Nonoperative management of splenic trauma. Conservative or radical treatment?

In a four-year experience with selective nonoperative management of splenic trauma in adults and children, 24 (35%) of 68 patients with documented splenic trauma were initially treated nonoperatively. In only one patient was an operation and laparotomy ultimately required. There was no morbidity or mortality in the nonoperative group. In the operative group (44 patients), 4% died after operation, largely of multiple injuries. Confirmation of splenic injury and follow-up of patients were mostly performed by splenic scintiscans. There was no significant difference in length of hospitalization between operative and nonoperative groups. Operative splenic repair and preservation of the spleen to prevent postsplenectomy sepsis often requires considerable experience and may be a lengthy, tedious procedure. Nonoperative therapy in adults and children is an attractive alternative in a selective group of patients.     

Is anything new in adult blunt splenic trauma?

Several decades ago, a shift occurred in the management of adult splenic injuries. Influenced by the experience in pediatric trauma patients, adult trauma surgeons began turning from mandatory operative treatment of all splenic injuries toward nonoperative management. Nonoperative treatment is now the most common method of management for patients with splenic injuries and is the most common method of splenic salvage. However, controversy exists about how to appropriately select patients for nonoperative treatment since bleeding from splenic injuries can incur significant morbidity and mortality. Recent refinements in the management of adult blunt splenic injuries will be reviewed.     

脾脏错构瘤的诊治体会(附六例报告)

目的探讨脾脏错构瘤的诊断和治疗方法。方法回顾性分析我院1994年~2004年收治的6例脾脏错构瘤的临床资料。结果本组6例均行脾切除术,均痊愈出院,随访至今仍健在。结论影像学检查对脾脏错构瘤有一定的诊断价值。外科医生在脾脏占位鉴别诊断时应考虑到本病的可能性。     

Route of hepatocyte delivery affects hepatocyte engraftment in the spleen

In laboratory animals, intrasplenic hepatocyte transplantation corrects the physiologic abnormalities associated with decompensated liver disease. The clinical experience with hepatocyte transplantation for cirrhosis has been disappointing when compared with laboratory experience. The route of hepatocyte delivery may influence hepatocyte engraftment and function. Outbred pigs were recipients of allogeneic pig hepatocytes. Donor hepatocytes were isolated by collagenase perfusion and labeled using 5(6)-carboxyfluorescein diacetate succinimidyl-ester (CMFSE). Cells were introduced into pig spleens by infusion through the splenic artery or by direct splenic puncture. Direct intrasplenic injection produced engraftment that was far superior to that obtained using splenic artery infusion. Splenic artery infusion produced a gastric erosion and large areas of splenic necrosis secondary to vascular occlusion with hepatocytes, whereas direct splenic injection was associated with clinically insignificant intraabdominal hemorrhage. The route of hepatocyte delivery may influence hepatocyte engraftment and explain the disparity in efficacy of hepatocyte transplantation between the laboratory and clinic.     

Open and laparoscopic treatment of nonparasitic splenic cysts

BACKGROUND: Nonparasitic splenic cysts are rare. Therefore, there is no 'evidence-based' information regarding their optimal surgical management. In the last years the laparoscopic approach has gained increasing acceptance in splenic surgery. The aim of this study is to present our experience with the laparoscopic management of splenic cysts. METHODS:The medical records of 7 patients with splenic cysts were reviewed retrospectively. RESULTS: One patient had an open partial splenic resection. Five patients, 3 of them with a posttraumatic and 2 with an epidermoid splenic cyst, underwent laparoscopic unroofing of the cyst. In 4 of these cases the postoperative course was uneventful, whereas in 1 case the patient developed a cyst relapse soon postoperatively. Later on this patient successfully underwent an open partial splenic resection. The 7th patient had an explorative laparoscopy. The cyst was located intrasplenically, entirely covered with unaffected splenic parenchyma, and reached the splenic hilus. Therefore, a conversion to open partial splenectomy was performed. CONCLUSION: Open partial splenectomy and laparoscopic cyst wall unroofing are both effective tools in the management of splenic nonparasitic cysts. Surgeons must master both techniques as nowadays spleen-preserving techniques should be attempted in every case of splenic nonparasitic cyst.     

Embolization of the splenic artery in liver cirrhosis

An experience with 70 embolizations of the splenic artery in 62 patients points to the importance of differential approach in choosing this method of treatment. Of primary importance in solving this problem is thought to be the degree of the disease which must determine the variant of reduction of the splenic bloodflow.     

