Venographic surveillance of tunneled venous access devices in adult oncology patients.

BACKGROUND: Tunneled venous access devices (VADs) are often essential in the care of patients with advanced malignancies, but they carry an uncertain risk of thrombosis. METHODS: To determine the incidence of venoocclusion related to silicone VADs in a population of adult oncology patients, we prospectively studied 50 individuals with upper extremity venograms approximately 6 weeks after their VADs had been implanted. Twenty-one of these patients were reevaluated with venograms approximately 12 weeks after catheterization. In addition, venograms were performed on a separate group of 24 patients who needed catheterization of axillary-subclavian veins that had been catheterized in the past. RESULTS: The 6-week venograms in the prospective study showed partial venous obstruction in 15 patients (30%), whereas three (6%) had developed symptomatic total venoocclusion by this time. The 12-week venograms showed two additional complete occlusions. Venograms of 30 previously catheterized veins showed complete venoocclusion in nine (30%), although only two had a history of thrombosis. CONCLUSIONS: Our observations indicate that VADs frequently cause partial venoocclusion within the first 6 weeks of catheterization and that permanent venous damage from VADs is common, even without a history of VAD-related thrombosis.

Upper extremity impedance plethysmography in patients with venous access devices.

Central venous access devices (VADs) are often associated with thrombotic obstruction of the axillary-subclavian venous system. To explore the accuracy of impedance plethysmography (IPG) in identifying this complication we performed IPG on 35 adult cancer patients before their VADs were placed and approximately 6 weeks later. At the time of the second IPG the patients also underwent contrast venography of the axillary-subclavian system. The venograms revealed partial venous obstruction in 12 patients (34%) and complete obstruction in two (5.7%). Although the IPG results from venographically normal and abnormal patients overlapped extensively, mean measurements of venous outflow were significantly lower in the patient population with abnormal venograms (P = 0.052 for Vo; P = 0.0036 for Vo/Vc). In our hands, therefore, upper extremity IPG cannot be used to make clinical decisions about individual patients with VADs, but it can distinguish venographically normal and abnormal populations.

Surgery in acute pancreatitis. The United States experience.

Considerable controversy has existed in the United States regarding the operative management of acute pancreatitis. Recently, areas of consensus have begun to form regarding necrotizing pancreatitis and biliary pancreatitis. However, the role of surgery and endoscopy for the prevention of recurrent acute pancreatitis in patients with pancreas divisum has not as yet been established. In the United States, few areas of contemporary surgery have remained as controversial as the operative approach to patients with acute pancreatitis. Recently, however, newer methodologies have appeared that seem capable of addressing those current surgical disputes that exist in necrotizing pancreatitis, biliary pancreatitis, pancreas divisum, and in the various complications of acute pancreatitis.