To save a child's spleen: 50 years from Toronto to ATOMAC.

Pediatric surgeons brought forth non-operative treatment for children with blunt spleen injury more than 50 years ago. At the time, this proposal was deemed reckless by many adult surgeons, and debate ensued for decades. Despite criticisms, pediatric surgeons refined the clinical pathways for children with spleen injury leading to current safe and efficient outcomes. These outcomes are defined by rare splenectomies, few blood transfusions, and short length of hospital stay. This review will address the role of the spleen through historical perceptions and scientific evidence. In addition, evolution of contemporary clinical pathways will be outlined.

Wandering spleen: a medical enigma, its natural history and rationalization.

INTRODUCTION: Wandering spleen is a rare condition in which the spleen is not located in the left upper quadrant but is found lower in the abdomen or in the pelvic region because of the laxity of the peritoneal attachments. Many patients with wandering spleen are asymptomatic, hence the condition can be discovered only by abdominal examination or at a hospital emergency department if a patient is admitted to hospital because of severe abdominal pain, vomiting or obstipation. METHODS: This article aims to provide a historical overview of wandering spleen diagnostics and surgical treatment supplemented with an analyses of articles on wandering spleen included in the PubMed database. RESULTS: One of the first clinical descriptions of a wandering spleen was written by Józef Dietl in 1854. The next years of vital importance are 1877 when A. Martin conducted the first splenectomy and in 1895 when Ludwik Rydygier carried out the first splenopexy to immobilize a wandering spleen. Since that time various techniques of splenectomy and splenopexy have been developed. CONCLUSIONS: Introducing medical technologies was a watershed in the development and treatment of wandering spleen, which is confirmed by the PubMed database. Despite the increased number of publications medical literature shows that a wandering spleen still remains a misdiagnosed condition, especially among children.

History of splenectomy.

BACKGROUND: The spleen has been considered for millennia a fascinating and mysterious organ with multiple functions. The spleen has long been an organ of interest in popular as well as medical literature. METHODS: A literature (Pubmed) and historical review about splenectomy has been performed. RESULTS: The importance of spleen and the related surgical procedure of splenectomy has been an important topic of scientific interest since the Ancient Greece culture to more modern times. CONCLUSIONS: Spleen and splenectomy have important roles in the medical literature and popular tradition. Nowadays laparoscopic splenectomy is increasingly popular and for certain indications it is considered the gold standard therapy.

The early days of splenectomy.

For centuries the function of the spleen was widely debated. Vesalius, while Professor of Anatomy in Padua in the first part of the 16th century, is reported to have removed the spleen in living animals and to have shown that this was consistent with survival. An English surgeon, Timothy Clark reported in 1663 that he had removed the spleen of a stray dog, that the animal lived in good health for a year following this, and was 'subsequently enthusiastic in its pursuit of sexual activity'.

Historical review. The light and shadow of Paul Kaznelson: his life and contribution to hematology.

Paul Kaznelson is credited with describing the first case of pure red cell aplasia. He was also known for his contribution to the discovery of the therapeutic role of splenectomy in idiopathic thrombocytopenic purpura. Most of his academic works appeared in 1910s and 1920s, when he used to work in Karl-Ferdinand University in Prague. Trail of his rather tragic postwar life is briefly added.

Splenectomy, interferon, and treatments of historical interest in hairy cell leukemia.

The evolution and "lessons learned" for therapeutic options and approaches in HCL, which subsequently evolved into the adenosine deaminase inhibitors as the treatment of choice, has been intriguing. The contributions to patient care and individual patient lives have been remarkable. Observation, splenectomy, and recombinant interferon are potential therapeutic are alternatives in select patients as initial therapy, and as therapeutic alternatives in the 10% of patients who have progressive disease after the purine nucleoside analogs.

Conservative management of splenic trauma: history and current trends.

Evolution of the present-day policy of conservative management of ruptured spleen has been hailed as one of the most notable advances in pediatric surgery. Until 1971, routine splenectomy used to be the sacrosanct treatment for splenic trauma. It was universally believed that non-operative management carried a high mortality of 90 to 100%. Sporadic reports of successful conservative treatment appeared in the early twentieth century, but regrettably, these were ignored. Likewise, experimental studies pointing to the danger of post-splenectomy sepsis were also disregarded. Dominant surgical opinion continued to practice removal of the injured spleen. In 1968, Upadhyaya and Simpson, based on a well-designed clinical analysis of 52 children made a convincing plea for conservative management. In 1971, Upadhyaya et al. presented results of a corroborative experimental study, which provided the conclusive evidence that isolated splenic tears are well tolerated and heal spontaneously by first intention. Seeing the surge of publications that followed this presentation, it becomes apparent that this study constituted the real turning point that changed the world opinion in favour of salvage of the ruptured spleen. By 1979, numerous authors had reported the safety of non-operative management in hundreds of children all over the world. Currently, the policy of routine splenectomy has been universally abandoned; and the reported salvage rate of ruptured spleen is more than 90%. This paper traces the historical perspectives in the management of injured spleen from the times of Aristotle to the present day.

[Surgery of the spleen in antiquity]. / La chirurgie splénique de l'Antiquité.

Splenic surgery, a common practice in Antiquity? Such a question will appear somewhat provocative despite an ample mention of such facts in Roman and Greek classic literature. This paper intends to explore the large border standing between myths where the spleen keeps a major place and reality which is, on this subject, far from easy to decipher. In final analysis, it seems likely that there had always existed, from the very early ages, some form of splenic cauterisation. The type of procedures reported in the texts cannot be interpreted as variant of the ritual scarifications widely practised until recently in many countries. On the other hand, the idea that physicians, at the time of Antiquity, could perform splenectomy does not seem, in spite of Ancient authors assumptions, to be considered. In fact, there is no direct testimony available on this subject in Latin or Greek medical literature. We suggest that the so-called "splenectomies" of Antiquity could have been surgical "make-believes" closely similar to the quack practices which can be yet observed in some remote countries.

Tribute to a triad: history of splenic anatomy, physiology, and surgery--part 1.

The spleen is an enigmatic organ with a peculiar anatomy and physiology. Though our understanding of this organ has improved vastly over the years, the spleen continues to produce problems for the surgeon, the hematologist, and the patient. The history of the spleen is full of fables and myths, but it is also full of realities. In the Talmud, the Midrash, and the writings of Hippocrates, Plato, Aristotle, Galen, and several other giants of the past, one can find a lot of Delphian and Byzantine ambiguities. At that time, splenectomy was the art of surgery for many splenic diseases. From antiquity to the Renaissance, efforts were made to study the structure, functions, and anatomy of the spleen. Vesalius questioned Galen; and Malpighi, the founder of microscopic anatomy, gave a sound account of the histology and the physiologic destiny of the spleen. Surgical inquiry gradually became a focal point, yet it was still not clear what purpose the spleen served. It has been within the past 50 years that the most significant advances in the knowledge of the spleen and splenic surgery have been made. The work of Campos Christo in 1962 about the segmental anatomy of the spleen helped surgeons perform a partial splenectomy, thereby avoiding complications of postsplenectomy infection. With the recent successes of laparoscopic splenectomy in selected cases, the future of splenic surgery will undoubtedly bring many more changes.