Clinical application of serial operations with preserving spleen

Polyglutamic Acid-Based Elastic and Tough Adhesive Patch Promotes Tissue Regeneration through In Situ Macrophage Modulation

Adhesive patches are advanced but challenging alternatives to suture, especially in treating fragile internal organs. So far there is no suture-free adhesive patch based on metabolizable poly(amino acid) materials with excellent mechanical strength as well as immunomodulation functionality. Here, a polyglutamic acid-based elastic and tough adhesive patch modified by photosensitive groups on the surface to achieve robust light-activated adhesion and sealing of flexible internal organs is explored. With the porous internal morphology and excellent biodegradability, the patches promote regeneration through a macrophage-regulating microenvironment. Treated rabbits achieve rapid full-thickness gastric regeneration with complete functional structure within 14 d, suggesting its robust tissue adhesion and repair-promoting ability.

Intermittent Splenic Artery Occlusion Plus Gauze Compression Is a Simple and Effective Treatment for Iatrogenic Splenic Injury

Background

The aim of this study was to evaluate the feasibility and safety of intermittent splenic artery occlusion plus gauze compression in treating iatrogenic splenic injury.

Material/Methods

We retrospectively analyzed 12 iatrogenic splenic injury cases (grade I to III) treated with intermittent splenic artery occlusion plus gauze compression. The hemostatic effect was then observed after unblocking and decompression. The total operation time, gauze compression time, total blood loss, blood loss from the injured spleen, and platelet counts of each patient before and 1 week after surgery were noted.

Results

The average operation time was 209.58±57.11 min, and the average gauze compression time after spleen artery occlusion was 23.75±4.33 min. The average total blood loss and blood loss due to iatrogenic spleen injury were 468.33±138.22 ml and 264.17±165.72 ml, respectively. Two cases (both grade I) had successful hemostasis after 15 min of splenic artery occlusion and wound compression. Another 9 cases (all grade II) and 1 case (grade III) attained hemostasis after 25 min and 30 min, respectively, of splenic artery occlusion and wound compression. The platelet counts of all patients were within the normal range before and 1 week after surgery. No postoperative complications occurred.

Conclusions

Intermittent splenic artery occlusion plus gauze compression is a simple and effective treatment for iatrogenic splenic injury.

Spleen-preserving proximal splenic-left intrahepatic portal shunt for the treatment of extrahepatic portal hypertension in children

PURPOSE

The Rex shunt has been employed successfully to treat patients with extrahepatic portal hypertension. In the conventional Rex shunt, the internal jugular vein is used as a venous graft. Inevitably, such a procedure requires neck exploration and sacrifice of the internal jugular vein. The authors describe a novel adaptation of spleen-preserving spleno-Rex bypass, successfully carried out in children with extrahepatic portal hypertension.

METHODS

The mean age of the four patients (1 boy, 3 girls) was 46 months at the time of operation. All children had a history of upper gastrointestinal bleeding, and suffered from splenomegaly and hypersplenism. Spleen-preserving proximal splenic-left intrahepatic portal shunt was performed in all patients. The splenic artery and vein were ligated at the splenic hilum, and the splenic vein was completely separated from the bed of the pancreas to its junction with the inferior mesenteric vein. The freed splenic vein was anastomosed to left portal vein. The short gastric and left gastroepiploic vessels were kept intact to supply and drain the spleen. All patients were followed-up for 7-33 months (median: 21.5 months).

RESULTS

The spleen-preserving spleno-Rex bypass was successfully performed in all 4 patients. The median operative time was 225 min (range: 215-260 min). One patient received blood transfusion, and the postoperative length of hospital stay varied from 4 to 6 days (median: 4.5 days). Intraoperative portal venous angiography demonstrated the patency of the shunt in all patients. Postoperatively, the complete blood count normalized and the biochemistry tests were within normal range. Postoperative ultrasound confirmed shunt patency and satisfactory flow in the proximal splenic-portal shunt in each patient. The size of the spleen decreased and there was no recurrence of variceal bleeding.

CONCLUSIONS

The spleen-preserving spleno-Rex bypass is a viable option to treat EHPVO in children.

A modified canine model of portal hypertension with hypersplenism

OBJECTIVE

The aim of this study was to develop and describe an experimental canine model of portal hypertension with hypersplenism.

