Splenectomy for massive splenomegaly

The technique, and short and long term results, of splenectomy for massive splenomegaly are presented. The latter was defined as a spleen weighing in excess of 1.5 kg. Thirty-five of the 38 patients had a serious haematological disorder as the indication for the operation, usually non-Hodgkin's lymphoma or myelofibrosis. All operations were carried out through abdominal incisions. Accessible splenic attachments were divided, and the splenic artery was ligated in continuity, prior to posterior mobilization. Two patients (5.3%) died as a result of the operation, both deaths being due to sepsis. Septic and thrombo-embolic complications were common, and occurred both early and late after the operation. Overall, eight of the 12 deaths during the first postoperative year were due to the primary disease, whereas all of the five deaths after that time were due to causes other than the primary disease. Twenty-four patients lived at least 1 year, and 10 patients are alive for more than 5 years.     

Splenectomy for massive splenomegaly

Twenty-four patients who underwent resection of giant spleen (spleen weight greater than 1.5 kg) have been reviewed to determine the difficulties and benefits of the procedure and, in particular, whether the use of adrenaline injection into the splenic artery could safely reduce technical difficulty. Although morbidity was higher in patients with giant spleens compared with those undergoing resection of smaller spleens the incidence of serious complications was small, and there were no operative or in-hospital deaths. In addition, virtually all patients benefited either on the basis of minimized haematological defect, or palliation of symptoms. Further, the injection of 1 ml of 1:10,000 adrenaline into the splenic artery before splenic mobilization reduced the splenic volume by approximately 40 per cent on average, and resulted in improved exposure, thereby facilitating the procedure.     

Splenectomy for massive splenomegaly

Removal of a massively enlarged spleen is a challenging surgical problem that is associated with higher death and complication rates than the removal of smaller spleens. Older age, serious and chronic primary diseases, and associated cardiopulmonary abnormalities contribute to the morbidity and mortality. Most patients with massive splenomegaly have been treated with corticosteroid and/or antineoplastic drugs, which impair wound healing, hemostatic function, and host resistance. Precise surgical technic is especially important in these cases because of the susceptibility to postoperative hemorrhage. Ligation of the splenic artery via the lesser peritoneal sac before mobilization of the spleen is associated with lower intraoperative transfusion requirements than when the spleen is mobilized before the splenic artery is ligated.     

Splenectomy for massive splenomegaly

Splenectomy was performed on 47 patients with massive splenomegaly (spleen weight greater than 1.5 kg). With one exception, all patients had a haematological malignancy. The indications for splenectomy were for the diagnosis of unknown cause (n = 5), for the relief of pain (n = 8), as the initial treatment of hairy cell or prolymphocytic leukaemia (n = 8), and for the correction of a haematological cytopenia (n = 26). Splenectomy was completely successful in relieving pain and in establishing a diagnosis, and provided effective palliation in patients with hairy cell and prolymphocytic leukaemia. An immediate correction of a haematological cytopenia was achieved in 24 patients, and the correction was maintained for over 1 year in 11 patients. There were no postoperative deaths and morbidity was acceptably low. We conclude that patients with massive splenomegaly can derive considerable benefit from splenectomy and that massive splenomegaly should not be regarded as a contra-indication to splenectomy.     

Splenectomy for massive splenomegaly due to myeloid metaplasia

From an analysis of these cases and those reported in the recent literature, earlier splenectomy is advocated for patients with myeloid metaplasia. Careful attention to preoperative preparation and “safe” operative technic has reduced the mortality to acceptable levels. Although postoperative mortality and morbidity in this series were high, they reflect primarily the advanced stage of the disease in patients finally referred for surgery. No patient should be denied operation on the basis of risk of operative mortality or on the basis of the spleen being the primary site of hematopoiesis.     

Splenectomy for undiagnosed splenomegaly.

During the 9-year period 1968-76 116 splenectomies were performed at the General Hospital, Nottingham. Of these, 13 (11 per cent) were undertaken for unexplained splenomegaly. In 6 patients a diagnosis was established by the operative procedure (2 with sarcoidosis, 2 splenic cysts, 1 Gaucher's disease and 1 haemangiosarcoma). Histological examination of the excised spleens in the remaining 7 patients showed no specific features. Two of these patients benefited considerably from removal of very large spleens. Another patient died from lymphosarcoma which was diagnosed 21 months after splenectomy. In the remaining 4 patients with mild to moderate splenomegaly, there were no real diagnostic or therapeutic advantages. It is concluded that splenectomy should always be considered in patients with unexplained moderate or gross splenomegaly but it may not be helpful in the patient whose spleen is only midly enlarged.     

