Splenectomy for idiopathic thrombocytopenic purpura: comparison of laparoscopic and conventional surgery.

BACKGROUND: This study aimed to compare the safety, efficacy, and clinical benefits of laparoscopic splenectomy (LS) to open splenectomy (OS) in patients with idiopathic thrombocytopenic purpura (ITP). METHODS: The results from 14 consecutive patients who underwent LS for ITP were reviewed and compared with the results from patients who underwent OS for the same disease. Demographics, concomitant disease on admission, and platelet counts were evaluated, as were details of the surgical procedure, postoperative physiologic status, and hospital stay. RESULTS: Mean operative time was 88.3 min for OS and 146.4 min in LS group (p < 0.05). The conversion rate to open splenectomy was 7.1. Therapeutic response to splenectomy was 92.8% in the LS group and 86.6% in the OS group. Bowel canalization, return to liquid diet, and length of hospital stay were all significantly delayed in the OS group as compared with those who underwent LS (p = 0.01, p = 0.02, p = 0.005, respectively). In the OS group the morbidity rate was 13.3%, whereas in the LS group it was 7.1%. CONCLUSIONS: Laparoscopic splenectomy represents a valid alternative to conventional splenectomy in the treatment of ITP.

Pre-operative chemoembolization of hepatocellular carcinoma in cirrhotic patients.

BACKGROUND/AIMS: The aim of the study was to evaluate clinical and pathological effects of transcatheter arterial chemoembolization (TACE) before surgical resection for hepatocellular carcinoma (HCC) in cirrhosis (55 patients); results were compared with a group of 45 patients undergoing surgical resection without TACE. METHODOLOGY: From March 1989 to December 1997, 55 cirrhotic patients, affected by surgically resectable HCC not larger than 5 cm with unifocal or bifocal tumor lesions, underwent TACE pre-operatively. RESULTS: Massive necrosis was observed in 26%, necrosis > 50% in 38% of lesions. Neoplastic cells were found in 47% of cases within the capsule or in the pericapsular tissue. Satellite nodules showed a low rate of necrosis. Mortality and morbidity in the pre-operative TACE group were 1.8% and 29%, respectively, and 4.4% and 33%, respectively, in the control group. One-, 3- and 5-year patient survival rates were 87%, 70% and 39%, respectively, versus 79%, 38% and 19%, respectively (p<0.02), in the control group. Disease-free survival was 40% and 28% at 3 years and 5 years with pre-operative TACE versus 20% and 11% (p<0.05). CONCLUSIONS: Pre-operative TACE can be performed with low morbidity. TACE can necrotize the main lesion and temporarily arrest portal diffusion of neoplastic cells by acting on microvascular infiltration. No evident effect on satellites and pericapsular neoplastic foci was observed. The long-term patients and disease-free survival rates were improved upon.

In vivo evaluation of timing, degree, and distribution of bacterial translocation following experimental small bowel transplantation.

These studies were designed to evaluate the correlation between morphologic and functional changes after heterotopic auxiliary small bowel isograft with systemic venous drainage and two ostomies in 20 Lewis rats. Morphologic damage of the graft was scored by full-thickness biopsies before surgery and 1, 3, 5, and 7 days after transplant. Functional evaluation of the graft was done, at the same time points, by urinary excretion of lactulose and mannitol injected in the proximal ostomy. The intestinal permeability was also studied by injecting Escherichia coli labeled with indium-111 oxine in the proximal ostomy. Translocation of radiolabeled bacteria was quantitated in extraintestinal tissues by radionuclide counts and number of viable organisms and in vivo by scintigraphic imaging. One day after transplant, significant graft damage (score 17.2 +/- 4.2) was observed when compared with the pretransplant value (7.3 +/- 2.6). The degree of tissue injury was similar on days 3 (15.8 +/- 3.5) and 5 (16.1 +/- 3.9) after transplant and remained high on day 7 (11.8 +/- 2.8). The lactulose to mannitol ratio showed a significantly increased permeability on day 1 (17.5) versus pretransplant values (2.6), remained high on day 3 (8.6), and returned to normal values on day 5 (2.8). Translocation of bacteria to distant organs, as measured by both radionuclide counts and number of viable organisms, was strikingly enhanced on day 1 after transplantation, compared with control animals, but returned to the pretransplant value on day 3. A good qualitative and quantitative correlation was observed between radionuclide counts in the extraintestinal organs and in vivo images obtained by scintigraphic scanning. In conclusion, in this model, timing and degree of bacterial translocation do not seem to correlate well, with the exception of the acute post-transplantation phase, with morphologic and permeability changes of the graft. Evaluation of translocation by scintigraphic imaging appears a suitable approach to study in vivo the kinetics and distribution of this process.