Laparoscopic splenectomy: single-centre experience of a district general hospital

We report the results of 20 consecutive laparoscopic splenectomies performed on haematology patients for a number of indications. Our series includes patients up to 77 years of age at the time of surgery and removal of spleens weighing up to 3530 g. The most significant benefit is the early rate of discharge post-operatively (median 2 d); however, there is a risk of conversion to open laparotomy (in this series 3/20, 15%). We show that laparoscopic splenectomy can be offered as a therapeutic option to patients unfit for conventional laparotomy and that even large and bulky spleens can be removed safely using this approach.

The gene mutated in bare patches and striated mice encodes a novel 3beta-hydroxysteroid dehydrogenase

X-linked dominant disorders that are exclusively lethal prenatally in hemizygous males have been described in human and mouse. None of the genes responsible has been isolated in either species. The bare patches (Bpa) and striated (Str) mouse mutations were originally identified in female offspring of X-irradiated males. Subsequently, additional independent alleles were described. We have previously mapped these X-linked dominant, male-lethal mutations to an overlapping region of 600 kb that is homologous to human Xq28 (ref. 4) and identified several candidate genes in this interval. Here we report mutations in one of these genes, Nsdhl, encoding an NAD(P)H steroid dehydrogenase-like protein, in two independent Bpa and three independent Str alleles. Quantitative analysis of sterols from tissues of affected Bpa mice support a role for Nsdhl in cholesterol biosynthesis. Our results demonstrate that Bpa and Str are allelic mutations and identify the first mammalian locus associated with an X-linked dominant, male-lethal phenotype. They also expand the spectrum of phenotypes associated with abnormalities of cholesterol metabolism.

Laparoscopic gastric banding for morbid obesity. Surgical outcome in 335 cases

BACKGROUND

Morbid obesity occurs in 2-5% of the population of Europe, Australia, and the United States and is becoming more common. Open surgical techniques, such as vertical banded gastroplasty and other divisional procedures in the stomach, have led to long-term weight reduction as well as an amelioration of the attendant medical problems in approximately two-thirds of patients.

MATERIALS AND METHODS

A total of 335 patients with a median age of 41 years underwent gastric banding. We emphasized the need for long-term maintenance and follow-up. The indications for surgery comprised a body mass index >35, a stated desire to undergo the procedure, and a full understanding of all possible complications.

RESULTS

All patients have needed band adjustments of 1-4 ml over the course of their follow-up. No patient had increased his or her weight during the follow-up, and only three patients have not enjoyed sustained weight loss.

CONCLUSIONS

Laparoscopic gastric banding has much to recommend it. Certainly in the short term, its results in terms of effectiveness of weight loss are at least as good as those of any open procedure. Longer follow-up will show whether this weight loss is maintainable. The procedure is technically demanding, and the major prerequisite of satisfactory performance of this surgery is laparoscopic experience.

Evaluation and comparison of three human monoclonal anti-S, two human polyclonal anti-S, and one murine anti-GPB

Polyclonal anti-S react with Met29 of red blood cell (RBC)-bound glycophorin B (GPB) but may also require adjacent amino acids. Treatment of RBCs with certain enzymes and sodium hypochlorite-based bleach (NaClO) affect the interaction of GPB with anti-S. Some, but not all, anti-S react with hybrid glycophorin molecules associated with the TSEN antigen. The purpose of this study was to characterize monoclonal anti-S and to compare their reactivity to polyclonal anti-S in order to determine their potential as blood group reagents and research tools. Furthermore, through inhibition experiments, we attempted to define the epitope recognized by the antibodies. Three monoclonal (MS-93; MS-94; MS-95) and two polyclonal (A1958; X1960) anti-S and a monoclonal anti-GPB (Mab 148) were tested by standard hemagglutination with RBCs of known common and rare phenotype, with S+ RBCs treated with enzymes, with different concentrations of NaClO, and after incubation with synthetic peptides. The anti-S gave different patterns of reactivity. Reactivity with sialidase-treated RBCs showed that MS-93, MS-95, Mab 148, and X1960 recognize sialic acid independent epitopes, whereas MS-94 and A1958 require sialic acid for optimal reactivity. MS-95 and X1960 were strongly reactive with TSEN+ RBCs and only Mab 148 agglutinated S- Dantu+ and S- St(a+) RBCs. MS-94 and Mab-148 agglutinated S+ RBCs treated with NaClO. MS-93 was inhibited only by the 14-mer S-specific synthetic peptide whereas MS-95 was inhibited by all three synthetic peptides containing S-relevant residues. This study clearly demonstrates that different anti-S have different characteristics that should be analyzed before selecting monoclonal antibodies for the basis of reagents for use in the clinical laboratory. These anti-S, because of their varied characteristics, will be useful research tools.

