Fast-track care with intraoperative blood salvage in laparoscopic splenectomy.

Fast-track surgery is claimed to reduce medical morbidity, eliminate the hospitalization needs, and shorten the convalescence period. Intraoperative bleeding as the main complication is also the primary cause of conversion from laparoscopic to open splenectomy. Intraoperative blood salvage can reduce transfusion requirements, decrease the conversion rate to open, and promote fast-tracking in laparoscopic splenectomy (LS). From November 2007 through December 2016 we collected medical data of 115 LS patients. There were three groups: 54 patients receiving routine care (we marks them as Group RT), 33 patients with fast-track care (Group FT), and 28 receiving fast-track care receiving intraoperative splenic blood salvage and autotransfusion (Group FT + ISBS). These medical data are comprised of included three phases (pre-, intra-, and postoperative). There were significant differences (P < 0.05) between RT, FT, and FT + ISBS groups. The hemoglobin level in Group FT + ISBS was significantly higher than in Group RT and Group FT. Comparing the duration of hospital stay of 3 groups, Group RT stayed for a significantly longer time than Group FT and Group FT + ISBS, Group FT + ISBSmuch shorter than Group FT. Comparing the hospitalization expense, GroupFT + ISBS significantly expended less than Group RT and Group FT. Our study shows that laparoscopic splenectomy with fast-track care is feasible, effective, and safe for patients who require splenectomy. Fast-tracking with intraoperative blood salvage improved the fast-track laparoscopic splenectomy procedure.

An opportunity for improvement in trauma care: 8-week booster vaccination adherence among patients after trauma splenectomy.

BACKGROUND: Splenectomies are common after abdominal trauma, and measures must be taken to prevent infection, namely, the administration of available conjugate vaccinations against encapsulated organisms. While initial immunization is frequently completed prior to discharge, the Advisory Council on Immunization Practices recommends administration of an 8-week vaccination booster against S. pneumoniae, and compliance with this practice is unknown. We hypothesized that patients undergoing splenectomy for trauma would not routinely receive the recommended immunization and subsequent booster. METHODS: All trauma admissions at our center who required splenectomy secondary to trauma between 2010 and 2015 were included. Demographic and injury data, splenectomy dates, immunization documentation, subsequent boosters received, and outcomes were collected from the medical record. RESULTS: Of the 9,965 patients observed, 44 patients underwent splenectomy, with 31 patients meeting inclusion/exclusion criteria. Two patients received subsequent boosters during office or hospital visits; however, no patient received any booster within Advisory Council on Immunization Practices' recommended timeframe with median time to subsequent boosters of 22 months. Seven patients have had a subsequent admission for infection or sepsis, with one presenting with S. pneumoniae meningitis. None of the patients subsequently admitted for infection or sepsis had received boosters. CONCLUSION: While trauma patients at our institution receive recommended immunizations after splenectomy prior to discharge, they receive boosters at a suboptimal rate and beyond the advised timeframe. We speculate that this phenomenon is widespread in the American trauma population. These data suggest a need for improved patient and provider education and coordination with primary care practitioners to ensure ideal defense against infectious complications.

Performance of Dutch hospitals in the management of splenectomized patients.

BACKGROUND: After splenectomy, patients are at increased risk of sepsis with considerable mortality. This risk can be reduced by taking preventive measures, such as prescribing immunizations and antibiotic prophylaxis. Studies from various countries show that a substantial percentage of patients are not managed adequately. The aim of the present study was to investigate the quality of care in the prevention of infections after splenectomy in Dutch hospitals. The research questions were two-fold: (1) Is there an association between hospital teaching status and guideline adherent preventive measures? (2) Which factors contribute to hospital performance? METHODS: A total of 28 Dutch hospitals (30%) participated in the study. A retrospective review of medical records of 536 splenectomy patients was performed. Adherence to prevention guidelines was assessed for all patients, and analyzed according to teaching status and the presence or absence of a post-splenectomy protocol. RESULTS: (1) University hospitals in the Netherlands offered higher quality of care than other teaching and nonteaching hospitals. There were only small differences between nonuniversity teaching and nonteaching hospitals. (2) The presence of a hospital post-splenectomy protocol did not improve vaccination rates. Other aspects of practice organization, such as surgical staff size and keeping a complication registry were only weakly related to performance. CONCLUSIONS: In the Netherlands, university hospitals deliver state-of-the-art care in the prevention of infections in asplenic patients more often than nonuniversity teaching and nonteaching hospitals. The availability of a hospital protocol does not seem to contribute to guideline adherence.

