Technical details for a robot-assisted hand-sewn esophago-gastric anastomosis during minimally invasive Ivor Lewis esophagectomy.

BACKGROUND: Minimally invasive Ivor Lewis esophagectomy (MIILE) provides better outcomes than open techniques, particularly in terms of post-operative recovery and pulmonary complications. However, in addition to requiring advanced technical skills, thoracoscopic access makes it hard to perform esophagogastric anastomosis safely, and the reported rates of anastomotic leak vary from 5 to 16%. Several minimally invasive esophago-gastric anastomotic techniques have been described, but to date strong evidence to support one technique over the others is still lacking. We herein report the technical details and preliminary results of a new robot-assisted hand-sewn esophago-gastric anastomosis technique. METHODS: From January 2018 to December 2020, 12 cases of laparoscopic/thoracoscopic Ivor Lewis esophagectomy with robot-assisted hand-sewn esophago-gastric anastomosis were performed. The gastric conduit was prepared and tailored taking care of vascularization with a complete resection of the gastric fundus. The anastomosis consisted of a robot-assisted, hand-sewn four layers of absorbable monofilament running barbed suture (V-lock). The posterior outer layer incorporated the gastric and esophageal staple lines. RESULTS: The post-operative course was uneventful in nine cases. Two patients developed chyloperitoneum, one patient a Sars-Cov-2 infection, and one patient a late anastomotic stricture. In all cases, there were no anastomotic leaks or delayed gastric conduit emptying. The median post-operative stay was 13 days (min 7, max 37 days); the longest in-hospital stay was recorded in patients who developed chyloperitoneum. CONCLUSION: Despite the small series, we believe that our technique looks to be promising, safe, and reproducible. Some key points may be useful to guarantee a low complications rate after MIILE, particularly regarding anastomotic leaks and delayed emptying: the resection of the gastric fundus, the use of robot assistance, the incorporation of the staple lines in the posterior aspect of the anastomosis, and the use of barbed suture. Further cases are needed to validate the preliminary, but very encouraging, results.

Robotic versus laparoscopic distal pancreatectomy: multicentre analysis.

BACKGROUND: The role of minimally invasive distal pancreatectomy is still unclear, and whether robotic distal pancreatectomy (RDP) offers benefits over laparoscopic distal pancreatectomy (LDP) is unknown because large multicentre studies are lacking. This study compared perioperative outcomes between RDP and LDP. METHODS: A multicentre international propensity score-matched study included patients who underwent RDP or LDP for any indication in 21 European centres from six countries that performed at least 15 distal pancreatectomies annually (January 2011 to June 2019). Propensity score matching was based on preoperative characteristics in a 1 : 1 ratio. The primary outcome was the major morbidity rate (Clavien-Dindo grade IIIa or above). RESULTS: A total of 1551 patients (407 RDP and 1144 LDP) were included in the study. Some 402 patients who had RDP were matched with 402 who underwent LDP. After matching, there was no difference between RDP and LDP groups in rates of major morbidity (14.2 versus 16.5 per cent respectively; P = 0.378), postoperative pancreatic fistula grade B/C (24.6 versus 26.5 per cent; P = 0.543) or 90-day mortality (0.5 versus 1.3 per cent; P = 0.268). RDP was associated with a longer duration of surgery than LDP (median 285 (i.q.r. 225-350) versus 240 (195-300) min respectively; P < 0.001), lower conversion rate (6.7 versus 15.2 per cent; P < 0.001), higher spleen preservation rate (81.4 versus 62.9 per cent; P = 0.001), longer hospital stay (median 8.5 (i.q.r. 7-12) versus 7 (6-10) days; P < 0.001) and lower readmission rate (11.0 versus 18.2 per cent; P = 0.004). CONCLUSION: The major morbidity rate was comparable between RDP and LDP. RDP was associated with improved rates of conversion, spleen preservation and readmission, to the detriment of longer duration of surgery and hospital stay.

