Splenectomy: indications, hazards and alternatives

Influences of Anatomorphological Features of the Portal Venous System on Postsplenectomy Hemodynamic Characteristics in Patients With Portal Hypertension: A Computational Model-Based Study

Splenectomy, as an effective surgery for relieving complications caused by portal hypertension, is often accompanied by a significantly increased incidence of postoperative thrombosis in the portal venous system (PVS). While the underlying mechanisms remain insufficiently understood, the marked changes in hemodynamic conditions in the PVS following splenectomy have been suggested to be a potential contributing factor. The aim of this study was to investigate the influences of the anatomorphological features of the PVS on hemodynamic characteristics before and after splenectomy, with emphasis on identifying the specific anatomorphological features that make postoperative hemodynamic conditions more clot-promoting. For this purpose, idealized computational hemodynamics models of the PVS were constructed based on general anatomical structures and population-averaged geometrical parameters of the PVS. In the models, we incorporated various anatomorphological variations to represent inter-patient variability. The analyses of hemodynamic data were focused on the spatial distribution of wall shear stress (WSS) and the area ratio of wall regions exposed to low WSS (ALS). Obtained results showed that preoperative hemodynamic conditions were comparable among different models in terms of space-averaged WSS and ALS (all were small) irrespective of the considerable differences in spatial distribution of WSS, whereas, the inter-model differences in ALS were significantly augmented after splenectomy, with the value of ALS reaching up to over 30% in some models, while being smaller than 15% in some other models. Postoperative ALS was mainly determined by the anatomical structure of the PVS, followed by some morphogeometrical parameters, such as the diameter and curvature of the splenic vein, and the distance between the inferior mesenteric vein and splenoportal junction. Relatively, the angles between tributary veins and trunk veins only had mild influences on ALS. In addition, a marked increase in blood viscosity was predicted after splenectomy, especially in regions with low WSS, which may play an additive role to low WSS in initiating thrombosis. These findings suggest that the anatomical structure and some morphogeometrical features of the PVS are important determinants of hemodynamic conditions following splenectomy, which may provide useful clues to assessing the risk of postsplenectomy thrombosis based on medical imaging data.

Partial Splenic Embolization Is a Safe and Effective Alternative in the Management of Portal Hypertension in Children

OBJECTIVE

There are multiple approaches to manage the clinical complications of portal hypertension (PHTN) to treat/prevent spontaneous hemorrhage by mitigating thrombocytopenia. No single approach is ideal for all patients given the heterogeneity of this population. Our goal was to determine whether partial splenic embolization (PSE) was safe and effective in the pediatric population.

METHODS

This is a retrospective review of our single-center experience for all patients ages 0 to 21 who underwent PSE between January 2010 and August 2017. The embolized splenic volume targeted was 60% to 70%.

RESULTS

Twenty-six patients underwent PSE due to thrombocytopenia and/or recurrent variceal bleeding. Patients ranged in age from 18 months to 20 years (mean 13.1 years). The median platelet count before PSE was 53.0 (×10/L). The platelet count improved after PSE with values >100,000 in 21 patients (80.8%). Children with prior esophageal varices showed improvement after PSE with only 9 (34.6%) requiring further endoscopic therapy. After PSE, patients developed transient abdominal pain, distention, fever, and perisplenic fluid collections. Serious complications such as splenic abscess, splenic rupture, bleeding, pancreatic infarction, opportunistic infection, or death were not observed. One patient experienced thrombotic complications after PSE and was later diagnosed with myelodysplastic syndrome.

CONCLUSIONS

PSE is a safe and effective alternative in the management of pediatric PHTN in select populations. PSE may be a favorable alternative to splenectomy and portal systemic shunting because it preserves functional spleen mass and avoids postprocedure accelerated liver disease or encephalopathy.

Efficacy and safety of partial splenic embolization for hypersplenism in pre- and post-liver transplant patients: A 16-year comparative analysis

PURPOSE

To report the effect of partial splenic embolization (PSE) on hematological indices and the procedure's safety in pre- and post-liver transplant (LT) patients.

MATERIALS AND METHODS

A single-center retrospective study evaluating all patients who underwent PSE over a 16-year period was performed. Inclusion criteria were splenomegaly confirmed by imaging and at least one of the following cytopenias: hemoglobin ≤10 g/dL, WBC count ≤1500 μL^-1, or platelet count ≤100,000 μL^-1. 38 of 102 patients (37%) met criteria (24 pre- and 14 post-LT) for a total of 40 PSEs.

RESULTS

No effect was seen on median hemoglobin beyond 2 weeks post-PSE. There was a significant and sustained increase in median WBC counts (from 3400 μL^-1 to 5400 μL^-1 at 2 years) and platelet count (from 65,000 μL^-1 to 117,000 μL^-1 at 3.5 years). In 6 out of 40 PSEs (15%) a major complication occurred which included pleural effusion, ascites, spontaneous bacterial peritonitis, pneumonia, and inferior vena cava thrombus. Similar efficacy was observed in pre- and post-LT cohorts, with a trend toward higher complication rate in pre-LT patients.

CONCLUSIONS

PSE is efficacious in increasing WBC count out to 2 years and platelet count out to 3.5 years in patients with hypersplenism. Efficacy and safety appeared independent of pre- or post-LT status. The intervention is associated with major complications and special care should be taken when selecting patients for PSE.

Effects of inferior splenic lobe pole fixation and gastrosplenic peritoneal membrane section on the vitality of the remanent of subtotal splenectomy in rats

PURPOSE

To investigate the vitality of the spleen lower pole after subtotal splenectomy with suture to the stomach and after posterior peritoneal gastro-splenic membrane section, using macro and microscopic evaluations.

METHODS

Sixty Wistar rats were used in this study and were randomly distributed in the three groups: Group 1: (n=20), subtotal splenectomy with lower pole preservation, Group 2: (n=20) subtotal splenectomy with lower pole preservation and suture to the stomach, Group 3: subtotal splenectomy with lower pole preservation and posterior peritoneal gastrosplenic ligament section. The animals were sacrificed 45 days after the surgery and the spleen lower poles were removed for macroscopic and microscopic examination.

