The ureteroscope-assisted “Mini-Perc” technique of placement of peritoneal dialysis catheters with a 16-Fr Peel-Away sheath: 3-year results in 47 patients

Objectives

This study was undertaken to evaluate the clinical feasibility, safety and effect of the ureteroscope-assisted “Mini-Perc” technique with a 16-Fr Peel-Away sheath for insertion of peritoneal dialysis catheters in end-stage renal disease (ESRD) patients.

Patients and methods

47 consecutive ESRD patients underwent ureteroscope-assisted placement of peritoneal dialysis catheters via a 16-Fr Peel-Away sheath. Informed consent form was signed by patients under principle of voluntary.

Results

The mean duration of the operation was 40 min (range, 21–75 min). Seven patients (14.9 %) experienced mechanical complications: catheter tip migration in 1 patient (2.1 %), slightly bloody ascites in 4 patients (8.5 %) and catheter-related peritonitis in 2 patients (4.3 %). Two catheters (4.3 %) were removed after renal transplantation. One patient (2.1 %) died from heart failure. One catheter (2.1 %) was explanted because of malfunction. After a mean follow-up time of 15 months (range, 2–36 months), 42 catheters are still functioning properly.

Conclusions

The ureteroscope-assisted “Mini-Perc” technique with a 16-Fr Peel-Away sheath is a simple, safe and effective method for placement of peritoneal dialysis catheters in ESRD patients.     

A single institutional experience of conversion of non-tunneled to tunneled hemodialysis catheters: a comparison to de novo placement

Purpose

To compare the outcomes of conversion of non-tunneled to tunneled hemodialysis catheters with de novo placement of tunneled catheters and to determine the effect of time to conversion of non-tunneled to tunneled catheters on the incidence of complications.

Materials and methods

A retrospective data analyses was performed on 1,154 patients who had de novo placement of tunneled hemodialysis catheters (control group) and 254 patients who underwent conversion of non-tunneled to tunneled catheters (study group). The outcomes including technical complications, infection, and catheter dysfunction were compared between the two groups.

Results

The technical success rate was 100 % in both the groups with no complications recorded at the time of procedure or within 24 h of insertion. The most common complication encountered in both the groups was catheter dysfunction (15.6 % in controls and 18.1 % in study). Infection rates/100 catheter days for the control and study groups were 0.17 and 0.19, respectively. Infection-free survival was not statistically different between the two groups. The time spent with non-tunneled catheter prior to conversion did not significantly alter the rates of catheter dysfunction and infection in the study group.

Conclusion

The efficacy and safety of conversion of non-tunneled to tunneled hemodialysis catheters are similar to de novo placement with no difference in the rates of technical success, catheter dysfunction, or infection. However, the exchange of non-tunneled to tunneled catheter can help in preservation of veins for future vascular access, which is of vital importance in patients with chronic renal disease.     

Infection rates of external ventricular drains are reduced by the use of silver-impregnated catheters

Background

External ventricular drainage (EVD) placement for temporary cerebrospinal fluid (CSF) diversion is a frequent therapeutic procedure. Several types of EVD catheters are currently available, some of which have an antibacterial effect. This study compares the rates of CSF infections in patients with different types of EVD catheters.

Methods

This is a retrospective study of 403 patients with a total of 529 implanted EVDs. We analyze the occurrence of EVD-associated infections, microbiological diagnosis, type of EVD catheter (plain polyurethane vs. silver-impregnated), duration of CSF diversion, primary disease, and outcome.

Results

There were a total of 29 patients with EVD infections in the whole study group (7.1 %). A pathogen was detected in all cases. Coagulase-negative staphylococci were detected most frequently (20 out of 29 cases, 70 %). The rate of infections by catheter type was 7.6 % (11 of 145) and 13.8 % (4 out of 29) for two different types of non-coated polyurethane catheters. Silver-impregnated polyurethane catheters became infected in 6.1 % (14 out of 228). The differences between non-coated and silver-coated catheters were statistically significant.

Conclusions

This study provides comparative data on EVD infections with regard to the type of catheter. Silver-impregnated catheters showed significantly lower infection rates when compared to non-impregnated catheters. The results are critically discussed and compared with the published literature.     

