Immune response capacity after human splenic autotransplantation: restoration of response to individual pneumococcal vaccine subtypes

Revitalize splenic functions. Following a splenectomy for trauma, a small amount of splenic autotransplantation was performed

INTRODUCTION

The spleen is a responsible significant part of the immune system; after Splenectomy following trauma, the immune system changes; splenic autotransplantation can preserve the immune system after trauma and Splenectomy.

BACKGROUND

Patients can be protected from immune dysfunction by autotransplanting splenic tissues after splenectomy following trauma because their immune systems and spleens are changed. Patients can gain their immune function after splenic autotransplantation.

METHODS

Patient classification methods are into three categories, Group A, 6 cases with auto-translation; Group B, 6 cases without transplantation; Group C, seven regular people serving as the control.

AIM OF WORK

The aim of the work is not to compare outcome methods or compare types of autotransplantation; This work aims to document postoperative radiological, immunological, clinical, and hematological investigations. We concentrated on the results of investigations more than the types of operation or approach or types of autotransplantation.

RESULTS

We showed that, after comparing each group with normal individuals subjects, patients who did not undergo autotransplantation had significantly higher platelet counts, a more significant percentage of micronucleated reticulocytes, increased levels of naive B lymphocytes, changes in class-switched memory and class-unswitched memory B cells, and higher levels of PD1 on CD8 + T lymphocytes. Nevertheless, neither splenic autotransplant patients nor the average general population showed any appreciable variations in any of the parameters.

CONCLUSIONS

Spleen's activities with adequate hemocatheter activity and recovery of the immunological deficit after splenic autotransplantation.

Immune function and the role of vaccination after splenic artery embolization for blunt splenic injury

The spleen is the most commonly injured solid organ following blunt abdominal trauma. Over recent decades, splenic artery embolization (SAE) has become the mainstay treatment for haemodynamically stable patients with high-grade blunt splenic trauma, with splenectomy the mainstay of treatment for unstable patients. Splenic function is complex but the spleen has an important role in immune function, particularly in protection against encapsulated bacteria. Established evidence suggests that following splenectomy immune function is impaired resulting in increased susceptibility to overwhelming post-splenectomy infection, however, immune function may be preserved following SAE. This review will discuss the current state of the literature on immune function following different treatments of blunt splenic injury, and the controversies surrounding what constitutes a quantitative test of splenic immune function.

Splenic auto-transplantation after splenectomy for trauma: evaluation of a new technique

BACKGROUND

Splenic autotransplantation is a promising method to recover splenic functions after traumatic splenectomy. However, it is associated with several postoperative complications, such as subphrenic abscess, intestinal obstruction and torsion of the omentum with necrosis of the implanted splenic tissues. Therefore, the aim of this study is to evaluate a new splenic autotransplantation technique that could overcome those complications.

MATERIALS AND METHODS

A single segment of the spleen was implanted inside a pedunculated omental pouch and fixed in the native site of the spleen in 15 patients who underwent splenectomy for abdominal trauma. This group of patients was compared with the next 17 patients who underwent splenectomy alone. Additionally, splenic functions of the patient and control groups were evaluated 3 months using peripheral blood smear [the presence of Howell-Jolly (HJ) bodies] and abdominal contrast-enhanced computed tomography (CECT).

RESULTS

All patients who underwent splenic autotransplantation showed evidence of a well-vascularised splenic tissue on CECT and normal peripheral blood smear without HJ bodies 3 months postoperatively. No postoperative complications related to splenic autotransplantation were observed, and platelet count after 3 months was significantly higher in patients who underwent splenectomy only (p = 0.04).

CONCLUSIONS

Splenic autotransplantation using the aforementioned technique could restore splenic functions with minimum postoperative complications related to the procedure.

Single segment of spleen autotransplantation, after splenectomy for trauma, can restore splenic functions

Background

Splenectomy is sometimes necessary after abdominal trauma, but splenectomized patients are at risk of sepsis due to impaired immunological functions.

To overcome this risk, autotransplantation of the spleen by using a new technique has been proposed, but so far, a demonstration of functionality of the transplanted tissue is lacking.

Methods

We therefore evaluated 5 patients who underwent a splenic autotransplant in comparison with 5 splenectomized patients without splenic autotransplant and 7 normal subjects.

Results

We confirmed that the patients not undergoing autotransplantation, when compared to normal subjects, had a higher platelet count, higher percentage of micronucleated reticulocytes (p = 0.002), increased levels of naive B lymphocytes (p = 0.01), a defect of class-switched memory (p = 0.001) and class-unswitched memory B cells (p = 0.002), and increased levels of PD1 on T lymphocytes CD8+ (p = 0.08). In contrast, no significant differences for any of the abovementioned parameters were recorded between patients who underwent spleen autotransplantation and normal subjects.

