Hepatocellular transplantation for experimental ischemic acute liver failure in dogs

Recovery from acute liver failure is possible if metabolic support can be provided during the period of exogenous liver regeneration. The ability of transplanted dispersed autologous hepatocytes to alter the course of experimental ischemic acute liver failure in dogs was tested. Liver failure was induced by occlusion of blood flow in the proximal portal vein and hepatic artery(s) 48 hr after creation of a side to side portacaval shunt and immediately after a left lateral hepatic lobectomy. Dogs in Group 1 had ischemic injury with no treatment. Dogs in Group II received intrasplenic autotransplants of hepatocytes (26 ± 4x × 10⁸ intact cells) after the ischemic period. Cells for transplantation were prepared from the excised lobe during the period of liver ischemia. Dogs in Group III received intrasplenic transplants of autologous hepatocytes (26 = 3 × 10⁸ intact cells) after liver ischemia and after ligation of the main splenic artery. Serum bilirubin, serum glutamic oxalocetic transaminase, lactate dehydrogenase, and alkaline phosphatase were measured before and serially after ischemia, and showed that the degree of liver injury in all three groups was similar, although survival in Group III was better. Only 20% of nontransplanted animals (Group I) survived 10 days. Liver histology in animals that died showed hemorrhagic necrosis situation around the terminal hepatic central veins. Transplantation did not improve survival in dogs with arterialized spleens and histological examination of dogs that died showed pulmonary infarcts and additional liver injury from embolization of hepatocytes. In contrast, 70% of the animals undergoing splenic artery ligation before intrasplenic transplantation of hepatocytes were alive at 10 days. Ligation of the splenic artery reduced the tendency for hepatocytes to escape into the splenic vein and the spleen remained viable due to collateral circulation. On histological examination, hepatocytes were readily identified in the splenic parenchyma at 24 hr. 2 and 4 weeks after transplantation. In conclusion, intrasplenic hepatocytes provide sufficient metabolic support for dogs to recover from otherwise lethal ischemically induced, acute liver failure.     

Adrenocortical response and regional T-lymphocyte activation patterns following minimally invasive surgery in a rat model

Background: Laparoscopic surgery is associated with less tissue trauma and postoperative pain as well as a more rapid recovery than open surgery. We hypothesized that these factors may result in less immune impairment following laparoscopic surgery. Methods: We measured mitogen-induced surface interleukin-2 receptor (IL2R) expression and lymphocyte proliferation in CD4⁺ and CD8⁺ T-lymphocytes as well as serum corticosterone levels in rats 24 h following open (OP) and laparoscopic (LAP) fundoplication. Results: Serum corticosterone levels were lower in LAP vs OP rats (p= 0.02). CD4⁺ IL2R expression was higher in the blood, but not in the spleen, in LAP vs OP animals (p= 0.02). CD8⁺ IL2R expression was similar in both groups. Mitogen-induced lymphocyte proliferation was no different in the blood but decreased in the spleen in LAP vs OP rats (p= 0.03). Conclusions: Compared to open surgery, laparoscopic fundoplication in the rat results in lower adrenocortical hormone levels and better-preserved T-helper-cell activation in the blood. Lymphocyte proliferation is suppressed in the spleen 24 h after laparoscopic surgery. Minimally invasive surgery may better preserve cell-mediated immunity in the early postoperative period. Received: 2 April 1997/Accepted: 15 July 1997     

Monitoring of Intrasplenic Hepatocyte Transplantation for Acute-on-Chronic Liver Failure: A Prospective Five-Year Follow-Up Study

Background

Acute-on-chronic liver failure (ACLF) is defined as an acute deterioration of chronic liver disease. Intrasplenic hepatocyte transplantation is increasingly recognized as a treatment for liver failure and genetic metabolic liver diseases. We describe our experience of intrasplenic hepatocyte transplantation in a small cohort of patients as bridge therapy or as an alternative to orthotopic liver transplantation (OLT).

