Objective: A significant proportion of patients with abdominal and thoracic aortic aneurysms (AA) do not proceed to intervention after reaching treatment threshold diameter due to a combination of poor cardiovascular reserve, frailty, and aortic morphology. This patient cohort has a high mortality; however, until this study, there exist no studies on the end-of -life care conservatively managed patients receive. Methods: This is a retrospective multicenter cohort study of 220 conservatively managed patients with AA referred to Leeds Vascular Institute (UK) and Maastricht University Medical Centre (the Netherlands) for intervention between 2017 and 2021. Demographic details, mortality, cause of death, advance care planning and palliative care outcomes were analysed to examine predictors of palliative care referral and efficacy of palliative care consultation. Results: A total of 1506 patients with AA were seen over this time period, giving a nonintervention rate of 15%. There was a 3-year mortality rate of 55%, a median survival of 364 days, and rupture was the reported cause of death in 18% of the decedents. Median follow-up was 34 months. Only 8% of all patients and 16% of decedents received a palliative care consultation, which took place a median of 3.5 days before death. Patients >81 years of age were more likely to have advance care planning. Only 5% and 23% of conservatively managed patients had documentation of preferred place of death and care priorities respectively. Patients with a palliative care consultation were more likely to have these services in place. Conclusions: Only a small proportion of conservatively treated patients had advance care planning and this was far below international guidelines on end-of-life care for adults, which recommends it for each of these patients. Pathways and guidance should be implemented to ensure patients not offered AA intervention receive end-of-life care and advance care planning.

BACKGROUNDS/AIMS:Pancreatic leak and fistula formation following pancreatic resection is a dreaded complication associated with significant morbidity and mortality. The perioperative use of inotropes has been implicated in anastomotic dehiscence in other types of gastrointestinal surgery but their impact in pancreatic surgery remains unclear and a potentially modifiable risk factor for pancreatic leak. This study aims to assess the impact of perioperative inotrope infusion on the incidence of pancreatic leak following pancreaticoduodenectomy.METHODS:Retrospective data analysis of all patients undergoing pancreaticoduodenectomy at a tertiary HPB institute. Multivariate analysis and regression models assessed the impact of inotrope use against other known risk factors such as pancreatic duct size and gland texture. Pancreatic fistulae were graded as per ISGPF as Grade A (biochemical leak), Grade B and Grade C fistula.RESULTS:One-hundred and twenty-three (123) patients were included. A total of 52 patients (42%) developed a leak (29 grade A, 15 grade B, and 8 Grade C). In the fistula group, 28 patients (55%) received perioperative inotropes compared to 26 (35%) in the no fistula group. On univariate analysis, patients receiving inotropes (p=0.04) and patients with a soft pancreatic texture (p=0.003) had a statistically higher incidence of developing a pancreatic fistula of any grade. On multivariate analysis, only inotrope use was associated with an increased risk of developing a pancreatic fistula of any grade (OR 2.46, p=0.026), independent of pancreatic texture and pancreatic duct size.CONCLUSIONS:Perioperative inotrope use is associated with an increase incidence of pancreatic leak following pancreaticoduodenectomy and should therefore be used judiciously.

Background: Elevated serum bilirubin has been shown to be a reliable predictor of pancreatic and biliary malignancy but the relationship between serum bilirubin and inadequate (C1), benign (C2) and indeterminate (C3) cellular samples has not been explored. The aim of this study is to determine the relationship between serum bilirubin and pancreatic, biliary or ampullary malignancy in the context of non-confirmatory cytology. Methods: This is a retrospective analysis of patients with obstructive jaundice undergoing investigation for possible pancreatic, peri-ampullary or biliary malignancy between 2009 and 2013. Results: 135 patients were included; 84 had a malignant diagnosis and 51 benign. All patients with C4 or C5 cytology (n=49) had confirmed malignancy. 35 out of 86 C1 – C3 samples were falsely negative. ROC curve analysis demonstrated a strong association (AUC 0.912) between elevated serum bilirubin and malignancy; serum bilirubin ≥ 100 µmol/L had a sensitivity of 86% and a specificity of 88%. In the C1-C3 subgroup, this association was maintained (AUC 0.905). Serum bilirubin ≥ 100 µmol/L had a sensitivity of 80% and specificity of 88%. Using this cut-off highlighted 28 out of 35 of the malignancies missed by cytology (p = 0.003). Conclusion: Our study demonstrates that a serum bilirubin ≥ 100 µmol/L is associated with malignancy and this relationship is maintained in C1-C3 cytology. When faced with non-confirmatory cytology in the absence of a benign aetiology and an elevated serum bilirubin ≥ 100 µmol/L, we advocate more aggressive investigation to avoid missing an occult malignancy.

