Laparoscopic splenectomy in beta-thalassemia major patients. Advantages and disadvantages

BACKGROUND: Splenectomy is indicated in patients with thalassemia major when they develop hypersplenism with subsequent need for increased transfusions. Extreme splenomegaly is considered a restrictive factor for laparoscopic splenectomy in these patients. METHODS: Laparoscopic splenectomy was undertaken in 12 beta-thalassemia major patients with massive splenomegaly. The devascularization of the organ was performed with serial ligations of the splenic vessels starting from the lower pole of the organ. The spleen was extracted from the abdominal cavity through a 5-cm incision in the left iliac fossa, which incorporated two port sites. RESULTS: The procedure was concluded laparoscopically in 10 cases, while two patients were converted due to difficulty in controlling bleeding from branches of the splenic vein. The patients tolerated the procedure well and had a postoperative hospital stay of 3-6 days. CONCLUSIONS: From our limited initial experience it seems that laparoscopic splenectomy in the difficult setting of thalassemia major patients is feasible, but extreme care is required in order to avoid hemorrhagic complications.     

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.     

Laparoscopy improves outcomes for pediatric splenectomy

BACKGROUND: Pediatric laparoscopic splenectomy is a relatively new surgical procedure with a limited number of reports comparing its outcomes to that of the open procedure. The authors have minimized the invasiveness of our procedure by using only three ports and have described the technique as well as compared it with the open method. METHODS: A retrospective review of seven laparoscopic splenectomies (LS) using a three port technique were compared with seven open splenectomies (OS) performed for similar indications at a single children's hospital. RESULTS: The average age in the LS group was 8.7 years compared with 8.9 years for OS, (P value not significant), and the average weights were also similar. The indications for splenectomy were hereditary spherocytosis, idiopathic thrombocytopenic purpura, sickle cell anemia, and splenic cyst. All splenectomies were performed safely with an average estimated blood loss of 41 mL for LS and 34 mL for OS (P value not significant). Operative time averaged 147 minutes for LS and 86 minutes for OS (P < .05). LS patients recovered more rapidly and were discharged home on a median of postoperative day (POD) 2 versus POD 4 for OS (P < .05). LS patients received significantly less total amount of intravenous pain medication with an average of 0.18 mg/kg of morphine sulfate versus 0.8 mg/kg for OS (P< .05). Total hospital charges were higher for LS with an average of $10,899 versus $8,275 for OS (P < .05). CONCLUSIONS: Laparoscopic splenectomy currently is a safe procedure, offering better cosmesis, much less pain, and a shorter hospital stay compared with the traditional open procedure. The more sophisticated equipment and time needed to carry out the procedure led to a modestly increased hospital cost.     

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.     

Laparoscopic splenectomy in children. Preliminary results and comparison with the open technique

To determine the safety and efficacy of laparoscopic splenectomy (LS) in children, a retrospective review of our preliminary experience using LS was compared to results in patients who previously underwent open splenectomy (OS). From July 1993 to January 1995, we performed eight LS procedures in six children with hereditary spherocytosis (HS) and two with immune thrombocytopenic purpura (ITP). Laparoscopic cholecystectomy was simultaneously done in one case with HS. There were 4 males and 4 females who ranged in age from 5 to 15 years--an average age of 8.8 years. Two cases in the early series required a counterincision because of bleeding. Eleven patients who previously underwent OS in our department were used to compare demographics, operative courses, and surgical outcomes. The ages, genders, diseases, body weights, and spleen weights were comparable between LS group and OS groups. The operative time for the LS group was statistically longer than for the OS group (226 +/- 24 min vs 101 +/- 8 min, P < 0.001). The estimated blood loss in the LS group was similar to that of the OS group (100 +/- 39 ml vs 73 +/- 11 ml. P = 0.97). There were no peri- or postoperative complications in two groups. The postoperative hospital stay of LS group was statistically shorter than that of the OS (6.8 +/- 0.6 days vs 10.4 +/- .05 days, P < 0.0001). LS provided better cosmesis and minimized trauma in children over OS. LS appears to be a safe and effective procedure in children, and is useful in the management of pediatric patients with HS or ITP.     

