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Pancreaticoureteral fistula following penetrating abdominal trauma [Case Report]

Wolf, Joshua H; Miller, George; Ashinoff, Russell; Dave, Jasmine; Lefleur, Richard S; Frangos, Spiros G; Miglietta, Maurizio A
CONTEXT: The main pancreatic duct can form a fistulous communication with another epithelium in the setting of prolonged inflammation, operative manipulation, or direct trauma. We present a rare complication of a pancreaticoureteral fistula following a trauma nephrectomy. CASE REPORT: A 17-year-old male who sustained a gunshot wound to the back arrived to our Emergency Room hyopotensive, tachycardic, and with free intraperitoneal fluid on focused assessment sonography for trauma (FAST) exam. He was taken to the operating room for an exploratory laporatomy where a left nephrectomy was performed to control active bleeding from the left renal hilum. Significant bleeding was also encountered at the portal venous confluence. After packing and damage control laparotomy, the periportal/pancreatic bleeding was controlled during a second procedure 6 hours later. After one month in the Intensive Care Unit with an open abdomen, a computed tomography (CT) scan revealed a fluid collection in the splenic fossa which was drained by catheter. Persistent drainage revealed a high amylase concentration (greater than 50,000 U/L). A fistulogram revealed interruption of the main pancreatic duct, and a fluid collection by the tail of the pancreas that was in communication with the left ureter. The patient's urine amylase was also elevated. The patient was treated non-operatively given the healing open abdomen and controlled fistula. He had an otherwise uncomplicated recovery. CONCLUSIONS: This is the second report of a pancreaticoureteral fistula in the literature. Treatment of this communication should be similar to that of other pancreatic fistulae
PMID: 17873469
ISSN: 1590-8577
CID: 74304

Osler-Weber-Rendu disease. Diagnosis and management of spontaneous hemothorax during pregnancy [see comments] [Comment]

Bevelaqua FA; Ordorica SA; Lefleur R; Young B
PMID: 1484630
ISSN: 0028-7628
CID: 13345

Significance of an enlarged splenic artery in patients with splenic vein thrombosis

Dumont AE; Lefleur RS
In an attempt to determine the relationship, if any, between the size of the splenic artery and various clinical aspects of splenic vein thrombosis, including splenomegaly, the clinical and angiographic findings in ten patients with this disorder were reviewed. The size of the splenic artery was found to be unrelated to the nature of the underlying disease, age of the patient, or history of variceal bleeding. An abnormally wide and tortuous splenic artery was identified only in those patients (five) in whom there was also radiographic evidence of splenic enlargement. Since the angiographic finding of an enlarged and tortuous splenic artery is known to correlate closely with increased flow in this vessel, this observation suggests that in patients with isolated splenic vein obstruction an increase in splenic artery flow accompanies splenic enlargement and is probably a critical component of the underlying derangement
PMID: 3178047
ISSN: 0003-1348
CID: 10945

Intralobar pulmonary sequestration: MR evaluation [Case Report]

Naidich DP; Rumancik WM; Lefleur RS; Estioko MR; Brown SM
This report documents the use of magnetic resonance (MR) in evaluation of intralobar pulmonary sequestration. Because of its distinctive multiplanar capabilities and nonreliance on contrast media to visualize blood vessels, MR can be used to define and characterize the size and course of anomalous arterial feeding vessels. Furthermore, MR can be of value in detecting the presence of mucoid-impacted bronchi within abnormal segments of the lung. It is concluded that in select cases MR may obviate the need for more invasive procedures to establish the diagnosis of pulmonary sequestration
PMID: 3571602
ISSN: 0363-8715
CID: 23440

CT evaluation of esophageal varices

Balthazar EJ; Naidich DP; Megibow AJ; Lefleur RS
CT findings in 20 consecutive patients with proven esophageal varices are reviewed and analyzed. In 85% of patients, abnormalities were seen involving the esophageal wall and/or periesophageal region. In 65%, findings specific to varices were present: thickening of esophageal wall, a scalloped contour, and intraluminal protrusions enhancing after a contrast bolus injection. These findings were seen alone or in association with periesophageal varices, which were seen in 45% of patients; evidence of portal hypertension with varices in the lesser omentum was present in 95%. CT has a sensitivity similar to barium esophagram but evaluates better the presence and extent of periesophageal varices and portal hypertension. Normal CT does not rule out esophageal varices because small varices may escape detection, particularly in scans done without a contrast bolus injection
PMID: 3491501
ISSN: 0361-803x
CID: 23441

Auto-injection of the corpus cavernosum with a vasoactive drug combination for vasculogenic impotence

