Posterolateral approach. An alternative strategy in laparoscopic splenectomy

Laparoscopic splenectomy (LS) is effective and technically feasible for treating various hematological diseases, especially idiopathic thrombocytopenic purpura (ITP). An anterior approach to the vascular pedicle is usually described. However, in this approach to the splenic hilum, the dissection of the splenic artery is often difficult. A total of 13 patients with ITP underwent elective laparoscopic splenectomy. We utilized a laparoscopic posterolateral approach involving dissection of the suspensory ligaments at the lower pole, then dissection and division of the posterolateral attachments, followed by the dissection and ligation of all splenic branches near the splenic parenchyma. This procedure was completed in 11 of our 13 patients and converted to open surgery in the other two patients. Mean operative time was 3 h; mean postoperative stay was 3 days. No blood transfusion was required, and no complications were noted in the postoperative period. The posterolateral approach provides better visualization and control of branches of the splenic vein and artery in the splenic hilum. It also permits visualization and control of surgical hemorrhage through the operating ports.     

Portal thrombosis. A rare complication of laparoscopic splenectomy

Portal thrombosis is a rare complication of splenectomy. We performed 12 laparoscopic splenectomies and observed this complication only in one patient with idiopathic thrombocytopenia (ITP). The right branch of the portal vein presented a partial thrombosis, while the left branch was completely obstructed by thrombi. Abdominal ultrasonography and an ultrasound doppler exam allowed us to diagnose this event and a retrograde angiography performed afterward confirmed our diagnosis. A 48-h intravenous heparin treatment was promptly begun, followed by anticoagulant drugs (dicumarol). The patient was dismissed 5 days afterward, presenting a steady-state ultrasound doppler pattern and a complete normalization of liver parameters. An ultrasound doppler exam performed 1 month after anticoagulant therapy showed a complete resolution of portal thrombosis. We believe that early diagnosis of this rare complication, prompt beginning of anticoagulant therapy, and care in surgical procedures may reduce patient life-threatening risks and assure complete remission.     

Hand-assisted laparoscopic splenectomy for hydatid cyst

Splenic hydatidosis is a rare condition. We performed a hand-assisted laparoscopic splenectomy for a large hydatid cyst localized in the center of the spleen. We discuss the advantages of the "helping hand."     

Elective laparoscopic splenectomy for hematologic disorders

Laparoscopic splenectomy has been reported to be the procedure of choice in selected patients with hematologic disorders. The purpose of this study is to review our experience with laparoscopic splenectomy in this patient population. The charts of all patients with hematologic disorders who presented for laparoscopic splenectomy over a 17-month period were reviewed. Fifteen patients, nine males and six females, aged 12 to 80 years (mean, 49 years) presented for laparoscopic splenectomy. Surgical indications included 13 cases of idiopathic thrombocytopenic purpura and one each of hemolytic anemia and Hodgkin's disease. Splenectomy was performed utilizing a four- or five-puncture laparoscopic technique. For completed laparoscopic splenectomies, the mean operative time was 129 minutes, and the mean estimated blood loss was 232 cc. Mean splenic weight was 210 g. There were no operative deaths. There was a single intraoperative complication, a 1700-cc hemorrhage, and two postoperative complications: pneumonitis and deep venous thrombosis. Overall morbidity was 20 per cent. A single patient (7%) required conversion to laparotomy for completion due to hemorrhage. For patients completed laparoscopically, the mean hospitalization was 1.5 days, and none required parenteral narcotics for pain control after the first 36 hours. Laparoscopic splenectomy for patients with hematologic disorders is a safe and technically feasible procedure. Decreased hospitalization and discomfort are the primary benefits. This technique should be added to the repertoire of surgeons treating patients with hematologic disorders.     

