Interventional recanalization therapy in patients with non-cirrhotic, non-malignant portal vein thrombosis: comparison between transjugular versus transhepatic access

Purpose To compare the safety and outcome of transjugular versus percutaneous technique in recanalization of non-cirrhotic, non-malignant portal vein thrombosis. Methods We present a retrospective bicentric analysis of 21 patients with non-cirrhotic, non-malignant PVT, who were treated between 2016 and 2021 by interventional recanalization via different access routes (percutaneous [PT] vs. transjugular in transhepatic portosystemic shunt [TIPS] technique). Complication rates with a focus on periprocedural bleeding and patency as well as outcome were compared. Results Of the 21 patients treated (median age 48 years, range of 19–78), seven (33%) patients had an underlying prothrombotic condition. While 14 (57%) patients were treated for acute PVT, seven (43%) patients had progressive thrombosis with known chronic PVT. Nine patients underwent initial recanalization via PT access and twelve via TIPS technique. There was no significant difference in complete technical success rate according to initial access route (55.5% in PT group vs. 83.3% in TIPS group, p = 0.331). However, creation of an actual TIPS was associated with higher technical success in restoring portal venous flow (86.6% vs. 33.3%, p = 0.030). 13 (61.9%) patients received thrombolysis. Nine (42.8%) patients experienced hemorrhagic complications. In a multivariate analysis, thrombolysis (p = 0.049) and PT access as the first procedure (p = 0.045) were significant risk factors for bleeding. Conclusion Invasive recanalization of the portal vein in patients with PVT and absence of cirrhosis and malignancy offers a good therapeutic option with high recanalization and patency rates. Bleeding complications result predominantly from a percutaneous access and high amounts of thrombolytics used; therefore, recanalization via TIPS technique should be favored.

Metatarsophalangeal arthrodesis of the hallux using a minimally invasive technique

Objective: To evaluate the outcomes of the metatarsophalangeal arthrodesis (MTPA) of the hallux using a percutaneous technique. Methods: The MTPA of the hallux was performed in a total of 27 feet: 20 patients diagnosed with hallux rigidus and 7 with rheumatoid arthritis. The mean postoperative follow-up time was 30.7 months. The results were evaluated using the visual analogue scale (VAS) for pain, the American Orthopaedic Foot & Ankle Society (AOFAS) forefoot score, and regards to union rate. Results: All 27 patients were operated percutaneously and noticed relief of the pain, with a mean increase of 50.9 points in AOFAS scores and a mean decrease of 7.4 points in the VAS. The mean union time was 10 weeks. There were no cases of nonunion. Conclusion: Percutaneous first MTP arthrodesis proved effective for treating hallux rigidus and degenerative rheumatic pathologies. Level of Evidence IV; Therapeutic Studies; Cases Series.

Alternative Dorsal Root Ganglion Neuromodulation Electrode Implantation: A Report of 2 Cases with 3 Different Techniques

Background and Study Aims The traditional percutaneous placement of dorsal root ganglion (DRG) electrodes may not be eligible for every patient. In this tertiary spine surgery and interventional pain therapy center, alternative neurostimulation implantation techniques were developed and applied where standard percutaneous approaches failed or were contraindicated. Case presentation Three alternative implantation techniques can be used: (1) open surgical placement of DRG leads, (2) two-lead insertion via a lateral to medial transforaminal approach (level L3), and (3) percutaneous approach with two leads close to the spinal nerves L4 (peripheral nerve stimulation). Results The placement of the leads occurred without complications and resulted in similar expected outcomes as with the common percutaneous technique with long-term stable pain suppression at 7 months and 1 year. Conclusions In patients in whom the DRG cannot be approached by the standard percutaneous approach, at least three alternatives may be used in experienced hands resulting in stable pain suppression of similar magnitude.

