Management of acute and chronic iliofemoral venous outflow obstruction: a multidisciplinary team consensus.

The aim of this manuscript was to establish a consensus for the management of acute and chronic venous obstruction among specialists in the UK. Specialist physicians representing vascular surgery, interventional radiology and hematology were invited to 3 meetings to discuss management of acute and chronic iliofemoral obstruction. The meetings outlined controversial areas, included a topic-by-topic review; and on completion reached a consensus when greater than 80% agreement was reached on each topic. Physicians from 19 UK hospitals agreed on treatment protocols and highlighted areas that need development. Potential standard treatment algorithms were created. It was decided to establish a national registry of venous patients led by representatives from the treating multidisciplinary teams. Technical improvements have facilitated invasive treatment of patients with acute and chronic venous obstruction; however, the evidence guiding treatment is weak. Treatment should be conducted in centers with multi-disciplinary input; robust, coordinated data collection; and regular outcome analysis to ensure safe and effective treatment and a basis for future evolvement.

Techniques for Infrapopliteal Arterial Bifurcation Stenting.

BACKGROUND: Endovascular treatment of infrapopliteal peripheral arterial disease (PAD) is an established and effective treatment strategy for patients with symptomatic PAD. Increasingly, complex infrapopliteal lesions are treated with an endovascular first approach, especially in the setting of critical limb ischemia (CLI) for limb salvage, avoiding major amputations which impact on mobility and quality of life. However, many complex infrapopliteal lesions involving the bifurcation of the tibial arteries remain challenging to treat because of recoil or acute dissection after angioplasty and may require stenting using specialized techniques. METHODS AND RESULTS: We illustrated techniques for infrapopliteal arterial bifurcation stenting using case-based examples. The techniques covered include the single-stent, culottes, kissing, crush, and T-stenting techniques, and each is considered based on individual strengths and limitations. CONCLUSIONS: Infrapopliteal bifurcation stenting allows complex bifurcation lesions to be treated effectively when flow-limiting complications are encountered after angioplasty.

Evaluating the Use of a Negative D-Dimer and Modified Low Wells Score in Excluding above Knee Deep Venous Thrombosis in an Outpatient Population, Assessing Need for Diagnostic Ultrasound.

Aims. Colour doppler ultrasonography (CDUS) is widely used in the diagnosis of deep venous thrombosis (DVT); however, the number of scans positive for above knee DVT is low. The present study evaluates the reliability of the D-dimer test combined with a clinical probability score (Wells score) in ruling out an above knee DVT and identifying patients who do not need a CDUS. Materials and Method. This study is a retrospective audit and reaudit of a total of 816 outpatients presenting with suspected lower limb DVT from March 2009 to March 2010 and from September 2011 to February 2012. Following the initial audit, a revised clinical diagnostic pathway was implemented. Results. In our initial audit, seven patients (4.9%) with a negative D-dimer and a low Wells score had a DVT. On review, all seven had a risk factor identified that was not included in the Wells score. No patient with negative D-dimer and low Wells score with no extra clinical risk factor had a DVT on CDUS (negative predictive value 100%). A reaudit confirmed adherence to our revised clinical diagnostic pathway. Conclusions. A negative D-dimer together with a low Wells score and no risk factors effectively excludes a lower limb DVT and an ultrasound is unnecessary in these patients.

Acute pancreatitis: the role of imaging in diagnosis and management.

Acute pancreatitis is one of the more commonly encountered aetiologies in the emergency setting and its incidence is rising. Presentations range from a mild-self limiting condition which usually responds to conservative management to one with significant morbidity and mortality in its most severe forms. While clinical criteria are necessary to make the initial diagnosis, contrast-enhanced CT is the mainstay of imaging and has a vital role in assessing the extent and evolution of the disease and its associated complications. The purpose of this article is to summarise the natural course of acute severe pancreatitis, clarify confusing nomenclature, demonstrate the morphological stages in conjunction with radiological scoring systems and illustrate the complications. We will review and illustrate the increasing and significant role interventional radiology has in the management of these patients, which are often life-saving and surgery-sparing.