Methods

Seven patients with ACLF with an expected survival of less than 8 weeks were enrolled into the study. The donor hepatocytes were collected from 2 healthy males and cryopreserved. Donor hepatocytes were transplanted into the spleen of recipients via catheterization of the femoral artery. All patients were followed up for 5 years or to death.

Results

A total of (4.2–6.0) × 10¹⁰ hepatocytes were harvested from the 2 donors' livers and their survival after recovery from the frozen stock was 63% ± 2.8% and 73.5% ± 3.2%, respectively. Following intrasplenic hepatocyte transplantation, 3 patients fully recovered from liver failure, 1 survived and subsequently underwent OLT, and the remaining 3 patients died between 2.5 and 12 months after intrasplenic hepatocyte transplantation. At month 48 post–intrasplenic hepatocyte transplantation, living hepatocyte signals were observed in the spleen using magnetic resonance imaging (MRI) with gadobenate dimeglumine (Gd-BOPTA).

Conclusions

Intrasplenic hepatocyte transplantation is a promising therapy for liver failure that may reduce mortality rates among patients with end-stage liver disease awaiting OLT. Conceivably, intrasplenic hepatocyte transplantation may be considered an alternative to OLT for patients with acute liver failure. MRI (Gd-BOPTA) is a useful tool for detecting living hepatocytes in the spleen after intrasplenic hepatocyte transplantation.     

Intermittent pneumatic sequential compression (ISC) of the lower extremities prevents venous stasis during laparoscopic cholecystectomy

Background: Fifty patients were included in a prospective randomized trial to evaluate the efficacy of intermittent sequential compression (ISC) of the lower extremities in preventing venous stasis during laparoscopic cholecystectomy. Methods: We treated 25 patients with (+ISC) and 25 without (–ISC) intermittent sequential compression. Peak flow velocity (PFV) and cross-sectional area (CSA) of the right femoral vein were measured by Doppler ultrasound before, during, and after capnopneumoperitoneum with 14 mm Hg. Results: PFV was 26.4 (8.4) cm/s and CSA was 1.03 (0.23) cm² before pneumoperitoneum was induced. During abdominal insufflation, PFV decreased to 61% of the baseline value in the (–ISC) group but remained unchanged in the (+ISC) group (t = 5.17, df = 42.8, p < 0.01). CSA was 1.06 (0.22) cm² before insufflation. It increased to 118% of the baseline in the (–ISC) group and to 108% in the (+ISC) group (t =–1.55, df = 47.1, p= 0.13). PFV and CSA returned to baseline values within 5 min after abdominal desufflation. Conclusions: ISC effectively neutralizes venous stasis during laparoscopic surgery and may decrease the risk of postoperative thromboembolic complication. Therefore, it is recommended for all prolonged laparoscopic procedures. Received: 10 April 1996/Accepted: 24 April 1997     

Pneumoperitoneum with carbon dioxide enhances liver metastases of cancer cells implanted into the portal vein in rabbits

Background: Little is known about the role of the CO₂ pneumoperitoneum on tumor cells that spread from the portal system into the liver during laparoscopic surgery for gastrointestinal malignancies. Therefore, we designed a study to investigate the effect of CO₂ pneumoperitoneum on cancer cells implanted in the portal vein in a rabbit model. Methods: Immediately after intraportal inoculation of 2.5 × 10⁵ cells of VX₂ cancer, the rabbits received either CO₂ pneumoperitoneum at a pressure of 10 mmHg for 30 min (pneumoperitoneum group, n= 14) or laparotomy alone for 30 min (laparotomy group, n= 14). Results: The number (p < 0.01) and area of cancer nodules (p= 0.045) on the liver surface on day 17 were greater in the pneumoperitoneum group than in the laparotomy group. The frequency of cancer nodules >3.0 mm in diameter was higher in the pneumoperitoneum group than in the laparotomy group (p < 0.001). Conclusions: Compared with laparotomy, CO₂ pneumoperitoneum enhanced the development of liver metastases in this experimental model. Received: 9 December 1998/Accepted: 3 April 1999     

Hepatic and portal vein blood flow during carbon dioxide pneumoperitoneum for laparoscopic hepatectomy

