Autologous splenic transplantation for splenic trauma

Autogenic splenic implantation versus splenectomy in patients undergoing distal pancreatectomy for benign or low-grade malignant lesions of the distal pancreas: study protocol for a multicentre, open-label, randomized controlled trial (RESTORE)

BACKGROUND

The spleen plays a significant role in the clearance of circulating microorganisms. Sequelae of splenectomy, especially immunodeficiency, can have a deleterious effect on a patient's health and even lead to death. Hence, splenectomy should be avoided and spleen preservation during elective surgery has become a treatment goal. However, this cannot be achieved in every patient due to intraoperative technical difficulties or oncological reasons. Autogenic splenic implantation (ASI) is currently the only possible way to preserve splenic function when a splenectomy is necessary. Experience largely stems from trauma patients with a splenic rupture. Splenic immune function can be measured by the body's clearing capacity of encapsulated bacteria. The aim of this study is to assess the splenic immune function after ASI was performed during minimally invasive (laparoscopic or robotic) distal pancreatectomy with splenectomy.

METHODS

This is the protocol for a multicentre, randomized, open-labelled trial. Thirty participants with benign or low-grade malignant lesions of the distal pancreas requiring minimally invasive distal pancreatectomy and splenectomy will be allocated to either additional intraoperative ASI (intervention) or no further intervention (control). An additional 15 patients who will undergo spleen-preserving distal pancreatectomy serve as the control group with normal splenic function. Six months postoperatively, after assumed restoration of splenic function, patients will be given a Salmonella typhi (Typhim Vi™) vaccine. The Salmonella typhi vaccine is a polysaccharide vaccine. The specific antibody titres immediately before and 4 to 6 weeks after vaccination will be measured. The ratio between pre- and post-vaccination antibody count is the primary outcome measure and secondary outcome measures include intraoperative details, length of hospital stay, 30-day mortality and morbidity.

DISCUSSION

This study will investigate the splenic immune function of patients who undergo ASI during minimally invasive distal pancreatectomy with splenectomy. The splenic immune function will be measured using the surrogate outcome of specific antibody titre after vaccination with a Salmonella typhi vaccine. The results will reveal details about splenic function after ASI and guide further treatment options for patients when a splenectomy cannot be avoided. It might eventually lead to a new standard of care making sometimes more demanding and time-consuming spleen-preserving procedures redundant.

TRIAL REGISTRATION

International Standard Randomized Controlled Trials Number (ISRCTN) ISRCTN10171587. Prospectively registered on 18 February 2019.

[Clinical Role of Interventional Radiology in Abdominal Solid Organ Trauma]

Interventional management is commonly used for traumatic injuries to the abdominal solid organs. The American Association for the Surgery of Trauma (AAST) and the World Society of Emergency Surgery (WSES) recently published guidelines for the management and treatment of liver, spleen, and kidney injuries, emphasizing the importance of interventions. Here, we discuss the characteristics of each organ and the procedure method for each organ that interventional radiologists need to know when treating trauma patients.

Diagnosis, management and outcome of splenic torsion; a systematic review of published studies

INTRODUCTION

Splenic torsion is a rare condition but one that many surgeons will encounter once in their career. Management options are varied but due to the rarity of the condition there are no contemporary evidence-based summaries to inform a treating clinician. We aim to describe patterns of presentation and provide an evidence-based guide to the management.

METHODS

A PRISMA structured meta-analysis was conducted of all published cases of splenic torsion and a recent case added from our institution.

RESULTS

408 cases were identified between 1888 and 2021 and a single case added from our institution, 312 cases were sourced from case reports and 96 from 40 case series. 8% of patients had a co-existing congenital anomaly and 28% an identified risk factor for splenic torsion. 82% required emergency surgery. A preoperative diagnosis is becoming more common, reaching 80% in 2020's. While spleen conserving surgery is feasible using a variety of techniques. splenectomy was the definitive management for the majority (82%). On histopatholy no occult disease was identified and a significant number of resected spleens were potentially viable; 32% were reported to be normal or congested and 14% demonstrated only partial or focal necrosis.

DISCUSSION

Despite the significant publication bias implied by the methodology this is a large dataset in a rare condition. Splenic torsion frequently occurs in a premorbid population. The presence of a palpable mass in the context of abdominal pain should increase suspicion and trigger cross sectional imaging. Conservation of the spleen, using the techniques discussed, should be seriously considered.

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.

Sonographic Discovery of Autotransplanted Splenic Implants in a Pregnant Patient

It is important to include splenic implants in the differential diagnosis of patients with a history of splenic trauma. Autotransplanted splenic implants may have a sonographic appearance similar to that of pathologies such as lymphadenopathy or carcinomatosis.

This is the first known case to discuss a pregnant patient with a history of autologous autotransplanted splenic tissue, which was discovered on sonography and confirmed during the patient’s cesearean section.

Splenic implant preservation after conservation in lactated Ringer´s solution

OBJECTIVE

to evaluate the morphology and function of autogenous splenic tissue implanted in the greater omentum, 24 hours after storage in Ringer-lactate solution.

METHODS

we divided 35 male rats into seven groups (n=5): Group 1: no splenectomy; Group 2: total splenectomy without implant; Group 3: total splenectomy and immediate autogenous implant; Group 4: total splenectomy, preservation of the spleen in Ringer-lactate at room temperature, then sliced ​​and implanted; Group 5: total splenectomy, ​​spleen sliced and preserved in Ringer-lactate at room temperature before implantation; Group 6: total splenectomy with preservation of the spleen in Ringer-lactate at 4°C and then sliced ​​and implanted; Group 7: total splenectomy and the spleen sliced for preservation in Ringer-lactate at 4°C before implantation. After 90 days, we performed scintigraphic studies with Tc99m-colloidal tin (liver, lung, spleen or implant and clot), haematological exams (erythrogram, leucometry, platelets), biochemical dosages (protein electrophoresis) and anatomopathological studies.

