A rare cause of acute pancreatitis: Percutaneous mechanical rheolytic thrombectomy of deep venous thrombosis.

INTRODUCTION: Percutaneous mechanical rheolytic thrombectomy is an effective treatment option for deep vein thrombosis as well as arterial and graft thromboses. Acute pancreatitis, a rare complication of this technique, is described in this case report. CASE REPORT: A 40-year-old man underwent AngioJet mechanical rheolytic thrombectomy for iliocaval deep vein thrombosis. He subsequently developed acute pancreatitis. This case report outlines the clinical presentation of acute pancreatitis after rheolytic thrombectomy and also discusses the possible pathogenesis and etiological factors.

Adoption of endovenous laser treatment as the primary treatment modality for varicose veins: the Auckland City Hospital experience.

AIM: To assess the effectiveness of adopting endovenous laser treatment (EVLT) as the primary treatment modality for varicose veins at Auckland City Hospital (Auckland, New Zealand). METHODS: The outcomes of 354 consecutive EVLT procedures performed between 2007 and 2013 were reviewed. Data was collected from a prospectively maintained procedural database and by retrospective chart review. RESULTS: Of the 319 patients who had an ultrasound, at 1 month post-procedure there was a saphenous vein occlusion rate of 96%. Side effects were minimal with no cases of DVT or skin burns and one case of self-limiting neuralgia. The procedure was well tolerated with a median pain score of 3. Since the adoption of EVLT there has been a large increase in the number of patients treated for varicose veins (28 in 2007 compared to 176 in 2013). CONCLUSIONS: EVLT is a safe and effective treatment for varicose veins and its adoption has allowed a large increase in the number of varicose vein patients treated at Auckland City Hospital.

Subclavian stump syndrome causing a posterior circulation stroke after thoracic endovascular aneurysm repair (TEVAR) with adjunctive carotid to subclavian bypass and endovascular embolization of the left subclavian artery.

BACKGROUND: Endovascular repair of thoracic aortic pathology has become increasingly common over the last decade. We highlight the case of an intentionally occluded left subclavian artery stump acting as a source of emboli after thoracic endovascular aneurysm repair (TEVAR) for type B dissection. METHODS: A 68-year-old man underwent TEVAR of a type B thoracic aortic dissection. A carotid subclavian bypass was performed, and an AMPLATZER™ endovascular plug (to occlude the left subclavian artery origin) was used to create an adequate proximal landing zone. RESULTS: The patient presented with a posterior circulation stroke 2 years later, which was thought to be due to emboli originating from the occluded subclavian artery stump. CONCLUSIONS: Consideration should be given to ligating the subclavian artery immediately proximal to the vertebral artery origin when performing adjunctive carotid subclavian bypass during TEVAR. If this is not done, surveillance computed tomography scans should monitor for the development of propagating thrombus in the subclavian stump.

Living donor kidney transplantation using laparoscopically procured multiple renal artery kidneys and right kidneys.

BACKGROUND: The use of kidneys with multiple renal arteries (MRA) and right kidneys procured laparoscopically for living donor kidney transplantation (LDKT) remains controversial. We aimed to evaluate the short- and long-term outcomes of recipients of LDKT using laparoscopically procured MRA and right kidneys. STUDY DESIGN: We reviewed the medical records of all LDKT recipients with laparoscopically procured kidneys from 2000 to 2009. Pediatric recipients and recipients of positive crossmatch and/or ABO-incompatible transplants were excluded. We compared the outcomes of recipients of MRA kidneys with those receiving single renal artery (SRA) kidneys and the outcomes of recipients of right kidneys with those of left kidneys. Renal function was measured by iothalamate clearance and estimated by the abbreviated Modification of Diet in Renal Disease equation. RESULTS: Multiple renal artery kidneys (192 2-artery and 18 3-artery kidneys) were used in 210 (18.5%) of 1,134 transplantations. The most common reconstructive technique used for MRA kidneys was a side-to-side anastomosis (64.3%). There were no significant differences in vascular complications (1.1% vs 2.4%, p = 0.17), urologic complications (3.1% vs 2.9%, p = 0.47), graft survival at 1 year (94.6% vs 96.1%, p = 0.37), and 1-year iothalamate clearance (64 mL/min/1.73 m(2) vs 66 mL/min/1.73 m(2), p = 0.52) between recipients of SRA and MRA kidneys. Five-year graft survival was similar for recipients of SRA and MRA kidneys (83.6% vs 82.6%, p = 0.82) and for recipients of left vs right kidneys (83.7% vs 82.6%, p = 0.70). CONCLUSIONS: Excellent long-term outcomes can be obtained after LDKT using laparoscopically procured MRA and right-sided donor kidneys. Unavailability of an SRA left kidney should not preclude LDKT.