Ambulatory Intercostal Drainage for the Management of Malignant Pleural Effusion: A Single Center Experience

Background

Malignant pleural effusions are common and can be difficult to manage. We have reviewed our use of ambulatory drains (Pleurex drains) in this regard with particular reference to hospital stay, duration of drainage, and incidence of complications.

Materials and Methods

Of 125 patients with malignant pleural effusion with trapped lung or failed previous pleurodesis who underwent insertion of ambulatory pleural drain, 41 patients were under local anesthesia and 84 patients were under general anesthesia. Mean age was 66.5 years with male:female = 80:45. Data were collected retrospectively from the clinical notes, and the family doctors’ clinics were contacted to enquire about the patients’ survival.

Results

When data collection concluded, 48 patients (38.4%) had died, giving mean survival following drain insertion of 84.1 days. There were no in-hospital deaths related to the procedure. One procedure was converted to a mini-thoracotomy to control bleeding from a lung tear. Mean duration of catheter placement was 87.01 days (5–434). Video-assisted thoracoscopic surgery was used in 77 patients (61.6%), and Seldinger’s technique was used in 48 patients (38.4%). Mesothelioma was the most common malignant cause. Minor complications were encountered in 15 patients (12%), and they were managed as outpatients.

Conclusion

The use of ambulatory pleural catheters for managing malignant pleural effusion is a safe and effective strategy. It has only minor complications that are related to prolonged drainage. We feel that this strategy should be considered the first choice option for these patients.     

Comparative efficacy of ultrasound-guided and stimulating popliteal-sciatic perineural catheters for postoperative analgesia

Purpose

Perineural catheter insertion using ultrasound guidance alone is a relatively new approach. Previous studies have shown that ultrasound-guided catheters take less time to place with high placement success rates, but the analgesic efficacy compared with the established stimulating catheter technique remains unknown. We tested the hypothesis that popliteal-sciatic perineural catheter insertion relying exclusively on ultrasound guidance results in superior postoperative analgesia compared with stimulating catheters.

Methods

Preoperatively, subjects receiving a popliteal-sciatic perineural catheter for foot or ankle surgery were assigned randomly to either ultrasound guidance (bolus via needle with non-stimulating catheter insertion) or electrical stimulation (bolus via catheter). We used 1.5% mepivacaine 40 mL for the primary surgical nerve block and 0.2% ropivacaine (basal 8 mL·hr^?1; bolus 4 mL; 30 min lockout) was infused postoperatively. The primary outcome was average surgical pain on postoperative day one.

Results

Forty of the 80 subjects enrolled were randomized to each treatment group. One of 40 subjects (2.5%) in the ultrasound group failed catheter placement per protocol vs nine of 40 (22.5%) in the stimulating catheter group (P = 0.014). The difference in procedural duration (mean [95% confidence interval (CI)]) was ?6.48 (?9.90 - ?3.05) min, with ultrasound requiring 7.0 (4.0-14.1) min vs stimulation requiring 11.0 (5.0-30.0) min (P < 0.001). The average pain scores of subjects who provided data on postoperative day one were somewhat higher for the 33 ultrasound subjects than for the 26 stimulation subjects (5.0 [1.0-7.8] vs 3.0 [0.0-6.5], respectively; P = 0.032), a difference (mean [95%CI]) of 1.37 (0.03-2.71).

Conclusion

For popliteal-sciatic perineural catheters, ultrasound guidance takes less time and results in fewer placement failures compared with stimulating catheters. However, analgesia may be mildly improved with successfully placed stimulating catheters. Clinical trial registration number NCT00876681.     

National trends in hospitalization from indwelling urinary catheter complications, 2001–2010

Purpose

The purpose of this study is to investigate national trends in hospitalization from indwelling urinary catheters complications from 2001 to 2010.

Materials and methods

The Healthcare Utilization Project Nationwide Inpatient Sample database was analyzed for this study. We examine hospitalization rates, patient demographics, hospital stays, insurance provider, hospital type, geographic location, and septicemia rates of patients hospitalized for indwelling urinary catheter complications from 2001 to 2010.

