Long-term haematological response and maintained immunological function after laparoscopic subtotal splenectomy in patients with hereditary spherocytosis.

INTRODUCTION: Subtotal or total splenectomy are recommended in severe and should be considered in intermediate forms of hereditary spherocytosis (HS). Data on laparoscopic subtotal splenectomy (LSTS) in HS patients are sparse. METHODS: Thirty three patients with HS (median age 10.7 years (yrs), range 1.8-15.5) underwent LSTS. Baseline and follow-up investigation included haematological parameters, microscopic analysis of pitted erythrocytes (pitE), and B-cell subpopulations assessed by flow cytometry. Results were compared to those of non-splenectomised HS patients, HS patients after total splenectomy (TS), and healthy individuals. RESULTS: After LSTS, haemoglobin levels were normalised in all patients. During median long-term follow-up of 3.9 yrs (range 1.1-14.9), only four patients presented mild anaemia. Despite re-growing of the remnant spleen none of the patients required a second surgical intervention. As compared to TS, PitE in LSTS patients were significantly lower and indicated normal to only moderately decreased spleen function. Relative but not absolute IgM memory B-cell counts were reduced in both LSTS and TS patients. CONCLUSIONS: LSTS is effective for the treatment of patients with HS. A small remnant spleen is sufficient to provide adequate phagocytic function and to induce a pool of IgM memory B-cells.

In situ subtotal spleen resection combined with selective pericardial devascularization for the treatment of portal hypertension.

BACKGROUND: Hypersplenism and esophageal varices bleeding are the major complications of portal hypertension (PHT). In recent years, increasing attention has been given to spleen preservation operations. The mode and long-term effects of subtotal splenectomy and selective pericardial devascularization for PHT remain controversial. AIM: To investigate the clinical efficacy and safety of subtotal splenectomy combined with selective pericardial devascularization for the treatment of PHT. METHODS: This was a retrospective study of 15 patients with PHT who underwent subtotal splenectomy not preserving the splenic artery or vein combined with selective pericardial devascularization in the Department of Hepatobiliary Surgery, Qilu Hospital of Shandong University from February 2011 to April 2022. Fifteen propensity score-matched patients with PHT who underwent total splenectomy at the same time served as the control group. The patients were followed for up to 11 years after surgery. We compared the postoperative platelet levels, perioperative splenic vein thrombosis, and serum immunoglobulin levels between the two groups. Abdominal enhanced computed tomography was used to evaluate the blood supply and function of the residual spleen. The operation time, intraoperative blood loss, evacuation time, and hospital stay were compared between the two groups. RESULTS: The postoperative platelet level of patients in the subtotal splenectomy group was significantly lower than that in the total splenectomy group (P < 0.05), and the postoperative portal system thrombosis rate in the subtotal splenectomy group was also much lower than that in the total splenectomy group. The levels of serum immunoglobulins (IgG, IgA, and IgM) showed no significant differences after surgery compared with before surgery in the subtotal splenectomy group (P > 0.05), but serum immunoglobulin IgG and IgM levels decreased dramatically after total splenectomy (P < 0.05). The operation time in the subtotal splenectomy group was longer than that in the total splenectomy group (P < 0.05), but there were no significant differences in the amount of intraoperative blood loss, evacuation time, or hospital stay between the two groups. CONCLUSION: Subtotal splenectomy not preserving the splenic artery or vein combined with selective pericardial devascularization is a safe and effective surgical treatment for patients with PHT, not only correcting hypersplenism but also preserving splenic function, especially immunological function.

Successful Simultaneous Subtotal Splenectomy During Left Lobe Auxiliary Liver Transplantation for Portal Inflow Modulation and Severe Hypersplenism Correction: A Case Report.

