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PubMed2006

A laparoscopic approach to partial splenectomy for children with hereditary spherocytosis.

BACKGROUND: Partial splenectomy is sometimes used for children with hereditary spherocytosis (HS) to reduce hemolysis while retaining some splenic immune function. Previous reports have described a partial splenic resection through a laparotomy incision. Whereas laparoscopic total splenectomy for HS is well-established, laparoscopic partial splenectomy (LPS) has not been described. The authors have developed a novel LPS technique that combines the benefits of partial splenectomy with those of a laparoscopic approach. METHODS: A chart review was conducted for three children with HS who underwent LPS, with approximately one-fourth of the spleen left on the basis of the short gastric arterial supply. RESULTS: The mean preoperative spleen size was 17.6 cm. The mean preoperative hemoglobin count was 100 g/l, and the postoperative hemoglobin count was 133 g/l. All three patients reported reduced malaise and increased energy levels. There was no recurrent anemia at the 1- to 2-year follow-up evaluation. CONCLUSION: The LPS procedure is a safe and effective approach to HS that resolves anemia, potentially retains some splenic immunity, and confers the benefits of a minimal access technique.

Adolescent↗

PubMed1998

Inadequate detection of accessory spleens and splenosis with laparoscopic splenectomy. A shortcoming of the laparoscopic approach in hematologic diseases.

BACKGROUND: The ultimate goal of surgery for hematological disorders is the complete removal of both the spleen and accessory spleens in order to avoid recurrence of the disease. Whereas splenectomy by open surgery provides excellent results, the validity of laparoscopic splenectomy in this regard remains unknown. OBJECTIVE: The purpose of this study was to evaluate the detection of accessory spleens during laparoscopic splenectomy for hematologic diseases. METHODS: We therefore evaluated the pre-, intra-, and postoperative detection of accessory spleens in a consecutive series of 18 patients treated by elective laparoscopic splenectomy for hematological diseases by using computed tomography (CT) and denatured red blood cell scintigraphy (DRBCS). RESULTS: Preoperative CT, DRBCS, and laparoscopic exploration detected 25%, 25%, and 75% of accessory spleens, respectively. At time of laparoscopy, 16 accessory spleens were detected in seven of the 18 patients (41%). In two patients (11%), laparoscopic exploration failed to detect accessory spleens, whereas preoperative CT (one case) and DRBCS (one case) did reveal them. Postoperatively, during a mean follow-up of 28 months (median, 24; range, 12-44 months), nine patients (50%) showed persistence of splenic tissue by DRBCS, and three of them had signs of disease recurrence. CONCLUSIONS: This prospective clinical study suggests that elective laparoscopic surgery for hematological diseases does not allow complete detection of accessory spleens. Moreover, after such a laparoscopic approach, residual splenic tissue is detectable in half of the patients during the follow-up.

Adolescent↗

PubMed1998

Laparoscopic splenectomy in beta-thalassemia major patients. Advantages and disadvantages.

BACKGROUND: Splenectomy is indicated in patients with thalassemia major when they develop hypersplenism with subsequent need for increased transfusions. Extreme splenomegaly is considered a restrictive factor for laparoscopic splenectomy in these patients. METHODS: Laparoscopic splenectomy was undertaken in 12 beta-thalassemia major patients with massive splenomegaly. The devascularization of the organ was performed with serial ligations of the splenic vessels starting from the lower pole of the organ. The spleen was extracted from the abdominal cavity through a 5-cm incision in the left iliac fossa, which incorporated two port sites. RESULTS: The procedure was concluded laparoscopically in 10 cases, while two patients were converted due to difficulty in controlling bleeding from branches of the splenic vein. The patients tolerated the procedure well and had a postoperative hospital stay of 3-6 days. CONCLUSIONS: From our limited initial experience it seems that laparoscopic splenectomy in the difficult setting of thalassemia major patients is feasible, but extreme care is required in order to avoid hemorrhagic complications.

Adolescent↗

PubMed1996

Laparoscopic splenectomy. The suspended pedicle technique.

