Incidence and function of residual splenic tissue following splenectomy for trauma in adults

A limited study of children requiring splenectomy for trauma suggested a 59% incidence of splenosis. We attempted to confirm these results in 40 adult patients with trauma. Residual splenic tissue, from either splenosis or accessory spleens, was seen in 26% of patients who underwent splenectomy for trauma and subsequent splenic scintigraphy. There was no significant difference in serum IgM levels between control patients and splenectomy patients with or without residual splenic tissue. There was also no difference in the percentage of pitted RBCs in splenectomized patients with or without residual splenic tissue. However, both groups of splenectomized patients had significantly higher numbers of pitted RBCs than did controls. These results indicate that the incidence of residual splenic tissue, though significant, is lower than previously reported, and that natural splenosis probably results in a small splenic mass incapable of restoring total splenic function.     

Evaluation of splenectomy in total gastrectomy for gastric cancer

It has been well accepted that extensive prophylactic lymphadenectomy is certainly effective for elevating cure rate after gastric cancer surgery, however, regarding to the prophylactic splenectomy the arguments are controversial. We studied the value of splenectomy in total gastrectomy for gastric cancer by examining the late survival rates, the accuracy of intraoperative judgement of splenic hilar lymph node metastasis and postoperative changes of serum immunosuppressive factors. In curatively resected stage III cases without splenic hilar lymph node metastasis, the nonsplenectomized group showed a significant better late survival rate than the splenectomized group, 5-year survival rate being 59.9% in the former and 30.8% in the latter. In cases with splenic hilar lymph node metastases, 2 of 9 splenectomized patients survived more than 10 years. In cases of noncuratively resection, splenectomy did not enhance the survival rate. Although further clinical randomized study is needed to draw a definitive conclusion, we had better take a splenic reserve operation for the patients without splenic hilar lymph node metastasis. On the other hand, splenectomy should be performed in cases with splenic hilar lymph node metastases.     

Autotransplantation of splenic tissue after splenectomy in rats offers partial protection against intravenous pneumococcal challenge

Thirty-six splenectomized Sprague-Dawley rats with omental implants of splenic tissue were challenged with intravenous pneumococci. The mortality rate in this group was compared to 31 similarly challenged splenectomized and 28 normosplenic rats. The results showed that while rats with implanted splenic tissue had a better survival rate (p = 0.04) than splenectomized rats, their survival was poorer than that of rats with normal spleens (p = 0.02) (Fischer's exact test).     

Immunorestorative effects of reimplanted splenic tissue and splenosis

Different immune functions were analysed in detail in 41 patients who had been splenectomized after a traumatic rupture of the spleen within four years after surgical intervention. Patients were assigned to one of the following groups as judged by liver/spleen scintigraphy: (1) patients with reimplanted splenic tissue, (2) patients with splenosis, and (3) patients without splenic tissue. Leukocytosis and an increased number of total lymphocytes as well as B-cells were observed in patients of all groups. In addition, the number of circulating T-suppressor cells was significantly increased in patients with no detectable splenic tissue. In contrast, serum concentrations of immunoglobulins and complement components were in the normal range; similarly, phagocytosis-associated functions of the patients' neutrophils and monocytes were found to be unimpaired (chemiluminescence and particle uptake). However, in all groups of splenectomized patients a deficiency in specific serum opsonic activity against a strain of Escherichia coli (O:102, H:6) could be detected. We conclude that neither splenosis nor autologous reimplantation of splenic tissue restores opsonic deficiency caused by splenectomy.     

