Postprocedure Hospital Research Articles

A systematic review of methods to palliate malignant gastric outlet obstruction

The traditional approach to palliating patients with malignant gastric outlet obstruction (GOO) has been open gastrojejunostomy (OGJ). More recently endoscopic stenting (ES) and laparoscopic gastrojejunostomy (LGJ) have been introduced as alternatives, and some studies have suggested improved outcomes with ES. The aim of this review is to compare ES with OGJ and LGJ in terms of clinical outcome. A systematic literature search and review was performed for the period January 1990 to May 2008. Original comparative studies were included where ES was compared with either LGJ or OGJ or both, for the palliation of malignant GOO. Thirteen studies met the inclusion criteria (10 retrospective cohort studies, two randomised controlled trials and one prospective study). Compared with OGJ, ES resulted in an increased likelihood of tolerating an oral intake [odds ratio (OR) 2.6, p = 0.02], a shorter time to tolerating an oral intake (mean difference 6.9 days, p < 0.001) and a shorter post-procedural hospital stay (mean difference 11.8 days, p < 0.001). There were no significant differences between 30-day mortality, complication rates or survival. There were an inadequate number of cases to quantitatively compare ES with LGJ. This review demonstrates improved clinical outcomes with ES over OGJ for patients with malignant GOO. However, there is insufficient data to adequately compare ES with LGJ, which is the current standard for operative management. As these conclusions are based on observational studies only, future large well-designed randomised controlled trials (RCTs) would be required to ensure the estimates of the relative efficacy of these interventions are valid.

A Meta-Analysis of Approaches to Palliate Malignant Gastric Outlet Obstruction

Background and Aims: The traditional approach for the palliation of patients with malignant gastric outlet obstruction has been open gastrojejunostomy (OGJ). In recent years, endoscopic stenting (ES) and laparoscopic gastrojejunostomy (LGJ) have been introduced as alternatives, and some studies have suggested improved outcomes with ES. The aim of this meta-analysis was to compare ES with OGJ and LGJ for clinical outcome. Methods: A systematic literature search and review was performed for the period January 1990 to May 2008. Original studies that compared ES to either LGJ or OGJ or both, for the palliation of malignant gastric outlet obstruction, were included. Due to limited availability of randomised controlled trials (RCTs) evaluating these interventions, prospective and retrospective cohort comparison studies were also included. The primary outcomes examined were: number of patients tolerating an oral intake, time to oral intake, length of hospital stay (after intervention to hospital discharge), 30-day mortality, survival and complications. Results: Thirteen studies met the inclusion criteria (10 retrospective cohort studies, 2 randomised controlled trials and 1 prospective study). Compared with OGJ, ES resulted in an increased likelihood of tolerating an oral intake (OR 2.6, p=0.02), a shorter time to tolerating an oral intake (mean difference 6.9 days, p<0.001) and a shorter post-procedural hospital stay (mean difference 11.8 days, p<0.001). There were no significant differences between mortality at 30 days, complication rates or survival. There were an inadequate number of cases to complete a formal meta-analysis comparing ES with LGJ. Conclusion: This meta-analysis has demonstrated improved outcomes with ES over OGJ for the palliation of symptoms associated with malignant gastric outlet obstruction. Further high-quality RCTs would be beneficial to confirm this benefit, and to further evaluate the role of LGJ. Overall, on the basis of the best available current evidence, most patients with malignant gastric outlet obstruction are likely to sustain a higher quality of life when treated with ES.