BACKGROUND: Elective splenectomy is often performed for hematological diseases, some of which cause only moderate enlargement of the spleen. The avoidance of an extensive upper abdominal incision is desirable in such cases and laparoscopic splenectomy offers significant potential advantages over the open operation if it can be performed safely and economically. METHODS: Eight consecutive patients underwent laparoscopic splenectomy. The operation was carried out with the patient at 40 degrees in the right lateral position so that rotating the operating table would make a full right lateral position possible. After fenestration of the gastrocolic omentum and division of the short gastric vessels, this position allowed the spleen to be pushed up under the diaphragm to facilitate access to the splenic vessels and the hilum. Vessels were divided individually between clips. RESULTS: All eight cases were completed laparoscopically. Mean length of operation was 259 min (range 230-285). Postoperative stay ranged from 2 to 7 days (median 4 days). There was no mortality, although minor complications did occur in three patients. CONCLUSIONS: We found laparoscopic splenectomy to be a safe and feasible procedure for the elective removal of the moderately enlarged spleen.

Adult↗

PubMed2005

Analysis of risk factors for massive intraoperative bleeding during laparoscopic splenectomy.

BACKGROUND/PURPOSE: Laparoscopic splenectomy is occasionally converted to open surgery due to massive intraoperative bleeding. The aim of this study was to identify the risk factors for massive bleeding during laparoscopic splenectomy. METHODS: Fifty-three patients underwent laparoscopic splenectomy. The indications were hematologic disease in 25 patients, liver cirrhosis in 17 patients, and other conditions in 11 patients. Univariate analysis was conducted with Fisher's exact test, and multivariate analysis was conducted with a stepwise logistic regression model. RESULTS: None of the patients required open surgery. Blood loss of more than 800 ml was defined as massive intraoperative bleeding. Univariate analysis showed significant risk factors for massive bleeding to be liver cirrhosis, portal hypertension, splenomegaly, Child class, and preoperative platelet count. Independent risk factors in the multivariate analysis were portal hypertension and Child class. CONCLUSIONS: Careful attention to intraoperative bleeding during laparoscopic splenectomy is necessary for patients with portal hypertension and/or deteriorated liver function.

Adult↗

PubMed2003

Portal vein thrombosis after splenectomy for gastric malignant lymphoma.

Portal vein thrombosis (PVT) has rarely been documented in patients after splenectomy for gastric malignancy. We report a case of PVT that occurred after splenectomy as part of an en-bloc node dissection performed to treat gastric malignant lymphoma. A 38-year-old man underwent total gastrectomy and splenectomy with en-bloc D2 lymph node dissection. The spleen weighed 480 g. On postoperative day (POD) 31, the patient complained of abdominal pain in the right upper quadrant accompanied by fever. Moderate elevations of C-reactive protein (CRP), aspartate transaminase (AST), and alanine transaminase (ALT) were noted. Contrast-enhanced computed tomography (CT) and ultrasonography disclosed thrombus in the portal vein and the splenic vein. There were no abnormalities in the levels of lupus anticoagulant, protein C antigen, protein S antigen, or antithrombin III (AT III). A diagnosis of PVT was made, and prompt treatment, including intravenous heparin combined with tissue plasminogen activator (tPA) was initiated, followed by longterm warfarin. This treatment resulted in clinical improvement, but failed to achieve thrombolysis in the portal vein. At follow-up after 6 months, the patient complained of postprandial abdominal pain with persistent peripheral edema and ascites. This case indicates that splenectomy for en-bloc node dissection in gastric malignancy is a possible cause of PVT. Because both the symptoms and the laboratory data in PVT are nonspecific, a high level of clinical suspicion and a low threshold for obtaining imaging examinations are important in the early diagnosis of PVT. Surgeons should remember PVT among several other complications whenever patients treated with radical gastrectomies are symptomatic and imaging studies are considered necessary.

Adult↗

PubMed1987

Massive hepatomegaly following splenectomy for myeloid metaplasia. Case report and review of the literature.

Massive compensatory hepatic myeloid metaplasia occurs infrequently after splenectomy for myeloid metaplasia, and it usually develops gradually over several years if it does occur. In this report, a patient is described in whom massive hepatomegaly and evidence of portal hypertension developed within three months of splenectomy. Early evidence for rapid hepatic growth was present at a second laparotomy three weeks after the first surgery, and probably should have triggered initiation of chemotherapy. Indications for splenectomy in these patients, surgical morbidity, and response to splenectomy are discussed.

Hepatomegaly↗

PubMed1978

Platelet aggregability after splenectomy in patients with normosplenism and hypersplenism.