Vaccination practices among North American trauma surgeons in splenectomy for trauma

BACKGROUND: The purpose of this study was to examine trama surgeons' practice patterns regarding immunization of splenic injury patients. METHODS: Data were analyzed from surgeons responding to a survey sent to 557 adult trauma surgeons in the United States and Canada. The survey queried the timing and use of vaccinations in splenic injury patients. RESULTS: Three hundred four (54.6%) surgeons responded to the survey, with 43 no longer active. Of the 261 active surgeons, 99.2% immunize their splenectomized patients, whereas 15.7% immunize those who undergo splenorrhaphy and 8.4% immunize those managed nonoperatively. Vaccines are administered anywhere from the immediate postoperative period to as long as 6 weeks later. All but two responding surgeons provide the pneumococcal vaccine, 62.8% also advocate meningococcal vaccination, 72.4% add the Haemophilus influenzae vaccine, and 56.7% give all three. Thirteen of the responding surgeons reimplant splenic tissue, most frequently in the omentum, and in quantities varying from two slices to the entire spleen. Revaccination practices are extremely varied-ranging from nothing at all to annually-and seldom follow Centers for Disease Control and Prevention guidelines. CONCLUSION: With the exception of immunizing splenectomized patients against pneumococcal infection, little consensus exists among surgeons regarding the immunization of patients sustaining splenic injury.     

Splenic regeneration following splenectomy for traumatic rupture

Thirty-three patients previously splenectomized following traumatic rupture of the spleen were assessed using a radionuclide technique. Splenic tissue was detected by this means in 22 patients (67%). Peripheral venous blood was examined for the presence of erythrocyte surface vacuoles. Vacuolated red blood cells were detected more frequently than in the normal population. The incidence of vacuolated red blood cells was inversely related to the estimated volume of regenerated splenic tissue.     

Optimal site and amount of splenic tissue for autotransplantation.

Clinical and basic studies have documented a high susceptibility to pneumococcal infection in asplenic humans and animals. It has been suggested that autotransplantation of splenic tissue might be a method of providing host resistance when total splenectomy is necessary. However, the effect of splenic autograft has remained controversial. This study was performed to evaluate the most effective site and amount of splenic autograft using rats. Rats were divided into five groups for the purpose of determining the site of splenic autotransplantation: splenectomy, sham operation, implantation into the omental pouch, intraperitoneal implantation, and intramuscular implantation. For determining the amount for autotransplantation, the rats were divided into seven groups: splenectomy, sham operation, and implantations of 25, 50, 100, 200, or 300 mg of splenic tissue. All animals were challenged with Streptococcus pneumoniae type 6, 16 weeks after surgery. Howell-Jolly bodies appeared postsplenectomy, but disappeared in the implanted rats 16 weeks after the operation. Histologically, the implanted tissue was indistinguishable from that of a normal spleen. Pneumococcal clearance from the bloodstream and survival rate were significantly higher in rats implanted in the omental pouch as compared with splenectomized rats. Intraperitoneal and intramuscular implanted rats did not show a significant difference from the splenectomized rats. More than 50% of splenic tissue for autograft showed a significant increase in pneumococcal clearance and survival rate as compared with that of splenectomized rats. It was suggested that the most effective site of autotransplantation is the omental pouch and approximately 50% of the whole spleen would be necessary for prevention from sepsis.     

Intraportal splenic autotransplantation in rats: Feasibility and effectiveness

This experiment was designed to see whether or not normal host resistance to infection could be reestablished in splenectomized animals by intraportal autotransplantation of homogenized splenic tissue. Part I studied the feasibility of the technique. Within 1 hr of splenectomy, 16 adult Lewis rats received an intraportal injection of autogenous splenic tissue which had been passed through a 500-μm screen. Five rats died acutely from hemorrhage at the site of injection. The others tolerated the infusion well, both acutely and chronically. The animals developed only transient elevations in liver enzymes; chronic portal hypertension did not occur. Histologically, splenic tissue could be demonstrated within terminal portal venules. Part II assessed the effectiveness of intraportal splenic autotransplantation. Eight to twelve months after splenectomy, autotransplantation, or sham operation, 103 Sprague-Dawley rats were challenged with intravenous boluses of 10⁵ to 10⁸ pneumococci. Mortality was 91% for splenectomized animals, 88% for animals bearing autotransplants, and 59% for controls. Thus intraportal splenic autotransplantation is technically feasible in rats. The grafts are well tolerated by the liver, and splenic tissue is preserved in intimate contact with the blood stream. Even after 8 to 12 months, however, such autografts are not capable of providing normal protection against massive pneumococcemia.     

