脾切除治疗儿童特发性血小板减少性紫癜

目的 评估脾切除术治疗儿童特发性血小板减少性紫癜（ITP）的安全性和有效性。方法 回顾分析5年37例ITP患儿行选择性脾切除术的疗效术后早期并发症。结果 所有患儿在转入外科前均在内科接受正规治疗。32例（86.6%)患儿脾切除后效果显著,5例（13.4%)部分显效,术后并发症有3例,其中1例为严重感染。结论 选择性脾切除术是儿童ITP一种安全和有效的治疗手段。     

腹腔镜脾切除术治疗特发性血小板减少性紫瘢

目的探讨腹腔脾切除术(LS)治疗特发性血小板减少性紫瘢(ITP)安全性和临床疗效。方法回顾分析2000年7月~2005年7月27例ITP患者行LS的临床资料。结果2例因术中出血中转开腹手术。25例完成LS,手术时间75~230 m in,平均138 m in,术中出血量20~350 m l,平均97 m l。5例发现副脾并切除。术后1~2在恢复饮食并下地活动。住院时间4~11天,平均5.4天。2例切口感染,1例切口皮下血肿,1例皮下气肿。随访时间2.5~62个月,平均22个月,17例有效(68%),4例部分有效(16%)。结论LS治疗ITP安全可行、效果良好。     

LAPAROSCOPIC SPLENECTOMY USING THE LATERAL POSITION: AN IMPROVED TECHNIQUE

An alternative approach to laparoscopic splenectomy is described. This technique uses a lateral position and modified port placement. Initial experience with three patients has demonstrated advantages over previously described approaches, by providing a more direct view of the splenic hilum and by eliminating the need for retraction of adjacent organs.     

原发性血小板减少性紫癜脾切除围手术期处理及并发症的防治

目的 降低血小板减少性紫瘢脾切除后的并发症。方法 对1982年1月至2003年1月收治的69例原发性血小板减少性紫瘢病人进行回顾性研究。结果 该病最常见而严重的并发症是感染和出血。结论 正确应用激素和抗生素是减少并发症的重要措施。     

TICLOPIDINE-INDUCED THROMBOTIC THROMBOCYTOPENIC PURPURA: TWO CASE REPORTS TREATED WITH PLASMA EXCHANGE PLUS STEROIDS

Thrombotic thrombocytopenic purpura (TTP) has a high mortality rate if left untreated with plasma exchange promptly. We report two cases of ticlopidine-induced TTP, which lesser dosages of ticlopidine (200–250 mg/day) were prescribed and were treated with plasma exchange (PE) plus steroids. The first case was treated successfully, but the second case did not respond to our treatment and died of a progressive disease complicated with pneumonia. In sum, we recommend careful use of ticlopidine, regardless of the dosages prescribe and regardless of how long the drug is used. Moreover, the adverse effect of ticlopidine should be closely monitored.     

腹腔镜脾切除术32例报告

目的探讨腹腔镜脾切除术（laparoscopic splenectomy，LS）的可行性。方法我院1999年6月-2005年12月行LS32例，超声刀游离脾周韧带，血管切割缝合器离断脾蒂，脾脏装入塑料袋剪碎取出。结果LS成功29例，手术时间60-270min，平均100min；术中出血量30-1000ml，平均230ml。术后住院3—7d，平均5d，无术后并发症。3例中转开腹，1例为脾蒂出血，1例为胃短血管出血，1例为脾周围炎粘连紧密出血。22例特发性血小板减少性紫癜中18例血小板恢复正常，4例术后无升高。2例溶血性贫血术后血红蛋白升高。4例肝炎后肝硬化合并脾功能亢进者术后血小板恢复正常。结论腹腔镜脾切除术安全可行．尤其适合于血液系统疾病中须行脾切除者及脾脏本身病变者。     

Hematological long-term results of laparoscopic splenectomy for patients with idiopathic thrombocytopenic purpura: a case control study

