Risk of splenic salvage after trauma. Analysis of 200 adults

Autogenic splenic implantation versus splenectomy in patients undergoing distal pancreatectomy for benign or low-grade malignant lesions of the distal pancreas: study protocol for a multicentre, open-label, randomized controlled trial (RESTORE)

BACKGROUND

The spleen plays a significant role in the clearance of circulating microorganisms. Sequelae of splenectomy, especially immunodeficiency, can have a deleterious effect on a patient's health and even lead to death. Hence, splenectomy should be avoided and spleen preservation during elective surgery has become a treatment goal. However, this cannot be achieved in every patient due to intraoperative technical difficulties or oncological reasons. Autogenic splenic implantation (ASI) is currently the only possible way to preserve splenic function when a splenectomy is necessary. Experience largely stems from trauma patients with a splenic rupture. Splenic immune function can be measured by the body's clearing capacity of encapsulated bacteria. The aim of this study is to assess the splenic immune function after ASI was performed during minimally invasive (laparoscopic or robotic) distal pancreatectomy with splenectomy.

METHODS

This is the protocol for a multicentre, randomized, open-labelled trial. Thirty participants with benign or low-grade malignant lesions of the distal pancreas requiring minimally invasive distal pancreatectomy and splenectomy will be allocated to either additional intraoperative ASI (intervention) or no further intervention (control). An additional 15 patients who will undergo spleen-preserving distal pancreatectomy serve as the control group with normal splenic function. Six months postoperatively, after assumed restoration of splenic function, patients will be given a Salmonella typhi (Typhim Vi™) vaccine. The Salmonella typhi vaccine is a polysaccharide vaccine. The specific antibody titres immediately before and 4 to 6 weeks after vaccination will be measured. The ratio between pre- and post-vaccination antibody count is the primary outcome measure and secondary outcome measures include intraoperative details, length of hospital stay, 30-day mortality and morbidity.

DISCUSSION

This study will investigate the splenic immune function of patients who undergo ASI during minimally invasive distal pancreatectomy with splenectomy. The splenic immune function will be measured using the surrogate outcome of specific antibody titre after vaccination with a Salmonella typhi vaccine. The results will reveal details about splenic function after ASI and guide further treatment options for patients when a splenectomy cannot be avoided. It might eventually lead to a new standard of care making sometimes more demanding and time-consuming spleen-preserving procedures redundant.

TRIAL REGISTRATION

International Standard Randomized Controlled Trials Number (ISRCTN) ISRCTN10171587. Prospectively registered on 18 February 2019.

Splenic autotransplantation: a systematic review

BACKGROUND

Splenectomy is a surgical procedure indicated in a variety of medical conditions including trauma. Post-operatively, there is a lifelong risk of developing overwhelming sepsis from encapsulated bacteria, most commonly due to Streptococcus pneumoniae. Splenic autotransplantation has been proposed as a method to recover splenic function in patients requiring splenectomy with otherwise normal spleens. This study aims to systematically review the literature to determine the efficacy of spleen autotransplantation.

METHODS

MEDLINE, PubMed and the Cochrane Library were searched for all studies assessing splenic autotransplantation (January 1947 to July 2018). Data were extracted on study characteristics, outcomes assessed, including spleen scintigraphy results, blood film counts and serum immunoglobulin (Ig) levels.

RESULTS

Data were obtained from 18 primary studies. All studies demonstrated return of regenerated spleen tissue in the majority of their patients (95.3%) on spleen scintigraphy. In 12 studies, 90.2% of patients had blood films return to normal following transplantation. Ig levels were shown to return to normal in all 12 studies where it was assessed. In 11 studies, 3.7% of patients had post-operative complications. In five studies, 1.3% of patients had post-operative infections in the follow-up period.

CONCLUSION

Splenic autotransplantation is a safe procedure with minimal complications that can return splenic filtration function and Ig levels to normal ranges. It has not been confirmed whether autotransplantation provides meaningful protection against overwhelming post-splenectomy infections.

A solution to the negative effects of splenectomy during colorectal trauma and surgery: an experimental study on splenic autotransplantation to the groin area

BACKGROUND

Splenectomy after combined colosplenic trauma or iatrogenic splenic injury during colorectal surgery associates with worse short- and long-term outcomes, including reduced survival in patients with colorectal cancer. Splenic autotransplantation may improve the outcomes of such patients. Omental splenic transplantation is the standard procedure but may be difficult when performing laparoscopic colorectal surgery or when total or subtotal omentectomy is required. This animal model study was performed to evaluate the impact of splenic autotransplantation to the groin area on colonic wound healing.

METHODS

Thirty rats were divided into three groups of ten animals. One group underwent colon anastomosis and sham splenectomy, the second underwent colon anastomosis and splenectomy, and the third underwent colon anastomosis, splenectomy, and intramuscular autotransplantation of the spleen. On postoperative day 7, anastomotic healing was evaluated by measuring bursting pressure and hydroxyproline levels. The third group was subjected to scintigraphy before sacrifice to assess whether the transplant was functional.

RESULTS

The mortality rates of the sham, splenectomized, and transplanted animals were 0 %, 30 %, and 20 %, respectively: the splenectomized animals had significantly lower mean bursting pressures than the other two groups (p = 0.002). The mean hydroxyproline levels of the three groups were 467.4, 335.3, and 412.7 mg hydroxyproline/g protein, respectively (p = 0.0856). Nine of the ten transplanted animals (90 %) had splenic activity on scintigraphy.

