High rate of recurrent venous thromboembolism in patients with myeloproliferative neoplasms and effect of prophylaxis with vitamin K antagonists.

The optimal duration of treatment with vitamin K antagonists (VKA) after venous thromboembolism (VTE) in patients with Philadelphia-negative myeloproliferative neoplasms (MPNs) is uncertain. To tackle this issue, we retrospectively studied 206 patients with MPN-related VTE (deep venous thrombosis of the legs and/or pulmonary embolism). After this index event, we recorded over 695 pt-years 45 recurrences, venous in 36 cases, with an incidence rate (IR) of 6.5 per 100 pt-years (95% confidence interval (CI): 4.9-8.6). One hundred fifty-five patients received VKA; the IR of recurrent thrombosis per 100 pt-years was 4.7 (95% CI: 2.8-7.3) on VKA and 8.9 (95% CI: 5.7-13.2) off VKA (P=0.03). In patients receiving VKA, the IR of recurrent thrombosis per 100 pt-years was 5.3 (95% CI: 3.2-8.4) among 108 patients on long-term VKA and 12.8 (95% CI: 7.3-20.7) after discontinuation among the 47 who ceased treatment (P=0.008), with a doubled risk of recurrence after stopping VKA (hazard ratio: 2.21, 95% CI: 1.19-5.30). The IR of major bleeding per 100 pt-years was 2.4 (95%: CI: 1.1-4.5) on VKA and 0.7 (95% CI: 0.08-2.5) off VKA (P=0.08). In conclusion, in MPN patients with VTE recurrent thrombosis is significantly reduced by VKA and caution should be adopted in discontinuation; however, the incidence of recurrence on treatment remains high, calling for clinical trials aimed to improve prophylaxis in this setting.

Surgical drain after open or laparoscopic splenectomy: is it needed or contraindicated?

OBJECTIVE: The Authors report their experience with the routine use of surgical drainage in a large series of splenectomies. SUMMARY OF BACKGROUND DATA: Benefits and risks related to surgical drains have been always discussed, with some surgeons in favor of them and skeptic others considering not physiological their use. After splenectomy, their use is also largely debated, especially because of susceptibility of operated patients to infections. PATIENTS AND METHODS: Two thousand nine cases have been reviewed. Indications for splenectomy, performed either by open or laparoscopic approach, included idiopathic thrombocytopenic purpura in 137 patients (65,4%), splenic lymphoma in 36 (17,2%), hereditary spherocytosis in 15 (7,4%), ß-thalassemia in 8 (3,7%), other diseases in 13 (6,1%). RESULTS: "Active" or "passive" drains were placed in 80% and 20% of cases, respectively. Drains were removed 2-3 days after surgery in 90,2%, within 10 days in 4,3%, within 2 months in 0,4% of cases. In 2 cases a post-operative bleeding, detected through the drainage, required re-operation. One patient developed a subphrenic abscess, successfully treated by a percutaneous drainage. One case of pancreatic fistula was observed. CONCLUSIONS: In Authors' experience, the use of drains after splenectomy does not affect the risk of subsequent infectious complications, independently on the type of the drainage system used. Early removal of drains in this series might have played an important role in the very low incidence of abdominal infections reported. The use of surgical drains after splenectomy might play an important role to early detect post-operative bleeding, as it happened in 2 cases of this series.

Laparoscopic splenectomy in patients with hereditary spherocytosis: report on 12 consecutive cases.

