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PubMed2004

Marked elevation of soluble fas ligand and cytokine secretion after splenectomy in aggressive natural killer cell leukemia/lymphoma.

We report a case of Epstein-Barr virus-associated aggressive natural killer cell leukemia/lymphoma with giant splenomegaly in which splenectomy resulted in progression of apoptosis and hemophagocytosis. The serum level of ferritin, triglycerides, interferon-gamma (IFN-gamma), interleukin 10 (IL-10), and soluble Fas ligand (sFasL) increased markedly, and liver damage progressed after splenectomy. The number of apoptotic cells in peripheral blood smears increased following splenectomy. In the present case, splenectomy caused disruption of the cytokine network, resulting in apoptosis of blood cells and hepatocytes, as well as phagocytosis.

Adolescent↗
PubMed2001

Clinical and quality of life outcomes of laparoscopic and open splenectomy for haematological diseases.

OBJECTIVE: To study the outcome of open and laparoscopic splenectomy for haematological diseases in terms of quality of life and haematological measures. DESIGN: Prospective non-randomised study. SETTING: Tertiary care hospital, USA. PARTICIPANTS: 44 patients, 27 treated laparoscopically and 17 by open splenectomy. MAIN OUTCOME MEASURES: Quality of life judged by the SF-36 and adequacy of control of the haematological disease. RESULTS: Both quality of life and haematological disease were significantly improved by operation; laparoscopically treated patients had less pain. CONCLUSION: In properly selected patients laparoscopic splenectomy is preferable to open splenectomy.

Adult↗
PubMed2002

A cause for conversion of laparoscopic splenectomy: splenic candidiasis.

Laparoscopic splenectomy (LS) is now considered the procedure of choice for removal of the spleen in several hematologic and traumatic splenic conditions. Perisplenitis is still considered a relative contraindication. We report a rare case of isolated splenic candidiasis treated by laparoscopic splenectomy. The technical challenges of the laparoscopic approach in cases of perisplenitis are outlined. Because of dense adhesions to the diaphragm, the LS was converted to open splenectomy, and the procedure was completed through a small subcostal incision. This case report suggests the need for and effectiveness of splenectomy in patients whose fungal infection is suspected to be localized to the spleen. Laparoscopic removal of the spleen in these cases is very difficult to accomplish because of the risk for diaphragm injuries and the technical problems encountered.

Adult↗
PubMed2003

Laparoscopic splenectomy for ruptured spleen: lessons learned from a case.

Splenic rupture is a frequent consequence of blunt abdominal trauma. When nonsurgical management is not indicated, splenic rupture is usually an emergency requiring surgery. Removal of the spleen (splenectomy) or alternative conservative procedures (splenorraphy, partial splenectomy, and hemostatic collagen application) are surgical treatment options. Recently, laparoscopic conservative techniques have been proposed. Laparoscopic splenectomy for a ruptured spleen has been reported only in a single case, in which a hand-assisted technique was used. We present the first reported case, to our knowledge, of successful removal of a ruptured spleen by means of a totally laparoscopic technique. Adequate technical instrumentation, such as the endostapler, harmonic scalpel, and red cell-saving machine, in addition to extensive experience with routine splenectomy, were essential factors to ensure a safe and effective procedure.

Accidents, Traffic↗
PubMed1999

Laparoscopic splenectomy in a rat model: developing an easy technique.

Laparoscopic surgery in small-animal models provides insight into basic physiopathological aspects of laparoscopy. However, laparoscopic work in small animals entails precise skill and long operative times. We present an easy and shorter three-trocar procedure (two of 5 mm and one of 2 mm) for splenectomy in a rat model. Miniature instruments (2-mm forceps, 3-mm endoscope, and 5-mm endoapplier) were used. Forty laparoscopic splenectomies were attempted. The operative time was 30 +/- 4 minutes. There was no postoperative mortality, and scintigraphy ruled out the presence of residual splenic tissue. Laparoscopic splenectomy in a rat is feasible. When using experimental laparoscopic models for splenectomy, an easy technique is of great importance in order to avoid cumbersome manuevers that can cause rupture of the splenic capsule and cell spillage or postoperative bleeding. The development of surgical laparoscopic instruments with thinner devices (5-mm endoclip appliers and 2-mm ports and instruments) facilitates the procedure and permits a significantly shorter operative time.

