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Adult splenectomy in the lizard, Scincus scincus, did not affect humoral immune response to rat erythrocytes until 30 days post-immunization, but severely depressed subsequent antibody production.
We have previously demonstrated that administration of killed streptococcal preparation (OK432), a biological modifier, increased the number of asialo GM1-positive cells in the liver, enhanced NK activity of hepatic mononuclear cells, and reduced the number of hepatic metastases of colon 38 adenocarcinoma that were inoculated into the superior mesenteric vein of C57BL/6 strain mice. In the present study, to clarify the role of the spleen in immune surveillance of the liver, the effect of splenectomy on hepatic metastasis of colon carcinoma and on hepatic NK activity has been examined. The number of hepatic metastasis increased in the splenectomized mice, compared with that in sham-operated mice. Administration of OK432 increased the number of asialo GM1-positive cells in the liver and enhanced NK activity of hepatic mononuclear cells in both groups, but NK activity of hepatic mononuclear cells in the splenectomized mice was less than that of the sham-operated mice. An enhanced NK activity of these cells was abolished by treatment with anti-asialo-GM1 antibody plus complement in vitro. Interleukin-2 mRNA expression was increased in the spleen 2 hr after OK432 administration and persisted until 8 hr, but was scarcely noted in the liver. On the other hand, NK activity of hepatic mononuclear cells in the asialo GM1-positive cell-depleted (previous administration of antiserum against asialo GM1) mice was enhanced after OK432 administration in the sham operated and splenectomized mice, but an enhanced NK activity in these mice was only partially or not at all abolished by treatment with anti-asialo GM1 antibody plus complement in vitro, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)
A fatal case of a postsplenectomy sepsis is presented which occurred in a 5-year-old boy 11 month following splenectomy due to trauma and reimplantation of splenic tissue. The patient died 4 h after admission to the hospital. The post mortem revealed an encephalitis and a sepsis although splenic regenerates were found in the omentum pouch. Our report increases the number of cases described to date in the literature to a total of 18. Autologous reimplantation of splenic tissue does not offer complete protection against over-whelming infection.
The authors report the incidence of portal thrombosis in their experience, of patients who have been operated on for splenectomy as treatment for portal hypertension with splenomegaly and hypersplenism without a portal systemic shunt. In 161 patients studied angiographically for portal hypertension due to cirrhosis, portal thrombosis was shown in 19 patients. Of these 19 patients 13 previously splenectomized. Only 6 were never operated upon.
BACKGROUND: The symptoms primarily described in Morbus Moschcowitz included thrombocytopenic purpura and hemolytic anemia. In addition it presents with a variety of clinical manifestations depending on the organs involved (i.e. neurological, renal, gastrointestinal, cardiac involvement). It is a rare disease and the pathogenesis still remains unclear. The efficacy of derived therapeutical concepts can hardly be assessed in controlled trials. CONCLUSION: Currently the main option seems to be plasma therapy. In non-responders surgical procedures (splenectomy) may be of benefit to the patient.
A 17 x 12 x 5-cm giant intrapelvic mass in a 14-year-old girl is reported. This mass developed 6 years after a splenectomy for splenic torsion. The heat-denatured 99mTc-labelled red cell scan and 99mTc-sulphur-colloid scan confirmed the specific red cell sequestration function and reticuloendothelial activity in the giant intrapelvic spleen. The size and development of the giant intrapelvic spleen are unusual. The usefulness of functional images to diagnosis the nature of the intrapelvic mass is well demonstrated.
