[Splenectomy and reimplantation of splenic tissue in children]

161 splenectomies are presented with a morbidity of 14.8% and a total mortality rate of 4.3%. The lethality rate due to severe infections (-3.9%), however, was high and mostly caused by an overwhelming postsplenectomy sepsis, pneumonia or meningitis. 61.5% of the infections were caused by pneumococcus. To drop that high lethality rate after splenectomy we replanted splenic tissue in seven patients. Scintigraphic investigations showed in all cases well vascularised splenic tissue. The immunoglobulins were in a normal range. Howell-Jolly bodies, however, did not disappear in all the patients. From our study as well as from the literature one has to conclude that replanted splenic tissue requires immunologic activity but a reduced capacity for phagocytosis. Therefore, in cases of traumatic injury to the spleen it is necessary to try to preserve as much of the organ as possible either by infrared coagulation, gluing with human fibrinogen or partial splenectomy. If these procedures are impossible a replantation of--50% of the original splenic tissue should be done and several thin homogenised particles replanted intra- or retroperitoneally. Out of that a preoperative vaccination against pneumococcal infection is necessary as well as a postoperative penicillin prophylaxis for about three years.

Emergency minilaparoscopy in abdominal trauma. An update

In 106 cases of blunt abdominal trauma, the emergency minilaparoscope was used as a diagnostic tool. In 57 patients (53.5 percent), the findings proved to be negative. In 22 patients (20.8 percent), the laparoscopic findings were corroborated by exploration. But, in 27 instances (25.4 percent), minimal to moderate hemoperitoneum was found and the laparoscopic view indicated that these patients could be treated nonoperatively with close observation. None of these patients required subsequent exploration. There were no complications of laparoscopy which required surgical intervention. In our opinion, minilaparoscopy is more diagnostically accurate than lavage. It is a fast and safe examination which can be performed at the bedside with the patient under local anesthesia. The number of unnecessary abdominal explorations in severely injured patients can be reduced to a negligible figure, thus decreasing morbidity, hospitalization time, and costs.

Splenogonadal fusion

A case of splenogonadal fusion of the discontinuous type in a 7-year-old boy is reported. The literature is reviewed and the common clinical features of the malformation are discussed. The condition should be considered in the differential diagnosis of scrotal tumours.

[Vascular segmentation of the spleen in the newborn infant. Anatomical support for partial resection]

Splenic artery moulds were studied from 66 full-term neonates, and the mode of termination in the hilum region and the intraparenchymatous distribution of the splenic artery analyzed. Segmental division of the neonate spleen was found to be similar to that in adults, with 2 (68,2%), 3 (10,6%) or 4 segments (4,5%). However, intersegmental anastomoses were observed in 16,7% of the specimens studied. Vascular morphology indicates that partial resection of the spleen in infants is possible.

Clearance of pneumococcal organisms after repair of injured spleens

Although the safety of splenic preservation has been demonstrated in a small number of cases, the follow-up in these cases has been too short to determine whether the patients are adequately protected from sepsis. The purpose of this study was to test the ability of the spleen to clear pneumococcal organisms after repairing lacerations with a surface hemostatic agent. Three groups of 20 New Zealand white rabbits were studied. Group I animals received sham operations, group II animals were given total splenectomies, and group III animals had splenic lacerations repaired with Collastat (American Medical Products Corp., Freehold, New Jersey), a local hemostatic agent. Three months later, when challenged with intracardiac Streptococcus pneumoni type III, the animals without spleens failed to clear pneumococcal organisms. This spleen-intact and spleen-repaired animals, however, both cleared pneumococcal organisms in a normal fashion.

Preservation of the spleen

Because the spleen can no longer be considered readily dispensable, a variety of alternatives to total splenectomy (splenic repair, partial resection, autotransplantation, ischemic therapy, reticuloendothelial blockade and irradiation) have been developed to preserve functioning remnants in trauma and hypersplenism. It remains unclear how much spleen adequately protects against OPSI or under persistent workload stimulus leads to recurrence of hypersplenism.

[Conservative treatment of injuries of the spleen in children]

Resolutely convinced of the necessity to preserve the spleen in all circumstances, the authors detail the indications and possibilities of non operative management and conservative surgery that allow the injured spleen to be salvaged. Of 55 cases observed from 1978 to 1982, only 22 required splenectomy because of our new experience; 13 of the remaining cases were treated non operatively and 20 had a conservative surgery. It is concluded that unless the child prognosis is directly and immediately involved, by the splenic injury (such cases require splenectomy or better still partial resection) every effort should be made to preserve a traumatized spleen.

Septic sequelae after splenectomy for trauma in adults

Of 619 trauma patients who underwent splenectomy, 503 lived more than 10 days postoperatively. In this group systemic sepsis developed in 114 patients (22.7 percent). The most frequent septic focus was intraabdominal abscess (59 patients). The incidence of postoperative septic complications increased with the severity of trauma. Of the 41 patients who died after the 10th postoperative day, 36 died from sepsis. There were no septic complications or deaths in the 13 patients under age 15 years. Septic morbidity and mortality rates in splenectomized patients were significantly (p less than 0.01) greater than those in 2,368 consecutive trauma patients treated from 1978 to 1979. Long-term follow-up information was obtained in 242 patients. Follow-up encompassed 1,046 patient-years, with a mean patient follow-up interval of 4.4 years. Severe bacterial infections have occurred in six patients (2.5 percent). Thus far there have been no deaths from overwhelming sepsis. Interestingly, 11.5 percent of the patients complained of more severe viral infections after splenectomy. Our data support the concept of preserving the traumatized spleen whenever possible.

