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Biomedical subjects

E J Ring

Publications and source records attributed to E J Ring.

At least 19 recordsLinked to original sources
PubMed1995

Multicenter investigation of the role of transjugular intrahepatic portosystemic shunt in management of portal hypertension.

PURPOSE: To determine the safety and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) placement, a prospective multicenter trial was undertaken. MATERIALS AND METHODS: In eight institutions, 96 patients underwent TIPS placement after failed sclero-therapy (Child-Pugh class A [n = 24], class B [n = 38], and class C [n = 34]), with follow-up for 6 months (with ultrasonography and angiography and clinical and laboratory studies). RESULTS: TIPS placement was successful in all patients (mean initial portosystemic pressure gradient, 22.8 mm Hg + 6.7 [standard deviation]; mean decrease after placement, 12.8 mm Hg + 5.2), with variceal embolization in 25 patients. Complications included liver capsule puncture (n = 12), hepatic artery puncture (n = 3), main portal vein puncture (n = 1), and increased encephalopathy (n = 28). The 30-day mortality rate was 0% for patients with Child class A disease, 18% for class B, and 40% for class C. At 6 months, primary patency was 88% and assisted patency was 94%. CONCLUSION: The risk associated with TIPS placement is reasonable, and it is an effective procedure for the treatment of portal hypertension.

Case-Control Studies↗
PubMed1995

Transjugular intrahepatic portosystemic shunts: current status.

The management of acute variceal hemorrhage from portal hypertension has traditionally included pharmacologic agents, mechanical compression with tamponading balloons, and endoscopic techniques including sclerotherapy and variceal banding. The role of operative portosystemic shunting has diminished in the past several years because of unpredictable postoperative morbidity from hepatic failure or encephalopathy [1-8]. Although orthotopic liver transplantation provides a unique and effective solution to these problems, it is often impractical in the emergent setting and may not be necessary if the hemorrhage can be reliably controlled by other means. The transjugular intrahepatic portosystemic shunt (TIPS) was developed to relieve portal hypertension without the mortality and morbidity of an open surgical procedure. This review summarizes the salient history, technique, and results of this procedure. The evolving role of TIPS in the management of portal hypertension, including indications, contraindications, and the durability of the procedure, is assessed.

Adult↗
PubMed1992

Using transjugular intrahepatic portosystemic shunts to control variceal bleeding before liver transplantation.

OBJECTIVE: To determine the safety and efficacy of transjugular intrahepatic portosystemic shunts (TIPS) in controlling bleeding from esophageal varices in patients awaiting liver transplantation. DESIGN: Prospective, uncontrolled trial. SETTING: University medical center with an active liver transplant program. PATIENTS: Thirteen patients referred for liver transplantation with either active variceal hemorrhage or recurrent variceal hemorrhage despite sclerotherapy; four patients had been previously treated with surgical portosystemic shunts. INTERVENTION: An intrahepatic portosystemic shunt created via a transjugular approach to the hepatic veins using expandable, flexible metallic stents. MEASUREMENTS: Portal pressures before and after the creation of the shunt, the direction of portal blood flow at differing diameters of the shunts, procedure-related complications, and outcome in terms of survival, liver transplantation, and recurrent variceal bleeding. MAIN RESULTS: The transjugular intrahepatic portosystemic shunt was placed successfully in 13 patients, and bleeding was controlled acutely in all 13. After the procedure, the mean portal pressure decreased from 34 +/- 8.9 cm H2O to 22.4 +/- 5.4 cm H2O (P less than 0.001). No complications were associated with the procedure; however, two patients died of causes unrelated to the procedure. Seven patients subsequently underwent liver transplantation and are doing well, and three patients are being managed conservatively. Bleeding recurred in one patient 102 days after the procedure secondary to shunt occlusion caused by neointimal proliferation. CONCLUSION: Placement of a transjugular intrahepatic portosystemic shunt is apparently safe and effective therapy for variceal hemorrhage in patients referred for liver transplantation.

Catheterization↗
PubMed1992

Nonoperative treatment of enteric fistulas: results in 53 patients.