Splenectomy for splenomegaly of more than 1000 grams. A retrospective study of 36 patients

Splenectomy for massive splenomegaly is frequently performed for hematologic disorders for diagnostic and therapeutic indications. The role of splenectomy is complex and controversial. The aims of our retrospective study were to focus on postoperative complications and advantages of splenectomy for massive splenomegaly. Thirty six patients with splenomegaly weighing 1000 g or more, underwent splenectomy at Centre Hospitalier Universitaire Lyon Sud, from January 1st, 1982, to December 31, 1995. Thirty-one (85%) of these patients had hematologic malignancy and more than half of them were older than sixty years. The main indications for splenectomy were hypersplenism (18 patients) and diagnosis (14). Preliminary ligation of the splenic artery was performed in 25 patients (42%). All patients had drainage. The mortality and morbidity rates were 5.5% and 20%, respectively. No major septic or thromboembolic complications occurred. There was only one major bleeding complication. The advantages of splenectomy included histopathological diagnosis in 13 of 14 patients with splenomegaly of unknown origin, permanent pain relief in all cases, and immediate correction of hematological cytopenia in 27 cases (75%). We conclude that the large weight of the spleen does not constitute a contraindication to splenectomy, but indications must be carefully selected, and the operative and perioperative management, must be appropriate.     

Intrathoracic goiter. Apropos of 36 cases

This article is concerned with 36 cases of plunging goiters responding to Eschapasse and Merlier definition. The frequency of plunging goiters is 5.2%, women are predominating with 96% and the average of age is 45 years. In 34%, these goiters gave rise to fow symptoms, while there was mediastinal complication in the others cases. Paraclinic investigations are limited to a face and profile pulmonary roentgenographies, and scintigraphy of the thyroid. In the treatment, cervicotomy proved to the completely satisfactory to removal of all the goiters and there were no need to sternotomy or thoracotomy. The pathology revealed two malignant tumors. Post operative evolution was uneventful except one death in the 10th post operative day by pulmonary emboli.     

Experience with seven cases of massive splenomegaly

BACKGROUND: Laparoscopic excision of extremely large spleens has been variously reported, but the usual consensus in the literature is that any patient with a spleen anything over 3000 g is simply not a proper candidate for laparoscopy. This report details our experience with 7 patients (out of 95 operated on) with spleens ranging in size up to 4800 g. METHODS: Our operative procedure involved 3 or 4 trocars placed along a virtually semicircular line centered over the splenic hilum. Splenic attachments were excised with the ultrasonic dissector, and the hilum divided with a stapler. Due to the size of the spleens, Pfannenstiel's incisions were utilized for hand-port placement in the extraction of the specimen. RESULTS: Surgery was successful in all 7 cases, and required no conversion to an open procedure. The average splenic weight was 3450 g (range, 3000-4800 g). Mean operative time was 168 minutes (range, 127-250 minutes). CONCLUSION: Because of improved instrumentation (i.e., laparoscopic stapler and ultrasonic dissector) and refinement of technique, spleens very much larger than what was once considered practicable can now be excised laparoscopically with similarly low morbidity as compared with open splenectomy.     

Splenectomy for splenomegaly and secondary hypersplenism

Splenomegaly and secondary hypersplenism may be associated with acute and chronic infections, autoimmune states, portal hypertension or splenic vein thrombosis, and a number of infiltrative and neoplastic conditions involving the spleen. Our experience and that of others with these various conditions demonstrates that the decision to perform splenectomy should be based on well-defined and often strictly limited indications. Except for idiopathic splenomegaly, the presence and severity of secondary hypersplenism or severely symptomatic splenomegaly should be well documented. In each case, the potential for palliation and known mean duration of expected response must be weighed against the increased morbidity and mortality of splenectomy (as compared to operation for primary hypersplenism).

---

Resumen Eplenomegalia e hiperesplenismo secundario pueden estar asociados con infecciones agudas y crónicas, estados autoinmunes (síndrome de Felty, lupus eritematoso sistémico), esplenomegalia congestiva por hipertensión portal o trombosis de la vena esplénica y con una variedad de entidades de tipo infiltrativo y neoplásico que afectan al bazo (sarcoidosis, enfermedad de Gaucher, varios desórdenes mieloproliferativos y linfomas). Nuestra experiencia, y aquella de otros autores, con tales condiciones demuestra que la decisión de realizar esplenectomía debe estar fundamentada en indicaciones bien definidas y estrictamente limitadas. Excepto en casos de esplenomegalia idiopática, la presencia y severidad del hiperesplenismo secundario o de esplenomegalia severamente sintomática debe ser bien documentada. En cada caso debe determinarse el potencial de paliación y la duración de la respuesta que se espera obtener frente a la incrementada morbilidad y mortalidad de la esplenectomía (en comparación con la operación que se realiza por hiperesplenismo primario).

