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Background: No evidence currently exists characterising global outcomes following major cancer surgery, including esophageal cancer. Therefore, this study aimed to characterise impact of high income countries (HIC) versus low and middle income countries (LMIC) on the outcomes following esophagectomy for esophageal cancer.Method: This international multi-center prospective study across 137 hospitals in 41 countries included patients who underwent an esophagectomy for esophageal cancer, with 90-day follow-up. The main explanatory variable was country income, defined according to the World Bank Data classification. The primary outcome was 90-day postoperative mortality, and secondary outcomes were composite leaks (anastomotic leak or conduit necrosis) and major complications (Clavien-Dindo Grade III - V). Multivariable generalized estimating equation models were used to produce adjusted odds ratios (ORs) and 95% confidence intervals (CI95%).Results: Between April 2018 to December 2018, 2247 patients were included. Patients from HIC were more significantly older, with higher ASA grade, and more advanced tumors. Patients from LMIC had almost three-fold increase in 90-day mortality, compared to HIC (9.4% vs 3.7%, p < 0.001). On adjusted analysis, LMIC were independently associated with higher 90-day mortality (OR: 2.31, CI95%: 1.17-4.55, p = 0.015). However, LMIC were not independently associated with higher rates of anastomotic leaks (OR: 1.06, CI95%: 0.57-1.99, p = 0.9) or major complications (OR: 0.85, CI95%: 0.54-1.32, p = 0.5), compared to HIC.Conclusion: Resections in LMIC were independently associated with higher 90-day postoperative mortality, likely reflecting a failure to rescue of these patients following esophagectomy, despite similar composite anastomotic leaks and major complication rates to HIC. These findings warrant further research, to identify potential issues and solutions to improve global outcomes following esophagectomy for cancer.

Endothelial injury and microvascular/macrovascular thrombosis are common pathophysiological features of coronavirus disease-2019 (COVID-19). However, the optimal thromboprophylactic regimens remain unknown across the spectrum of illness severity of COVID-19. A variety of antithrombotic agents, doses, and durations of therapy are being assessed in ongoing randomized controlled trials (RCTs) that focus on outpatients, hospitalized patients in medical wards, and patients critically ill with COVID-19. This paper provides a perspective of the ongoing or completed RCTs related to antithrombotic strategies used in COVID-19, the opportunities and challenges for the clinical trial enterprise, and areas of existing knowledge, as well as data gaps that may motivate the design of future RCTs.

ObjectivesThe study evaluates the plausibility and applicability of prediction, pattern recognition and modelling of complications post-endovascular aneurysm repair (EVAR) by artificial intelligence for more accurate surveillance in practice.MethodsA single-centre prospective data collection on ( n = 250) EVAR cases with n = 26 preoperative attributes (factors) on endpoint of endoleak (types I–VI), occlusion, migration and mortality over a 13-year period was conducted. In addition to the traditional statistical analysis, data was subjected to machine learning algorithm through artificial neural network. The predictive accuracy (specificity and –1 sensitivity) on each endpoint is presented with percentage and receiver operative curve. The pattern recognition and model classification were conducted using discriminate analysis, decision tree, logistic regression, naive Bayes and support vector machines, and the best fit model was deployed for pattern recognition and modelling.ResultsThe accuracy of the training, validation and predictive ability of artificial neural network in detection of endoleak type I was 95, 96 and 94%, type II (94, 83, 90 and 82%) and type III was 96, 94 and 96%, respectively. Endpoints are associated with increase in weights through predictive modeling that were not detected through statistical analytics. The overall accuracy of the model was >86%.ConclusionThe study highlights the applicability, accuracy and reliability of artificial intelligence in the detection of adverse outcomes post-EVAR for an accurate surveillance stratification.

Laparoscopic total gastrectomy is on the rise. One of the most technically demanding steps of the approach is the construction of esophago-jejunal anastomosis. Several laparoscopic anastomotic techniques have been described, like linear stapler side-to-side or circular stapler end-to-side anastomosis, limited data exist regarding hand-sewn esophago-jejunal anastomosis. The study took place between January 2018 and June 2021. Patients enrolled in this study were adults with proximal gastric or esophago-gastric junction Siewert type III tumors that underwent 3D-assisted laparoscopic total gastrectomy. A hand-sewn esophago-jejunal anastomosis was performed in all cases laparoscopically. Forty consecutive cases were performed during the study period. Median anastomotic suturing time was 55 min, with intra-operative methylene blue leak test being negative in all cases. Median operating time was 240 min, and there were no conversions to open. The anastomotic leak rate and postoperative stricture rate were zero. The 30- and 90-day mortality rates were zero. Laparoscopic manual esophago-jejunal anastomosis utilizing a 3D platform in total gastrectomy for cancer can be performed with excellent outcomes regarding anastomotic leak and stricture rate. This anastomotic approach, although technically challenging, is safe and reproducible, with prominent results that can be disseminated in the surgical community.