Hereditary spherocytosis is an inherited hemolytic anemia caused by a deficiency in erythrocyte membrane proteins. Removal of the spleen may reduce the intra-splenic hemolytic process of the disease and, therefore, may correct the anemia. Furthermore, it seems to decrease the levels of serum bilirubin, thus reducing the formation of gallbladder stones. Indications and timing of splenectomy, however, are still debated. Twelve patients with severe hereditary spherocytosis operated on with laparoscopic splenectomy were retrospectively reviewed. Median age at diagnosis was 13.8 years (range 8-25 years). Male to female ratio was 5/7. Indications for laparoscopic removal of the spleen included anemia unresponsive to iron supplementation in eight patients (66.6 %) with increase need for red cells transfusions, and jaundice with symptoms related to cholelitiasis in four patients (33.3 %). Laparoscopic splenectomy was associated in four cases to laparoscopic cholecystectomy. Mean operative time was 50 min (range 40-75 min) with no conversion to open surgery. Mean hospital stay ranged from 3 to 7 days. In a 16-month follow-up, no complications were recorded and a persistent correction of anemia was observed. With the advent of laparoscopic surgery, splenectomy has been performed by this mini-invasive approach in referral centers. Laparoscopic splenectomy is an effective technique, when performed in patients with hereditary spherocytosis. Low complication rate and persistent correction of the hematologic disorders can be expected after the laparoscopic splenectomy, provided that a proper technique is performed and an experienced surgical team is available.

Endothelial activation and injury by cigarette smoke exposure.

Endothelial activation/injury following exposure to cigarette smoke may explain incidence of atherosclerosis and cardiovascular disease in smokers. We investigated cigarette smoke extract (CSE) effects relative to activation, injury, and survival of human umbilical vein endothelial cells (HUVEC) and compared circulating levels of specific endothelial activation markers between smokers and healthy non-smokers before and after smoking cessation. Viability and toxicity of HUVEC were tested by MTT and LDH assay. Release (by endothelial cells) and circulating levels (in smokers) of von Willebrand Factor (vWF), thrombomodulin (TM), was evaluated by ELISA. Incubation with increasing concentrations of CSE reduced the percentage of viable cells, being 33.9%, 23.9% after CSE 4%, 6% respectively. Dose- and time-dependent release of LDH was observed after incubation with CSE. vWF, TM release were assayed after CSE 2% HUVEC stimulation. Significant 42%, 61%, 76% increase in vWF concentration was detected respectively at 30', 60', 120'. Reduction in circulating levels of vWF, from a median value of 144.0% to 123.7%, was observed in the quitters group after smoking cessation. Exposure to cigarette smoke is cytotoxic and induces activation/injury of endothelium in vitro and in vivo. These findings may provide pathogenetic basis by which smoking can predispose to development of atherothrombosis and cardiovascular disease.

Laparoscopic splenectomy in patients under the age of eighteen. Experience in 18 cases.

BACKGROUND: Pediatric surgery is now in the forefront of minimal access procedures. Although pediatric surgeons have been skeptic about laparoscopic splenectomy, recently minimally invasive approach for spleen removal has been revaluated also in young patients. Purpose of this study was to report Authors' personal experience in patients under eighteen who underwent laparoscopic splenectomy. Results of the procedure were evaluated. PATIENTS AND METHODS: A retrospective review was undertaken in 18 splenectomised patients under the age of eighteen. Indications were hereditary spherocytosis in 10 patients, ß-thalassemia in 4, idiopathic thrombocytopenic purpura in 3 and a splenic cyst in 1 child. RESULTS: No intra-operative complications occurred. No conversion to open surgery was reported. During the follow-up one case of portal vein thrombosis, treated by medical therapy, was encountered and no other postoperative complications were observed. CONCLUSIONS: Laparoscopic approach has to be preferable for all those children undergoing spleen surgery. In experienced hands, it is of beneficial effects with a very reasonable rate of complications.

How to prevent intraoperative risks and complications in laparoscopic splenectomy.

Since its introduction in 1992 laparoscopic splenectomy (LS) has become the technique of choice for surgical removal of the spleen in several centres. The procedure, however, is associated with risks and complications, either during surgery or in the postoperative phase. Although the incidence of intraoperative complications is unknown, intraoperative risks in patients undergoing laparoscopic splenectomy are not uncommon. In this article, we reviewed the literature on risks and complications during LS, and we point out, based on our personal series and on the experiences reported by other Authors, how to prevent, whenever possible, these complications.

