External Drainage Research Articles

Clinical Results of Percutaneous Transhepatic Biliary Drainage With Different Hepatic Access and Methods in the Treatment of Obstructive Jaundice

Background: Percutaneous transhepatic biliary drainage (PTBD) is a common procedure for biliary obstruction jaundice caused by biliary tract obstruction. PTBD can be performed using external or external-internal methods, by the right or left lobe approach. However, differences in both the method used and the hepatic approach may affect success rates and complications. Therefore, this study aimed to examine the outcomes and complications of PTBD and compare them according to different methods and hepatic approaches. Methods: Patients who underwent PTBD procedures in our interventional radiology department due to benign or malignant pathologies between March 2021 and March 2024 were included in the study. The diagnoses of the patients, and total and direct bilirubin values before and after the procedure were recorded. The clinical results and the complications of PTBD were compared statistically according to the hepatic approach and method. Univariate logistic regression analysis was performed to determine significant factors associated with PTBD success and complications. Results: Sixty patients were included in our study (32 men, 28 women; mean age: 67.14±13.61 y). The most common indication was malignant bile duct obstruction (90%). The obstruction was mostly at the level of the common bile duct (46.7%). The success rate of PTBD was the highest with the left-side external biliary drainage approach (left-side external biliary drainage, 81.2%; right-side internal-external biliary drainage, 77.8%; right-side external biliary drainage, 69.2%; P=0.596). The complication rate was higher for right-side access (right side 15.9%, left side 12.5%, P=0.744). Univariate logistic regression analysis revealed that PTBD success in females was 5 times higher than in males [Exp(B): 5.000, β: 1.609, P<0.05]. Univariate logistic regression analysis revealed that methods used, entry lobes, and entry levels did not significantly affect PTBD success and complication incidence (P>0.05). Conclusion: All approaches and methods used during PTBD were associated with low complications and high success rates. Nevertheless, external biliary drainage with right hepatic access has the lowest clinical success rate and a higher complication rate than the left-lobe approach. We observed that left-sided external biliary drainage was the most successful method and had fewer complications.

Percutaneous transhepatic biliary drainage in patients with cholestasis following liver transplantation.

Biliary strictures are among the most common complications following liver transplantation (LT). If endoscopic retrograde cholangiography fails, percutaneous transhepatic biliary drainage (PTBD) may serve as an alternative approach. Description of clinical important short- and long-term outcomes as well as outcome prediction following PTBD after LT are scarce. We analyzed outcomes of 56 liver-transplanted adults with biliary complications receiving a PTBD. We described the safety and longitudinal laboratory changes. We analyzed as endpoints, incidence of biliary complications, need for surgical biliary revision/re-LT and overall-survival at 12- and 60-months. We used simple comparison tests accordingly and performed competing risk analysis and multivariate competing risk regression as well as log-rank test and cox proportional hazard regression for further analysis. PTBD procedures had a high technical success rate (98%) and tolerable safety profile. Multiple laboratory indicators improved during follow-up (37 patients with complete biochemical follow-up). Incidence of subsequent biliary complications was highly dependent on the nature of present biliary strictures (Anastomotic stricture (AS): adjusted SHR: 0.26, 95% CI: 0.09-0.78, p = 0.016). Need for surgical biliary revision/re-LT remained below 15%. 12-month survival was significantly better, if drainage into the small intestine was achieved at first attempt compared to completely external drainage (internal: 92.9 vs. external: 67.9%, p = 0.018). Patients with AS had a numerically higher long-term-survival and higher C-reactive-protein (CRP) and lower body-mass-index (BMI) at baseline were significantly associated with inferior short- and long-term-survival. PTBD for biliary complications following LT had a high technical success and a tolerable safety profile. Incidence of subsequent biliary complications was highly dependent on the nature of biliary strictures and increased mortality was found in patients with higher CRP, lower BMI and failure of initial PTBD internalization.