CONCLUSIONS

Splenectomy impaired the healing of the colonic anastomosis. This effect was largely reversed by splenic autotransplantation. Intramuscular autotransplantation to the groin area appears to be feasible and effective.

Blunt splenic trauma: Assessment, management and outcomes

BACKGROUND

The approach for diagnosis and management of blunt splenic injury (BSI) has been considerably shifted towards non-operative management (NOM). We aimed to review the current practice for the evaluation, diagnosis and management of BSI.

METHODS

A traditional narrative literature review was carried out using PubMed, MEDLINE and Google scholar search engines. We used the keywords "Traumatic Splenic injury", "Blunt splenic trauma", "management" between December 1954 and November 2014.

RESULTS

Most of the current guidelines support the NOM or minimally approaches in hemodynamically stable patients. Improvement in the diagnostic modalities guide the surgeons to decide the timely management pathway Though, there is an increasing shift from operative management (OM) to NOM of BSI; NOM of high grade injury is associated with a greater rate of failure, prolonged hospital stay, risk of delayed hemorrhage and transfusion-associated infections. Some cases with high grade BSI could be successfully treated conservatively, if clinically feasible, while some patients with lower grade injury might end-up with delayed splenic rupture. Therefore, the selection of treatment modalities for BSI should be governed by patient clinical presentation, surgeon's experience in addition to radiographic findings.

CONCLUSION

About one-fourth of the blunt abdominal trauma accounted for BSI. A high index of clinical suspicion along with radiological diagnosis helps to identify and characterize splenic injuries with high accuracy and is useful for timely decision-making to choose between OM or NOM. Careful selection of NOM is associated with high success rate with a lower rate of morbidity and mortality.

Phagocytic function of lower spleen pole and autogenous splenic implants in rats

PURPOSE

To investigate whether there are differences between the phagocytic function of the remaining lower spleen pole after subtotal splenectomy and autogenous splenic implants.

METHODS

Thirty-six male Wistar rats, weighting 364 ± 60g were used. They were subjected to subtotal splenectomy preserving the lower spleen pole and to autogenous splenic implant in the greater omentum. Its viability was assessed microscopically. Phagocytic function was assessed by splenic uptake of the radioisotope-labeled colloid and by macrophages counting.

RESULTS

The viability of the autogenous splenic implant and of the lower spleen pole was found in 33 animals, with no difference between them. The weight of the implants was higher than the lower pole of animals from groups G1, G7, G30, G60 and G120. The implants phagocytic function by radioisotope uptake was higher than the lower pole in G7 and G120 groups and it did not differ from the other groups. The number of macrophages was higher in G1, G60, G90 and G120 and did not differ from the other groups.

CONCLUSION

Until the 16th week, the phagocytic function was more pronounced in autogenous splenic implants when compared with the lower spleen pole, but it became similar thereafter.

Induction of tolerance in renal transplantation using splenic transplantation: experimental study in a canine model

OBJECTIVE

To evaluate in a canine model the induction of tolerance to renal transplantation after splenectomy and splenosis.

MATERIALS AND METHODS

This prospective, experimental, comparative, longitudinal study included 4 experimental groups, each comprising 4 dogs. Group 1 (control group) underwent renal transplantation only; group 2 underwent renal transplantation and splenectomy; group 3 underwent renal transplantation and splenosis; and group 4 underwent renal transplantation, splenectomy, and splenosis. Survival and degree of rejection were compared between the 4 groups.

RESULTS

Splenosis improved renal function after transplantation, as indicated by increased serum creatinine concentration (group 3, 6.2 mg/dL vs group 1, 12.9 mg/dL). Comparison of weighted survival curves (corrected for degree of rejection) demonstrated a significant difference between group 2 (66.0 days) and group 4 (66.2 days) vs group 1 (52.7 days) and group 3 (41.2 days) (P = .05, Wilcoxon rank sum test).

CONCLUSION

These results suggest that in this experimental model of renal transplantation, splenosis and splenectomy induce clinical tolerance, as indicated by improved renal function and prolonged recipient survival.

Radiographic characteristics of postinjury splenic autotransplantation: avoiding a diagnostic dilemma

BACKGROUND

Splenic autotransplantation after postinjury splenectomy has been advocated to augment the immune response to infection and prevent overwhelming postsplenectomy sepsis. Postoperative computed tomographic (CT) scans in patients undergoing splenic autotransplantation reveal multiple intra-abdominal fluid collections that may appear similar to abscesses. This presents a diagnostic dilemma. In the past, one of our patients underwent percutaneous drainage of such collections that were sterile, and one patient required operative evacuation of infected implants. The purpose of this study was to determine whether there is a characteristic radiographic appearance of splenic implants, whether this appearance changes with time, and whether implants can be differentiated from abdominal abscesses.

STUDY DESIGN

Patients at our Level I trauma center who underwent operative therapy for splenic injury from January 1995 to May 2002 were identified using our trauma registry. Charts were reviewed and CT scans read in a blinded fashion by a radiologist.

RESULTS

During the study period, 505 patients were admitted for splenic trauma. One hundred forty-five patients (29%) required operative intervention for splenic injuries. Splenorrhaphy was performed in 27 patients and splenectomy was required in 118 patients. Twenty-three patients had splenic autotransplantation into the omentum, of whom 11 underwent postoperative CT scanning for clinical suspicion of intra-abdominal abscess. On average, 2.7 scans were obtained per patient, ranging from 4 to 113 days postoperatively. Imaging revealed low-density fluid collections in the anterior abdomen in 10 of 11 patients. Time-related radiographic changes (early rim enhancement and late shrinkage) of the implants were noted, but splenic implants lacked surrounding omental fat stranding or other inflammatory changes typical of an abscess. The patient with infected splenic implants had air bubbles within the fluid collections, a characteristic finding of an abscess.