RESULTS

All animals in this series survived. No macroscopic differences were encountered between the groups. Microscopic evaluation observed statistic difference concerning fibrosis between group 1 and 3 (p ≤ 0.05), but the analysis for necrosis and inflammation presented no differences.

CONCLUSION

Vitality of the spleen lower pole after subtotal splenectomy is minimally modified when it is fixed to the stomach or when the posterior peritoneal gastrosplenic ligament is resected.

Splenic injury: diagnosis and management

Better understanding of the dual functionality of the spleen has led to a conservative approach to splenic trauma. With accurate assessment and vigilant clinical examination up to two thirds of splenic injuries can be managed expectantly; when surgery is unavoidable, splenic preserving techniques may be used to maintain function.

Pattern of splenectomy indications in kashan shahid-beheshti hospital: a 5-year study

BACKGROUND

The spleen is amongst the most vulnerable organs which are easily injured in abdominal trauma. Nowadays, blunt trauma is the most prevalent indication of splenectomy.

OBJECTIVES

We conducted this study to determine the pattern of indications for open splenectomies carried out during the past five years in Shahid-Beheshti hospital, a central hospital in Kashan, Iran.

PATIENTS AND METHODS

Demographic data of all patients who had undergone an open splenectomy in Kashan Shahid-Beheshti hospital during the past five years (2007-2012), indications for this type of surgery and outcome of patients were collected and entered into the study.

RESULTS

During the study period, the data from a total of 99 open splenectomies were entered in our study. Sixty-eight (68.7%) patients were male and 31 (31.1%) female. The mean age was 31.64 years, 75.8% of the cases had indications of trauma and 24.2% were elective. The most prevalent indication for trauma was motor-bike rider accidents and for elective ones portal hypertension.

CONCLUSIONS

Most cases of splenectomy in our center caused by trauma, and among the different types of trauma, blunt trauma is the dominant cause. Road traffic accidents, in particular motor vehicle accidents, especially motorbike injures, are the most frequent cause of splenectomy. Due to the instability of trauma patients, a mortality rate of 8% seems to be reasonable for splenectomy. We recommend that more research be conducted in this area and more cases enrolled with a reasonable follow-up period for splenectomy complications in this study.

Non-operative management of malarial splenic rupture: the Khartoum experience and an international review

Malarial splenic rupture (MSR) occurs in a subset of patients and can be an acute surgical emergency. MSR is a well-known entity for more than 100 years, yet there are no well-structured studies in the literature that systematically evaluate this complication. While it has become increasingly recognized that splenic salvage can be vital to the long term immunity and health of these patients, there are few data to guide a safe approach to non-operative management of these patients. Current knowledge of spontaneous rupture of the spleen has been gained largely though reported cases. We present 2 cases of MSR and a review of the literature of the management of MSR. We present an algorithm for the management of MSR. Of the 60 cases of MSR in the literature 31 were managed with splenectomy, 21 were managed non-operatively, and 8 early deaths occurred during initial presentation. The most common presenting symptoms were fever (67%) and abdominal pain (51%). Seventy-two percent of patients were hypotensive and tachycardic on presentation. Fifteen (71%) of 21 patients had successful non-operative management for MSR. Of the six patients that failed non-operative treatment, 4 patients eventually needed splenectomy, and 2 patients died without operation. We recommend that patients presenting with fever, abdominal pain, hypotension, and spenomegaly receive urgent resuscitation, ultrasonography (where available) to evaluate for blood in the abdomen, and surgical consultation. Patients who are hemodynamically stable before or after resuscitation can be selectively chosen for non-operative management.

Clinical efficacy of organ-preserving pancreatectomy for benign or low-grade malignant potential lesion

The clinical usefulness of organ-preserving pancreatectomy is not well established due to technical difficulty and ambiguity of functional merit. The purpose of this study is to evaluate the clinical efficacy of organ-preserving pancreatectomy such as duodenum-preserving resection of the head of the pancreas (DPRHP), pancreatic head resection with segmental duodenectomy (PHRSD), central pancreatectomy (CP) and spleen-preserving distal pancreatectomy (SPDP). Between 1995 and 2007, the DPRHP were performed in 14 patients, the PHRSD in 16 patients, the CP in 13 patients, and the SPDP in 45 patients for preoperatively diagnosed benign lesions or tumors with low-grade malignant potential. The clinical outcomes including surgical details, postoperative complications and long-term functional outcomes were compared between organ-preserving pancreatectomy and conventional pancreatectomy group. Major postoperative complications constituted the following: bile duct stricture (7.1% [1/14]) in DPRHP, delayed gastric emptying (31.2% [5/16]) in PHRSD, pancreatic fistula (21.4% [3/14]) in CP. There were no significant differences in postoperative complications and long-term functional outcomes between two groups. Organ-preserving pancreatectomy is associated with tolerable postoperative complications, and good long-term outcome comparing to conventional pancreatectomy. Organ-preserving pancreatectomy could be alternative treatment for benign or low-grade malignant potential lesion of the pancreas or ampullary/parapapillary duodenum.

Haematological splenectomy. Changing indications and complications

Review of splenectomies carried out for haematological disease over a ten-year period, at a district hospital, shows that the indications for splenectomy have changed substantially over this time. Fewer patients with idiopathic thrombocytopenic purpura now require splenectomy, however its role in the management of lymphoproliferative disorders has expanded. Splenectomy remains an important therapeutic option for a range of haematological disorders: this series shows it to be a safe and effective operation in selected patients, although it is not without both short and long-term sequelae.

Esplenectomia parcial para tratar hemangioma esplênico

Apesar de a esplenectomia ser eficaz na abordagem terapêutica de pacientes com hemangioma esplênico, esse procedimento é acompanhado de elevada morbidade e até mortalidade, principalmente devido à sepse, quando realizado em crianças e adolescentes com sistema imunitário ainda imaturo. Para prevenir os efeitos adversos da asplenia, propõe-se neste artigo a esplenectomia parcial, com a retirada apenas da região do hemangioma, mantendo o restante do baço e preservando suas importantes funções.

The impact of splenectomy on outcomes after distal and total pancreatectomy

Background

Several authors advocate spleen preserving distal pancreatectomy, because of the increased complication rate after splenectomy.

