Surgical treatment of acute limb iscahemia in the presence of malignancy

AbstractObjectivesThe aim of this study was to examine the outcome of surgical treatment of acute limb ischaemia (ALI) developing in the presence of malignancy.MethodsPatients undergoing emergency surgery were identified from theatre registers, notes were reviewed, and data collected in relation to indications for, and outcome following operation. All patients with a current or past medical history of histologically confirmed malignant disease were identified and their notes specifically reviewed to determine the staging of their tumours. The results of the malignancy cohort were compared to a group of patients undergoing surgery for ALI of other aetiologies.ResultsFourteen patients with a malignancy were identified with ALI and in addition there were 102 without malignancy. The cohort with a malignancy contained a higher proportion of males (p=0.0305), and a greater number of smokers (p=0.037) than those with other aetiologies for ALI. The peri-operative management of the 2 groups was similar. Histological examination revealed tumour thrombus in only 1 case. The recurrence (29% versus 18%; p=0.328) and amputation rates (29% versus 17%; p=0.278) were similar, however, the 30-day (50% versus 30%; p=0.038) and 60-day mortality rates (100% versus 35%; p<0.001) were significantly higher in the malignancy group.ConclusionsThe development of ALI in patients with malignant disease may be regarded as a terminal event despite comparable performance status at the time of surgery to those with other cause for ALI. The role of surgery in patients with known advanced malignancies appears to be of dubious benefit with little survival benefit

Mucinous adenocarcinoma presenting as an isolated sternal metastasis

<p>Abstract</p> <p>Background</p> <p>As a result of improvements in diagnostic accuracy, the primary source of the tumour is identified in more than 99% of cases presenting with a malignancy. Whilst the axial skeleton is a common site of metastases, the sternum is rarely affected, especially by isolated metastases.</p> <p>Case presentation</p> <p>We report a case of a 68 year old male who was referred to the surgical outpatient clinic with a six month history of sternal pain. The patient was known to have essential thrombocythaemia, which had recently transformed into acute myeloid leukaemia but a sternal biospy showed mucinous adenocarcinoma. He had not localising symptoms and full evaluation failed to localise the primary tumour.</p> <p>Conclusion</p> <p>Solitary sternal metastases are rare and when found an underlying neoplasm is usually identified allowing targeted treatment. If however, there is no symptomatic tumour, the metastasis should simply be treated symptomatically.</p

Internal jugular vein thrombosis in a warfarinised patient: a case report

<p>Abstract</p> <p>Introduction</p> <p>Internal jugular vein thrombosis (IJVT) is a rare but potentially fatal condition. It usually arises following trauma to the internal jugular vein but is also seen in association with coagulopathies and advanced malignancies as part of a para-neoplastic syndrome.</p> <p>Case presentation</p> <p>We report a case of a 44 year old woman with a strong past medical history and family history of thrombotic disease who presented with abdominal pain and ascites. A stage III ovarian carcinoma was diagnosed and she underwent debulking of the tumour. She sustained a peri-operative haemorrhage and required insertion of a central line into the right internal jugular vein. At one month follow-up she presented as an emergency with a left neck mass and painful swallowing. A duplex ultrasound of her neck identified a left IJVT to the level of the brachiocephalic vein which had occurred despite warfarinisation and an INR of greater than 2. She was commenced on intravenous heparin and the swelling resolved over the course of a week.</p> <p>Conclusion</p> <p>This case illustrates an unusual presentation of a rare condition. In this case, the precise aetiology is unclear as the IJVT may have been related to a coagulopathy or the presence of advanced malignancy and occurred despite adequate anticoagulation.</p

Perigraft air is not always pathological: a case report

© 2007 Ball et al; licensee BioMed Central Ltd

Post coital aortic dissection: a case report

<p>Abstract</p> <p>Background</p> <p>Sudden onset peri- or post-coital cardiovascular disease is well documented in the literature including myocardial infarction, pulmonary embolus and subarachnoid haemorrhage. The occurrence of aortic dissection in this setting has been reported only once previously.</p> <p>Case presentation</p> <p>We report the case of a 47 year old man who developed sudden onset right leg pain during coitus. This was initially believed to be neurological due to nerve impingement but an MRI failed to identify a prolapse. On further review after 6 weeks, pulses were noted to be absent in the patient's right leg and an urgent vascular review with investigation identified a dissection of the aorta which was subsequently successfully treated.</p> <p>Conclusion</p> <p>This case illustrates a rare presentation of aortic dissection and demonstrates the importance of a thorough vascular assessment in the presence of sudden onset limb pain.</p

Pancreatic cancer and predictors of survival: comparing the CA 19-9/bilirubin ratio with the McGill Brisbane Symptom Score