Background/aim Circumferential resection margin involvement is an independent prognostic factor in patients with adenocarcinoma of the distal esophagus and esophago-gastric junction. However, there is currently no consensus on the extent and the technique of hiatal dissection. We describe a minimally invasive technique of circumferential hiatal dissection for adenocarcinoma of the distal esophagus and esophago-gastric junction with its related histopathological results. Patients and methods A prospective study of 40 consecutive patients undergoing hybrid (laparoscopic/thoracotomic) or totally minimally invasive Ivor-Lewis esophagogastrectomy over a period of 21 months was conducted. Dissection of the hiatus included peri-esophageal surrounding tissues in a cylindrical fashion maximizing the distance from the oesophageal wall. Crural muscle fibers and pleura bilaterally, pericardial fat anteriorly and pre-aortic tissue posteriorly were excised en bloc. Histopathological results particularly focused on involvement of the circumferential resection margin. Neoadjuvant chemotherapy was given to 24 (60%) patients. Results Complete histological clearance (R0) was achieved in 92.5% (n=37) according to the criteria of the College of American Pathologists and in 87.5% (n=35) according to those of the Royal College of Pathologists. In pT3 tumors (n=22), the circumferential resection margin was negative in 20 patients (91%) according to the College of American Pathologists, and in 17 (77%) according to the Royal College of Pathologists. Conclusion Adoption of this safe and reproducible technique might reduce the incidence of circumferential resection margin involvement and improve pathological outcomes. In addition, there may be positive implications for training and quality control.

Objective: The aim of this study is to examine the application of virtual artificial intelligence (AI) in the prediction of functional maturation (FM) and pattern recognition of factors in autogenous radiocephalic arteriovenous fistula (RCAVF) formation. Materials and Methods: A prospective database of 266 individuals over a four-year period with n=10 variables were used to train, validate and test an artificial neural network (ANN). The ANN was constructed to create a predictive model and evaluate the impact of variables on the endpoint of FM. Results: The overall accuracy of the training, validation, testing and all data on each output matrix at detecting FM was 86.4%, 82.5%, 77.5% and 84.5%, respectively. The results corresponded with their area under the curve for each output matrix at best sensitivity and at 1-specificity with the log-rank test p89%). AI has the ability of predicting with a high grade of accuracy FM and recognising patterns that influence it. Conclusion: AI is a replicable tool that could remain up to date and flexible to ongoing deep learning with further data feed ensuring substantial enhancement in its accuracy. AI could serve as a clinical decision-making tool and its application in vascular access requires further evaluation.

Objective UK national guidelines recommend pancreatic enzyme replacement therapy (PERT) in pancreatic cancer. Over 80% of pancreatic cancers are unresectable and managed in non-surgical units. The aim was to assess variation in PERT prescribing, determine factors associated with its use and identify potential actions to improve prescription rates. Design RICOCHET was a national prospective audit of malignant pancreatic, peri-ampullary lesions or malignant biliary obstruction between April and August 2018. This analysis focuses on pancreatic cancer patients and is reported to STROBE guidelines. Multivariable regression analysis was undertaken to assess factors associated with PERT prescribing. Results Rates of PERT prescribing varied among the 1350 patients included. 74.4% of patients with potentially resectable disease were prescribed PERT compared to 45.3% with unresectable disease. PERT prescription varied across surgical hospitals but high prescribing rates did not disseminate out to the respective referring network. PERT prescription appeared to be related to the treatment aim for the patient and the amount of clinician contact a patient has. PERT prescription in potentially resectable patients was positively associated with dietitian referral (p = 0.001) and management at hepaticopancreaticobiliary (p = 0.049) or pancreatic unit (p = 0.009). Prescription in unresectable patients also had a negative association with Charlson comorbidity score 5–7 (p = 0.045) or >7 (p = 0.010) and a positive association with clinical nurse specialist review (p = 0.028). Conclusion Despite national guidance, wide variation and under-treatment with PERT exists. Given that most patients with pancreatic cancer have unresectable disease and are treated in non-surgical hospitals, where prescribing is lowest, strategies to disseminate best practice and overcome barriers to prescribing are urgently required.

Objective It has been hypothesized that a novel measurement technique of arteriovenous ratio (AVR) index obtained from inflow (radial artery diameter) to that of outflow (cephalic vein diameter) and its application through the Bernoulli effect has no impact on the primary functional maturation (FM) of autogenous radiocephalic arteriovenous fistula (RCAVF). Methods A prospective consecutive single-center cohort study with intention to treat of 324 patients undergoing RCAVF during a period of 4 years was conducted. Variables of demographics, anatomic factors, laterality, comorbidities, anesthesia type, presence of intraoperative thrill, angle of anastomosis, and AVR index were assessed through univariate and multivariate logistic regression analysis on the end point of FM. The AVR was subjected to three decimal points to ensure maximal accuracy for best sensitivity and 1 − specificity by receiver operating characteristic curve. The χ 2 (subgroup) analyses were undertaken to investigate the differences in FM incidence within different ranges of AVR. Test of probability ( P value) was considered to be significant with P Results Among all variables, the AVR index remained the only independent factor associated with FM (66%; n = 214/324) of RCAVFs ( P = .001; 95% confidence interval, 0.08-0.26). AVR of 1 to 1.06 was associated with 100% FM in RCAVFs. Decrease or increase of this index was associated with stepwise reduction in FM of RCAVFs ( P Conclusions The suggested novel measurement technique (AVR index) is an independent predictor of FM in RCAVFs. This study implies that minimal diameter (ie, inflow artery dimeter to outflow cephalic vein diameter) mismatch (AVR, 1-1.06) irrespective of other variables remains crucial for optimal hemodynamics (pressure and velocity) of RACVFs and their primary FM.

Background: Esophagectomy in situs inversus is challenging. With long-segment supercharged reconstruction, it becomes more perplexing and multidisciplinary surgical skills are needed. Challenges met and the surgical technique used is presented in this case report. Methods: The case of a 49-year old patient with situs inversus abdominus and a locally advanced distal esophageal adenocarcinoma extending to the stomach is presented. Results: Following neoadjuvant chemotherapy and due to inability to use the stomach as a conduit, a thoracoscopic total esophagogastrectomy with long-segment reconstruction was performed. The conduit used was the left colon and was supercharged with venous and arterial anastomoses in the neck. Conduit perfusion, as assessed by the Spy system revealed marked improvement post supercharging. No anastomotic leak was noted and oral diet was started on day 4. On day 26 the patient developed pneumonia necessitating intubation that was declined. Organ support was withheld with patient death at day 29. Conclusion: In long-segment esophageal reconstruction with supercharged colon, although thoracoscopy is feasible, laparoscopy is found unsafe. Careful preoperative planning and colon assessment via computed tomography(CT) colonography/angiography and a multidisciplinary team approach is recommended. Adjuncts to assess conduit perfusion like the Spy system are helpful. Supercharging the long colonic conduit is a way of minimizing ischemia-related complications.