The relationship between platelet count and aggregability was serially evaluated after splenectomy in patients with normosplenism and hypersplenism, and the results were compared with those found in patients undergoing only upper abdominal surgery. The preoperative count and aggregability of platelets were significantly suppressed in patients with cirrhosis of the liver, idiopathic portal hypertension, and prehepatic portal obstruction. However, the platelet aggregability of these patients markedly increased in accordance with the platelet counts after splenectomy. In the patients with normal splenic function preoperatively, splenectomy caused a simultaneous increase in platelet count and aggregability. The platelet function was not always reflected by the count in the patients with idiopathic thrombocytopenic purpura. On the other hand, in the control patients undergoing only laparatomy the platelet count substantially increased two weeks after operation, but platelet aggregability did not differ from the preoperative value. The present results suggest that additional factors for thromboembolism such as hypotension, acidosis, or stagnant blood flow should be avoided during the peak period of reactive thrombocytosis after splenectomy, and that an appropriate use of anticoagulants or inhibitors of platelet aggregation is recommended if and when necessary.

Adenosine Diphosphate↗

PubMed1986

Effect of splenectomy on liver regeneration and polyamine metabolism after partial hepatectomy.

The effect of splenectomy on hepatic ornithine decarboxylase (ODC) induction, DNA synthesis, and mitosis of hepatocytes was studied in rat liver after partial hepatectomy. ODC activity markedly increased in the early stages of liver regeneration, and the increase in the activity was significantly enhanced in splenectomized rats. Splenectomy specifically induced ODC since tyrosine aminotransferase and general protein synthesis were not affected. Splenectomy also enhanced increase in hepatic polyamines, DNA synthesis, and mitosis in regenerating liver. The results suggest that splenectomy affects liver regeneration after partial hepatectomy by enhancing induction of ODC activity, which is an important biochemical event in the early stage of liver regeneration.

Animals↗

PubMed1986

Partial splenectomy with the CO2 laser: an alternative technique.

Because total splenectomy has been shown to affect immunocompetence in children, partial splenectomy is advocated as an alternative to total splenectomy in traumatic injury as well as in treatment of benign cysts. Present techniques include elaborate hemostatic techniques and extensive suture repair which has led to the development of massive abdominal adhesions. We have investigated CO2 laser sealing of splenic wounds to obviate the need for extensive repair and to minimize intraabdominal reaction. Five dogs underwent partial splenectomy with a scalpel. Hemostasis was obtained with CO2 laser coagulation; a defocused laser beam at 8 W (power density 30-50 W/cm2). After 3 weeks, the laser sealed splenic tissue was amputated and, on this occasion, hemostasis was obtained using a standard suture technique of Teflon pledget-bolstered chromic sutures. Three weeks later the dogs were explored and the sutured splenic tissue was removed. Gross findings on the first exploration demonstrated no signs of hemorrhage and minimal adhesions of the laser sealed spleens. In contrast, exploration after suture repair revealed dense adhesions containing the spleen, omentum, mesentery, and small and large bowel. Microscopic examination of the laser sealed spleen showed a zone of injury only 2-3-mm thick. Excellent hemostasis of the cut surface of the spleen can be accomplished using the CO2 laser. In addition, the minimal depth of injury and the absence of foreign material in the peritoneal cavity make this an attractive alternative to conventional methods.

Animals↗

PubMed1988

The protective effect of pneumococcal vaccination following partial splenectomy.

Weanling CD-1 male rats were subjected to 100, 75, and 50% splenectomy. One week following splenectomy, animals received either a sham immunization with 0.1 ml NS or pneumococcal immunization with 0.1 ml of a polyvalent (23) vaccine. Eight weeks following surgery, all animals received an intraperitoneal inoculation with 10(6) Streptococcus pneumoniae Type 3 organisms and were observed for mortality. Significant differences in mortality were seen between sham and immunized animals undergoing 100 or 75% splenectomy, while in the 50% group a difference was noted which did not reach statistical significance (Mantel-Cox log rank test). Patients undergoing greater than 50% splenectomy may be afforded greater protection against overwhelming pneumococcal infections by immunization with pneumococcal vaccine.

Animals↗

PubMed1989

Splenectomy during primary maximal cytoreductive surgery for epithelial ovarian cancer.

