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Biomedical subjects

R L Gordon

Publications and source records attributed to R L Gordon.

At least 127 records · Page 7Linked to original sources
PubMedDate not supplied

Current status and future possibilities of transjugular intrahepatic portosystemic shunts in the management of portal hypertension.

Transjugular intrahepatic portosystemic shunt (TIPS) is an exciting new method for treating complications of cirrhosis. Technical advances have allowed TIPS to be widely applied in the treatment of variceal bleeding. This article presents and discusses the results of recent experiences in TIPS placement. TIPS can be successfully placed in almost all patients. The complication rate of the procedure is low. TIPS is an effective means of controlling variceal bleeding and is especially useful for controlling bleeding in patients awaiting liver transplantation. It may also have a role in the treatment of ascites and other conditions related to portal hypertension. The most important issue facing TIPS is the long-term patency of the shunt. Potential solutions to the problem of long-term shunt patency are discussed.

Forecasting↗
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The injection technique for repositioning central venous catheters: technical note.

Malpositioned central venous catheters must be repositioned in order to avoid damage caused by concentrated or irritating infusates. Floppy catheters may be repositioned rapidly with a brisk injection of fluid. The ease of this technique, with its anticipated low risk of infection, makes it an attractive alternative to manipulation using guidewires.

Adult↗
PubMedDate not supplied

Incidence of important hemobilia following transhepatic biliary drainage: left-sided versus right-sided approaches.

Our purpose here is to describe our experience with important hemobilia following PTBD and to determine whether left-sided percutaneous transhepatic biliary drainage (PTBD) is associated with an increased incidence of important hemobilia compared to right-sided drainages. We reviewed 346 transhepatic biliary drainages over a four-year period and identified eight patients (2.3%) with important hemobilia requiring transcatheter embolization. The charts and radiographic files of these patients were reviewed. The side of the PTBD (left versus right), and the order of the biliary ductal branch entered (first, second, or third) were recorded. Of the 346 PTBDs, 269 were right-sided and 77 were left-sided. Of the eight cases of important hemobilia requiring transcatheter embolization, four followed right-sided and four followed left-sided PTBD, corresponding to a bleeding incidence of 1.5% (4/269) for right PTBD and 5.2% (4/77) for left PTBD. The higher incidence of hemobilia associated with left-sided PTBD approached, but did not reach the threshold of statistical significance (p = 0.077). In six of the eight patients requiring transcatheter embolization, first or second order biliary branches were accessed by catheter for PTBD. All patients with left-sided bleeding had first or proximal second order branches accessed by biliary drainage catheters. In conclusion, a higher incidence of hemobilia followed left-versus right-sided PTBD in this study, but the increased incidence did not reach statistical significance.

Adult↗
PubMedDate not supplied

Talc pleurodesis through small-bore percutaneous tubes.

Pleurodesis using talc as the sclerosing agent is an effective procedure for preventing reaccumulation of malignant pleural effusions. Because of its thickness, the talc slurry is usually instilled through large bore (20-28 Fr), surgically placed thorocostomy tubes. However, these tubes often cause considerable patient discomfort. Herein we report a series of eight patients in whom the talc slurry was inserted through 10 and 12 Fr percutaneous chest tubes. Six of the eight patients (75%) had a successful pleurodesis without a reaccumulation of fluid. We conclude that this is an acceptable method for treating patients with malignant pleural effusions.

Adult↗
PubMedDate not supplied

Response of Wallstents to dilation: therapeutic implications.

PURPOSE: The authors document the degree of in vitro shortening of the Wallstent when expanded to different diameters and demonstrate the clinical importance of this property. MATERIALS AND METHODS: Forty-two-, 68- and 94-mm size Wallstents were expanded within cylinders that were 6, 8, 10, and 12 mm in diameter, and their lengths were measured. RESULTS: Progressive stent shortening occurred between diameters of 6 and 10 mm. Extreme shortening occurred at overdilation to 12 mm: At this diameter a 42-mm stent is 24.5 mm long (vs 46 mm at a 10-mm diameter), a 68-mm stent is 40 mm (vs 65 mm), and a 94-mm stent is 64 mm (vs 95 mm). CONCLUSIONS: Specific knowledge of stent lengths at different diameters is required for proper stent choice and accurate deployment. Over-dilation to a 12-mm diameter is useful in correcting excessive stenting and resistant stent narrowings, but it can result in excessive shortening requiring additional stent placement.

Biomechanical Phenomena↗
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Histopathologic study of stenotic and occluded transjugular intrahepatic portosystemic shunts.

