Salvage Technique Research Articles

The occlusion balloon reduction technique for de novo placement and salvage of malpositioned enteric tubes.

Nasoenteric, gastrojejunostomy, and jejunostomy tubes are methods of enteral nutrition in patients with functioning gastrointestinal tracts who cannot maintain adequate oral intake. Current placements; however, may be complicated by redundant wire and catheter loops within the stomach preventing operators from optimal feeding tube placement and predisposing patients to feeding tube prolapse. This report describes the occlusion balloon reduction technique for salvage of malpositioned tubes and placement of new enteric tubes in the setting of redundant loops. Five patients underwent the occlusion balloon reduction technique for jejunostomy (n = 3), gastrojejunostomy (n = 1), or nasojejunal tube placement (n = 1). All patients (n = 5) had redundant wires coiled within the stomach. In all patients (n = 5), a 9-French × 32mm × 120cm Coda balloon was inserted over the wire and passed into the small bowel. The balloon was inflated after which reduction of redundancy in the upper gastrointestinal tract was performed. Feeding tubes were then placed with tips in the distal jejunum. Technical success of the occlusion balloon reduction technique, successful placement of enteric tube, complications, and follow-up were recorded. The occlusion balloon reduction was technically successful in all patients (n = 5). Feeding tube placement was successful in all patients (n = 5). No minor or major complication occurred. Mean follow-up was 56days. The occlusion balloon reduction technique provides a method for reduction of redundant wire and catheter loops within the stomach during enteric tube placement or repositioning.

Peritoneal Dialysis Cuff-Shaving-A Salvage Therapy for Refractory Exit-Site Infections.

Introduction:Cuff-shaving has been described as a salvage technique for refractory exit-site infections, with conflicting data regarding infection and catheter outcomes. We describe our experience with cuff-shaving as a rescue therapy for exit-site infections unresponsive to systemic therapy.Methods:We retrospectively reviewed patients who underwent cuff-shaving between January 2012 and June 2017. Refractory exit-site infection was defined as purulent discharge from the exit site with no clinical response after 3 weeks of systemic antibiotic treatment.Results:Fifty-three cuff-shavings were included, mean age was 53.4 ± 13.4 years, 26 patients were male. Median dialysis vintage was 29 months (interquartile range [IQR] 14.3 - 38), and 39 (73.6%) were on continuous ambulatory peritoneal dialysis (CAPD). The exit-site infection rate before cuff-shaving was 1.12 episodes per patient-year and the median time from infection to shaving was 52 days (IQR 35 - 76). The most frequent agents were Staphylococcus aureus (34%), Corynebacterium spp. (17%) and Pseudomonas aeruginosa (15%). Median follow-up was 9 months (IQR 1 - 18.5), during which time 35 catheters were removed, 5 due to non-infectious reasons. Using the Kaplan-Meier survival analysis, median catheter survival was 24 months (95% confidence interval [CI] 4.17 - 43.83). At 12 months, the probability of catheter survival was 54% and was not statistically different between gram-positive and gram-negative agents, although it was significantly shorter for fungal agents.Conclusion:Cuff-shaving is a feasible rescue therapy to treat refractory exit-site infections. In our experience, it allowed resolution of infections in a significant proportion of cases, except for fungal agents, and therefore extended catheter survival time, besides being associated with a small rate of complications.

Pedicled, vascularized occipital bone graft to supplement atlantoaxial arthrodesis for the treatment of pseudoarthrosis