Background: Laparoscopy under carbon dioxide (CO₂) pneumoperitoneum has many advantages. However, the risks of CO₂ pneumoperitoneum during laparoscopic hepatectomy (LH) have not been defined. Methods: The hemodynamics of the hepatic vein were examined during CO₂ pneumoperitoneum both pre- and posthepatectomy in eight pigs. Portal blood flow was measured with Doppler ultrasound during laparoscopic cholecystectomy in 10 human patients. Results: Experimentally, elevated intraabdominal pressure (IAP) with CO₂ insufflation produced significant increases in CO₂ partial pressure and echogenicity of the hepatic vein in the posthepatectomy group. Clinically, elevated IAP caused significant narrowing of the portal vein and significant decreases in portal blood velocity. The mean portal flow was significantly decreased with elevation of IAP >10 mmHg. Conclusions: LH with CO₂ pneumoperitoneum may lead to embolism caused by CO₂ bubbling through the hepatic vein. Elevated IAP may cause a decrease in hepatic blood flow and induce severe liver damage, especially in patients with poor liver function. Gasless laparoscopy using abdominal wall lifting should be employed in LH to avoid the risks of CO₂ embolism and liver damage. Received: 28 March 1997/Accepted: 12 September 1997     

Transplantation of Hepatocytes for Prevention of Intracranial Hypertension in Pigs With Ischemic Liver Failure

Intracranial hypertension leading to brain stem herniation is a major cause of death in fulminant hepatic failure (FHF). Mannitol, barbiturates, and hyperventilation have been used to treat brain swelling, but most patients are either refractory to medical management or cannot be treated because of concurrent medical problems or side effects. In this study, we examined whether allogeneic hepatocellular transplantation may prevent development of intracranial hypertension in pigs with experimentally induced liver failure. Of the two preparations tested—total hepatectomy (n = 47), and liver devascularization (n = 16)—only pigs with liver ischemia developed brain edema provided, however, that animals were maintained normothermic throughout the postoperative period. This model was then used in transplantation studies, in which six pigs received intrasplenic injection of allogeneic hepatocytes (2.5 × 10⁹ cells/pig) and 3 days later acute liver failure was induced. In both models (anhepatic state, liver devascularization), pigs allowed to become hypothermic had significantly longer survival compared to those maintained normothermic. Normothermic pigs with liver ischemia had, at all time points studied, ICP greater than 20 mmHg. Pigs that received hepatocellular transplants had ICP below 15 mmHg until death; at the same time, cerebral perfusion pressure (CPP) in transplanted pigs was consistently higher than in controls (45 ± 11 mmHg vs. 16 ± 18 mmHg; p < 0.05). Spleens of transplanted pigs contained clusters of viable hepatocytes (hematoxylin-eosin, CAM 5.2). It was concluded that removal of the liver does not result in intracranial hypertension; hypothermia prolongs survival time in both anhepatic pigs and pigs with liver devascularization, and intrasplenic transplantation of allogeneic hepatocytes prevents development of intracranial hypertension in pigs with acute ischemic liver failure.     

