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Lower pole splenectomy with preservation of residual splenic function was successfully performed in a 3-year-old boy with a symptomatic splenic hamartoma. Following resection, several of the patient's constitutional symptoms resolved. This is the first reported case of a splenic hamartoma treated by partial splenectomy.
We report our initial experience and describe the operative technique used in three patients who underwent laparoscopic splenectomy for hematologic disorders between September 1991 and February 1992. No early or late complications have been found at an average follow-up of 9 months. All have remained asymptomatic and continue to have normal cell counts. We believe that splenectomy is a feasible extension of minimally invasive surgery in the hands of experienced surgeons. However, recognition of its limitations and ability to convert to the open procedure to assure safe excision is essential.
Splenic, portal, or mesenteric venous thrombosis after splenectomy for hematologic disease has not been reported in the pediatric literature. It is a rare complication associated with significant morbidity and mortality in adult reports. Between 1981 and 1991, 3 patients (13-year-old boy with hereditary elliptocytosis [HE], 13-year-old boy with thalassemia intermedia [TI], and 18-year-old girl with idiopathic thrombocytopenic purpura [ITP]) presented with abdominal pain, nausea, with or without fever, at 4, 11, and 13 days postsplenectomy, respectively. Abdominal Doppler ultrasound (US) and/or computed tomography (CT) showed: (1) an intraluminal filling defect with partial obstruction to flow in the right branch of the portal vein with the remaining vessels patent (HE); (2) splenic vein thrombosis with complete occlusion of the main portal vein and proximal superior mesenteric vein (TI); and (3) complete thrombosis of the splenic vein, proximal superior mesenteric vein and portal vein (including central radicles), with retrogastric collateralization (ITP). Subsequent imaging showed either complete resolution of vascular obstruction on no treatment (patient 1), or portal venous cavernomatous transformation with hepatofugal flow after 6 months of systemic anticoagulation (patients 2 and 3), and all 3 patients are currently asymptomatic. Postoperative sonographic evaluation of a consecutive series of pediatric splenectomies for hematologic disease (n = 16), was performed at a median of 51 days (range, 3 to 124). This demonstrated one case of asymptomatic left portal venous thrombosis with subsequent recanalization in the absence of treatment.(ABSTRACT TRUNCATED AT 250 WORDS)
The authors describe their technique for laparoscopic splenectomy in childhood. Five ports, including one 12-mm port for an endoscopic stapler, are placed. With the patient in the supine position, the short gastric vessels are divided between clips. The patient is then placed in the lateral decubitus position for mobilization of the splenic flexure of the colon, division of the posterolateral ligamentous attachments, and en masse transection of the splenic hilum using the EndoGIA stapler. The freed spleen is placed in a nylon reinforced Lap Sac, which is exteriorized at the neck. The spleen is morcellated and the sac removed. Concomitant cholecystectomy is performed in patients with hereditary spherocytosis who have cholelithiasis or sludge. The procedure has been performed without complication in six patients who had hematologic disorders. For another patient, the procedure was converted to an open splenectomy to achieve better hemostasis.
Thrombospondin (TSP), is a major constituent of human blood platelet alpha-granules. Stimulation of platelets causes the release of TSP in parallel with other alpha-granule constituents such as beta-thromboglobulin (beta-TG) and platelet factor 4 (PF4) but the thrombospondin plasma in vivo half life is significantly greater than beta-TG and PF4. The aim of this study was to assay TSP levels in plasma of patients with chronic renal failure (CRF), liver disease (LD) and following splenectomy. The TSP values were then compared to the patients plasma levels of two traditional markers of platelet activation, beta-TG and PF4, and to fibronectin (FN) and von Willebrand factor (VIII:vWF). Plasma TSP levels (67.6 +/- 16.9 ng/ml) assayed in 14 CRF patients were significantly higher (p less than 0.05) than those measured in 28 donors (55.5 +/- 11.7 ng/ml). No correlation was observed, in CRF patients, between the TSP level and PF4 (2.5 +/- 1.5 ng/ml), beta-TG (131.1 +/- 21 ng/ml), FVIII:vWF (252 +/- 85%), or FN (102 +/- 33%) plasma levels. The TSP plasma level in CRF patients was significantly correlated (p less than 0.02) with that of fibrinopeptide A (4.1 +/- 1.9 ng/ml). Although the beta-TG (23.5 +/- 6.9 ng/ml) and PF4 (2.9 +/- 2 ng/ml) plasma levels in six LD patients were normal, the TSP levels (82.5 +/- 39.1 ng/ml) were significantly increased (p less than 0.01). Thrombospondin plasma levels (77.1 +/- 20.1 ng/ml) in 14 patients having undergone splenectomy were significantly increased (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)
A patient with recurrent epithelial carcinoma of the ovary undergoing cytoreductive surgery including splenectomy is presented. The role of extensive debulking surgery in ovarian cancer is now well established. Aggressive tumor reductive procedures including splenectomy may be indicated in patients with no prior platinum-containing chemotherapy.