Atlantoaxial pseudoarthrosis is a challenging postoperative complication. The use of a local, vascularized bone graft, without free tissue transfer, to support a revision atlantoaxial fusion has not been previously described. We report the first surgical patient who received a semispinalis capitis muscle pedicled, occipital bone graft for supplementation of a revision atlantoaxial arthrodesis. A 72-year-old female had a failed atlantoaxial fusion and developed neck pain from continued instability and fractured hardware. The fixation and fusion were revised and supplemented with a novel, pedicled occipital bone graft. A craniectomy was performed in the occipital bone while still attached to the semispinalis capitis muscle to provide graft vascularity. This graft was rotated inferiorly from the skull base to the C1 arch and C2 spinous process in order to supplement a revision atlantoaxial arthrodesis. The patient had excellent clinical recovery over 18-month clinical follow up. The bone graft harvesting and rotation were performed safely and without complication. The 6-month postoperative CT scan showed partial fusion into the graft. This novel surgical technique leverages the advantages of vascularized structural autograft without adding extensive time or morbidity to the procedure as observed in free-tissue transfers. It is a safe and useful salvage technique to supplement revision atlantoaxial fusion surgeries.

Ankle Arthrodesis With Structural Grafts Can Work for the Salvage of Failed Total Ankle Arthroplasty.

Background. Treatment options after failed total ankle arthroplasty (TAA) are limited. This study reports midterm outcomes and radiographic results in a single-surgeon group of patients who have undergone ankle arthrodesis with intramedullary nail fixation and structural allograft augmentation following failed TAA. Methods. A retrospective review on patients who underwent failed TAA revision with structural femoral head allograft and intramedullary tibiotalocalcaneal (TTC) nail fixation was completed. Foot Function Index (FFI), American Orthopaedic Foot & Ankle Society (AOFAS) outcome scores, and radiographs were obtained at each visit with 5-year follow-up. Results. Five patients were followed to an average of 5.2 years (range 4.7-5.6). Enrollment FFI was 34.82 (range 8.82-75.88); at midterm follow-up it was 20.42 (range 0-35.38). Enrollment AOFAS scores averaged 66.6 (range 61-77); at midterm follow-up it was 70.33 (range 54-88). Radiographs showed union in 4 of 5 patients at enrollment and 2 of 3 patients at midterm. Conclusions. Utilization of TTC fusion with femoral head allograft is a salvage technique that can produce a functional limb salvage. Our results show continued improvement in patient-reported outcomes, with preservation of limb length and reasonable union rate. Levels of Evidence: Therapeutic, Level II: Prospective, comparative trial.

'Tramline Rescue': A salvage technique for the failed elliptical excision on the leg.

We outline an approach to achieve wound closure in the event of a failed elliptical excision on the leg. The various steps are shown, and a clinical example is presented.

Treatment for venous aneurysm: A salvage technique of AVF with an early cannulation prosthetic graft

Aim: A Venous aneurysm (VA) is one of the complications of arteriovenous fistulas (AVF) and may lead to rupture and potentially fatal bleeding. VA formation in AVF is mostly seen in the upper arm. Material and Methods: Between January 2018 and December 2018, a total of 12 VA patients underwent surgery to end-to-end anastomosis using a vascular graft. Results: Eight of the patients (66%) were males, and the mean age was 43.1 years (range 25-69 years). All of the fistulas were in the upper arm; two were basilic transpositions, and 10 were brachiocephalic AVF. Mean VA diameter was 4,7 cm (range 3-7 cm). All patients cannulated successfully within 24-48 hours from the newly placed AV access. Conclusions: The procedure we described in this series is a successful and effective method for the treatment of VA in AFV. Postoperatively, most of the patients discharged early, and the VA site could be used for HD in 24-48 hours.

Atlantoaxial fixation using C1 posterior arch screws: feasibility study, morphometric data, and biomechanical analysis.

