Risk Of Air Embolism Research Articles

December 2022-Printed Issue

The December 2022 issue of Patient Safety is available to read and download at no charge. Our latest publication offers vital information, tools, resources, and articles that can help improve the safety and well-being of patients and healthcare workers in the new year. • Taylor et al. describea patient safety initiative that reduced the incidence of perioperative emergence delirium at a Veterans Affairs hospital (https://patientsafetyj.com/index.php/patientsaf/article/view/emergence-delirium)—and provide you with everything you need to replicate their work. • What is the past, present, and future of nursing? Nursing professor Eileen Fruchtl discusses how nursing education has been evolving and what it may become (https://patientsafetyj.com/index.php/patientsaf/article/view/nursing-education) following the pandemic, and Toothaker et al. look at the challenges recently graduated nurses face as they transition into the workforce (https://patientsafetyj.com/index.php/patientsaf/article/view/nurse-transition). • John Olsen et al. describe the success and impact of Jefferson Health’s peer support program, RISE (https://patientsafetyj.com/index.php/patientsaf/article/view/Jefferson-rise) (Resilience in Stressful Events). • Abigail Baluyot et al. share communication problems they identified in patient hand-offs between hospitals and skilled nursing facilities (https://patientsafetyj.com/index.php/patientsaf/article/view/hospital-snf-communication), and what they did to improve the process. This issue also includes an important safety alert about the risk of air embolism during cardiac ablation procedures (https://patientsafetyj.com/index.php/patientsaf/article/view/air-embolism), an update to acute care reporting rates in Pennsylvania last year (https://patientsafetyj.com/index.php/patientsaf/article/view/2021-data-update), and an inside look at how prison systems in Pennsylvania deliver healthcare to inmates (how%20prison%20systems%20in%20Pennsylvania%20deliver%20healthcare%20to%20inmates). Patient Safety is fully open access (no fees for authors or readers). We welcome submissions from all over the world. If your work can help advance patient safety, please submit it to us for consideration (https://patientsafetyj.com/for-authors), and kindly share our journal with friends, family, colleagues, and caregivers.

Gas Pressure From the Endoscope: An Unexplored Contributor to Morbidity and Mortality?

Background It has been shown that the incidence of venous air embolism and venous carbon dioxide (CO2) embolism is high during endoscopic retrograde cholangiopancreatography (ERCP). We examined insufflating gas flow and maximum pressure produced by three types of commonly used endoscopes because we could not readily locate technical data for endoscope gas flow and maximum emitted pressure in the manufacturer's manuals. Methods We tested the Olympus GIF-Q180 used for esophagogastroduodenoscopy, the CF-Q180 used for colonoscopy, and the TJF-Q180 used for ERCP (Olympus America Inc., Center Valley, Pennsylvania). Under three different clinical gas insufflation scenarios, we measured in vitro maximum gas pressure transduced from a closed space created at the endoscope tip in a worst-case scenario analysis. Results We showed that it is readily possible to generate a pressure (>5-30 times normal central venous pressure) in the air space at the tip of all three endoscopes when insufflation is activatedand the gas egress is limited. Conclusions These findings shedadditional light on in vivo occurrences of gas embolism during gastrointestinal endoscopy. We postulate that in addition to using exclusively CO2 as the insufflating gas, the risk of gas embolism can be further diminished by regulating insufflating gas pressure at the tip of endoscopes.

Thoracic endovascular aortic repair: Current evidence and challenges.

In 1987 Nikolay Volodos performed the world's first endovascular treatment of aortic aneurysms. Endovascular technology has progressed significantly since then. There are now many thoracic endovascular aortic repair (TEVAR) systems commercially available. By applying them, we can treat many pathologies: aneurysms, dissections, aortic ruptures, and penetrating aortic ulcers. However, TEVAR technology still has its limitations, namely the risk of a retrograde type A dissection, the issue of precise landing in the distal landing zone, and the risk of air embolism and paraplegia. Furthermore, there are no appropriate stent grafts widely available to treat acute dissections. Those currently used are designed for aneurysms, not for dissections. As a result, there are several challenges facing the future TEVAR surgical community, such as the need to develop new and more precise systems with retrograde deployment for the distal landing zone, as well as to introduce flexible stent grafts to treat dissections. The endo-Bentall is being developed as an alternative treatment method for acute type-A aortic dissection.

