Autologous splenic transplantation for splenic trauma.

OBJECTIVE: The authors reviewed the experimental evidence, surgical technique, complications, and results of clinical trials evaluating the role of autologous splenic transplantation for splenic trauma. SUMMARY BACKGROUND DATA: Splenorrhaphy and nonoperative management of splenic injuries have now become routine aspects in the management of splenic trauma. Unfortunately, not all splenic injuries are readily amenable to conventional spleen-conserving approaches. Heterotopic splenic autotransplantation has been advocated for patients with severe grade IV and V injuries that would otherwise mandate splenectomy. For this subset of patients, splenic salvage by autotransplantation would theoretically preserve the critical role the spleen plays in the host's defense against infection. METHODS: The relevant literature relating to experimental or clinical aspects of splenic autotransplantation was identified and reviewed. Data are presented on the experimental evaluation of autogenous splenic transplantation, methods and complications of autotransplantation, choice of anatomic site and autograft size, and results of clinical trials in humans. RESULTS: The most commonly used technique of autotransplantation in humans involves implanting tissue homogenates or sections of splenic parenchyma into pouches created in the gastrocolic omentum. Most authors have observed evidence of splenic function with normalization of postsplenectomy thrombocytosis, immunoglobulin M levels, and peripheral blood smears. Some degree of immune function of transplanted grafts has been demonstrated with in vivo assays, but the full extent of immunoprotection provided by human splenic autotransplants is currently unknown. CONCLUSIONS: Multiple human and animal studies have established that splenic autotransplantation is a relatively safe and easily performed procedure that results in the return of some hematologic and immunologic parameters to baseline levels. Some aspects of reticuloendothelial function are also preserved. Whether this translates into a real reduction in the morbidity or mortality rates from overwhelming bacterial infection is unknown and requires further investigation.     

Complications arising from splenic embolization after blunt splenic trauma

Background

Nonoperative management (NOM) of splenic trauma is now the standard in stable trauma patients. Splenic artery embolization (SAE) is an increasingly used adjunct to NOM. We examined complications arising from SAE.

Methods

Patients admitted to a level I trauma center with splenic trauma over a 26-month period were identified. Management method, operative or nonoperative, was noted. SAE patients were analyzed in detail.

Results

There were 284 splenic trauma admissions. Ninety-three patients underwent operative management, and 191 received NOM. Fifteen patients (7.8%) underwent SAE. Embolization was proximal in 10, distal in 1, and combined in 4 patients. No NOM failures occurred. Major complications (27%) included splenic bleeding, splenic infarction, splenic abscess, and contrast-induced renal insufficiency. Minor complications of fever, pleural effusions, and coil migration occurred in 53% of patients. No relationship between SAE location and the presence of complications was noted.

Conclusions

SAE is an effective and safe procedure. Both major and minor complications can arise after SAE.     

Limitations of splenic angioembolization in treating blunt splenic injury

BACKGROUND: When angiography is performed in all hemodynamically normal patients with splenic injury, only 30% require embolization. This study examines the use of selective splenic angioembolization (SAE) as part of a management algorithm for adult splenic injury. METHODS: Criteria for selective SAE were added to our adult splenic injury protocol in July 1999. SAE was performed in hemodynamically stable patients if computed tomographic (CT) scan revealed injury to the hilum or vascular blush and when nonoperative patients had a gradual decrease in hematocrit. Patients were grouped by management strategy: nonoperative; operative; or SAE. Demographics, injury severity, and outcomes of the different groups were compared. Medical records, CT scans, and registry data were reviewed for all SAE cases, deaths, and treatment failures. Data are means +/- SE. p < 0.05 versus nonoperative management by analysis of variance. RESULTS: From July 1999 to August 2003, 194 adults were treated for splenic injury. Nine patients underwent SAE, six for CT findings (1 vascular blush) and three for decreasing hematocrit. Three patients failed SAE (33%), one for bleeding and two for delayed splenic infarction. Eleven patients failed nonoperative therapy (8%); splenorrhaphy was performed in three and splenectomy in eight. Operative patients were more seriously injured and had higher Injury Severity Scores and mortality; splenectomy (39 of 48) was more commonly performed than splenorrhaphy (9 of 48) in this group. CONCLUSION: Use of a splenic injury algorithm is associated with a high success rate for nonoperative management of splenic trauma. Using selective criteria, only 5% of patients were treated with SAE. SAE salvaged six patients with high-grade splenic injury or decreasing hematocrit but had a 33% failure rate. Failure of nonoperative management was most commonly caused by errors in judgment, primarily recognition of "high-risk" injury patterns on CT scan or attempting nonoperative management in anticoagulated or coagulopathic patients.     