Laparoscopic splenectomy in adults and children: experience with 31 patients

BACKGROUND: Open surgery is the standard approach for splenectomy in hematologic disorders, but a few cases of successful laparoscopic splenectomy have been reported. METHODS: Thirty-one patients (18 adults, group 1; and 13 children, group 2) underwent laparoscopic splenectomy. Indications for surgery included idiopathic thrombocytopenic purpura (25 patients), congenital spherocytosis (4 patients), and hemolytic anemia (2 patients). In 97% of the patients the diameter of the spleen was less than 15 cm. RESULTS: Laparoscopic splenectomy was successful in 94% of the patients; conversion to open surgery was mainly related to hemorrhage. Accessory spleen was found in 39% in group 1 and 8% in group 2. Two adults received intraoperative autotransfusion. Postoperative morbidity was minimal. The median postoperative stay was 3 days (range, 2 to 12 days) in group 1 and 2 days (range, 2 to 5 days) in group 2. CONCLUSIONS: Laparoscopic splenectomy is safe in both adults and children. Adequate selection of patients (small-size spleen, splenic destruction on preoperative scanning of platelets), appropriate preparation in patients with idiopathic thrombocytopenic purpura (immunoglobulin G), and meticulous surgical technique (with routine opening of the gastrocolic ligament to search for accessory spleen) are key factors in obtaining the same long-term results as with open surgery.     

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.     

Laparoscopic splenectomy. Technique and results in a series of 27 cases

Between early 1992 and December 1994, laparoscopic splenectomy was performed in 27 patients with idiopathic thrombocytopenia (ITP), hairy-cell leucemia, HIV, or Hodgkin's disease. In all cases medical treatment, especially cortisone therapy, failed. In Hodgkin's disease the splenectomy was combined with liver biopsies and dissection of parailiacal, paraaortic, and mesenteric lymph nodes for abdominal staging. The operation was performed using four trocars; the splenic vessels were divided by a linear stapler. In general the spleen was removed in a bag through a slightly enlarged trocar incision or after morcellation. Three patients needed a small laparotomy for the removal (laparoscopic assisted). In a recent case of Hodgkin's disease the intact spleen was removed via posterior colpotomy. In 22 of 27 cases (81%) the operation was finished laparoscopically. Five times a conversion to conventional laparotomy was necessary because of bleeding of enlarged lymph nodes at the hilum. Wound infections occurred in two cases. In one patient with ITP the platelet count did not improve and continuous blood loss led to relaparotomy at the 1st postoperative day. No surgical bleeding was found. All patients tolerated a fluid diet at the 1st postoperative day and hospitalization time was 4.4 days (range 3-14). Regarding the low complication rate and the advantages of a smaller abdominal trauma in the postoperative period, the laparoscopic approach for elective splenectomy and laparoscopic abdominal staging has a substantial benefit for the patients.     

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.     

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.     

The lateral approach for open splenectomy

BACKGROUND: Laparoscopic splenectomy (LS) has been used increasingly to treat children with hematologic disorders and has been reported to have advantages over open splenectomy performed through a standard vertical or subcostal incision. The authors perform open splenectomy (OS) through a lateral, muscle-splitting approach, and believe their approach is more reasonable in comparison with LS. METHODS: Thirty-nine consecutive open splenectomies performed between 1991 and 1995 were reviewed retrospectively and compared with recent reports of LS. The series included 24 boys and 15 girls with an average age of 9 years and average weight of 37.5 kg. Indications included immune thrombocytopenic purpura (n = 20), hereditary spherocytosis (n = 18), and sickle cell anemia (n = 1). The operation was performed with the child in the lateral decubitus position through a left upper abdominal muscle-splitting incision (off the 11th rib), sparing the rectus muscle. RESULTS: All 39 cases were completed without intraoperative complications with an average surgical time of 98.0 minutes (range, 30 to 302). The average surgical blood loss was 89 mL (range, 10 to 300). The children started feeding an average of 1.2 days (range, 0 to 4) postoperatively, were on a regular diet at an average of 2.0 days (range, 1 to 6) postoperatively, and had an average length of stay of 2.7 days (range, 1 to 6). There was no mortality or morbidity. CONCLUSIONS: Open lateral splenectomy is performed with shorter surgical times, less blood loss, an excellent cosmetic result, no complications, and a length of stay comparable to any of the published series on laparoscopic splenectomy in children. This approach provides a reasonable basis for comparison with laparoscopic splenectomy.     

