Near-total splenectomy: a new technique for the management of hereditary spherocytosis

[Torsion of the wandering spleen in childhood - report of 3 cases]

A vándorlép gyermekkorban ritkán előforduló fejlődési rendellenesség, melynek lényege, hogy a lépet a has bal felső kvadránsában rögzítő szalagok vagy lazák, vagy hiányoznak. Ez az anatómiai környezet kedvez a lépcsavarodásnak, mely a leggyakoribb szövődmény vándorlép esetén. Ammenyiben vándorlép igazolódik, műtétre van szükség. Két műtéti stratégia közül választhatunk: megtartjuk és fixáljuk, vagy egyértelmű infarktus esetén eltávolítjuk a lépet. A szerzők egy 16 éves periódust (2004–2020) tekintenek át, amelynek során két intézetben három gyermeket kezeltek lépcsavarodás miatt. A hasi panaszok kezdetétől 12–48 órán belül történt hasi ultrahangvizsgálat. A gyermeksebészeti vizsgálatok előtt a gyermekek székrekedés gyanúja miatt mindhárom esetben béltisztító kezelést kaptak, mivel az első észlelők a vándorlépet kitapintva skybalának tartották. A képalkotó vizsgálatok ectopiás helyen lévő lépet igazoltak, és felvetették a lépcsavarodás gyanúját. Nyitott műtét során mindhárom esetben lépmegtartó műtét történt. Posztoperatív szövődmény nem alakult ki. A megtartott lépek életképességét illetően nyomon követéses vizsgálatok történtek. Orv Hetil. 2024; 165(22): 866–871.

Long-term haematological response and maintained immunological function after laparoscopic subtotal splenectomy in patients with hereditary spherocytosis

INTRODUCTION

Subtotal or total splenectomy are recommended in severe and should be considered in intermediate forms of hereditary spherocytosis (HS). Data on laparoscopic subtotal splenectomy (LSTS) in HS patients are sparse.

METHODS

Thirty three patients with HS (median age 10.7 years (yrs), range 1.8-15.5) underwent LSTS. Baseline and follow-up investigation included haematological parameters, microscopic analysis of pitted erythrocytes (pitE), and B-cell subpopulations assessed by flow cytometry. Results were compared to those of non-splenectomised HS patients, HS patients after total splenectomy (TS), and healthy individuals.

RESULTS

After LSTS, haemoglobin levels were normalised in all patients. During median long-term follow-up of 3.9 yrs (range 1.1-14.9), only four patients presented mild anaemia. Despite re-growing of the remnant spleen none of the patients required a second surgical intervention. As compared to TS, PitE in LSTS patients were significantly lower and indicated normal to only moderately decreased spleen function. Relative but not absolute IgM memory B-cell counts were reduced in both LSTS and TS patients.

CONCLUSIONS

LSTS is effective for the treatment of patients with HS. A small remnant spleen is sufficient to provide adequate phagocytic function and to induce a pool of IgM memory B-cells.

Role of Partial Splenectomy in Hematologic Childhood Disorders

The spleen is a secondary lymphoid organ that belongs to the reticular-endothelial system, directly connected to blood circulation. The spleen is greatly involved in the immune response, especially against capsulated bacteria. Splenectomy plays a fundamental role in the treatment of numerous pediatric hematologic disorders. Taking into account all the possible complications (especially infections) linked to this procedure, alternatives to total splenectomy have been sought. Partial splenectomy has been proposed as a treatment that allows the reduction of infectious risk. This approach has proven safe and feasible in most patients, but multicentric and prospective studies are necessary to more accurately define the indications for performing partial splenectomy. However, vaccinations and antibiotic prophylaxis remain fundamental for preventing serious infections, even in the case of partial splenectomy. We review anatomical and functional properties of the spleen, with a focus on medical or surgical indications to splenectomy, aiming to give practical educational information to patients and their families after splenectomy. Furthermore, we discuss the feasibility of partial splenectomy in children with hematologic diseases who require splenectomy.

