Long-term follow-up of partial splenectomy in Gaucher's disease

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

BACKGROUND/PURPOSE

In order to avoid consequences of total splenectomy (including severe postsplenectomy sepsis), partial splenectomy (PS) is increasingly reported. Without guidelines and indications concerning a rarely-indicated procedure, a review of literature should be an asset.

METHODS

A systematic review of all PSs from 1960 to December 2017 was performed, with special focus on surgical indications, sites of resection, approaches and techniques of vascular dissection and parenchymal section/hemostasis of the spleen, perioperative morbidity/mortality, including complications compelling to perform total splenectomy.

RESULTS

Among 2130 PSs, indications for resection were hematological disease in 1013 cases and nonhematological conditions in 1078, including various tumors in 142 and trauma in 184. Parenchymal transection was performed using several techniques through the years, most frequently after having induced partial ischemia by splenic hilum vascular dissection/ligation. 371 laparoscopic/robotic PSs were reported. Rescue total splenectomy was required in 75 patients.

CONCLUSIONS

Although good results are probably overestimated by such a retrospective review, PS should be considered as a procedure associated with a low morbidity/mortality. Nevertheless, severe complications are also reported, and the need of total splenectomy should not to be minimized. Laparoscopic/robotic procedures are increasingly performed, with good results and rare conversions.

TYPE OF STUDY

Systematic review.

LEVEL OF EVIDENCE

IV.

Hereditary spherocytosis and partial splenectomy in children: review of surgical technique and the role of imaging

The risks associated with total splenectomy, including overwhelming postsplenectomy infection, have led to an interest in the use of partial splenectomy as an alternative surgical option for children with congenital hemolytic anemias and hypersplenism. Partial splenectomy, a procedure designed to remove enough spleen to improve anemia and avoid complications of splenic sequestration while preserving splenic function, has shown promise in children. Radiologic imaging is essential for the preoperative evaluation and postoperative care for children undergoing partial splenectomy and offers a broad range of critical clinical information essential for care of these complex children. It is imperative for radiologists involved in the care of these children to be familiar with the surgical technique and imaging options for these procedures. This article reviews the surgical technique as well as the current status of various diagnostic imaging options used for children undergoing partial splenectomy, highlighting technical aspects and specific clinical information obtained by each modality.

Follow-up of partial splenectomy in children with hereditary spherocytosis

BACKGROUND/PURPOSE

The aim of this report is to study the short- and long-term consequences of partial splenectomy (PS) in hereditary spherocytosis (HS).

METHODS

The authors reviewed the files of 5 children who underwent PS from 1993 to 1998. The data collected included clinical presentation, age, gender, indication for the operation, radiographic examination, need for blood transfusion and hematologic values, description of surgical procedure, and early- and late-occurring complications.

RESULTS

From 1993 to 1998, 5 children from one year, 9 months to 7 years of age underwent PS. Indications were hypersplenism and severe anemia. The average age at the time of the operation was 3 years, 5 months. The 2 youngest children (one year, 9 months and 2 years old) needed a second operation because of the recurrence of hypersplenism.

CONCLUSIONS

Subtotal splenectomy seems to preserve the immune role of the spleen and can reduce the need for blood transfusion. But PS is associated with a regrowth of the splenic remnant in children suffering from chronic hemolysis with hypersplenism and seems to be effective for a relatively short period only, especially in young children. Thus, a second operation to perform a total splenectomy can be necessary. The decision to perform a PS on young children with HS as an alternative to total splenectomy with appropriate preoperative vaccination and postoperative prophylactic antibiotics therefore should be weighed carefully, keeping in mind, however, the benefit of postponing total splenectomy in these patients.