Optimizing laparoscopic splenectomy. Technical details and experience in 59 patients

BACKGROUND: Laparoscopic splenectomy (LS), like other advanced laparoscopic procedures, is still an evolving procedure. The indications for surgery, criteria for patient selection, and operative technique are not yet well defined. We have therefore modified the standard technique for performing LS in an attempt to optimize the procedure. METHODS: Over the past 2 years, we have performed LS in 59 patients. The last 43 patients were operated using a standardized technique that we believe to be optimal. It includes the routine use of the right lateral position, operating through three trocars, the mass transection of the splenic vasculature with a vascular endoscopic stapler, and the use of a self-retaining retrieval bag. RESULTS: The average operating time was 79 min. Average blood loss was 95 cc, and average postoperative hospitalization was 2.3 days. There was one intraoperative complication and one postoperative complication. These results are superior to those we achieved earlier in our own experience, as well as to similar series that have been published recently. CONCLUSIONS: In our experience, the use of this new technique resulted in relatively short procedures with low morbidity. We believe that these results justify the use of LS as the procedure of choice for elective splenectomy in patients with normal or moderately enlarged spleens.     

Pediatric laparoscopic splenectomy using the lateral approach

Laparoscopic splenectomy in children has been shown to be safe, to reduce postoperative pain and hospital stay, and to accelerate return to full activities. We describe our experience with a four-port "lateral" approach in 18 patients. Patients were placed in the lateral decubitus position and the table was flexed to separate the left subcostal margin and iliac crest. The camera port was inserted at the umbilicus and additional ports were placed in the epigastrium and left lower quadrant. After mobilization of the splenic flexure a port was inserted in the left flank below the 12th rib for elevation of the spleen. A 30 degrees laparoscope was used and the splenic vessels were controlled with an endo-GIA and/or clips. The spleens were placed in a bag, morcellated, and extracted through a port site. Eight females and 10 males with a median age of 12.5 years (5-17 years) and weight of 55.5 kg (17-124 kg) underwent splenectomy of idiopathic thrombocytopenia purpora (10), spherocytosis (6), elliptocytosis (1), and Hodgkin's disease (1). The median operating time was 160 min (90-300 min) and median blood loss was 105 ml (5-350 ml). Accessory spleens were removed in four cases. Three patients required extensions of a port site to remove large spleens which could not be placed in a bag. The sole complication was a transient pancreatitis with associated pleural effusion. The median postoperative hospital stay was 2 days (1-11 days) and time to full activities was 8 days (3-25 days). The lateral approach affords excellent visualization of the splenic vessels, pancreas, and accessory spleens. This approach is safe and reliable and is our preferred approach for laparoscopic splenectomy in children.     

An unusual embolization of a projectile in the superficial femoral artery

The authors present an account on a gunshot wound which penetrated into the lateral side of the distal chest on the right. They describe acute treatment of severe haemorrhagic shock by suture of a lacerated with liver segment and resection of the upper pole of the right kidney. The projectile was not searched for because of the patients general serious condition. After 30 days the patient was discharged in a good condition. Shortly after discharge, i.e. cca one month after the injury, the patient developed signs of chronic ischaemia of the left lower extremity-finally claudications after 150 meters. Based on peripheral arteriography, which revealed the projectile in the area of the beginning of the superficial femoral artery and an ample collateral circulation, surgery was initiated. The bullet was extracted from the lumen of the superficial femoral artery from longitudinal arteriotomy. The artery was then treated by thrombectomy and a venous patch. Peroperative arteriography indicates satisfactory passage into the periphery. The authors try to reconstruct the pathway of the shot and in particular how the projectile penetrated into the artery. They emphasize the necessity to look for the projectice at the site of the shot wound. The objective of the paper is to make readers familiar with a case of uncommon embolization of a projectile into the superficial femoral artery and mistakes which may occur during treatment of a gunshot wound. The result is that the patient is quite free from complaints, as was confirmed by repeated out-patient check-ups.     