Predictive factors for shunt dependency in patients with spontaneous intraventricular hemorrhage

Intraventricular hemorrhage (IVH) occurs in approximately 30–50% patients with spontaneous intracerebral hemorrhage (ICH), with a high 30-day mortality rate. Excess accumulation of parenchymal or ventricular blood associated with the development of acute hydrocephalus leads to poor outcomes. The prediction of shunt dependency is important to identify patients susceptible to requiring permanent shunt placement and benefit from the diversion. This retrospective analytical study aimed to establish a predictive model of shunt dependency in patients with IVH. This study included 179 patients with primary IVH with supratentorial origin or spontaneous ICH with extension into the ventricles between 2015 and 2021. Patients were grouped into “shunt required” and “shunt not required” groups. Variables, including age, sex, preexisting hypertension and diabetes, initial Glasgow Coma Scale scores, ICH location and volume, urokinase administration, modified Graeb score (mGraeb score), and bicaudate index, were analyzed. The shunt required group had significantly higher mGraeb scores (12.0 (6.5–15.0) vs. 7.0 (4.0–12.0), p = 0.001) and higher bicaudate index (0.20 (0.17–0.23) vs. 0.16 (0.13–0.18), P < 0.001) than the shunt not required group. The receiver operating characteristic curve (ROC curve) analysis revealed that a cut-off value of 0.16 of the bicaudate index was significantly related to shunt dependency. The subgroup statistical analysis revealed that neither urokinase administration (p = 0.533) nor urokinase dosage (p = 0.117) showed significant relevance in shunt dependency in patients who received external ventricular drainage. In logistic regression adjusted for the confounders, thalamic ICH (odds ratio (OR) 3.55; 95% confidence interval [(95%CI), 1.13–11.18], an mGraeb score greater than 8 (OR, 3.93; 95%CI, 1.84–8.38), and a bicaudate index greater than 0.16 (OR, 9.87; 95%CI, 3.79–25.73) were factors associated with a higher tendency for shunting. The findings of this study may help identify patients at risk for a permanent shunt after IVH.

Cerebrospinal fluid red blood cells and total protein are associated with clinical outcome in spontaneous subarachnoid hemorrhage.

Prognostication in patients with spontaneous subarachnoid hemorrhage (SAH) can be challenging. The aim of this study was to assess whether cerebrospinal fluid (CSF) red blood cell (RBC) count and total protein (TP) concentration are associated with SAH prognosis. Patients with SAH treated at the neurological intensive care unit (ICU) in Innsbruck were included in this real-world, observational study. Longitudinal CSF samples were collected as part of routine diagnostics. RBC count and CSF TP at the time of admission (RBCfirst, TPfirst), in Week 1 (RBCDays1-7, TPDays1-7), Week 2 (RBCDays8-14, TPDays8-14), and Week 3 or thereafter (RBCDay>14, TPDay>14), the highest detected value (RBChighest, TPhighest), as well as the RBC count adjusted for disease duration (RBCadjusted) were assessed. Primary outcomes were good functional outcome after 3 months, defined as modified Rankin scale score ≤2 and ICU survival. A total of 183 SAH patients with a female predominance (69%), a median (interquartile range [IQR]) age of 60 (50-70) years and median (IQR) Hunt and Hess score of 4 (3-5) were included. Multivariable analyses revealed that lower values of RBCfirst, RBCadjusted, RBChighest, TPfirst and TPhighest were associated with good functional outcome and hospital survival. Lower TP concentrations in Weeks 1, 2 and 3 were associated with good functional outcome, and in Weeks 1 and 2 with ICU survival. Early RBC measurements (Week 1) were associated with good functional outcome and ICU survival. Low CSF RBC counts and TP concentrations were associated with good functional outcome and ICU survival in a real-world cohort of SAH patients requiring external ventricular drainage.

