Post-splenectomy thrombocytopenia: implications for regional analgesia.

Hospital computerised records were reviewed to identify patients who had undergone splenectomy, then chart their platelet count before and for the 5 days after the operation. A pre-operative platelet count less than 100 x 10(9).l-1 occurred in 66% of leukaemia (n = 35), 56% of lymphoma (n = 41) and 5% of solid tumour (n = 39) patients. Platelet supplementation prior to epidural catheter insertion may reduce the risks of spinal bleeding. However, accidental catheter removal during a postoperative period of thrombocytopenia may lead to formation of an epidural haematoma. The lowest postoperative platelet count was less than 100 x 10(9).l-1 in 66% of leukaemia, 27% of lymphoma and 13% of solid tumour patients. Platelet counts varied considerably, so predicting an individual patient's postoperative nadir from the pre-operative count would be impossible. Consequently, placement of an epidural catheter in many of these patients could expose them to an increased risk of spinal bleeding if the catheter is removed accidentally.

Inclusion of peripancreatic lymph node cells prevents recurrent autoimmune destruction of islet transplants: evidence of donor chimerism.

BACKGROUND: Recurrent autoimmune beta-cell destruction may contribute to the poor results of clinical islet transplantation. Pancreas transplants from diabetes-resistant BB rats (BB-DR) are uniformly successful in autoimmune diabetic BB rats (BB-Ac), but isolated islets are destroyed, despite immunosuppression. In this study we tested the hypothesis that whole pancreas transplants abrogate autoimmunity by passive transfer to the host of an autoregulatory T-cell subset. METHODS: BB-Ac rats served as recipients of BB-DR or Wistar Furth (WF) pancreas or islet transplants. Two cohorts of islet transplants included 50 or 100 x 10(6) peripancreatic lymph node cells (LNCs). Recipients were monitored for recurrent diabetes and subjected to fluorescence-activated cell sorter analysis of peripheral blood lymphocytes after 200 days by using monoclonal antibodies to class I, CD4, CD8, RT6.2, and RT6.1. RESULTS: BB-DR pancreas transplants replete the RT6.1+ T-cell subset in BB-Ac rats, whereas BB-DR islet transplants, which are susceptible to recurrent autoimmunity, do not. Addition of 100 x 10(6) LNC results in repletion of RT6.1 to the same degree as the whole pancreas and leads to complete protection of the islets. WF pancreas transplants result in the appearance of RT6.2+ T cells in BB-Ac recipients, an RT allele that BB rats lack. CONCLUSIONS: BB-Ac rat recipients of whole pancreatic or islets plus LNCs transplants become chimeric for a donor T-cell population that prevents recurrent autoimmune diabetes. Deliberate inclusion of donor lymphoid cells with clinical islet transplants may be beneficial.

Radiotracer measurement of ureteric blood flow.

This paper describes a novel technique using the blood flow tracer C14-iodoantipyrine to measure ureteric blood flow in anesthetized Sprague-Dawley rats. The ureters were divided into five equal segments, and the blood flow was measured using a modification of the Fick principle. There was a gradient down the ureter with a significant difference between upper (159 ml./100 gm./min.) and lower (83 ml./100 gm./min.) ureteric segmental blood flows. This technique may allow the role of ureteric ischemia to be investigated in a variety of disease states.

Laparoscopic herniorrhaphy: initial experience in 126 patients.

The initial experience in laparoscopic transabdominal preperitoneal mesh (TAPP) repairs is reviewed. In this study, consecutive TAPP repairs were performed in 126 patients. There were no intraoperative complications, and only 1 procedure had to be converted to open surgery. Forty-six patients had direct inguinal hernias, 56 had indirect inguinal hernias, and 24 had both, of which 21 were recurrent. Fifty-one hernias were right sided, 46 were left sided, and 29 were bilaterals. The male/female ratio was 116:10, and the mean age of the patients was 49.8 (range 17-76). Minor complications included parasthesia over the distribution of the lateral cutaneous nerve of the thigh in 2 patients, hydrocoeles in 2 patients, hematomata in 6 patients, and testicular pain in 4 patients, all of which resolved on conservative management. Incomplete bowel obstruction has been the only major postoperative complication to date, where an area of bowel herniated between two staples in the peritoneum. This was further complicated by an aspiration pneumonia and death of the patient. The mean hospital stay was 1.2 days (range 1-3), and the mean return to unrestricted activity was 8 days (range 3-12). There have been 2 true recurrences to date. One patient had a tender swelling after the repair, which was thought to be a recurrent strangulated hernia. On investigation, it was found to be a hematoma. The mean follow-up has been 7 months (range 1-18). Although early results of the TAPP repair are encouraging, we have had 1 significant complication that may have been avoided if an endoscopic extraperitoneal approach was employed.

