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Purpose To evaluate the rate and risk factors for hemorrhage in patients undergoing real-time, ultrasound-guided paracentesis by radiologists without correction of coagulopathy. Materials and Methods This was a retrospective study of all patients who underwent real-time, ultrasound-guided paracentesis at a single institution over a 2-year period. In total, 3116 paracentesis procedures were performed: 757 (24%) inpatients and 2,359 (76%) outpatients. Ninety-five percent of patients had a diagnosis of cirrhosis. Mean patient age was 56.6 years. Mean international normalized ratio (INR) was 1.6; INR was > 2 in 437 (14%) of cases. Mean platelet count was 122 x 103/μL; platelet count was Results Significant post-paracentesis hemorrhage occurred in 6 (0.19%) patients, and only 1 patient required an angiogram with embolization. No predictors of post-procedure bleeding were found, including INR and platelet count. Transfusion of 1125 units of fresh frozen plasma and 366 units of platelets were avoided, for a transfusion-associated cost savings of $816,000. Conclusions Without correction of coagulation abnormalities with prophylactic blood product transfusion, post-procedural hemorrhage is very rare when paracentesis is performed with real-time ultrasound guidance by radiologists.

Objectives Although no longer a contraindication to liver transplant, portal vein thrombosis may lead to longer operative time and complexities in venous reconstruction. Strategies to maintain preoperative patency include systemic anticoagulation and/or transjugular intrahepatic portosystemic shunt placement. The former may not be ideal in cirrhotic patients prone to luminal gastrointestinal tract bleeding, and factors that predict improvements in portal vein thrombosis with the latter have not been well defined. Our goal was to evaluate the effectiveness of transjugular intrahepatic portosystemic shunt placement as monotherapy to improve and/or resolve portal vein thrombosis in otherwise eligible liver transplant candidates with partial or complete portal vein thrombosis and to identify factors predicting success. Materials and methods We identified 30 patients from 2010 to 2015 who had transjugular intrahepatic portosystemic shunt placementfor primary indication to maintain portal vein patency. Results The main portal vein was completely thrombosed in 5 of 30 (16.6%), nearly completely thrombosed in 9 of 30 (30%), and partially thrombosed in 16 patients (53.3%). Twenty-four patients (80%) had improvement and/or resolution of portal vein thrombosis after transjugular intrahepatic portosystemic shunt placement, with 18 of these (75%) having complete resolution. All 5 patients (20.8%) with complete thrombosis had improvement/resolution of portal vein thrombosis. Nine patients (30%) required hospitalization within 3 months for hepatic encephalopathy. There were 3 deaths (10%) not related to transjugular intrahepatic portosystemic shunt placement (10%). Nine patients underwent liver transplant after shunt placement (median 2.9 mo; range, 0.3-32 mo); all 9 received endto-end anastomosis without need for intraoperative thrombectomy. Conclusions Transjugular intrahepatic portosystemic shunt placement may be effective as monotherapy for maintaining or restoring portal vein patency in selected livertransplant candidates, even in those with complete portal vein thrombosis. Further studies are needed to define potential responders to this approach.

Hepatic encephalopathy (HE) is a common complication of elective transjugular intrahepatic portosystemic shunt (TIPS) placement and is often successfully medically managed. Risk factors for refractory hepatic encephalopathy (RHE) necessitating revision of TIPS are not well defined. We evaluated the incidence, predictors, and outcomes of post-TIPS RHE necessitating TIPS revision. In a retrospective cohort study of 174 consecutive patients undergoing elective TIPS placement (2010–2015), we evaluated the incidence of post-TIPS RHE. Clinical demographics and procedural variables were collected. 1-year outcomes after revision were collected. Ten of 174 patients (5.7%) developed post-TIPS RHE requiring revision. Significant differences between RHE and non-refractory groups were shunt size > 8 versus ≤ 8 mm (18.5 vs. 3.4%, p = 0.001), history of HE (14 vs. 2%, p = 0.007), and serum albumin levels ≤ 2.5 versus > 2.5 g/dL (13.1 vs. 3.1%, p = 0.020). On multivariate analysis, shunt size > 8 mm (p = 0.001), history of HE prior to TIPS (p = 0.006), and low serum albumin (≤ 2.5 g/dL) (p = 0.022) remained independent predictors of RHE, controlling for age and Model for End-Stage Liver Disease score. RHE improved in 8 of 10 patients but survival at 1 year without liver transplantation (LT) was only 10%. While TIPS revision successfully improves RHE in most cases, 1-year mortality rates are high, limiting the value of revision in non-LT candidates. Patients with previous history of HE and low serum albumin levels prior to TIPS may benefit most from the use of shunt sizes

The development of aortic aneurysms in post-transplant patients is a rare but potentially lethal problem. De novo aortic aneurysm formation and rapid growth are postulated to result from an imbalance between pro- and anti-inflammatory vascular endothelial factors after transplant. Here, we present a case of de novo thoracic aneurysm formation within 2 months of orthotopic liver transplant. Prompt clinical recognition allowed for successful endovascular repair. Transplant clinicians should be aware of this potentially life-threatening complication and monitor at-risk recipients accordingly.