RESULTS

regeneration of autogenous splenic implants occurred in the animals of the groups with preservation of the spleen at 4ºC. The uptake of colloidal tin was higher in groups 1, 3, 6 and 7 compared with the others. There was no difference in hematimetric values ​​in the seven groups. Protein electrophoresis showed a decrease in the gamma fraction in the group of splenectomized animals in relation to the operated groups.

CONCLUSION

the splenic tissue preserved in Ringer-lactate solution at 4ºC maintains its morphological structure and allows functional recovery after being implanted on the greater omentum.

Splenic trauma: WSES classification and guidelines for adult and pediatric patients

Spleen injuries are among the most frequent trauma-related injuries. At present, they are classified according to the anatomy of the injury. The optimal treatment strategy, however, should keep into consideration the hemodynamic status, the anatomic derangement, and the associated injuries. The management of splenic trauma patients aims to restore the homeostasis and the normal physiopathology especially considering the modern tools for bleeding management. Thus, the management of splenic trauma should be ultimately multidisciplinary and based on the physiology of the patient, the anatomy of the injury, and the associated lesions. Lastly, as the management of adults and children must be different, children should always be treated in dedicated pediatric trauma centers. In fact, the vast majority of pediatric patients with blunt splenic trauma can be managed non-operatively. This paper presents the World Society of Emergency Surgery (WSES) classification of splenic trauma and the management guidelines.

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.

Splenosis: A Rare Etiology for Bowel Obstruction-A Case Report and Review of the Literature

Splenosis is a historically uncommon etiology for bowel obstruction. Autotransplanted splenic tissues following surgery or trauma of the spleen are known to occur in multiple locations of the abdominal cavity and pelvis. The small bowel mesentery is a blood vessel-rich environment for growth of splenic fragments. We present a case of a 36-year-old male patient who sustained a gunshot wound to his left abdomen requiring a splenectomy and bowel resection fifteen years prior to his presentation with small bowel obstruction requiring exploration, adhesiolysis, and resection of the mesenteric splenic deposit. Our aim in this report is to provide awareness of splenosis as an etiology for bowel obstruction, especially with increased incidence and survival following abdominal traumas requiring splenectomies. We also stress on the importance of history and physical examination to include splenosis on the list of differential diagnoses for bowel obstruction.

Spleen function after preservation in a physiological solution

BACKGROUND

The purpose of this study was to evaluate the morphology and function of implanted autogenous spleen tissue after 24 h of preservation in a physiological solution.

MATERIAL AND METHODS

Thirty-five male rats were divided into seven groups (n = 5): group 1, without surgical procedure; group 2, total splenectomy; group 3, total splenectomy and immediate implant of autogenous spleen tissue; group 4, total splenectomy and preservation of the entire spleen in lactated Ringer solution at room temperature for 24 h, followed by spleen sectioning and implantation; group 5, total splenectomy, followed by spleen sectioning and preservation in lactated Ringer solution at room temperature for 24 h and subsequent implantation of the slices; group 6, total splenectomy and preservation of the entire spleen in lactated Ringer solution at 4°C for 24 h, followed by spleen sectioning and implantation; and group 7, total splenectomy, the spleen was sliced and preserved in lactate Ringer solution at 4°C for 24 h, followed by implantation of the slices. After 90 d, scintigraphic studies using sulfur colloid labeled with 99mTc of the liver, lungs, spleen, implants, and a blood clot were performed. Hematological (erythrogram, leukogram, and platelets) and histologic studies were carried out.

RESULTS

The autogenous splenic implants regenerated in all animals that received those implants preserved at 4°C and immediately after excision. The scintigraphic study showed a better phagocytic function in groups 1, 3, 6, and 7. No difference was observed in the hematological study.

CONCLUSIONS

Spleen tissue preserved in lactated Ringer solution at 4°C for 24 h maintains its vitality and capacity to recover hematological and phagocytic functions.

Single-incision laparoscopic splenectomy and splenic autotransplantation for an enlarged wandering spleen with torsion

A wandering spleen is a rare condition in which the spleen is not located in the left upper quadrant, but instead is found in the lower abdomen or in the pelvic region because of the laxity of the peritoneal attachments. The unusually long pedicle is susceptible to twisting, which can lead to ischemia, and eventually to necrosis. We herein report a case of an enlarged wandering spleen with torsion, successfully treated by single-incision laparoscopic splenectomy and autotransplantation. The transplanted splenic tissues could be identified on a spleen scintigram obtained 3 months after the surgery. Howell-Jolly bodies were not observed in blood specimens. This procedure is able to prevent an overwhelming postsplenectomy infection, and leads to satisfactory cosmetic results.

Subcutaneous splenosis of the abdominal wall: report of a case and review of the literature

Splenosis is a common benign condition that occurs after splenic rupture via trauma or surgery. The mechanism behind splenic cell autotransplantation begins with the splenic rupture, either from trauma or surgical removal. Splenosis is usually found incidentally and, unless symptomatic, surgical therapy is not indicated. Subcutaneous splenosis is an extremely rare form of splenosis, mostly observed in abdominal surgical scars. We report a case of subcutaneous splenosis, as well as a comprehensive review of the literature. In our case, a 43-year-old woman who had splenectomy after traumatic splenic rupture at the age of 7 years old presented for plastic reconstruction of her postoperative scar. Upon surgery, two asymptomatic subcutaneous nodules were incidentally discovered. The presence of splenic tissue was confirmed by the histological study. The nodules were not excised, as the patient was not symptomatic.