Present status of laparoscopic splenectomy for hematologic diseases: certitudes and unresolved issues

Laparoscopic splenectomy is considered to be the "gold-standard" treatment of benign hematologic diseases, with normal or slightly enlarged spleens. Laparoscopic treatment of malignant diseases and splenomegalies remains more controversial. The procedure requires a great surgeon's laparoscopic expertise, appropriate positioning of the patient and trocar insertion, and gentle and meticulous dissection of the spleen. The technique is feasible in 91% of the patients with a 0.9% operative mortality and a postoperative complications rate of 12%. When compared with open splenectomy in retrospective case-controlled studies, the laparoscopic approach includes a longer operative time and higher operative room costs. However, advantages include reduced postoperative hospital stay and faster return to normal activities. Despite scarce reported data, long-term hematologic cure rate seems to be equivalent in patients with idiopathic thrombocytopenic purpura. The accuracy of laparoscopic exploration to detect all accessory spleens is however questioned, and residual postoperative accessory splenic tissues have been observed. Prospective randomized controlled trials comparing short- and long-term results of open and laparoscopic splenectomies are required to confirm definitely the role of laparoscopy in the management of hematologic disorders.     

Trends in rates of occupational fatal injuries in the United States (1983-92)

Recent advancements in laparoscopic surgery have made laparoscopic splenectomy possible. We retrospectively compared the outcomes of laparoscopic versus open splenectomy in patients with idiopathic thrombocytopenic purpura (ITP) or beta-thalassemia. From July 1993 to July 1997, 52 patients (ITP, 43 cases; beta-thalassemia, 9 cases) underwent either laparoscopic (30 patients, 9 men, 21 women; average age, 36.9 years) or conventional open splenectomy (22 patients, 5 men, 17 women; average age, 34.3 years). The two groups were similar in terms of sex, age, diagnosis, duration of disease, preoperative platelet count, and spleen size. The mean surgical time, estimated amount of blood loss, duration of postoperative recovery, analgesic usage, and complications were compared between the two groups. Laparoscopic splenectomy was successful in 29 (97%) of the 30 patients. The mean surgical time in the laparoscopy group was longer than in the open splenectomy group (190.6 vs 113.9 minutes, p < 0.01). The laparoscopy group had earlier postoperative oral intake (15.2 vs 52.6 hours, p < 0.01), less usage of analgesics (meperidine 50 mg/unit, 1.1 vs 2.8 units, p < 0.01) and a shorter postoperative hospital stay (4.1 vs 6.8 days, p < 0.01). The estimated blood loss, incidence of accessory spleen, surgical complication rate, and recurrence rate of thrombocytopenia were similar in the two groups. Our findings show that laparoscopic splenectomy in patients with ITP or beta-thalassemia is as safe as the open approach. While laparoscopy required a longer surgical time, the recovery period was shorter, analgesic use was less, and physical discomfort was less severe.     