Splenectomy versus splenic salvage for spleens ruptured by blunt trauma

Of 339 patients treated in three Charlotte hospitals from January 1960 through March 1983 for splenic rupture caused by blunt trauma, 317 (93.5%) underwent splenectomy, and 22 (6.5%) underwent splenic salvage operations. Perioperative mortality for splenectomized patients was 7.9 per cent, and that for those who received splenic salvage operations was 22.7 per cent. Perioperative sepsis occurred in 4.4 per cent of the splenectomized patients and in 9 per cent of those whose spleens were salvaged. Perioperative deaths and sepsis in both groups were related to associated injuries, not to splenic injuries. Follow-ups from 5 months to 22.4 years (mean, 9.5 years) of the 292 splenectomized patients who survived their injuries show that 252 (86.3%) are living, 22 (7.5%) have died of causes unrelated to splenic injuries, 18 (6.1%) could not be found, and none of the patients traced has died of sepsis. One patient (0.34%) experienced an episode of sepsis i.e., a nonfatal septicemia 7 years postsplenectomy, that may be related to splenectomy. These data suggest that the importance of splenic salvage for prevention of postsplenectomy sepsis has been overemphasized and that expeditious splenectomy remains the procedure of choice for patients with ruptured spleens, especially for those with hypovolemic hypotension, anemia from hemorrhage, or multiple injuries. Data to substantiate these views will be presented.     

脾切除对肺内细菌清除和移位的影响

目的:探讨脾切除对肺内细菌清除及移位的影响,同时观察自体脾组织移植的应用效果.方法:将Wistar大鼠90只随机分为假手术组、脾切除组和半脾移植组,采用肺炎球菌悬液雾化吸入方法攻击动物,观察肺组织学病变,肺内细菌清除和移位状况.结果:脾切除组动物肺组织严重充血肿胀,炎性细胞浸润少,肺内细菌清除功能降低,细菌向肺门淋巴结移位和侵入血流加快,与假手术组比较有显著性差异(P<0.05),但半脾移植组动物能基本恢复对肺炎球菌的抵抗能力.结论:脾切除后动物肺抗菌功能降低,而自体脾组织移植是保留脾功能的有益术式.     

Serum antibody responses to pneumococcal vaccine after splenic autotransplantation

Immunization with pneumococcal capsular polysaccharide vaccines is advocated after splenectomy; however, experimental and clinical data suggest an impaired antibody response in splenectomized individuals. This study examined the value of splenic autotransplantation at various sites in augmenting the antibody response to Type III pneumococcal capsular polysaccharide in mice immunized 3 months after operation. Splenectomy resulted in impaired antibody responses compared to sham-operated mice (p less than 0.001) using an enzyme-linked immunosorbent assay. Mice with intraperitoneal splenic autotransplants, but not mice with subcutaneous or intramuscular transplants, had greater antibody responses compared to splenectomized mice (p less than 0.05). Antibody responses were elevated only in mice autotransplanted with 50% or more of the original splenic mass. Since autotransplantation of splenic tissue augments the antibody response to pneumococcal capsular polysaccharides, the combination of splenic autotransplantation and pneumococcal vaccination may confer more protection than either modality alone in individuals who must undergo splenectomy.     

Does concommitant splenectomy raise the mortality of liver transplant recipients?

Abstract Within a 17-month period, 130 orthotopic liver transplantations were performed in our hospital. Nine of these were retransplantations and were not included in our analysis. In the remaining 121 patients, splenectomy was performed in 34 patients, either synchronously with the transplant procedure (27 patients) or in the postoperative period (7 patients). Indications for splenectomy were lienalis-teal syndrome in 15 patients and hypersplenism in 15 cases. The number of rejection episodes was fairly equal in both groups (splenectomized vs. non-plenectomized, 61.7% vs. 63.9%, respectively). There was a marked difference in the frequency of infectious episodes (61.7% vs. 25.3%) that resulted in a decreased survival rate (77.5% vs. 95.4%) for splenectomized patients. Therefore, we recommend splenectomy only for very selected patients and investigate the banding of the splenic artery as an alternative.     

Splenic autotransplantation provides protection against fatal sepsis in young but not in old rats.