PURPOSE: A detailed histopathologic analysis of three stenotic and two occluded transjugular intrahepatic portosystemic shunts was performed to evaluate the nature and cause of each shunt abnormality. PATIENTS AND METHODS: The study group consists of five patients who developed a shunt stenosis or occlusion and subsequently underwent liver transplantation or autopsy. Shunt specimens were examined grossly and microscopically. RESULTS: The pseudointima was composed of granulation tissue, which was generally denser and more cellular near the luminal surface. Pseudointima was thicker in the parenchymal portion of the shunt than at the venous ends. A contiguous single layer of endothelial-like cells lined the majority of the luminal surface of each shunt. Scattered debris and clot covered 10%-15% of the luminal surfaces. Transected bile ducts were noted in three cases. Bile staining was detected around the transected ducts, and bile pigment was incorporated into the developing pseudointima. CONCLUSIONS: Pseudointimal hyperplasia appears to be the causative lesion in these obstructions. An inflammatory reaction incited by bile extravasation may have contributed to pseudointimal proliferation in three cases.

Adult↗
PubMedDate not supplied

Heat ablation of the normal gallbladder in pigs.

PURPOSE: The safety and efficacy of ablating gallbladder mucosa was investigated with a percutaneously placed heater catheter in an animal study. MATERIALS AND METHODS: The study was performed in three stages with 39 pigs. In stage 1 (15 heat-treated animals, one control), the configuration of the heater catheter was progressively improved and the temperature settings for stage 2 were defined. In stage 2 (11 heat-treated animals, four controls), the predetermined settings were used with mechanical mixing and cystic duct ligation to test for safety and efficacy. In stage 3 (eight animals), prior heat ablation of the cystic duct was added to reduce epithelial regeneration. RESULTS: Gallbladder ablation was achieved at temperatures below 60 degrees C. Mechanical mixing of the intraluminal contents was essential for even heat distribution for ablation and to reduce the incidence of adjacent organ damage. Thermal injury to adjacent organs occurred when gallbladder ablation temperature exceeded 54 degrees C and serosal temperatures of adjacent organs exceeded 43 degrees C. Thermal ablation at 54 degrees C for 35 minutes was completely successful in 25%, partially successful in 50%, and failed in 25% of animals. Cystic duct ablation improved overall results and appears vital in removing duct epithelium as a source for regeneration of the mucosal lining. CONCLUSION: Defunctionalization of the retained gallbladder is potentially achievable with use of thermal techniques, but the thermal range between complete gallbladder ablation and adjacent organ injury is narrow.

Animals↗
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Anatomy of the portal vein bifurcation: intra- versus extrahepatic location--implications for transjugular intrahepatic portosystemic shunts.

PURPOSE: To delineate the relationship of the main portal vein bifurcation to the liver capsule, an anatomic study of the portal vein bifurcation was undertaken in 31 cadavers. MATERIALS AND METHODS: The portal bifurcation was characterized as intrahepatic, extrahepatic, or at the liver capsule (junctional). When the bifurcation was extrahepatic, the exposed portions of the right and left portal veins were measured. RESULTS: The portal bifurcation was intrahepatic in eight cadavers (25.8%), at the liver capsule in eight cadavers (25.8%), and extrahepatic in 15 cadavers (48.4%). The maximum lengths of exposed extrahepatic right and left portal veins were 3.0 cm and 2.5 cm, respectively. CONCLUSION: These findings suggest that for transjugular intrahepatic portosystemic shunt placement, a portal vein puncture site 3 cm from the portal bifurcation will be intrahepatic in most cases.

Aged↗
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Liver transplantation complicated by malpositioned transjugular intrahepatic portosystemic shunts.

PURPOSE: To report the surgical problems encountered during orthotopic liver transplantation as a result of a malpositioned transjugular intrahepatic portosystemic shunt (TIPS). PATIENTS AND METHODS: Three patients are described in whom TIPS stents were malpositioned in the following locations: extending into the main portal vein, extending into the suprahepatic inferior vena cava, and extending into the right atrium. RESULTS: Malpositioning of TIPS stents altered and prolonged the operation in all of these patients by interfering with cross-clamping at the usual vascular sites during liver transplantation. Incorporation of the stents into the vascular wall prevented transcatheter retrieval and increased the difficulty of intraoperative removal. CONCLUSION: Awareness of hepatic vascular anatomy is necessary in avoiding stent malpositioning. If malpositioning is identified, transcatheter approaches may be helpful in repositioning the stent. Otherwise, the transplant surgery team must be made aware of the problem for proper surgical planning prior to liver transplantation.

Adult↗
PubMedDate not supplied

Successful reversal of hepatic encephalopathy with intentional occlusion of transjugular intrahepatic portosystemic shunts.

PURPOSE: To establish a safe and effective method for occluding a transjugular intrahepatic portosystemic shunt (TIPS) in patients who develop uncontrollable, disabling encephalopathy. PATIENTS AND METHODS: The study population consisted of five patients who developed refractory encephalopathy following TIPS. The indication for TIPS was bleeding in four patients and ascites in one. Wallstents that were 10 mm in diameter and 68 mm long were used to bridge the hepatic parenchyma in all patients. The onset of encephalopathy from the time of the TIPS procedure ranged from 24 hours to 210 days. Because encephalopathy was not responsive to conventional medical management, shunt thrombosis was induced by means of temporary inflation of an 11.5-mm-diameter latex occlusion balloon within the midportion of the stent. RESULTS: All shunts were successfully thrombosed when the balloon was inflated for 12 hours or more. Encephalopathy resolved in four patients and improved in the remaining patient. One patient experienced recurrent bleeding within 24 hours of the TIPS occlusion that was controlled medically. CONCLUSION: Temporary occlusion of a TIPS with latex balloons successfully induces shunt thrombosis and improves encephalopathy. However, the patient is again exposed to risks related to complications of portal hypertension.