OBJECTIVEC1-2 is a highly mobile complex that presents unique surgical challenges to achieving biomechanical rigidity and fusion. Posterior wiring methods have been largely replaced with segmental constructs using the C1 lateral mass, C1 pedicle, C2 pars, and C2 pedicle. Modifications to reduce surgical morbidity led to the development of C2 laminar screws. The C1 posterior arch has been utilized mostly as a salvage technique, but recent data indicate that this method provides significant rigidity in flexion-extension and axial rotation. The authors performed biomechanical testing of a C1 posterior arch screw (PAS)/C2 pars screw construct, collected morphometric data from a population of 150 CT scans, and performed a feasibility study of a freehand C1 PAS technique in 45 cadaveric specimens.METHODSCervical spine CT scans from 150 patients were analyzed to determine the average C1 posterior tubercle thickness and size of C1 posterior arches. Eight cadavers were used to compare biomechanical stability of intact specimens, C1 lateral mass/C2 pars screw, and C1 PAS/C2 pars screw constructs. Paired comparisons were made using repeated-measures ANOVA and Holm-Sidak tests. Forty-five cadaveric specimens were used to demonstrate the feasibility and safety of the C1 PAS freehand technique.RESULTSMorphometric data showed the average craniocaudal thickness of the C1 posterior tubercle was 12.3 ± 1.94 mm. Eight percent (12/150) of cases showed thin posterior tubercles or midline defects. Average posterior arch thickness was 6.1 ± 1.1 mm and right and left average posterior arch length was 28.7 mm ± 2.53 mm and 28.9 ± 2.29 mm, respectively. Biomechanical testing demonstrated C1 lateral mass/C2 pars and C1 PAS/C2 pars constructs significantly reduced motion in flexion-extension and axial rotation compared with intact specimens (p < 0.05). The C1 lateral mass/C2 pars screw construct provided significant rigidity in lateral bending (p < 0.05). There was no statistically significant difference between the two constructs in flexion-extension, lateral bending, or axial rotation. Of the C1 posterior arches, 91.3% were successfully cannulated using a freehand technique with a low incidence of cortical breach (4.4%).CONCLUSIONSThis biomechanical analysis indicates equivalent stability of the C1 PAS/C2 pars screw construct compared with a traditional C1 lateral mass/C2 pars screw construct. Both provide significant rigidity in flexion-extension and axial rotation. Feasibility testing in 45 cadaveric specimens indicates a high degree of accuracy with low incidence of cortical breach. These findings are supported by a separate radiographic morphometric analysis.

Technique and Results of Permanent Medial Tarsorrhaphy for Complex Eyelid Malposition.

To evaluate the results of permanent medial tarsorrhaphy and to describe the surgical technique. Medial tarsorrhaphy was performed on 30 eyelids with symptomatic exposure keratopathy secondary to eyelid malposition. Observational, retrospective review of preoperative and postoperative examination findings was performed. Average age of the cohort was 66 years (31-91). Medial tarsorrhaphy was performed to correct eyelid retraction (100%), exposure keratopathy (80%), lagophthalmos (57%), and ectropion (17%) in patients with cranial nerve VII palsy (47%), Graves eye disease (13%), eczema (7%), floppy eyelid syndrome (7%), after Mohs reconstruction (7%), orbital myositis (3%), and neurofibromatosis (3%). Seventy-three percent (73%) of patients had an average of 3 surgeries (N = 22, standard deviation = 1.12, range = 2-7) before undergoing medial tarsorrhaphy. Medial tarsorrhaphy was performed in combination with another procedure in 53% of cases. Palpebral fissure decreased postoperatively an average of 1.1 mm (N = 20; p = 0.005), inferior scleral show decreased 0.72 mm (N = 22; p = 0.03), lagophthalmos decreased 0.4 mm (N = 15; p = 0.27), and superficial punctate keratopathy improved by 61% (N = 27; p = 0.009). Ectropion completely resolved in 4 of 10 patients (40%). Seven patients (23%) required additional surgery following tarsorrhaphy an average of 8 months later (range = 2-16). In 1 patient (3%), a tarsorrhaphy opened prematurely, and 1 patient (3%) requested partial opening of the tarsorrhaphy. Average duration of follow up was 13 months (N = 30, standard deviation = 14.97, range = 0.2-45.7). Medial tarsorrhaphy is a safe and effective primary or salvage technique to address complex causes of eyelid retraction, lagophthalmos, ectropion, and exposure keratopathy.