Methods

Postoperative complications and survival after distal and total pancreatectomy, were recorded and retrospectively analyzed according to spleen preservation. Patients, who underwent distal and total pancreatectomy without histologically proven adenocarcinoma, or extrapancreatic disease, were included in the cohort which was divided into splenectomy and no splenectomy groups. Statistical analysis was performed using Fisher's test.

Results

The study group consisted of 62 patients who underwent distal and total pancreatectomy between 26/11/1987 to 6/1/2006. Splenectomy was performed in 35 out of 62 patients (56.5%), distal pancreatectomy was performed in 49 out of 62 patients (79%). Morbidity rate was 28.6% in splenectomy group and 14.8% in the no splenectomy group (p = 0.235), while 30 days mortality rate was 2.9%; one patient died in the splenectomy group (p = 1).

Conclusion

Spleen-preservation did not influence the outcomes after distal and total pancreatectomy in our series.

Subtotal splenectomy preserving the lower pole in rats: technical, morphological and functional aspects

PURPOSE: To assess the possibility of preserving the lower pole of the spleen, supplied by the inferior lobar vessels and segmental vessels, or by vessels of the gastrosplenic ligament, in subtotal splenectomy; to study the viability and function of the lower pole of the spleen. METHODS: Thirty-six male Wistar rats were used in this study. Said animals weighed 273-390 g ( 355.2 ± 30.5 g ), and were randomly distributed into three groups. Group 1 comprised ten animals which were submitted to exploratory laparotomy with spleen manipulation (sham operation). Group 2 comprised 16 animals which were submitted to total splenectomy. Group 3 comprised ten animals which were submitted to subtotal splenectomy, preserving the lower pole of the spleen. Blood was collected from all animals before and 90 days after surgery to measure the levels of cholesterol and triglycerides. The animals were sacrificed 90 days after surgery. Spleens and remaining spleens were removed for macroscopic and microscopic examination. RESULTS: Surgery was performed with no complications in all groups. Six animals died in group 2. Spleens of groups 1 and 2, and lower poles of group 3 were macroscopically viable. Apparent white pulp hyperplasia was observed in group 1. In group 3, slight inflammation and capsular fibrosis were observed at the incision site, as well as diffuse hemosiderosis in the red pulp. Average mass of remaining spleen was 35.84% ± 4.31%. No significant difference was observed between preoperative and late postoperative lipid levels in groups 1 and 3 (p > 0.05). Late postoperative lipid levels significantly increased in group 2. CONCLUSIONS: Preservation of the lower pole of the spleen (supplied by gastrosplenic vessels or inferior lobar vessels and segmental vessels) was possible with subtotal splenectomy. The lower pole was macroscopically and microscopically viable in all cases. Subtotal splenectomy preserving the lower pole prevented changes in lipid levels, which were observed in rats submitted to total splenectomy. Plasma lipid levels in rats submitted to subtotal splenectomy were similar to those observed in sham operated rats.

Late follow-up of patients submitted to subtotal splenectomy

BACKGROUND

Over the past 21years, we have performed more than 200 subtotal splenectomies, in which the upper splenic pole vascularized only by the gastrosplenic pole vascularized only by the gastrosplenic vessels is preserved, to treat different pathologic conditions. A meticulous follow-up of the postoperative results of this procedure is of fundamental importance.

METHODS

All patients undergoing subtotal splenectomy were invited to be reviewed. A total of 86 patients who had undergone surgery 1-20years ago were gathered; the surgical procedure was performed for one of the following conditions: portal hypertension due to schistosomiasis (n=43), trauma (n=31), Gaucher's disease (n=4), myeloid hepatosplenomegaly due to myelofibrosis (n=3), splenomegalic retarded growth and sexual development (n=2), severe pain due to splenic ischemia (n=2) and pancreatic cystadenoma (n=1). Patients underwent a hematological examination, an immunological assessment, abdominal ultrasonography, computed tomography, scintigraphy and endoscopy.

RESULTS

Increased white blood cell count and platelets were the only hematological abnormalities. No immunological deficit was found. Esophageal varices were still present in patients who underwent surgery because of portal hypertension although without rebleeding. The ultrasound, tomography and scintigraphy examinations confirmed the presence of functional splenic remnants without significant size alteration.

CONCLUSIONS

Subtotal splenectomy seems to be a safe procedure that can be useful in treating conditions involving the spleen. The functions of the splenic remnants are preserved during long periods of time.

Late postoperative follow-up of patients undergoing subtotal splenectomy

PURPOSE

Over the past 21 years, we have performed more than 200 subtotal splenectomies, in which the upper splenic pole vascularized only by the gastrosplenic pole vascularized only by the gastrosplenic vessels is preserved, to treat different pathologic conditions. A meticulous follow-up of the postoperative results of this procedure is of fundamental importance.

METHODS

All patients undergoing subtotal splenectomy were invited to be reviewed. A total of 86 patients who had undergone surgery 1 to 20 years ago were gathered; the surgical procedure was performed for one of the following conditions: portal hypertension due to schistosomiasis (n = 43), trauma (n = 31), Gaucher's disease (n = 4), myeloid hepatosplenomegaly due to myelofibrosis (n = 3), splenomegalic retarded growth and sexual development (n = 2), severe pain due to splenic ischemia (n = 2) and pancreatic cystadenoma (n = 1). Patients underwent a hematologic exam, an immunologic assessment, abdominal ultrasonography, computed tomography, scintigraphy and endoscopy.

RESULTS

Increased white blood cell count and platelets were the only hematological abnormalities. No immunologic deficit was found. Esophageal varices were still present in patients who underwent surgery because of portal hypertension although without rebleeding. The ultrasound, tomography and scintigraphy exams confirmed the presence of functional splenic remnants without significant size alteration.

CONCLUSIONS

Subtotal splenectomy seems to be a safe procedure that can be useful in treating conditions involving the spleen. The functions of the splenic remnants are preserved during long periods of time.

Long-term efficacy of partial splenic embolization in children

PURPOSE

To elucidate the role of partial splenic embolization (PSE) procedures, long-term outcome was assessed in terms of the recurrence of thrombocytopenia.

