Dual antiplatelet therapy plus postoperative heparin and dextran is safe and effective for reducing risk of embolic stroke during aneurysm coiling

Background

Thromboembolic events represent a clinically significant cause of neurological morbidity during the endovascular management of cerebral aneurysms. We have implemented an anti-thromboembolic regimen consisting of pre- and postoperative dual antiplatelet therapy, as well as postoperative anticoagulation using heparin and dextran. The aims of our study were to examine the effect of this regimen on thromboembolic rates during elective aneurysm coiling, and to elucidate risk factors associated with the development of thromboembolic events in this setting.

Methods

We conducted a retrospective review of patients who underwent elective intracranial aneurysm coiling between January 2005 and February 2012. The primary outcome of interest was the occurrence of a clinically significant peri-procedural thromboembolic event. Secondary outcomes included the occurrence of a central nervous system (CNS) or systemic hemorrhage.

Results

During the study period, 312 patients underwent elective aneurysm coiling and six (2 %) thromboembolic events occurred; three (1 %) occurred in the group that received the anti-thromboembolic regimen (261 patients) and three (6 %) occurred in the group that did not receive the regimen (51 patients), resulting in a statistically significant difference (P?=?0.024). Both the presence of a hypercoagulable state (P?=?0.014) and the lack of the anti-thromboembolic regimen (P?=?0.043) were significantly associated with the occurrence of a thromboembolic event.

Conclusions

This study provides evidence that the regimen described here is safe and reduces thromboembolic complications during elective aneurysm coiling. Ours is likely the most aggressive regimen in the published literature and significantly reduced the rate of thromboembolism without any significant increase hemorrhagic complications.     

Feasibility of insertion of a microcatheter through a Y-stent in coil embolization of cerebral aneurysms and its detailed geometry by micro-computed tomography

Background

In Y-stent-assisted coil embolization for cerebral aneurysms, open or closed cell stents are used. Different microcatheters for coil insertion are available. We investigated which microcatheter could be navigated into an aneurysm through a Y-stent with different stents.

Methods

Double Neuroform open-cell stents or double Enterprise closed-cell stents were deployed in Y-configuration in a silicon model of a bifurcation aneurysm. Two endovascular neurosurgeons independently tried to navigate an SL-10 microcatheter for 0.010” coils or a PX Slim microcatheter for 0.020” Penumbra coils into the aneurysm through the Y-stent. In addition, we measured lengths of stent pores of the Y-stents with double Enterprise stents deployed in the model by micro-computed tomography.

Results

It was feasible to navigate an SL-10 microcatheter into the aneurysm through the Y-stent with Enterprise or Neuroform stents. Navigation of a PX Slim microcatheter was feasible in the Y-stents only with Neuroform stents. In the Y-stent with double Enterprise stents, the lengths of the second stent pores were significantly smaller than those of the first stent (0.41?±?0.18 mm vs 0.69?±?0.20 mm; P?=?0.008). The SL-10 microcatheter was smaller than approximately 80 % of the stent pores of the first stent and 30 % of those of the second stent. The PX Slim microcatheter was smaller than 20 % of the stent pores of the first stent and 0 % of those of the second stent.

Conclusions

It was feasible to insert an SL-10 microcatheter into the aneurysm through Y-stents with Enterprise or Neuroform stents. Navigation of a PX Slim microcatheter for 0.020” Penumbra coils was feasible in Y-stents with Neuroform stents, but not with double Enterprise stents. The measurements of stent pores by micro-computed tomography supported this feasibility study. These results may be helpful to select appropriate stents and microcatheters in Y-stent-assisted coil embolization, especially in case of retreatments.     

Predictors of thromboembolism during coil embolization in patients with unruptured intracranial aneurysm

Objectives

To identify the incidence of thromboembolic complications based on magnetic resonance imaging (MRI) and to explore the potential risk factors for thromboembolism (TE) during the periprocedural period of elective coil embolization for unruptured intracranial aneurysms.

Methods

We retrospectively reviewed all aneurysm cases treated with coil insertion between January 2008 and March 2011. Two hundred eighty-two coiling procedures for unruptured aneurysms were included in this study. The patients’ demographic characteristics were documented and records reviewed for abnormalities in diffusion-weighted imaging (DWI) seen on post-procedure MRI, intraoperative thrombus formation, and clinical signs of stroke.

