Mid-term follow-up of percutaneous access for standard and complex EVAR using the ProGlide device.

OBJECTIVES: Endovascular Aneurysm Repair is an established treatment for abdominal aortic aneurysm which requires arterial access via the groin. Most centres perform percutaneous ultrasound-guided access into the common femoral artery for delivery of the stent graft. The profile of endovascular devices necessitates large sheath sizes, therefore formal closure of the arterial puncture site is required. Various percutaneous devices are available, with data lacking on efficacy and mid-term safety profile. We present outcomes from a single centre with the Perclose ProGlide™ (Abbott Vascular Devices, CA, USA) suture-mediated system, using the well described "pre-close" technique. MATERIALS & METHODS: Data were collected from operative records and electronic medical records. Patients undergoing standard (EVAR) or complex (F/B-EVAR) aneurysm repair between March 2015 and September 2019 were included. Complications were recorded per-patient and per-groin procedure. RESULTS: 266 patients were included; 182 (68.4%) standard infrarenal EVAR, 84 (31.6%) F/B-EVAR. There were a total of 484 groin procedures performed. Intraoperative Perclose ProGlide™ success was 98.1% (per patient) or 99.0% (per groin procedure). 30-day groin complication rate was 6.1% (per patient) or 3.1% (per groin procedure). There were no pre- or peri-operative factors which predicted the occurrence of groin complications. The rate of groin complications was not related to sheath size. CONCLUSIONS: Our data support the use of percutaneous access with a pre-close technique for a variety of endovascular aneurysm repair procedures with both large- and small-bore access. The Perclose ProGlide™ system provides excellent mid-term complication-free and reintervention-free outcomes for groin procedures.

Spiral Laminar Flow: a Survey of a Three-Dimensional Arterial Flow Pattern in a Group of Volunteers.

OBJECTIVE: Spiral laminar flow was suggested as potentially the predominant arterial blood flow pattern many years ago. Computational fluid dynamics and flow rig testing have suggested there are advantages to spiral laminar flow. The aim of this study was to identify whether spiral laminar is the predominant flow pattern in a cohort of volunteers. METHODS: This study included 42 volunteers (mean age 66.8 years). Eleven arterial sites were examined, comprising bilateral examination of the common carotid artery, internal carotid artery, external carotid artery, common femoral artery, superficial femoral artery, and the infra renal aorta. The presence or absence of spiral laminar flow, the peak systolic velocity, and the rotational velocity were assessed by colour Duplex scanning. RESULTS: The incidence of spiral laminar flow ranged from 81% in the internal carotid artery to 90% in the common carotid artery and the infra renal aorta. Overall, in 58% of all right-sided arteries the rotation was clockwise and 42% anticlockwise. In all left-sided arteries these numbers were reversed. Analysis on the basis of volunteer rather than examination site showed that 41/42 (97%) had more sites with spiral laminar flow than without. Only one volunteer had more sites exhibiting non-spiral laminar flow. CONCLUSION: Spiral laminar flow was the predominant flow pattern in the study population. This observation raises questions and suggests a need for further studies concerning the form and function of the left ventricle, the geometry of the arterial system, and the function of the arterial wall.

Necrotizing soft tissue infections in intravenous drug users: a vascular surgical emergency.

OBJECTIVE: To assess the short and long-term outcomes of necrotizing soft tissue infection (NSTI) in intravenous drug users (IVDU) in a regional vascular centre. METHODS: This was a retrospective analysis of all IVDUs with NSTI admitted to the regional vascular surgical unit between January 2009 and July 2014. Clinical outcome measures were interval between admission and surgery, length of ITU/HDU and hospital stays, post-operative complications, in hospital and one year mortality. RESULTS: 25 patients were admitted. The median age was 39 years (range 30-53 years) with a female to male ratio of 1:3.3. The median interval between admission and surgery was 23 hours (range 2-195 hours), however, this was significantly less when the admitting specialty was directly to vascular surgery (median 4 hours, range 2-7) compared with other specialties (median 38 hours, range 7-195 hours). Ten patients required HDU/ITU care with a median duration of 4 days (range 1-12 days). Five patients (20%) required amputation, of whom two (40%) had a prosthetic limb fitted. There was one in hospital death (4%). Another patient died while awaiting limb fitting 4 months post discharge, giving a 1 year mortality of 8%. CONCLUSIONS: NSTI in IVDUs carries high risk of amputation with a very low rate of limb fitting. Intervention is significantly delayed when the admitting specialty is not vascular surgery, and half of these patients require HDU/ITU care, with significant morbidity and mortality. Early diagnosis and referral to vascular surgery is crucial in management of these patients.