Renal Replacement Therapy for Patients Requiring Extracorporeal Membrane Oxygenation: A Multicenter International Survey

Introduction: Patients receiving extracorporeal membrane oxygenation (ECMO) often require renal replacement therapy (RRT). The challenge of inserting a dialysis catheter (DC) could be solved by direct connection of RRT lines on an ECMO circuit (DCRE) without published guidelines. This study aimed to describe the practice of RRT in patients on ECMO, including the DCRE as well as the perception and concerns related to this technique. Methods: An international survey was worldwide sent via email to professionals involved in the management of ECMO. Respondents always or often performing RRT via the ECMO circuit were classified in the ECMO group, and those using a DC were classified in the DC group. Results: From March 2019 to October 2019, 298 participants answered the questionnaire from 46 different countries. Only 28% were working in pediatric departments. Among the 165 participants commonly performing RRT in patients on ECMO, 100 (61%) performed mainly RRT via the ECMO circuit, and 65 (39%) performed RRT via DC. Pediatric practice and a longer experience were the only noticeable characteristics of the ECMO group. The most reported concern regarding DCRE was the risk of air embolism (n = 84, 28%), but the most encountered problem was unmanageable pressure alarms in RRT devices. Conclusion: The present study showed significant heterogeneity in RRT practices in patients on ECMO. The lower experience of the DC group, the high rates of concerns toward DCRE, and pressure alarm issues suggested that protocols and training may overcome reluctance and technical difficulties.

New 5-mm laparoscopic pneumodissector device to improve laparoscopic dissection: an experimental study of its safety in a swine model.

To improve the laparoscopic surgical dissection, the aim of the study was to assess the safety of burst of high-pressure CO2 using a 5-mm laparoscopic pneumodissector (PD) operating at different flow rates and for different operating times regarding the risk of gas embolism (GE) in a swine model. The first step was to define the settings use of the PD device ensuring no GE. Successive procedures were conducted by laparotomy: cholecystectomy, the PD was placed 10mm deep in the liver and the PD was directly introduced into the lumen of the inferior vena cava. Different PD flow rates of 5, 10, and 15mL/s were used. The second step was to assess the safety of the device (PD group) during a laparoscopic dissection task (cystic and hepatic pedicles dissection, cholecystectomy and right nephrectomy) in comparison with the use of a standard laparoscopic hook device (control group). PD flow rate was 10mL/s and consecutive burst of high-pressure CO2 was delivered for 3-5s. In the first step (n = 17 swine), no GE occurred during cholecystectomy regardless of the PD flow rate used. When the PD was placed in the liver or into the inferior vena cava, no severe or fatal GE occurred when a burst of high-pressure CO2 was applied for 3 or 5s with PD flow rates of 5 and 10mL/s. In the second step (PD group, n = 10; control group, n = 10), no GE occurred in the PD group. The use of the PD did not increase operative time or blood loss. The quality of the dissection was significantly improved compared to the control group. The 5-mm laparoscopic PD appears to be free from CO2 GE risk when consecutive bursts of high-pressure CO2 are delivered for 3-5s with a flow rate of 10mL/s.

Cone-Beam Computed Tomography-Guided Marking of Small Pulmonary Nodules with Surgical Clips.

Preoperative computed tomography-guided marking can help identify small non-palpable pulmonary nodules during surgery. However, this technique is associated with the risk of air embolism. We retrospectively evaluated whether small pulmonary nodules could be intraoperatively localized using cone-beam computed tomography (CBCT). A hybrid operating room permitting stable lateral positioning and scanning from the pulmonary apex to the base was used in all patients. CBCT images were obtained using a 10-s protocol with 180º rotation of the C-arm flat panel detector around the patient. Clips were placed on the visceral pleura to help guide pulmonary nodule localization. Partial pulmonary resection was performed using video-assisted thoracoscopic surgery at the predicted nodule site. Between July 2013 and June 2019, 132 patients with 145 lesions underwent this procedure at our center. The detection rate of lesions on CBCT was 100%. The pathological diagnoses were primary lung cancer, metastatic pulmonary tumors, and benign lesions. The average consolidation-to-tumor ratio was 0.65 for all nodules, with ratios of 0.33, 0.96, and 0.70 for primary lung cancer, metastatic pulmonary tumors, and benign lesions, respectively. No complications related to this localization method were observed. CBCT-guided intraoperative localization is safe and feasible for non-palpable small pulmonary nodules. This technique may eliminate the risk of serious complications such as air embolism.

