Reliability and validity of splenic volume measurement by 3‐D ultrasound

Aim: We prospectively evaluated the reliability and validity of splenic volume with 3‐D ultrasound measurement and clarified its clinical usefulness. Methods: Thirty healthy volunteers and 30 patients with cirrhosis were included in this study. All 3‐D ultrasound examinations of splenic volumes were performed twice by two experienced sonographers with transabdominal ultrasound using virtual organ computer‐aided analysis (VOCAL). Reliability was confirmed among all subjects by evaluating within‐observer repeatability and between‐observer reproducibility using intraclass correlation coefficients (ICC) and Bland–Altman plots. Overall between‐instrument agreement of the measurements and computed tomography (CT) volumetry among cirrhotic patients were performed to determine validity. Results: For all 240 examinations, 3‐D ultrasound visualization and measurement of the spleen volume was possible. Mean spleen volume was 104.0 mL for the volunteers and 283.5 mL for the cirrhotic patients. The repeatability was high, with ICC (95% confidence interval) of 0.996 (0.993–0.997) for observer A and 0.997 (0.994–0.998) for observer B. Moreover, the interobserver ICC was 0.996, indicating high reproducibility. Despite the difference in volume between the volunteers and cirrhotic patients, sensitivity analyses indicated consistent results for both groups. Regarding the validity of the 3‐D ultrasound measurement, it also showed moderate to high agreement with CT volumetry, with mean ICC of 0.922 and 0.924 for observers A and B, respectively. The reliability and validity results from the Bland–Altman plots were similar to those from the ICC, with limits of agreement consistently narrow from a clinically practical view. Conclusion: 3‐D ultrasound measurements using VOCAL are valid and reliable in spleen volume examinations.     

Hyper-reactive Malarial Splenomegaly (HMS) in malaria endemic area in Eastern Sudan

Hyper-reactive Malarial Splenomegaly (HMS) is massive enlargement of the spleen resulting from abnormal immune response to repeated attacks of malaria. The present study was carried out in Kassala city, Eastern Sudan where HMS is considered as highly prevalent. The objectives of this study were to determine the incidence of HMS in Eastern Sudan, and to identify basic laboratory and clinical characteristics of this condition in Sudanese patients. In the period between January and March 2004, a cross-sectional study was carried out in four health centers in Kassala city. In the current study 114 out 1010 (11%) medical cases examined were found to have enlarged spleens, 87 (9%) of them were diagnosed as HMS. Sixty-three percent of HMS cases were males and the rest were females. The mean age of HMS patients was 28 years. Clinical investigations showed that all cases suffered from abdominal pain in the upper left quadrant and all had a palpable firm spleen (10-26cm) below the costal margin. Laboratory examinations showed that 74% of the cases were anaemic and the mean white blood count for all cases was 4237cell/mL(3). Serum concentration of IgM in all subjects was above the threshold of the mean value plus 2 S.D. for 35 asymptomatic controls. In more than 70% of the HMS patients (53 individuals) the spleens were impalpable after the third month of the treatment. Our data indicate that HMS is one of the major causes of tropical splenomegaly in Eastern Sudan.     

Results of laparoscopic splenectomy for treatment of malignant conditions

BackgroundLaparoscopic splenectomy (LS) is widely accepted for treatment of benign diseases, but there are few reports of its use in cases of haematological malignancy. In addition, comparative studies with open operation are lacking. Malignant haematological diseases have specific clinical features-notably splenomegaly and impaired general health-which can impact on the immediate outcome after LS. The immediate outcome of LS comparing benign with malignant diagnoses has been analysed in a prospective series of 137 operations.Patients and methodsBetween February 1993 and April 2000, 137 patients with a wide range of splenic disorders received LS. Clinical data and immediate outcome were prospectively recorded,and age, diagnosis, operation time, perioperative transfusion requirement, spleen weight, conversion rate, accessory incision, hospital stay and complications were analysed.ResultsThe series included 100 benign cases and 37 suspected malignancies. In patients with malignant diseases the mean age was greater (37 years [3–85] vs 60 years [27–82], p<0.0l), LS took longer (138 min [60–400] vs 161 min [75–300], p<0.05) and an accessory incision for spleen retrieval was required more frequently (18% vs 93%, p<0.0l) because the spleen was larger (279 g [60–1640] vs 1210 g [248–3100], p <0.01). However, the rate of conversion to open operation (5% vs 14%), postoperative morbidity rate (13% vs 22%) and transfusion requirement (15% vs 26%) did not differ between benign and malignant cases. Hospital stay was longer in malignant cases (3.7 days [2–14] vs 5 days [2–14], p<0.05).ConclusionLS is a safe procedure in patients with malignant disease requiring splenectomy in spite of the longer operative time and the higher conversion rate.     

