A total of 40 patients with pancreatitis had associated extrahepatic biliary obstruction. Eighteen had biliary-induced pancreatitis. Comprehensive correction of the biliary tract disease, including cholecystectomy, common duct exploration and, when indicated, transduodenal sphincteroplasty, resulted in a high recovery rate (83%) with no recurrence of pancreatitis. Twenty-two patients had chronic pancreatitis with involvement of the terminal biliary tract by a long tapering stenosis. Nineteen of these patients had chronic fibrocalcific pancreatitis secondary to chronic alcohol abuse. In five patients, the stenosis produced a high grade obstruction which required biliary bypass with choledochoduodenostomy (four) or cholecystoduodenostomy (one). The remaining 14 patients maintained patency of the biliary tract following correction of the underlying pancreatic pathology. The latter consisted of drainage (nine) or resection (five) of 14 associated pseudocysts (present in 64% of the 22 patients), combined with side-to-side pancreaticojejunostomy to decompress an obstruction of the major pancreatic duct. In assessing the degree of terminal bile duct stenosis, calibration of the duct with Bakes dilators or rubber catheters was a useful aid. Two of the 22 patients ultimately proved to have carcinomas, producing obstruction of the pancreatic duct in the head of the gland. Both were treated initially with choledochoduodenostomy. This possibility must be considered in the management of these patients.

Associates , Lake Charles , LouisianaWires and pins are some of the appliances most widely used by orthopaedic surgeons to obtain fixation. The migratory tendency of these implants has also been documented, especially around the shoulder. 1,6,7,9,12,14 This case report emphasizes the hazards of migration of pins used for sternoclavicular joint stabilization. CASE REPORTA 45-year-old woman sustained a traumatic anterior dislocation of her right sternoclavicular joint. At another institution, she had a closed reduction and percutaneous pinning using two smooth Kirschner wires.Approximately 5 weeks after the operation she complained of retrosternal discomfort and pain in the left third intercostal area. Roentgenograms of the chest showed mediastinal migration of one of the Kirschner wires ( Fig. 1). Computerized tomography demonstrated the pin in the mediastinum, parallel to the aorta (Fig. 2). She was referred to our institution for further treatment.Vital signs were normal on admission. Examination was unremarkable except for erythema, mild swelling, and mild tenderness around the right sternoclavicular joint. In addition, there was mild tenderness at the left third intercostal area. The patient was admitted for elective thoracotomy to be done the next morning.Shortly after admission, she developed signs and symptoms of cardiac tamponade, as demonstrated by tachypnea, severe retrosternal pressure, hypotension, and jugular venous distension. An emergency thoracotomy was performed through a median sternotomy. A large pericardial hematoma Figure 1. Chest radiograph showing migration of Kirschner wire into mediastinum.was encountered as well as a laceration in the right ventricle secondary to the Kirschner wire, which was in the right ventricle. The Kirschner wire was removed, and the myocardial laceration was repaired.In addition, the right sternoclavicular joint was explored and the remaining Kirschner wire was removed. Debridement of the joint was done, and a Gram's stain of the material showed Gram-positive cocci. Intravenous antibiotics were given and cultures showed Staphylococcus epidermidis. Antibiotic treatment was rendered. Her postoperative course was uneventful, and she was discharged from the hospital approximately 11 days after the operation.Six weeks after the operation, she had full range of motion of her shoulder without pain and demonstrated no instability of the sternoclavicular joint.t Address correspondence and reprint requests to: David Drez, Jr., MD, 2615 Enterprise Boulevard, Lake Charles, LA 70601.