Results

Overall, there were 87 (30.9 %) procedure-related complications in 282 aneurysms treated: 2 (0.7 %) procedural ruptures, 5 (1.8 %) symptomatic infarctions, and 80 (28.3 %) asymptomatic infarctions. Thromboembolic events during the procedure were observed more often in the the hyperlipidemia group (32/71 aneurysms, 45.1 %) than in the normal lipid profile group (39/196 aneurysms, 25.6 %; p?=?0.002; chi-squre test). The coiling technique and size of the aneurysm were also associated with TE (p?<?0.001 and p?=?0.004).

Conclusion

Hyperlipidemia seems to be associated with a significant increase in the rate of thromboembolic events. In preventive procedures, modifiable risk factors should be managed to reduce complications. Although permanent deficits are rare, the high rate of thromboembolic events suggests that improvements in the technique, such as the addition of antiplatelet agents and the development of new embolic materials, are necessary.     

Postoperative Bleeding Complications after Gastric Cancer Surgery in Patients Receiving Anticoagulation and/or Antiplatelet Agents

Background

Perioperative antithrombotic treatment for gastric cancer patients receiving chronic anticoagulation and/or antiplatelet agents requires an understanding of potential bleeding and thromboembolic risks. However, no study has examined the safety aspects of perioperative antithrombotic treatment during radical gastrectomy. This study sought to evaluate postoperative bleeding and thromboembolic complications after radical gastrectomy in patients undergoing perioperative antithrombotic treatment.

Methods

The medical records of patient treated by radical gastrectomy from January 2006 to December 2010 were retrospectively reviewed. Those in the thromboprophylaxis group had received one of three regimens of perioperative antithrombotic treatment according to the clinical indications of chronic anticoagulation and/or antiplatelet agents and several published evidence-based recommendations: (1) bridging therapy with unfractionated heparin; (2) continuation of aspirin; or (3) both 1 and 2. multivariate analysis was used to identify risk factors for postoperative bleeding complications after radical gastrectomy.

Results

During the study period, 340 patients underwent radical gastrectomy. Of these, 62 patients received perioperative antithrombotic treatment; this thromboprophylaxis group had a significantly higher postoperative bleeding rate (8.1 vs. 0.7?%, P?=?0.003). However, other complications, including thromboembolic events, were similar in the two study groups. Multivariate analysis revealed that perioperative antithrombotic treatment was the only independent risk factor of postoperative bleeding complications after radical gastrectomy (odds ratio, 8.53; 95?% confidence interval, 1.47?C49.39; P?=?0.017).

Conclusions

Perioperative antithrombotic treatment is an independent risk factor of postoperative bleeding complications in patients with gastric cancer undergoing radical gastrectomy, although such treatment was effective in preventing postoperative thromboembolic events.     

Complications of hip fracture surgery on patients receiving clopidogrel therapy

Introduction

Clopidogrel (Plavix^®) may influence patient safety during fracture surgery. Our study examines the incidence of complications for patients undergoing hemiarthroplasty on clopidogrel therapy.

Materials and methods

All patients, who underwent hemiarthroplasty between 2005 and 2011 were retrospectively reviewed. Patients were placed in two comparative groups based on the use of clopidogrel antiplatelet therapy. Records were reviewed for patient demographics, ASA score, pre and postoperative hemoglobin, time to surgery, length of stay, bleeding events, transfusions and complications. Comparative statistical analysis was performed using Fisher’s exact test and Student’s t test, using P < 0.05 to identify statistical significance.

Results

A total of 203 charts were reviewed, of which 162 patients met inclusion/exclusion criteria. One hundred and twelve females and 50 males with mean age of 84 years were identified. The clopidogrel group consisted of 15 (9.3 %) patients and the nonclopidogrel group 147 (90.7 %). The clopidogrel group had more comorbidities resulting in a significantly higher ASA score (3.9 vs. 2.9), and lower preoperative hemoglobin (11.3 vs. 12.0). There was no significant difference identified in time to surgery, intraoperative blood loss, hemoglobin on days 1–3, or number of transfusions received between groups. Patients on clopidogrel were seen to have significantly longer hospital stays (10.6 vs. 7.4 days). However, a similar rate of wound and bleeding related complications (6.7 vs. 6.1 %) was seen.