Dexmedetomidine versus magnesium sulphate as an adjuvant to local anesthesia in single-injection percutaneous peribulbar anesthesia for cataract extraction

Background The aim of the study was to evaluate the impact of addition of dexmedetomidine or magnesium sulphate to the standard local anesthetics mixture as a primary objective and to compare between both as a secondary objective utilizing the single-injection percutaneous technique for peribulbar block. In this prospective randomized double-blinded clinical trial (RCT), sixty patients, both sexes, aged 45 to 75, with an ASA of I to III, were scheduled for cataract extraction operation. They were divided into three equal groups; each received a single injection peribulbar block of a mixture of 0.5% bupivacaine (3 ml) + 2 percent lidocaine (3 ml) + 120 IU hyaluronidase + (control group (C): 0.5 ml of normal saline; group D: 50 μg of dexmedetomidine; group M: 50 mg of magnesium sulphate in 0.5 ml) with a total injected volume of 7 ml each. The duration of sensory, motor block, need for supplementary doses, hemodynamics, and satisfaction of patients and surgeons were assessed. Results For the primary outcome, both the dexmedetomidine and magnesium groups revealed statistically significant differences from the control group with shorter onsets of sensory block and lid akinesia (p value< 0.001 for both), shorter onset of globe akinesia for dexmedetomidine (p value<0.001) and for magnesium sulphate (p value=0.022), prolonged duration of lid and globe akinesia and sensory block (p value<0.001), better patient satisfaction (p value=0.044) but insignificant difference regarding surgeons’ satisfaction (p value= 0.117) and a less frequent, but statistically insignificant need for supplementary injection (p value=0.075). The demographic and clinical hemodynamics and oxygen saturation parameters were comparable between the three groups. For the secondary outcome, dexmedetomidine was superior to magnesium sulphate regarding onset of globe and lid akinesia (p value= 0.047 and 0.003, respectively), and durations of globe akinesia and sensory block (p value= 0.02 and 0.016, respectively). No complications related to the drugs or procedure were recorded. Conclusions When compared to 50 mg magnesium sulphate, dexmedetomidine at a dose of 50 μg is a superior adjunct to local anesthetic combination in peribulbar block for cataract procedures in terms of start and duration of peribulbar block.

Four-Corner Arthrodesis: Comparative Analysis of Open Technique Versus Percutaneous Technique with Arthroscopic Assistance

Introduction Four-corner arthrodesis is a salvage technique for patients with carpal advanced osteoarthritis. Nowadays, percutaneous techniques with arthroscopic assistance have been described, achieving favorable results with minimally invasive techniques advantages over open surgery. Objective To compare functional and radiological results in patients with SLAC or SNAC wrists operated with open surgical technique versus percutaneous surgery with arthroscopic assistance. Materials and Methods Retrospective case-control study of clinical records and radiological images of patients with carpal advanced osteoarthritis operated with both surgical techniques. We studied demographic variables, pain with visual analog scale (VAS) score, function in ranges of mobility, time of consolidation, and correction of DISI deformity. Results A total of 22 male patients with an average age of 32.5 years were studied. Thirteen patients in the case group (percutaneous technique with arthroscopic assistance) and nine patients in the control group (open surgery). Pain score in VAS at discharge was 3 for cases and 5 in controls (p = 0.008), and at 30 days postoperatively, it was 0 and 3 respectively (p = 0.00). The extension and flexion ranges were 52.6°and 38.7° in the cases and 35.7° and 32.4° in the control group (p = 0.119 and 0.0016, respectively). The capitolunate angle was 10°in the controls and 5°in the cases (p = 0.0008). The time of consolidation was 8.8 weeks in cases and 12.5 weeks in controls (p = 0.039). Conclusions The percutaneous technique with arthroscopic assistance for the 4-courner arthrodesis is a reproducible technique and is effective in achieving consolidation, pain reduction and preservation of wrist motion. In the present study, we demonstrate superiority of this technique over the open surgery. Level of Evidence This is a Level III, therapeutic study.