A new technique for spleen autotransplantation

PURPOSE

Although the efficacy of spleen autotransplantation is debated, this approach remains the only possibility for preserving splenic function after traumatic splenectomy. This report describes an alternative method for splenic autotransplantation in case of splenic trauma.

METHODS

After splenectomy, the organ was weighed and the undamaged part was cut transversely to prepare a segment of approximately 4 × 3 × 2 cm in size and of 35 g of weight to be transplanted. The greater omentum was pedunculated in its left lateral portion, and the previously prepared splenic tissue was implanted in a pouch created at the lower edge of the omentum. The omental peduncle containing the splenic tissue was fixed to the parietal peritoneum of posterior left upper quadrant of the abdomen where the native spleen was previously located.

RESULTS

This technique was performed in 4 patients after informed consent had been obtained. The functionality of the splenic implant was assessed after 3 months by abdominal computed tomography and scintigraphy. These exams showed the functioning of the trasplanted splenic tissue in all patients.

CONCLUSION

This new technique needs further evaluation, but it appears to be an easy and safe alternative for spleen autotransplantation.

Splenic autotransplantation in a patient with human immunodeficiency virus infection: a case report

Introduction

Splenectomy is performed mostly because of traumatic events that cause rupture of the spleen. Postsplenectomy, a patient has a higher risk of developing sepsis. Autotransplantation of splenic tissue decreases the risk of opportunistic infection and sepsis, but its role in patients with human immunodeficiency virus is debated because the spleen is a replication site, especially during the asymptomatic phase of this infection. We present a case of a patient with human immunodeficiency virus infection who was admitted to our hospital for a traumatic rupture of the spleen and underwent spleen autotransplantation.

Case presentation

A 36-year-old Caucasian man was admitted to the shock trauma center of our hospital after a car accident. Anamnesis showed that the patient had been human immunodeficiency virus-positive for 13 years. A computed tomography scan showed abundant fluid collection in his superior and inferior abdomen caused by splenic rupture, with no other associated intra-abdominal lesions. During surgery, the spleen appeared severely damaged. A splenectomy was performed, and 35 g of splenic tissue was autotransplanted in a pouch created in the omentum. No complications occurred after surgery, and our patient was discharged from our hospital nine days after the operation. One year later, computed tomography and scintigraphy showed that the transplanted tissue was functioning well.

Conclusions

Autotransplantation of splenic tissue decreases the risk of opportunistic infection and sepsis, and it might also be useful in patients with human immunodeficiency virus. Other studies need to be done to validate this hypothesis.

Subtotal laparoscopic splenectomy in rats with preservation of the inferior pole

Purpose: To evaluate the feasibility and safety of subtotal splenectomy by laparoscopy with inferior pole preservation and to determine the viability of the splenic remnant. Methods: Twenty male Wistar rats weighing between 365 g and 474 g (mean 417.92 ± 36.15g SD) were operated and randomly assigned to two groups : Group 1 rats were killed on postoperative day 10 (n = 10), and Group 2 on the postoperative day 80 (n = 10). Both the inferior splenic pole and the superior part of the spleen, which was used as a control to measure inferior pole viability, were weighed and morphologically examined. Results: The technique was feasible in all cases. There were two postoperative deaths on immediate postoperative and one not well defined. The average weight percentage of the inferior pole, measured indirectly on the 10th day, was 53.67% ± 11.59% and on the 80th day was 62.69% ± 6.89%. The inferior pole was necrotic, with abscess formation in one case (5.9%) and appeared normal in all other cases. Microscopy showed features that were compatible with normality. Conclusions: Subtotal splenectomy with preservation of the inferior pole by laparoscopy was feasible and safety. The lower splenic pole was viable in 94.1% of animals.

Splenic autotransplantation restores IL-17 production and antibody response to Streptococcus pneumoniae in splenectomized mice

The high incidence of overwhelming postsplenectomy infection caused by Streptococcus pneumoniae can be reduced by splenic autotransplantation. In this study the effect of splenectomy and splenic autotransplantation on the immune response to S. pneumoniae infection was investigated. Balb/c mice were divided into three groups: splenectomized (SP), splenectomized and autotransplanted (AT), and sham operated control (CT). Five days post-infection the serum antibody levels were measured and the number of S. pneumoniae CFU, neutrophil accumulation and IL-17 production in the liver and lungs were investigated. SP mice showed greater number of bacteria in both organs and lower serum levels of S. pneumoniae-specific IgM, IgG1 and IgG2a antibodies. IL-17 production and neutrophil recruitment to the liver and lungs were lower in SP mice, in comparison with both the CT and the AT groups. Levels of S. pneumoniae-specific IgM, CFU counts, neutrophil accumulation and IL-17 production did not differ significantly between the CT and AT groups. These results suggest that splenic autotransplantation restores the capacity of splenectomized mice to fight S. pneumoniae infection.

The effects of splenectomy and splenic autotransplantation on plasma lipid levels

PURPOSE

Atherosclerosis observations after splenectomy for trauma and hypersplenism suggests a possible role for the spleen in lipid metabolism. The authors examined the effects of splenectomy on serum lipids in rats and also cholesterol-fed rats with experimental atherosclerosis.

METHODS

This study was designed on rats. The rats were divided into five groups: splenectomy, normal diet (SP-N, n: 8), splenectomy, cholesterol-fed groups (SP-C, n: 8), splenic autotransplantation after splenectomy, normal diet (SA-N, n: 8), splenic autotransplantation after splenectomy, cholesterol-fed groups (SA-C, n: 8) and sham groups (n: 8). Total triglyceride, total cholesterol, HDL (high-density lipoprotein), LDL (low-density lipoprotein), and VLDL (very low-density lipoprotein) levels were determined in 40 rats. The rats were classified into five groups based on the surgical procedures. The spleens were removed and then the rats were fed a normal diet in Group SP-N (n = 8). The spleens were removed and then the rats were fed a diet containing 1% cholesterol in Group SP-C (n = 8). Splenectomy and splenic autotransplantations were performed and then the rats were fed a normal diet in Group SA-N (n = 8). Splenectomy and splenic autotransplantations were performed and then the rats were fed a diet containing 1% cholesterol in Group SA-C (n = 8). The rats were sham-operated in the control group (Group S, n = 8). An active splenic function was shown in rats that underwent splenic autotransplantation in both groups by using Technicium 99 m sulphurcolloide sintiscan on day 30. Blood lipid levels were repeated 6 months later.