Conclusions

The optimal treatment for hip fracture patients on antiplatelet therapy is unclear. However, in this study there appears to be no significant difference with regards to bleeding and bleeding related wound complications, suggesting it is safe to proceed with hemiarthroplasty for patients receiving clopidogrel.     

Stent salvage using the Enterprise stent for procedure-related complication during coil embolization of ruptured intracranial aneurysms

Background

Despite accumulated experience and improved understanding of the tools, endovascular treatment of intracranial aneurysms continues to have risks linked to the technique itself, and induces procedure-related complications. The purpose of this study was to report our series of stent salvage using the Enterprise stent for procedure-related complication during coil embolization in patients with ruptured intracranial aneurysms.

Methods

Parent artery thrombosis, parent artery dissection, and coil protrusion were considered to be the procedure-related complications. There were 18 consecutive cases (3 unruptured and 15 ruptured aneurysms) with procedure-related complications rescued by the Enterprise stent from December 2008 to December 2011. Follow-up angiography was performed in 14 of the 15 patients with ruptured aneurysms between 6 and 30 months (mean 14.6 months) after the procedure.

Results

The procedure-related complications were parent artery dissection (n?=?1), parent artery thrombosis (n?=?4), and coil protrusion (n?=?10). There was no complication related to delivering or deploying of the Enterprise stent. Initial radiographic results showed 8 cases of complete occlusion and 7 cases of neck remnant. There was no change in the angiographic results during the follow-up periods.

Conclusions

Facing with procedure-related complications during coil embolization of ruptured intracranial aneurysms, the closed-cell designed Enterprise stent might be a useful option for the salvage technique by restoring blood flow and minimizing thromboembolic events.     

Brief review: Coronary drug-eluting stents and anesthesia

Purpose

Anesthesiologists managing patients with drug-eluting stents (DES) face the challenge of balancing the risks of bleedingvs perioperative stent thrombosis (ST). This article reviews DES and the influence of antiplatelet medications related to their use. A perioperative management algorithm is suggested. Novel P2Y12 antagonists currently under investigation, including cangrelor and prasugrel are considered, as well as their potential role in modification of perioperative cardiovascular risks and management of patients with DES.

Source

A PubMed search of the relevant literature over the period 1985–2005 was undertaken using the terms “drug-eluting stent”, “coronary artery stent”, “bare metal stent”, “antiplatelet medication”, “aspirin”, “clopidogrel.”

Principal findings

Delayed re-endothelialization may render both sirolimus-eluting and paclitaxel-eluting stents susceptible to thrombosis for a longer duration than bare metal stents. Stent thrombosis may be associated with resistance to antiplatelet medication. In patients with a DES, a preoperative cardiology consultation is essential. Elective surgery should be postponed if the duration between DES placement and noncardiac surgery is less than six months. For semi-emergent procedures, both aspirin and clopidogrel should be continued during surgery unless clearly contraindicated by the nature of the surgery. If the risk of bleeding is high, then modification of antiplatelet medications should be considered on a case-by-case basis.

Conclusion

A profound increase in the number of patients with DES requires anesthesiologists to be familiar with their associated antiplatelet medications, and strategies for risk modification of ST and possible hemorrhagic complications in the perioperative setting.     

Is discontinuation of clopidogrel necessary for intracapsular hip fracture surgery? Analysis of 102 hemiarthroplasties

Background

An increasing number of elderly patients are managed with long-term antiplatelet therapy. Such patients often present with hip fracture requiring surgical intervention and may be at increased risk of perioperative bleeding and complications. The aim of this study was to ascertain whether it is necessary to stop clopidogrel preoperatively to avoid postoperative complications following hip hemiarthroplasty surgery in patients with intracapsular hip fracture.