The efficacy of neuroendoscopic surgery treating patients with thalamic hemorrhage accompanied by intraventricular hematoma

ObjectiveNeuroendoscopic surgery (NES) has been proven to be safe and effective in hematoma evacuation for cerebral hemorrhage. However, its efficacy for thalamic hemorrhage accompanied by intraventricular hematoma (THAVH) remains unclear. The aim of this study is to determine the efficacy of NES in treating THAVH.MethodA retrospective study was carried out. The data of patients diagnosed with THAVH were collected from January 1st, 2019, to January 1st, 2022. Patients received the NES or external ventricle drainage (EVD) treatment were assigned to the NES or EVD group, respectively. As primary outcomes, the hematoma evacuation volume, residual hematoma volume, and hematoma clearance rate were separately calculated based on the hematoma site; and the 180-day-mRS score was assessed. As secondary outcomes, the length of stay in the ICU and hospital, and the adverse events were also compared.ResultsThirty-five patients, aged 66.37 ± 6.62 years, were in the NES group; and 40 patients, aged 68.75 ± 7.22 years, were in the EVD group. The baseline characteristics in the two groups were similar (P &amp;gt; 0.05). The gross hematoma evacuation volume, volume of hematoma evacuated in the thalamus or the ventricle, and the hematoma clearance rate were greater in the NES group than in the EVD group on the 1st day after surgery (P &amp;lt; 0.05). The patients had a better rank of mRS in the NES group (P &amp;lt; 0.05). Compared with patients with mRS &amp;gt; 3, the mean residual hematoma volume in the thalamus of patients with mRS ≤3 on the 1st and 7th day were less in each group (P &amp;lt; 0.05), respectively. A residual hematoma volume in the ventricle of patients with mRS ≤3 was less than that of patients with mRS &amp;gt;3 in the EVD group on the 1st day after surgery (P &amp;lt; 0.05). GCS score on the 3rd day was greater in the NES group (P &amp;lt; 0.05). The incidence of lung infection was lower in the NES group (P &amp;lt; 0.05). The length of stay in the ICU and hospitalization duration were shorter in the NES group (P &amp;lt; 0.05).ConclusionsNeuroendoscopic surgery has a greater hematoma clearance rate, a lower lung infection rate and a shorter duration in the hospital. Neuroendoscopic surgery might improve patients’ prognosis. Neuroendoscopic surgery is a safe and effective procedure for treating thalamic hemorrhage accompanied by intraventricular hematoma.

Non-invasive assessment of intracranial pressure through the eyes: current developments, limitations, and future directions

Detecting and monitoring elevated intracranial pressure (ICP) is crucial in managing various neurologic and neuro-ophthalmic conditions, where early detection is essential to prevent complications such as seizures and stroke. Although traditional methods such as lumbar puncture, intraparenchymal and intraventricular cannulation, and external ventricular drainage are effective, they are invasive and carry risks of infection and brain hemorrhage. This has prompted the development of non-invasive techniques. Given that direct, non-invasive access to the brain is limited, a significant portion of research has focused on utilizing the eyes, which uniquely provide direct access to their internal structure and offer a cost-effective tool for non-invasive ICP assessment. This review explores the existing non-invasive ocular techniques for assessing chronically elevated ICP. Additionally, to provide a comprehensive perspective on the current landscape, invasive techniques are also examined. The discussion extends to the limitations inherent to each technique and the prospective pathways for future advancements in the field.

ASSESSMENT OF METHODS OF DIAGNOSIS AND TREATMENT OF PANCREATIC CYSTS

Abstract. The frequency of formation of pancreatic cysts in acute and chronic pancreatitis is 5-30%, and in destructive forms it increases to 60-70%. Persons of working age from 30 to 60 years old are mainly prone to the disease, which confirms the social significance of this problem. The aim: increase the effectiveness of surgical treatment of pancreatic cysts by using advanced diagnostics and methods of external and internal drainage. Materials and methods: the study is based on the analysis of the results of surgical treatment of patients with pancreatic cysts who were treated at VRCH n.a. M.I. Pirogov in the period from 01.01.2018 to 01.06.2024. A total of 65 patients were observed. The results: infection of the postoperative wound was observed in 6.15% of patients. 1.54% of patients developed adhesions, which were treated conservatively. The average time for removing drains with laparoscopic drainage is 21.2±1.5 days. There were no fatal consequences. Conclusions: the use of advanced diagnostics followed by differential selection of the treatment method significantly reduces the number of complications, reduces mortality and the length of stay of patients in the hospital.