MATERIAL AND METHODS

Twenty-five dogs were used randomly divided into three groups: group I (control group, n = 5), group II (PVS, n = 10) and group III (PVS + SVS, n = 10). Portal vein stenosis (PVS) was performed in dogs of group II; in group III dogs the model was first prepared by PVS and additional splenic vein stenosis 3 weeks later (PVS + SVS). Portal vein pressure (PVP), length of spleen and fluctuation of hematocyte counts were measured and recorded at the appointed times. Surgery permitted visual verification of portosystemic collateral circulation. Histopathological variation of the spleen and condition of the bone marrow hyperplasia were examined to confirm the development of hypersplenism.

RESULT

Both group II and group III developed prehepatic portal hypertension; group III also presented satisfactory hypersplenism compared to the control group and group II, as documented at surgery and by hematologic and pathologic examination.

CONCLUSIONS

Based on this study, the modified model of portal hypertension (by PVS + SVS) appears appropriate when studying the relationship between hypersplenism and hemodynamics in portal hypertension. It is also likely to be useful in studying the influence of diseased spleen in the treatment of portal hypertension.

Changes in peripheral lymphocyte subsets in patients after partial microwave ablation of the spleen for secondary splenomegaly and hypersplenism: a preliminary study

PURPOSE

Microwave ablation therapy for secondary splenomegaly and hypersplenism has been shown to be effective from pre-clinical animal models and clinical investigations. This study was performed to determine its effects on the status of peripheral lymphocyte subsets in patients receiving microwave ablation of the spleen.

MATERIALS AND METHODS

Ten patients with secondary splenomegaly and hypersplenism received microwave ablation of the spleen during laparoscopy or percutaneously under ultrasound guidance. The percentage peripheral blood T cells, B lymphocytes and NK cells were measured using flow cytometry before and on days 1, 3 and 7 after therapy, as well as 1 and 3 months afterwards.

RESULTS

Percentages of CD3(+) and CD4(+) cells increased rapidly 1 month after therapy. There was no significant change in CD8(+), CD4(+)/CD8(+) or NK cells of the pre- and post-therapy levels and B lymphocytes increased significantly after therapy. In patients with an ablation volume (AV) less than 20% (group A), T cells increased 1 month after ablation but decreased 3 months after ablation. B lymphocytes increased significantly after surgery. Levels of NK cells were lower than that before therapy on each testing. In patients with 20-40% AV (group B), levels of T cells, B lymphocytes and NK cells showed an increase. Levels of CD4(+) cells were significantly higher in group B than in group A, 3 months after therapy.

CONCLUSIONS

Microwave ablation therapy for splenomegaly and hypersplenism appears to have a favourable effect on peripheral lymphocyte subsets. A relationship may exist between the ablation volume and the level of peripheral lymphocyte subsets.

Effect of esophagogastric devascularization with splenectomy on schistossomal portal hypertension patients' immunity

BACKGROUND: Surgical treatment of hemorrhagic complication in schistosomal portal hypertension in our hospital is an esophagogastric devascularization procedure with splenectomy. Infectious risks and immunological alterations imputed to splenectomy may have significant importance. To minimize the consequences of spleen absence, the use of subtotal splenectomy and spleen auto-transplantation were stimulated. AIM: To verify the immunologic alterations imposed by this procedure in our patients. METHOD: Twenty-eight patients with schistosomal portal hypertension and previous history of upper digestive bleeding due to esophagogastric varices rupture underwent elective esophagogastric devascularization and splenectomy. They were prospectively studied before esophagogastric devascularization procedure with splenectomy, 15 and 30 days, 3 and 6 months after the procedure. T and B-lymphocytes, CD4 and CD8 subpopulations were determinated by monoclonal antibodies. Immunoglobulins A, M, G and C3, C4 components of the complement were determinated by radial immunodiffusion. RESULTS: We observed important reduction of all immune cells, increase of IgG and normal levels of IgM, IgA, C3 and C4 at preoperative. CD4/CD8 relation was normal. Six months after esophagogastric devascularization procedure with splenectomy, significant increase in T-lymphocytes, CD4, CD8 and B-lymphocytes were observed. CD4/CD8 relation remained normal. We noted significant increase in C3. IgA, IgM, IgG and C4 had increased, but without significant difference. CONCLUSION: Esophagogastric devascularization procedure with splenectomy determines an increase in T and B-lymphocytes, CD4 and CD8 subpopulations without compromising immunoglobulins and components of complement levels.

Ten-year experience with living related donated splenic transplantation for the treatment of hemophilia A

AIM

Six cases of hemophilia A treated with living related donated splenic transplantation (LRDST) were performed over 10 years.