Materials and methods

A retrospective review of 102 patients with intracapsular hip fracture with either perioperative clopidogrel therapy [clopidogrel group (CG)] or no previous clopidogrel exposure [no clopidogrel group (NCG)] who underwent hip hemiarthroplasty surgery was undertaken. Statistical comparison on pre- and postoperative haemoglobin, American Society of Anesthesiologists (ASA) grade, comorbidities, operative time, transfusion requirements, hospital length of stay (LOS), wound infection, haematoma and reoperation rate between the two groups was undertaken. Regression analysis was undertaken to ascertain the risk ratios (RR) of complications and transfusion associated with clopidogrel.

Results

There was no difference with respect to ASA grade, comorbidities (except cardiac comorbidities), pre- and postoperative haemoglobin levels, operation time, age or gender between the two groups. Four and two patients, respectively, required transfusion postoperatively in the CG and NCG (p = 0.37). There was no difference with respect to LOS, wound infection, haematoma or reoperation rate between the two groups postoperatively. The covariate-adjusted RR for complications and transfusion while being on clopidogrel were 0.43 [95 % confidence interval (CI) 0.07–2.60] and 3.96 (95 % CI 0.40–39.68), respectively.

Conclusion

Continuing clopidogrel therapy throughout the perioperative period in patients with intracapsular hip fracture is not associated with an increased risk of complications following hip hemiarthroplasty surgery.     

Newly designed large cell Niti-S stent for malignant hilar biliary obstruction: a pilot study

Background

Whether uni- or bilateral drainage should be performed for malignant hilar biliary obstruction remains a matter of debate. Moreover, endoscopic placement of bilateral metallic stents has been considered difficult and complicated. Although the Y-stent with a central wide-open mesh facilitates bilateral stent placement, it has limitations. This study evaluated the feasibility and efficacy of the Niti-S large cell D-type biliary stent (LCD) with a uniform large cell for both uni- and bilateral drainage of malignant hilar biliary obstruction.

Methods

From April 2008 to March 2009, a total of 12 consecutive patients with unresectable malignant hilar biliary obstruction of Bismuth type 2 or greater underwent placement of LCD. Before LCD placement, all the patients underwent endoscopic unilateral biliary drainage using a plastic stent or a nasobiliary drainage tube. If jaundice improved after the procedure, the plastic stent or nasobiliary drainage tube was replaced with the unilateral LCD. If jaundice did not resolve or contralateral cholangitis occurred, bilateral LCD placement was performed.

Results

Seven patients had unilateral and five patients had bilateral LCD placement. Technical success was achieved for all 12 patients. An early complication occurred for one patient (8%), and stent occlusion occurred for six patients (50%) because of tumor ingrowth (n?=?4) or sludge (n?=?2). These patients were managed by insertion of plastic stents (n?=?4) or percutaneous transhepatic biliary drainage (n?=?2). The median stent patency period was 202?days.

Conclusions

The newly designed endoscopic metallic stent may be feasible and effective for malignant hilar biliary obstruction, and endoscopic reintervention is relatively simple.     

Impact of oral anticoagulation on morbidity of transurethral resection of the prostate

Aim

To assess the impact of oral anticoagulation (OA) on morbidity of transurethral resection of the prostate (TURP). OA included warfarin and platelet aggregation inhibitors (PAI).

Patients and Method

Multicenter analysis of patients operated for symptomatic benign prostatic hyperplasia (BPH) by TURP. Patients under OA were compared to those with no OA.

Results

Out of 612 patients included in the analysis, 206 (33%) were on OA prior surgery (55 warfarin, 142 PAI, and 9 warfarin and PAI). No patient continued warfarin and clopidogrel during the operating period. Patients under OA were significantly older (75 vs. 71 yo, P?<?0.001), had larger prostate volume (56 vs. 49?ml, P?=?0.05), and had higher rate of bladder catheter prior surgery (26 vs. 17%, P?=?0.02). At 3?months follow-up, patients in the OA group had a higher weight of resected tissue (24 vs. 21.7?g, P?<?0.001), a longer duration of hospitalization (6.4 vs. 4.7?days P?<?0.001), a higher rate of bladder clots (13 vs. 4.7%, P?<?0.001), red cell transfusion (1.9 vs. 1.0%, P?=?0.026), late hematuria (15.0 vs. 8.4%, P?=?0.004), and thromboembolic events (2.4 vs. 0.7, P?=?0.02). In multivariable analysis, OA status was the sole independent parameter associated with bladder clots (P?=?0.004) and with late hematuria (P?=?0.03).