S2317 ERCP-Associated Air Embolism, Bacteremia, and Septic Cerebral Infarction

INTRODUCTION: Rare complications of endoscopic retrograde cholangiopancreatography (ERCP) are duodenal perforation, necrotizing pancreatitis, systemic air embolism (AE), and septic cerebral infarction. We present a case of ERCP associated AE, bacteremia, and septic cerebral infarction in one patient that survived. CASE DESCRIPTION/METHODS: A 52-year-old female with a history of choledocholithiasis, ERCP lithotripsy and stent placement 1 month prior, presented for outpatient ERCP and underwent stent removal, duct dilation and removal of multiple stones. Immediately post procedure, she became unresponsive with supraventricular tachycardia and hypotension requiring ICU admission and intubation. A stat EKG showed diffuse ST elevations with near complete resolution on repeat EKG 20 minutes later. Additionally, a stat abdominal CT showed portal venous gas confirming the presence of an AE (Figure 1). However, troponins eventually rose to 17 ng/mL, thus heparin was started until NSTEMI could be ruled out. Empiric antibiotics were also started due to persistent hypotension and infectious workup ensued. Urgent cardiac catheterization showed non-occlusive disease, and heparin was stopped. Her blood cultures grew Enterobacter hormaechei, thought to have seeded during ERCP, and antibiotics were streamlined. Despite hemodynamic improvement, she had difficulty awakening from sedation and a subsequent brain MRI revealed bifrontal hemorrhagic emboli, likely septic due to involvement of various vascular territories and known ERCP-associated bacteremia. Furthermore, there was no pneumocephalus, ruling out cerebral AE, and no vegetation on transesophageal echo, ruling out endocarditis. DISCUSSION: AE may be confused with an anesthetic side effect or acute ischemic event. It should be considered with sudden clinical deterioration during or immediately after ERCP. The diagnosis is often made post-mortem, thus clinical suspicion is paramount and may be confirmed after visualizing air in the vena cava, portal vein, heart, or brain. Air can be absorbed rapidly thus diagnosis can be made on clinical suspicion alone. Air insufflation into the portal vein can occur during sphincterotomy and use of CO2 can minimize risk of AE. Anticoagulation is not indicated and treating NSTEMI may have allowed for hemorrhagic conversion of septic emboli, which are already prone to hemorrhage. Septic cerebral emboli from ERCP are exceedingly rare, with a handful of reported cases. Our case urges awareness of potential catastrophic sequela of ERCP.Figure 1.: Abdominal CT without contrast demonstrating the peripheral pattern of portal venous gas (arrows) as well as the central gas pattern of pneumobilia (ellipse).Figure 2.: Coronal abdominal CT demonstrating air in the portal venous system.

Endoscopic supracerebellar infratentorial approach to pineal and posterior third ventricle lesions in prone position with head extension: a technical note

ABSTRACT Objective The supracerebellar infratentorial (SCIT) approach is frequently used for the treatment of lesions in the pineal and posterior third ventricle region and can be performed in a sitting or prone position. We describe our experience with the purely endoscopic SCIT approach, using a prone position, with neck extension and head rotation. Methods We analysed all paediatric and adult patients operated on between July 2013 and January 2018 using the purely endoscopic SCIT approach. The surgical procedure was conducted through a paramedian subtorcular key-hole suboccipital craniotomy. The assistant held the endoscope and the surgeon used fine, long shaft instruments for bimanual tumour dissection. The prone position with head retroflexion allowed a gravity-aided enlargement of the anatomical surgical corridor between tentorium and cerebellum and enhanced venous blood drainage, similarly to the sitting or semi-sitting position, but with a decreased risk of air embolism. Results The approach allowed a complete removal of lesions located in the pineal region and in the posterior part of the third ventricle. Seven patients have been operated with this approach. All of them had the tumour completely removed. No permanent neurological deficits have been observed. Conclusions The endoscopic SCIT approach enables effective and safe removal of pineal and posterior third ventricle lesions, even of moderate dimensions (up to 3 cm). The endoscope guarantees a detailed view and illumination of the deep-seated structures. The tumour resection can be performed with bimanual use of microsurgical instruments.