部分性脾栓塞术后栓塞百分率的计算方法探讨

目的寻找一种客观准确地计算脾脏栓塞百分率的方法。方法分别用部分容积分析(PVA)法、临界值法计算40名患者的各层残脾组织百分率和总的栓塞百分率,并对结果进行比较。结果PVA法和临界值法计算出的各层残脾组织百分率在脾脏的两端差异有显著意义(P<0.01);在脾脏中间大部分层面,两者的计算结果无显著性差异(P>0.05);40例患者全脾脏栓塞百分率差异也无显著性意义(P>0.05)。结论两种方法均能较准确地计算出脾脏栓塞百分率,临界值法的稳定性更好。     

Spontaneous splenic rupture due to splenic metastasis of lung cancer

We report the case of a patient who underwent splenectomy for spontaneous rupture of the spleen due to splenic metastasis. Pathologic examination revealed diffuse infiltration by carcinoma. Chest X-ray revealed a right lung superior lobe tumor, related to poorly differentiated carcinoma. Total splenectomy is a good option for diagnosis and treatment of splenic metastases.     

间歇性脾动脉阻断在医源性脾损伤中的应用

目的总结间歇性脾动脉阻断联合明胶海绵压迫在医源性脾损伤保脾手术中的应用。方法回顾分析2013年1月至2015年12月徐州医学院附属医院收治的胃癌手术操作相关的Ⅰ、Ⅱ级脾损伤病例共18例,所有病例均采用间歇性脾动脉阻断联合明胶海绵压迫创面止血,脾动脉阻断时间首次为15 min,如仍有出血,再依次继续阻断10 min、5 min,然后解除阻断及压迫观察止血效果。结果14例经阻断后压迫15 min成功止血,4例经阻断压迫25 min成功止血。术后均无再次出血、腹腔脓肿、脾脏坏死等并发症,术后3周内血小板计数均500×10~9/L。结论对于工级、Ⅱ级医源性脾损伤间歇性脾动脉阻断联合明胶海绵压迫止血安全有效。     

Partial splenic decapsulation: a simplified operation for splenic pseudocyst

Splenic pseudocysts have traditionally required splenectomy because of the risks imposed by partial splenectomy or excision of the cyst lining. During the past 2 years, a 6-year-old boy and a 9-year-old girl presenting with vague upper abdominal discomfort, palpable splenomegaly, and a large unilocular sonolucent cyst within the spleen, were treated by partial splenic decapsulation with preservation of the hilar blood supply. This procedure involves mobilizing the spleen by dividing the renal, colic, and diaphragmatic attachments; decompressing the liquefied cyst contents through a thoracostomy trochar; excising the outer splenic capsule and gaining hemostasis of the splenic wall with a running interlocked silk suture; and providing external tube drainage of the left upper quadrant. During the follow-up period of 26 and 12 months, splenic size has returned to normal. Serial nuclear scan and ultrasound show a small residual crescent-shaped deformity of the functioning splenic remnant. We conclude that partial splenic decapsulation for splenic pseudocyst is simpler and safer than other preservation procedures attempted, and carries no increased risk of recurrence from leaving a portion of the pseudocyst wall.     

客观认识脾功能 合理开展脾手术

经过近半个世纪的研究,人们对脾脏的功能已有初步认识.从脾脏无用到保脾手术,以至今日的选择性保脾,我国脾脏外科取得了长足的发展,现代脾脏外科观念已被多数学者所接受.然而目前我们对脾功能的了解还是很少,脾脏外科中尚存在许多争议.不断探索和正确认识脾功能(生理及病理状态下)将有助于解决上述争议,以便针对不同情况采取最佳的治疗方式,合理开展脾手术.     

Two-stage splenic rupture

Of the 185 patients with splenic trauma, in 27 (14.6%), a two-step splenic rupture was revealed. Diagnosis of the given pathology is difficult. After the operation, 12 patients developed complications, 4 died.     