Conclusion

OA had a significant and independent impact on TURP outcome in terms of bleeding complications. This data could be used for treatment decision and for patient??s information prior BPH surgery.     

Spontaneous intracerebral hemorrhage with antiplatelets/anticoagulants/none: a comparison analysis

Background

Problems that the risk of using antiplatelet/anticoagulant may overwhelm its benefits have been raised. We analyzed patients with spontaneous intracerebral hemorrhage who had received antiplatelet/anticoagulant therapy.

Method

A consecutive series of patients with spontaneous intracerebral hemorrhage who underwent brain computed tomographic (CT) scans within 48 h from attack. We analyzed the clinical manifestations and radiologic findings of the patients according to antiplatelet/anticoagulant therapy: Antiplatelet group, Anticoagulant group, and None group.

Results

A total of 338 patients were included in the study. The initial volume of hematoma was 46.8 ml in the Anticoagulant group, and 24.1 ml in the None group. There were significant differences among the groups in terms of intraventricular hemorrhage (Antiplatelet group: 45.6 %, Anticoagulant group: 20 %, None: 26.4 %, p?=?0.008), and the proportion of hydrocephalus in the Antiplatelet group was higher than in another group (p?=?0.017). Also, herniation and expansion of spontaneous intracerebral hemorrhage had significant differences among the groups. The prognoses of the None group were the best among the groups. There was also significant difference in the mortality among the groups.

Conclusions

In comparison with the None group, the spontaneous intracerebral hemorrhages of the Antiplatelet/Anticoagulant group were a little more extensive and they had more intraventricular hemorrhage, hydrocephalus, herniation, and expansion of spontaneous intracerebral hemorrhage that would come to poor prognosis. Therefore, antiplatelets and anticoagulants should be used under strict indications.     

Outcome of palliative self-expanding metal stent placement in malignant colorectal obstruction according to stent type and manufacturer

Background

Self-expandable metallic stents (SEMS) of varying designs and materials have been developed to reduce complications, but few comparative data are available with regard to the type of stent and the stent manufacturer. We analyzed the success rates and complication rates, according to stent type (uncovered vs. covered stent) and individual stent manufacturer, in malignant colorectal obstruction.

Methods

From November 2001 to August 2008, 103 patients were retrospectively included in this study: four types of uncovered stents in 73 patients and two types of covered stents in 30 patients. The SEMS was inserted into the obstructive site by using the through-the-scope method.

Results

Technical and clinical success rates were not different between stent type or among stent manufacturers: 100 and 100% (p?=?ns) and 100 and 96.6% (p?>?0.05), respectively, in uncovered and covered stents. Stent occlusion and migration rates were 12.3 and 3.3% (p?=?0.274) and 13.7 and 16.7% (p?=?0.761), respectively, in uncovered and covered stents, and 11.1, 5, and 9% (p?=?0.761) and 25.9, 15, and 0% (p?=?0.037) in Wallstent, Niti-S, and Bonastent uncovered stents, respectively.

Conclusions

The placement of SEMS is an effective and safe treatment for patients with malignant colorectal obstruction. Although minor differences in outcome were detected according to the type and the manufacturer of the stents, no statistically significant difference was observed, except in stent migration among the stent manufacturer.     

Risk of wound hematoma at carotid endarterectomy under dual antiplatelet therapy

Background and purpose

This study aims to assess perioperative incidence of wound hematoma and bleeding in patients who underwent carotid endarterectomy (CEA) under dual antiplatelet therapy.

Methods

Consecutive patients with initial CEA receiving aspirin, clopidogrel, or a combination of both were subjected to standard patch endarterectomy. Postoperative wound hematoma was assessed as moderate (subcutaneous bleeding, nonspace-occupying hematoma, and oozing suture bleeding) or severe, i.e., needing operative re-exploration.