Cystic masses of the spleen

Cystic masses of the spleen are unusual, and identification of their origin is critical to proper management. Presenting symptoms frequently are due to compressive effects of the mass or are due to infection. These cystic splenic masses are most commonly secondary cysts that lack a true epithelial lining and are usually related to prior splenic injury. Primary splenic cysts are rare and have an epidermal lining. Computed abdominal tomography outlines the anatomy and character of cystic masses of the spleen. Cystic splenic masses that are large, inflammatory in origin, involve the splenic hilum, or are infected, should be excised by splenectomy. Cysts localized to a single pole can be treated by partial splenectomy. An experience with three illustrative cases is presented.     

Management of blunt splenic injury in patients with concurrent infectious mononucleosis

Selective nonoperative management is appropriate for most blunt splenic injuries in adults and children, but the efficacy of this approach is unknown when injury occurs in patients with concurrent infectious mononucleosis. We have reviewed our experience during the past 23 years with the selective nonoperative management of blunt splenic injury in these patients. Medical record review identified nine patients with blunt splenic injury and infectious mononucleosis from 1978 to 2001, representing 3.3 per cent of our total trauma population with blunt splenic injury treated during that interval. Two patients underwent immediate splenectomy because of hemodynamic instability. Seven patients were admitted with the intent to treat nonoperatively. Five patients were successfully managed nonoperatively. Two patients failed nonoperative management and underwent splenectomy, one because of hemodynamic instability and one because of an infected splenic hematoma. Concurrent infectious mononucleosis does not preclude the successful nonoperative management of blunt splenic injury. This small subset of patients may be managed nonoperatively using the same criteria as for patients whose splenic injuries are not complicated by infectious mononucleosis.     

Splenic preservation: an additional haemostatic measure during mesh splenorrhaphy

BACKGROUND: Various treatment measures have been described in achieving splenic preservation following splenic injury. We describe an additional measure in achieving haemostasis during mesh splenorrhaphy. METHODS: Oxycel (BD, Franklin Lakes, NJ, USA) (topical haemostatic agent composed of oxidized cellulose) is sutured onto the inside of Dexon (Sherwood, Davis & Geck, St Louis, MO, USA) (polyglycolic acid) mesh. RESULTS: Two patients with splenic lacerations were operated on from July 2002 to February 2003 using this technique and both patients did not experience postoperative abdominal complications and were clinically well at follow up 1-2 months later. CONCLUSIONS: In our experience this technique made the Dexon mesh bulkier and easier to secure as well as more haemostatic.     

A minimally invasive approach to the treatment of aberrant splenic artery aneurysms: a report of two cases

Symptomatic aneurysms of an aberrant splenic artery originating from the superior mesenteric artery are rare, with only five previous reports in the literature. The retropancreatic position renders their treatment more complex than aneurysms of orthotopic splenic arteries. Traditional treatment has been open surgical repair, with or without maintenance of flow through the splenic artery. We present our experience with two patients treated with a combination of coil embolization and laparoscopic occlusion of the splenic artery achieved by developing a retropancreatic plane and applying clips immediately distal to the aneurysm. This appears a promising minimally invasive technique to treat this rare condition. Long term follow up, however, is necessary to determine the applicability and results.     

Splenic trauma: splenectomy in every case?

The authors report their experience in the conservative treatment of splenic traumas observed in the period 1987-1997. They point out the difference in the incidence of splenectomy in comparison with conservative treatment (p < 0.001) and nonoperative management (p < 0.05) in the two periods examined (1987-92 and 1993-97). They stress the manifold functions of the spleen and his role in the immunitary defense above all in pediatric age, and emphasize, on the base of their experience, the conservative treatment of traumatic splenic injuries in patient carefully selected. This curative strategy is supported by the notable contribution offered by sophisticated methods of radiological imaging (echography, CT, angiography) and by the commercialization of substances at high stick capacity (Tissucol). The lack of complications at short and middle term (reoperation for restart of the hemorrhage and ischemic necrosis after ligature of the splenic artery) induces the authors to consider the conservative treatment of the splenic traumas, in the cases in which it is pursuable, an ideal therapeutic solution.     