METHODS

A retrospective study was performed after 41 PSE procedures in 36 patients for hypersplenism owing to portal hypertension. The underlying disease was biliary atresia in 32 patients, extrahepatic portal obstruction in 3, and idiopathic cirrhosis in 1.

RESULTS

The average volume embolized was 70.1%. The patients were followed up from 20 days to 182 months (average, 70.8 months). Five patients subsequently died, and 6 underwent liver transplantation. The causes of death or the reasons for liver transplantation were not related to hypersplenism. Eleven patients (30.6%) had recurrence of thrombocytopenia (<100,000/mm3). There was no significant difference in the volume embolized or platelet count before PSE between the patients with and without recurrence of thrombocytopenia. The peak value of platelet count after PSE was significantly lower in the patients with recurrence of thrombocytopenia (P =.0091). In 17 of 24 survivors without liver transplantation, platelet counts remained normal throughout the follow-up period.

CONCLUSIONS

PSE is a safe and effective procedure. Hematologic indices improved in all 36 patients after PSE, and its long-term efficacy was shown in 70% of the survivors.

[Splenectomy technic]

Splenectomy has been performed in trauma in a number of benign lesions of the spleen and in a certain haematological diseases. When performed for trauma a luxation technique of splenectomy is applied since it allows quick haemostasis. When performed in other indications, the spleen is usually enlarged. In those patients "splenectomy in situ" is recommended. That means, first, division of the short gastric vessels and gastrosplenic ligament, second, ligation of the splenic artery and finally division of the hilar vessels after which the spleen may be simply removed. Details of operative technique, management of accessory spleens and prevention of operative complications are described.

Aderência e atividade microbicida de monócitos em portadores de esquistossomose mansônica na forma hepatoesplênica cirúrgica

A cirurgia nas crianças portadoras de esquistossomose mansônica inclui esplenectomia, ligadura da veia gástrica esquerda e o auto-implante de tecido esplênico no omento maior. A eficácia desse procedimento pode ser responsável pelo desaparecimento da sepse fulminante pós-esplenectomia (SFPE) neste tipo de paciente. Esta condição é atribuída à diminuição de IgM, de linfócitos circulantes, de properdina e ausência de tuftsina, o que conduz a deficiência da atividade das células macrófágicas, que são responsáveis pela aderência à bactéria, fagocitose e destruição das mesmas. OBJETIVO: Analisar os aspectos funcionais dos monócitos destes pacientes, operados quando crianças, no Serviço de Cirurgia Geral da Criança do Hospital das Clínicas da UFPE, entre 1991 a 2000. MÉTODOS: Foram analisados os índices de aderência in vitro dos monócitos e a geração do ânion superóxido (O2-), em três grupos. O 1º, auto-implante (AI), constituído por 18 portadores de esquistossomose mansônica na forma hepatoesplênica, submetidos a esplenectomia, ligadura da veia gástrica esquerda e auto-implante de tecido esplênico no omento maior; o 2º, (ESP), formado por nove pacientes similares, submetidos a esplenectomia e desconexão ázigo-portal, e o 3º,(CT), constituído por 12 adolescentes sadios, oriundos da mesma condição sócio-econômica-geográfica. RESULTADOS: Não houve diferença no índice de aderência entre os três grupos. Os monócitos dos pacientes do grupo AI tiveram a geração de O2- semelhante à dos indivíduos do grupo CT, e significantemente maior do que os pacientes do grupo ESP. CONCLUSÕES: Os monócitos dos portadores de esquistossomose hepatoesplênica submetidos a esplenectomia, ligadura da veia gástrica esquerda e auto-implante de tecido esplênico no omento maior se mostram funcionalmente similares aos de indivíduos normais da mesma condição sócio-econômica-geográfica.

Dexon Mesh Splenorrhaphy for Intraoperative Splenic Injuries

The preferred management option for intraoperative splenic injuries is organ repair and preservation rather than splenectomy given the important immunologic function of the spleen. Wrapping the injured spleen with a Dexon mesh has been shown to be an effective alternative to splenectomy for significant splenic bleeding. However, this technique uses a foreign body that carries a theoretical infectious risk particularly in cases in which the alimentary tract has been opened. This study was undertaken to evaluate whether Dexon mesh splenorrhaphy when used for intraoperative splenic injuries was associated with significant infectious complications. The clinical courses of 23 patients who had Dexon mesh splenorrhaphy performed at a university teaching hospital for intraoperative splenic injury from 1991 to 1999 were reviewed. Eleven patients (48%) had their gastrointestinal tract opened during the surgery. No patients developed an intra-abdominal abscess or required reoperation for bleeding. The most common postoperative complications were left lower lobe atelectasis (18 patients, 78%), postoperative fever (13 patients, 56%), and left pleural effusion (12 patients, 52%). Dexon mesh splenorrhaphy effectively controls splenic bleeding due to intraoperative injury without significant infectious complications.

Laparoscopic pancreatic surgery in patients with chronic pancreatitis

BACKGROUND

In recent years, technological advances and technical refinements to laparoscopic instruments have encouraged some surgeons to explore the application of laparoscopic methods to benign disorders of the pancreas. The aim of this report was to evaluate the feasibility and outcome of laparoscopic pancreatic surgery in patients with chronic pancreatitis.

METHODS

One group of five patients with disease of nonalcoholic origin localized in the body-tail of the pancreas underwent distal pancreatectomy with preservation of the splenic vessels; a second group of six patients with symptomatic pancreatic pseudocysts (alcoholic origin in four cases and idiopathic in two cases) underwent laparoscopic transgastric drainage. For distal pancreatectomy and spleen salvage, the patient's positioning was half-lateral decubitus with the left side up. Four ports were used. A comparison was made with 41 patients with chronic, pancreatitis who underwent conventional open distal pancreatectomy. For the patients with laparoscopic distal pancreatectomy, the mean operative time was 4 h (range 3-5).

RESULTS

There were no pancreatic-related complications, but one patient was reoperated for perforation of duodenal ulcer. The mean hospital stay was 6 days and the mean time to resume normal daily activities was 3 weeks. Laparoscopic pseudocyst drainage was performed in four patients via laparoscopic anterior gastrostomy and two patients via laparoscopic intraluminal cystogastrostomy. The mean operative time was 100 min (range 60-160). There was no morbidity. The mean hospital stay was 5 days, and the mean time to resume normal daily activities was 2 weeks.