Surgical Treatment Of Coats Disease

In the treatment of Coats' Disease, conservative ablation methods such as laser photocoagulation and cryotherapy are preferred in the early stages and more comprehensive surgical interventions are required for advanced stages (Stage 3 and 4). At these stages, the expanding subretinal fluid and exudates limit the effectiveness of vascular ablation, necessitating the addition of drainage for subretinal fluid and exudates to the treatment. The most commonly accepted method is the transscleral external drainage of subretinal fluid, which is relatively safe as it preserves retinal integrity. However, the development of epiretinal membrane (ERM) are seen quite frequently, especially in patients who have received multiple ablative treatments. In patients with significant ERM, adding pars plana vitrectomy (PPV) and membrane peeling to the external drainage surgery can increase anatomical success by reducing the VEGF load in the vitreous and relieving retinal tractions, potentially reducing the need for additional ablation treatments. Considering the low visual expectations in Stage 3A-4 Coats' disease, the focus of post-surgical treatment expectations in these patients should shift from improving vision to preserving the globe and controlling the disease activity.

8594 Pasireotide and Pasireotide Combined Treatment in Aggressive, Giant Pituitary Neuroendocrine Tumours

Abstract Disclosure: K. Ciszek: None. A. Bogusławska: None. M. Komisarz-Calik: None. J. Kunicki: None. A. Hubalewska-Dydejczyk: None. A. Gilis-Januszewska: None. Pasireotide is a second-generation somatostatin analogue that gained recognition as a treatment option for acromegaly and Cushing disease. Recently, there are single reports of pasireotide treatment in other subtype of pituitary neuroendocrine tumours (PitNETs).We present a case series of aggressive, giant PitNETs which were treated with pasireotide alone or as combined multimodal treatment. Case 1: A 59-year-old male presented in our Unit due to severe headaches and visual field deficits. The patient underwent transsphenoidal surgery (TSS) ten years ago. Histopathology results showed partially acidophilic adenoma (FSH- LH- GH- ACTH- PRL-). Control MRI showed tumour regrowth - 56x56x89mm and invasion of local structures. The patient was qualified for radiotherapy, to which he did not consent. Due to the progression of symptoms, temozolomide and pasireotide were introduced. After 5 months, significant improvement in headaches and vision was observed. In MRI stable pituitary mass was noted. Case 2: A 17-year-old male presented in our clinic due to daily severe headaches and peripheral vision loss who underwent two non-radical surgeries for dopamine-resistant giant prolactinoma. In control MRIs progressing mass 38x34x33mm invading local structures was observed. Due to resistance to dopamine agonists and worsening of the symptoms, pasireotide was introduced resulting in a decrease of headaches and improvement in vision. The tumour size remained stationary. Case 3: A 59-year-old male presented with severe headaches and life threatening tumour mass effect.In MRI a 48x48x33mm mass was observed. The patient underwent two non-radical TSS, 4 cycles of pasireotide, and cyberknife treatment. Histopathology showed gonadotroph PitNET. MRI showed tumour shrinkage to 45x46x29mm, with persistent severe headaches. The patient was re-qualified for pasireotide treatment. Case 4: A 33-year-old male reported to the Clinic due to severe headaches and vomiting. In MRI pituitary mass 33x39x55mm and a cerebral oedema were revealed. TSS with external ventricular drainage was performed -histopathology results showed densely granulated silent corticotroph adenoma subtype 1, Ki67&amp;lt;1%. After 3 months, MRI showed tumour progression to 39x40x30mm. Two emergency TSS followed by stereotactic radiotherapy were performed. Combined therapy with pasireotide, cabergoline and temozolomide was introduced. After 18 months, stabilization of the disease was observed with the complete disappearance of headaches. Conclusions: Our study demonstrates the clinical potential of pasireotide treatment in aggressive, giant PitNETs. The therapy alone, or in combination has a potential role in reducing the tumour size, and allows the stabilization of the disease. The analgesic and anti-inflammatory effect of pasireotide could potentially alleviate headaches in this subset of patients. Presentation: 6/2/2024

Closed traumatism of the distal pancreas (A case series of 6 patients)