A comparison of direct endoscopic necrosectomy with transmural endoscopic drainage for the treatment of walled-off pancreatic necrosis

Endoscopic therapy of walled-off pancreatic necrosis (WOPN) via direct intracavitary debridement is described. To compare direct endoscopic necrosectomy with conventional transmural endoscopic drainage for the treatment of WOPN. Retrospective, comparative study. Academic tertiary-care center. Patients referred to Mayo Clinic, Rochester, Minnesota, since April 1998 for endoscopic drainage of WOPN. Each patient underwent standard endoscopic drainage that consisted of transmural cavity puncture, dilation of the fistula tract, and placement of a large-bore stent(s). Patients were classified into the direct endoscopic necrosectomy group if, during any of their procedures, adjunctive direct endoscopic necrosectomy was performed; all others were in the standard drainage group. Success was defined as resolution of the necrotic cavity without the need for operative or percutaneous intervention. Forty-five patients were identified who met study criteria: 25 underwent direct endoscopic necrosectomy, and 20 underwent standard endoscopic drainage. There were no differences in baseline patient or cavity characteristics. Successful resolution was accomplished in 88% who underwent direct endoscopic necrosectomy versus 45% who received standard drainage (P < .01), without a change in the total number of procedures. The maximum size of tract dilation was larger in the direct endoscopic necrosectomy group (17 mm vs 14 mm, P < .02). Complications were limited to mild periprocedural bleeding with equivalent rates between groups. Retrospective, referral bias, single center. Direct endoscopic necrosectomy achieves higher rates of resolution, without a concomitant change in the number of endoscopic procedures, complication rate, or time to resolution compared with standard endoscopic drainage for WOPN. The need for fewer postprocedural inpatient hospital days and a decrease in the rate of cavity recurrence are also likely benefits of this technique.

Modified technique for EUS-guided drainage of pelvic abscess (with video)

We previously described a technique for EUS-guided drainage of pelvic abscess by means of transrectal catheter placement. However, drainage catheters are prone to accidental dislodgement, and their management has mandated a prolonged inpatient hospital stay. To evaluate the effectiveness of a combined technique by using EUS-guided transrectal drainage catheter and stent placement for management of patients with pelvic abscesses. An observational study. Academic tertiary-referral center. Four patients underwent EUS-guided drainage of pelvic abscesses that were not amenable for drainage by US and/or CT guidance. A 10F drainage catheter and one or two 7F double-pigtail stents were deployed in the abscess cavity under EUS guidance. Subsequently, the drainage catheter was periodically flushed and aspirated for 36 hours until improvement in size of the abscess was confirmed by CT imaging. The drainage catheter was then discontinued, and the patients were discharged from the hospital. If resolution of the abscess was noted on outpatient CT at 2 weeks, then the stents were retrieved by sigmoidoscopy. Short-term treatment success was defined as improvement in clinical symptoms and a decrease in size of the pelvic abscess on postprocedure CT obtained at 36 hours. Medium-term treatment success was defined as resolution of clinical symptoms and pelvic abscess on follow-up CT at 2 weeks. The procedure was technically successful in all 4 patients. The mean size of the abscess was 93 x 61 mm. No procedural complications were encountered. Treatment was successful both in the short and medium term in all 4 patients, and the mean duration of the postprocedure hospital stay was 2 days. At a mean follow-up of 221 days (range, 65-416 days), all 4 patients were doing well, without any symptoms of pelvic-abscess recurrence. The small number of patients and the absence of a comparative treatment group. The combined placement of a transrectal drainage catheter and a stent under EUS guidance was a technically feasible, safe, and effective technique for management of patients with pelvic abscess. This technique minimized the possibility of accidental dislodgement of the drainage catheter and facilitated earlier patient discharge from the hospital.

