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.

Recognition of laparoscopic bile duct injuries by intraoperative ultrasonography

BACKGROUND

The purpose of this study was to investigate the possibility of detecting bile duct injuries using laparoscopic intraoperative ultrasound (LIOU).

METHODS

Fifty bile duct injuries were created using laparoscopic techniques in ten farmer pigs. The lesions created were: (1) partial occlusion, (2) complete occlusion (1 clip), (3) complete occlusion (2 clips), (4) transection between clips, (5) excision between clips.

RESULTS

All injuries were easily visualized using LIOU. The relation of clips impinging upon or occluding the bile duct was readily visualized on LIOU in all cases. In some cases it was difficult to distinguish between partial and complete occlusion. It was also difficult to distinguish between transection and excision due to retraction of the severed bile duct.

CONCLUSIONS

In cases of iatrogenic occlusion of the bile duct involving hemoclips (including transection or excision between clips), LIOU is a potentially useful modality that may allow earlier recognition and repair. Further studies are needed to evaluate the efficacy of LIOU in detection of bile duct injuries that do not involve hemoclips.

Serum prolactin, electrode placement, and the convulsive threshold during ECT

This study examines the relationship of serum prolactin changes (delta PRL) to variations in electrode placement after controlling for differences in the convulsive threshold. Previous studies showing greater release of PRL with bilateral (BL) compared with right unilateral (RUL) electrode placement were conducted without knowledge of the convulsive threshold. Twenty-two patients each received threshold RUL, threshold BL, 2.25 times threshold RUL, and 2.25 times threshold BL ECT. Serum PRL was collected 5 min before and 15 min after each electroconvulsive therapy (ECT). The convulsive threshold was greater for BL than RUL electrode placement. delta PRL was greater with BL than RUL ECT at comparable relative stimulus intensities. delta PRL was not correlated with seizure duration or absolute stimulus dose.

Cost-effective management of complicated choledocholithiasis: laparoscopic transcystic duct exploration or endoscopic sphincterotomy

BACKGROUND

In the United States of America, approximately 700,000 patients undergo laparoscopic cholecystectomy (LC) each year and at least 10 percent of these patients will have common bile duct stones (CBDS). The purpose of this study was to evaluate patients with choledocholithiasis and compare the economic and clinical results obtained by LC with endoscopic sphincterotomy (ES) with those of LC with laparoscopic transcystic common bile duct exploration (LTCBDE).

STUDY DESIGN

From June 1991 to September 1994 patients undergoing LC plus LTCBDE and those undergoing LC plus ES at a single institution were compared where cost data were available. Of the 76 patients with choledocholithiasis, 59 patients underwent LC plus LTCBDE (group 1) and 17 patients underwent LC plus ES (group 2). A subset of group 1 patients undergoing urgent LC plus LTCBDE (group 3) for cholecystitis, cholangitis, or pancreatitis plus laparoscopy were examined separately.

RESULTS

Laparoscopic cholecystectomy plus LTCBDE, whether including all-comers (group 1) or just urgent cases (group 3), was associated with a significantly decreased length of hospital stay (6.1 and 6.9 days, respectively, compared with group 2, 12.4 days) (p < 0.001). The morbidity of patients in group 1 was also markedly lower than for patients in group 2; 12 percent compared with 41 percent, respectively. Patients in group 1 had a significantly decreased cost of hospitalization (+13,151), when compared with patients in group 2 (+18,712) (p = 0.05). This difference is even more pronounced when professional fee reimbursement is considered. The cost of treatment for patients in group 1 was +14,732 compared with +21,125 for patients in group 2 (p < 0.05). The total hospital cost for patients in group 3 was only +13,564 compared with +18,712 for patients in group 2. When professional reimbursement was considered, the cost was +15,150 for patients in group 3 compared with +21,125 for patients in group 2.

CONCLUSIONS

Patients undergoing LC plus LTCBDE for CBDS, whether urgently or electively, have markedly decreased morbidity rates, length of hospital stay, and costs when compared with patients undergoing LC plus ES.