Six patients with epithelial ovarian cancer underwent splenectomy as part of their extensive primary cytoreductive surgical management at the Johannesburg University Hospital. These patients represented 7.6% (6 of 79) of advanced-disease patients (stages III and IV) followed during the study period. Five splenectomies were performed because of metastatic disease confirmed on microscopy. One of these showed parenchymal involvement and represented only the third case in the world literature. The remaining patient required splenectomy for capsular avulsion injury and resultant bleeding. Late thrombotic complications occurred in 4 of 6 (67%) patients, resulting in death of one patient from massive pulmonary embolism 20 days after surgery. Three patients (50%) currently have no evidence of disease 14, 25, and 32 months after surgery. The remaining 2 patients died of recurrent disease 19 and 58 months following primary operation. This, the largest reported series in the English literature, indicates that splenectomy, albeit potentially hazardous, is justified when it permits optimal cytoreductive surgery.

Adult↗

PubMed1985

The potential benefits of therapeutic splenectomy for patients with Hodgkin's disease and non-Hodgkin's lymphomas.

Thirty-four patients with Hodgkin's disease and non-Hodgkin's lymphoma underwent therapeutic splenectomies to improve hematologic tolerance for chemotherapy. The mean age was 40 years; there were 16 males and 18 females. Fourteen had Hodgkin's disease, 19 had non-Hodgkin's lymphoma, and 1 had malignant histiocytosis. Nineteen had palpable splenomegaly, 19 had marrow involvement and 20 had splenic involvement by lymphoma. The following data were analyzed before and after splenectomy: mean white blood cell count (WBC) and platelet count on planned first day of cycle, delay ratio of chemotherapy delivery and percent maximal dose rate. Thirteen patients had non-Hodgkin's lymphoma, splenomegaly and positive bone marrow and showed significant benefit in all of the aforementioned parameters. Of the patients with prior irradiation, only those who completed their radiation greater than six months prior to splenectomy showed benefit. Ten patients had Hodgkin's disease, negative bone marrow and no splenomegaly. This group showed significant improvement in mean platelet count but more limited benefit in delay ratio and percent maximal dose rate. Thus, selected patients with lymphoma who are experiencing delays in chemotherapy because of poor count tolerance may benefit from splenectomy.

Adolescent↗

PubMed1990

Distribution of IL-3 activity in mice transplanted with IL-3 producing T cells (STIL-3): abrogation of the distribution of STIL-3 cells into the liver and liver hemopoiesis by splenectomy.

Distribution of IL-3 producing T cells, STIL-3, in splenectomized mice after intravenous injection was studied in order to determine the site of IL-3 production in the splenectomized mice. Hematological features of STIL-3-inoculated mice after splenectomy were also studied. Splenectomy prior to inoculation of STIL-3 cells resulted in a slight increase in the level of IL-3 activity in most lymphohemopoietic tissues, but resulted in a slight decrease in the level of IL-3 activity in the plasma. The splenectomy also abrogated granulocytosis which was evident in sham-operated host mice. Hepatomegaly and a number of granulocytic foci in the liver were observed in STIL-3 inoculated mice, but this was again abrogated completely by the splenectomy. These results suggest that the spleen is the major site of granulopoiesis in response to the stimulus with IL-3, and also that the spleen is essential for the migration or metastasis of STIL-3 cells to the liver.

Animals↗

PubMed2003

101 laparoscopic splenectomies for the treatment of benign and malignant hematologic disorders.

BACKGROUND: Laparoscopic splenectomy (LS) is the surgical approach of choice for patients with hematologic disorders requiring splenectomy. Patients with idiopathic thrombocytopenic purpura (ITP) have normal to slightly enlarged spleens and benefit the most from LS. METHODS: We reviewed the perioperative outcomes in 101 patients who underwent LS between May 1996 and December 2002. Patients were divided into three groups--ITP, other benign, and malignant hematologic disorders--and compared. RESULTS: The ITP patients (n = 48) had significantly smaller spleens and operative times compared with the other groups. Splenomegaly in the other benign (n = 23) and malignant hematologic disorders (n = 30) groups was responsible for higher open conversion rates and greater need for hand-assisted laparoscopic splenectomy (HALS). CONCLUSIONS: Laparoscopic splenectomy and HALS can be performed with good results for benign and malignant hematologic disorders. The benefits of HALS are similar to LS, so there should be a low threshold for HALS in patients with large spleens.

Case-Control Studies↗

PubMed2004

Appraisal of concomitant splenectomy in liver resection for hepatocellular carcinoma in cirrhotic patients with hypersplenic thrombocytopenia.