Early anastomotic complications in colorectal surgery: a systematic review of techniques for endoscopic salvage

BackgroundAnastomotic complications following colorectal surgery are associated with significant morbidity and mortality. For patients in whom systemic sepsis is absent or well controlled, minimal access techniques, such as endoscopic therapies, are being increasingly employed to reduce the morbidity of surgical re-intervention. In this review, we aim to assess the utility of endoscopic management in the acute setting of colorectal anastomotic complications, focusing on anastomotic leak.MethodA literature search was performed for published full text articles using the PubMed, Cochrane and Scopus databases using the search criteria string “colorectal anastomotic (“leak” OR “bleed”), “endoscopy”, endoscopic management”. Additional papers were detected by scanning the references of relevant papers. Data were extracted from each study by two authors onto a dedicated pro-forma. Given the nature of the data extracted, no meta-analysis was performed.ResultsA total of 89 papers were identified, 16 of which were included in this review; an additional 14 papers were obtained from reference searches. In patients who are not physiologically compromised, there are promising data regarding the salvage rate of stents, over-the-scope endoscopic clips, vacuum therapy and fibrin glue in the early management of colorectal anastomotic leak. There is no consensus regarding the optimal approach, and data to assist the physician in patient selection are lacking. Whilst data on salvage (i.e. healing and avoidance of surgery) are well understood, no data on functional outcomes are reported.ConclusionEndoscopic therapy in the management of stable patients with colorectal anastomotic leaks appears safe and in selected patients is associated with high rates of technical success. Challenges remain in selecting the most appropriate strategy, patient selection, and understanding the functional and long-term sequelae of this approach. Further evidence from large prospective cohort studies are needed to further evaluate the role of these novel strategies.

Urethral Bulking and Salvage Techniques for Post-Prostatectomy Incontinence

Despite limited evidence and efficacy, urethral bulking remains a common treatment for post-prostatectomy stress urinary incontinence (PP-SUI). Herein we provide an overview of the existing evidence for synthetic bulking agents and emerging evidence for stem cell-based sphincter rejuvenation in this setting. We also touch upon salvage techniques for management of PP-SUI after failed anti-incontinence interventions. Autologous stem cell (ASC) therapies are currently undergoing phase III trials for use in female SUI and are poised to enter the market within the next decade. Early data suggests that they may have a future role in PP-SUI management as well. The artificial urinary sphincter (AUS) has emerged as the standard of care for salvage PP-SUI treatment. Treatment paradigms for PP-SUI continue to evolve. Synthetic bulking remains common while autologous bulking looms as a potential future therapy. The AUS remains the last line of defense.

Free Latismus Dorsi Muscle Flap with a Flow-Through Technique for Lower Limb Salvage

Free Latismus Dorsi Muscle Flap with a Flow-Through Technique for Lower Limb Salvage

Complex reconstruction following traumatic forequarter amputation

Interscapulothoracic amputation is a radical and morbid procedure used for the management of upper extremity trauma and more commonly for resection of solid tumors. Traumatic forequarter amputation poses a unique challenge for achieving adequate tissue coverage depending on the condition of the muscle and soft tissue of the ipsilateral extremity. We present a case of a 38-year-old construction worker who suffered an almost complete forequarter amputation of his right upper extremity secondary to blunt force trauma from a crane pulley that fell from 60 ft. This is a unique mechanism of injury, as most traumatic forequarter amputations occur as a result of traction injury. Details of the case report including the unique challenges, techniques for tissue salvage, fillet flaps, and chest wall reconstruction are presented.

Intraoperative Usage of Blood Products in Patients Undergoing Cardiac Surgery on Cardiopulmonary Bypass