Risk factors for conversion to hand assisted laparoscopic or open surgery during laparoscopic renal surgery are incompletely defined.We reviewed our institutional database of 759 standard laparoscopic and 833 hand assisted laparoscopic radical, simple, donor and partial nephrectomies, pyeloplasties and nephroureterectomies from June 1996 to February 2009, representing a total of 1,592 cases. We identified the incidence of and indications for conversion to hand assisted laparoscopic and open surgery, and determined risk factors for conversion.Of all 1,592 procedures 20 (1.3%) required conversion to open surgery. Of 759 standard laparoscopic procedures 21 (2.8%) were converted to hand assisted laparoscopic surgery and 1.7% were converted to open surgery for an overall standard laparoscopy conversion rate of 4.6%. Only 0.7% of hand assisted laparoscopic procedures were converted to open surgery. The rate of conversion to open surgery ranged from 0.3% for laparoscopic partial to 2.5% for laparoscopic simple nephrectomy. The rate of conversion to hand assisted laparoscopic surgery ranged from 0% for laparoscopic pyeloplasty to 6.5% for laparoscopic partial nephrectomy. Conversion to open surgery was most likely due to hemorrhage (50% of cases) or failure to progress (40%) while conversion to hand assisted laparoscopic surgery was most likely due to failure to progress (76%) and tumor anatomy (19%). Multivariate analysis revealed that the only significant risk factor for conversion to open surgery was greater American Society of Anesthesiologists score. Conversion to hand assisted laparoscopic surgery was associated with greater body mass index, American Society of Anesthesiologists score and partial nephrectomy.Conversion during laparoscopic renal surgery to open or hand assisted laparoscopic surgery is a rare but important event in laparoscopic surgery. The risk is influenced by the nature of the procedure and overall patient health.

Objective To present an efficient technique for simple cystectomy. Urinary diversion for benign indications is a relatively rare procedure. However, diversion alone without accompanying cystectomy results in a significant risk of complications, such as pyocystis, hematuria, pain, and secondary carcinoma. Methods We retrospectively reviewed our institutional experience with this simple cystectomy technique, which included 23 patients from 2007–2010 performed by 3 surgeons. There were 14 females and 9 males. All patients had exhausted all other possible conservative therapies. Indication for the procedure included neurogenic bladder and resulting complications in 9 patients, complications from prostate radiation therapy in 5 patients, refractory interstitial cystitis in 5 patients, and refractory incontinence in 4 patients. Results The average patient was 63.3 years old and had undergone 2.7 prior abdominal or pelvic surgeries and 3.6 prior urinary operations. The average operative time was 27.5 minutes for the simple cystectomy portion of the case (recorded in 19 cases) and average blood loss was 46.7 mL (recorded in 12 cases). For the entire procedure, including diversion with bowel segment, the average blood loss was 231.5 mL. The mean entire operative time was 318.5 minutes. There were no complications noted intraoperatively or postoperatively specifically attributed to the cystectomy portion. All pathology specimens revealed no evidence of malignancy. Mean follow-up was 8 months (range 1–33). Conclusion This simple cystectomy technique, in most cases of urinary diversion for benign indications, can be performed quickly with minimal blood loss and complications.

Objectives To evaluate commonalities in presentation and long-term efficacy of treatment by percutaneous nephrostolithotomy of matrix stones, a rare form of urinary calculi. Methods The clinical data of 9 consecutive patients with urinary matrix calculi in 11 kidneys treated at our institution between 1995 and 2007 were retrospectively reviewed. Results The matrix component in all 11 kidneys was successfully treated with percutaneous nephrostolithotomy, with few complications. Among 8 patients (9 kidneys) with follow-up, none has had recurrence of matrix stones after a mean follow-up of 3.8 years. Along with previously known risk factors for matrix stones, such as urinary tract infections and renal insufficiency, we identified smoking as another possible risk factor. Long-term antimicrobial prophylaxis was used in only 1 patient and thus does not seem necessary for prevention of recurrence. Conclusions Matrix stone treatment with percutaneous nephrostolithotomy is durable and should remain the treatment modality of choice.