Iatrogenic splenic injury

BACKGROUND: Iatrogenic injury to the spleen is a recognised complication of abdominal surgery but the extent of the problem is often under-estimated. This may be due to failure to report splenic injury on the operation note or inaccurate recording of the indication for splenectomy. In this review article we have tried to estimate the incidence of iatrogenic splenic injury during abdominal surgery, the morbidity and mortality associated with splenic injury and the risk factors for injury to the spleen. We have also identified the common types and mechanisms of injury to the spleen and have made suggestions as to how splenic injury can be avoided and, when it occurs, how it should be managed. METHODS: A Medline literature search was performed to identify articles relating to "incidental splenectomy", "iatrogenic splenic injury", "iatrogenic splenectomy" and "splenectomy as a complication of common abdominal procedures". The relevant articles from the reference lists were also obtained. RESULTS: Up to 40% of all splenectomies are performed for iatrogenic injury. The risk of splenic injury is highest during left hemicolectomy (1-8%), open anti-reflux procedures (3-20%), left nephrectomy (4-13%) and during exposure and reconstruction of the proximal abdominal aorta and its branches (21-60%). Splenic injury results in prolonged operating time, increased blood loss and longer hospital stay. It is also associated with a two to ten-fold increase in infection rate and up to a doubling of morbidity rates. Mortality is also reported to be higher in patients undergoing splenectomy for iatrogenic injury. The risk of injury to the spleen is higher in patients who have previously undergone abdominal surgery, in the elderly and in obese patients. A transperitoneal approach significantly increases the risk of splenic injury during left nephrectomy compared with an extraperitoneal approach and the risk is even higher if the indication for surgery is malignancy. Excessive traction, injudicious use of retractors and direct trauma are the commonest mechanisms of injury. CONCLUSIONS: The incidence of iatrogenic splenic injury is underestimated because of poor documentation. Splenic injury during abdominal surgery can be reduced by achieving good exposure and adequate visualisation, avoiding undue traction and by early careful division of splenic ligaments and adhesions. When the spleen is injured splenic preservation is desirable and often feasible, but this should not be at the expense of excessive blood loss     

Primary splenic hydatidosis

BACKGROUND: A hydatid cyst is still a serious health problem in endemic areas. Invasion of the spleen is rare in hydatid disease. In the medical literature, reports about isolated splenic hydatidoses are quite rare. Also there is not a consensus about the way of treatment. METHODS: Between 1978 and 2000, in our clinic approximately 900 patients were operated on for an abdominal hydatidosis; 850 of these patients were treated for a hepatic hydatidosis and 14 patients for an isolated splenic hydatidosis. Six (42.8%) of the latter patients were male and 8 (57.1%) were female. The mean age of the patients was 47.14 +/- 4.9 (range 17-72) years. Ten patients (71.4%) presented with a painful mass in the left upper quadrant of the abdomen, and the other 4 patients (28.5%) were asymptomatic and were diagnosed incidentally. RESULTS: All of the patients underwent elective splenectomy. There was no mortality, but complications occurred in 4 (28.5%) patients. The period of hospitalization ranged from 7 to 17 days with a mean of 9.8 days. 1 patient died from an acute myocardial infarction during the 2nd postoperative year, and 1 patient died as a consequence of a traffic accident during the 5th postoperative year. Nine patients, after follow-up periods of between 2 and 14 years, are living free from disease. No recurrence occurred in any of them. In the remaining 3 patients, long-term follow-up could not be maintained. CONCLUSIONS: A hydatid cyst must be included in the differential diagnosis of cystic lesions of the spleen. A splenic hydatid cyst should be treated surgically due to the high risk of a rupture, and the ideal procedure in adulthood is standard splenectomy.     

Laparoscopic splenic autotransplantation

Since 1990, we have performed splenic autotransplantation in more than 100 patients to treat splenic trauma, portal hypertension, myeloid metaplasia due to myelofibrosis, chronic lymphocytic leukemia, and Gaucher disease. The aim of this present study was to present splenic autotransplantation performed by laparoscopic means. A 33-year-old woman with severe splenic pain due to ischemia caused by multiple focal thromboses of splenic arterial branches was successfully treated by laparoscopic splenectomy and splenic tissue autotransplantation. The spleen was removed and cut in 20 fragments that were sutured to the greater omentum. This procedure was safely conducted with minor bleeding and no technical difficulties or complications. The postoperative follow-up of 12 months has been uneventful; the patient's pain disappeared on the first postoperative day. Hematologic, immunologic, tomographic, and scintigraphic examinations confirmed the functions of the splenic autotransplants. It is feasible and safe to perform splenic autotransplants by laparoscopic means.