Biomedical subjects
Publications and source records attributed to J I Bilbao.
Percutaneous and endovascular techniques have shown their efficacy in the treatment of a great variety of pathologies. The advances in diagnostic imaging as well as the development of new materials have made it possible to carry out new procedures that were unthinkable not many years ago. The irruption of this new form of treating patients has had, is having, and will have a clear impact on the multidisciplinary approach to numerous diseases.
INTRODUCTION: Major abdominal surgery can be contraindicated in some cirrhotic patients because of severe portal hypertension. The present study reports our experience of three patients with abdominal tumours prepared for surgery by transjugular intrahepatic portosystemic shunts (TIPS) in order to reduce portal hypertension and the risk of intraoperative bleeding. PATIENTS AND METHODS: Three patients with cirrhosis and portal hypertension diagnosed with a right colon carcinoma, an adenocarcinoma of pancreas and a gastric and sigmoid synchronic tumours in the same patient. Because portal hypertension was the leading cause of surgical contraindication, neoadjuvant TIPS placement was proposed before surgery. RESULTS: TIPS placement was performed without intra-procedure complications. An average reduction of 18 mmHg was achieved in portosystemic gradients. The planned operations were performed with a delay of 14-45 days after TIPS without intraoperative bleeding. Complications occurred in one patient without operative mortality. CONCLUSION: TIPS placement allows a pre-operative portal decompression in cirrhotic patients with portal hypertension and abdominal tumours that require surgical treatment. This procedure reduces the risk of bleeding by reducing the portosystemic gradient and the varices around the tumoral area. This procedure is less invasive than conventional shunt surgery, but it is not free of complications and should be performed by experienced interventional radiologists on selected patients. This is still an experimental indication of TIPS which efficacy must be confirmed in larger series.
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The aim of this study was to evaluate the technical aspects and efficacy of placing tunneled central venous access catheters (CVA) in the inferior vena cava (IVC) via a direct translumbar approach. Between August 1994 and July 1998, 50 CVA (Hickman 13.5 F) were placed in the IVC via a direct translumbar approach in 46 patients (10 males, 36 females) with a mean age of 39.9 years (age range 10-87 years). The indications were chemotherapy administration plus leukoaphoresis (n = 39), bone marrow transplantation (n = 2) and hemodialysis (n = 5). The reasons for placing the CVA in the IVC were cosmetic (n = 34), supradiaphragmatic venous thrombosis (n = 8), previous catheter infection (n = 2), and non-functioning arteriovenous fistula (n = 2). There were no immediate complications. The mean period of time the CVA was in place was 3 months (15 days to 15 months), during which the function was excellent. The commonest late complication was infection (4 local, 6 bacteremia). Others included: pain (n = 2), ureteric fistula (n = 1), pericatheter fibrin sheath formation (n = 6) and catheter-tip impaction (n = 2). Two catheters were damaged due to postprocedural inappropriate manipulations and two others fell off due to incorrect fixation. Due to these complications, it was necessary to remove ten catheters, replace an additional four and reposition two. Direct translumbar catheterization of the IVC is a safe and effective way of placing a long-term CVA with a moderate complication rate.
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Although ultrasound guidance is extensively used in percutaneous interventional procedures, the limitations of B-mode, gray-scale sonographic guidance can restrict clinical use. Little attention has been paid to the use of color Doppler sonography during such procedures. There are several ways in which color Doppler sonography can facilitate percutaneous procedures that involve insertion of a needle or catheter. The advantages of color Doppler sonography include the following: (a) better visualization of the shaft and tip of the needle, especially in solid, echogenic lesions, when the needle is moving, or when the beam-needle angle is narrow; (b) improved targeting of either vessels or non-vascular structures (ie, biliary ducts) to be punctured; (c) avoidance of interposed vascular structures and highly vascular areas during puncture of lesions; (d) improved visualization of poorly echogenic catheters, allowing proper placement; and (e) prompt detection of complications, including active bleeding, after withdrawal of the needle.
To assess the potential role of ultrasound (US) in evaluating transjugularly inserted intrahepatic portosystemic shunts, the authors performed sonographic, including duplex and color Doppler, studies in 23 patients. Imaging was performed before, during the first week after, and 2-3 months after shunt placement. The prostheses were readily visualized and shunt patency was easily determined with Doppler US in all patients. The mean of the maximum blood flow velocity in the main portal vein increased from 7 (range, 3-16) cm/sec before shunting to 24 (range, 18-47) cm/sec 2-3 months after shunting. Flow reversal was detected in the intrahepatic portal branches in 16 (69%) of the 23 patients. US allowed prompt detection and management of two cases of incomplete stent expansion and one case of shunt stenosis due to pseudo-intimal hyperplasia. Sonography is a valuable tool for evaluation of changes in hepatic hemodynamics after transjugular intrahepatic shunt placement.
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Intestinal hemorrhage due to arteriodigestive fistula is described to be a rare and serious complication of radiotherapy. Three cases of this type of fistula in gastric cancer patients treated with gastrectomy, intraoperative electron boost (15 Gy), and fractionated external beam irradiation (46 Gy) are reported. Selective angiography is most helpful in the diagnosis and immediate surgery could be lifesaving. An attempt to explain the etiopathogenesis is made.
In the treatment of active chronic hepatitis and hepatocellular carcinoma some effective drugs can produce myelosuppression. Hypersplenism may considerably limit the dosage of such drugs. Splenectomy is an effective treatment for hypersplenism, although it is not without complications. Partial splenic embolization is a good and safe procedure; 15 patients were treated in order to achieve higher platelet and leukocyte counts. Embolization has been performed with gelfoam with local and systemic antibiotics (Spigos' protocol) and 50-75% of the splenic parenchyma was infarcted. All patients could be treated for the underlying hepatopathy with adequate dosages of interferon or chemotherapeutic drugs.
Two cases are presented in which conventional approaches did not permit dilation of and stent placement in obstructed ureters. In patients with iatrogenic ureteral laceration or rigid ureteral kinking, direct percutaneous translumbar puncture may provide a safe alternative. The authors' technique is described.
Percutaneous placement of portosystemic shunts requires access to the portal system from a transjugular approach. Color Doppler sonography was used to direct the transjugular puncture in intrahepatic portosystemic shunt procedures in four patients. In each case, the technique allowed quick, safe transjugular puncture of the portal vein and close real-time monitoring of the procedure.
From 1982 to 1989, 18 eligible patients (median age 50.5 years, range 30-72 years) with inflammatory breast carcinoma have been treated with neoadjuvant intra-arterial (IA) chemotherapy. The treatment regimen includes IA cisplatin, adriamycin, mytomycin C and thiotepa on Day 1 and intravenous 5-fluorouracil on Days 1 and 2. An objective clinical response rate of 100% (eight complete and 10 partial) has been observed. The median disease-free and overall survivals are 27 months (range 5-85+ months) and 33 months (range 8-85+ months), respectively. With a median follow-up of 21.5 months, six (33.3%) patients remain alive and free of disease and 12 patients have died because of distant metastases. No local recurrences have been observed. Intra-arterial chemotherapy is an attractive technique for the treatment of locally advanced breast carcinoma with mild toxicity and high local control rate.
Direct percutaneous drainage of pancreatic pseudocysts in communication with the duct of Wirsung can lead to pancreaticocutaneous fistula. These patients are safely treated with the percutaneous transgastric approach. In a gastrectomized patient who developed a pseudocyst, we percutaneously placed in internal endoprosthesis from the duct of Wirsung to the afferent loop and gastric pouch.