The aim of this systematic review is to establish the efficacy of revision using distal inflow (RUDI) on the primary endpoints of complete dialysis access steal syndrome (DASS) resolution and arteriovenous fistula (AVF) longevity. An electronic search of literature from 1966 to 2017 in CINAHL, Medline, Embase and the Cochrane library according to PRISMA standards was conducted. Quality evaluations and recommendations for practice were examined. Data on power, age, gender, comorbidities, arterial inflow, conduit material, fistulae type, follow-up, failure incidence, ischaemia grade, modality of diagnosis, morbidity and mortality were subjected to pooled analysis of prevalence at a 95% confidence interval (CI). Eleven studies involving 130 individuals with a median age of 57 [interquartile ranges (IQR), 54-65] and equal gender distribution were conducted. Of the patients with diabetes mellitus (67.3%), the most common type of AVF with DASS was brachiocephalic AVF (73.7%). Overall, the prevalence of success was 82.0% (95%CI, 74.4%-89.6%) over 12 months (IQR, 1-40 months). Grade 3 ischaemia was the most common type of DASS (49.2%). Grade 4 had the worst outcomes compared with grades 2 and 3. The overall morbidity was 3% with no mortality. Overall, RUDI is an effective treatment for various grades of DASS and their longevity.

Introduction The objective of this study is to test the null hypothesis that an S-shaped surgical incision versus conventional (straight) skin incision in the creation of autogenous radiocephalic arteriovenous fistulas (RCAVFs) have no impact on the primary end-point of primary functional maturation and secondary end points of stenosis and thrombosis. Methods A prospective observational comparative consecutive study with intention-to-treat on individuals undergoing only radiocephalic arteriovenous fistula (RCAVFs) over a period of 12 months was conducted. Variables on patient's demographics, comorbidities, anesthesia type, mean arterial blood pressure, thrill, laterality, cephalic vein and radial artery diameter were collated. The test of probability was assessed through Chi-Square, Kaplan-Meier survival estimator and Log-Rank analysis. Results Total of n = 83 individuals with median age of 67 years (IQR, 20–89) and male predominance 83% during this period were subjected to RCAVF formation. Total of n = 45 patients in straight skin incision were compared to n = 38 individuals in S-shaped group. Despite equal prevalence of demographics, comorbidities, anesthesia type, mean arterial blood pressure (MAP), thrill, laterality, cephalic vein and radial artery diameter (p > 0.05) higher incidence of juxta-anastomotic stenosis was noted in the straight skin incision group (p = 0.029) in comparative and survival analysis (Log-Rank, p = 0.036). The maturation of the entire cohort was 69% (S-shaped 76% vs. straight group 62%) (p > 0.05). Conclusion The outcome of this study demonstrates that S-shaped surgical skin incision is associated with a lower incidence of stenosis in comparison to straight incision type in RCAVF formation., Highlights • S-shaped skin incision is an alternative to the conventional skin incision for creation of radiocephalic arteriovenous fistula (RCAVF). • This approach permits better exposure for both vessels and minimise the need for extensive mobilisation of cephalic vein. • S-shaped skin incision is associated with lower incidence of stenosis within the maturation period.

The aim of this study was to evaluate the collective and/or independent impact of patient demographics, comorbidities, anatomical factors, and peri-operative parameters on the primary functional maturation of RCAVFs. This study also aimed to identify the range and best cut off value for each variable and evaluate the likelihood, significance and percentage of primary functional maturation of RCAVFs.This was a prospective consecutive single centre cohort study over a 4 year period; it was conducted on patients with the intention-to-treat using a radiocephalic arteriovenous fistula (RCAVF) (Brescia-Cimino). During this period 548 vascular access procedures, inclusive of RCAVF, were performed. Variables included patient demographics (age, gender), anatomical variance (cephalic vein, radial artery diameter, laterality), comorbidities (diabetes mellitus, ischaemic heart disease, congestive cardiac failure, hypertension), aetiology of renal failure, and anaesthesia type (local versus general anaesthesia).Of the total, 324 patients, cephalic vein diameter1.5 mm (OR 4.57, 95% CI, 2.42-8.63, p .001) (non-augmented) and radial artery diameter 1.6 mm (OR 12.26, 95% CI, 6.27-23.97, p .001) were found to be independently associated with the primary functional maturation of 86% in the RCAVF formation.Of all the variables, cephalic vein and radial artery diameter are independently associated with the primary functional maturation of RCAVFs.

