Central Stenoses Research Articles

Percutaneous endoscopic decompression of the central degenerative stenoses of the lumbosacral spine

Background. Degenerative stenosis of the spinal canal is a condition observed mostly in the elderly. It significantly decreases their quality of life and physical activity. Surgical treatment of the patients is frequently associated with significant surgical and anesthesiologic risks especially during conventional open decompression. The problem of decreasing invasiveness of surgical interventions is important for these patients because in their case lighter postoperative injury and decreased recovery duration after surgery are crucial. Aim. To evaluate clinical outcomes in patients with central degenerative lumbosacral stenoses after percutaneous endoscopic decompression. Materials and methods. Comparison of clinical and radiological characteristics before surgery, on day 1 and month 6 after surgery was performed. Among clinical characteristics, pain syndrome in the leg / legs per the Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) were evaluated. The evaluated radiological characteristic was the spinal canal cross-sectional area (CSA) in cm2 per the magnetic resonance imaging. Statistical analysis was performed using the SPSS Statistics v. 26.0 (IBM, USA) software. Results. Pain syndrome in the leg / legs (decreased VAS score) after surgery decreased significantly (р = 0.006). No significant difference between the VAS scores on day 1 and 6 months after the surgery was found (adjusted significance level padj = 1.000). Similarly, disability index changes were statistically significant after surgery (р = 0.005): ODI score decreased. Additionally, no statistically significant differences between ODI score on day 1 and 6 months after surgery were observed (padj = 1.000). Increase in CSA of the spinal canal was statistically significant (р = 0.001), no differences in this parameter on day 1 and 6 months after surgery were found. Conversion to microsurgical access was necessary in 4 (23.5 %) of 17 patients. No statistically significant differences in VAS, ODI scores and CSA changes at different time points were observed in patients who required conversion. Conclusion. Results of the study show significant improvement of the patients’ clinical status (per the VAS and ODI) and achievement of adequate radiological decompression (increased spinal canal CSA) which persisted for 6 months after percutaneous endoscopic interventions.

3D printed drug-eluting stents: Toward personalized therapy for airway stenosis

Airway stents are life-saving medical devices used to treat malignant or benign central airway stenoses. Unfortunately, these devices, typically manufactured from silicone alone and/or nitinol, can result in serious complications, such as stent migration, bacterial colonization, and tissue granulation, eventually forcing stent removal. Customized airway stents exhibit reduced migration and they can be tailored to address other complications by releasing drugs, such as the antibiotic levofloxacin and the antifibrotic drug nintedanib. Herein, the incorporation of these molecules in customized, bioresorbable 3D printed airway stents was investigated. Nintedanib (1.5 wt%) and levofloxacin (2.0 wt%) were incorporated in the polymer-based resin, which was used to 3D print tracheal stents with adequate mechanical and drug release properties. The drug-loaded stents were then deployed into rabbit tracheas and found to deliver the drugs locally with minimal systemic exposure. Drug activities were demonstrated by inhibition of bacterial colonization and reduced interleukin 8 (IL8) local expression. Although the application of these tracheal stents requires further exploration in larger animal models, this work paves the way for the rapid manufacturing of personalized medical devices with therapeutic functions.

Influence of balloon type and lesion location on outcomes following fistuloplasty.

There is limited evidence supporting the optimal use of fistuloplasty to maintain vascular access at various lesion sites, despite its critical role in facilitating renal replacement therapy and the overall high failure rates of arteriovenous fistulas (AVFs). This study aims to identify covariates affecting primary and secondary patency following fistuloplasty of native upper limb vascular access AVFs. This retrospective study included all patients who underwent fistuloplasty at a tertiary vascular centre over 4years. Baseline characteristics were recorded, and factors associated with primary and secondary patency rates were analysed. A total of 206 patients (88 male, 118 female) with a mean age of 68 (±14) years underwent fistuloplasty during the study period. The prevalence of diabetes, ischaemic heart disease and antiplatelet usage were 33%, 21% and 70%, respectively. The median number of fistuloplasties per access during the follow-up period was 2 [1-3]. Fistulas were classified as radiocephalic (65), brachiocephalic (102) and brachiobasilic transposition (39). Recurrent stenosis (RS) was identified in 60 patients who had previous fistuloplasty before the study period, while 146 patients had de novo stenoses (DNS). Stenosis location significantly differed between RS and DNS (p = .03), with DNS primarily being anastomotic and RS predominantly in central and mixed locations. Younger fistulas were more likely to have anastomotic stenoses compared to those older than 1year (p = .001). While no significant differences in primary patency (PP) were observed, secondary patency (SP) varied by stenosis location: Central 32 [13-42] months, Fistula vein 20 [12.5-35.5] months, Mixed 25 [13.5-37.5] months and Anastomotic 19 [7-29.5] months (p = .012). Stenosis location in AVFs is associated with the age and type of the fistula. Younger fistulas often fail due to anastomotic stenoses, which have lower secondary patency compared to stenoses at other sites. Preliminary data suggest that central stenoses, primarily occurring in older fistulas, exhibit better secondary patency following fistuloplasty than stenoses at other locations.