Abstract Background: Transfusion of blood products is increasingly recognised as an independent predictor of poor outcome after cardiac surgery. The aim of this study was to audit blood transfusion usage in a cardiothoracic unit at a tertiary academic centre, as part of a plan to establish a blood-conservation protocol. Methods: A descriptive, retrospective audit. A consecutive convenience sampling method was used. One hundred and twenty-two adult patients who underwent their first elective cardiac surgery on cardiopulmonary bypass (CPB) were enrolled. Results: The mean age of the population studied was 46.7 (16.2) years. Patients were predominantly male (60.7%). The mean (standard deviation) body mass index was 21.4 (5.6) kg/m2. Preoperative haemoglobin (Hb) and platelet counts were 12.8 (2.3) g/dl and 274.4 (121.9) 109/l, respectively. Following a clear fluid prime CPB technique, with a median [interquartile range (IQR)] priming volume of 1500 (1000–2000) ml, the first Hb measured on CPB was 8.9 (1.6) g/dl. Overall, 110 (90.2%) patients received donor blood products. Eighty-five (77.3%) patients received red blood cells (RBCs), 103 (93.6%) fresh frozen plasma (FFP) and 35 (31.8%) platelet transfusion. A total of 255 RBC, 225 FFP and 37 platelet units were transfused. Cell salvage technique was used in 94 (77.0%) patients. The median (IQR) volume of salvaged blood was 535 (250–754) ml. Conclusion: A high rate of homologous blood product transfusion was found in patients undergoing cardiac surgery. Lack of institution-specific guidelines, point-of-care devices and use of higher Hb thresholds before initiating blood product transfusions contributed to high rate of transfusions.

Posterior Extensive Circumferential Decompressive Reconstructive Technique in Surgical Treatment of Upper Thoracic Spine Compressive Lesions

Complexity in ventral surgical exposure and presence of scapula and large parascapular musculature during posterior surgery are the main obstacles in operative treatment of upper thoracic spine compressive lesions (UTSCLs), such as trauma, tuberculosis, and neoplasm. Recently, the advantages of combined ventrodorsal surgery could be successfully gained using a 1-stage posterior salvage technique with enough accessibility to all 3 spinal columns. This was a retrospective evaluation of 35 patients with UTSCLs treated by the posterior extensive circumferential decompressive reconstructive (PECDR) procedure. Traumatic, tuberculosis, and neoplastic lesions were involved between 2009 and 2012. All patients were examined pre- and postoperatively and during follow-up clinically (pain by visual analog scale), neurologically (sensory and motor deficit by American Spinal Injury Association grading), functionally (Oswestry Disability Index), radiologically (kyphosis correction, loss of correction, and fusion time), and with laboratory investigations in patients with tuberculosis. Two authors plus an independent observer performed the final clinical, neurologic, and radiologic examination. Operative time, hospital stay, blood loss, and complications were documented. The mean follow-up period was 36 ± 5.5 months. Local symptoms, deformity correction, and neurologic recovery significantly improved postoperatively. Solid fusion was evident in 32 cases. No major complications were reported. Three patients developed wound infection and 3 had intercostal neuralgia; both complications were resolved uneventfully and did not influence the outcomes. Because of difficult ventral exposure, the PECDR technique is a feasible tool for maintained deformity correction, bony fusion, thecal decompression, and functional improvement in surgical treatment of UTSCLs. However, tuberculosis had better satisfactory results than traumatic and neoplastic lesions.

Self-expandable metal stents in patients with postoperative delayed gastric emptying after distal gastrectomy.

AIMTo investigate the efficacy and safety of endoscopic stent insertion in patients with delayed gastric emptying after gastrectomy.METHODSIn this study, we prospectively collected data from patients who underwent stent placement for delayed gastric emptying (DGE) after distal gastrectomy between June 2010 and April 2017, at a tertiary referral academic center. Clinical improvement, complications, and consequences after stent insertion were analyzed.RESULTSTechnical success was achieved in all patients (100%). Early symptom improvement was observed in 15 of 20 patients (75%) and clinical success was achieved in all patients. Mean follow-up period was 1178.3 ± 844.1 d and median stent maintenance period was 51 d (range 6-2114 d). During the follow-up period, inserted stents were passed spontaneously per rectum without any complications in 14 of 20 patients (70%). Symptom improvement was maintained after stent placement without the requirement of any additional intervention in 19 of 20 patients (95%).CONCLUSIONEndoscopic stent placement provides prompt relief of obstructive symptoms. Thus, it can be considered an effective and safe salvage technique for post-operative DGE.