INTRODUCTION Oesophagectomy for oesophageal carcinoma carries a high risk of significant morbidity and mortality. Delayed gastric emptying is a relatively common complication following this procedure. A variety of medical, surgical and endoscopic strategies have been described to manage it. The vast majority of cases are related to post-operative pyloric dysfunction and are amenable to conventional management strategies. PATIENTS AND METHODS We present a new case of a patient with a duodenal hiatus hernia resulting in extrinsic gastroduodenal compression by the massively distended gastric conduit as a cause of gastric outlet obstruction following laparoscopic-assisted Ivor-Lewis oesophagectomy 2 years previously. RESULTS AND CONCLUSIONS Surgical repair of the hiatus hernia restored the post-oesophagectomy anatomy and resolved this patient's symptoms where conventional management of post-oesophagectomy gastric outlet obstruction had failed on multiple occasions. Most cases of delayed gastric emptying post-oesophagectomy occur as a result of pyloric dysfunction and can be managed using a combination of prokinetics, surgical intervention or more commonly, endoscopic dilatation. Other potential causes and therefore investigative and management strategies should be considered in patients who repeatedly fail conventional management. We offer an alternative diagnosis that may be considered in these patients and present a novel approach to their investigation and management.

BACKGROUND/AIM Surgical resection for esophageal cancer has remained the gold-standard therapy provided worldwide. Subcarinal lymph-nodes are classified as peri-esophageal nodes and their dissection may be performed during a 2- or 3-stage esophagectomy. The necessity and prognostic value of subcarinal lymphadenectomy is still debatable. The purpose of this study was to investigate the rate of invaded subcarinal lymph-nodes out of the total lymph-nodes resected. Detection of invaded nodes was correlated with clinical staging and tumor differentiation. PATIENTS AND METHODS This is a retrospective analysis of consecutive esophagectomies for cancer, performed in a UK tertiary center. The study was conducted over a 3-year period. RESULTS The rate of subcarinal lymph-node invasion was extremely low according to the results of our analysis. CONCLUSION Lymphadenectomy is not devoid of clinical impact on patients and therefore, the decision should actually be the outcome of a dynamic balance between complications and survival benefit.

Objective Visceral artery aneurysms as a result of arterial degenerative disease are rare (0.1%-2%), and the superior mesenteric artery (SMA) accounts for 3.2% of all reported series. The current incidence of inferior mesenteric artery (IMA) aneurysm is unknown. However, infective causes (mycotic) of SMA and IMA aneurysm as a result of primary, secondary, and cryptogenic etiology remain a separate entity and attain fewer cases in the literature. Currently, there is no consensus on their presentation, diagnosis, and overall management. Methods A systematic review and meta-aggregation of literature from 1944 to March 2015 in the English language and of adult subjects in MEDLINE, Ovid, CINAHL, and the Cochrane database was conducted. Results The median age of patients with SMA aneurysm was 36 (range, 14-92) years, with a significant male predominance (73% vs 27%). In order of prevalence, abdominal pain (n = 25; 65%), low-grade fever (n = 23; 60%), malaise (n = 10; 26%), weight loss (n = 9; 23%), and nausea and vomiting (n = 8; 20%) were the most common presenting signs and symptoms. The most common microorganism was Streptococcus (n = 18; 47%), followed by Staphylococcus (n = 11; 28%). The investigative modality of choice was computed tomography (n = 22; 57.8%), followed by ultrasonography of the abdomen (n = 9; 23%). Primary etiology was noted in 5.4%, secondary in 71%, and cryptogenic in 13% of all cases. Aneurysmectomy alone was associated with bowel resection in four cases (10.5%), whereas aneurysmectomy with interposition vein grafting required no further intervention. The inpatient mortality after surgery was 7.8%, and the overall mortality was 15%. The median follow-up was 12 months (range, 2-120 months). The median age of patients with IMA aneurysm was 48 (range, 22-64) years, with a male predominance of 2:1 and abdominal pain in all cases (n = 3; 100%). The most common microorganism was Streptococcus (n = 2; 66.6%), and the operation of choice was aneurysmectomy (n = 2; 66.6%) after computed tomography scan (n = 3; 100%) as an investigative modality of choice. Conclusions The pentad of abdominal pain, pyrexia of unknown origin, malaise, weight loss, and nausea remains the most convincing presentation of mycotic aneurysms of the SMA and IMA. Computed tomography is the investigative modality of choice, and such patients are best served with aneurysmectomy alone in IMA aneurysms and interposition vein grafting in SMA aneurysms after initiation of antimicrobial therapy on suspicion of the diagnosis.

Background Hem-o-lok clips are widely deployed in various laparoscopic and robotic operations. Their migration is not very common and majority of reported cases are limited to biliary, prostatic and vesico-urethral cases. Methods Herein, we would like to report the first case of transmural migration of Hem-o-lok clip from azygous vein stump following totally minimally invasive two-stage oesophagectomy for squamous cell carcinoma of the distal oesophagus, into the gastric conduit 3-months following uneventful discharge. The patient presented with 5-days history of worsening dysphagia. Results The subsequent gastroscopy revealed normal gastric conduit with two Hem-o-lok clips containing the azygous vein stump within its lumen at the level of the oesophago-gastric anastomosis, propagating a food bolus obstruction. The foreign body was successfully removed and the patient was discharged the same day without any complications at 5 months follow up. Conclusion Hem-o-lok clip migration trends to be a well-established event. However, their mechanism and exact incidence remains elusive to this date. To the best of our knowledge, their migration in oesophageal cancer surgery has not been reported.

Objective Vascular access-induced ischemia remains a rare but significant complication of arteriovenous fistulas. Distal revascularization and interval ligation (DRIL) is one form of treatment. However, its collated efficacy through a systematic review is yet to be established. Methods An electronic and systematic search of the literature in MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Embase, and Cochrane Library from 1966 to 2017 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted. Quality assessment of the articles was performed using the Oxford Critical Appraisal Skills Programme, and the recommendation for practice was examined through the National Institute for Health and Care Excellence. Data of treated cases, success, time to ischemia, follow-up, age, sex, diabetes mellitus, fistula type, conduit type, and grade of ischemia were extracted and subjected to a pooled variance-weighted random-effects model. Results Twenty-two studies (n = 459 individuals) were subjected to DRIL. Time to ischemia was 196 days (interquartile range, 30-600 days). Ischemia grade 3/4 (52%) was the most common presentation. The overall success (grades 1-4) was 81% (95% confidence interval, 80.9%-82.5%) during a mean and median follow-up of 22.2 months (interquartile range, 1-60 months) and 18 months, respectively. The conduit of choice was the great saphenous vein (n = 300/459 [65%]), and bypass thrombosis was highest in the polytetrafluoroethylene group (n = 19/44 [43%]). Conclusions DRIL with adequate long-term outcomes is an effective technique for the treatment of vascular access-induced ischemia.