CONCLUSION

This study provides information about the possibilities of performing laparoscopic surgery in patients with chronic pancreatitis. Laparoscopic distal pancreatectomy with preservation of the splenic vessels and laparoscopic transgastric drainage are feasible and safe techniques. They offer obvious advantages, such as reduction of the parietal damage to the abdomen, a shorter hospital stay, and an earlier postoperative recovery than can be obtained with conventional open pancreatic resection.

Nonoperative treatment of splenic rupture in malaria tropica: review of literature and case report

In many parts of the world malaria still is a major medical problem. Heavy international and transcontinental traveling carries malaria to non-endemic areas. Practicing physicians must be aware of the common, but also the rare and severe complications of malaria. During malaria changes in splenic structure can result in asymptomatic enlargement or complications such as hematoma formation, rupture, hypersplenism, ectopic spleen, torsion, or cyst formation. An abnormal immunological response may result in massive splenic enlargement. Spontaneous rupture of the spleen is an important and life threatening complication of Plasmodium vivax infection, but is rarely seen in Plasmodium falciparum malaria. The ability to properly diagnose and manage these complications is important. Spleen-conserving procedures should be the standard whenever possible especially in patients with a high likelihood of future exposure to malaria.

Risk of infection and death among post-splenectomy patients

OBJECTIVES

The true incidence of post-splenectomy sepsis remains undetermined.

METHODS

An English literature review on post-splenectomy sepsis was undertaken by means of databases of MEDLINE for the period 1966-96. The data registered included age at splenectomy, indication for splenectomy, incidence of infection and death, interval between splenectomy and infection, and microbial aetiology.

RESULTS

The reports include 19 680 patients having undergone splenectomy with a median follow up of 6.9 years. The incidence of infection after splenectomy was 3.2% and the mortality rate was 1.4%. Only 6942 reports were sufficiently detailed to allow useful analysis. The incidence of infection among children and adults was similar, 3.3% and 3.2%, respectively. However, the death rates among children were higher than adults (1.7% vs. 1.3%). The incidence of infection was highest among patients with thalassemia major (8.2%), and sickle-cell anaemia (7.3%). The highest mortality rates were observed among patients with thalassaemia major (5.1%), and sickle-cell anaemia (4.8%).

CONCLUSION

The incidence of sepsis among post-splenectomy patients is low, however, it carries a high mortality rate especially among children with hematological disorders.

Splenic complications of the sickling syndromes and the role of splenectomy

PURPOSE

To analyze the authors' experience with splenectomy for sickling disorders and evaluate the indications, complications, and outcome.

PATIENTS AND METHODS

Over a period of 10 years (1987-1997), 113 patients with sickling disorders (100 with sickle cell disease and 13 with sickle-beta-thalassemia) had splenectomy at the authors' hospital as part of their management. The indications for splenectomy were hypersplenism (26 patients), major splenic sequestration crisis (MSSC) (23 patients), minor recurrent splenic sequestration crisis (MRSSC) (50 patients), splenic abscess (12 patients), and massive splenic infarction (2 patients).

RESULTS

Splenectomy in patients with sickle cell disease (SCD) and sickle-beta-thalassemia (S-beta-Thal) was beneficial in reducing their transfusion requirements and its attendant risks, eliminating the discomfort from mechanical pressure of the enlarged spleen, and avoiding the risks of acute splenic sequestration crisis. It also was curative for patients with splenic abscess and massive splenic infarction. Twenty-four patients with SCD (24%) had splenectomy and cholecystectomy caused by concomitant gallstones. There was no mortality, and the postoperative morbidity was 7%.

CONCLUSIONS

With careful perioperative management, splenectomy is both safe and beneficial in a select group of patients with SCD and S-beta-Thal.

Splenectomy for hematological diseases: The Qatif Central Hospital experience

BACKGROUND

In the Eastern Province of Saudi Arabia, an area known for various hemoglobinopathies, splenectomy is performed rather frequently. This study is an analysis of our experience with splenectomy performed for various hematological disorders between 1988 and 1997, outlining the indications, complications and outcome.

PATIENTS AND METHODS

This is a retrospective analysis of all patients who had splenectomy at our hospital during this period. One hundred and forty-three patients were treated for various hematological disorders at our hospital. These disorders included sickle cell disease (SCD) (100 patients), sickle ss-thalassemia (S-ss-thal) (13 patients), ss-thalassemia major (15 patients), Hb H disease (3 patients), idiopathic thrombocytopenic purpura (ITP) (5 patients), Gaucherâs disease (2 patients), hereditary spherocytosis (1 patient), autoimmune hemolytic anemia (1 patient), thalassemia intermediate (2 patients) and chronic myeloid leukemia (1 patient).

RESULTS

The indications for splenectomy in those with SCD and S-ss-thal were: hypersplenism (26 patients), major splenic sequestration crisis (23 patients), minor recurrent splenic sequestration crisis (50 patients), splenic abscess (12 patients), and massive splenic infarction (2 patients). Splenectomy in these patients was beneficial in reducing their transfusion requirements and its attendant risks, eliminating the discomfort from mechanical pressure of the enlarged spleen, avoiding the risks of acute splenic sequestration crisis, and managing splenic abscess. For those with thalassemia, total splenectomy was beneficial in reducing their transfusion requirements, while partial splenectomy was beneficial only as a temporary measure, as regrowth of splenic remnant in these patients subsequently led to increase in their transfusion requirements. Those with ITP, hereditary spherocytosis, and autoimmune hemolytic anemia showed excellent response following splenectomy. There was no mortality, and the postoperative morbidity was 5.6%.

CONCLUSION

With careful perioperative management, splenectomy is both safe and beneficial in a selected group of patients with hematological diseases.

Value of splenic preservation during distal pancreatectomy for chronic pancreatitis

BACKGROUND

Pain relief after distal pancreatectomy for chronic pancreatitis is reportedly satisfactory in 50-80 per cent of patients. This study attempted to determine clinical and radiological features that might select patients likely to benefit from distal pancreatectomy, and whether splenic preservation influenced the outcome.