Open Versus Percutaneous Approach of Renal Tumor Biopsy at Cipto Mangunkusumo Hospital: A Single-center Experience

BACKGROUND: Renal tumor biopsy is beneficial as it is capable of distinguishing between histological types of renal tumor; hence, it plays an important role in deciding the best therapy regimen. AIM: This study aims to evaluate the clinical experiences of renal biopsy in Cipto Mangunkusumo National Referral Hospital (RSCM), with both a percutaneous and open approach. It also aims to analyze the indications, results, intraoperative information, and complications of the two approaches. METHODS: This study was conducted using the retrospective cohort design; meanwhile, data were collected from RSCM from 1990 to 2019. The biopsy sample was taken using percutaneous and open renal biopsy, while comparative analysis was done between the two biopsy approaches. RESULTS: Data were collected from 33 patients that underwent renal biopsy from 1990 to 2019. Majority of the cases were diagnosed as unresectable renal tumor, while histological examination found clear cell carcinoma in most of the cases (73%). Furthermore, the open approach showed longer duration and higher blood loss compared to percutaneous technique with median 60 (30–120) versus 30 (5–60) min (p < 0.001) and 100 (5–650) versus 2 (1–5) ml (p < 0.001), respectively. In general, complications were reported to be low for both techniques. CONCLUSION: Based on the results, percutaneous renal biopsy has similar efficacy and complications rates in tumor sampling for histopathology together with open approach. However, there were significant differences in the duration and blood loss; hence, percutaneous biopsy is more favorable.

Tracheostomy Timing and Outcome in Severe COVID-19: The WeanTrach Multicenter Study

Background: Tracheostomy can be performed safely in patients with coronavirus disease 2019 (COVID-19). However, little is known about the optimal timing, effects on outcome, and complications. Methods: A multicenter, retrospective, observational study. This study included 153 tracheostomized COVID-19 patients from 11 intensive care units (ICUs). The primary endpoint was the median time to tracheostomy in critically ill COVID-19 patients. Secondary endpoints were survival rate, length of ICU stay, and post-tracheostomy complications, stratified by tracheostomy timing (early versus late) and technique (surgical versus percutaneous). Results: The median time to tracheostomy was 15 (1–64) days. There was no significant difference in survival between critically ill COVID-19 patients who received tracheostomy before versus after day 15, nor between surgical and percutaneous techniques. ICU length of stay was shorter with early compared to late tracheostomy (p < 0.001) and percutaneous compared to surgical tracheostomy (p = 0.050). The rate of lower respiratory tract infections was higher with surgical versus percutaneous technique (p = 0.007). Conclusions: Among critically ill patients with COVID-19, neither early nor percutaneous tracheostomy improved outcomes, but did shorten ICU stay. Infectious complications were less frequent with percutaneous than surgical tracheostomy.

Forty years after the first totally implantable venous access device (TIVAD) implant: the pure surgical cut-down technique only avoids immediate complications that can be fatal

Aim Even though TIVADs have been implanted for a long time, immediate complications are still occurring. The aim of this work was to review different techniques of placing TIVAD implants to evaluate the aetiology of immediate complications. Methods A systematic literature review was performed using the PubMed, Cochrane and Google Scholar databases in accordance with the PRISMA guidelines. The patient numbers, number of implanted devices, specialists involved, implant techniques, implant sites and immediate complication onsets were studied. Results Of the 1256 manuscripts reviewed, 36 were eligible for inclusion in the study, for a total of 17,388 patients with equivalent TIVAD implantation. A total of 2745 patients (15.8%) were treated with a surgical technique and 14,643 patients (84.2%) were treated with a percutaneous technique. Of the 2745 devices (15.8%) implanted by a surgical technique, 1721 devices (62.7%) were placed in the cephalic vein (CFV). Of the 14,643 implants (84.2%) placed with a percutaneous technique, 5784 devices (39.5%) were placed in the internal jugular vein (IJV), and 5321 devices (36.3%) were placed in the subclavian vein (SCV). The number of immediate complications in patients undergoing surgical techniques was 32 (1.2%) HMMs. In patients treated with a percutaneous technique, the number of total complications were 333 (2.8%): 71 PNX (0.5%), 2 HMT (0.01%), 175 accidental artery punctures AAP (1.2%) and 85 HMM (0.6%). No mortality was reported with either technique. Conclusion The percutaneous approach is currently the most commonly used technique to implant a TIVAD, but despite specialist’s best efforts, immediate complications are still occurring. Surgical cut-down, 40 years after the first implant, is still the only technique that can avoid all of the immediate complications that can be fatal.