RESULTS

There was no difference between pre- and postoperative lipid levels in the sham group and SA-N group (p >.05). All lipid levels including HDL were increased significantly in SP-C group (p <.05). Also VLDL and total tryglyceride levels were increased significantly in SP-N and SA-C groups (p <.05).

CONCLUSIONS

This study showed that the spleen might have an important effect on lipid metabolism and splenic autotransplantation may be protective in conditions with increased lipid levels.

Beyond splenectomy — options for the management of splenic trauma

The spleen remains a vulnerable organ to blunt or penetrating abdominal trauma and recognition of its important immunological role has meant that alternatives to mandatory splenectomy for splenic injury are now available. This article examines the alternatives to splenectomy and then discusses the post-splenectomy management of patients.

Staphylococcus aureus infection after splenectomy and splenic autotransplantation in BALB/c mice

Splenectomy results in an increased risk of sepsis. The autogenous transplant of the spleen is an option for preserving splenic functions after total splenectomy. In this study, the capacity of animals undergoing autogenous spleen transplantation to respond to Staphylococcus aureus infection was investigated. BALB/c mice were divided into three groups: splenectomy followed by autotransplantation in the retroperitonium (AT), splenectomized only (SP) and operated non-splenectomized sham control (CT). Thirty days after surgery the mice were infected intravenously with S. aureus. Splenectomized mice had a higher number of colony-forming units (CFU) of S. aureus in liver and lungs in comparison with either AT or with CT mice (P < 0.05). Higher CFU numbers in lung of SP mice correlated with elevated production of interleukin-10 associated with a lower production of interferon-gamma and tumour necrosis factor-alpha. However, systemically, the level of tumour necrosis factor-alpha was higher in the SP group than in CT or AT. Lower titres of specific anti-S. aureus immunoglobulin (Ig)M and IgG1 were observed 6 days after infection in SP mice in comparison either with the AT or CT groups. Thus, splenectomy is detrimental to the immune response of BALB/c mice against infection by S. aureus which can be re-established by autogenous implantation of the spleen.

Ruptured splenic cavernous hemangioma in a neonate

We present a case of a term neonate with hypovolemic shock after spontaneous vaginal delivery. Hemodynamic instability persisted despite resuscitation with packed red cells, fresh frozen plasma, and platelets. An ultrasound scan at 48 hours after birth followed by a computed tomographic scan demonstrated a splenic lesion and hemoperitoneum. She underwent an emergency laparotomy and splenectomy for splenic rupture. Histologic findings demonstrated a ruptured cavernous hemangioma of the spleen. Exsanguinating intraabdominal hemorrhage in the newborn infant is rare. The diagnosis and management, with particular reference to splenic cavernous hemangioma and splenic rupture, is discussed.

Development and function of the mammalian spleen

The vertebrate spleen has important functions in immunity and haematopoiesis, many of which have been well studied. In contrast, we know much less about the mechanisms governing its early embryonic development. However, as a result of work over the past decade-mostly using knockout mice--significant progress has been made in unravelling the genetic processes governing the spleen's early development. Key genetic regulators, such as Tlx1 and Pbx1, have been identified, and we know some of the early transcriptional hierarchies that control the early patterning and proliferation of the splenic primordium. In mouse and humans, asplenia can arise as a result of laterality defects, or the spleen can be absent with no other discernible abnormalities. Surprisingly, given the spleen's diverse functions, asplenic individuals suffer no major haematopoietic or immune defects apart from a susceptibility to infection with encapsulated bacteria. Recent evidence has shed light on a previously unknown role of the spleen in the development and maintenance of specific B cell populations that are involved in the initial response to infection caused by encapsulated bacteria. The lack of these populations in asplenic mice and humans may go some way to explaining this susceptibility.

Laparoscopic splenic autotransplantation

Since 1990, we have performed splenic autotransplantation in more than 100 patients to treat splenic trauma, portal hypertension, myeloid metaplasia due to myelofibrosis, chronic lymphocytic leukemia, and Gaucher disease. The aim of this present study was to present splenic autotransplantation performed by laparoscopic means. A 33-year-old woman with severe splenic pain due to ischemia caused by multiple focal thromboses of splenic arterial branches was successfully treated by laparoscopic splenectomy and splenic tissue autotransplantation. The spleen was removed and cut in 20 fragments that were sutured to the greater omentum. This procedure was safely conducted with minor bleeding and no technical difficulties or complications. The postoperative follow-up of 12 months has been uneventful; the patient's pain disappeared on the first postoperative day. Hematologic, immunologic, tomographic, and scintigraphic examinations confirmed the functions of the splenic autotransplants. It is feasible and safe to perform splenic autotransplants by laparoscopic means.

Splenic autotransplantation for a congested and enlarged wandering spleen with torsion: report of a case

In children with diseases of the spleen, every effort should be made to preserve the organ, to prevent severe infections postsplenectomy. We report the case of a 7-year-old girl with torsion of a wandering spleen who we treated by autotransplantation of splenic tissues following splenectomy, when fixation of the enlarged spleen seemed impossible. Spleen scintigraphy showed uptake in the regenerating splenic tissues 9 months after surgery, and evidence of an increase in the size of the tissues 23 months after surgery. Howell-Jolly bodies had disappeared by 16 months after surgery. These findings suggested that the transplanted splenic tissues were resuming splenic functions. Based on our experience with this case, we conclude that autotransplantation after splenectomy is a treatment option for wandering spleen with torsion when fixation seems difficult because of splenic congestion and enlargement.

