Partial splenectomy: Who, when and how. A systematic review of the 2130 published cases

Clinical factors and outcomes of spleen-conserving surgery versus total splenectomy in splenic injuries: A nationwide database study

BACKGROUND

The objective of this study was to identify factors associated with the use of spleen-conserving surgeries, as well as patient outcomes, on a national scale.

METHODS

This retrospective cohort study (2010-2015) included patients (age≥16 years) with splenic injury in the National Trauma Data Bank. Patients who received a total splenectomy or a spleen-conserving surgery were compared for demographics and clinical outcomes.

RESULTS

During the study period, 18,425 received a total splenectomy and 1,825 received a spleen-conserving surgery. Total splenectomy was more likely to be performed for patients with age>65 (odds ratio [OR]: 0.63, p ​< ​0.001), systolic blood pressure<90 (OR: 0.63, p ​< ​0.001), heart rate>120 (OR: 0.83, p ​= ​0.007), and high-grade injuries (OR: 0.18, p ​< ​0.001). Penetrating trauma patients were more likely to undergo a spleen-conserving surgery (OR: 3.31, p ​< ​0.001). The use of spleen-conserving surgery was associated with a lower risk of pneumonia (OR: 0.79, p ​= ​0.009) and venous thromboembolism (OR: 0.72, p ​= ​0.006).

CONCLUSIONS

Spleen-conserving surgeries may be considered for patients with penetrating trauma, age<65, hemodynamic stability, and low-grade injuries. Spleen-conserving surgeries have decreased risk of pneumonia and venous thromboembolism.

A Glimpse into the Role and Effectiveness of Splenectomy for Isolated Metachronous Spleen Metastasis of Colorectal Cancer Origin: Long-Term Survivals Can Be Achieved

Background: Many papers exploring the role of resectioning metastases in colorectal cancer (CRC) have focused mainly on liver and lung sites, showing improved survival compared with non-resectional therapies. However, data about exceptional metastatic sites such as splenic metastases (SMs) are scarce. This paper aims to assess the role and effectiveness of splenectomy in the case of isolated metachronous SM of CRC origin. Methods: The patients' data were extracted after a comprehensive literature search through public databases for articles reporting patients with splenectomies for isolated metachronous SM of CRC origin. Potential predictors of survival were explored, along with demographic, diagnostic, pathology, and treatment data for each patient. Results: A total of 83 patients with splenectomies for isolated metachronous SM of CRC origin were identified. The primary CRC was at an advanced stage (Duke's C-70.3%) and on the left colon (45.5%) for most patients, while the median interval between CRC resection and SM was 24 months. The median overall survival after splenectomy was 84 months, and patients younger than 62 years presented statistically significantly worse overall survival rates than those ≥62 years old (p = 0.011). There was no significant impact on the long-term outcomes for factors including primary tumor location or adjuvant chemotherapy (p values ≥ 0.070, ns). Laparoscopic splenectomy was increasingly used in the last 20 years from 2002 (33.3% vs. 0%, p < 0.001). Conclusions: Splenectomy is the optimal treatment for patients with isolated metachronous SM of CRC, with the laparoscopic approach being increasingly used and having the potential to become a standard of care. Encouraging long-term survival rates were reported in the context of a multidisciplinary approach. Younger ages are associated with worse survival. Perioperative chemotherapy in the context of a patient diagnosed with SM of CRC origin appears to be a reasonable option, although the present study failed to show any significant impact on long-term survival.

Splenic hamartomas in children

Splenic hamartomas (SHs) are uncommon, benign vascular lesions of unclear etiology and are mostly found incidentally on abdominal images, at surgery, or at autopsy. Since the first case description, in 1861, less than 50 pediatric SH cases have been reported in the literature. In this article, we have performed an analysis of all SH cases in children published in the literature to date and presented our case of an 8-year-old male with SH. These lesions in children were shown to cause symptoms more often than in the adult population. The observed SH sizes in children ranged from a few millimeters to 18 cm, and the symptomatic lesions were mostly larger or multiple. The most common clinical finding was splenomegaly. Signs of hypersplenism were present in children with a single SH larger than 4.5 cm (diameter range: 4.5-18.0 cm) and in those with multiple hamartomas, ranging from a few millimeters to 5 cm. Eighty percent of patients with available laboratory findings had hematological abnormalities such as anemia, thrombocytopenia, or pancytopenia. Other symptoms and signs included abdominal pain, recurrent infections, fever, night sweats, lethargy, growth retardation, and weight loss. The use of multiple imaging modalities may suggest the preoperative diagnosis of a splenic mass in children and determine the therapeutic approach. However, the final diagnosis of SH relies on histopathological evaluation. Surgery, including total or partial splenectomy (PS), is the mainstay of SH management. Although total splenectomy carries a greater risk of overwhelming post-splenectomy infection than PS it has remained the most performed surgical procedure in children with SH. In the majority of pediatric patients with symptomatic SH, resolution of symptoms and resolution or improvement of cytopenias occurred after surgical treatment.