New Zealand's first two-pair kidney transplant chain.

Kidney transplantation is the treatment of choice for end-stage renal disease, providing better quality and quantity of life compared with dialysis. Living donor transplantation is being increasingly utilised to match the demand, however it is limited by HLA antigens or ABO blood group incompatibility between the donor and recipient. Organising a kidney transplant chain can overcome such incompatibilities through recipients 'exchanging' incompatible for compatible donors. We have reported New Zealand's first two-pair kidney transplant chain, outlining the reasons for this new technique, its benefits and some of its limitations.

Nocturnal nutritional supplementation improves total body protein status of patients with liver cirrhosis: a randomized 12-month trial.

UNLABELLED: Patients with liver cirrhosis exhibit early onset of gluconeogenesis after short-term fasting. This accelerated metabolic reaction to starvation may underlie their increased protein requirements and muscle depletion. A randomized controlled trial was conducted to test the hypothesis that provision of a late-evening nutritional supplement over a 12-month period would improve body protein stores in patients with cirrhosis. A total of 103 patients (68 male, 35 female; median age 51, range 28-74; Child-Pugh grading: 52A, 31B, 20C) were randomized to receive either daytime (between 0900 and 1900 hours) or nighttime (between 2100 and 0700 hours) supplementary nutrition (710 kcal/day). Primary etiology of liver disease was chronic viral hepatitis (67), alcohol (15), cholestatic (6), and other (15). Total body protein (TBP) was measured by neutron activation analysis at baseline, 3, 6, and 12 months. Total daily energy and protein intakes were assessed at baseline and at 3 months by comprehensive dietary recall. As a percentage of values predicted when well, TBP at baseline was similar for the daytime (85 +/- 2[standard error of the mean]%) and nighttime (84 +/- 2%) groups. For the nighttime group, significant increases in TBP were measured at 3 (0.38 +/- 0.10 kg, P = 0.0004), 6 (0.48 +/- 0.13 kg, P = 0.0007), and 12 months (0.53 +/- 0.17 kg, P = 0.003) compared to baseline. For the daytime group, no significant changes in TBP were seen. Daily energy and protein intakes at 3 months were higher than at baseline in both groups (P < 0.0001), and these changes did not differ between the groups. CONCLUSION: Provision of a nighttime feed to patients with cirrhosis results in body protein accretion equivalent to about 2 kg of lean tissue sustained over 12 months. This improved nutritional status may have important implications for the clinical course of these patients.

Strategies to reduce the rate of type II endoleaks: routine intraoperative embolization of the inferior mesenteric artery and thrombin injection into the aneurysm sac.

PURPOSE: To determine whether the rate of type II endoleaks following endovascular aneurysm repair (EVAR) can be decreased using a branch vessel management strategy. METHODS: The branch vessel management strategy consisted of routine intraoperative embolization of all patent inferior mesenteric arteries (IMA) and thrombin injection into all aneurysm sacs that showed branch vessel filling on the "sacogram." Sixty-nine consecutive patients (65 men; median age 77 years, range 58-90) undergoing elective EVAR since the protocol was introduced in July 2003 were included; 69 consecutive patients (65 men; median age 76 years, range 60-90) who underwent EVAR immediately prior to the protocol were used as controls. Primary outcome measures were type II endoleak rates and secondary intervention rates. RESULTS: The median follow-up was 36 months (range 0.25-72) for the pre-protocol group and 12 months (range 0.25-24) for the post-protocol group. The type II endoleak rate for the pre-protocol group was 26% compared to 14% for the post-protocol group (p=0.14). This difference was not significant on Kaplan-Meir analysis (p=0.23). The 18 type II endoleaks in the pre-protocol group included 14 lumbar endoleaks, 1 IMA endoleak, and 3 combined lumbar and IMA endoleaks. The 10 type II endoleaks in the post-protocol group included 9 lumbar artery endoleaks and 1 IMA endoleak. Ten (14%) patients in the pre-protocol group required 15 interventions for type II endoleak compared to 2 (3%) in the post-protocol group who required 3 secondary procedures for type II endoleak (p=0.03). This difference was not significant on Kaplan-Meier analysis (p=0.22). Of the 12 interventions for lumbar endoleaks, only 5 (42%) were successful. CONCLUSION: Although there was a trend toward lower type II endoleak rates with our branch vessel management strategy, this did not reach statistical significance. Our data also indicated that there is a high incidence of lumbar endoleaks, and they are difficult to treat. Therefore, we believe there should be ongoing research into means to prevent lumbar endoleaks.