Subtotal splenectomy preserving the lower pole in rats: technical, morphological and functional aspects

PURPOSE: To assess the possibility of preserving the lower pole of the spleen, supplied by the inferior lobar vessels and segmental vessels, or by vessels of the gastrosplenic ligament, in subtotal splenectomy; to study the viability and function of the lower pole of the spleen. METHODS: Thirty-six male Wistar rats were used in this study. Said animals weighed 273-390 g ( 355.2 ± 30.5 g ), and were randomly distributed into three groups. Group 1 comprised ten animals which were submitted to exploratory laparotomy with spleen manipulation (sham operation). Group 2 comprised 16 animals which were submitted to total splenectomy. Group 3 comprised ten animals which were submitted to subtotal splenectomy, preserving the lower pole of the spleen. Blood was collected from all animals before and 90 days after surgery to measure the levels of cholesterol and triglycerides. The animals were sacrificed 90 days after surgery. Spleens and remaining spleens were removed for macroscopic and microscopic examination. RESULTS: Surgery was performed with no complications in all groups. Six animals died in group 2. Spleens of groups 1 and 2, and lower poles of group 3 were macroscopically viable. Apparent white pulp hyperplasia was observed in group 1. In group 3, slight inflammation and capsular fibrosis were observed at the incision site, as well as diffuse hemosiderosis in the red pulp. Average mass of remaining spleen was 35.84% ± 4.31%. No significant difference was observed between preoperative and late postoperative lipid levels in groups 1 and 3 (p > 0.05). Late postoperative lipid levels significantly increased in group 2. CONCLUSIONS: Preservation of the lower pole of the spleen (supplied by gastrosplenic vessels or inferior lobar vessels and segmental vessels) was possible with subtotal splenectomy. The lower pole was macroscopically and microscopically viable in all cases. Subtotal splenectomy preserving the lower pole prevented changes in lipid levels, which were observed in rats submitted to total splenectomy. Plasma lipid levels in rats submitted to subtotal splenectomy were similar to those observed in sham operated rats.

Antibody Response of Autogenous Splenic Tissue Implanted in the Abdominal Cavity of Mice

There is still controversy about the immunologic function of autotransplanted splenic tissue. In this study, splenic autotransplantation was performed in the abdominal cavity of mice, and the plaque-forming cell (PFC) assay was used to investigate the frequency of antibody-forming cells in response to sheep red blood cell (SRBC) immunization. BALB/c mice were divided into four groups according to the location of the autogenous graft: intraomental (IO), free peritoneal splenosis (FPS), retroperitoneal (RP), and nongrafted control (CT). Thirty days after surgery the mice were immunized intraperitoneally with SRBCs, and 4 days later splenic immunoglobulin M anti-SRBC-secreting cells were determined by counting the number of PFCs. All the immunized mice showed increased numbers of PFCs that were about 2 logs higher than those in the the nonimmunized controls (P < 0.005). The frequencies of anti-SRBC-producing cells in the tissues grafted in various sites of the abdominal cavity (IO, FPS, RP), in the normal spleen from nonoperated controls (CT), or in the sham-operated control group (SCT) were not notably different (5582 +/- 2475 PFC/10(7) cells for IO; 4849 +/- 1856 for FPS; 6604 +/- 2903 for RP; 5940 +/- 5029 for CT; and 6172 +/- 2203 for SCT). Similar histology with small architectural variations was observed in all implants; less white pulp was involved, and there was more congestion in the red pulp, with extensive sinusoids and reticular fiber proliferation. This study shows that the T cell-dependent antibody response in implanted splenic tissues is as efficient as in the intact spleen, with no difference between the graft sites studied. This immune response does not depend on the slight architectural variations observed in the splenic implants.

Níveis de lípides plasmáticos em ratos submetidos à esplenectomia total, ligadura simultânea dos vasos esplênicos e à esplenectomia subtotal com preservação do pólo inferior

OBJETIVO: Verificar o efeito da esplenectomia total, da ligadura dos vasos esplênicos principais e da esplenectomia subtotal com preservação do pólo inferior, nos lípides plasmáticos de ratos alimentados com dieta-controle ou dieta acrescida com 2,5% de colesterol. MÉTODO: Foram utilizados 111 ratos Wistar, machos, pesando entre 273g e 427g, com idade aproximada de 12 semanas, assim distribuídos: Grupo 1, controle (N = 20), não operado; Grupo 2 (N = 20) submetido à manipulação do baço; Grupo 3 (N = 31) submetido à esplenectomia total; Grupo 4 (N = 20), ligadura simultânea da artéria e veia esplênicas; Grupo 5 (N = 20), esplenectomia subtotal com preservação do pólo inferior. Foram dosados os lípides plasmáticos, e os ratos foram distribuídos em dois subgrupos, de acordo com a dieta (Subgrupo A- dieta-controle; Subgrupo B - dieta acrescida com 2,5% de colesterol). Todos os animais foram submetidos à nova colheita de sangue após 90 dias do início do experimento. RESULTADOS: Os animais submetidos à esplenectomia total, independentemente do tipo de dieta, apresentaram aumento significante (p < 0,05) do colesterol total, LDL, VLDL e triglicérides. O aumento da HDL foi significante nos ratos alimentados com dieta-controle (p < 0,05) e não significante nos alimentados com dieta acrescida com 2,5% de colesterol (p > 0,05). Os animais submetidos à ligadura simultânea da artéria e veia esplênicas e à esplenectomia subtotal com preservação do pólo inferior e alimentados com dieta-controle, não apresentaram alterações nos níveis de lípides plasmáticos, exceto pelo aumento da HDL (p < 0,05) observado no grupo da esplenectomia subtotal. Nos animais desses grupos, alimentados com dieta acrescida com 2,5% de colesterol, houve aumento significante de colesterol total, LDL, e VLDL e triglicérides. CONCLUSÕES: A esplenectomia total produz aumento significante do colesterol total, das frações LDL e VLDL e dos triglicérides, tanto nos ratos alimentados com dieta-controle quanto nos alimentados com dieta acrescida com 2,5% de colesterol. O aumento é mais significante nos animais alimentados com dieta acrescida com 2,5% de colesterol. A ligadura simultânea da artéria e veia esplênicas e a esplenectomia subtotal com preservação do pólo inferior previnem contra as alterações dos níveis de lípides plasmáticos observadas em ratos submetidos à esplenectomia total alimentados com dieta-controle ou acrescida com 2,5% de colesterol.

