Posttraumatic splenic replantation in children

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.

Histological aspects of autologous transplantation of different fragments of the spleen in rats

PURPOSE

To evaluate macro and microscopically the evolution of autotransplants of fragments of spleen different fragments in the greater omentum, after eight weeks of observation.

METHODS

Twenty rats Wistar were used, males and adults, submitted to total splenectomy and divided in two groups. The group I - ten animals with implant of spleen fragment (25% weight of spleen) in the omentum; and group II - ten animals with implant of spleen fragment (30% weight of spleen) in the omentum. It was analyzed macro and microscopically the evolution of the implant.

RESULTS

It was observed adherences to the adjacent tissues and vascularization in all of the fragments transplanted. The group I and II presented white pulp with follicular formations and lymphoid tissue preserved, and the red pulp in cordon aspect. The group II presented white pulp more disorganized and red pulp hemorrhagic. The active macrophages were observed in the group I and II.

CONCLUSION

The splenic autotransplantation of the group I showed better regeneration.

Late histological aspects of spleen autologous transplantation in rats

PURPOSE

To evaluate macro and microscopically the late evolution of autotransplants of fragments of spleen in the greater omentum, mesenterium and peritoneal cavity, after 24 weeks of observation.

METHODS

Fifty two Wistar rats were used, males and adults, submitted to total splenectomy and divided in four groups. The group I--seventeen animals with implant of spleen fragment in the peritoneal cavity; group II--eighteen animals with implant in the omentum and group III--seventeen animals with implant fixed in mesenterium root. The group control (group IV) was formed by eight animals chosen aleatorily among the three groups. It was analyzed macro and microscopically the evolution of the implant, and in the histological study qualitative and quantitative criteria were adopted, with the counting of no cellular e cellular elements.

RESULTS

It was observed adherences to the adjacent tissues and vascularization in all of the fragments transplanted. The group I presented white pulp and preserved vascularization. In the group II were observed white pulp with follicular formations and lymphoid tissue preserved, and the red pulp in cordon aspect and hemorrhagic. In the group III were observed with depletion of white and red pulp, while others evidenced better preservation of the pulps. The counting of lymphocytes revealed significant difference between the groups I and IV and the group III and IV (p < 0.05). The counting of active macrophages revealed significant difference between the groups II and III (p < 0.05) and similarity between II and IV (p > 0.05). The other elements: active macrophages phagocyting hemosiderine, plasmocytes, fibroblasts, fibrocytes, giant cells, monocytes, interstitial spaces and fibers of collagen, did not show significant difference among the groups.

CONCLUSIONS

The splenic autotransplantation is feasible, being the better place the greater omentum. This research demonstrated through qualitative and quantitative histological analysis that the splenic tissue autotransplanted in the omentum of Wistar rats preserves its function of defense of the organisms.

Autotransplant of spleen tissue in children with schistosomiasis: evaluation of splenic function after splenosis

Autotransplantation of spleen tissue has been done, in the past ten years, in children with schistosomiasis mansoni with bleeding varices. The purposes of this investigation were: (1) to study the morphology and function of the remnant spleen tissue; (2) to quantify the production of tuftsin; and (3) to assess the immune response to pneumococcal vaccine of these patients. Twenty three children, who underwent splenectomy and autologous implantation of spleen tissue into the greater omentum were included in this investigation. The average postoperative follow-up is five years. Splenosis was proved by colloid liver-spleen scans. Search for Howell-Jolly bodies assessed the filtration function. Tuftsin and the titer of pneumococcal antibodies were quantified by ELISA. Splenosis was evident in all children; however, it was insufficient in two. Howell-Jolly bodies were found only in these two patients. The mean tuftsin serum concentration (335.0 +/- 29.8 ng/ml) was inside the normal range. The immune response to pneumococcal vaccination was adequate in 15 patients; intermediate in four; and inadequate in four. From the results the following conclusions can be drawn: splenosis was efficient in maintaining the filtration splenic function in more than 90% and produced tuftsin inside the range of normality. It also provided the immunologic splenic response to pneumococcal vaccination in 65% of the patients of this series.

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.

Autotransplantation of spleen tissue in children with mansonic schistosomiasis who underwent splenectomy: Evaluation of splenic residual functions

Autotransplantation of spleen tissue is an attempt for maintenance of splenic functions when splenectomy is indicated in children. It minimizes the risks of overwhelming postsplenectomy infection and it has been done in children with severe portal hypertension due to hepatosplenic mansonic schistosomiasis that underwent splenectomy. The purposes of this investigation were to study the morphology of the residual splenic tissue; to evaluate the residual filtration function of this splenosis; and to assess the immune response to polyvalent pneumococcal vaccine of these patients. Twenty-three children with portal hypertension from mansonic schistosomiasis who underwent splenectomy, ligature of the left gastric vein, autotransplantation of spleen tissue into an omental pouch were evaluated for residual splenic parenchyma and functions. Tc-99m sulfur colloid liver-spleen scans were used for detection of splenic nodules. The search for Howell Jolly bodies were used for assessing the filtration function and Enzyme-linked immunosorbent assay was used for measuring the relative rise in titter of specific pneumococcal antibodies. Splenosis was evident in all children; however, in two there were less than five splenic nodules in the greater omentum, which was considered insufficient. Howell-Jolly bodies were found in the peripheral blood only in these two patients with less evident splenosis. The immune response was adequate in 15 patients; it was intermediate in 4 patients and inadequate in 4 patients. Autotransplantation of spleen tissue into an omental pouch is efficient in maintaining the filtration splenic function in more than 90% of the cases and the immune response to pneumococcal vaccination in approximately 65% of the children.