Introduction and importanceThe aim of this retrospective study was to present six cases of trauma to the distal pancreas, highlighting the challenges associated with their diagnosis and management, while underlining their seriousness and the various complications potentially encountered. Our case series highlights individual patient outcomes, demonstrating the diversity of clinical presentations and the importance of customized treatment strategies. Case seriesBetween January 2015 and December 2020, six cases of distal pancreas trauma were identified. In two cases, the diagnosis was made based on emergency abdominal CT scans, while in the other four patients, the diagnosis was made directly intraoperatively, mainly because of the severity of the associated lesions, which necessitated laparotomy for exploration. Clinical discussionOut of 115 cases of closed abdominal trauma, injury to the distal pancreas was identified in 6 patients, (5.2 %), with a mean age of 21 years. Despite the use of abdominal CT scans for all patients, pancreatic trauma was directly diagnosed intraoperatively in 4 cases (67 %). All patients presented with concomitant abdominal injuries (100 %), and 3 patients (50 %) exhibited multiple severe injuries. Additionally, a significant elevation in pancreatic serum markers was observed in 3 patients (50 %). The pancreatic injuries predominantly involved the tail of the pancreas (67 %), while the body was affected in one patient, and the isthmus was completely transected in another.Three of our patients developed a pancreatic fistula (50 %) and two patients (33 %) passed away; the first had severe associated lesions, and the second, despite undergoing several iterative laparotomies, succumbed to postoperative complications following a left pancreatectomy. ConclusionClosed traumatism of the distal pancreas, although rare, is a significant problem. It is often diagnosed during emergency laparotomy but can sometimes be found on preoperative CT scans. When the patient's condition permits, it is highly advisable to undergo a left pancreatectomy. Simple external drainage is reserved for certain specific situations.

Safe external ventricular drain management for infection prevention and control: a narrative review

Introduction: External ventricular drain (EVD) placement is a common neurosurgical procedure. Nurses play a crucial role in care, troubleshooting, and monitoring of EVD-related complications, making their education and training in this area of paramount importance. A well-trained nurse possesses the necessary knowledge and skills to recognize and respond promptly to EVD-related complications, such as infections, bleeding, and blockages. External ventricular drainage is associated with a high rate of nosocomial meningitis. The introduction of a well- implemented EVD care bundle can significantly decrease EVD infection rates. The support of the multi-item bundle for EVD is considered very important to reduce EVD-related infections.Aim: To summarize the most recent available evidence for the prevention and control of EVD infections. Methods: Comprehensive literature search had been done using the PubMed (Medline), Embase, CINAHL, and Cochrane databases. The narrative review was performed according to the PRISMA Extension for Scoping Review checklist (PRISMA-ScR).Results: The query identified 4266 studies; after duplicate removal and exclusion of papers due to non-pertinent criteria, 26 studies were included. Only three papers were related to pediatric patients and all were about EVD anchoring. Regarding the risk of infection, bundles and protocols are important for the reduction of the occurrence rate; however, staff adherence to these is fundamental.Conclusion: Multidisciplinary staff and training are fundamental to improve EVD management. Avoiding routine or daily sampling reduces the EVD infection rate. When the procedure is requested, it is important to follow a strict protocol and to use sterile techniques. Hydrocolloid dressings, SecurAcath, gauze, and film dressings were used to anchor the cover EVD in the studies.

Optimization of cholecystectomy timing during staged treatment of acute cholecystitis in elderly and senile patients with cholecystostomy

Aim. To determine optimal timing for laparoscopic cholecystectomy in elderly and senile patients with cholecystostomy.Materials and methods. Treatment results of 37 patients aged 60 years and over at different terms after cholecystostomy formation were analyzed. The degree of senile asthenia, concomitant diseases, technical features of surgical aid, dynamics of the postoperative period, as well as morphological features of inflammatory changes in the gallbladder wall were assessed.Results. Pre-asthenia was detected in 12 (32%) patients, mild senile asthenia – in 14 (38%) patients, and moderate senile asthenia – in 11 (30%) patients. Polymorbidity was determined in all patients, with 23 patients having four or more diseases. In 3 (8%), 15 (40.5%), 15 (40.5%), and 4 (11%) cases, laparoscopic cholecystectomy was performed 3–9 days, 10–30 days, 2–6 months, and 6 months or more (1 conversion) after cholecystostomy.Conclusion. In elderly and senile patients, laparoscopic cholecystectomy performed 10–30 days after cholecystostomy is optimal, safe, and affordable. Radical intervention in this period is not associated with technical difficulties. Reduced terms of external drainage of the gallbladder contribute to improving the elderly patient’s quality of life and their social adaptation, while shortening the period of postoperative recovery. When planning surgical interventions in a patient over 60 years old, account should be taken of comorbidities, polypragmasy, and senile asthenia.

