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Splenectomies were performed in 30 children out of a total of 183 with idiopathic thrombocytopenic purpura (ITP). Of these 30, ten splenectomies were performed on an emergency basis. Significant spontaneous gross hematuria, gastrointestinal bleeding or epistaxis appear to represent harbingers of intracranial hemorrhage and constitute indications for emergency splenectomy.
The critical role of the spleen in protecting subjects from systemic bacterial infection is well known. Plasma fibronectin (PF), cold-insoluble globulin, and opsonic alpha2 surface binding glycoprotein, has regulatory influence on reticuloendothelial system clearance activity and it is important for maximal phagocytosis. Ascorbic acid (AA) also appears to play an important role in phagocytic cell function. The purposes of this study were to determine the effects of splenectomy and splenectomy with autoimplantation, with and without dietary AA supplementation, on PF levels. Six-week-old male Sprague-Dawley rats were divided into four experimental groups of 20 animals each: Nonoperated controls, sham-operated controls, totally splenectomized animals, and splenectomized animals with intraperitoneal autoimplantation. Each group was further randomly divided into two subgroups of 10 animals, those receiving dietary AA supplementation and those not receiving AA. PF levels were measured with a colorimetric assay immediately prior to and at 4 and 8 weeks after operation. Plasma AA determinations documented the effectiveness of dietary AA supplementation. PF levels in nonoperated and sham-operated controls increased significantly during the 8 weeks of experimentation. In contrast, PF levels decreased significantly following total splenectomy from 328 +/- 46 mcg/mL (mean +/- S.D.) to 285 +/- 46 at 4 weeks and rose to 303 +/- 77 at 8 weeks postoperatively in non-AA supplemented animals. Splenic autoimplantation eliminated this decrease in PF levels at 4 weeks. AA supplementation also protected against the decrease in PF levels in the splenectomized group. In the intragroup comparisons, AA supplementation did not produce a significant elevation of PF.(ABSTRACT TRUNCATED AT 250 WORDS)
Splenectomy is a recognized factor predisposing to the late complication of serious sepsis. The meningococcus has been listed as an important organism in postsplenectomy infection. A survey of the literature, however, revealed a total of only 13 documented case reports over a 31-year period, including ten pediatric cases. No documented cases of meningococcal sepsis in children following splenectomy for trauma were found. In an experimental mouse meningococcal infection model, the intraperitoneal LD50 was similar between normal and splenectomized mice (4 X 10(8) v 4 X 10(7) cfu, respectively; P = not significant). Bacteremic patterns were similar in both groups. Uniform survival was seen in normal and splenectomized mice after various intravenous challenge doses of meningococci up to 10(6) cfu. This was associated with efficient bacterial clearance in both groups. It appears unlikely that the defect resulting from splenectomy alone is an important predisposing factor in meningococcal sepsis.
The authors report a case of pyruvate kinase deficiency in a 4-year-old patient who required monthly blood transfusions. A partial splenectomy was performed to decrease the transfusion requirements and at the same time preserve splenic function. After removal of 80% of splenic tissue there was no amelioration of her transfusion needs. She responded well to subsequent total splenectomy performed 6 months later, and is currently well and transfusion independent. Rapid splenic regeneration possibly caused by erythrophagocytosis and extramedullary hematopoiesis is the presumed reason for this patient's failure to respond to partial splenectomy.
BACKGROUND & PURPOSE: The indications and results of elective partial splenectomy in children remain uncertain. The aim of this study was to determine (1) the indications for elective partial splenectomy (EPS), (2) the extent of splenic resection, and (3) the complications of EPS. METHODS: Patients who underwent EPS from three centers over a 10-year period (1986 through 1996) were studied. Variables analyzed included clinical presentation and indications for EPS, extent of resection performed, perioperative transfusions, and complications. Postoperatively, splenic viability was determined by regular Doppler ultrasound scan and splenic function on peripheral blood film analysis. RESULTS: EPS was attempted in 12 children for various conditions: giant epithelial cyst (n = 6), hypersplenism and metabolic disease (n = 4), pseudotumor (n = 1), and abscess (n = 1). One procedure was converted to total splenectomy because of thin splenic tissue around an infected giant cyst. No child required transfusion for splenic bleeding. There were no postoperative complications or deaths. Only 7 of the 12 children received prophylactic preoperative immunisation. In the 11 successful cases splenic remnant viability remains confirmed by ultrasound scan and normal blood film. There has been no significant splenic regrowth or recurrent hypersplenism in the four children with metabolic disorders. CONCLUSIONS: EPS is suitable for benign splenic conditions and can be performed without major blood loss. Preoperative vaccination is advisable. Up to 95% of the spleen can be safely removed, basing the blood supply of the residual spleen tissue on peripheral polar vessels, with adequate postoperative function.