Effect of degree of obesity on renal transplant outcome.

Obesity in renal transplantation has proven to affect both patient and graft survival. The scientific community seems to be split into 2 groups: one claims similar outcomes among obese and nonobese, showing only marginally increased postoperative complications; whereas the other group report a higher rate of complications, including graft loss and mortality. These results did not provide sufficient evidence to be applied in practice. In this study we analyzed the outcomes of obese recipients of renal transplant in our institution. One hundred fourteen renal transplantations were performed between January 1993 and December 2003. To estimate the impact of various degrees of obesity, the patients were allocated into 2 cohorts: Group A (body mass index [BMI] 30-34.9) and Group B (BMI 35 and greater). We analyzed patient and donor characteristics. Wound infection rates were similar in the 2 groups. The aggregate Group A and B patient survival rate was 95.6% at 1 year and 93% at 5 years. Graft survival rate was 93.9% at 1 year and 88% at 5 years. However, the analysis of the outcomes in the 2 groups with different degrees of obesity showed that the patient survival rate at 1 year in Group A was 98.9% (1 death) and 95.6% at 5 years (4 deaths). In Group B the patient survival rate at 1 year was 87.5% (3 deaths; P = .007) and at 5 years was 79.2% (P = .006). Graft survival rate in Group A was 98.9% (1 graft loss) at 1 year and 94.5% (5 graft losses) at 5 years; in Group B the graft survival rate was 75% (6 graft loss) at 1 year and 63% (9 graft losses) at 5 years (P < .0001 both at 1 and 5 years). The present study showed that overall obese recipient outcomes were as expected when evaluating the obese as a single group of recipients with a BMI >30. The overall patient and graft survival did not show particularly different results from already published studies claiming similar outcomes. However, this series showed different outcomes when we divided them into 2 groups by BMI. There was a remarkable difference between moderate obese (Group A) and morbid obese (Group B) recipients as regards patient and graft survival. It is possible that the excellent outcome in Group A may be the result of super-selection and stringent cardiovascular risk screening that is implemented for this category of potential recipients. Obese recipients with a BMI of >35 are a high-risk category. Because of the difference in the outcomes of the 2 groups, it does not seem reasonable to address obese recipients as a single group. We believe that obese patients should not be discriminated simply on the basis of the BMI. A strict evaluation should be performed before denying the opportunity to receive a renal transplant to these patients.

Idiopathic severe elevation of serum alkaline phosphatase following adult renal transplantation: case reports.

Transient hyperphosphatasemia (TH) in infancy is a benign condition characterized by elevated alkaline phosphatase (ALP) levels severalfold the adult upper limits, occurring mainly in children under 5 years, without evidence of liver or bone disease, and a return to normal ALP levels by 4 months. Herein we have reported 3 cases of TH in adults following renal transplantation. The first case, a 47-year-old woman, blood group AB positive, had hypertensive renal disease. Five months after successful renal transplantation from a deceased donor she had a 50-fold increase in ALP. The second case, a 34-year-old man, blood group A positive, had renal failure due to IgA nephropathy. Nine weeks after a second renal transplant from a deceased donor a 25-fold increase in ALP was noted. The third case, a 45-year-old woman, blood group A positive, experienced renal failure 15 years earlier of unknown etiology. Thirteen years after her second renal transplant a 12-fold increase in ALP was observed during a routine follow-up. In all cases, the isolated ALP serum levels returned to normal limits within 12 weeks. Bone scans and abdominal ultrasounds during these periods were normal with no evidence of bone or liver disease. ALP isoenzyme electrophoresis revealed a pattern characteristic of TH of infancy and childhood. The 3 cases reported highlight the occurrence of benign TH in adults, with renal transplantation. However, liver disease, bone disease, and infection should be excluded first in these susceptible individuals on immunosuppression before establishing the diagnosis of TH.

Polar nephrectomy in a transplanted kidney: a case report.