A Single-Centre Analysis of Surgical Techniques for Myelomeningocele Closure: Methods, Outcomes, and Complications.

(1) Background: Neural tube defects are a prevalent cause of congenital malformations, myelomeningocele (MMC) being the most severe form. This study evaluates the clinical outcome and postoperative-associated complications following MMC surgical closures, focusing on the following three techniques: direct suture (DS); VY advancement flap (VYF); and Limberg flap (LF). (2) Methods: A retrospective observational study was conducted from March 2015 to February 2023, and the inclusion criteria were newborns who underwent lumbosacral MMC within 24 h of birth. (3) Results: Out of 20 cases, 45% underwent DS closure; 25% underwent VY-F closure; 15% underwent LF closure, and 15% (n = 3) underwent combined flap closure. A significant statistical correlation was observed between intracranial hypertension (IH), the need for external ventricular drainage (EVD), and DS closure type. In the DS group, 60% of patients required EVD (p = 0.041), and 90% had IH (p = 0.027). CSF fistula was present in 40% of LF cases and 30% of DS cases, while wound dehiscence was observed in 60% of LF cases and 30% of DS cases. (4) Conclusions: Our study demonstrated that DS was linked to higher rates of complications. The VY-F is the safest method for closing MMC defects.

Treatment of post-thalamic hemorrhage hydrocephalus: ventriculoperitoneal shunt or endoscopic third ventriculostomy? A retrospective observational study

BackgroundThe aim of this study was to compare the efficacy of ventriculoperitoneal shunt (VPS) and endoscopic third ventriculostomy (ETV) for the treatment of hydrocephalus after thalamic hemorrhage (TH) where external ventricular drainage (EVD) could not be removed after hematoma absorption, and to provide a theoretical basis for the clinical treatment of hydrocephalus after TH.MethodsThe clinical data of patients with hydrocephalus after TH whose EVD could not be removed after hematoma absorption were retrospectively analyzed. According to the patients’ surgical methods, the patients were divided into the VPS group and ETV group. The operative time, length of hospital stay, complications, and reoperation rates of the two groups were compared.ResultsThere was no statistically significant difference in intraoperative bleeding, length of hospital stay between the two groups. The EVD tubes were successfully removed in all patients after surgery. There were 4 (9.5%) complications in the ETV group and 3 (6.7%) complications in the VPS group, with no statistically significant difference in postoperative complications between the two groups. During the 1-year follow-up, 7 patients (16.7%) in the ETV group and 3 patients (6.7%) in the VPS group required reoperation. In the subgroup analysis of TH combined with fourth ventricular hemorrhage, 6 patients (14.3%) in the ETV group and 1 patient (2.2%) in the VPS group required reoperation, and the difference between the two groups was statistically significant.ConclusionsETV had good efficacy in treating hydrocephalus caused by TH and TH that broke into the lateral ventricle and the third ventricle. However, if hydrocephalus was caused by TH with the fourth ventricular hematoma, VPS was a better surgical method because the recurrence rate of hydrocephalus in ETV was higher than that in VPS. Therefore, the choice of surgical method should be based on the patient’s clinical features and hematoma location.

Primary ventriculitis caused by Streptococcus intermedius - a rare case and challenge with uncertain clinical outcome. Case report.

