REPAIRS Delphi: A UK and Ireland Consensus Statement on the Management of Infected Arterial Pseudoaneurysms Secondary to Groin Injecting Drug Use.

OBJECTIVE: Consensus guidelines on the optimal management of infected arterial pseudoaneurysms secondary to groin injecting drug use are lacking. This pathology is a problem in the UK and globally, yet operative management options remain contentious. This study was designed to establish consensus to promote better management of these patients, drawing on the expert experience of those in a location with a high prevalence of illicit drug use. METHODS: A three round modified Delphi was undertaken, systematically surveying consultant vascular surgeons in the UK and Ireland using an online platform. Seventy five vascular surgery units were invited to participate, with one consultant providing the unit consensus practice. Round one responses were thematically analysed to generate statements for round two. These statements were evaluated by participants using a five point Likert scale. Consensus was achieved at a threshold of 70% or more agreement or disagreement. Those statements not reaching consensus were assessed and modified for round three. The results of the Delphi process constituted the consensus statement. RESULTS: Round one received 64 (86%) responses, round two 59 (79%) responses, and round three 62 (83%) responses; 73 (97%) of 75 units contributed. Round two comprised 150 statements and round three 24 statements. Ninety one statements achieved consensus agreement and 15 consensus disagreement. The Delphi statements covered sequential management of these patients from diagnosis and imaging, antibiotics and microbiology, surgical approach, wound management, follow up, and additional considerations. Pre-operative imaging achieved consensus agreement (97%), with computerised tomography angiography being the modality of choice (97%). Ligation and debridement without arterial reconstruction was the preferred approach at initial surgical intervention (89%). Multidisciplinary management, ensuring holistic care and access to substance use services, also gained consensus agreement. CONCLUSION: This comprehensive consensus statement provides a strong insight into the standard of care for these patients.

Predicting necrotising soft tissue infections in people who inject drugs: poor performance of the Laboratory Risk Indicator for Necrotising Fasciitis score and development of a novel clinical predictive nomogram in a retrospective cohort with internal validation.

INTRODUCTION: Necrotising soft tissue infections (NSTI) can threaten life and limb. Early identification and urgent surgical debridement are key for improved outcomes. NSTI can be insidious. Scoring systems, like the Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC), exist to aid diagnosis. People who inject drugs (PWID) are high risk for NSTI. This study aimed to assess the utility of the LRINEC in PWID with lower limb infections and develop a predictive nomogram. METHODS: A retrospective database of all hospital admissions due to limb-related complications secondary to injecting drug use between December 2011 and December 2020 was compiled through discharge codes and a prospectively maintained Vascular Surgery database. All lower limb infections were extracted from this database, dichotomised by NSTI and non-NSTI with the LRINEC applied. Specialty management times were evaluated. Statistical analyses involved: chi-square; Analysis of "variance"; Kaplan-Meier, and receiver operating characteristic curves. Nomograms were developed to facilitate diagnosis and predict survival. RESULTS: There were 557 admissions for 378 patients, with 124 (22.3%; 111 patients) NSTI. Time from admission to: theatre and computed tomography imaging respectively varied significantly between specialties ( P =0.001). Surgical specialties were faster than medical ( P =0.001). Vascular surgery received the most admissions and had the quickest time to theatre. During follow-up there were 79 (20.9%) deaths: 27 (24.3%) NSTI and 52 (19.5%) non-NSTI. LRINEC ≥6 had a positive predictive value of 33.3% and sensitivity of 74% for NSTI. LRINEC <6 had a negative predictive value of 90.7% and specificity of 63.2% for non-NSTI. Area under the curve was 0.697 (95% CI: 0.615-0.778). Nomogram models found age, C-reactive protein, and non-linear albumin to be significant predictors of NSTI, with age, white cell count, sodium, creatinine, C-reactive protein, and albumin being significant in predicting survival on discharge. CONCLUSION: There was reduced performance of the LRINEC in this PWID cohort. Diagnosis may be enhanced through use of this predictive nomogram.

The Needle and the Damage Done: A Retrospective Review of the Health Impact of Recreational Intravenous Drug Use and the Collateral Consequences for Vascular Surgery.