CONCLUSION

Autotransplanted splenic tissue may resemble an abscess on CT scanning, but splenic implants have distinct and time-related characteristic findings. Recognition of these unique features may allow differentiation of a splenic implant from an abscess, thus avoiding unwarranted intervention.

Bacterial phagocytosis by macrophage of autogenous splenic implant

Autogenous splenic implant seems to be the only alternative for preservation of splenic tissue after total splenectomy. This work was carried out to analyze the morphologic regeneration of autotransplanted splenic tissue in Wistar rats and to determine the bacterial phagocytic function of their macrophages. We utilized an experimental model with thirty-two rats, of both sexes, submitted to total splenectomy combined with autotransplantation in greater omentum of slices of the whole spleen mass. The animals were divided into two groups: I - young rats weighing 100 to 150 g; and II - adult rats weighing 250 to 300 g. Sixteen weeks later animals were intravenously inoculated with a suspension of Escherichia coli AB1157. Twenty minutes after inoculation, the animals were sacrificed and the splenic autotransplants were removed for morphological study. There was regeneration of autotransplanted splenic tissue in all animals. A similar morphological aspect among all animals was observed, with splenic tissue showing red and white pulps, lymphoid follicles, and marginal zone, with a moderate architectural disarrangement. Macrophages containing gram-negative bacterial aggregates as well as macrophages with hemosiderin pigments within the cytoplasm were observed. Blood vessels showed preserved walls, with no signs of vasculitis or thrombosis. The present results suggest that autogenous splenic implants in the greater omentum of the rat acquire the macro- and microscopic architecture of a normal spleen, with reduced dimensions, and preserve bacterial phagocyte function.

[Surgical anatomy of the spleen with special emphasis on its segmental architecture]

The authors have analyzed several aspects of the surgical anatomy of spleen, commencing with historical data, topography, peritoneal ligaments, variations in shape, embryology and accessory spleens and venous system of the spleen. The mode of splenic artery branching, variations of polar arteries, and intra- and extraparenchymatous arterial anastomoses were thoroughly analyzed. It was shown that the spleen in most cases consists of five vascular territories (segments) clearly demarcated from each other, stressing the practical significance of splenic anatomy in segmental dearterialization of the spleen.

Infecção fulminante pós-esplenectomia

RACIONAL: A esplenectomia, em qualquer faixa etária e por qualquer indicação, aumenta o risco de morte por infecção fulminante. OBJETIVO: Avaliar a definição, a etiologia, a incidência, os fatores de risco e a profilaxia da infeção fulminante pós-esplenectomia, bem como os métodos existentes para preservação de tecido esplênico quando a esplenectomia total faz-se necessária. MÉTODO: Revisão bibliográfica. RESULTADOS: Os agentes etiológicos mais freqüentemente encontrados nesse quadro séptico são Streptococcus pneumoniae, Haemophilus influenza e tipo B, e Neisseria meningitidis. Outras bactérias, como Escherichia coli, Streptococcus b-hemolítico, Staphylococcus aureus e Pseudomonas sp, também representam risco significativo. Similarmente, grande variedade de agentes, incluindo outros microrganismos entéricos Gram-negativos e patógenos não-bacterianos, também é relatada esporadicamente. A profilaxia situa-se em três categorias principais: educação dos pacientes, imunoprofilaxia e quimioprofilaxia. Contudo, essas medidas não são suficientes para debelar o grande risco de desenvolvimento dessa enfermidade. Quando a esplenectomia total for necessária, o auto-implante esplênico heterotópico parece constituir a única alternativa para preservação de tecido esplênico. Estudos clínicos e experimentais têm mostrado que, após um período de regeneração, desenvolve-se tecido esplênico viável, com características estruturais similares a um baço normal e com preservação da função imune esplênica. CONCLUSÕES: Com a caracterização mais detalhada da infecção fulminante pós-esplenectomia, a indicação para esplenectomia total, tanto no trauma, como em diversas enfermidades, vem nitidamente decrescendo. Métodos profiláticos foram desenvolvidos visando à minimização dos efeitos dessa grave enfermidade. Muitas pesquisas vêm tentando determinar o grau de imunocompetência que o enxerto esplênico autógeno pode prover ao hospedeiro, em resposta à invasão bacteriana.

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.

Vaccination practices among North American trauma surgeons in splenectomy for trauma

BACKGROUND

The purpose of this study was to examine trama surgeons' practice patterns regarding immunization of splenic injury patients.

METHODS

Data were analyzed from surgeons responding to a survey sent to 557 adult trauma surgeons in the United States and Canada. The survey queried the timing and use of vaccinations in splenic injury patients.

RESULTS

Three hundred four (54.6%) surgeons responded to the survey, with 43 no longer active. Of the 261 active surgeons, 99.2% immunize their splenectomized patients, whereas 15.7% immunize those who undergo splenorrhaphy and 8.4% immunize those managed nonoperatively. Vaccines are administered anywhere from the immediate postoperative period to as long as 6 weeks later. All but two responding surgeons provide the pneumococcal vaccine, 62.8% also advocate meningococcal vaccination, 72.4% add the Haemophilus influenzae vaccine, and 56.7% give all three. Thirteen of the responding surgeons reimplant splenic tissue, most frequently in the omentum, and in quantities varying from two slices to the entire spleen. Revaccination practices are extremely varied-ranging from nothing at all to annually-and seldom follow Centers for Disease Control and Prevention guidelines.