Intraperitoneal immunity and pneumoperitoneum

Background: Carbon dioxide (CO₂) pneumoperitoneum has been implicated as a possible factor in depressed intraperitoneal immunity. Using in vitro functional assays, CO₂ has been shown to decrease the function of peritoneal macrophages harvested from insufflated mice. However, an effective in vivo assessment is lacking. Listeria monocytogenes (LM), an intracellular pathogen, has served as a well-established in vivo model to study cell-mediated immune responses in mice. This study examines the immune competence of mice based on their ability to clear intraperitoneally administered LM following CO₂ vs helium (He) insufflation. Methods: Eighty-five mice (C57Bl/6, males, 4–6 weeks old) were divided between the following four treatment groups: CO₂ insufflation, He insufflation, abdominal laparotomy (Lap), and control (anesthesia only). Immediately postoperatively, each group was inoculated percutaneously and intraperitoneally with a sublethal dose (.015 × 10⁶ org) of virulent LM (EGD strain). Half of the animals were killed on postoperative day 3 and half on day 5. Spleens and livers (sites of bacterial predilection) were harvested, homogenized, and plated on TSB agar. The amount of bacteria (1 × 10⁶ LM/spleen and liver) from each group was then compared. Statistical significance was set at p≤ 0.05. Results: Control animals had nominal bacteria on day 3 (0.016 × 10⁶ LM/spleen and liver), and the bacterial burden remained low at day 5 (0.038 × 10⁶ LM/spleen and liver) postchallenge. On day 3, the bacterial burden was significantly higher in the CO₂ group (5.46 × 10⁶ LM/spleen and liver) as compared to He (0.093 × 10⁶ LM/spleen and liver) and controls. The Lap group (3.44 × 10⁶ LM/spleen and liver) had significantly more bacteria than the controls. There were no significant differences between any of the groups on day 5. Conclusions: In this animal model, CO₂ pneumoperitoneum impaired cell-mediated intraperitoneal immunity significantly more than He pneumoperitoneum and controls on day 3. Also on day 3, laparotomy caused impairment of intraperitoneal immunity when compared to controls. Finally, intraperitoneal immunosuppression resolved by day 5. Received: 22 July 1998/Accepted: 3 March 1999     

Human Serum Albumin Microspheres Approximate Initial Organ-Specific Biodistributions of Transplanted Hepatocytes and Are Effective Cell Surrogates for Safety Studies

Liver repopulation with transplanted hepatocytes will generate novel cell-based therapies, although translocation of transplanted cells into lungs through portasystemic shunts has the potential for embolic complications. To facilitate safety analysis of hepatocyte transplantation, we wished to obtain effective cell surrogates and analyzed biodistributions of similarly sized ^99mTc-labeled human serum albumin microspheres and rat hepatocytes. Image analysis with dual ^99mTc and ¹¹¹In labels indicated that cells and microspheres were similarly distributed in the liver when injected into normal rats via the spleen. Also, their distributions were similar when injected via a femoral vein or the superior mesenteric vein with cells and microspheres localizing in lungs or liver, respectively. Upon intraportal injection in rats with portal hypertension, microspheres localized in both liver and lungs, consistent with portasystemic shunting. These data demonstrate that human serum albumin microspheres are effective cell surrogates for approximating the safety of hepatocyte transplantation and should be clinically useful.     

The cytokinetic behavior of donor hepatocytes after syngenic hepatocyte transplantation into the spleen

The cytokinetic behavior of isolated hepatocytes transplanted into the spleen of syngenic normal Wistar rats was studied. Hepatocyte transplantation (HTX) was performed by the intrasplenic injection of 10(7) isolated hepatocytes. The proliferation index (PI) of intrasplenic donor hepatocytes was assessed by immunocytochemical visualization of DNA-synthesizing cells after pulse-labeling with bromodeoxyuridine (BrdU), a thymidine analogue. A method for determination of intrasplenic liver mass based on tissue glutamate dehydrogenase content was developed. The spontaneous PI of donor hepatocytes at 12 and at 20 weeks post-HTX amounted to around 3%. A significant increase of intrasplenic liver mass was demonstrated between the 12th and 20th week post-HTX (from 8.1 +/- 0.8% to 10.8 +/- 0.8% of spleen weight, P less than 0.05). After partial hepatectomy (PH) at 12 weeks post-HTX, the PI of liver cells in the spleen showed a transient increase up to about 10%, which rapidly declined to the "spontaneous" level of 3%. However, PH did not cause an additional increase in intrasplenic liver mass. This study shows that continuous mitotic activity of intrasplenic hepatocytes results in an actual increase of liver mass in spleen. Although a short-lived increase of proliferative activity of ectopically grafted hepatocytes was shown to occur after PH in the HTX-treated rat, this procedure did not result in an additional increase of intrasplenic liver tissue.     