Valoración de la función esplénica mediante gammagrafía dinámica y estudio de «pits» de la membrana eritrocitaria y de vacuolas submembranarias en los pacientes con traumatismo leve y grave de bazo tratados de forma conservadora o mediante esplenectomía / Evaluation of splenic function by dynamic gammagraphy, study of pitted erythrocytes and submembranous vacuoles in patients with slight and severe splenic trauma receiving conservative treatment or splenectomy

Fundamento y objetivo: Cuantificar la función esplénica de los pacientes controlados en el Servicio de Cirugía General y Digestiva del Hospital Universitari Germans Trias i Pujol (HUGTiP) desde 1985 hasta 2003 tras haber sufrido diferentes grados de lesión traumática del bazo según la clasificación de la American Association for the Surgery of Trauma (AAST) del año 1994 y relacionarla con el tratamiento recibido (no operatorio, esplenectomía total con o sin esplenosis y esplenectomía más autotrasplante), con la finalidad de detectar disfunciones esplénicas que predispongan al desarrollo de la sepsis tras la esplenectomía. Pacientes y método: Se ha realizado a 43 pacientes un estudio isotópico con gammagrafía esplénica «dinámica», estudio de «pits» de la membrana eritrocitaria (óptica de Nomarsky) y de vacuolas submembranarias (microscopia electrónica de transmisión). Resultados: El grupo de no operados presenta una función normal de fagocitosis y filtración, con una mediana de velocidad de captación esplénica de 3,46 Kcts/s2 (intervalo, 0,8-6,98). El porcentaje mediano de «pits» de membrana fue del 2% (intervalo, 0-8,8%); el número de «pits» por hematíes, de 0,03 (intervalo, 0-0,12), y el porcentaje de hematíes con 1, 2, 3 y 4 «pits», del 1,6, el 0,4, el 0 y el 0%, respectivamente. El porcentaje mediano de hematíes con vacuolas submembranarias fue el 2,55% (intervalo, 0-5,6%); el número de vacuolas por hematíe, de 0,03 (intervalo, 0-0,06), y el porcentaje de hematíes con 1, 2, 3 y 4 vacuolas, del 2, el 0,2, el 0 y el 0%, respectivamente. En el grupo operado, la velocidad mediana de captación esplénica fue de 0,08 Kcts/s2 (intervalo, 0-1,75; p < 0,0001); el porcentaje mediano de «pits» de membrana, del 38% (intervalo, 0,2-64; p < 0,0001); el número mediano de «pits» por hematíe, de 0,86 (intervalo, 0-1,8; p < 0,0001), y el porcentaje de hematíes con 1, 2, 3 y 4 «pits», del 16,39, el 7,2, el 3,59 y el 2,52%, respectivamente (p < 0,0001). La mediana del porcentaje de hematíes con vacuolas submembranarias fue del 11,2% (intervalo, 1,8-31,9; p = 0,0006); el número mediano de vacuolas por hematíe, de 0,16 (p = 0,0022), y el porcentaje de hematíes con 1, 2, 3 y 4 vacuolas, del 6,51, el 1,73, el 0,4 y el 0,2%, respectivamente (p = 0,0246; p = 0,0010; p < 0,0001, y p = 0,0002, respectivamente). Conclusiones: La función esplénica de los pacientes con antecedentes de traumatismo esplénico tratados de forma conservadora es normal, independientemente del grado de la lesión. Ello refuerza la conveniencia de aplicar de entrada esta actitud a todos los protocolos para intentar evitar la sepsis tras la esplenectomía. En los casos tratados con esplenectomía, con o sin esplenosis, la función esplénica está ausente o muy alterada, mientras que en los casos tratados con esplenectomía y autotrasplante está parcialmente conservada