Animals↗
PubMed2005

Laparoscopic splenectomy with the da Vinci robot.

BACKGROUND: We report our first series of minimally invasive splenectomies with a robotic surgical system. METHODS: From August 2001 to October 2003, laparoscopic splenectomies with the da Vinci operating robot were performed in 7 patients (five females and two males, ages 20 to 74 years). RESULTS: Indications for splenectomy were hematologic disorders in four patients and hypersplenism in three patients. Median dimensions of the resected spleens were 140 +/- 34 mm x 80 +/- 11 mm x 50 +/- 17 mm and median weight was 307 +/- 193 g. Median total operative time was 147 +/- 58 minutes including 107 +/- 49 minutes for the robotic act. There were no intraoperative complications and no conversions to open surgery. The median postoperative hospital stay was 7 days. CONCLUSION: This first series suggests that robotic splenectomy with the da Vinci surgical system is technically feasible and safe. It provides an alternative to the conventional laparoscopic procedure. Nevertheless, justification for this new technique will require a larger prospective series and longer follow-up.

Adult↗
PubMed2006

Splenic retrieval after laparoscopic splenectomy: a new bag.

BACKGROUND: Laparoscopic splenectomy has become the gold-standard surgical approach for patients undergoing elective splenectomy. Little data exist concerning the technical difficulties of splenic retrieval. When the spleen is large, popular commercial retrieval bags are often too small to facilitate removal. The aim of this study was to compare our clinical experience utilizing two different retrieval bags, the Endocatch II (Autosuture, London, UK) and the developing E200 (Espiner Ltd., Bristol, UK). MATERIALS AND METHODS: We performed a retrospective review of all laparoscopic splenectomies performed at Hull Royal Infirmary, Kingston upon Hull, from March 1997 to July 2003. Patient demographics, morbidity, mortality, and clinical outcome had been entered prospectively into a database. Two patient groups were examined, depending on the type of retrieval bag utilized. Complications and instrument failure during splenic retrieval were analysed. RESULTS: A total of 83 laparoscopic splenectomies were performed. No retrieval bag was used in 8 cases (10%). The Endocatch retrieval bag was used for 45 (60%) patients and the E200 for 30 (40%) patients. The mean operative time for the former group was 65 minutes (range, 50-127 minutes) and for the latter, 120 minutes (range, 80-180 minutes) (P < 0.05). Bag-related complications were 2 (4%) perforations and 2 (4%) failures to deploy while using the Endocatch bag. CONCLUSION: The Endocatch bag is easy to deploy but is associated with perforation and cannot be used for large spleens. The E200 bag is more useful for large spleens but is associated with prolonged operative time due to poor maneuverability. Improved technology is still required.

Adult↗
PubMed2006

Laparoscopic versus open splenectomy in patients with beta thalassemia major.

BACKGROUND: Laparoscopic splenectomy is considered the standard of care for the removal of the spleen in benign diseases. There are not sufficient data for the routine application of this technique in patients with beta thalassemia major. MATERIALS AND METHODS: Twenty-eight consecutive beta thalassemia major patients who underwent elective splenectomy were randomized for open and laparoscopic splenectomy. Patient demographics, operative time, intraoperative and postoperative complications, conversion rate, transfusions, and length of stay were recorded. RESULTS: There was no mortality in this series. There was no difference in complication rates between the two groups. Operative time was markedly increased in the group treated laparoscopically, as was the need for blood transfusions. Median hospital stay was decreased in the laparoscopic group (5 days) compared to the open group (6.5 days). CONCLUSIONS: Laparoscopic splenectomy in patients with beta thalassemia major is feasible; however, it is more time consuming and bleeding occurs more often.

Adult↗
PubMed1994

Long-term results of alpha interferon as initial therapy and splenectomy as consolidation therapy in patients with hairy cell leukemia. Final report from the Italian Cooperative Group for HCL.

