Chylothorax--a complication of subclavian vein catheterization.

Insertion complications of subclavian vein catheter placement are well documented. Thoracic duct injury is a potential problem which has rarely been reported. A patient with duct injury and resultant chylothorax is presented. The management of this problem is discussed with emphasis placed on chyle leakage from both the nutritional and mechanical aspect. The anatomy and function of the thoracic duct as well as the pathophysiology and treatment of chylothorax are detailed.

Central catheter fibrin sleeve--heparin effect.

Intravascular abnormalities were well documented with central venous catheters. A prospective randomized study was undertaken to assess the actual incidence of such abnormalities with a silicone catheter and the effect of heparin in small doses on the formation of such abnormalities. Silicone catheters placed via the subclavian route were inserted for intravenous nutritional support. A standard solution of 5% amino acid and 20 to 25% dextrose was utilized and patients were randomized to receive 1000 units of heparin per liter or no heparin. Catheter venograms were performed at the conclusion of therapy. Thirty-four patients were completed with 17 patients in the heparin group and 17 in the control group. There was obvious fibrin sleeve formation in nine of 17 (53%) in the heparin group and 11 of 17 (65%) in the control group. The duration of catheter stay correlates with the incidence of intravascular fibrin sleeve formation. Intravascular reactions to central catheters occur, regardless of catheter compositions, and result in fibrinous material adherent to the venous wall. Low doses of heparin do not eradicate this problem. Although fibrin sleeve formation was a significant problem, there was no incidence of central venous thrombosis when silicone catheters were utilized.

Gastric malignancy: ten year experience at a community teaching hospital.

A ten-year review of gastric malignancy was undertaken and several factors examined. The degree of organ involvement played a significant role in determination of survival. Surgical resection, either palliative or curative, was associated with a more favorable short-term survival and bypass alone appeared to add nothing to patient survival time. The general lack of symptoms in early gastric cancer appears to be a majority determinant of the advanced state of malignancy in these patients. Early screening may represent a partial solution to this dilemma.

Adenocarcinoma of the appendix in older patients.

Acute inflammation of the appendix secondary to luminal obstruction is the chief reason for appendectomy. The rare association of a malignant neoplastic process with the inflammatory process is usually an unexpected finding and is often not diagnosed until the histologic study has been completed. Two patients with adenocarcinoma of the appendix are presented. They exemplify the diverse situations of intraoperative recognition with immediate definitive treatment, or surgical management after appendectomy alone. A review of the literature confirms the rarity of appendiceal adenocarcinoma in older patients. In this report, the pathophysiology of appendiceal carcinoma and guidelines for therapy are outlined. Emphasis is placed on the possible occurrence of a malignant appendiceal lesion in the elderly patient with acute appendicitis.