Determination by the immune system of chemo- and immunotherapy of a murine tumor was investigated. The effect of cyclophosphamide and levan (polyfructose) in single and combined treatment on the growth of the F10 variant of B16 melanoma was tested in splenectomized and non-splenectomized mice. Splenectomy was found to increase markedly the efficiency of all treatments, particularly the combined treatment, as judged by the delay of appearance and size of the subcutaneous tumors at the site of inoculation. Nevertheless, mortality rate was not always in correlation with the rate of local tumor evolution: some of the treated splenectomized mice died earlier than expected, with relatively small local tumors, due to enhanced metastasis. The results indicate that elements in the spleen of C57BL mice decrease the therapeutic efficiency of the drugs tested. It can be deduced that splenectomy must not be considered to increase the risk of a tumor-bearing host in all cases. On the contrary, it may improve the efficiency of cancer treatment in certain tumor-host systems.
There is a well documented risk of late infection following both splenectomy and bone marrow transplantation. In asplenic patients, the phagocytic and antibody producing roles of the spleen are lost and there is a lifelong susceptibility to infection which may be overwhelming and fatal. Patients most at risk are children, those with underlying lymphoproliferative disorders and those receiving immunosuppressive therapy. Although it is hard to prove benefit from preventative strategies, patients are likely to benefit from prophylactic antibiotic therapy and from immunisation with pneumococcal, Haemophilus influenzae-B and meningococcal vaccine given prior to splenectomy. Following an allogeneic bone marrow transplant (BMT), recovery of immune function takes up to a year. During this time, patients are at high risk from cytomegalovirus (CMV) and varicella zoster virus (VZV) infections and also from pneumocystis pneumonia. Prophylactic medications are used to good effect. The major threat of late infection occurs in patients with chronic graft versus host disease (cGVHD)--there is increased susceptibility to bacterial, fungal and viral infections. Many patients without cGVHD recover immune function fully and many develop antibodies to specific recall antigens. This does not occur in all patients and although there is a low risk of infection with organisms against which vaccines are available. If it is not possible to measure specific antibody titres and consequently offer selective re-immunisation, then a universal vaccination strategy should be in force. Response to vaccines is likely to be poor before one year post BMT. For autologous transplant recipients, immune recovery is probably complete and routine re-immunisation is not likely to offer much benefit. For both asplenic and bone marrow transplant patients, education of patient and physician is important.
BACKGROUND: The previously reported cases of giant cell hepatitis with autoimmune hemolytic anemia were improved by prednisone plus azathioprine. CASE REPORT: A 14-month-old boy suffered from giant cell hepatitis with auto-immune hemolytic anemia and positive direct Coombs test. Prednisone and azathioprine administration improved the liver disease but failed to control hemolysis so that repeated blood transfusions were necessary. Persistance of severe degree of hemolysis required splenectomy that was promptly and definitively effective. Azathioprine and prednisone were pursued for a total duration of five years. Twelve years after the onset of the disease, the child is well without any treatment. CONCLUSION: This is the first reported case of such an association in which poorly controlled auto-immune hemolytic anemia benefited from splenectomy.
BACKGROUND: The current study was undertaken to define the learning curve for laparoscopic splenectomy (LS) in patients with immune thrombocytopenic purpura (ITP). METHODS: The data of 50 patients who underwent LS for ITP between March 1996 and February 2003 were reviewed. Patients were divided into sequential groups of 10. Operative time, estimated blood loss, conversion to open procedure, length of stay (LOS), time to oral intake, complications, and mortality rates were analyzed. RESULTS: The mean OR time in the 3rd, 4th, and 5th groups of 10 were significantly shorter than the 1st and 2nd groups of 10. There were no significant differences in estimated blood loss, LOS, or time to oral intake between the groups. Three conversions to open splenectomy occurred; one each in the 2nd, 3rd, and 4th groups of 10. Complications were evenly distributed between groups. There were no deaths. CONCLUSION: The learning curve for LS in patients with ITP is a minimum of 20 cases.
Multilobular biliary cirrhosis and portal hypertension are frequent complications of cystic fibrosis liver disease, leading to esophageal varices and splenomegaly. Therapy is focused on variceal bleeding control; however, reduction of spleen volume is also important to restore gastric volume and resolve invalidating abdominal discomfort. We report long-term follow up (median duration, 5.5 years; range, 14 months-21.5 years) of 6 patients with cystic fibrosis (4 men, 2 women; median age, 14 years; range, 8-18 years) who underwent splenectomy with a splenorenal shunt operation. Three patients received elective surgery for massive splenomegaly with important abdominal discomfort, recurrent variceal bleeding, and hypersplenism. Three were urgently treated to control variceal bleeding after several sessions of sclerotherapy. All but 2 received antipneumococcal vaccination before surgery. Four patients had a weight gain of 10% within 3 months of surgery, and 3 developed spontaneous puberty. Lung function remained stable, and there was an overall reduction of respiratory tract infections. The youngest patient, however, died of overwhelming septicemia during treatment with steroids. Although total splenectomy has important risks, in well-selected cases, it can have benefits. Immuno- and chemoprophylaxis, combined with patient awareness of supplementary risk of infections is indispensable to minimize septic complications.