Splenic autotransplantation for treatment of portal hypertension

BACKGROUND

When total splenectomy is unavoidable it is important to preserve splenic function in some form in order to prevent the complications of asplenism. Splenic autotransplantation is a good alternative in such cases. We describe the use of splenic autotransplantation for the treatment of portal hypertension.

METHODS

We carried out total splenectomy on 31 patients (21 men, 10 women), ranging in age from 21 to 68 years, with schistosomal portal hypertension. From each removed spleen, we took 20 fragments and implanted them on the greater omentum. This procedure was combined with abdominal portal-variceal disconnection. Transgastric running suture of the lower esophageal and gastric varices completed the treatment of portal hypertension. All patients underwent clinical, hematologic, immunologic and scintigraphic assessment. The results with respect to morbidity and mortality, and hematologic and immunologic findings were compared with those in 36 patients submitted to other splenic procedures.

RESULTS

There was no complication related to the splenic implants and none of the patients died. Hematologic and immunologic findings were normal. Scintigraphy registered images of splenic tissue in all cases.

CONCLUSION

The implantation of splenic fragments on the greater omentum seems to be a safe and useful procedure for maintaining splenic function after total splenectomy.

Estudo da regeneração esplênica autóloga e heterotópica em ratos

OBJETIVO: estudar a regeneração esplênica dos fragmentos de baço autólogos e heterotópicos implantados na cavidade peritoneal e na tela subcutânea em ratos e comparar os seus aspectos histológicos e citológicos com baço normal. MÉTODOS: 44 ratos Wistar foram submetidos a esplenectomia e receberam fragmentos de auto-implante: GA = na tela subcutânea (n=22) e GB na cavidade peritoneal (n=22). GAI (n=11) e GAII (n=11) receberam implante de fragmento único. GBIII (n=11) e GBIV (n=11) receberam implantes de quatro fragmentos. O baço remanescente foi usado como controle. Após 5 semanas de foram submetidos à eutanásia e foram investigados os aspectos macroscópicos e microscópicos (histológicos e citológicos) dos fragmentos nos seus locais de implante. Os resultados foram submetidos a testes estatísticos não paramétricos(p>0,05). RESULTADOS: Não houve diferença estatística significante entre o grupo que recebeu implante na tela subcutânea (n=22) e o grupo da cavidade peritoneal (n=22). Quanto à presença ou ausência de tecidos esplênicos regenerados (p=0,182), também não apresentou diferença com significância estatística. Os estudos histológicos e citológicos do tecido regenerado não evidenciaram diferenças em relação ao grupo controle. CONCLUSÃO: A regeneração do tecido esplênico autólogo e heterotópico em ratos ocorre nas mesmas proporções tanto na tela subcutânea como na cavidade peritoneal. Os aspectos histológicos e citológicos são semelhantes aos do baço normal.

A rare diagnosis for a pancreatic mass: splenosis

Splenosis, the autotransplantation of splenic tissue, has been designed to preserve organ functions after splenectomy. We present the first case of laparoscopic resection of a pancreatic splenosis, in a patient who had undergone a splenectomy 31 years before, complaining of abdominal pain and diarrhea. Abdominal computed tomography (CT) scan showed an enhancing hypervascular 3-cm solid mass in the body of the pancreas, mimicking a pancreatic cancer or a neuroendocrine tumor. A diagnostic laparoscopy was planned, and a 3-cm peripancreatic nodule with a long pedicle was visualized, with many nodules close to the tail of the pancreas and in the greater omentum. They were all resected, and the specimens obtained were immediately sent for frozen-section examination, which confirmed the diagnosis of heterotopic splenic tissue. Splenosis should be included in the differential diagnosis of the pancreatic masses in patients with previous splenic surgery. A hypervascular mass on CT scan should be regarded as an adenocarcinoma of the pancreas until proven otherwise. The possibility of a neuroendocrine tumor mandates an octreotide scan and gastrointestinal hormones dosage. In the unlikely event that all tests may produce equivocal results, a diagnostic laparoscopy is mandatory, in order to obtain an accurate histopathologic diagnosis.

Radiographic characteristics of postinjury splenic autotransplantation: avoiding a diagnostic dilemma

BACKGROUND

Splenic autotransplantation after postinjury splenectomy has been advocated to augment the immune response to infection and prevent overwhelming postsplenectomy sepsis. Postoperative computed tomographic (CT) scans in patients undergoing splenic autotransplantation reveal multiple intra-abdominal fluid collections that may appear similar to abscesses. This presents a diagnostic dilemma. In the past, one of our patients underwent percutaneous drainage of such collections that were sterile, and one patient required operative evacuation of infected implants. The purpose of this study was to determine whether there is a characteristic radiographic appearance of splenic implants, whether this appearance changes with time, and whether implants can be differentiated from abdominal abscesses.