Results

Hospitalization from indwelling urinary catheters almost quadrupled from 11,742 in 2001 to 40,429 in 2010. The increases have been due to patients who are older and predominantly male compared to all hospitalization. The “national bill” increased from $213 million to $1.3 billion (a factor of 6) after adjusting for inflation. Most patients had urinary tract infections, 77 % in 2001 and 87 % in 2010. Septicemia in indwelling urinary catheter hospitalization patients has increased from 21 % in 2001 to 40 % in 2010. In 2010, secondary diseases associated with hospitalization due to indwelling urinary catheters included urinary tract infections (86.5 %), adverse effects of medical care (61.9 %), bacterial infection (48.6 %), and septicemia (40.3 %).

Conclusions

Hospitalization due to indwelling urinary catheter complications has almost quadrupled from 11,742 in 2001 to 40,429 in 2010, and the majority of patients had urinary tract infections. Septicemia is of particular concern since rates have almost doubled (from 21 to 40 % over the period) in these patients. The specific medical indication for urinary catheters used postoperatively should be scrutinized, and the duration of placement should be minimized to reduce future complication rates.     

A novel adaptation of laparoscopic Tenckhoff catheter insertion technique to enhance catheter stability and function in automated peritoneal dialysis

Introduction

Automated peritoneal dialysis (APD) normally takes place overnight. Maintaining a stable PD catheter position, independent of body position, omental wrapping or catheter displacement secondary to bowel movements is essential in maintaining effective catheter function.

Methods

We developed a new procedure of catheter placement through combining and adapting several previously described operative techniques including laparoscopic placement of a curled double cuff Tenckhoff catheter with subcutaneous tunneling superior to the rectus sheet, an oblique course through the abdominal wall, deep entry into the pelvic peritoneum and directed placement of the curled tip within the pouch of Douglas. Retrospective analysis of catheter function was conducted, evaluating catheter position, function, complication rate and catheter survival against findings for current insertion techniques described within literature.

Results

Between March 2009 and November 2011, 54 patients underwent PD catheter insertion. The observation period was an average of 343?±?273 days. All patients received abdominal plain film showing optimal catheter position in 89 %. Reported catheter function was very good in 85.2 %, with no or few alarms per week during APD, moderate in 9.3 % with occasional minor dysfunctions (≤2 alarms per night), and poor in 5.6 %, with regular alarm disturbance. In one case, primary dysfunction led to catheter replacement. At completion, stable catheter function with occasional minor dysfunction was achieved in 52 of 54 cases. Catheter-related complications (leakage, hydrocele formation, infection and need for replacement) were observed in 14.8 %. At the end of the observation period, 55.6 % of catheters remained in use. Patient dropout occurred through death (18.5 %), renal transplantation (7.4 %), renal recovery (1.9 %), removal secondary to infection or dysfunction (9.3 %) and conversion to HD due to poor dialysis quality (7.4 %).

Conclusion

The above technique combines and optimises previously described laparoscopic catheter implantation techniques, allowing increased catheter stability resulting in an undisturbed catheter function suitable for APD.     

Catheter-related infections in chronic hemodialysis: a clinical and economic perspective

Purpose

Central venous catheters emerged as a major risk factor for infectious complications in hemodialysis (HD) patients. We aimed to assess the incidence of bacteremia in catheter-dependent HD patients and to characterize its clinical and economic impact.

Methods

We retrospectively collected clinical data and healthcare costs from 15 months for 75 admitted catheter-dependent HD patients, to document the type of bacteremia (complicated or not), pathogen and inflammation.

Results

Bacteremia (97 % with Staphylococcus aureus, 33 % methicillin-resistant) was present in 51 % patients, with an overall infections incidence of 5.79 per 1,000 catheter-days. Metastatic complications occurred in 21 % of bacteremic patients and were associated with higher mortality (38 vs. 4 %; p = 0.001). Although, in patients starting dialysis on catheter (41 %) as compared to those using catheter as bridge angioaccess, inflammation (higher C-reactive protein; p = 0.006) and anemia (lower Hb; p = 0.008) were more pronounced, bacteremia occurred in a lower proportion (32 vs. 64 %, p = 0.007). The total medical costs were 47 % higher in patients with complicated bacteremia than in those without bacteremia (p = 0.008) and 45 % higher in patients starting HD on catheter than in those using catheter as bridge angioaccess (p = 0.002).