INTRODUCTION:Vascular surgeons increasingly encounter flow limitation of iliac arteries (FLIA) in endurance athletes. An experience of managing this condition is reported. REPORT:This is a retrospective cohort analysis of prospectively collected data at a single vascular centre. Between 2001 and 2017, 12 athletes with exercise induced pain underwent investigation and assessment. Patients with significant radiological findings (iliac kinking ± stenosis demonstrated on duplex ultrasound or catheter angiography) and dynamic flow changes (marked reduction in ankle brachial pressure indices following exertion, or increase in the common iliac artery peak systolic velocity during hip flexion on duplex) underwent surgery after trialling conservative management; the majority were open iliac shortening procedures. Patients with radiological findings, but no dynamic flow changes were managed conservatively. All patients were followed up. DISCUSSION:There were 10 men and two women with a median age of 40 years. Nine patients had iliac kinking (five in isolation, four associated with stenosis), two had stenosis, and one had no iliac disease. Eight patients had severe symptoms (absolute loss of power on maximal exertion) demonstrated dynamic post-exertional flow changes. Seven patients successfully underwent surgery, returning to their sport at similar intensity. One procedure was abandoned owing to severe adhesions from a prior procedure. This patient subsequently changed sport. Three patients with mild symptoms (two had reduction in power at maximal intensity, one was an incidental finding) and who demonstrated no clinical signs of FLIA continued their sport at a lower intensity. Kinking of the iliac arteries in athletes can occur with or without of iliac stenosis. Patients with the most severe iliac symptoms demonstrate dynamic post-exertional flow limitation and may benefit from surgery following a period of conservative management. Patients who have milder symptoms and no dynamic exercise flow limitations can be managed conservatively.

To compare outcomes of laparoscopic repair to open repair of umbilical and paraumbilical hernias.

Introduction: Post surgical pyoderma gangrenosum (PSPG) is rare cutaneous inflammatory skin disorder, which is characterised by painful and necrotic ulceration. We present two patients who developed PSPG following breast reconstructions.

Background: The management of neurosurgical disorders has become increasingly specialised. The care of patients with subarachnoid haemorrhage (SAH) has generally been part of core neurosurgical practice, provided by general neurosurgeons whatever their specialist interest. The aim of this present study therefore is to ascertain if, and to what extent care provided by a dedicated neurovascular team (compared to care provided by a general neurosurgical team) change patient disposition in SAH.Methods: This is a retrospective analysis of SAH patients, identified from a departmental database of a single neurosurgical centre. In 2008, the service was reorganised such that a neurovascular team cared for all SAH patients. We compared clinical outcome in people admitted prior to this service reorganisation (Period A, 2004-2007) with patients admitted afterwards (Period B, 2009-2011). Survival and recovery were assessed according to the Glasgow Outcome Scale (GUS). Multi-factorial logistic regression analysis was performed to determine the injury and age adjusted incidence of complications, odds of survival at discharge, discharge home, mortality, good recovery (GOS 5) and favourable outcome, by dichotomising GUS (GUS 4-5 vs. GUS 1-3) at 3 months.Results: 1114 patients were included in the study. The mean age of patients presenting in Period A (n = 543) was younger [50 years (SD 13.5)] than those in Period B (n=571) [53 years (SD 13)]. Patients admitted in Period B were more likely to present as poor grade (World Federation of Neurological surgeons (WFNS) grades 4 and 5) compared to Period A (26.5% vs. 21.3%). No statistical differences between the groups in the incidence of pre-operative re-bleeding (3% vs. 5%) or rates of delayed cerebral ischaemia (16.1% vs. 16.1%) were observed. After adjustment for age, sex and injury severity, the odds of patient time to discharge, discharge home and good recovery (GUS 5) were 27% (p<0.001), 45% (p=0.001) and 93% (p<0.001) higher respectively in Period B than Period A.Conclusions: The data presented here demonstrates that management of SAH by a dedicated neurovascular team improves the potential for patient recovery. (C) 2015 Elsevier B.V. All rights reserved.