EUS versus surgical cyst-gastrostomy for management of pancreatic pseudocysts

Although EUS-guided cyst-gastrostomy is increasingly being performed, there are no studies that compare the clinical outcomes and cost-effectiveness with surgical cyst-gastrostomy. To compare the clinical outcomes of EUS-guided cyst-gastrostomy with surgical cyst-gastrostomy for the management of patients with uncomplicated pancreatic pseudocysts and to perform a cost analysis of each treatment modality. A retrospective case-controlled study. A tertiary-referral center. Consecutive patients with uncomplicated pancreatic pseudocysts managed by surgical and EUS-guided cyst-gastrostomy. An independent observer blinded to all clinic outcomes matched each patient who underwent a surgical cyst-gastrostomy with 2 patients who underwent an EUS-guided cyst-gastrostomy for age, etiology of pancreatitis, and the size of the pseudocyst. Rates of treatment success, complications, and reinterventions; length of postprocedure hospital stay; and cost associated with each treatment modality. Ten patients (6 men; mean age 42.3 years, range 22-65 years) who underwent surgical cyst-gastrostomy were matched with 20 patients who underwent an EUS-guided cyst-gastrostomy. There were no significant differences in demographics, major comorbidities, and clinical characteristics between both cohorts. Although there were no significant differences in rates of treatment success (100% vs 95%, P = .36), procedural complications (none in either cohort), or reinterventions (10% vs 0%, P = .13) between surgery versus an EUS-guided cyst-gastrostomy, the mean length of a postprocedure hospital stay for an EUS-guided cyst-gastrostomy was significantly shorter than for surgical cyst-gastrostomy (2.65 vs 6.5 days, P = .008). The average direct cost per case for EUS-guided cyst-gastrostomy was significantly less when compared with surgical cyst-gastrostomy ($9077 vs $14,815, P = .01), which corresponded to a cost savings of $5738 per patient. Retrospective, nonrandomized design; patients with pancreatic abscess or necrosis were not evaluated; a limited sample size and a short duration of follow-up. EUS-guided cyst-gastrostomy should be considered as a first-line treatment approach for patients with uncomplicated pancreatic pseudocysts, because the procedure is cost saving and is associated with a shorter length of a postprocedure hospital stay when compared with surgical cyst-gastrostomy. There was no significant difference in clinical outcomes between both treatment modalities.

Incidence and Outcomes of Contrast-Induced AKI Following Computed Tomography

Most studies of contrast-induced acute kidney injury (CIAKI) have focused on patients undergoing angiographic procedures. The incidence and outcomes of CIAKI in patients undergoing nonemergent, contrast-enhanced computed tomography in the inpatient and outpatient setting were assessed. Patients with estimated glomerular filtration rates (GFRs) <60 ml/min per 1.73 m(2) undergoing nonemergent computed tomography with intravenous iodinated radiocontrast at an academic VA Medical Center were prospectively identified. Serum creatinine was assessed 48 to 96 h postprocedure to quantify the incidence of CIAKI, and the need for postprocedure dialysis, hospital admission, and 30-d mortality was tracked to examine the associations of CIAKI with these medical outcomes. A total of 421 patients with a median estimated GFR of 53 ml/min per 1.73 m(2) were enrolled. Overall, 6.5% of patients developed an increase in serum creatinine >or=25%, and 3.5% demonstrated a rise in serum creatinine >or=0.5 mg/dl. Although only 6% of outpatients received preprocedure and postprocedure intravenous fluid, <1% of outpatients with estimated GFRs >45 ml/min per 1.73 m(2) manifested an increase in serum creatinine >or=0.5 mg/dl. None of the study participants required postprocedure dialysis. Forty-six patients (10.9%) were hospitalized and 10 (2.4%) died by 30-d follow-up; however, CIAKI was not associated with these outcomes. Clinically significant CIAKI following nonemergent computed tomography is uncommon among outpatients with mild baseline kidney disease. These findings have important implications for providers ordering and performing computed tomography and for future clinical trials of CIAKI.