Laparoscopic treatment of hydatid cysts of the liver and spleen

Background: The short-term results from laparoscopic treatment of hydatid cysts of the liver and spleen were reported previously. The procedure was shown to be feasible and safe, offering the advantages of laparoscopic surgery. This is the first report on the long-term follow-up of this operation in a large group of patients. Methods: In this study, 108 hydatid cysts of the liver and spleen in 83 consecutive patients (43 males [52%] and 40 females [48%]) were approached laparoscopically. The mean age of the patients was 40 years (range, 13–85 years). There were 104 liver cysts and 4 spleen cysts. The liver cysts were located in the right lobe in 42 patients (53%), in the left lobe in 21 patients (26%) and in both lobes in 16 patients (21%). Of the 104 cysts, 44 (42%) were uniloculated and 60 (58%) were multiloculated. Results: All cysts were approached laparoscopically. The mean operative time was 80 min (range, 40–180 min). The conversion rate was 3%. The mean hospital stay was 3 days (range, 2–7 days). There were no mortalities, and complications occurred in nine patients (11%). All were managed conservatively except one patient in whom a laparotomy was needed. All patients were followed up for a mean period of 30 months (range, 4–54 months) with serological testing and ultrasonography if needed. In three patients (3.6%) recurrence of the disease developed. Conclusion: The laparoscopic approach to uncomplicated hydatid cysts of the liver and spleen is a safe and effective option with favorable long-term results. Received: 27 August 1998/Accepted: 13 July 1999     

Acute impairment of hepatic microcirculation and recruitment of nonparenchymal cells by intrasplenic hepatocyte transplantation

Background/Purpose

Over the last 20 years, hepatocyte transplantation (HcTx) has advanced from the experimental to the clinical stage. To date, HcTx has been performed in 30 patients in the United States. Regardless whether hepatocytes are transplanted into the spleen and migrate to the liver or are injected directly into the portal vein, transplanted liver cells will, to some extent, congest the recipient liver microcirculation. The potential negative consequences of intrasplenic HcTx were the subject of this study.

Methods

By using intravital microscopy, the authors investigated whether intrasplenic HcTx of 20 × 10⁶ allogenic hepatocytes would influence liver perfusion, excretory liver function, and nonparenchymal cells (Kupffer and Ito cells) in vivo.

Results

The sinusoidal perfusion rate declined significantly from 94% (control) to 84% on day 1 and 76% on day 7. Bile acid excretion decreased in a similar fashion from 0.924 mg/h (control) to 0.669 mg/h on day 7. The authors observed a significant increase of Ito cells from 81.1 cells per microscopic field (control) to 97.1 (day 1) and an increase of Kupffer cells (KC; 6.1 cells per microscopic field on day 1 v 3.8 on control).

Conclusions

This study shows an acute impairment of hepatic microcirculation and hepatucellular function along with an recruitment and activation of nonparenchymal cells in the early posttransplantation period after intrasplenic HcTx. Kupffer cell recruitment indicates an activation of local host defense, and Ito cell activation implies the initiation of liver repair mechanisms owing to ischemia-related cell damage.     

A simple and effective method to improve intrasplenic rat hepatocyte transplantation

Transplanted hepatocytes integrate, survive, and express their specific functions in the liver parenchyma. The aim of this study was to determine whether a large number of hepatocytes could move from the spleen to the liver when the cells are injected together with sodium nitroprusside, and if the improved hepatocyte migration may be related with portal vein dilatation. Wistar rats were transplanted in the spleen with fluorescent-labeled hepatocytes alone or together with sodium nitroprusside. At 1, 3, 6, and 24 h after the transplant, the liver from recipient animals was removed and morphometric analyses were performed. Portal and arterial pressures were also measured immediately after intrasplenic injection of a solution of sodium nitroprusside, hepatocytes alone, or hepatocytes plus sodium nitroprusside. Intrasplenically injected sodium nitroprusside produced a transient drop in arterial pressure and a sustained reduction in portal pressure. During hepatocyte transplantation it increased the number of transplanted cells migrating to the liver after 3 h. Sodium nitroprusside simultaneously injected with hepatocytes in the spleen allowed more cells to migrate into the liver of the host animal without risk in animal survival.     