Adult↗
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Catheter tract hemorrhage during percutaneous biliary intervention: management with use of a retained transhepatic guide wire.

PURPOSE: The authors present their experience in managing freely flowing hemorrhage from immature catheter tracts in patients undergoing biliary drainage. PATIENTS AND METHODS: Transhepatic guide wires were maintained securely whenever catheters were removed from the liver. Six patients among 71 hemorrhaged profusely when drains were manipulated within 4 days of initial catheterization. Management was attempted with use of the transhepatic guide wires. RESULTS: Maneuvers performed over the retained guide wire controlled bleeding in all six patients. Reintubation constituted definitive therapy in five patients. A biliary-portal venous fistula in the remaining patient was treated with thrombin. The retained guide wire proved necessary in all cases. CONCLUSION: Hemorrhage from immature catheter tracts can be managed, often definitively, with maneuvers performed over a retained transhepatic guide wire. Accordingly, a secure transhepatic guide wire is essential prior to removal of hepatic catheters and should remain in place until the absence of bleeding is established. These maneuvers may become increasingly important as courses of biliary catheterization become shorter.

Aged↗
PubMedDate not supplied

Percutaneous transhepatic hepatic venography in the delineation and treatment of Budd-Chiari syndrome.

PURPOSE: To assess the usefulness of percutaneous transhepatic hepatic venography (PTHV) in planning interventional radiologic treatment of Budd-Chiari syndrome (BCS). MATERIALS AND METHODS: Six patients aged 14-56 years underwent examination for BCS. After preliminary transfemoral inferior vena cavography and selective hepatic venography failed in determining the extent of venous obstruction, PTHV was performed. RESULTS: PTHV completely depicted the proximal and distal extent of hepatic venous occlusion. Intraluminal thrombus in the right and middle hepatic veins shown in one patient was treated with fibrinolytic infusion and balloon thrombectomy. Central obstruction of the right hepatic vein shown in two patients was treated with venoplasty or venoplasty and stent placement. In three patients. PTHV showed a "spider web" appearance of diffuse obliteration of the normal intrahepatic venous architecture; a transjugular intrahepatic portosystemic shunt was placed in two of these patients. CONCLUSION: PTHV provides information not available with conventional venography that is useful in planning the treatment of BCS.

Adolescent↗
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Bleomycin sclerosis of pelvic lymphoceles.

PURPOSE: To describe the results of postoperative pelvic lymphocele treatment by means of percutaneous drainage and sclerosis with bleomycin. MATERIALS AND METHODS: Four patients underwent treatment of pelvic lymphoceles by percutaneous tube drainage followed by instillation of bleomycin under fluoroscopic guidance at a concentration of 1 unit/mL. Bleomycin instillation was repeated at weekly intervals until the tube output was less than 10 mL per day. Three of four patients underwent unsuccessful sclerosis previously with alcohol, doxycycline, or povidone iodine. RESULTS: Lymphocele drainage was reduced to less than 10 mL per 24 hours after bleomycin sclerosis in all patients. Three patients required two sessions, and the fourth patient required three sessions. No patient developed recurrent symptoms suggesting reaccumulation of lymph during an average follow-up period of 11 months (range, 6-18 months). No complications related to percutaneous lymphocele drainage or sclerosant therapy were encountered. CONCLUSION: Percutaneous intracavitary instillation of bleomycin may be considered as an alternative to surgery in patients who have undergone unsuccessful lymphocele sclerosis with other agents.

Adult↗
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Transcatheter embolization of biopsy-related vascular injury in the transplant kidney: immediate and long-term outcome.

PURPOSE: To assess the effect of transcatheter embolization for treatment of biopsy-related vascular injury in renal allografts, specifically evaluating technical success, clinical benefit, and long-term effect on renal function. MATERIALS AND METHODS: A retrospective review was performed of all postbiopsy renal allograft vascular injuries referred for embolization during a 113-month period. The likelihood of a prolonged detrimental effect on allograft function was estimated from observed variation in serum creatinine levels before and after the procedure. RESULTS: Embolic therapy with use of metallic coils and superselective technique was performed in 21 renal transplant patients. Technical success was achieved in 95% of cases. There were no serious complications. Eradication of the clinical sign or symptom prompting referral was seen in 15 of 17 (88%) patients. Eleven of 19 (58%) patients analyzed demonstrated no evidence of a long-term detrimental effect on allograft function. A detrimental effect was possibly present in six of 19 (32%) patients, and probable in only two of 19 (10%) patients. CONCLUSIONS: Transcatheter embolization can be an appropriate and effective therapeutic choice for biopsy-related renal allograft vascular injury.

Adolescent↗