Conclusion

These findings suggest that splenic autotransplantation is able to restore an adequate hemocatheretic activity as well as recover the immunological deficit after splenectomy.

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.

Thoracic Splenosis after Splenic and Diaphragmatic Injury

Thoracic splenosis is a rare disease that develops as a result of autotransplantation of splenic tissue into the thoracic cavity following splenic and diaphragmatic injury. We report the case of a 53-year-old man with a chief complaint of heartburn and cough. He had a history of traumatic diaphragmatic rupture treated with surgical repair and splenectomy 15 years ago. Imaging studies revealed a paraesophageal mass, and surgical resection was performed considering the possibility of Castleman disease or an esophageal submucosal tumor. Pathologic results showed findings of normal splenic tissue. The patient was discharged on postoperative day 5 without any complications.

Splenosis of the Liver Capsule

Splenosis, a form of ectopic splenic tissue, is generally caused by heterotopic autotransplantation of splenic tissues after traumatic splenic rupture or splenectomy. The implants are often localized intraperitoneally, mostly in the left upper quadrant and splenic region. Hepatic foci are seen only on rare occasions. The differential diagnosis of splenosis foci from malignant masses can be challenging by conventional imaging and lead to unnecessary invasive procedures. This manuscript presents radiological and scintigraphic images of splenosis foci located in the peritoneal cavity and liver capsule of a 46-year-old man who underwent splenectomy due to traumatic splenic rupture 30 years ago.

Intrahepatic splenosis mimics hepatocellular carcinoma in a patient with chronic hepatitis B: A case report and literature review

BACKGROUND

Splenosis is a benign and relatively uncommon condition caused by trauma or splenectomy or other procedures involving splenic tissue. It is usually asymptomatic, and often diagnosed accidentally, especially misdiagnosed as malignant tumor.

METHODS

A 54-year-old man with prior history of chronic hepatitis B virus infection and underwent splenectomy for traumatic splenic rupture following a traffic accident 23 years previously was admitted to our hospital and found a hepatic mass in the right upper quadrant during an imaging examination. The diagnosis of his was not clear and finally he agreed to receive a surgical treatment.

RESULTS

During the operation, we found a mass in the right posterior lobe of the liver and a hard nodule on the right side of the diaphragm, both were completely resected, and postoperative histopathologic examination revealed that all excised tissues were proved to have histological structure typical for the spleen.

CONCLUSIONS

The occurrence of intrahepatic splenosis is rare with only few cases previously reported in the literature. It is a benign disease and sometimes difficult to distinguish from diseases of the liver. The need for positive surgical resection of splenosis is still controversial.

Great Vessel Injury in Thoracic Surgery

The potential for intraoperative bleeding is inherent to the practice of thoracic surgery due to the presence of multiple vital vascular structures, complex anatomy, and constant cardiorespiratory motion. Careful and detailed preoperative evaluation and planning, comprehensive review of imaging studies, and a thorough knowledge of the operative procedure, anatomic relationships, and potential complications are of the highest importance in prevention and avoidance of bleeding complications. Preparation with a clear crisis management plan ensures an effective and expedited response when intraoperative bleeding occurs.

Combined Intrathoracic and Subcutaneous Splenosis Discovered 51 Years after Abdominal Trauma

Splenosis is a rare condition that results from the autotransplantation of splenic parenchyma into unexpected locations such as the abdomen or subcutaneous tissue. In the presence of coexisting injury to the diaphragm intrathoracic transplantation can occur emerging as single or multiple pleural-based masses. This occurs after traumatic rupture of the spleen and is usually asymptomatic, only to be discovered incidentally on routine thoracic or abdominal imaging. To our knowledge this is the third documented case of combined intrathoracic and subcutaneous splenosis found in English literature. This occurred in a 71-year-old male involved in a motor vehicle accident at age 19 requiring urgent splenectomy. He has a significant cigarette smoking history and was referred to our hospital for further evaluation of an abnormality seen on shoulder X-ray.

Vaccination considerations in the asplenic patient

Overwhelming postsplenectomy sepsis is a rare but devastating and often lethal disease. Although vaccines are available, their proper use may be questioned. Standardization of protocols for the immunization of asplenic patients should be universal, thus, likely improving on their use. This article reviews the vaccines to be administered to the asplenic patient.

Thoracic Splenosis More Than 40 Years After Thoracoabdominal Trauma

Splenosis is a rare occurrence that is defined as autotransplantation of splenic tissue usually after splenic rupture due to trauma and subsequent splenectomy. Although splenosis most commonly occurs in the abdomen, the authors report a rare case of thoracic splenosis after remote thoracoabdominal trauma. A 62-year-old woman was found to have lower-lobe, pleural-based nodular lesions in juxtaposition to the posteromedial segment of the lung during workup for an abdominal hernia. Surgical excision of the mass confirmed the diagnosis of ectopic splenic tissue, and splenosis was diagnosed. This woman was among the rare 18% of people who are found to have splenosis in the intrathoracic space. In the workup of pulmonary nodules in patients with a history of trauma, splenosis should be a consideration.

