Liver transplantation in recipients receiving renal replacement therapy: outcomes analysis and the role of intraoperative hemodialysis.

The Model for End-Stage Liver Disease (MELD) system has dramatically increased the number of recipients requiring pretransplant renal replacement therapy (RRT) prior to liver transplantation (LT). Factors affecting post-LT outcomes and the need for intraoperative RRT (IORRT) were analyzed in 500 consecutive recipients receiving pretransplant RRT, including comparisons among recipients not receiving IORRT (No-IORRT, n = 401), receiving planned IORRT (Pl-IORRT, n = 70), and receiving emergent, unplanned RRT after LT initiation (Em-IORRT, n = 29). Despite a median MELD of 39, overall 30-day, 1-, 3- and 5-year survivals were 93%, 75%, 68% and 65%, respectively. Em-IORRT recipients had significantly more intraoperative complications (arrhythmias, postreperfusion syndrome, coagulopathy) compared with both No-IORRT and Pl-IORRT and greater 30-day graft loss (28% vs. 10%, p = 0.004) and need for retransplantation (24% vs. 10%, p = 0.099) compared with No-IORRT. A risk score based on multivariate predictors of IORRT accurately identified recipients with chronic (sensitivity 84%, specificity 72%, concordance-statistic [c-statistic] 0.829) and acute (sensitivity 93%, specificity 61%, c-statistic 0.776) liver failure requiring IORRT. In this largest experience of LT in recipients receiving RRT, we report excellent survival and propose a practical model that accurately identifies recipients who may benefit from IORRT. For this select group, timely initiation of IORRT reduces intraoperative complications and improves posttransplant outcomes.

Antiviral prophylaxis and recurrence of hepatocellular carcinoma following liver transplantation in patients with hepatitis B.

BACKGROUND: Orthotopic liver transplantation (OLT) is a viable treatment option for patients with hepatitis B (HBV) and concomitant hepatocellular carcinoma (HCC). However, cancer recurrence following transplantation approaches 20%. This study sought to identify the clinical and pathological factors associated with post-OLT survival. METHODS: Univariate and multivariate analyses considered the following variables: combination viral prophylaxis, HBV recurrence, tumor stage, vascular invasion, distribution, nodularity, pre- and post-OLT tumor size, pre-OLT alpha-fetoprotein (AFP), Milan and UCSF criteria, and Asian race. RESULTS: Cumulatively, HCC recurrence-free survival was 77%, 62%, and 53% at 1, 3, and 5 years, respectively, and was significantly better in patients who were free of viral recurrence post-OLT. Similarly, patients treated with combination prophylaxis had a significantly lower mortality than those who were not. CONCLUSIONS: Multivariate analysis revealed that AFP>500 ng/mL, presence of vascular invasion by explant, HBV recurrence, and combination prophylaxis were independent predictors of HCC recurrence-free survival.

Splenectomy for splenic metastases: a changing clinical spectrum.

Splenic metastases from solid tumors are unusual with only scattered case reports of patients treated with splenectomy before 1987. We conducted a retrospective chart review at our large tertiary-care private teaching hospital between January 1990 and September 1999 and found splenic metastases in 31 patients. In eight patients (26%), the spleen was the only site of metastatic disease. Of the 31 splenectomies for metastases, 23 were performed for ovarian neoplasms, five during primary operative procedures, and 18 during secondary cytoreductive procedures or explorations for late recurrences at an average of 3.9 years after the original operation. Nearly half of the metastases (15 of 31) appeared entirely within the splenic parenchyma, representing probable hematogenous spread, whereas seven involved both the splenic parenchyma and capsule and nine involved the capsule only. Between 1990 and 1999 we identified a statistically significant increase in use of splenectomy for treatment of metastatic tumor with a Spearman rank correlation value of 0.86 (P < 0.05). Most of this increase was attributable to ovarian cancer cases and may be due to expansion of treatment options or improved imaging methods. We report the largest series of splenectomy for splenic metastases and the ninth case report in the world literature of splenectomy for isolated splenic metastasis due to colorectal cancer.