CONCLUSION

With the exception of immunizing splenectomized patients against pneumococcal infection, little consensus exists among surgeons regarding the immunization of patients sustaining splenic injury.

Management of splenic trauma in the pediatric hemophiliac patient: Case series and review of the literature

In July and August 1998, 3 patients who attend the Hemophilia Treatment Center required emergency admission to the authors' hospital for management of hemorrhagic shock caused by splenic injury. Computed tomography was used to diagnose and grade the splenic injuries, which ranged from II to IV on the organ injury scale. Two patients had Christmas disease (Factor IX deficiency) and were treated with splenorrhaphy and factor IX replacement. One patient who has severe von Willebrand disease (Type 3) had grade II splenic injury that required splenectomy to secure hemostasis. The coagulopathic deficiency was aggressively treated in each patient. All patients required operative intervention with attempted splenorrhaphy. All patients survived their operative experience, and none suffered a rebleeding episode. With correction of the coagulopathy throughout the perioperative period and local hemostatic control by operative techniques, salvage procedures for splenic injury were successful for 2 of these 3 patients.

Estudo funcional tardio do auto-implante esplênico após trauma complexo do baço humano

OBJETIVO: Avaliar as repercussões clínicas e laboratoriais em pacientes submetidos a auto-implantes esplênicos. MÉTODOS: Foram estudados 29 pacientes com lesões graves do baço, 20 que receberam auto-implantes esplênicos (grupo I), nove a esplenectomia total sem preservação de tecido esplênico (grupo II) e 22 pacientes com baços íntegros constituíram o grupo controle (grupo III). Investigaram-se as complicações pós-operatórias imediatas e tardias. No pós-operatório tardio realizaram-se exames hematológicos (hematimetria, hemoglobina, hematócrito, plaquetas, leucócitos globais e segmentados, linfócitos e corpúsculos de Howell Jolly). Dosaram-se as imunoglobulinas (IgA, IgM e IgG) e linfócitos T totais (LTT), linfócitos T ativos (LTA) e linfócitos B. Realizou-se cintilografia esplênica com enxofre coloidal marcado com o 99mTc. RESULTADOS: Em nenhum dos grupos verificou-se leucocitose ou trombocitose. Os corpúsculos de Howell-Jolly foram observados no grupo II e neste grupo a IgM esteve reduzida. A cintilografia mostrou tecido esplênico captante no grupo I. CONCLUSÃO: O auto-implante é uma boa alternativa quando a esplenectomia total for necessária.

Changing patterns in the management of splenic trauma: the impact of nonoperative management

OBJECTIVE

The recognition that splenectomy renders patients susceptible to lifelong risks of septic complications has led to routine attempts at splenic conservation after trauma. In 1990, the authors reported that over an 11-year study period involving 193 patients, splenorrhaphy was the most common splenic salvage method (66% overall) noted, with nonoperative management employed in only 13% of blunt splenic injuries. This report describes changing patterns of therapy in 190 consecutive patients with splenic injuries seen during a subsequent 6-year period (1990 to 1996). An algorithmic approach for patient management and pitfalls to be avoided to ensure safe nonoperative management are detailed.

METHODS

Nonoperative management criteria included hemodynamic stability and computed tomographic examination without shattered spleen or other injuries requiring celiotomy.

RESULTS

Of 190 consecutive patients, 102 (54%) were managed nonoperatively: 96 (65%) of 147 patients with blunt splenic injuries, which included 15 patients with intrinsic splenic pathology, and 6 hemodynamically stable patients with isolated stab wounds (24% of all splenic stab wounds). Fifty-six patients underwent splenectomy (29%) and 32 splenorrhaphy (17%). The mean transfusion requirement was 6 units for splenectomy survivors and 0.8 units for nonoperative therapy (85% received no transfusions). Fifteen of the 16 major infectious complications that occurred followed splenectomy. Two patients failed nonoperative therapy (2%) and underwent splenectomy, and one patient required splenectomy after partial splenic resection. There no missed enteric injuries in patients managed nonoperatively. The overall mortality rate was 5.2%, with no deaths following nonoperative management.

CONCLUSIONS

Nonoperative management of blunt splenic injuries has replaced splenorrhaphy as the most common method of splenic conservation. The criteria have been extended to include patients previously excluded from this form of therapy. As a result, 65% of all blunt splenic injuries and select stab wounds can be managed with minimal transfusions, morbidity, or mortality, with a success rate of 98%. Splenectomy, when necessary, continues to be associated with excessive transfusion and an inordinately high postoperative sepsis rate.