Conclusions

Despite the limitations resulting from retrospective cross-sectional single-center design, our study suggests that patients already on HD who required catheters as bridge angioaccess were more prone to bacteremia. This highlights the importance of close angioaccess monitoring to avoid unnecessary catheter usage. A similar increase in costs when initiating dialysis on catheter as in case of complicated bacteremia strongly supports the initial placement of a native arteriovenous fistula.     

Microbial biofilm formation and catheter-associated bacteriuria in patients with suprapubic catheterisation

Purpose

Catheter-associated bacteriuria (CAB) with transurethral catheters is almost inevitable. Suprapubic catheters (SPCs) are widely considered to decrease the risk of CAB. However, SPCs are implants similarly prone to microbial biofilm formation. The spectrum of colonising pathogens has not been investigated. The aim of this prospective study was: (1) to assess the diversity of microbial suprapubic catheter colonisation (MSPCC), (2) to identify risk factors and (3) to investigate its association with CAB and catheter-associated urinary tract infection (CA-UTI).

Methods

A total of 218 SPCs from 112 patients were studied. Urine specimens were obtained after device replacement or removal. Sonication was performed to dislodge adherent microorganisms. Data of patient sex, age, indwelling time, and underlying disease were recorded.

Results

Sonicate-fluid culture (SFC) detected MSPCC in 95 %. Increasing indwelling time correlated with MSPCC (p < 0.05). Negative SFC was more frequent when antibiotic prophylaxis was applied at time of catheter placement (15 vs. 2 %, p < 0.05). Most commonly isolated were Enterobacteriaceae (45.8 %), followed by Enterococcus spp. (25.7 %) and Pseudomonas aeruginosa (10.3 %). CAB and CA-UTI were observed in 95 and 11 %, respectively.

Conclusions

This study provides the first analysis of MSPCC. Indwelling time increases, whereas antibiotic prophylaxis decreases the risk of MSPCC. The spectrum of pathogens is comparable to the one obtained from urethral catheter biofilms. Urine specimens could not demonstrate the microbial diversity of MSPCC. SPCs are not preferable to urethral catheters to reduce CAB. Whether the risk of CA-UTI could be minimised by SPCs remains to be clarified.     

Image-guided implantation of pre-calibrated catheters in the ICU: a feasibility study

Background

Image-guided implantation of intracranial catheters is a routine procedure. Although time for surgery is short, transport from the intensive care unit (ICU) to the operation room (OR) is time-consuming and endangers patients in vulnerable intracranial pressure phases. Unfortunately, technical aspects of image guidance have so far required surgery to be performed in the operation room. In this observational study we investigated the feasibility of image-guided catheter placement in the ICU using a pre-calibrated stylet for implantation of intracranial catheters for a variety of indications and compare the results of procedures performed in the OR.

Methods

Twenty-three patients received implantation of 31 image-guided intracranial catheters or external ventricular drains using a pre-calibrated stylet in the ICU or in the OR. The times required for navigation planning, transport and surgery were assessed. Pre-operative trajectory planning, intra-operative screenshots of the navigation system and postoperative computed tomography (CT) scans were compared.

Results

Eleven external ventricular drains and nine intracranial catheters for fibrinolytic therapy of intracerebral haemorrhage were implanted in the OR, whereas ten external ventricular drains and one catheter for fibrinolytic therapy were implanted in the ICU. All catheters implanted on the ICU, 81.8 % of external ventricular drains and 88.8 % of lysis catheters placed in the OR had an optimal position to function.

Conclusion

A pre-calibrated stylet in combination with the flexible headband equipped with reference arrays allows the application of image guidance in the ICU. It reduced time expended for patients and employees, and avoided the risks of ICU transport to the OR.     

The Outcomes of Percutaneous Versus Open Placement of Peritoneal Dialysis Catheters

Background

Peritoneal dialysis catheters (PDCs) can be inserted by a percutaneous, open surgical, or laparoscopic approach. Considerable controversy surrounds the mode of catheter placement and its impact on technical success. We compared the complications and survival characteristics of PDCs that were inserted by the open approach versus those inserted percutaneously.

