Sarcoidosis of the pancreas: case report and review of the literature.

Sarcoidosis involving the pancreas is rare. Patients can present with symptoms that mimic pancreatic cancer. We report a case of a male patient with clinical and radiographic findings suggestive of pancreatic cancer as the initial manifestation of sarcoidosis.

Extrapericardial tamponade with herniated omentum after transhiatal esophagectomy.

An unusual complication following transhiatal esophagectomy for lower esophageal carcinoma is reported in which extrapericardial tamponade and profound shock occurred secondary to a herniated section of omentum in the immediate postoperative period. The two-dimensional echocardiogram was nondiagnostic, but the diagnosis was confirmed during reexploration of the abdomen. Anatomic and pathophysiologic considerations of this unusual but life-threatening complication are discussed. The literature suggests that computed tomography is the study of choice to confirm the clinical diagnosis of pericardial pathology, and this case report is yet another example to support routine closure of the esophageal aperture.

The consequences of a cavalier approach to central venous catheterization.

A cavalier approach on the part of some physicians, and poor research on the part of some equipment manufacturers, has made central venous catheterization more dangerous to the patient than it need be. Here, the relationship between these factors is discussed, with special reference to the fact that central venous catheterization is an invasive surgical operation which should not be taken lightly by its practitioners.

Internal hernia and gangrenous intestine. A rare complication of a femoral--femoral bypass graft.

An unusual case of an internal hernia related to a retropubic femoral-femoral bypass graft is presented. An orifice between the left and right inguinal ligaments and a protruding intraperitoneal portion of the prosthetic graft material resulted in herniation and strangulation of a portion of the small intestine. Technical factors (graft redundancy or misplacement) and natural factors (pulsatile erosion or age elongation) may be implicated. The potential for this complication exists in all grafts currently placed. The subcutaneous location appears to be a better technique.

Primary adenocarcinoma of the appendix. Can preoperative or intraoperative diagnosis be made?

Adenocarcinoma of the appendix is a rare entity with a reported incidence of .03 to .08 per cent. A review of all appendectomies performed at St. Joseph Mercy Hospital (a private community hospital) between 1963 and 1979 was undertaken to assess the efficacy of preoperative diagnosis. Six adenocarcinomas were found, consisting of five male patients and one female patient with a mean age of 65 years. Symptoms were present for 24 hours or greater in all cases. A preoperative diagnosis was not made in any patient. Three patients later required a definitive therapeutic procedure, and two patients died from metastatic disease during their initial hospitalization. The literature was reviewed to evaluate methods of preoperative and intraoperative diagnosis of appendical adenocarcinoma. A suspicion of carcinoma of the appendix should be entertained for patients over the age of 50 years who present with signs and symptoms of appendicitis for greater than 24 hours. A barium enema performed preoperatively and especially a frozen section at the time of surgery of any suspicious appendiceal lesions may improve the diagnostic accuracy and survival of patients with this disease entity. If preoperative or intraoperative diagnosis is made, the patient can be better prepared and definitive surgical therapy carried out. This avoids delay in treatment and a second operative procedure.

Total intravenous nutrition with peripherally inserted silicone elastomer central venous catheters.

Long-term indwelling central venous catheters inserted peripherally for total intravenous nutrition have been complicated by thrombophlebitis in most instances. However, experiences with silicone elastomer catheters used in this manner have not been previously reported. In this investigation a crank introducer unit has been developed that has allowed 61-cm silicone elastomer catheters to be placed in the superior vena cava with insertion in the basillic or cephalic vein. Thirty-five patients (36 catheter placements) received total intravenous nutrition exclusively via these silicone elastomer catheters. The mean time indwelling was 20.4 days (range, four to 56 days). Thirty of the 36 catheters were removed when total intravenous nutrition was discontinued. Only six catheters were removed for nonvenous and venous reactions. These results have shown the safety and efficacy of peripherally inserted silicone elastomer central venous catheters.