Ten years retrospective study of using primary microsurgery technology to treat patients with severe lower extremities injury

Objective To clarify the role of microsurgery in limb salvage procedure and its efficiency in longterm functional results through a retrospective review of patients who sustained severe injury of lower extremities and had been treated Shanghai 6th people's hospital, in recent 10 years. Methods Patients who sustained severe injury of lower extremities and treated with microsurgical techniques in January, 2006 to January, 2016 were studied. Patients' general information, classification of open fracture, and MESS were noted. The enrolled patients were divided into two groups(group A: primary microsurgical reconstruction; group B: non-microsurgical reconstruction) according to whether primary microsurgical reconstruction was performed or not. Each group were also further divided into subgroup according to preoperative MESS(MESS<7 and MESS≥7). The reconstruction methods, hospitalization days, operation times, postoperative complications, as well as the SIP were then recorded for each groups. The differences of these data among each groups were analyzed and compared. Results The main objection was patient with Gustilo grade III open fracture, totally 548 patients were admitted, with 312 males and 236 females. The main age was 35.6 years old. The main etiology was road traffic accident (79.7%). There were 211 patients (38.5%) in group A, and 337 patients (61.5%) in group B. In group A, there were 37 patients in subgroup one (MESS<7), and 174 patients in subgroup two(MESS ≥7). The rate of delayed amputation was 2.8%, while the complication rate was 11.8%. In group B, there were 181 patients in subgroup one(MESS<7), and 156 patients in subgroup two (MESS≥7). The rate of delayed amputation was 4.0%, while the complication rate was 13.3%. In long-term survey, the average VAS score of group B was higher than that of group A, but no significant difference was noted. The average VAS scores in 2 year postoperatively in the subgroups (MESS≥7) were higher than those in the other subgroups(MESS<7). The results of SIP scores were similar with VAS scores in two groups. Conclusion The techniques of microsurgery has been promoting the successful rates and outcomes for limb salvage procedure over the recent decades. Meanwhile, the current evaluating system for severe limb injury needs to be updated to meet the demands of ever-developing limb salvage techniques. Key words: Severe lower limb injury; Limb salvage; MESS; Microsurgical technique

Through the Scope Removal and Resheath of a Lumen Apposing Metal Stent as Salvage Technique After Misdeployment During EUS-Guided Choledochoduodenostomy Presidential Poster Award

Introduction EUS-guided choledochoduodenostomy offers a less invasive option for the management of biliary obstruction due to pancreatic head tumor after failed ERCP or impossibility to reach the papilla. Lumen apposing metal stent (LAMS) deployment using electrocautery-enhanced catheters has decreased procedure times under one minute. Broader availability of this stents has shifted its use from highly specialized therapeutic endoscopists to others with minimal or no therapeutic experience. Although a relatively fast procedure, complications are common and management options are required. Case description We present the case of a 42-year-old patient with a non-resectable stage IV pancreatic head cancer presenting with cholangitis. The papilla was not accessible due to duodenal stricture. EUS-guided choledochoduodenostomy with an 8x8mm LAMS was performed using an electrocautery enhanced delivery cathether. Access was obtained using a free hand technique. Although the catheter appeared to be into the common bile duct (CBD) the distal flange deployed between the CBD and the duodenal wall. A guidewire was inserted and the partially deployed LAMS was removed over the wire through the scope. The stent was re-sheathed and advanced over the wire. The distal flange was deployed again between the CBD and the duodenal wall leading to the notion that the image of the guidewire into the CBD was a ghost image. The partially deployed stent was removed again over the wire and re-sheathed. Given the possibility of a ghost image we removed the guidewire and obtained access through a nearby point performing a successful delivery of the stent and creating the choledochoduodenostomy that drained pus abundantly. A perforation wasn't visible. The patient presented with mild discomfort after the procedure but no signs of perforation. Discussion Although EUS-guided choledochoduodenostomy with LAMS deployment using an electrocautery-enhanced catheter has greatly facilitated the technique broadening its use, possible complications should not be underestimated. This case highlights two practical tips: 1/ a guidewire should always be available and proficiency in over the wire exchanges is recommended; and 2/ a half deployed 6x8mm or 8x8mm LAMS using this delivery system can be safely removed through the scope. In our experience in bench models larger stents are prone to dislodge during removal obstructing the working channel. Watch the video: https://goo.gl/iSCkn9

Salvage of Threatened Cardiovascular Implantable Electronic Devices: Case Series and Review of Literature.