After renal transplantation, infarction of the lower pole may be observed. We report an unusual case of lower pole infarction and perforation of the lower calyx due to thrombosis of a lower polar artery. This was managed successfully with partial nephrectomy (nephron-sparing surgery).

Internal iliac artery pseudoaneurysm following renal transplant biopsy successfully treated with endovascular stenting and thrombosis: a case report.

A 49-year-old man underwent living donor renal transplantation in November 2005. The transplant renal artery was anastomosed to the right internal iliac artery with an end-to-end anastomosis. The patient achieved immediate graft function and the allograft was normally perfused. Seven weeks later, renal allograft function deteriorated with a serum creatinine level increased to 244 micromol/L. An ultrasound scan revealed adequate perfusion to the kidney and the absence of hydronephrosis. A transplant biopsy revealed Banff IB rejection, which was treated with high-dose prednisolone. Following biopsy, the patient's renal function rapidly deteriorated with a serum creatinine level increased to 627 micromol/L, requiring hemodialysis. A computed tomography (CT) angiogram demonstrated a 6-cm diameter pseudoaneurysm arising from the internal iliac artery with absence of kidney perfusion. The aneurysm was accessed percutaneously with a 4-F catheter and 1000 U of human thrombin injected, resulting in partial thrombosis of the pseudoaneurysm. A balloon expandable covered metal stent was then placed across the site of the transplant renal artery anastomosis, resulting in successful occlusion of the aneurysm. Intrarenal blood flow was established by dilating 2 intrarenal branches with 3-mm diameter balloons. The serum creatinine level started to decrease within 24 hours of the procedure and renal function improved rapidly to a level achieved immediately after transplantation. Three months later the patient had a well-functioning allograft with a serum creatinine level of 176 micromol/L, follow-up CT scan demonstrated good perfusion of the transplanted kidney with no further change in the pseudoaneurysm. At 12 months follow-up the patient remains with a well-functioning allograft.

Modifications of coagulation and fibrinolytic parameters in laparoscopic cholecystectomy.

BACKGROUND: The incidence of deep vein thrombosis and pulmonary embolism following laparoscopic surgery is unknown and studies on alterations of hemostasis after laparoscopy are inconclusive. METHODS: In this study we prospectively evaluated changes in prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen (Fg), antithrombin III (ATIII), prothrombin fragment F 1 + 2, beta-thromboglobulin (betaTG) and D-dimer (D-D), preoperatively and 24 h after laparoscopic surgery in 16 patients. RESULTS: Comparing pre- and postoperative values, no statistical differences were observed in aPTT, F1 + 2, and ATIII measurements. Postoperative PT values increased slightly (p approximately 0.05) after surgery. Conversely, Fg, betaTG, and D-D values were statistically higher in the 24-h evaluation (p = 0.008, 0.01, and 0.045, respectively). CONCLUSIONS: These data suggest that laparoscopic surgery induces activation of coagulation and fibrinolytic pathways and, additionaly, betaTG elevation, which has never been reported and might account for postoperative platelet activation and a greater risk of thrombogenicity. Therefore, routine thromboembolic prophylaxis in patients undergoing laparoscopic surgery is recommended.

Making, disseminating and using clinical guidelines.

Clinical guidelines are statements designed to help physicians make decisions about appropriate health care for specific circumstances. The constant rise in the number of published guidelines has been accelerated by the need of healthcare organizations to integrate evidence from clinical research with rational health policy, with the prospect of improving the quality and reducing the costs of health care at a local level. The best guidelines are developed from a systematic examination and appraisal of good evidence from well conducted trials, supported by appropriate clinical expertise, and leading to unambiguous recommendations. Great care needs to be taken both to maximize the validity of guidelines and to ensure their use within clinical practice. Moreover, the evidence on which clinical guidelines are based can change with time and therefore they should be reviewed regularly. The critical approaches to making high-quality guidelines, the value of implementation strategies, and how healthcare organizations and individual physicians can use medical guidelines to enhance clinical effectiveness will be discussed.