METHODS

Thirty-eight patients with chronic pancreatitis, who underwent distal pancreatectomy between 1982 and 1998, were reviewed retrospectively. The outcome of surgery was correlated with the aetiology of pancreatitis and radiological appearance on endoscopic retrograde cholangiopancreatography and computed tomography.

RESULTS

Good results were achieved in 23 of 36 patients for whom follow-up (median 48 months) was available, including all 11 with obstructive pancreatitis. The spleen was preserved in 22 patients. Twelve patients became diabetic after surgery: three of 20 in whom the spleen was preserved and nine of 16 who underwent splenectomy.

CONCLUSION

Non-alcoholic patients with a normal pancreas proximal to a dominant ductal stricture had a consistently good outcome from surgery. Spleen-preserving distal pancreatectomy, although technically demanding, can be performed safely with results equivalent to those of distal pancreatectomy with splenectomy or autotransplantation. Splenic preservation, apart from preventing postsplenectomy sepsis, might also delay the onset of diabetes.

Protective procedures following splenic rupture

The aim of the present study was to improve spleen-preserving procedures in patients undergoing laparotomy following abdominal trauma. Of a total 288 patients who underwent laparotomy for abdominal trauma in the Fourth General Surgical Department of Hardarpaşa Teaching Hospital between 1989 and 1996, 94 patients with splenic injuries were retrospectively analyzed. The mean age of these 94 patients, 69% whom were male, was 28.9 +/- 3.5 years. Traffic accidents were found to be the major cause of splenic injuries (71.3%) and diagnostic peritoneal lavage was frequently used as a diagnostic tool (58.8%). Grades IV and V splenic injuries were seen in 71 patients (75.4%), all of whom required splenectomy. Omentoplasty with partial splenectomy or omentoplasty with splenorrhaphy successfully controlled hemorrhage from the spleen in 22 patients (23.4%). The complication rate was calculated at 18.06% in this study, but no deaths occurred as a direct result of splenic injury. In conclusion, omentoplasty, partial splenectomy, and splenorrhaphy are safe and successful methods of controlling bleeding from a damaged spleen of grade III in patients without multiple injuries.

Is there a place for central pancreatectomy in pancreatic surgery?

Tumors located in the neck of the pancreas that are not small and superficial enough to be enucleated are usually resected with a pancreaticoduodenectomy or left splenopancreatectomy. Such operations may cause digestive disorders, glucose intolerance, and late postsplenectomy infection. Central pancreatectomy is a segmental resection whereby the cephalic stump is sutured and the distal stump anastomosed with a Roux-en-Y jejunal loop. The purpose of this study was to evaluate whether central pancreatectomy has a place in pancreatic surgery. Thirteen patients with the following tumors underwent central pancreatectomy: five endocrine tumors, one mucinous and six serous cystadenomas, and one solid cystic-papillary tumor. Mean operative time was 250 minutes. Operative mortality was zero. Complications occurred in three patients (23%). At mean follow-up of 68 months, no recurrences were found. Postoperative oral glucose tolerance, pancreolauryl, and fecal fat excretion tests were normal in all patients. We believe that central pancreatectomy does have a place in pancreatic surgery; it is a reliable technique for benign or low-grade malignant tumors and has a surgical risk similar to that of standard operations. Its principal advantage is that it preserves pancreatic parenchyma and the anatomy of the upper gastrointestinal and biliary tract and the spleen better than pancreaticoduodenectomy or distal pancreatic and splenic resection. (J Gastrointest Surg 1998;2:509-517.)

Overwhelming postsplenectomy infection

The incidence of overwhelming sepsis in asplenic patients is low. It carries, however, an unacceptably high morbidity rate and mortality rate. The risk of development is related to the age of the patient as well as the duration since and the reason for splenectomy. It may also occur in functionally hyposplenic states. The rapidly lethal clinical course demands intense efforts toward prevention by both physician and patient, rapid recognition within the initial medical setting, and aggressive intervention with broad-spectrum antibiotics and other supportive measures.

Conservative surgery for splenic hydatid cyst

Splenectomy has been the treatment of choice for hydatid cyst of the spleen. By successful enucleation of a deep-seated splenic hydatid cyst and preservation of the spleen, the authors show the technical feasibility of such a procedure and recommend it as the treatment of choice.

A new option for splenic preservation in normal sized spleen based on preserved histology and phagocytic function of the upper pole using upper short gastric vessels

Despite the recognized desirability of splenic salvage, forced splenectomy remains the rule in many operative situations, including trauma and pancreatic cancer. An anatomic study was conducted to assess whether the upper short gastric arteries provide sufficient collateral circulation to the spleen that the upper pole could remain viable even when the hilum is resected and the splenic artery and vein no longer intact. The anatomy of the upper short gastric vessels was studied in 59 human spleens and 18 albino rat spleens. Fifty-four human specimens (92%) and 18 (100%) of the rat spleens showed at least 1 upper short gastric artery and 1 vein connecting the fundus of the stomach with the interior of the upper pole of the spleen with no connection to the major hilar vessels. Lower two-thirds splenectomy, which included excision of the hilum of the spleen after ligation of both the splenic artery and vein, was performed on 14 of the 18 rats. The remaining 4 rats served as control animals. The upper pole of the spleen was preserved solely on the upper short gastric vessels that pass directly between the stomach and the interior of the spleen. Structure and macrophage function in the residual splenic tissue was shown to be preserved at 1 hour and 2 weeks postoperatively, based on results of the India ink technique for demonstrating phagocytic function and on results of regular histologic examination. Preservation was attributed to the fact that blood supply for the residual splenic tissue after splenic mass reduction remained adequate through the upper short gastric vessels. Splenic mass reduction is essential to improve perfusion to the residual splenic tissue if excision of the splenic hilum or ligation of the main splenic vessels becomes an operative necessity.