METHODS

We reviewed the six consecutive cases of LRDST from 1992 to 2002. Three patients received whole spleen allografts and the other three, partial spleen allografts. All allografts were transplanted to the extraperitoneal space in the right iliac fossa by an end-to-end anastomosis between the splenic artery and the internal iliac artery and an end-to-side anastomosis between the splenic vein and the external (or common) iliac vein. After the operation, a combined regimen with cyclosporine, azathioprine, anti-lymphocyte globulin, OKT3, was administered to suppress the immune reaction.

RESULTS

The functional period of the allografts varied between 30 days to 4 years. Patient factor-VIII (F-VIII) levels rose from less than 5% before operation to 15% to 56% postoperatively. One patient died from central nervous system complications. Another lost his graft because exogenous F-VIII was not supplemented in timely fashion at the onset of rejection. And the third could no longer afford the expensive immunosuppressive drugs at 2 years after the operation and eventually lost the spleen. The remaining three patients presently have regained self-support, among whom one has survived for 4 years.

CONCLUSION

Though the sample pool is relatively small, our clinical observations tend to confirm LRDST as a feasible, effective treatment for hemophilia A.

Evaluation of a canine model of secondary hypersplenism induced by splenic vein ligation

AIM

To introduce and evaluate a canine model of secondary hypersplenism induced by splenic vein ligation.

METHODS

Eighteen healthy mongrel dogs were randomly divided into three groups. The first group (n = 4) underwent laparotomy, the second (n = 10) and third groups (n = 4) underwent laparotomy plus ligation of splenic vein and its collateral branches to induce congestive splenomegaly. At the end of the third week, splenectomy was performed in the third group. The blood cell counts for peripheral venous blood were determined weekly, and the radiographic and histopathological changes of spleen also obtained regularly.

RESULTS

The erythrocyte and platelet counts decreased in the first week, and were significantly lowered (erythrocyte count of (6.8 ± 1.2)×10¹²/L in control vs (5.1± 0.7)×10¹²/L in second group, P<0.01; and platelet counts of (398 ± 58)×10⁹/L vs (230 ± 86)109/L, P<0.05 respectively) at the end of 3rd week after splenic vein ligation thereafter sustained. The splenomegaly, erythrocytopenia and thrombocytopenia had remained over 9 weeks. No significant changes of the leukocyte counts were observed after splenic vein ligation throughout the experiment (P>0.05). The abnormal status of erythrocytopenia and thrombocytopenia was ameliolated by splenectomy, and the erythrocyte and platelet counts were similarly to the levels of the control group in the second week after splenectomy. After the end of 3rd week after splenic vein ligation, the splenic histopathological changes conformed to the changes of chronic congestive splenomagely.

CONCLUSION

The method of splenic vein ligation to induce experimental secondary hypersplenism is simple and effective. This is a relative ideal model for surgical or interventional therapy on hypersplenism.

Experimental study on the feasibility and safety of radiofrequency ablation for secondary splenomagely and hypersplenism

AIM: To assess the feasibility and safety of radiofrequency ablation (RFA) in treatment of secondary splenomagely and hypersplenism.

METHODS: Sixteen healthy mongrel dogs were randomly divided into two groups, group I (n = 4) and group II (n = 12). Congestive splenomegaly was induced by ligation of splenic vein and its collateral branches in both groups. At the end of 3rd week postoperation, RFA in spleen was performed in group II via laparotomy, complications of RFA were observed, CT scan was performed and the spleens were obtained. The radiofrequency (RF) thermal lesions and histopathology of spleen were examined regularly.

RESULTS: No complication or death was observed in both groups; CT revealed that the splenomegaly lasted over 2 months after ligation of splenic vein; the segmental RF lesions included hyperintense zone of coagulative necrosis and more extensive peripheral hypointense infarcted zone, the latter was called “bystander effect”. The infarcted zone would be absorbed and subsequently disappeared in 4-6 weeks after RFA accompanied with shrinkage of the remnant spleen. The fundamental histopathological changes of splenic lesions caused by RF thermal energy included local coagulative necrosis, peripheral thrombotic infarction zone, subsequent tissue absorption and fibrosis in the zone of thrombotic infarction, the occlusion of vessels in remnant viable spleen, deposition of extensive fibrous protein, and disappearance of congestive splenic sinusoid - “splenic carnification”. Those pathologic changes were underline of shrinkage of spleen.

CONCLUSION: It is feasible and safe to perform RFA in spleen to treat experimental splenomegaly and hypersplenism. The RFA could be safely performed clinically via laparotomy or laparoscopic procedure while spleen was strictly separated from surrounding organs.