Safety and Performance of a Cell-Impermeable Endoprosthesis for Hemodialysis Vascular Access Outflow Stenosis: A Brazilian Multicenter Retrospective Study

PurposeTo evaluate the safety and performance of Wrapsody™, a cell-impermeable endoprosthesis (CIE), for treating hemodialysis vascular access outflow stenosis.Materials and MethodsInvestigators retrospectively analyzed 113 hemodialysis patients treated with a CIE (11/2021–12/2022) across four centers in Brazil. De novo or restenotic lesions were treated. The primary efficacy outcome measure was target lesion primary patency (TLPP) at 1, 3, 6, and 12 months; the primary safety outcome measure was the absence of serious local or systemic adverse events within the first 30 days post-procedure. Secondary outcome measures included technical and procedural success, access circuit primary patency (ACPP), and secondary patency at 1, 3, 6, and 12 months post-procedure.ResultsThirty-nine patients (34.5%) had thrombosed access at the initial presentation, and 38 patients (33.6%) presented with recurrent stenosis. TLPP rates at 1, 3, 6, and 12 months were 100%, 96.4%, 86.4%, and 69.7%, respectively. ACPP rates were 100% at 1 month, 89.2% at 3 months, 70.9% at 6 months, and 56.0% at 12 months. The target lesion secondary patency rates at 1, 3, 6, and 12 months were 100%, 97.3%, 93.6%, and 91.7%, respectively. In the adjusted multivariate Cox regression analysis, male sex and endoprosthesis with diameters of 10, 12, 14, and 16 mm were associated with improved primary patency rates. No localized or systemic serious adverse event was observed through the first 30 days post-procedure.ConclusionThe CIE evaluated in this study is safe and effective for treating peripheral and central outflow stenoses in hemodialysis vascular access.Level of EvidenceLevel 2b, cohort study.Graphical

Diagnostic utility of 3D MRI sequences in the assessment of central, recess and foraminal stenoses of the spine: a systematic review.

To perform a systematic literature review on the diagnostic utility of 3D MRI sequences in the assessment of central canal, recess and foraminal stenosis in the spine. The databases PubMed, MEDLINE (via OVID) and The Cochrane Central Register of Controlled Trials, were searched for studies that investigated the diagnostic use of 3D MRI to evaluate stenoses in various parts of the spine in humans. Three reviewers examined the literature and conducted systematic review according to PRISMA 2020 guidelines. Thirty studies were retrieved from 2 595 publications for this systematic review. The overall diagnostic performance of 3D MRI outperformed the conventional 2D MRI with reported sensitivities ranging from 79 to 100% and specificities ranging from 86 to 100% regarding the evaluation of central, recess and foraminal stenoses. In general, high level of agreement (both intra- and interrater) regarding visibility and pathology on 3D sequences was reported. Studies show that well-optimized 3D sequences allow the use of higher spatial resolution, similar scan time and increased SNR and CNR when compared to corresponding 2D sequences. However, the benefit of 3D sequences is in the additional information provided by them and in the possibility to save total protocol scan times. The literature on the spine 3D MRI assessment of stenoses is heterogeneous with varying MRI protocols and diagnostic results. However, the 3D sequences offer similar or superior detection of stenoses with high reliability. Especially, the advantage of 3D MRI seems to be the better evaluation of recess stenoses.

