IntroductionAn internal hernia is a protrusion of bowel through a normal or abnormal orifice in the peritoneum or mesentery. Although they are considered as a rare cause of intestinal obstruction, paraduodenal hernias are the most common type of congenital hernias.MethodsA literature search using PubMed was performed to identify all published cases of left paraduodenal hernia (LPDH).ResultsIn Literature search between 1980 and 2012 using PubMed revealed only 44 case reports before the present one. Median age was 47 years (range 18 – 82 years). Nearly 50% reported previous mild symptoms. Two-third of patients required emergency surgery in form of laparotomy or laparoscopic repair. Reduction of hernia contents with widening or suture repair of the hernia orifice were the most common standards in surgical management of LPDH.ConclusionIntestinal obstruction secondary to internal hernias is a rare presentation. High index of suspicion and preoperative imaging are essential to make an early diagnosis in order to improve outcome.

Venous pro-inflammatory cytokine changes (IL-6) are consistent with significantly greater lower-torso reperfusion injury in patients undergoing OR. Smaller responses were seen after ER (IL-6 and IL-8), although both groups showed a similar anti-inflammatory response (IL-10); this pro- and anti-inflammatory imbalance may account for the increased morbidity associated with OR.

AimsTo investigate whether aneurysm shape and extent, which indicate whether a patient with ruptured abdominal aortic aneurysm (rAAA) is eligible for endovascular repair (EVAR), influence the outcome of both EVAR and open surgical repair.Methods and resultsThe influence of six morphological parameters (maximum aortic diameter, aneurysm neck diameter, length and conicality, proximal neck angle, and maximum common iliac diameter) on mortality and reinterventions within 30 days was investigated in rAAA patients randomized before morphological assessment in the Immediate Management of the Patient with Rupture: Open Versus Endovascular strategies (IMPROVE) trial. Patients with a proven diagnosis of rAAA, who underwent repair and had their admission computerized tomography scan submitted to the core laboratory, were included. Among 458 patients (364 men, mean age 76 years), who had either EVAR (n = 177) or open repair (n = 281) started, there were 155 deaths and 88 re-interventions within 30 days of randomization analysed according to a pre-specified plan. The mean maximum aortic diameter was 8.6 cm. There were no substantial correlations between the six morphological variables. Aneurysm neck length was shorter in those undergoing open repair (vs. EVAR). Aneurysm neck length (mean 23.3, SD 16.1 mm) was inversely associated with mortality for open repair and overall: adjusted OR 0.72 (95% CI 0.57, 0.92) for each 16 mm (SD) increase in length. There were no convincing associations of morphological parameters with reinterventions.ConclusionShort aneurysm necks adversely influence mortality after open repair of rAAA and preclude conventional EVAR. This may help explain why observational studies, but not randomized trials, have shown an early survival benefit for EVAR.Clinical trial registration:ISRCTN 48334791.

Medical therapy to improve symptoms, stabilise the underlying vascular disease and improve lower limb outcomes is an important and effective adjunct to lifestyle modification and surgical or endovascular interventions in patients with IC. Randomised placebo controlled trials have shown that the phosphodiesterase III inhibitor cilostazol 100mg bid improves pain-free and maximum walking distance, as well as quality of life, in a range of patients with intermittent claudication in whom there is no evidence of tissue necrosis or rest pain. This review summarises the evidence from 8 pivotal trials of cilostazol involving over 2000 patients with intermittent claudication treated for up to 6 months. There is comparatively less evidence to support the use of other treatment modalities for relief of symptoms in intermittent claudication, but there is considerable interest in therapeutic angiogenesis to promote new vessel formation and enhance collateralisation of the lower limb using recombinant growth factor proteins or gene transfer strategies. The rationale for therapeutic angiogenesis is discussed, together with the most recent results from randomised trials in patients with peripheral arterial disease.

PGE1 and iloprost enhance muscle blood flow at 4-h reperfusion, though neither abolishes low reflow; PGE2 improved flow at 10 and 120 min but not after 240 min. This study demonstrates a potentially beneficial role for prostaglandins in improving muscle blood flow in skeletal muscle ischaemia-reperfusion injury.