Methods

We reviewed the outcomes of 167 patients who received PDCs between September 2009 and February 2012. Of these, 89 were placed percutaneously and 78 were placed by open surgical techniques. The mechanical complication rates, including catheter bleeding, wrapping, migration, leakage, and technical failure of intraperitoneal placement were compared between the two groups. Additionally, peritonitis episodes, exit site infection rates, and tunnel infection rates were compared between groups.

Results

The incidence of one or more previous intra-abdominal surgeries was significantly higher in the open group (4.5 percutaneous vs 21.7 % open; P = 0.001). Although the overall number of complications did not differ between the two groups, the incidence of early mechanical complications (11.2 vs 0 %; P = 0.002) and the number of catheter removals due to mechanical complications (7.9 vs 1.3 %; P = 0.047) were higher in the percutaneous group. Of the 15 mechanical complications in the percutaneous group, one third were due to technical failures compared to none in the open group (5.6 vs 0 %; P = 0.034). The 1 year survival rate of the PDCs for the percutaneous and open groups was 89.9 and 93.3 %, respectively (P = 0.249).

Conclusions

The placement modality did not affect catheter survival. However, early mechanical complications, including technical failures, were more frequent in the percutaneous group, despite the proportion of patients with a history of one or more previous intra-abdominal surgeries being significantly lower in that group. The direct visualized open method of catheter insertion may provide the most reliable and secure access for a PDC.     

Low concentration of heparin used for permanent catheters canal locking is effective and diminishes the risk of bleeding

Purpose

There is an increasing number of patients being dialyzed with permanent catheters (PC). In the majority of cases, heparin is used to maintain PC patency. This practice causes clotting disturbances due to heparin leakage and may predispose the patient to bleeding episodes. It has not been well studied whether lowering heparin concentration for canal locking decreases short-term bleeding complications after PC placement.

Methods

This was a prospective single-center randomized open-label trial conducted in hemodialyzed patients undergoing PC insertion. Low concentration of heparin (LCH) 2,500 IU/ml versus high concentration of heparin (HCH) 5,000 IU/ml was randomly used for catheter lumens locking. The primary endpoint was the occurrence of bleeding within 24 h after catheter placement. The effects of clinical and laboratory data on bleeding events were analyzed as secondary endpoints.

Results

Seventy-five patients (37 in LCH) were enrolled in the study. Only in the HCH group we found a significant prolongation of activated partial thromboplastin time (APTT) 2 h after PC placement (p < 0.001). There was a higher number of bleeding episodes in the HCH group (n = 16; 42.1%) than in the LCH group (n = 7; 18.9%) (χ² = 4.74; p = 0.029). In univariate analysis, assignment to HCH, baseline APTT, use of low molecular weight heparin, and femoral localization were associated with bleeding events. In multivariate analysis, the use of HCH (odds ratio [OR] 3.64; 95% confidence interval [95% CI] 1.10–12.05) and baseline APTT (OR 1.12; 95% CI 1.002–1.250) predicted bleeding after PC insertion.

Conclusion

LCH used for canals locking decreases bleeding events in the first 24 hours after permanent catheter placement, compared to HCH.     

Non-assisted versus neuro-navigated and XperCT-guided external ventricular catheter placement: a comparative cadaver study

Background and purpose

Accurate placement of an external ventricular drain (EVD) for the treatment of hydrocephalus is of paramount importance for its functionality and in order to minimize morbidity and complications. The aim of this study was to compare two different drain insertion assistance tools with the traditional free-hand anatomical landmark method, and to measure efficacy, safety and precision.

Methods

Ten cadaver heads were prepared by opening large bone windows centered on Kocher’s points on both sides. Nineteen physicians, divided in two groups (trainees and board certified neurosurgeons) performed EVD insertions. The target for the ventricular drain tip was the ipsilateral foramen of Monro. Each participant inserted the external ventricular catheter in three different ways: 1) free-hand by anatomical landmarks, 2) neuronavigation-assisted (NN), and 3) XperCT-guided (XCT). The number of ventricular hits and dangerous trajectories; time to proceed; radiation exposure of patients and physicians; distance of the catheter tip to target and size of deviations projected in the orthogonal plans were measured and compared.

