Surgical aspects of splenic disease and lymphoma

Cutaneous Malignant Melanoma Presenting as an Isolated Splenic Metastasis: An Update

Although the spleen is a highly vascularized organ, metastatic deposits from non-hematolymphoid solid malignancies are rare. This is reasoned to the inherent resistance of the splenic parenchyma to harbor metastases. The splenic capsule, lack of afferent lymphatics, contractile properties of the spleen, and the angular and gyroid course of the splenic artery form several barriers against the metastatic spread of malignant tumors. Moreover, the immune cells in the white and red pulps of the spleen have strong defensive ability against the tumor cells. Metastasis from solid tumors to the spleen often occurs only during widespread distant spread. Malignant melanoma is a rare but fatal malignancy. Isolated splenic metastasis from malignant melanoma is exceptionally rare. Studies that addressed the splenic metastasis from cutaneous malignant melanoma are scarce. This minireview was performed to address this subject. Here we present an overview of the clinicopathologic features of isolated splenic metastatic melanoma. The diagnostic biochemical markers in melanoma are also discussed.

Squamous cell carcinoma of the spleen: A case report

Tumor incidence in the spleen is relatively low compared with that in other organs. The majority of primary splenic tumors are benign, and the majority of malignant tumors are lymphoma or fibrosarcoma. While the occurrence of single squamous cell carcinoma in the spleen is rare, the present study reports a case of single splenic squamous cell carcinoma in which the patient received surgery, chemotherapy and Chinese herbal treatment, and died 14 months after diagnosis. As to the best of our knowledge this case type has not been previously reported; the present study provides insight into the response for standard treatment and the prognosis of the splenic squamous cell carcinoma for a single case.

A new technique for partial splenectomy with radiofrequency technology

The advantage of partial splenectomy is the preservation of its immunologic function. In this series, 8 patients underwent a spleen preservation procedure with radiofrequency. Four of the partial splenectomy procedures were performed in elective situations, whereas the other 4 cases were performed to control traumatic bleeding in emergency situations. A harrow-like radiofrequency probe with 6 needles was applied to the spleen, and the division of the splenic parenchyma was completed using a surgical scalpel through the midline of the ablated tissue. This safe, fast, and simple technique allows for preservation of splenic function with minimum blood loss.

Prevention and management of complications of laparoscopic splenectomy

Laparoscopic splenectomy (LS) has become a commonly performed minimal-access operation. With increasing experience, surgeons are undertaking LS for multiple pathologies and tackling spleens of diverse sizes. LS remains a challenging procedure to be performed by experienced laparoscopic surgeons, well supported by a team. Bleeding remains the commonest intraoperative complication and perhaps the commonest reason for conversion to a laparotomy. Although the incidence of postoperative complications following LS is lower than that after open splenectomy, thrombosis of the splenoportal axis is being increasingly recognised. The present review describes both the common as well as uncommon intraoperative and postoperative complications of LS and outlines measures to be taken for their prevention and management.

Partial splenectomy using an electromagnetic thermal surgery system in a porcine model

PURPOSE

Partial splenectomy is technically more complicated than total splenectomy due to difficulty in haemostasis, but it can preserve splenic function after operation. We evaluated the feasibility and safety of partial splenectomy performed by an electromagnetic thermal surgery system in a porcine model.

METHODS

Our system was comprised of an alternating electromagnetic field generator, an extensible coil applicator, comb-needle arrays, and a temperature feedback control component. Ten Lanyu pigs were anaesthetised to conduct partial splenectomy. Two rows of comb-like stainless-steel needle arrays were inserted into the tissue at 15 cm from the distal tip of the spleen. The temperature of the tissues around the needle arrays was raised to 150°C for 3 min and the spleen was transected directly between the needle arrays and then sent for histological examination. Two weeks later, the animals underwent a second celiotomy to remove the remaining spleen for histological examination.