FULMINANT CEREBRAL AIR EMBOLISM FOLLOWING ENDOVAC-THERAPY IN ESOPHAGEAL ANASTOMOTIC LEAKAGE – A RARE COMPLICATION

Abstract Aim Anastomotic leakages after esophageal surgery is a major complication with an increased risk of mortality and an extended ICU and hospital stay. Surgical revisions or endoscopic interventions are standard procedures in treatment of such complications. The use of endoscopic endoluminal vacuum therapy (EVT) as introduced in the last years is considered a safe treatment. Background & Methods We analyzed 78 patients who underwent a surgical resection of the esophagus from January 2015 until December 2018. We compared patients with endovac-therapy to patients without such endoscopic intervention. Length of stay in ICU and in hospital, patient’s demographics and perioperative parameters were analyzed. Results In our center, we performed 78 esophageal resections from January 2015 to December 2018. In 14.1% (11 patients) an anastomotic leakage appeared, in 10 patients (12.8% of all cases) we performed an endovac-therapy. In the endovac- group, the mean postoperative hospital stay was 39 days (± 18 days), which is a significant longer postoperative in-hospital time in compare to the other patients (mean 17 days, ±8 days, p=0,004). Patients demographics and perioperative parameters were comparable in both groups. The postoperative 90-days mortality in the endovac-group was 20% (2 patients), in compare to a 90-days mortality rate of 4.4% in the group without an EVT. In one case we found the rare complication of an air embolism following an extended 35 days endovac-therapy. Endovac-therapy is a useful tool in the treatment of anastomotic leakage, although it is associated with a significantly prolonged hospital stay. Air embolism during endovac-therapy such as reported in this analysis, is a rare complication associated with endoscopic treatments. This is the first reported case of such an air embolism during endovac-therapy. Using carbon dioxide for endoscopic interventions might reduce the risk for air embolism, especially in high-risk-patients.

Hysteroscopy and the risk of gas embolism: A review

Hysteroscopy is one of the most frequent procedures that a gynecologist will perform over their career. It is also one of the safest procedures. Operative hysteroscopy has an increased risk profile due to the nature of the surgery. The following review will address the issue of gas embolism in hysteroscopy. This review will look at the evidence regarding the likely causation, rates, and potential methods of minimizing risk to patients as well as treatment options available should this complication arise.

Are Cardiac Anomalies and Persistent Fetal Circulation a Risk Factor for Cardiovascular Events During Minimally Invasive Surgery in Neonates?

Introduction: Minimally invasive surgery (MIS) in neonates is progressively performed. The aim of this study was to evaluate the risk for cardiovascular events during endoscopic surgery in neonates and to analyze the influence of persistent fetal circulation and/or cardiac anomalies. Materials and Methods: This is a retrospective single institution study including all neonates undergoing MIS. The charts were reviewed for intraoperative cardiovascular events and operative procedure was performed. Special attention was paid to cardiac anomalies and persistent fetal circulation. In addition, a review of the literature was performed. Results: Between January 2004 and December 2012, 108 neonates underwent MIS at our institution. Laparoscopic surgery was performed in 91 (84.3%) and thoracoscopy in 17 (15.7%) babies. None of these 108 patients developed a cardiovascular event during endoscopic surgery (0.0%). Persistent fetal circulation and/or cardiac anomalies were evaluated in 50 of 108 (46.3%) neonates. In the additionally performed review of the literature, four single case reports were identified. All 4 authors published a major cardiovascular event during laparoscopic surgery in neonates. In all 4 patients, gas embolism through a patent umbilical vein was assumed to be responsible for the cardiovascular event. Conclusions: In our opinion, the main risk factor for the development of a major cardiovascular event during MIS in neonates is vascular injury of a persistent umbilical vein. Persistent fetal circulation and/or cardiac anomalies seem to be less important. In case of injury of a persistent umbilical vein, the risk of gas embolism has to be respected and conversion to the open approach has to be considered.

Surgical Strategy in Large Vestibular Schwannoma.

