Laparoscopic treatment of symptomatic lymphoceles after kidney transplantation

BACKGROUND

The incidence of lymphocele after kidney transplantation ranges from 0.6% to 18%. This study examines the use of laparoscopic ultrasound for the location of lymphoceles during laparoscopic drainage.

METHODS

Between July 1993 and October 1998, we performed 147 kidney transplants. A symptomatic lymphocele was observed in 19 patients (12.9%). All of these patients underwent peritoneal laparoscopic fenestration of the lymphocele. The graft, kidney hilum, ureter, iliac vessels, and lymphoceles were identified by laparoscopic ultrasound.

RESULTS

All but one patient were discharged within 24 h. One recurrence (5.2%), which was successfully treated by laparoscopy, was observed at a mean follow-up of 15.5 months. We had one complication (5.2 %)-a left hydrocele that occurred 2 days after drainage of a lymphocele located in the left iliac fossa.

CONCLUSIONS

Laparoscopic peritoneal drainage of posttransplant lymphoceles shares the well known advantages of laparoscopy. Furthermore, laparoscopic ultrasound is a useful tool that allows the recognition of anatomical structures and decreases the risk of iatrogenic lesions.

Laparoscopic vs open splenectomy in the management of hematologic diseases

BACKGROUND

Laparoscopic splenectomy (LS) is becoming the gold standard in the treatment of several splenic diseases. Shorter postoperative stay and more rapid return to full activity are the primary advantages of LS.

METHODS

Prospective data collection of 44 consecutive LS (group 1) and comparison with a historical control group of 56 consecutive open splenectomies (OS) (group 2) were performed for hematologic diseases.

RESULTS

The LS patients started earlier on an oral diet (p < 0.0001) and left the hospital sooner (p < 0.0002) than OS patients. Less blood transfusion (p < 0.004) and pain medication (p < 0.0001) was required by LS patients. They also had fewer postoperative complications (p < 0.03). Compared by diagnosis, patients with laparoscopic idiopathic thrombocytopenic purpura or Hodgkin's disease started to eat earlier (p < 0.0001) and left the hospital sooner (p < 0.01). Multivariate analysis showed that time to oral diet and postoperative stay was related to operative technique and age. Morbidity and pain medications were related, respectively, to transfusion requirements and type of surgical approach.

CONCLUSIONS

Used to manage hematologic diseases, LS is feasible, effective, and safe. It offers several advantages over the open approach. The type of surgical approach seems to be the crucial factor in determining the length of the postoperative course.

Laparoscopic splenectomy for haematological diseases: review of current concepts and opinions

Laparoscopic splenectomy is now currently used by most surgeons in the treatment of many haematological diseases. The operative technique varies depending on the surgeon, but results are usually comparable among published series. We have reviewed 104 papers about laparoscopic splenectomy for haematological diseases and paid particular attention to surgical aspects and early postoperative results. We searched MEDLINE from January 1989 to April 1998, and of the 104 papers that we found 41 fulfilled our criteria of large series published in peer-reviewed journals that had been cited often. They usually compared laparoscopic and open splenectomy and focused on common problems (such as accessory spleens) and technical aspects (such as bleeding). Laparoscopic splenectomy is reported by most authors to be as safe and effective as open splenectomy for haematological diseases. It also has several advantages over the open approach, such as shorter and less complicated postoperative stay with better cosmetic results and more rapid return to full activities.