RESULTS

The average duration of the partial splenectomy was 10 min as timed from insertion of the needle arrays to the transection of the spleen. There was no blood loss during the procedure. The cut surface of the spleen was well coagulated without any oozing sites. During the re-exploration, no intra-abdominal blood was found. There were dense adhesions between the spleen and the surrounding organs. Histological examination of the cut surface of the excised portion of the spleen showed coagulative necrosis with clot formation in the blood vessels.

CONCLUSIONS

Partial splenectomy using our electromagnetic thermal system can achieve effective haemostasis and is safe and easy to perform.

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Long-term outcome after laparoscopic splenectomy related to hematologic diagnosis

BACKGROUND

Laparoscopic splenectomy (LS) has been demonstrated as an effective and safe treatment for hematological disorders requiring spleen removal, especially in cases of normal-sized spleens. However, although results are promising, long-term outcome data are lacking. We reviewed our clinical experience with LS in a series of 255 cases, with particular attention to the long-term outcome related to the disease process requiring LS.

METHODS

From February 1993 to October 2003, LS was attempted in 255 patients (100 males and 155 females with a mean age of 45 +/- 19 years) and clinical information was recorded in a prospective database. Indications for splenectomy included idiopathic thrombocytopenic purpura (ITP) (n = 115), HIV-ITP (n = 9), Evans syndrome (n = 6), autoimmune hemolytic anemia (AIHA) (n = 13), hereditary spherocytosis (HS) (n = 19), hematologic malignancy (n = 66), thrombotic thrombocytopenic purpura (n = 1), and others (n = 26). Long-term postoperative follow-up evaluation was obtained through clinical notes, follow-up visits by the referring hematologist, and by phone interviews both with patients and with the referring hematologist.

RESULTS

A total of 186 patients (73%) were available for a mean follow-up of 35 months (range, 1-104). Of the ITP patients, 87 (76%) were followed up, with a remission rate of 89% (complete remission in 75%). A similar remission rate was observed in ITP-HIV; in patients available for follow-up (78%), complete remission was achieved in 83%. In Evans, complete remission was achieved in all patients available for follow-up (67%). Clinical response for hemolytic disease ranged between 70% for AIHA and 100% for HS. In the malignant group, the late mortality rate was 22%. The mortality rate in the miscellaneous group was 5%. No cases of splenectomy-related sepsis occurred during follow-up.

CONCLUSIONS

LS offers advantages for all types of splenic diseases requiring surgery. It provides not only good clinical short-term outcome but also satisfactory long-term hematological results.

Partial splenectomy using a coupled saline-radiofrequency hemostatic device

BACKGROUND

Partial splenectomy is indicated for benign tumors and cysts of the spleen, as well as, operative management of splenic trauma limited to one pole of the spleen. Despite improved technique, bleeding from the cut surface of the spleen still remains an obstacle.

METHODS

We describe our technique for partial splenectomy using a new device based on coupling saline with radiofrequency energy to achieve hemostasis while dividing the splenic parenchyma.

RESULTS

Use of this technique has led to blood loss of less than 50 cc, while achieving splenic preservation.

Results of laparoscopic splenectomy for treatment of malignant conditions

BACKGROUND

Laparoscopic splenectomy (LS) is widely accepted for treatment of benign diseases, but there are few reports of its use in cases of haematological malignancy. In addition, comparative studies with open operation are lacking. Malignant haematological diseases have specific clinical features-notably splenomegaly and impaired general health-which can impact on the immediate outcome after LS. The immediate outcome of LS comparing benign with malignant diagnoses has been analysed in a prospective series of 137 operations.

PATIENTS AND METHODS

Between February 1993 and April 2000, 137 patients with a wide range of splenic disorders received LS. Clinical data and immediate outcome were prospectively recorded,and age, diagnosis, operation time, perioperative transfusion requirement, spleen weight, conversion rate, accessory incision, hospital stay and complications were analysed.