Results

Six hundred eighty-four (80.9?%) patients with one of the three types of antiplatelet therapy out of 844 patients registered from 1995 to 2010 were enrolled. Wound hematoma occurred in 27 of 112 (24.1?%) patients under combined aspirin and clopidogrel, 33 of 162 (20.4?%) under clopidogrel, and 48 of 410 (11.7?%) under aspirin. Relative risk compared to aspirin was 2.4 (95?% CI, 1.4 to 4.1) for aspirin and clopidogrel and 1.9 (95?% CI, 1.2 to 3.1) for clopidogrel. Severe space-occupying hematoma needing operative re-exploration occurred in four (3.6?%) patients under aspirin and clopidogrel, seven (4.3?%) under clopidogrel, and five (1.2?%) under aspirin. Corresponding relative risks were 3.0 (95?% CI, 0.8 to 11.4) for aspirin and clopidogrel and 3.7 (95?% CI, 1.1 to 11.7) for clopidogrel. Relative risks remained without relevant change after adjustment for potentially confounding variables.

Conclusions

Dual antiplatelet therapy with combined aspirin and clopidogrel as well as clopidogrel is associated with an increased incidence of perioperative wound hematoma compared to aspirin but on an acceptable low level of incidence. The latter may be achieved by adapting operative procedures to more intensive antiplatelet regimes.     

Management of Electrothermal Injury of Common Bile Duct with a Degradable Biliary Stent: an Experimental Study in a Porcine Model

Background

Electrothermal injury of common bile duct is a frequent type of biliary injury. A long-term postoperative course and biliary leakage after removing T-tube are associated with external drainage. A method was developed to repair the injury with a degradable biliary stent instead of T-tube insertion.

Methods

Pigs were divided into a stent repair (SR) group (n?=?18), a T-tube repair (TR) group (n?=?4), and a suturing repair (SUR) group (n?=?4). An electrothermal injury model was made by electric coagulation. Pigs in the SR group were further divided into five subgroups according to the observation time (2 weeks and 1, 3, 6, and 18 months). Pigs in the TR group and SUR group were observed for 6 months. Cholangiography was repeated and bilirubin level was monitored. Pigs were reoperated for further evaluation at the end of observation.

Results

No biliary stricture, bile leakage, or bile duct necrosis occurred in the SR group. The stent could be detected in the first 2 months. No stent migration or stent-related obstruction was observed. Three pigs in the SUR group had biliary stricture with elevated bilirubin levels.

Conclusions

These results suggested that the developed method for repairing electrothermal injury of common bile duct is feasible and safe.     

Prothrombin complex concentrate facilitates emergency spinal surgery in anticoagulated patients

Background

Oral anticoagulants are commonly used in the ageing population and therefore, spine surgeons are increasingly confronted with anticoagulated patients requiring surgical therapy. ‘Bridging therapies’ with heparins are established in elective settings, but the time frame for haemostasis restoration may be too long for patients presenting with acute spinal pathology and impending disability. The goal of this study was to analyse the feasibility of prothrombin complex concentrate (PCC) administration to facilitate emergency spinal surgery in anticoagulated patients.

Method

A retrospective analysis of the institutional database of neurosurgical patients receiving PCC from February 2007 to December 2013 (n?=?485) identified 18 patients who received PCC prior to emergency spinal surgery. Clinical characteristics, as well as modalities of PCC administration and parameters of haemostasis were analysed. Furthermore, haemorrhagic complications and thromboembolic events in the further course were evaluated.

Results

Spinal pathologies requiring urgent neurosurgical decompression were spinal haematoma (n?=?9), spinal metastasis (n?=?5), vertebral body fracture (n?=?2), and disc herniation (n?=?2). The mean international normalized ratio (INR) on admission was 2.27?±?1.20 and after administration of PCC (mean: 1,944?±?953 I.U.), INR significantly decreased to 1.12?±?0.10 (p?<?0.001). Emergency surgery was initiated within 4.4 h after PCC administration (range: 0–16.6 h). Postoperatively, symptoms improved in 12 patients (66.7 %). There were two deaths (11 %), one caused by acute myocardial infarction on the fourth postoperative day. Bleeding complications occurred in two patients (epidural haemorrhage n?=?1, rectal tumour haemorrhage n?=?1).

