Uncovering the truth about covered stents: is there a difference between covered versus uncovered stents with transjugular intrahepatic portosystemic shunts?

INTRODUCTION: Polytetrafluoroethylene (PTFE)-covered transjugular intrahepatic portosystemic shunt (TIPS) stents purportedly provide superior patency. This study was undertaken to determine whether covered stents provide better long-term patency and outcomes after TIPSs. METHODS: Patients with portal hypertension undergoing TIPS at a large teaching hospital from 2001 to 2010 were studied. Median data are presented. RESULTS: Two hundred forty-six patients underwent TIPS; 70 received uncovered stents, and 176 received covered stents. Patients who received uncovered stents had more severely impaired liver function (41% were Child class C cirrhotics). The follow-up was longer with uncovered stents (48 vs 24 months, P < .01). Reinterventions for stenosis were undertaken in 33% with uncovered stents versus 19% with covered stents (P = .01). Shunt dysfunction occurred in 57% with uncovered stents versus 21% covered (P = .05). A deterioration of hepatic function occurred in 31% with uncovered stents versus 30% with covered (P = .32). Survival with uncovered stents was 31 months versus 33 months with covered stents (P = .55, Kaplan-Meier). CONCLUSIONS: Covered stents may improve patency but do not mitigate postshunt hepatic dysfunction and do not improve survival.

Laparoendoscopic single-site Heller myotomy with anterior fundoplication for achalasia.

BACKGROUND: Laparoendoscopic single-site (LESS) surgery is beginning to include advanced laparoscopic operations such as Heller myotomy with anterior fundoplication. However, the efficacy of LESS Heller myotomy has not been established. This study aimed to evaluate the authors' initial experience with LESS Heller myotomy for achalasia. METHODS: Transumbilical LESS Heller myotomy with concomitant anterior fundoplication for achalasia was undertaken for 66 patients after October 2007. Outcomes including operative time, complications, and length of hospital stay were recorded and compared with those for an earlier contiguous group of 66 consecutive patients undergoing conventional multi-incision laparoscopic Heller myotomy with anterior fundoplication. Symptoms before and after myotomy were scored by the patients using a Likert scale ranging from 0 (never/not severe) to 10 (always/very severe). Data were analyzed using the Mann-Whitney U test, the Wilcoxon matched-pairs test, and Fisher's exact test where appropriate. RESULTS: Patients undergoing LESS Heller myotomy were similar to those undergoing conventional laparoscopic Heller myotomy in gender, age, body mass index (BMI), blood loss, and length of hospital stay. However, the patients undergoing LESS Heller myotomies had operations of significantly longer duration (median, 117 vs. 93 min with the conventional laparoscopic approach) (p<0.003). For 11 patients (16%) undergoing LESS Heller myotomy, additional ports/incisions were required. No patients were converted to "open" operations, and no patients had procedure-specific complications. Symptom reduction was dramatic and satisfying after both LESS and conventional laparoscopic myotomy with fundoplication. The symptom reduction was similar with the two procedures. The LESS approach left no apparent umbilical scar. CONCLUSION: Heller myotomy with anterior fundoplication effectively treats achalasia. The findings showed LESS Heller myotomy with anterior fundoplication to be feasible, safe, and efficacious. Although the LESS approach increases operative time, it does not increase procedure-related morbidity or hospital length of stay and avoids apparent umbilical scarring. Laparoendoscopic single-site surgery represents a paradigm shift to more minimally invasive surgery and is applicable to advanced laparoscopic operations such as Heller myotomy and anterior fundoplication.