[Pancreas-preserving duodenectomy in acute situations. Surgical treatment of an iatrogenic hemorrhage in the duodenal wall]. / Pankreaserhaltende Duodenektomie in der Akutsituation.: Operative Therapie einer iatrogenen Einblutung in die Duodenalwand.

We report the case of a 24-year-old patient who underwent a duodenal biopsy due to the suspicion of graft-versus-host disease following allogeneic stem cell transplantation 3 months previously. The patient developed severe upper abdominal pain after the biopsy. A computed tomography scan revealed diffuse hemorrhaging in the duodenal wall and mesenteric root. Following supraselective angioembolization to stop the bleeding a control computed tomography scan was carried out the following day and revealed increasing destruction of the duodenal wall due to a dissecting aneurysm. A pancreas-preserving duodectomy was carried out.

Traumatic arteriovenous fistula of the internal mammary vessels.

An uncommon case of traumatic arteriovenous fistula of the left internal mammary artery following penetrating chest trauma is presented. The patient developed a left parasternal machinery murmur six days after thoracotomy to repair a pericardial tamponade after a penetrating left parasternal stab wound. Selective digital subtraction angiography revealed pseudoaneurysm formation with fistulous connection of the left internal mammary artery to the adjacent vein. The fistula was successfully occluded with coil embolization.

[Successful catheter-guided local thrombolysis in acute pulmonary embolism in the early postoperative period after pancreatic head resection]. / Erfolgreiche lokale Katheterfragmentation und Thrombolyse bei akuter Lungenembolie in der frühen postoperativen Phase nach Pankreaskopfresektion.

Pulmonary embolism in the early postoperative period is characterized by high morbidity and mortality. Systemic application of thrombolytic agents during this time is contraindicated; operative thrombectomy also has a high mortality rate. We report a case of successful local lysis in combination with catheter fragmentation of a massive two-sided pulmonary embolism diagnosed on the 4th postoperative day after pylorus-preserving duodenopancreatectomy for distal carcinoma of the common bile duct. Thrombolysis was performed in three sessions by a combination of catheter-supported interventional fragmentation of the thrombus with local rt-PA lysis. There were no bleeding complications or disturbances of anastomotic healing. The patient was discharged from the hospital on the 23rd postoperative day after changing anticoagulation to a vitamin K antagonist. The case presented demonstrates the possibility of local lysis in combination with interventional methods as a therapeutic option for pulmonary embolism in the early postoperative period as an alternative to surgical strategies.

[Diagnosis and management of an intraoperative vertebral artery injury]. / Diagnose und Notfallmanagement einer intraoperativen Verletzung der Arteria vertebralis.

A patient with cervical myelopathy caused by marked degenerative alterations of the cervical spinal column at the level of cervical vertebrae 3/4 and relative spinal canal stenosis in the area of cervical vertebrae 5-7 was treated in the department of neurosurgery because of progressive myatrophy and paresis of muscles innervated from cervical nerves 5-7. The operation was performed with vertebrectomy of cervical vertebra 6, implantation of a Harms titanium cage with autograft and a plate and spongy bone screw fixation system. There exists an unusual--and not often publicized--complication during this surgical procedure in the area of the cervical spine, namely penetrating injury of the vertebral artery caused by the treatment with a plate and spongy bone screw fixation system. We describe such an injury of the left vertebral artery. The vertebral artery was intraoperatively embolized using mechanical embolization coils.

Serum levels of extracellular matrix in acute pancreatitis.

BACKGROUND/AIMS: Elevated levels of serum markers of extracellular matrix, i.e., the amino-terminal procollagen-III-peptide, hyaluronic acid and laminin are found in various diseases. The study aims to examine a panel of these parameters in patients with acute pancreatitis and correlate them with the course and severity of the disease. METHODOLOGY: We prospectively examined the time-course of procollagen-III-peptide, hyaluronic acid and laminin in 24 consecutive patients with acute necrotizing (n = 13) or edematous (n = 11) pancreatitis. Patients with chronic pancreatitis with (n = 10) or without (n = 17) acute pain, and 6 patients in complete remission after an episode of acute pancreatitis as well as healthy individuals served as controls. In addition, serum levels of collagen VI and undulin were followed in 10 and 9 patients with acute necrotizing pancreatitis, respectively. RESULTS: The serum concentrations of procollagen-III-peptide, hyaluronic acid and laminin were significantly higher at the onset of acute necrotizing pancreatitis compared to edematous pancreatitis and the controls. They returned to almost normal levels during the course of the disease when the patient recovered, but remained elevated in patients with a lethal course. Laminin allowed us to discriminate between patients with necrotizing pancreatitis from all other forms of pancreatitis on admission (specificity 82%, sensitivity 92%, PPV 86%, NPV 90%). Collagen type VI levels were 2-3-fold higher in sera of patients with acute pancreatitis than in healthy controls, whereas the results for undulin were inconclusive. CONCLUSIONS: Since markers of matrix metabolism (especially laminin) are differently elevated in acute necrotizing versus edematous pancreatitis, we suggest that they might be used as parameters for the outcome.

[Spontaneous, massive liver hemorrhage as a complication of thrombolysis with ultra-high dose streptokinase in deep thrombophlebitis]. / Spontane, massive Leberblutung als Komplikation der Thrombolyse mit ultrahoch-dosierter Streptokinase bei tiefer Beinvenenthrombose.

We report on a rare case of spontaneous, life-threatening liver bleeding as a major complication of thrombolysis using short-term, ultrahigh streptokinase in deep venous thrombosis. The event occurred in a female patient (age 40 years) who presented no contraindication to thrombolytic therapy. Intraabdominal bleeding was suspected during intravenous streptokinase infusion. Emergency laparotomy revealed four liter of unclotted blood resulting from two ruptured subcapsular liver haematomas. Local haemostasis was achieved and the integrity of the liver restored. Multiple transfusions of red blood cells, fresh frozen plasma and fibrinogen were given. The postoperative period was uneventful and the patient recovered gradually. The patient could be discharged from the hospital in good health. Diagnostic and therapeutic approaches to this rare complication of thrombolysis are discussed. Additionally, a brief review of previously reported cases is provided.

[Coronary artery fistula--surgical or percutaneous embolization treatment?]. / Koronararterienfistel--chirurgische oder perkutane Embolisationsbehandlung?

Three children aged 4 months, 2.7 and 7 years with the unusual fistula of the left coronary artery to the right atrium were observed over a 2-year period. The two younger children underwent emergency surgery although they showed no clinical symptoms. The reasons for surgical intervention were an aneurysm in the right atrium with obstruction of the vena cava superior and a considerably enlarged fistula, respectively. In the older child, we percutaneously embolized a terminate fistula of the ramus circumflexus with two platinum microcoils without complications. Two-dimensional-echocardiography and color flow mapping were used to confirm the diagnosis. After such diagnosis we recommend a coronary angiography in every case. The transcatheter-coil-embolization is an alternative method to surgical closure in selected cases. We recommend an early onset intervention in case of congenital coronary artery fistula.