Lumbar sympathectomy can improve symptoms associated with ischaemia, vasculitis, diabetic neuropathy and hyperhidrosis affecting the lower extremities-a single-centre experience.

BACKGROUND: Lumbar sympthectomy (LS) was traditionally performed for intermittent claudication but is now eclipsed by revascularisation for that indication. However, it retains a role in the management of critical limb ischaemia and other conditions causing lower limb pain with or without ischaemia. We report the role of LS in modern surgical practice when revascularisation and pain management options have been exhausted. METHODS: A medical chart review was performed on all patients who underwent LS in our unit from 2005 to 2016 (inclusive). Symptomatology, surgical indications and patient outcomes were reported. RESULTS: Twenty-seven cases were performed in total (21 unilateral, 3 bilateral). Underlying diagnoses were as follows: PAD [59.3% (n = 16)], hyperhidrosis [18.5% (n = 5)] and equal numbers of complex regional pain syndrome, diabetic neuropathy and vasculitis [7.4% (n = 2) each]. Overall, 85.2% (n = 23) had improvement or resolution of symptoms at 1 month and 70.3% (n = 19) had persistent improvement of symptoms at 1 year. Non-PAD patients had superior outcomes with 90.9% (n = 10) reporting improved symptomatology at 1 month and nearly three quarters [72.8% (n = 8)] maintaining this improvement at 1 year. Only four patients required subsequent major amputation, all in the severe PAD group. CONCLUSION: Lumbar sympathectomy can improve symptoms associated with ischaemia, vasculitis, diabetic neuropathy and hyperhidrosis. Non-PAD patients have the greatest benefit.

Two Cases of Popliteal Cystic Adventitial Disease Treated With Excision and Primary Bypass Graft: A Review of the Literature.

Cystic adventitial disease (CAD) is a rare vascular pathology which predominantly affects peripheral vessels of young otherwise healthy males. Much debate exists regarding its exact etiology. It is characterized by a collection of mucinous material within the adventitial wall layer of the affected vessel, resulting in arterial stenosis and rapidly progressive calf claudication. Treatment is primarily surgical, although radiological interventions have been reported. Its rarity makes evidence-based surgical or radiological management difficult. With this in mind, we report two cases of popliteal artery CAD treated successfully with primary excision and bypass grafting. We analyzed all literature published on CAD since first reported in 1947 and we propose an algorithm for appropriate management pathways.

Gross-dependent lower limb lymphoedema.

Gross-dependent lower limb lymphoedema is an unusual condition which can be painful particularly if ulceration occurs. Focused history and clinical examination in addition to appropriate radiological investigation aid in the diagnosis. It is difficult to treat and requires a multidisciplinary team including vascular surgeons, dermatologists and clinical nurse specialists. The primary treatment option is compression bandaging.

Hybrid management of a spontaneous ilio-iliac arteriovenous fistula: a case report.

INTRODUCTION: Spontaneous iliac arteriovenous fistulae are a rare clinical entity. Such localized fistulation is usually a result of penetrating traumatic or iatrogenic injury. Clinical presentation can vary greatly but commonly includes back pain, high-output congestive cardiac failure and the presence of an abdominal bruit. Diagnosis, therefore, is often incidental or delayed. CASE PRESENTATION: We report a case of a spontaneous ilio-iliac arteriovenous fistula in a 68-year-old Caucasian man detected following presentation with unilateral claudication and congestive cardiac failure. Following computed tomography evaluation, the fistula was successfully treated with a combined endovascular (aorto-uni-iliac device) and open (femoro-femoral crossover) approach. CONCLUSION: Endovascular surgery has revolutionized the management of such fistulae and we report an interesting case of a high-output iliac arteriovenous fistulae successfully treated with a hybrid vascular approach.

GIST with a twist--upregulation of PDGF-B resulting in metachronous gastrointestinal stromal tumor and dermatofibrosarcoma protuberans.