Perforated appendicitis is not a contraindication to laparoscopy.

Recent studies have reported an increased risk of intra-abdominal abscess formation following laparoscopic operation for perforated appendicitis. We undertook this study to compare laparoscopic versus open appendectomy in the treatment of perforated appendicitis. Records of all patients undergoing an appendectomy between January 1994 and June 1997 were reviewed, classifying appendicitis as acute, gangrenous, or perforated based on the intraoperative findings. Operative procedures were categorized as open, laparoscopic converted to open, or laparoscopic. The study group included 690 patients; four hundred fourteen (60%) were acute, 77 (11%) were gangrenous, and 199 (29%) were perforated. Although mean length of stay was shorter for all patients undergoing laparoscopic appendectomy, patients with perforated appendicitis had similar length of stay between treatment groups. Mean operative time for open appendectomy was significantly shorter than for converted or laparoscopic appendectomy regardless of diagnosis (P<0.01). Ten patients (1.4%) developed an intra-abdominal abscess: six after open appendectomy (1.7%), one after converted appendectomy (3.7%), and three after laparoscopic appendectomy (1%). There was no significant difference in rate of abscess formation in patients with perforated appendicitis undergoing open, converted, or laparoscopic appendectomy. We conclude that laparoscopic appendectomy for perforated appendicitis is not associated with an increased rate of intra-abdominal abscess formation.

Tuberculous infection of the descending thoracic and abdominal aorta: case report and literature review.

We report here a case of infrarenal aortic disruption and aortoduodenal fistula secondary to tuberculous aortitis in a 77-year-old man. From a review of experience with operative management of tuberculous infection of the descending thoracic and abdominal aorta reported in the English-language literature, including the current report, we found that operative repair was attempted in 26 patients with tuberculous aortitis of the abdominal (n = 16), thoracic (n = 8), and thoracoabdominal (n = 2) aorta. Six patients had emergent operations for massive hemoptysis (n = 2), aortoduodenal fistula (n = 2), or abdominal rupture (n = 2), with an associated 30-day mortality of 50%. Elective or semi-elective repair was undertaken in 20 patients, of whom 19 (95%) survived for at least 30 days. On the basis of limited experience with this rare entity, in situ graft replacement is an appropriate treatment of tuberculous aneurysms and pseudoaneurysms of the descending thoracic and abdominal aorta.

Multiple organ failure: by the time you predict it, it's already there.

OBJECTIVE: Validate an at-risk population to study multiple organ failure and to determine the importance of organ dysfunction 24 hours after injury in determining the ultimate severity of multiple organ failure. METHODS: We evaluated 105 patients admitted to five academic trauma centers during a 1-year period who survived for more than 24 hours with Injury Severity Scores > or = 25 and who received 6 or more units of blood. Organ dysfunction was scored daily with a modified multiple organ failure scoring system made up of individual adult respiratory distress syndrome score, renal dysfunction, hepatic dysfunction, and cardiac dysfunction scores. Multiple organ failure (MOF) severity was quantitated using the maximum daily multiple organ failure score and the cumulative sum of daily multiple organ failure scores for the first 7 days (MOF 7) and 10 days (MOF 10). Independent variables included markers of tissue injury, shock, host factors, physiologic response, therapeutic factors, and organ dysfunction within the first 24 hours after admission. Data were subjected to a conditional stepwise multiple regression analysis, first excluding and then including 24-hour MOF as an independent variable. RESULTS: Of the 105 high-risk patients, 69 (66%) developed a maximum daily multiple organ failure score > or = 1; 50 (72%) did so on day 1 one and 60 (87%) did so by day 2. In multiple regression models, the multiple correlation coefficient increased from 0.537 to 0.720 when maximum MOF was the dependent variable, from 0.449 to 0.719 when maximum daily MOF was the dependent variable, from 0.519 to 0.812 when MOF 7 was the dependent variable, and from 0.514 to 0.759 when MOF 10 was the dependent variable. CONCLUSION: We have confirmed that the population of patients with Injury Severity Scores > or = 25 who received 6 or more units of blood represent a high-risk group for the development of multiple organ failure. Our data also indicate that multiple organ failure after trauma is established within 24 hours of injury in the majority of patients who develop it. It appears that multiple organ failure is already present at the time when most published models are trying to predict whether or not it will occur.