BACKGROUND: Pancreatic resection for severe acute necrotizing pancreatitis has been associated with prohibitive mortality rates and has been hence replaced by piecemeal debridement, either by the open or the laparoscopic technique. We report the results of deliberate subtotal pancreatectomy with splenectomy for infected pancreatic necrosis. MATERIALS AND METHODS: Six-year prospective audit of patients treated by a single surgeon, with an interest in pancreatic disease, within a Low Volume Hospital (LVH) setting. Results are presented as median (IQR). RESULTS: During the study period 18 patients (9 males) with complicated severe acute pancreatitis underwent radical pancreatic resection. The median age was 61 years (range 36-69). The median time to operation after presentation was 27 days (range 2-74). Microbiological culture confirmed infection in 14 (78%) patients. Three patients (17%) died within 30 days of operation. Twelve of the 15 survivors (80%) underwent a single operative procedure. Three patients required a further laparotomy, of whom 2 required colectomy for ischemia. Median hospital and ICU stays were 43 (range 30-57) and 5 (range 4-6) days respectively. Six patients (40% of survivors) developed an infection of the left half of the chevron incision; however, all wounds were fully healed within 3 months. Long-term follow-up of survivors (n=14) revealed 8 (57%) to need at least occasional pancreatic enzyme supplementation and 5 (36%) to have diabetes mellitus. Two patients (14%) developed an incisional hernia. CONCLUSIONS: Radical resection of pancreas and spleen, combined with postoperative irrigation, was associated with comparatively low rates of morbidity and mortality for patients with infected pancreatic necrosis in a LVH setting.
Castleman's disease (CD) is a rare disorder of the lymphoid tissue in which the clinical manifestations often mimic a malignant lymphoma. Despite the absence of monoclonality of the lymphoid proliferation, the multicentric variant of the disease (MCD) is characterized by severe symptoms and poor prognosis. Etiologic, pathogenetic, and therapeutic aspects of MCD are still uncertain. We report the case of a 57-year-old patient affected by MCD complicated by severe immunohemolytic anemia. Whereas the clinical and laboratory response to steroids and chemotherapeutic agents was only partial, splenectomy induced a complete remission of hemolysis and disappearance of the constitutional symptoms and of all generalized lymphadenopathies.
Iatrogenic injury of a lumbar artery is very rare and mostly causes retroperitoneal hemorrhage. We report a case of a lumbar artery pseudoaneurysm and a concomitant arteriovenous fistula complicating laparoscopic splenectomy and provoking renal colic-like flank pain due to mass effect on the left ureter. Definitive treatment of both vascular lesions was obtained after percutaneous transcatheter embolization of several lumbar arteries. Control computed tomography scan 3 months after embolization showed almost complete resorption of the retroperitoneal hematoma.
BACKGROUND: Laparoscopic splenectomy (LS) is becoming the gold standard for the treatment of hematological disease in children. Intraoperative bleeding is the main complication and main cause of conversion during LS. We present the use of the LigaSure Vessel Sealing System for achieving a safe vascular control, compared with previous techniques. METHODS: LigaSure is an energy-based device which works by applying a precise amount of bipolar energy and pressure to the tissue, thus achieving a permanent seal. We have performed a total of 15 LS in children during 6 years, on 6 males and 9 females with a median age of 11 years (range 5-17). Seven children had hereditary spherocytosis, 4 thrombocytopenic idiopatic purpura (ITP), 3 beta talassemia, and 1 hemolytic anemia. Patients were divided into two groups according to the method of dissection: group 1 ultrasonic coagulation+endostapler (8 pts); group 2 LigaSure (7 pts). We employed a 4 trocars technique with right semilateral position. RESULTS: The groups were well-matched for age, gender, weight, indication and spleen size. Fourteen LS were completed with one conversion (7%) because of hilar bleeding due to accidental injury with endostapler. Median operative time of the series was 140 min (range 90-205), significantly shorter in the group 2 (130 min versus 155 min, P<0.05), as well as median blood loss (group 1, 180 ml versus group 2, 70 ml, P<0.05). There was no mortality, with one postoperative complication (7%) (pulmonary atelectasis). The median postoperative hospital stay was 4 days (range 2-5) without differences between groups. CONCLUSIONS: Each method of dissection seems to be safe and effective. Otherwise LigaSure results in a reduction of operating time and blood loss.