BACKGROUND: The UK has one of the highest rates of recreational drug use and consequent deaths in Europe. Scotland is the "Drug deaths capital of Europe." Intravenous drug use can result in limb- and life-threatening pathology. This study aimed to characterise limb-related admissions associated with intravenous drug use, outcomes and healthcare expenditure. METHODS: Retrospective data collection between December 2011 and August 2018. Patients were identified through discharge codes. Admission details were extracted from electronic records and a database compiled. Statistical analyses were performed using Statistical Package for the Social Science, P < 0.05 denoted significance. RESULTS: There were 558 admissions for 330 patients (1-9 admissions/patient), mean age 37 years (+/-7.6 SD) and 196 (59.2%; 319 admissions, 57.2%) were male. Three hundred forty-eight (62.4%) admissions were to surgical specialties, predominantly Vascular Surgery (247). Including onward referrals, Vascular ultimately managed 54.8% of admissions. Patients presented with multiple pathologies: 249 groin abscesses; 38 other abscesses; 74 pseudoaneurysms; 102 necrotising soft tissue infections (NSTI); 85 cellulitis; 138 deep venous thrombosis (DVTs); 28 infected DVTs and 70 other diagnoses. Two hundred and seventy-seven admissions (220 patients) required operations, with 361 procedures performed (1-7 operations/admission). There were 24 major limb amputations and 74 arterial ligations. Eleven amputations were due to NSTI and 13 followed ligation (17.6% of ligations). During follow-up 50 (15.2%) patients died, of which 6 (12%) had amputations (OR 3.2, 95% CI 1.04-9.61, P = 0.043). Cumulative cost of acute care was £4,783,241. CONCLUSIONS: Limb-related sequalae of intravenous drug use represents a substantial surgical workload, especially for Vascular. These are complex, high-risk patients with poor outcomes and high healthcare costs.

Giant Carotid Artery Aneurysm.

Carotid artery aneurysms account for 4% of peripheral aneurysms and may present as a neck mass, with hemispheric ischaemic symptoms, or with symptoms secondary to local compression. This case explores the presentation, investigations and management of a presumed mycotic common carotid artery aneurysm in a 77-year-old male, which was repaired using end-to-end interposition vein graft using long saphenous vein. This report discusses the aetiology, presentation and surgical management for carotid artery aneurysms, as well as focusing on that of the rare mycotic carotid artery aneurysm.

Enhancing junior doctors' working lives.

Junior doctor wellbeing has been a topic of increasing interest in recent years. There is increasing evidence of poor workplace satisfaction, rising levels of burnout and increasing diaspora of UK-trained junior doctors. There is therefore a pressing need to address the wellbeing of our trainees and recent concerted efforts at local, national and international levels are working towards this, with the ultimate goal of also improving patient care. The tension between the personal and the professional may never be so keenly felt as during the unique challenges we are facing this year, in 2020, as we tackle the biggest global health emergency of our lives brought about by COVID-19. There are many positive examples of new initiatives aimed at supporting the medical community at this time; however, we must all work together to sustain these endeavors in post-pandemic times. We here summarize a number of pertinent issues affecting trainee wellbeing, outline current attempts at addressing these and make further suggestions as how to enhance the working lives of our junior doctors. However there is much still to be done.

A prospective observational study of the utility of early diagnostic laparoscopy for right lower abdominal pain: a safe and effective diagnostic and therapeutic tool.

BACKGROUND AND AIMS: Diagnostic laparoscopy is commonly performed for diagnosis of right lower abdominal pain and its use is increasing in the emergency setting. Some studies have reported that diagnostic laparoscopy and laparoscopic appendicectomy have advantages over conventional surgery. Many emergency surgeons now perform diagnostic laparoscopy for both clinically diagnosed appendicitis and when the diagnosis is in doubt. The aim of the present study was to assess whether the use of diagnostic laparoscopy is justified and safe for those admitted with right lower abdominal pain. METHODS AND RESULTS: Data were collected prospectively on consecutive patients attending the acute surgical receiving unit with right iliac fossa pain or a suspected diagnosis of acute appendicitis. A total of 284 patients underwent diagnostic laparoscopy. Of them 233 (82%) had a positive finding at laparoscopy, 207 (88%) underwent appendicectomy, the majority of which were carried out laparoscopically. Surgical trainees performed the majority of operations and this did not have a negative impact on operative findings (p 0.856), operation performed (0.642), or operative duration (0.831). No intra-operative complications were sustained. Ultrasound examination was carried out in 49 patients, while CT was carried out in 24. CONCLUSION: The results of the present study highlight the utility of early diagnostic laparoscopy as both a diagnostic and therapeutic tool in the acute setting.

Natural history of upper limb arterio-venous fistulae for chronic hemodialysis.