ERCP and EUS Complication Rates Are Not Increased in Elderly Patients

Introduction: As the elderly population continues to grow, further studies evaluating the safety of advanced endoscopic procedures in this population are needed. The purpose of this study was to evaluate the safety of endoscopic retrograde cholangiopancreatography (ERCP) ± sphincterotomy and endoscopic ultrasound (EUS) ± FNA in the elderly population. Methods: This is a retrospective review of 650 consecutive patients in which ERCP and/or EUS ± FNA were performed over a 20 month period at our tertiary care institution. The study population was divided into two cohorts. The elderly cohort consisted of patients ≥75 years old. The non-elderly cohort consisted of patients <75 years old. Collected data included patient demographics, type of procedure completed, procedure medication used and endoscopic intervention preformed. Complications included any event which occurred up to one month post procedure. Complications were defined as hemodynamic or respiratory compromise, over sedation, pancreatitis, bleeding, perforation, infection, abdominal pain or any event leading to post procedure hospital admission. The data was analyzed between the cohorts using either a Fisher's test or Student's t-test. Results: There were 650 procedures included, 409 ERCPs (63%) and 241 EUS (37%). The study population was 55% male. The mean age of the elderly cohort was 80 yrs (75-95) and included 130 patients. The mean age of the non-elderly cohort was 53 yrs (13-74) and included 520 patients. The elderly cohort ERCP complication rate was 9 %, the non-elderly cohort ERCP complication rate was 9 % (P = 0.47). The elderly cohort EUS complication rate was 2 %, the non-elderly cohort EUS complication rate was 2% (P = 0.30). The overall complication rates for the elderly and non-elderly cohorts were 8% and 7 % respectively (P = 0.45). There was no significant difference in the rate of sphincterotomy related complications between cohorts (P = 0.40). All EUS complications were associated with FNA. The sedation doses of droperidol, fentanyl and midazolam were significantly higher for the non-elderly cohort (P < 0.01). There was a significantly higher rate of post procedure admission for observation for the elderly cohort (P = 0.016). Conclusions: Advanced age is not a contraindication for advanced endoscopic procedures. There is no significant increase in the rate of procedure related complications seen with either ERCP or EUS procedures in elderly patients. Less procedure related sedation medications are required for elderly patients. Gastroenterologists are more likely to admit elderly patients for observation overnight after advanced endoscopic procedures.

Transpancreatic Precut Sphincterotomy for Cannulation of Inaccessible Common Bile Duct

Obstruction of the biliary tract can lead to severe complications. The common treatment of patients with biliary tract obstruction is the decompression by endoscopic procedures. However, cannulation of the common bile duct can be difficult under certain instances because of anatomical variations or obstruction at the biliary entrance level. Needle-knife or precut sphincterotomy has been described as technique to facilitate biliary access in patients with difficult bile duct cannulation. In the current study, we evaluated success and complication rates of a wire-guided transpancreatic precut technique at our hospital. Between January 2003 and June 2006, a total of 108 patients with jaundice but with inaccessible bile ducts using classic techniques (failed primary cannulation or failed needle-knife papillotomy) underwent a wire-guided transpancreatic precut sphincterotomy. Precuts were performed using a soft guide wire placed in the pancreatic duct without injection of contrast fluid into the pancreatic duct. We studied cannulation success and complications associated with postprocedural hospitalization. Bile duct cannulation was successful in 103 (95.4%) of the 108 patients. Five patients (4.6%) required a percutaneous transhepatic biliary drainage. In 108 patients, there were 12 patients (11.1%) with procedure-related complications including acute pancreatitis (n = 6) and bleeding (n=6). Four patients had a mild and transient pancreatitis (pain improvement after 2 days), 2 had severe pancreatitis that was reversible after 7 days of conservative treatment. In 4 cases, a blood transfusion (each with 2 erythrocyte concentrates) became necessary. Perforations and other severe procedure-related deaths did not occur. Transpancreatic precut sphincterotomy using a soft guide wire is a safe and effective procedure in patients with difficult bile duct access where classic sphincterotomy or needle-knife procedures fail.

One-year clinical results and total costs of drug-eluting stents implantation in multivessel coronary artery disease