Patient awareness of risk factors for peripheral vascular disease.

Our aim was to document patient awareness of the risk factors that predispose to peripheral vascular disease (PVD) before and after consultation with a vascular specialist. Two cohorts of patients attending vascular outpatient clinics were interviewed before or after consultation with a vascular surgeon. They were interviewed according to an agreed protocol to determine if they knew that they had PVD and if they knew what the risk factors for vascular disease were. They were specifically asked about smoking, diabetes, hypertension, and hypercholesterolemia. Of 102 patients recruited, 52 were interviewed prior to specialist vascular assessment and 50 after such an assessment. Seventy-nine percent of patients knew that they had PVD before assessment and 96% knew that they had PVD after specialist assessment (P = 0.009). Overall, 60% of patients acknowledged that they received advice about vascular risk factors and 33% recalled receiving such advice from their general practitioner. There was a statistically significant improvement in patient awareness of smoking (73-90%, P = 0.028) and diabetes (23-66%, P = 0.001) as vascular risk factors after specialist consultation. There was no improvement with regard to hypertension and hypercholesterolemia. Identifying and modifying risk factors is an essential part of the treatment of patients with PVD. This study demonstrates that patient awareness of vascular risk factors is generally low and further work is required to establish means for vascular surgical units to improve education for patients with PVD.

Role of intraoperative frozen section in the management of thyroid nodules.

BACKGROUND: The role of intraoperative frozen section in the management of thyroid nodules is controversial. Its potential benefit is to facilitate one-stage total thyroidectomy. Most literature on this topic originates from overseas tertiary referral centres with a high percentage of cancer cases and a fully resourced frozen section service. The aim of the present study was to review all patients undergoing frozen section at a typical general surgical department in New Zealand (North Shore Hospital, Auckland) to see how often frozen section altered surgical strategy. METHODS: A retrospective review of all frozen sections between November 1999 and June 2003 was performed. Patient records, operation notes and pathology reports were reviewed. RESULTS: Forty-seven sequential frozen sections were included in the study. Thirteen patients had thyroid carcinoma (five follicular, three Hurthle cell, and five papillary). In only one patient did the result of an intraoperative frozen section result in a total thyroidectomy being performed instead of a thyroid lobectomy. The reason for this was the rare condition of Riedel's thyroiditis. In no patients did frozen section detect a cancer that was not diagnosed on preoperative fine-needle aspirate biopsy. CONCLUSION: The present review found little benefit in performing intraoperative frozen section in this setting. As a diagnostic test the cost of frozen section (NZ $200 for each frozen section) needs to be weighed against its low clinical benefit.

The Auckland experience with laparoscopic donor nephrectomy.

AIMS: To examine the initial experience of laparoscopic donor nephrectomy (LDN) in New Zealand and compare it with open donor nephrectomy (ODN). METHODS: All LDNs performed between June 2000 and June 2002 were reviewed. An equal number of ODNs were reviewed. Data were also collected on the recipients of the grafts. Key clinical data were prospectively collected; remaining data were collected by retrospectively reviewing patient charts. Auckland Hospital databases were accessed for costing analysis. RESULTS: Thirty five cases of each procedure had been performed. There has been 100% LDN graft survival. There was no significant difference in graft function (serum creatinine) at one and 12 months (p = 0.25 and 0.35) between the two groups. There was no significant difference in donor morbidity (26% vs 31%, p = 0.59). LDN resulted in a shorter hospital stay (3 vs 6.5 days, p <0.0001) and convalescence period (3 vs 6 weeks, p <0.0001). LDN was significantly more expensive (13 357 dollars vs 6713 dollars, p <0.0001). CONCLUSIONS: LDN in the New Zealand setting provides effective grafts for renal transplant recipients and is safe for the donor. Advantages for the donor are a shorter hospital stay and convalescence period. The major disadvantage of LDN is its higher cost compared with ODN.