Background and objective: The splenic function of patients followed by the Department of General and Digestive Surgery in the Hospital Universitari Germans Trias i Pujol (HUGTiP) from 1985 to 2003 for different degrees of splenic trauma according to the classification of the American Association for the Surgery of Trauma (AAST) 1994 was quantified and related to the treatment received (non surgical, total splenectomy with or without splenosis and splenectomy plus autotransplantation) to detect splenic dysfunction predisposing the development of postsplenectomy sepsis (PSS). Patients and method: 43 patients underwent an isotopic study with dynamic splenic gammagraphy and pitted erythrocytes (Normarsky optics) and submembranous vacuoles (transmission electron microscopy) were evaluated. Results: The non surgical group presented normal phagocytic and filtration function with the median speed of splenic enhancement being 3.46 Kcts/s2 (interval: 0.8-6.98). The percentage of pitted erythrocytes was 2% (0-8.8), the number of pits per erythrocyte was 0.03 (0-0.12) and the percentage of erythrocytes with 1,2,3 and 4 pits was 1.6%, 0.4%, 0% and 0%, respectively. The percentage of red cells with submembranous vacuoles was 2.55% (0-5.6), the number of vacuoles per red cell was 0.03 (0-0.06) and the percentage of red cells with 1,2,3 and 4 vacuoles was 2%, 0.2%, 0% and 0%, respectively. In the operated group, the splenic enhancement speed was 0.08 Kcts/s2 (0-1.75) (p < 0.0001). The percentage of pitted erythrocytes was 38% (0.2-64) (p < 0.0001), the number of pits per erythrocyte was 0.86 (0-1.8) (p < 0.0001) and the percentage of erythrocytes with 1,2,3 and 4 pits was 16.39%, 7.2%, 3.59% and 2.52%, respectively (p < 0.0001). The percentage of red cells with submembranous vacuoles was 11.2% (1.8-31.9) (p = 0.0006); the number of vacuoles per cell was 0.16 (p = 0.0022) and the percentage of red cells with 1,2,3 and 4 vacuoles was 6.51%, 1.73%, 0.4% and 0.2%, respectively (p = 0.0246, 0.0010, < 0.0001 and 0.0002, respectively). Conclusions: Splenic function of patients with a history of splenic trauma receiving conservative treatment is normal, independently of the degree of the lesion, thereby reinforcing the use of this therapeutic approach to avoid the development of postsplenectomy sepsis. In the patients treated with splenectomy, with or without splenosis, splenic function was absent or very altered being partially conserved in cases treated with splenectomy plus autotransplantation

Laparoscopic splenectomy at Middlemore Hospital, New Zealand: a safe procedure with heterogeneous indications.

AIM: To perform an audit on a decade of laparoscopic splenectomy (LS) at Middlemore Hospital. METHODS: Electronic case records of patients who had undergone LS from 1996 to 2005 were reviewed. Data were collected on demographics, operative time, hospital stay, complication rates, conversion rates, and haematological response rates. RESULTS: Forty-two patients (14 male, 28 female) were analysed. Mean age was 53 years (16-91 years), and the mean follow-up was 22 months. The indication for surgery was idiopathic thrombocytopaenic purpura [ITP] (47.6%), haematological malignancy [HM] (40.5%), haemolytic anaemia [HA] (9.5%), and Evan's syndrome (2.4%). Median operating time was 112.0 (60-188) minutes, and median hospital stay was 5 (3-11) days, with a significant increase in the length of hospital stay for those converted. Four operations (9.5%) were converted to open surgery and there was a 26.2% morbidity rate and 0% mortality rate. Haematological response rates were as follows: ITP-complete in 70.0%, partial in 25.0% and none in 5.0%; HA-complete in 75.0%, none in 25%; and HM-desirable response in 88.2%. CONCLUSIONS: In Middlemore Hospital, LS can be performed safely. The haematological responses to surgery compare favourably with meta-analyses of LS, as well as with responses seen in open surgery.

[Laparoscopic splenectomy in congenital hemolytic anemia in children]. / Laparoskopicheskaia splenéktomiia pri vrozhdennoi gemoliticheskoi anemii u detei.

