Robotic Warshaw technique with special attention to prevent postoperative splenic infarction preserving splenic blood flow.

Prevention of postoperative splenic infarction in the robotic Warshaw technique requires rigorous evaluation of blood flow to the spleen. Shibuya and colleagues recommend checking: (1) conventional splenic color change, (2) intrasplenic artery waveform by ultrasound Doppler examination, (3) blood flow using indocyanine green, and (4) pulsatile regurgitation from the splenic artery.

Bevacizumab Does Not Influence the Efficacy of Partial Splenic Embolization in the Management of Chemotherapy-Induced Hypersplenism.

BACKGROUND: Antiangiogenics attenuate chemotherapy-related hepatotoxicity and portal hypertension. The potential impact of bevacizumab on the efficacy and safety of partial splenic embolization (PSE) in the management of chemotherapy-induced hypersplenism (CIH) has never been investigated. PATIENTS AND METHODS: We conducted a retrospective study with gastrointestinal cancer patients who have undergone PSE for the treatment of thrombocytopenia resulting from hypersplenism. Pre- and post-PSE platelet count (PC), the percentage of patients who resumed systemic therapy, and complication rates were compared between patients exposed and not exposed to bevacizumab. RESULTS: A total of 110 patients were eligible. Colorectal cancer was the predominant neoplasm (60%), and 5-fluorouracil, oxaliplatin, and bevacizumab were the most commonly provided drugs (70%, 65%, and 65% of patients, respectively). After PSE, 80% of patients recovered PC ≥ 100 × 109/L (100K). Systemic therapy was resumed in 81% of patients. Seventy-one patients exposed to bevacizumab had a median PC before PSE of 77.5K and after PSE of 167.0K, with a mean difference of 108K (P < .0001). Thirty-nine patients not exposed to bevacizumab had a median PC of pre-PSE of 73.0K and post-PSE of 187.0K, with a mean difference of 117.7K (P < .0001). Both groups had similar values of percentages of patients with PC post-PSE ≥ 100K (83% vs. 74%; P = .463), resumption of systemic therapy (85% vs. 74%; P = .213), and complication rates. A linear association between splenic infarction rate and increment in PC was found (P < .0001). CONCLUSION: PSE is a safe and effective procedure in the management of CIH, regardless of the provision of bevacizumab. Splenic infarction rate should be optimized to enhance patient outcomes.

Three-dimensional computed tomography analysis of the vascular anatomy of the splenic hilum for gastric cancer surgery.

PURPOSE: Splenic infarction may occur if the splenic branches are injured or ligated accidentally during gastrectomy. We used three-dimensional computed tomography (3D-CT) imaging to distinguish the vascular anatomy of the splenic hilum in individual patients, focusing on the splenic polar branches and the gastric branches. METHODS: The subjects of this study were 104 patients who underwent computed tomography (CT) with intravenous contrast before gastrectomy. SYNAPSE 3D® (Fujifilm Medical, Tokyo, Japan) was used to generate the 3D-CT images. The total spleen volume and the area supplied by the superior polar artery (SPA) in each patient were estimated using the "liver analysis" function. RESULTS: The SPA without the gastric branch (supplying only the spleen), the SPA with the gastric branch (supplying both the stomach and the spleen), and the posterior gastric artery (supplying only the stomach) were present in 14, 45, and 18% of the patients, respectively. The SPA supplied 12% of the total spleen volume on average; however, it supplied over 30% in two patients. CONCLUSION: We identified the vascular anatomy around the splenic hilum in over 100 patients. Based on our findings, we recommend preservation of the SPA when it is supplying a large area of the spleen. Preoperative 3D-CT analysis provides useful information to optimize safe gastrectomy.

[Lymphoma-induced antiphospholipid syndrome as a cause of splenic infarction]. / Lymphom-induziertes Antiphospholipidsyndrom als Ursache von Milzinfarkten.

HISTORY AND ADMISSION FINDINGS: A 71-year-old man presented with bilateral sialadenosis of the parotid gland, episodes of fever up to 39 °C, general malaise and weight loss of 5 kg within the last 6 weeks. At physical examination peripheral lymph nodes were not palpable. INVESTIGATIONS: Laboratory studies revealed a normal white blood cell count, anemia and thrombocytopenia. Serum C-reactive protein and lactate dehydrogenase were elevated on admission and rose further. Plasmatic coagulation was characterized by prolonged partial thromboplastin time and reduced prothrombin time. Abdominal computed tomography showed an enlarged spleen with irregular hypodense areas, indicating splenic infarctions. Enlarged lymph nodes were noted at the paraaortic region and in the splenic hilum. DIAGNOSIS: As the patient`s condition deteriorated from day to day a diagnosis had to be enforced. Splenectomy was thus performed which confirmed the CT findings of numerous infarcted areas. A marginal zone lymphoma was found within the splenic hilar lymph nodes. High titer serum antibodies against cardiolipin confirmed the diagnosis of secondary antiphospholipid syndrome (APS). TREATMENT AND COURSE: Oral anticoagulation with phenprocoumone was started; in addition, chemotherapy with rituximab, cyclophosphamide, vincristin and prednisolone (R-CHOP) was initiated. Despite clinical recovery serological markers of APS remained elevated. The lymphoma recurred only six months after chemotherapy had been completed, and the patient died two months later. CONCLUSION: Because of its potentially fatal consequences anticoagulation and treatment of the underlying disease are crucial in secondary APS.