One hundred consecutive laparoscopic cholangiograms. Results and conclusions

BACKGROUND

In 100 consecutive patients who underwent laparoscopic cholecystectomy, the feasibility, reliability, and cost of routine laparoscopic cholangiography were prospectively studied.

METHODS

Fluoroscopic cholangiograms with multiple exposures were successfully completed in all patients in an average time of 6.9 min.

RESULTS

Twenty-one percent were abnormal, and 15 common duct stones and 6 significant anatomic anomalies detected. Thirteen out of 15 patients with common duct stones had preoperative suspicion of common duct stones. Two out of 15 were completely unsuspected. The average cost of cholangiography was $768, and there were no complications related to the procedure. There were no false interpretations.

CONCLUSIONS

When compared with selective preoperative endoscopic retrograde cholangiopancreatography (ERCP), routine laparoscopic cholangiography is safer, more accurate, and less costly, and may have the added benefit of potentially reducing iatrogenic injuries in patients with anatomic variations. Routine laparoscopic cholangiography should be considered by all surgeons.

Short-term variability of mood ratings in unipolar and bipolar depressed patients

The ability of depressed patients to assess their mood states is controversial. We devised a scale consisting of a global item and 23 multiple visual analog items based on the Carroll/Klein model of depression. Short-term reliability of self-ratings in 13 unipolar and 11 bipolar depressed patients was tested. Subjects completed the scale and were retested 1 h later. Global clinician and self-ratings demonstrated similar episode severity between the groups and global self-ratings were highly reliable at retest for both groups. Unipolar depressed patients demonstrated high retest reliability on individual items of the MVAS. Bipolar patients demonstrated greater variability of responses suggesting greater short-term mood fluctuation in bipolar patients.

The Drop Volume Method for Interfacial Tension Determination: An Error Analysis

An error analysis of the drop volume method of determination of surface or interfacial tension is presented. It is shown that the presence of the empirical correction term may lead to either a decrease or an increase in the final uncertainty of the calculated tension. Recommendations to maximize the precision of measurement are made. It is further shown that the systematic error due to the correction term is less than 0.04%; under the conditions recommended to minimize the statistical uncertainty, the systematic error should be less than half this figure. Tabulations of recommended values of the correction function are given.

Laparoscopic colectomy vs traditional colectomy for diverticulitis. Outcome and costs

BACKGROUND

The aim of this study was to evaluate the outcome of patients undergoing laparoscopic colectomy for diverticulitis.

METHODS

Fourteen consecutive patients undergoing laparoscopic sigmoid colectomy (LSC) for diverticulitis were evaluated. Medical records from a control group of 14 matched patients undergoing traditional open sigmoid colectomy (OSC) for diverticulitis were reviewed for comparison.

RESULTS

Mean age, operative time, morbidity, and mortality of the LSC and OSC groups were not significantly different. However, the mean estimated blood loss (171cc vs 321cc), days to p.o. liquids (2.9 vs 6.1), and postoperative stay (6.3 vs 9.2 days) were all significantly less in the LSC patients. Although the mean operating room charges were greater in the LSC patients ($10,589 vs $8,207) the mean total hospital charges ($29,981 vs $36,745) and costs ($11,528 vs $13,426) were markedly less.

CONCLUSIONS

Compared with OSC for diverticulitis, LSC results in a more rapid return of bowel function and shortened hospital stay. Despite the greater operating room charges of LSC, the total hospital charges and costs are lessened.

Continuing hazards of the learning curve in laparoscopic cholecystectomy

Bile duct injury is one of the most serious complications of laparoscopic cholecystectomy (LC). In open cholecystectomy (OC) the reported incidence of injury is less than 0.2 per cent. In LC, the aggregate reported experience, in many thousands of cases, is three or four times this number. Although "the learning curve" has been considered the principal factor in the heightened incidence of this complication with LC, there are hazards inherent in this new surgical modality that may never allow elimination of the increased risk of bile duct injury. As a sequel to an earlier report of 1200 cases of OC before the laparoscopic era from a single institution, this report deals with the next 2427 consecutive cases of LC from the same institution. In the first 1284 cases of LC, there were seven bile duct injuries (0.58%); in the ensuing 1143 cases there were six bile duct injuries (0.50%). The overall incidence nationwide is even higher, as evidenced by widespread reports of repair of bile duct injuries referred to major tertiary care centers. Routine operative cholangiography is of the utmost importance in the early recognition and immediate repair of ductal injuries. In 12 of the 13 cases reported here, early recognition and repair during the primary surgery resulted in a successful outcome.