Vascular training in Scotland and Northern Ireland: The trainee perspective prior to introduction of the new vascular curriculum.

BACKGROUND: The last decade has seen the evolution of vascular surgery from a sub-specialty of general surgery to that of an independent, stand-alone specialty. The introduction of a vascular-only curriculum is anticipated to require significant change from the current provision for vascular surgical training to allow vascular trainees to acquire the specialist skills in elective, emergency, and endovascular surgery to provide endovascular services in the future. AIM: To provide an insight into current vascular training in Scotland and Northern Ireland. METHOD: Specialty trainees in general surgery, with a sub-specialty interest in vascular in Scotland and Northern Ireland were asked to carry out a voluntary online survey between May 2012 and July 2012. RESULTS: 22 specialty trainees/specialist registrars who have declared a sub-specialty interest in vascular surgery were identified and polled. 20 trainees completed the survey. 13 trainees still participated in general surgical on-call rotas. Formal teaching opportunities were readily available but only 10 trainees could attend regularly. All trainees worked in units offering endovascular treatment for aneurysm and occlusive disease, but few had dedicated training sessions in endovascular skills. All endovascular simulation-based training was industry sponsored. The majority of trainees report a good overall training experience and are keen to see the implementation of a vascular-specific curriculum. 15 trainees had undertaken a dedicated period of research towards a higher degree, with only 50% based on a vascular topic. CONCLUSION: The majority of trainees reported a positive training experience with Scotland and Northern Ireland having great potential as vascular training deaneries. The survey identifies specific areas that could be improved by the development of the new curriculum in vascular surgery to provide excellent vascular training in Scotland and Northern Ireland.

The impact of operative approach for oesophageal cancer on outcome: the transhiatal approach may influence circumferential margin involvement.

AIM: Surgery for oesophageal cancer remains the only means of cure for invasive tumours. It is claimed that the surgical approach for these cancers impacts on morbidity and may influence the ability to achieve tumour clearance and therefore survival, however there is no conclusive evidence to support one approach over another. This study aims to determine the impact of operative approach on tumour margin involvement and survival. METHODS: Data were extracted from the Scottish Audit of Gastric and Oesophageal Cancer (SAGOC), a prospective population-based audit of all oesophageal and gastric cancers in Scotland between 1997 and 1999 with a minimum of five-year follow up. Analysis focused on the three commonest approaches (Ivor Lewis n = 140, transhiatal n = 68, left thoraco-laparotomy n = 142) for oesophageal cancer. RESULTS: Operative approach had no significant impact on post-operative morbidity, mortality, overall margin involvement and survival. Transhiatal approach resulted in significantly more circumferential margin involvement (p = 0.019), and the presence of circumferential margin involvement significantly reduced five-year survival (median survival 13 months) compared to no margin involvement (median survival 25 months, p = 0.001). CONCLUSION: Surgical approach for oesophageal cancer had no significant effect on morbidity, post-operative mortality and five-year survival. Non-selective use of the transhiatal approach is associated with a significantly greater circumferential margin involvement, with positive circumferential margin impacting adversely on 5-year survival.

Outcome of right- and left-sided colonic and rectal cancer following surgical resection.