Aprotinin: the ideal anti-coagulant?

The serine proteinase inhibitor, aprotinin, significantly reduces transfusion requirements during open heart surgery. Whether this benefit is associated with an increased tendency to thrombosis has not been studied. We investigated the effect of aprotinin in an experimental arterial thrombosis model. In 17 male Sprague-Dawley rats, the infrarenal aorta was replaced with 1.0-mm diameter PTFE grafts of varying lengths. The time to graft occlusion, recorded by palpation, Doppler ultrasound and a distal bleeding test, was 20.2 +/- 1.8 min, 35.8 +/- 6.1 min and 43.7 +/- 6.6 min for grafts of 10, 7.5 and 5.0 mm respectively (r = -0.98, p less than 0.05). Following PTFE graft placement 24 Sprague-Dawley rats were given saline (n = 6), aprotinin (n = 6), heparin (n = 6), and heparin + aprotinin (n = 6). The time to occlusion was significantly prolonged in the aprotinin group (71.7 +/- 20.4 min vs. 20.2 +/- 1.8 min, p less than 0.05). The time to thrombosis for heparin + aprotinin and heparin alone was also significantly prolonged (p less than 0.05). Prothrombin times (PT) were 21.9 +/- 3.0 s for control, 29.4 +/- 6.2 s for aprotinin, 40.7 +/- 2.5 s for heparin and 39.9 +/- 14.5 s for heparin + aprotinin (p less than 0.05 vs. control for all values). Bleeding time was not prolonged with aprotinin (3.0 +/- 0.9 min vs. 2.9 +/- 0.7 min). The bleeding time was 18.9 +/- 4.1 min for heparin + aprotinin and 22.5 +/- 2.3 min for heparin alone (p less than 0.05 vs. control for both values).(ABSTRACT TRUNCATED AT 250 WORDS)

Laparoscopic cholecystectomy: a hundred consecutive cases.

Laparoscopic cholecystectomy is a new, minimaly invasive technique for removing the gallbladder which has several advantages over the traditional laparotomy cholecystectomy. We reviewed our initial experience with 100 consecutive patients in whom laparoscopic cholecystectomy was attempted. The indications for operation were biliary colic, chronic cholecystitis, acute gallbladder and gallstone pancreatitis. Laparoscopic cholecystectomy was successfully performed in 87 patients. Anaesthesia time was 144 +/- 52 min. There was no mortality while overall morbidity was 14%. One patient had a retained common bile duct stone. Postoperative hospital stay was 4.1 +/- 2.2 days and the mean time to full activity in a random sample of 25 patients was 13.7 +/- 11.7 days. Laparoscopic cholecystectomy is a safe effective procedure which removes the gallbladder. We suggest that this technique be considered in all patients undergoing cholecystectomy.

Reduced postoperative hospitalization after laparoscopic cholecystectomy.

An initial experience of laparoscopic cholecystectomy in 50 consecutive patients was reviewed and the results compared with those of a group of 25 patients who underwent laparotomy cholecystectomy during the 3 months before the introduction of laparoscopic cholecystectomy. Laparoscopic cholecystectomy was successfully performed in 44 of 50 consecutive patients in whom it was attempted. When compared with laparotomy, laparoscopy cholecystectomy was associated with longer mean (s.d.) anaesthesia, 155 (61) min versus 102 (31) min (P less than 0.001), shorter mean postoperative hospital stay, 3.5 (1.5) versus 8.8 (3.2) days (P less than 0.001), and reduced mean cost, pounds 895 (376) versus pounds 2210 (822) (P less than 0.001). Perioperative morbidity was also reduced following laparoscopy cholecystectomy (9 per cent versus 16 per cent) but not significantly so. Laparoscopic cholecystectomy is a safe, effective procedure which completely removes the gallbladder. It significantly reduces hospital stay, is cosmetically satisfactory and has financial benefits. We suggest that this technique be considered for all patients having cholecystectomy.