Adult-to-adult living donor liver transplantation with small partial liver grafts often requires intraoperative portal inflow modulation to prevent portal hyperperfusion and subsequent small-for-size syndrome (SFSS). However, there are concerns about the specific morbidity of these modulation techniques. This study aims to lower post-perfusion portal venous pressure and correct severe hypersplenism in a patient with end-stage liver cirrhosis by simultaneous subtotal splenectomy during auxiliary partial orthotopic liver transplantation (APOLT). A 29-year-old man was diagnosed with cryptogenic cirrhosis and severe portal hypertension suffered recurrent acute variceal bleeding, severe thrombocytopenia, and massive ascites before admission to our hospital. After the recipient's left liver was resected, we performed APOLT using his 51-year-old father's left lobe graft with a graft-to-recipient weight ratio of 0.55%. Intraoperatively, simultaneous subtotal splenectomy was performed to lower graft post-perfusion portal vein pressure below 15 mmHg and correct severe hypersplenism-related pancytopenia. The recipient's postoperative hospital course was uneventful with no occurrence of SFSS and procedure-related complications. Platelet and leukocyte counts remained in the normal ranges postoperatively. The living donor was discharged 6 days after the operation and recovered well-with no complications. After a follow-up period of 35.3 months, both the recipient and donor live with good liver function and overall condition. This is the first case report of simultaneous subtotal splenectomy during APOLT using small-for-size living-donated left liver lobes, which is demonstrated to be a viable procedure for modulating portal inflow and correcting severe hypersplenism in selected adult patients with end-stage liver cirrhosis. APOLT using a small-for-size liver graft may be a safe and feasible treatment option for selected adult patients with end-stage liver cirrhosis.

Partial splenectomy: Who, when and how. A systematic review of the 2130 published cases.

BACKGROUND/PURPOSE: In order to avoid consequences of total splenectomy (including severe postsplenectomy sepsis), partial splenectomy (PS) is increasingly reported. Without guidelines and indications concerning a rarely-indicated procedure, a review of literature should be an asset. METHODS: A systematic review of all PSs from 1960 to December 2017 was performed, with special focus on surgical indications, sites of resection, approaches and techniques of vascular dissection and parenchymal section/hemostasis of the spleen, perioperative morbidity/mortality, including complications compelling to perform total splenectomy. RESULTS: Among 2130 PSs, indications for resection were hematological disease in 1013 cases and nonhematological conditions in 1078, including various tumors in 142 and trauma in 184. Parenchymal transection was performed using several techniques through the years, most frequently after having induced partial ischemia by splenic hilum vascular dissection/ligation. 371 laparoscopic/robotic PSs were reported. Rescue total splenectomy was required in 75 patients. CONCLUSIONS: Although good results are probably overestimated by such a retrospective review, PS should be considered as a procedure associated with a low morbidity/mortality. Nevertheless, severe complications are also reported, and the need of total splenectomy should not to be minimized. Laparoscopic/robotic procedures are increasingly performed, with good results and rare conversions. TYPE OF STUDY: Systematic review. LEVEL OF EVIDENCE: IV.

Results after laparoscopic partial splenectomy for children with hereditary spherocytosis: Are outcomes influenced by genetic mutation?

BACKGROUND: Laparoscopic partial splenectomy (LPS) theoretically maintains long-term splenic immune function for children with hereditary spherocytosis (HS). Our goal was to review our results after LPS and to determine if specific genetic mutations influence outcome. METHODS: All children with HS undergoing LPS between 2005 and 2016 were reviewed. RESULTS: Thirty-one children underwent LPS (16 male) at a median age of 9 (range 2-18) years. All experienced an increase in hemoglobin and decrease in reticulocyte count early after LPS and at last follow-up. Twenty-two were sent for genetic analysis. Mutations in α-spectrin, ß-spectrin, and Ankyrin were identified in 6, 5, and 11 patients, respectively. Gene mutation was not correlated with complications, perioperative transfusion, length of hospital stay, or median hemoglobin, platelet, or reticulocyte counts. Three children required completion splenectomy at 10.9, 6.9, and 3.2years post-LPS, each with a different gene mutation. CONCLUSIONS: LPS is effective in reversing anemia and reducing reticulocytosis. So far less than 10% have required completion splenectomy, and those children did benefit from delaying the risks of asplenia. In this preliminary analysis, genetic mutation did not influence outcome after LPS. A larger multicenter study is necessary to further investigate potential correlations with specific genetic mutations. TYPE OF STUDY: Prognosis Study. LEVEL OF EVIDENCE: IV.

A long-term follow-up study of subtotal splenectomy in children with hereditary spherocytosis.