To present a case of primary ventriculitis in a 53-year-old patient caused by Streptococcus intermedius, emphasizing the rarity of the condition and the challenges in achieving clinical improvement despite targeted therapy. The patient underwent clinical evaluation, including CT and MRI imaging, as well as CSF analysis. Empirical antibiotic therapy was initiated with cefotaxime and metronidazole, followed by targeted therapy based on CSF culture results. External ventricular drainage was performed surgically. No predisposing factors were identified in the patient. Initial imaging showed no acute changes, but follow-up imaging revealed significant ventricular inflammation. CSF analysis confirmed the presence of Streptococcus intermedius. Despite early and targeted antibiotic therapy, and surgical intervention, the patient's clinical condition did not improve. This case highlights the rarity of primary ventriculitis caused by Streptococcus intermedius and the challenges in managing it. The lack of clinical improvement despite prompt and targeted treatment underscores the need for further research to develop more effective therapeutic strategies for such infections.

Contrast-enhanced ultrasound-guided percutaneous transhepatic cholangiodrainage is a safe and effective procedure for patients with malignant biliary obstruction and stage 3 chronic kidney disease

ObjectivesThis study aimed to validate the efficacy and safety of contrast-enhanced ultrasound-guided percutaneous transhepatic cholangiodrainage (CEUS-PTCD) as a biliary drainage procedure in patients with malignant biliary obstruction and stage 3 chronic kidney disease (CKD3). Materials and methodsBetween January 2019 and December 2023, 634 patients who underwent CEUS-PTCD were retrospectively enrolled in this study. During the procedure, imaging parameters such as the maximum diameter of the dilated bile duct, presence of ascites, detailed findings from CEUS, and clinical outcomes were meticulously recorded. Laboratory results, including serum bilirubin levels, liver function tests, and estimated glomerular filtration rate (eGFR), were evaluated in one day before and three days after procedure. The aforementioned parameters were compared using the paired-sample t test and the Wilcoxon test. ResultsA total of 66 (10.41 %) patients with malignant biliary obstruction and CKD3 were included in the final analysis (median age: 66, range: 30–89 years, 46 males and 20 females). Procedure records indicated that 23 patients (34.8 %) had a maximum biliary duct dilation diameter of ≤ 4 mm, while 5 patients (7.6 %) exhibited mild ascites. Additionally, 24 patients (36.4 %) had ultrasound contrast agent entry into both the biliary duct and bloodstream. All patients successfully achieved external bile drainage following CEUS-PTCD, with no significant complications observed during or after the intervention. Post-procedure, there was a statistically significant reduction in all previously elevated serum bilirubin and liver enzyme levels (P-values were less than 0.05). Furthermore, no statistically significant alterations in eGFR were observed prior to or following CEUS-PTCD across all patients (P = 0.295), including comparisons between groups with and without the ultrasound contrast agent into the bloodstream (P = 0.254). ConclusionCEUS-PTCD is a safe and effective biliary drainage procedure for patients with malignant biliary obstruction and CKD3.

Risk factors and chlorhexidine dressings in external ventricular drainage: a retrospective analysis on infection rates.

This retrospective study endeavors to scrutinize risk factors associated with infections resulting from external ventricular drainage (EVD) and to assess the effectiveness of chlorhexidine dressing in mitigating infection rates. Conducted from January 2018 to July 2023, this single-center study encompassed 108 EVD patients. Comprehensive data on demographics, comorbidities, surgical procedures, and the utilization of chlorhexidine dressing were meticulously compiled. The primary endpoint was the incidence of EVD-associated infections based on CDC criteria. Infection rates attributable to EVD were 24.32% without and 20.59% with chlorhexidine dressing. Notably, diabetes mellitus emerged as the solitary significant infection risk factor (p < 0.01). Although the application of chlorhexidine dressing suggested a propensity for diminishing infection rates, statistical significance remained elusive. No notable disparities were discerned in variables such as catheter type, procedural location, and underlying diseases. Diabetes mellitus has been identified as a significant risk factor for EVD-associated infections. While the utilization of chlorhexidine dressing exhibited a potential reduction in infection rates, the lack of statistical significance underscores the imperative for further research, encompassing more expansive randomized trials, to comprehensively evaluate the safety and efficacy of chlorhexidine dressings in preventing EVD-associated infections.