[Spleen infarction and S hemoglobinopathies S in the high altitude lands]. / Infarto de bazo y hemoglobinopatía S en la altura.

The hemoglobin S is a consequence of the substitution of valine for glutamic acid at position 6 of beta globin chain. The problem arises when some individuals with Hb S is moved to the mountains and exposed to hypoxia. The decrease in oxygen saturation distorts the red blood cell with HbS-shaped crescent (sickle cell). Sickle cell (rigid and fragile) tends to adhere to the other red blood cells, generating a series of intravascular alterations that can lead to tissue ischemia or infarction. The spleen by type of movement and lack of lateral communications between the branches of the splenic artery was the most susceptible to sickle cell crisis. Splenic infarction at altitude corresponding to different circumstances can evolve in three stages: a) Acute (focal, uncomplicated), b) massive attack (more than 50% of parenchyma) and c) spontaneous rupture.Early diagnosis is crucial, allowing the quick and timely introduction of various measures, including adequate hydration and oxygenation continues until its evacuation to lower altitude locations. These measures would reduce the phenomenon of sickle and some patients may overcome this acute trance without major complications. The delay in diagnosis leads to action that can exacerbate tissue hypoxia and cause ischemia or infarction of various organs. A large population of black and mixed race of African descent living in the Peruvian coast, 10% and 2% respectively have hemoglobin S; Caucasian subjects with Mediterranean ancestry this hemoglobin also can carry. It is therefore essential to disseminate within the clinicians working in regions of high status and to thus prevent potentially fatal complications in patients with Hb S; is also essential to promote preventive measures for individuals with African or Mediterranean ancestry know their sickle cell status before traveling to places above 2,500 m.

Framing the research agenda for sickle cell trait: building on the current understanding of clinical events and their potential implications.

Sickle Cell Trait (HbAS), the heterozygous state for the sickle hemoglobin beta globin gene is carried by as many as 100 million individuals including up to 25% of the population in some regions of the world (World Health Organization, Provisional agenda item 4.8, EB117/34 (22 December 2005) or World Health Organization, Provisional agenda item 11.4 (24 April 2006)). Persons with HbAS have some resistance to falciparum malaria infection in early childhood (Piel FB, Patil AP, Howes RE, et al., Nat Commun 2010;1104:1-7 and Aidoo M, Terlouw DJ, Kolczak M, et al., Lancet 2002;359:1311-1312) and as a result individuals with HbAS living in malarial endemic regions of Africa have a survival advantage over individuals with HbAA. Reports from the US emphasize possible health risks for individuals with HbAS including increased incidence of renal failure and malignancy, thromboembolic disorders, splenic infarction as a high altitude complication, and exercise-related sudden death. The National Heart, Lung, and Blood Institute, National Institutes of Health convened a workshop in Bethesda, Maryland on June 3-4, 2010, Framing the Research Agenda for Sickle Cell Trait, to review the clinical manifestations of HbAS, discuss the exercise-related sudden death reports in HbAS, and examine the public health, societal, and ethical implications of policies regarding HbAS. The goal of the workshop was to identify potential research questions to address knowledge gaps.

[Viability of the spleen in rats after ligation of the splenic vessels: effects of hyperbaric oxygen therapy]. / Viabilidade do baço de ratos após a ligadura dos vasos esplênicos: efeito do tratamento com oxigênio hiperbárico.

OBJECTIVE: To investigate the effects of splenic artery and vein ligation and the influence of hyperbaric oxygen after the double vascular ligation on the viability of spleen tissue. METHODS: Sixty nine adult male Wistar rats (285-375 g) were randomly separated in three groups: group 1, four rats, sham operated, group 2, 34 rats, submitted to simultaneous splenic artery and vein ligation and group 3, 31 rats, submitted to hyperbaric oxygen during 11 days, after double vascular ligation. All animals were killed on day 12 after surgery. The spleen was removed and paraffin embedded for microscopic examination. RESULTS: In the groups submitted to vascular ligation, the spleen was normal in 8.82% of rats not treated with hyperbaric oxygen and in 45.16% of rats that received hyperbaric oxygen after vascular ligation (p=0.01). In the spleens with white infarct, the mass of preserved splenic tissue in relation to the total body mass did not differ between the groups treated or not with hyperbaric oxygen. The preserved splenic tissue had normal histology in both groups. The healing process was more accelerated in the group of rats treated with hyperbaric oxygen. CONCLUSION: Results demonstrate that exposure to hyperbaric oxygen increased the frequency of total spleen mass preservation after simultaneous ligation of the splenic artery and vein but did not alter the percentage of the spleen's viable area, however the healing process in necrotic areas was accelerated.