[Surgery for primary splenic tumors and metastases of the spleen]

The correct indications for surgical treatment of primary splenic tumors as well as metastases of the spleen are challenging due to the rarity of the various entities. Primary solid splenic tumors include benign lesions, such as hemangiomas, hamartomas and sclerosing angiomatous nodular transformation (SANT) of the spleen. In these cases, surgical treatment is indicated only in the case of inconclusive imaging and after careful consideration of the risk-benefit ratio, even in the case of pronounced symptoms. In contrast, primary angiosarcoma or undifferentiated pleomorphic sarcoma as highly malignant tumors represent an urgent indication for surgery. Although more frequent than primary splenic malignancies, secondary splenic tumors are also not that frequent. Solitary splenic metastases are rare; however, from an oncological point of view they can be treated by resection. In the case of oligometastasis with splenic involvement, splenectomy is used only as part of a palliative concept in cases of pronounced symptoms or in the context of cytoreductive surgery. In general, the laparoscopic approach is to be preferred when the operation is technically feasible as it is associated with fewer pulmonary and infectious complications and a shorter hospital stay. In addition, to reduce the risk of severe infections after splenectomy, the option of partial splenectomy should be considered, especially for benign lesions. A thorough informing of the patient regarding both intraoperative and perioperative risks as well as potential long-term sequelae, especially severe infectious diseases, is an essential component of informed consent before surgery.

[Splenic surgery in hematological diseases : Indications and surgical technique]

BACKGROUND

Splenic surgery in hematological disorders requires a well-weighted decision on the indications because the medical treatment has rapidly changed in recent years due to new pharmaceutical approaches.

OBJECTIVE

Summary of the indications, surgical procedures and perioperative management regarding operative interventions on the spleen in hematological disorders.

MATERIAL AND METHODS

Selective literature search and summary of reviews and guideline recommendations.

RESULTS

In hematological disorders surgical procedures of the spleen (splenectomy and partial splenectomy) are an important part of the repertoire in the treatment. In recent years the indications for surgery have become narrower because of new forms of medicinal treatment. Especially in hereditary spherocytosis, immune thrombocytopenia and symptomatic splenomegaly and hypersplenism it is still of importance. The minimally invasive splenectomy is regarded as the gold standard. The spleen has an important immune and sequestration function, therefore preoperative and postoperative infectious and thromboembolic events have to be anticipated and prevented. A close interdisciplinary cooperation with hematologists is essential for an optimal outcome of patients.

CONCLUSION

The minimally invasive splenectomy and partial splenectomy are part of the surgical repertoire in the diagnostics and treatment of hematological disorders. Because of novel medicinal approaches the therapeutic protocols are continuously changing. A close cooperation with hematologists is important for the optimal evaluation of the indications and the perioperative management.

Long-term Results of Splenectomy in Transfusion-dependent Thalassemia

Splenectomy is indicated in transfusion-dependent thalassemia (TDT) only in certain situations. This study aimed to present the effectiveness, complications, and long-term follow-up results of splenectomy in children with TDT. We performed a 30-year single-institution analysis of cases of splenectomy for TDT between 1987 and 2017 and their follow-up until 2021. A total of 39 children (female/male: 24/15) were included. The mean age at splenectomy was 11.2±3.2 years, and their mean follow-up duration after splenectomy was 21.5±6.4 years. Response was defined according to the patient's annual transfusion requirement in the first year postsplenectomy and on the last follow-up year. Complete response was not seen in any of the cases; partial response was observed in 32.3% and no response in 67.6%. Thrombocytosis was seen in 87% of the patients. The platelet counts of 7 (17.9%) patients were >1000 (10 9 /L), and aspirin prophylaxis was given to 22 (56.4%) patients. Complications were thrombosis in 2 (5.1%) patients, infections in 11 (28.2%) patients, and pulmonary hypertension in 4 (10.2%) patients. Our study showed that after splenectomy, the need for transfusion only partially decreased in a small number of TDT patients. We think splenectomy can be delayed with appropriate chelation therapy up to higher annual transfusion requirement values.

Study of the upper pole after subtotal splenectomy in rats

PURPOSE

To evaluate macro/microscopic viability of the upper pole (UP) in rats after 80 days of subtotal splenectomy preserving the upper pole (SSPUP).

METHODS

Twenty-five male Wistar rats were submitted to SSPUP. After 80 days, the rats were euthanized, and the remaining UP was evaluated macroscopically regarding appearance, color, consistency, length, width, thickness, and presence of fibrosis/necrosis; and microscopically regarding presence of red and white pulp, fibrosis/necrosis.

RESULTS

Two rats died during surgery and were removed from the statistical analysis. There was statistically significant increase in length and width between the pre and postoperative in the experimental group, with no significant difference in thickness. In the manipulation group, the macroscopic appearance of the spleen was normal in pre and postoperative, with viability preserved. In the experimental group, two UP of the spleen were not found during the second surgery. Macroscopically, it was observed absence of fibrosis and necrosis in all cases. Microscopically, the white and red pulp were intact in both groups. Two spleens of rats in the manipulation group presented areas with fibrosis and necrosis focus, which were not enough to be considered inviable.