Massive blood transfusion and outcome in 1062 polytrauma patients: a prospective study based on the Trauma Registry of the German Trauma Society

BACKGROUND AND OBJECTIVES: About 15% of polytrauma patients receive massive blood transfusion (MBT) defined as > or = 10 units of packed red blood cells (PRBC). In general, the prognosis of trauma patients receiving MBT is considered to be poor. The purpose of this study was to investigate the impact of MBT on the outcome of polytrauma patients. MATERIALS AND METHODS: Records of 10 997 patients in the Trauma Registry of the German Trauma Society were analysed. Transfusion data were available from 8182 severe trauma patients with a mean injury severity score of 24.5 and, of these 8182 patients, 1062 received > or = 10 units of PRBC. First, a logistic regression model for the predictors of mortality was performed. Second, incidences of organ failure and sepsis as well as survival rates were analysed. RESULTS: The highest risk for mortality was age over 55 years (odds ratios [OR] 4.7; confidence intervals [CI 95%], 3.5-6.5) followed by Glasgow Coma Scale < or = 8 (OR 4.6; 3.4-6.1), MBT > or = 20 units of PRBC (OR 3.3; 2.1-5.4), thromboplastin time < 50% (OR 3.2; 2.2-4.4) and injury severity score > or = 24 (OR 2.9; 2.1-4.1). Transfusion of 10-19 PRBC was identified as the variable with the lowest risk for mortality (OR 1.5; 1.0-2.3). Risk of organ failure, sepsis and death correlated with increasing transfusion amount. For the MBT patients, the survival rate was 56.9% (CI 95%, 53.9-59.9%) compared to 85.2% (84.4-86.0%) of non-MBT patients (P < 0.001). In the MBT group with > 30 PRBC (mean 40.6 PRBC) 39.6% survived (31.7-47.5%). CONCLUSION: Massive blood transfusion is one main prognostic factor for mortality in trauma. Although MBT is generally considered to be critical, every second trauma patient with MBT survived. A cut-off value for the number of PRBC could not be determined. Extended transfusion management even with high amounts of PRBC seems to be justified.     

Evaluation of the potassium adsorption capacity of a potassium adsorption filter during rapid blood transfusion

The concentration of extracellular potassium in red blood cell concentrates (RCCs) increases during storage, leading to risk of hyperkalemia. A potassium adsorption filter (PAF) can eliminate the potassium at normal blood transfusion. This study aimed to investigate the potassium adsorption capacity of a PAF during rapid blood transfusion. We tested several different potassium concentrations under a rapid transfusion condition using a pressure bag. The adsorption rates of the 70‐mEq/l model were 76·8%. The PAF showed good potassium adsorption capacity, suggesting that this filter may provide a convenient method to prevent hyperkalemia during rapid blood transfusion.     

Use of splenic volume estimation to distinguish primary thrombocythaemia from reactive thrombocytosis

Splenic volume was measured by visual assessment of planar images of the spleen, and also by single photon emission computerised tomography (SPECT) using 99mtechnetium tin colloid, in a group of 33 patients with primary thrombocythaemia (PT) or reactive thrombocytosis. Volumes greater than 337 cm3 correlated strongly though not absolutely with PT, all patients with volumes greater than this figure being in the PT group. Simple visual assessment of planar images by an experienced observer matched measured splenic volumes very closely.     

Body contouring following massive weight loss

Obesity is a global disease with epidemic proportions. Bariatric surgery or modified lifestyles go a long way in mitigating the vast weight gain. Patients following these interventions usually undergo massive weight loss. This results in redundant tissues in various parts of the body. Loose skin causes increased morbidity and psychological trauma. This demands various body contouring procedures that are usually excisional. These procedures are complex and part of a painstaking process that needs a committed patient and an industrious plastic surgeon. As complications in these patients can be quite frequent, both the patient and the surgeon need to be aware and willing to deal with them.     

Utilisation bénéfique de facteur VIIa recombinant chez deux patients porteurs d’une assistance biventriculaire (Thoratec)

Massive bleeding is a dreaded complication of biventricular mechanical assistance implantation. Its origin is multifactorial. Blood products transfusion associated with correction of coagulopathy are sometimes insufficient. We report two cases of massive bleeding after a Thoratec^® biventricular assistance implantation. After surgical haemostasis failure and despite the correction of coagulation disorders, a major bleeding persisted, so these patients received a single injection of 90 μg/kg of rFVIIa. This allowed in both cases a significant reduction of the bleeding and the restoration of normal haemodynamic conditions. This treatment was not complicated by any thrombotic accident.