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.

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.

CD34 expression in adult acute lymphoblastic leukemia.

The expression of the pluripotent stem cell antigen CD34 was evaluated at diagnosis in forty-five adult patients with de novo ALL. Comparison of clinical and hematological features between CD34 positive (24/45) and CD34 negative (21/45) patients showed that the former were of older age, had more pronounced lymphoid organ involvement and higher serum LDH levels. Immunophenotypic analysis of marrow blast cells revealed a significant predominance of the 'null' phenotype in the CD34 positive group, together with a strong expression of the VLA-4 and VLA-5 integrins (fibronectin receptors). CD34 positive ALL were also more frequently associated with either aberrant myeloid-related antigens (CD13, CD33) or the P-gp/MDR-1 phenotype. Only 11 out of 24 (45%) CD34 positive patients achieved complete remission after induction chemotherapy, compared to 20/21 (95%) CD34 negative cases. Furthermore, survival was significantly shorter in the CD34 positive group (6.6 mo. vs 13.5 mo.). These results suggest that in ALL, as in AML, CD34 positivity may predict a poor prognosis.

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.

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.

[The response of the airways in asthmatic patients to kinin inhalations define a type-B2 receptor profile]. / La risposta delle vie aeree di pazienti asmatici ad inalazioni di chinine definisce un profilo recettoriale di tipo B2.

Kinins (i.e. bradykinin, kallidin and [desArg9]-bradykinin) are vasoactive oligopeptides which may contribute as mediators in the pathogenesis of asthma by interacting with specific receptors designated as B1 and B2. The aim of the present study was to investigate the airway response to inhaled histamine, bradykinin, kallidin and [desArg9]-bradykinin in normal and asthmatic subjects. Changes in airway caliber were followed as FEV1 (forced expiratory volume in 1 sec) and as Vp30 (maximum expiratory flow at 30% of the vital capacity). Neither histamine, bradykinin, kallidin nor [desArg9]-bradykinin had any measurable bronchoconstrictor effect in the normal subjects. However, in the asthmatic subjects, histamine, bradykinin and kallidin, but not [desArg9]-bradykinin, produced prompt concentration-related bronchoconstriction. The geometric mean PC20FEV1 (provocation-concentration of inhaled agonist reducing the FEV1 by 20% from baseline) values were 0.027, 0.082 and 0.44 mg/mL for bradykinin, kallidin and histamine respectively. Because bradykinin and kallidin are agonists of B2 receptors and [desArg9]-bradykinin is an agonist for B1 receptors, our data suggest that asthmatic, but not normal, airways are hyperresponsive to kinins and that this potent bronchoconstrictor response is due to a specific pharmacologic effect compatible with the stimulation of B2 receptors.

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.

Opposite effects of inhaled bradykinin and [desArg9]-bradykinin on tracheobronchial clearance in normal humans.

Kinins may affect lung mucociliary clearance in man by interacting with specific surface receptors designated B1 and B2. To evaluate this possibility, we have compared the effect of inhaled bradykinin and [desArg9]-bradykinin on mucociliary clearance in healthy volunteers. Four subjects attended the laboratory on three separate occasions to undertake tracheobronchial clearance studies, by a noninvasive radioisotopic technique, followed by inhalation with either bradykinin (8 mg.mL-1), [desArg9]-bradykinin (8 mg.mL-1), or vehicle placebo 30 min after radioaerosol inhalation. Half-hourly whole lung counts were measured for 6 h with two collimated scintillation counters and a tracheobronchial clearance curve was plotted for each subject on each occasion. In all the subjects studied, mucociliary clearance, expressed as the area under the tracheobronchial radioaerosol retention curve calculated for the first 6 h (AUCo-6h) was enhanced after inhaling bradykinin and prolonged following exposure with [desArg9]-bradykinin when compared to placebo. The median values (range) for AUCo-6h were significantly reduced from 123 (83-152)%.h to 92 (51-133)%.h with placebo and bradykinin, respectively, and significantly augmented to 269 (144-331)%.h after exposure with [desArg9]-bradykinin. This small study suggests that acute exposure with inhaled bradykinin accelerates, whilst [desArg9]-bradykinin delays, tracheobronchial clearance in normal human airways.

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.

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.

[Fc gamma+ T-lymphocytes and depressed polyclonal immunoglobulin synthesis in multiple myeloma]. / T-linfociti Fc gamma+ e depressa sintesi policlonale immunoglobulinica nel mieloma multiplo.

In the present study the effects on the polyclonal Ig synthesis of peripheral MM T gamma and T non-gamma cell fractions when cocultured with autologous and normal allogenic B-lymphocytes have been reported. Five untreated MM patients (three IgG-kappa, two IgG-lambda) were studied employing a five-day PWM-stimulated co-culture technique, in which the percentage of cells with detectable amounts of cytoplasmic Ig was evaluated by direct immunofluorescence. Our results indicated that depressed polyclonal Ig synthesis in human MM could be ascribed not only to an increased "suppressive" activity of T gamma cells but also to an impaired "inducer" function of T non-gamma lymphocytes and to an intrinsic B-lymphocyte disfunction as well. In addition, it was noteworthy that MM T gamma cells showed on normal Ig synthesis a selective suppressive effect mainly for those Ig chains corresponding to the monoclonal Ig which characterizes the own myeloma type. The significance of this datum, so far not yet reported, remains to be established.

Beta-1-integrin expression in adult acute lymphoblastic leukemia: possible relationship with the stem cell antigen CD34.

In the hemopoietic system, interactions between stem cells and components of the bone marrow microenvironment play a pivotal role in blood cell proliferation and differentiation. Among the adhesion molecules, the integrins of the beta 1-subfamily are known to direct cell-cell and cell-matrix interactions and evidence has been provided that CD34-positive stem cells bind either to the bone marrow stroma or to the extracellular matrix proteins through the beta 1-integrins. It seems that changes in their expression pattern or signalling function are likely to reflect disturbances at the hemopoietic bone marrow microenvironmental level. Any alteration of their biological functions makes them attractive candidates for playing decisive roles in the leukemic processes. In this view, beta 1-integrins have been recognized to mediate those cellular interactions and migrations that are important in the biology of leukemia. In this paper we review some aspects of the role played by beta 1-integrins, especially VLA-4 and VLA-5, in adult acute lymphoblastic leukemia in relation with the expression rate of the stem cell antigen CD34.

Cutaneous vasculitis in non Hodgkin's lymphoma.

Cutaneous vasculitis has been described in association with various hematological malignancies, but it seems to be very uncommon among non Hodgkin's lymphomas (NHL). For this reason no attention has been given to the peculiarity of this rare association. We identified 5 cases of cutaneous vasculitis among 315 NHL patients examined at our Institution from 1984 through 1990 and after the appearance of vasculitis, we observed some heterogeneity in either the degree of activity or in the clinical outcome of the NHL. The onset of cutaneous vasculitis appeared to mark two different clinical patterns: a vasculitis present from diagnosis characterized an indolent course of the neoplasia, while a late-appearing vasculitis was followed by rapid lymphoma progression and short survival.