Splenectomy increases the risk of contracting infections with high mortality. Thus, splenic tissue should be repaired orthotopically whenever possible. If all attempts fail, splenic autotransplantation might be a suitable method for splenic salvage. The protective function of such transplants in adults has been questioned, leading to a decreased frequency of splenic autotransplantations. However, the regeneration of splenic tissue is better in the young organism than in the old, suggesting that the protection provided by regenerated splenic tissue might be more reliable in children than in adults. In addition, children are at a higher risk in the case of overwhelming postsplenectomy sepsis. The protection warranted by regenerated splenic tissue after autotransplantation at different ages was examined using a highly standardized animal model. Sham operation, splenectomy, and splenic autotransplantation were performed on adult, weanling, and newborn rats, and Streptococcus pneumoniae was applied intranasally 9 months after the operation. After pneumococcal challenge about 80% of the splenectomized animals in the different age groups died of infection, whereas only 20% of the sham operated rats died. Regenerated splenic tissue resulting from splenic autotransplantation performed on adult or weanling rats demonstrated no protective function. However, in newborn rats with transplanted splenic tissue, both survival rate and survival time were increased significantly. Determination of lymphocyte subsets in the blood did not allow the protective role of splenic transplants to be predicted. This study indicates that disappointing results of splenic autotransplantation in adult patients should not lead to false pessimism about the role of this operation in children.     

Comparison of omental splenic autotransplant to partial splenectomy. Protective effect against septic death

The possible benefit of either partial splenectomy or splenic autotransplantation as protection against post-splenectomy sepsis was investigated. Sprague-Dawley rats were challenged with intravenous Streptococcus pneumoniae and the incidence of bacteremia and mortality were recorded. Animals were divided into four groups based upon the amount of splenic tissue conserved: total splenectomy (0%), partial splenectomy (62%), splenic autotransplantation (27%), or sham celiotomy (100%). A statistically significant (P 0.05) decrease in the incidence of septic death was seen in comparing the total splenectomized animals (63%) to the autotransplant group (27%), the partial splenectomy (4%) and the control group (4%). This diminishing mortality is inversely proportional to the amount of splenic remnant in the respective groups. There was a similar, parallel relationship in the incidence of Streptococcus pneumoniae bacteremia. Thus, the greater the amount of remaining splenic tissue, the lower the incidence of bacteremia and subsequent mortality, implying the preservation of immunologic function with splenic conservation.     

Conservative management in blunt splenic trauma

We reviewed for analysis the charts of two groups of adults patients with blunt splenic injuries issued from two University Hospital Centers; the group 1 (G1) of 22 patients and the group 2 (G2) of 20 patients. The results of actually therapeutic procedures concerning blunt splenic injuries and subsequently the effectiveness of non operative treatment were evaluated. Splenectomy was performed in G1 for 11 patients, instead of 19 patients in G2 (p = 0.0003), whereas, the non surgical treatment was done in 9 patients and 1 patient, respectively (p = 0.02). The mean Splenic Injury Score (SIS) was 2,95 in G1 and 3.47 in G2 (p = 0.03). The spleen was preserved in G1 for 8 patients, instead 1 patient in G2 (p = 0.04). In G1, the non operative treatment was successfully accomplished in 66% of patients. It was obtained with lack of mortality, with a lower overall morbidity and a lower length of hospital stay than in splenectomized patients, but the latter group accounted higher values of Injury Severity Scores (p < 0.05). If proper selection criteria for non operative management are used, more than a third of patients with blunt splenic injury can be treated by splenic preservation at least as safely as splenectomized patients.     

Intra-abdominal infection following combined spleen-colon trauma

The reality of late overwhelming post-splenectomy sepsis in adults as well as children has led to more frequent attempts at splenic salvage following splenic trauma. Less attention has been paid to early septic postoperative complications in the splenectomized patient. Associated colon injury has been believed to be a relative contraindication to splenic conservation. If splenectomy enhances the chance of early postoperative infection, then associated colon injury should be an indication for splenic salvage One hundred sixty one patients who had either splenic trauma (58), colon trauma (90), or combined spleen-colon trauma (13) were studied. All patients with splenic trauma had a splenectomy. There was a significantly higher incidence of intra-abdominal sepsis requiring reoperation in the spleen-colon patients (46.7%) than in either of the other groups (spleen = 5.7%, colon = 8.9%, P less than .002 for both comparisons). It is concluded that splenectomy enhances infection in the early postoperative period. When possible, combined spleen-colon trauma should be an indication rather than a contraindication for splenic salvage.     

