Successful management of a blunt pancreatic trauma by endoscopic stent placement.

The present study reports a case involving a 17-year-old man who was brought to the emergency department of our hospital with severe upper abdominal pain following a blow received in a rugby game. Emergency computed tomography (CT) revealed severe pancreatic neck injury, and the patient was subsequently given conservative treatment in the High Care Unit. Forty-eight hours later, follow-up enhanced CT revealed that the pancreas was clearly lacerated and the amount of peripancreatic fluid was increasing; furthermore, serum amylase and elastase levels were elevated. Endoscopic retrograde pancreatography revealed that contrast medium in the main pancreatic duct (MPD) had leaked to the parenchyma, indicating an MPD injury. To prevent traumatic pancreatitis from worsening, a stent was inserted endoscopically to a site distal to the injured portion of the MPD. Thereafter, the patient's condition dramatically improved, and his serum amylase levels returned to normal. CT revealed that the apparent pancreatic edema and peripheral fluid were also decreased. During a short-term follow-up period of 6 months, removal of the stent was uneventfully carried out and the patient did not develop any exocrine or endocrine insufficiency. We suggest that, in some cases, endoscopic management of traumatic pancreatic duct disruption is feasible and effective.

Clinical and social consequences of Buerger disease.

PURPOSE: This study was undertaken to assess the clinical course of Buerger disease and to analyze the social problems that influence quality of life of affected patients. PATIENTS AND METHODS: One hundred ten patients with Buerger disease (106 men, 4 women; mean age, 40.0 years) for whom complete data since onset of disease were available were included in this retrospective study (mean follow-up, 10.6 years). Data were obtained by means of direct interview, written reports, or telephone. Data for deceased subjects were gathered from their families via written report or telephone. Graft patency was evaluated by means of ankle pressure measurement; and in all patients with decreased ankle pressure arteriography was performed. RESULTS: Seven of 110 study patients (6%) died during follow-up. Cumulative survival rate was 84% up to 25 years after the initial consultation. Results of bypass operations (n = 46) were not satisfactory. Primary graft patency was 41% at 1 year after operation, 32% at 5 years, and 30% at 10 years. Secondary graft patency was 54% at 1 year of follow-up, 47% at 5 years, and 39% at 10 years. However, major amputation was necessary in only 5 of 35 limbs (14%) with failed grafts. Forty-seven patients (43%) underwent 108 amputation procedures, either major amputation (13 patients) or minor amputation (34 patients), of an upper or lower limb. No ischemic ulcers occurred or recurred in patients older than 60 years. Forty-one patients who stopped smoking did not undergo major amputation. Furthermore, of 69 patients who continued smoking, 13 patients (19%) underwent major amputation. There was a correlation between incidence of continued smoking and limb amputation (P =.0070). In addition, 11 of 13 patients who underwent major lower limb amputation (85%) lost their job, compared with 9 of 97 patients without major amputation (9%). There was an association between limb amputation and job loss (P <.0001). All patients who lost their jobs were engaged in manual labor. CONCLUSION: The natural course of life and limb is favorable in many patients with Buerger disease. Occurrence or recurrence of necrotic lesions usually is arrested in patients older than 60 years. To avoid factors that markedly influence quality of life, early treatment and strict instruction to prohibit smoking are mandatory. Arterial reconstruction shortens the healing process of ischemic ulcers, despite poor long-term results. However, bypass surgery to treat intermittent claudication should be limited.

Simultaneous open and endoluminal repair of ruptured abdominal and thoracic aortic aneurysms: report of a case.

A 66-year-old woman was transferred to our hospital for emergency treatment of a ruptured abdominal aortic aneurysm (AAA) and impending rupture of a descending thoracic aortic aneurysm (TAA) caused by a Stanford type-B dissection. She had severe coronary artery disease and a highly calcified aorta, and had been taking long-term steroids for rheumatoid arthritis. Endovascular repair of the TAA failed because the femoral artery was too small, so we performed simultaneous repair of the TAA and the AAA. A temporary axillofemoral bypass was constructed and the AAA was replaced with a bifurcated prosthetic graft. A thoracic stent graft was delivered successfully through a chimney graft of the abdominal graft. About 4 months later, the TAA extended proximally, causing hemoptysis, which was stopped by placing a new stent graft proximal to the previous one. This case report shows that a combination of open and endovascular repair is useful for treating a TAA with an AAA, especially in a small or frail patient.