Laparoscopic Partial Splenectomy: A Critical Appraisal of an Emerging Technique. A Review of the First 457 Published Cases

Background: Laparoscopic partial splenectomy (LPS) may allow avoiding total splenectomy (TS) complications and maximizing the advantages of mini-invasive approach. The objective of this review is to assess feasibility and safety of LPS, to compare this approach with alternative options. Materials and Methods: A literature review of articles reporting LPS is performed. Several parameters, including age, indication, surgical technique, devices used for splenic section/hemostasis, adverse outcomes, including morbidity/mortality, conversions to open surgery, conversions to TS, operative time (OT), and hospital stay (HS), are analyzed. Articles comparing LPS' results with those of open partial splenectomy and laparoscopic TS are also analyzed. Results: Fifty-nine articles reporting 457 LPS were included. Patients' characteristics varied widely, concerning age and indications, including hematological disease (hereditary spherocytosis, drepanocytosis), splenic focal masses, and trauma. Several technical options are reported. Mean OT and HS are 128 ± 43.7 minutes and 4.9 ± 3.8 days, respectively. No mortality and 5.7% morbidity are reported. Conversion rates to open surgery and to TS are 3.9% and 3.7%, respectively. Conclusions: In conclusion LPS is feasible and safe, with no mortality, low morbidity, and low conversion rates to laparotomy and to TS. LPS may be accomplished by various techniques and tools. Major complications are sporadically reported, thus potential risks should not be underestimated.

Laparoscopic near-total splenectomy. Report of a case

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We describe a case report of near total splenectomy managed by laparoscopy for a large lesion of the upper pole of the spleen.

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When total splenectomy is performed, an increased risk of potentially lethal infections arises. Asplenia and impaired splenic function are related to the increase of morbidity and mortality from infectious complications.

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The overwhelming post splenectomy infections (OPSI) are mostly represented by fulminating sepsis, meningitis or pneumonia.

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laparoscopic near total splenectomy is an innovative partial splenectomy technique consisting on preserving a residual spleen volume.

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The comparison between other spleen preserving techniques shows that LNTS is associated with a lower rate of secondary surgery and postoperative recurrence of anaemia.

Introduction

Splenectomy is a surgical procedure indicated for the treatment of most benign and malignant splenic diseases, especially hematologic disorders. Laparoscopic approach is preferable to the open surgery for most indications because it reduces intra- and post-operative complications and shortens hospital stay. Laparoscopic approach is also feasible for partial splenectomy. Spleen-preserving techniques reduce the risk of severe infections and thromboembolic events that can occur after total splenectomy

Case presentation

We report a case of a 50-year old woman with an incidentally discovered voluminous lesion in the superior pole of spleen. A laparoscopic near-total splenectomy was performed.

Discussion

The evidence about the potential complications in splenectomised patients speaks in favour of performing spleen-sparing surgical techniques whenever possible. Most common indications for laparoscopic partial splenectomy are non-parasitic splenic cystic, benign splenic tumors, splenic haematological diseases, non-cystic intraparenchymal lesions, spleen rupture, splenic abscess, vascular abnormalities. Laparoscopic near total splenectomy is an innovative partial splenectomy technique consisting on preserving a residual spleen volume.

Conclusion

LNTS seems to be a safe and effective technique for the management of benign spleen diseases. The comparison between other spleen preserving techniques shows that LNTS is associated with a lower rate of secondary surgery and postoperative recurrence of anaemia.

Simultaneous Huge Splenic and Mesenteric Hydatid Cyst

Hydatid disease (HD) is caused by Echinococcus granulosus and is endemic in many parts of the world. This parasitic tapeworm can produce cysts in almost every organ of the body, with the liver and lung being the most frequently targeted organs. The spleen and mesentery are unusual locations. We report a case of simultaneous huge splenic and mesenteric hydatid cyst in a 91-year-old male patient. The patient was presented with chronic abdominal pain, increased frequency of defecation, and typical history of animal contact (cattle, sheep, and dogs). After performing imaging studies, he was diagnosed with a simultaneous huge spleen and pelvic mesentery hydatid cyst that was managed surgically by splenectomy, pelvic mesenteric cyst deroofing, and partial cystectomy.

Partial splenectomy: Who, when and how. A systematic review of the 2130 published cases

BACKGROUND/PURPOSE

In order to avoid consequences of total splenectomy (including severe postsplenectomy sepsis), partial splenectomy (PS) is increasingly reported. Without guidelines and indications concerning a rarely-indicated procedure, a review of literature should be an asset.

METHODS

A systematic review of all PSs from 1960 to December 2017 was performed, with special focus on surgical indications, sites of resection, approaches and techniques of vascular dissection and parenchymal section/hemostasis of the spleen, perioperative morbidity/mortality, including complications compelling to perform total splenectomy.

RESULTS

Among 2130 PSs, indications for resection were hematological disease in 1013 cases and nonhematological conditions in 1078, including various tumors in 142 and trauma in 184. Parenchymal transection was performed using several techniques through the years, most frequently after having induced partial ischemia by splenic hilum vascular dissection/ligation. 371 laparoscopic/robotic PSs were reported. Rescue total splenectomy was required in 75 patients.