Background Laparoscopic splenectomy (LS) for idiopathic thrombocytopenic purpura (ITP) appears, when compared to open splenectomy (OS), associated with immediate important advantages. However, in a number of patients splenectomy does not lead to an adequate response, or after initial adequate response a relapse occurs after some time. A relapse may be associated to the presence of accessory spleens and splenosis. The purpose of this study was to compare the operative outcome and the hematological results on the long term of a series of LS with a historic series of OS for the treatment of ITP.Methods A retrospective review was done of 50 consecutive patients who underwent LS for ITP. Patient characteristics, outcome of surgery, and hematological results were compared to a historical group of patients who underwent conventional splenectomy for ITP (n = 31). Response to splenectomy was defined in three groups: complete remission, partial remission, and no response. Grouping was based on hematological data.Results Concerning operative outcome and postoperative complications, there was a significant difference in favor of LS. Moreover, the hematological outcome of both groups showed no differences after a median period of 66 months (OS) and 35 months (LS), respectively.Conclusions Hematological results after laparoscopic splenectomy for ITP are comparable to those after open splenectomy in both the short and the long term.     

THROMBOTIC THROMBOCYTOPENIC PURPURA IN A CASE OF SCLERODERMA RENAL CRISIS TREATED WITH TWICE-DAILY THERAPEUTIC PLASMA EXCHANGE

We report the rare complication of thrombotic thrombocytopenic purpura (TTP) in an elderly patient with the uncommon scleroderma renal crisis (SRC) at the advanced age of 85 years. Initially, she was treated by standard daily one and a half plasma volume therapeutic plasma exchange (TPE), in combination with steroid therapy. Due to an unsatisfactory clinical response, she was consequently, treated by an intensive twice-daily one and a half plasma volume TPE regimen. Although there was an increase in the platelet count, a 7-day course of the intensive regimen did not elicit further propitious laboratory test results or a clinical improvement and the patient expired secondary to the pulmonary and cardiac conditions related to SRC. Intensive TPE administration has been advocated in few specific patients who are refractory to standard daily treatment. The unfavorable outcome in this case may be attributed to the multiple complications associated with her primary disorder. In conclusion, we observed intensive twice-daily TPE to increase temporarily the platelet count, but not to be of benefit in a patient with SRC and multiple organ failure. The two TPE regimens and outcomes are compared and the pathogenesis of TTP and scleroderma are discussed.     

腹腔镜脾切除术治疗特发性血小板减少性紫癜62例临床分析

目的探讨腹腔镜脾切除术(laparoscopic splenectomy,LS)治疗特发陛血小板减少性紫癜(idiopathic thrombocytopenic purpura,ITP)的安全性及疗效。方法对62例ITP患者采用腹腔镜脾切除术。结果 62例患者术前血小板(33.18±19.36)×10~9/L,术中发现副脾6例,手术时间(202.66±23.95)分钟,术中出血(226.45±106.93)rnl,住院时间(9.44±1.71)天,住院费用(29457±2946)元。无死亡患者,术后1周血小板明显上升为(171.32±89.00)×10~9/L,随访3~12个月,总有效率88.7%(55/62)。结论 LS治疗ITP,安全、有效,手术费用偏高,可避免患者长期服用激素。     

THE RESULTS OF TREATMENT OF LARYNGEAL CANCER IN AUCKLAND NEW ZEALAND 1965–1979

A retrospective review of laryngeal cancer in Auckland over the period 1965–1979 has revealed a generally poorer prognosis for supraglottic cancer than for glottic cancer. The use of radiotherapy for supraglottic cancer and for advanced glottic cancer has not been as successful as primary surgery but has yielded good results in early glottic carcinoma. Salvage surgery after failed radiotherapy was significantly more successful for glottic tumours than supraglottic. Stomal recurrence was more likely if a patient had required an emergency tracheotomy for airway obstruction.     

ANTIBODY RESPONSES FOLLOWING SPLENECTOMY: IMPLICATIONS FOR THE TIMING OF PROPHYLACTIC VACCINATION

Book reviews in this article: Antibody responses are reduced both in the short- and long-term after splenectomy. It is not known if this reduction is more profound in the immediate postoperative period compared to later, and consequently, whether there would be an advantage in delaying prophylactic vaccination to ensure a greater antibody response. To investigate this, the effect of splenectomy on the primary and secondary antibody response to sheep red blood cells (SRBC) injected into the peritoneum (IP) of adult male Porton rats was measured after either splenectomy (Spx), sham splenectomy (Sham), anaesthesia only (Ans) or no procedure at all (Con). There was no difference in the titres of antibody between the Con and the Ans rats. There was no difference in the titres of antibody between the Sham and Spx rats, but both had significantly lower titres than the Con rats. In a separate experiment, rats were immunized 1 month or I year after splenectomy or sham-splenectomy. One month after the operation the antibody response of the Sham rats had increased and did not differ from that of Con rats, but in rats which had been splenectomized there was a long-term suppression of the antibody response, which did not improve for at least one year. The results suggest that, in patients requiring splenectomy for trauma and not able to be vaccinated before operation, there may be no advantage in delaying prophylactic vaccination postoperatively.     