[Surgical repair of the spleen in children]

Splenectomy is the easiest solution, and a still widespread surgical approach for the management of traumatic spleen rupture. Nevertheless, the evidence of an increased risk of overwhelming sepsis in splenectomy patients has encouraged the development of techniques for organ repair and conservation. We report on four patients with spleen rupture repaired surgically in our institution. In two of them we performed a splenorrhaphy alone and in the remaining two this was completed with a partial splenectomy. There were no immediate or late postoperative complications. The patients have been followed-up for periods ranging from 1 to 2 1/2 years and all show isotopic evidence of spleen activity in amount related to the remaining organ. We feel that splenic repair and conservation is possible in most cases and must always be given a trial.

[Organ-preserving therapy of splenic injuries in childhood--radiologic and immunologic follow-up studies]

Care of traumatized spleen has undergone an interesting change. In view of the fact that children without spleen are exposed to an increased infection risk, attempts are now directed at preserving the organ. The author's own patients included 9 children whose spleen had been traumatized at an age between 5 4/12 and 11 7/12 years. 4 children were given conservative treatment under intensive care, whereas surgery of the traumatized spleen was performed five times. 7 children were followed up. The changed morphological structure and the immunological situation were factors of particular interest. Depending upon the degree of severity of the injury to the spleen, scars remain in the parenchyma which are of different extension and which are associated with corresponding storage defects. The humoral and cell-promoted immunity is maintained.

Intratesticular transplants of islet xenografts (rat to mouse)

Freshly isolated rat islets were transplanted into the testis of diabetic mice. The intratesticular islet xenografts produced normoglycemia in the diabetic recipients. The survival time of the intratesticular xenografts was significantly longer than intrasplenic, intrahepatic, and renal subcapsular sites of transplantation of xenografts of freshly isolated rat islets. Three of the recipients with intratesticular islet grafts were still normoglycemic at 60 days after transplantation, and orchidectomy resulted in a return to the diabetic state. The findings indicate that the testis provided a more privileged immunologic site than either the spleen, liver, or kidney and the lower temperature of the testis apparently did not affect the function of the islet grafts since the recipients became normoglycemic.

Splenic preservation in adults after blunt and penetrating trauma

This study was carried out to evaluate the possibility and safety of splenic preservation in adults subjected to both blunt and penetrating. In an 18 month period there were a total of 36 splenic injuries studied (in 36 patients): 18 due to blunt trauma, 11 due to gunshot wounds, and 7 due to stab wounds. A total of 18 spleens were repaired: 8 (45 percent) in the blunt trauma group, 4 (36 percent) in the gunshot group, and 6 (85 percent) in the stab wound group. There were no deaths in the entire group nor were there any complications associated with splenic salvage. Splenic preservation after both blunt and penetrating trauma is both safe and feasible in the adult population, except in those instances specified herein.

Characterization of amyloid deposits and P component from a patient with factor X deficiency reveals proteins derived from a lambda VI light chain

Amyloid fibrils were isolated from a spleen obtained at surgery from a 58-year-old white man with primary amyloidosis presenting with factor X deficiency and responding dramatically to splenectomy. Gel filtration on Ultragel ACA 54 in 5 M guanidine 1 M acetic acid yielded components with molecular weights between 17,000 and 13,000. Two of them (17K and 15K) were studied in detail. Antigenic and amino acid sequence analysis showed that these proteins were related to lambda VI immunoglobulin light chain. The predominant protein subunits of the amyloid fibril of the deposits (17K) was processed at the carboxy terminus in the same section of the constant region as the only other lambda VI amyloid protein previously reported. Amino terminal sequence of the 15K protein revealed not only degradation at the C terminal, but also minor degradation at the amino terminal (three residues difference from the 17K species). P component was also isolated from the spleen and characterized. This represents the first antigenic and sequence analysis of tissue amyloid proteins and P component from a patient presenting with factor X deficiency and another example of amyloid proteins derived from the newly discovered amyloidogenic lambda VI light chain subgroup.

[Treatment of nonpenetrating spleen injuries]

On the basis of the experience with the treatment of 100 patients with the ruptured spleen (in 44 of them the injury was associated with injuries of other organs of the abdominal cavity, skeleton bones or cranio-cerebral traumas) the authors recommend to use organ-preserving operations more often (in 42-46% of the patients). A technique of one of the operations--a compression ("hammering") of the spleen by a peritoneum grafts--is described.

[Conservative surgery of the spleen]

Conservative surgery of the spleen only has to overcome certain prejudices to become generally accepted. Today, we are convinced of the essential role of the spleen in the body's anti-infection defence mechanisms and the surgeon now has the means to repair a damaged spleen. We report the simplicity, effectiveness and reliability of three techniques of splenorraphy. Two of these techniques are our own and have been well tested in very extensive animal experiments and in our first clinical applications. Capsular sutures or partial splenectomy can treat the great majority of the lesions seen. When this is not possible, devascularisation of the spleen or autotransplantation of the splenic tissue are simple palliative measures, although there functional value has not been clearly established. The results of this approach are now numerous with adequate follow-up and have revealed no complications, immediate or delayed, inherent in the technique.