Introduction Despite ongoing research currently, there is no well-defined strategy in inhibition of sub interventional and small abdominal aortic aneurysm (AAA) progression. Therefore, the objective of this is to identify factors associated with AAA growth and suggested a therapeutic regimen for their inhibition. Material and methods An electronic search of Medline from 1966 to January 2015 in English and adult subjected using the following mesh terms: abdominal aortic aneurysm growth and/or risk factors and/or genetic predisposition, abdominal aortic aneurysm and/or sac expansion and/or risk factors was performed. After application of inclusion criterion 21 articles were retrieved and discussed in this review. Conclusion Antibiotics, statins, anti-inflammatory agents, selenium, vitamin D (25-hydroxyvitamin D), ace-inhibitors, smoking cessation and well-controlled COPD inhibit AAA growth. Other novel therapies could aid in regression of AAA in future and their long-term results are awaited.

Purpose The aim of this study is to determine the optimal range of cephalic vein and radial artery diameter following preoperative duplex imaging to enhance maturation and primary patency of Brescia-Cimino radiocephalic arteriovenous fistula. Methods A systematic review and meta-aggregation of literature from 1966 to January 2015 in English language and adult subjects in Pubmed, OVID, CINHAL and Cochrane database was conducted. Results This search produced a total of thirty-six (n = 36) articles. Following the application of recruitment criteria, only twelve articles (n = 12) were found eligible. Their quality was assessed by Oxford Critical Appraisal skills Programme (CASP) and their recommendation for practice was examined through National Institute for Health and Care Excellence (NICE). Conclusions The current literature suggests that the optimal range of radial artery for maximum performance (maturation and primary patency) of RCAVF is at least 2 mm (level 2, grade a). The cephalic vein diameter of at least 2 mm (non-augmented) can result in best maturation and primary patency outcomes (level 2, grade a) and threshold below 1.5 mm is not advocated (level 2, grade b).

Lipomas of gastrointestinal (GI) tract could occur at any anatomical level and represent 1–2% of all GI tumours. Amongst them

Introduction: The benefit of intermittent pneumatic compression (IPC) for the prevention of venous thromboembolism and lymphedema has been well established in the literature. Recent evidence suggests that IPC plays a beneficial role in circulation, hemodynamic peripheral pump, intravascular coagulation and arterial skin perfusion. Despite such evidence, the use of IPC in the treatment of resistant and chronic venous leg ulcers, has received little attention in practice. Case Presentation: We would like to report the case of successfully treated chronic and bilateral venous leg ulcer in an obese patient with IPC application and a review of the literature. Results: The use of IPC as an adjuvant therapy to the traditional multilayered compression therapy permitted significant resolution of the ulcers, reduced secondary infection incidence and prevented ulcer recurrence. Conclusion: In obese, minimally mobile patients with venous ulcers not responding to the traditional multilayered compression therapy application of IPC, an adjuvant therapy is recommended.

Introduction To test the null hypothesis that the proposed abdominal aortic aneurysm (AAA) dilation ratio (AADR) obtained by dividing the widest diameter of the infra-renal AAA by the immediate native (normal) infra-renal aorta in millimetres, fails to provide accurate information about the risk of rupture in the female population, small or various sizes of infra-renal AAAs. Methods A retrospective study of 112 patients that underwent an infra-renal AAA repair on elective, urgent and or immediate basis with prior computed tomography angiogram (CTA) or computed tomography (CT). Results The mean AADR was 2.3 for asymptomatic group ( n =73) and 3.3 for symptomatic group ( n =28) ( p n =14) and 3.78 for the ruptured group ( n =14) ( p Conclusion Study suggests a lower threshold for female population that do not meet the interventional size. AADR≤2.8 could be a reasonable criteria for intervention irrespective of the aneurysm size. AADR can assist in doubtful or borderline scenarios, especially during the management of symptomatic patients as higher AADR>2.8 warrants an immediate operation. Finally, the AADR can be important in less privileged centres where ultrasonography (USS) and not repeated CT scan is permissible.

Purpose The aim of this study is to examine the efficacy of normal saline (0.9% sodium chloride) as a flush solution on patency of arterial lines in comparison to heparin flush. Data have been examined in various categories of specialty (medical, surgical, cardiac, burns, gynecology), frequency of flushes, strength and volume of flushes, continuous versus bolus, duration of each flush and patency incidence (range, ≤24 to ≥96 hours). The secondary aim focused on the incidences of reported heparin-induced thrombocytopenia (HIT type I and II). Methods A comprehensive review of the literature from 1951 to 2012. An electronic search of OVID, Medline, Embase, Cochrane, Scopus and CINAHL database in English language was conducted. The search was limited to adult subjects only. The following keywords were used: heparin flush, saline flush, 0.9% sodium chloride flush, arterial line and indwelling vascular line. A total of ten papers (n=10) were found eligible. Results The evidence suggests patency is feasible with both solutions but if longer duration of use (arterial line) is advocated, heparin is superior in the long term. Furthermore, heparin flush effects are dose dependent and require fewer numbers of flushes. In addition, no adverse effects were found with heparin flush solution. Conclusion There is level 1 evidence to support heparin as a flush solution once the time frame exceeds 48 hours. In addition, there is level 1 evidence to suggest that heparin at higher doses and in continuous infusion has better patency incidence with no reports of HIT type II or I.

