Rationale for and methods of splenic preservation following trauma

"How safe is splenectomy?"

The increased risk of sepsis in patients following splenectomy has been well documented. Fear of overwhelming post-splenectomy sepsis (OPSI) has resulted in a generalized trend towards splenic salvage among surgeons. However, splenorrhaphy and attempts at splenic salvage may of themselves predispose to significant morbidity, sometimes more serious than increased susceptibility to infection associated with splenectomy. This study aims to assess the risk of splenectomy and subsequent asplenia. We reviewed 246 patients who underwent splenectomy over a 16 year period. Indications for splenectomy were considered under the following headings: haematological (N = 116), trauma (N = 69), visceral carcinoma (N = 28), incidental (N = 13) and miscellaneous (N = 20). There were 28 deaths in the series, primarily among those in the intra-abdominal carcinoma (13) and multiple trauma (13) groups. Two deaths were recorded among patients undergoing elective splenectomy for benign disease. Thrombo-embolic complications were recorded in nine patients; respiratory tract infection in 36 patients and intra-abdominal abscess in two patients. Two cases of post-splenectomy pneumococcal septicaemia were documented, neither of which was fatal. While not an entirely benign procedure, splenectomy can be performed relatively safely, especially when performed for benign disease in an adult population.

Hemostasis and healing of superficial splenic injuries using Nd:YAG laser and nonsuture techniques: preliminary report

This study was designed to compare Nd:YAG laser to fibrin glue, electrocautery, and avitene in the management of superficial splenic injury. Six dogs were submitted to laparotomy. A #11 blade scalpel was used to sharply excise the splenic capsule inflicting four 1" x 1" superficial injuries on each spleen. The lesions were treated. All animals had a second laparotomy ("first relaparotomy"); 2 dogs each were reexplored on postop days 3, 7, and 14. Morphologic and histologic observations were made. A third and final relaparotomy was performed on all dogs at 21 days with repeated morphologic and histologic assessments. Hemostatic times, grades of adhesions, and microscopic changes were not significantly different among the various treatments (P > 0.25). Capsular plaque formations were significantly different at the first relaparotomy (P < 0.01) and at final relaparotomy (P < 0.05). Both adhesions and capsular plaque formation were least at fibrin glue-treated sites, whereas Nd:YAG (1.06 microns) was most effective for average hemostatic time (mean = 109.67 s). Electrocautery produced the greatest necrosis at treatment sites. We conclude that all modalities are effective in controlling hemorrhage.

Autotransplantation of splenic tissue in an isolated segment of small intestine

The ability of splenic tissue to regenerate when implanted in an isolated segment of small intestine with intact circulation was studied in six pigs. After total splenectomy, 10 per cent of the weight of the spleen was implanted in a 10-15-cm long isolated segment of small intestine with an intact vascular supply. Bowel continuity was established by end-to-end anastomosis. Before implantation, the mucosal layer was completely removed from the isolated segment of the small intestine. The animals were killed 6 months later and the isolated segment of small bowel containing the splenic tissue identified. Most of the implanted splenic tissue was recovered in the isolated segment of small intestine; the weight ranged from 43 to 120 (mean 80) per cent of that of the implanted tissue. An isolated segment of small intestine with an intact circulation produces a higher index of regeneration than other previously reported sites.

Stapled partial splenectomy for splenic abscess in a child

This is the case report of a boy with a splenic abscess that was successfully treated by partial splenectomy using an automatic stapler. The abscess was caused by Serratia marcescens, a nosocomial pathogen.

Immune consequences of nonoperative treatment of splenic trauma in the rat model

To investigate the immunologic consequences of non-operative management of splenic injury, three parameters were studied: survival following pneumococcal sepsis, clearance of blood-borne bacteria, following Hemophilus influenzae challenge, and antibody response to type III pneumococcal capsular polysaccharide. Two hundred twenty-five Sprague-Dawley rats were divided into three groups and subjected either to a splenectomy, a sham operation, or standard blunt trauma. A significant increase in mortality was noted in the splenectomized group as compared with both the traumatized and control groups when challenged with Streptococcus pneumoniae. In both the control and trauma groups, H influenzae cleared significantly within 18 hours. Blood-borne bacteria persisted at the same level for 72 hours in the splenectomized animals. Four and 11 days later, the antibody level in both traumatized and control groups was higher than in the splenectomized subjects (P less than .001). There was no difference in the serum antibody level between the control and trauma groups at four days. However, at 11 days the trauma group showed a significant decrease in the antibody level (P less than .05). It can be concluded that following spontaneously-healing splenic trauma in the rat model, survival, bacterial clearance, and antibody response were all superior to that observed in the splenectomized subjects. In addition, the healed splenic disruption did not impair clearance of blood-borne encapsulated bacteria.