STUDY DESIGN

Patients at our Level I trauma center who underwent operative therapy for splenic injury from January 1995 to May 2002 were identified using our trauma registry. Charts were reviewed and CT scans read in a blinded fashion by a radiologist.

RESULTS

During the study period, 505 patients were admitted for splenic trauma. One hundred forty-five patients (29%) required operative intervention for splenic injuries. Splenorrhaphy was performed in 27 patients and splenectomy was required in 118 patients. Twenty-three patients had splenic autotransplantation into the omentum, of whom 11 underwent postoperative CT scanning for clinical suspicion of intra-abdominal abscess. On average, 2.7 scans were obtained per patient, ranging from 4 to 113 days postoperatively. Imaging revealed low-density fluid collections in the anterior abdomen in 10 of 11 patients. Time-related radiographic changes (early rim enhancement and late shrinkage) of the implants were noted, but splenic implants lacked surrounding omental fat stranding or other inflammatory changes typical of an abscess. The patient with infected splenic implants had air bubbles within the fluid collections, a characteristic finding of an abscess.

CONCLUSION

Autotransplanted splenic tissue may resemble an abscess on CT scanning, but splenic implants have distinct and time-related characteristic findings. Recognition of these unique features may allow differentiation of a splenic implant from an abscess, thus avoiding unwarranted intervention.

Regeneration of the spleen in intact animals and radiation chimeras

Regeneration of the splenic tissue after partial splenectomy is incomplete in adult non-irradiated mice and lethally irradiated animals reconstituted with donor syngeneic bone marrow. Transplantation of the splenic tissue to intact adult animals after partial splenectomy resulted in virtually complete regeneration of the spleen. In chimeras recovery of the splenic tissue was decreased; autotransplantation of the whole spleen or its part did not lead to appreciable changes in the weight and cellularity of this organ. No more than 30% splenic tissue is restored after complete splenectomy and transplantation of the splenic tissue in intact and chimeric mice.

Vaccination practices among North American trauma surgeons in splenectomy for trauma

BACKGROUND

The purpose of this study was to examine trama surgeons' practice patterns regarding immunization of splenic injury patients.

METHODS

Data were analyzed from surgeons responding to a survey sent to 557 adult trauma surgeons in the United States and Canada. The survey queried the timing and use of vaccinations in splenic injury patients.

RESULTS

Three hundred four (54.6%) surgeons responded to the survey, with 43 no longer active. Of the 261 active surgeons, 99.2% immunize their splenectomized patients, whereas 15.7% immunize those who undergo splenorrhaphy and 8.4% immunize those managed nonoperatively. Vaccines are administered anywhere from the immediate postoperative period to as long as 6 weeks later. All but two responding surgeons provide the pneumococcal vaccine, 62.8% also advocate meningococcal vaccination, 72.4% add the Haemophilus influenzae vaccine, and 56.7% give all three. Thirteen of the responding surgeons reimplant splenic tissue, most frequently in the omentum, and in quantities varying from two slices to the entire spleen. Revaccination practices are extremely varied-ranging from nothing at all to annually-and seldom follow Centers for Disease Control and Prevention guidelines.

CONCLUSION

With the exception of immunizing splenectomized patients against pneumococcal infection, little consensus exists among surgeons regarding the immunization of patients sustaining splenic injury.

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.

Risk and patterns of bacteraemia after splenectomy: a population-based study

During a period in which vaccination of splenectomized patients has been recommended, we analysed the patterns of severe post-splenectomy infections (i.e. bacteraemia or meningitis) in a defined population-based cohort. A total of 561 patients undergoing splenectomy were identified during 1984-93 in a Danish county, and the 538 eligible patients were followed for 1731 person-years. After splenectomy, 38 patients contracted a bacteraemia, of which 45% occurred within 30 d (i.e. during the postoperative period). No cases of meningitis were found. Among splenectomized patients the incidence rate of bacteraemia was 2.3 per 100 person-years at risk. Beyond the postoperative period we found an 8-fold increased risk of bacteraemia. Enterobacteria were the predominant cause (45%), and only 1 case due to Streptococcus pneumoniae was recorded. 89 (17%) died during the postoperative period, and the overall mortality rate was 18.4 per 100 person-years at risk. In all, 60% of the patients had been given a pneumococcal vaccination, and a Cox proportional hazard regression model showed that vaccination significantly reduced the risk of bacteraemia of any cause beyond the postoperative period. We conclude that splenectomy increases the risk of severe infections, and that vaccinated patients carry a lower risk of infection than non-vaccinated ones.

Advances in the management of pediatric trauma

BACKGROUND

Numerous important advances have been made in the management of trauma in childhood in prevention, prehospitalization and intrahospital care, postoperative management, and rehabilitation. As with adult trauma care, the development of trauma systems has impacted greatly on morbidity and mortality in injured children.

DATA SOURCES

Recent literature was searched for information regarding selected aspects of pediatric trauma care where significant improvements in outcome have occurred. The specific areas selected because of their contribution to improved outcomes include changes in the organization of care including the establishment of trauma centers and trauma systems, understanding trauma physiology as a basis for care, selective management of blunt trauma, management of burn injury, and prevention.

CONCLUSION

Because of the various advances in the understanding of the effects of injury that have been translated to improved approaches to treatment, overall treatment mortality in childhood has dropped 45% over the last 20 years and mortality with burn injury has been reduced by half in patients with over 60% of body surface burn and almost eliminated below that level unless there are additional circumstances. Nonetheless, trauma is still the leading cause of death in childhood, so continuing commitment by pediatric surgeons to advancing trauma care for children is in order as well as providing education for adult surgeons willing to commit themselves to care of the injured child.