Haemorrhage-induced splenic vasodilation in the rat is mediated by sympathetic vasomotor nerves

A marked decrease in splenic vascular resistance, with an increase in blood flow to the spleen, occurs already 5 min after an acute and severe hypotensive bleeding in awake rats. This response is virtually abolished in rats pretreated with a beta-adrenergic blocking agent. We have now studied the contribution of the sympathetic vasomotor innervation and of adrenal gland-derived catecholamines to the splenic vasodilation. Splenic blood flow was determined with the microsphere method in heavily bled (1.5% of body weight) awake rats. The sympathetic neurones in one group of rats had been chemically destroyed with 6-hydroxydopamine. In another group of rats we had removed the adrenal glands. In the control and in sympathectomized rats, splenic vascular resistance fell to 35 and 64%, respectively, of baseline 5 min after bleeding. Splenic blood flow about doubled during this period in the control rats, and then declined gradually to baseline over the next 24 h. In the sympathectomized rats, splenic blood flow decreased gradually over the first 12 h to reach 66% of baseline. The removal of the adrenal glands did not appreciably influence the splenic vascular response to bleeding. We conclude that an increased activity in the splenic sympathetic vasomotor neurones is a prerequisite for the observed vasodilation and concomitant large increase in splenic blood flow after haemorrhage in intact, awake rats. Catecholamines from the adrenal glands did not contribute detectably to the splenic vasodilation.

Partial splenic embolization in children with hypersplenism

As an alternative to surgical splenectomy, partial splenic embolization was performed in seven children for hypersplenism manifested by splenomegaly, thrombocytopenia, leukopenia, and erythrocyte hemolysis. Within a few days, platelet and leukocyte counts rose significantly in all patients and were maintained in six of seven patients during a follow-up period of 9 to 69 months. Spleen size and abdominal distention also decreased significantly in all children. There were no infectious complications.

Immune restoration in children after partial splenectomy

Splenectomy (SE) is recognized to be a therapeutical approach in treating children with severe autoimmune diseases (chronic idiopathic thrombocytopenia; hemolytic anemia) or hypersplenism because of portal hypertension. Nevertheless, removal of a main immune organ results in elevated infection risk for these patients. Partial splenectomy (PSE) was developed as a therapeutical compromise to retain immunologically active spleen tissue. Here, we document the analysis of immune parameters obtained from children after both partial and total splenectomy, which have been followed up for a period of more than 6 years: (i) Lymphocytes from both groups of patients failed to produce IgG in response to pokeweed mitogen in vitro. This was observed in 11/20 splenectomized patients even 10 years after operation, whereas in PSE patients a restoration of this parameter after 1-2 years was seen. (ii) In patients after PSE, but not in splenectomized persons, an elevated number of HLA-class II positive cells had been detected suggesting a different situation of immune regulation following this operation. However, in parallel with an improvement of B cell in vitro activity this parameter was found to achieve normal values. Our findings indicate that partial splenectomy may be a therapeutical alternative, if the therapeutic goal can be achieved by this procedure.

A simple and safe method for preservation of the injured spleen

A total of 29 patients sustaining closed injuries of the spleen was evaluated after repair of the organ; 11 were children. The injuries were classified as grade II, 5; grade III, 22; and grade IV, 2. The spleens were repaired with figure-of-eight, 0 chromic catgut stitches placed at right-angles to the rupture using a liver needle. A thin layer of Surgicel was placed over the tear and each free side of the stitch. Haemorrhage from the spleen was controlled with this technique in 27 patients. Two patients with grade IV injury underwent ligation of the lower pole vessels and hemisplenectomy combined with patching and suture. Postoperative bleeding occurred in two patients with grade III injury, who then underwent splenectomy. The splenic function after splenorrhaphy was established to be perfect and there were no deaths. This modified technique of repair is a simple and safe method for preservation of the injured spleen.

Prospective study in adults of splenic preservation after traumatic rupture

Seventy-five adults with splenic injury were evaluated prospectively over 45 months to examine the possibility of splenic preservation. Haemodynamically unstable patients underwent surgery with the intent of splenic preservation. Stable patients received non-operative treatment regardless of the grade of splenic injury determined by ultrasonography and computed tomography. Thirty-seven patients required splenectomy and in 38 the organ was preserved (20 operative preservation, 18 non-operative treatment). Of 22 patients initially receiving non-operative treatment, there were four secondary haemorrhages after 7, 7, 10 and 13 days making surgery necessary. Three of these patients underwent splenectomy and in one the spleen was preserved by partial resection. After splenectomy four patients required reoperation because of rebleeding or for evacuation of a haematoma. Patients who had undergone splenectomy had a significantly increased infection rate (P < 0.005) compared with those in whom the spleen was preserved, even when patients were matched with respect to multiple trauma using the Injury Severity Score (P < 0.01).

Marked splenic hyperaemia during post-haemorrhagic hypotension in the rat, rabbit and cat

1. The regulation of the splenic perfusion during normal and pathological conditions is incompletely understood. We studied the time course of splenic blood flow during the initial (0-24 h) development of haemorrhagic anaemia in awake and anaesthetized rats, as well as in awake rabbits and cats. Another group of rats had either normovolaemic anaemia or beginning polycythaemia. 2. The microsphere method was used to measure splenic blood flow. The awake rats were rendered anaemic either by a heavy (1.5% of body weight) or a moderate (0.7% of body weight) bleeding (hypovolaemia), by haemolysis (normovolaemia) or by bleeding (1.5% of body weight) followed by transfusion of autologous plasma (normovolaemia). Polycythaemia was induced with injections of erythropoietin. The anaesthetized rats as well as the awake rabbits and cats were also bled heavily (1.5% of body weight). 3. In awake rats, splenic blood flow increased to 215% of control within the first 5 min after bleeding. The perfusion declined nearly to baseline over the next 24 h. A similar, but less prominent splenic hyperaemia was detected in the awake rabbits and cats. However, this hyperaemic response was not detected in the normovolaemic, the polycythaemic or the anaesthetized and bled rats. 4. Administration of the adrenergic beta-blocking agent propranolol prior to bleeding significantly attenuated the splenic hyperaemia in the awake rats, while the alpha-blocking agent phentolamine or the cholinergic blocking agent atropine had no effect. 5. Concomitant with the initial increase in splenic perfusion, cardiac output increased to 123% of control in the awake, heavily bled rats. In the bled, anaesthetized rats cardiac output decreased to 91% of control 5 min after bleeding. A decrease in cardiac output to 64 and 70% of control was observed in the awake rabbits and cats, respectively. 6. Immediately following the bleeding, we noticed a substantial release of platelets from the rat spleen. 7. It appears that a heavy acute blood loss in awake rats, rabbits and cats elicits a marked reduction in splenic vascular tone, perhaps mediated by beta-adrenergic receptor activity. Anaesthesia abolished this response in rats. Possibly, the induced hypovolaemia triggered an accelerated release of platelets from the rat spleen, dependent on an augmented splenic blood flow.