CONCLUSIONS

Although good results are probably overestimated by such a retrospective review, PS should be considered as a procedure associated with a low morbidity/mortality. Nevertheless, severe complications are also reported, and the need of total splenectomy should not to be minimized. Laparoscopic/robotic procedures are increasingly performed, with good results and rare conversions.

TYPE OF STUDY

Systematic review.

LEVEL OF EVIDENCE

IV.

Splenic Localization of Primary Hydatid Cyst in a 27-Year-Old Sportsman Treated by PAIR Technique: Imaging Anatomy Assessment

Introduction:

In this paper, we report our experience with a case of primary hydatid cyst involving only the spleen in a 27-year-old sportsman treated by PAIR technique.

Case Report:

Five years before, a 27-year-old handball player being admitted to our hospital, it was detected the cyst in his spleen which size was 35 x 30 mm in diameter, by abdominal ultrasound during a systematic examination. There was no pain or any other symptoms at that time. Tests on the presence of echinococcus cysts were negative. After a period of 5 years, and regular check-ups, the patient began to feel a dull pain in the left upper quadrant area. The Echinococcus test was again negative. Puncture and aspiration of content was performed and sent to cytological analysis that confirmed the presence of Echinococcus. The CT finding showed the spleen in a normal position, shape, enlarged, 185 mm in longitudinal diameter (splenomegaly), with inhomogeneous parenchyma on the expense of rounded area with hyperdense halo, which did not opacify after contrast, located in the dorsal area of the spleen, 100x98 mm in diameter and which corresponded to the echinococcal cyst in differential diagnosis–clean dense contents (protein / haemorrhagic).

Conclusion:

The reported case is very specific, considering that handball is contact sport, where it is almost impossible to avoid the physical contact between players, which is sometimes even rough. Due to rough contacts, spleen trauma is something we should be very aware about, especially in cases of splenomegaly with hydatid cyst, where the spleen rupture might lead to fatal outcome. According to all this, careful follow up of this patient is necessary.

A long-term follow-up study of subtotal splenectomy in children with hereditary spherocytosis

BACKGROUND

Hereditary spherocytosis (HS) is a heterogeneous hemolytic anemia treated with splenectomy in patients suffering from severe or moderate disease. Total splenectomy, however, renders patients vulnerable to overwhelming postsplenectomy infection despite preventive measures. Although subtotal splenectomy has been advocated as an alternative to total splenectomy, long-term follow-up data are scarce. We investigated how often hematologic recurrences requiring secondary total splenectomy occurred.

PROCEDURE

With a follow-up of at least 5 years, we analyzed the data of 12 patients, aged 11 years maximum (median 6.5 years), who had undergone intended subtotal splenectomy, and 9 patients (median age 11.9 years), who had undergone total splenectomy. We compared their hematologic results and searched for factors associated with secondary spleen surgery.

RESULTS

Hemolysis was reduced after subtotal splenectomy and absent after total splenectomy. Subtotal splenectomy was not successful in three children because no functional splenic remnant remained after 6 months (one conversion at surgery; one necrosis of splenic remnant; one early secondary splenectomy). Four children required secondary splenectomy after a median of 5 years for hematologic recurrence. In the remaining five patients, a functional splenic remnant was present for at least 5.5 years. The median time to secondary total splenectomy after intended subtotal splenectomy was 5.2 years. In all patients requiring secondary total splenectomy, increased reticulocyte levels within 2 years indicated hematologic recurrence.

CONCLUSIONS

Subtotal splenectomy can be an alternative for total splenectomy in young patients with HS. It allows for hematologic improvement and may preserve splenic immune function for as many as 5 years.

Total versus partial splenectomy in pediatric hereditary spherocytosis: A systematic review and meta-analysis

To compare the clinical effectiveness of total splenectomy (TS) or partial splenectomy (PS) in pediatric hereditary spherocytosis, a systematic review and meta-analysis was performed (PROSPERO registration CRD42015030056). There were 14 observational studies comparing pre- and postoperative hematologic parameters. Secondary outcomes include in-hospital infections, surgical complications, symptomatic recurrence, and biliary disease. TS is more effective than PS to increase hemoglobin (3.6 g/dl vs. 2.2 g/dl) and reduce reticulocytes (12.5% vs. 6.5%) after 1 year; outcomes following PS are stable for at least 6 years. There were no cases of overwhelming postsplenectomy sepsis. A population-based patient registry is needed for long-term follow-up.