Emergent management of multisystem injuries by a general trauma surgeon.

OBJECTIVE: To determine the requisite education and scope of practice for a general surgeon trained to deliver emergent trauma care without the need for specialty consultation. DESIGN: Retrospective case review. SETTING: Private Level I trauma center. PATIENTS: 4097 trauma patients admitted between 1/1/92 and 30/6/97. MAIN OUTCOME MEASURES: Mechanisms of injury; operations (total within the first 24 h) by mechanism and by surgical specialty. RESULTS: Of 4097 trauma patients, 1086 (27%) underwent 1772 operative procedures within 24 h of admission, and 246 (6%) underwent 484 later operations. Orthopaedic and general surgical procedures were most common (51% of early operations). Early operations were most commonly orthopaedic for blunt trauma and general surgical for penetrating trauma. Although 685 patients (16.7%) received neurosurgical evaluation, only 150 early operations were performed (8% of the total early operations). At least 1244 procedures (55%) fell within the scope of current trauma general surgical practice advocated by some authorities. CONCLUSIONS: The contribution of the various specialties to early operative trauma management is a function of the injury mechanism. As orthopaedics and neurosurgery together comprise 34% of emergency practice, a fully credentialed general surgeon with additional training in these disciplines could perform up to 90% of early operations.

Laparoscopy identifies unexpected groin hernias.

Diagnostic laparoscopy performed before laparoscopic repair of groin hernias offers an opportunity to examine all hernial orifices. This study was undertaken to evaluate the accuracy of the preoperative clinical diagnoses and to determine the frequency of unexpected groin hernias. Between December 1990 and November 1997, 253 patients (243 male) underwent laparoscopic repair of 560 hernias. The total extraperitoneal technique was used in 93 per cent of the cases. Diagnostic laparoscopy was performed before and after the preperitoneal dissection and repair. Preoperatively, hernias were thought to be unilateral in 73 patients (Group A) and bilateral in 180 patients (Group B). Incorrect diagnoses in 50 of 73 patients (68%) thought to have unilateral hernias included bilateral hernias in 37 patients (50%), a different type of ipsilateral inguinal hernia in 7 patients (10%), or a femoral hernia in 6 patients (8%). Incorrect diagnoses in 91 of 180 patients (50%) thought to have bilateral hernias included a different and/or additional type of ipsilateral inguinal hernia on either side in 63 patients (35%), a femoral hernia in 21 patients (12%), or a unilateral hernia in 7 patients (4%). Unexpected hernias that would not have been treated with an anterior approach were found in 64 patients (25%; 27 were femoral and 37 were contralateral). The laparoscopic technique allows for identification and repair of previously undiagnosed contralateral and femoral hernias at the first operation.

Colorectal cancer: comparison of laparoscopic with open approaches.

PURPOSE: We compared laparoscopic with open colectomy for treatment of colorectal cancer. METHODS: We performed a retrospective review of patients undergoing colectomy for colorectal cancer between January 1991 and March 1996 at a large private metropolitan teaching hospital. Operative techniques included open (n=90) and laparoscopic (n=80) colectomy. Laparoscopic colectomy was further subdivided into the following groups: facilitated (n=62), with extracorporeal anastomosis; near-complete (n=9), with small incision for specimen delivery only; complete (n=3), with specimen removal through the rectum; and converted to an open procedure (n=6). Main outcome measures included operative time, blood loss, time to oral intake, length of postoperative hospitalization, morbidity, lymph node yield, recurrence, survival, and costs. RESULTS: Operative time was equivalent in the laparoscopic and open groups (laparoscopic, 161 minutes; open, 163 minutes; P=0.94). Blood loss was less for the laparoscopic group (laparoscopic, 104 ml; open, 184 ml; P=0.001), and resumption of oral intake was earlier (laparoscopic, 3.9 days; open, 4.9 days; P=0.001), but length of hospitalization was similar. Mean lymph node yield in the laparoscopic group was 12 compared with 16 in the open group (P=0.16). Rates of morbidity, recurrence, and survival were similar in both groups. No port-site recurrences occurred. CONCLUSIONS: Laparoscopic and open colectomy were therapeutically similar for treatment of colorectal cancer in terms of operative time, length of hospitalization, recurrence, and survival rates. The laparoscopic approach was superior in blood loss and resumption of oral intake.