The treatment of infected or exposed cardiac pacing and defibrillator devices is controversial. The conservative and widely accepted management calls for removal of the device and leads with immediate or delayed replacement of new components in a new site. Lead extraction carries a 2% major complication risk. In this article, we describe our experience with device salvage techniques and review the current literature. This is a retrospective case series of consecutive patients with infected, exposed, or at-risk implanted cardiac devices that were treated with aggressive surgical debridement, local pocket irrigation, and revision. A comprehensive review of the literature regarding device infection management was performed. Ten patients with threatened devices were identified. Surgical revision with the aim to salvage the device was successful in 8 (80%) of 10 cases. Seventeen retrospective publications were reviewed. All indicate success with attempted salvage surgery, but heterogeneity of data limits formal meta-analysis and prevents management recommendations. Cardiac pacing and defibrillator devices with low-grade infection or threatened exposure may be salvaged without explantation. Despite the lack of clear management guidelines or data, plastic surgeons may be asked to assist in the management of threatened cardiac devices. Further prospective trials are required to evaluate the safety, efficacy, and cost-effectiveness of attempted implant salvage.

The utilization of resuscitative endovascular balloon occlusion of the aorta: preparation, technique, and the implementation of a novel approach to stabilizing hemorrhage.

Noncompressible torso hemorrhage (NCTH), if not controlled promptly, leads to death. In the acute setting, aortic occlusion can be performed as damage control surgery (DCS) for hemorrhage originating from the abdomen and pelvis. With the development of endovascular technology, an intra-aortic balloon can be used to achieve aortic occlusion and decrease hemorrhage. Recently, resuscitative endovascular balloon occlusion of the aorta (REBOA) has been accepted as a salvage technique for the temporary stabilization of patients with NCTH. However, balloon occlusion is not easily performed in trauma patients. In this article, we described preparation, technical description, and conceptual understanding of REBOA.

Prospective multicenter study of primary EUS-guided choledochoduodenostomy using a covered metal stent

Background and Objectives:EUS-guided biliary drainage (EUS-BD) is increasingly reported as a salvage technique after failed endoscopic retrograde cholangiopancreatography, but it is still controversial whether EUS-BD can replace transpapillary biliary stenting. Therefore, we conducted this multicenter, prospective study of EUS-guided choledochoduodenostomy (EUS-CDS) using a covered metallic stent (CMS) as primary biliary drainage for unresectable distal malignant biliary obstruction (MBO).Methods:Patients with unresectable distal MBO without any prior drainage are enrolled. Primary endpoint is a technical success and secondary endpoints are adverse events, functional success, and recurrent biliary obstruction (RBO) of EUS-CDS. Clinical outcomes were compared between EUS-CDS and transpapillary stenting as a control.Results:A total of 34 patients were enrolled in 10 Japanese institutions. The cause of MBO was pancreatic cancer in 28 patients. Median tumor size and common bile duct diameter were 31 and 13 mm, respectively. Technical success rate was 97% with a median procedure time of 25 min and functional success rate was 100%. The rate of RBO was 29% and the causes of RBO were nontumor related: Migration in 18%, sludge/food impaction in 9%, and stent impaction to the duodenal wall in 3%. Other adverse events were abdominal pain in 6% and cholecystitis in 9%. A median cumulative time to RBO was 11.3 months. The rate of RBO and cumulative time to RBO of EUS-CDS were comparable to those of transpapillary stenting (36% and 9.1 months, respectively).Conclusion:EUS-CDS using a CMS as primary biliary drainage was technically feasible and its safety appeared comparable to transpapillary stenting.