Atraumatic splenic rupture precipitated by splenic vein thrombosis

We present the case of a 59-year-old man with atraumatic splenic rupture because of splenic vein thrombosis who was successfully treated with splenic artery embolization.

Laparoscopic splenectomy for hereditary spherocytosis-preliminary report

Splenectomy is considered standard surgical therapy in hereditary spherocytosis. The procedure is indicated in patients with severe anemia, recurrent hemolytic, and aplastic crises. The aim of the study was to assess treatment outcomes in patients with hereditary spherocytosis who underwent total or partial laparoscopic splenectomy. Fifteen patients aged 4-17 yr underwent laparoscopic splenectomy from 2009 to 2012. Partial and total splenectomies were performed (five and 10 children, respectively). Hematologic parameters, liver function tests, and splenic volume before and after the surgery were analyzed retrospectively. Total follow-up was 1-30 months. Hospitalization and operating time were similar in both groups. In partial splenectomy group, branches of splenic arteries gave better blood supply than short gastric vessels. In both groups, hematologic parameters were improved. Postoperative markedly elevated platelet count was maintained up to 6 months, and after that, platelet count gradually decreased to normal values. Bilirubin level was decreased in early postoperative period; however, it increased later to achieve levels lower than in preoperative period. No severe general infections were observed in both groups. Laboratory parameters (hemoglobin and bilirubin concentrations and RBC) after the surgery improved in all patients, and the effect was maintained during 12 months of follow-up. Platelet count increased significantly after the surgery and was maintained at high levels during the next 6 months. However, it returned to preoperative levels within a year after the surgery. Our study showed that partial splenectomy was not inferior to total splenectomy. However, full assessment requires longer follow-up and larger group of patients.

OPSI threat in hematological patients

Overwhelming post-splenectomy infection (OPSI) is a rare medical emergency, mainly caused by encapsulated bacteria, shortly progressing from a mild flu-like syndrome to a fulminant, potentially fatal, sepsis. The risk of OPSI is higher in children and in patients with underlying benign or malignant hematological disorders. We retrospectively assessed OPSI magnitude in a high risk cohort of 162 adult splenectomized patients with malignant (19%) and non malignant (81%) hematological diseases, over a 25-year period: 59 of them splenectomized after immunization against encapsulated bacteria, and 103, splenectomized in the previous 12-year study, receiving only life-long oral penicillin prophylaxis. The influence of splenectomy on the immune system, as well as the incidence, diagnosis, risk factors, preventive measures and management of OPSI are also outlined. OPSI occurred in 7 patients (4%) with a median age of 37 years at time interval from splenectomy ranging from 10 days to 12 years. All OPSIs occurred in non immunized patients, except one fatal Staphylococcus aureus -mediated OPSI in a patient adequately immunized before splenectomy. Our analysis further provides evidence that OPSI is a lifelong risk and that current immune prophylaxis significantly decreases OPSI development. Improvement in patients' education about long-term risk of OPSI and increased physician awareness to face a potentially lethal medical emergency, according to the current surviving sepsis guidelines, represent mandatory strategies for preventing and managing OPSI appropriately.

Comparative effectiveness of different types of splenectomy for children with congenital hemolytic anemias

OBJECTIVE

To compare the effectiveness of different types of splenectomy in children with congenital hemolytic anemias.

STUDY DESIGN

We constructed key questions that addressed outcomes relevant to clinicians and families on effects of partial or total splenectomy, including hematologic effect, splenic function, and the risk of adverse events. We identified from Pubmed and Embase 703 studies that evaluated different types of splenectomy and accepted 93 studies that satisfied entry criteria. We graded the quality of each report and summarized the overall strength of research evidence for each key question.

RESULTS

We did not identify any randomized clinical trials. All types of splenectomy have favorable clinical outcomes in most diseases. We did not identify any hematologic advantage of laparoscopy compared with laparotomy. Adverse events are uncommon in most studies and are minimized with use of laparoscopy.

CONCLUSIONS

There is a need for randomized clinical trials and improved data collection of different types of splenectomy in congenital hemolytic anemias. Outcomes studied should address the concerns of families and clinicians to assess the risks and benefits of various treatments.

Partial splenectomy for hereditary spherocytosis: a multi-institutional review

BACKGROUND/PURPOSE

Partial splenectomy has emerged as a surgical option for selected children with hereditary spherocytosis, with the goal of reducing anemia while preserving splenic function. This multi-institutional study is the largest series to date examining outcomes data for partial splenectomy in patients with hereditary spherocytosis.

METHODS

Data were collected retrospectively from 5 North American pediatric hospitals. Sixty-two children underwent partial splenectomy for hereditary spherocytosis between 1990 and 2008.