Indications for and Outcomes of Three Unilateral Biportal Endoscopic Approaches for the Decompression of Degenerative Lumbar Spinal Stenosis: A Systematic Review

In this systematic review, we summarized the indications for and outcomes of three main unilateral biportal endoscopic (UBE) approaches for the decompression of degenerative lumbar spinal stenosis (DLSS). A comprehensive search of the literature was performed using Ovid Embase, PubMed, Web of Science, and Ovid's Cochrane Library. The following information was collected: surgical data; patients' scores on the Visual Analog Scale (VAS), Oswestry Disability Index (ODI), and Macnab criteria; and surgical complications. In total, 23 articles comprising 7 retrospective comparative studies, 2 prospective comparative studies, 12 retrospectives case series, and 2 randomized controlled trials were selected for quantitative analysis. The interlaminar approach for central and bilateral lateral recess stenoses, contralateral approach for isolated lateral recess stenosis, and paraspinal approach for foraminal stenosis were used in 16, 2, and 4 studies, respectively. In one study, both interlaminar and contralateral approaches were used. L4-5 was the most common level decompressed using the interlaminar and contralateral approaches, whereas L5-S1 was the most common level decompressed using the paraspinal approach. All three approaches provided favorable clinical outcomes at the final follow-up, with considerable improvements in patients' VAS scores for leg pain (63.6-73.5%) and ODI scores (67.2-71%). The overall complication rate was <6%. The three approaches of UBE surgery are effective and safe for the decompression of various types of DLSS. In the future, long-term prospective studies and randomized control trials are warranted to explore this new technique further and to compare it with conventional surgical techniques.

Magnetic Resonance Imaging Grading Systems for Central Canal and Neural Foraminal Stenoses of the Lumbar and Cervical Spines With a Focus on the Lee Grading System.

Magnetic resonance imaging (MRI) is a standard imaging modality for diagnosing spinal stenosis, which is a common degenerative disorder in the elderly population. Standardized interpretation of spinal MRI for diagnosing and grading the severity of spinal stenosis is necessary to ensure correct communication with clinicians and to conduct clinical research. In this review, we revisit the Lee grading system for central canal and neural foraminal stenosis of the cervical and lumbar spine, which are based on the pathophysiology and radiologic findings of spinal stenosis.

Indications, Contraindications, and Complications of Biportal Endoscopic Decompressive Surgery for the Treatment of Lumbar Stenosis: A Systematic Review

Biportal endoscopic spine surgery is gaining popularity in managing degenerative lumbar diseases and has optimal indications and contraindications. The perioperative complications related to the biportal endoscopic approach affect the postoperative outcomes. Therefore, this study aimed to review the indications, contraindications, and complications of biportal endoscopic decompression for lumbar stenosis. For this systematic review, articles on biportal endoscopic decompressive surgery for lumbar stenosis, including central, lateral recess and foraminal stenoses, were searched for and reviewed. Additionally, the complications, indications, and contraindications of biportal endoscopic surgery for lumbar stenosis were reviewed. Forty-one articles were included in this study. The indications for biportal endoscopic decompression are central lumbar stenosis, central stenosis with lipomatosis, lateral recess stenosis, foraminal stenosis, and the far-out syndrome. The contraindications include trauma, infection, tumor, instability, high-grade spondylolisthesis, isthmic spondylolisthesis, and severe scoliosis. Perioperative complications are typically minor; major complications include durotomy, epidural hematoma, incomplete decompression, infection, facet joint injury, neural injury, increased epidural pressure, and postoperative instability. Favorable indications for a biportal endoscopic approach are central lumbar, lateral recess, foraminal, extraforaminal stenoses, and the Bertolotti syndrome. Incidental durotomy and postoperative epidural hematomas are common complications of biportal endoscopic decompression.

Alagille Syndrome and Repeat Oxygenator Failure during Cardiopulmonary Bypass: A Word of Caution

Alagille syndrome is an autosomal dominant disorder that is caused by heterozygous mutation of JAG1 or NOTCH2 gene that impacts several multisystem organs including but may not be limited to the liver, heart, musculoskeletal, skin, and the eyes. The most common congenital heart defect associated with Alagille syndrome is multilevel right ventricular outflow tract obstruction with multiple central and peripheral branch pulmonary arterial stenoses occurring in up to two-thirds of these patients. We report two cases of Alagille syndrome who underwent extensive pulmonary arterial branch rehabilitation and experienced unusual oxygenator failure during cardiopulmonary bypass (CPB). We present lessons learned from these two cases and the changes that we implemented in our practice that facilitated smooth conduct of CPB in other cases that we performed subsequently.