Anatomical and surgical aspects of splenic segmentectomies

Based upon the anatomicosurgical segments of the spleen, suggested by DiDio and demonstrated in cadavers, classified and named by Neder (1958) and Zappalá (1958, 1959, 1963), the normal segmental organization was anatomically and radiologically confirmed in 51 human spleens, after studying corrosion casts and radiograms of intraparenchymal vessels (Christo, 1959 a, b, 1960, 1962, 1963, 1993). From 1958 to 1965, pioneer segmental resections were performed successfully in 34 dogs and in 9 patients to safely remove traumatic injured splenic segments. At the same time, the overwhelming postsplenectomy infection (OPSI) became well identified. Consequently, to save normally functioning splenic parenchyma became the most important issue in the management of splenic injuries. The anatomical basis for partial splenectomy and splenic segmentectomy is discussed. The term "splenorrhaphy" was employed to designate all conservative or parenchyma saving operations of spleen based upon its vascular supply: from topical packings to splenic sutures including "cappings" and partial splenectomies. From analysis of 38 consecutive reports in 20 years, covering 4,076 patients, it was concluded that "splenorrhaphies" had been electively employed in 46% of the injuries and partial splenectomies were identified in 8.6% of these surgical interventions. However, the critical minimal mass of splenic tissue to be preserved after partial splenectomies is still to be defined. Postoperative complications directly related to "splenorrhaphies" are rare. Uncommonly performed after splenectomies, the heterotopical splenic autotransplantation has presented dubious results. Trials with nonoperative management of splenic blunt trauma injuries have been safer among children, whose spleens are predominantly transversally disrupted and have a higher relationship "capsular resistance/parenchymal bulk". Splenectomies have been most frequently the ultimate result of delayed laparotomy and underlying risks of growing blood requirements may surpass the advantages of preventing OPSI.

Rupture of the pathologic spleen: is there a role for nonoperative therapy?

INTRODUCTION

While nonoperative management of blunt splenic injury in the stable patient has become the standard of care, splenectomy is still advocated as the safest management for rupture of the diseased spleen. The combination of splenectomy and underlying immunosuppression may render these patients particularly susceptible to postsplenectomy infection, and thus we undertook a prospective trial of nonoperative management of the ruptured pathologic spleen.

METHODS

Hemodynamically stable patients with preexisting pathologic splenomegaly and isolated splenic disruptions diagnosed by computed tomographic (CT) scan (American Association for the Surgery of Trauma (AAST) grades 1-4) requiring 2 or less units blood transfusion were prospectively studied. Patients were monitored in a critical care setting, and resolution of splenic disruption was followed by serial CT examinations.

RESULTS

Nonoperative management was successful in all 11 patients (eight, HIV/AIDS; one each, acute leukemia, infectious mononucleosis, sickle cell anemia). The mean transfusion requirement was 0.7 units; the mean length of stay was 16 days.

CONCLUSIONS

The pathologic spleen can heal after parenchymal disruption. While not appropriate for all patients, a subset of hemodynamically stable patients can be successfully managed nonoperatively using CT diagnosis, close clinical monitoring, and minimal transfusions.

Splenosis is regulated by a circulating factor

Splenic rupture may result in splenosis, the growth of splenic fragments. We used a parabiotic model to test the hypothesis that splenotic growth is governed by a circulating mediator(s). Pairs of C57B1/6 mice underwent side-to-side anastomosis. After 2 weeks, each of four groups underwent a second operation in which one or both of the partners had a sham operation or a splenectomy, or had splenic fragments transplanted into their peritoneums, or some combination thereof. Six weeks later, splenotic fragments were excised and weighed. Spleen fragments involuted when inserted into the pairs that had two intact spleens. In contrast, in pairs with one intact spleen and one set of fragments, multiple splenules developed, whose aggregate mass was approximately half (ratio, 0.53 +/- 0.04 [mean +/- SE]) that of the original transplanted fragments. Significantly more splenosis (P < .01) developed in pairs with no intact spleens and one set of fragments (0.82 +/- 0.04). The pairs with no intact spleens and twice as many fragments had an intermediate amount of splenosis (0.66 +/- 0.08). The authors conclude that (1) splenosis is inhibited by a factor (or factors) that circulates across the capillary network in a parabiotic pair of mice, and (2) the level of inhibition of splenosis appears to be directly proportional to total splenic mass. The authors speculate that spleen-saving operations, even if partial, may decrease the incidence of splenosis in the patient with a shattered spleen.

Autologous splenic transplantation for splenic trauma

OBJECTIVE

The authors reviewed the experimental evidence, surgical technique, complications, and results of clinical trials evaluating the role of autologous splenic transplantation for splenic trauma.

SUMMARY BACKGROUND DATA

Splenorrhaphy and nonoperative management of splenic injuries have now become routine aspects in the management of splenic trauma. Unfortunately, not all splenic injuries are readily amenable to conventional spleen-conserving approaches. Heterotopic splenic autotransplantation has been advocated for patients with severe grade IV and V injuries that would otherwise mandate splenectomy. For this subset of patients, splenic salvage by autotransplantation would theoretically preserve the critical role the spleen plays in the host's defense against infection.

METHODS

The relevant literature relating to experimental or clinical aspects of splenic autotransplantation was identified and reviewed. Data are presented on the experimental evaluation of autogenous splenic transplantation, methods and complications of autotransplantation, choice of anatomic site and autograft size, and results of clinical trials in humans.

RESULTS

The most commonly used technique of autotransplantation in humans involves implanting tissue homogenates or sections of splenic parenchyma into pouches created in the gastrocolic omentum. Most authors have observed evidence of splenic function with normalization of postsplenectomy thrombocytosis, immunoglobulin M levels, and peripheral blood smears. Some degree of immune function of transplanted grafts has been demonstrated with in vivo assays, but the full extent of immunoprotection provided by human splenic autotransplants is currently unknown.

CONCLUSIONS

Multiple human and animal studies have established that splenic autotransplantation is a relatively safe and easily performed procedure that results in the return of some hematologic and immunologic parameters to baseline levels. Some aspects of reticuloendothelial function are also preserved. Whether this translates into a real reduction in the morbidity or mortality rates from overwhelming bacterial infection is unknown and requires further investigation.