Splenectomy: its place in operations for inflammatory disease of the pancreas

Involvement of the spleen or its vasculature in inflammatory disease of the pancreas may result in life-threatening hemorrhage. Retrospective analysis of six patients having direct splenic involvement and/or occlusion of the splenic vein secondary to pancreatitis or pseudocyst showed that removal of the spleen as a portion of an appropriately timed operation for complications of pancreatitis uniformly resulted in an uncomplicated course and survival (3 patients). Leaving the spleen in place when it was directly involved in a pseudocyst and/or when the splenic vein was occluded resulted in postoperative bleeding, the requirement for reoperation, and death from septic sequelae (2 patients). One patient died of progressive respiratory and renal failure because initial operation was inappropriately delayed. We recommend splenectomy as a portion of an appropriately timed operation for complications of pancreatitis when the splenic vessels are involved and/or when the spleen is directly involved in a pseudocyst or lesser sac collection.     

Laparoscopic treatment of a benign splenic cyst

With an understanding of the spleen's important immunologic function, splenectomy for benign splenic disorders has given way to a variety of splenic conservation techniques. Treatment options for benign nonparasitic splenic cysts include partial splenectomy, total cystectomy, or partial cyst decapsulation. External cyst wall decapsulation is a simplified operative procedure that carries no increased risk of cyst recurrence. However, a conventional upper abdominal laparotomy may subject patients to significant morbidity. We successfully performed a laparoscopic partial cyst decapsulation, achieving meticulous hemostasis with use of a laparoscopic-GIA stapling device. The patient tolerated the procedure well and was discharged on postoperative day 2. Follow-up has demonstrated no evidence of recurrent cyst formation.     

bcl-2 protein is strongly expressed in post-transplant lymphoproliferative disorders

BACKGROUND: Splenic complications of sickle-cell disease (SCD) are associated with morbidity, and in some it may lead to mortality. This paper presents our experience with 43 patients with SCD who had splenectomy as part of their management. PATIENTS AND METHODS: The records of 43 patients with SCD who had splenectomy were examined for age at operation, sex, hemoglobin (Hb) electrophoresis, indication for splenectomy, pre- and postoperative medications, operative procedures, and postoperative complications. RESULTS: The indications for splenectomy were acute splenic sequestration crisis (ASSC) in 21 patients, hypersplenism in 15, and splenic abscess in 7. In 17 patients, the spleen was also found to be massively enlarged causing discomfort and intervening with everyday activity. For those with hypersplenism, there was a significant postoperative increase in total Hb (P < 0.0001), hematocrit (P < 0.0001), white blood cells (P < 0.0001), and platelet count (P < 0.0001). CONCLUSIONS: With careful perioperative management and proper follow-up, splenectomy in patients with SCD is beneficial in reducing their transfusion requirements and its attendant risks, eliminating the discomfort from mechanical pressure of the enlarged spleen, avoiding the risks of ASSC, and managing splenic abscess.     

Quantitative studies of splenic erythropoiesis in polycythaemia vera and myelofibrosis

A quantitative scanning method employing cyclotron-produced 52Fe has been developed to assess splenic erythropoiesis in patients with myeloproliferative disorders. In 12 patients with myelofibrosis splenic uptake of 52Fe was from 5.0% to 48% of the injected dose. Although a single patient with classical polycythaemia vera had a minor uptake of 2.8% of six other patients with this diagnosis showed no concentration of isotope in the splenic area. The fraction of 52Fe in the spleen of four patients with 'transitional' myeloproliferative disorders characterized by a high red cell mass, hypercellular bone marrow and a leucoerythroblastic blood film varied from 5% to 41%. No clear relationship was noted between the degree of splenic erythropoiesis as defined by this technique and the level of haemoglobin, the degree of splenomegaly, the effectiveness of erythropoiesis of traditional 59Fe surface counting. If splenectomy is considered in patients with myelofibrosis splenic 52Fe quantitation will provide more precise data on the contribution of splenic erythropoiesis than 59Fe surface counting alone.     

Splenic sepsis in sickle cell disease

We describe two patients with sickle cell disease (SCD) who developed infections situated in the spleen. One patient had a splenic abscess and there was strong clinical evidence for an infected splenic infarct in the second patient. SCD predisposes to splenic infection because of functional hyposplenism, defective phagocyte function and splenic infarction. Splenic infections can occur in patients who might be considered to have an absent spleen and the diagnosis of splenic abscess should be considered in individuals with SCD who present with fever and abdominal pain.     