Infusions of intravenous gamma-globulin (IVGG) are an effective, nontoxic therapy for chronic idiopathic thrombocytopenic purpura (ITP) that would be more widely accepted if the therapeutic agent were not so expensive. The costs and outcomes of managing such children with splenectomy and IVGG were modeled with Markov processes. Children unresponsive to one treatment were considered to have received the alternative. The model accounted for spontaneous remissions, therapeutic responses, traumatic events, episodes of sepsis, and operative deaths. For a 10-year-old child with chronic ITP, the strategy of initial treatment with splenectomy had associated costs of $17,000 and a 97.9% ten-year survival rate, whereas the strategy of initial treatment with IVGG had associated costs of $21,000 but a 98.6% survival rate. Each additional life saved by employing the IVGG strategy cost $540,000, or $8,000 per year for a life expectancy of 70 years. Sensitivity analyses demonstrated that for older children the IVGG strategy continued to result in improved survival rates but was more costly than the splenectomy strategy. For younger children, the IVGG strategy dominated, with improved survival rates and lower costs.
Laparoscopic splenectomy can be taught and performed safely. It presents less significant morbidity than does open surgery, and efficacy in the control of hematologic disease is comparable while offering the proven benefits of the minimally invasive approach. Laparoscopic splenectomy for selected hematologic disorders should replace open splenectomy as the technique of choice and prompt earlier consideration of surgery when it is indicated.
Dramatic decreases in length of hospital stay and time to complete recovery with laparoscopic cholecystectomy have led to the development of more advanced laparoscopic procedures. The rationale, technique, and early results with laparoscopic splenectomy are described in this article. Laparoscopic splenectomy is a complex procedure with a real potential for significant operative bleeding, but it can be accomplished successfully in greater than 80% of selected patients with minimal blood loss. If successful, length of stay is reduced in most patients to 1 to 3 days, but this benefit is not always seen in patients with complicated medical problems or with massive splenomegaly. The effects of increased blood loss in patients whose operations are converted to open operations are also not yet clear. Laparoscopic splenectomy is a procedure with great potential, but it is still in evolution.
Despite heterotopic splenic tissue, fatal fulminating pneumococcal septicaemia occurred in 2 patients who had had splenectomy for trauma. A girl aged 12 who died 8 years after splenectomy had over a hundred nodules, the largest weighing 3 g. A man of 19 who died 9 years after splenectomy had splenic tissue weighing 92 g. The presence of splenic tissue did not itself protect these patients from overwhelming infection and its ectopic situation with the consequent alteration in blood-supply may be of greater importance than the amount of splenic tissue present.
Splenectomy is commonly carried out before bone-marrow transplantation in chronic granulocytic leukaemia to reduce tumour burden and prevent relapse and blastic transformation. In a retrospective analysis of 210 European patients transplanted between 1980 and 1984, 105 splenectomised and 105 not, neither splenectomy nor splenic irradiation was found to alter survival and relapse. Debulking in this disease is of no value, and routine splenectomy before transplantation should be abandoned.
INTRODUCTION: Spontaneous splenic ruptures are rare but life-threatening complications of infectious diseases. Splenectomy is still the treatment of choice but numerous recent reports have documented favorable outcome with conservative treatment. EXEGESIS: We report three cases of splenic rupture occurring respectively with infectious mononucleosis, P. vivax infection and dengue fever. Diagnosis, treatment and indications are reviewed, an approach to management is suggested. The study included three military men respectively aged 23, 24 and 35 years, admitted for acute abdominal pain in the left upper quadrant. The abdominal computed tomography confirmed partial rupture (splenic hematoma) in the first two cases, and an hemoperitoneum in the dengue case. Splenic ruptures can reveal or complicate an evolving infection. Rupture can happen spontaneously or as a result of trauma, which may be minor and unnoticed. The typical presentation is acute, but progressive forms are described. The diagnosis is made by ultrasound and CT scan. Splenectomy dogma tends to be supplanted by conservative treatment. Non-operative management can be successful if appropriate criteria and a long period of follow-up are applied in carefully selected cases. When an operative approach is selected, conservative surgical treatment is attractive. Splenectomy should be reserved for patients with uncontrollable rupture or with recurrent splenic bleeding. CONCLUSION: Spontaneous splenic rupture are uncommon in infectious diseases. A multidisciplinary management is necessary. A conservative treatment should be considered in selected, closely monitored patients.
