Endovascular repair of acute juxtarenal and thoracoabdominal aortic aneurysms with surgeon-modified fenestrated endografts.

OBJECTIVE: The objective of this study was to report the short- and medium-term outcome of surgeon-modified fenestrated endovascular aneurysm repair (SM-FEVAR) for acute complex aortic aneurysms. METHODS: Interrogation of a prospectively maintained database identified consecutive patients who underwent SM-FEVAR for acute complex aortic aneurysms (including mycotic aneurysms treated with rifampicin-soaked endografts) in a single institution between October 2009 and November 2018. RESULTS: A total of 54 patients (37 men; median age, 73 years [range, 50-85 years]; aneurysm diameter, 76 mm [interquartile range, 58-90 mm]) with acute thoracoabdominal aortic aneurysms (n = 50; 40 symptomatic, 10 ruptured; 19 extent I-III, 31 extent IV) or symptomatic type IA endoleaks after infrarenal endovascular aneurysm repair (n = 4) underwent SM-FEVAR. Seven of the patients had adjunct chimney and periscope stent grafts or surgical bypasses. A total of 187 vessels (mean, 3.4 [range, 1-5] per patient) were targeted for preservation; nine occluded intraoperatively or within 30 days. The 30-day/in-hospital mortality was 16.7% (n = 9; symptomatic, 7.4%; rupture, 50%) and fell significantly from 29.6% (n = 8) in the first 27 patients to 3.7% (n = 1) in the most recent 27 patients (P = .0243). Spinal cord ischemia occurred in one patient (1.9%) who died within 30 days. No survivors required permanent renal dialysis. Estimated survival at 12 and 24 months was 73.2% (standard error [SE], 6.2%). Eight patients underwent 12 late aorta- or graft-related reinterventions. Estimated freedom from reintervention at 12 months and 24 months was 87.9% (SE, 5.2%) and 81.6% (SE, 6.4%), respectively. CONCLUSIONS: In patients with acute complex aneurysms, SM-FEVAR provides a customized solution that is associated with good medium-term survival and durability. The knowledge and skills to perform safe SM-FEVAR should be within the capabilities of high-volume specialist aortic centers.

The Warwick Experience of the Oncotype DX® Breast Recurrence Score® Assay as a Predictor of Chemotherapy Administration.

INTRODUCTION: Oncotype DX® analyses the expression of 21 genes within tumour tissue to determine a Recurrence Score® (RS). RS is a marker of risk for distant recurrence in oestrogen receptor-positive early breast cancer, allowing patient-specific benefit of chemotherapy to be evaluated. Our aim was to determine whether the introduction of Oncotype DX led to a net reduction in chemotherapy use. METHODS: Consecutive patients that underwent Oncotype DX at Warwick Hospital were reviewed. Patients were anonymised and re-discussed at a multidisciplinary team meeting (MDM; without RS), and treatment recommendations were recorded. This was compared to the original MDM outcome (recommendations made with RS). Differences were analysed using Wilcoxon signed-rank test. RESULTS: 67 patients were identified. Proportions of high, intermediate and low risk were 28, 33 and 39% (n = 19/22/26), respectively. Without RS, 56 (84%) patients were recommended for chemotherapy and 3 were not. The remaining 8 patients were deemed borderline for requiring chemotherapy and referred for discussion with an oncologist. With availability of RS, 34 (50%) patients were recommended for chemotherapy, and 24 (43%) patients were spared chemotherapy (p < 0.0005). The net reduction in chemotherapy was 33%. CONCLUSION: There has been a significant reduction in chemotherapy usage in patients at Warwick since the introduction of Oncotype DX.

Postsplenectomy Prophylaxis: A Persistent Failure to Meet Standard?

A retrospective case review of patients that underwent emergency splenectomy or splenic preservation from May 2003 to April 2014 was undertaken at a single center. The results highlight failures in administration of postsplenectomy vaccination for emergency splenectomy patients. In this study, we highlight methods to improve postsplenectomy care.

Fournier's gangrene secondary to an acutely inflamed appendix herniating into the deep inguinal ring.

Fournier's gangrene (FG) requires prompt recognition and management. We report the case of a 68-year-old man who presented with extensive pain and purple discolouration from the right iliac fossa to perineum. Computed tomography demonstrated gas within the right hemiscrotum extending into the inguinal canal and right buttock, with a right pelvic fluid and air collection. At debridement necrotic fluid was arising from the superficial inguinal ring so laparotomy was performed, revealing a grossly inflamed appendix herniating into the inguinal canal; a right hemicolectomy was performed. Unfortunately, the patient went into cardiac arrest and passed away on the operating table. Histological analysis demonstrated acute-on-chronic inflammation involving the appendix. The condition where appendicitis is implicated in FG is usually due to retroperitoneal rupture and tracking into the perineal spaces. This is the first case reported of an inflamed appendix herniating into the inguinal canal and thus causing FG.

Persistent air-leak after transhiatal oesophagectomy: A case report.

INTRODUCTION: Transhiatal oesophagectomy is a widely accepted technique for resection of tumours of the lower oesophagus. We present a life-threatening complication associated with the placement of a corrugated neck drain during this procedure. PRESENTATION OF CASE: Our patient underwent a transhiatal oesophagectomy for a lower oesophageal tumour. He developed persistent bilateral pneumothoraces despite chest drain insertions. Following removal of the corrugated neck drain, both lungs were successfully re-inflated. DISCUSSION: To the authors' knowledge, this serious complication has been described only once before in the medical literature; other surgeons should be made aware of this problem. CONCLUSION: Alternative drainage systems should be considered to help prevent this injury. Exercise caution if positioning corrugated drains in the neck.

Detection and survival of colorectal cancer from a 2 week wait service.

AIM: To determine detection strategies for colorectal cancer (CRC) and to analyse subsequent survival from a 2 week wait (2WW) service. METHOD: Retrospective analysis of 2WW and hospital CRC databases from January 2006 to July 2009. Survival was assessed using Kaplan Meier survival curves and Cox's proportional hazard models. Proximal cancers were those proximal to and including the splenic flexure. RESULTS: From 1725 patients seen in a 2WW clinic, 108 were identified with CRC. Median follow-up in survivors was 514 days (interquartile range 160-788 days). Of 23 patients investigated for iron deficient anaemia and/or abdominal mass, 78% (18) were found to have proximal cancers. Of 85 patients with symptoms of change in bowel habit, rectal bleeding or abdominal pain, 15% (13) were found to have proximal cancers. Age, haemoglobin and mean corpuscular volumes between these 13 patients and the 72 distal cancers in this group were not significantly different. Multivariable analysis showed that survival was lower for those presenting with proximal cancers (hazard ratio 2.912, 95% confidence interval 1.361-6.227, p=0.006) and for those with increasing Dukes stage (p<0.001). CONCLUSIONS: Flexible sigmoidoscopy would have missed 15% of cancers in those presenting with symptoms alone. Patients with proximal tumours had a worse prognosis. Further research is needed to identify those presenting with symptoms alone who are at high risk of having proximal tumours and thus requiring whole colonic imaging.