T-CELL LYMPHOMA CAUSING CENTRAL AIRWAY OBSTRUCTION TREATED WITH TRACHEOBRONCHIAL SELF-EXPANDING METALLIC STENT

T-CELL LYMPHOMA CAUSING CENTRAL AIRWAY OBSTRUCTION TREATED WITH TRACHEOBRONCHIAL SELF-EXPANDING METALLIC STENT

Probability for surgical treatment in patients with lumbar spinal stenosis according to the stenotic lesion severity: a 5–10-year follow-up study

BackgroundWe aimed (1) to clarify difference in the natural history of lumbar spinal stenosis (LSS) with respect to surgical treatment according to severity of stenosis on magnetic resonance imaging (MRI) using qualitative grading system and (2) to estimate surgical probabilities depending on radiological severity.MethodsWith the design of retrospective observational study, a total of 1,248 patients diagnosed with LSS between 2011 and 2014 at our hospital were followed up for the mean duration of 7.7 years (5.17–9.8 years). We investigated severity of central and foraminal stenoses on initial MRI using qualitative grading system and whether surgical treatment was performed. Logistic regression models were used to identify risk factors for surgery.ResultsDuring the mean follow-up period of 7.7 years, grade 3 maximal central stenosis showed the highest percentage of surgical treatment (57.9%–62.3%) with no significant difference in surgical probabilities according to concomitant foraminal stenosis. Surgical probabilities in grade 2 and 3 maximal foraminal stenosis, were 22.2%–62.3% and 33.3%–57.9%, respectively, depending on concomitant central stenosis. Maximal central stenosis of grades 1, 2, and 3 (odds ratio [OR]: 1.79, 2.21, and 6.26, respectively), and maximal foraminal stenosis of grades 2 and 3 (OR: 2.22 and 2.12, respectively) were significant risk factors for surgical treatment.ConclusionsThe high grades of maximal central and foraminal stenoses were risk factors for surgical treatment. Surgical probabilities were 57.9%–62.3% in grade 3 maximal central stenosis, 22.2%–62.3% and 33.3%–57.9%, respectively, in grade 2 and 3 maximal foraminal stenosis during the mean follow-up period of 7.7 years. These results indicate that the natural history of LSS differs according to grade of maximal central and foraminal stenoses.

Prospective First-in-Human Study of the Merit WRAPSODY Endovascular Stent Graft for Treatment of Access Circuit Outflow Stenosis in Hemodialysis Patients

The aim of this study was to evaluate the safety and effectiveness of the WRAPSODY stent graft in the treatment of outflow and central (brachiocephalic and/or subclavian) stenoses or occlusions in the arteriovenous venous circuit of persons requiring dialysis for end-stage renal disease.

Clinical outcomes and survival following placement of self‐expandable metallic stents for central airway stenosis and fistula

BackgroundSelf‐expandable metallic stent (SEMS) placement is an urgent procedure for patients with malignant central airway stenoses (CASs) and central airway fistulas (CAFs). The aim of this study was to determine the outcome and survival after SEMS placement in patients with malignant CASs and CAFs.MethodsSEMSs were inserted into 20 patients with malignant CASs and four with malignant CAFs. Hospital records, the modified Medical Research Council dyspnea scale (mMRC) grade, performance status (PS), symptoms, procedure‐related complications and survival after placement were retrospectively reviewed.ResultsSpiral Z stents were inserted in nine patients, covered Ultraflex stents in 14, and a bare Ultraflex in one patient. After SEMS placement, 20 patients (83.3%) showed improvement in mMRC grade, 19 (79.2%) showed improvement in PS, and 21 (87.5%) showed improvement in symptoms. There were three patients whose stents migrated out of place, but there were no patients with obstructive granulation, infection, or mucous plugs. Median survival days after stent insertion was 98 days for CAS and 103 days for CAF, and mean survival days was 383 ± 707 days for CAS and 93 ± 33 days for CAF. Two patients with CAS by malignant lymphoma and thymic cancer survived more than six years because they were also treated with efficient therapies. The five‐year survival rate after stent insertion was 7.7%.ConclusionsSEMS placement for CAS and CAF is associated with improvement in mMRC grade, PS and symptoms in 87.5% of patients. Patients with a malignant CAS are usually terminal, but the possibility of increasing survival rate will become a reality with new efficient therapies.Key pointsSignificant findings of the study Reasonable clinical outcomes and improved survival of patients following SEMS placement for thoracic malignancy with central airway stenosis and fistula. What this study adds The possibility of increasing survival rate will become a reality with new efficient therapies.