BACKGROUND: Liver resection usually is not recommended for hepatocellular carcinoma (HCC) in cirrhotic patients with portal hypertension. The role of concomitant splenectomy in liver resection for HCC in cirrhotic patients with hypersplenic thrombocytopenia (HT) resulting from portal hypertension remains undefined. METHODS: Among 526 cirrhotic patients who underwent liver resection for HCC, 41 underwent a concomitant splenectomy (Sp group) because of HT (platelet count </=80 x 10(3)/mm(3)). The patients' backgrounds, pathologic characteristics of HCC, and short- and long-term results after liver resection of Sp group were compared with those of the other 485 cirrhotic patients who did not undergo splenectomy (non-Sp group). RESULTS: Compared to the non-Sp group, the liver function was worse, the tumor size was smaller, the liver resection extent was narrower, and tumor stages were earlier in the Sp group. The postoperative morbidity, mortality, hospital stay, and hospital costs were not significantly different between the groups. The disease-free survival rate of the Sp group was better than that of non-Sp group, but the actuarial survival rates of both groups were similar. After stratification with UICC-TNM stages, there were no significant differences regarding the disease-free and actuarial survival rates in each stage. CONCLUSIONS: Concomitant splenectomy extends the indication of liver resection for HCC in cirrhotic patients with portal hypertension. It is justified in selected cirrhotic patients with HCC and HT.

Aged↗

PubMed2002

Portal vein thrombosis after splenectomy.

BACKGROUND: Portal vein thrombosis (PVT) has been described after splenectomy, but the factors associated with its development and the clinical outcomes are poorly characterized. METHODS: Case logs of four surgeons from 1996 to 2001 were retrospectively reviewed to identify cases of postsplenectomy PVT. RESULTS: Eight cases of PVT (8%) among 101 splenectomies were identified. Indications for splenectomy in patients with PVT were myeloproliferative disease (n = 4), hemolytic anemia (n = 3), and myelodysplastic disorder (n = 1). All patients had splenomegaly (mean 1698 g, range 360 to 3150 g). Among 10 patients with myeloproliferative disease (MP), 4 patients (40%) developed PVT, compared with 4 of 12 patients (25%) with hemolytic anemia. Three of 4 patients (75%) with MP disease and spleen weight greater than 3,000 g developed PVT. Five patients developed PVT despite receiving prophylactic subcutaneous heparin postoperatively. Presenting symptoms included anorexia in 7 (88%), abdominal pain in 6 (75%), and both elevated leukocyte and platelet counts in 8 patients (100%). All diagnoses were made by contrast-enhanced computed tomography scan, and anticoagulation was initiated immediately. One patient died of intraabdominal sepsis; the others are alive with no clinical sequelae at 38 months of follow-up. CONCLUSIONS: PVT is a relatively common complication of splenectomy in patients with splenomegaly. A high index of suspicion, early diagnosis by contrast-enhanced computed tomography, and prompt anticoagulation are key to a successful outcome.

Adult↗

PubMed2003

Functions of the splenic remnant after subtotal splenectomy for treatment of severe splenic injuries.

BACKGROUND: To evaluate the clinical and laboratory characteristics of patients submitted to subtotal splenectomy during the immediate and late postoperative period. METHODS: The study was conducted on 34 patients, 25 of whom were submitted to subtotal splenectomy (group I), and 9 to total splenectomy without preservation of splenic tissue (group II), and on 22 patients with intact spleens (group III, control). The immediate and late postoperative complications were investigated. Hematological examinations were performed during the late postoperative period (red cell count, hemoglobin, platelets, total and segmented leukocytes, lymphocytes, and Howell-Jolly bodies). Immunoglobulins (IgA, IgM, and IgG) and total T lymphocytes (TTL), active T lymphocytes (ATL), and B lymphocytes were also determined. Splenic scintigraphy with (99m)Tc colloidal sulfur was performed. RESULTS: Groups I and III did not presented abnormal blood bodies and their hematological and immunological pattern were normal. None of the groups showed leukocytosis or thrombocytosis. Howell-Jolly bodies were observed only in group II, which also showed reduced IgM levels. Scintigraphy showed filtering splenic tissue in group I. CONCLUSIONS: We conclude that subtotal splenectomy is a good surgical alternative for serious distal spleen lesion or when the main splenic pedicle is injured.

Adolescent↗