RESULTS

The series included 100 benign cases and 37 suspected malignancies. In patients with malignant diseases the mean age was greater (37 years [3-85] vs 60 years [27-82], p<0.01), LS took longer (138 min [60-400] vs 161 min [75-300], p<0.05) and an accessory incision for spleen retrieval was required more frequently (18% vs 93%, p<0.01) because the spleen was larger (279 g [60-1640] vs 1210 g [248-3100], p <0.01). However, the rate of conversion to open operation (5% vs 14%), postoperative morbidity rate (13% vs 22%) and transfusion requirement (15% vs 26%) did not differ between benign and malignant cases. Hospital stay was longer in malignant cases (3.7 days [2-14] vs 5 days [2-14], p<0.05).

CONCLUSION

LS is a safe procedure in patients with malignant disease requiring splenectomy in spite of the longer operative time and the higher conversion rate.

Laparoscopic excision of accessory spleen

BACKGROUND

Laparoscopic splenectomy has become an accepted procedure in the management of several hematologic diseases. Less clear is the effectiveness of laparoscopic excision of accessory spleens after initial splenectomy in the management of recurrent hematologic disease. We report here our early experience of this technique.

METHODS

All patients who underwent laparoscopic excision of accessory spleens (LEAS) after initial splenectomy were reviewed for preoperative studies, technical success, and effects on either platelet count or hemoglobin level.

RESULTS

In 5 patients LEAS was attempted. Two patients had initial open splenectomies, and 3 had initial laparoscopic splenectomies. Hematologic diagnoses were immune thrombocytopenic purpura (3), chronic lymphocytic leukemia-induced thrombocytopenia (1), and autoimmune hemolytic anemia (1). All patients underwent preoperative damaged red blood cell scintigraphy, which demonstrated functioning splenic tissue, and abdominal computed tomography scans, which demonstrated a nodule in 4 of 5 patients. LEAS was technically successful in 4 patients, with the 1 failure also being the patient in whom the computed tomography scan could not demonstrate the accessory spleen. However, only 2 of the 4 patients after LEAS had durable hematologic responses to surgery, despite follow-up damaged red blood cell scintigraphy showing no residual functioning splenic tissue.

CONCLUSION

LEAS can be technically successful when the accessory spleen is demonstrated on both damaged red blood cell scintigraphy and computed tomography scan; therefore, adequate visualization in both studies is required. However, hematologic response to excision may be less effective than with the initial splenectomy. Further study is needed to determine the causes of these outcomes.

The response to splenectomy in pediatric patients with idiopathic thrombocytopenic purpura who fail high-dose intravenous immune globulin

BACKGROUND

A recent article by Law et al concluded that patients with idiopathic thrombocytopenic purpura (ITP) who have a poor response to intravenous immune globulin (IgG) are unlikely to have a good or excellent response to surgical splenectomy.

METHODS

The authors studied retrospectively 23 pediatric patients age 11.7 +/- 1.0 years with ITP who had been treated with IgG before undergoing splenectomy. As in the aforementioned article, the responses to the 2 treatments were classified on the basis of the platelet count as poor (<50,000/mm3), good (50,000 to 150,000/mm3), or excellent (>150,000/mm3). For patients who received multiple IgG treatments, both initial and final treatment responses were analyzed.

RESULTS

Sixteen patients had an excellent or good initial response to IgG. Of these 16 patients, 14 had an excellent or good response to splenectomy. Among the 7 patients who had a poor response to IgG there were 3 who had an excellent or good response to splenectomy (43%), and 4 patients who had a poor response to splenectomy. A good or excellent response to initial treatment with IgG was associated with a significant probability of a good or excellent response to splenectomy (P = .045).

CONCLUSIONS

A good or excellent response to IgG may be predictive of a favorable response to splenectomy. However, a poor response to IgG does not preclude a satisfactory response to splenectomy in pediatric patients with ITP.