One hundred and eleven consecutive patients with multivessel coronary artery disease treated with percutaneous coronary intervention with multiple drug-eluting stents were examined to investigate 1-year clinical results and initial and total costs. Clinical and procedural characteristics, duration of hospital stay and 12-month follow-up events were considered. Real costs of multivessel percutaneous coronary intervention with multiple drug-eluting stents were calculated, including disposables, personnel, equipment depreciation and hospital stay, whereas medical resources consumption at 12 months were calculated as disease related group reimbursement tariffs. The patient population (69% males, mean age 65 +/- 10 years) presented mid to high-risk clinical and anatomical characteristics. The mean number of treated vessels was 2.36 per patient with 2.8 drug-eluting stents per patient. A complete revascularization was achieved in 70% of cases. In-hospital events were post-procedural non-Q myocardial infarction in 5.4% and two retroperitoneal haemorrhages. Post-procedural hospital stay was 2.5 +/- 2.3 days (mean total hospital stay = 5.3 +/- 3 days). At 12-month follow-up, total mortality and acute myocardial infarction incidence were 3.6% and 1.8%, respectively; only one patient (0.9%) presented subacute stent thrombosis at 3 months, which was treated by urgent re-percutaneous coronary intervention. Target vessel revascularization rate was 12.6% and the incidence of cumulative major adverse cardiac events was 15.3%. Initial hospital costs were 8992 euros +/- 2825 (5518 euros +/- 1098 for procedure and 3473 euros+/- 2347 for hospital stay); follow-up costs were 222 euros+/- 3087, leading to 12-month total costs of 10214 euros+/- 4184. Multivessel percutaneous coronary intervention with drug-eluting stents showed good early and medium-term results with acceptable total costs. Despite not completely being covered by actual disease related group reimbursement, the initial and final costs were substantially lower than that of disease related group reimbursement for coronary artery bypass graft.

Risk-Stratified Evaluation of Amiodarone to Prevent Atrial Fibrillation After Cardiac Surgery

Amiodarone prophylaxis (AMP) reduces the prevalence of postoperative atrial fibrillation (POAF) after cardiac surgery. We investigated the impact of AMP on the frequency and duration of POAF, the intensive care unit and hospital length of stay, and its cost-effectiveness in a risk-stratified cohort. A retrospective, observational analysis of 509 patients who underwent cardiac surgery in 2003 was performed. Data sources included The Society of Thoracic Surgeons national database; medical and medication administration records; and the activity-based cost data from our institution. Risk stratification for POAF was determined using a validated risk index. Cost-effectiveness was determined from the hospital's perspective. The mean patient age was 63 years, 27% were female, 80% underwent coronary artery bypass grafting, and 29% underwent valve surgery. When a risk-stratified evaluation was made, 50% of patients were at an elevated risk for having POAF develop. When compared with nonprophylaxed patients, those receiving AMP (59%) experienced less POAF (31% vs 22%; p = 0.027) and shorter durations of POAF (4.7 vs 2.7 days; p = 0.025). In the elevated-risk group, AMP clinically (but not significantly) reduced length of stay in the intensive care unit (101 vs 68 hours; p > 0.05) and post-procedural hospital length of stay (9.7 vs. 7.9 days, p > 0.05). In the elevated-risk group, AMP was robustly cost-effective in reducing POAF. Amiodarone prophylaxis reduced the prevalence and duration of POAF. Baseline risk for POAF was a major determinant of the overall cost-effectiveness of AMP. The greatest cost savings with AMP was seen in patients at an elevated risk for POAF. These findings suggest the need for risk stratification when prescribing AMP.

Percutaneous carotid artery stenting: a strategy in evolution

Carotid stenting was initially proposed as an alternative to surgical endarterectomy for selected high-risk patients. More recently, patients of standard surgical risk are being considered for percutaneous treatment of their carotid disease. To describe the clinical outcomes of an initial consecutive cohort of patients treated by carotid stenting at one institution. Between December 1997 and July 2003, 111 patients underwent stenting of 118 carotid arteries. Peri-procedural and long-term outcome data were collected. Most patients (>70%) were high-risk candidates for endarterectomy. Stents were successfully placed in 117/118 carotid arteries (99.2%). Distal protection devices were used in 43/118 (36.4%). The peri-procedural rate of death or disabling stroke was 3/118 (2.5%). Death or any stroke occurred in 11/118 (9.3%). However, only 7/118 (5.9%) procedures resulted in death or any persistent stroke (neurological deficit >1 week post-procedure). No myocardial infarction occurred. Median length of post-procedure hospitalization was 1 day. Long-term follow up was possible for 101 patients (91.0%) over a mean period of 27.1 months. The Kaplan-Meier estimate of survival free of ipsilateral stroke 36 and 66 months after carotid stenting was 77.0 +/- 9.5% and 68.2 +/- 15.1%, respectively. The estimated survival free of any stroke or stent failure was 70.9 +/- 10.7% and 60.7 +/- 17.4%, respectively. The majority of late deaths (7/11) were due to cardiac disease. We conclude that stenting of carotid stenoses is feasible, with a high procedural success rate and low complication rate. Carotid stenting should be considered the procedure of choice for high-risk patients.

