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Defective activation of neutrophils after splenectomy.

Neutrophil chemotaxis and phagocytosis in the presence of serum from 20 patients who had undergone splenectomy and from 15 healthy volunteers was studied. The mean distance migrated by normal neutrophils in the presence of serum from the patients after splenectomy was significantly less than that when normal serum was used (p less than 0.005). The percentage of neutrophils phagocytosing a yeast was also significantly reduced in the presence of serum from patients after splenectomy (p less than 0.02). In addition, when neutrophils from these patients were studied both chemotaxis and phagocytosis were enhanced in normal compared with autologous serum (p less than 0.05).

Adolescent↗

Influence of splenectomy on hemodynamics during cardiac tamponade.

The effect of prior splenectomy on the hemodynamics of cardiac tamponade was investigated in 15 closed-chest pentobarbital sodium-anesthetized dogs. Hemodynamics were compared at baseline and during staged cardiac tamponade (pericardial pressures of 5, 10, and 15 mmHg) at control (n = 15) and after splenectomy (n = 8) and sham operation (n = 7). The fall in mean arterial pressure with cardiac tamponade was significantly greater in splenectomized dogs than in either sham-operated or control dogs (P less than 0.001). Cardiac output was more depressed at the third level of cardiac tamponade in splenectomized than in sham-operated or control dogs (12.8 +/- 14.5 vs. 29.3 +/- 8.7 and 25.4 +/- 9.4 ml.min-1.kg-1, respectively; both P less than 0.05 vs. splenectomy). Hemodynamic failure, defined as an inability to maintain mean arterial pressure greater than 50 mmHg for 5 min, occurred at a lower pericardial pressure in splenectomized than in sham-operated dogs (13.1 +/- 3.8 vs. 18.1 +/- 3.5 mmHg, P less than 0.05). Hematocrit increased significantly with cardiac tamponade in controls and sham-operated but not splenectomized dogs. The percent increase in hematocrit from baseline to the third stage of cardiac tamponade was 19.6 +/- 9.8 and 22.3 +/- 5.6% in control and sham dogs, respectively. Thus the canine spleen plays an important role in cardiovascular compensation to cardiac tamponade. Parallel changes in hematocrit suggest that a part of this response is due to splenic autotransfusion.

Animals↗

Splenectomy impairs diffusive oxygen transport in the lung of dogs.

The spleen acts as an erythrocyte reservoir in highly aerobic species such as the dog and horse. Sympathetic-mediated splenic contraction during exercise reversibly enhances convective O2 transport by increasing hematocrit, blood volume, and O2-carrying capacity. Based on theoretical interactions between erythrocytes and capillary membrane (Hsia CCW, Johnson RL Jr, and Shah D. J Appl Physiol 86: 1460-1467, 1999) and experimental findings in horses of a postsplenectomy reduction in peripheral O2-diffusing capacity (Wagner PD, Erickson BK, Kubo K, Hiraga A, Kai M, Yamaya Y, Richardson R, and Seaman J. Equine Vet J 18, Suppl: 82-89, 1995), we hypothesized that splenic contraction also augments diffusive O2 transport in the lung. Therefore, we have measured lung diffusing capacity (DL(CO)) and its components during exercise by a rebreathing technique in six adult foxhounds before and after splenectomy. Splenectomy eliminated exercise-induced polycythemia, associated with a 30% reduction in maximal O2 uptake. At any given pulmonary blood flow, DL(CO) was significantly lower after splenectomy owing to a lower membrane diffusing capacity, whereas pulmonary capillary blood volume changed variably; microvascular recruitment, indicated by the slope of the increase in DL(CO) with respect to pulmonary blood flow, was also reduced. We conclude that splenic contraction enhances both convective and diffusive O2 transport and provides another compensatory mechanism for maintaining alveolar O2 transport in the presence of restrictive lung disease or ambient hypoxia.

Animals↗

High-dose dexamethasone for splenectomy in patients with idiopathic thrombocytopenic purpura.