Laparoscopic liver surgery

Background: An effort was made to evaluate the indications, safety, and therapeutic efficacy of laparoscopic liver surgery. Methods: Between 1989 and 1996, 28 patients, 23 to 88 years old were operated upon laparoscopically. Pathology consisted of simple cyst (ten), polycystic liver disease (seven), hydatid cyst (three, two of them calcified), abscess (one), focal nodular hyperplasia (six), and metastatic breast cancer (one). Results: Operations included 17 fenestrations, three pericystectomies, and eight resections (two lateral lobes). Operative time was 45 to 525 min with only four cases longer than 4 h. There was a 21% morbidity rate. There were no mortalities. Follow-up was 1–67 months with one asymptomatic recurrence. Conclusions: Laparoscopic hepatic surgery can be performed safely with good results by surgeons with hepatic and laparoscopic experience when careful selection criteria are followed. We advocate the ``four-hands technique' for simultaneous dissection and control of bleeding and bile ducts during resections. Received: 10 May 1996/Accepted: 26 July 1996     

The laparoscopic management of post-transplant lymphocele

Background: The management of lymphocele in patients following kidney (KT) and kidney pancreas (KPT) transplants is evolving. Open surgery has been the traditional treatment, but some authors have advocated laparoscopic drainage in selected patients. Methods: We retrospectively reviewed our results in lymphocele treatment since developing a laparoscopic program at our institution. Results: Between May 1994 and June 1995, 186 KTs and 48 KPTs were performed, and 1,354 patients are currently being followed. Eight patients developed symptomatic lymphoceles an average of 26 months (range 4–59) following 6 KTs and 2 KPTs. All patients diagnosed were successfully drained laparoscopically, with no conversions to open surgery. Laparoscopic ultrasound was used to help with localization of the fluid collection. Operative time averaged 59 min, median hospital stay was 1 day (range 1–4), and there were no perioperative complications. Follow-up imaging was obtained on six patients, 3–16 months following their procedures, and no recurrences were noted. A review of the literature demonstrates a 5.3% rate of major complications and a 7% incidence of lymphocele recurrence. Conclusions: Intraoperative laparoscopic ultrasound can help localize fluid collections and prevent organ injuries. Laparoscopic drainage of lymphocele following transplantation results in minimal disability and an acceptable complication rate, although it is higher than with open drainage. Therefore, laparoscopic drainage should be considered as primary treatment for all patients with symptomatic post-transplant lymphocele. Received: 15 March 1996/Accepted: 3 July 1996     

Laparoscopic management of accessory spleens in immune thrombocytopenic purpura

Background: A disparity exists between the incidence of accessory spleens reported in the open (15–30%) versus the laparoscopic (0–12%) literature. This disparity implies that a percentage of laparoscopic patients will require a reoperation for accessory splenectomy. We present our experience with the laparoscopic management of accessory spleens discovered after primary splenectomy for idiopathic thrombocytopenic purpura (ITP). Methods: Seventeen patients who underwent primary splenectomy for ITP were reviewed (1 open, 16 laparoscopic). In the laparoscopic group, the incidence of accessory spleens was 3 in 16 (19%). In 1 of these 3 patients, the accessory spleen was found and removed at the initial operation, whereas in 2 of the 16 patients (13%), the accessory spleens were missed. A third patient, whose initial operation was open, presented with recurrent thrombocytopenia after primary splenectomy. After recurrent thrombocytopenia developed, radio nuclide spleen scans were performed showing accessory spleens in all three patients. These three patients underwent accessory splenectomy using a four-port laparoscopic approach. Results: Laparoscopic accessory splenectomy was successfully performed in all three patients. Location of accessory spleens correlated with the spleen scan in each case. Mean operation time was 180 min. There were no conversions to open surgery and no complications. All patients were discharged from the hospital on postoperation day 1. The three patients had a good clinical response and were weaned effectively from their steroid medications. Conclusions: Patients undergoing a laparoscopic splenectomy for chronic ITP have a higher probability of requiring a reoperation for a missed accessory spleen. To minimize missing an accessory spleen, a systematic search should be made at the beginning of the laparoscopic operation. We have found that preoperation imaging with heat-treated erythrocyte scans is valuable for locating accessory spleens before reoperation. When reoperation for accessory splenectomy is necessary, a laparoscopic approach is safe and effective. Received: 22 July 1998/Accepted: 13 October 1998     