Conclusions

The administration of PCC facilitates emergency spinal surgery in anticoagulated patients who present with acute spinal pathology requiring urgent neurosurgical decompression. The risk of PCC-associated thromboembolic events seems to be low and justifies the use of PCC in order to avoid permanent disablement resulting from delayed surgery or non-operation.     

Fully covered removable nitinol self-expandable metal stents (SEMS) in malignant strictures of the esophagus: a multicenter analysis

Background

Fully covered esophageal self-expandable metallic stents (SEMS) often are used for palliation of malignant dysphagia. However, experience and data on these stents are still limited. The purpose of this multicenter study was to evaluate the efficacy and safety of fully covered nitinol SEMS in patients with malignant dysphagia.

Methods

37 patients underwent placement of a SEMS during a 3?year period. Five patients underwent SEMS placement as a bridge to surgery: one for tracheoesophageal fistula in the setting of squamous cell carcinoma of the esophagus, one for perforation in setting of esophageal adenocarcinoma, 27 for unresectable esophageal cancer (16 adenocarcinoma, 11 squamous cell carcinoma), two for lung cancer, and one for breast-cancer-related esophageal strictures.

Results

SEMS placement was successful in all 37 patients. Immediate complications after stent deployment included chest pain (n?=?6), severe heartburn (n?=?1), and upper gastrointestinal bleeding requiring SEMS revision (n?=?1). Dysphagia scores improved significantly from 3.2?±?0.4 before stent placement to 1.4?±?1.0 at 1?month (P?P?P?=?0.0018) at 6?months. The stent was removed in 11 patients (30%) for the following indications: resolution of stricture (n?=?3), stent malfunction (n?=?5), and stent migration (n?=?3). After stent removal, three patients were restented, three underwent dilation, and two underwent PEG placement. Mean survival for the 37 patients after stent placement was 146.3?±?143.6 (range, 13–680) days.

Conclusions

Our study suggests that fully covered SEMS placement improve dysphagia scores in patients with malignant strictures, particularly in the unresectable population. Further technical improvements in design to minimize long-term malfunction and migration are required.     

Non-enhanced magnetic resonance angiography can evaluate restenosis after carotid artery stenting with the Carotid Wallstent

Background

Carotid artery stenting (CAS) requires follow-up imaging to assess in-stent restenosis (ISR). This study aimed to determine whether non-enhanced magnetic resonance angiography (NE-MRA) is useful for evaluating ISR.

Method

Between 2009 and 2013, we performed 118 consecutive CAS procedures using the Precise stent (n?=?78) and the Carotid Wallstent (n?=?40). We reviewed 1.5 T NE-MRA and examined visualization of the stent lumen and the degree of ISR if present. Other imaging modalities were used as references.

Results

NE-MRA performed just after CAS was not able to visualize the stent lumen in all patients because of metal artifacts. In the Carotid Wallstent group, follow-up NE-MRA was available in 22 patients. The stent lumen was visible more than three months after CAS in all patients. Among them, >40 % ISR was observed by other modalities in eight lesions. The degree of restenosis measured by NE-MRA (y%) had a linear relationship with that measured by conventional angiography (x%) (y?=?0.97x-0.4, r?=?0.79, P?=?0.021). In one case among 17 without ISR (6 %), NE-MRA showed false ISR. In the Precise stent group, NE-MRA did not visualize the stent lumen in the follow-up period.

Conclusions

NE-MRA can visualize the stent lumen in the Carotid Wallstent more than three months after CAS, but not in the Precise stent at follow-up. This delayed visualization might depend on endothelialization of the stent lumen. The degree of ISR measured by NE-MRA is comparable to that by conventional angiography. NE-MRA can evaluate ISR after CAS with the Carotid Wallstent (100 % sensitivity and 94 % specificity).     

Comparison of One-Stage Managements of Obstructing Left-Sided Colon and Rectal Cancer: Stent-Laparoscopic Approach vs. Intraoperative Colonic Lavage

Purpose

We evaluated the operative outcomes of laparoscopic surgery following self-expandable metallic stent compared to one-stage emergency surgical treatment.

Methods

From April 1996 to October 2007, 95 consecutive patients with left-sided malignant colorectal obstruction were enrolled. Twenty-five patients were assigned to the preoperative stenting and elective laparoscopic surgical treatment group (SLAP) and 70 to the emergency open surgery with intraoperative colon lavage group (OLAV).

