Revascularization of the superior mesenteric artery alone for treatment of intestinal ischemia.

OBJECTIVE: Complete revascularization is recommended by many authors for treatment of intestinal ischemia. The observation that postprandial intestinal hyperemia is limited to the superior mesenteric artery (SMA) has suggested to us that SMA revascularization alone should be adequate treatment. We preferentially manage intestinal ischemia with a single bypass graft to the SMA and herein update our results using this approach. METHODS: Patients were identified from a prospectively established vascular surgical registry. Each patient was assessed for acute versus chronic intestinal ischemia, preoperative angiographic findings, operation used, perioperative morbidity and mortality, late symptomatic relief, cause of death, and life table-determined survival and graft patency. Graft patency was determined by follow-up angiography or duplex scanning. RESULTS: Fifty bypass grafts to the SMA alone were performed in 49 patients (31 women, 18 men; mean age, 62 years) for treatment of intestinal ischemia. In all patients additional splanchnic arteries were available for bypass grafting. Operative indications were acute symptoms in 21 patients, 14 of whom had bowel infarction; chronic symptoms in 26 patients; and prophylaxis in conjunction with infrarenal aortic surgery in 3 patients. Thirty-two grafts originated from the aorta or an iliac artery, and 18 originated from an aortic graft. There were 40 prosthetic and 10 autogenous conduits. Perioperative mortality was 3% in patients with chronic symptoms and 12% overall. All survivors were symptomatically improved. Mean follow-up was 44 months. Nine-year assisted primary graft patency was 79%, and 5-year patient survival was 61%. Two late deaths occurred in patients with recurrent intestinal ischemia resulting from graft occlusions. CONCLUSIONS: Bypass grafting to the SMA alone appears to be both an effective and durable procedure for treatment of intestinal ischemia. Our results appear equal to those reported for "complete" revascularization for intestinal ischemia. When the SMA is a suitable recipient vessel, multiple bypass grafts to other splanchnic vessels are unnecessary in the treatment of intestinal ischemia.

Laparoscopy improves outcomes for pediatric splenectomy.

BACKGROUND: Pediatric laparoscopic splenectomy is a relatively new surgical procedure with a limited number of reports comparing its outcomes to that of the open procedure. The authors have minimized the invasiveness of our procedure by using only three ports and have described the technique as well as compared it with the open method. METHODS: A retrospective review of seven laparoscopic splenectomies (LS) using a three port technique were compared with seven open splenectomies (OS) performed for similar indications at a single children's hospital. RESULTS: The average age in the LS group was 8.7 years compared with 8.9 years for OS, (P value not significant), and the average weights were also similar. The indications for splenectomy were hereditary spherocytosis, idiopathic thrombocytopenic purpura, sickle cell anemia, and splenic cyst. All splenectomies were performed safely with an average estimated blood loss of 41 mL for LS and 34 mL for OS (P value not significant). Operative time averaged 147 minutes for LS and 86 minutes for OS (P < .05). LS patients recovered more rapidly and were discharged home on a median of postoperative day (POD) 2 versus POD 4 for OS (P < .05). LS patients received significantly less total amount of intravenous pain medication with an average of 0.18 mg/kg of morphine sulfate versus 0.8 mg/kg for OS (P< .05). Total hospital charges were higher for LS with an average of $10,899 versus $8,275 for OS (P < .05). CONCLUSIONS: Laparoscopic splenectomy currently is a safe procedure, offering better cosmesis, much less pain, and a shorter hospital stay compared with the traditional open procedure. The more sophisticated equipment and time needed to carry out the procedure led to a modestly increased hospital cost.