A novel two-stage approach to the treatment of renal cell carcinoma with intra-cardiac tumour extension and Budd-Chiari syndrome.

OBJECTIVE: To present the early results of a new technique for the treatment of renal cell carcinoma with intra-cardiac tumour extension and Budd-Chiari syndrome. PATIENTS AND METHODS: The first stage involves transdiaphragmatic debulking of the right heart, inferior vena cava (IVC) and hepatic veins via median sternotomy, followed by a purse-string suture placed in the IVC below the hepatic veins. The second stage is performed separately and involves en bloc resection of the affected kidney, and IVC and vascular reconstruction via an abdominal incision. RESULTS: Three of five patients presented with clinical Budd-Chiari syndrome; two had radiological features only. The median time between surgical procedures was 12 days (IQR 13 days). Four of the five patients had a R0 resection. While all five patients successfully completed both operative stages, one patient died 22 days after the second stage. Of the remaining four, all survive with no disease recurrence. CONCLUSION: While we continue to compile longer-term data for a larger follow-up series, these preliminary findings show the feasibility of this technique and support the development of this programme of surgery.

Detection, management, and prevention of diabetes-related foot disease in the Australian context.

Diabetes-related foot disease (DFD) is a widely feared complication among people who live with diabetes. In Australia and globally, rates of disability, cardio-vascular disease, lower extremity amputation, and mortality are significantly increased in patients with DFD. In order to understand and prevent these outcomes, we analyse the common pathogenetic processes of neuropathy, arterial disease, and infection. The review then summarises important management considerations through the interdisciplinary lens. Using Australian and international guidelines, we offer a stepwise, evidence-based practical approach to the care of patients with DFD.

Modalities of endovascular management for internal iliac artery aneurysms.

BACKGROUND: Internal iliac artery aneurysms (IIAA) are uncommon. Open repair is technically challenging and has been associated with increased morbidity and mortality compared with repair of abdominal aortic aneurysms. The aim of this study is to assess the outcomes of endovascular treatment of IIAA and incidence of postoperative pelvic ischaemia. METHODS: A single-centre retrospective analysis was performed for IIAAs treated with endovascular repair between January 2005 and December 2017. Aneurysm morphology, mode of presentation and operative technique were evaluated. Primary outcomes were 30-day mortality and incidence of pelvic ischaemia. Secondary outcomes were technical success, major complications and reintervention. RESULTS: Twenty-nine IIAAs were treated in 23 patients with a mean age of 74 */- 9 years. Six patients had isolated IIAAs (26%); the remaining 17 patients had aortoiliac aneurysms. Five patients (22%) required emergent repair for ruptured IIAAs. Mean IIAA size was 4.1 cm */- 1.8 and ruptures occurred at mean 6.1 cm */- 2.6. Endovascular techniques used: stent graft occlusion of the internal iliac artery (IIA) ostium (n = 16), deployment of iliac branch device (n = 9), and other endovascular techniques (n = 4). The 30-day mortality was zero. Three patients (13%) experienced post-operative pelvic ischemia which were all minor chronic gluteal claudication after IIA occlusion. Primary technical success was achieved in 27 repairs (93%). There was one late reintervention (3%). CONCLUSION: IIAAs are often asymptomatic and diagnosed incidentally, however, a significant proportion present emergently. Endovascular treatment is feasible for both ruptured and non-ruptured aneurysms with low perioperative morbidity, mortality and reintervention rates.

Acute Upper Limb Ischemia Due to Delayed Presentation of a Brachial Artery Pseudoaneurysm Post-Venipuncture.

Brachial artery pseudoaneurysms (BAPs) are rare but could lead to complications of high morbidity. We report a case of a BAP presenting with hand ischemia and median nerve neuropathy nearly a decade after the inciting iatrogenic trauma, successfully treated with excision and direct repair. This report highlights that untreated pseudoaneurysms can be indolent and present late with both symptoms of embolization and local compression.

Fractured osteochondroma presenting with popliteal pseudoaneurysm: Case report and review of literature.

Osteochondroma, the most common tumor of bone, is usually asymptomatic. Vascular complications are an atypical presentation and include true or false aneurysm formation, deep venous thrombosis, and arterial insufficiency. A review of the English literature identified 130 cases of osteochondroma-related vascular complications. We describe the case of a 38-year-old man presenting with left calf pain and swelling who was diagnosed with the rare constellation of a popliteal pseudoaneurysm and incidental peroneal vein thrombosis secondary to a fractured femoral sessile osteochondroma. This was treated with resection of the osteochondroma, excision of the aneurysm, and primary end-to-end anastomosis of the artery.

Nuclear reprogramming and induced pluripotent stem cells: a review for surgeons.

Induced pluripotent stem cells (iPSCs) are generated from somatic cells by the exogenous expression of defined transcription factors. iPSCs share the defining features of embryonic stem cells (ESCs) in that they are able to self-renew indefinitely and maintain the potential to develop into all cell types of the body. These cells have key advantages over ESCs in that they are autologous to the donor cells and can be generated from individuals at any age. iPSCs also circumvent ethical and political issues surrounding the destruction of embryos that is necessary in the isolation of ESCs. This review briefly describes the advent of iPSC technology and the concepts of nuclear reprogramming, and discusses the potential application of this powerful biological tool in both surgical research and regenerative medicine.

Nuclear reprogramming and induced pluripotent stem cells: a review for surgeons.

Induced pluripotent stem cells (iPSCs) are generated from somatic cells by the exogenous expression of defined transcription factors. iPSCs share the defining features of embryonic stem cells (ESCs) in that they are able to self renew indefinitely and maintain the potential to develop into all cell types of the body. These cells have key advantages over ESCs in that they are autologous to the donor cells and can be generated from individuals at any age. iPSCs also circumvent ethical and political issues surrounding the destruction of embryos that is necessary in the isolation of ESCs. This review briefly describes the advent of iPSC technology and the concepts of nuclear reprogramming, and discusses the potential application of this powerful biological tool in both surgical research and regenerative medicine.

Transplantation of adult mouse iPS cell-derived photoreceptor precursors restores retinal structure and function in degenerative mice.

This study was designed to determine whether adult mouse induced pluripotent stem cells (iPSCs), could be used to produce retinal precursors and subsequently photoreceptor cells for retinal transplantation to restore retinal function in degenerative hosts. iPSCs were generated using adult dsRed mouse dermal fibroblasts via retroviral induction of the transcription factors Oct4, Sox2, KLF4 and c-Myc. As with normal mouse ES cells, adult dsRed iPSCs expressed the pluripotency genes SSEA1, Oct4, Sox2, KLF4, c-Myc and Nanog. Following transplantation into the eye of immune-compromised retinal degenerative mice these cells proceeded to form teratomas containing tissue comprising all three germ layers. At 33 days post-differentiation a large proportion of the cells expressed the retinal progenitor cell marker Pax6 and went on to express the photoreceptor markers, CRX, recoverin, and rhodopsin. When tested using calcium imaging these cells were shown to exhibit characteristics of normal retinal physiology, responding to delivery of neurotransmitters. Following subretinal transplantation into degenerative hosts differentiated iPSCs took up residence in the retinal outer nuclear layer and gave rise to increased electro retinal function as determined by ERG and functional anatomy. As such, adult fibroblast-derived iPSCs provide a viable source for the production of retinal precursors to be used for transplantation and treatment of retinal degenerative disease.