Viabilidade do baço de ratos após a ligadura dos vasos esplênicos: efeito do tratamento com oxigênio hiperbárico / Viability of the spleen in rats after ligation of the splenic vessels: effects of hyperbaric oxygen therapy

OBJETIVO: Verificar o efeito da ligadura dos vasos esplênicos principais no baço de ratos e a influência do tratamento com o oxigênio hiperbárico após a ligadura. MÉTODOS: Foram operados 69 ratos Wistar, machos, de 285g a 375 g. Os animais foram divididos aleatoriamente em três grupos: grupo 1: quatro ratos, simulação; grupo 2: 34 ratos, ligadura simultânea da artéria e veia esplênica; grupo 3: 31 ratos, ligadura da artéria e veia esplênica seguida de oxigenioterapia hiperbárica no pós-operatório por 11 dias, sendo mortos no 12° dia. O baço era retirado e incluído em parafina para estudo microscópico. RESULTADOS: O baço era normal em 8,82 por cento e 45,16 por cento, respectivamente, no grupo que sofreu a ligadura vascular sem ou com oxigenioterapia hiperbárica (p= 0,01). O percentual de massa viável do tecido esplênico nos baços que infartaram em relação ao percentual da massa corporal dos animais não diferiu entre os grupos 2 e 3. O aspecto histopatológico mostrou arquitetura preservada na porção não infartada nos dois grupos e neoformação conjuntivo-vascular cicatricial mais acentuada no grupo que recebeu oxigênio hiperbárico. CONCLUSÕES: O tratamento com oxigênio hiperbárico, a partir do pós-operatório imediato, após a ligadura simultânea da artéria e da veia esplênicas, reduziu significativamente a freqüência dos infartos, mas não alterou o percentual de massa viável dos baços, quando o infarto ocorreu, e acelerou o processo de cicatrização, com aumento da proliferação de fibroblastos e da neoformação vascular.

Air following splenic embolization: infection or incidental finding?

The use of splenic embolization for nonoperative management has increased. With increased use of this adjunct, a new and frequent finding has been air within the areas of infarction in patients with or without clinical signs of infection. The purpose of this study was to determine if air within areas of splenic infarction is pathologic of infection or rather an incidental finding. A retrospective review over the past 3 years of inpatients undergoing splenic embolization and having pre- and postembolization abdominal computed tomography scans were reviewed for the findings of free air as well as any clinical signs of infection. A total of 96 consecutive patients were included. Of these, 12 had evidence of infarction with air. Six of these patients had undergone distal embolization with intraparenchymal air, but no symptoms. These were successfully observed. Two patients demonstrated subcapsular air/fluid levels, which underwent drainage with splenic preservation. Cultures were negative for infection. The remaining 4 underwent splenectomy. Of these, all had large collections of air. Two of these 4 spleens were infected: 1 with alpha-hemolytic Streptococcus and one with Clostridia perfringens. The remainder was sterile. This gave an overall infection rate of 17 per cent of patients with evidence of air. This yield increased to 33 per cent if the patient had symptoms and 50 per cent in those with large amounts of air and symptoms. Overall, we feel that air following embolization is a concern, but does not constitute infection. Patients with large amounts of air and signs and symptoms of infection will have a far higher infectious rate, 50 per cent in this limited series. In these patients, evaluation for infection is indicated; that being percutaneous sampling versus splenectomy.

[The trial use of alpha-IFN in treating a case of chronic myelomonocytic leukemia with splenic infarction].

A 75-year-old man, previously diagnosed as having chronic myelomonocytic leukemia, suffered an attack of severe left hypochondralgia in July 1986. A splenic infarction was diagnosed by both ultrasound tomography and computerized tomography. The patient was treated with alpha-Interferon (600 M.U./day i.m.) for cytoreduction in order to prevent a recurrence of the splenic infarction. Twenty-one days later, the peripheral white blood cell count decreased from 44,110 microliters to 9800/microliters and the monocytoid immature cells disappeared. However, severe dementia appeared and so alpha-Interferon therapy was abandoned. In this report the beneficial effects and side effects of alpha-interferon in the treatment of chronic myelomonocytic leukemia are discussed.