AIM: To determine the outcome of surgery for colorectal cancer from a single region and to see whether location of the primary cancer influences prognosis. METHOD: Patients with colorectal cancer diagnosed from January 2002 to December 2006, entered into a prospective database were followed until death or to December 2008. Right-sided (caecum to transverse colon) and left-sided (splenic flexure to rectosigmoid junction) colonic cancers and rectal cancers (distal to rectosigmoid junction to the anus) were identified. Statistical analysis was performed using Pearson's chi-square test, Kaplan-Meier (log-rank statistic) and Cox regression analysis with a P-value < 0.05 denoting significance. RESULTS: Of 841 patients with solitary colorectal cancers identified (median age 72 [30-101] years; 53% male), 283 (33.7%) were right-sided colonic, 330 (39.2%) were left-sided colonic and 228 (27.1%) were rectal. Respective resection rates were 82.7%, 77.9% and 91.6%, and curative resection rates were 79.9%, 82.9.0% and 85.7%, respectively. There was no significant difference in recurrence rates between right- (16.1%), left-sided (23.0%) colonic and rectal (20.7%) cancers (P = 0.207). Respective mean survival rates were 54.4, 59.8 and 63.6 months (P = 0.007). CONCLUSION: Right-sided colorectal cancers had a worse prognosis than left-sided and rectal cancers, possibly because of more advanced staging and fewer curative resections.

MR imaging of fistula in ano: indications and contribution to surgical assessment.

BACKGROUND: Magnetic Resonance Imaging (MRI) is the imaging modality of choice for fistula in ano. The purpose of this study was to analyse the use of MRI, and to assess its contribution towards the assessment of this sometimes difficult condition. METHODS: A retrospective analysis of all patients with fistula in ano between January 2003 and December 2007 was performed, focussing on those who had MRI assessment. The primary pathology, indication for MRI and the contribution of this investigation to assessment of fistula in ano were analysed. RESULTS: MRI was performed in 40 patients. The primary pathologies included: perianal sepsis in 20 (50%), Crohn's disease in 11 (27.5%), primary fistula in ano in 6 (15%) and others in 3 (7.5%) patients. Indications for MRI were to assess the fistula anatomy in 17 (42.5%), to assess a clinically suspected fistula in 12 (30%), to assess a complex fistula found at Examination Under Anaesthesia (EUA) in 6 (15%) and to exclude a fistula in 5 (12.5%). MRI was considered helpful in 34 (85%) of all cases. MRI established the fistula anatomy and guided further surgery in 47.1%, correlated with EUA findings in 38.2% and excluded a suspected fistula in 14.7% of these. CONCLUSIONS: This study further supports the benefit of using MRI to assess fistula in ano. When used in selected patients, it was of benefit in 85% of cases, by establishing fistula anatomy and guiding further surgery, correlating EUA findings or excluding a clinically suspected fistula.

Positron emission tomography for monitoring response to neoadjuvant therapy in patients with oesophageal and gastro-oesophageal junction carcinoma.

AIMS: The aim of this review is to consolidate our knowledge on an important and rapidly expanding area of expertise. Numerous methods for predicting response (in terms of pathological response and survival) to neoadjuvant therapy (chemotherapy/chemo-radiotherapy) in oesophageal and junctional cancers have been proposed. This review concerns itself only with the use of positron emission tomography for such a purpose. At present there are no standardised criteria amongst PET trials as to what determines a response according to PET, what is the optimal time to perform PET in relation to the timing of neoadjuvant therapy, and what is the ideal method of quantifying PET tracer uptake. METHODS: An electronic search was performed of PubMed, Ovid and Embase websites to identify studies, in the English language, using the search terms: PET; oesophageal; oesophago-gastric; survival; cancer; response; chemotherapy and chemo-radiotherapy. The reference lists were searched manually to identify further relevant studies. RESULTS: Twenty-two studies were identified, all using (18)FDG as the tracer, using PET to predict response in terms of pathological response and survival following neoadjuvant therapy (chemotherapy/chemo-radiotherapy). PET had a varying degree of success in predicting both pathological response and survival outcomes, with only one study using PET to influence management decisions. CONCLUSIONS: PET seems a promising technique, but large-scale conclusions are hindered by small study numbers, lack of criteria as to what constitutes a response and markedly differing PET imaging times. A large randomised trial concerning a homogeneous group of patients and tumours is required before PET might be used to influence management.

Risk assessment in acute pancreatitis.