Comparison of laparoscopic and open staging in Hodgkin disease.

BACKGROUND: Staging laparotomy provides useful information for management of Hodgkin disease but has fallen into disfavor because procedure-related morbidity exceeds that of new chemotherapeutic regimens. OBJECTIVE: To determine the feasibility, effectiveness, and safety of laparoscopic staging for Hodgkin disease compared with those of open staging. PATIENTS: Fifty-five patients with Hodgkin disease of cell types including nodular sclerosis in 43 (78%), mixed cellularity in 9 (16%), and lymphocyte predominance in 3 (5%). STUDY DESIGN: Concurrent evaluation of laparoscopic staging (n = 15) and retrospective review of open staging (n = 40). INTERVENTIONS: Laparoscopic and open techniques of surgical staging for Hodgkin disease, including splenectomy, liver biopsies, and lymph node sampling. MAIN OUTCOME MEASURES: Operative time, duration of postoperative ileus and of postoperative hospitalization, morbidity, number of lymph nodes retrieved, alteration in pathologic stage, recurrence, and survival. RESULTS: For laparoscopic staging vs open staging groups, mean operative time was 202 vs 144 minutes (P=.001); mean postoperative ileus was 1.9 vs 3.2 days (P<.001); mean postoperative hospitalization was 4.4 vs 6.7 days (P<.001); complications occurred in 3 patients (20%) vs 11 patients (28%) (P=.57); and mean number of lymph nodes retrieved was 8.5 vs 4.6 (P=.05). In the laparoscopic staging group, 2 cases (13%) were upstaged and 2 cases (13%) were downstaged. In the open staging group, 6 cases (15%) were upstaged and 3 cases (7.5%) were downstaged. Follow-up data were available for all patients in the laparoscopic staging group, at a mean of 23.5 months postoperatively. All were alive, none had recurrent disease below the diaphragm, and 2 (13%) had residual mediastinal disease. Follow-up data were available for 31 patients (78%) in the open staging group at a mean of 52.5 months postoperatively. All were alive, 27 (87%) were disease free, 3 (10%) had had relapses above the diaphragm, and 1 (3%) had residual mediastinal disease. CONCLUSIONS: Compared with open staging, laparoscopic staging of Hodgkin disease is oncologically equivalent and functionally superior. These data should encourage reappraisal of the role of operative staging in the management of Hodgkin disease.

The clinical spectrum of splenic infarction.

Two recent cases of splenic infarction of unusual cause stimulated a review of our experience with this condition. We conducted a retrospective chart review of selected patients with pathologic diagnosis of splenic infarction seen at a large metropolitan private teaching hospital during the past 30 years. Variables analyzed included sex, age, etiology of infarction, underlying diseases, diagnostic tests, splenic pathology, and complications. Splenic infarction occurred in 59 patients (33 male and 26 female; average age, 55 years; range, 2-87 years). Etiologies included hematologic disorders (n = 35), thromboembolic disorders (n = 17), and other diseases (n = 7). Symptoms were present in 69 per cent of the patients and included abdominal pain, fever and chills, and constitutional symptoms; 18 patients were asymptomatic. Patients with nonmalignant hematologic conditions were often asymptomatic (55%); abdominal pain was common in all groups, and fever was especially common in patients with embolic conditions (70%). CT scan was the most frequent radiologic study. Patients with hematologic conditions usually were explored for complications of those conditions (69%), while complications of splenic infarction were a frequent indication for operation in patients with emboli (60%). Overall morbidity was 36 per cent, with pulmonary complications most frequent, and mortality was 5 per cent. We conclude that splenic infarction must be suspected in patients with known hematologic or thromboembolic conditions who develop left upper quadrant pain and signs of localized or systemic inflammation. CT scan is currently the preferred diagnostic test, but ultimate diagnosis depends on pathologic examination of the spleen. Surgical complications of splenic infarction include abscess and rupture.