Introduction Various studies have suggested seasonal and monthly atmospheric pressure correlation to Abdominal Aortic Aneurysm (AAA) rupture frequencies. However, such correlation to monthly/seasonal temperature and its alteration has never been studied directly. The objective of this study is to demonstrate whether temperature and its alteration are indeed associated with incidences of infra-renal AAA rupture. Patients and methods A total of 50 (n=50) ruptured AAA over a 5-year period were recruited. Local meteorological data on temperature were obtained from UK Meteorological Office. Results The p value ( Conclusion The findings appear to confirm that temperature alteration on monthly/seasonal basis has no impact on AAA rupture incidences.

Gastric banding is a popular method for the treatment of morbid obesity. Amongst complications, gastric erosion remains uncommon but could prove fatal. Multiple techniques, from open surgery to endoscopic and standard laparoscopic technique for their removal, have been previously detailed in the literature. However, only a few reports have mentioned their total laparoscopic transgastric removal in the literature. Herein, we report a successful removal of an eroding gastric band with its technical suggestion in a 43-year-old female patient 22 months following its application.

Two-stage minimally invasive esophagectomy (MIE) has gained popularity in the surgical treatment of esophageal cancer. MIE’s limitation is embedded in the construction of intrathoracic anastomosis. Various anastomotic techniques have been reported; however, the mechanical one remains the most commonly adopted. This pilot study aims to describe an efficient, safe, and reproducible way of performing a hand-sewn intrathoracic esophagogastric anastomosis in conjunction with short-term results using 2D and 3D thoracoscopic approaches. A total of n = 13 patients (mean age 67.4) underwent MIE for distal esophageal or gastroesophageal junction adenocarcinoma between January and September 2016. Resection was performed in prone position, and the esophagogastric anastomosis was constructed in an end-to-side manner in two layers with barbed knotless suture. A 2D thoracoscopic approach was used in n = 10 patients (77%) and a 3D approach in n = 3 (23%). n = 8 patients (61.5%) had neo-adjuvant chemotherapy and n = 5 (38.5%) had primary surgery. The mean operating time was 420 min, and the average length of stay was 10 days with no associated mortality. n = 1 (7.7%) developed a radiological leak that did not require an intervention. Thoracoscopic approach with the glasses-based 3D optical system using the angulating-tip 100° camera provided a far superior view for precise lymphadenectomy in combination to an efficient and safe construction of the anastomosis. The barbed knotless suturing technique in MIE is an efficient and safe method of constructing the esophagogastric anastomosis with promising short-term outcomes. A 3D thoracoscopic approach appears to be superior in performing the anastomosis to that of a 2D technique.

Description This is a video of a hand-sewn 2-layer end-to-side intra-thoracic esophago-gastric anastomosis performed thoracoscopically during a totally minimally invasive 2-stage esophagectomy for cancer. The suture material used is the barbed V-Lock. We routine perform this anastomosis in all 2-stage minimally invasive esophagectomies in our Unit since 2016. We have performed about 50 consecutive esophagectomies with this anastomosis with Disclosure All authors have declared no conflicts of interest.

The aim of this study is to establish the nature (urgent vs. non-urgent), demographics, presentation and management of Achenbach’s syndrome and to formulate an algorithmic approach for their diagnosis and management. A systematic review and met-aggregation of literature from 1944 to 2015 in English language in MedLine, Embase and Cochrane database were conducted. Achenbach’s syndrome is a female-dominant disease with median age of 49.5 years (range 22–76) (age ≤60, n = 11/12, 91 %). It presents with unilateral volar discoloration of a finger (100 %). It is associated with pain (n = 7/12, 58. %), edema (n = 7/12, 58 %), and paresthesia (n = 3/12, 25 %). The median time to resolution of symptoms without any intervention was 4 days (range 2–14). AS is self-limiting and a non-urgent surgical condition. It can be differentiated from other pathologies by clinical spectrum, patient demographics and in doubtful circumstances (acute limb ischemia) by Doppler sonography. An algorithmic approach can avoid hospital admissions, partially unnecessary investigation and assist in patient assurance.

INTRODUCTIONTraumatic abdominal wall hernias (TAWHs) are uncommon and to date less than 50 cases have been reported in the literature. Furthermore mesenteric avulsion is a rare complication of TAWHs and occurs in less than 5% of all cases.PRESENTATION OF CASEA 47-year-old lady presented to the emergency department after a road traffic accident. In spite of seat belt use and airbag deployment, the patient presented with a visible left paramedian abdominal mass, which was tender and irreducible on examination. Subsequent computed tomography (CT) of the abdomen confirmed herniation of the small bowel with no free air or fluid in an otherwise stable patient. Intra-operative findings confirmed mesenteric avulsion and bowel necrosis.DISCUSSIONThe role of emergency or elective repair of TAWHs remains unclear. As 58% of blunt mesenteric and bowel injuries due to avulsion are missed on initial work-up, it is advisable for clinicians to balance the risk of unnecessary and non-therapeutic emergency laparotomy with the morbidity and mortality associated with delay in diagnosis.CONCLUSIONMesenteric avulsion in TAWH is rare and difficult to diagnose and a high index of suspicion is warranted despite normal findings on initial assessments.