RESULTS

At 1 year following partial splenectomy, mean hemoglobin significantly increased by 3.0 ± 1.4 g/dL (n = 52), reticulocyte count decreased by 6.6% ± 6.6% (n = 41), and bilirubin level decreased by 1.3 ± 0.9 mg/dL (n = 25). Patients with poor or transient hematologic response were found to have significantly more splenic regeneration postoperatively compared with patients with a durable clinical response (maximal spleen dimension, 9.0 ± 3.4 vs 6.3 ± 2.2 cm). Clinically significant recurrence of anemia or abdominal pain led to completion splenectomy in 4.84% of patients. No patients developed postsplenectomy sepsis.

CONCLUSIONS

Our multi-institutional review indicates that partial splenectomy for hereditary spherocytosis leads to sustained and clinically significant improvement in hematologic profiles and clinical symptoms in most patients. Our data support partial splenectomy as an alternative for selected children with hereditary spherocytosis.

Institutional experience with laparoscopic partial splenectomy for hereditary spherocytosis

BACKGROUND/PURPOSE

Moderate to severe hereditary spherocytosis (HS) is treated with splenectomy. However, total splenectomy leads to decreased immunologic function with the risk of overwhelming postsplenectomy sepsis. Splenic preservation is postulated as a method to avoid this potentially fatal complication. Although mainly performed through laparotomy, we report our experience with a laparoscopic approach to partial splenectomy for HS.

METHODS

A retrospective review was conducted on 9 laparoscopic partial splenectomies performed for HS at our institution. Follow-up was from 1 to 3.5 years. Data included preoperative and postoperative hemoglobin, absolute reticulocyte count, splenic size, operative time, complications, and length of stay.

RESULTS

All patients successfully underwent laparoscopic partial splenectomy with a radiologically determined upper-pole remnant of 10% to 30% and preservation of the blood supply through the upper short gastric arteries. The mean preoperative spleen length was 13 cm. Mean hospital stay was 3.6 days (range, 1-6 days). There was 1 intraoperative complication (a small bowel tear during spleen extraction) and 2 minor postoperative complications (ileus and wound infection). One patient underwent completion total splenectomy 2 years after partial splenectomy.

CONCLUSION

Laparoscopic partial splenectomy is a feasible and effective procedure that addresses the hematologic consequences of HS while retaining a portion of functional spleen, in addition to conferring the advantages of laparoscopy.

Laparoscopic partial vs total splenectomy in children with hereditary spherocytosis

BACKGROUND

Open partial splenectomy provides reversal of anemia and relief of symptomatic splenomegaly while theoretically retaining splenic immune function for hereditary spherocytosis. We recently developed a laparoscopic approach for partial splenectomy. The purpose of the present study is to compare the outcomes in a group of patients undergoing laparoscopic partial splenectomy (LPS) with those in a group of children undergoing laparoscopic total splenectomy (LTS) over the same period.

METHODS

Systematic chart review was conducted of all children with hereditary spherocytosis who had LTS or LPS from 2000 to 2006 at the Hospital for Sick Children, Toronto, Ontario, Canada. T tests were used for continuous data, and chi(2) for proportional data; P value of less than .05 was considered significant.

RESULTS

There were 9 patients (14 males) in each group. Groups were similar in sex, age, concomitant cholecystectomy, and preoperative hospitalizations, transfusions, and spleen size. Estimated blood loss was greater in the LPS group (188 + 53 vs 67 + 17 mL; P = .02), but transfusion requirements were similar (1/9 vs 0/9). Complication rate was similar between groups. The LPS group had higher morphine use (4.1 + 0.6 vs 2.4 + 0.2 days; P = .03), greater time to oral intake (4.4 + 0.7 vs 2.0 + 0.2 days; P = .01), and longer hospital stay (6.3 + 1.0 vs 2.7 + 0.3 days; P = .005) than the LTS group. Nuclear scan 6 to 8 weeks postoperatively demonstrated residual perfused splenic tissue in all LPS patients. No completion splenectomy was necessary after a mean follow-up of 25 months.

CONCLUSION

These data suggest that LPS is as effective as LTS for control of symptoms. However, LPS is associated with more pain, longer time to oral intake, and longer hospital stay. These disadvantages may be balanced by retained splenic immune function, but further studies are required to assess long-term splenic function in these patients.