Results of Stenting for Central Venous Occlusions and Stenoses in the Hemodialysis Patients.

Objectives: We aim to investigate the results of stenting for central venous occlusions and stenoses in the hemodialysis patients.Methods: Twenty-nine cases treated with endovascular recanalization with deployment of bare metal stent (BMS) for central venous occlusions (24 cases) and recurrent stenoses (5 cases) between 2014 and 2018 were retrospectively analyzed. Results of these procedures including success rate, operative time, estimated blood loss, morbidity, primary patency, assisted primary patency and freedom from target-lesion revascularization (TLR) were evaluated.Results: Nine lesions were in brachiocephalic vein (Occlusion/Stenosis: 8/1) and 20 lesions were in subclavian vein (Occlusion/Stenosis: 16/4). Procedural success was 94% (29/31 cases) and operation time/estimated blood loss was 68±39 min/28±54 g. Symptom were relieved or disappeared in all successful cases. Morbidity (extravasation of contrast medium) was 3% (1/29). During the period of observation, 1 stent fracture with occlusion and 1 stent migration to periphery were recognized. 1-year primary patency, freedom from TLR, and assisted primary patency were 40% (median patent time: 256 days), 67% (median patent time: 524 days), and 77%, respectively.Conclusion: Stenting for central venous occlusions and stenoses in the hemodialysis patients is safe and durable treatment option. However, considering its off-label use and potential hazard including vessel rupture, stent migration, and stent fracture, the indication for BMS deployment should be conservative, and interventionist should be well acquainted with prevention and measures to these complications. (This is a translation of Jpn J Vasc Surg 2019; 28: 193–198.)

Histologic and morphologic character of pediatric renal artery occlusive disease

ObjectiveThe pathologic nature of pediatric renal artery occlusive lesions causing renovascular hypertension has been the subject of numerous anecdotal reports. This study was undertaken to define the character of childhood renal artery stenoses. A better understanding of this disease is particularly germane, given its unknown etiology and the limited success of certain contemporary treatment options. MethodsRenal artery specimens obtained during open operations in children being treated for renovascular hypertension from 2004 to 2016 were studied. Excluded from study were arteries subjected to earlier open or endovascular operations. Histologic preparations employing hematoxylin-eosin, Movat, Masson trichrome, and Verhoeff-van Gieson stains allowed characterization of the intima, media, and adventitial tissues. External and luminal diameters were measured. Microscopic data were correlated with preoperative arteriographic images. The histologic and morphologic findings were assessed in regard to coexistent nonrenal arterial and aortic lesions as well as known syndromic diseases. ResultsThirty-three stenotic renal arteries from 28 children were subjected to examination. Stenoses involved the proximal-ostial renal arteries (24), central renal arteries (7), and distal segmental renal arteries (2). Ostial stenoses commonly exhibited preocclusive concentric hyperplasia of intimal tissues, frequent internal elastic lamina disruptions, and diminutive and discontinuous media. Central and distal renal stenoses most often exhibited lesser intimal cellular hyperplasia and more noticeable fibrodysplasia of the media and adventitia. The mean external and luminal diameters of the renal arteries having ostial stenoses were smaller than the expected renal artery size for a given age. Abdominal aortic coarctation or hypoplastic aortas occurred in 14 children. Neurofibromatosis type 1 affected four children with ostial renal artery disease and one child with midrenal artery disease, but there were no distinguishing features unique to their stenoses. ConclusionsPediatric renal artery stenotic disease affects exceedingly small arteries. Ostial lesions frequently exhibit extensive luminal encroachments characterized by cellular hyperplasia of intimal tissues and scant medial smooth muscle. Central and distal renal arterial stenoses were characterized most often by extensive fibrodysplasia of the media and adventitia. The early success and durability of catheter-based angioplasty may be compromised by the cellular abnormalities of pediatric renal artery occlusive disease observed in this investigation.