CONCLUSIONS

The UP of the spleen remained viable in 91.3% of the cases.

Surgical treatment of benign splenic lesions in pediatric patients: a case series of 30 cases from a single center

Background

Benign splenic lesions are rarely encountered. This study aimed to review the clinical characteristics and surgical outcomes in a case series of 30 pediatric patients.

Methods

From January 1st, 2001 to December 31st, 2021, 30 pediatric patients from a single center were consecutively included. Electronic medical records were reviewed and patients were followed up. Clinical presentations, imaging features, surgical procedures, pathological diagnoses, and prognoses were summarized. The lesion locations and 7-day postoperative platelet levels were compared between total and partial splenectomy patients.

Results

Eighteen males and twelve females were included, with mean age at surgery 116.4 ± 43.6 months. The clinical presentations included abdominal pain (16/30), splenomegaly (6/30), skin petechia (2/30), hemolytic jaundice (1/30), and no symptoms (5/30). Pathological diagnoses included congenital epithelial cyst (CEC, 17/30), vascular malformation (8/30), sclerosing angiomatoid nodular transformation (SANT, 3/30), hamartoma (1/30), and leiomyoma (1/30). Patients undergone total splenectomy were more likely to have a lesion involving the hilum than those undergone partial splenectomy (68.4% vs 31.6%, P = 0.021). The 7-day postoperative platelet level was higher in total splenectomy patients than partial splenectomy patients (adjusted means 694.4 × 10⁹/L vs 402.4 × 10⁹/L, P = 0.002).

Conclusions

Various clinical characteristics of pediatric benign splenic lesions are summarized. The most common pathological diagnoses are congenital epithelial cyst and vascular malformation. Partial and total splenectomy result in good prognosis with a low recurrence rate, and the former is preferred to preserve splenic function if possible.

High-fat diet activates splenic NOD1 and enhances neutrophil recruitment and neutrophil extracellular traps release in the spleen of ApoE-deficient mice

In the course of atherogenesis, the spleen plays an important role in the regulation of extramedullary hematopoiesis, and in the control of circulating immune cells, which contributes to plaque progression. Here, we have investigated the role of splenic nucleotide-binding oligomerization domain 1 (NOD1) in the recruitment of circulating immune cells, as well as the involvement of this immune organ in extramedullary hematopoiesis in mice fed on a high-fat high-cholesterol diet (HFD). Under HFD conditions, the absence of NOD1 enhances the mobilization of immune cells, mainly neutrophils, from the bone marrow to the blood. To determine the effect of NOD1-dependent mobilization of immune cells under pro-atherogenic conditions, Apoe^−/− and Apoe^−/−Nod1^−/− mice fed on HFD for 4 weeks were used. Splenic NOD1 from Apoe^−/− mice was activated after feeding HFD as inferred by the phosphorylation of the NOD1 downstream targets RIPK2 and TAK1. Moreover, this activation was accompanied by the release of neutrophil extracellular traps (NETs), as determined by the increase in the expression of peptidyl arginine deiminase 4, and the identification of citrullinated histone H3 in this organ. This formation of NETs was significantly reduced in Apoe^−/−Nod1^−/− mice. Indeed, the presence of Ly6G⁺ cells and the lipidic content in the spleen of mice deficient in Apoe and Nod1 was reduced when compared to the Apoe^−/− counterparts, which suggests that the mobilization and activation of circulating immune cells are altered in the absence of NOD1. Furthermore, confirming previous studies, Apoe^−/−Nod1^−/− mice showed a reduced atherogenic disease, and diminished recruitment of neutrophils in the spleen, compared to Apoe^−/− mice. However, splenic artery ligation reduced the atherogenic burden in Apoe^−/− mice an effect that, unexpectedly was lost in Apoe^−/−Nod1^−/− mice. Together, these results suggest that neutrophil accumulation and activity in the spleen are driven in part by NOD1 activation in mice fed on HFD, contributing in this way to regulating atherogenic progression.

Laparoscopic management of benign splenic tumors in children

Background

The splenic tumor is relatively rare in children. However, diagnosing and managing this disease remain controversial. This study aimed to evaluate the clinical characteristics and pathological features of benign splenic tumors and to explore the feasibility and safety of laparoscopic splenectomy in children.

Methods

The clinical data of all patients who were diagnosed with benign splenic tumors and admitted to our center between January 2014 and December 2020 were analyzed retrospectively. Factors that were documented included demographic criteria, clinical manifestations, preoperative examinations, surgical methods, histopathological characteristics, postoperative complications and outcomes.

Results

Totally, 24 consecutive patients with a mean age of 10.21±2.59 years were operated laparoscopically. Nine patients presented with recurrent abdominal pain, vomiting or backache. The remaining 15 cases were asymptomatic and were identified incidentally. Laparoscopic total splenectomy (LTS) was performed in 12 cases, laparoscopic partial splenectomy (LPS) in 9 cases and deroofing of splenic cyst in 3 cases. No significant differences were observed in operation time, intraoperative bleeding and postoperative abdominal drainage between the LTS and LPS groups. Histopathology examination reported 12 cases of splenic epithelial cyst, 5 cases of splenic lymphangioma or lymphatic malformation, 3 cases of splenic hamartoma, 3 cases of splenic littoral cell angioma and 1 case of splenic hemangioma. No postoperative complications and tumor recurrence were observed.