Management of Biliary Neoplastic Obstruction with Two Different Metallic Stents Implanted in One Session

The efficacy of the "one-step" technique using two different metallic stents (Wallstent and Ultraflex) and associated rate of complications was studied in 87 patients with jaundice secondary to malignant biliary obstruction, with bilirubin level less than 15 mg/dl and Bismuth type 1 or 2 strictures. The study group, composed of 40 men and 47 women with a mean age of 59.4 years (range 37-81 years), was treated with a "one-step" percutaneous transhepatic implantation of self-expanding stents. The cause of the obstruction was pancreatic carcinoma in 38 patients (44%), lymph node metastasis in 20 patients (23%), gallbladder carcinoma in 13 patients (15%), cholangiocarcinoma in 12 patients (14%) and ampullary carcinoma in four patients (5%). A significant reduction in jaundice was obtained in all but one patient, with a drop of total serum bilirubin level from a mean of 13.7 mg/dl to 4.3 mg/dl within the first 4 days. The mean postprocedural hospitalization period was 5.4 days in the Wallstent group and 6.4 days in the Ultraflex group. Mean survival rate was 7.8 months (Wallstent group) and 7.1 months (Ultraflex group). The use of both stents did not reveal any significant difference in parameters tested. The implantation of these self-expandable stents in one session, in selected patients, is clinically effective, devoid of important complications and cost-effective due to the reduction in hospitalization.

Percutaneous endoscopic colostomy of the left colon: a new technique for management of intractable constipation in children

Background The antegrade colonic enema is accepted as effective for management of intractable constipation in children when conventional bowel management has failed. This study describes experience with a new, minimally invasive technique, the distal antegrade colonic enema, which involves percutaneous endoscopic colostomy of the left colon. Methods Fifteen children with refractory constipation and soiling who had radiographic evidence of megarectum and/or distal colonic delay were selected for the procedure. The junction of the descending and the sigmoid colon was identified colonoscopically, and the percutaneous endoscopic colostomy tube, through which antegrade distal colonic enema are administered, was inserted. Results Fourteen children underwent distal percutaneous endoscopic colostomy insertion. The median time required for the procedure was 30 minutes (20-50 minutes). Excluding one child (technical difficulties with percutaneous endoscopic colosotomy placement), median post-procedural hospital stay was 4 days (2-27 days). Thirteen children were no longer soiling, and improvement in quality of life was reported at 2 months' follow-up. At 6 months' follow-up, 90% of children were clean during intervals between enemas. All children evaluated at 12 months' follow-up remained clean. Median duration of follow-up was 12.5 months (2-51 months). Conclusions The distal percutaneous endoscopic colostomy is a simple alternative to established methods for delivery of antegrade enemas. It is less invasive and on reversal leaves only minor scarring.

Comparison of treatment outcomes in patients ≥80 years undergoing transradial versus transfemoral coronary intervention

We assessed the effect of transradial access (vs transfemoral access) for percutaneous coronary intervention on postprocedure length of stay and patient outcomes (in-hospital complications and all-cause and cardiac death at 6 and 12 months) in 225 elderly patients (≥80 years old). Raw differences between transradial and transfemoral accesses were compared, and 3 forms of propensity score analysis were used to determine the true effect of transradial access. After matching to adjust for baseline differences in patient characteristics, remaining differences in outcomes and postprocedure length of stay were small and not statistically significant at the 95% level, but a decrease in postprocedural length of stay of nearly 1 day was observed and likely was not due to chance. Transradial access in patients ≥80 years old undergoing percutaneous coronary intervention should be preferred due to equivalent success rate and safety and likely reduction in postprocedural hospitalization.

Post-herniographic abdominal pain syndrome.