The aim of this study is to establish the biomechanics, presentation and diagnosis of mesenteric avulsions following blunt abdominal trauma and reach a consensus on their overall management. A systematic review of literature in MedLine, Embase, Scopus and CINHAL in English language from 1951 to November 2014 was performed. A total of 20 reported cases were identified. Variables including patient’s demographics, signs and symptoms, mechanism of injury, investigative modality, management, length of stay, follow-up and outcomes were reviewed and analyzed. The median age of the cohort was 28.5 years (range 10–58 years), with a male-to-female ratio of 3:1. The commonest mechanism of injury was road traffic accident due to seat belt restraint (n = 12, 60 %). The commonest presentation was diffuse abdominal tenderness (n = 10, 45 %) followed by ecchymosis/bruising (n = 9, 40 %). Computed tomography (CT) remained the investigative modality of choice (n = 9, 45 %). All cases had an emergency exploratory laparotomy (n = 18, 90 %) within the initial 24 h and the median length of stay was 19 days (range 4–90 days). The overall mortality was 15 % (n = 3). Mesenteric avulsion is rare and has a complex and vague presentation. Due to its potential mortality and morbidity, emergency physicians should keep a high index of suspicion in individuals with blunt abdominal trauma from any mechanism of injury.

IntroductionVanek's tumour or Inflammatory Fibroid Polyp (IFP) are rare, benign localised lesions originating from the sub-mucosa of the gastrointestinal tract (GI) tract.1 They have been widely reported as occurring within the stomach, Duodenum, Jejunum and Ileum, more rarely (

Background In recent years the role of neutrophil to lymphocyte ratio (NLR) as an independent predictor of mortality and morbidity has gained significant attention in colorectal, upper gastrointestinal and cancer surgery. To date, no study has examined this in ruptured abdominal aortic aneurysms (rAAAs). This study aims to assess the role of NLR as a prognostic marker of 30-day (30d) morbidity and mortality in patients undergoing repair of rAAAs. Methods Data from 80 consecutive patients with a diagnosis of rAAAs from November 2007 to June 2014 were included. Receiver operating characteristic curve analysis was used to identify the optimal value for NLR in relation to 30d mortality and morbidity. Univariate and multivariate logistic regression analysis were used to determine the role of NLR after stratification by several clinical factors. Results 25 patients (31.2%) had a low NLR (LNLR) and 55 patients (68.8%) had a high NLR (HNLR). Elevated NLR was significantly associated with low Hemoglobin and it was not associated with gender, age, AAA Size, history of HTN, COPD, smoking and renal failure. Patients with HNLR had higher 30d morbidity compared with the LNLR group (35 vs. 6 p = 0.001) but no difference in intraoperative blood loss, length of hospital, ITU stay and 30d mortality. High NLR through multivariate analysis was an independent prognostic factor for 30d morbidity [OR = 4.28, 95% (1.27–14.42), p = 0.02]. Conclusion A preoperative NLR >5 is an independent predictive marker of 30d morbidity in rAAAs. This appears to be in line with earlier literature demonstrating similar outcome in the elective group of abdominal aortic aneurysm.

Purpose The purpose of this study is to investigate the pathogenesis, presentation and diagnosis of donor artery aneurysm formation following arteriovenous fistula (AVF) ligation and reach a consensus on their management. Methods A systematic review of literature in Ovid, MedLine, Embase, Scopus and CINHAL in the English language from 1951 to 2014 was performed. This was accompanied by two case reports. A total of 12 articles with 23 case reports were identified. Variables including patient's demographics, signs, symptoms, fistula type, duration of fistula use, time to aneurysm formation, renal transplantation, diagnostic modality, aneurysm type and size, type of surgery and outcome were reviewed. Results The data demonstrate a male predominance (5:1) and a median age of 47 years (range, 27-75 years). The median duration of access was 54 months (range, 6-300 months). The median time from ligation to aneurysm was 120 months (range, 6-280 months). The commonest aneurysm was of the brachial artery (BA, n = 21, 84%). The commonest type of AVF was radiocephalic (n = 15, 60%) followed by brachiocephalic AVF (n = 9, 36%). The management of choice was aneurysmectomy followed by interposition vein grafting (n = 12, 50%) with a median reported patency of 12 months (range, 1-38 months). This was followed by polytetrafluoroethylene (PTFE) grafting (n = 6, 25%) with a median reported patency of 6 months (range, 1-48 months). Conclusions The pathogenesis of donor artery aneurysms remains contentious. This review suggests that duplex is the investigative modality of choice and aneurysmectomy with interposition grafting is preferred over bypass.

Thrombolysis with tissue plasminogen activator is a well-established treatment for acute ischaemic stroke. We report a case of an 87-year-old woman who developed an acute ischaemic limb, on the background of stroke thrombolysis, and underwent an embolectomy. A rare but serious complication, there are few reports of similar thromboembolic events, particularly in patients with known atrial fibrillation as presented in this case. Early recognition of this rare complication may prevent long-term, and at times fatal, complications.