Partial splenectomy for hereditary spherocytosis

The significant risks associated with total splenectomy have led to interest in the use of partial splenectomy as an alternative surgical therapy for children who have congenital hemolytic anemia. Partial splenectomy is designed to remove enough spleen to gain desired hematologic outcomes while preserving splenic immune function. Although preliminary data demonstrate successful laboratory and clinical outcomes after partial splenectomy in various congenital hemolytic anemias, conclusive data comparing the efficacy of partial splenectomy to total splenectomy are not reported. Based on preliminary data, a definitive clinical trial of partial splenectomy in children who have severe congenital hemolytic anemia may be warranted.

Immunocompetence of the severely injured spleen verified by differential interference contrast microscopy: the red blood cell pit test

OBJECTIVE

To determine the immunocompetence of the successfully nonoperatively managed injured spleen warranting vaccinations for overwhelming postsplenectomy sepsis by differential interference contrast microscopy (DICM).

METHODS

Cull an urban Level I trauma systems data bank for all patients with grade IV or V splenic injuries (those with the greatest potential to compromise immunologic function) successfully managed nonoperatively and those who have required splenectomies since 1996 and verify the Association for the Surgery of Trauma grading. Contact or obtain written consent of these patients and acquire a blood sample for DICM (red blood cell [RBC] pit analysis) and IgM levels (as a control). Compare values of those sustaining splenic injuries with those of two control groups: patients with splenectomies and those with normal splenic function.

RESULTS

Forty patients were contacted, consented, and volunteered blood samples: 10 patients with grade IV splenic injuries, 1 patient with a grade V injury, 14 patients with splenectomies, and 15 controls. Average RBC pit levels and IgM levels for patients sustaining injuries (15) and successfully nonoperatively managed were 0.6% (0%-2% nL) and 91 mg/dL (46-304 nL), respectively. Patients with splenectomies had levels of 20.4% and 86 mg/dL whereas controls had levels of 0.7% and 110 mg/dL, respectively. The average time frame from injury to RBC pit test was 3.1 years. Comparing the successfully nonoperatively managed group with the splenectomy group using t test with Satterthwaite's method because of unequal variances, there was a statistically significant difference (p = 0.0002). Comparing the same study group with those with normal splenic function using t test with pooled variance, there was no statistical significant difference between groups (p = 0.489).

CONCLUSION

DICM, a commonly used test to evaluate splenic-based immunocompetence in patients with sickle cell anemia, hemoglobinopathies, and patients undergoing partial splenectomies, also confirms splenic immunocompetence in patients sustaining up to grade IV splenic injuries. IgM levels earlier thought to be low in patients after splenectomy normalize.

Mode of splenectomy and immunogenicity of meningococcal vaccination in patients with hereditary spherocytosis

Background

Splenectomy predisposes patients to invasive disease from pneumococci, meningococci, and Haemophilus influenzae; immunization is mandatory. However, data on the impact of the splenectomy on vaccine immunogenicity are scarce.

Methods

A total of 41 children with hereditary spherocytosis (aged 5·8–14·4 years) had complete (16) or near-total (25) splenectomy. All received one dose of monovalent meningococcal C conjugate vaccine (MCV-C) and, 2 months later, a tetravalent meningococcal polysaccharide vaccine (MPV-ACWY). Serum bactericidal activity and antibodies against serogroups A and C were determined before and after they received MCV-C, and 4 weeks after they received MPV-ACWY.

Results

Before vaccination, only four of the 16 children who had a complete splenectomy were protected against serogroup A, compared with 15 of the 25 who had near-total splenectomy (P < 0·050), with the latter responding to immunization with significantly higher serogroup A serum bactericidal activity: geometric mean (95 per cent confidence interval) 1625.5 (49.9 to 3201.1) versus 980.6 (2.00 to 6204.1) (P < 0·050). All patients achieved putative protective serum bactericidal activity titres (at least 8) against serogroup C.

Conclusion

Near-total splenectomy provides a favourable immunological basis for natural and vaccine-induced protection against meningococcal serogroup A and C infections. Sequential meningococcal vaccination is immunogenic in patients splenectomized for hereditary spherocytosis.

Partial splenic embolization in children with hereditary spherocytosis

OBJECTIVES

Although total splenectomy is able to reduce clinical symptoms in patients with hereditary spherocytosis (HS), splenectomized patients are at risk to develop overwhelming bacterial infections and, to a lesser extent, thromboembolic complications. In contrast, partial splenectomy or partial splenic embolization (PSE) may also decrease the rate of hemolytic complications while maintaining residual splenic function. The aim of this study was to investigate the benefit of PSE in children with moderate to severe HS.