Splenic embolization in liver transplant recipients: early outcomes

Clinical improvement has been reported following splenic embolization for a wide variety of indications. Improvement following splenic embolization has been described in cirrhotic patients awaiting hepatic transplantation who are not candidates for surgical splenectomy. Occasionally, patients who have undergone hepatic transplantation have conditions that may also benefit from nonsurgical intervention with splenic embolization. Indications include persistent hypersplenism and pancytopenia precluding optimal treatment with antiviral therapy or chemotherapy, risk for persistent gastroesophageal variceal hemorrhage, and splenic artery steal syndrome attenuating hepatic arterial perfusion. Limited data is available on the outcome of splenic embolization in liver transplant recipients. We present the early outcomes of liver transplant recipients who were treated with splenic embolization. A retrospective chart review of all liver transplant recipients who underwent splenic embolization between 1997 and 2006 was performed, under minimal-risk study approval by the institutional review board. Five liver transplant recipients received splenic embolization: 3 for persistent hypersplenism, 1 for increased risk of gastroesophageal variceal hemorrhage, and 1 for splenic artery steal syndrome. The patients with hypersplenism demonstrated hematologic improvement, the patient with gastroesophageal varices did not experience any hemorrhage on follow-up, and the patient with splenic artery steal experienced resolution of the steal phenomenon. Postembolization syndrome was observed but no splenic abscess or death occurred. Mean follow-up was 20.2 months. In conclusion, splenic embolization is a safe and effective nonsurgical alternative for a variety of indications in liver transplant recipients.     

脾外伤129例的诊治分析

目的总结外伤性脾破裂治疗经验。方法对1984年至2004年收治的129例外伤性脾破裂的临床资料进行回顾性分析。结果本组非手术治疗17例,手术治疗110例,均无死亡。术后发生并发症10例,其中术后再出血3例,均为膈面渗血,均再次行剖腹手术,缝扎止血治愈;胰尾漏2例,予以引流、给予广谱抗生素、生长抑素及营养支持治疗,2～3周后胰漏闭合;膈下感染5例,经引流、应用广谱抗生素、对症治疗后治愈。术前死亡2例,患者均为复合伤合并严重脾破裂,就诊时间过晚,入院时血压为0,虽经积极抢救,仍于入院后2h内死于失血性休克。结论脾外伤的治疗应根据患者个体情况及脾破裂的类型而定。必要时采用联合多种方式保脾。     

Splenic Autotransplantation for a Congested and Enlarged Wandering Spleen with Torsion: Report of a Case

In children with diseases of the spleen, every effort should be made to preserve the organ, to prevent severe infections postsplenectomy. We report the case of a 7-year-old girl with torsion of a wandering spleen who we treated by autotransplantation of splenic tissues following splenectomy, when fixation of the enlarged spleen seemed impossible. Spleen scintigraphy showed uptake in the regenerating splenic tissues 9 months after surgery, and evidence of an increase in the size of the tissues 23 months after surgery. Howell–Jolly bodies had disappeared by 16 months after surgery. These findings suggested that the transplanted splenic tissues were resuming splenic functions. Based on our experience with this case, we conclude that autotransplantation after splenectomy is a treatment option for wandering spleen with torsion when fixation seems difficult because of splenic congestion and enlargement.     

The management of splenic trauma in a trauma system

Large teaching centers have reported splenic salvage rates of 40% to 50% in adults after splenic trauma. It is unknown whether similar salvage rates can be achieved safely in community trauma centers with a lower volume of patients and less experience. Between August 1984 and August 1988, 117 patients with splenic injury were treated at a level I center and 311 were treated at four level II centers. Splenectomy was performed in 252 patients (59%), splenorrhaphy was performed in 160 patients (37%), and 16 patients (4%) were observed. While the splenic salvage rate was higher at the level I center (50% vs 38%), selective splenorrhaphy was successful in the level II centers where the volume of splenic injury was lower (15 to 25 cases per year).     

脾脏肿瘤治疗经验

目的　总结研究脾脏肿瘤的诊治经验。方法　回顾分析我院 16年来 16例脾脏肿瘤的病理类型、对其的诊断和治疗以及患者的生存期限。结果　 16例脾脏肿瘤中 ,良性肿瘤占 9例 ,恶性肿瘤占 7例。良性肿瘤主要为脾血管瘤、错构瘤、淋巴管瘤及炎性假瘤 ;恶性肿瘤主要为恶性淋巴瘤、血管肉瘤、纤维肉瘤及胃癌脾脏转移癌。病变早期无明显症状和体征 ,诊断主要依靠体检和影像学检查。治疗主要是脾切除术 ,恶性肿瘤同时应用化疗和放疗。良性肿瘤对生存期无明显影响 ,恶性肿瘤的生存期限较短。结论　早期诊断和早期治疗是提高恶性肿瘤生存率和延长生存时间的关键。完善的体检和准确的影像学检查是提高脾脏肿瘤检出率的主要手段。     

Splenic infarction – A rare cause of acute abdominal pain following gastric surgery: A case series