Low-dose high-frequency enzyme replacement therapy prevents fractures without complete suppression of painful bone crises in patients with severe juvenile onset type I Gaucher disease

Patients with type I Gaucher disease often present as adults with a mild disease and with less severe genetic mutations, especially 1226G/1226G (N370S/N370S). Patients presenting as children have an excess of compound heterozygotes of N370S and other mutations, such as 84GG, 1448C (L444P) and IVS2 + 1 in whom bone disease is common. We report our experience with low-dose high-frequency enzyme replacement therapy in such severely affected children. Ten patients (with severe juvenile onset type I Gaucher disease) were treated. Alglucerase (Ceredase) was infused at 30 units/kg/month in 13 fractions/month for more than one year. Bone disease was used as the main criterion for evaluating treatment results. No fractures occurred in spite of the fact that bone crises occurred in four patients after 12 to 24 months of treatment, in two during the third year, and in one during the fifth year. Nonosseous manifestations improved with treatment. The ability of low-dose high frequency alglucerase to prevent fractures in the presence of continuing bone crises was demonstrated.

Splenic "regeneration" after partial splenectomy for Gaucher disease: histological features

Partial splenectomy for Gaucher disease is often followed by reenlargement of the splenic remnant. It remains unclear if this process is due to tissue regeneration or to continued deposition of glucocerebroside in the reticuloendothelial system or both. We compared the splenic architecture before and after reenlargement in three cases of failed repeated partial splenectomy after two, six and five years. Using the number of lymphoid follicles per hundred low power fields (LF/LPF) as an arbitrary index, we found that prior to the first operation 18, 20 and 27 lymphoid follicles were present per one hundred low power fields, while at the second operation, the corresponding rates were 11, 15 and 17; in control spleens, an average of 712.5 lymphoid follicles were present in one hundred low power fields. The difference in the LF/LPF ratio before and after reenlargement, led us to speculate that splenic re-enlargement in Gaucher disease is mainly the result of the continued deposition of the glucocerebroside in the reticuloendothelial system of the splenic remnant, though some degree of true regeneration as well cannot be completely ruled out. These findings are compared with animal studies and results for partial splenectomy on humans, performed for trauma. Further studies in patients with Gaucher disease are warranted to better define the underlying mechanism of splenic reenlargement.

The health-related quality of life of adults with Gaucher's disease receiving enzyme replacement therapy: results from a retrospective study

Few studies have reported on the effect of Gaucher's disease on patient-reported, health-related quality of life (HRQoL) and we do not know how the HRQoL burden of Gaucher's disease compares to that of other chronic conditions, what areas of HRQoL are most affected or how the course of change in HRQoL compares with that observed for other conditions or for the general adult population. The purpose of this study was to estimate (1) the HRQoL burden associated with Gaucher's disease managed by enzyme replacement therapy (ERT), (2) recalled changes in HRQoL since ERT initiation and (3) risk factors predictive of HRQoL outcomes. We sampled 212 patients with Gaucher's disease recruited from 146 physicians prescribing ERT in the US. The patients were at least 14 years of age and had been on ERT from 1 to 51 months. The mean (SD) age of the participants was 45 (17) years. Forty-nine percent had had a prior splenectomy and 26% had had a joint replacement. We administered the SF-36 Health Survey (SF-36) and three questions about changes in physical, mental and general HRQoL since starting ERT. The patients with Gaucher's disease scored significantly worse than the age- and gender-adjusted US norms on five of the eight SF-36 subscales (p < 0.05). Age (p < 0.0001) and joint replacement (p < 0.001) were negatively associated with physical health. The presence of an intact spleen (p < 0.01) and a longer duration of ERT (p < 0.01) were associated with better mental health. When asked about changes in HRQoL since starting ERT, at least half of the patients reported fewer limitations in physical activities (53%), better general health perceptions (77%) and less negative emotions (49%) at the time of the interview. Patients who had been receiving ERT for approximately 4 years recalled four and five times more improvement in general HRQoL in comparison with recalled changes over a 4 year period among adults in the general population (p < 0.001) and a congestive heart failure population (p < 0.01), respectively. Odds ratios (ORs) revealed that female patients were more likely to report improvements in general HRQoL than males (OR = 4.50 and 95% CI = 2.19-9.25) and 45 year old patients were less likely to report improvements than 35 year olds (OR = 0.76 and 95% CI = 0.62-0.94). Relative to patients who had been receiving ERT for 1 year, those who had been receiving ERT for 2 and 4 years were 1.40 (95% CI = 1.06-1.84) and 2.75 (95% CI = 1.20-6.27) times more likely to report improvements in general HRQoL, respectively. In summary, patients with Gaucher's disease on ERT reported an improvement in HRQoL that was greater than that reported by patients with other chronic diseases. However, Gaucher's patients treated for up to 51 months scored below equivalent adults in the general population. The risk factors, including age and history of splenectomy and joint replacement, warrant further study. Standardized HRQoL measures are likely to prove useful in understanding better the outcomes from the Gaucher's patient's perspective.