Particular care to facial nerve function preservation should be the ultimate goal in surgery for large vestibular schwannomas. We present a 60-year-old patient who presented with an enlarging right vestibular schwannoma and nonserviceable hearing. The patient was operated in the semisitting position after a patent foramen ovale was ruled out. During the positioning, the feet were positioned at the level of the heart. Precordial Doppler was used to monitor for air embolism. Straight skin incision and retrosigmoid craniotomy was performed. Specific attention to venous bleeding was made during the approach. Meticulous arachnoid dissection of the capsule preserving the arachnoid plane at the surface of the brain stem and the facial nerve can be achieved more efficiently with the patient in the semisiting position and with bimanual microdissection technique. After drilling of the internal auditory canal (IAC), we were able to achieve near total removal of the tumor, leaving a tiny tumor carpet due to extreme adherence to the nerve. Water-tight dura closure and replacement of the bone flap was performed. The patient woke up with a House–Brackmann grade III facial weakness which improved to grade I at 6 weeks postoperatively. Postoperative magnetic resonance imaging (MRI) showed a tiny residual at the surface of the facial nerve at the entrance of the IAC. Near total (> 98%) resection of large vestibular schwannomas is an acceptable surgical strategy with excellent facial nerve outcome. With appropriate patient positioning in semisitting and proper anesthesiological and surgical management, the risk of air embolism is negligible. The link to video can be found at: https://youtu.be/ErG9VexbiGw .

A prospective case series evaluating use of an in-line air detection and purging system to reduce air burden during major surgery

BackgroundIntravascular air embolism (AE) is a preventable but potentially catastrophic complication caused by intravenous tubing, trauma, and diagnostic and surgical procedures. The potentially fatal risks of arterial AE are well-known, and emerging evidence demonstrates impact of venous AEs on inflammatory response and coagulation factors. A novel FDA-approved in-line air detection and purging system was used to detect and remove air caused by administering a rapid fluid bolus during surgery.MethodsA prospective, randomized, case series was conducted. Subjects were observed using standard monitors, including transesophageal echocardiography (TEE) in the operating room. After general anesthesia was induced, an introducer and pulmonary artery catheter was inserted in the right internal jugular to administer fluids and monitor cardiac pressures. Six patients undergoing cardiac surgery were studied. Each patient received four randomized fluid boluses: two with the in-line air purging device, two without. For each bolus, a bulb infuser was squeezed three times (10–15 mL) over 5 s. The TEE was positioned in the mid-esophageal right atrium (RA) to quantify peak air clearance, and images were video recorded throughout each bolus. Air was quantified using optical densitometry (OD) from images demonstrating maximal air in the RA.ResultsAll subjects demonstrated significantly lower air burden when the air reduction device was used (p = 0.004), and the average time to clear 90% of air was also lower, 3.7 ± 1.2 s vs. 5.3 ± 1.3 s (p < 0.001).ConclusionAn air purging system reduced air burden from bolus administration and could consequently reduce the risk of harmful or fatal AEs during surgery.

James Blundell, Obstetrical Hemorrhage, and the Origins of Transfusion Medicine.

Although James Blundell is rightly acknowledged as the father of modern transfusion therapy, a review of the events surrounding the initial human-to-human transfusions in the first decades of the 19th century reveals substantial contributions by Blundell's collaborators. Bundell's uncle John Haighton provided substantial support for animal experimentation in the growing field of physiology studies. John Leacock of Barbados provided the essential original experiments that focused the path of investigation on within-species transfusions. London instrument makers such as Laundy and Lloyd provided precision-made syringes without risk of air embolism. Fellow obstetricians Charles Waller and Edward Doubleday became ardent supporters of the new therapy and brought case referrals to Blundell's attention and care. British medical journals, such as The Lancet, provided much needed dissemination of early successes to curious medical practitioners. This 200th anniversary year of the first successful attempts at human-to-human transfusion presents an opportunity to review the failures and successes which occurred during the first days of what would ultimately become a life-saving treatment for millions worldwide.

Application of beach chair position and lateral decubitus position in shoulder arthroscopy