Two cases of accessory spleen persisting after splenectomy for autoimmune thrombocytopenic purpura are reported. The diagnosis of accessory spleen must be considered whenever post-splenectomy blood smears fail to show pitted erythrocytes or Jolly's bodies in red cells. Isotopic methods, now completed by computerized tomography, will then confirm the persistence of splenic tissue. As illustrated by one of our patients, only large accessory spleens would produce a relapse of autoimmune thrombocytopenic purpura. In case of major thrombocytopenia a second splenectomy is worth attempting, although its benefits are inconstant and unpredictable.
AIMS: The purpose of this retrospective study was to evaluate whether a more radical resection, including total gastrectomy (TG), D2 lymphadenectomy and splenectomy, or subtotal gastrectomy (SG), improves the prognosis of patients with an adenocarcinoma located on the distal third of the stomach. PATIENTS AND METHODS: Seventy-four consecutive patients with an antral carcinoma underwent gastric resection. Forty-three had a TG and 31 an SG. D2 lymph node dissection was carried out in 70% of all patients (30/43) and 100% (21/21) of patients with curative resection in the TG group, whereas in the SG group the patients had only a standard D1 lymph node dissection. Splenectomy was carried out in 84% (36/43) of patients in the TG group, whereas in the SG group the spleen was preserved in all patients. Follow-up was complete for 100% of the patients, with a median follow-up time of 74 months. MAIN END-POINTS OF INTEREST: Overall survival rates, mortality and morbidity rates. RESULTS: The postoperative 30-day mortality rate was 7% in the TG group and 3.2% in the SG group. The overall morbidity rate was increased from 19% after SG to 37% after TG. There was no microscopic evidence of involvement of proximal resection margins in any of 31 subtotal resected gastric specimens. Lymph node metastases to the splenic hilus (no. 10 nodes) or along the splenic artery (no. 11 nodes) were not found in any of 36 patients who underwent splenectomy and lymphadenectomy. The 5- or 10-year survival rates did not differ significantly between both groups. Analysis of survival showed no significant difference between the TG and SG groups when related to subgroups of patients with curative resection (UICC-RO resection), nodal status (pN), tumour depth (pT-category), tumour stage (pTNM), or Lauren classification (intestinal or diffuse type of carcinoma). The survival rates for patients with curative resection after 5 or 10 years were 58% in the TG group and 66% or 51% in SG group, respectively (P = 0.66). CONCLUSION: Since D2 total gastrectomy carried an increased overall morbidity risk and did not improve survival in patients with intestinal or diffuse type carcinoma, it seems that with regard to luminal gastric resection, SG is the treatment of choice for carcinomas located in the distal third of the stomach. Whether extensive radical D2 lymphadenectomy should be routinely performed in addition to SG is still controversial.The spleen should be preserved in most cases.
BACKGROUND: Understanding the immunologic properties of the spleen has enabled surgeons to practice splenic conservation surgery. If the upper pole of the spleen can be preserved solely on the upper short gastric vessels, will phagocytic function of macrophages in remnant splenic tissue be affected? The aim of this experimental study was to evaluate the phagocytic function of macrophages in partially resected spleens, with hilar excision preserving the short gastric vessels. STUDY DESIGN: Forty-eight female Wistar albino rats were divided into four groups. Groups 1 and 2 underwent sham operations and groups 3 and 4 underwent partial splenectomy. One milliliter of sodium chloride 0.9% was injected into the abdomen of the rats in groups 1 and 3 and 1 mL of Streptococcus pneumoniae type III as an antigenic stimulus was injected into the abdomen of the rats in groups 2 and 4, 6 weeks after the first operation. Forty-eight hours later, relaparotomy was performed in all animals. India ink was used to determine the capacity of uptake in the splenic phagocytes. To evaluate the phagocytic function of the splenic tissues, histologic examinations were performed according to a macrophage grading system. RESULTS: All spleens in all four groups were stained black after injection of India ink. Phagocytic activity of macrophages was reduced in the partially splenectomized groups, compared with intact spleen groups (group 3 versus group 1; p < 0.0001, group 4 versus group 2; p < 0.0001). There was a significant difference between groups 1 and 2 according to phagocytic function of macrophages (p = 0.0121). Also, after Streptococcus pneumoniae type III injection as an antigenic stimulus in group 4, we found that the phagocytic functions of macrophages increased compared with those of the sodium chloride 0.9%-injected group 3 after partial splenectomy (p < 0.0001). CONCLUSIONS: Phagocytic function of macrophages in rats decreased after partial splenectomy. Nevertheless, the remnant spleens in rats could be stimulated when challenged with an antigenic stimulus.