We identified 33 Malawians who had undergone total splenectomy for traumatic injury. We reviewed these and 33 controls by clinical and parasitological examination monthly for 1 year. Splenectomized patients (S) were 2.5 times as likely as controls (C) to complain about febrile symptoms during the month preceding a visit (P < 0.0001). They were nearly twice as likely as controls to have Plasmodium falciparum parasitaemia (S: 176/283 person visits; C: 86/262; P < 0.0001). Parasitaemia was more likely to be associated with febrile symptoms in splenectomized individuals (S: 104/176, 59%; C: 24/86, 28%; P < 0.0001). There were three deaths (two non-malarial, one unexplained) among splenectomized subjects and none in the control group. Parasite densities reached significantly higher levels, and mature parasite stages were more often seen in the peripheral blood, in asplenic individuals. In a partially immune population, asplenic individuals are at increased risk of malarial infections and illness. In a larger group without the benefit of regular review and prompt therapy, there may be an increased risk of life-threatening malaria. Splenectomy should be avoided when possible in an area with endemic transmission of P. falciparum.
Because of the incidence of overwhelming postsplenectomy sepsis that occurs after splenectomy, there is an increased incentive to try to salvage the spleen in patients with splenic injury. Even though operative time is increased by this technique, the advantage of immunologic competence is well worth the added operative time. In hemodynamically unstable patients, however, splenectomy remains the method of choice.
BACKGROUND: Although the recent development of hand-assisted laparoscopic surgery (HALS) has made the laparoscopic retraction of large spleens feasible, the laparoscopic removal of massively enlarged spleens (>1,000 g) remains a significant problem because these spleens do not fit into endoscopic bags. Consequently, in order to remove massive spleens either a large abdominal incision or morcellation of the spleen outside of an endoscopy bag is required. METHODS: Two patients, with spleens weighing 2,510 g and 1,720 g, underwent laparoscopic splenectomy using a hand port to ensure safe retraction. The massive spleen was placed into a Lahey bag that was inserted into the abdomen through the hand port site. While in the Lahey bag, the spleen was removed piecemeal through the hand port site. RESULTS: Both operations were completed laparoscopically without complications. The patients were discharged on postoperative day 2 and experienced minimal morbidity. CONCLUSIONS: The Lahey bag facilitates laparoscopic splenectomy for massive splenomegaly as even the most massive spleens will fit into a Lahey bag. A massive spleen may be removed piecemeal from the Lahey bag through the small hand port incision without risking a large abdominal incision, splenosis, or the insertion of a morcellator.
BACKGROUND: Partial splenectomy is indicated for benign tumors and cysts of the spleen, as well as, operative management of splenic trauma limited to one pole of the spleen. Despite improved technique, bleeding from the cut surface of the spleen still remains an obstacle. METHODS: We describe our technique for partial splenectomy using a new device based on coupling saline with radiofrequency energy to achieve hemostasis while dividing the splenic parenchyma. RESULTS: Use of this technique has led to blood loss of less than 50 cc, while achieving splenic preservation.
Compared with total parenteral nutrition, enteral feeding via jejunostomy reduces septic complications in patients with severe trauma. However, violation of the bowel with insertion of a jejunostomy tube may increase the risk of intra-abdominal abscess (IAA), particularly if no simultaneous gastrointestinal tract injury exists. The records of 123 patients requiring splenectomy for trauma at a level I trauma center during a 6-year period (1986 to 1992) were reviewed to examine the incidence of IAA in patients with and without simultaneous jejunostomy placement in the presence and absence of gastrointestinal tract injuries. Thirty patients had jejunostomies placed (J), and 93 did not (NoJ). There were no significant differences between the groups in age, Abdominal Trauma Index, Injury Severity Score, or transfusion requirements. The incidence of IAA was not significantly different between the J and NoJ groups in the presence or absence of gastrointestinal tract injuries. Thus, jejunostomy placement does not increase the incidence of IAA after splenectomy regardless of the presence of a gastrointestinal tract injury.
The spectrum of disease was assessed in 43 patients with Felty's syndrome. Twenty-three underwent splenectomy. Although complete remission of neutropenia occurred in only two nonoperated patients, most of the patients had no serious infections during the subsequent period of observation. Operative morbidity was minimal in the splenectomized patients. On the basis of natural history of this condition, splenectomy should probably be restricted to neutropenic patients with serious or recurrent infections, patients with severe anemia requiring transfusions, those with the rare circumstance of profound thrombocytopenia, and those with non-healing leg ulcers.
Splenectomy was performed in 20 patients with refractory cytopenias associated with systemic lupus erythematosus. An immediate and sustained increase in platelet count (greater than 150,000 cells/mm3) was achieved in 12 of 18 patients whose principal indication for operation was thrombocytopenia. Of seven patients with hemolytic anemia, which was linked with thrombocytopenia in five, six had an increase in the hematocrit value of 20 percent or more after operation. The white blood count increased to normal values in three leukopenic patients. We believe that although removal of the spleen is not uniformly successful in correcting cytopenias in patients with systemic lupus erythematosus, splenectomy should be considered in patients refractory to other modalities of treatment.