Ligation of the splenic artery; effects on the injured spleen and its function

Angiography and embolisation in blunt splenic injury: a review

The surgical care of patients has evolved over the last 50 years. Operative intervention in the face of blunt spleen injury has been supplanted by non-operative techniques. Two of the newest techniques, angiography and embolisation, are reviewed in this article with references to patient selection, technique used and outcomes. Furthermore, current weaknesses in the data available are discussed in order to provide surgeons with a complete overview of the techniques.

Angiography for blunt splenic trauma does not improve the success rate of nonoperative management

BACKGROUND

Splenic artery arteriography with possible therapeutic embolization (SAE) has been postulated to improve the success rate of nonoperative management of blunt splenic injuries and increase splenic salvage. Previous reports, however, have compared SAE with historical controls. We compared nonoperative success with SAE with a contemporaneous group treated nonoperatively without SAE.

METHODS

Patients who suffered blunt splenic trauma from 2000 to 2004 were identified. Demographic and outcome data were abstracted. Data on the performance of SAE, type of vessel embolized, and success or failure of nonoperative management were collected. Analysis of variance, chi, and regression analysis were used to evaluate the impact of SAE on outcome.

RESULTS

There were 570 patients who suffered blunt splenic trauma and 221 (39%) were treated operatively. There were 349 patients who were treated nonoperatively and 46 (13.2%) underwent SAE. SAE was more frequently used for patients with spleen Abbreviated Injury Score (AIS) > or =3 (31%) than AIS = 2 (6.7%). For patients with spleen AIS > or =3, there was no difference in age, gender, Injury Severity Score, or admission blood pressure between those who did or did not undergo SAE. The nonoperative success rate was similar for patients who did (79.3%) and those that did not (78.8%) undergo SAE.

CONCLUSIONS

Patients who underwent splenic arteriography did not have improved nonoperative splenic salvage rates compared with a contemporaneous control group of similarly injured patients. Subsets of patients with blunt trauma may benefit from SAE but further study will be required to define these patients.

Proximal Splenic Artery Embolization for Blunt Splenic Injury: Clinical, Immunologic, and Ultrasound-Doppler Follow-Up

BACKGROUND

To evaluate the clinical, US (ultrasound)-Doppler and hematologic findings after proximal splenic artery embolization (PSAE) for blunt injury.

METHODS

From August 1998 to February 2003, 37 patients (28 men and 9 women; 20-89 years old, mean 40 years) underwent PSAE for blunt injuries. One patient required secondary splenectomy after PSAE. Early complications were investigated during the hospital stay. Delayed follow-up included review of the outpatient records, telephone interview, consultation, US-Doppler splenic study, Howell-Jolly body search, and serum antibody titer determinations (pneumococcus and Haemophilus influenzae B).

RESULTS

No early postprocedural complications were depicted. Ten patients were lost on follow-up. Two patients had a telephone interview that revealed no complication. Twenty-four patients were examined 6 to 63 (mean 26) months after the embolization. No late complication was reported. Splenic measurements were in the normal range: length (53-110 mm; mean, 73), width (49-110 mm; 76), thickness (26-56 mm; 38), volume (61-508 mL; 226), standard ellipsoid formula volume (32-265 mL; 118), corrected volume (29-238 mL; 106), and splenic volumetric index (2.3-18.8; 8.4). The spleen was homogeneous in 23 patients (96%). Intrasplenic vascularization was present and splenic vein was patent in all patients. Howell-Jolly bodies were found in two patients. All patients (24 of 24) evaluated for exposure-driven immunity against Haemophilus Influenza b had sufficient immunity. Seventeen of the 18 patients (94%) evaluated for exposure-driven immunity against pneumococcus had sufficient immunity. Five of the six patients (83%) evaluated for pneumococcus vaccine response had a sufficient response.

CONCLUSIONS

Proximal splenic artery embolization in blunt splenic injuries is a well-tolerated technique without major long-term impact on the splenic anatomy and immune function.

The function of the spleen in adults after ligation of the splenic artery of the traumatized spleen in childhood

BACKGROUND

Ligation of the splenic artery (LSA) has been successfully used as a spleen-saving procedure in rare cases of splenic trauma in children in which management with splenorrhaphy or partial splenectomy alone was not possible. There are no data regarding the long-term effects of the procedure on the functional status of the spleen. The purpose of this study is to present and discuss our clinical and laboratory findings in adults who underwent LSA in childhood.

METHODS

Our first 2 patients in whom LSA was done at ages 4 and 2 years in 1977 underwent the following examinations in the year 2000: 1, imaging of the spleen; 2, immunologic studies; and 3, peripheral blood tests. Their ages at reexamination were 27 and 25 years, respectively.

RESULTS

Results were as follows: triplex ultrasound revealed normal size and echomorphology; Doppler techniques revealed normal vasculature; 99mTc-Tin colloid scanning revealed normal uptake. Immunoglobulins (IgG1 to IgG4, IgA, IgM, IgE), complement fraction (C3, C4), antibodies response to vaccinations, and peripheral blood tests all had normal results. No Howell-Jolly bodies were found.

CONCLUSION

Laboratory investigations in adults with LSA during childhood disclosed undisturbed function of the spleen. LSA can be used as an adjunct to splenorrhaphy in children with rare splenic injuries involving major hilar vessels.

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.