Final score in laparoscopic cholecystectomy. Cholangiogram 1207, no cholangiogram 116.

BACKGROUND: The role of intraoperative fluorocholangiography (IOC) in laparoscopic cholecystectomy (LC) is controversial. We evaluated the use of IOC at an institution where the study is performed routinely. METHODS: Records of all patients undergoing LC during a 3-year period ending January 1, 1996 were reviewed. RESULTS: A total of 1207 patients received IOC, whereas 116 patients did not. IOC findings were categorized as follows: normal, 1016 cases (84%); CBD stone, 149 cases (12.3%); anomalies, 23 cases (1.9%); duodenal diverticula, 10 cases (0.8%); ductal strictures, four cases (0.3%); and CBD diverticula, 5 cases (0.4%). In the 116 patients who did not receive IOC, 35 of the procedures could not be performed, whereas 81 were not attempted. Of the 149 IOC that showed CBD stones, two were false positives. Anomalies included accessory right hepatic ducts (11 cases), cystic ducts joining the right hepatic duct (seven cases), and abnormal cystic duct entries (five cases). Duct injuries occurred in 5 cases (0.4%), three before and two after IOC. Four injuries were minor; IOC prevented CBD transection. CONCLUSIONS: Routine IOC is feasible, safe, accurate, and provides critical information of immediate use during LC. By treating ductal stones at operation and identifying patients without CBD stones, IOC minimizes need for postoperative studies, including endoscopic retrograde cholangiography (ERC).

Mesh configurations in laparoscopic extraperitoneal herniorrhaphy. A comparison of techniques.

BACKGROUND: Laparoscopic total extraperitoneal (TEP) hernia repair utilizes slit mesh that is placed around the spermatic cord to secure the prosthesis and prevent recurrence. Because of concern that encircling of the cord might increase pain and morbidity, we compared patients with mesh repairs using encircled and nonencircled techniques. METHODS: The 191 male patients who underwent bilateral TEP repairs were divided into three groups. In 100 consecutive patients (group A), the slit mesh was closed around both spermatic cords; in 56 patients (group B), the slit mesh was tucked under the spermatic cords but not closed; in 35 consecutive patients (group C), the slit was closed around one cord and tucked under the other, in a randomized fashion. RESULTS: The groups had similar operative times (A: 83 +/- 25 min; B: 79 +/- 21; C; 77 +/- 24), use of pain medication (A: 2.7 +/- 2.5 days; B: 2.4 +/- 1.9; C: 3.1 +/- 2.4), and recovery before return to work (A: 7.9 +/- 7.0 days; B: 8.2 +/- 6.1; C: 6.7 +/- 4.8). The incidence of indirect hernias was similar in all groups. Complication rate was 20% in A, 20% in B, and 14% in C (p = NS). Chronic pain was more frequent in A (A: 6, B: 0, p = 0. 06). In group C, fluid collections were more common on the closed side (closed: 3, tucked: 0; p = 0.08). There were no recurrences in any group. CONCLUSIONS: Closing the slit around the spermatic cord in laparoscopic inguinal hernia repair is not essential for prevention of early recurrence. Fluid collections tended to be more frequent when the mesh was closed around the cord, and chronic pain was more frequent in the group with closed mesh bilaterally.

The conquest of Addison's disease.

