Laparoscopic splenectomy: outcome and efficacy in 103 consecutive patients

OBJECTIVE: To study the safety and efficacy of laparoscopic splenectomy (LS) in patients with predominantly benign hematologic disorders. SUMMARY BACKGROUND DATA: The technical feasibility of LS has been recently established. However, data regarding the efficacy of the procedure in a large cohort of patients are scarce. METHODS: One hundred three consecutive patients underwent LS between June 1992 and October 1997. Data were collected prospectively on all patients. RESULTS: Indications were idiopathic thrombocytopenic purpura (ITP), hereditary spherocytosis, autoimmune hemolytic anemia, thrombotic thrombocytopenic purpura, and others. Mean spleen size was 14 cm and mean weight was 263 g. Accessory spleens were found in 12 patients with ITP and in 5 patients without ITP. There were no deaths. Complications occurred in six patients, one requiring a second procedure for small bowel obstruction. Six patients received transfusions, and four procedures were converted to open splenectomy for bleeding. Mean surgical time was 161 minutes and was greater in the first 10 cases than the last 10. Mean postsurgical stay was 2.5 days. Thrombocytopenia resolved after surgery in 84% of patients with ITP, and hematocrit levels increased significantly in 70% of patients with chronic hemolytic anemias. A positive response was noted in 92% of patients with hereditary spherocytosis, without relapse for the duration of the observation. ITP relapsed in four patients during follow-up, three within 12 months. CONCLUSIONS: LS can be performed safely and effectively in a teaching institution. Rigorous technique will minimize capsular fractures, reducing the risk of splenosis. Accessory spleens can be successfully localized, thus improving response and limiting recurrence of ITP. LS should become the technique of choice for treatment of intractable benign hematologic disease.     

Dopamine receptor subtypes expressed in vertebrate (carp and eel) retinae: cloning, sequencing and comparison of five D1-like and three D2-like receptors

Eight dopamine receptor-like cDNA clones were isolated from the carp (Cyprinus carpio) retina and four dopamine receptor-like cDNA clones were isolated from the European eel (Anguilla anguilla) retina. These cDNA clones show high sequence and structural homology to the known dopamine receptor subtypes. The sequence similarity and phylogenetic analysis revealed that five subtypes (D1A3, D1A4, D1B, D1C and D1X) in the carp retina and four subtypes (D1A1, D1A2, D1B and D1C) in the eel retina are D1-like receptor subtypes, and three (D2, D4A and D4B) in the carp retina are D2-like receptor subtypes; no D2-like receptor was found in the eel. Carp D1A3 and D1A4, carp D4A and D4B, and eel D1A1 and D1A2 are highly homologous pairs of receptors which show significant, domain-specific differences to each other and to their species homologues. The structure of the third cytoplasmic loop in the carp D1X receptor was particularly different from the other D1-like receptors. The implications of these structural differences in terms of dopamine receptor activation and signalling are discussed. It is suggested that the known diverse physiological and pharmacological effects of dopamine on the retinal neurones are likely to be mediated through these multiple receptor subtypes which may be coupled to different signal transduction pathways.     

The nondigestible fat sucrose polyester does not stimulate gallbladder emptying in humans

BACKGROUND: We determined the effect of oral ingestion of sucrose polyester, which was approved as a fat replacer in the United States, on gallbladder motility and on the release of cholecystokinin, the hormone that mediates gallbladder emptying. OBJECTIVE: Our objective was to measure effects of sucrose polyester on gallbladder emptying and cholecystokinin release. DESIGN: Eight healthy volunteers (3 men and 5 women) drank 60 mL sucrose polyester, digestible fat, or saline solution in a balanced crossover design on 3 separate days. RESULTS: Mean (+/-SEM) gallbladder emptying, when integrated over time, was low in response to both sucrose polyester (-150 +/- 214 mL x 120 min) and saline solution (-89 +/- 123 mL x 120 min). In contrast, there was marked emptying in response to digestible fat (1069 +/- 253 mL x 120 min). Sucrose polyester did not affect plasma cholecystokinin concentrations (-9.3 +/- 15.0 pmol x 120 min/L), whereas digestible fat resulted in a significant increase (89.5 +/- 44.8 pmol x 120 min/L, P = 0.014) compared with saline solution (-3.0 +/- 13.8 pmol x 120 min/L). CONCLUSIONS: Ingestion of sucrose polyester, in contrast with digestible fat, did not stimulate gallbladder emptying or release of cholecystokinin.     

The evaluation of argon laser photocoagulation in a series of animal models of upper gastrointestinal bleeding

During the past five years we have evaluated argon laser photocoagulation in various canine models of upper gastrointestinal hemorrhage. In gastric erosions, the eight-watt argon laser was uniformly effective in stopping bleeding. In our standard acute ulcer model the seven-watt argon laser was effective in stopping bleeding from most ulcers and only occasionally produced deep injury. With the addition of a jet of CO2 exiting the laser catheter coaxial to the laser beam, the argon laser was 100% effective and no deep injury resulted. The application of the argon laser in a more physiologic canine bleeding model using a single bleeding vessel in an ulcer base is currently under study. The development of improved animal models of gastrointestinal bleeding should contribute to the identification of effective and safe endoscopic hemostatic methods.     

A new algorithm for suboptimal stochastic control

An apparently new stochastic control algorithm, calledM-measurement-optimal feedback control, is described for discrete-time systems. This scheme incorporatesMfuture measurements into the control computations: whenMis zero,it reduces to the well-known open-loop-optimal feedback control; whenMis the actual number of measurements remaining in the problem, it becomes the truly optimal stochastic control. This new algorithm may also be used to simplify computations when the plant is nonlinear, when the controls are constrained, or when the cost is nonquadratic. Simulation results are presented which show the superiority of the new algorithm over the open-loop-optimal feedback control.