High-dose intravenous immune globulin (IV IgG) is currently the treatment of choice for patients with idiopathic thrombocytopenic purpura (ITP) who undergo splenectomy; however, this treatment is extremely expensive. We report on 13 ITP patients with severe thrombocytopenia (<20 x 10(9)/l) who were prepared for laparoscopic splenectomy with a 4-day oral course of high-dose (40 mg/day) dexamethasone (DEX). Four patients had an excellent response with platelet counts that increased to above 150 x 10(9)/l. Seven patients had a good response with a platelet count that increased to between 50 and 150 x 10(9)/l (median 121 x 10(9)/l). Two patients were resistant both to DEX and IV IgG. The operation was uneventful in all the patients, including the 2 who had resistant ITP and were operated on while their platelet count was very low (5 x 10(9)/l). Thus, high-dose DEX, which is an easy, effective and inexpensive treatment, is recommended for the preparation of ITP patients prior to splenectomy.

Administration, Oral↗

Advanced waldenström's macroglobulinemia: a case of possible cure after systemic chemotherapy, splenic radiation and splenectomy.

A 41-year-old man with advanced Waldenström's macroglobulinemia (WM) associated with the hyperviscosity syndrome, massive splenomegaly and with IgM concentration of 10 g/dl, was treated in January 1984 with plasmapheresis, systemic chemotherapy (M2 protocol) and splenic radiotherapy. He rapidly improved and was discharged 1 month later. Fourteen months later he underwent splenectomy since a mild splenomegaly persisted though the normalization of bone marrow, peripheral blood and electrophoresis with an IgM concentration of 140 mg/dl. However, at this time immunofixation and immunoelectrophoresis showed a small IgM-kappa monoclonal component. The histological and immunohistochemical analysis showed minimal splenic involvement by WM. Two months after splenectomy, immunofixation and immunoelectrophoresis showed no monoclonal component. The spleen was the probable site of minimal residual disease. The patient was treated with monthly chlorambucil and prednisone for 2 years. Subsequently clinical and laboratory tests persisted within normal limits. The last control performed in January 2002 showed that the patient was in good health; bone marrow examination (aspiration, biopsy with immunohistochemical analysis) and immunofixation persisted normally. This interesting case report, with advanced WM, alive, in good health and without signs of disease 18 years from diagnosis, is presented here and the role of splenectomy is debated.

Adult↗

Laparoscopic splenectomy for hematological disorders.

OBJECTIVES: The aim of this prospective study was to evaluate the safety and feasibility of laparoscopic splenectomy (LS) in patients with hematological disorders of the spleen. SUBJECTS AND METHODS: Between 1999 and 2001, 15 patients (11 female and 4 male), with a mean age of 30 years, underwent LS after preoperative evaluation. If difficulties were encountered in LS, one trocar site incision was enlarged to 7-8 cm to engage the left hand for hand-assisted laparoscopic splenectomy (HALS) and the procedure was completed. Various parameters were reported, including spleen size as assessed by ultrasound scan, postoperative mortality and morbidity rates, accessory spleen removal, conversion rate, operative times and length of hospital stay. LS was successfully completed in 9 patients (60%) and HALS was performed in 4 patients (26.6%). Two patients required conversion to open splenectomy. RESULTS: The mean operative time was 209 min and the mean hospital stay was 8.1 days. The hospital stay was significantly longer among HALS patients than LS patients. The mean age of patients and splenic size were associated with a significantly higher conversion rate. No deaths were attributed to the procedure. Complications occurred in 2 of 15 patients. Accessory spleens were identified in 2 patients. CONCLUSIONS: LS is both a safe and feasible procedure, but it requires great technical care to avoid serious complications.

Adolescent↗

Hand-assisted laparoscopic splenectomy for splenic tumors.

BACKGROUND: The feasibility of hand-assisted laparoscopic splenectomy (HALS) for splenic tumors including benign or malignant neoplasms and the associated clinical outcome of the patients remain unclear. METHODS: A total of 10 patients with splenic tumors undergoing HALS were retrospectively analyzed in this study. The intraoperative course, postoperative course, and postoperative recovery were evaluated. RESULTS: Ten patients with splenic tumors consisted of 5 with benign tumors and 5 with malignant tumors. HALS was not converted to an open splenectomy in any of the patients. Mean operative time was 170 min (range 100-310 min). Mean estimated blood loss was 105 g (range 10-900 g). Mean splenic size and splenic weight was 13 cm and 478 g, respectively. Splenomegaly based on size or weight occurred in 50% of the patients. There were no intra- or postoperative complications. Postoperative chemotherapy was given to 4 patients with malignant tumors including metastatic carcinomas and malignant lymphomas. All the patients were alive at a mean follow-up of 26 months, ranging from 15 to 43 months after surgery. There was no port-site recurrence after surgery in our study. Mean time to first flatus, mean time to first walking, mean time to resumption of oral intake, mean length of hospital stay, and mean duration of epidural analgesia were 1.8, 1, 1.5, 10.8 and 3.1 days, respectively. The results were equal in terms of intra- and postoperative course to those seen with a standard laparoscopic splenectomy for 13 patients with idiopathic thrombocytopenic purpura. CONCLUSION: HALS may be a good indication for malignant tumors as well as benign tumors of the spleen.