Experience of 48 laparoscopic splenectomies in children aged from 3 to 14 years with congenital hemolytic anemia is analyzed. The main stages of laparoscopic splenectomy were the following: isolation of the inferior pole of the spleen, transection of the gastro-splenic ligament, transection of the splenic vascular trunk (with endostapler or intracorporeal ligature), dissection of the splenic ligaments, removal of the organ (with endoscopic sac or morcellator). One-stage cholecystectomy for cholelithiasis was performed in 11 patients. Time of surgery was 110-115 minutes, on the average. One-stage cholecystectomy prolonged surgery by 30-40 minutes. There were no intraoperative and postoperative complications. Conversion to open surgery was necessary in 2 cases because of endostapler failure. Patients were discharged on the 5-8th day after surgery. Physical activity restored completely 10-14 days after surgery. There were no lethal outcomes. Excellent cosmetic results were achieved in all the patients. Laparoscopic splenectomy in congenital hemolytic anemia is safe, sparing and effective endoscopic surgery in childhood.

Esplenectomía: Análisis de Casos, una Revisión Clínico-Quirúrgica / Splenectomy: Analysis of Cases, a Clinical Surgical Review

Se realizó un análisos retrospectivo de 112 pacientes, a quienes se les había practicado esplenectomía por diferentes causas en el Hospital Universitario Ramón González Valencia durante 19 años, comprendidos entre enero de 1974 y diciembre de 1993. Se encontró que el 61.60 por ciento fueron esplenectomizados por indicaciones no traumáticas y el 38.39 por ciento por traumas, resultado no esperado por la característica del hospital donde se realizó el estudio, ya que se atiende en su gran mayoría casos de traumatismo de toda el área metropolitana y de su área de influencia. En las esplenectomías de indicación no traumática, el 58.9 por ciento fueron por indicaciones hematológicas, estando estas distribuidas así: 23.8 por ciento por esferocitosis hereditaria; 11.9 por ciento por púrpura trombocitopénica autoinmune; 3.8 por ciento por anemia hemolítica autoinmune, las otras fueron por talasemia menor, paludismo crónico, Kala-Azar, enfermedad de Hodgkin, mielofibrosis y anemia hemolítica por deficiencia de piruvato kinasa. El sexo femenino predominó en los casos de Púrpura trombocitopénica autoinmune y de anemia hemollítica autoinmune, sin haber una diferencia significativa en los casos de Esferocitosis hereditaria. En términos generales no se encontró una diferencia importante del sexo en los casos de esplenectomías practicadas por indicaciones no tramáticas. El tipo de incisión más utilizada para el abordaje de las esplenectomías fue la mediana en el 86.3 por ciento de los casos totales, siendo el 100 por ciento en las indicaciones traumáticas, por la necesidad que tiene el cirujano de explorar la cavidad abdominal en estos pacientes. No se encontró una relación directa entre el tipo de incisión empleada con las complicaciones anotadas, que fueron básicamente las infecciones 10.7 por ciento y las hemorragias 3.5 por ciento, siendo la primera más frecuentemente en las indicaciones no traumáticas. El seguimiento de los pacientes para establecer procesos infecciosos y estados inmunológicos a largo plazo no se pudo realizar debido a la pérdida de la gran mayoría de ellos

Avaliaçäo da regeneraçäo hepática após esplenectomias total e parcial; estudo experimental em ratos / Informations concerning hepatic regeneration after large splenoctomy; experimental study in rats

A presente investigaçäo foi feita com intuito de se avaliar a influência da ressecçäo parcial do baço sobre regeneraçäo hepática. O estudo foi realizado com ratos da raça Wistar, que foram divididos em quatro grupos a saber: Grupo A - (sham) ratos submetidos à laparotomia e à suave manipulaçäo do fígado e do baço. Grupo B - (controle) ratos submetidos à ressecçäo de 68 por cento do parênquima hepático. Grupo C - ratos submetidos à ressecçäo de 68 por cento do parênquima hepático e à esplenectomia. Grupo D - ratos submetidos à ressecçäo de 68 por cento do parênquema hepático e à hemiesplenectomia. Todos os animais foram sacrificados após 72 horas de observaçäo. O critério utilizado para avaliar a regeneraçäo hepática foi a contagem do número de mitoses, em 20 campos de médio aumento, com objetiva de 25 vezes, ocorridas nos hepatócitos e nas células de Kupffer, durante o primeiro ciclo do processo de regeneraçäo. Os resultados demonstraram aumento do número de mitoses no grupo C e diminuiçäo de mitoses no grupo D (p<0,01). Concluímos, após análise dos grupos do nosso experimento, que a esplenectomia intensifica a regeneraçäo hepática e que apenas a metade do parênquima esplênico é capaz de desencadear um efeito inibidor deste fenômeno no rato