Phenotypic characterization of immunomagnetically purified umbilical cord blood CD34+ cells

This study describes the multilineage differentiation pattern of purified CD34+ stem cells obtained from human umbilical cord blood. CD34+ cells were collected from 49 umbilical cord blood samples. Following immunomagnetic purification, cells were double stained with anti CD34 and CD71, CD61, CD7, CD19, CD33, CD36 and triple stained with anti CD34, CD38 and HLA-DR. Analysis were performed using a FACScan flow cytometer. After purification, the mean CD34+ cells' purity was 85.49 +/- 7.08%. Several subpopulations of umbilical cord blood CD34+ cells were identified indicating different lineage commitment. The majority of CD34+ cells expressed both CD38 and HLA-DR (91.74 +/- 3.76%), while those lacking CD38 were 3.43 +/- 2.12% (CD38-DR+) and 1.81 +/- 1.54% (CD38-DR-). These data were compared to the expression of lineage commitment markers on purified CD34+ cells from 5 mobilized peripheral blood samples. The percentage of peripheral blood CD34+CD38-DR+) and CD34+CD38-DR- cells was significantly lower than umbilical cord blood, 0.24 +/- 0.18% and 0.04 +/- 0.03% respectively. The knowledge and standardized of umbilical cord blood CD34+ cells phenotype is critical since umbilical cord blood volume is limited. The homogeneity of CD34+ subpopulation phenotype suggests that monitoring of lineage differentiation antigens may not be relevant for clinical use of umbilical cord blood samples. However, the observed higher percentage of pluripotent CD34+38- stem cells in umbilical cord blood compared to peripheral blood, that might explain the successful clinical use of umbilical cord blood even when low number of cells are used, candidates these antigens as the predictive parameter for clinical use of umbilical cord blood samples.

Splenectomy in hematology. Current practice and new perspectives

BACKGROUND AND OBJECTIVE

Progress and changes in the management of blood diseases, in surgery and in video technology stimulate a critical reappraisal of splenectomy in hematology.

DESIGN AND METHODS

We have collected information on the current practice of splenectomy in hematology in Italy and we have reviewed the results of a new technique of laparoscopic splenectomy (LS).

RESULTS

Current splenectomy practice: the current practice in Italy is to offer splenectomy as front-line treatment for hereditary spherocytosis and as second-line for idiopathic thrombocytopenic purpura (ITP) and hemolytic anemia. Splenectomy is also offered in selected cases of leukemia and lymphoma but is going out of practice for hairy cell leukemia and Hodgkin's disease. The number of splenectomies that are performed every year is estimated to be higher than 10x10(6) persons (more than 500 cases per year). Laparoscopic splenectomy (LS): more than 700 cases of LS have been reported so far, for thrombocytopenia (470 cases) as well as for many other hematologic indications. The procedure carries a mortality of 0.8%, and a complication rate of 12%. Time spent in the operating theater ranges from 1.5 to 4 hours, blood transfusion requirement is minimal and the mean post-operative hospital stay is 3 days.

INTERPRETATION AND CONCLUSIONS

Although a prospective comparison is not available, the results of LS compare favorably with the results of classic open splenectomy, so that LS is likely to become the technique of choice especially when the spleen is small, as in ITP. LS can also have some advantages in other cases of splenectomy, including splenomegaly for leukemia and lymphoma. These data and suggestions should stimulate and renew a discussion about splenectomy in hematology, with the purpose of establishing evidence-based guidelines.

Elective transumbilical compared with standard laparoscopic cholecystectomy

OBJECTIVE

To compare the transumbilical technique of laparoscopic cholecystectomy with standard laparoscopic cholecystectomy.

DESIGN

Randomised open study.

SETTING

Teaching hospital, Italy.

SUBJECTS

90 patients who required elective cholecystectomy under general anaesthesia.

INTERVENTIONS

Standard laparoscopic cholecystectomy through 4 ports or transumbilical cholecystectomy through 2 ports.

MAIN OUTCOME MEASURES

Amount of pain and analgesia, cost, side effects, and cosmesis.

RESULTS

25 patients were excluded from analysis (8 in the standard group because relevant data were not recorded; and 17 in the transumbilical group in 4 of whom relevant data were not recorded, and 13 for technical reasons). 32 patients who had standard, and 25 who had transumbilical cholecystectomy had operative cholangiograms. There were no complications, no side effects, and no conversions to open cholecystectomy. Those who had transumbilical cholecystectomy had significantly lower pain scores (p<0.05) and required significantly less analgesia during the first 24 hours (p<0.05) than those who had standard laparoscopic cholecystectomy.

