It is suggested that arterio-venous fistulae using proximal radial or ulnar arteries can be performed before brachio-cephalic fistulae since they offer long-term patency and reduced incidence of steal syndrome. Brachio-cephalic AVF can be performed subsequently if necessary.

Introduction: Laparoscopic assisted colonoscopic polypectomies have been well described in the literature and are well established in surgical practice, for removal of large, inaccessible, or flat based polyps. Laparoscope allows the endoscopist a serosal viewpoint and thus clear indication of perforation, in addition to enhancing endoscopic positioning through colonic mobilisation, facilitating polypectomy. We describe a previously rarely published technique, in which the colonoscope directs the surgeon to polyps and laparoscopy enables wedge resection of benign polyps using Endo GIA staplers. Using this method, the colonoscope provides an intra-luminal view ensuring adequate excision with margins whilst the laparoscope provides intra-peritoneal access for the wedge resection. Methods: This is a case series of 12 patients with large tubulovillous adenomas, found and biopsied at colonoscopy. Under a general anaesthetic, an on table colonoscopy was performed to identify and reassess the polyp, whilst a laparoscopy was performed to excise the polyp via wedge resection, using the endoscopic view as guidance. Results: The polyp was identified and completely resected in our 12 patients. All patients were discharged on the first post-operative day. Of the polyps excised, a focus of adenocarcinoma was detected in one and an adjacent endocrine tumour was found in another patient in histology along with tubulovillous adenoma. Rest were all tubulovillous adenomas only. Conclusion: We propose that this technique should be regarded as an alternative to Right hemicolectomies and difficult endoscopic mucosal resections for large adenomas, and be regarded as a definitive and safe procedure in its own right.

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Boerhaave's syndrome is a rare clinical entity. It is caused by severe straining, vomiting or prolonged severe coughing, affecting the distal intrathoracic part of oesophagus. The clinical presentation is varied and associated with high mortality if there is a delayed diagnosis. Therefore, the mainstay of treatment is early diagnosis, drainage of intrathoracic collection if indicated and restoration of the oesophagal integrity. The recurrent Boerhaave's syndrome is rare, and only a few cases have been reported in the literature. We present a 27-year-old female diagnosed to have Boerhaave's a year back which was managed conservatively, presented to hospital with sudden onset of epigastric pain radiating to left shoulder and chest associated with multiple episodes of vomiting. Abdominal examination revealed a tender epigastric region with elevated white cells and C-reactive protein. CTTAP showed a recurrent para-oesophageal collection of fluid and gas adjacent to the distal oesophagus at the same site, with no pneumoperitoneum. She was managed conservatively for a week with peripheral nutrition. The CTTAP was repeated with oral contrast, which showed partially improved left para-oesophageal collection, and surrounding inflammatory changes had also partly improved with no leak of contrast. She was hemodynamically stable, clinically well, and tolerated oral feeds, so she was discharged from the hospital. As the recurrent presentation is rare, the treatment should be customised for individuals as per their clinical condition. We emphasis on recognising this condition in both acute and chronic condition, which could be vital in preventing the mortality from this condition.

Boerhaave's syndrome is a rare but well established clinical condition with spontaneous longitudinal rupture of the oesophagus. It is a life-threatening condition with a mortality rate of up to 40%. The symptoms are variable or classical Mackler triad of Vomiting, chest pain and subcutaneous emphysema are noted. However, it is challenging or missed to diagnose this condition in patients with chronic symptoms. We present an unusual presentation of Boerhaave syndrome in a 27-year-old female with no comorbidity presented to the emergency department with acute onset of shortness of breath and chest pain. Blood tests showed elevated D-Dimer on initial evaluation, and the rest of them were unremarkable. A CT pulmonary angiogram was done, which showed thickened lower oesophagus. She was reassured and sent home from the emergency department. Further discussion of the CT images in the upper GI MDT revealed that she had a small sealed off perforation of the oesophagus. The repeat scan after a few days as Outpatient demonstrated a sealed oesophageal perforation and a small collection. The water-soluble contrast swallow did not reveal any leak or stricture in the oesophagus. The patient had a gastroscopy after two months which was reported to be normal. Retrospectively, the patient mentioned that she had an episode of vomiting a few weeks earlier to this acute presentation to the hospital. The knowledge about this condition and high suspicion in patients with chronic presentation is vital to diagnosing this potentially lethal condition which could be critical in preventing mortality and morbidity from this condition.