Laparoscopic versus open extended radical left pancreatectomy for pancreatic ductal adenocarcinoma: an international propensity-score matched study.

BACKGROUND: A radical left pancreatectomy in patients with pancreatic ductal adenocarcinoma (PDAC) may require extended, multivisceral resections. The role of a laparoscopic approach in extended radical left pancreatectomy (ERLP) is unclear since comparative studies are lacking. The aim of this study was to compare outcomes after laparoscopic vs open ERLP in patients with PDAC. METHODS: An international multicenter propensity-score matched study including patients who underwent either laparoscopic or open ERLP (L-ERLP; O-ERLP) for PDAC was performed (2007-2015). The ISGPS definition for extended resection was used. Primary outcomes were overall survival, margin negative rate (R0), and lymph node retrieval. RESULTS: Between 2007 and 2015, 320 patients underwent ERLP in 34 centers from 12 countries (65 L-ERLP vs. 255 O-ERLP). After propensity-score matching, 44 L-ERLP could be matched to 44 O-ERLP. In the matched cohort, the conversion rate in L-ERLP group was 35%. The L-ERLP R0 resection rate (matched cohort) was comparable to O-ERLP (67% vs 48%; P = 0.063) but the lymph node yield was lower for L-ERLP than O-ERLP (median 11 vs 19, P = 0.023). L-ERLP was associated with less delayed gastric emptying (0% vs 16%, P = 0.006) and shorter hospital stay (median 9 vs 13 days, P = 0.005), as compared to O-ERLP. Outcomes were comparable for additional organ resections, vascular resections (besides splenic vessels), Clavien-Dindo grade ≥ III complications, or 90-day mortality (2% vs 2%, P = 0.973). The median overall survival was comparable between both groups (19 vs 20 months, P = 0.571). Conversion did not worsen outcomes in L-ERLP. CONCLUSION: The laparoscopic approach may be used safely in selected patients requiring ERLP for PDAC, since morbidity, mortality, and overall survival seem comparable, as compared to O-ERLP. L-ERLP is associated with a high conversion rate and reduced lymph node yield but also with less delayed gastric emptying and a shorter hospital stay, as compared to O-ERLP.

Quality of life and psychopathology in candidates to bariatric surgery: relationship with BMI class.

PURPOSE: This cross-sectional study aimed at comparing the quality of life (Qol), the prevalence of psychiatric diagnosis and pharmacological treatment in 104 candidates to bariatric surgery according to the degree of obesity (class 2 vs. class ≥ 3 obesity). METHODS: All surgical candidates underwent a detailed psychiatric interview based on DSM-5 criteria, including sociodemographic, clinical, psychological and psychiatric data. Participants completed the Binge Eating Scale (BES) and the 12-Item Short Form Health Survey (SF-12). RESULTS: Overall, bariatric candidates reported a significant impairment in the physical (PCS 38.8 [95% CI 36.2-41.5]) and mental (MCS 42.2 [95% CI 40.4-43.9]) components of Qol compared to population norms (p < 0.001 for both). Subjects with class 2 obesity scored significantly lower in the MCS compared to those with class 3 (38.7 (8.1) vs. 43.6 (8.4), p = 0.008). No other statistically significant differences were found between the two groups in terms of sociodemographic and clinical variables. CONCLUSION: These data support the usefulness of Qol assessment in bariatric candidates as a sensible screening parameter, especially in patients with lower BMI, in whom MCS could identify the need for early psychosocial intervention. LEVEL OF EVIDENCE: Level III, case-control analytic study.

Toward the improvement of 3D-printed vessels' anatomical models for robotic surgery training.