BACKGROUND: Hereditary spherocytosis (HS) is a heterogeneous hemolytic anemia treated with splenectomy in patients suffering from severe or moderate disease. Total splenectomy, however, renders patients vulnerable to overwhelming postsplenectomy infection despite preventive measures. Although subtotal splenectomy has been advocated as an alternative to total splenectomy, long-term follow-up data are scarce. We investigated how often hematologic recurrences requiring secondary total splenectomy occurred. PROCEDURE: With a follow-up of at least 5 years, we analyzed the data of 12 patients, aged 11 years maximum (median 6.5 years), who had undergone intended subtotal splenectomy, and 9 patients (median age 11.9 years), who had undergone total splenectomy. We compared their hematologic results and searched for factors associated with secondary spleen surgery. RESULTS: Hemolysis was reduced after subtotal splenectomy and absent after total splenectomy. Subtotal splenectomy was not successful in three children because no functional splenic remnant remained after 6 months (one conversion at surgery; one necrosis of splenic remnant; one early secondary splenectomy). Four children required secondary splenectomy after a median of 5 years for hematologic recurrence. In the remaining five patients, a functional splenic remnant was present for at least 5.5 years. The median time to secondary total splenectomy after intended subtotal splenectomy was 5.2 years. In all patients requiring secondary total splenectomy, increased reticulocyte levels within 2 years indicated hematologic recurrence. CONCLUSIONS: Subtotal splenectomy can be an alternative for total splenectomy in young patients with HS. It allows for hematologic improvement and may preserve splenic immune function for as many as 5 years.

Analysis of the phagocytic function and spleen regeneration after subtotal splenectomy and splenic autotransplantation in senile rats

Objective. Compare the fagocitary function and the splenic regeneration of senile rats submitted to subtotal splenectomy or total splenectomy followed by splenic autotransplantation. Methods. Thirty Wistar rats have been ramdomly distributed into two groups with fifiteen animals each. One group named subtotal splenectomy (SS) have been submitted to a subtotal splenectomy surgery and the other group, autoimplant (AT) have been submitted to total splenectomy followed by autotransplantation. The animals from SS group have been redistributed again into three subgroups (n = 5) SS-1, SS-2 and SS-3 and submitted to reoperation and euthanasia on the 15th, 30th and 60th days respectively. In reoperation, the remaining spleen from SE group and the autotransplantation fragments from the AT animals group have been removed and histologically analised observing and classifying the degree of spleen regeneration into absent (0), discrete (1), moderate (2) and intense (3) and also counting the carbon colloidal marked macrophages. Results. All the rats submited to subtotal splenectomy was sacrificed with 15, 30, and 60 days and presented na intense splenic regeneration. In another group 80 % of the rats does not presented a splenic regeneration, but with 30 and 60 days, 60% of the rats had a moderate regeneration. Regeneration level considered as important and 300 or more macrophages were found in samples of all animals from subgroups SS-1, SS-2 and SS-3. In samples of animalsfrom subgroups AT-1, AT-2 and AT-3, regeneration level from absent to moderate and less than 200 macrophages were found. Conclusion. Under the conditions that this study was performed, the splenic regeneration and the fagocitary function of senile rats after subtotal splenectomy were more evident than those of autotransplantation.