Laparoscopic splenectomy: a personal series of 140 consecutive cases

Introduction

Laparoscopic splenectomy has emerged as a safe and effective treatment for a variety of haematological conditions. The objective was to review the results from a large personal series from the perspective of outcomes according to operative time, conversion to open operation, complications and mortality. The application of laparoscopic splenectomy to cases of splenomegaly without hand assistance is examined.

Patients and Methods

A retrospective review of 140 patients undergoing laparoscopic splenectomy at a single university hospital by one surgeon during 1994-2006. Case notes were reviewed and data collected on operative time, conversion to open procedure, morbidity and mortality. Particular reference was made towards the results of cases of splenomegaly.

Results

In total 140 laparoscopic splenectomies were performed with a complication rate of 15% and no mortality. The median operative time was 100 min and conversion to open procedure was necessary in 2.1%. Conversion for cases of splenomegaly was only 5.7%. The median hospital stay was 3 days.

Conclusions

Laparoscopic splenectomy is a safe procedure with acceptable morbidity. A laparoscopic approach for splenomegaly is feasible.     

Accessory spleens: preoperative diagnostics limitations and operational strategy in laparoscopic approach to splenectomy in idiopathic thrombocytopenic purpura patients

Aim The preoperative detection of accessory spleen (AS) is still a very important and serious problem. The aim of the study was to assess the reasons for failure and the long-term results of laparoscopic splenectomy (LS) in patients with idiopathic thrombocytopenic purpura (ITP).Method Fifty-eight ITP patients underwent LS between June 1998 and December 2002. There were 42 women and 16 men. Preoperatively, we performed computed tomography (CT) and sonography to evaluate the size of the spleen and possibly to recognize the presence of the accessory spleens, which were found preoperatively in three cases.Results Intraoperatively, ASs were found in the course of laparoscopy in six cases overall, three preoperatively false negative. During follow-up (median time 31 months), in three patients the low platelet count was recognized, respectively after 5 months and 1.5 and 1.8 years. In all those cases scintigraphy was performed and in one case the residual accessory spleen, missed both in preoperative examination and during laparoscopy, was revealed. In two other patients, in spite of thrombocytopenia, no residual spleens were found.Conclusion We conclude that the problem of accessory spleens can be managed by careful videoscopic examination of the abdominal cavity during splenectomy, while the use of preoperative imaging techniques in detection of accessory spleens is still limited by the insufficient sensitivity of the examination.     

RESTORATIVE PROCTOCOLECTOMY WITH ILEAL POUCH–ANAL ANASTOMOSIS IN 203 PATIENTS: THE AUCKLAND EXPERIENCE

Background : Restorative proctocolectomy with ileal pouch–anal anastomosis (IPAA) has become an established operation for patients with ulcerative colitis and familial adenomatous polyposis (FAP). The results of a 15-year experience with IPAA are reported. Methods : Between September 1982 and June 1997, 203 patients had IPAA surgery. From a review of the charts, data were collected on the surgical procedure, the diagnosis and early and late complications. Pouch function was assessed by means of a postal questionnaire. Results : Of the 201 patients (median age of 32 years; 89 women) with complete records, 122 had J pouches, 65 had W pouches and 14 S pouches were constructed. The pre-operative diagnosis in 88% was ulcerative colitis and in 10% it was FAP. During a median follow-up time of 6.1 years the diagnoses were changed for 8% of the patients; in 4% the diagnosis was changed to Crohn’s disease. The overall mortality was 1.5% (early = 2, late = 1) The overall morbidity was 62% (early = 17%, late = 52%). The pouch was removed or was non-functional in 9%. All patients with a final diagnosis of Crohn’s disease have had their pouch excised. The median stool frequency was 4.0 (range 1.3–8.7) during the day, and 0.7 (range 0–2.1) during the night. The fewer night-time stools (J = 1.0 ± 0.6; W = 0.4 ± 0.5 P < 0.0001) and the reduced requirement of the W-pouch patients for anti-diarrhoeals (P = 0.004) were offset by the need for two W-pouch patients to pass a catheter to empty their pouches. Conclusions : The type of patients who present for IPAA surgery and the outcomes observed in this series of Auckland patients are similar to those reported from major centres elsewhere.     