BACKGROUND: Immune thrombocytopenic purpura (ITP) is a condition with potential hazard during pregnancy for both mother and fetus if platelet concentrations fall below a critical level. This report describes the use of laparoscopic splenectomy following unsuccessful medical management. CASE: A 35-year-old primigravid woman with systemic lupus erythematosis (SLE) developed ITP several years before becoming pregnant. She was treated early in pregnancy with high-dose oral prednisone and weekly intravenous immunoglobulin (IVIG) alternating with anti-D immune globulin, but laparoscopic splenectomy was indicated at 20 weeks' gestation because of thrombocytopenia. Following surgery, she continued prednisone and intermittent IVIG therapy until spontaneous delivery at 34 weeks' gestation. A small accessory spleen was identified postpartum by nuclear medicine scan. Satisfactory platelet concentrations were maintained postpartum using danazol and prednisone. CONCLUSION: Laparoscopic splenectomy is a therapeutic option for women with ITP during pregnancy that fails to respond to medical management.
A randomized trial is reported which evaluates the effect of early diagnostic splenectomy on the prognosis of patients with Hodgkin's disease (HD) and uncertain prognosis. This was started in January 1973 and concluded in April 1979. Sixty-seven patients were entered in the study and 31 were randomized for splenectomy. All patients except 2 received total nodal irradiation, excluding the splenic and hepatic areas. After 40 months' observation there was no difference between the groups in respect of survival and the number of recurrences. However, relapses occurred earlier in the splenectomized patients. Pneumococcal septicaemia was recorded in 2 splenectomized patients. It is concluded that prognosis is not improved by diagnostic splenectomy in HD patients with uncertain prognosis and treated with total nodal irradiation.
The risks of second primary cancer were analysed in 2846 patients with Hodgkin's disease treated within the British National Lymphoma Investigation during 1970-87. The relative risk (RR) of leukaemia was significantly greater in women (RR = 30.1; 95% confidence limits (CL) 13.0-59.5) than in men (RR = 10.9; 95% CL 4.7-21.5), and showed a significant trend of greater risk with younger age at first treatment (P < 0.001). The relative risk of solid cancers was similar between the sexes, but again significantly greater at young than at older ages of first treatment (P < 0.01). Non-Hodgkin's lymphoma relative risks, although not related to sex or age, were significantly related to histology of the original Hodgkin's disease, and were greatest after lymphocyte predominant Hodgkin's disease (RR = 55.6; 95% CL 18.0-129.7). The relative risk of second cancers did not vary significantly according to whether or not splenectomy had been performed. Leukaemia risk was non-significantly greater after splenectomy than with no splenectomy, which accorded with previous evidence of a modest increased risk associated with this operation. If the greater relative risk of solid second cancers after treatment at young than at older ages persists with longer follow-up, the incidence rates of these second primaries in patients treated young for Hodgkin's disease will become very substantial as they age. This emphasises the need to maintain long-term follow-up surveillance of young Hodgkin's disease patients apparently cured of their disease, and to continue to develop new less carcinogenic treatment regimens.
A distal pancreatectomy is often performed simultaneously with splenectomy and total gastrectomy in the treatment of gastric carcinoma to facilitate dissection of the lymph nodes around the splenic artery. However, the morbidity of partial pancreatectomy is high. Patients undergoing pancreaticosplenectomy in conjunction with total gastrectomy are subject to leaks from the pancreatic stump, which may cause further complications. We performed a retrospective analysis to evaluate the end results of simultaneous distal pancreatectomy with total gastrectomy. The effect of distal pancreatectomy on survival was studied by examination of the records of 174 patients who underwent splenectomy and total gastrectomy for gastric carcinoma. Of these, 93 underwent distal pancreatectomy. Prognostic factors were determined and were examined in relation to the post-operative complications. There was no significant difference in the 5-year survival of the patients who did or did not undergo distal pancreatectomy. There was no correlation between any prognostic factor and distal pancreatectomy. In contrast, distal pancreatectomy was independently associated with post-operative complications. In this retrospective study, the addition of distal pancreatectomy to splenectomy at total gastrectomy for patients with gastric cancer did not affect survival but was associated with severe complications.