Pneumococcal Infections in Splenectomized Children Are Preventable

ABSTRACT. Through the Danish National Patient Registry we identified all children 0–15 years old who had been splenectomized during the period 1979–87 and all children of the same age who, during the same period of time, had been admitted to a hospital because of either meningitis or bacteraemia caused by Streptococcus pneumoniae. We wanted to see whether any of the splenectomized children had developed invasive pneumococcal infection during the observation period.
A similar Danish study covering the period 1969–78, when pneumococcal vaccine was not available, has already been published (3). Four per cent of the children splenectomized during that period developed invasive pneumococcal infection in contrast to none of the children splenectomized and vaccinated during the period 1979–87. Since 1982 antibiotic treatment of splenectomized patients running a fever has been recommended, and we show that the program of pneumococcal vaccination and defined antibiotic prophylaxis has been highly efficacious in preventing post-splenectomy infections in children.     

Elevated tricuspid regurgitation velocity in congenital hemolytic anemias: Prevalence and laboratory correlates

Elevated tricuspid valve regurgitation jet velocity (TRV ≥ 2.5 m/s) is associated with mortality among adults with sickle cell disease (SCD), but correlative biomarkers are not studied according to treatment exposure or genotypes. To investigate the associations between biomarkers and TRV elevation, we examined the relationship between TRV and hemolytic, inflammatory, and cardiac biomarkers, stratified by disease‐modifying treatments and SCD genotype. In total, 294 participants with SCD (mean age, 11.0 ± 3.7 years) and 49 hereditary spherocytosis (HS; mean age, 22.9 ± 19.75 years) were included for comparison and enrolled. TRV was elevated in 30.7% of children with SCD overall: 18.8% in HbSC/HbSβ⁺‐thalassemia, 28.9% in untreated HbSS/HbSβ⁰‐thalassemia, 34.2% in HbSS/HbSβ⁰‐thalassemia hydroxyurea‐treated, and 57% in HbSS/HbSβ⁰‐thalassemia chronic transfusion treated. TRV was elevated in 10.7% and 27.8% in HS children and adults, respectively. In children with SCD, elevated TRV was correlated with hemoglobin (odds ratio [OR] = 0.78, P = 0.004), lactate dehydrogenase (LDH; OR = 2.52, P = 0.005), and N‐terminal pro‐brain natriuretic peptide (NT‐pro BNP; OR = 1.003, P = 0.004). In multivariable logistic regression, adjusting for genotype, sex, hemolytic index, and treatment, hemoglobin concentration remained the only significant variable associated with elevated TRV in untreated HbSS/HbSβ⁰‐thalassemia participants. TRV was not associated with inflammatory markers, other markers of hemolysis, or NT‐pro BNP in untreated HbSS/HbSβ⁰‐thalassemia. Neither hemoglobin nor LDH was associated with TRV in HbSC/HbSβ⁺‐thalassemia. These results suggest that elevated TRV is influenced by the degree of anemia, possibly reflecting sickling as part of the disease pathophysiology. Prospective studies should monitor hemoglobin concentration as children with SCD age into adulthood, prompting initiation of TRV screening and monitoring.     

Dapsone for primary immune thrombocytopenia in adults and children: an evidence‐based review

Primary immune thrombocytopenia is a potentially life‐threatening condition. Approximately two‐thirds of adult patients do not have a sustained response to steroids (first‐line therapy). For these patients, a number of other treatment options exist, such as rituximab, splenectomy, immunosuppressants, and thrombopoietin receptor agonists, but they are costly and have side effects. Dapsone is an inexpensive drug with a well‐established safety profile. Unfortunately, this treatment option has not been explored adequately. This review is aimed at analyzing the currently available evidence for the use of dapsone as second‐line or third‐line therapy in primary immune thrombocytopenia.     

腹腔镜门奇静脉联合断流术

目的探讨腹腔镜门奇静脉联合断流术的手术方法和临床效果。方法回顾分析我院2002年10月至2006年10月间28例腹腔镜下门奇静脉联合断流术的手术时间、术中失血量、术后并发症等。结果28例中25例腹腔镜手术成功,其中5例完全在腹腔镜下完成,20例在手助下完成。3例中转开腹。腹腔镜手术时间150～280min,平均220min。术中出血400—1700ml,平均790ml。切除脾500～1900g,平均780g。腹腔镜手术患者住院时间9-19d,平均10．6d。术后患者恢复顺利,疼痛少,无死亡病例。结论腹腔镜行门奇静脉联合断流术不但安全可行,而且具有微创手术的优点,但需正确掌握手术适应证,可根据不同的病情选择不同的手术方式。     

腹腔镜脾切除术33例临床分析

目的 探讨腹腔镜脾切除术的方法和疗效,方法回顾性分析2006年1月～2009年1月新疆医科大学附属中医医院普外一科行腹腔镜脾切除术的33例患者的临床资料.结果 33例患者手术均获得成功,平均手术时间为150min,术中平均出血量为125 ml,切除脾重量平均为665g,平均住院时间为8 d,术后无出血、感染等并发症发生.术后平均血小板数从42×109/L上升至189×109/L.结论 腹腔镜脾切除术是一种安全、有效、微创的手术.     