Localization of a gene for familial hemophagocytic lymphohistiocytosis at chromosome 9q21.3-22 by homozygosity mapping

Familial hemophagocytic lymphohistiocytosis (FHL), also known as familial erythrophagocytic lymphohistiocytosis and familial histiocytic reticulosis, is a rare autosomal recessive disorder of early childhood characterized by excessive immune activation. Linkage of the disease gene to an approximately 7.8-cM region between markers D9S1867 and D9S1790 at 9q21.3-22 was identified by homozygosity mapping in four inbred FHL families of Pakistani descent with a combined maximum multipoint LOD score of 6.05. This is the first genetic locus to be described in FHL. However, homozygosity by descent across this interval could not be demonstrated in an additional affected kindred of Arab origin, whose maximum multipoint LOD score was -0.12. The combined sample revealed significant evidence for linkage to 9q markers (LOD score with heterogeneity, 5.00). Identification of the gene(s) involved in the pathogenesis of FHL will contribute to an understanding of the control of T-lymphocyte and macrophage activation, which is central to homeostasis in the immune system.

"You worked on your own, making your own decisions and coping on your own": midwifery knowledge, practice and independence in the workplace in Britain, 1936 to the early 1950s

Midwifery knowledge is a complex entity-comprising of training and experiential elements-not fixed but mutable, both informed and altered by practice. This study uses oral history accounts to explore how midwives viewed themselves and how they interacted with widwifery knowledge in an attempt to gain a greater understanding of their power and independence in the workplace and, as a result, of their professional status. Midwifery knowledge cannot simply be defined as the technical skills taught in training; it was also shaped by the environment in which practice took place and midwife's relationships with women and with doctors.

Deglycosylation of flavonoid and isoflavonoid glycosides by human small intestine and liver beta-glucosidase activity

Flavonoid and isoflavonoid glycosides are common dietary phenolics which may be absorbed from the small intestine of humans. The ability of cell-free extracts from human small intestine and liver to deglycosylate various (iso)flavonoid glycosides was investigated. Quercetin 4'-glucoside, naringenin 7-glucoside, apigenin 7-glucoside, genistein 7-glucoside and daidzein 7-glucoside were rapidly deglycosylated by both tissue extracts, whereas quercetin 3,4'-diglucoside, quercetin 3-glucoside, kaempferol 3-glucoside, quercetin 3-rhamnoglucoside and naringenin 7-rhamnoglucoside remained unchanged. The Km for hydrolysis of quercetin 4'-glucoside and genistein 7-glucoside was approximately 32+/-12 and approximately 14+/-3 microM in both tissues respectively. The enzymatic activity of the cell-free extracts exhibits similar properties to the cytosolic broad-specificity -glucosidase previously described in mammals.

Towards T-tube free laparoscopic bile duct exploration: a methodologic evolution during 300 consecutive procedures

OBJECTIVE

To establish a simple, reproducible, and safe technique of laparoscopic common bile duct exploration (CBDE) with high clearance rates and low morbidity and mortality rates.

SUMMARY BACKGROUND DATA

For most general surgeons, laparoscopic CBDE appears an unduly complex and demanding procedure. Since the introduction of laparoscopic cholecystectomy, many surgeons use endoscopic cholangiography (ERC) and endoscopic sphincterotomy as their only option in treating bile duct stones. ERC is more specific if used after surgery, but it carries an appreciable morbidity rate and has the disadvantage of requiring a second procedure to deal with bile duct stones. To this end, various methods of laparoscopic CBDE have been developed.

METHODS

Between August 1991 and February 1997, 300 consecutive unselected patients underwent laparoscopic CBDE.