Blood Loss, Surgical↗

Portal venous pressure following splenectomy in patients with portal hypertension of differing etiology.

To clarify the effect of splenomegaly on portal hemodynamics in patients with portal hypertension and esophageal varices, manometric studies were carried out before and after splenectomy during an operation for esophageal varices. The 118 patients evaluated retrospectively had underlying liver cirrhosis (LC) (62), idiopathic portal hypertension (IPH) (42), and extrahepatic portal occlusion (EHO) (14). The weight of the spleen did not differ significantly among the three diagnostic groups: 640 +/- 473.5 g for LC, 780 +/- 414.6 g for IPH, and 683 +/- 457.2 g for EHO. Before splenectomy, portal pressure was significantly elevated in the patients with EHO (410 +/- 85.2 mm H2O) as compared to either the LC or IPH groups (348 +/- 64.1 and 348 +/- 73.5 mm H2O). Following splenectomy the reduction of portal pressure was significantly greater in the EHO group (29 +/- 15.5%) than in either the LC (18 +/- 17.4%) or IPH (19 +/- 17.0%) groups. Each group was subdivided according to severity of splenomegaly: marked (spleen weight > or = 500 g) or slight (spleen weight < 500 g). Patients with LC and marked splenomegaly showed a reduction in liver function parameters as shown by the prolongation of indocyanine retention rate at 15 min as compared to those with slight splenomegaly. Though it is not statistically significant, the average portal pressure tended to be higher among those with marked splenomegaly.(ABSTRACT TRUNCATED AT 250 WORDS)

Esophageal and Gastric Varices↗

The role of splenectomy in cadaveric renal transplantation.

We analyzed 50 consecutive cadaver renal transplants to ascertain what benefit, if any, accrued from pretransplantation splenectomy. Because antithymocyte globulin was administered in a random fashion to some patients, its effects were also analyzed. Recipient modification with either modality enhanced graft survival in first transplants when compared to no modification (splenectomy versus no modification 62 versus 27%, p = 0.06; ATG versus modification 75 versus 27%, p = 0.01). The collective experience with splenectomy, its rationale, and its complications are discussed.

Cadaver↗

Influence of splenectomy on human acute tubular necrosis.

The incidence of acute tubular necrosis (need for hemodialysis immediately after transplantation) and its severity (the number of days dialysis was needed) were studied in 299 patients who were randomized prior to transplantation into undergoing splenectomy or not having splenectomy. There was no difference in the incidence of acute tubular necrosis between splenectomized and nonsplenectomized patients who received cadaveric grafts or kidneys from living related donors. In those patients in the cadaveric group who had acute tubular necrosis, the duration of need for dialysis was significantly less (p less than 0.05) in the splenectomized group (means = 8.9 days) when compared to the non-splenectomized group (means = 13.2 days). Animal experiments indicate that sustained prostaglandin release may be responsible for the decreased incidence and amelioration of acute tubular necrosis in splenectomized animals. Our study suggests that conclusions made in dogs about the influence of splenectomy on acute tubular necrosis may be applied to humans. Prostaglandin infusion may be a worthwhile method to abolish or ameliorate human acute tubular necrosis.

Acute Kidney Injury↗

T lymphocyte subsets and platelet-associated IgG in idiopathic thrombocytopenic purpura: effect of splenectomy.