Does laparoscopy make splenectomy a safe ambulatory operation?: Preliminary results

Our aim is to explore the feasibility of ambulatory laparoscopic splenectomy. Of 11 patients, five were not suitable for ambulatory care. Of the remaining six, four (67%) were successfully completed on an ambulatory basis. Two patients (33%) required admission to hospital, one for pain control and one because of oozing with a low platelet count. Both were discharged well the next morning. One of the ambulatory patients developed a splenic bed hematoma, treated symptomatically as an outpatient. This early experience suggests that laparoscopic splenectomy can be a safe ambulatory operation.     

CANCER OF THE TONGUE AND ORAL CAVITY IN AUCKLAND,NEW ZEALAND, 1970–86

This report comprises a retrospective review of the clinical data on 157 patients seen in the auckland area having a diagnosis of cancer of the tongue, floor of the mouth, inferior alveolus, or buccal mucosa (retromolar area, vestibule of the mouth, and cheek mucosa) during 1970–86. One hundred patients were male, 95% were european, 85% were cigarette smokers, and 58% had a history of high alcohol intake. All primary tumours were squamous cell carcinomas, 50% were located in the tongue, 27% in the floor of the mouth, and 11.5% each in the buccal mucosa and inferior alveolus. The majority (60%) of patients with tongue cancer were clinically stage i at presentation while other intra-oral tumours were evenly distributed between stages i and iv. Surgical resection of the primary intra-oral lesion produced local control in 90% of stage i tumours, but this fell to below 70% in stage ii—iv tumours. Most patients (82%) who recurred locally had positive or ‘close’ margins, and this rate of local tumour recurrence as a consequence of narrow margins did not decrease with the addition of adjuvant radiotherapy. Of those patients with stage i disease who received only treatment of the primary lesion, 20% later developed regional nodal disease which was controlled in more than half by neck dissection, but control was achieved only in 11% of patients treated with radiation. The presence of regional disease at presentation was associated with a poor prognosis. It is concluded that local control of inferior oral cavity tumours can be achieved if resection is accomplished with clear margins. Regional control can be obtained in 50% of patients with neck dissection. Considered together, the high rate of regional recurrence with stage i lesions, and the poor results following salvage therapy (12% 2 year survival) indicate that these patients require as aggressive initial therapy (often involving neck dissection) as do those with more advanced disease.     

PRIMARY ADRENAL TUMOURS – A TEN-YEAR EXPERIENCE

The experience of 31 patients with primary adrenal turnours seen in one teaching hospital over a 10–year period is reviewed. There were 10 patients who had benign cortical adenomas; 11 had adrenal cortical carcinomas, and 10 had phaeochromocytomas, one of which was malignant. During the review period, a primary adrenal mass was discovered in 5% of 2951 autopsies performed in the study institution. The diagnosis and management of these uncommon turnours is reviewed.     

SQUAMOUS CELL CARCINOMA OF THE LIP: A RETROSPECTIVE REVIEW OF THE PETER M ACCALLUM CANCER INSTITUTE EXPERIENCE 1979–88

Background : Squamous cell carcinoma (SCC) of the lower lip is a common malignancy in Australia. Surgical excision and/or radiotherapy are used in treatment, and are regarded as equally effective. Methods : A retrospective review of 323 patients treated at the Peter MacCallum Cancer Institute with either surgical excision and/or radiotherapy, evaluated disease recurrence, cause‐specific mortality, and the incidence of metachronous lesions. Results : Recurrence‐free survival at 10 years was estimated to be 92.5%, and cause‐specific survival at 10 years was estimated to be 98.0%. Equivalent rates of local control were obtained with surgery and radiotherapy. Recurrence was related to tumour stage and differentiation. A high incidence of metachronous lesions was noted, 25 patients had a lesion prior to presentation and 33 patients developed second lip lesions during the study period. Conclusions : Squamous cell carcinoma of the lower lip is well treated with surgery or radiotherapy. The preferred treatment for most patients with SCC of the lower lip in the Australian population is surgical excision. This study has shown a significant incidence of metachronous lip neoplasia, except in those patients whose whole lip had been resurfaced.