Multi-Detector Computed Tomography is nowadays the gold standard for the pre-operative imaging for several surgical interventions, thanks to its excellent morphological definition. As for vascular structures, only the blood flowing inside vessels can be highlighted, while vessels' wall remains mostly invisible. Image segmentation and three-dimensional-printing technology can be used to create physical replica of patient-specific anatomy, to be used for the training of novice surgeons in robotic surgery. To this aim, it is fundamental that the model correctly resembles the morphological properties of the structure of interest, especially concerning vessels on which crucial operations are performed during the intervention. To reach the goal, vessels' actual size must be restored, including information on their wall. Starting from the correlation between vessels' lumen diameter and their wall thickness, we developed a semi-automatic approach to compute the local vessels' wall, bringing the vascular structures as close as possible to their actual size. The optimized virtual models are suitable for manufacturing by means of three-dimensional-printing technology to build patient-specific phantoms for the surgical simulation of robotic abdominal interventions. The proposed approach can effectively lead to the generation of vascular models of optimized thickness wall. The feasibility of the approach is also tested on a selection of clinical cases in abdominal surgery, on which the robotic surgery is performed on the three-dimensional-printed replica before the actual intervention.

Psychological Aspects and Psychopharmacologic Treatment in the Very Early Period After Kidney Transplantation: Role of a Multidisciplinary Approach.

BACKGROUND: In the context of kidney transplantation (KT), multidisciplinary interventions, including assessment and management of psychosocial aspects, are important to improve transplant's outcome. The aim of this study was to describe a multidisciplinary team approach to KT, with a specific focus on early detection and treatment of psychological distress and psychopathologic conditions in the early phase postsurgery. METHODS: The multidisciplinary team in kidney transplantation was implemented in January 2016. In this team approach, all transplant recipients are invited to 3 scheduled appointments for a multidisciplinary evaluation at 1, 3, and 6 months posttransplant, including a psychiatric interview, with the aim to assess the patient's adjustment after transplantation and provide support when necessary. RESULTS: This pilot study involved all 41 KT recipients consecutively referred for the first multidisciplinary appointment after transplantation. Five subjects (12% of the study sample) presented with a current psychiatric diagnosis. Psychopharmacologic treatment was confirmed or introduced for all these patients. Further psychological support was suggested to 4 other patients (10%). CONCLUSION: KT significantly improves patients' quality of life. However, the percentage of subjects receiving psychopharmacologic treatment and referred for further psychological and psychiatric support (22%) suggests the need for careful monitoring of psychosocial aspects over the long term.

Living Kidney Donation Is Recipient Age Sensitive and Has a High Rate of Donor Organ Disqualifications.

BACKGROUND: Living donor kidney transplantation (LDKT) is the best therapy for patients with chronic renal failure. Its advantages, compared with cadaveric transplantation, include the possibility of avoiding dialysis, the likelihood of best outcome, and donor pool expansion. Careful assessment of potential donors is important to minimize the risks and ensure success. However, the proportion of donors disqualified has been poorly investigated. The aim of this work is to describe our experience and present the main reasons for missed donation. METHODS: This was a single-center, retrospective study of all potential donors and recipients evaluated for LDKT between January 2008 and December 2017. RESULTS: During the period of study, 81 donor-recipient pairs were evaluated. Of these, 45.7% were disqualified and 37 LDKTs were carried out. LDKT was the first choice in 68% of cases and preemptive in 20%; 60% of transplants were among family members. Sex distribution revealed a prevalence of females in the donor group (69%) and males in the recipient group (70%). The mean living donor age was 53 ± 9.5 years; the mean recipient age was lower in recipients listed in the living transplant program than those listed for cadaver transplantation (45.8 ± 13.4 vs 54.2 ± 11.08; P < .0001). Reasons for denial included hypertension (18.9%), deceased donor transplant performed during the study period (16.2%), urologic pathology (13.5%), incompatibility (13.5%), withdrawal of consent by donor or recipient (13.5%), psychological unsuitability (8.1%), donor cancer (5.4%), and reduced renal clearance (2.7%). CONCLUSION: LDKT is considered an option especially for younger recipients. Of the potential kidney living donors, 45.7% were disqualified during the evaluation, with medical reasons being the primary cause.