CONCLUSION

Once the learning curve has been completed, transumbilical cholecystectomy is possible without some of difficulties associated with standard laparoscopic cholecystectomy.

Laparoscopic versus open splenectomy in the management of splenomegaly: our preliminary experience

BACKGROUND

Laparoscopic splenectomy for normal-sized spleens has several advantages compared with laparotomy. Only a few cases of splenomegaly done by laparoscopy are reported in the literature. The purpose of this study is to show that laparoscopy for splenomegaly is feasible and has several advantages over the open operation.

METHODS

We performed retrospective chart review of 8 cases of splenomegaly managed by laparoscopy (group 1), 15 cases of open splenomegaly (group 2), and 27 cases of laparoscopic splenectomy for normal-sized spleens (group 3). Comparison has been done between groups 1 and 2 and groups 1 and 3 in terms of operative time, intraoperative estimated blood loss, need for blood transfusion, postoperative ileus, postoperative stay, and mortality and morbidity rates.

RESULTS

Patients in group 1 required longer operative time and significantly less intraoperative blood transfusion compared with group 2. The postoperative course was less complicated and shorter in group 1 than in group 2. Operative time was longer in group 1 compared with group 3. No significant differences in terms of postoperative course have been found between groups 1 and 3.

CONCLUSIONS

Laparoscopy for splenomegaly is a feasible, effective, and safe technique for experienced laparoscopic surgeons. This approach seems to have several advantages over the open operation. Prospective, randomized trials would be required for a proper quantitative evaluation.

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.

[Laparoscopic versus laparotomic adrenalectomy: preliminary experiences]

The authors report their experience about laparoscopic surgery in the treatment of adrenal tumours. Three laparoscopic right adrenalectomies were performed. From a comparison with five open adrenalectomies, microinvasive surgery is more advantageous than traditional management: recovery is earlier, incisions are smaller, post-operative discomfort is less, physiologic functions recover in a short time, return to full professional activity in one week.

[Surgical treatment of liver metastases of breast carcinoma. Our experience]

The authors report their experience in the surgical treatment of breast cancer liver metastases. Although with a restricted number of cases (4 patients), the short-term results are satisfactory; this is in agreement with the literature. The survival of those patients treated with a loco-regional approach to metastases (chemotherapy and surgery), is longer than one obtained using systemic chemotherapy. This is still an open question requiring further experience.

Percutaneous large core needle biopsy versus surgical biopsy in the diagnosis of breast lesions

OBJECTIVE

To value LCNB accuracy in the determination of morphobiological parameters and as an alternative to the open SB diagnostic procedure of breast lesions.

SETTING

University Hospital, Italy.

SUBJECTS

From May 1992 to February 1995 196 biopsies have been performed. The diameter of the neoplasms examined varied from 0.6 to 7 cm with an average of 1.9 cm.

MAIN OUTCOME MEASURES

The accuracy of the two methods in the evaluation of histological degree, receptor state, protein c-erb B2 and p53 were compared.

RESULTS

No inadequate sampling were ever recorded. LCNB has shown values of 97% sensitivity and 100% specificity. The positivity and negativity predicted values obtained were 100% and 89% respectively. Retrospectively 70 sample-cases of carcinoma were selected and the morphobiological parameters evaluated. The correlation coefficients for the data obtained with SB and LCNB in the evaluation of Progesteron and Oestrogen receptor expression, protein c-erb B2 and p53 were excellent. Furthermore it was noted that LCNB allows a saving of at least 1/3 of the cost vs intraoperative SB.

CONCLUSIONS

Percutaneous LCNB has high diagnostic accuracy for histological classification. LCNB has the same accuracy as SB for morphobiological parameters. The cost of LCNB is markedly lower than SB.