Diagnostic workup of primary sclerosing cholangitis: The benefit of adding gadoxetic acid-enhanced T1-weighted magnetic resonance cholangiography to conventional T2-weighted magnetic resonance cholangiography

To evaluate the value of gadoxetic acid-enhanced T1-weighted (T1W) magnetic resonance cholangiography (MRC) versus conventional T2-weighted (T2W) MRC compared to endoscopic retrograde cholangiopancreatography (ERCP) in patients with primary sclerosing cholangitis (PSC). Based on T1W MRC, PSC patients were classified into a regular (RG) and a delayed (DG) excreting group, with an absence of gadoxetic acid in the common bile duct at 20 min. Beading, pruning, and gradation of central bile duct stenosis, evaluated by T1W and T2W MRC, were compared to ERCP. Liver parenchymal enhancement was measured in both study groups and compared to a reference group (n = 20) without a history of liver disease. Two readers performed all measurements. Based on beading and pruning of the peripheral bile ducts, sensitivities, specificities, and accuracies for reader 1 were 0.17/0.43, 0/0.17, and 0.15/0.31 for T1W MRC, and 0.83/0.86, 1/0.83, and 0.85/0.85 for T2W MRC (p = 0.004). For reader 2 sensitivities, specificities, and accuracies were 0.25/0.57, 0/0.33, and 0.23/0.46 for T1W MRC, and 0.92/1, 1/0.83, and 0.92/0.92 for T2W MRC (p = 0.012). Compared to ERCP, central bile duct stenoses were significantly overestimated (p < 0.001) by T2W MRC. A significantly lower parenchymal enhancement was found in the DG (n = 7) compared to the RG (n = 13), and compared to the reference group (p < 0.001). The combined performance of T2W and T1W MRC may provide a comprehensive imaging workup of PSC, including morphological and functional information resulting in optimal management.

Outcome of TiNi Stent Treatments in Symptomatic Central Airway Stenoses Caused by Aspergillus fumigatus Infections After Lung Transplantation

BackgroundCentral airway stenoses due to Aspergillus fumigatus infections have been a significant cause of morbidity and mortality after lung transplantation. We reviewed our experience using self-expandable braided TiNi-metallic stents in the management of 4 single-lung transplant recipients with central airways stenoses between January 2003 and June 2010. MethodsThirty-six single-lung transplant recipients were subjected to pulmonary function testing and surveillance bronchoscopy with biopsy at predetermined intervals and when clinically indicated. Bronchial wash fluid and biopsy material were examined by appropriate fungal stain and culture techniques. ResultsNine of 36 patients (25%) were diagnosed with Aspergillus fumigatus infections; 4 (11.1%) showed rapid decrease in pulmonary function and developed severe upper airway narrowings with about 80% of the central airway obstructed by thick plugs of mucus, heavily laden with Aspergillus species. All 4 patients were managed with stent placement as well as antifungal treatments and showed a forced vital capacity and forced expiratory volume in 1 second improvement of 11.3% and 25.9%, respectively after 1 month. ConclusionsTiNi stent applications in combination with antifungal drugs are sufficient to treat central airway stenoses after lung transplantation.

Silicone stents, the rigid bronchoscope, and the standard of care in central airway stenosis

Central airway stenoses often represent a therapeutic challenge and require a multidisciplinary approach involving interventional pulmonologists and thoracic surgeons. While surgery is often the preferred definitive modality, advances in bronchoscopic techniques have led to substantial improvements in patient symptoms and long-term quality of life using minimally invasive techniques generally safe when performed by experienced proceduralists. Endobronchial laser therapy, cryotherapy, conventional electrocautery, or argon plasma coagulation and photodynamic therapy have been used successfully. A variety of stents, silicone or self-expandable (covered or non-covered metallic stents), have been used though little significant progress has been achieved since the description of the dedicated airway silicone stents first described by Jean-Francois Dumon in the 1980s. Rigid bronchoscopy remains the method of choice for the treatment of both benign and malignant central airway obstruction, but significant technological advances allow for effective treatments using the flexible bronchoscope. Metallic non-covered stents are generally not recommended, except in selected patients with poor short-term prognosis.