Splenic artery aneurysms in liver transplant patients. Liver Transplant Group

BACKGROUND/AIMS: The purpose of the study was to investigate the incidence of and risk factors for splenic artery aneurysms in liver transplant patients. METHODS: Medical records and the pre- and 1-year postoperative angiograms of 337 liver transplant patients were reviewed to assess the presence and characteristics of these aneurysms. RESULTS: Forty-five patients with aneurysms were identified (13%): 41 cases in 242 adult patients (17%) and four (4%) in 95 children (p<0.01). The female-to-male ratio was 2:1. The majority of the aneurysms (87%) were located in the distal third of the splenic artery and the majority (87%) of the patients presented multiple aneurysms. In patients without portal hypertension no aneurysms were identified, whereas in 16% of the patients with portal hypertension aneurysms were found (p<0.001). In adult patients the incidence of splenic artery aneurysms was significantly higher in patients with parenchymal diseases than in patients with cholestatic diseases (p<0.0001). Two patients (4%) died due to rupture of the aneurysms. Control angiographies, 1 year after liver transplantation, showed no changes in size and number of the aneurysms, and no new aneurysms were identified. CONCLUSIONS: The incidence of splenic artery aneurysms in liver transplant patients is 13%. They are generally multiple and located in the distal third of the splenic artery. The incidence is higher in women and in patients with parenchymal liver disease and portal hypertension. The incidence of rupture was 4%.     

Imaging in periodontology. An update

Traditional diagnostic procedures for periodontal diseases, such as probing and radiographic assessment, provide information on previous disease experience but not of present site-specific disease activity. Recent advances in computer-based image acquisition and processing techniques has increased the importance of radiography in periodontal diagnosis. The era of digital imaging has commenced in dentistry with definite diagnostic advantages. Significant dose reductions and image quality enhancement are among major advantages. The aim of this paper is to review the the imaging techniques being used in periodontology. There is a bright future of imaging technology on the horizon of dentistry.     

Hereditary spherocytosis. Studies of erythrocyte enzymes and fetal hemoglobin before and after splenectomy

A survey is given on development, proof and clinical importance of an M-gradient which is to be demarcated in the electrophoresis. A M-gradient refers to an excessive increase of the number of monoclonic immunoglobulins (= paraproteins). As investigation method the electrophoresis on agar or agarose, respectively, is best suited. The immunoelectrophoresis is necessary for the further differentiation into several classes and types as well as for the demarcation of pseudo-M-gradients. The proof of a M-gradient alone does not allow a diagnosis. M-gradients obligatorily appear in the plasmocytoma, in Waldenstroem's macroglobulinaemia and associated neoplasias of the lympho-plasma-cellular tissue. However, M-gradients can also be observed in carcinomas, chronic liver diseases and chronic inflammatory processes as well as in clinically healthy persons in individual cases. The differentiation according to the cause of the M-gradient is possible only then, when the total clinical picture is taken into consideration, in individual cases, however, according to the course of the disease.     

A new technique for laparoscopic splenectomy with massively enlarged spleens

Splenectomy is indicated in several hematological disorders and it can be particularly challenging in children with sickle cell disease, splenomegaly, and recurrent sequestration. Over the last 6 months, we have developed a new technique for laparoscopic splenectomy (LS) for hypersplenism and splenomegaly in five children with sickle cell disease. The average age of our patients was 6 years (range, 2-11), and the average weight was 18.7 kg (range, 13.2-30.1). On preoperative ultrasound, spleen size index ranged from 0.42 to 0.76. For the LS, four trochars were placed. One patient, who also underwent a laparoscopic cholecystectomy, had six trochars placed, two of which were used for both cholecystectomy and splenectomy. After laparoscopic mobilization of the spleen and hilar vascular stapling, a Steiner electromechanical morcellator was inserted through the 12-mm port to extract cores of splenic tissue until complete splenectomy was achieved. No patient required conversion to an open procedure or creation of a larger incision to remove the massively enlarged spleen. Operative time averaged 190 minutes; the combined LS and cholecystectomy took 245 minutes. Postoperative length of stay was <2 days for all patients. There were no complications, and no patient required postoperative transfusion. Based on these early findings, we conclude that intracorporeal coring of splenic tissue allows for safe and complete laparoscopic removal of very large spleens in small children. It provides expedient recovery and minimal postoperative pain and scarring. This new technique should enable surgeons to perform LS even in patients with massive splenomegaly, eliminating the need for large and cumbersome intracorporeal bags or the creation of additional incisions to remove the spleen.     