Conclusions

It is still difficult to precisely diagnose the splenic tumor preoperatively. Laparoscopic splenectomy is safe and feasible in treating the benign splenic tumors, and partial splenectomy is of great significance in preserving the immune function in children.

Splenectomy perspective for hematological disorders: a cross-sectional study in the Eastern Province of KSA

Objectives

Splenectomy is considered a therapeutic modality for several hematological diseases, although complications are possible. This study assessed the effects of splenectomy on various hematological disorders and the roles of prophylactic measures on postoperative outcomes.

Methods

This was a cross-sectional study performed in KSA on adult patients with underlying non-malignant hematological disorders who had undergone splenectomy.

Results

This study examined 179 patients with various hematological disorders, 38 (21.1%) of whom had undergone a splenectomy. Of those 38 patients, more than two-thirds (73.7%) had an open splenectomy. The average hospital stay was 2–7 days, and no significant difference was observed between the open and laparoscopic approaches. Approximately 95% of the patients showed overall improvements in their condition after splenectomy. However, 26.3% of patients reported a recurrence or need for further treatment 1 year or more after splenectomy. Approximately 16% of patients had an increased incidence of postoperative infectious complications, particularly patients with sickle cell disease and beta thalassemia. More than half the patients who developed complications had not received vaccination preoperatively, whereas 44.4% of vaccinated patients experienced complications (p = 0.04).

Conclusion

Splenectomy is considered a universal line of treatment for most non-malignant hematological diseases. Although splenectomy is an effective treatment, the reasons why patients with the same disease can have different responses remains unclear. Infection is a common postoperative complication, and vaccinations are underused. This study emphasizes the roles of patient education, scheduled vaccinations and proper selection of patients in the use of splenectomy for the treatment of non-malignant hematological diseases.

Clinical effect of laparoscopic partial splenectomy for both benign tumours and trauma-10 years of experience at a single institution

BACKGROUND

This retrospective study aimed to present our surgical experience in patients with benign tumour or trauma in spleen who underwent laparoscopic partial splenectomy (LPS) and to compare the results with those of patients who underwent an open partial splenectomy (OPS).

METHODS

We analysed the medical data of patients who underwent LPS or OPS between January 2010 and January 2020.

RESULTS

In total, 41 patients were enrolled. Nine patients underwent open surgery, 32 patients underwent laparoscopic surgery. The proportion of patients with tumours in the upper pole in LPS group was more than patients in OPS group. No difference was observed in estimated blood loss, allogeneic transfusion, postoperative stay, pathology and complications between LPS and OPS groups. The operation time in the LPS group (137.5 ± 30.8 min) was longer than that in the OPS group (88.3 ± 30.1 min) for patients with splenic traumatic rupture (P = 0.019).

CONCLUSIONS

LPS is an effective and safe spleen-preserving surgery as OPS. The advantages are small trauma, light pain and quick recovery. It is suitable for patients with benign tumours or trauma confined to one side of the spleen.

Partial splenectomy after preoperative embolization in a patient with metastatic melanoma – A case report

Introduction and importance

There is lack of evidence regarding the best treatment option for metastatic melanoma. In patients with a single splenic metastasis, preoperative superselective embolization followed by partial splenectomy (PS) could be a feasible treatment strategy to preserve splenic function and hopefully reduce the risk of postoperative bleeding. To our knowledge, this two-step procedure has yet not been published in patients with splenic metastasis.

Case presentation

We present the case of a 73-year-old man with stage IV melanoma consisting of a single splenic metastasis located at the lower pole. Four days prior to surgery, the patient underwent percutaneous superselective embolization of the segmental arteries going to the lower splenic pole. Subsequent, PS was performed using an upper midline laparotomy were a clearly visible tumor was found at the devascularized lower third of the spleen. The splenic parenchyma was divided using an energy device and hemostasis was secured with diathermia and a hemostatic patch. The patient had an uncomplicated recovery and was discharged home on postoperative day 8. Histology revealed an 8 mm, partly necrotic metastasis from a melanoma. There were no signs of recurrency at his last control four months postoperative.

Clinical discussion

There are no guidelines on how splenic metastasis from melanoma are to be removed, nor any literature on postoperative splenic function or survival after PS.

Conclusion

Superselective embolization followed by PS for metastatic melanoma could be a feasible treatment approach in highly selective patients where there is a strong desire to preserve splenic function.