IntroductionThe dissection of splenic hilar lymph nodes in gastric cancer surgery is indispensable for treating gastric cancers located in the proximal third of the stomach. Splenic vascular injury is a matter of debate resulting on time or delayed splenectomy. We aimed to share our experience and plausible mechanisms causing this complication in two case reports.Case presentationsTwo male patients with gastric cancer were diagnosed with acute splenic infarction following gastric surgery in the early postoperative period. Both underwent emergent exploratory laparotomy. Splenectomy was performed due to splenic infarction.DiscussionBecause we observed this rare complication in recent patients whose surgery was performed using vessel-sealing device for splenic hilar dissection, we suggested that extensive mobilization of the surrounding tissues of splenic vascular structures hilum using the vessel sealer could be the reason.ConclusionIn case of acute abdominal pain radiating to left shoulder, splenic complications should be taken into consideration in gastric cancer patients performed radical gastrectomy. Meticulous dissection of splenic hilar lymph nodes should be carried out to avoid any splenic vascular injury.     

Nonoperative management of blunt splenic trauma: a multicenter experience

The experience of six referral trauma centers with 832 blunt splenic injuries was reviewed to determine the indications, methods, and outcome of nonoperative management. During this 5-year period, 112 splenic injuries were intentionally managed by observation. There were 40 (36%) patients less than 16 years old and 72 adults. The diagnosis was established by computed tomography in 89 (79%) patients, nuclear scan in 23 (21%), ultrasound in four (4%), and arteriography in two (2%). There were 28 Class I, 51 Class II, 31 Class III, two Class IV, and no Class V splenic injuries. Nonoperative management was unsuccessful in one (2%) child and 12 (17%) adults (p less than 0.05). Failure was due to ongoing hemorrhage in 12 patients and delayed recognition of pancreatic injury in one patient. Of the 12 patients ultimately requiring laparotomy for control of hemorrhage, seven (58%) were successfully treated with splenic salvage techniques. Overall mortality was 3%; none of the four deaths was due to splenic or associated abdominal injury. This contemporary multicenter experience suggests that patients with Class I, II, or III splenic injuries after blunt trauma are candidates for nonoperative management if there is: 1) no hemodynamic instability after initial fluid resuscitation; 2) no serious associated abdominal organ injury; and 3) no extra-abdominal condition which precludes assessment of the abdomen. Strict adherence to these principles yielded initial nonoperative success in 98% of children and 83% of adults. Application of standard splenic salvage techniques to treat the patients with persistent hemorrhage resulted in ultimate splenic preservation in 100% of children and 93% of adults.     

脾占位性病变50例临床分析

目的 提高脾占位性病变的诊治水平。方法 回顾性分析50例脾占位性病变的诊断及治疗,总结经验体会。结果 50例脾占位性病变主要靠B超和CT发现,其中良性占76％（38／50）,恶性占24％（12／50）。31例行手术治疗,1例术后发生严重感染,余无手术并发症。良性病变疗效好,恶性肿瘤预后差。结论 影像检查是脾占位性病变的主要诊断手段,但对病变发现容易,定性,确诊难。脾脏炎症性病变以非手术治疗为主,对原发性碑肿瘤原则上一旦发现应积极手术。     

Has nonoperative management of solid visceral injuries adversely affected resident operative experience?

The purpose of this study was to assess the impact of increased use of nonoperative management of blunt injuries to the spleen or liver on surgical residents' operative experience with solid visceral injuries. We conducted a 10-year retrospective study of blunt spleen and liver injuries at a state-designated Level I trauma center and a survey of chief residents' operative experience with splenic and hepatic injuries from blunt trauma during the same time period. From 1990 through 1999, 431 patients were admitted with splenic injuries and 634 patients were admitted with liver injuries; 350 splenic injuries (81%) were due to blunt trauma; 317 liver injuries (50%) were caused by blunt mechanisms. In 1990 100 per cent of patients with splenic injuries and 93 per cent of those with liver injuries underwent surgery for those injuries. These rates were 19 and 28 per cent respectively in 1999. The number of patients with blunt solid visceral injuries increased more than fourfold from 1990 through 1999. The number of operations for splenic and hepatic injuries performed by chief residents did not decline significantly during this time period (5.5 cases per chief resident in 1990; 4.6 cases per chief resident in 1999). The increased numbers of patients with solid visceral injuries were due to two factors: increased proportion of blunt trauma admissions especially from motor vehicle collisions and improved recognition of spleen and liver injuries by expanded use of CT scans. We conclude that nonoperative management of blunt solid visceral injuries does not necessarily lead to a diminution of operations nor jeopardize resident education. However, trauma volumes must be high enough to support adequate operative experience.