RESULTS

Of 300 laparoscopic CBDE procedures, 173 (58%) were managed using a transcystic approach and 127 (42%) with choledochotomy. Successful laparoscopic stone clearance was achieved in 271 (90%). Of the 29 (10%) patients not cleared laparoscopically, 10 had an elective postsurgical ERC, 12 were converted to an open procedure early in the series, and 7 had unexpected retained stones. There was one death (mortality rate 0.3%) and major morbidity occurred in 22 patients (7%). The last 100 procedures were performed from July 1995 to February 1997, and stone clearance was unsuccessful in only two patients.

CONCLUSIONS

Laparoscopic transcystic basket extraction of common duct stones under fluoroscopic guidance is a relatively quick, successful, and safe technique. Choledochotomy, when required, is associated with a higher morbidity rate, particularly with T-tube insertion, and the authors advocate primary bile duct closure with or without insertion of a biliary stent as a more satisfactory technique for both surgeon and patient. Most patients with gallbladder and common duct calculi should expect a curative one-stage laparoscopic procedure without the need for external biliary drainage or ERC.

A high-resolution microsatellite map of the mouse genome

The European Collaborative Interspecific Backcross (EUCIB) resource was constructed for the purposes of high-resolution genetic mapping of the mouse genome (). The large Mus spretus/C57BL/6 backcross of 982 progeny has a genetic resolution of 0.3 cM at the 95% confidence level ( approximately 500 kb in the mouse genome). We have used the EUCIB mapping resource to develop a genome-wide high-resolution genetic map incorporating 3368 microsatellites. The microsatellites are distributed among 2302 genetically separated bins with 1.46 markers per bin on average. Average bin separation is 0.61 cM. This high-resolution genetic map will aid the construction of a robust physical map of the mouse genome.

Utility of chest radiographs after guidewire exchanges of central venous catheters

OBJECTIVE

To determine whether chest radiographs are warranted after uncomplicated guidewire exchanges of central venous catheters in patients admitted to a Level I trauma intensive care unit.

DESIGN

Prospective study performed in two phases.

SETTING

Intensive care unit in a Level I trauma center.

PATIENTS

Patients admitted to a Level I trauma center intensive care unit who required central venous catheter guidewire exchanges.

INTERVENTIONS

Criteria for uncomplicated guidewire exchanges were established and followed. A catheter exchange checklist was completed at each procedure, and a chest radiograph was performed after each guidewire exchange. The complications followed were catheter malposition, pneumothorax, hemothorax, and cardiac tamponade. Results were reviewed after 3 mos, and a second phase of the study was initiated in which chest radiographs were obtained selectively and were not performed for uncomplicated exchanges. If obtained, subsequent radiographs were reviewed, and patients were followed to discharge for complications.

MEASUREMENTS AND MAIN RESULTS

One hundred central venous catheter exchanges with postprocedure radiographs were evaluated in phase I. The only complication identified was one malpositioned catheter. In phase II, 110 patients were followed. Eighty-four patients did not have chest radiographs performed after guidewire exchange; 69 patients had subsequent radiographs documenting good placement of the catheter, and 15 patients did not have a radiograph before death (n = 2) or discharge from the hospital (n = 13). Sixteen patients had postprocedure radiographs performed. There were no malpositioned catheters or complications related to guidewire exchanges.

CONCLUSIONS

Chest radiographs are unwarranted after uncomplicated guidewire exchanges of central venous catheters in hemodynamically stable, monitored patients. Eliminating these radiographs will result in significant cost and time savings without adversely affecting patient outcome.

Randomised trial of laparoscopic exploration of common bile duct versus postoperative endoscopic retrograde cholangiography for common bile duct stones

BACKGROUND

The management of stones in the common bile duct in the laparoscopic era is controversial. The three major options are preoperative endoscopic retrograde cholangiography (ERCP), laparoscopic exploration of the common bile duct (LECBD), or postoperative ERCP.