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Total splenectomy is associated with an increased risk of infections, thromboembolism and certain malignancies

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Partial splenectomy (PS) may be considered to preserve splenic function in cases where a splenic lesion is to be removed

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Preoperative superselective arterial embolization can be used to devascularize the relevant splenic segment prior to PS

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To our knowledge, superselective splenic embolization followed by PS has not been published in patients with splenic metastasis

Minimally Invasive Partial Spleen Resection Preserving the Lower Pole in Children: A Technical Report on Feasibility and Safety

Background: Laparoscopic partial splenectomy is a surgical option for removing part of the spleen with a pathological mass in a way that ensures preservation of the spleen's physiological functions. We aimed to evaluate the efficacy and feasibility of this procedure, performed while preserving the blood supply from the left gastroepiploic artery, in children. Materials and Methods: Following institutional review board approval, this retrospective study was conducted on patients who, between January 2015 and December 2019, underwent laparoscopic partial splenectomy with preservation of blood supply from the left gastroepiploic vessels. In the article, we described patient indications for surgery, surgical technique, surgery time, complications, and follow-up outcomes. Results: Eleven patients (mean age: 12.3 ± 3.4 years) underwent laparoscopic partial splenectomy. Indications for surgery included nonparasitic cysts (n = 8), pseudocysts (n = 2), and hamartomas (n = 1). The mean benign mass diameter was 60 ± 22 mm. The mean operative time was 193.2 ± 55.1 minutes. The mean size of the retained lower pole was 31.1% ± 3.8%. There was no conversion to open splenectomy or any significant complication. The mean postoperative stay was 9 ± 0.7 days. No thrombosis of the splenic and portal veins was noted in the follow-up period, and no splenic remnant infarction occurred. Conclusions: Laparoscopic partial splenectomy with preservation of blood supply arising from the left gastroepiploic vessels seems to be safe in children. However, a larger study is needed to confirm our results.

Partial splenectomy in children: Long-term reoperative outcomes☆

PURPOSE

Partial, or subtotal, splenectomy (PS) has become an accepted alternative to total splenectomy (TS) for management of hematologic disorders in children, but little is known about its long-term outcomes. Here, we present our institutional experience with partial splenectomy, to determine rate of subsequent TS or cholecystectomy and identify if any factors affected this need.

METHODS

All patients who underwent partial splenectomy at a single tertiary children's hospital were retrospectively reviewed from 2002 through 2019 after IRB approval. Primary outcome of interest was rate of reoperation to completion splenectomy (CS) and rate of cholecystectomy. Secondary outcome were positive predictor(s) for these subsequent procedures.

RESULTS

Twenty-four patients underwent PS, at median age 6.0 years, with preoperative spleen size of 12.7 cm by ultrasound. At median follow up time of 8.0 years, 29% of all patients and 24% of hereditary spherocytosis (HS) patients underwent completion splenectomy at median 34 months and 45 months, respectively. Amongst HS patients who did not have a cholecystectomy with or prior to PS, 39% underwent a delayed cholecystectomy following PS. There were no significant differences in age at index procedure, preoperative splenic volume, weight of splenic specimen removed, transfusion requirements, preoperative or postoperative hematologic parameters (including hemoglobin, hematocrit, total bilirubin, and reticulocyte count) amongst patients of all diagnoses and HS only who underwent PS alone compared to those who went on to CS. There were no cases of OPSS or deaths.

CONCLUSION

Partial splenectomy is a safe alternative to total splenectomy in children with hematologic disease with theoretical decreased susceptibility to OPSS. However, families should be counseled of a 29% chance of reoperation to completion splenectomy, and, in HS patients, a 39% chance of delayed cholecystectomy if not performed prior to or with PS. Further studies are needed to understand predictors of these outcomes.

Laparoscopic fenestration and omentopexy as treatment for large splenic pseudocyst: Case report

INTRODUCTION AND IMPORTANCE

Pseudocysts of the spleen are rare entities with cystic lesions of the spleen being uncommon in general. It is estimated that splenic cysts occur in about 0, 07% of the population1. In general, splenic cystic lesions are discovered incidentally or by mass effect. In the literature, only a limited number of splenic cysts are reported. We report a case of splenic pseudocyst with mass effect where we used laparoscopic fenestration of the pseudocyst with omentopexy as a treatment of choice.

CASE PRESENTATION

The patient is a 62-year-old male with no previous history of trauma. He visited his GP for abdominal pain with flaring towards the left shoulder accompanied by early satiety, occasional obstipation, and breathing difficulties. He was referred to our hospital after enhanced computed tomography showed a 15 × 13 cm splenic cyst with displaced stomach and pancreatic tail medially and left kidney downward. Management options were discussed with the patient and he opted for a laparoscopic approach. In this case, we performed laparoscopic fenestration of the pseudocyst with omentopexy.

CLINICAL DISCUSSION

Until recently splenectomy was the surgical treatment of choice for all large or symptomatic cystic lesions of the spleen2, however with growing knowledge about the protective role of the spleen an approach with spleen protection is advocated.

CONCLUSION

There are many advantages to the laparoscopic approach of splenic cystic lesions and it may be the treatment of choice for this uncommon surgical problem.

