Aneurysmal degeneration of vein conduit used for vascular reconstruction-Case report and literature review.

INTRODUCTION: Popliteal artery aneurysms (PAA) are the most prevalent form of peripheral arterial aneurysms. Greater saphenous vein grafts and endoaneurysmorrhaphy remains the mainstay therapy for open repair of PAA. True aneurysmal degeneration of lower extremity infrainguinal autologous vein grafts are relatively rare and its etiology is not completely understood. CASE PRESENTATION: We present a case of a 57-year-old man with recurrent autologous venous graft aneurysmal dilatations following a surgical popliteal artery aneurysm repair. DISCUSSION: The pathogenesis of true aneurysmal graft dilatation remains speculative with possible pathogenesis including progression of underlying atherosclerosis, systemic dilating diathesis, autologous venous graft varicosities, low-grade infections and post-stenotic dilatations. Management of venous graft aneurysms should be subjected to the same criteria as other aneurysms. Diagnosis requires a high index of suspicion. The initial study of choice is duplex ultrasonography as it can diagnose the aneurysm and distinguish it from other popliteal masses, provide accurately measurements and identify thrombus within the aneurysm. Once diagnosed, surgical repair should be performed as soon as possible as graft dilatation tends to occur overtime and is typically followed by a rapid increase in size over a short period of time. CONCLUSION: Aneurysmal degeneration of autologous saphenous venous graft following PAA repairs occur infrequently. Its etiology remains largely speculative. Accurate diagnosis and early surgical intervention can prevent progression of aneurysmal dilatation and minimize the potential of complications.

Day case laparoscopic cholecystectomy, room for improvement: A United Kingdom District General Hospital experience

Background: Laparoscopic cholecystectomy (LC) is the surgical treatment of choice for symptomatic gallstones. The current NHS innovation drive is to perform 60 % of all elective laparoscopic cholecystectomies as day cases. Methods: A retrospective data analysis was performed for all day case laparoscopic cholecystectomies in a single institution between January 2009 and December 2011. Causes of failed discharges, post-operative complications and readmission rates were recorded. Results: A total of 476 patients were listed as day-cases. 348 patients (73 %) were discharged the same day. 128 patients (27 %) were admitted, of these 89 (69.5 %) were discharged within 24 hours and 21 (16 %) were discharged within 2 days. 39 patients who failed discharge were due to pain only (30 %), 6 due to nausea & vomiting (5 °A)), 55 due to other reasons (43 %) and the remaining 28 due to a combination of symptoms. All 15 patients who had a drain inserted, stayed overnight (P < 0.001). All those patients who had a procedure lasting longer than two hours, failed same day discharge (P < 0.001). Our overall rates for complications, conversions to open and readmission were 2.5 %, 1.5 % and 1.7 % respectively. Our day case rate doubled from 22 % in 2009 to 50 °A) in 2010 and then plateaued at 48 °A) in 2011 as more emergency cases were being performed over this period. Conclusion: Day case laparoscopic Cholecystectomy is a feasible and a safe treatment for symptomatic gallstones. Patients should be listed on a morning list and drain insertion avoided whenever possible, with robust protocols for management of post-operative pain and vomiting (AU)

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Systematic review of home-based exercise programmes for individuals with intermittent claudication.

We aimed to conduct a systematic review of the evidence for structured, home-based exercise programmes (HEPs) in patients with intermittent claudication. The Medline, PsycINFO, EMBASE, and Cochrane databases were searched up to April 2013 for terms related to walking, self-management, and intermittent claudication. Descriptive, methodological and outcome data were extracted from eligible articles. Trial quality was assessed using the GRADE system. Seventeen studies were included with 1,457 participants. Six studies compared HEPs with supervised exercise training, five compared HEPs with usual care/observation control, and seven evaluated HEPs in a single-group design. Trial heterogeneity prevented meta-analysis. Nevertheless, there was "low-level" evidence that HEPs can improve walking capacity and quality of life in patients with intermittent claudication when compared with baseline or in comparison to usual care/observation control. In addition, improvements with HEPs may be inferior to those evoked by supervised exercise training. Considerable uncertainty exists regarding the long-term clinical and cost effectiveness of HEPs in patients with intermittent claudication. Thus, more robust trials are needed to build evidence about these interventions. Nevertheless, clinicians should consider using structured interventions to promote self-managed walking in patients with intermittent claudication, as opposed to simple "go home and walk" advice, when supervised exercise training is unavailable or impractical.