Fifty-three patients with enterocutaneous fistulas were treated nonoperatively. While most of the fistulas resulted as a complication of surgery, other causes included inflammatory disease, trauma, and malignancy. Fistulas originated from the esophagus (n = 4), stomach (n = 4), duodenum (n = 5), small bowel (n = 27), colonic-small bowel anastomosis (n = 2), colon (n = 10), and Hartmann pouch (n = 1), and included both high-output (n = 29) and low-output (n = 24) types. Nonoperative management resulted in spontaneous fistula closure in 57%. Most of the spontaneous closures (83%) occurred within 2 months of treatment. Spontaneous closure rates were similar for low-output and for high-output fistulas (52% vs 63%), but the treatment duration was longer for high-output than for low-output fistulas (mean treatment duration, 17 days vs 41 days). Colonic fistulas were particularly difficult to manage and closed spontaneously in only 10% of patients (one of 10).

Adult↗
PubMed1992

Transjugular intrahepatic portosystemic shunts: preliminary results in 25 patients.

A retrospective study of transjugular intrahepatic shunts performed between June 1990 and June 1991 is reported. Twelve patients were actively bleeding at the time of the procedure; 12 other patients had had one to five bleeding episodes within the previous 2 weeks, and one patient had massive ascites from Budd-Chiari syndrome. Most patients had severe liver disease: 21 Child's class C, three Child's class B, and one Child's class A. Transjugular intrahepatic shunting was technically successful in all cases. Portal vein pressures were reduced on average from 36 +/- 7 cm H2O to 22 +/- 6 cm H2O. Variceal bleeding ceased after transjugular intrahepatic shunting in all patients who were actively bleeding. Five patients died (30-day mortality, 20%), and eight patients subsequently underwent elective liver transplantation. The transjugular intrahepatic shunts in the 12 other patients have remained patent an average of 5.5 months. Shunt occlusion occurred in three patients at 21, 24, and 102 days, respectively. All three occlusions were successfully reopened with percutaneous techniques, yielding a primary shunt patency of 88% and secondary shunt patency of 100%. Complications included new onset encephalopathy in one patient, which cleared with medical therapy and transient renal failure in one patient. These preliminary data suggest that transjugular intrahepatic shunting is a safe and effective therapy for the short-term treatment of patients with variceal hemorrhage, particularly in patients with severe liver disease awaiting transplantation. The long-term benefit of transjugular intrahepatic shunting awaits further follow-up.

Adolescent↗
PubMed1992

Malignant biliary obstruction: treatment with expandable metallic stents--follow-up of 50 consecutive patients.

A consecutive series of 50 patients with malignant biliary obstruction were treated by means of palliative drainage with a metallic expandable stent. Stent placement was successful in all patients. The patients were followed up prospectively at 2-month intervals over a period of 9-22 months. Forty-one patients (82%) died; nine (18%) are still living. The overall patency and survival rates for the 50 patients were 5.8 months and 7.5 months, respectively. The 30-day mortality rate was 8% (n = 4), the minor complication rate was 18% (n = 9), and the major complication rate was 8% (n = 4). One patient (2%) had intrahepatic arterial bleeding that required embolization, one (2%) had a right subphrenic abscess, and two patients (4%) had transient septic events. Stent occlusion requiring a second intervention occurred in 24% of patients (n = 12). Excellent palliation was achieved in most patients. No stent migration occurred. No great clinical advantages in prolonged patency compared with those of other published series involving the use of plastic stents were demonstrated. Ease of placement and versatility may offset the high cost of the stent.

Aged↗
PubMed1992

Role of parallel transjugular intrahepatic portosystemic shunts in patients with persistent portal hypertension.

Transjugular intrahepatic portosystemic shunts (TIPS) were placed in 93 patients between June 1990 and January 1992 for treatment of variceal hemorrhage. In each case, a Wallstent (Schneider USA, Minneapolis) was used to support the hepatic parenchymal tract between the hepatic and portal veins. Currently, these stents have a maximal diameter of 10 mm. In eight of 93 patients, major portal hypertension persisted after placement of a 10-mm-diameter shunt, manifested by continued rapid variceal filling and elevated portosystemic gradients. A second TIPS was placed parallel to the first in these patients to allow further portal decompression. In two other patients, a second TIPS was placed because the initial shunt functioned suboptimally. The mean postprocedural portosystemic gradient in the patients who received one TIPS was 10.2 mm Hg +/- 3.7. In patients who received two TIPS, the mean postprocedural gradient was 19.1 mm Hg +/- 3.8 after placement of the first TIPS and 12.5 mm Hg +/- 3.5 after placement of the second. Two patients developed their first episode of encephalopathy after placement of two TIPS. The methods and indications for placing two TIPS in this select population are discussed.