METHODS

Between August, 1995, and August, 1997, 471 laparoscopic cholecystectomies were done in our department. In 427 (91%), satisfactory peroperative cholangiography was obtained. In 80 (17%) of these cases there were stones in the common bile duct, 40 patients were randomised to LECBD and 40 to postoperative ERCP. If LECBD failed, patients had either open exploration of the common bile duct or postoperative ERCP. If one postoperative ERCP failed, the procedure was repeated until the common bile duct was cleared of stones or an endoprosthesis was placed to prevent stone impaction. The primary endpoints were duct-clearance rates, morbidity, operating time, and hospital stay. Analyses were by intention to treat.

FINDINGS

Age and sex distribution of patients was similar in the randomised groups. Duct clearance after the first intervention was 75% in both groups. By the end of treatment, duct clearance was 100% in the laparoscopic group compared with 93% in the ERCP group. Duration of treatment was a median of 90 min (range 25-310) in the laparoscopic group (including ERCPs for failed LECBD) compared with 105 min (range 60-255) in the postoperative ERCP group (p = 0.1, 95% CI for difference -5 to 40). Hospital stay was a median of 1 day (range 1-26) in the laparoscopic group compared with 3.5 days (range 1-11) in the ERCP group (p = 0.0001, 95% CI 1-2).

INTERPRETATION

LECBD is as effective as ERCP in clearing the common bile duct of stones. There is a non-significant trend to shorter time in the operating theatre and a significantly shorter hospital stay in patients treated by LECBD.

Laparoscopic management of acute small bowel obstruction

BACKGROUND

Laparoscopic management of acute small bowel obstruction is hypothetically attractive but little is known of its clinical potential.

METHODS

A retrospective study was undertaken of patients with acute small bowel obstruction requiring surgery, managed by a laparoscopic unit (LU; n = 69) and a general unit (GU; n = 70).

RESULTS

Laparoscopy was performed in 55 patients (80 per cent) in the LU compared with ten (14 per cent) in the GU. Laparoscopic surgery completed treatment in 31 patients (45 per cent) in the LU and assisted in a further 15 (22 per cent). Patients treated laparoscopically were discharged earlier than those treated by laparotomy (median 3 (range 1-15) versus median 8 (range 1-46) days). Patients treated laparoscopically had a higher chance of early unplanned reoperation than those treated by laparotomy (five of 35 versus four of 88) (P < 0.05).

CONCLUSION

Laparoscopy can be performed in a high percentage of patients requiring surgery for acute small bowel obstruction. Hospital stay was reduced but the risk of early unplanned reoperation was increased in patients managed laparoscopically.

Outcome of blunt thoracic aortic injury in a level I trauma center: an 8-year review

BACKGROUND

The purpose of this study was to evaluate our experience with blunt thoracic aortic injury and identify factors predictive of outcome.

METHODS

Hospital charts, trauma registry data, and autopsies of 64 patients with blunt thoracic aortic injury from 1988 to 1995 were reviewed.

RESULTS

Patients were identified and segregated based on admission physiology. Group 1 patients (n = 19) arrived in arrest. Group 2 patients (n = 10) arrived in shock with systolic BP 90. Group 3 patients (n = 35) arrived with systolic BP>90. All patients in groups 1 and 2 expired. Injury Severity Scores for nonsurvivors in group 3 (n = 12) were significantly higher than survivors. There were no significant differences when comparing time of injury to repair or arrival between groups, or in mortality or paralysis comparing repair techniques or clamp/bypass times. Double lumen endotracheal tubes caused significant operative delays compared to single lumen tubes.

CONCLUSIONS

Predictors of survivability were hemodynamic stability on arrival and lower Injury Severity Scores. In thoracic aortic injury patients arriving hemodynamically stable, Injury Severity Score correlated with mortality but not paralysis.

Arterial embolization is a rapid and effective technique for controlling pelvic fracture hemorrhage

OBJECTIVE

To review the success rate of embolization in stopping hemorrhage for unstable patients with severe pelvic fractures, to calculate the time to achieve embolization, and to determine the yield from angiography.

DESIGN

Retrospective review of patients admitted to a Level I trauma center with pelvic fractures during a 5-year period.

MATERIALS AND METHODS

Charts were reviewed for Injury Severity Score, age, blood pressure, prothrombin time/partial thromboplastin time, pelvic fracture type, mortality, time to reach the angiography suite, time to achieve embolization, and mechanism of injury.