Elective partial splenectomy in childhood

BACKGROUND & PURPOSE

The indications and results of elective partial splenectomy in children remain uncertain. The aim of this study was to determine (1) the indications for elective partial splenectomy (EPS), (2) the extent of splenic resection, and (3) the complications of EPS.

METHODS

Patients who underwent EPS from three centers over a 10-year period (1986 through 1996) were studied. Variables analyzed included clinical presentation and indications for EPS, extent of resection performed, perioperative transfusions, and complications. Postoperatively, splenic viability was determined by regular Doppler ultrasound scan and splenic function on peripheral blood film analysis.

RESULTS

EPS was attempted in 12 children for various conditions: giant epithelial cyst (n = 6), hypersplenism and metabolic disease (n = 4), pseudotumor (n = 1), and abscess (n = 1). One procedure was converted to total splenectomy because of thin splenic tissue around an infected giant cyst. No child required transfusion for splenic bleeding. There were no postoperative complications or deaths. Only 7 of the 12 children received prophylactic preoperative immunisation. In the 11 successful cases splenic remnant viability remains confirmed by ultrasound scan and normal blood film. There has been no significant splenic regrowth or recurrent hypersplenism in the four children with metabolic disorders.

CONCLUSIONS

EPS is suitable for benign splenic conditions and can be performed without major blood loss. Preoperative vaccination is advisable. Up to 95% of the spleen can be safely removed, basing the blood supply of the residual spleen tissue on peripheral polar vessels, with adequate postoperative function.

Should repeated partial splenectomy be attempted in patients with hematological diseases? Technical pitfalls and causes of failure in Gaucher's disease

BACKGROUND/PURPOSE

The awareness of the risk of overwhelming sepsis after splenectomy prompted surgeons to attempt splenic preservation in patients who had hematologic diseases for which splenectomy was the conventional treatment. Partial splenectomy for Gaucher's disease was widely performed before the introduction of alglucerase. In sporadic cases a second partial splenectomy had also been attempted.

METHODS

The authors present three cases of failed repeated partial splenectomy attempted before alglucerase was available. The role of angiography in planning operative strategy and the surgical pitfalls of this unusual reintervention are discussed.

CONCLUSION

New indications for partial splenectomy in other hematologic diseases makes the experience gained with Gaucher's disease valuable for management decisions.

Effective treatment of painful bone crises in type I gaucher's disease with high dose prednisolone

In type I Gaucher's disease, episodes of severe disabling bone pain, the so called bone crises, may be resistant to all analgesics, including narcotics. The demonstration of subperiosteal oedema on magnetic resonance imaging (MRI) led to an attempt to use steroids to relieve the oedema and thereby the pain. On eight occasions, five patients with documented bone crises received conventional dose steroids (20 mg/m2/day) with considerable shortening of the attacks. On six occasions five further patients received high dose methylprednisolone (30 mg/kg intravenously or 1 g/m2 orally daily for two days), which was followed by oral prednisone for three to five days on the last four occasions. In this later group, pain relief was evident within several hours. Three treatments were given on an ambulatory basis. The MRI scan of one of these patients showed no subperiosteal fluid collection five days after high dose steroids had been started, and on subsequent x ray examination, there was no periosteal elevation. This treatment should be considered in cases of Gaucher's disease with bone crises.

Outcome of partial splenectomy for type I Gaucher disease

Partial splenectomy was introduced to achieve the benefits of splenectomy and to avoid the risk of overwhelming infection in patients with symptomatic Gaucher disease. We observed regrowth of the splenic remnant, reemergence of preoperative symptoms, and new bone involvement among most of our patients who had undergone partial splenectomy. Enzyme replacement therapy has markedly limited indications for splenectomy, partial or total, for Gaucher disease.