Distribution of unlinked transpositions of a Ds element from a T-DNA locus on tomato chromosome 4

In maize, receptor sites for unlinked transpositions of Activator (Ac) elements are not distributed randomly. To test whether the same is true in tomato, the receptor sites for a Dissociation (Ds) element derived from Ac, were mapped for 26 transpositions unlinked to a donor T-DNA locus on chromosome 4. Four independent transposed Dss mapped to sites on chromosome 4 genetically unlinked to the donor T-DNA, consistent with a preference for transposition to unlinked sites on the same chromosome as opposed to sites on other chromosomes. There was little preference among the nondonor chromosomes, except perhaps for chromosome 2, which carried seven transposed Dss, but these could not be proven to be independent. However, these data, when combined with those from other studies in tomato examining the distribution of transposed Acs or Dss among nondonor chromosomes, suggest there may be absolute preferences for transposition irrespective of the chromosomal location of the donor site. If true, transposition to nondonor chromosomes in tomato would differ from that in maize, where the preference seems to be determined by the spatial arrangement of chromosomes in the interphase nucleus. The tomato lines carrying Ds elements at known locations are available for targeted transposon tagging experiments.

Complications of laparoscopic cholecystectomy in HIV and AIDS patients

We retrospectively evaluated the results of laparoscopic cholecystectomy in patients infected with the human immunodeficiency virus (HIV) with and without acquired immunodeficiency syndrome (AIDS). One thousand one hundred twenty-seven consecutive patients underwent laparoscopic cholecystectomy by our surgical group. Eighteen of these patients were known to be infected with the HIV virus; 6 were asymptomatic and 12 had AIDS. We reviewed the medical records of all HIV-positive individuals with regard to morbidity, mortality, and postoperative outcome following laparoscopic cholecystectomy. In the six HIV-patients without AIDS, five (83%) had improvement of symptoms postoperatively. There was one minor complication (17%). In contrast, only one of the 12 patients with AIDS had postoperative improvement of symptoms and eight (66%) had complications after surgery. There were four deaths (33%) within 30 days of surgery in this group. Only a small percentage of AIDS patients benefit from laparoscopic cholecystectomy. There is a significantly morbidity and mortality following this procedure in this group. Strategies to improve outcome are presented.

Bile duct stones in the laparoscopic era. Is preoperative sphincterotomy necessary?

OBJECTIVE

To evaluate treatments for common bile duct stones (CBDS).

DESIGN

Retrospective review of authors' case series.

SETTING

Large private metropolitan teaching hospital.

PATIENTS

All patients with CBDS (N = 145) from a series of 1231 patients who underwent laparoscopic cholecystectomy, 99% with intraoperative fluorocholangiography.

INTERVENTIONS

Treatments for CBDS included one or more of the following: laparoscopic transcystic duct exploration (n = 123), laparoscopic choledochotomy (n = 10), open choledochotomy (n = 7), preoperative endoscopic sphincterotomy (ES) (n = 9), intraoperative ES (n = 2), post-operative ES (n = 11), or observation (n = 10).

MAIN OUTCOME MEASURES

Success of various interventions for CBDS, morbidity and mortality, frequency of retained stones, operative time, and length of postoperative hospitalization.

RESULTS

Laparoscopic transcystic duct exploration was successful in 91% of attempts and resulted in the shortest postoperative stay (3.4 days), least morbidity (5%), and fewest retained stones (5%). Endoscopic sphincterotomy was successful in 56% of preoperative attempts, 50% of intraoperative attempts, and 91% of postoperative attempts. There were no reoperations and one death.