BACKGROUND: A review of the understanding and treatment of adrenal insufficiency was undertaken to emphasize common themes in the history of endocrine disorders. METHODS: Literature survey. RESULTS: The presence of the adrenal glands, initially ignored by anatomists, was first described by Eustachius and later confirmed by Casserius. Bartholin identified the glands as ductless. In 1855, Thomas Addison described the clinical syndrome of adrenal insufficiency. Medullary hormonal effects were described by Oliver and Shäfer in 1895; epinephrine was isolated by Takamini, and the secretory patterns were characterized by Cannon. Cortical function was elucidated by Biedl and Stewart and Rogoff, and the first cortical hormones were synthesized by Reichenstein. Hormonal replacement therapy paved the way for the first bilateral adrenalectomy, which was performed in 1950. CONCLUSIONS: This review underscores the historical themes in endocrine diseases: discovery of the glands, identification of their hormonal products, use of the hormones for therapy, and biosynthesis for pharmacologic applications.

Comparison of laparoscopic and open adrenalectomy.

This review compares the outcomes of patients who have undergone laparoscopic and open adrenalectomy. Records of all patients who underwent adrenalectomy between January 1993 and December 1996 at Cedars-Sinai Medical Center, Los Angeles, were reviewed. Ten patients underwent laparoscopic, and ten patients underwent open adrenalectomy. The average age in the laparoscopic group (LA) was 48 years (range, 23-64) and 47 years (range, 28-79) in the open group (OA). The LA had smaller tumor size (2.9 +/- 2.0 versus 6.1 +/- 2.8 cm; P = 0.01), longer operative times (164 +/- 47 versus 124 +/- 29 minutes; P = 0.03), shorter length of postsurgical stay (4.1 +/- 2.5 versus 5.9 +/- 1.1 days; P = 0.05), and fewer days of parenteral pain medication (1.9 +/- 1.8 versus 3.4 +/- 1.0 days; P = 0.04). Although the differences did not reach statistical significance, LA also had lower estimated blood loss (118 +/- 158 versus 210 +/- 172 cc; P = 0.23), less time to oral intake (1.8 +/- 2.2 versus 2.8 +/- 1.3 days; P = 0.24), and less direct cost ($3645 +/- 1502 versus $5752 +/- 2948; P = 0.07). Complications of LA included one patient who had a prolonged ileus and adrenal insufficiency and another patient who required readmission for adrenal insufficiency. Complications of OA included one patient who had a prolonged ileus and one patient who had a 20 per cent pneumothorax. Laparoscopic adrenalectomy is the preferred technique in nonmalignant adrenal lesions less than 6 cm in size.

Laparoscopic or open splenectomy for hematologic disease: which approach is superior?

BACKGROUND: This study was undertaken to compare safety, outcome, and costs of laparoscopic (LS) and open splenectomy (OS) for a variety of hematologic diseases. STUDY DESIGN: The records of 137 patients who underwent splenectomy (63 LS and 74 OS) at a large private teaching hospital between March 1991 and April 1996 were reviewed retrospectively. Diagnosis, age, gender, operative time, blood loss, splenic weight, time to resumption of oral diet, postoperative hospital stay, morbidity, mortality, and costs (direct and operative) were analyzed by multivariate statistical analysis. RESULTS: Laparoscopic splenectomy patients had significantly shorter hospitalization and time to resumption of an oral diet (p < 0.01); although operative costs were higher, total direct costs were not. Idiopathic thrombocytopenic purpura patients had earlier resumption of an oral diet after LS, shorter postoperative stay, and comparable OR time. Five patients (7%) were converted, with outcomes similar to OS except for greater operative time and cost. Grade II complications occurred in three LS and four OS patients; Grade III in three OS patients; and Grade IV in two OS patients. There were two major complications of LS and eight of OS, with two deaths. Multivariate analysis showed that operative time and time to resumption of oral intake were significantly related to age, diagnosis, operative technique, and splenic weight. Duration of postoperative hospitalization was related to operative technique, splenic weight, and major complications. Costs (direct and operative) were related to age, splenic weight, and major complications, but not to operative technique. CONCLUSIONS: LS results are influenced by splenic weight, disease, and age. Splenic weight appears to be the crucial determinant of operative time and length of hospitalization. LS is a superior treatment for patients with idiopathic thrombocytopenic purpura and patients with small spleens.