Liver Transplantation for Biliary Atresia in Adulthood: Single-Centre Surgical Experience

Background: Biliary atresia (BA) is the most common indicator for liver transplant (LT) in children, however, approximately 22% will reach adulthood with their native liver, and of these, half will require transplantation later in life. The aim of this study was to analyse the surgical challenges and outcomes of patients with BA undergoing LT in adulthood. Methods: Patients with BA requiring LT at the age of 16 or older in our unit between 1989 and 2020 were included. Pretransplant, perioperative variables and outcomes were analysed. Pretransplant imaging was reviewed to assess liver appearance, spontaneous visceral portosystemic shunting (SPSS), splenomegaly, splenic artery (SA) size, and aneurysms. Results: Thirty-four patients who underwent LT for BA fulfilled the inclusion criteria, at a median age of 24 years. The main indicators for LT were synthetic failure and recurrent cholangitis. In total, 57.6% had significant enlargement of the SA, 21% had multiple SA aneurysm, and SPSS was present in 72.7% of the patients. Graft and patient survival at 1, 5, and 10 years was 97.1%, 91.2%, 91.2% and 100%, 94%, 94%, respectively Conclusions: Good outcomes after LT for BA in young patients can be achieved with careful donor selection and surgery to minimise the risk of complications. Identification of anatomical variants and shunting are helpful in guiding attitude at the time of transplant.

Comparison of perioperative outcomes between laparoscopic and open partial splenectomy in children and adolescents

BACKGROUND

In order to avoid consequences of total splenectomy, partial splenectomy (PS) is increasingly reported. The purpose of this study was to compare perioperative outcomes of laparoscopic PS (LPS) and open PS (OPS) in children and adolescents.

AIM

To compare perioperative outcomes of patients with LPS and OPS.

METHODS

After institutional review board approval, a total of 26 patients that underwent LPS or OPS between January 2008 and July 2018 were identified from the database of our tertiary referral center. In total, 10 patients had LPS, and 16 patients underwent OPS. Blood loss was calculated by Mercuriali’s formula. Pain scores, analgesic requirements and complications were assessed. The Wilcoxon rank sum test was used for comparison. To compare categorical variables, Fisher’s exact test was applied.

RESULTS

LPS was performed in 10 patients; 16 patients had OPS. Demographics (except for body mass index and duration of follow-up), indicating primary disease, preoperative spleen size and postoperative spleen volume, perioperative hematological parameters, postoperative pain scores, analgesic requirements, adverse events according to the Clavien-Dindo classification and the comprehensive complication index, median time from operation to initiation of feeds, median time from operation to full feeds, median time from operation to mobilization and median length of hospital stay did not differ between LPS and OPS. Median (range) operative time (min) was longer in LPS compared to the OPS group [185 (135-298) vs 144 (112-270), respectively; P = 0.048]. Calculated perioperative blood loss (mL of red blood cell count) was higher in the LPS group compared to OPS [87 (-45-777) vs -37 (-114-553), respectively; P = 0.039].

CONCLUSION

This is the first study that compared outcomes of LPS and OPS. Both operative approaches had comparable perioperative outcomes. LPS appears to be a viable alternative to OPS.

Two cases of non-parasitic splenic cysts and spleen-preserving therapy

We review two different presentations of non-parasitic splenic cysts, both of which are post-traumatic in aetiology. The first case was of slower onset and was managed electively. The second case was of acute onset and was managed as an emergency. Non-parasitic splenic cysts are uncommon and the optimal management strategy for them is not well defined. Historically, treatment has been with open splenectomy; however, infection rates following this surgery have been high, making it an unattractive management option. Both cases were managed successfully with laparoscopic fenestration with no recurrence at subsequent follow-up.

Partial Splenectomy for a Sizeable Cavernous Hemangioma: Case Report and a Review of the Literature

The recent awareness of the spleen's important role, especially its immune function, has fundamentally changed the management of splenic diseases, promoting the splenic preserving surgery, and protecting from the significant risk of total splenectomy: overwhelming post-splenectomy sepsis. Partial splenectomy is a safe and feasible technique that offers, according to the literature, the same results of a total approach, either in achieving hematological benefits in congenital hemolytic anemia, or treating the focal splenic lesion such as hemangioma, while preserving the immune function.

Laparoscopic Partial Splenectomy: A Critical Appraisal of an Emerging Technique. A Review of the First 457 Published Cases

Background: Laparoscopic partial splenectomy (LPS) may allow avoiding total splenectomy (TS) complications and maximizing the advantages of mini-invasive approach. The objective of this review is to assess feasibility and safety of LPS, to compare this approach with alternative options. Materials and Methods: A literature review of articles reporting LPS is performed. Several parameters, including age, indication, surgical technique, devices used for splenic section/hemostasis, adverse outcomes, including morbidity/mortality, conversions to open surgery, conversions to TS, operative time (OT), and hospital stay (HS), are analyzed. Articles comparing LPS' results with those of open partial splenectomy and laparoscopic TS are also analyzed. Results: Fifty-nine articles reporting 457 LPS were included. Patients' characteristics varied widely, concerning age and indications, including hematological disease (hereditary spherocytosis, drepanocytosis), splenic focal masses, and trauma. Several technical options are reported. Mean OT and HS are 128 ± 43.7 minutes and 4.9 ± 3.8 days, respectively. No mortality and 5.7% morbidity are reported. Conversion rates to open surgery and to TS are 3.9% and 3.7%, respectively. Conclusions: In conclusion LPS is feasible and safe, with no mortality, low morbidity, and low conversion rates to laparotomy and to TS. LPS may be accomplished by various techniques and tools. Major complications are sporadically reported, thus potential risks should not be underestimated.