CONCLUSIONS

For patients requiring cholecystectomy, laparoscopic transcystic duct exploration is safe and effective, treats CBDS in one session, and if unsuccessful still allows for open choledochotomy or postoperative ES. Preoperative endoscopic retrograde cholangiography and ES should be reserved for patients with serious illness or possible malignant disease.

Germinal transpositions of the maize element Dissociation from T-DNA loci in tomato

We have analyzed the pattern of germinal transpositions of artificial Dissociation (Ds) transposons in tomato. T-DNA constructs carrying Ds were transformed into tomato, and the elements were trans-activated by crossing to lines transformed with a stabilized Activator (sAc) that expressed the transposase gene. The sAc T-DNA carried a GUS gene to monitor its segregation. The Ds elements were inserted in a marker gene so that excision from the T-DNA could be monitored. The Ds elements also carried a genetic marker that was intended to be used for reinsertion selection of the elements after excision. Unfortunately, this gene was irreversibly inactivated on crossing to sAc. Germinal excision frequencies of Ds averaged 15-40%, but there was large variation between and within plants. Southern hybridization analysis of stable transposed Ds elements indicated that although unique transpositions predominate, early transposition events can lead to large clonal sectors in the germline of developing plants and to sibling offspring carrying the same transposition event. Multiple germinal transpositions from three different loci were examined for uniqueness, and 15 different transpositions were identified from each of three T-DNA loci that carried a single independent Ds. These were mapped relative to the donor T-DNA loci, and for each locus 70-80% of the transposed elements were closely linked to the donor site.

Incidence of complications following laparoscopic hernioplasty

Smaller individual series on the outcome of laparoscopic hernioplasty techniques have been reported. This study reports on the complications of 3,229 laparoscopic hernia repairs performed by the authors in 2,559 patients. The TAPP (transabdominal preperitoneal) technique was the most frequently performed: 1,944 (60%). The totally preperitoneal technique was performed 578 (18%) times. The IPOM (intraperitoneal onlay mesh) repair was performed 345 (11%) times. The plug-and-patch technique was used 286 (9%) times and simple closure of the hernia defect without mesh was used in 76 (2%) repairs. Overall, there were 336 (10%) complications: 17 (0.5%) major and 265 (8%) minor. There were 54 (1.6%) recurrences, with a mean follow-up of 22 months. The TAPP technique had 19 (1%) recurrences and 141 (7%) complications. There were four bowel obstructions in this subgroup from herniation of small bowel through the peritoneal closure and trocar sites. The totally preperitoneal technique had no recurrence and 60 (10%) complications. The IPOM group had 7 (2%) recurrences and 47 (14%) complications. The plug-and-patch technique had 26 (9%) recurrences and 24 (8%) complications. The simple closure of the internal ring had 2 (3%) recurrences and 10 (13%) complications. Laparoscopic hernioplasty is not without complications. Laparoscopic hernioplasty is not without complications. Training, experience, and attention to technique will prevent some of these complications.

Laparoscopic trans-cystic-duct common-bile-duct exploration

One thousand seventy-one consecutive laparoscopic cholecystectomies were performed. Routine cholangiography was employed with a 99% success rate. One hundred thirty patients were found to have common duct stones (CBDS). In 48 (37%) patients they were unsuspected. One hundred eleven patients underwent attempted trans-cystic-duct extraction techniques (TCD-CBDE). One hundred three (93%) were successful. The following techniques were employed: 101--biliary endoscopy, 23--ampullary balloon dilation, 2--fluoroscopic basket retrieval. The average operative time was 136 min. The average postsurgical stay was 3.7 days. There were 19 (17%) complications--6 (5%) major. There were 4 retained stones (2 intentional) and 1 death. Patients over 65 years of age had more complications and patients with unsuspected CBDS under 65 years of age had the fewest. TCD-CBDE is a safe, effective way to extract common duct calculi. Endoscopy and basket stone retrieval was the primary technique employed.