Unique case of intramural colonic splenosis

Splenosis is usually a sequel of splenic rupture from abdominal trauma but can be associated with elective splenectomy. Recurrence of the hematological disorder for which the patient underwent splenectomy may occur, and splenic nodules can be found anywhere in the thoracic or abdominal cavity, as well as subcutaneously. We are presenting intramural colonic splenosis, a large inoculum of the splenic tissue that has been found to have the capacity to maintain anemia and thrombocytopenia, in a child previously splenectomized because of a hematological problem.     

Spontaneous splenic rupture following infectious mononucleosis

Four cases of spontaneous splenic rupture after infectious mononucleosis (IM) have been treated at this institution since 1978. The condition is rare, occurring in 0.1-0.5 per cent of patients with proven infectious mononucleosis. Splenectomy is considered the treatment of choice for these patients. However, because recent trends in the management of traumatic splenic rupture are moving towards nonoperative treatment with selected patients, a similar approach has been considered for the patient with spontaneous splenic rupture following IM. The major reason for avoiding splenectomy is the increased incidence of sepsis in splenectomized patients. Yet, splenic rupture is accompanied by hemorrhage and the risks associated with blood transfusion for ongoing hemorrhage are of similar magnitude as those of sepsis following splenectomy. In addition, the grossly abnormal spleens seen at operation tend to include large, contained hematomas that may also be prone to rupture. Therefore, operative management still appears to be the preferred treatment for spontaneous splenic rupture following IM. Splenectomy is curative, safe, and obviates the need for transfusion, extended hospitalization, and activity restriction.     

Reimmunization and splenic autotransplantation: A long-term study of immunologic response and survival following pneumococcal challenge

Splenic autografts have phagocytic function and increase survival after experimental sepsis. The long-term effect of transplant viability, phagocytic capacity, and immunologic responsiveness were evaluated. Rats were divided into experimental groups: control, splenectomized, and splenic autotransplant rats. Approximately one-half of the rats were immunized against pneumococcus. Twelve months later, the rats were reimmunized, and the pneumococcal antibody titers were measured. The effect of operation and immunization was determined by challenging rats with intravenously administered pneumococci. Bacterial clearance from the bloodstream was measured and mortality recorded. Spleens were weighed and examined histologically. In unimmunized rats, pneumococcus was cleared from the bloodstream of control rats, whereas splenectomized and splenic autotransplant rats demonstrated a progressive increase of pneumococci in the bloodstream. However, splenic autotransplant rats grew fewer bacteria after challenge (P < 0.05). All control rats survived. Thirty-three percent of splenic autotransplant rats were alive, but significantly fewer splenectomized rats (6%) survived (P < 0.05). After reimmunization, highest antibody titers were noted in control rats (P < 0.05). Splenic autotransplant rats had higher antibody titers than did splenectomized rats (P < 0.05). Reimmunized splenic autotransplant rats had greater survivorship (71%) when compared with reimmunized splenectomized rats (26%) (P < 0.003). At 1 year, transplants were smaller than control spleens (P < 0.001), although histologic integrity was maintained. Splenic autotransplantation results in better phagocytic function, improved response to reimmunization, and increased survival after pneumococcal challenge and may be an important measure in preventing postsplenectomy sepsis.     

Differences between the histology of normal spleen and that of regenerated ectopically implanted splenic tissue

The histology of regenerated ectopically implanted spleen (splenotic tissue) from splenectomized rats was compared with that of normal rat spleen. Computer-assisted morphometric analysis revealed significant decreases in both the number and area of splenic nodules in splenotic tissue when compared with normal spleen. It is suggested that the reduction in the amount of white pulp present could explain at least in part the reduced ability of splenotic tissue to deal with infection.