Concomitant laparoscopic cholecystectomy and splenectomy for surgical management of hereditary spherocytosis.

Laparoscopic splenectomy is rapidly becoming a common treatment modality in the surgical management of hematological processes involving the spleen. Hereditary spherocytosis is the most common red blood cell membrane disorder, and its diagnosis is often associated with hemolytic crisis and premature cholelithiasis. This condition has not been successfully treated laparoscopically until recently, and to our knowledge, the technique of concomitant laparoscopic splenectomy and cholecystectomy described here is the first reported in U.S. literature. Our patients, a 16-year-old 5-foot 3-inch-tall 90 pound emaciated albino, presented with cholelithiasis, splenomegaly, and anemia. Because of persistent anemia and gastrointestinal symptoms, the patient underwent laparoscopic cholecystectomy and splenectomy. The cholecystectomy was performed in a standard laparoscopic fashion. An additional 12-mm trocar was utilized for takedown of the spleen. The umbilical incision was extended to 4.5 cm, and the spleen was extracted manually. Total operative time was 12 hours. Examination demonstrated a 15 x 10 x 5-cm spleen, which weighed 350 grams. The gallbladder microscopically showed cholecystitis and had several stones. In conclusion, we present a combined laparoscopic cholecystectomy and splenectomy for hereditary spherocytosis associated with splenomegaly, cholelithiasis, and cholecystitis.

Successful utilization of ECMO to treat an adult burn patient with ARDS.

We present an interesting case of the first adult reported in the United States to suffer from thermal burns, adult respiratory distress syndrome (ARDS) and to be treated with extracorporeal membrane oxygenation (ECMO) who survived. Our patient is a 26 year old male who sustained thermal burns (12% TBSA) to his face and anterior trunk and broncoscopically demonstrable inhalation injury. He was transported to our regional burn center for burn wound care and ventilatory support. The patient was treated with silver sulfadiazine 1% to his wounds which healed per primam. Because of low oxygen saturation he required increasing FIO2. The following parameters: FIO2= 1, PEEP = 17, minute ventilation of 15.1 1, peak airway pressure of 45 and mean of 27, along with chest X-rays corroborated the severity of ARDS. The patient failed volume control ventilation. A trial of pressure ventilation was attempted but the patient only reached O2 saturation in the low 80s. At this point, the decision was made to transfer the patient to a hospital capable of ECMO treatment. The patient was subsequently treated with veno venous ECMO. Six weeks later the patient was discharged from the hospital off all ventilatory support.

Trilaminar skin coverage combined with cultured epithelial autografts--a new technique for treating the elderly patient with burn injuries.

Additional morbidity may be associated with standard split-thickness skin graft donor sites in elderly (65 years or older) patients with burn injuries. In an attempt to minimize the area of the donor sites and maximize autografts, we describe a new technique that uses trilaminar harvesting of skin grafts with dermolipectomy closure, and permanent coverage of the autograft layers achieved with cultured epithelial autografts in an elderly burn victim. An 80-year-old man was admitted with a 15% total body surface area burn to the bilateral lower extremities and buttocks. All meshed split-thickness skin grafts (12) applied showed excellent take, and it was reported that the cultured epithelial autograft take was approximately 90%. All dermolipectomy sites healed without infection. Our procedure proved to be a useful technique in the permanent closure of full- and partial-thickness burns in an elderly patient admitted to the burn unit.

Underutilization of breast-conservation surgery with radiation therapy for women with stage Tis, I or II breast cancer.

Despite clinical evidence from the National Institutes of Health consensus panel in 1991 that breast-conservation surgery (BCS) with radiation therapy (RT) is appropriate treatment in early-stage breast cancer, the overall rate of acceptance and actual practice of BCS with RT has remained low. We retrospectively reviewed 228 cases of breast cancer in female patients with stage Tis, I or II breast cancer treated between 1987 and 1995. Thirty-five cases (15.4%) were stage Tis, 70 cases (30.7%) were stage I, and 123 cases (53.9%) were stage II, Overall, 57% of Tis, I or II breast cancers received conservative treatment; 57% of stage Tis, 79% of stage I, and 44% of stage II tumors. These rates of conservative therapy are higher than in other reported series in the literature. BCS with RT produces equivalent rates of morbidity and survival as MRM, and, because it preserves the breast, is preferable for the majority of women who present with stage Tis, I, or II breast cancer.