MEASUREMENTS AND MAIN RESULTS

Of 806 patients admitted with pelvic fractures, 35 underwent pelvic angiography, and 15 (1.9%) required embolization. Embolization was successful for all patients. No deaths resulted from ongoing hemorrhage. Angiography yield in initially unstable patients was 64%. The mean age and initial hemodynamic instability were significantly greater in nonsurvivors. The time from arrival in the trauma bay to arrival in the angiography suite ranged from 50 to 1,140 minutes, and the time spent in the angiography suite performing embolization ranged from 50 to 140 minutes, with an average time of 90 minutes. Patients who were embolized within 3 hours of arrival had a significantly greater survival rate.

CONCLUSION

Only a small percentage of patients with pelvic fractures require embolization, but when it is used, embolization can be 100% effective. Age, time to achieve embolization, and initial hemodynamic instability appear to be important factors in survival.

Laparoscopic colectomy

BACKGROUND

Laparoscopic colectomy has developed with the explosion of technology that has followed laparoscopic cholecystectomy. Accumulation of skills in general laparoscopic surgery has made complex surgery, such as colectomy, feasible.

METHODS

Three hundred fifty-nine laparoscopic cases were prospectively studied. Data has been kept on benign and malignant cases, operative results, hospital stay, and morbidity. Special care has been taken to follow malignant cases, looking for recurrence of disease.

RESULTS

There were 359 cases (206 females, 153 male) average age 58.8 years (18-94), and 149 patients had malignancy. All types of resections were performed, including 151 anterior resections, 66 right hemicolectomies (RHC), 36 total colectomies, and 22 rectopexies. Operating times fell with experience-the last 20 cases of anterior resection took 150 min (110-240) and of RHC took 130 min (65-210). Twenty-six (7%) cases were converted to open surgery. Hospital stays for anterior resection lasted 5-7 days (2-33); in the last 20 cases the average stay was 4 days. Morbidity included seven leaks (2.7%), four strictures (1.2%), 12 wound infections (3.3%), and nine ileus (2.5%). There were six deaths within 30 days-sepsis, myocardial infarction, aspiration pneumonia, and disseminated liver metastases. One hundred forty-nine cancer cases have had ten recurrences: one pelvic recurrence, six liver metastases, two para-aortic nodal, and one case of disseminated disease. Average time of recurrence was 33 months (15-46 months).

CONCLUSIONS

Laparoscopy in the hands of experienced laparoscopic surgeons is a safe, efficient procedure. All types of procedures are possible. Early results in 149 malignancies are encouraging and recurrence rates are low. Prospective studies, now that skills are developed to a level comparable to that of open surgery, are now being performed to further assess laparoscopy's possible role in treating cancer.

Structure-activity relationship studies of the amide functionality in (p-O-sulfamoyl)-N-alkanoyl tyramines as estrone sulfatase inhibitors

Recently, we reported the synthesis and biomedical studies of a series of (p-O-sulfamoyl)-N-alkanoyl tyramines as nonsteroidal estrone sulfatase inhibitors. One of the most potent inhibitors in this series is (p-O-sulfamoyl)-N-tridecanoyl tyramine 1 with an 1C50 value of 61.3 nM. In this study, we synthesized four analogs of 1 (compounds 2-5) to investigate the structure-activity relationships of the amide functionality in (p-O-sulfamoyl)-N-tridecanoyl tyramine. Replacement of the amide functionality in 1 with an ethylene moiety to form the alkyl analog 5 resulted in complete loss of sulfatase inhibitory activity (IC50 of 61.3 nM vs. > 20 microM). The keto, hydroxy, and ester analogs (inhibitors 2-4) are 8-15 times less in affinity to the sulfatase than inhibitor 1. However, their inhibitory activities are significantly higher than the alkyl analog 5. The results suggest that the amide functionality is favorable for sulfatase inhibitory activity and that there may be a hydrogen bonding component to the enzyme interaction in this region.

