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En bloc vascular resection and reconstruction for contiguous tumor involvement is feasible and safe in selected patients. Advanced pelvic tumors involving iliac vessels should not be precluded from curative surgery in specialized institutions.

1 We have identi®ed the P 2 receptors mediating vasomotor responses in the rabbit pulmonary artery. 2 Neither ATP nor UTP contracted intact or endothelium-denuded rings. However, both relaxed intact rings of rabbit pulmonary artery that had been preconstricted with phenylephrine (pD 2 5.2 and 5.6, respectively). 3 The vasodilator e ect of UTP was endothelium-dependent and abolished by the nitric oxide synthaseThe vasodilator e ect of ATP was only partially inhibited by removal of endothelium or addition of L-NOARG, suggesting an additional direct e ect on vascular smooth muscle. 5 The endothelium-dependent vasodilator responses to UTP and ATP were competitively antagonized by suramin. 6 Preconstricted, endothelium-denuded rings were also relaxed by 2-methylthio ATP (pD 2 6.6), a P 2Y receptor agonist. 7 Ca 2+ -mobilizing P 2U receptors were identi®ed on smooth muscle cells on the basis of single cell responses to ATP (pD 2 7.8) and UTP (pD 2 7.9; 6.7 in the presence of 100 mM suramin). 8 There was no evidence of a Ca 2+ -mobilizing P 2Y receptor in these cultured cells. 9 The data suggest the presence of (i) a suramin-sensitive P 2U receptor on endothelial cells that induces vasorelaxation through NO release, (ii) a suramin-sensitive P 2U receptor on cultured smooth muscle cells that mobilizes Ca 2+ but is not coupled to vasomotor responses and (iii) a putative P 2Y receptor on vascular smooth muscle cells that induces relaxation via a Ca 2+ -independent signal transduction pathway.

Aortoduodenal fistula 2 years after elective endovascular repair of an abdominal aortic aneurysm Aortoenteric fistula (AEF) is a rare complication after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysm (AAA). 1 An AEF is a pathological connection between the aorta and gastrointestinal tract that is invariably life-threatening. Primary AEFs occur de novo due to mechanical factors, aortic inflammation or infection. Secondary AEFs commonly involve a previously placed aortic graft. Almost all secondary AEF occur after open AAA repair but cases following EVAR are reported. 1-6 We present our experience with this rare complication, which is unique because it was only identified at time of operation. An 85-year-old female with a history of chronic lymphocytic leukaemia on ibrutinib and atrial fibrillation on rivaroxaban was referred to a vascular surgeon with a 38 × 30 mm incidental saccular infrarenal aortic aneurysm. There was no clinical evidence that the aneurysm was mycotic. She underwent an uncomplicated endovascular graft repair using a Gore Excluder AAA Endograft (W. L. Gore & Associates, Inc.; Newark, Delaware, US). Follow-up duplex ultrasound at 24 months post-operatively demonstrated a patent stent graft with no evidence of endoleak. Twenty-five months post-operatively, the patient developed left lower quadrant abdominal pain, night sweats and constipation. She denied any gastrointestinal bleeding. Investigation of her abdominal pain including a colonoscopy did not identify a cause. She

We present a highly unusual case of massive pulmonary embolism with secondary paradoxical systemic embolisation that was successfully resuscitated with veno-arterial extracorporeal membrane oxygenation (ECMO). This enabled subsequent successful bridging to pulmonary embolectomy.

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1 We con®rmed that endothelium-independent contraction of the rabbit pulmonary artery (RPA) is mediated through both an endothelin A (ET A R) and endothelin B (ET B2 R) receptor. 2 The response of endothelium-denuded RPA rings to endothelin-1 (ET-1, pD 2 =7.84+0.03) was only partially inhibited by BQ123 (10 mM), an ET A R antagonist. 3 Pretreatment with 1 nM sarafotoxin S6c (S6c), an ET B R agonist, desensitized the ET B2 R and signi®cantly attenuated the response to ET-3 (pD 2 =7.40+0.02 before, 56.50 after S6c). 4 Pretreatment with S6c had little e ect on the response to ET-1, but BQ123 (10 mM) caused a parallel shift to the right of the residual ET A R-mediated response to ET-1 (pD 2 =7.84+0.03 before S6c, 7.93+0.03 after S6c, 6.81+0.05 after BQ123). 5 Binding of radiolabelled ET-1 to early passage cultures of RPA vascular smooth muscle cells (VSMC) displayed two patterns of competitive displacement characteristic of the ET A R (BQ123 pIC 50 =8.73+0.05) or ET B2 R (S6c pIC 50 =10.15). 6 Competitive displacement experiments using membranes from late passage VSMC con®rmed only the presence of the ET A R (ET-1 pIC 50 =9.3, BQ123 pIC 50 =8.0, S6c pIC 50 56.0). 7 The ET A R was functionally active and coupled to rises in intracellular calcium which exhibited prolonged homologous desensitization. 8 Using a reverse transcriptase polymerase chain reaction for the rabbit ET B2 R, we demonstrated the absence of mRNA expression in phenotypically modi®ed VSMC. 9 We conclude that the ET B2 R expressed by VSMC which mediates contraction of RPA is rapidly down-regulated at the transcriptional level during phenotypic modulation in vitro.

BackgroundTo ensure the quality of surgical teaching within our graduate entry medical program, a distinctive surgical teaching program has been developed at Sydney Medical School-Central. Spanning 2 years, the program includes lectures, small group surgical clinical tutorials, and formal student surgical grand rounds presentations, plus clinical placements and attendance in operating theaters. We sought to evaluate the effectiveness of the program.MethodsIn 2013, at the completion of year 4, all graduating students (n=54) were asked to complete an open and closed-ended questionnaire regarding their experience of the surgical program.ResultsA total of 44/54 (81%) students completed the questionnaire. Students reported a high level of engagement with their experience in clinical tutorials, and a moderate level of engagement in surgical lectures. Students found the clinical attachment to be the least useful method of teaching, with the surgical grand rounds presentation also eliciting a poor response from students.ConclusionWhile both large group lectures and small group learner-centered teaching methods were highly valued by students, changes are needed to enhance clinical attachments for students in surgical wards. The benefits of students being made to feel part of a team during their surgical clinical attachments, along with adequate inpatient contact and formative feedback, should not be underestimated.