Intracranial pressure. Effects of pneumoperitoneum in a large-animal model.

BACKGROUND: The effects of pneumoperitoneum on intracranial pressure (ICP) have received relatively little attention. This study was undertaken to investigate the changes in ICP occurring as a result of increased intraabdominal pressure (IAP) and positioning in animals with normal and elevated ICP. METHOD: Five pigs (average weight 60 lb) were studied. A subarachnoid screw was placed for ICP monitoring. End tidal CO2 was monitored. Ventilation was performed to keep PCO2 between 30 and 50 mmHg. Measurements of arterial blood gases, mean arterial blood pressure, and ICP were recorded at four different levels of intraabdominal pressure (IAP 0, 8, 16, and 24 mmHg), both in the supine and Trendelenburg positions. A Foley catheter was introduced into the subarachnoid space to elevate the intracranial pressure, and the same measurements were performed. RESULTS: There was a significant and linear increase in ICP with increased IAP and Trendelenburg position. The combination of increased IAP of 16 mmHg and Trendelenburg position increased ICP 150% over control levels. CONCLUSIONS: Patient positioning and level of IAP should be taken into consideration when performing laparoscopy on patients with head trauma, cerebral aneurysms, and other conditions associated with increased ICP.

Limited value of routine followup CT scans in nonoperative management of blunt liver and splenic injuries.

The objective was to determine the utility of a second CT scan in nonoperative management of blunt liver and splenic trauma. The design was a retrospective review of consecutive cases over a 2-year period in two trauma centers. Subjects were 152 patients with blunt abdominal trauma and isolated injuries to liver and/or spleen. Thirty patients received immediate laparotomy, whereas 122 patients (80%) underwent CT scanning that showed splenic (n = 64), liver (n = 44), or combined (n = 14) injuries. Nonoperative management was undertaken in 99 of the 122 (81% of the patients who received CT scans; 65% of the overall series) and was ultimately successful in 94 (95%). Second CT scans were used in 26 patients (26%), one of whom received laparotomy for drainage of a bile leak and three for ongoing bleeding. None of the followup scans showed major progression of injury, and scan findings did not influence decisions for operation in any patients. Routine followup CT scanning is not a justifiable component of nonoperative management protocols for blunt liver and splenic injuries.

Laparoscopic splenectomy for ITP. The gold standard.

BACKGROUND: A comparison of safety, efficacy, and cost of laparoscopic splenectomy (LS) vs open splenectomy (OS) for idiopathic thrombocytopenic purpura (ITP) was performed. METHODS: The records of 49 consecutive patients who underwent splenectomy for ITP (31 LS and 18 OS) at a large metropolitan teaching hospital between 3/91 and 8/95 were reviewed. Morbidity, mortality, hospital stay, operative time, blood loss, time to oral fluid intake, direct costs, and operating room (OR) costs were analyzed. RESULTS: Age, sex, comorbidity, and spleen size were similar in both groups. LS was successful in 94% of patients in whom it was attempted. Operative times showed a learning curve for LS, with average times for the last ten cases (94 +/- 35 min) significantly shorter than for the first ten (p = 0.01) and also shorter than for OS (103 +/- 45 min). Postsurgical hospital stay was 2.9 +/- 1.3 days for LS and 6.9 +/- 3. 0 days for OS (p < 0.001). Patients tolerated an oral diet 1.2 +/- 0. 5 days after LS and 3.2 + 0.7 days after OS (p < 0.001). Direct hospital cost was $5,509 +/- 3,636 for LS and $9,031 +/- 12,752 for OS. In the LS group, six patients (21%) had accessory spleens identified and removed, compared with two patients (11%) in the OS group. Platelet counts did not respond in two (7%) patients in the LS group, but no accessory spleens were identified by nuclear scan. One major complication occurred in the LS group. There were no cases of splenosis or mortality in either group. CONCLUSIONS: LS is a safe and effective treatment for ITP, with significantly shorter postoperative hospital stay than OS.