An innovative strategy for the identification and 3D reconstruction of pancreatic cancer from CT images.

We propose an innovative tool for Pancreatic Ductal AdenoCarcinoma 3D reconstruction from Multi-Detector-Computed Tomography. The tumor mass is discriminated from health tissue, and the resulting segmentation labels are rendered preserving information on different hypodensity levels. The final 3D virtual model includes also pancreas and main peri-pancreatic vessels, and it is suitable for 3D printing. We performed a preliminary evaluation of the tool effectiveness presenting ten cases of Pancreatic Ductal AdenoCarcinoma processed with the tool to an expert radiologist who can correct the result of the discrimination. In seven of ten cases, the 3D reconstruction is accepted without any modification, while in three cases, only 1.88, 5.13, and 5.70 %, respectively, of the segmentation labels are modified, preliminary proving the high effectiveness of the tool.

Perivascular fibrosis and IgG4-related disease: a case report.

Immunoglobulin G4-related disease (IgG4-RD) is a newly recognized fibroinflammatory condition which can potentially involve any organ. Some characteristic histopathologic features with lymphoplasmacytic infiltrate, an increased number of IgG4+ cells, storiform fibrosis and obliterative phlebitis are the mainstay for diagnosis. Serum IgG4 levels often increase. We report the case of a patient with perivascular fibrotic lesions involving the aortic arch and the splenic hilum, with a surgical biopsy-proven diagnosis of IgG4-related disease. The patient is now undergoing a low-dose corticosteroid maintenance therapy without evidence of new localizations of the disease. This case highlights the need for increasing awareness and recognition of this new, emerging clinical condition.

Immunomodulatory properties of porcine, bone marrow-derived multipotent mesenchymal stromal cells and comparison with their human counterpart.

Thanks to their immunonodulatory properties, multipotent mesenchymal stromal cells (MSCs) are a promising strategy for preventing/reducing the risk of graft rejection after hematopoietic cell and solid organ transplantation. We have previously demonstrated that porcine MSCs (pMSCs) can be isolated from bone marrow and display similar morphology and differentiative capacity as compared to human MSC (hMSCs). In this study, we investigated the in vitro immunomodulatory properties (namely the ability to suppress lymphocyte proliferation in response to phytohemagglutinin and the cytokine production in the culture supernatants) of pMSCs from six Large White 6-month old piglets. Similarly to hMSCs, pMSCs reduced the phytohemagglutinin-induced lymphocyte proliferation. High levels of IL-6 were found in culture supernatants, whereas IL-10 and TGF-ß were not detectable. In conclusion, ex vivo expanded pMSCs share selected biological/functional properties with hMSCs. pMSCs may be used in in vivo models to investigate novel approaches of prevention of graft rejection in solid organ transplantation.

Robotic-assisted laparoscopic donor nephrectomy with transvaginal extraction of the kidney.

Transvaginal recovery of the kidney has recently been reported, in a donor who had previously undergone a hysterectomy, as a less-invasive approach to perform laparoscopic live-donor nephrectomy. Also, robotic-assisted laparoscopic kidney donation was suggested to enhance the surgeon's skills during renal dissection and to facilitate, in a different setting, the closure of the vaginal wall after a colpotomy. We report here the technique used for the first case of robotic-assisted laparoscopic live-donor nephrectomy with transvaginal extraction of the graft in a patient with the uterus in place. The procedure was carried out by a multidisciplinary team, including a gynecologist. Total operative time was 215 min with a robotic time of 95 min. Warm ischemia time was 3 min and 15 s. The kidney was pre-entrapped in a bag and extracted transvaginally. There was no intra- or postoperative complication. No infection was seen in the donor or in the recipient. The donor did not require postoperative analgesia and was discharged from the hospital 24 h after surgery. Our initial experience with the combination of robotic surgery and transvaginal extraction of the donated kidney appears to open a new opportunity to further minimize the trauma to selected donors.