Thoracic splenosis as a differential diagnosis of juxtapleural nodules

Thoracic splenosis is rare and consists of ectopic implantation of splenic tissue into the chest after concomitant thoracic and abdominal trauma with diaphragm injury. It occurs in about 18% of cases of splenic ruptures. In almost all cases, diagnosis is given incidentally once patients are usually asymptomatic. Thoracic splenosis should be considered as a differential diagnosis in all patients with history of trauma presenting with juxtapleural nodules in chest computed tomography. However, malignant conditions should be ruled out firstly. Biopsy is not essential for the diagnosis once nuclear medicine can confirm splenosis in patients with pertinent history of trauma and suggestive tomographic image. We present a typical case of thoracic splenosis whose diagnosis was made by nuclear medicine and no invasive procedures were required.

Liver-spleen axis: Intersection between immunity, infections and metabolism

Spleen has been considered a neglected organ so far, even though is strictly linked to liver. The spleen plays an important role in the modulation of the immune system and in the maintenance of peripheral tolerance via the clearance of circulating apoptotic cells, the differentiation and activation of T and B cells and production of antibodies in the white pulp. Moreover, splenic macrophages are able to remove bacteria from the blood and protect from sepsis during systemic infections. We review the spleen function and its assessment in humans starting from the description of spleen diseases, ranging from the congenital asplenia to secondary hyposplenism. From the literature data it is clear that obesity in humans affects different compartments of immune system, even thought there are still few data available on the implicated mechamisms. The intent is to enable clinicians to evaluate the newly recognized role of metabolic and endocrine functions of the spleen with special emphasis to obesity and nonalcoholic fatty liver disease in the context of the available literature. Moreover, understanding the spleen function could be important to develop appropriate prevention strategies in order to counteract the pandemia of obesity. In this direction, we suggest spleen longitudinal diameter at ultrasonography, as simple, cheap and largely available tool, be used as new marker for assessing splenic function, in the context of the so-called liver-spleen axis.

Parenchymal thoracic splenosis: history and nuclear imaging without invasive procedures may provide diagnosis

Splenosis is a rare finding of ectopic splenic tissue found within the thoracic cavity, abdomen or peritoneal cavity. Most cases occur in the abdomen and the thoracic location is a comparatively rare finding. In thoracic splenosis the splenic tissue most often grows in the form of a nodule and the autotransplantation is usually caused by a previous operation and/or most commonly a penetrating or blunt trauma to the thoracoabdominal region, resulting in splenic rupture and in some cases left diaphragmatic tear. In majority of the cases the patients are asymptomatic and are incidentally diagnosed with left hemithorax pulmonary lesions found via chest radiography or thoracic computed tomography. We present a 45-year-old Caucasian male who was incidentally diagnosed with parenchymal thoracic splenosis secondary to a gunshot wound to the abdomen 13 years ago that resulted in distal pancreatectomy, splenectomy and gastrorrhaphy. In this case report we will briefly discuss the current updates in the literature regarding thoracic splenosis, and highlight the fact that the findings raise the suspicion of malignancy requiring numerous investigations yet early recognition of thoracic splenosis can prevent unnecessary tests and procedures. Preoperative diagnosis of splenosis should be made with the use of nuclear imaging studies such as the ^99mTc heat-damaged erythrocyte study rather than computed tomography-guided biopsy or invasive surgery.

TNF receptor-1 is required for the formation of splenic compartments during adult, but not embryonic life

Lymphotoxin β-receptor (LTβR) and TNF receptor-1 (TNFR1) are important for the development of secondary lymphoid organs during embryonic life. The significance of LTβR and TNFR1 for the formation of lymphoid tissue during adult life is not well understood. Immunohistochemistry, morphometry, flow cytometry, and laser microdissection were used to compare wild-type, LTβR(-/-), TNFR1(-/-) spleens with splenic tissue that has been newly formed 8 wk after avascular implantation into adult mice. During ontogeny, LTβR is sufficient to induce formation of the marginal zone, similar-sized T and B cell zones, and a mixed T/B cell zone that completely surrounded the T cell zone. Strikingly, in adult mice, the formation of splenic compartments required both LTβR and TNFR1 expression, demonstrating that the molecular requirements for lymphoid tissue formation are different during embryonic and adult life. Thus, interfering with the TNFR1 pathway offers the possibility to selectively block the formation of ectopic lymphoid tissue and at the same time to spare secondary lymphoid organs such as spleen and lymph nodes. This opens a new perspective for the treatment of autoimmune and inflammatory diseases.