[Pneumococcus-induced septicemia in normal and splenectomized rabbits]

A new rabbit model to study the consequences of splenectomy in host resistance to induced pneumococcal septicaemia is presented. A simple, fast, non-invasive and complication-free technique of bacterial inoculation into the rabbit airways, using transcutaneous cannulation of the trachea, is also described. Sixteen normal and 24 splenectomised animals were used. The optimal dose of pneumonococcus (serotype B, type III) was found to be 1 x 10(7) organisms. The above dose of bacteria given transtracheally failed to cause signs of pneumonia or death in any of the normal rabbits. However the same dose introduced using the same technique resulted reproducibly in the death of the low-resistance splenectomised animals.

Distal pancreatectomy with and without splenectomy

Splenectomy is performed routinely during distal pancreatectomy, yet the spleen has an important role in host defence and can often be preserved. A personal series of 100 distal pancreatectomies undertaken for pancreatic disease between 1978 and 1990 included 23 patients undergoing total pancreatic resection. The remaining 77 patients, who form the basis of the present report, underwent primary distal pancreatectomy and comprised 34 women and 43 men with a median age of 41 years (range 17-78 years). Conventional distal pancreatectomy including splenectomy was performed in 42 patients (55 per cent) for chronic pancreatitis (34 patients), pancreatic neoplasia (six patients), suspected pancreatitis (one patient) or pancreatitic trauma (one patient). Conservative resection with splenic preservation was performed in 35 patients (45 per cent) for chronic pancreatitis (12 patients), suspected pancreatitis (13 patients, including eight patients with pancreas divisum), pancreatic neoplasia (six patients), recurrent acute pancreatitis (two patients) and pancreatic trauma (two patients). There were no postoperative deaths in either group. Early complications followed conventional resection in 10 patients (24 per cent) and conservative resection in seven patients (20 per cent). In five patients the splenic vessels were ligated away from the splenic hilum and the spleen was left in situ, but subsequent isotope scans and haematological indices showed no hyposplenism. The spleen can safely be preserved in many distal pancreatic resections, including those for inflammatory disease, and we now prefer a retrograde technique for dissecting the pancreas off the splenic vessels.

[Fatal infection after splenectomy despite reimplantation of splenic tissue]

A fatal case of a postsplenectomy sepsis is presented which occurred in a 5-year-old boy 11 month following splenectomy due to trauma and reimplantation of splenic tissue. The patient died 4 h after admission to the hospital. The post mortem revealed an encephalitis and a sepsis although splenic regenerates were found in the omentum pouch. Our report increases the number of cases described to date in the literature to a total of 18. Autologous reimplantation of splenic tissue does not offer complete protection against over-whelming infection.

Splenic injury. An assessment of splenic conservation

Splenic salvage has been undertaken increasingly in the past decade. The optimal method is not determined in adults. Sixty-seven consecutive cases of splenic injury were reviewed during a time of change in management policy. Splenic salvage rose from 10% of cases in 1980-83 to 57% in 1984-88. Treatment by observation resulted in 46% of patients undergoing delayed laparotomy. Injury to other intra-abdominal organs required laparotomy in 23% of patients with multiple injuries. Operative splenic salvage in the adult is feasible and may result in a higher rate of splenic salvage.

Penetrating gastric ulcer as a cause of mixed bacterial and fungal pericarditis

We describe a case of pneumopyopericarditis caused by a mixture of fungal and bacterial pathogens. This originated from a gastric ulcer (within a hiatus hernia) which had eroded into the pericardial sac. Further complications included the late discovery of the ulcer and asplenism. Similar cases have been reported, but to the best of the authors' knowledge, none with an actual mixture of the two pathogens.

Human hybridomas derived from CD5+ B lymphocytes of patients with chronic lymphocytic leukemia (B-CLL) produce multi-specific natural IgM (kappa) antibodies

Great numbers of CD5+ B lymphocytes were detected in the peripheral blood of patients with B-CLL. To study the antibody repertoire of this immune cell subpopulation on a monoclonal level, we fused the lymphocytes derived from five different donors to a highly efficient HAT-sensitive heteromyeloma line (CB-F7). A fusion frequency of up to 10(-5) allowed us to analyse hundreds of initial hybridoma lines per fusion. In all culture supernatants in three out of five fusions IgM lambda antibodies were detected, in two experiments only IgM kappa was measured, suggesting monoclonality of the primary hybridoma cell lines. The later fusions resulted in hybridomas producing multi-specific antibodies against both an autoantigen and an infectious agent: (i) dsDNA/influenza virus haemagglutinin; (ii) dsDNA/class V outer membrane protein type C from Neisseria meningitidis. However, no antibodies of the described specificity were detected in blood sera of patients, indicating a 'switch-on' of the immunoglobulin secretion capacity of malignant B cells during fusion to a myeloma partner. We discuss the results as further evidence for the natural multi-reactive antibody repertoire of CD5+ B cells.

Patient awareness of health precautions after splenectomy

Sepsis after splenectomy is a lifelong risk, and patients who have had splenectomy should be educated about this risk. This study examines patient knowledge after splenectomy. We reviewed hospital records of 118 patients who had splenectomies performed between 1982 and 1988 at New Hanover Memorial Hospital. Twenty-four patients have died since their surgery; one death was suspected to be due to postsplenectomy sepsis. Of the 89 patients alive and eligible for follow-up, we were able to query 63. Only 16% were aware of any health precautions. After prompting, patient awareness improved to 40%. We also surveyed 11 of the 14 surgeons who performed the splenectomies. They indicated that they always discuss with their patients the immunologic consequences of spleen removal and the increased risks of infection, although they do not always recommend pneumococcal vaccine. We conclude that splenectomy patients have a low level of knowledge about postsplenectomy infection risks and precautions. We developed an educational pamphlet to aid the surgeon in patient education.