Prolonged pneumoperitoneum at 15 mmHg causes lactic acidosis

Background: Acute increases in intraabdominal pressure (IAP) induce systemic and regional circulatory changes. Besides, mechanical compression on the capillary beds may decrease oxygen availability to the tissues. The purpose of this clinical study was to analyze the effects of increased IAP on acid-base disturbances and plasma lactate levels during prolonged carbon dioxide pneumoperitoneum. Methods: Twenty-eight patients undergoing laparoscopic sigmoidectomy were included in this study. Fourteen of them (group A) had IAP of 15 ± 1 mmHg while the remaining 14 (group B) had IAP of 10 ± 1 mmHg. The control group included six patients undergoing conventional sigmoidectomy. Results: A progressive significant increase in PaCO₂ was observed in the laparoscopic groups (p < 0.01). Plasma lactate levels in group A significantly increased 90 min after insufflation (p < 0.05) and reached the highest value 1 h after deflation (9.9 ± 1 vs 31.9 ± 2.5 mg/dl, p < 0.005). Simultaneously, arterial pH decreased in all groups; however, at 1 h after surgery, it was significantly lower (p= 0.02) in group A. There was a significant correlation between acid concentration due to lactate and lactate concentration (GA: R ²= 0.717, p= 0.03; GB: R ²= 0.879, p= 0.006 and GC: R ²= 0.853, p= 0.008). Conclusion: High IAP causes lactic acidic accumulation in patients undergoing prolonged laparoscopic procedures. Received: 1 April 1996/Accepted: 19 November 1996     

Laparoscopic splenectomy

Background: With the evolution of laparoscopic surgery comes the need for specific instruments that apply traction to parenchymal tissue, like the spleen, without exposing the organ to the associated high risk of bleeding. To meet this need, we designed and developed a suction-cup grasper that allows easy grasping and manipulation of the spleen. Some of the difficulties usually encountered during laparoscopic splenectomy may be overcome by using this device. Materials: The instrument consists of a cone-shaped, silicone rubber suction cup designed with an antislip internal surface. The cup is connected to a support arm with a flexible distal end that can be rotated. Traction is exerted with a commonly available suction system. The device is inserted through a 12-mm-diameter guide sheath. Results: The two interventions performed with the atraumatic device were completed with laparoscopic technique. No complications arose during or after the operations. The average operating time was 110 min. The patients were discharged after 4 and 5 days postoperative, respectively. Conclusions: As a device specifically designed for grasping parenchymal organs, the atraumatic suction grasper affords the operator a faster and safer technique in laparoscopic splenectomy. Received: 18 October 1996/Accepted: 16 May 1997     

Laparoscopic fundoplication in infants and children

Background: Laparoscopic fundoplication is a new method for treating gastroesophageal reflux in children. We present 160 children with gastroesophageal reflux treated by laparoscopic fundoplication. Methods: Patients underwent either a laparoscopic Nissen or Toupet fundoplication. Many patients also required gastrostomies and gastric outlet procedures. Results: Twelve patients (7.5%) were converted to open fundoplication. Laparoscopic gastrostomies were placed in 112 patients (75.7%) and laparoscopic gastric outlet procedures in 62 patients (41.9%). Feedings were initiated by postoperative day 2 in 126 children (85.7%). Sixty-four percent were discharged by postoperative day 3. Complications occurred in 11 of 148 fundoplications (7.4%), in nine of 112 gastrostomies (8.0%), and in three of 62 gastric outlet procedures (4.8%). One patient died as a result of a surgical error in placing a gastrostomy (0.7%). Conclusion: Laparoscopic fundoplication appears to foster a more rapid recovery and decreased hospital stay while maintaining complication rates similar to or better than open fundoplication. Received: 22 March 1996/Accepted: 12 June 1996