How I approach hereditary hemolytic anemia and splenectomy

Hereditary hemolytic anemias (HHA) are a heterogeneous group of anemias associated with decreased red cell survival. While there can be clinical benefit of splenectomy in many cases, splenectomy is not appropriate for all types of HHA. Additionally, there are significant risks during and following splenectomy including surgical risks, postsplenectomy sepsis, and thrombotic complications. This review discusses the diagnostic approach to HHA as well as the role of splenectomy in the management. Surgical approaches and outcomes for total and partial splenectomy are discussed.

Splenic function is not maintained long-term after partial splenectomy in children with sickle cell disease

BACKGROUND

Partial splenectomy (PS) may allow preservation of splenic function in cases where splenectomy is indicated for hematologic diseases; however, the long-term outcomes are uncertain. We investigated the long-term outcomes of PS in patients with sickle cell disease (SCD).

METHODS

A single-institution retrospective chart review was performed for children with SCD who underwent PS from 1997 to 2017. For comparison, we reviewed outcomes for patients who underwent PS for hereditary spherocytosis (HS). The primary endpoint was viability of the splenic remnant as inferred by the presence of remnant perfusion on ultrasound and/or liver spleen scan.

RESULTS

Nine patients with SCD and 26 patients with HS underwent PS at a median age of 11 (IQR, 9-14) and 7.5 (IQR, 6-13) years, respectively. All underwent laparoscopic PS with three (7.9%) conversions to open. Two SCD patients were lost to long-term follow-up. The remaining seven SCD patients had initial postoperative splenic remnant perfusion demonstrated by ultrasonography. By 42 months postoperatively, however, none had a functioning splenic remnant. The median time to loss of splenic remnant was 12.6 (IQR 9.2-28.5) months. In contrast, all HS patients demonstrated robust splenic remnant blood flow with a median follow-up of 46 (IQR 37-82) months.

CONCLUSION

No patient with SCD who underwent PS had viable splenic tissue for more than 42 months, likely due to continued autoinfarction typical of patients with this disease. Therefore, we believe that PS to preserve splenic function is not indicated in patients with SCD.

LEVEL OF EVIDENCE

III.

Laparoscopic middle segment splenectomy for central splenic hemangioma: A case report

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Laparoscopic middle segment splenectomy for central splenic hemangioma is a new technique.

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Laparoscopic middle segment splenectomy for central splenic hemangioma is very useful for some selected patients.

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In patients with splenic artery bifurcation point far from the splenic hilus parenchyma and in those cases where the blood supply of the upper and lower pole splenic segments can be ensured, when the splenic tumor is resected, performing LPS and retaining some upper and lower splenic segments is possible to ensure sufficient residual spleen.

Introduction

Laparoscopic surgery plays an important role in the treatment of splenichematologic pathologies and solid lesions. Splenic hemangioma is the most common benign tumor of the spleen. In patients with benign splenic space-occupying lesions, laparoscopic partial splenectomy (LPS) has a lower incidence of postoperative complications than laparoscopic total splenectomy (LTS). Currently, no uniform standard for the indication of LPS is available.

Presentation of case

Herein, we report a case of hemangioma in a 23-year-old woman treated with LPS. After multidisciplinary evaluation, laparoscopic splenectomy was indicated in this case; upon evaluating the age of the patient and the affected spleen portion, a middle segment splenectomy was proposed, with preservation of the upper and lower pole. The intraoperative frozen section of the specimen was negative for malignancies.

Discussion

Surgery remains the first choice in the treatment of solid lesions of the spleen. In this case, the volume of splenic hemangioma was large and accumulated in the upper and lower segments of the spleen. After the middle branch of splenic artery was cut off, the tumor was completely contained in the middle of upper and lower ischemic lines splenic segment. We think that the central type of benign splenic space occupying is not an absolute contraindication of LPS. For the patients whose splenic artery bifurcation point is far from the splenic hilus parenchyma and in those cases where the blood supply of the upper and lower poles of the splenic segments can be ensured, when the splenic tumor is resected, performing LPS and retaining some parts of the upper and lower splenic segments is possible to ensure sufficient residual spleen.

Macro and microscopic comparison of the upper pole of the spleen with the lower pole in partial splenectomy

Purpose

To evaluate the viability of the upper (UP) and lower pole (LP) of the spleen from a macro and microscopic point of view, after subtotal splenectomy with preservation (SSP) of the UP and the LP.

Methods

Seventeen male Wistar rats, two months old, were submitted to SSPUP and SSPLP and 5 to simulated operation (SG). After 80 days, the rats were euthanized, and the remaining LP and UP and intact spleens were evaluated macroscopically and microscopically.

