Mesenteric lymphangioma is a benign cystic tumour of the lymphatic vessels that occurs rarely in adults. Due to the infrequency of cases and the insidious presentation, these tumours can be diagnosed late and become massive. Resection of mesenteric lymphangioma in its entirety is the recommended management in order to prevent recurrence. This case report describes the finding of a massive mesenteric lymphangioma (dimensions 420×470×100 mm) in a young man, the investigations leading to diagnosis, and the subsequent surgical management. The substantial size of this tumour produced considerable challenges for the surgical team, including involvement of adjacent small bowel and mesenteric vasculature. Preoperative diagnosis and assessment of the anatomy was pivotal in achieving a complete resection and a good patient outcome.

Dialysis access steal syndrome is a well-recognised complication, affecting 1%–8% of all patients who undergo arteriovenous fistula formation particularly those that are brachial based. We present a case of ongoing steal syndrome following a DRIL procedure via retrograde flow in the ulnar artery. This was managed via a hybrid procedure and the use of an Amplatzer plug. This case demonstrates a novel use for the Amplatzer occlusion device, it is also a reminder that failure to occlude the vessel close to the fistula anastomosis can result in continued steal despite a functioning DRIL bypass.

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SirI would like to correct a misinterpretation of my recommendations relating to the scope of surgery for venous ulceration in limbs with post-thrombotic deep vein incompetence as quoted in the article by Negus and Friedgood (Br J Sztrg 1983: 70: 623-7). The source of this misinformation was a presentation of mine to the First International Vascular Symposium. London 198 I , entitled 'Chronic lower limb insufficiency -evaluation classification and the scope of surgery'. The proceedings of this symposium were not published but are available for verification on tape.In Those limbs in the latter IWO groups manifest varying degrees of post-thrombotic deep venous insufficiency. Pre-operatively the group with MVI delineated on the basis that AVP measurements revealed significant superficial insufficiency superimposed on the deep venous deficit. Evaluation of these limbs after surgical elimination of the superficial incompetences which included ligation of perforators confirmed the haemodynamic significance of the superficial incompetences and confirmed the deep venous insufficiency component in those limbs. The fourth group of limbs were classified as post-phlebitic on the basis that AVP measurement failed to reveal any evidence of haemodynamically significant superficial venous insufficiency. These limbs were not subjected to operation. It might be that surgery to superficial incompetences would improve these limbs as Negus and Friedgood suggest. However as yet there are no haemodynamic data to suggest such an improvement. In support of my policy is the observation that in the group of limbs with MVI the operative gain from elimination of superficial incompetences was altogether in keeping with the pre-operative prediction of improvement based on AVP measurements.What I do advocate is documentation ot the venous naemodynamics in all these complicated limbs with post-thrombotic deep venous insufficiency, to identify those limbs with significant superficial incompetences where predictable haemodynamic improvement will result from surgery to the superficial veins. I have yet to be convinced of the value of surgery to superficial incompetences in the post-phlebetic limb where the pre-operative venous pressure measurements do not produce any significant improvement on application of a superficial tourniquet. P.E. Kiely Sidney Place CorkAuthor's response: reply from Mr D. Negus SirThank you for allowing me to reply to Mr Patrick Kiely's letter. If I have misinterpreted him I unreservedly apologize. I entirely agree that objective evaluation must be the basis for the effective treatment of any venous disorder and particularly in the management of the post-phlebetic limb. Like him, we use Doppler ultrasound and phlebography in our clinic, though we prefer the non-invasiveness of photoplethysmography to venous manometry. There is usually no indication for surgery in the post-phlebetic limb without ulceration, unless proximal stenosis requires some form of by-pass procedure. Kiely does not make it clear whether his group (d) is...

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