Results

Insertion using XCT increased the probability of ventricular puncture from 69.2 to 90.2 % (p?=?0.02). Non-assisted placements were significantly less precise (catheter tip to target distance 14.3?±?7.4 mm versus 9.6?±?7.2 mm, p?=?0.0003). The insertion time to proceed increased from 3.04?±?2.06 min. to 7.3?±?3.6 min. (p?<?0.001). The X-ray exposure for XCT was 32.23 mSv, but could be reduced to 13.9 mSv if patients were initially imaged in the hybrid-operating suite. No supplementary radiation exposure is needed for NN if patients are imaged according to a navigation protocol initially.

Conclusion

This ex vivo study demonstrates a significantly improved accuracy and safety using either NN or XCT-assisted methods. Therefore, efforts should be undertaken to implement these new technologies into daily clinical practice. However, the accuracy versus urgency of an EVD placement has to be balanced, as the image-guided insertion technique will implicate a longer preparation time due to a specific image acquisition and trajectory planning.     

Usefulness of the introducer method for percutaneous endoscopic gastrostomy using ultrathin transnasal endoscopy

Background

The introducer method of percutaneous endoscopic gastrostomy (PEG) minimizes procedure-related peristomal infection. Ultrathin transnasal endoscopy (UTE) allows comfortable endoscopic examination of patients with fewer adverse effects and passage of the endoscope through a narrow esophagus or oropharynx. This study aimed to investigate the clinical outcomes for the introducer method of PEG with UTE.

Methods

Patients who underwent the introducer method of PEG with UTE between March 2009 and May 2012 were analyzed. The outcomes and complications of the patients within 180 days after gastrostomy placement were investigated.

Result

During the study period, 92 patients (31.9 % male; age, 67.7 ± 16.6 years) underwent the introducer method of PEG with UTE. The major indications for PEG insertion were stroke (40.4 %), esophageal cancer or head and neck cancer (27.1 %), and neurologic disorder (14.9 %). Esophageal stenosis was identified by endoscopy or imaging in 14 patients before PEG. In all the patients, UTE was successfully introduced through the nasal cavity. In 90 (97.8 %) of the 92 patients, PEG was successfully inserted. Insertion of the endoscope into the stomach was impossible in two patients because head and neck cancer caused severe narrowing of the upper esophagus. No procedure-related peristomal infection, gastric contents leakage, or bleeding occurred within 30 days after gastrostomy placement. In eight patients (8.7 %), catheter displacement occurred within 30 days. Catheter displacement in 44 patients (47.8 %) and gastric contents leakage in eight patients (9 %) occurred within 30–180 days after gastrostomy placement.

Conclusion

Introducer PEG with UTE is a useful method for gastrostomy placement with a high success rate. This technique allows procedure-related complications to be avoided and permits the use of endoscopy in patients with narrow esophagi or oropharynges. However, the long-term durability of the balloon-type catheter is questionable.     

Low-pressure hydrocephalus: indication for custom-made catheters? Technical report

Background

Low-pressure hydrocephalus (LPH) is characterized by ventriculomegaly with persistent low intracranial pressure (ICP). Sub-zero drainage is needed for its management and multiple solutions have been described. Our aim is to report our experience with custom-made peritoneal catheters with larger inner diameter as an alternative treatment option.

Methods

We made a retrospective review of all patients diagnosed with LPH and treated with custom-made peritoneal catheters at the Virgen del Rocío Pediatric Neurosurgical Unit. Catheters were coated with antibiotic or silver. The inner diameter of ventricular catheters was 1.4 mm; peritoneal catheters were larger than usual (1.9 mm inner diameter).

Results

We identified four patients in whom five custom-made peritoneal catheters were used over a 3-year period. There were two males and the mean age was 10 years (6 months–17 years). In all patients, placement of an EVD was necessary for sub-zero drainage, with maximum negative pressure of ?8 cm H20. The mean time of maintenance of EVD was 102 days (10 days–1 year). Finally, three ventriculoperitoneal (VP) valveless systems, one with antigravitation device, and one Pro-GAV VP shunt were placed, all of them with larger custom-made peritoneal catheters. After a mean follow-up period of 2.3 years (6 months–3 years), two patients are completely recovered, one patient is partially dependent for daily activities with good cognitive status, and the last one is a child who died due to his brain tumor.