Blunt trauma to the spleen

BACKGROUND

The management of splenic injury resulting from blunt trauma in adults is controversial, with an increasing trend towards non-operative management and conservation of the spleen. A retrospective review was performed on adult patients treated in a single institution for splenic injury resulting from blunt trauma in an attempt to identify factors important in selecting an appropriate management option and predicting the success of that option.

METHODS

Associated injuries (standardized using Injury Severity Scores), clinical signs at presentation, computed tomographic grading of splenic injury, and transfusion requirements were documented. Statistical analysis was performed using non-parametric Mann-Whitney, Chi-squared, Kolmogorov-Smirnov and multivariate logistic regression tests.

RESULTS

Eighty-five patients were identified. Non-operative management was used on 39 patients, splenic conservation on 14 patients, and splenectomy on 32 patients. The mean Injury Severity Score was significantly lower in the non-operative group. Computed tomographic grading of the splenic injury was not found to correlate well with intraoperative findings. Transfusion requirements were lower in the non-operative group. Non-operative management failed in four patients; two had continued splenic bleeding, and two required surgery for other intra-abdominal injuries. Overall mortality was 7%. There was one death in the splenic conservation group, unrelated to the splenic injury, and two patients required a second laparotomy and splenectomy for persistent splenic bleeding. There were five deaths in the splenectomy group, only one of which was related to the splenic surgery.

CONCLUSION

Management of blunt splenic injury remains controversial. The decision to pursue non-operative management rather than splenic conservation or splenectomy depends on the individual merits of each case. There is an increasing trend towards splenic conservation, particularly in younger, stable patients with single organ injury.

Spleen autotransplantation provides restoration of functional splenic lymphoid compartments and improves the humoral immune response to pneumococcal polysaccharide vaccine

After splenectomy, patients have an increased risk of overwhelming post-splenectomy infection (OPSI) or sepsis involving encapsulated bacteria such as pneumococcus. The value of spleen autotransplantation after splenectomy because of trauma has long been questioned. Much attention has been given to the restoration of mononuclear phagocyte system (MPS) function, which appeared to be similar to that of splenectomized individuals. The presence of specific anti-pneumococcal antibodies may enhance phagocytosis of opsonized bacteria by other parts of the MPS, as present in the liver. Therefore, in the present study we have evaluated the restoration of the humoral immune response after spleen autotransplantation, especially to pneumococcal capsular polysaccharides (PPS). Wistar rats were divided into three groups which were operated as follows: splenectomy, splenectomy followed by autotransplantation, and sham operation. After 12 weeks the rats were vaccinated with 23-valent pneumococcal vaccine. Blood samples were taken after 3 days, 3 and 6 weeks for anti-PPS IgM and IgG ELISA against types 3, 4, 6, 9, 14 and 23. In addition, immunohistological studies were performed on the autotransplants. Significant antibody titre rises were found in a main proportion of the autotransplanted rats, comparable to sham-operated rats. Splenectomized rats showed as well a significantly lower increase in immunoglobulin levels, as significant differences in the proportion of rats showing a minimum two-fold increase of antibody level, considered to represent an adequate response. The titres were highest 3 days after vaccination. Immunohistochemical studies demonstrated structurally functional autotransplants, including an intact marginal zone. Considering this significant anti- pneumococcal antibody response, spleen autotransplants can be expected to enable an improved humoral response to PPS, and to contribute to protection against OPSI after splenectomy.

Esplenectomia subtotal, em cães, com preservação do pólo inferior(PI) suprido por vasos do ligamento gastroesplênico

O objetivo desse trabalho foi estudar a viabilidade do pólo inferior (PI) do baço de cães, após a ligadura e secção da artéria e veia esplênicas. Foram operados 24 cães, mestiços, machos, com peso variando entre 12kg e 14kg. Os animais anestesiados foram submetidos a laparotomia mediana supra e infra-umbilical, com 12cm de comprimento. Nos do grupo 1 fez-se a ligadura e secção da porção superior do ligamento gastroesplênico, ligadura e secção da artéria e veia esplênicas. Após a ligadura do ramo descendente dos vasos esplênicos, o baço foi seccionado transversalmente, a superfície de corte do PI foi suturada e a peça enviada para estudo microscópico. A parede abdominal foi suturada por planos. Os cães foram mantidos vivos e sacrificados no sétimo (subgrupo I A - quatro cães), 15° (subgrupo 18 - cinco cães), trigésimo (subgrupo I C - quatro cães) e septuagésimo dia (subgrupo I D - três cães). Nessa ocasião, o Pl foi retirado para estudo. No grupo 2, três cães foram submetidos a laparotomia e manipulação do baço (controle 2 - simulação), para controle morfológico. Esse procedimento foi feito no 15° dia (subgrupo 2A - dois cães) e no sexagésimo dia (subgrupo 28 - um cão). Dos 24 cães operados, cinco foram a óbito. A causa foi evisceração (dois cães), hemorragia intraperitoneal (um cão), hemorragia digestiva baixa de causa não esclarecida (um cão) e indeterminada (um caso). O exame macroscópico do PI comparado àquele dos controles I e 2 mostrou aspecto duvidoso em apenas dois casos, onde o PI apresentava-se aderido firmemente à parede abdominal e alças intestinais. Não houve, no entanto, diferença estatisticamente significante (p>O.O5 - teste exato de Fisher) no número de casos viáveis entre os grupos controles e grupo I. O exame microscópico do PI, comparado àqueles do restante do baço (controle I) e ao controle 2 (simulação), mostrou que a referida porção apresentou alterações morfológicas discretas, na maioria dos casos, e sinais de regressão em dois casos. Esse número não induziu, também, resultados estatisticamente significante (p>O.O5). A análise dos nossos resultados nos permitiu concluir que o PI do baço de cães manteve-se viável em 86,6% dos casos, mesmo com a ligadura da artéria e veia esplênicas.