Beta-endorphin response to exercise. An update

Opioid receptor subtype antagonists differentially alter food intake under deprivation (24 h), glucoprivic (2-deoxy-D-glucose, 500 mg/kg, i.p.) or palatable (10% sucrose) conditions with mu (beta-funaltrexamine) and kappa (nor-binaltorphamine), but not delta1 ([D-Ala2,Leu5,Cys6]enkephalin) opioid antagonists reducing each form of intake following ventricular microinjection. Both mu and kappa opioid antagonists microinjected into either the hypothalamic paraventricular nucleus or the nucleus accumbens reduce intake under deprivation and glucoprivic conditions. Palatable intake is reduced by both antagonists in the paraventricular nucleus, but only mu antagonists are active in the accumbens. Food intake is stimulated by mu and delta, but not kappa, opioid agonists microinjected into the ventral tegmental area. The present study examined whether food intake under either deprivation, glucoprivic or palatable conditions was altered by bilateral administration of general (naltrexone), mu, kappa, delta1 or delta2 (naltrindole isothiocyanate) opioid antagonists into the ventral tegmental area. Deprivation (24 h)-induced feeding was significantly reduced by high (50 microg), but not lower (10-20 microg) doses of naltrexone (21%), and by delta2 (4 microg, 19%) antagonism in the ventral tegmental area. 2-Deoxy-D-glucose (500 mg/kg, i.p.)-induced hyperphagia was significantly reduced by high (50 microg), but not lower (20 microg) doses of naltrexone (64%), and by delta2 (4 microg, 27%) antagonism in the ventral tegmental area. Sucrose (10%) intake was significantly reduced by naltrexone (20-50 microg, 25-39%) and delta2 (4 microg, 25%) antagonism in the ventral tegmental area. Neither mu, kappa nor delta1 antagonists were effective in reducing any form of intake following microinjection into the ventral tegmental area. These data indicate that the ventral tegmental area plays a relatively minor role in the elicitation of these forms of food intake, and that delta2, rather than mu, kappa or delta1 opioid receptors appear responsible for mediation of these forms of intake by this nucleus.     

A learning curve for laparoscopic splenectomy at an academic institution

Variceal hemorrhage continues to be a major cause of morbidity and mortality in cirrhotic patients. Transjugular intrahepatic portosystemic shunt (TIPS) is gaining wide acceptance as a treatment for several complications of portal hypertension. The aim of the current randomized study was to compare the transjugular shunt and endoscopic sclerotherapy (ES) for the prevention of variceal rebleeding (VB) in cirrhotic patients. Forty-six consecutive cirrhotic patients with variceal bleeding were randomly allocated to receive either transjugular shunt (22 patients) or ES (24 patients) 24 hours after control of bleeding. VB (50% vs. 9%) and early (first 6 weeks) VB (33% vs. 5%) were significantly more frequent in sclerotherapy patients; the actuarial probability of being free of VB was higher in the shunt group (P <.002). Eight patients (33%) of the sclerotherapy group and 3 patients (15%) of the shunt group died; the actuarial probability of survival was higher for the shunted patients (P <.05); 6 patients in the sclerotherapy group and none in the shunt group died from VB (P <.05). No difference was found in the proportion of patients with clinically evident hepatic encephalopathy (HE). These results show that the transjugular shunt is more effective than sclerotherapy in the prevention of both early and long-term VB. Moreover, a significant improvement in survival was found in the shunt group.     