Conclusion

The custom-made peritoneal catheters with larger inner diameter could be a good option for the management of this complex pathology.     

Is a small-bore catheter efficient for most pleural pathologies?

Purpose

Chest tubes are used for drainage of the pleural cavity. Traditionally, large-bore catheters are inserted for all indications, but there has been a recent tendency to use small-bore catheters. We share the results of our experience of using small-bore catheters for almost all indications routinely in our clinic.

Methods

A collective total of 309 small-bore chest catheters (10 F) were inserted via the Seldinger technique in 287 patients during a 5-year-period. Malignant pleural effusion and pneumothorax were the most common indications for chest tube insertion.

Results

The mean catheter duration was 5.6 days, being 5 days for pneumothorax and 6 days for malignant pleural effusion. Pleurodesis was performed effectively for malignant pleural effusions. In this series, the failure rate of small-bore catheters was 7.2 %.

Conclusion

Based on our clinical experience of using small-bore catheters, we believe that they are potentially effective for almost all pleural pathologies. Our results concur with those in the literature, but this series also includes different pleural diseases requiring chest tube insertion.     

Management of peripancreatic fluid collections following partial pancreatectomy: a comparison of percutaneous versus EUS-guided drainage

Background

Peripancreatic fluid collections (PFCs) occur in up to 30 % of patients following partial pancreatic resections. Traditionally, postoperative PFCs are managed via percutaneous drainage (PD). EUS-guided transgastric drainage has been shown to be effective for the management of PFCs secondary to acute pancreatitis. However, there are limited data on the use of EUS-guided drainage (EUSD) for the management of postoperative PFCs.

Objective

To compare the safety and efficacy of PD versus EUSD of PFCs in patients who have undergone partial pancreatic resections.

Design

Retrospective analysis of patients with symptomatic PFCs following pancreatic enucleation or distal pancreatectomy at MSKCC between January 2008 and December 2010. Patients were identified using an electronic medical records query in addition to a prospectively maintained pancreatic surgery complications database.

Setting

Single, academic, tertiary referral center.

Patients

Twenty-three patients with symptomatic PFCs following pancreatic enucleation or distal pancreatectomy were retrospectively identified.

Interventions

CT-guided PD versus endoscopic ultrasound-guided drainage (EUSD)

Main outcome measures

Outcomes included technical success, clinical success, number of interventions, and complications. Technical success was defined as successful localization of the PFC by fine-needle aspiration and placement of a drainage catheter or stent. Clinical success was defined as radiographic resolution of the PFC and removal of the drain or stent, without the need for an alternative drainage procedure or surgery.

Results

PD was initially performed in 14 patients and EUSD initially in 9 patients. Three patients with initial PD had recurrence of PFC after removal of the external drain and underwent subsequent EUSD. The mean size of the fluid collections was 10.0 cm in the PD group and 8.9 cm in the EUSD group. Technical success was achieved in all patients in both groups. Clinical success was achieved in 11 of 14 (79 %) patients in the PD group compared with 11 of 11 (100 %) in the EUSD group, with one patient in the EUSD group lost to follow-up. One patient with initial PD required two additional percutaneous procedures before complete PFC resolution. Five EUSD patients required repeat endoscopy for stent revision or necrosectomy. The median number of interventions was two [range 1–5] in the PD group and two [range 1–5] in the EUSD group. The median number of days the drainage catheters were in place was 44.5 [range 2–87] in the PD group versus 57 [range 32–217] in the EUSD group. There were no procedure-related complications in either group. Adverse events in the PD group included splenic artery stump bleeding, pleural effusion, cysto-colonic and cysto-cutaneous fistulae, and persistent catheter site pain. One patient in the EUSD group developed a small-bowel obstruction and bleeding gastric ulcer.

Limitations

Retrospective, nonrandomized study and small numbers.

Conclusions

EUSD of postoperative PFCs appears to be safe and technically feasible. This technique appears to be as successful as PD for the management of PFCs with the advantage of not requiring an external drainage apparatus and should be considered as a therapeutic option in this group of patients. Further evaluation, with analysis of cost and quality of life, should be considered in a prospective, randomized trial.     

