The role of percutaneous cholecystostomy (PC) in the management of acute cholecystitis and cholangitis is outlined in the revised 2013 Tokyo Guidelines. These two emergencies constitute the vast majority of PC performed today for therapeutic purposes, and research has repeatedly shown the utility of PC in these conditions. PC is typically employed in the management of critically ill patients who are not surgical candidates. Indications and contraindications to PC are reviewed. Additional innovative applications of PC have been developed since it was first described in 1980. These include biliary drainage, dilation of biliary strictures, and stenting of the biliary tree including the common bile duct. Special consideration must be given to the patient selection criteria when deciding who can benefit from PC. Patient comorbidities can also influence the PC technique employed. Both transhepatic and transperitoneal approaches have distinct advantages and disadvantages. The technical success rate for PC is 95 to 100% and the complication rate is extremely low. Most complications are minor.
The pathophysiology of myocardial injury that results from cardiac ischemia and reperfusion (I/R) is incompletely understood. Experimental evidence from murine models indicates that innate immune mechanisms including complement activation via the classical and lectin pathways are crucial. Whether factor B (fB), a component of the alternative complement pathway required for amplification of complement cascade activation, participates in the pathophysiology of myocardial I/R injury has not been addressed. We induced regional myocardial I/R injury by transient coronary ligation in WT C57BL/6 mice, a manipulation that resulted in marked myocardial necrosis associated with activation of fB protein and myocardial deposition of C3 activation products. In contrast, in fB-/- mice, the same procedure resulted in significantly reduced myocardial necrosis (% ventricular tissue necrotic; fB-/- mice, 20 ± 4%; WT mice, 45 ± 3%; P < 0.05) and diminished deposition of C3 activation products in the myocardial tissue (fB-/- mice, 0 ± 0%; WT mice, 31 ± 6%; P<0.05). Reconstitution of fB-/- mice with WT serum followed by cardiac I/R restored the myocardial necrosis and activated C3 deposition in the myocardium. In translational human studies we measured levels of activated fB (Bb) in intracoronary blood samples obtained during cardio-pulmonary bypass surgery before and after aortic cross clamping (AXCL), during which global heart ischemia was induced. Intracoronary Bb increased immediately after AXCL, and the levels were directly correlated with peripheral blood levels of cardiac troponin I, an established biomarker of myocardial necrosis (Spearman coefficient = 0.465, P < 0.01). Taken together, our results support the conclusion that circulating fB is a crucial pathophysiological amplifier of I/R-induced, complement-dependent myocardial necrosis and identify fB as a potential therapeutic target for prevention of human myocardial I/R injury.
This study aims to assess long-term survival outcomes of ablative segmental radioembolization with yttrium-90 [radiation segmentectomy (RS)] for early stage hepatocellular carcinoma (HCC). Materials: With IRB approval, we included patients from our prospectively acquired database that were treated with RS for HCC between 2004-2017. Intention to treat (ITT) overall survival (OS) was estimated using Kaplan Meier method from date of treatment. Censored OS was estimated by censoring patients who underwent curative liver transplantation or resection. Further OS sub-analysis was done on patients with HCC 3 cm. Results: 269 patients met the inclusion criteria. 66% (n ¼ 177) were males and mean age was 66 years (range, 22-96). At baseline, 51% (n ¼ 136) were Child-Pugh (CP) A, 43% (n ¼ 115) CP B, and 7% (n ¼ 18) CP C. According to UNOS tumor staging, 14% (n ¼ 37) patients had T1 tumors, 79% (n ¼ 212) had T2, and 7% (n ¼ 20) had T3 tumors. 38% (n ¼ 103) of patients were bridged to liver transplant. 4% (n ¼ 10) had surgical resection after RS. 8.5% (n ¼ 23) developed new grade 3/4 bilirubin toxicity, and 1.5% (n ¼ 4) developed new grade 3 albumin toxicity. Censored OS was 80.3 (CI: 44-80.3) months for CP A and 27 (CI:17-31) months for CP B. ITT OS was 102 (CI: 80.3-120) months for CP A and 39 (CI:29-82.5) months for CP B patients. Further stratification for CP A by size demonstrated survival difference by tumor size 3 cm vs >3 cm, with median censored OS of 80 (CI: 44:80.3) and 47 (CI: 29.3:61) months, respectively (p ¼ 0.05). For this (3 cm) select cohort (n ¼ 87), 1-,3-and 5-year survival rates was 99%, 79%, 69% respectively. On multivariate analysis baseline albumin, and AFP > 100 ng/dl were significant prognosticators of survival. Conclusions: Radiation segmentectomy is a safe and effective treatment for patients with early stage HCC. Patients with CP A liver function and HCC 3 cm exhibit survival outcomes similar to other curative surgical and ablative treatments.
Global heart ischemia occurs in the normal course of cardiac surgery during aortic cross-clamping (AXCL), and plasma level of cardiac troponin, a specific myocardial injury marker, increases during reperfusion after releasing the clamp. Earlier clinical studies also found C3, the common factor in three complement pathways, is activated during cardiac surgery. In this prospective study, we investigated three complement pathways in the involvement of myocardial injury during cardiac surgery. Fifty patients undergoing open heart surgery were enrolled. Coronary sinus and peripheral blood were collected at different peri-operative time points. Plasma levels of the initial factors in the complement pathways were analyzed. Our results showed that the level of complement factor B, the initial component in the alternative pathway, increased significantly in both coronary sinus and peripheral blood after release of AXCL compared to samples taken prior to AXCL. Spearman correlation analysis showed that this post-AXCL increase in factor B was significantly correlated with the cardiac troponin level sampled immediately after the operation. In contrast, there was no significant correlation between the initial factors in the classical or the lectin complement pathways and post-operation troponin levels. Thus, alternative complement pathway is activated during open heart surgery and may play a role in human myocardial ischemic injury.
Background Mediastinal and abdominal lymphatic malformations may not be diagnosed until adulthood. Radiologic and pathologic diagnosis is often challenging due to the rarity of the lesion. Surgical excision of these lesions may be curative but lymphatic leak is a known complication. Lymphatic duct embolization may then be required to treat the leak. Case presentation We describe a patient with post-surgical chylothorax where thoracic duct lymphangiography and embolization was performed by catheterizing the thoracic duct at the venous angle where it drains into the subclavian vein. Conclusion Lymphatic duct embolization can be challenging in patients with lymphatic malformations. In these patients, if there is adequate visualization on ultrasound or fluoroscopy, terminal aspect of the thoracic duct can be accessed through the subclavian vein to perform the procedure.
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