Investigation of interactions between poly-L-lysine-coated boron nitride nanotubes and C2C12 cells: up-take, cytocompatibility, and differentiation.

Boron nitride nanotubes (BNNTs) have generated considerable interest within the scientific community by virtue of their unique physical properties, which can be exploited in the biomedical field. In the present in vitro study, we investigated the interactions of poly-l-lysine-coated BNNTs with C2C12 cells, as a model of muscle cells, in terms of cytocompatibility and BNNT internalization. The latter was performed using both confocal and transmission electron microscopy. Finally, we investigated myoblast differentiation in the presence of BNNTs, evaluating the protein synthesis of differentiating cells, myotube formation, and expression of some constitutive myoblastic markers, such as MyoD and Cx43, by reverse transcription - polymerase chain reaction and Western blot analysis. We demonstrated that BNNTs are highly internalized by C2C12 cells, with neither adversely affecting C2C12 myoblast viability nor significantly interfering with myotube formation.

Ultrasound guided robotic biopsy using augmented reality and human-robot cooperative control.

Ultrasound-guided biopsy is a proficient mininvasive approach for tumors staging but requires very long training and particular manual and 3D space perception abilities of the physician, for the planning of the needle trajectory and the execution of the procedure. In order to simplify this difficult task, we have developed an integrated system that provides the clinician two types of assistance: an augmented reality visualization allows accurate and easy planning of needle trajectory and target reaching verification; a robot arm with a six-degree-of-freedom force sensor allows the precise positioning of the needle holder and allows the clinician to adjust the planned trajectory (cooperative control) to overcome needle deflection and target motion. Preliminary tests have been executed on an ultrasound phantom showing high precision of the system in static conditions and the utility and usability of the cooperative control in simulated no-rigid conditions.

Laparoscopic donor nephrectomy: short learning curve.

INTRODUCTION: The learning curve of laparoscopic donor nephrectomy (LDN) may represent a great technical challenge at centers with low volume of living donors. The number of LDNs required to overcome the learning curve is still unclear. Here we report the modality of approach to LDN at a low-volume living donor transplant center. MATERIALS AND METHODS: We reviewed the records of two groups of donors operated by two different surgeons between January 2002 and October 2005. We compared donor hospital stay, operative time, presence of multiple renal arteries, blood loss, operative details, and complications. RESULTS: The first six operations (group A) were performed by a well-trained laparoscopic surgeon (A.P.) with a consolidated experience in the LDN procedure, attended by our training surgeon (R.D.V.) who conducted the other six cases (group B). No conversion to an open procedure was necessary and there were no major minor complications. Mean operative time was 267.5 (+/-55.9) minutes in group A and 300 (+/-43.4) minutes in group B (P = .28). Mean warm ischemia time was 125 (+/-61.6) seconds in group A and 189.2 (+/-18.6) seconds in group B (P = .035). Mean hospital stay was 5.3 days in group A and 5.6 days in group B. CONCLUSIONS: LDN can be performed safely and efficiently in transplant centers with initial experience. A collaborative approach to this difficult procedure with a surgeon skilled in donor nephrectomy minimizes the risk to the donor and reduces the learning curve.

University of Wisconsin solution versus Celsior solution in clinical pancreas transplantation.

