Feasibility of a 3 mm arteriotomy for brachiocephalic fistula formation.

BACKGROUND: The arteriovenous fistula is the modality of choice for long-term haemodialysis access. We describe the feasibility of routinely fashioning a brachiocephalic fistula utilising a 3 mm long arteriotomy in an attempt to reduce the incidence of symptomatic steal syndrome yet while maintaining satisfactory clinical outcomes. METHODS: All patients who underwent brachiocephalic fistula formation using a routine 3 mm long arteriotomy within Hammersmith Hospital between January 2017 and March 2018 were included. Primary outcomes included primary failure, failure of maturation, secondary patency and steal syndrome. RESULTS: Sixty-eight brachiocephalic arteriovenous fistula were fashioned utilising a 3 mm long arteriotomy during the study period. Mean age was 60.5 years with 59% having a history of diabetes mellitus. Mean followup was 368 days. Primary failure occurred in 10 (14.7%) patients. Cannulation was achieved in 67.3% of remaining fistula within 3-months, rising to 87.3% by 6-months. Primary patency at 6 and 12 months was 76% and 69%, respectively. Secondary patency at 6 and 12 months was 94% and 91%, respectively. Dialysis access steal syndrome was clinically apparent in three (4.4%) patients with all cases being managed conservatively. CONCLUSION: A 3 mm long arteriotomy may be routinely utilised for brachiocephalic fistula creation in an attempt to limit the incidence of steal syndrome yet while maintaining clinical patency outcomes.

Pre-operative prediction of pancreatic fistula: is it possible?

BACKGROUND/OBJECTIVES: Understanding a patient's risk of pancreatic fistula (PF) prior to pancreatoduodenectomy (PD) would permit an individualised approach to patient selection, consent and, potentially, treatment. Various intra and post operative factors including pancreatic duct width and steatosis are associated with PF. We sought to identify whether information available in the pre-operative phase can predict PF. METHODS: Associations between patient characteristics, pre-operative blood test results, data from pre-operative CT imaging and PF were explored. Pancreatic density (Hounsfield units, Hu), pancreatic duct size and gland thickness were measured using CT imaging. RESULTS: PF occurred in 42 of 155 cases (types A, B and C: 32, 8, 2 respectively). An inverse relationship between duct width and PF was observed. The odds ratio of PF, for each 1 mm increase in duct width, was 0.639 (95% CI = 0.531-0.769, p < 0.001). The gland thickness and density at the pancreatic resection margin were positively associated with PF (both p = 0.03). No patient variable was associated with PF. CONCLUSIONS: Pancreatic duct width has previously been assessed at the time of operation and simply regarded as normal or wide. Consideration of duct width as a continuous variable using pre-operative CT imaging can be used to simply predict risk of PF. The association between pancreatic density and PF is a novel finding. Whether pancreatic density in Hu relates to steatosis, as it does for hepatic steatosis, merits further review given the association between pancreatic steatosis and PF.

Nonobstructive urinary tract dilatation in children with diabetes insipidus.

We report 4 boys with diabetes insipidus associated with renal impairment and hydroureteronephrosis. The high flow states caused the bladder to become trabeculated in the absence of infravesical obstruction. Urodynamics have shown the bladder itself to be compliant, but drainage is poor leading to further renal impairment and overflow incontinence. All 4 boys have been managed with cystostomy button drainage and have done well on close follow-up.

Mucosa associated lymphoid tissue lymphoma presenting within a solitary anti-mesenteric dilated segment of ileum: a case report.

INTRODUCTION: Mucosa associated lymphoid tissue (MALT) lymphoma is the third most common non-Hodgkin's lymphoma subtype. Clinical presentation is often insidious as a low-grade lesion and disease tends to remain localised for a long period of time. Ileal involvement is rare and presentation within an area of focal anti-mesenteric ileal wall dilation simulating a large diverticulum has not been reported. CASE PRESENTATION: A 59-year-old man of Caucasian origin presented to a general surgical outpatients clinic with an 18-month history of intermittent upper abdominal pain following meals. Following normal gastroscopy and abdominal ultrasound, a focally dilated segment of ileum was seen on computed tomography and further clarified by barium investigation. Histology of this segment demonstrated MALT lymphoma of the small bowel. CONCLUSION: A solitary focally dilated segment of ileal wall may be neoplastic in nature and surgical resection needs to be considered.