Severe Sports-Related Spleen Injury

In brief Most minor spleen injuries can be managed conservatively, but severe splenic ruptures often require operative treatment. In this case report, however, a young football player who severely injured his spleen was able to recover nonoperatively because he was hemodynamically stable. His case highlights issues of diagnosis, injury classification, and treatment options, as well as when to return an athlete to play.

Subtotal splenectomy in Gaucher's disease: towards a definition of critical splenic mass

Partial splenectomy is currently the favoured surgical approach for Gaucher's disease. Preservation of splenic tissue is indicated to prevent susceptibility to overwhelming postsplenectomy sepsis, to delay the massive deposition of glucocerebroside in the liver and bones, and to relieve symptoms of hypersplenism. Controversial issues and technical problems related to partial splenectomy for Gaucher's disease are discussed and a definition of critical splenic mass considered.

Splenic salvage using an absorbable mesh: feasibility, reliability and safety

Forty-nine adults underwent surgery for splenic injury: 17 (group 1) had salvage with a splenic mesh, seven (group 2) underwent other preservation techniques, and 25 (group 3) underwent splenectomy. There were six, zero and 11 hilar lesions in groups 1, 2 and 3, respectively. Seven of 15 associated lesions involved the digestive tract. There was no significant difference in transfusion requirements, length of operation or postoperative complications. One patient died in each of groups 1 and 2, and eight in group 3. Secondary splenectomy was performed once in groups 1 and 2. The duration of hospital stay was shorter in the preservation groups (1 and 2) than in group 3. Splenic preservation was feasible in 24 of 49 adults with splenic injury requiring surgery. The splenic mesh wrap is safe and reliable, and allows splenic salvage even with hilar injury.

Management of splenic trauma

This article examines the current management of trauma to the spleen. The incidence, mechanism, classification, diagnosis, treatment and complications of splenic trauma are reviewed. Modern radiological investigations are assessed in view of the recent vogue for non-operative management. The effects of splenectomy and particularly of overwhelming postsplenectomy sepsis are discussed. The role of non-operative management of splenic injuries in children and in adults without associated injuries is emphasized. Means of repairing and preserving the spleen are detailed. Prompt splenectomy is necessary in seriously traumatized patients, especially those with head or multiple injuries.

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.

Regeneration of the spleen and splenic autotransplantation

This paper reviews the subject of regeneration of the spleen and discusses the role of splenic autotransplantation following splenectomy for trauma.

Splenic artery ligation: a ten-year experience in the treatment of selected cases of splenic injuries in children

Splenic artery ligation (SAL) combined with either splenorrhaphy or partial splenectomy has been used as a spleen saving procedure in the management of massively bleeding splenic injuries. During the last 10 years, 37 children have been submitted to SAL following a selective management schedule. This study was jointly undertaken by two separate Pediatric Surgical Units in two different countries, in order to evaluate some preliminary observations published previously, with regard to; 1) the percentage of splenic injuries requiring ligation of the splenic artery; 2) the effect of this procedure on the arrest of bleeding; 3) the postoperative complications related to dearterialization of the spleen; 4) the immunological status after the operation and; 5) the postoperative imaging of the spleen using radioscintigrams and ultrasonograms. The mean age of the patients was 6.9 years and the follow up period ranged from 1 to 10 years. Thus, SAL was concluded to be an effective mode of treatment for rare cases of splenic injury unable to be treated nonoperatively or by splenorrhaphy alone. No postoperative complications were recorded in this series, while the immunological status remained undisturbed postoperatively and imaging of the spleen revealed intact and functional tissue with adequate healing.

Splenic trauma. Choice of management

The modern era for splenic surgery for injury began in 1892 when Riegner reported a splenectomy in a 14-year-old construction worker who fell from a height and presented with abdominal pain, distension, tachycardia, and oliguria. This report set the stage for routine splenectomy, which was performed for all splenic injury in the next two generations. Despite early reports by Pearce and by Morris and Bullock that splenectomy in animals caused impaired defenses against infection, little challenge to routine splenectomy was made until King and Schumacker in 1952 reported a syndrome of "overwhelming postsplenectomy infection" (OPSI). Many studies have since demonstrated the importance of the spleen in preventing infections, particularly from the encapsulated organisms. Overwhelming postsplenectomy infection occurs in about 0.6% of children and 0.3% of adults. Intraoperative splenic salvage has become more popular and can be achieved safely in most patients by delivering the spleen with the pancreas to the incision, carefully repairing the spleen under direct vision, and using the many adjuncts to suture repair, including hemostatic agents and splenic wrapping. Intraoperative splenic salvage is not indicated in patients actively bleeding from other organs or in the presence of alcoholic cirrhosis. The role of splenic replantation in those patients requiring operative splenectomy needs further study but may provide significant long-term splenic function. Although nonoperative splenic salvage was first suggested more than 100 years ago by Billroth, this modality did not become popular in children until the 1960s or in adults until the latter 1980s. Patients with intrasplenic hematomas or with splenic fractures that do not extend to the hilum as judged by computed tomography usually can be observed successfully without operative intervention and without blood transfusion. Nonoperative splenic salvage is less likely with fractures that involve the splenic hilum and with the severely shattered spleen; these patients usually are treated best by early operative intervention. Following splenectomy for injury, polyvalent pneumococcal vaccine decreases the likelihood of OPSI and should be used routinely. The role of prophylactic penicillin is uncertain but the use of antibiotics for minor infectious problems is indicated after splenectomy.