Results

Among the 25 patients in the SLAP group, a primary anastomosis was possible in all patients and a diverting stoma was needed in one patient. The operative time was shorter in the SLAP group (198.53 vs. 262.17 min, P?=?0.002). Tumor size, number of retrieved lymph nodes, and pathological stage were similar in both groups. The rate of anastomotic failure was similar and postoperative complications occurred less in the SLAP group (5.9% vs. 31.4%, P?=?0.034). The passage of flatus and oral intake were resumed earlier in the SLAP group (2.88 vs. 3.68 days, P?=?0.046 and 5.18 vs. 6.65 days, P?<?0.001, respectively). The postoperative hospital stay was shorter in the SLAP group (10 vs. 15.4 days, P?=?0.013).

Conclusions

In patients with left-sided malignant colon and rectal obstruction, laparoscopic surgery after SEMS could be safely performed with successful early postoperative outcomes.     

Surgical Outcomes and Clinical Characteristics of Elderly Patients Undergoing Curative Hepatectomy for Hepatocellular Carcinoma

Background

The aim of this study was to investigate the clinical characteristics and outcomes of elderly patients (≥70 years old) undergoing curative hepatectomy for hepatocellular carcinoma (HCC).

Methods

Clinicopathological data and treatment outcomes in 100 elderly patients (≥70 years old) and 120 control patients (≤70 years old) with HCC who underwent curative hepatectomy between 2000 and 2011 were retrospectively collected and compared.

Results

The overall survival rate was similar between the two groups, but the disease-free survival rate was worse in the elderly group when compared with the control group. Prognostic factors for overall and disease-free survival were the same when comparing the two groups. The elderly group had higher rate of females (p?=?0.0230), higher hepatitis C virus infection rate (p?=?0.0090), higher postoperative pulmonary complication rate (p?=?0.0484), lower rate of response to interferon (IFN) therapy (p?=?0.0203) and shorter surgical time (p?=?0.0337) when compared with the control group. The overall recurrence rate was higher in the elderly group than in the control group (p?=?0.0346), but the rate of recurrence within 2 years after the operation was similar when comparing the two groups.

Conclusion

The survival of elderly patients with HCC was similar to that of younger patients. However, the disease-free survival was worse in elderly patients than in younger patients. Aggressive antiviral therapy (e.g. IFN therapy) may be necessary to improve the disease-free survival, even in elderly patients. Additionally, clinicians should be aware of the risk of pulmonary complications in elderly patients after hepatectomy.     

Esophageal Stenting and Radiotherapy: A Multimodal Approach for the Palliation of Symptomatic Malignant Dysphagia

Background

Esophageal stents provide immediate palliation of malignant dysphagia; however, radiotherapy (RT) is a superior long-term option. We review the outcomes of combined esophageal stenting and RT for patients with malignant dysphagia.

Methods

We retrospectively reviewed patients with esophageal stents placed for palliation of malignant dysphagia from esophageal stricture, esophageal extrinsic compression, or malignant tracheoesophageal fistula (TEF). We excluded patients with radiation-induced TEF in the absence of tumor. We analyzed and compared outcomes between patients with no RT, RT before stent placement, and RT after stent placement.

Results

We placed stents in 45 patients for esophageal stricture from esophageal cancer (n?=?30; 66.7?%), malignant TEF (n?=?8; 17.7?%), and esophageal compression from airway, mediastinal, or metastatic malignancies (n?=?7; 15.6?%). Twenty patients (44.4?%) had no RT; 25 patients had RT before stent placement (n?=?16; 35.6?%), RT after stent placement (n?=?8; 17.8?%), or both (n?=?1; 2.2?%). Median follow-up was 30?days. Complications requiring stent revision were similar with or without RT. Subjective symptom relief was achieved in 68.9?% of all patients, with no differences noted between groups (p?=?0.99). The 30-day mortality was 15.6?%. Patients with RT after stent placement had a longer median survival compared to those without RT (98 vs. 38?days).

Conclusions

Esophageal stent placement with RT is a safe approach for malignant dysphagia.