INTRODUCTION: This study compared the safety and efficacy of University of Wisconsin solution (UW) and Celsior solution (C) in pancreas transplantation (PTx). METHODS: A retrospective review of 154 PTx performed over a 61-month period included 77 grafts preserved with UW and 77 with C. The two groups were comparable for both donor and recipient characteristics. RESULTS: After a mean cold ischemia time of 624 minutes (range 360 to 945 minutes) for UW versus 672 minutes (range 415 to 1005 minutes) for C (P = NS), no primary endocrine nonfunction occurred. Delayed endocrine function was diagnosed in two grafts in the UW group (2.6%) versus none in the C group (P = NS). After a minimum follow-up of 4 months (mean 26.5 +/- 15.2 months), 22 recipients (UW = 11 vs C = 11; P = NS) required relaparotomy. Overall, 18 pancreata were lost due to either patient death with functioning graft (UW = 4 vs C = 1; P = NS) or graft loss due to other reasons (UW = 8 vs C = 5; P = NS). Actuarial 1- and 5-year patient survival rates were 93.5% and 86.8% for UW compared with 98.7% and 98.7% for C (P = .04). Actuarial graft survival rates at the same times were 88.3% and 75.0% for UW compared with 90.4% and 90.4% for C (P = NS). CONCLUSIONS: Within the range of cold ischemia times reported in this study, UW and C show similar safety and efficacy profiles for PTx.

Pancreas transplants from donors aged 45 years or older.

AIMS: Since donor age of 45 years or more is considered a relative contraindication for pancreas transplantation (PTx), we herein report our experience with these donors. METHODS: Pancreases from donors aged 45 years or older were used in 16 of 147 PTx procedures (11%). The final decision to accept a graft for PTx was based mainly on the quality of visceral perfusion and the gross appearance of the pancreas and the vessels. There were 9 men and 7 women, ranging in age from 45 to 55 years (average, 48.9 years) who were donors, due to cerebrovascular accidents (n = 11; 68.7%). Among the donor group, 5 patients were receiving multiple vasopressor agents (31.2%), and 2 had a history of cardiac arrest (12.5%). Pancreases were transplanted either simultaneously with a cadaveric kidney (n = 6) or as solitary grafts (n = 10). RESULTS: After a mean period of cold preservation of 616 minutes (range, 475 to 844 min), delayed endocrine function occurred in 1 recipient (6%), who subsequently achieved insulin independence. Two recipients died suddenly, with functioning grafts. Two further grafts were lost due to portal vein thrombosis (6%) or late arterial thrombosis (6%). Three patients required repeat surgery (18.7%). After a mean follow-up period of 26.6 months, actuarial 1-year and 5-year patient survival rates were 87.5%, with insulin independence in 81.2% and 67.7%, respectively. CONCLUSIONS: Meticulous donor selection and short preservation times allow the safe use of pancreases procured from donors aged 45 years or older, thus expanding the donor pool for PTx procedures.

Phenotype-genotype relationships of SULT1A1 in human liver and variations in the IC50 of the SULT1A1 inhibitor quercetin.

Human sulfotransferases catalyze sulfate conjugation and 2 polymorphic genes, SULT1A1 and SULT1A2 in this family of transferases have been identified, encoding for 2 isoenzymes with very similar properties and substrate specificities. In order to test the hypothesis that variability in sulfation is due to genetic polymorphism in SULT1A1, the sulfation rate of 4-nitrophenol, a diagnostic substrate, was measured in 50 human liver samples and the genotype at the SULT1A1 locus was analyzed. The rate of 4-nitrophenol sulfation varied from 473 - 1,405 pmol/min/mg between the 5th and 95th percentiles, with a median and a mean +/- SD of 757 and 807 +/- 292 pmol/min/mg, respectively. The activities detected among the SULT1A1*2/*2 homozygotes (5 cases) were significantly lower than those of the other 2 genotypes, SULTA1*11/*1 and SULT1A1*1/*2 (5 and 40 cases, respectively), whereas there was no significant difference found between the SULT1A1*1/*1 and SULT1A1*1/*2 genotypes. To evaluate the possible influence of SULT1A2 polymorphism, genotype assays were also performed for this locus. No SULT1A2*2/*2 carrier, 26 SULT1A2*1/*1 and 24 SULT1A2*1/*2 were detected in the population sample under study. However, no correlation between the rate of 4-nitrophenol sulfation and the SULT1A2 genotype was detected. These results confirm that the variation in the rate of 4-nitrophenol sulfation in human liver is mainly due to SULT1A. Since SULT1A1*1/*2 polymorphism accounts for no more than 10% of the phenotypic variation seen in this cohort, other factors must also contribute to the variability in the rate of 4-nitrophenol sulfation in human liver. However, on the basis of the data obtained, variations in age, gender and liver function as possible causative factors can be excluded. The IC50 of quercetin, a potent inhibitor of 4-nitrophenol sulfation, was measured in the liver samples and ranged from 4.6 to 17.3 nM between the 5th and 95th percentiles. The median and the mean +/- SD were 7.7 nM and 8.3 +/- 2.5 nM, respectively. There was a weak but significant correlation between the IC50 value and age of the liver donors (r = 0.283, p = 0.046). The observed variation did not correlate with the genotypes at the SULT1A1 and SULT1A2 loci.