Many vital organs, including the endocrine glands, are affected by iron deposition in thalassemic (Thal.) patients. Involvement of the adrenal gland, although not uncommon, is usually not clinically evident, especially in non-stressful situations. Although the pituitary-adrenal axis (PAA) has been evaluated by several investigators, the impact of surgical stress has not yet been assessed. Do Thal. patients have an adequate adrenocorticotropic hormone (ACTH) cortisol response upon surgical insult? The PAA of 27 (8 female, 19 male) Thal. patients aged 4-15 years (mean 8.96) admitted during 1996-1997 for splenectomy was evaluated before and after surgical stress. Blood samples for measurement of ACTH and cortisol were taken 1 day before and about 2 h after the surgical insult. For comparison, 22 (9 female, 13 male) non-thalassemic (N. Thal.) patients aged 3.5-14 years (mean 7.95) admitted for elective laparotomy who had no evidence of chronic disease or malnutrition served as controls. Timing of blood sampling was similar to that of the study group. The cortisol response after surgical stress was significantly higher than baseline for both the Thal. (17.4 +/- 6.3 vs 30.81 +/- 11.49 microg/dl; P < 0.001) and N. Thal. groups (20.65 +/- 9.1 vs 36.87 +/- 11.08 microg/dl; P < 0.001). N. Thal. patients showed significant elevation of ACTH upon surgical stress (72.5 +/- 39.5 vs 129.09 +/- 67.9 pg/ml; P < 0.001), while the difference between pre- and post-stress was not statistically remarkable in Thal. patients (104.15 +/- 60.74 vs 186.8 +/- 246.24 pg/ml; P = 0.123). However, ACTH before operation in Thal. was significantly higher than that of N. Thal. patients (104.15 +/- 60.74 vs 72.5 +/- 39.5 pg/ml; P < 0.042), with no remarkable difference after surgical stress between both groups (186.8 +/- 246.24 vs 129.09 +/- 67.9; P = 0.261). The serum ferritin in 8 of 13 young Thal. patients (4-8 years old) was < 2,000 ng/ml and 2,000-3,000 in the remaining 5, while in the 14 older patients (9-15 years) it was < 2,000 in 5, 2,000-3,000 in 7, and more than 3,000 ng/ml in the oldest 2 (13 and 15 years). The PAA is usually intact and responsive in Thal. patients. However, the underlying cause of the significantly increased preoperative ACTH concentrations may be a decreased adrenal reserve, presumably related to age and iron load. For this reason, the possibility of primary partial or early adrenal insufficiency in spite of adequate but probably less than expected cortisol synthesis before and after surgical stress should be considered in every prepubertal or older Thal. patient.
BACKGROUND: The training of surgeons and residents in laparoscopic surgery has become an important issue. The purpose of this study is to determine if the training of a laparoscopic fellow affects outcomes in patients undergoing laparoscopic splenectomy (LS). METHODS: Data were obtained from a prospectively collected database of patients who underwent LS from August 1994 to November 1999. Outcomes of the last 25 cases, performed by fellows under supervision, were compared to 25 cases performed by staff surgeons prior to the introduction of fellows. RESULTS: Patient demographics, preoperative platelet count, and splenic size were similar for the two groups. Outcome measures comparing the staff and the fellows group including operative time (151 vs 178 min, p = 0.055), blood loss (214 vs 162 ml, p = 0.40), intraoperative complications (3 vs 2, p = 1.0), need for transfusion (2 vs 3, p = 1.0), conversions (1 vs 0, p = 1.0), length of hospital stay (3.3 vs 2.5 days, p = 0.13), and postoperative complications (1 vs 2, p = 1.0) were similar for the two groups. CONCLUSION: When performed by a fellow under supervision, LS has the same outcomes as when the procedure is performed by the teaching staff surgeon.