PURPOSE: Arterio-venous fistulae (AVF) for hemodialysis are prone to problems, ultimately leading to failure of the fistulae. Our aim was to determine the site and time to first stenosis and time to and factors influencing AVF failure for radio-cephalic (RC), brachio-cephalic (BC), and transposed brachio-basilic (BB) AVF. METHODS: Retrospective analysis of native AVF constructed within a single vascular unit between January 2002-December 2008. Patients followed up to the end points of death, AVF failure or end of study period. Data collected included: age, sex, AVF type, time and site of first stenosis and time to failure. The relationship between fistula type, stenosis, and failure were examined. RESULTS: In total, 398 native AVF were included in the study (91 RC, 208 BC, and 99 BB), with a mean age of 66 years. A total of 215 (54%) AVF developed a flow limiting stenosis, and over time 151 (40%) AVF failed. Stenoses developed significantly earlier in RC AVF (median 113 days) compared to BC (median 277 days), compared to BB (median days 414), P=.029. There was no statistically significant difference in time to failure (RC median 1344 days; BC median 1576 days; BB median 1159 days), P=.673. The presence of stenosis was the only variable found to have a significant impact on AVF failure in multivariate analysis. CONCLUSIONS: Type of upper limb fistula did not impact on failure rates. Flow limiting stenoses impacted on fistula failure.

Does the outcome of colonic flexure cancers differ from the other colonic sites?

BACKGROUND: Anecdotally, colonic flexure cancers (FC) appear to have a poorer prognosis compared to other colonic cancers (OCC). The aim of this study was to determine the outcome of colonic flexure cancers compared to the cancers of the rest of the colon. METHODS: Patients with a diagnosis of colonic cancer over a 5-year period (2002-2006) were retrieved from a prospective database. Analysis was performed on flexure (hepatic/splenic) cancers versus remaining colon cancers. Overall, 1-, 3- and 5-year survival rates were calculated. All patients were followed up until death or end of study period (December 2008), with median follow-up of 32 months. Statistical analysis was performed using Kaplan-Meier with log rank statistic and Pearson chi-square test. RESULTS: Of 613 patients (54% males) with colonic cancers with median age 71 years, range (30-100), 67 (10.9%) were FC (35 hepatic/32 splenic) and 546 (89.1%) were arising from OCC. The curative resection rates were FC 73.2% (41 of 56) and OCC 83.4% (359 of 435) (p = 0.05). Post-operative mortality for FC and OCC was 10.7% (6 of 56) and 4.2% (18 of 434), respectively (p = 0.04). FC presented at a more advanced Dukes stage (p = 0.003). Recurrence rates were 9.8% (4 of 41) for FC and 20.9% (75 of 359) for OCC sites (p = 0.088). The overall mean survival was 48.8 and 58.2 m for FC and OCC, respectively (p = 0.158). Of 1-, 3- and 5-year survival, only 1-year survival was significantly different between the two groups (OCC (85%) vs FC (75%), p = 0.018). CONCLUSIONS: Nearly one in ten colonic cancers is located at a flexure. Despite FC presenting at an advanced stage, leading to a lower curative resection rate, no significant survival difference was noted compared to other colonic sites, beyond the first year.

The value of procalcitonin at predicting the severity of acute pancreatitis and development of infected pancreatic necrosis: systematic review.

BACKGROUND: Many studies have evaluated serum levels of procalcitonin (PCT) as a predictor in the development of severe acute pancreatitis (SAP) and infected pancreatic necrosis (IPN). This study assesses the value of PCT as a marker of development of SAP and IPN. METHODS: Medline, Web of Science, the Cochrane clinical trials register, and international conference proceedings were searched systematically for prospective studies, which evaluated the usefulness of PCT as a marker of SAP and IPN. The sensitivity, specificity, and diagnostic odds ratios (DORs) were calculated for each study, and the study quality and heterogeneity among the studies were evaluated. RESULTS: Twenty-four of 59 studies identified were included in data extraction. The sensitivity and specificity of PCT for development of SAP were 0.72 and 0.86, respectively (area under the curve [AUC] = 0.87; DOR = 14.9; 95% confidence interval [CI] = 5.6-39.8), albeit with a significant degree of heterogeneity (Q = 28.56, P < .01). The sensitivity and specificity of PCT for prediction of infected pancreatic necrosis were 0.80 and 0.91 (AUC = 0.91; DOR = 28.3; 95% CI = 13.8-58.3) with no significant heterogeneity (Q = 7.83, P = .18). No significant heterogeneity was observed among the studies when only higher quality studies (AUC = 0.91; DOR = 30.7; 95% CI = 10.7-87.8) or studies that used a cutoff PCT level >0.5 ng/mL (AUC = 0.88, 32.8; 95% CI = 10.1-106.6) were included. CONCLUSION: Serum measurements of PCT may be valuable in predicting the severity of acute pancreatitis and the risk of developing infected pancreatic necrosis.