BACKGROUND: Acute pancreatitis has a variable natural history and in a proportion of patients is associated with severe complications and a significant risk of death. The various tools available for risk assessment in acute pancreatitis are reviewed. METHODS: Relevant medical literature from PubMed, Ovid, Embase, Web of Science and The Cochrane Library websites to May 2008 was reviewed. RESULTS AND CONCLUSION: Over the past 30 years several scoring systems have been developed to predict the severity of acute pancreatitis in the first 48-72 h. Biochemical and immunological markers, imaging modalities and novel predictive models may help identify patients at high risk of complications or death. Recently, there has been a recognition of the importance of the systemic inflammatory response syndrome and organ dysfunction.

Outcome from abdominal aortic aneurysms in Scotland, 1991-2006.

BACKGROUND: This study assessed the impact of sex, presentation and treatment on outcome from abdominal aortic aneurysm (AAA) in Scotland. METHODS: All patients admitted from January 1991 to December 2006 with a primary diagnosis of AAA were identified. Patients were stratified by age, sex, admission diagnosis (ruptured versus intact) and procedure performed (endovascular versus open repair). Multivariable logistic regression analysis was used to determine predictors of mortality. RESULTS: Some 9779 men and 2927 women were admitted with a principal diagnosis of AAA. Women were significantly older than men (median (range) age 75 (35-97) versus 71 (17-96) years; P < 0.001). A higher proportion of women presented with a ruptured AAA (29.5 versus 27.5 per cent; P = 0.043). Age (odds ratio (OR) 2.52 (95 per cent confidence interval 2.36 to 2.74); P < 0.001), female sex (OR 1.63 (1.48 to 1.78); P < 0.001) and admission diagnosis (OR 10.49 (9.53 to 11.54); P < 0.001) were independent predictors of early death, whereas endovascular repair predicted survival (OR 0.67 (0.58 to 0.76); P < 0.001). CONCLUSION: Women presenting with an AAA were older and more likely to be admitted with a ruptured aneurysm. Female sex was an independent risk factor for death from AAA.

[18F]2-fluoro-2-deoxy-D-glucose incorporation by AGS gastric adenocarcinoma cells in vitro during response to epirubicin, cisplatin and 5-fluorouracil.

Decreased tumour [(18)F]2-fluoro-2-deoxy-D-glucose ((18)FDG) incorporation is related to response however its significance at the cell level in gastro-oesophageal cancer and how it relates to cell death is unknown. Here human gastric adenocarcinoma (AGS) cells were treated with lethal dose 10 and 50 (LD(10) and LD(50)), determined by using the MTT assay, of the three drugs, epirubicin, 5-fluorouracil and cisplatin, commonly used in the treatment of patients with gastro-oesophageal cancer. (18)FDG incorporation was determined after 48 and 72 h of treatment with each drug and related to drug-induced changes in glucose transport, hexokinase activity, cell cycle distribution and annexin V-PE binding (a measure of apoptosis). Treatment of cells for 48 and 72 h with LD(50) doses of cisplatin resulted in reductions in (18)FDG incorporation of 27 and 25% respectively and of 5-fluorouracil reduced (18)FDG incorporation by 34 and 33% respectively: epirubicin treatment reduced incorporation by 30 and 69% respectively. Cells that had been treated for 72 h with each drug were incubated in drug-free media for a further 6 days to determine their ability to recover. Comparison of the ability to recover from the chemotherapy agent, with (18)FDG incorporation before the recovery period allowed an assessment of the predictive ability of (18)FDG incorporation. Cells treated with either 5-fluorouracil or cisplatin demonstrated recovery on removal of the drug. In contrast, cells treated with epirubicin did not recover corresponding with the greatest 72 h treatment decrease in (18)FDG incorporation. In contrast to adherent cells treated with cisplatin or 5-fluorouracil, adherent epirubicin-treated cells also exhibited very high levels of apoptosis. Glucose transport was decreased after each treatment whilst hexokinase activity was only decreased after 72 h of treatment with each drug. There was no consistent relationship observed between (18)FDG incorporation and cell cycle distribution. Our results show that at the tumour cell level in gastric tumour cells, decreased (18)FDG incorporation and glucose transport, accompanies therapeutic growth inhibition. (18)FDG incorporation is particularly diminished in cells exhibiting apoptosis.