Stereologic analysis of tissue compartments of gunshot-injured and blunt-injured spleen

The spleen is composed of several tissue compartments and the respective histoquantitative data are essential for complete understanding of immune or pathological processes in this organ. The aim of our study was to determine and compare the stereologic parameters of all tissue compartments of the gunshot-injured and blunt-injured human spleen. The model-based stereology with point-counting method was utilized to study the volume densities of red pulp, perifollicular zone, marginal zone, white pulp (follicles and periarteriolar lymphoid sheath), and connective tissue. The areal numerical density (the number of follicles per mm(2) of tissue section), the numerical density (the number of follicles per mm(3) of tissue) of lymphoid follicles and the mean follicle diameter were also determined. Our study provides stereological parameters for all tissue compartments of the human spleen. No morphometric differences were registered between tissue compartments of the blunt-injured and gunshot-injured spleen. As the gunshot-injured spleen was taken as presumably unstimulated in immunological regard, our results suggest that both gunshot-injured and blunt-injured organs may be used as models of the normal human spleen.

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.

Esplenectomia parcial para tratar hemangioma esplênico

Apesar de a esplenectomia ser eficaz na abordagem terapêutica de pacientes com hemangioma esplênico, esse procedimento é acompanhado de elevada morbidade e até mortalidade, principalmente devido à sepse, quando realizado em crianças e adolescentes com sistema imunitário ainda imaturo. Para prevenir os efeitos adversos da asplenia, propõe-se neste artigo a esplenectomia parcial, com a retirada apenas da região do hemangioma, mantendo o restante do baço e preservando suas importantes funções.

Effect of non-operative management (NOM) of splenic rupture versus splenectomy on the distribution of peripheral blood lymphocyte populations and cytokine production by T cells

Post-traumatic splenectomy is associated with increased postoperative morbidity and mortality and long-term impairment of humoral and cellular immunity. Alternatives to surgery have been developed to minimize or avoid the immediate and/or long-term complications of splenectomy. Herein we investigated the long-term effect of non-operative management (NOM) of the traumatic rupture of the spleen on the distribution of peripheral blood (PB) lymphocyte populations and cytokine production by T cells. PB samples were drawn from six NOM patients, 13 age-matched adults who had undergone splenectomy after trauma (SP patients) and 31 age-matched controls. Cellular phenotypes and the intracellular production of interferon (IFN)-gamma, interleukin (IL)-2, IL-4 and IL-10 cytokines in T cells were determined in whole blood +/- mitogens by flow cytometry. NOM patients did not show any changes in the absolute numbers of lymphocytes or the distribution of their subsets, compared to the controls. In contrast, SP patients showed a sustained increase in the percentage and/or absolute numbers of lymphocytes, CD8 T cells, activated CD8 T cells, natural killer (NK) T cells, NK cells and gammadelta T cells, and a reduction in naive CD4 T cells. The constitutive or induced cytokine production by T cells of the NOM group was similar to the control group, whereas SP patients had increased percentages of constitutive IL-2- and IFN-gamma-producing CD8 T cells and IFN-gamma-producing CD4 T cells. Our findings indicate collectively that the healing process in NOM does not affect the architecture of the spleen to such an extent that it would lead to long-term alterations of the proportions of PB lymphocytes or the T cell cytokine profiles.

Influência do baço, da asplenia e do implante esplênico autógeno no metabolismo lipídico de camundongos

OBJETIVO: Estudar a influência do baço, da asplenia e do implante esplênico autógeno no metabolismo lipídico, por meio da avaliação do lipidograma sérico de camundongos e da verificação do efeito do transplante autógeno de baço em diferentes locais do abdome. MÉTODO: Foram utilizados camundongos BALB/c distribuídos em sete grupos de 10 animais: controle normal (CN); controle obeso (CO); operação simulada (OS); esplenectomia total (ET); três grupos submetidos ao transplante autógeno do baço: omento maior (OM), retroperitônio (RP), tecido subcutâneo da parede abdominal (PA). Os animais, com exceção do grupo CN, foram submetidos a dieta com 1,25% de colesterol. A intervenção cirúrgica foi realizada 30 dias após o início da dieta. A coleta de sangue ocorreu no 60º dia pós-operatório. Foram dosados os níveis de triglicérides, de colesterol total e de suas frações, bem como a glicemia. O baço, os implantes esplênicos e o fígado foram submetidos a estudo histológico. RESULTADOS: A dieta aumentou os níveis plasmáticos de colesterol total, HDL e LDL dos camundongos (p < 0,05 versus CN). Entre os animais em uso da dieta, não houve diferença no lipidograma dos grupos controles (CO e OS) quando comparados ao grupo esplenectomizado (ET), assim como em relação aos animais submetidos ao transplante autógeno do baço (OM, RP, PA). A capacidade de preservação da arquitetura histológica esplênica foi semelhante nos três locais de implante. Todos os animais que utilizaram a dieta enriquecida apresentaram esteatose hepática. CONCLUSÃO: De acordo com os resultados obtidos o baço não parece participar da regulação dos níveis de lipídeos plasmáticos em camundongos BALB/c.