The clinical application of arthroscopic minimally invasive treatment of shoulder joint disease technology has become a routine, and it has been widely carried out around the world. Compared with the traditional open surgery, it only needs to establish a few channels in the shoulder and then the diagnosis and treatment of the structure under the acromion and glenoid joint internal lesions can be completed through the arthroscopic technique under direct vision, of course, including local collection of pathological specimens. Shoulder arthroscopic surgery has the advantages of simple operation technique, small economic burden of patients, small tissue trauma, quick recovery and high accuracy of disease diagnosis. At present, there are two main options for shoulder arthroscopy: the beach chair position (BCP) and the lateral decubitus position (LDP). The choice of surgical position for surgeons is closely related to the intraoperative operation, the risk of complications, the effi-cacy of surgery, and the cost of setting the posture. Shoulder arthroscopy of these two positions have their own advantages and disadvantages: in the BCP, the surgeon gets a better anatomical operation experience, if necessary, can be converted into open surgery at any time. Without continuous traction, upper limb nerve and vascular damage caused by traction can be avoid. But the incidence of cerebral ischemic events in patients may increase in the BCP. There is also possibility of the nerve damage of the pillow small nerve, great auricular nerve, lateral femoral cutaneous nerve and other nerves. In theory the risk of air embo-lism in the patients will increase in the BCP, and the cost of setting the position is also higher than the LDP. While in the LDP due to the patient's forearm continuous traction, the surgeon can get a more extensive operating space, and the occur-rence of cerebral ischemic events is very rare. In the treatment of anterior shoulder instability after shoulder arthroscopic sur-gery, there is a lower recurrence rate in the LDP. The cost of setting the position is also significantly lower than the BCP. Of course, the disadvantages of the LDP is also obvious. In the LDP, the brachial plexus and other nerves or vascular injury may increase due to the continuous traction of the forearm. Meanwhile sustained traction in the LDP is also a risk factor for throm-bosis, and so on. Therefore, there is still a debate about the optimal location of the shoulder arthroscopy. Many clinicians choose shoulder arthroscopic position based on their own experience and habits.

Techniques and innovations in liver surgery.

Since the development of laparoscopic cholecystectomy in 1987, the laparoscopic approach extended to several abdominal procedures. However, liver laparoscopic approach remains during a long time limited, contrarily to abdominal surgery. It is mainly due to the technical complexity of interventions, the lack of appropriate instrumentation, the risk of gas embolism, of uncontrolled bleeding, the difficulty to detect intra-operatively in real time the tumour, the fear of not being able to follow oncological principles with a subsequent risk of tumoral dissemination.

Experiences with the Sitting Position in Posterior Fossa Surgery in 310 Patients

Introduction: The sitting position for lesions in the posterior fossa has been controversially discussed in the literature because of high risk of air embolism. We report our experience with the sitting position and evaluate the risk of air embolism. Material and Methods: We performed a retrospective analysis of patient charts (N=310), surgical and anesthesiological reports to evaluate the occurrence of intraoperative complications. Pre and post-operative MRIs were also evaluated for occurrence of embolic infarctions. The patients were operated in our department from 2009–2013. Results: Only 0.6% of patients suffered from embolic infarctions. Most of the complications were similar to the complications which occur in the lateral oblique position. Preoperatively, all patients were evaluated with echocardiography to exclude a patent foramen ovale (those patients were not operated in the sitting position). Conclusion: The sitting position is excellent for surgery in the posterior fossa since blood is washed out and does not intervene with the surgical field. The risk of air embolism is very low when a patent foramen ovale has been excluded. Intraoperatively, a right ventricular catheter is inserted to aspirate air if needed. Meticulous coagulation, irrigation of the surgical domane and application of bone wax to the craniotomy edges reduces the risk of venous air embolism.

Hydrogen peroxide: risk of gas embolism during surgery

Hydrogen peroxide: risk of gas embolism during surgery

Current advances in liver surgery

Hepatobiliary surgery has taken a big step forward in recent decades especially in the minimally invasive approach for hepatectomy. From being sceptical at the beginning of the 1990s when laparoscopic surgery had become prevalent, to now, where laparoscopic hepatectomy has been well-established, especially in minor hepatectomies; this new technique has evolved rapidly over the past 20-years demonstrating better short-term outcomes and equivalent oncological outcomes in selected patients and in expert hands. Laparoscopic hepatectomy is indeed, more difficult to master than the open procedure with restrictions in working space, difficulty in haemostasis and the potential risk of gas embolism. However, with better visibility of the operative field around the liver, especially beneath the costal margin, the magnified view and theoretical advantage of pneumoperitoneum acting as haemostatic pressure have made laparoscopic hepatectomy increasingly popular. Another important advancement is the new surgical technique of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS). This procedure induces more rapid liver hypertrophy within a median period of 9-days, allowing resection to be performed in candidates with borderline functional liver remnant and at an earlier date. However, studies have shown that ALPPS is associated with a relatively higher rate of morbidity and mortality. Therefore, it remains a highly controversial treatment option and more studies have to be performed to establish its usefulness and define its role in liver surgery.

Neurologic complications of percutaneus nephrolithotomy.

Neurologic complications of percutaneus nephrolithotomy.