Elderly valve replacement with bioprostheses and mechanical prostheses. Comparison by composites of complications.

AIM: The goal of aortic valve replacement (AVR) surgery in the elderly (= or >75 years) is to extend survival and minimize valve-related morbidity, mortality and reoperation. As the elderly population lives longer, those with implanted valves are at risk of suffering valve related complications. We hypothesize that bioprostheses are appropriate for the elderly. METHODS: The follow-up evaluation of 966 patients with valves (AVR, 666; mitral valve replacements [MVR], 226; multiple valve replacements [MR], 74) implanted between 1975 and 1999 was examined. There were 879 bioprotheses (BP) and 87 mechanical prostheses (MP). The mean age was 78.9+/-3.3 years (range 75-94.6 years). Concomitant coronary artery bypass was performed in AVR in 51.7%, MVR in 50.4% and MR in 28.4%. Valve type, valve lesion, coronary artery bypass (previous/concomitant), age and gender were considered as independent predictors of composites and survival. The total follow-up was 3905 patient-years. RESULTS: Early mortality was for AVR 9.6% (64), MVR 15.0% (34) and MR 25.7% (19). The late mortality was for AVR 8.8%, MVR 10.4% and MR 8.8%/patient-year. The only independent predictor of survival and valve-related mortality, morbidity and reoperation was age for survival in those with AVR, hazard ratio 1.15 [CL 1.03-1.27] p=0.0094). The BP reoperative rate was 0.5%/patient-year (reoperation was fatal in 6/15) of total, MP reoperative rate was 0% [reasons for reoperation structural valve deterioration (4), non-structural dysfunction (6), prosthetic valve endocarditis (5), reoperation fatality due to non-structural dysfunction (2), prosthetic valve endocarditis (4)]. Overall patient survival at 10 and 15 years, respectively, was 30.5+/-2.4% and 3.6+/-2.2% irrespective of valve position and type. Overall actual and actuarial freedom from valve-related morbidity at 15 years was 96.8+/-0.9% and 93.7+/-2.3%, respectively. Actual and actuarial overall freedom from valve-related mortality at 15 years was 84.3+/-2.4% and 58.4+/-0.9%, respectively. Overall actual and actuarial freedom from valve related reoperation at 15 years was 95.8+/-1.6% and 74.8+/-16.9%, respectively. CONCLUSIONS: BP valves are further confirmed to be a good option for AVR in patients = or >75 years of age.

Perforation of the terminal ileum: a possible complication of nicorandil therapy.

Recent reports have implicated nicorandil as a possible causative agent in the pathogenesis of anal and oral ulceration. We report a case of ulceration and perforation of the terminal ileum in a patient taking nicorandil. The possibility of an association between nicorandil therapy and gastrointestinal ulceration is discussed.

Outcome after intra- and extra-corporeal laparoscopic appendectomy techniques.

BACKGROUND: This study aimed to assess the outcome after intracorporeal (IC) and extracorporeal (EC) laparoscopic appendectomy technique in a single institution over a 5-year period. METHODS: Records of all children ( n = 60) who underwent laparoscopic appendectomy at the Royal Aberdeen Children's Hospital between February 1997 and March 2002 were retrieved and evaluated. Observations were made regarding operative technique, anesthetic time, intra- and postoperative complications, postoperative analgesic requirement, and postoperative hospital stay. RESULTS: There were 30 children in each group who had a similar demographic profile. The magnitude of appendicitis severity in both groups was similar. The mean anesthetic time was 67.8 min for the IC group and 50.7 min for the EC group (p = 0.001). There were no recorded intraoperative complications, although a single case in the EC group required conversion to open procedure. The postoperative analgesic requirement in both groups was similar. The mean postoperative stay was 2.1 days in the IC group and 2.5 days in the EC group. Two postoperative complications were noted in the IC group; one intraperitoneal collection and one postoperative chest infection. Four complications occurred in the EC group; one intraperitoneal collection and three minor port-site wound infections. CONCLUSIONS: The authors' experience shows the EC technique to be significantly quicker, although with a slightly increased complication rate. Either technique can be applied safely for acute appendicitis.