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.

Operações laparoscópicas conservadoras do baço para tratar dor esplênica por isquemia

RACIONAL: Desde 1979 este grupo de autores executa esplenectomia conservadora através de esplenectomia sub-total e autotransplante esplênico. Estes procedimentos foram realizados em mais de 300 pacientes para tratar diferentes condições patológicas. OBJETIVO: Apresentar proposta original e inédita em seres humanos de esplenectomia subtotal, preservando apenas o pólo superior do baço por via laparoscópica e esplenectomia total complementada por implante autógeno de tecido esplênico, também pela via laparoscópica, como nova forma de tratamento da dor severa devida à isquemia do baço. MÉTODOS: Três pacientes com intensa dor no hipocôndrio esquerdo foram submetidos a grande número de exames para concluir que sua dor era provocada por isquemia de parte do baço. A dor era resistente a todos os métodos conservadores utilizados. Decidiu-se, então, pelo tratamento cirúrgico por meio da esplenectomia subtotal, preservando o pólo superior do baço suprido pelos vasos esplenogástricos em dois casos, e esplenectomia total complementada por implante no omento maior de 20 fragmentos retirados desse baço, no terceiro caso. As três operações foram realizadas por via laparoscópica. Os três doentes foram acompanhados com exames hematológicos, imunológicos, tomográficos e cintilográficos. RESULTADOS: Esses procedimentos foram conduzidos sem risco para os paciente e com sangramento mínimo. Não houve dificuldade técnica nem complicações per ou pós-operatórias. No seguimento, não foram constatadas anormalidades, comprovando-se a vitalidade e a função dos remanescentes esplênicos. A dor esplênica desapareceu desde o dia da operação e não retornou durante o período de acompanhamento. CONCLUSÃO: A esplenectomia subtotal e os auto-implantes esplênicos são factíveis por via laparoscópica, de maneira segura para os doentes e devem deve ser considerados no tratamento da dor de origem isquêmica do baço.

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 and oesophageal transection anastomosis in patients with portal hypertension (26 years clinical observation)

The surgical treatment methods for cirrhosis patients complicated with portal hypertension are complicated. In this study, we evaluated the effectiveness of a new treatment strategy: splenic auto-transplantation and oesophageal transection anastomosis on 274 patients from three aspects: clinical observation, splenic immunology and portal dynamics. From 1979 to 2005, 274 cirrhosis patients with portal hypertension who underwent the new treatment strategy were followed up to observe different clinical indexes, which were then compared with those of the traditional surgery treatment. From 1999 to 2002, a randomized control trial (RCT) was performed on 40 patients to compare their immune function after operation. From 1994 to 2004, another RCT was carried out on 28 patients to compare the portal dynamics through three-dimensional dynamic contrast enhanced MR angiography (3D DEC MRA) investigation after operation. Among 274 patients (mean age 41.8 years), the emergency operative mortality (4.4%), selective operative mortality (2.2%), complication rate (17.9%), morbidity of hepatic encephalopathy (<1%), bleeding rate of portal hypertension gastritis (PHG) (9.1%), and morbidity of hepatic carcinoma (8%) were similar to those under traditional operation; the spleen immunology function (Tuftsin, IgM) decreased among the groups 2 months after operation. Through 3D DCE MRA, the cross section area, the velocity and volume of blood flow of main portal vein decrease significantly after operation in both groups, the auto transplantation group was significantly lower in velocity and volume of blood flow than in the control group. Splenic auto transplantation and esophageal transection anastomosis are a safe, effective, and reasonable treatment strategy for portal hypertension with varicial bleeding. It can not only correct hypersplenism but also completely stanch blood, and auto transplanted spleen in the retroperitoneal space can preserve immune function and establish abroad collateral circulation.

Cellular and serological changes in the peripheral blood of splenectomized and spleen autotransplanted mice

BACKGROUND

Our department worked out a modified surgical form of spleen autotransplantation earlier, named "spleen apron method" introduced already into the clinical practice. Recently we tested the immunological changes in a group of patients autotransplanted with about 10-15% of their spleen, what was the at least always implantable amount after the severe splenic injuries. In the current work we aimed at measuring some cellular and serological changes in the peripheral blood of splenectomized and spleen autotransplanted inbred mice two and eight months after the operations in order to get more unambiguous results than that we could obtain in our patients with this technique.

MATERIALS AND METHODS

We divided 96 two months old Balb/c female mice into eight groups (n = 12/group). The group of controls, sham operated, splenectomized and autotransplanted animals with two and eight months of survival time after the operations. During the autotransplantation we inserted the same amount of spleen, five slices, "chips," about 10-15% of total mass of spleen, into the greater omentum similarly as it was used in the patients. The concentration of serum proteins were measured by laser nephelometry. The lymphocyte subsets were analyzed by flow cytometry.

