Splenectomy associated with ligature of the left gastric vein in children with surgical schistosomiasis: analysis of the hepatic functional reserve

Splenectomy and ligature of the left gastric vein in children with hepatosplenic schistosomiasis mansoni and bleeding esophageal varices produce a decrease of the portal hepatic blood flow and increase in the hepatic arterial flow. The effects of these hemodinamic changes in the liver could, theoretically, deteriorate the hepatic functional reserve of these patients. Forty children with this pathology underwent that kind of treatment and they were followed-up, prospectively , mean follow up of 48 months, regard to their hepatic functional reserve. Before surgery, thirteen children were classified as "good risk - grade A" in the Childs criteria for assessment of the hepatic reserve and twenty seven as "moderate risk - grade B". The mean serum albumin concentration was 3.16g/dl ± 0.62g/dl. Only in one patient the serum bilirubin concentration was slightly greater than 2mg/dl. After surgery, fifteen patients were diagnosed as "good risk - A" and twenty five as "moderate risk - B". The mean serum albumin concentration was 3.25g/dl ± 0.50g/dl. Similarly one patient in the post-operative follow-up has presented with serum bilirubin concentration greater than 2mg/dl. Additionally, after surgery there was a significant improvement in the plasma prothrombin levels. These findings support the idea that there has been no deterioration of the hepatic functional reserve of these patients.

Foram submetidas 40 crianças, portadoras de esquistosomíase mansônica hepatoesplemica e sangramento de varizes esofágica, à esplenectomia e ligadura da veia gástrica esquerda. Foram acompanhadas durante 48 meses de pós-operatório, determinando-se a reserva funcional hepática durante esse período. Antes do tratamento cirúrgico, 13 crianças classificadas como grau A de Child's e 27 como grau B. A concentração média da albumina sérica era 3.16g/dl ± 0.62g/dl. Apenas em 1 paciente a concentração de bilirrubina sérica era pouco maior do que 2mg/dl. Após intervenção operatória, 15 pacientes foram diagnosticados como grau A de Child's e 25 como grau B. A concentração média de albumina sérica foi 3.25g/dl ± 0.50g/dl. Um paciente apresentava ainda na evolução pós-operatória concentração de bilirrubina sérica maior que 2mg/dl. Houve melhora significante após operação dos níveis de protrombina plásmica. Concluiu-se que não houve deteriorização da reserva funcional hepática nos pacientes operados.

Bone mineral content reduction in youth with surgical form of Schistosomiasis mansoni: factors involved in the pathogenesis

Thirty two children and adolescents from 14 to 20 years of age, suffering from hepatosplenic schistosomiasis mansoni and bleeding esophageal varicose veins, were evaluated for bone mineral density (BMD), before undergoing medical and surgical treatment. The surgical protocol was splenectomy, autoimplantation of spleen tissue into a pouch of the major omentum and ligature of the left gastric vein. Follow up of these patients ranges from one to ten years with a mean of five years. The BMD was measured at the lumbar spine (L2 - L4) through the dual energy absorptionmetry X-ray (DEXA), using a LUNAR DPX-L densitometer. The degree of Symmers´ fibrosis was assessed by semiautomatic hystomorphometry. In eleven patients, the serum magnesium was measured before an intravenous overload of this ion and subsequently after eight and twenty four hours. Urine was collected 24 hours before and 24 hours after the magnesium overload. Deficiency of magnesium was considered when the uptake of this ion was greater than 40%. There was a significant trend of association between the status of bone mineral content and the Symmers´ fibrosis degree (c² = 6.606 R = 0.01017). There was also a moderate agreement between the greater fibrosis densities ( > the mean percentage) and bone mineral deficits. Although the normal bone mineral content was more found among the patients with better hepatic functional reserve, the results did not reach statistical significance. There was a marked magnesium retention (>95%) in one patient who had severe osteoporosis and a slight depletion ( 5%) in another patient, who presented no bone mineral deficit. It was concluded that the patients included in this series, showed an important BMD deficit, specially among the females which has had a significant improvement after medical and surgical treatment. Bone mineral deficit was associated with the degree of Symmers´ fibrosis. Magnesium depletion was present in two out of eleven patients. It is speculated that magnesium supplementation may be warranted to forestall the progression of bone mineral deficit in patients with more impaired hepatic functional reserve.

Trinta e duas crianças e adolescentes, de 14 a 20 anos de idade, portadores de esquistossomose mansônica na forma hepatoesplênica e varizes sangrentas do esôfago, foram avaliadas para conteúdo mineral ósseo (BMD), antes de serem submetidas a tratamento clínico-cirúrgico. O protocolo cirúrgico constou de esplenectomia, ligadura da veia gástrica esquerda e autoimplante de tecido esplênico em bolsa no omento maior. O seguimento pós-operatório desses pacientes varia entre um e dez anos, com uma média de cinco anos. O BMD foi medido na vértebra lombar (L2-l4), através de aparelho de raio-X de dupla absorção e energia (DEXA), usando um densitômetro modelo LUNAR DPX-L. O grau de fibrose de Symmers foi avaliado por histomorfometria semi-automática. Em onze pacientes, o magnésio sérico foi medido antes e subseqüentemente oito e vinte e quatro horas após infusão desse íon. A deficiência de magnésio foi considerada quando a retenção desse íon fosse maior que 40%. Houve uma tendência à associação entre o padrão do conteúdo mineral ósseo e o grau da fibrose de Symmers (c² = 6,606 R = 0,01017). Houve ainda uma moderada concordância entre o maior grau de densidade fibrótica (acima da percentagem média) e o déficit mineral ósseo. Embora o conteúdo mineral ósseo normal estivesse mais evidente entre os pacientes com melhor reserva funcional hepática, os resultados não alcançaram significação estatística. Houve uma acentuada retenção de magnésio infundido (>95%) em uma paciente que tinha osteoporose e uma retenção desse íon discretamente acima de 40% em um paciente que não apresentava déficit conteúdo mineral ósseo. Em conclusão, os pacientes incluídos nesta série mostravam um importante déficit de BMD, especialmente entre as meninas, que obtiveram melhora significativa após tratamento clínico e cirúrgico. O déficit mineral ósseo desses pacientes estava associado ao grau de fibrose de Symmers. Depleção de magnésio esteve presente em dois de onze desses pacientes. Pode-se especular que a suplementação de magnésio possa ser útil para deter a progressão do déficit do conteúdo mineral ósseo nos pacientes com reserva funcional hepática mais comprometida.