CASE REPORT: A 61-year-old male was referred following an incidental radiological discovery of an intra-abdominal mass. His medical history included excision of a lumbar dermatofibrosarcoma protuberans (DFSP) 5 years previously. A CT scan of the abdomen revealed a mass arising from the greater curvature of the stomach. Upper GI endoscopy was normal. He underwent successful laparoscopic resection of this mass. MATERIALS AND METHODS: The histology of the abdominal mass revealed a gastrointestinal stromal tumor (GIST) with poor prognostic indicators. Immunohistochemical analysis of the GIST and his previous DFSP was performed. RESULTS: Immunohistochemistry suggested a link between the GIST and his previous DFSP involving the PDGF signalling system. DISCUSSION: Both GIST and DFSP are extremely rare tumors. A mutation in the platelet-derived growth factor receptor alpha (PDGFR-alpha) has been described in 5-15% of GISTs. It has been shown that DFSP is frequently associated with a translocation between PDGF-B (Chr 22) and COL1A1 (Chr 17), causing continuous activation of PDGFR-beta. Literature review confirms that there are no previously reported cases of both of these tumors occurring in the same patient. CONCLUSION: We hypothesize that this patient may have a previously undescribed genetic mutation involving the PDGF signalling system, resulting in these two very rare malignancies. Immunohistochemistry studies confirmed the link on this occasion. Improvements in our understanding of the molecular biology of the PDGF system may novel therapeutic targets in the future.

Cyclooxygenase-2 plays a central role in the genesis of pancreatitis and associated lung injury.

BACKGROUND: The exact mechanism by which cyclooxygenase-2 (COX-2) promotes inflammation in pancreatitis in obscure. This study was undertaken to investigate the role of COX-2 inhibition in an animal model of pancreatitis, a disease process characterized by a systemic inflammatory response and ensuing neutrophil-mediated lung injury. METHODS: Pancreatitis was induced in 24 Sprague-Dawley rats by intraperitoneal injection of 20% L-arginine (500 mg/100 g body weight). The animals were randomized into 3 groups (8 rats in each group): controls and rats with pancreatitis intravenously resuscitated with either normal saline (0.9% NaCl 3 ml/kg)at 24 and 48 hours or COX-2 inhibitor (parecoxib 1 mg/kg). Pancreatic and lung injuries were assessed histologically. Lung injury was assessed utilizing wet:dry ratio and myeloperoxidase activity to indicate pulmonary neutrophil infiltration. A Western blot was used to determine COX-2 protein expression in pancreatic tissue. RESULTS: The animals treated with COX-2 inhibitors displayed significantly less pancreatic and lung injuries than their normal saline counterparts. Histological pancreatic and lung injury scores were significantly reduced (P<0.05) in the COX-2 treated group. Lung wet:dry ratios were significantly improved and pulmonary neutrophil infiltration was attenuated in the COX-2 group (P<0.05). Western blot analysis confirmed attenuated COX-2 protein expression. CONCLUSION: This study shows, for the first time in a rat model, that adjuvant COX-2 inhibition significantly attenuates the severity of both pancreatitis and its associated systemic inflammatory response and end-organ injury.

Bacterial lipoprotein induces resistance to Gram-negative sepsis in TLR4-deficient mice via enhanced bacterial clearance.

TLRs are highly conserved pathogen recognition receptors. As a result, TLR4-deficient C3H/HeJ mice are highly susceptible to Gram-negative sepsis. We have previously demonstrated that tolerance induced by bacterial lipoprotein (BLP) protects wild-type mice against polymicrobial sepsis-induced lethality. In this study, we assessed whether pretreatment of C3H/HeJ mice with BLP could induce resistance to a subsequent Gram-negative Salmonella typhimurium infection. Pretreatment with BLP resulted in a significant survival benefit in TLR4-deficient C3H/HeJ mice (p < 0.0002 vs control C3H/HeJ) after challenge with live S. typhimurium (0.25 x 10(6) CFU/mouse). This survival benefit was associated with enhanced bacterial clearance from the circulation and in the visceral organs (p < 0.05 vs control C3H/HeJ). Furthermore, pretreatment with BLP resulted in significant increases in complement receptor type 3 (CR3) and FcgammaIII/IIR expression on polymorphonuclear neutrophils (PMNs) and macrophages (p < 0.05 vs control C3H/HeJ). There was impaired bacterial recognition and phagocytosis in TLR4-deficient mice compared with wild-type mice. However, a significant augmented uptake, ingestion, and intracellular killing of S. typhimurium by PMNs and peritoneal macrophages was evident in BLP-pretreated C3H/HeJ mice (p < 0.05 vs control C3H/HeJ). An up-regulation of inducible NO synthase and increased production of intracellular NO were observed in peritoneal macrophages from BLP-pretreated C3H/HeJ mice (p < 0.05 vs control C3H/HeJ). Depletion of PMNs did not diminish the beneficial effects of BLP with regard to both animal survival and bacterial clearance. These results indicate that BLP, a TLR2 ligand, protects highly susceptible TLR4-deficient mice from Gram-negative sepsis via enhanced bacterial clearance.