RESULTS

We found that two months after the operations the number of CD 19+ B-cells increased in the splenectomized but decreased in the autotransplanted animals. Eight months after the operations the number of both CD3+ T and CD19+ B lymphocytes decreased both in the splenectomized and autotransplanted animals compared to the controls and sham operated mice. However, the numbers of T and B cells were slightly but not significantly higher in the autotransplanted than in the splenectomized mice. The serum level of IgM was also decreased in the splenectomized and autotransplanted mice at both time points, however, eight months after the operations the concentration of IgM was significantly higher in the autotransplanted group than in the splenectomized animals.

CONCLUSION

The effects of autotransplanted "chips" were different at the various ages of the animals. Additionally, they showed some immunological benefit being quantitatively in accordance to the amount of the transplanted spleen. The elevated level of serum IgM what we found in the autotransplanted mice even with this amount of transplanted spleen eight months after the operations, however, might have the potentially greatest importance compared to splenectomy. These experiments can prove that the attempts for autotransplantation may have real perspectives but their efficacy depends on the amount of the successfully transplanted (saved) mass of spleen.

Splenic artery ligation ameliorates hepatic ischemia and reperfusion injury in rats

BACKGROUND/AIMS

Hepatic injury caused by ischemia/reperfusion (I/R) is a key clinical problem associated with liver transplantation and liver surgery. The spleen is involved in hepatic I/R injury. In this study, we examined the effects of splenic artery ligation on hepatic I/R injury.

METHODS

Splenic artery ligation was performed 7 days, 3 days, or just before the hepatic ischemia. Hepatic ischemia was conducted by occluding the blood vessels to the median and left lateral lobes with an atraumatic vascular clamp. Hepatic I/R injury was induced by 45 min of ischemia followed by 120 min of reperfusion.

RESULTS

When splenic artery ligation was performed at 3 days or just before the ischemia, serum aspartate transaminase and alanine transaminase activities, as markers for hepatic injury, decreased as compared with the rats with I/R alone. Splenic artery ligation also reduced the myeloperoxidase activity, an enzyme present in neutrophils, and the expression of interleukin-6 mRNA, a proinflammatory cytokine, in rat livers with I/R. Efficacy of splenic artery ligation on hepatic I/R injury was also confirmed by histology. On the other hand, when splenic artery ligation was conducted 7 days before the ischemia, efficacy of splenic artery ligation was disappeared.

CONCLUSIONS

Splenic artery ligation ameliorates hepatic I/R injury in rats. These results strongly suggest the clinical usefulness of this surgical procedure to protect the liver against I/R injury.

Functional hypersplenism in mice induced by adoptive transfer of syngeneic spleen cells

Investigation of peripheral blood cell count alterations in cases with hypersplenism, and an understanding of the relationship between splenic function and hematopoietic cell production require suitable experimental animal models. Previously described methods are either traumatic or require surgical intervention. We suggest a relatively simple method for achievement of a state mimicking hypersplenism in mice by intraperitoneal inoculation of syngeneic spleen cells. Mice were inoculated intraperitoneally with 3 x 10(7) splenocytes suspended in 0.3 ml phosphate buffered saline (PBS). After 2 months, the inoculated animals showed a progressive decrease in the peripheral white blood cell (WBC) counts and hyperplastic bone marrow that persisted until the experimental end point (7 months). Five days after inoculation of splenocytes stained with carboxy-fluorescein diacetate succinimidyl ester (CFSE), the majority of the stained cells was present in the peritoneal cavity (33%) and in the liver (13%), whereas the percentage of stained cells in the peripheral blood and the spleen cell suspension was negligible. The mitogen response of the peripheral blood mononuclear cells (PBMC) from treated mice to concanavalin A (Con A) remained unaltered. Splenocyte-inoculated mice that were further splenectomized did not show leukocytosis after splenectomy, as was observed in animals in which the spleen was removed without any pretreatment. The lack of any signs of discomfort in animals from the study group, in comparison with the visibly ill appearance and even death of mice in which hypersplenism was achieved by repeated injections of methylcellulose (MC), which served as controls, favors the convenience of the method.