Presacral myelolipoma. A case report.

Presacral myelolipoma is a rare benign tumour composed of fat and haemopoietic tissue. Ultrasound, computed tomography and magnetic resonance imaging are of help to achieve the diagnosis, but pathologic confirmation is mandatory. The Authors report an asymptomatic case whose diagnosis has been achieved by means of CT scan-guided percutaneous needle biopsy. Unnecessary surgical treatment was avoided in this case. Clinical approach and role of surgery are discussed.

Laparoscopic cholecystectomy in adult patients with sickle cell disease.

Cholecystectomy is a common surgical procedure performed in patients with sickle cell disease (SCD). Postoperative complications, including acute painful vaso-occlusive crisis and acute chest syndrome, have been described frequently after either traditional or laparoscopic cholecystectomy (LC). It's still not clear if preoperative blood transfusion, hyperhydration, intraoperative body temperature conservation may reduce complications rate. The Authors reviewed the charts of seven patients with SCD operated on LC for symptomatic gallbladder lithiasis and describe their perioperative management. In 3 patients preoperative endoscopic removal of stones was achieved. Five patients with HB lower than 9 g/dl and/or HbS higher than 40% were transfused preoperatively and all the patients were hyperhydrated. Intraoperative monitoring was achieved for early recognition of ventilation to perfusion mismatch and acid-base balance or temperature modifications. The Authors reported only one case of postoperative lower extremities pain. This study suggests that LC is a safe procedure in SCD if appropriate monitoring and perioperative management are achieved.

[Delayed diagnosis of odontoid fracture after whiplash trauma of the cervical spine]. / Verzögerte Diagnose einer Odontoidfraktur nach Schleudertrauma der Halswirbelsäule.

Fractures of the odontoid process represent about 10-20% of all diagnosed cervical spine fractures. Approximately 35% of these fractures are classified as Type II according to Anderson and D'Alonzo. They can be potentially unstable especially if combined with a dens displacement of over 6 mm. In severe cervical spine trauma, these fractures do not usually cause difficulties in diagnosis. However, in whiplash injuries, which are very common and only rarely associated with such fractures, the surgical management can be complicated if they are underestimated. These patients can present without significant neurological deficits or the situation can be complicated due to intoxication or additional trauma. Under these circumstances in particular, the diagnosis can be delayed or missed, if no strict protocols for diagnostic effort in all whiplash injuries are employed. A case of delayed diagnosis of an odontoid fracture in a neurological asymptomatic patient after whiplash injury is presented.

Predictive factors of response to splenectomy in adult chronic idiopathic thrombocytopenic purpura.

A total of 26 surgical patients with chronic idiopathic thrombocytopenic purpura (ITP) were reviewed and results of splenectomy were statistically related to age and sex, length of and response to pre-operative corticosteroid therapy, pre-operative platelet count and time interval between diagnosis and surgery. Median age was 37 years (range, 17-81 years) and the male:female ratio was 1.16. Pre-operative platelet count ranged from 2-70 x 10(9)/l. The length of pre-surgical corticosteroid therapy (prednisone 1-2 mg/kg/day) varied from 2 weeks to 3 years. Steroid therapy was unsuccessful in 15 patients and only achieved temporary remission in the remaining 11 cases. The time interval between diagnosis and splenectomy ranged from 4-60 months. There were 21 responders (80.4%) and 5 non-responders (19.6%) to splenectomy. Using the chi-square test, differences in age, length and response to pre-operative steroid therapy and diagnosis-to-splenectomy interval did not achieve statistical significance when responder and non-responder groups to splenectomy were compared. Conversely, a significant difference was found comparing male to female groups, since 92.9% of males and only 66.7% of females were successfully treated by surgery (P approximately 0.01). In addition, patients with a pre-operative platelet count less than 30 x 10(9)/l responded at an higher rate (100% versus 70.6%; P approximately 0.05) to splenectomy.