ThP5.4 - Which Resection for Distal Cholangiocarcinoma?: Retrospective Study

Abstract Introduction The treatment of distal cholangiocarcinoma (DCC) is contingent upon the patient's condition and the local and lymphatic extent of the disease. Surgery remains the sole radical treatment, albeit infrequently feasible and often followed by biliary drainage. The surgical procedure involves resecting the bile duct with healthy distal and proximal margins, accompanied by lymphadenectomy. Cephalic pancreatectomy (DPC) is deemed the optimal oncological treatment for DCC. Method This retrospective study encompasses cancers of the main bile duct. Various factors influencing treatment were analyzed, focusing on the type of resection (biliary and pancreatic). Results From January 2014 to December 2021, 119 patients were treated for distal cholangiocarcinoma (88 men, 31 women, average age: 61 years). Twenty-one patients underwent endoscopic drainage, 17 transhepatic drainage, and 55 surgical interventions. Among them, 9 underwent preoperative drainage, 28 radical resection, 10 DPC, 18 biliary resections, and one total pancreatectomy. In 27 patients, radical surgery was impossible; 20 underwent drainage, and 7 did not. Three early surgical revisions in the biliary resection group, with incidents of digestive hemorrhage and hemoperitoneum. Two moderate pancreatic fistulas and immediate postoperative hypoglycemia were recorded. Two deaths in the biliary resection group and 7 in-hospital deaths in the biliary drainage group. All patients with external drainage died before 12 months, while 8 patients from the endoscopic drainage group survived after 12 months. Patients with radical surgery and adjuvant treatment exhibited longer survivals (36 months vs. 45 months). Conclusion Improving the prognosis of DCC requires early diagnosis and radical surgery combined with adjuvant treatment.

Comparative analysis of treatment results of craniotomy and external closed drain in patients with chronic subdural hematomas

Aim. To conduct a comparative analysis of the treatment results of the patients with chronic subdural hematoma using two methods: closed external drainage and craniotomy.Materials and methods. The data of 55 patients with chronic subdural hematoma operated in the I.I. Dzhanelidze St. Petersburg Research Institute of Emergency Medicine from 2019 to mid-2023 was analyses retrospectively. Depending on the treatment method, patients were divided into 2 groups: external subdural drains (n = 30, 55.5 %) and evacuation of hematoma via craniotomy (n = 25, 45.5 %). The patients in the groups were comparable in clinical features, radiological characteristics and the Charlson comorbidity index. In the postoperative period, the following were assessed: hematoma thickness and displacement of median structures, occurrence of surgical complications, and mortality.Results. There were no differences between the groupsin the midline shift, the frequency of postoperative complications, reoperation and deaths. The thickness of the hematomas according to the control computed tomography scans of the brain was lower in the craniotomy group, but this did not determine the outcome of treatment. Patients with a Charlson Comorbidity Index value of 4 points or higher were significantly more likely to have an unfavorable outcome. The sensitivity and specificity of the index in predicting an unfavorable outcome was 71.4 and 69.7 %, respectively.Conclusion. There were no differencesin the effectiveness of craniotomy and externalsubdural drains of chronic subdural hematoma. In this regard, it is necessary to give preference to minimally invasive methods of treatment. Assessment of the comorbid status allows predicting an unfavorable outcome of treatment.

Thunderclap headache as a first manifestation of acute disseminated encephalomyelitis: case report and literature review

BackgroundAcute Disseminated Encephalomyelitis (ADEM) is an acute demyelinating disorder of the central nervous system, characterize by multiple white matter hyperintensities on T2 MRI. Patients usually present with subacute progressive encephalopathy and polyfocal neurological deficits. Possible treatments are corticosteroids, immunoglobulins and plasma exchange. Full clinical recovery is seen in more than half of the cases.CaseWe describe a case of a 62-year-old patient presenting with thunderclap headache as the first symptom, two weeks after an upper respiratory tract infection. The clinical course was complicated by progressive coma and intracranial hypertension mandating external ventricular drainage and sedation. Initial treatment with methylprednisolone was unsuccessful but clinical resolution and radiological regression was achieved after plasma exchanges and cyclophosphamide.ConclusionTo our knowledge, this is the first reported case of ADEM presenting with thunderclap headache. Intracranial hypertension with the need for invasive neuromonitoring and pressure management is also a very rare complication of ADEM. In this report, we describe the findings of the literature review concerning ADEM, thunderclap headache and intracranial hypertension.