PATIENTS AND METHODS

We performed PSE via retrograde transfemoral access in eight children (four female, four male) with moderate to severe HS at a median age of 8 yr. HS-related complications before PSE included gallstones in six and aplastic crises in four children. One patient was transfusion-dependent.

RESULTS

No acute side effects were seen during or after PSE. Median hemoglobin increased significantly from levels between 7.5 g/dL and 11.65 g/dL before PSE to levels between 8.4 g/dL and 13.35 g/dL after PSE (P = 0.012). Median splenic sizes before PSE ranged from 9.7 cm/m2 to 19.0 cm/m2 and significantly decreased to values between 4.4 cm/m2 and 15.65 cm/m2 during follow-up (P = 0.012).

CONCLUSIONS

PSE appears to be a safe, effective and feasible treatment option for the management of children with moderate to severe HS.

Laparoscopic Splenic Procedures in Children

OBJECTIVES

The purpose of this report is to evaluate the efficacy of and complications observed after laparoscopic splenic procedures in children.

METHODS

Review of a prospective database at a single institution (1995-2006) identified 231 children (129 boys; 102 girls; average age 7.69 years) undergoing laparoscopic splenic procedures.

RESULTS

Two hundred twenty-three children underwent laparoscopic splenectomy (211 total; 12 partial) by the lateral approach. Indication for splenectomy was hereditary spherocytosis (111), immune thrombocytopenic purpura (36), sickle cell disease (SCD) (51), and other (25). Four (2%) required conversion to an open procedure. Eight additional laparoscopic splenic procedures were performed: splenic cystectomy for epithelial (4) or traumatic (2) cyst, and splenopexy for wandering spleen (2). Average length of stay was 1.5 days. Complications (11% overall, 22% in SCD patients) included ileus (5), bleeding (4), acute chest syndrome (5), pneumonia (2), portal vein thrombosis (1), priapism (1), hemolytic uremic syndrome (1), diaphragm perforation (2), colonic injury (1), missed accessory spleen (1), trocar site hernia (1), subsequent total splenectomy after an initial partial (1), and recurrent cyst (1). Subsequent operations were open in 3 (colon repair, hernia, and missed accessory spleen) and laparoscopic in 2 (completion splenectomy, and cyst excision). There were no deaths, wound infections, or instances of pancreatitis.

CONCLUSIONS

Laparoscopic splenic procedures are safe and effective in children and are associated with low morbidity, higher complication rate in SCD, low conversion rate, zero mortality, and short length of stay. Laparoscopic splenectomy has become the procedure of choice for most children requiring a splenic procedure.

[Evaluation of splenic function by dynamic gammagraphy, study of pitted erythrocytes and submembranous vacuoles in patients with slight and severe splenic trauma receiving conservative treatment or splenectomy]

BACKGROUND AND OBJECTIVE

The splenic function of patients followed by the Department of General and Digestive Surgery in the Hospital Universitari Germans Trias i Pujol (HUGTiP) from 1985 to 2003 for different degrees of splenic trauma according to the classification of the American Association for the Surgery of Trauma (AAST) 1994 was quantified and related to the treatment received (non surgical, total splenectomy with or without splenosis and splenectomy plus autotransplantation) to detect splenic dysfunction predisposing the development of postsplenectomy sepsis (PSS).

PATIENTS AND METHOD

43 patients underwent an isotopic study with dynamic splenic gammagraphy and pitted erythrocytes (Normarsky optics) and submembranous vacuoles (transmission electron microscopy) were evaluated.

RESULTS

The non surgical group presented normal phagocytic and filtration function with the median speed of splenic enhancement being 3.46 Kcts/s2 (interval: 0.8-6.98). The percentage of pitted erythrocytes was 2% (0-8.8), the number of pits per erythrocyte was 0.03 (0-0.12) and the percentage of erythrocytes with 1, 2, 3 and 4 pits was 1.6%, 0.4%, 0% and 0%, respectively. The percentage of red cells with submembranous vacuoles was 2.55% (0-5.6), the number of vacuoles per red cell was 0.03 (0-0.06) and the percentage of red cells with 1, 2, 3 and 4 vacuoles was 2%, 0.2%, 0% and 0%, respectively. In the operated group, the splenic enhancement speed was 0.08 Kcts/s2 (0-1.75) (p < 0.0001). The percentage of pitted erythrocytes was 38% (0.2-64) (p < 0.0001), the number of pits per erythrocyte was 0.86 (0-1.8) (p < 0.0001) and the percentage of erythrocytes with 1,2,3 and 4 pits was 16.39%, 7.2%, 3.59% and 2.52%, respectively (p < 0.0001). The percentage of red cells with submembranous vacuoles was 11.2% (1.8-31.9) (p = 0.0006); the number of vacuoles per cell was 0.16 (p = 0.0022) and the percentage of red cells with 1, 2, 3 and 4 vacuoles was 6.51%, 1.73%, 0.4% and 0.2%, respectively (p = 0.0246, 0.0010, < 0.0001 and 0.0002, respectively).