Abdominal wound tumor recurrence after open and laparoscopic-assisted splenectomy in a murine model

PURPOSE: The cause of abdominal wall tumor recurrences after laparoscopic surgery for cancer remains unknown. A recent study from our laboratory using a murine splenic tumor model suggests that poor surgical technique (i.e., crushing of the tumor) and not the CO2 pneumoperitoneum is responsible for port wound tumors. However, in that experiment no actual laparoscopic procedure or manipulation was performed. The purpose of the current study was to determine the rate of abdominal wound tumors after laparoscopic-assisted splenectomy performed via a CO2 pneumoperitoneum vs. open splenectomy using the mouse splenic tumor model. METHODS: To establish splenic tumors, female BALB/c mice (N=72) were given subcapsular splenic injections of a 0.1-ml suspension containing 10(5) C-26 colon adenocarcinoma cells via a left flank incision at the initial procedure. Eight days later, animals were randomized into one of two groups: 1) laparoscopic-assisted splenectomy, or 2) open splenectomy. Laparoscopic-assisted splenectomy animals had three laparoscopic ports placed and then underwent laparoscopic mobilization of the spleen under a CO2 pneumoperitoneum followed by extracorporeal splenectomy via a subcostal incision. Group 2 animals underwent open splenectomy via a subcostal incision after three port incisions were made in the same locations as for laparoscopic-assisted splenectomy mice. The incision was closed after 20 minutes in both groups. Ten days later, the mice were killed and inspected for abdominal wall tumor implants. The experiment was performed via two separate trials. RESULTS: When results of the two trials were combined, there was no significant difference in the incidence of animals in each group with at least 1 port tumor (open, 21 percent; laparoscopic-assisted splenectomy, 33 percent; P=0.14). However, the overall incidence of port site tumors (number of ports with tumors/total number of ports for each group) was significantly higher in the laparoscopic-assisted splenectomy group than in the open group (20 vs. 7 percent; P=0.01). The subcostal incisional tumor recurrence rate was also higher in the laparoscopic-assisted splenectomy group (50 vs. 21 percent; P=0.02). as was the perioperative mortality rate (21 vs. 7 percent; P=0.08). Results of the two individual trials were also considered separately. The incidence of port wound tumors decreased significantly from the first to the second laparoscopic-assisted splenectomy trial (36 vs. 9 percent; P=0.003), although the incidence of tumors at the subcostal incision and the mortality rate for the two laparoscopic-assisted splenectomy group trials were not significantly different. The open group tumor incidences did not change from trial to trial. CONCLUSIONS: Overall, significantly more port and incisional tumors were noted in the laparoscopic-assisted group. Although not statistically significant, mortality rate of the laparoscopic-assisted group was higher than the open group. The reasons for these findings are unclear. Laparoscopic mobilization was quite difficult and required excessive splenic manipulation, which may have liberated tumor cells from the primary tumor and facilitated port tumor formation. With increased experience, less manipulation was required to complete mobilization. Of note, the incidence of port tumors in the laparoscopic-assisted splenectomy group decreased significantly from the first to the second trials; therefore, it is possible that surgical technique is a factor in port tumor formation. However, the persistently high tumor incidence at the subcostal incision site argues against the hypothesis that the second trial's laparoscopic mobilizations were less traumatic. The CO2 pneumoperitoneum may also be a factor. Further studies are warranted to clarify these issues.     

Red blood cell glutathione status in patients with gastrointestinal malignancies treated with 5-fluorouracil

As an alternative to surgical splenectomy, partial splenic embolization was performed in seven children for hypersplenism manifested by splenomegaly, thrombocytopenia, leukopenia, and erythrocyte hemolysis. Within a few days, platelet and leukocyte counts rose significantly in all patients and were maintained in six of seven patients during a follow-up period of 9 to 69 months. Spleen size and abdominal distention also decreased significantly in all children. There were no infectious complications.