Antibioticoprofilaxia e cuidados especiais em pacientes esplenectomizados / Antibioticprophylaxis and special care for the splenectomized patient

As consequencias da esplenectomia sobre o sistema imunologico e o potencial aumento no risco de infeccoes severas sao avaliadas nesta revisao critica da literatura. Diferentes metodos tem sido apresentados visando reduzir a incidencia destas infeccoes em pacientes esplenectomizados. A eficacia destes metodos e aqui discutida

Actividad funcional postesplenectomía: valor de la esplenosis espontánea o inducida-autotrasplante / Postsplenectomy functional activity: value of spontaneous plenosis or autotransplantation induced

Se presenta la experiencia de 9 pacientes esplenectomizados y en los que se les practicó autotrasplante y de 29 pacientes también esplenectomizados en que no se les efectuó autotrasplante. Se concluye que la existencia de una actividad esplénica recidival, espontánea o inducida -autotrasplante-, aunque tiende a restablecer algunos de los parámetros del funcionalismo esplénico, no implica la existencia de diferencias significativas en los mismos, con respecto a los pacientes que carecen de esta actividad o ésta es mínima

Manejo do trauma esplênico / The management of splenic trauma

De setembro de 1979 a fevereiro de 1991, 58 pacientes requerendo esplenectomia, esplenorrafia, hemiesplenectomia ou autotransplante foram tratados em duas instituiçöes gerais. Foi realizado um estudo descritivo transversal com o objetivo de revisar a esperiência dos autores a luz da literatura. Foram coletados dados referentes a faixa etária, sexo, mecanismo do trauma, grau do trauma, cirurgia realizada, traumas associados, complicaçöes pós-operatórias, tempo de internaçäo e mortalidade. A média de idade foi de 30,5 anos e 81% eram do sexo masculino. O mecanismo do trauma foi fechado em 91,4% dos pacientes, sobressaindo-se o acidente por moto ou veículo (AMV). A esplenectomia foi o tratamento principal em 91,4% dos pacientes. Houve trauma esplênico isolado em 60,3%. As complicaçöes mais frequentes foram de origem pulmonar em 13,7%. O tempo de internaçäo diferiu significativamente entre o trauma esplênico isolado e associado (p < 0,01). A mortalidade foi de 1,7%. Concluiu-se que a lesäo esplênica ocorreu principalmente através de trauma fechado. O procedimento cirúrgico depende diretamente do tipo de trauma. O tempo de permanência hospitalar, bem como a mortalidade, estäo associados a lesöes de outros orgäos

Doença de Gaucher: achados ultra-sonográficos / Gaucher disease: sonographic findings

Foram avaliados, ultra-sonograficamente, 9 pacientes, sendo 8 do sexo feminino e um do sexo masculino, cujas idades variaram de 2 a 45 anos, sendo 3 pacientes esplenectomizados. Os achados evidenciaram hepatoesplenomegalia em todos os casos. Em alguns casos, foi evidenciado aumento da ecogenicidade hepática. Um caso evideciou múltiplas lesöes hipoecóicas com anel hiperecogênico no baço. As alteraçöes esplênicas no Gaucher podem sugerir a doença. É importante conhecer os aspectos ultra-sonográficos para que ela seja considerada no diagnóstico diferencial das hepatoesplenomegalias e, particularmente, das lesöes focais esplênicas

[Regeneration of splenic tissue after splenectomy]. / Regeneratsiia selezenochnoi tkani posle splenektomii.

From analysis of experience in 284 splenectomies undertaken for various indications, in cases with accessory spleens and the formation of splenoids, and the results of heterotopic autotransplantation of splenic tissue, the authors concluded that the latter possesses high regenerative properties. The possibility of hematogenous spreading of pulp cells with subsequent formation of accessory spleens cannot be excluded, in view of which scrupulous care is needed in relation to operative techniques in performing splenectomy for hematological indications.

[Autotransplantation of splenic tissue after splenectomy]. / Autotransplantatsiia selezenochnoi tkani posle splenektomii.

The authors have performed heterotopic autotransplantation of the spleen tissue into the greater omentum pocket as a suspension or tissue sections in 14 patients with emergency splenectomies. The method of autotransplantation is described. No complications resulting from autotransplantation were noted.