Is There a Role for Endoscopic Therapy as a Definitive Treatment for Post-Laparoscopic Bile Duct Injuries?

Excellent results of surgical reconstruction of major bile duct injuries (BDIs) have been well-documented. Reports of successful definitive management of central bile duct leakage and stenoses have been reported infrequently. The aim of this study was to assess treatment and outcomes for operative and endoscopic treatment of BDI after laparoscopic cholecystectomy (LC) and define the role of endoscopy in management. All patients undergoing treatment for post-laparoscopic BDI from 1998 to 2007 at Mayo Clinic, Rochester, Minnesota were reviewed. Outcomes of surgical and endoscopic intervention were analyzed. BDI was identified in 159 patients (mean age 51 years). Injury was recognized intraoperatively in 39 (25%) patients. Primary intervention was surgical in 59 (37%) and endoscopic in 100 (63%) patients. Class A BDIs (n = 77) were successfully treated endoscopically in 76 (99%) patients. Seven had class D BDIs; 4 were managed surgically, and 3 endoscopically. Of 66 patients with E1 to E4 BDI, 44 (67%) were initially managed surgically and 22 (33%) endoscopically. Thirteen of the latter 22 underwent sustained endoscopic therapy (median stent time 7 months), which was successful in 10 (77%). Four patients with E5 were managed surgically. Median follow-up was 45 months. Sixty-three patients underwent Roux-en-Y hepaticojejunostomy reconstruction at Mayo; 3 (5%) failed and required stenting. None required operative revision. Endoscopic management of class A BDI has excellent outcomes. Although surgical management remains the preferred therapy, short-term endoscopic treatment for class E1 to E4 can optimize the patient and operative field for reconstruction. Prolonged stenting in select patients with E1 to E4 characterized by stenosis is successful in the majority.

The Norwood procedure using a right ventricle–pulmonary artery conduit: Comparison of the right-sided versus left-sided conduit position

We proposed that a right-sided right ventricle-pulmonary artery conduit during the stage I Norwood procedure would facilitate pulmonary artery reconstruction during the stage II procedure. Between 2002 and 2006, 153 patients underwent Norwood stage I reconstruction with a right ventricle-pulmonary artery conduit (125 in the right-sided group and 28 in the left-sided group). The previous 150 consecutive classic Norwood procedures (1997-2002) were used as a control group. Outcomes from stages I and II were analyzed, including ventricular function and pulmonary artery morphology. The 30-day survival was 88% (110/125) in the right-sided group, 75% (21/28) in the left-sided group, and 70% (105/150) in the control group (P < .001, right-sided vs control groups). The conduit length was 35 +/- 9 mm in the right-sided group and 26 +/- 8 mm in the left-sided group (P = .001). Survival at 6 months demonstrated a significant survival benefit in the right-sided right ventricle-pulmonary artery conduit group over the control group (P = .009, log-rank test). There was no difference in ventricular function between the groups and no regional dyskinesia associated with the right ventricle-pulmonary artery conduit. Despite larger branch pulmonary artery size in the right ventricle-pulmonary artery conduit groups (compared with the control group), central pulmonary artery stenoses were common (62% in the right conduit and 80% in the left conduit). Bypass and ischemic times at stage II were 49 +/- 10 and 23 +/- 13 minutes in the right-sided group compared with 61.5 +/- 9.5 and 31 +/- 14 minutes in the left-sided group (P < .001 and P = .03, respectively). The 30-day mortality after the stage II procedure was 1.3% (1/76) in the right-sided group, 0% (0/18) in the left-sided group, and 3.3% (3/90) in the control group. The right-sided conduit is a safe technique and has improved 30-day and overall post-stage II survival compared with that seen with the classic Norwood procedure. The right ventricle-pulmonary artery conduit is associated with central pulmonary artery stenosis but good development of the branch pulmonary arteries and preservation of ventricular function. The right-sided conduit significantly reduces cardiopulmonary bypass times at stage II.