A successfully treated case of Lemmel syndrome with pancreaticobiliary maljunction: A case report.

BACKGROUND: Lemmel syndrome is a rare condition that leads to cholangitis and/or pancreatitis due to intraduodenal diverticulum. Surgery is considered for the treatment of severe or repeated symptoms in patients with this condition. CASE PRESENTATION: An 81-year-old woman was admitted to our hospital, complaining of general fatigue, BT 38.8 degree, and right hypochondoralgia. Her hepatobiliary enzyme levels were elevated, and enhanced abdominal computed tomography revealed dilation of the common bile duct and intraduodenal diverticulum. After restarting oral intake, her symptoms were exacerbated. Endoscopic retrograde cholangio-pancreatography (ERCP) revealed pancreaticobiliary maljunction and parapapillary diverticulum. Under a diagnosis of Lemmel syndrome with pancreaticobiliary maljunction complicated by acute pancreatitis and cholangitis, we performed extrahepatic bile duct resection with cholecystectomy and papilloplasty. Her postoperative course was uneventful, and the patient was discharged 20 days after surgery. She remains well at 5 months after surgery. CONCLUSION: We herein report a successfully diagnosed and treated case of Lemmel syndrome with pancreaticobiliary maljunction.

Long-term results of microscopic lymphatic vessel-isolated vein anastomosis for secondary lymphedema of the lower extremities.

PURPOSE: To evaluate the effectiveness of microscopic lymphatic vessel-isolated vein anastomosis in patients with secondary obstructive lymphedema of a lower extremity, refractory to nonoperative management. METHODS: Nine women suffered from nonpitting edema of one or both legs (11 limbs) after radical hysterectomy with postoperative irradiation for uterine cancer. The indications for this operation were repeated cellulitis and severe nonpitting edema impairing limb function. Under microscopy of 3.2 on average, the identified lymphatic vessels were anastomosed to an isolated saphenous vein using the pull-through technique with modifications. RESULTS: The follow-up period ranged from 21 to 87 months and the operation achieved excellent reduction, of more than 5 cm, in six limbs; good reduction, of 2-5 cm, in two limbs; and poor reduction, of less than 2 cm, in three limbs. The frequency of cellulitis decreased from 2.4 infections per patient per year to 0.2 infections per patient per year. CONCLUSION: These results show that microscopic lymphatic vessel-isolated vein anastomosis is a minimally invasive operation, with good long-term effects, making it the treatment of choice for intractable secondary lymphedema of the lower extremities refractory to physiotherapy.

Autologous peripheral blood mononuclear cell implantation for patients with peripheral arterial disease improves limb ischemia.

BACKGROUND: Implantation of bone marrow mononuclear cells, including endothelial progenitor cells, into ischemic limbs has been shown to improve collateral vessel formation. In the present study the safety and feasibility of autologous peripheral blood mononuclear cells (PBMNCs) implantation after granulocyte-colony stimulating factor (G-CSF)-induced mobilization was investigated in patients with severe peripheral arterial disease. METHODS AND RESULTS: Six cases were enrolled: 5 of thromboangitis obliterans and 1 of arteriosclerosis obliterans. Following administration of G-CSF (10 microg . kg(-1) . day(-1)), PBMNCs were harvested and injected intramuscularly (5 legs and 1 arm) for 2 days for the patients with ischemia of the legs. No serious adverse events related to G-CSF administration, harvest or implantation were observed during this study period. Improvement in the ankle - brachial pressure index (ABI: >0.1) was seen in 4 patients at 4 weeks and ischemic ulcers improved in 3 of 3 patients. The mean maximum walking distance significantly increased from 203 m to 559 m (p=0.031) at 4 weeks and was sustained for 24 weeks. Significant improvement was seen in physiological functioning subscale of Short Form-36. CONCLUSION: Implantation of PBMNCs collected after G-CSF administration could be an alternative to therapeutic angioplasty in patients with severe peripheral arterial disease.

Air plethysmographic assessment of external valvuloplasty in patients with valvular incompetence of the saphenous and deep veins.

PURPOSE: The indications for deep venous valvuloplasty remain controversial in patients with incompetent deep vein valves associated with primary varicose veins. The purpose of this study was to evaluate the usefulness of external femoral valvuloplasty performed simultaneously with varicose vein surgery from the standpoint of venous function determined with air plethysmography. PATIENTS AND METHODS: Thirty-one limbs of 25 patients (12 men, 13 women; mean age, 56.3 years; range, 33 to 80 years) with chronic venous insufficiency caused by valvular incompetence of both deep veins and saphenous veins were studied in a prospective, nonrandomized fashion. Descending phlebography showed moderate to severe reflux of grade 3 or 4 with Herman and Kistner classifications. Clinical severity of disease was CEAP classification 2S (in six limbs), classification 3 (in three limbs), classification 4 (in 16 limbs), classification 5 (in two limbs), and classification 6 (in four limbs). We performed superficial venous surgery alone in 14 limbs (control group), which consisted of stripping or ligation of incompetent saphenous veins and ligation of all incompetent perforators. In the remaining 17 limbs (study group), we performed superficial venous surgery simultaneously with external valvuloplasty of the femoral vein with intraoperative endoscopic observation. Venous reflux of the limbs was evaluated with air plethysmographic examination before surgery and at 1, 6, 12, and 24 months after surgery in both groups. RESULTS: Preoperative venous filling index (mean +/- standard deviation) in the control and study groups was 9.4 +/- 3.8 mL/min and 8.8 +/- 3.5 mL/min, respectively (not significant), and it decreased to 7.0 +/- 3.6 mL/min (P <.01) and 2.8 +/- 1.0 mL/min (P <.01), respectively, 1 month after surgery. Postoperative index values in the study group were significantly lower than values in the control group (P <.01), and this difference continued for more than 2 years after surgery (P <.05). After a follow-up period of 12 to 37 months (average, 25 months), the venous clinical severity score was higher in the control group (3.4 +/- 1.7) than in the study group (2.1 +/- 0.3; P <.05), and the venous disability score was higher in the control group (1.4 +/- 0.6) than in the study group (0.8 +/- 0.8; P <.05). CONCLUSION: Although further follow-up study is necessary, these results point to the functional and clinical usefulness of femoral valvuloplasty performed simultaneously with varicose vein surgery in patients with moderate to severe deep venous reflux. The venous filling index obtained with air plethysmography is an excellent predictor of the clinical severity of the disease and of postoperative clinical results.