Transabdominal preperitoneal laparoscopic approach for the treatment of sportsman's hernia.

BACKGROUND: Groin pain in athletes presents a diagnostic and therapeutic challenge, particularly in distinguishing between those that will respond to nonoperative management and those that require surgery. Repair of sportsman's hernia, using the Modified Bassini darn or tension-free Lictenstein mesh technique, have been well described. The aim of this study was to assess the role of laparoscopy in the management of these hernias. PATIENTS AND METHODS: Seventeen consecutive male patients (median age, 27 years), presenting with symptoms and signs of sportsman's hernia to a district general hospital were reviewed. Five patients presented with unilateral groin pain, whereas 12 had bilateral symptoms. All patients underwent a diagnostic laparoscopy, followed by transabdominal preperitoneal polypropelene mesh (15 x 10 cm) repair. All patients except 1 were discharged within 24 hours of surgery, and their rehabilitation was supervised by a single physiotherapist. All patients were assessed postoperatively by the authors and at a median follow-up of 23 weeks. RESULTS: The laparoscopy confirmed posterior wall weakness in all patients with bilateral symptoms and in 4 of 5 patients with unilateral groin pain. Following repair, no surgical morbidity occurred and the median return to sporting activities was 42 days. All but 1 patient returned to the level of sport reached prior to injury, and mild pain was experienced in 5 groins, which did not interfere with either normal daily or sports activity. CONCLUSION: The transabdominal preperitoneal laparoscopic approach is safe and feasible in the diagnosis and treatment of Sportsman's hernia, enabling a full return to sports activities.

Can intra-operative intraperitoneal free cancer cell detection techniques identify patients at higher recurrence risk following curative colorectal cancer resection: a meta-analysis.

BACKGROUND: Accurate staging of colorectal cancer is important for predicting prognosis and guiding treatment. This study uses meta-analysis to investigate if the pre- or post-resection detection of intraperitoneal free cancer cells can predict recurrence in patients undergoing curative colorectal cancer surgery. METHODS: A literature search was performed on all studies between January 1990 and July 2007 comparing the detection of intraperitoneal free cancer cells either pre- or post-resection with prognosis in colorectal cancer. The following prognostic outcomes were meta-analyzed: overall recurrence rate and local recurrence rate. A random-effect model was used and heterogeneity was assessed. RESULTS: Nine studies reporting on a total of 1182 subjects matched the selection criteria. Free cancer cells were detected prior to tumor resection in 125/822 (15.2%) of patients and following resection in 64/533 (12%) of patients. Preresection, the absence of tumor cells was associated with a lower overall recurrence (25.2%) compared to the presence of tumor cells [46.4%, odds ratio (OR) = 0.41, confidence interval (CI) 0.19-0.88]; as well as a significantly lower local recurrence (12.2% versus 21.1%, OR = 0.42, CI 0.21-0.82). Postresection, the absence of tumor cells also resulted in significantly lower overall recurrence (17.3%) when compared to the presence of tumor cells (52.6%, OR = 0.07, CI 0.03-0.18). CONCLUSIONS: The detection of intraperitoneal free cancer cells is associated with higher recurrence and poorer prognosis. Use of these techniques can identify patients at higher recurrence risk. This could be particularly valuable in stage II disease to identify patients who may benefit from adjuvant chemotherapy.

Epidermotropic cutaneous metastases from hypopharyngeal carcinoma.

Cutaneous metastases from laryngeal and hypopharyngeal squamous carcinomas are extremely rare. A high index of clinical suspicion, supplemented with histopathologic evidence, aids in the diagnosis. The prognosis is extremely poor, and treatment is aimed only at palliation of symptoms and improving quality of life.