Objetivo. Comparar a função fagocitária e a regeneração esplênica de ratos senis submetidos a esplenectomia subtotal ou a esplenectomia total seguida de autoimplante esplênico. Métodos. Trinta ratos Wistar foram separados aleatoriamente em dois grupos com quinze animais em cada, a saber: grupo esplenectomia subtotal (SS) que foram submetidos a esplenectomia subtotal e o grupo do autoimplante (AT) que foram submetidos a esplenectomia total seguida de autoimplante. Os animais do grupo SS foram redistribuídos aleatoriamente em três subgrupos (n = 5) SS-1, SS-2 e SS-3 e submetidos a reoperação e eutanásia após 15, 30 e 60 dias respectivamente. Três horas antes da reoperação, todos os animais receberam uma única dose intravenosa de carbono coloidal. Os animais do grupo AT também foram redistribuídos aleatoriamente em três subgrupos com cinco animais cada, AT-1, AT-2 e AT-3 e submetidos a reoperação e eutanásia após 15, 30 e 60 dias respectivamente. Na reoperação, o baço remanescente do grupo SS e os fragmentos autoimplantandos nos animais do grupo AT foram removidos e analisados histologicamente quanto ao grau de regeneração esplênica classificada em ausente (0), discreta (1), moderada (2) intensa (3) e contagem dos macrófagos marcados com carbono coloidal. Resultados. Todos os ratos submetidos à esplenectomia subtotal sacrificados com 15, 30 e 60 dias tiveram regeneração intensa do baço. No grupo submetido à esplenectomia e autoimplante, quinze dias após o procedimento, 80% dos ratos não apresentaram regeneração do baço. Porém, com trinta dias, 60% apresentaram regeneração moderada. O mesmo resultado foi observado após sessenta dias. O nível de regeneração foi considerado importante e 300 ou mais macrófagos foram encontrados em todos os animais dos grupos SS-1, SS-2 e SS-3. No grupo correspondente a AT-1, AT-2 e AT-3, o nível de regeneração encontrado foi ausente ou moderado e sempre menos de 200 macrófagos por campo foram identificados. Conclusão. Nas condições...

Subtotal splenectomy for splenic abscess / Esplenectomia subtotal para abscesso esplênico

BACKGROUND: Splenic abscess is a rare condition but carries high mortality (up to 100 percent when untreated) and surgery has been the standard of therapy. CASE REPORT: An adult male had been undergone thrombolytic therapy for a heart attack and presented spontaneous intrasplenic hematoma which, subsequently, have turned into an abscess. Once it was a large multiloculated collection, subtotal splenectomy was the only treatment that could spare some splenic tissue. This approach was carried out successfully and the patient is presently healthy. CONCLUSION: Subtotal splenectomy is an effective option for the management of splenic abscesses.

INTRODUÇÃO: Abcesso esplênico é condição rara e trás consigo alta mortalidade (quase 100 por cento quando não tratado) e a cirurgia é a forma de tratamento de escolha. RELATO DE CASO: Homem adulto foi submetido à terapia tromboembólica como tratamento de enfarte de miocárdio e apresentou hematoma espontâneo de baço, o qual tranformou-se em abcesso. Desde que ele era multiloculado e grande, esplenectomia subtotal foi considerada o único tratamento que poderia retirar todo o tecido comprometido. Este procedimento foi realizado com sucesso e o paciente evoluiu bem sem complicações. CONCLUSÃO: Esplenectomia sub-total é uma efetiva opção para o manuseio dos abcessos esplênicos.

Operações laparoscópicas conservadoras do baço para tratar dor esplênica por isquemia / Conservative laparoscopic operations of the spleen for treatment of splenic pain due to ischemia

RACIONAL: Desde 1979 este grupo de autores executa esplenectomia conservadora através de esplenectomia sub-total e autotransplante esplênico. Estes procedimentos foram realizados em mais de 300 pacientes para tratar diferentes condições patológicas. OBJETIVO: Apresentar proposta original e inédita em seres humanos de esplenectomia subtotal, preservando apenas o pólo superior do baço por via laparoscópica e esplenectomia total complementada por implante autógeno de tecido esplênico, também pela via laparoscópica, como nova forma de tratamento da dor severa devida à isquemia do baço. MÉTODOS: Três pacientes com intensa dor no hipocôndrio esquerdo foram submetidos a grande número de exames para concluir que sua dor era provocada por isquemia de parte do baço. A dor era resistente a todos os métodos conservadores utilizados. Decidiu-se, então, pelo tratamento cirúrgico por meio da esplenectomia subtotal, preservando o pólo superior do baço suprido pelos vasos esplenogástricos em dois casos, e esplenectomia total complementada por implante no omento maior de 20 fragmentos retirados desse baço, no terceiro caso. As três operações foram realizadas por via laparoscópica. Os três doentes foram acompanhados com exames hematológicos, imunológicos, tomográficos e cintilográficos. RESULTADOS: Esses procedimentos foram conduzidos sem risco para os paciente e com sangramento mínimo. Não houve dificuldade técnica nem complicações per ou pós-operatórias. No seguimento, não foram constatadas anormalidades, comprovando-se a vitalidade e a função dos remanescentes esplênicos. A dor esplênica desapareceu desde o dia da operação e não retornou durante o período de acompanhamento. CONCLUSÃO: A esplenectomia subtotal e os auto-implantes esplênicos são factíveis por via laparoscópica, de maneira segura para os doentes e devem deve ser considerados no tratamento da dor de origem isquêmica do baço.