Simultaneous pancreas-kidney transplantation is improved by living kidney donation program.

BACKGROUND: Shortage of suitable donors and current graft allocation priorities reduce the number of cadaveric kidneys available to diabetic recipients. The concurrent excess of solitary cadaveric pancreata and the excellent results of living kidney transplantation make simultaneous cadaveric pancreas-living kidney transplantation (SPLKTx) an attractive alternative to simultaneous pancreas-kidney transplantation (SPKTx). METHODS: Between June 2001 and June 2003, 80 recipients were enrolled in the SPKTx waiting list. Each recipient's family was counseled about living kidney donation (LKD). Twenty-nine (36.2%) candidates were evaluated for LKD and 8 (27.6%) were disqualified. The remaining 21 candidates were scheduled for LKD and 18 actually donated. RESULTS: Thanks to LKD 18 additional recipients were transplanted, thus expanding the donor pool from 33 to 51 (P =.004). The median waiting time for SPLKTx was 14 days as compared with 95 days for SPKTx (P =.006). Without LKD the median waiting time for SPKTx would have been 198 days (P =.02). Similarly, 1 year after the enrollment on the waiting list 60% of recipients had been transplanted, while without LKD only 42% would had been grafted (P =.01). Two-year recipient survival rate was 100% for SPLKTx compared with 96.9% for SPKTx. Equivalent figures for kidney and pancreas were 80.0% and 84.0% for SPLKTx compared with 96.9% and 96.9% for SPKTx. CONCLUSIONS: LKD expanded the kidney donor pool, reduced the waiting time of recipients listed for a totally cadaveric procedure, and increased their chance to get a timely graft. One-year outcome of SPLKTx equaled that of SPKTx.

Thrombosis in the portal venous system after elective laparoscopic splenectomy.

BACKGROUND: The occurrence of thrombosis in the portal system is an underappreciated complication of splenectomy. Presenting symptoms are usually mild and nonspecific. The short hospital stay associated with the laparoscopic approach could delay the early diagnosis of this condition unless routine imaging controls are planned after discharge. METHODS: The records of 40 patients who underwent laparoscopic splenectomy at our institution were reviewed for clinical signs of thrombosis in the portal system and associated factors. All patients were also enrolled in a color Doppler ultrasound surveillance program. RESULTS: Nine patients (22.5%) developed thrombosis of the splenic vein, progressing to the portal vein in five cases (12.5%). Six patients (15%) were symptomatic. Thrombosis occurred even as late as 4 months after splenectomy. Spleen weight was the only significant factor predictive of postoperative thrombosis. The combination of splenomegaly and an elevated preoperative platelet count was associated with a 75% incidence of this complication. CONCLUSION: The high risk of thrombosis after the laparoscopic resection of large spleens should prompt strict postoperative imaging surveillance, combined with a more aggressive anticoagulation prophylaxis.