Sutureless hemisplenectomy

Splenic salvage following blunt injury can fail when parenchymal bleeding is uncontrollable. To define the usefulness of an argon beam coagulator for hemostasis, we used the instrument in a laboratory trial of partial splenic resection. New Zealand white rabbits, weighing 4 to 5 kg, had sharp excision of the lower half of the spleen. No sutures were used to control hemorrhage from the cut splenic surface or the hilar vessels. Hemostasis was achieved with 2 to 4 seconds of electrocoagulation delivered by a beam of argon gas. All animals survived the procedure and were in good health when killed between the fourth and sixth week following the procedure. At necropsy, the spleen was viable in all animals with no abscess or hematoma. Minimal adhesions from the treated splenic surface to the omentum were found. The scar at the cut surface was 1 mm in depth, and the histology of the remainder of the spleen was normal. In this simulated splenic injury model, argon beam coagulation was uniformly successful in achieving hemostasis. Minimal tissue destruction and lack of infection were noted. The argon beam coagulator may be useful in patients with severe splenic injuries and other situations requiring partial splenectomy.

Initial evaluation of the patient with blunt abdominal trauma

Unrecognized abdominal injury remains a distressingly frequent cause of preventable death following blunt trauma. Peritoneal signs are often subtle, overshadowed by pain from associated injury, and masked by head trauma or intoxicants. The initial management of the patient with blunt abdominal trauma should parallel the primary survey of airway, breathing, and circulation. Diagnostic peritoneal lavage remains the cornerstone of triage in patients with life-threatening blunt abdominal trauma. The only absolute contraindication to the procedure is an existing indication for laparotomy. Computed tomography is useful as a complementary diagnostic tool in selected patients, and it is the critical test for guiding nonoperative management of known intraperitoneal trauma. Routine ancillary tests for potentially occult injuries include nasogastric-tube placement for ruptures of the left diaphragm, Gastrografin contrast study for duodenum perforation, and pyelography for urologic injury. Ultrasonography may become a valuable tool in the initial assessment of the injured abdomen. Ultimately, the most important principle in the management of blunt abdominal trauma is repeat physical examination by an experienced surgeon.

Management of splenic injuries

The structure and function of the spleen are reviewed in the context of providing a rational basis for splenic salvage after trauma. Guidelines for operative and nonoperative management are provided, and the results of treatment from recent large series are summarized.

Experience with selective operative and nonoperative treatment of splenic injuries in 193 patients

During the past decade splenic salvage procedures rather than splenectomy have been considered the preferred treatment for traumatic splenic injuries. Splenic preservation has been most often accomplished by splenorrhaphy and more recently by a controversial nonoperative approach. This report delineates indications, contraindications, and results with splenectomy, splenorrhaphy, and nonoperative treatment based on an 11-year experience (1978 to 1989) in which 193 consecutive adult patients with splenic injuries were treated. One hundred sixty-seven patients (86.5%) underwent urgent operation. Of these, 111 (66%) were treated by splenorrhaphy or partial splenectomy and 56 (34%) were treated by splenectomy. During the last 4 years, 26 additional patients (13.5%) were managed without operation. Patients considered for nonoperative treatment were alert, hemodynamically stable with computed tomographic evidence of isolated grades I to III splenic injuries. Overall 24% of the injuries resulted from penetrating trauma, whereas 76% of the patients sustained blunt injuries. Complications were rare, with two patients in the splenorrhaphy group experiencing re-bleeding (1.8%) and one patient (4%) failing nonoperative treatment. The mortality rate for the entire group was 4%. This report documents that splenorrhaphy can safely be performed in 65% to 75% of splenic injuries. Splenectomy is indicated for more extensive injuries or when patients are hemodynamically unstable in the presence of life-threatening injuries. Nonoperative therapy can be accomplished safely in a small select group (15% to 20%), with a success rate of nearly 90% if strict criteria for selection are met.

Splenorrhaphy. The alternative

From 1980 to 1989, 240 adult patients underwent splenorrhaphy at one urban trauma center. This represents 43.4% of all splenic injuries seen during this time interval. Splenic injuries were graded I to V, and splenorrhaphy was attempted except when the spleen was shattered or when multiple injuries with associated hypotension were present. Penetrating wounds, blunt trauma, or iatrogenic/unknown etiologies were present in 54.2%, 41.6%, and 4.2% of patients, respectively. Grade I or II injuries were present in 51.7% of patients, grade III in 34.6%, grade IV or V in 9.6%, and unknown grade in 4.1%. The technique of splenorrhaphy was simple suture (usually chromic) with or without the addition of topical hemostatic agents in 200 patients (83.3%), topical agents alone in 12 (5%), unknown type of repair in 12 (5%), compression, cautery, or nonbleeding injury in 9 (3.8%), and partial or hemisplenectomy in 7 (2.9%). Postoperative rebleeding occurred in three patients (1.3%) with grade II, III, and IV injuries, respectively, and led to splenectomy at reoperation. In another patient who had a hemisplenectomy performed for a grade IV injury, subphrenic abscesses and septic shock led to the death of the patient. Splenorrhaphy can be safely performed in properly selected adult patients after a variety of injuries. The risk of rebleeding is practically nil when the spleen is fully mobilized and visualized during repair.

