Safety and application of laparoscopic gastrectomy for benign gastric disease and gastric cancer.

INTRODUCTION: Laparoscopic gastrectomy is rapidly expanding despite reservations by some surgeons regarding its safety and radicality. The aim of this study was to evaluate patients undergoing laparoscopic gastrectomy for both benign and malignant disease with particular emphasis on technical feasibility, safety, effectiveness and complications. PATIENTS AND METHODS: Review of prospectively collected data of patients who underwent laparoscopic gastrectomy from May 2005 to September 2009 under the care of one consultant surgeon. RESULTS: A total of 61 laparoscopic gastrectomies were performed (35 men and 26 women) with a median age of 68 years (range, 41-90 years). There were 39 distal gastrectomies (19 adenocarcinoma, 6 gastrointestinal stromal tumour [GIST], 4 benign gastric outlet obstruction, 4 high-grade dysplasia in gastric adenomas, 4 non-healing ulcers, 2 gastric antral vascular ectasia [GAVE]); 15 sub-total gastrectomies (13 adenocarcinomas, 2 GIST); and 7 total gastrectomies (5 adenocarcinomas, 1 GIST, 1 carcinoid). Median follow-up was for 48 months (range, 1-72 months). There was one death, two major and six minor complications. All patients with complications made a satisfactory recovery. CONCLUSIONS: Laparoscopic gastrectomy is associated with a low mortality (1.75%) and major morbidity (3.50%). Although technically demanding, especially when a D2 lymphadenectomy is performed, our results have shown that tailored laparoscopic resection based on tumour characteristics with either D1 or D2 lymphadenectomy results in good surgical and oncological outcomes.

A 10-year experience of using femoro-popliteal vein for re-vascularisation in graft and arterial infections.

BACKGROUND: Infected prosthetic grafts and mycotic aneurysms carry a high mortality and morbidity rate, with a substantial risk of persistent graft infection, but there is evidence that this can be minimised by using femoro-popliteal vein for arterial reconstruction after debridement and graft excision. We present our 10-year experience of this technique. METHODS: Forty-six patients underwent 48 arterial reconstructions with femoro-popliteal vein (24 aortic). Six had mycotic aneurysms (three aortic) and 40 had graft infections (16 aortic). RESULTS: There were two early postoperative deaths (4.3%) and two patients with pre-existing ischaemia underwent major amputation despite a patent graft. Median follow-up was 4.1 ears (range: 2 months to 10 years). Patient survival was 70% and limb salvage 96% at 5 years. Primary graft patency was 75% and 62% and secondary patency 93% and 91% at 2 and 5 years, respectively. Two patients required further surgery for recurrent infection. Anastomotic or graft stenosis occurred in 11 patients (24%). There were three major wound infections. Donor-limb swelling was transient. CONCLUSION: For arterial and prosthetic graft infections, femoro-popliteal vein is an excellent conduit for vascular reconstruction after drainage and debridement of infected tissue and graft material under antibiotic cover, providing good long-term survival and limb salvage.

Optimising the timing of carotid surgery using a carotid risk scoring system.

OBJECTIVES: Transient ischaemic attacks (TIA's) have 4-20% risk of evolving into a major stroke within 90 days, with half of them occurring in the first 2 days. The Department of Health, UK, guidelines (2007) suggests all higher-risk patients with TIA and minor stroke need to be assessed by a specialist and treated within 24 hours. However, the reality in the health system is that the delay between the last cerebrovascular event (CVE) and surgery is often in excess of 90 days. Recently validated ABCD(2) scoring stratifies the risk of stroke after CVE and can help in prioritizing patients for investigations and urgent carotid endarterectomy (CEA). The aim of this pilot study was to stratify patients who underwent CEA, post cerebrovascular event, using the ABCD(2) scoring method. This would help us assess our current CEA practice and, in future, prioritise surgery according to estimated stroke risk. DESIGN & METHODS: Retrospective analysis of ABCD(2) scoring of patients who underwent CEA. RESULTS: The average delay between first presentation and carotid endarterectomy was 172.8 days (range 3 to 837 days). This average delay for the low, moderate and high risk groups was 200.8, 154.1 and 156.5 days, respectively. CONCLUSION: The ABCD(2) scoring is an easily applicable method to stratify patients post CVE at risk of further stroke. Our results suggest that to maximize the benefit of CEA within a limited resource health system, patients with a high ABCD(2) score should be given the highest priority for investigations followed by CEA.

'Extension technique': a modified technique for brachio-cephalic fistula to prevent dialysis access-associated steal syndrome.