Results

Two rats died during the operation. Macroscopic analysis showed that in 15 LP, one of them was not viable and in 15 UP and in 5 spleens in the SG, all were viable. In the statistical analysis, there was no difference in relation to viability. The LP and UP analyzed showed variation. As for the length, the UP increased significantly; however, in relation to the width, there was a significant increase in the LP in relation to the UP. In addition, the weight of the UP was significantly greater than that of the LP. Microscopic analysis attested viability of the splenic remnants.

Conclusion

There was no significant difference regarding the viability of UP and LP, in macroscopy and microscopy.

Laparoscopic near-total splenectomy. Report of a case

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We describe a case report of near total splenectomy managed by laparoscopy for a large lesion of the upper pole of the spleen.

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When total splenectomy is performed, an increased risk of potentially lethal infections arises. Asplenia and impaired splenic function are related to the increase of morbidity and mortality from infectious complications.

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The overwhelming post splenectomy infections (OPSI) are mostly represented by fulminating sepsis, meningitis or pneumonia.

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laparoscopic near total splenectomy is an innovative partial splenectomy technique consisting on preserving a residual spleen volume.

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The comparison between other spleen preserving techniques shows that LNTS is associated with a lower rate of secondary surgery and postoperative recurrence of anaemia.

Introduction

Splenectomy is a surgical procedure indicated for the treatment of most benign and malignant splenic diseases, especially hematologic disorders. Laparoscopic approach is preferable to the open surgery for most indications because it reduces intra- and post-operative complications and shortens hospital stay. Laparoscopic approach is also feasible for partial splenectomy. Spleen-preserving techniques reduce the risk of severe infections and thromboembolic events that can occur after total splenectomy

Case presentation

We report a case of a 50-year old woman with an incidentally discovered voluminous lesion in the superior pole of spleen. A laparoscopic near-total splenectomy was performed.

Discussion

The evidence about the potential complications in splenectomised patients speaks in favour of performing spleen-sparing surgical techniques whenever possible. Most common indications for laparoscopic partial splenectomy are non-parasitic splenic cystic, benign splenic tumors, splenic haematological diseases, non-cystic intraparenchymal lesions, spleen rupture, splenic abscess, vascular abnormalities. Laparoscopic near total splenectomy is an innovative partial splenectomy technique consisting on preserving a residual spleen volume.

Conclusion

LNTS seems to be a safe and effective technique for the management of benign spleen diseases. The comparison between other spleen preserving techniques shows that LNTS is associated with a lower rate of secondary surgery and postoperative recurrence of anaemia.

A Study on the Efficacy of Empirical Antibiotic Therapy for Splenectomized Children with Fever

Thalassemia represents a heterogeneous group of inherited diseases characterized by the lack or reduced production of hemoglobin β-chains. Many patients with thalassemia require splenectomy. What should be considered in the evaluation and management of candidates for splenectomy is to cover vaccination against infections such as pneumococci and the implementation of antibiotic prophylaxis. This study aimed to investigate the effect of the antibiotic type on the outcome of acute post-splenectomy infection in patients with thalassemia. This investigation is a retrospective cohort study. One hundred fifty medical records of hemoglobinopathy patients who underwent splenectomy were collected from the Ali-Asghar Hospital, Tehran, Iran. SPSS v. 20 and SAS v. 1.9 were used to analyze the data. A total of 150 patients that were vaccinated against post-splenectomy infections and were under antibiotic prophylaxis underwent splenectomy. The most commonly prescribed drugs were ceftriaxone or cefotaxime (132 cases, 88%), followed by ceftriaxone plus clindamycin (5.3%), ceftriaxone plus amikacin (3.3%), clindamycin (1.3%), vancomycin plus amikacin (0.7%), and others (1.3%). In terms of treatment outcomes, 143 cases (95.3%) were treated with the same antibiotics, and 4 (2.7%) experienced a changed antibiotic regimen with vancomycin. The results show that perceptions of treatment for fever in splenectomized children need to be changed, and most of them do not require hospitalization and initiation of broad-spectrum antibiotics such as vancomycin for initially refractory cases, and can only be treated with daily intravenous ceftriaxone.

Precision Technique for Splenectomy Limits Mouse Stress Responses for Accurate and Realistic Measurements for Investigating Inflammation and Immunity

Splenectomy in an animal model requires a standardized technique utilizing best practice to avoid variability which can result in adverse impact to the animal resulting in flawed physiologic responses simply due to technique rather than to the studied variables. In the case of the spleen, often investigators are analyzing the animal immune or inflammatory responses. Surgical splenectomy involves many variables from the training and expertise of the surgeon, which directly correlates to surgical technique to the length of operation and ease of the procedure. This operation, in turn, impacts blood loss and insensible fluid losses, sterile technique, unintended trauma to the spleen and surrounding organs, the length of the incision and the duration of the operation with more prolonged exposure to anesthetic agents. All these variables ultimately play a significant role in the experiment since they directly affect the response of the model in terms of inflammation, immune activation, or even suppression. Undesired variables such as these go unnoticed and lead to inaccurate and misleading data.