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.

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.

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.

Autotransplantation of lymph node fragments. Structure and function of regenerated tissue

In pigs slices of autologous lymph nodes were implanted in the subcutaneous fat, under the muscular fascia or under the kidney capsule to study the regeneration of autotransplanted lymph node tissue. The regenerated nodules consisted of all the normal compartments found in lymph nodes and there was evidence that afferent lymphatics reached these nodules. Superficial inguinal lymph nodes regenerated more often and with a better structure than mesenteric lymph nodes. The sites under the kidney capsule and the fascia of muscles were found to be a less stimulating microenvironment for regeneration than the subcutaneous tissue. Regeneration of transplanted lymph node tissue was observed in pigs which had been operated on as young piglets or as adults. The regeneration of autotransplanted lymph node tissue might be a useful model for draining lymphedema, especially from the extremities.

Incidence of septic and thromboembolic-related deaths after splenectomy in adults

In a review of 37,012 autopsies over the last 20 years 202 deceased adults who had had a splenectomy were investigated. The incidence of infections and thromboembolic complications related to death in these patients was compared with that of a matched deceased population (n = 403) who had not undergone splenectomy. Death-related pneumonia was diagnosed frequently in the splenectomy group and to a lesser extent in the control group (57.9 versus 24.1 per cent, P less than 0.001). Lethal sepsis with multiple organ failure occurred in 6.9 per cent of the splenectomy group and in 1.5 per cent of the controls (P less than 0.001). Purulent pyelonephritis was observed in 7.9 per cent of the splenectomy group and was significantly more frequent than in the control group with its rate of 2.2 per cent (P less than 0.001). Finally, pulmonary embolism was the major or a contributory cause of death more often in the splenectomy group than in the control group (35.6 versus 9.7 per cent, P less than 0.001). We conclude that splenectomy generates a considerable life-long risk of severe infection and of thromboembolism.

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.

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 splenic tissue

Autotransplantation of splenic fragments has already been carried out in humans. The optimal size of the particles and amount of tissue required for this procedure has yet to be found. In normal young pigs and miniature piglets, autologous splenic tissue was transplanted into the greater omentum. The regenerated splenic mass, splenic blood flow, and histology were studied six months later. Implanting small splenic particles produced comparable results to implanting thin slices of splenic tissue. The mass of regenerated splenic tissue was only 3.1 g after implanting the whole spleen and 4.5 g after transplanting half of the spleen, which means 5.3% and 7.8% respectively of the weight of control spleens. The blood flow per gram in the regenerated splenic tissue was much lower than in the normal spleen. The blood flow in the whole of the splenic tissue is important for the clearance function of the spleen. Six months after transplanting the whole or half of the spleen, the blood flow to the regenerated splenic tissue was only 1% of that in the control minipigs. When half of the spleen was left in situ, as a model for a partial splenectomy, and the other half transplanted, the regenerated mass was only 3.4% of all splenic tissue and the blood flow 1.5% of the total splenic blood flow. In this model the regenerated splenic mass was independent of the size of the implants and the mass of implanted tissue. The extremely low blood flow indicates an inadequate clearance function and thus the protective function would probably be negligible.

Multisystem trauma

Several unique features of childhood anatomy and physiology mandate an approach to evaluation and treatment of multiply injured children that differs from that applied to adults. Details of this approach have been presented, with particular emphasis, on early, aggressive multimodal imaging, nonoperative management of splenic, hepatic, renal, and duodenal injuries, and specific aids in early precise definition of extent of injury (contrast-enhanced CT, serum levels of hepatic enzymes, and diagnostic peritoneal lavage). The outcome of this approach preserves maximum function and minimizes morbidity when performed in an institution having the requisite supportive resources.

The effect of the immunomodulator corynebacterium parvum on hemisplenectomized mice

The immunomodulator Corynebacterium parvum stimulates the reticuloendothelial system and causes splenic hypertrophy. The ability of C parvum to stimulate splenic regeneration in hemisplenectomized mice and decrease susceptibility to intranasal pneumococcal challenge was studied. Mice were divided into two groups, control sham-operated (n = 48) and hemisplenectomized (n = 47) animals. Ten days later, each group was divided into two subgroups, those injected with C parvum (700 mcg IVP) and those injected with an equivalent volume of saline. The animals were challenged with Streptococcus pneumoniae, which was injected into one nostril three weeks postoperatively, and mortality was assessed. Four and one-half weeks postoperatively, splenic tissue was removed, measured, weighed, and submitted for histologic examination. The number of spleen cells per gram of tissue was assessed. Treatment with C parvum resulted in a significant increase in the splenic weight in both hemisplenectomized and control animals compared to similar saline-injected mice (P less than 0.001). The percentage increase in spleen weight of hemisplenectomized mice (106%) was significantly greater than that for control animals (56%; P less than 0.01). There was no significant difference among experimental groups in the number of spleen cells per gram of splenic tissue or in the histologic characteristics, indicating that C parvum stimulated relatively normal splenic growth. Survival following pneumococcal challenge was significantly increased for hemisplenectomized mice by C parvum treatment to a level that did not significantly differ from control mice. This study demonstrates that in mice the deficits related to resistance to infection and spleen size following hemisplenectomy are significantly improved by treatment with C parvum.