BACKGROUND: Since 1979 this group of authors is doing conservative splenic surgical procedures by mean of subtotal splenectomy and splenic autotransplantation. These procedures were used in over 300 patients to treat different pathological conditions. AIM: To present for the first time in the world subtotal splenectomy and splenic autotransplantation by laparoscopic means, as a new treatment for severe pain due to ischemic spleen. METHODS: Three patients presented left abdominal severe pain due to diffuse ischemia of the spleen. This symptom was resistant to all conservative treatment. Laparoscopic subtotal splenectomy, with preservation of the upper splenic pole was indicated in two cases because this was the only part of the spleen without signs of ischemia. In a third patient ischemia was diffuse and total splenectomy with 20 implants of the splenic tissue on the greater was carried out. RESULTS: These procedures were safely conducted with minor bleeding and no technical difficulties or complications. The postoperative follow-up has been uneventful and hematological, immunological, tomographic and scintigraphic exams confirmed the vitality and functionality of the splenic remnants. The pain disappeared since the first post-operative day in the three patients. CONCLUSION: It is feasible and safe to perform subtotal splenectomy and splenic autotransplants by laparoscopy and these procedures seem to be a good treatment for pain due to ischemic spleen.

Influência das operações sobre o baço na distribuição da escherichia coli no sistema mononuclear fagocitário / Influence of surgical procedures on spleen on distribution of escherichia coli in mononuclear phagocyte system

OBJETIVOS: Para se evitar o estado asplênico, muitas medidas preservadoras do baço têm sido propostas na literatura, como a esplenorrafia, a esplenectomia parcial com preservação dos vasos hilares e o auto-implante de tecido esplênico. A esplenectomia subtotal, com conservação do pólo superior do baço, nutrido apenas pelos vasos esplenogástricos é uma alternativa quando o pedículo esplênico precisa ser ligado. O objetivo deste estudo foi avaliar a influência das esplenectomias parcial, subtotal e total na distribuição da Escherichia coli no sistema mononuclear fagocitário. MÉTODO: Foram estudados 32 ratos divididos em 4 grupos: operação simulada (mantendo todo o baço), esplenectomia parcial, esplenectomia subtotal e esplenectomia total. Após cinco semanas da operação, uma alíquota de Escherichia coli marcada com 99m-tecnécio foi injetada por via venosa. Após 20 minutos, os animais foram mortos, e o baço, os pulmões e o fígado foram retirados para se verificar a distribuição das bactérias marcadas. RESULTADOS: A quantidade de Escherichia coli no tecido esplênico foi maior no grupo com o baço íntegro em comparação com os grupos esplenectomia parcial e subtotal. A distribuição da bactéria marcada pelo baço não diferiu nos grupos com esplenectomia parcial ou subtotal. A quantidade de bactérias no pulmão foi maior no grupo esplenectomia parcial do que a do grupo com esplenectomia subtotal. Após esplenectomia subtotal, a distribuição da bactéria marcada foi maior no fígado em comparação com a captação desse órgão nos demais grupos. CONCLUSÕES: O pólo superior do baço, suprido apenas pelos vasos esplenogástricos, tem capacidade de remover da circulação bactérias vivas, mostrando que, mesmo sem a vascularização pelo pedículo esplênico, há uma eficiente depuração sangüínea. A distribuição da Escherichia coli pelo sistema mononuclear fagocitário apresenta comportamentos diferentes, dependendo do tipo de esplenectomia a que o animal é submetido.