Splenic repair for trauma

The risks of overwhelming post-splenectomy infection (OPSI) are now well documented both in children and adults. Although the incidence of OPSI is comparatively low following splenectomy for trauma, it has a high mortality. Splenectomy is no longer the treatment of choice for splenic injury and splenic salvage is recommended whenever feasible. Since 1982, in the Isle of Wight hospitals, 13 cases of splenic injury following trauma have been treated applying various salvage procedures and are reported here.

Splenic reticuloendothelial function after splenectomy, spleen repair, and spleen autotransplantation

Overwhelming infection after splenectomy remains a problem despite the introduction of vaccine and antimicrobial prophylaxis. To evaluate prospectively various procedures proposed for salvage of the spleen, we measured reticuloendothelial function for two to five years in 51 patients who had initially presented with abdominal trauma and suspected splenic rupture. The mean percentage of pocked erythrocytes and the clearance of antibody-coated autologous erythrocytes in 8 patients who had splenic repair and in 6 who had partial splenectomy were the same as in 11 controls with intraabdominal injury that did not involve the spleen. The mean percentage of pocked erythrocytes remained significantly elevated in 19 patients who had undergone total splenectomy without autotransplantation of splenic tissue. One of seven patients who underwent splenic autotransplantation had a normal level of pocked erythrocytes 18 months after surgery, and a second patient had only a slight elevation at 24 months. The mean (+/- SEM) half-time clearance of labeled erythrocytes was significantly longer in the group that had total splenectomy without autotransplantation (421.1 +/- 74.5 hours) than in the autotransplantation group (91.6 +/- 20.0) or in the controls (5.4 +/- 2.0). We conclude that reticuloendothelial function was better preserved after partial splenectomy and splenic repair than after splenic autotransplantation, but that autotransplantation was superior to total splenectomy and appeared to be safe. Splenic autotransplantation deserves further study in patients who have had splenic trauma when other surgical maneuvers to save the spleen are not possible.

Spleen-saving procedures in paediatric splenic trauma

The aim of this study is to assess the advantages of 'spleen-saving procedures' in paediatric splenic trauma. Since January 1979, 87 children with splenic trauma were treated. Six were treated without operation. Eighty-one patients were treated surgically. Sixteen cases with type I splenic injury were subject to simple splenorrhaphy, and twenty-three cases with type II splenic injury underwent splenorrhaphy plus omentoplasty. Twenty-four cases had type III splenic injury; of these, 20 were treated by ligation of the splenic artery (the main splenic artery in 14 cases and the upper segmental artery in six cases) with splenorrhaphy and omentoplasty, and the remaining four cases were treated by partial splenectomy and omentoplasty. In 16 of the 18 patients with type IV splenic injury, splenectomy was inevitable and heterotopic splenic autotransplantation was added. In the remaining two cases, it was possible partially to preserve the spleen. No complication was observed due to any of these spleen-saving procedures. Moreover, splenic implants increased complement C3 levels and improved filtration function. Despite other injuries, the mortality rate of this group was 5.7 per cent. The splenic salvage rate was 82 per cent.

Nonoperative observation therapy for splenic injuries: a safe therapeutic option?

Combining these reported and estimated incidences of mortality from overwhelming postsplenectomy infection, splenic salvage with nonoperative observation therapy and operative therapy, and the incidence of posttransfusion hepatitis and related mortality provides a conditional probability estimation of the risks of death with nonoperative observation therapy and operative therapy (Figure 4). The combined mortality rates for nonoperative observation and operative therapies are based on the following measured and estimated statistics: The post-transfusion hepatitis death rate per unit of blood transfused is 0.14 percent. Forty percent of children and 20 percent of adults who have successful nonoperative observation therapy receive an average of 2 units of blood. One hundred percent of children and adults in whom nonoperative observation therapy is unsuccessful receive an average of 4 units of blood. Twenty percent of children and adults who undergo operation initially receive an average of 2 units of blood. Ten percent of observed children require laparotomy and 75 percent of these patients then undergo splenectomy. Forty percent of adults who have nonoperative observation initially later require laparotomy, 93 percent of whom also require splenectomy. Ten percent of children and adults treated with initial operation later require splenectomy. Death from overwhelming postsplenectomy infection occurs in 0.026 percent of adults who undergo splenectomy and 0.052 percent of children who undergo splenectomy. Given these assumptions, the conditional probability of death in a child who initially undergoes nonoperative observation therapy is 0.17 percent compared with 0.06 percent for initial operative therapy. In adults, 0.26 percent of the observed patients die compared with 0.06 percent for those operated on initially. As stated, many of the percentages or probabilities listed are estimations based on the best available clinical data. The inability to establish a mortality rate from overwhelming postsplenectomy infection remotely resembling that reported for otherwise healthy patients required an unsubstantiated estimate. However, even when mortality rates from overwhelming postsplenectomy infection of 0.43 percent and 0.6 percent were substituted, early laparotomy still produced lower mortality rates. This continues to be true if one assumes that early laparotomy will result in 50 percent or even 100 percent of patients undergoing splenectomy, although in these cases the statistical differences would be less. We acknowledge that these statistics may exceed or underestimate the true risk of either treatment plan.(ABSTRACT TRUNCATED AT 400 WORDS)

Splenic trauma and overwhelming postsplenectomy infection

This review examines the incidence and implications of overwhelming infection in patients who have undergone splenectomy following trauma.

[Autotransplantation of the spleen]

No clinical parameter can prove that the autotransplantation of splenic tissue will restore all splenic functions especially in the immune reaction. Therefore this method is not an alternative to other methods of preservation of the ruptured spleen. Autotransplantation should be used only, when splenic rupture makes splenectomy necessary.