无原发病外伤性脾切除患者术后血小板变化的研究

目的:探讨无原发疾病创伤性脾破裂行脾切除术后血小板计数的变化及处理措施。方法:无原发疾病创伤性脾破裂116例,脾切除术前查血小板,术后每2日连续查血小板,持续2～6周,术后血小板上升至450～500×109/L者,使用抗凝药和抗血小板药物,单独或联合应用直至血小板降至400×109/L以下停药。结果:所有病例术后均有异常的血小板计数升高,大多数在药物处理后2～6周降至400×109/L以下。无1例血栓形成或死亡。结论:无原发疾病外伤性脾切除患者均会出现不同程度血小板升高,血小板计数和血凝四项应作为常规监测指标,及时正确的抗凝治疗可避免继发血小板增多而引起血栓形成等并发症。     

NOTES: approach to the liver and spleen

Background

Minimally invasive abdominal surgery means minimal trauma to the abdominal wall, thus reducing postoperative pain and wound complications, and facilitating earlier mobilization and shorter hospitalization in comparison with conventional surgery. Natural orifice translumenal endoscopic surgery (NOTES) has the potential to further reduce the invasiveness of surgery in human patients. Here we report an experimental study of NOTES to access the liver and spleen, discuss its current status, and review the related literature.

Methods

The utility of transgastric peritoneoscopy was evaluated using one 15-kg pig and four 8-kg dogs on the basis of acute experiments. Under general anesthesia with endotracheal intubation, a forward-viewing, double-channel endoscope was advanced into the peritoneal cavity through a gastric hole. Liver biopsy from the edge of the liver was performed using routine biopsy forceps. Splenectomy was performed using a laparoscopically assisted procedure, and then the spleen was pulled into the stomach using an endoscopic polypectomy snare after enlargement of the gastric orifice. The animals were then sacrificed and necropsy was performed.

Results

There were no complications during incision of the gastric wall and entry into the peritoneal cavity. Peritoneoscopy gave satisfactory visualization of the abdominal cavity in all directions. Liver biopsy was performed successfully without any bleeding and adequate samples were obtained in all cases. Splenectomies were also accomplished uneventfully, except for injury of the splenic parenchyma due to excessive force during pulling into the stomach. Necropsy revealed no particular damage to other intraperitoneal organs related to this transgastric procedure.

Conclusion

Although NOTES is a feasible procedure and offers several advantages to patients, surgeons and endoscopists need to resolve several key issues before its clinical introduction for routine surgical work and to establish a training system for NOTES in order to avoid critical complications.     

I-gel喉罩在肝硬化脾脏切除手术中的应用效果评价

目的了解I-gel喉罩在肝硬化门体静脉断流术患者中的应用效果。方法将肝硬化门体静脉断流术患者60例随机分为三组(n=20),T组(气管插管组)、P组(Proseal喉罩组)和I组(I-gel喉罩组),麻醉诱导后置入气管导管或各型喉罩。记录气管导管或喉罩置入时间,置入和拔除喉罩及气管导管前后MAP、HR,术中PetCO2、Ppeak、SpO2,胃管置入一次成功率和术后两天内咽喉痛和声音嘶哑的发生情况。结果与T组比较,I组、P组置入和拔出喉罩对血液动力学干扰更小,MAP、HR变化差异有统计学意义(P<0.05),术后第一天和第二天咽喉痛发生率较低,差异有统计学意义(P<0.05),I组与P组相比,喉罩置入时间更短(P<0.01)。结论 I-gel喉罩置入比Proseal喉罩置入更快捷方便,术后咽痛发生率更低,更适合肝硬化脾脏切除手术。     

Vacuum Stabilization of the Spleen in Laparoscopic Splenectomy

Background and Objectives:

Recovery from laparoscopic splenectomy is greatly enhanced when compared with recovery from the laparotomy approach, yet a minority of spleens are removed laparoscopically. The spleen is smooth, rounded, and vascular, making it difficult to directly grasp, stabilize, or retract laparoscopically. The LiVac Retractor is a laparoscopic liver retractor comprising a soft silicone open ring that apposes 2 substantially planar surfaces when a vacuum is applied. It was evaluated for its efficacy in stabilization of the spleen during 2 laparoscopic splenectomies.

Methods:

The 2 patients gave consent for laparoscopic splenectomy with splenic retraction using the LiVac Retractor. The entire 3-port laparoscopic procedure was video recorded, with the resected spleens weighed as wet specimens. The patients'' postoperative courses are described.

Results:

The spleen was retracted securely for the duration of the hilar dissection in both patients. Exposure of the splenic hilum was excellent. There were no visible signs of injury to either spleen and recovery of both patients was unremarkable.

Conclusions:

The LiVac Retractor provided stable retraction and excellent exposure of the splenic hilum during both laparoscopic splenectomies, without organ injury. Early hilar dissection with vascular control was facilitated, reducing the risk of bleeding from other components of the dissection.     

彩色多普勒对肝硬化门脉系统血流动力学改变的意义

目的观察肝硬化患者门静脉系统血流动力学改变并探讨其对预后的影响.方法用彩色多普勒测量肝硬化腹水、无腹水及上消化道出血患者门静脉和脾静脉内径、血流速度及血流量,同时检测肝功能,并设正常对照组.结果肝硬化患者门静脉、脾静脉内径及血流量大于正常对照组(P＜0.01),门静脉血流速度小于正常对照组(P＜0.01).肝硬化消化道出血组门静脉血流速度小于腹水组和无腹水组(P＜0.05),肝硬化腹水组和消化道出血组门静脉血流量小于无腹水组(P＜0.05),肝硬化消化道出血组脾静脉血流速度大于无腹水组及腹水组(P＜0.01).结论脾静脉血流量的增多是导致门静脉高压的重要原因之一,并导致肝功能预后不良,脾静脉血流速度增快的肝硬化患者容易并发上消化道出血.