To disclose the frequency of abdominal pain that led to post-procedure hospitalization and the outcome of this major complication. 576 patients who had undergone herniography during a 13-year period were retrospectively analysed. Nine out of 576 patients (1.6%) undergoing herniography with an iodine contrast medium developed abdominal pain. The pain resolved within 24 h in 6 patients while 3 patients had pain for up to 3 days. Patients who present with this pain syndrome thus only need careful clinical observation until asymptomatic, with no need for laparotomy or X-ray examination. Prior to herniography, the patients should be informed about this potential complication.

Percutaneous biliary metal wall stenting in malignant obstructive jaundice.

Most patients with advanced stage malignant obstructive jaundice will be suitable for palliation only. Metallic stents are safe, effective and minimally invasive. A review of case notes of patients who had Wallstents inserted percutaneously from January 1996 to December 2000. Eighty-nine patients with a median age of 72 years underwent percutaneous insertion of biliary metal stents. The diagnoses were cholangiocarcinoma (41.5%), pancreatic carcinoma (40.5%), nodal metastases at the porta hepatis (14.6%) and gall bladder cancer (3.4%). Ninety-six per cent of patients improved their hyperbilirubinaemia to normal levels by 1 month. The median post-procedure hospital stay was 16 days. Early overall complications (within 30 days of stenting) occurred in 30% of patients (70% of these were disease related). The 30 day mortality rate was 20% (n = 18). Fifty (70%) patients were readmitted to hospital, most commonly because of carcinomatosis (16) or stent obstruction (12). The symptom-free period ranged from 2 weeks to 13 months. Median survival for all patients was 3.5 months. Survival correlated inversely with serum bilirubin at presentation (r = -0.34, P = 0.001), but not with other liver function tests. Metal wall stenting for malignant obstructive jaundice provides good palliation with low, procedure-related morbidity and mortality, but poor overall survival from disease-related morbidity. Survival significantly correlates with pre-stenting serum bilirubin levels. There is a need to identify the subgroup of patients in whom stenting has no beneficial effect.

Primary Treatment of Malignant Pleural Effusions: Video-Assisted Thoracoscopic Surgery Poudrage versus Tube Thoracostomy

The objective of this study is to show that primary treatment of malignant pleural effusions secondary to ovarian carcinoma with video-assisted thoracoscopic surgery (VATS)-assisted talc poudrage (VATS-ATP) results in shorter hospital stays and reduced time with a chest tube than primary treatment with a chest tube and chemical pleurodesis. We conducted a retrospective chart review of all patients with a symptomatic pleural effusion secondary to primary ovarian carcinoma receiving intervention from January 1996 to December 2000. Patients either received tube thoracostomy with pleurodesis (n = 22) or VATS-ATP (n = 12). Of the patients treated with tube thoracostomy 18 per cent (4/21) died in the hospital before pleurodesis, 77 per cent (14/19) had successful pleurodesis, and 22 per cent (4/18) failed pleurodesis requiring VATS-ATP. In the group treated primarily with tube thoracostomy the chest tube was in place 8.36 +/- 2.61 days with a hospital stay of 12.64 +/- 5.80 days after the procedure. In the group treated with VATS-ATP there was 100 per cent successful pleurodesis. There were no mortalities. There was one prolonged intubation of 3 days and one incomplete lung reexpansion. The chest tube was in place for 4.58 +/- 1.78 days and a hospital stay of 7.50 +/- 4.12 days postprocedure. Groups treated by tube thoracostomy and VATS were statistically different; P < 0.001 for days with a chest tube and P = 0.011 for hospital days. We conclude that both tube thoracostomy with chemical pleurodesis and VATS-ATP provide adequate treatment of ovarian carcinoma-associated malignant pleural effusions. VATS-ATP provides a shorter duration of chest tube placement and postprocedure hospital stay.