Distribution of peripheral blood cells in mice after splenectomy or autotransplantation

Our aim was to compare the distribution changes of peripheral leukocytes and erythrocytes in splenectomized and spleen-autotransplanted BALB/c female mice (n = 96), 2 and 8 months after surgery. In total, there were eight groups of animals: splenectomy, autotransplantation, sham, and untreated controls at both time points. We used the spleen-apron method of Furka et al. (Khirurgiia (Mosk) 1989;9:125-127), inserting five spleen chips into the greater omentum, for autotransplantation. Quantitative and qualitative blood cell counts and the phagocytic activity of cells (stimulated with zymosan) were determined. In splenectomized animals, the number of neutrophils significantly increased 8 months after surgery. The greatest phagocytic activity of neutrophils, however, was observed in autotransplanted animals of the same age. In splenectomized animals, erythrocyte volumes were significantly higher in the second postoperative month, but normalized by the eighth month. In conclusion, spleen autotransplantation has some beneficial effects, including clearing erythrocytes and preserving the phagocytic activity of neutrophils in peripheral blood.

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.

Laparoscopic spleen-preserving distal pancreatectomy

Distal pancreatectomy with spleen preservation may be the preferred procedure for certain benign tumors and cystic lesions of the pancreatic body or tail. Alternatively, laparoscopic removal including either distal pancreatectomy with splenectomy or splenic-preservation with ligation of the splenic vessels have also been described. We describe, herein, our method to perform spleen-preserving laparoscopic distal pancreatectomy that preserves the splenic vessels and hence splenic function. The described technique of spleen-preserving distal pancreatectomy has been used in two patients with favorable results. Both patients underwent laparoscopic distal pancreatectomy with splenic conservation for an oligocystic serous cystadenoma and serous cystadenoma. Operative time was 3-6 hours with total blood loss of less than 200 cc in both cases. The length of stay in the hospital was 4-8 days and both patients returned to work within 3 weeks. Laparoscopic spleen-preserving distal pancreatectomy should be considered for younger patients with select body or tail lesions that are not candidates for less extensive procedures.

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.

Age-dependent development of the splenic marginal zone in human infants is associated with different causes of death

Infants are more susceptible to infections caused by T cell- independent type 2 (TI-2) polysaccharide antigens of certain encapsulated bacteria. Immune responses against this type of antigen are related to the splenic marginal zone (MZ). However, only few data exist on the age-dependent developmental stages of the human spleen in early childhood and on their association with different diseases. Therefore, the present study aimed to investigate spleens of a large number of children at very young ages (12 days to 32 months), derived from autopsy cases. Immunohistochemical labeling was performed on paraffin sections of 34 spleens using a panel of monoclonal antibodies. The shape and size of the white pulp compartments were examined and correlated to the cause of death of the children. Results show that the development of the different compartments was statistically age-dependent, but no clear-cut time point for the maturity of each compartment was seen. Furthermore, the MZ was significantly more often missing when sudden infant death (SID) and/or infection were the cause of death, compared with other violent or traumatic reasons that served as controls. This association supports the concept that an immature state of the spleen and especially of the MZ might contribute to the increased susceptibility to bacterial infections in young infants.

Selective role of nuclear medicine in evaluating the acute abdomen

The imaging evaluation of the acute abdomen has clearly evolved with the introduction of high-resolution imaging techniques, such as CT, US, and MR imaging, leaving scintigraphic examinations an important, though selective, role based on their noninvasive, physiologic, and functional nature. Proper use of these examinations among all the diagnostic methods requires a good understanding of their strengths and limitations.

Prevention of life-threatening infections due to encapsulated bacteria in children with hyposplenia or asplenia: a brief review of current recommendations for practical purposes

The aim of the present work was to summarise in a single paper all the options for prevention of life-threatening infections due to encapsulated bacteria in patients with hyposplenism or asplenia. Prevention of these infections should be obtained in all patients with 1) patient and family education, 2) prophylaxis by means of vaccination against Haemophilus influenzae and Streptococcus pneumoniae, 3) antibiotic prophylaxis, based primarily on penicillin, 4) delay of elective splenectomy or use methods of tissue salvage in splenic trauma. Vaccination is not effective against all serotypes of S. pneumoniae and Neisseria meningitidis causing life-threatening infections in hypo/asplenic patients. Moreover, antibacterial prophylaxis could select antibacterial-resistant pathogens and is highly conditioned by patient's compliance. Therefore, empirical antibacterial therapy of fever and/or suspected infection should be recommended to all splenectomised patients independently from time elapsing from splenectomy, vaccinal status and assumption of antibacterial prophylaxis.

Bacterial phagocytosis by macrophage of autogenous splenic implant

Autogenous splenic implant seems to be the only alternative for preservation of splenic tissue after total splenectomy. This work was carried out to analyze the morphologic regeneration of autotransplanted splenic tissue in Wistar rats and to determine the bacterial phagocytic function of their macrophages. We utilized an experimental model with thirty-two rats, of both sexes, submitted to total splenectomy combined with autotransplantation in greater omentum of slices of the whole spleen mass. The animals were divided into two groups: I - young rats weighing 100 to 150 g; and II - adult rats weighing 250 to 300 g. Sixteen weeks later animals were intravenously inoculated with a suspension of Escherichia coli AB1157. Twenty minutes after inoculation, the animals were sacrificed and the splenic autotransplants were removed for morphological study. There was regeneration of autotransplanted splenic tissue in all animals. A similar morphological aspect among all animals was observed, with splenic tissue showing red and white pulps, lymphoid follicles, and marginal zone, with a moderate architectural disarrangement. Macrophages containing gram-negative bacterial aggregates as well as macrophages with hemosiderin pigments within the cytoplasm were observed. Blood vessels showed preserved walls, with no signs of vasculitis or thrombosis. The present results suggest that autogenous splenic implants in the greater omentum of the rat acquire the macro- and microscopic architecture of a normal spleen, with reduced dimensions, and preserve bacterial phagocyte function.

