), and shunt failure (18 versus 10; p = 0.10) were compared; all were more common after TIPS. Through the index admission, TIPS cost $48,188 +/- $43,355 whereas HGPCS cost $61,552 +/- $47,615. With follow-up, TIPS cost $69,276 +/- $52,712 and HGPCS cost $66,034 +/- $49,118. CONCLUSIONS: Early cost of TIPS was less than, though not different from, cost of HGPCS. With follow-up, costs after TIPS mounted. The initially lower cost of TIPS is offset by higher rates of subsequent occlusion and rehemorrhage.