Palliative Venting Gastrostomy in Patients with Malignant Bowel Obstruction and Ascites

Background

Fluoroscopic-guided placement of a percutaneous decompression gastrostomy tube (PDGT) is used to palliate patients with malignant bowel obstruction (MBO). We report our clinical experience in cases of MBO and ascites that were known to be technically difficult and at increased risk for complications after PDGT placement.

Methods

Between October 2005 and April 2010, a total of 89 consecutive oncology patients with MBO and ascites underwent at least one attempt at PDGT placement. We retrospectively reviewed the electronic medical record to collect demographic details, procedure information, and morbidity and mortality data. Kaplan–Meier curves were used to calculate median survival after PDGT.

Results

Ninety-three new gastrostomy encounters occurred in 89 patients. The primary and secondary technical success rates were 72 % (67 of 93) and 77.4 % (72 of 93), respectively. Inadequate gastric distention was the reason for failure in 84.6 % (22 of 26) of the cases in which the initial PDGT attempt was unsuccessful. For ascites management, 13 patients underwent paracentesis and 78 patients underwent placement of an intraperitoneal catheter. The overall complication rate in successful placements was 13.9 %, with a major complication rate of 9.7 %. After PDGT, the median overall survival rate was 28.5 days (95 % confidence interval 20–42).

Conclusions

PDGT is feasible in the majority of patients with MBO and ascites, although there is an inherent risk of major complications. An intraperitoneal catheter can be used to manage ascites to facilitate PDGT.     

A comparative study on the use of tamsulosin versus alfuzosin in spontaneous micturition recovery after transurethral catheter removal in patients with benign prostatic growth

Purpose

To compare the efficacy and safety of tamsulosin and alfuzosin in patients with acute urinary retention (AUR) secondary to benign prostatic hyperplasia (BPH).

Methods

Ninety men with AUR due to BPH underwent urinary catheterization and were randomly assigned to treatment groups with tamsulosin 0.4 mg (37 patients), alfuzosin 10 mg (34 patients), and placebo (19 patients). After 4 days of the drug treatment, the catheters were removed, and the patients underwent trial without catheter (TWOC). A TWOC was considered successful if the patient had a voided volume >100 ml and post-void residual urine <200 ml.

Results

TWOC was successful in 16 patients (43.2 %) in the tamsulosin group, 12 patients (35.2 %) in the alfuzosin group, and 5 patients (26.3 %) in the placebo group. Logistic regression analysis showed that both drugs were equally effective and that the type of alpha-blocker was not a predictive factor for TWOC success (OR 1.137, 95 % CI 0.639–2.022) (p = 0.662).

Conclusion

Even though there were no statistically significant differences when comparing the three groups, tamsulosin showed a tendency to be more effective in a successful catheter removal. The lack of objective criteria in the definition of successful micturition leads us to believe that the effectiveness of both drugs reported in the literature is overestimated.     

Computed Tomography (CT) Venography Using a Multidetector CT Prior to the Percutaneous External Jugular Vein Approach for an Implantable Venous-Access Port

Background and Purpose

The objective of this study was to determine the success rate and complications of using the percutaneous approach of the external jugular vein (EJV) for placement of a totally implantable venous-access port (TIVAP) with a preoperative estimate of the detailed anatomical orientation of the cervical venous plexus using computed tomography venography (CT-V).

Methods

A prospective cohort study of 45 patients in whom placement of a TIVAP was attempted via the right EJV was conducted. The preoperative anatomical estimation of the cervical venous plexus was performed with CT-V using a Multidetector Helical 16-section CT. The angulation between the right EJV and the right subclavian vein, anterior jugular vein, transverse cervical vein, and suprascapular vein was estimated.

Results

CT-V success was achieved in 45 of 45 patients (100 %). A plexus of veins under the clavicle was most commonly responsible for the insertion of the central venous catheter. The EJV approach resulted in a successful cannulation rate of 93 %. No initial complications of pneumothorax or carotid artery puncture occurred during insertion procedures. Late complications occurred in three patients. These included one port erosion (2 %), one catheter occlusion (2 %), and one wound hematoma (2 %). Catheter-related infections were observed in one patient (2 %).

Conclusions

The percutaneous EJV approach with CT-V guidance is an optional method for patients with multiple central venous cannulations, those in hemodialysis, or those with long catheter indwelling periods.