BACKGROUND: We reviewed retrospectively the records of all patients who underwent laparoscopic splenectomy (LS) at our institution for a wide range of hematological disorders. We compared our experience to those reported in the literature and analyzed various aspects of the treatment that are still under discussion and in need of confirmation, such as the treatment of malignant blood diseases, the indication in case of splenomegaly, and the adequacy of the detection of accessory spleens. METHODS: Between June 1997 and June 2001, we performed 43 LS. The patients were classified into three groups according to clinical diagnosis: idiopathic thrombocytopenic purpura (ITP) (n = 23), hemolytic anemia (HA) (n = 5), and hematological malignancy (HM) (n = 15). Statistical analyses were done to compare the three groups. RESULTS: LS was completed in 41 patients, with a conversion rate of 5%. Splenomegaly was present in 37% of all patients (73% of HM). Mean operative time was 128 min. The incidence of accessory spleens was 20%. A concomitant laparoscopic procedure was done in three cases (cholecystectomy). Postoperative complications occurred in eight patients (18%). Duration of surgery, length of hospital stay, transfusions rate, and some demographics features, such as age and spleen weight and length, were significantly different in each group. No deaths were attributed to the procedure. CONCLUSIONS: The statistical analysis of our series shows that, the laparoscopic approach reliable even in the management of malignant and nonmalignant blood diseases.
BACKGROUND: Enlarged spleens increase the technical difficulties associated with laparoscopic splenectomy (LS). The aim of this study was to analyze the impact of splenic weight on the results of LS. METHODS: We performed a prospective analysis of 20 LS for splenomegaly and 40 LS for normal spleen in terms of intraoperative and early postoperative outcome. RESULTS: Patients with splenomegaly had longer operative times and higher conversion and transfusion rates than those with normal spleens. Patients with spleens weighing < 2000 G experienced less blood loss, fewer conversions, and a shorter postoperative hospital stay than those with spleens > 2000 g. No differences-except for the longer operative time-were observed between normal-sized spleens and those weighing < 2000 G. CONCLUSIONS: LS for splenomegaly is feasible for experienced laparoscopic surgeons. For spleens weighing < 2000 G, the outcome was comparable to that of normal spleens, whereas LS for spleens >2000 g was associated with a higher conversion rate, greater blood loss, a longer hospital stay, and increased morbidity.
BACKGROUND: Intraoperative bleeding is the main complication and main cause of conversion during laparoscopic splenectomy (LS). We present the advantages of the use of the Ligasure Vessel Sealing System added to lateral approach for achieving a safe vascular control. METHODS: Ligasure is an energy-based device which works applying a precise amount of bipolar energy and pressure to the tissue, achieving a permanent seal. We have performed a total of 35 LS in a 5-year period using different approaches and methods of dissection, including the anterior approach, monopolar coagulation, clips, endostaplers, and ultrasonic shears. In the last 10 patients (4 males and 6 females, mean age 24 yr) we employed a technique with 4 trocars, right semilateral position associated with the entire dissection of the spleen and vessels sealing (lower pole vessels, main vascular pedicles, short gastric vessels) performed with Ligasure. Six had thrombocytopenic idiopatic purpura (ITP), 2 hereditary spherocytosis and one each b-thalassemia and hemolytic anemia. RESULTS: Nine LS were completed with one (10%) conversion because of hilar bleeding due to accidental injury with Ligasure. The average splenic weight was 485 g (range 265-1800), with an average diameter of 16 cm (range 12-25). In all but one patients (the converted one) the intraoperative blood loss was less than 100 mL (range 50-100 mL, average 80 mL). No blood transfusion were needed. The average operative time was 120 min (range 90-165), including 2 patients undergoing combined laparoscopic cholecystectomy. There was no mortality, with one (10%) postoperative complication (thrombosis of the spleno-portal axis), treated with a conservative approach. The average postoperative hospital stay was 3.5 days (range 3-6). CONCLUSIONS: The use of Ligasure, associated with the lateral position, results in a gain of time and safety. Furthermore, the average intraoperative bleeding of this series is very low.