PURPOSE: In 1987 the Italian Cooperative Group for the Study of hairy cell leukemia (HCL) started a prospective trial with the following three major aims: 1) to confirm the effectiveness of alpha-IFN as first-line treatment; 2) to assess the usefulness of splenectomy as consolidation treatment in patients achieving a satisfactory partial remission (PR) with alpha-IFN, and 3) to explore whether splenectomy in patients achieving complete remission (CR) with alpha-IFN can reduce the risk of relapse after discontinuation of the drug. PATIENTS AND METHODS: One-hundred seventy-seven patients with histologically-confirmed HCL were registered in the HCL88-A trial between December 1987 and January 1992. Inclusion criteria included no previous treatment and age less than 66 years. All patients received total doses of 3 MU of alpha-IFN daily for 12 months except for those who achieved early CR and would stop treatment after 6 or 9 months. Patients could be treated with different alpha-IFNs. At the time of the present analysis, 166 patients (93.8%) were fully evaluable. RESULTS: Treatment of HCL patients with alpha-IFN at the onset of the disease resulted in 28 CR (16.9%), 103 PR (62.0%), and 27 Minor Remissions (MR) (16.3%). Patients treated with different alpha-IFNs achieved similar results: the overall response rate (CR + PR + MR) was 92.7%, 97.2%, and 95.3% for patients treated with r-alpha-2a, r-alpha 2b, and alpha-N1, respectively. The presence of a leukemic phase and a poor performance status were associated with a statistically significant lower response rate. Patients who were randomly assigned and underwent splenectomy after achieving a PR had a better but not significant 4-year progression-free survival than cases randomized for observation (53% vs. 22%, p = 0.116). Overall, 5 patients died after study entry, with an actuarial 5-year survival rate of 96% for the entire group of 166 patients. After a mean follow-up time of 38 months, only one second malignancy has been recorded. CONCLUSIONS: Initial therapy with alpha-IFN, regardless of the type of alpha-IFN used, induces satisfactory responses in the majority of patients with HCL, but in most instances discontinuation of treatment results in recurrence of disease. In most cases alpha-IFN improves the performance status of patients and favors a satisfactory bone marrow recovery and thus could still play a role in the initial management of the disease. Although splenectomy following alpha-IFN could prolong the progression free survival, its use should be restricted to selected cases.

Adult↗
PubMed1999

Splenectomy for refractory thrombocytopenia in the antiphospholipid syndrome.

OBJECTIVE: Thrombocytopenia, usually mild, is one of the clinical criteria of the antiphospholipid syndrome (APS). Rarely, this disorder requires treatment and, due to the shared characteristics with idiopathic thrombocytopenic purpura (ITP), similar rules are followed. We report our experience in patients who required splenectomy after being refractory to steroids and immunosuppressive therapy. METHODS: Fifty-five APS patients with a platelet count of < 100 x 10(9)/l at least twice were analysed retrospectively. Therapeutic response or remission was considered when the platelet count was > 100 x 10(9)/l after 1 month and with no relapse on stopping or tapering the steroid dose. No response or refractory disease was defined as an absence of increase in platelet count, a total count that never exceeded 50 x 10(9)/l during treatment or when the dose requirements were such that the patient developed serious side-effects. RESULTS: Fifty patients were classified as having secondary APS associated with systemic lupus erythematosus (SLE) and five were identified as primary APS (PAPS). Splenectomy was performed in 11 cases (20%), two PAPS and nine SLE-APS, with an average time of 28 +/- 9 months after the development of thrombocytopenia. Eight patients were initially characterized as ITP (six SLE-APS, two PAPS) with an average time of 4.4 +/- 1.1 yr until the APS diagnosis. All but two were responsive to splenectomy. CONCLUSION: Splenectomy was required in 11 (20%) of the patients with APS-associated thrombocytopenia. There was a high rate of good and long-term response.

Adult↗
PubMed1976

Incidental splenectomy: a review of the literature and the New York Hospital experience.

981 consecutive splenectomies at The New York Hospital were reviewed. 18.9% were removed incidental to some other procedure, either to facilitate exposure or because of uncontrolled bleeding from capsular tears. The primary operation with which this was most frequently associated was gastric resection for peptic ulcer disease, accounting for 20.5% of the spleens so removed. Conversely, the incidental splenectomy was noted in only 0.91% of all gastrectomies and 1.4% of all left colectomies designated as nonradical procedures. It is therefore seldom a necessary procedure. Incidental splenectomy is more frequent when midline abdoiminal incisions are employed, less frequent with paramedian or left rectus splitting incisions. 85% of the spleens removed incidentally were grossly and microscopically unremarkable; lacerations most probably result from excessive manipulation rather than pathological changes predisposing to rupture. The postoperative morbidity and mortality is discussed and is felt to be increased significantly by the incidental splenectomy.