Systematic review and meta-analysis of duplex ultrasonography, contrast-enhanced ultrasonography or computed tomography for surveillance after endovascular aneurysm repair.

BACKGROUND: Previous analyses suggested that duplex ultrasonography (DUS) detected endoleaks after endovascular aneurysm repair (EVAR) with insufficient sensitivity; they did not specifically examine types 1 and 3 endoleak, which, if untreated, may lead to aneurysm-related death. In light of changes to clinical practice, the diagnostic accuracy of DUS and contrast-enhanced ultrasonography (CEUS) for types 1 and 3 endoleak required focused reappraisal. METHODS: Studies comparing DUS or CEUS with computed tomography (CT) for endoleak detection were identified. CT was taken as the standard in bivariable meta-analysis. RESULTS: Twenty-five studies (3975 paired scans) compared DUS with CT for all endoleaks. The pooled sensitivity was 0·74 (95 per cent confidence interval 0·62 to 0·83) and the pooled specificity was 0·94 (0·90 to 0·97). Thirteen studies (2650 paired scans) reported detection of types 1 and 3 endoleak by DUS; the pooled sensitivity of DUS was 0·83 (0·40 to 0·97) and the pooled specificity was 1·00 (0·97 to 1·00). Eleven studies (961 paired scans) compared CEUS with CT for all endoleaks. The pooled sensitivity of CEUS was 0·96 (0·85 to 0·99) and the pooled specificity was 0·85 (0·76 to 0·92). Eight studies (887 paired scans) reported detection of types 1 and 3 endoleak by CEUS. The pooled sensitivity of CEUS was 0·99 (0·25 to 1·00) and the pooled specificity was 1·00 (0·98 to 1·00). CONCLUSION: Both CEUS and DUS were specific for detection of types 1 and 3 endoleak. Estimates of their sensitivity were uncertain but there was no evidence of a clinically important difference. DUS detects types 1 and 3 endoleak with sufficient accuracy for surveillance after EVAR.

Percutaneous cholecystostomy as an alternative to cholecystectomy in high risk patients with biliary sepsis: a district general hospital experience.

INTRODUCTION: Cholecystectomy is the standard treatment for patients with acute cholecystitis. However, percutaneous cholecystostomy (PC) is an alternative for patients at high risk for surgery. We present our five-year clinical experience with the aim of evaluating the efficacy of PC in high risk patients. METHODS: A retrospective review was performed on 30 consecutive patients who underwent PC at our institution. The indications for cholecystostomy, route of insertion, technical success, clinical improvement, length of hospitalisation, in-hospital or 30-day mortality, complications, subsequent admissions and performance of interval cholecystectomy were recorded. The median follow-up period was 25 months (range: 1-52 months). RESULTS: Thirty-two PCs were performed in thirty patients (mean age: 76.1 years; range: 52-90 years). The indications for PC were acute calculous cholecystitis (29/32), acalculous cholecystitis (1/32) and emphysematous cholecystitis (2/32). The route of insertion was transperitoneal for 22/32 PCs (68.8%) and transhepatic for 10/32 (31.2%). The procedure was technically successful in all patients although 2/22 transperitoneal drains (9.1%) were dislodged subsequently. Twenty-seven PCs (84.4%) resulted in clinical improvement within five days. The in-hospital or 30-day mortality rate was 16.7% (5/30). Eleven patients (36.7%) had a subsequent cholecystectomy: 6 were laparoscopic and 5 converted to open procedures at a median interval of 58 days (range: 1-124 days). CONCLUSIONS: PCs are straightforward with few complications. Most patients improve clinically and the procedure can therefore be used as a definitive treatment in unfit patients or as a bridge to surgery in those who might subsequently prove fit for a definitive operation.