BACKGROUND: To avoid asplenic state, many approaches preserving the spleen have been proposed, such as splenorraphy, partial splenectomy with hilum vessels preservation and autotransplantation. Subtotal splenectomy preserving the upper splenic pole supplied only by splenogastric vessels, is an alternative when splenic pedicle cannot be maintained. The purpose of this study is to evaluate the influence of partial, subtotal and total splenectomy on Escherichia coli distribution in mononuclear phagocyte system. METHODS: Thirty-two rats were divided into the following 4 groups: sham operation (no splenectomy), partial splenectomy, subtotal splenectomy and total splenectomy. In the fifth week postoperative, an aliquot of Escherichia coli labelled with technetium-99m was intravenously injected. After 20 minutes, the animals were killed to remove spleen, lungs and liver, in order to verify the labelled bacteria distribution. RESULTS: The amount of Escherichia coli in the splenic tissue was greater in the group with intact spleen. The bacteria uptake by the spleen was not different from partial or subtotal splenectomy groups. The amount of bacteria in the lungs was greater in the partial splenectomy group than in the subtotal group. After subtotal splenectomy, the distribution of labelled bacteria was greater in the liver than in the others all groups. CONCLUSIONS: The upper splenic pole, supplied only by splenogastric vessels, is able to remove alive bacteria from the blood stream, showing that, even in absence of splenic pedicle, blood clearance continues to be effective. The distribution of Escherichia coli in mononuclear phagocyte system shows different behaviors, depending on the type of splenectomy.

Esplenectomia subtotal para tratamento do hipodesenvolvimento somático e sexual secundário a esplenomegalia / Subtotal splenectomy for treatment of splenomegalic growth and sexual hypodevelopments

OBJETIVO: "Nanismo esplênico" é condição clínica decorrente de processo imunitário relacionado ao baço e tem como tratamento preconizado a esplenectomia total. Seguindo uma linha de pesquisa voltada ao estudo da esplenectomia subtotal em diferentes afecções, o objetivo do presente trabalho foi avaliar o crescimento somático de pacientes portadores deste hipodesenvolvimento esplenomegálico, submetidos à esplenectomia subtotal com preservação do pólo superior esplênico irrigado apenas pelos vasos esplenogástricos. MÉTODO: Quatro pacientes masculinos (14, 14, 16 e 17 anos) com esplenomegalia (três de etiologia esquistossomática e um com cirrose auto-imune) e retardo do desenvolvimento somático e sexual foram submetidos à esplenectomia subtotal. As indicações para cirurgia foram sangramento de varizes do esôfago e pancitopenia. RESULTADOS: Em todos os casos houve retomada do crescimento e após um ano eles já se encontravam dentro da faixa de desenvolvimento somático e sexual compatível com a idade. CONCLUSÃO: O hipodesenvolvimento esplenomegálico não é decorrente da presença do baço, mas de seu crescimento; a esplenectomia subtotal é um procedimento adequado para tratar o retardo de desenvolvimento somático e sexual por esplenomegalia.

BACKGROUND: According to the literature, splenic dwarfism is an immune disease due to the splenic presence and its treatment is total splenectomy. Following a line research related to subtotal splenectomy, the aim of this study was to verify whether a conservative procedure on the spleen by preserving the upper splenic pole vascularized only by the splenogastrics vessels is an adequate procedure to treat splenic dwarfism. METHOD: Four male teenagers (14, 14, 16 and 17 years old) with splenomegaly (3 due to schistosomiasis and other due to auto-immune cirrhosis) presented growth and sexual hypodevelopment and were submited to subtotal splenectomy. Surgical indications were oesophageal and gastric variceal haemorrhages and pancytopenia. RESULTS: The four boys increased their growth reaching in one year adequate somatic and sexual development. CONCLUSION: We conclude that dwarfism is not due to the presence of the spleen, but rather due to splenomegaly and subtotal splenectomy should be considered for the treatment of splenomegalic growth and sexual hypodevelopment.

Clinical application of orthotopic spleen-preserved operati on characterized of taking advantage of collateral circulation / 中国综合临床

Objective To explore the feasibility of orthotopic spleen-p re served operation characterized of taking advantage of collateral circulation.Methods 12 cases with severe injuries of the spleen and its pedicle underwent splenic pedicel ligation and irregular subtotal splenectomy.R esults All patients had good operative and postoperative results and no postoperative complications.Ultrasonography and CT scanning showed that the remn ant of spleen had no infarct and secondary hemorrhage.Conclusion Orthotopic spleen-preserved operation using collateral circulation is useful i n treating severe traumatic rupture of spleen accomplied by destruction of sple nic pedicles.