Regeneration and phagocytic function of devascularized spleens

The phagocytic function of normal splenic tissue and of regenerated tissue following splenic artery ligation was investigated in rats using radiolabelled stannous fluoride colloid. Colloidal carbon was used to determine the histological location of phagocytosis within the spleen. Six months after ligation, the median weight of the devascularized spleens was 25% of that of spleens in control rats. Technetium stannous colloid clearance by devascularized spleens was reduced to 10% of normal and 25% when corrected for spleen weight. The colloidal carbon injected intravenously was observed primarily in the marginal zone in both normal and devascularized spleens. Histologically, devascularized spleens contained significantly less white pulp and marginal zone. The splenic tissue which regenerates following ligation does not have the phagocytic ability of normal splenic tissue. This may be due to the decreased regrowth of the lymphoid compartments of the spleen.

Partial splenic embolization in hypersplenism

Four patients with portal hypertension, oesophageal varices and severe hypersplenism were treated by partial splenic embolization. All showed improvement of blood and platelet counts early in the postoperative period. Three months after embolization IgA and C3 levels increased significantly. All patients had a decrease in the incidence of variceal bleeding and this procedure provides an acceptable alternative to splenectomy.

Influence of dextran on pneumococcal septicemia in splenic artery-ligated or splenectomized rats

Splenic artery ligation is one of several methods in splenic preservation. In this experimental work the susceptibility of splenectomized rats and rats treated with splenic artery ligation to pneumococcal infection and the influence of the plasma expander dextran in the same groups were studied. The mortality among splenectomized rats was 100% vs nil after sham operation. Animals treated with splenic artery ligation and saline had a 23% mortality in pneumococcal septicemia, significantly different (P less than 0.05) from the 59% mortality after splenic artery ligation and dextran. A significant increase (P less than 0.05) in number of abscesses was also seen among rats given dextran.

Late return of function after intrathoracic torsion of the spleen in congenital diaphragmatic hernia

A case of late presentation of a left posterolateral diaphragmatic hernia in a four-year-old boy is reported. Shortly after incidental diagnosis of the diaphragmatic hernia, he was admitted with acute abdominal symptoms and laparotomy was performed. The stomach, small intestine, part of the colon, and the spleen were intrathoracic. There was a 720 degree torsion of the splenic pedicle. After reduction, the spleen was placed in the abdomen. At scintiscans 12 days and 14 weeks after operation, no certain splenic function was demonstrated, but at follow-up up 21/2 years later the splenic scan was normal.

Partial splenic ablation in preparation for renal transplantation in children

Patients with end-stage renal disease who develop hypersplenism, patients with mild neutropenia, and those patients whose WBC fails to increase in response to cortisol administration will develop significant neutropenia following transplantation with routine doses of azathioprine. This "intolerance" of azathioprine mandates a reduction in the dose of azathioprine often resulting in allograft rejection. Splenectomy will prevent azathioprine-induced neutropenia, but the hazards of splenectomy in these immunosuppressed patients have led to attempts to salvage at least part of the spleen. Partial splenic ablation by embolization has been utilized in adults prior to transplantation to prevent azathioprine-induced neutropenia while preserving the spleen's protective mechanisms against infection. Eight children in our series of transplant candidates required a reduction of splenic function to prevent azathioprine induced neutropenia. One child had a functioning renal allograft but had recurrent neutropenia limiting the azathioprine dose. Partial splenic embolization was attempted in four children and was initially successful in two. Both patients later developed recurrent neutropenia and needed partial splenectomy. The two patients in whom partial splenic embolization was unsuccessful and five further patients in whom embolization was not attempted also underwent partial splenectomy. Approximately 75% to 80% of the spleen was resected. Six children have since undergone renal transplantation and one child had a transplant with chronic rejection at the time of partial splenectomy. Routine doses of azathioprine have been used in these children with no episodes of neutropenia or sepsis observed. We recommend partial splenectomy in those children requiring renal transplantation who are at risk for development of azathioprine induced neutropenia.

Splenic artery ligation in splenic injuries

The risk of sepsis after splenectomy is well known. This chiefly concerns the surgeon, who should make every effort to save an injured spleen. This may be achieved by not operating on selected cases, by partial resection, or by suturing the splenic ruptures. Another treatment is ligation of the splenic artery, which is simple and effective in controlling even severe bleeding without splenectomy. Five patients have been treated in this way without complications.

Arterial segmentation of the human spleen by post-mortem angiograms and corrosion-casts

In a series of seventy adult human spleens, obtained from embalmed dissecting-room cadavers and post-mortem bodies, the extrasplenic division and intrasplenic architecture of the terminal branches of the splenic artery and of its polar arteries were studied via extrasplenic dissection, angiograms and injection-corrosion casts. The results showed that the splenic artery is divided into two (85.7%), or three (14.3%) primary branches, each of which is subdivided, mostly, into two to four secondary branches. Moreover, a superior polar artery (60.0%) and inferior polar arteries (80.0%) are given from the splenic trunk or from one of its primary branches. The human spleen is divided accordingly into two or three main arterial segments, separated by a definite avascular plane. Also, a rather constant avascular plane separated the polar segments from the remaining of the organ. Each main segment is also subdivided, usually into two to four less constant secondary segments, the architecture of which and the avascular planes between them are very variable. The findings of this study and other relative studies consist the anatomical basis for highly conservative surgical management, as an alternative to splenectomy, in cases of splenic rupture.

Splenic and hepatic trauma in children

The concepts for proper management of splenic and hepatic injuries have been evolving over the last several years. The recognition that aggressive surgical therapy in some instances was responsible for the number of life-threatening complications led to a reappraisal of the principles of care for these traumatic lesions. The emerging consensus of opinion is that often nonoperative therapy or more "conservative" operations are preferable. The accumulated experience to date supports the view that this more selective therapeutic approach will result in lower morbidity and mortality for children sustaining splenic or hepatic injuries. Fortunately, the recent technologic improvements in the field of radiology have enabled the clinician to diagnose and serially evaluate these major intra-abdominal injuries with a high degree of confidence.