Subtotal splenectomy for the treatment of chronic lymphocytic leukemia

Adenosine 2A receptor antagonists promote lymphocyte proliferation in sepsis by inhibiting Treg expression of PD-L1 in spleen

The spleen is essential for lymphocyte proliferation, which is associated to sepsis prognosis. Adenosine 2A receptor (A2AR) blocking promotes lymphocyte proliferation in sepsis, however the mechanism is uncertain. Our sepsis cecum ligation perforation model showed that blocking A2AR increased survival and CD4+ cell numbers in a spleen-dependent mechanism. The sequencing of the transcriptome of the spleen indicated alterations in the expression of genes involved in the control of lymphocyte proliferation by inhibiting A2AR, including a reduction in the expression of PD-L1. Flow cytometry analysis of PD-L1 expression intensity in splenic cell subpopulations revealed that the Treg cell subpopulation was the strongest PD-L1-expressing cell population, and Treg PD-L1 expression decreased after blocking A2AR. In vitro activation of A2AR was able to upregulate PD-L1 expression of Treg and boost Treg capacity to limit lymphocyte proliferation, while blockage of PD-L1 partly reduced A2AR-activated Treg's ability to inhibit lymphocyte proliferation. In addition, blocking CREB phosphorylation significantly inhibited A2AR-induced PD-L1 expression. According to the findings of our research, inhibiting A2AR improves the prognosis of sepsis by lowering the level of PD-L1 expression by Treg in the spleen and reducing the inhibition of lymphocyte proliferation.

Macro and microscopic comparison of the upper pole of the spleen with the lower pole in partial splenectomy

Purpose

To evaluate the viability of the upper (UP) and lower pole (LP) of the spleen from a macro and microscopic point of view, after subtotal splenectomy with preservation (SSP) of the UP and the LP.

Methods

Seventeen male Wistar rats, two months old, were submitted to SSPUP and SSPLP and 5 to simulated operation (SG). After 80 days, the rats were euthanized, and the remaining LP and UP and intact spleens were evaluated macroscopically and microscopically.

Results

Two rats died during the operation. Macroscopic analysis showed that in 15 LP, one of them was not viable and in 15 UP and in 5 spleens in the SG, all were viable. In the statistical analysis, there was no difference in relation to viability. The LP and UP analyzed showed variation. As for the length, the UP increased significantly; however, in relation to the width, there was a significant increase in the LP in relation to the UP. In addition, the weight of the UP was significantly greater than that of the LP. Microscopic analysis attested viability of the splenic remnants.

Conclusion

There was no significant difference regarding the viability of UP and LP, in macroscopy and microscopy.

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.

Emergency splenectomy for trauma in the setting of splenomegaly, axillary lymphadenopathy, and incidental B-cell chronic lymphocytic leukemia: A case report

INTRODUCTION

The spleen is the most commonly injured intra-abdominal solid organ following blunt trauma. B-cell chronic lymphocytic leukemia (CLL) is the most common leukocytic dyscrasia affecting adults in Western countries. Splenomegaly with axillary and retroperitoneal lymphadenopathy are common physical findings. This case investigates an emergency splenectomy in a community hospital involving a 45-year-old man with blunt abdominal trauma following an assault with incidental splenomegaly and axillary lymphadenopathy, with surgical pathology findings of B-cell CLL.

PRESENTATION OF CASE

A 45- year-old man without past medical or family history who was the victim of an assault presented to the emergency department 6h later with left upper quadrant pain and radiation to the left flank and a positive Kehr sign. An elevated absolute lymphocyte count above 7×109 and CT confirmation of a Grade V splenic laceration with splenomegaly, axillary lymphadenopathy, with hemodynamic compromise led to an exploratory laparotomy and emergency splenectomy regardless of the potential for malignancy.

DISCUSSION

Hemoperitoneum with blunt splenic injury (BSI) caused by abdominal trauma with hemodynamic instability should be treated with exploratory laparotomy and splenectomy even in the face of potential malignancy with splenomegaly and axillary lymphadenopathy. An appropriate oncologic work up and treatment can be provided after the emergency intervention.

CONCLUSION

An emergency splenectomy is an appropriate operative intervention for a grade V splenic laceration with hemoperitoneum, splenomegaly, and axillary lymphadenopathy regardless of the potential for a neoplastic process such as B-cell CLL. Post-splenectomy vaccinations and oncologic follow-up for systemic chemotherapy should be facilitated after recovery.

Selective Spleen Embolization of Splenomegaly to Improve Thrombocytopenia Facilitating Open Aortic Aneurysm Repair: A Staged Approach

We present an 82-year-old man with a history of hairy cell leukemia, having an 11-cm abdominal aortic aneurysm, who also had severe thrombocytopenia (about 20 000 platelets/μL) and splenomegaly at presentation. The patient had unfavorable anatomy for endovascular aneurysm repair, and therefore, an open procedure was planned. To reduce risk for perioperative bleeding and optimize patient preoperative status, a staged approach was employed. Initially, several sessions of embolization of 2 splenic artery branches were performed with the intent to decrease spleen size and to increase platelet count thus decreasing the perioperative bleeding risk. Then, after successfully increasing platelet count (280 000 PLT/μL), open repair of the aneurysm was conducted. This case demonstrates that selective splenic embolization in patients with hypersplenism and subsequent thrombocytopenia who are in need for major surgery may achieve a significant rise in platelet count and optimize patient's preoperative status in order to avoid bleeding complications.

Effects of inferior splenic lobe pole fixation and gastrosplenic peritoneal membrane section on the vitality of the remanent of subtotal splenectomy in rats

PURPOSE

To investigate the vitality of the spleen lower pole after subtotal splenectomy with suture to the stomach and after posterior peritoneal gastro-splenic membrane section, using macro and microscopic evaluations.

METHODS

Sixty Wistar rats were used in this study and were randomly distributed in the three groups: Group 1: (n=20), subtotal splenectomy with lower pole preservation, Group 2: (n=20) subtotal splenectomy with lower pole preservation and suture to the stomach, Group 3: subtotal splenectomy with lower pole preservation and posterior peritoneal gastrosplenic ligament section. The animals were sacrificed 45 days after the surgery and the spleen lower poles were removed for macroscopic and microscopic examination.

RESULTS

All animals in this series survived. No macroscopic differences were encountered between the groups. Microscopic evaluation observed statistic difference concerning fibrosis between group 1 and 3 (p ≤ 0.05), but the analysis for necrosis and inflammation presented no differences.

CONCLUSION

Vitality of the spleen lower pole after subtotal splenectomy is minimally modified when it is fixed to the stomach or when the posterior peritoneal gastrosplenic ligament is resected.