AbstractIntroductionFew tools predict survival from pancreatic cancer (PAC). The McGill Brisbane Symptom Score (MBSS) based on symptoms at presentation (weight loss, pain, jaundice and smoking) was recently validated. The present study compares the ability of four strategies to predict 9-month survival: MBSS, carbohydrate antigen 19-9 (CA 19-9) alone, CA19-9-to-bilirubin ratio and a combination of MBSS and the CA19-9-to-bilirubin ratio.MethodologyA retrospective review of 133 patients diagnosed with PAC between 2005 and 2011 was performed. Survival was determined from the Quebec civil registry. Blood CA 19-9 and bilirubin values were collected (n = 52) at the time of diagnosis. Receiver-operating characteristic (ROC) curves were used to determine a cutoff for optimal test characteristics of CA 19-9 and CA19-9-to-total bilirubin ratio in predicting survival at 9 months. Predictive characteristics were then calculated for the four strategies.ResultsOf the four strategies, the one with the greatest negative predictive value was the MBSS: negative predictive value (NPV) was 90.2% (76.9–97.3%) and the positive likelihood ratio (LR) was the greatest. The ability of CA 19-9 levels alone, at baseline, to predict survival was low. For the CA19-9-to-bilirubin ratio, the test characteristics improved but remained non-significant. The best performing strategy according to likelihood ratios was the combined MBSS and CA19-9 to the bilirubin ratio.ConclusionCA19-9 levels and the CA19-9-to-bilirubin ratio are poor predictors of survival for PAC, whereas the MBSS is a far better predictor, confirming its clinical value. By adding the CA19-9-to-bilirubin ratio to the MBSS the predictive characteristics improved

Circulating Fibroblast Growth Factor 21 Levels Are Closely Associated with Hepatic Fat Content: A Cross-Sectional Study

BACKGROUND AND AIMS: Fibroblasts growth factor 21 (FGF21), a liver-secreted endocrine factor involved in regulating glucose and lipid metabolism, has been shown to be elevated in patients with non-alcoholic fatty liver disease (NAFLD). This study aimed to evaluate the quantitative correlation between serum FGF21 level and hepatic fat content. METHODS: A total of 138 subjects (72 male and 66 female) aged from 18 to 65 years with abnormal glucose metabolism and B-ultrasonography diagnosed fatty liver were enrolled in the study. Serum FGF21 levels were determined by an in-house chemiluminescence immunoassay and hepatic fat contents were measured by proton magnetic resonance spectroscopy. RESULTS: Serum FGF21 increased progressively with the increase of hepatic fat content, but when hepatic fat content increased to the fourth quartile, FGF21 tended to decline. Serum FGF21 concentrations were positively correlated with hepatic fat content especially in subjects with mild/moderate hepatic steatosis (r = 0.276, p = 0.009). Within the range of hepatic steatosis from the first to third quartile, FGF21 was superior to any other traditional clinical markers including ALT to reflect hepatic fat content. When the patients with severe hepatic steatosis (the fourth quartile) were included, the quantitative correlation between FGF21 and hepatic fat content was weakened. CONCLUSIONS: Serum FGF21 was a potential biomarker to reflect the hepatic fat content in patients with mild or moderate NAFLD. In severe NAFLD patients, FGF21 concentration might decrease due to liver inflammation or injury

Outcome and quality of life after aorto-bifemoral bypass surgery

<p>Abstract</p> <p>Background</p> <p>Aorto-bifemoral bypass (AFB) is commonly performed to treat aorto-iliac disease and a durable long-term outcome is achieved. Most studies documenting beneficial outcomes after AFB have been limited to mortality and morbidity rates, costs and length of hospital stay (LOS). Few studies have examined the dependency of patients and how their perception of their own health changes after surgery. The aim of the present study was to evaluate outcome after AFB and to study its determinants.</p> <p>Methods</p> <p>This retrospective study was carried out in the multidisciplinary Post-Anaesthesia Care Unit (PACU) with five intensive care beds. Out of 1597 intensive care patients admitted to the PACU, 75 were submitted to infrarenal AFB and admitted to these intensive care unit (ICU) beds over 2 years. Preoperative characteristics and outcome were evaluated by comparing occlusive disease with aneurysmatic disease patients. Six months after discharge, the patients were contacted to complete a Short Form-36 questionnaire (SF-36) and to have their dependency in Activities of Daily Living (ADL) evaluated. Patient's characteristics and postoperative follow-up data were compared using Mann-Whitney U test, t test for independent groups, chi-square or Fisher's exact test. Patient preoperative characteristics were evaluated for associations with mortality using a multiple logistic regression analysis.</p> <p>Results</p> <p>The mortality rate was 12% at six months. Multivariate analysis identified congestive heart disease and APACHE II as independent determinants for mortality. Patients submitted to AFB for occlusive disease had worse SF-36 scores in role physical and general health perception. Patients submitted to AFB had worse SF-36 scores for all domains than a comparable urban population and had similar scores to other PACU patients. Sixty-six percent and 23% of patients were dependent in at least one activity in instrumental and personal ADL, respectively, but 64% reported having better general health.</p> <p>Conclusion</p> <p>This study shows that congestive heart disease and APACHE II were risk factors for mortality after AFB surgery. Survivors who have undergone AFB perceive an improved quality of life although they are more dependent in ADL tasks and have worse scores in almost all SF-36 than the population to which they belong.</p