Microcoil embolisation of mycotic cystic artery pseudoaneurysm: a viable option in high-risk patients.

Mycotic cystic artery pseudoaneurysm is a rare complication of cholecystitis, of which the main treatment has been cholecystectomy plus ligation of the cystic artery. We highlight our experience with successful coil embolisation of this condition without the need for surgical intervention. This is followed by a comprehensive review of the literature regarding management of this unusual condition.

Use of a Javidtrade mark shunt in the management of axillary artery injury as a complication of fracture of the surgical neck of the humerus: a case report.

INTRODUCTION: Axillary artery injury is a rare but severe complication of fractures of the surgical neck of the humerus. CASE PRESENTATION: We present a case of axillary artery pseudoaneurysm secondary to such a fracture, in a 82-year-old white woman, presenting 10 weeks after the initial injury, successfully treated with subclavian to brachial reversed vein bypass together with simultaneous open reduction and internal fixation of the fracture. We discuss the use of a Javidtrade mark shunt during combined upper limb revascularisation and open reduction and internal fixation of the fractured humerus. CONCLUSION: This case highlights the usefulness of a Javidtrade mark shunt, over other forms of vascular shunts, in prompt restoration of blood flow to effect limb salvage. It can be considered as a temporary measure whilst awaiting definitive revascularisation which can be performed following fracture fixation.

Optimal gastric pouch reconstruction post-gastrectomy.

BACKGROUND: Gastric pouches have the potential to improve nutrition following total gastrectomy, compared with standard reconstruction. However, a consensus view of clinical benefit is not available, at least partly due to a lack of standardization of pouch design or size. This study was undertaken to identify optimal conditions for pouch design. METHODS: A mathematical model was established and a porcine model constructed to evaluate the pressure/volume dynamics of the pouch. A "J" pouch was constructed at anastomotic lengths of 5, 10, 15, and 20 cm. Each pouch was distended with saline and the pressure/volume relationship established. RESULTS: Mathematically, increasing the anastomotic length of the pouch to 15 cm increases the volume significantly; thereafter, there is minimal benefit of increasing the pouch length further. For smaller pouches (5 and 10 cm) a 350-to 400-ml volume (approximate meal volume in the elderly) is never achieved until higher pressures (45 cmH(2)O) are applied. However, in the larger pouches (15 and 20 cm) a 350-to 400-ml volume is readily achieved at basal pressures of 15 cmH(2)O. CONCLUSION: Smaller pouches never achieve adequate volumes at basal pressures; accordingly, it is unlikely that they will lead to any clinical benefit. Further in-vivo studies should therefore be based upon 15-cm pouch designs.

The impact of operative approach on outcome of surgery for gastro-oesophageal tumours.

BACKGROUND: The choice of operation for tumours at or around the gastro-oesophageal junction remains controversial with little evidence to support one technique over another. This study examines the prevalence of margin involvement and nodal disease and their impact on outcome following three surgical approaches (Ivor Lewis, transhiatal and left thoraco-laparotomy) for these tumours. METHODS: A retrospective analysis was conducted of patients undergoing surgery for distal oesophageal and gastro-oesophageal junction tumours by a single surgeon over ten years. Comparisons were undertaken in terms of tumour clearance, nodal yield, postoperative morbidity, mortality, and median survival. All patients were followed up until death or the end of the data collection (mean follow up 33.2 months). RESULTS: A total of 104 patients were operated on of which 102 underwent resection (98%). Median age was 64.1 yrs (range 32.1-79.4) with 77 males and 25 females. Procedures included 29 Ivor Lewis, 31 transhiatal and 42 left-thoraco-laparotomies. Postoperative mortality was 2.9% and median survival 23 months. Margin involvement was 24.1% (two distal, one proximal and 17 circumferential margins). Operative approach had no significant effect on nodal clearance, margin involvement, postoperative mortality or morbidity and survival. Lymph node positive disease had a significantly worse median survival of 15.8 months compared to 39.7 months for node negative (p = 0.007), irrespective of approach. CONCLUSION: Surgical approach had no effect on postoperative mortality, circumferential tumour, nodal clearance or survival. This suggests that the choice of operative approach for tumours at the gastro-oesophageal junction may be based on the individual patient and tumour location rather than surgical dogma.