Laparoscopic splenectomy

Laparoscopic splenectomy was attempted in 16 patients and was performed successfully in 13 (81%) patients with the diagnosis of idiopathic thrombocytopenic purpura (ITP), AIDS-related thrombocytopenia, Hodgkin's disease, or lymphoma. The operative time averaged 157 min, and autologous transfusion was required in four patients. The postsurgical stay averaged 3 days in patients with completely laparoscopic splenectomies and 4 days in patients whose spleens were removed through small counterincisions. No major complications secondary to the procedure itself occurred postoperatively. Conversion to open operation was necessary in three (19%) patients because of bleeding or splenomegaly. With careful selection of patients and mastery of the technique, laparoscopic splenectomy can be safely performed on normal or slightly enlarged spleens. The advantages are less pain, shorter hospitalization, and reduced disability as compared to "open" splenectomy.

Comparison of laparoscopic cholecystectomy in obese and non-obese patients

Results of laparoscopic cholecystectomy in obese and non-obese patients were analyzed prospectively. Laparoscopic cholecystectomy was performed in 841 patients-179 obese (Group I) and 662 non-obese (Group II). Operative time averaged 73.1 minutes in Group I and 73.7 minutes in Group II. There were no statistically significant differences in the ability to perform cholangiography (99.4% Group I; 97.9% Group II), conversion rate (1.1% Group I; 1.5% Group II), or complications (4.5% Group I; 3.8% Group II). In Group I no pulmonary complications were noted, nor any cases of venous thromboembolic disease. Risk of laparoscopic cholecystectomy appears comparable in obese and non-obese patients. Based on historical comparisons, laparoscopic cholecystectomy may be safer than traditional cholecystectomy in obese patients.

Laparoscopic transcystic choledochoscopy

Preoperative prediction of common bile duct stones (CBDS) is imprecise. Cholangiography during laparoscopic cholecystectomy (LC) is the best method for detection of CBDS. Treatment of most stones detected at LC can be safely accomplished using transcystic choledochoscopy and stone extraction. This technique is applicable in nearly 90% of patients with CBD calculi. It may be preferable to endoscopic sphincterotomy (ES) in younger patients and is probably equivalent to ES in patients over 65 years of age.

Analysis of the chromosomal distribution of transposon-carrying T-DNAs in tomato using the inverse polymerase chain reaction

We are developing a system for isolating tomato genes by transposon mutagenesis. In maize and tobacco, the transposon Activator (Ac) transposes preferentially to genetically linked sites. To identify transposons linked to various target genes, we have determined the RFLP map locations of Ac- and Dissociation (Ds)-carrying T-DNAs in a number of transformants. T-DNA flanking sequences were isolated using the inverse polymerase chain reaction (IPCR) and located on the RFLP map of tomato. The authenticity of IPCR reaction products was tested by several criteria including nested primer amplification, DNA sequence analysis and PCR amplification of the corresponding insertion target sequences. We report the RFLP map locations of 37 transposon-carrying T-DNAs. We also report the map locations of nine transposed Ds elements. T-DNAs were identified on all chromosomes except chromosome 6. Our data revealed no apparent chromosomal preference for T-DNA integration events. Lines carrying transposons at known map locations have been established which should prove a useful resource for isolating tomato genes by transposon mutagenesis.

Brain mechanisms in manic depression

Manic depressive illness (bipolar disorder) is the mood disorder classically considered to have a strong biological basis. During manic depressive cycles, patients show dramatic fluctuations of mood, energy, activity, information processing, and behaviors. Theories of brain function and mood disorders must deal with the case of bipolar disorder, not simply unipolar depression. Shifts in the nosologic concepts of how manic depression is related to other mood disorders are discussed in this overview, and the renewed adoption of the Kraepelinian "spectrum" concept is recommended. The variable clinical presentations of manic depressive illness are emphasized. New genetic mechanisms that must be considered as candidate factors in relation to this phenotypic heterogeneity are discussed. Finally, the correlation of clinical symptom clusters with brain systems is considered in the context of a three-component model of manic depression.