OBJECTIVES: To describe a modification in brachio-cephalic fistula formation for prevention of dialysis access-associated steal syndrome (DASS). DESIGN: Short report. MATERIALS: From September 2001 to December 2003, 32 upper arm autogenous fistulae were formed using the 'extension technique' in patients at high-risk for developing DASS i.e. diabetics. METHODS: In this technique, the fistula is formed by anastomosing the median vein to the radial or ulnar artery just below the brachial bifurcation, thus preserving part of the blood supply to the hand, to prevent steal syndrome. All patients were evaluated for patency, adequacy of needling and the absence of steal symptoms. RESULTS: Only 1 patient (3.1%) developed DASS. On investigation, he was found to have the fistula formed distal to the origin of a posterior branch with the bifurcation further distally. Symptoms improved with revision of the fistula. Thrombosis of the cephalic vein (6.2%), difficulty in needling (3.1%) and deep cephalic vein in upper arm that required superficialization (15.6%) were the other complications noted. CONCLUSIONS: The 'extension technique' has been found to be a safe and effective procedure for prevention of DASS, with a good patency rate. Additional advantage of this technique is maturation of both cephalic and basilic veins.

Non-traumatic lower limb vascular complications in endurance athletes. Review of literature.

OBJECTIVES: To review the importance, clinical features, investigations, management and prognosis of non-traumatic vascular injuries, affecting the lower limbs of endurance athletes. DESIGN: Review of literature. MATERIALS AND METHODS: A literature search was conducted from Medline, Pubmed, the National Electronic Library for Health, Google and Yahoo search engines for related articles and case reports regarding non-traumatic vascular complications involving the lower limb of endurance athletes. CONCLUSIONS: Non-traumatic vascular complications affecting the lower limbs include endofibrosis, stenosis/kinking of iliac arteries, dissection of external iliac artery, adductor canal syndrome, popliteal entrapment syndrome, chronic exertional compartment syndrome and effort-induced venous thrombosis. These are important as they affect athletes at the peak of their career and can be confusing to diagnose. The management is relatively well documented and produces good results in short term but the long term results are not known.

ATMTN: a telemammography network architecture.

One of the goals of the National Cancer Institute (NCI) to reach more than 80% of eligible women in mammography screening by the year 2000 yet remains as a challenge. In fact, a recent medical report reveals that while other types of cancer are experiencing negative growth, breast cancer has been the only one with a positive growth rate over the last few years. This is primarily due to the fact that 1) examination process is a complex and lengthy one and 2) it is not available to the majority of women who live in remote sites. Currently for mammography screening, women have to go to doctors or cancer centers/hospitals annually while high-risk patients may have to visit more often. One way to resolve these problems is by the use of advanced networking technologies and signal processing algorithms. On one hand, software modules can help detect, with high precision, true negatives (TN), while marking true positives (TP) for further investigation. Unavoidably, in this process some false negatives (FN) will be generated that are potentially life threatening; however, inclusion of the detection software improves the TP detection and, hence, reduces FNs drastically. Since TNs are the majority of examinations on a randomly selected population, this first step reduces the load on radiologists by a tremendous amount. On the other hand, high-speed networking equipment can accelerate the required clinic-lab connection and make detection, segmentation, and image enhancement algorithms readily available to the radiologists. This will bring the breast cancer care, caregiver, and the facilities to the patients and expand diagnostics and treatment to the remote sites. This research describes asynchronous transfer mode telemammography network (ATMTN) architecture for real-time, online screening, detection and diagnosis of breast cancer. ATMTN is a unique high-speed network integrated with automatic robust computer-assisted diagnosis-detection/digital signal processing (CAD/DSP) methods for mass detection, region of interest (ROI) compression algorithms using Digital Imaging and Communications in Medicine (DICOM) 3.0 medical image standard. While ATMTN has the advantage of higher penetration for cancer screening, it provides the diagnosis with higher efficiency, better accuracy and potentially lower cost. This paper presents the development of the infrastructure and algorithm design for ATMTN-based telemammography. The research goals involved: 1) networking stations for telemammography to demonstrate, evaluate, and validate technologies and methods for delivering mammography screening services via high-speed (155 MB/s) links, performing real-time network-transmitted, high-resolution mammograms for immediate diagnosis as a "second opinion" strategy; 2) development of object-oriented compression methods for storage, retrieval and transmission of mammograms; 3) inclusion and optimization of detection algorithms for identification of normal images in different resolutions to increase the speed and effectiveness of telemammography as a "second opinion" strategy; 4) resolving the compatibility issues between images from different equipment (DICOM standards); and 5) optimization of an integrated ATMTN with adaptive CAD/DSP methods that are robust for large image databases and input sources.