Gastrectomy↗
PubMed1977

The morbidity and mortality of splenectomy in childhood.

One hundred and eighty-two patients undergoing splenectomy in infancy and childhood were followed for periods of 2 to 15 years. Serious infections occurred in 11 patients (6%) with death in 6 (3.3%). In 10 patients the infection was sepsis, and in all but one patient the infection occurred within 2 years of splenectomy. Among children over 2 years of age the risk of infection was still appreciable except when the spleen was removed incidentally or for traumatic rupture. Splenectomy for thalassemia and portal hypertension resulted in an increased risk of serious infections when compared with removal of the spleen for hereditary spherocytosis, idiopathic thrombocytopenic purpura, trauma, or for technical reasons in the course of another operation. Post-splenectomy infections tended to follow a characteristic pattern. The infecting organism was predominantly pneumococcus, the course was fulminating and the mortality high.

Adolescent↗
PubMed1978

Splenectomy in myeloid metaplasia.

A retrospective review of 19 patients with documented myeloid metaplasia undergoing, elective splenectomy during the past ten years at the Peter Bent Brigham Hospital is presented. The primary indications for splenectomy in 17 of these 19 were either hypersplenism or symptomatic splenomegaly. Eighteen of the 19 underwent both 59Fe-ferrokinetic studies and 51Cr-sequestration studies or, alternatively, 111In-marrow scintigraphy as a part of their routine preoperative evaluation. The death from sepsis of one patient six weeks post-operatively, whose marrow function was poor and whose level of splenic sequestration was minimal, confirms the efficacy of these studies in the preoperative prediction of hematologic response to splenectomy. Eighteen of the 19 patients benefited from the operation in terms of symptomatic relief and/or hematologic improvement, although surgery presumably did nothing to prolong survival in these patients. We conclude that splenectomy is indicated as a palliative maneuver for carefully selected patients with myeloid metaplasia without prohibitive operative risk, provided the criteria for selection of patients are adhered to and the surgeon and hematologist work together as a team.

Boston↗
PubMed1981

Evolving concepts in splenic surgery: splenorrhaphy versus splenectomy and postsplenectomy drainage: experience in 105 patients.

A major advance in recent years has been the demonstration in children that most injuries of the spleen can safely be repaired. There is, however, a relative paucity of data regarding primary suture repair of the spleen in adults. This report describes experience with the treatment of 27 consecutive injuries of the spleen between 1978-1980. Splenorrhaphy was successful in 24 of 27 patients. Eighteen of the 24 patients were older than 15 years of age. Seven injuries resulted from penetrating trauma, 13 from blunt trauma, and four from injuries during operation. Repair included debridement, partial splenectomy, and primary suture repair, often in conjunction with Avitene((R)). There were no reoperations for bleeding or postoperative infection. Three splenectomies (11%) were necessary because of either complete destruction of the splenic pulp, or separation of the spleen from its blood supply at the hilum. A separate question for decades has been the influence of types of drainage on infection following splenectomy. To study this question, between 1976-1978, 78 patients undergoing splenectomy were randomized prospectively by sealed envelopes into three groups. Group I-no drainage (23 patients); Group II-closed drainage with Jackson-Pratt drains (30 patients); Group III-open drainage with Penrose drains (25 patients). All but three drains were removed within 48 hours. In these three patients, the drains were removed after 96 hours. In the 53 patients in Group I and II, there were no infections. In Group III (Penrose drains) there were two complications: evisceration of a loop of small bowel through the drain site, and one subphrenic abscess in a patient with a concomitant colonic injury. Present experience does not show any significant difference among the three groups. Concomitant enteric injuries and the duration of drainage maybe the most significant factors influencing infection. The presence or absence of drains per se does not seem significant.

Adolescent↗
PubMed1984

Splenectomy for hematologic disease. The UCLA experience with 306 patients.

