Transmesenteric-transfemoral method of intrahepatic portosystemic shunt placement with minilaparotomy.

PURPOSE: To determine whether the transmesenteric-transfemoral method of intrahepatic portosystemic shunt (IPS) placement is safer and more efficient than the transjugular method. PATIENTS AND METHODS: Sixty-six consecutive patients with cirrhosis and bleeding varices underwent 67 IPS procedures. Sixty-one of these procedures were performed using a combination of transfemoral access to the hepatic vein with transmesenteric access to the portal system provided by means of minilaparotomy. Follow-up days were collected periodically by means of clinical evaluation and duplex sonography of the shunt. Angiographic evaluation was performed when necessary. RESULTS: No technical failures or periprocedural deaths occurred. The radiologic and surgical portions of the procedure were accomplished within 45 and 55 minutes, respectively. In cases without portal thrombosis, maximum fluoroscopy time was 12 minutes. During follow-up (mean, 16 months), eight shunt revisions including one additional shunt placement were necessary. CONCLUSION: Transmesenteric-transfemoral IPS placement requires surgical participation but may offer improved efficiency and safety compared with regular transjugular IPS placement.

Open versus closed treatment of necrotizing pancreatitis.

The records of 30 consecutive patients who underwent operative procedures for infected (25 patients) and sterile (5 patients) necrotizing pancreatitis were reviewed. 17 patients were managed by an open procedure and 13 patients by a closed procedure. Overall mortality was six patients (20%). All the mortalities were among the 25 infected patients and among the 16 patients managed open. Open management was associated with higher Apache II scores at admission (13.5 vs. 8.5) (p < .05). Nonsurvivors had a higher Ranson prognostic criteria score, first CT severity index, and Apache II score versus survivors (16.8 vs. 10) (p < .05). Open management was associated with more operations, more transfusions of blood, and longer length of intensive care unit and hospital stays. All mortalities were secondary to multiple organ failure. There were more local complications in the open group (fistulas and colon necrosis). At the initial operation, infected patients demonstrated predominantly emerging resistant flora. Open management is associated with a higher morbidity and mortality; however, due to the progressive nature of the pathology, repeated explorations are necessary in the more severely ill patients with necrotizing pancreatitis.