CONCLUSIONS

Splenic function of patients with a history of splenic trauma receiving conservative treatment is normal, independently of the degree of the lesion, thereby reinforcing the use of this therapeutic approach to avoid the development of postsplenectomy sepsis. In the patients treated with splenectomy, with or without splenosis, splenic function was absent or very altered being partially conserved in cases treated with splenectomy plus autotransplantation.

Laparoscopic Partial Splenectomy Using Radiofrequency Ablation for Nonparasitic Splenic Cysts in Two Children

Nonparasitic splenic cysts are uncommon lesions, for which partial splenectomy offers a definitive treatment while preserving splenic function. We report the use of radiofrequency energy for laparoscopic partial splenectomy to treat two children with nonparasitic splenic cysts by creating a 1-cm thick coagulated parenchyma resection plane, allowing bloodless splenic transection. This approach spares the need for blood transfusions, reduces hospital stay, and offers great promise for partial splenectomy in children.

Laparoscopic subtotal splenectomy in hereditary spherocytosis

BACKGROUND

Clinical manifestations of hereditary spherocytosis can be controlled by splenectomy. The use of this procedure has been restricted due to concerns regarding exposure of patients to a lifelong risk of overwhelming infections. Subtotal splenectomy, which removes 85-90% of the enlarged spleen, is a logical alternative. In the first cases performed by laparoscopy we have chosen to preserve the upper pole. However, this technique showed some disadvantages, especially concerning the correct intraoperative evaluation of the splenic remnant volume. Therefore, we developed a new variant of the procedure by preserving the lower pole of the spleen.

METHODS

Based on the authors' experience in laparoscopy (176 laparoscopic splenectomies), 10 laparoscopic subtotal splenectomies were performed in patients with hereditary microspherocytosis, preserving either the upper or the lower splenic pole.

RESULTS

Patient age ranged between 5 and 35 years. The mean volume of the remnant spleen was 41.4 cm3. There were no complications, and no transfusions were needed. Follow-up for 1-30 months was available.

CONCLUSIONS

Subtotal splenectomy appears to control hemolysis while maintaining splenic function. The laparoscopic approach is safe and effective and should be considered the procedure of choice in hereditary microspherocytosis. Laparoscopic subtotal splenectomy presents an advantage over open subtotal splenectomy, resulting in decreased blood loss, shorter hospital stay, no conversions, fewer operative and postoperative complications, and excellent remission rates. On the basis of our experience, the preservation of the lower pole of the spleen seems to be a first-line option for the optimal evaluation of the residual splenic mass.

Immunogenicity of sequential pneumococcal vaccination in subjects splenectomised for hereditary spherocytosis

Splenectomy predisposes for invasive pneumococcal disease. We investigated the immune response of splenectomised hereditary spherocytosis (HS) patients upon sequential pneumococcal vaccination. Thirty-nine HS-patients (2- to 18-year-old) had undergone near-total or total splenectomy. All received one dose of 7-valent pneumococcal conjugate vaccine (PCV-7) and 23-valent-pneumococcal-polysaccharide vaccine (PPV-23) 2 months apart. Pneumococcal antibodies against serotypes 5/6B/7/14/18C/19F/23F and immunoglobulin serum concentrations were determined before PCV-7 and 4 weeks after PPV-23. Significant rises in antibody geometric mean concentrations were observed after PCV-7 except for serotypes 5 and 7, which increased after PPV-23. We found no impact of the mode of splenectomy.

Near-total splenectomy for hereditary spherocytosis: clinical prospects in relation to disease severity

We prospectively studied the efficacy of near total splenectomy (NTS) for managing hereditary spherocytosis (HS) based on haemoglobin (Hb), total bilirubin and splenic remnant regrowth in 30 children receiving NTS for HS between November 1996 and December 2004 (mean followup 3.6 years). Patients were classified into three severity groups. At followup, mean Hb had increased by 2.9-5.0 g/dl (P = 0.110) and bilirubin dropped by 15.4-56.4 mumol/l. Remnant regrowth was moderate, within the weight-specific norm. Amongst spleen-preserving techniques, NTS shows markedly lower rates of recurrent haemolysis, remnant regrowth and secondary operations, thus potentially benefiting all clinical forms of HS.