A case controlled comparison of open and laparoscopic splenectomy in children

BACKGROUND: This case controlled study compares the efficacy, safety, and cost of laparoscopic splenectomy (LS) and open splenectomy (OS) for hematologic disorders in children. METHODS: The records of 82 consecutive children and adolescents undergoing splenectomy for hematologic disorders between August 1994 and September 1997 were reviewed retrospectively. RESULTS: Fifty patients underwent LS by a lateral approach and 32 underwent OS through a left subcostal incision. Mean age was 7.76 years for LS and 6.9 years for OS. Patient weights were similar: (LS, mean 30.5 kg; OS, mean 27.6 kg). Hematologic indications included hereditary spherocytosis in 43 children (LS 26, OS 17), sickle cell anemia with sequestration in 13 (LS 7, OS 6), immune thrombocytopenic purpura in 14 (LS 8, OS 6), and 12 with other disorders (LS 9, OS 3). Concomitant cholecystectomy was performed in 10 of 50 LS and 6 of 32 OS cases. Accessory spleens were identified in 8 of 32 (25%) OS and 9 of 50 (18%) LS cases (P = .578). No LS procedures required conversion to OS. The mean estimated blood loss was 54.4 mL for LS and 49.0 mL for OS (P = .233). LS required a longer operative time (115 vs 83 minutes, P = .002), less need for postoperative intravenous narcotic (51% vs 100%, P < .0001), lower total narcotic doses (0.239 vs 0.480 mg/kg morphine, P = .006), shorter length of hospital stay (1.4 +/- 0.97 vs 2.5 +/- 1.43 days, P = .0001), and lower average total hospital charges ($5713 vs $6564) than OS. There were no deaths or major complications in either group. CONCLUSIONS: Laparoscopic splenectomy is a safe and effective procedure in children with hematologic disorders resulting in longer operative times, less narcotic administration, shorter length of stay, and lower total hospital charge.     

Surfactant replacement therapy. An update on applications

Surfactant replacement therapy has been shown to be an effective and often life-saving treatment for newborn infants with respiratory distress syndrome (RDS). This article provides the clinician with an update regarding the various other applications of surfactant replacement therapy, as well as issues related to surfactant administration for the preparations approved for use in pediatric patients.     

Coronary artery perforation repair using microcoil embolization

An 82-year-old woman undergoing percutaneous transluminal coronary angioplasty experienced perforation of the terminal portion of the left anterior descending coronary artery caused by guidewire trauma. The coronary artery perforation was successfully closed using a vascular occlusion system consisting of individual thrombogenic coils delivered to the site. Coronary artery perforation (CAP) during percutaneous transluminal coronary angioplasty (PTCA) has been reported to occur in less than 1% of cases. The incidence seems to be higher with the new interventional devices, e.g., DCA, TEC, and laser CAP may result in pericardial hemorrhage and cardiac tamponade or a coronary artery fistula to either the left or right ventricle. The management of CAP may include prolonged balloon inflations, reversal of anticoagulation, pericardiocentesis, and emergency surgery. Proximal perforations sometimes can be managed with vein covered stents. We describe another option in the treatment of distal CAP using a vascular occlusion system.     

Research activities in psychology: An update.

Presents an update on research activities in psychology, based on 14,634 responses to the American Psychological Association's (APA) 1982 Human Resources Survey (J. Stapp et al, 1983). The characteristics of APA members involved in research activities and funded research are described and compared to data from the 1978 Human Resources Survey (R. P. Lowman and J. Stapp [see PA, Vol 67:12943]). There has been little change in these characteristics; over 90% of APA members involved in research hold doctorates. Women were somewhat less likely than men to report involvement in research, and minorities were slightly more likely than nonminorities. The subfields, employment settings, and types of positions of those involved in research are also described. Of the projects reported in the 1982 survey, approximately half were funded (either by intramural or outside sources). Both funded and unfunded projects were primarily applied research and secondarily basic research; the institutional bases for research projects were most likely to be universities and colleges. Funded research activities are further described in terms of sources of funding, as well as the mechanism, length, and amount of funding. (3 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)