High-throughput microsatellite analysis using fluorescent dUTPs for high-resolution genetic mapping of the mouse genome

The use of fluorescent end-labeled primers has proved successful for rapid, semiautomated genotyping of microsatellite loci. However, custom synthesis is expensive and costs can be prohibitive when a wide range of markers is to be analyzed for only a few genotypings. This particularly applies to high-resolution genetic mapping in the mouse either in the construction of global maps or in the production of local high-resolution genetic maps for positional cloning. We demonstrate here the use of fluorescent dUTPs for cost-effective, high-throughput microsatellite genotyping in the mouse. This alternative to the use of fluorescent end-labeled primers for semiautomated genotyping is potentially applicable to the construction of linkage maps in other species.

Defining "dead on arrival": impact on a level I trauma center

OBJECTIVE

To determine the potential impact of defining criteria for "dead on arrival" (DOA) on a Level I trauma center.

METHODS

From 1990 to 1994, trauma patients having cardiopulmonary resuscitation (CPR) performed by certified prehospital personnel were reviewed for time of CPR, outcome, and costs to determine whether any benefit would have been realized had DOA criteria been followed.

RESULTS

A total of 106 patients had prehospital CPR; 20 did not meet DOA criteria and underwent resuscitation, three survived (15%). Eighty-six patients met DOA criteria; 16 were pronounced dead without further resuscitative efforts (in-hospital costs of $200/patient), while 70 (81%) had continued resuscitation with no survivors (in-hospital costs of $4150/patient). The positive predictive value for criteria was 100%. Had criteria been implemented, total cost savings over the 5-year period would have been $290,000.

CONCLUSIONS

National DOA criteria could dramatically reduce the burden on trauma centers with an estimated minimum annual savings of $14 million.

A preliminary study on the effect of germination on saponin content and composition of lentils and chick peas

Two cultivars of chick peas (Cicer arietinum) and one cultivar of lentils (Lens culinaris) were subjected to germination in the dark for 6 days at 20 degrees C. Soyasaponin VI, also known as soyasaponin beta g, a DDMP- (2,3-dihydro-2,5-dihydroxy-6-methyl-4H-pyran-4-one-) conjugated form of soyasaponin I, was the only saponin detected in both the unprocessed and germinated seed. No significant changes in saponin content were observed for chick peas or lentils after a 6-day germination.

Laparoscopic Nissen fundoplication and postoperative dysphagia-can it be predicted?

Temporary swallowing difficulty has been reported in up to 100% of patients after laparoscopic Nissen fundoplication for gastro-oesophageal reflux, but the long-term prevalence of dysphagia is not known. If reliable predictors of persistent postoperative dysphagia exist, their identification may permit tailoring of the fundoplication for specific cases at risk. Of 475 consecutive cases of laparoscopic fundoplication, 202 have undergone detailed symptom scoring at 1 year postoperatively. In each case, a short, 360 degrees loose wrap was constructed over an intra-oesophageal bougie, and short gastric vessels were divided when insufficient fundal mobility was encountered. At one year postoperatively, 24% complained of grade 1 dysphagia (intermittent sensation of food sticking), 9% of grade 2 (food sticking requiring liquids to clear) and 1 patient had regular dysphagia for solids (grade 3). Gender, preoperative complaint of dysphagia, endoscopic grade of oesophagitis, oesophageal motility, lower oesophageal sphincter pressure, and division of short gastric vessels were reviewed in relation to dysphagia. Dysphagia is common after laparoscopic Nissen fundoplication, but is less prevalent than before operation. It is usually mild, intermittent and improves with time. Those with division of short gastric vessels had a reduced risk of postoperative dysphagia.

Laparoscopic choledochoduodenostomy

Choledochoduodenostomy is less often performed since the advent of ERCP and endoscopic sphincterotomy (ES). It may, however, still prove necessary in patients where ERCP and ES fail to provide long-term biliary drainage or when CBD stones recur after ES. We have performed laparoscopic choledochoduodenostomy in two patients (aged 66 and 71 years). Surgery was performed in one patient for recurrent CBD stones 25 years after cholecystectomy where three attempts at ERCP failed to cannulate the CBD. In the second patient it was performed for recurrent CBD stones 16 years after cholecystectomy and after two previous endoscopic sphincterotomies. Surgery was completed in just over 3 h in both cases and postoperative stay was 4 days. Laparoscopic choledochoduodenostomy is a viable technique which may prove valuable in the management of patients in whom ERCP and ES has failed to provide long-term biliary drainage.