[Solid papillary tumor of the pancreas. A clinical case]

The solid papillary tumor of the pancreas is a relative rare neoplasm that often is unknown because of its diagnostic difficulties. It is frequent in young women. It has no typical clinical signs, sometimes produces abdominal mass, sometimes is found casually during investigations for other diseases. Instead the prognosis of this tumor is more typical: long-term survival is good. The natural history of the solid papillary is the same as neoplasm with a low malignancy potential. For this reason, it's important to make up a differential diagnosis between it and the other pancreatic tumors. Unlike the other malignancies, surgical conservative therapy is enough without making great demolitions of the pancreas. Lumpectomy gives a complete cure, decreasing surgical risk and dangerous functional complications. In the present paper, a case of solid papillary tumour of the pancreas is reported. It was diagnosed in a young woman and treated with simple lumpectomy. She is alive and disease free.

[Hemoperitoneum caused by lesions to the appendix epiploica. An unusual complication of colonoscopy]

A rare case of hemoperitoneum in a young man who performed a diagnostic colonoscopy is reported. The rupture of an epiploic appendix among rectum and colon sigma caused massive bleeding into the peritoneum cavity followed by haemorrhagic shock. Diagnostic and therapeutic colonoscopy has a low rate of morbility; perforation and bleeding are the most common events; hemoperitoneum following colonscopy is usually due to spleen rupture. Among other complications, ileal and cecal volvolus, incarceration of hernias and subcutaneous emphysema are reported.

[Trans-umbilical cholecystectomy: a new laparoscopic cholecystectomy technique. Description of the technique and preliminary results]

The aim of videolaparo-cholecystectomy is to achieve a good results with minimal surgical trauma. Recently there has been an evolution of this technique toward the progressive reduction of trauma with an improvement of the results, also from the aesthetical point of view. In this article we describe our new videolaparo-cholecystectomy technique. Trans-umbilical videolaparo-cholecystectomy represents a variant of the traditional technique. This new method allows the operation to perform with only two trocars positioned in the peritoneum cavity through only one umbilical incision. The technical innovation of this method consists of the substitution of the others trocars, utilized in the traditional technique, with an equal number of trans-parietal suspension wires. Up to now, we have given 95 patients this kind of operation being successful in 67% of the cases. We think that this new technique, requiring as it does only standard laparoscopic instruments, is in accordance with the philosophy of mini-invasive surgery. The suspension wires are responsible for minimal bile spreading which is not an important complication if the surgeon performs an accurate and through cleaning of the abdominal cavity at the end of the surgical procedure. The patient better accepts this technique because of its better aesthetical results. In spite of this there should be more evaluable data about trans-umbilical videolaparo-cholecystectomy especially about the incidence of post-operatory complications.

[Dunbar's syndrome: clinical reality or physiopathologic hypothesis?]

The authors report the cases of two patients presenting a symptomatic intestinal angina caused by median arcuate ligament compression. Arteriography demonstrates severe coeliac artery stenosis in both of them and a retrograde filling of the coeliac axis from the superior mesenteric artery branch collateral vessels. The patients became asymptomatic after surgical release of the celiac trunk by section of the median arcuate ligament of the diaphragm. At 2 and 3 years follow-up, both patients report no further abdominal pain. Dunbar's syndrome is still a questionable subject; how can be a narrowing or an occlusion of the celiac artery semeiotically and clinically important? Some have proposed an ischemic base to explain the abdominal pain: the compression of the celiac trunk could be responsible of a celiac steal which results in shunting of blood from the superior mesenteric artery to the celiac distribution through the collateral system. There are very strong proofs that partial or even complete obstruction of the celiac artery should not lead to visceral ischemia such as: the rich collateral anastomosis of the celiac axis, the surgical ligation of the celiac axis performed without untoward consequences, the finding of asymptomatic celiac stenosis in the 49% of an arteriographic study, impossibility to formulate a consistent and rational for the surgical results. Shearing this view, few authors would prove that a stenotic type of the celiac artery is only a normal anatomic variant, refuting the existence of this syndrome.