Adult↗
PubMed1992

Treatment of pulmonary arteriovenous malformations by therapeutic embolization. Rest and exercise physiology in eight patients.

Pulmonary arteriovenous malformations (AVM) lead to chronic hypoxemia and systemic emboli. These lesions can now be treated by catheter embolization. In order to examine physiologic abnormalities during exercise in AVM patients, and to evaluate functional improvement after therapeutic embolization, eight patients underwent detailed physiologic studies at rest and during exercise before and after therapeutic embolization. Before treatment, six patients noted dyspnea on exertion and three had symptoms suggesting paradoxical embolism. Resting studies showed hypoxemia, abnormally increased shunt fractions, chronic alveolar hyperventilation, mild decreases in diffusing capacity, and abnormal wasted ventilation (VD). During exercise, oxygenation changed little from the resting values but VD increased markedly. Functional impairment was observed in most patients, and was correlated with shunt fraction. Obliteration of the AVM was accomplished by therapeutic embolization with placement of coils or balloons in the feeder vessels. This treatment resulted in immediate relief of dyspnea and improvement in resting PaO2 and shunt fraction. Exercise studies after embolization showed improvement in exercise capacity and gas exchange. However, chronic alveolar hyperventilation and reduced diffusing capacity remained unchanged. In summary, therapeutic embolization effectively reduces the degree of shunting, with improvement in respiratory symptoms, exercise capacity, and gas exchange at rest and during exercise. The abnormally decreased diffusing capacity and increased VD suggest the presence of a diffuse pulmonary vascular abnormality, of which further study is warranted.

Adult↗
PubMed1991

Differential diagnosis of sclerosing cholangiocarcinomas of the common hepatic duct (Klatskin tumors).

Although it is recognized that some other lesion may be the cause, a presumptive diagnosis of Klatskin tumor is usually made when a focal stenotic lesion of the common hepatic duct is seen on a cholangiogram of a jaundiced patient. Biopsy is so often nondiagnostic that decisions about therapy are usually made on the basis of the imaging tests and lack of evidence for some other disease. Because the accuracy and consequences of this strategy have never been tested, we contrasted the preoperative diagnosis of Klatskin tumor with the final diagnosis in 98 consecutive patients treated from 1985 to 1990. Preoperative investigations included ultrasound and computed tomographic scans, percutaneous transhepatic cholangiography, endoscopic retrograde cholangiopancreatography, and angiography. Sclerosing cholangiocarcinomas of the bile duct were correctly diagnosed in 68 cases. The final diagnosis was other than a sclerosing adenocarcinoma in 30 (31%) cases. There were 5 papillary bile duct carcinomas, 12 gallbladder carcinomas invading the bile duct, 5 metastatic tumors to the bile duct, 2 cases of Mirizzi syndrome, 3 granulomas, and 3 cases of idiopathic benign focal stenosis. Patients with papillary adenocarcinomas had an extensive filling defect of the duct, which was often thought to be unresectable. However, four of these five lesions could be completely excised, and the tumor was confined to the duct wall in all four. The outcome of surgical treatment of the other eight patients with benign lesions was good in most cases. These findings demonstrate the pitfalls of assuming that a focal stenosis of the hepatic duct represents a sclerosing adenocarcinoma. The diagnosis is much less specific than is generally thought, so there is considerable opportunity for mismanaging such patients.

Adenoma, Bile Duct↗
PubMed1991

Delayed gallbladder rupture following percutaneous cholecystostomy.

Percutaneous cholecystostomy has become an accepted therapeutic alternative for high-risk patients with acute cholecystitis. However, some authors have cautioned that patients with gallbladder wall necrosis and gangrene may not be effectively treated by means of percutaneous drainage alone. A case is reported in which gallbladder wall necrosis progressed following technically successful percutaneous drainage. Spontaneous gallbladder rupture ensued, necessitating emergent cholecystectomy. Cholecystography 2 weeks following tube placement and 1 week prior to rupture showed a markedly abnormal, irregular gallbladder lumen. The authors suggest that follow-up cholecystography may be a useful tool for evaluating patient response to percutaneous cholecystostomy and for determining subsequent patient management.