Zorgniotti AW; Lefleur RS
Intracavernous injection of papaverine hydrochloride with phentolamine mesylate rapidly produces transitory penile tumescence, which can be followed by erection and coitus provided there is sexual stimulation. Coital penetration was possible in 59 of 62 patients with impotence of divers etiologies (vascular, diabetic, iatrogenic and Peyronie's disease) who underwent injection and were sent home to attempt coitus. One patient had a prolonged erection that was treated successfully with aspiration of a corpus. When coitus was successful the patient was offered training in self-injection. With self-injection 18 patients have had satisfactory coitus without a noteworthy complication; 5 for more than 12 months. The long-term effects of intracavernous injections remain unknown. Intracavernous injection of vasoactive substances (chemical prosthesis) may become a useful alternative treatment. Administration should be restricted to urologists able to manage the possible complication of priapism
PMID: 2578067
ISSN: 0022-5347
CID: 23443

CT evaluation of pancreatic injury following splenectomy

Balthazar EJ; Megibow A; Rothberg M; Lefleur RS
A fluid collection in the left subphrenic space immediately after splenectomy is often associated with pancreatic injury. The configuration, location, and vascular supply of the tail of the pancreas explain this postoperative complication. Depending on the degree of injury, the CT findings may show swelling of the tail of the pancreas, ill-defined fluid collections, or a well-encapsulated pancreatic pseudocyst. The diagnosis is confirmed by percutaneous aspiration with amylase determinations and the demonstration of a pancreatic fistula. Failure to diagnose this complication promptly may lead to a protracted postoperative clinical course and the development of a subphrenic abscess or a pancreatic pseudocyst
PMID: 3996828
ISSN: 0364-2356
CID: 23442

Portal venous thrombosis: correlative analysis of sonography, CT and angiography

Subramanyam BR; Balthazar EJ; Lefleur RS; Horii SC; Hulnick DH
In 17 patients with portal venous thrombosis; nine due to venous invasion by liver tumors, and eight due to benign causes, sonograms and CT scans were reviewed, and the results were correlated with angiography. Sonography detected portal venous thrombosis in 94% and CT in 76%. Sonography was better than CT in the demonstration of the extent of thrombosis. By the detection of solid masses in the liver, and contiguous thrombosis of the segmental portal veins, both sonography and CT were accurate in the differentiation of venous invasion by tumor from benign thrombosis. Angiography was 91% accurate and was unique in the demonstration of arterioportal shunting and detailed vascular anatomy of the portal venous system
PMID: 6385690
ISSN: 0002-9270
CID: 43900

Ultrasonic features of cholangiocarcinoma

Subramanyam BR; Raghavendra BN; Balthazar EJ; Horii SC; LeFleur RS; Rosen RJ
Sonographic features in 12 cases of proven cholangiocarcinoma were analyzed and correlated with findings on direct cholangiography. Proximal bile duct dilation was present in all cases of cholangiocarcinoma of the intrahepatic ducts except one. A neoplastic bile duct segment was detected in nine of the 12 cases. The neoplasms were seen as narrowed, normal-sized, or enlarged ducts, and contained intraluminal soft-tissue echoes or echogenic bands across the lumens. The sonographic accuracy was greater for lesions involving the bifurcation and the common hepatic duct than for common bile duct lesions. Cholangiography was superior to sonography in determining the length of the involved segment, whereas sonography was superior in detecting hepatic invasion and lymphadenopathy
PMID: 6090688
ISSN: 0278-4297
CID: 23444

Computed tomographic recognition of gastric varices

Balthazar EJ; Megibow A; Naidich D; LeFleur RS
The computed tomographic (CT) findings in 13 consecutive patients with proven gastric varices were analyzed and correlated with the radiographic, angiographic, and gastroscopic evaluations. In 11 patients, CT clearly identified large (five) or smaller (six) varices located mainly along the posteromedial wall of the gastric fundus and proximal body of the stomach. Well defined rounded or tubular densities that enhanced during intravenous administration of contrast material and could not be distinguished from the gastric wall were identified. Dense, enhancing, round or tubular, intraluminal filling defects were seen in the cases where the stomach was distended with water. In two patients, the CT diagnosis of gastric varices could not be confidently made. All patients had associated intraabdominal collateral circulation, situated medial to the stomach within the lesser omentum, along the distribution of the coronary venous system. In seven patients, the CT examination correctly diagnosed the pathogenesis of gastric varices by identifying hepatic cirrhosis, calcific pancreatitis, and carcinoma of the pancreas
PMID: 6609594
ISSN: 0361-803x
CID: 23445