Intraarterial Lidocaine for Pain Control after Uterine Artery Embolization for Leiomyomata

To evaluate the effectiveness of intraarterial lidocaine in controlling pain after uterine artery embolization (UAE). In this double-blind prospective study, patients undergoing UAE received preservative-free 1% lidocaine or saline solution (control) in the uterine arteries before embolization. Postprocedural pain was managed with patient-controlled intravenous morphine. Attempted doses, number of doses received, total morphine dose, and maximum pain numeric rating scale (NRS) score during the postprocedural hospitalization were recorded and compared. Three-month follow-up magnetic resonance (MR) imaging and symptomatic questionnaires were collected and compared. Ten patients received lidocaine and eight patients received placebo. Moderate to severe vasospasm was noted in seven patients after lidocaine injection, whereas no vasospasm was noted in the placebo group (P =.004). Patients in the lidocaine group had lower NRS pain scores than those in the placebo group (P =.012), whereas there was no difference in morphine requirement between treated patients and control subjects. The study was terminated after 18 patients were treated as a result of unexpected vasospasm. Intraarterial 1% lidocaine is associated with moderate to severe vasospasm. Lidocaine significantly lowers subjective pain, but there is no difference in analgesic requirements. The routine use of intraarterial lidocaine is not recommended for pain control until the long-term effects of vasospasm on outcome is known.

Determinants of Postembolization Syndrome after Hepatic Chemoembolization

Postembolization syndrome (PES) occurs in the majority of patients undergoing hepatic chemoembolization, and is the major reason for hospitalization after the procedure. The ability to identify which groups of patients are at increased or decreased risk of PES would be useful to better counsel patients, to minimize toxicity, and to plan inpatient versus outpatient therapy. Seventy hepatic chemoembolization procedures were performed in 29 patients using cytotoxic drugs mixed with Ethiodol and polyvinyl alcohol. The following procedural variables were retrospectively assessed and evaluated for association with PES and length of postprocedural hospitalization: gallbladder embolization, lobe embolized, percentage liver volume embolized, percentage embolized volume occupied by tumor, previous embolization of the same territory, and dose of chemoembolic emulsion. Logistic regression was used to quantify the relative effect of each procedural variable. Gallbladder embolization and dose administered were associated with an increased risk of PES and an extended hospitalization, with odds ratios of 2.8 and 3.0, and 3.0 and 4.6, respectively. Previous embolization was associated with a decreased risk of both PES and extended hospitalization, with odds ratios of 0.5 and 0.4, respectively. There was a statistical trend toward significance for gallbladder embolization (P = .06), dose administered (P = .07), and previous embolization (P = .14). Clinically relevant predictors of the severity of PES and length of postprocedural hospitalization may exist. Avoiding embolization of the gallbladder reduces the risk of PES. Re-embolization of previously treated vessels is associated with decreased toxicity and may assist in selecting patients for treatment on an outpatient basis, especially when a reduced dose is required.

Pain after Uterine Artery Embolization for Leiomyomata: Can Its Severity be Predicted and Does Severity Predict Outcome?

To determine whether the severity of postprocedure pain associated with uterine artery embolization (UAE) for leiomyomata can be predicted and if its severity can predict outcome. Eighty-one patients underwent UAE and had postprocedure pain managed with use of patient-controlled analgesia (PCA) in the form of an intravenous morphine pump. Baseline uterine and dominant fibroid volumes were calculated for each patient. Attempted doses, doses given, total morphine dose, and maximum numerical rating scale (NRS) score during postprocedure hospitalization were recorded. At 3 months postprocedure, repeat imaging was used to determine uterine and dominant fibroid volume reduction. Each patient also completed a questionnaire assessing change in menstrual bleeding, pelvic pain and pressure symptoms, and satisfaction with symptomatic outcome. Simple regression analysis was used to determine if baseline volumes predicted postprocedure pain and if the pain-related variables could be used to predict outcome. Neither baseline uterine volume nor dominant fibroid volume predicted the severity of postprocedure pain. Similarly, none of the pain-related variables predicted uterine or fibroid volume reduction, symptomatic improvement, or satisfaction with outcome. Postprocedural pain cannot be predicted based on baseline uterine or fibroid volume and the severity of pain experienced cannot be used to predict outcome.