Acute Disease↗
PubMed1991

Histopathologic study of transjugular intrahepatic portosystemic shunts.

A detailed histopathologic analysis of intrahepatic portosystemic shunts was performed following liver transplantation in five patients. Gross examination revealed that all stents were patent and unchanged in size, shape, and position from initial placement. Histologic examination at 4 days revealed an irregular luminal surface with liver parenchyma protruding between the stent wires and a single, patchy layer of endothelial cells lining the shunt surface. By 3 weeks, the stent wires were covered by a pseudointima of granulation tissue, and the luminal surface was lined with a contiguous layer of endothelial cells. Excessive pseudointimal proliferation resulted in shunt occlusion at 3 months in one patient whose shunt was subsequently reopened percutaneously.

Female↗
PubMed1991

Malignant biliary obstruction complicated by ascites: transjugular insertion of an expandable metallic endoprosthesis.

Although the transjugular approach has long been used to provide safe access to the liver, it has not been used for placement of stents in biliary obstruction. The recent development of an expandable metallic endoprosthesis now makes this method more feasible. The case of a patient with malignant biliary obstruction complicated by ascites is presented herein. Palliation was achieved with an expandable biliary endoprosthesis placed by the transjugular-hepatic vein approach.

Aged↗
PubMed1991

Percutaneous intrahepatic portosystemic shunt created via a femoral vein approach.

Creation of a percutaneous intrahepatic portosystemic shunt was attempted in a patient with portal hypertension and acute variceal hemorrhage. Abnormal hepatic venous anatomy precluded formation of the shunt with the standard transjugular method. An alternate technique was devised in which a femoral vein approach was used to construct an intrahepatic channel between the inferior right hepatic vein and the right portal vein. The patient stopped bleeding after the procedure and has not rebled during an 8-month follow-up period.

Esophageal and Gastric Varices↗
PubMed1990

Percutaneous transhepatic portal vein angioplasty and stent placement after liver transplantation: early experience.

In four patients who underwent liver transplantation, portal vein thrombosis was associated with esophageal varices and significant gastrointestinal bleeding. In a fifth liver transplant patient, portal vein stenosis was suspected when evidence of hepatic ischemia was revealed at liver biopsy. Four patients were treated with percutaneous transhepatic portal vein angioplasty. Percutaneous recanalization was precluded by technical factors in the remaining patient. Early in the series, one patient required surgical excision of what proved to be a thick cuff of fibrous tissue and lymph nodes after angioplasty failed to widen the stenosis significantly. Later, a patient with residual stenosis was treated successfully by means of intravascular stent placement. Of the four patients treated, three eventually died secondary to multiple problems unrelated to the percutaneous procedure. This early experience suggests that transhepatic portal vein interventions are feasible in patients who have received liver transplants and may prove useful at least in the early postprocedure period.

Adult↗
PubMed1990

Percutaneous transhepatic placement of biliary endoprostheses: results in 100 consecutive patients.

One hundred patients with malignant biliary obstruction underwent palliative therapy by means of percutaneous transhepatic placement of 114 biliary endoprostheses. All patients were then followed up for at least 18 months or until death. Retrospective evaluation of the 95 patients who died showed an average survival time of 5.0 months. The five remaining patients have survived an average of 29.8 months. During the 1st week after stent insertion, a second manipulation was performed to improve stent function in nine patients. Overall, 14 (12.3%) of the stents became obstructed and six (5.2%) migrated; 86 patients required no further therapy for biliary obstruction or stent malfunction. The 30-day mortality rate was 12%; none of the deaths were directly attributable to a complication of the stent placement procedure.

Biliary Tract Neoplasms↗
PubMed1990

The management of T tube leaks in orthotopic liver transplant recipients with endoscopically placed nasobiliary catheters.

Biliary tract problems remain an important cause of complication following orthotopic hepatic transplantation. We describe 12 liver transplantation patients who developed bile peritonitis secondary to a biliary leak after T tube removal. Each of these patients underwent an urgent ERCP that exhibited leakage outside the T tube tract and nondilated intrahepatic ducts. At the time of the ERCP, a nasobiliary catheter was inserted to divert the bile flow. All of these patients resolved their symptoms and closed their leak. We advocate endoscopic placement of a nasobiliary catheter as first-line therapy for significant T tube tract leaks after liver transplantation.

Adult↗