Between 1956 and 1981, 306 splenectomies for hematologic diseases were performed at the UCLA Medical Center. Of these operations, more than 75% were performed for therapeutic reasons to control anemia, thrombocytopenia, neutropenia, or painful symptoms of splenomegaly. Of the 65 patients who had idiopathic thrombocytopenic purpura, 77% showed an excellent response, and of the 39 patients who had hereditary spherocytosis, 90% responded. Other diseases with predictably good response rates were autoimmune hemolytic anemias, Felty's syndrome, and hairy cell leukemia. Forty patients with Hodgkin's disease had splenectomies for diagnostic purposes the last 10 years. The overall morbidity and mortality were 24% and 6%, respectively, the most common complications being pneumonia, wound infections, and local postoperative bleeding, and the most common cause of death being sepsis. The review supports the thesis that in carefully selected patients, therapeutic splenectomy can have desirable palliative effects and that diagnostic splenectomy has a sufficiently low risk to warrant its consideration in patients with Hodgkin's disease.

Adolescent↗
PubMed1987

Partial splenectomy for Gaucher's disease.

Gaucher's disease is an autosomal recessive disorder caused by deficiency of beta glucocerebrosidase, resulting in an accumulation of glucocerebroside in the reticuloendothelial system. These patients have massive splenomegaly and bone pain, but may have normal life expectancy. Traditionally, splenectomy has been used to treat hypersplenism, but may be associated with a high incidence of postsplenectomy sepsis and accelerated hepatic and bone lipid deposition. Two children are reported who had partial splenectomy for symptoms of Gaucher's disease. Both patients had laboratory evidence of hypersplenism. A 90% splenectomy was performed, and the residual splenic fragment was wrapped in Vicryl mesh. Both patients are currently asymptomatic with normal hematologic parameters. Postoperative radionuclide scans demonstrate increase in the size of the residual splenic fragment. Partial splenectomy may benefit patients with Gaucher's disease, but long-term follow-up care is necessary.

Child↗
PubMed1990

HIV-1-associated thrombocytopenia. The role of splenectomy.

Thrombocytopenic purpura is a common hematologic abnormality occurring in individuals infected with the human immunodeficiency virus, HIV-1. Of the nearly two million people infected with HIV-1, approximately 11% have platelet counts of less than 100,000/mm3. If no etiology other than HIV-1 infection can be found for the thrombocytopenia, the syndrome is referred to as HIV-1-associated thrombocytopenia (HAT). Steroids lead to an improvement in the platelet count in 60% to 80% of effected individuals but the majority of those who respond cannot maintain a normal platelet count when steroids are withdrawn. Furthermore concern over chronic steroid therapy in HIV-1-infected individuals has led to the investigation of other forms of treatment for this syndrome. This report describes the experience at Duke University Medical Center with eight patients who developed HAT and subsequently underwent splenectomy. In this group there was 1 complete response, 5 partial responses, and 2 patients who did not respond. There were no perioperative deaths and minimal perioperative morbidity. No evidence for the progression of HIV-1 infection in asymptomatic patients after splenectomy to AIDS related complex (ARC) or to the acquired immune deficiency syndrome (AIDS) was seen. In addition no increase in the susceptibility to infections by encapsulated organisms as a result of splenectomy was observed after a mean follow-up of 13.25 months. A review of 79 other cases reported in the literature suggests a higher response rate than that observed in our patients. Reasons for this discrepancy are discussed and an algorithm defining the role of splenectomy in the management of HAT is presented.

AIDS-Related Complex↗
PubMed1982

The effect of splenectomy on gram-negative bacteremia.

Both clinical and laboratory studies have demonstrated an increased risk of fatal sepsis after splenectomy. The importance of the spleen in clearing a bacterial challenge from pneumococci or other encapsulated organisms is now well accepted. The role of the spleen in handling a bacteremia due to nonencapsulated (Gram negative) organisms is not well established. Rats were subjected to either sham operation or splenectomy. Two weeks after surgery, all animals received 10(6) E. coli by intraperitoneal injection. Tail vein blood samples for quantitative culture were obtained at multiple time intervals after the bacterial challenge. All animals developed a bacteremia. Initially, the mean bloodstream bacterial counts were comparable in the sham and splenectomy groups. Sham-operated rats cleared all bacteria from the bloodstream within 240 minutes. In contrast, 240 minutes after bacterial injection, E. coli could still be recovered from the blood of asplenic rats at levels comparable to those noted at the start of the experiment. The present study shows that splenectomy does impair the animal's ability to clear a Gram-negative bacteremia.

Animals↗