The modifications of cell-mediated immunity in idiopathic thrombocytopenic purpura (ITP) were investigated using the technique of Moretta et al. [J. exp. Med. 151: 969-974, 1980] to study T lymphocyte subsets in 35 ITP subjects at various clinical stages. In all these patients, platelet-associated IgG (PAIgG) were measured by a complement lysis inhibition technique. Untreated ITP patients did not show significant modifications of T lymphocyte subsets. Patients with thrombocytopenia not responsive to corticoids or splenectomy and increased PAIgG levels showed significant reduction of Fc-gamma-bearing T lymphocytes (T-gamma). Patients 'cured' by splenectomy (12 out of 17) showed a normal PAIgG level, a marked increase of T-gamma cells and a reduction of T-mu cells; patients 'not cured' by splenectomy showed an increased PAIgG level and a reduction of T-gamma cells. An increase of PAIgG levels and a reduction of T-gamma cells were found in 2 splenectomized patients after relapse. An association between chronic nonresponsive ITP and decrease of T-gamma cells was established.

Adolescent↗

Emergency splenectomy in hairy cell leukemia.

The role of splenectomy in the treatment of hairy cell leukemia (HCL) is now well established. There are however some particular situations which indicate splenectomy as a possible emergency therapy in markedly cytopenic cases with severe antibiotic-resistant infections. The aim of the emergency splenectomy in such conditions is to temporarily increase neutrophils and to permit the improvement of the infectious disease. We describe 2 cases of HCL with severe infectious disease, successfully splenectomized.

Emergencies↗

Congenital dyserythropoietic anaemias: splenectomy as a mode of therapy.

3 cases of congenital dyserythropoietic anaemia (type I, case 3; type III, cases 1 and 2) are reported with a follow-up of 8-10 years. Conventional therapy with vitamins, steroids and/or anabolic hormones was ineffective. Regular blood transfusions were required to maintain the haemoglobin levels around 8 g/dl. Splenectomy, however, resulted in a sustained rise in haemoglobin without blood transfusions. During the follow-up period varying from 40 to 77 months after splenectomy, diabetes mellitus was detected in all 3 patients. Liver biopsy showed haemosiderosis in 2 patients with cirrhosis in one of them. It is suggested that splenectomy could be an effective mode of therapy to reduce the need for blood transfusion in congenital dyserythropoietic anaemias.

Adult↗

Serum ferritin levels in thalassemias and the effect of splenectomy.

Iron overload is a constant and the more important complication in thalassemia. Serum ferritin concentration accurately reflects body iron stores. A total of 245 thalassemic patients aged 12-55 years were examined, 71 having Hb H disease and 174 beta-thalassemia/Hb E disease. The patients received minimal or no blood transfusions. 73 patients with beta-thalassemia/Hb E were studied 1-28 years after splenectomy. The serum ferritin levels in both Hb H and beta-thalassemia/Hb E patients were higher than normal. They were higher in beta-thalassemia/Hb E than Hb H disease. Most striking was the significantly higher serum ferritin levels in splenectomized patients with beta-thalassemia/Hb E disease than in the nonsplenectomized ones. The observation is compatible with previous observations that splenectomy in thalassemia is associated with increased iron deposition and increased transferrin iron saturation. The further increase in iron overload after splenectomy in thalassemia should be borne in considering removal of this organ.

Adolescent↗

Autoimmune antibodies after splenectomy.

Sera of 41 splenectomized subjects were tested for presence of autoantibodies by the indirect immunofluorescent method. 11 of them (26%) revealed the presence of one or more types of autoantibodies. Antiheart antibodies were the most common type (9 subjects). The incidence of antibodies was higher in the subjects splenectomized for trauma than in those who underwent elective splenectomy (39 and 25%, respectively). There was no significant difference between the subjects with positive and negative results with respect to mean age at examination, but the positive results tend to occur more frequently in those who underwent splenectomy at younger age. None of the subjects with any type of antibodies suffered from autoimmune disease. Although it is still impossible to evaluate the clinical importance of these findings, they suggest that splenectomy may disturb the regulatory processes in the immune system. We postulate that this is due to the reduction of the number of suppressor T cells for which the spleen is a major pool.

Adolescent↗

Effects of corticosteroids and splenectomy on the immune clearance and destruction of erythrocytes.