Splenic repair for trauma

The risks of overwhelming post-splenectomy infection (OPSI) are now well documented both in children and adults. Although the incidence of OPSI is comparatively low following splenectomy for trauma, it has a high mortality. Splenectomy is no longer the treatment of choice for splenic injury and splenic salvage is recommended whenever feasible. Since 1982, in the Isle of Wight hospitals, 13 cases of splenic injury following trauma have been treated applying various salvage procedures and are reported here.

Malaria infection in rats with stimulated splenic red pulp: the blood flow and protective effect in normal and transplanted splenic tissue

After splenic autotransplantation both weight and blood flow of the regenerated splenic tissue are decreased. In addition, the protective function of the transplant is less compared to that of the normal spleen. In the present study, the red pulp of normal and transplanted splenic tissue was stimulated by injections of phenylhydrazine to increase the weight, the blood flow, and the protective function. After stimulation, the weight of the normal spleen increased to 900 +/- 70 mg (control 530 +/- 20 mg) and the transplanted tissue to 240 +/- 70 mg (control 70 +/- 20 mg). This enlargement was caused by an increase in the splenic red pulp. However, the relative blood flow decreased in both the normal spleen and the transplant to 50% of the normal value. To evaluate the protective function of the stimulated splenic tissue, normal, splenectomized and transplanted rats were infected with Plasmodium berghei. Despite the dramatic increase in the red pulp, neither the normal nor the transplanted animals showed a survival rate superior to that of the splenectomized animals. The mass of splenic tissue obviously does not correlate with the protective effect of the spleen in parasitic infections.

Segmental splenectomy using the ultrasonic surgical aspirator

The technique described seems to significantly decrease blood loss in segmental splenectomy. Resection of the damaged splenic segments offers the potential advantage of reducing rebleeding and secondary hemorrhage from sites of repaired lacerations. Also, the viable splenic fragment that is left behind may afford protection from postsplenectomy sepsis. The ultrasonic surgical aspirator seems well suited for the purpose of segmental splenectomy in both the trauma and staging laparotomy setting.

Ultrasound in abdominal injury in children

Ultrasonography has been used as an investigation in children with abdominal signs after blunt injury. Sixteen children were examined, of whom nine had abnormal findings. Free intraperitoneal fluid was demonstrated in four cases. The injuries found are detailed and subsequent management of the patients is described. The children with normal scans settled with no sequelae. It is suggested that ultrasonography offers a valuable, non-invasive method of investigating blunt abdominal injury.

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.

Delayed and occult splenic rupture

Four patients with delayed splenic rupture were evaluated by CT or US and liver-spleen scan. The cases and radiographic findings and their significance are presented. The importance of this entity, in light of recent surgical trends, is discussed.

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.

Demonstration of functioning heterotopic splenic autografts by scintigraphy

The use of heterotopic splenic autografts is demonstrated as a means of preserving functioning splenic tissue in 15 patients undergoing splenectomy for trauma. In all patients, functioning splenic autografts could be shown by scintigraphy, using 99mTc-labelled erythrocytes or 99mTc-labelled sulphur colloid, performed 12 weeks after implantation.

Splenic capping: an experimental study of a new technique for splenorrhaphy using woven polyglycolic acid mesh

The use of polyglycolic acid (PGA) stretchable mesh applied to the experimentally injured canine spleen can achieve satisfactory immediate hemostasis by tamponade and simplifies the use of sutures to control remaining areas of hemorrhage. PGA mesh with 1/4" and 1/8" openings was utilized for splenorrhaphy in 12 adult mongrel dogs subjected to sharp splenic trauma. By gross and histologic examination, the PGA mesh material appears to undergo progressive absorption to complete absorption by 85 days. For the 12 animals and 30 operative procedures the only complications of the use of the mesh were the occurrence of an intrasplenic seroma in a single animal at 6 weeks after operation and three wound infections. With this material, rapid, simple canine splenic injury repair can be achieved. PGA mesh further assists in the healing process, and in maintaining maximum splenic architecture and function. The material used in this study was manufactured and supplied by Davis & Geck, American Cyanamid, Danbury, Connecticut.

Abdominal trauma

Abdominal trauma continues to be the major cause of morbidity and mortality in this country. Unnecessary deaths and complications can be minimized by improved resuscitation, evaluation, and treatment. Rapid resuscitation is necessary to save the unstable but salvageable patient with abdominal trauma. Accurate diagnosis and avoidance of unneeded surgery is an important goal of evaluation. However, most avoidable deaths result from failure to resuscitate and operate on surgically correctable injuries. When the diagnosis is in doubt and clinical judgment suggests surgery, exploration provides definitive treatment as well as diagnosis; moreover, the risks of negative exploration have become acceptable. The new techniques and diagnostic tools available are important in the management of abdominal trauma. These improved methods, however, still depend on experience and clinical judgment for application and determination of the best care for the injured patient.