Wandering spleen (WS) is a rare condition where the spleen, free from its ligaments, is allowed to move inside the abdomen predisposing the patient to life-threatening complications due to torsion of the vascular pedicle; splenic infarction, portal hypertension, bleeding and acute abdomen may occur. WS is rarely suspected at presentation since symptoms are usually not specific and definitive diagnosis is usually reached only by imaging technologies such as color flow ultrasonography and angio-spiral computer tomography. A 42-year-old woman was referred to our institute from the Emergency and Accident ward, complaining of a sudden onset of sharp abdominal pain together with nausea and vomiting. At examination a large, painful mass was present on the left middle-lower abdominal quadrant. A pelvic spleen was revealed at abdominal ultrasonography (US) and confirmed by abdominal CT. Emergency laparoscopy was carried out. The spleen was barely attached to the peritoneum of the anterior abdominal wall, covered by the greater omentum, the small bowel, and the transverse colon. Once mobilization of the spleen was concluded, the vascular pedicle appeared torted and thrombosed and laparoscopic splenectomy was performed. The patient was discharged on the 4th postoperative day with no complications. To date, only 5 cases of laparoscopic approach to WS have been reported. A review of the literature confirms that the reduction of postoperative stay, wound complications, and overall morbidity and a faster return to normal activity make laparoscopy the "gold standard" approach to the spleen as for treatment of many hematological disorders or more unusual splenic diseases.
BACKGROUND: Bleeding is the main complication and cause of conversion during laparoscopic splenectomy (LS). We present the advantages of the LigaSure vessel sealing system added to the lateral approach for achieving safe vascular control. METHODS: We performed 63 consecutive LS in a 3-year period using LigaSure in two affiliated university hospitals. We employed a right semilateral position technique with dissection of the spleen and vessel sealing using LigaSure. Forty-two patients had benign hematological disease, 19 had malignant disease, and two had splenic cysts. RESULTS: A total of 58 LS were completed with five conversions due to hilar bleeding (three cases), difficult dissection (one), and massive splenomegaly (one). In all but five patients, blood loss was less than 100 ml. No transfusions were needed. There were five postoperative complications: portal thrombosis (one case), hemoperitoneum (two), surgical wound infection (one), and pleural effusion (one). CONCLUSIONS: The use of LigaSure, and the semilateral position, results in a gain of time and safety. Furthermore, average intraoperative bleeding is very low.
BACKGROUND: Preoperative determination of the accessory spleen still is a major factor in the failure of both laparoscopic and conventional techniques. This study aimed to evaluate the practicability and efficacy of a handheld gamma probe in identifying accessory spleens at the initial intervention. METHODS: This study evaluated 17 patients undergoing laparoscopic splenectomy attributable to benign hematologic disorders. All the patients had preoperative ultrasonography, computed tomography (CT) scan, and nuclear scintigraphic examination of the abdominal cavity to assess the size of the spleen, and to determine the existence of the accessory spleen or spleens. For all the patients, a handheld gamma probe count was used intraoperatively as an adjuvant method to define the presence and location of the accessory splenic tissue. Control nuclear scintigraphic examinations of all the patients were performed 1 month after the surgical procedure. RESULTS: In two cases, intraoperatively accessory splenic tissue was detected by gamma probe, confirming the preoperative CT findings for the patients. One of these patients had three accessory spleens, although preoperative CT scan showed only two of them. However, by the help of the gamma probe, a third spleen located retroperitoneally was defined. For two patients, laparoscopic exploration and handheld gamma probe count did not identify any accessory splenic tissue, although preoperative CT scan indicated accessory spleens. For detecting accessory splenic tissue, the sensitivities of the studied techniques were 0% for ultrasonography, 75% for CT scan, 0% for preoperative nuclear scintigraphy, 75% for laparoscopic exploration, and 100% for perioperative gamma probe examination. CONCLUSION: Preoperative imaging methods for accessory spleen determination still have limited benefits because of their limited sensitivity. Thus, the handheld gamma probe technique may be an adjuvant method for laparoscopic exploration ensuring that no accessory splenic tissue is missed during the initial surgical treatment of benign hematologic disorders.