Corticosteroids and splenectomy constitute two important therapeutic modalities in the treatment of autoimmune hemolytic anemia. Each of these may affect both the rate of synthesis of autoantibody and the clearance of antibody sensitized cells. The latter possibility has been examined in an experimental model which allows evaluation of the role of antibody and complement in the immune clearance of erythrocytes in molecular terms. The in vivo clearance of (51)Cr-labeled guinea pig erythrocytes sensitized with purified rabbit IgG or IgM antibody to produce a known number of complement-fixing sites per cell was studied. Corticosteroid therapy increased the survival of both IgG and IgM sensitized erythrocytes by decreasing sequestration in the reticuloendothelial system (RES). 5 days of therapy prior to injection of antibody coated cells were required for a maximal effect. It appeared that the RES of cortisone-treated animals had a lowered sensitivity to erythrocytes coated with antibody and complement and the cells were removed as though they were coated with fewer complement sites/cell. The general pattern and kinetics of clearance and the localization of sequestered cells were not modified by corticosteroids. As the number of IgG C1-fixing sites was increased, the difference betwen cortisone treated and control animals was less marked. Splenectomy led to an increased survival of IgG-coated cells and a sixfold increase in IgG C1-fixing sites was necessary in order to obtain similar rates of clearance in splenectomized and control animals. The liver was responsible for this much less efficient clearance of cells in splenectomized animals: the clearance pattern was typical of that noted for IgG. No effect at all was noted on the clearance of IgM sensitized cells in splenectomized animals. These experiments clearly demonstrate that both corticosteroid therapy and splenectomy act to decrease the in vivo clearance of IgG-sensitized cells: only corticosteroids alter the clearance of IgM-sensitized erythrocytes. This effect may be of major importance in explaining the efficacy of these therapeutic modalities in autoimune hemolytic anemia.

Anemia, Hemolytic, Autoimmune↗

Influence of splenectomy upon immunologic reactivity of patients with Hodgkin's disease.

Since most patients with Hodgkin's disease benefit from splenectomy, a study was designed to explore whether these beneficial effects could be attributed to the recovery of patients' immunologic reactivity. Using a series of ordinary skin test (PPD-tuberculine, Varidase and Candidin) determination of absolute T and B lymphocyte counts in peripheral blood and their mitogenic responsiveness, assessment of immunologic reactivity was performed in 28 Hodgkin's disease patients, prior to and 14 days after splenectomy. The results showed that overall immunologic reactivity of these patients was suppressed as judged by low absolute lymphocyte counts (1747.2 +/- 171.9), lower counts of T (592.0 +/- 92.1) and B cells (295.9 +/- 40.5) and their poor capacity to respond to phytohemagglutinin (PHA) (20342.6 +/- 3662.8 cpm), although the reactivity towards skin test antigens seemed to be well preserved. After splenectomy the reactivity improved, absolute lymphocyte counts raised to 2654.9 +/- 468.8 and were parallelled by an increase in T (936.7 +/- 138.0) and B cell counts (402.2 +/- 81.2). PHA reactivity recovered as well (26965.5 +/- 4035.6 cpm), however, its remained lower than in control cultures. Furthermore, the immunocompetence of patients' spleens was assessed. The possible influence of some suppressive mechanisms such as serum-blocking factor and prostaglandins is discussed.

Adolescent↗

Present status of laparoscopic splenectomy for hematologic diseases: certitudes and unresolved issues.

Laparoscopic splenectomy is considered to be the "gold-standard" treatment of benign hematologic diseases, with normal or slightly enlarged spleens. Laparoscopic treatment of malignant diseases and splenomegalies remains more controversial. The procedure requires a great surgeon's laparoscopic expertise, appropriate positioning of the patient and trocar insertion, and gentle and meticulous dissection of the spleen. The technique is feasible in 91% of the patients with a 0.9% operative mortality and a postoperative complications rate of 12%. When compared with open splenectomy in retrospective case-controlled studies, the laparoscopic approach includes a longer operative time and higher operative room costs. However, advantages include reduced postoperative hospital stay and faster return to normal activities. Despite scarce reported data, long-term hematologic cure rate seems to be equivalent in patients with idiopathic thrombocytopenic purpura. The accuracy of laparoscopic exploration to detect all accessory spleens is however questioned, and residual postoperative accessory splenic tissues have been observed. Prospective randomized controlled trials comparing short- and long-term results of open and laparoscopic splenectomies are required to confirm definitely the role of laparoscopy in the management of hematologic disorders.

Costs and Cost Analysis↗