Dear Colleagues,Thank you for your interest in our recent article [1,2]. We wouldliketoagreewithourcolleaguesthatthereisaconflictingdegreeofevidence explaining the causal correlation of atmospheric pressure(AP) and rupture incidences of abdominal aortic aneurysm (AAA)worldwide. In our review we only focused on the UK metrologicalAP variationsandderived ata conclusionrecommended forthis re-gion due the following factors: Firstly, the atmospheric pressureand its subsequentalteration is subjected toaltitude and this variesfrom one country to another [3]. In addition, AP is not uniformacrossthecountriesandvariesfrom980 mBto1050mBdependingon the metrological divisions of the globe where AP and its differ-ence are significant (equatorial low-pressure, subtropical highpressure). Secondly, United Kingdom in particular is subjected torecurring low-pressure weather systems know as depressions ascompared to the rest of the European region and is only similarto those in rocky mountains and Tibetan plateaus [4,5]. Therefore,the consistency of the obtained data in our reviewand our analysissuggesting higher incidencesof rupturein loweratmosphericpres-sure seasons and its possible recurrence in UK since 1998 (Table 1.2of the original manuscript) could not be a coincidence despite theirreliance onpostulated hypothesis. In addition, we believe interpre-tation of the results derived from various countries should be incontrast to significance of AP alterations, definition of low or highpressure and in correspondence to the specific region. We alsorevisited our data to assess whether there is a correlation betweenage/gender with ruptured abdominal aortic aneurysm (rAAA) inci-denceatagivenAP.Wefoundnostatisticallysignificantcorrelationbetween age and atmospheric pressure on day of rupture(p ¼ 0.250, p ¼ 0.080) or between age and difference in atmo-spheric pressure on the day of rupture and day before (p ¼ 0.055,p ¼ 0.705). Similarly, gender did not correlate with atmosphericpressureon dayofrupture (p ¼ 0.137,p ¼ 0.343)ordifference in at-mospheric pressure between day of rupture and the day before

Paraumbilical hernia sac usually contains omentum, bowel loop and rarely appendicular epiploicae, metastatic deposits and vermiform appendix. Presentation of acute appendicitis in a paraumbilical hernia is rare and limited to few case reports in the literature. Herein, we would like to report a case of a successfully treated acute appendicitis presenting in a paraumbilical hernia in an 84-year-old lady with 6-month follow-up.

Pseudoaneurysm of the posterior tibial artery (PTA) is uncommon, and they mainly occur following high-velocity trauma, open fractures and can be iatrogenic in nature. To the best of our knowledge, this is the first reported and successfully treated case of PTA pseudoaneurysm identified as a consequence of tibia fracture nonunion in an otherwise healthy young individual 6 months following the original incident with a novel intraoperative technique.

Visceral artery aneurysms as a result of arterial degenerative disease are rare (0.1–2%), and superior mesenteric artery (SMA) accounts for 3.2% of all reported series. However, mycotic SMA aneurysms (SMAAs) are even rarer, and to the best of our knowledge, this is the first report of cryptogenic mycotic aneurysm of SMA by Enterococcus faecalis (EF). We report a case of 77-year-old man with 6-week history of supra pubic/left iliac fossa pain, weight loss and fever. The computed tomography demonstrated an incidental finding of 4.4 × 3-cm SMAA with no primary foci. The subsequent serology and specimen confirmed EF. Aneurysmectomy without bypass grafting along with antimicrobial therapy resulted in full recovery of the patient.

Introduction Gastroparesis is a debilitating disorder of gastric motility resulting in symptoms of nausea, vomiting, bloating and abdominal pain. In non-responders to medical treatment, Gastric Electrical Stimulation (GES) can improve symptoms leading to an improved quality of life. We present our 14-year experience with GES insertion in gastroparetic patients resistant to medical treatment. Method Data was prospectively collected from December 2000 to January 2015 in a local database. Information on patient demographics, pre and post GES insertion scores for nausea, vomiting, satiety, bloating and abdominal pain were collated. Factors such as aetiology of gastroparesis, comorbidities and feeding requirements were also recorded. Data on surgical intervention, complications and number of hospital admissions pre and post GES insertion were also included. Quality of life was assessed by SF-36 questionnaires. Results A total of 104 patients underwent GES insertion (Female 76, Male 28). The median length of stay was seven days (range 1–45 days) and follow up was 42.5 months (6–168 months). There were significant improvements in nausea severity score (p = Conclusion GES improves patient symptoms and quality of life. It reduces health care utilisation by avoiding long-term hospital stays and repeated admissions with a reduction in assisted feeding. The current study shows GES is a safe and an effective procedure in the treatment of refractory gastroparesis. To the best of our knowledge, our presented series is the longest consecutive study in Europe and UK alike. Disclosure of interest None Declared.

Background The aim of this study is to describe a case of ruptured cryptogenic mycotic abdominal aortic aneurysm by Salmonella enteritidis (SE) and present a comprehensive review of the literature. Methods A 66-year-old man with a past medical history of coronary artery bypass graft (CABG) and polymylagia rheumatica (PMR) presented with a 2-day history of right-flank-to-groin pain and fever. He was found to have tenderness on the right of the umbilical region and laboratory data showed leukocytosis, raised C-reactive protein, and a significant drop in hemoglobin level as compared with his first visit 17 days earlier, with no hemodynamic instability. An immediate computed tomography angiogram (CTA) was performed, which showed a 4-cm, fusiform, ruptured infrarenal aortic aneurysm. Exploratory laparatomy was performed and the aorta was isolated and excised from the infrarenal level to the common iliac bificuration. A straight silver Dacron graft soaked in rifampicin was placed with an end-to-end anastomosis. The excised aorta and the lymph nodes were sent for histologic and microbiologic assessment. Results Blood culture and specimen microbiology grew Salmonella enteritidis (SE). The histology exhibited atherosclerosis at the rupture point with decreasing neutrophil deposition from the intima to the adventitia layer, respectively. Conclusions Infrarenal abdominal mycotic aneurysm (MA) by SE was observed and showed vague, nonspecific signs and symptoms. We recommend a high index of suspicion and low threshold for use of CT imaging in any infected patient of age >60 years with fever and abdominal pain on a background of diabetes and connective tissue disease. A comprehensive review of the literature was performed due to a lack of consensus on the best surgical treatment and limited information on the path of SE-induced aortitis or MA from presentation to final outcome.