After chemotherapy, functional humoral response capacity is restored before complete restoration of lymphoid compartments

Chemotherapy has, besides the beneficial effects, several adverse effects. Suppression of the immune system is one of the most important problems. Infections caused by encapsulated bacteria like Streptococcus pneumoniae are responsible for a major part of infectious problems during and after treatment. The splenic marginal zone is essential in the initiation of an immune response to encapsulated bacteria. In this study, we analysed the effects of three different cytostatic agents on humoral immune responses. We found a reduced, but detectable immune response capacity at two days after treatment although the marginal zone B cell population is severely reduced at this time point. Twenty-four days after cessation of treatment, the immune response capacity was largely restored although lymphoid compartments were still not completely restored at that time point. Apparently, the presence of only few marginal zone B cells is sufficient to evoke a rise in antibody titres and although antibody titre increases are low, even small rises are most likely clinically relevant.

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.

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.

Recurrent penicillin-resistant pneumococcal sepsis after matched unrelated donor (MUD) transplantation for refractory T cell lymphoma

Patients who undergo splenectomy and recipients of allogeneic marrow (alloBMT) or peripheral stem cell transplantation are at increased risk of overwhelming infection from encapsulated organisms such as Streptococcus pneumoniae, Haemophilus influenzae and Neisseria meningitidis. As prophylaxis against these pathogens splenectomised patients are immunised and may also receive antibiotics for life. We report relapsing overwhelming sepsis caused by penicillin-resistant pneumococcus in a patient who was immunised and received prophylactic phenoxymethylpenicillin for 8 months following splenectomy and matched unrelated donor (MUD) marrow transplantation for refractory T cell lymphoma. No obvious focus of sepsis was found during any of the three episodes and S. pneumoniae serogroup 6, subtype 6B was isolated from blood cultures on each occasion. He was treated with i.v. cephalosporins, as the organisms were resistant to penicillin with a minimum inhibitory concentration (MIC) of 2.0, and there was complete resolution of symptoms each time. In the light of recurrent sepsis with this penicillin-resistant organism the decision was made to give prophylactic levofloxacin for the next 12 months. This case illustrates that the choice of prophylactic regimen and the treatment of sepsis in immunocompromised patients remain difficult and challenging issues.

Splenectomy selectively affects the distribution and mobility of the recirculating lymphocyte pool

The spleen plays a major role in immune surveillance, but the impact that splenectomy exerts on the immune competence of an individual is not fully resolved. Here we show that neonatal splenectomy in sheep does not abrogate the development of a large, nonrecirculating pool of lymphocytes and that it has no effect on the acquisition of a normal blood lymphocyte profile. Splenectomy did, however, result in a significant decrease in blood residency time of recirculating lymphocytes and in an enhanced accumulation of recirculating lymphocytes in lymph nodes. Furthermore, nonrecirculating peripheral blood lymphocytes were less likely to migrate to the lung, possibly because of saturation of the marginal pool by recirculating lymphocytes. Although splenectomy has little effect on the development or distribution of lymphocyte subsets in blood and lymph, it has marked effects on the rate of recirculation of lymphocytes, which may have significant implications for peripheral immune surveillance in patients who undergo splenectomy.

Splenectomy selectively affects the distribution and mobility of the recirculating lymphocyte pool

The spleen plays a major role in immune surveillance, but the impact that splenectomy exerts on the immune competence of an individual is not fully resolved. Here we show that neonatal splenectomy in sheep does not abrogate the development of a large, nonrecirculating pool of lymphocytes and that it has no effect on the acquisition of a normal blood lymphocyte profile. Splenectomy did, however, result in a significant decrease in blood residency time of recirculating lymphocytes and in an enhanced accumulation of recirculating lymphocytes in lymph nodes. Furthermore, nonrecirculating peripheral blood lymphocytes were less likely to migrate to the lung, possibly because of saturation of the marginal pool by recirculating lymphocytes. Although splenectomy has little effect on the development or distribution of lymphocyte subsets in blood and lymph, it has marked effects on the rate of recirculation of lymphocytes, which may have significant implications for peripheral immune surveillance in patients who undergo splenectomy.