Mortality after transjugular intrahepatic portosystemic shunt in older adult patients with cirrhosis: A validated prediction model

Background and Aims: Implantation of a transjugular intrahepatic portosystemic shunt (TIPS) improves survival in patients with cirrhosis with refractory ascites and portal hypertensive bleeding. However, the indication for TIPS in older adult patients (greater than or equal to 70 years) is debated, and a specific prediction model developed in this particular setting is lacking. The aim of this study was to develop and validate a multivariable model for an accurate prediction of mortality in older adults. // Approach and Results: We prospectively enrolled 411 consecutive patients observed at four referral centers with de novo TIPS implantation for refractory ascites or secondary prophylaxis of variceal bleeding (derivation cohort) and an external cohort of 415 patients with similar indications for TIPS (validation cohort). Older adult patients in the two cohorts were 99 and 76, respectively. A cause‐specific Cox competing risks model was used to predict liver‐related mortality, with orthotopic liver transplant and death for extrahepatic causes as competing events. Age, alcoholic etiology, creatinine levels, and international normalized ratio in the overall cohort, and creatinine and sodium levels in older adults were independent risk factors for liver‐related death by multivariable analysis. // Conclusions: After TIPS implantation, mortality is increased by aging, but TIPS placement should not be precluded in patients older than 70 years. In older adults, creatinine and sodium levels are useful predictors for decision making. Further efforts to update the prediction model with larger sample size are warranted

Common hepatic artery aneurysm successfully treated with a celiac axis stent graft. Two years of follow up

Purpose To present a case of partially thrombosed 5 cm wide aneurysm of the origin of common hepatic artery with occlusion of common hepatic artery distal to the aneurysm and proper hepatic artery revascularized by gastroduodenal and superior mesenteric arteries. Case report After a preliminary 3D rotational angiography evaluation a stent graft was deployed in the celiac axis to exclude the common hepatic artery and the aneurysm taking the advantage of developed complete collateral liver blood supply. Two year CT follow up showed stent patency without clinical and radiological evidence of visceral ischemic damage. Clinical and technical considerations are discussed. Conclusions The positive mid-term outcome confirms the efficacy of endovascular exclusion with stent graft, in the treatment of hepatic artery aneurysm in selected cases

EcoDoppler Transcranico con tecnica CPS e SonoVue nella valutazione della perfusione cerebrale. Nuove prospettive diagnostiche

EcoDoppler Transcranico con tecnica CPS e SonoVue nella valutazione della perfusione cerebrale. Nuove prospettive diagnostich

Ergonomia ed estetica nell’intervento di appendicectomia laparoscopica: tecnica personale.

We analyzed our case series in order to evaluate the evolution of our laparoscopic technique in ergonomic and cosmetic terms, leading to the right compromise between these aspects. We retrospectively analyzed 136 diagnostic laparoscopies for suspected appendicitis, using scheme A in the first 98 cases (one 10/12-mm umbilical trocar for the optics and two 5-mm operative trocars placed above the pubis on the right and left side) and scheme B in the other 38 cases (one 10/12-mm umbilical trocar for the optics and two 5-mm operative trocars, one placed over the pubis and the other one on the right hip, just on the umbilical line). The diagnosis of appendicitis was confirmed in 117 patients, while other diseases were present in 19 patients. There were no differences between the two groups in mean operative time (45 min), postoperative complications (0.7%) and clinical course (hospital stay: 36 hours on average). We believe that the right compromise between ergonomic and cosmetic considerations is the one shown in scheme B. In this way it is possible to perform all diagnostic and therapeutic manoeuvres such as pulling the appendix out through the umbilical trocar and using suprapubic trocars as an access route for a possible drainage