---

Réumé La splénomégalie avec hypersplénisme secondaire relève de multiples causes: infection aigue ou chronique, états autoimmunologiques, hypertension portale, thrombose de la veine splénique, lésions tumorales spléniques. L'expérience de l'auteur qui rejoint celle de nombreux collègues lui permet d'affirmer que les indications de la splénectomie doivent être bien définies et sont strictement limitées. A l'exception de la splénomégalie idiopathique, l'existence et l'intensité de l'hypersplénisme, l'importance des symptomes provoqués par la splénomégalie doivent être aprréciées avec précision. Dans chaque cas le potentiel de la rémission de l'affection et la durée de la rémission doivent être pris en considération en fonction de l'éventuelle morbidité et de l'éventuelle mortalité de la splénectomie (par comparaison avec la splénectomie pour hypersplénisme primaire).

     

全脾切除术治疗门静脉高压性脾功能亢进症

全脾切除术治疗门静脉高压性脾功能亢进(hypersplenism,简称脾亢),长期以来一直是外科治疗的首选。近年来,由于对脾脏功能的深入研究和重新认识,选择这种治疗方式是否得2例死亡。这一发现后来被命名为全脾切除术后凶险性感染(OPSI),使人们对脾功能的认识有了根本的改变。从此,被冷落的脾部分切除术、外伤性脾缝合修补术重新得到关注,脾动脉部分栓塞术、自体脾组织移植术、脾消融术等各种保脾手术应运而生,同时引发了门静脉高压性病理脾切与保的争论。由此可以看出,全脾切除术治疗门静脉高压性病理脾,既是一个老问题,也是一个新问题。主张…     

Laparoscopic splenectomy for massive splenomegaly

BACKGROUND: Laparoscopic splenectomy (LS) is the preferred operative approach for diseases involving normal-sized spleens. Our experience with laparoscopic splenectomy in the setting of massive splenomegaly is presented. METHODS: A prospective review of patients undergoing LS for massive splenomegaly was conducted. Massive splenomegaly (MS) in adults was defined as a craniocaudal length >or=17 cm or a morcellated weight >or=600 g. In children, spleens measuring fourfold larger than normal for age were considered massive. RESULTS: Forty-nine patients with MS were treated with LS. The most common primary diagnoses were lymphoma and leukemia. Mean splenic length was 20 cm (15 to 27 cm), with weights ranging from 600 to 4,750 g. Twelve patients with supermassive splenomegaly (length >22 cm) required a hand-assisted laparoscopic approach. There were no conversions to open surgery. Mean operating time was 171 minutes (90 to 369). Mean blood loss was 114 cc (<30 to 600 cc). Average length of stay was 2.3 days (1 to 16). Minor postoperative complications occurred in 3 patients. CONCLUSIONS: Laparoscopic splenectomy in the setting of splenomegaly is safe and appears to minimize perioperative morbidity. In patients with supermassive splenomegaly, a hand-assisted laparoscopic approach may be required.     

Splenectomy in chronic idiopathic thrombopenic purpura in adults. Apropos of 49 cases

The authors reviewed the case files of 49 adult patients undergoing splenectomy for chronic idiopathic thrombocytopenic purpura at the Centre Henri Becquerel between 1970 and 1987. Although the postoperative course was straightforward in 83.7% of cases, one reoperation for subphrenic abscess was necessary and there was one postoperative death. Remission from thrombocytopenia was obtained in 87.5% of the patients, but only transiently in 8.5% of them. No preoperative predictive factors could be demonstrated. An early postoperative rise in the platelet count to more than 500 G/litre appears to ensure a good subsequent result. Secondary infectious complications are not exceptional and can be fatal (one death in our series); they require prophylaxis by anti-pneumococcal vaccination. The place of prophylactic antibiotic therapy has yet to be defined.     

Splenectomy in high-risk patients with splenomegaly

BACKGROUND: Splenectomy in patients with massive splenomegaly and hematologic malignancy results in higher morbidity and mortality with primarily palliative benefit. METHODS: From a 14-year experience with 172 splenectomies, the perioperative course of 39 high-risk patients with splenomegaly was reviewed for comorbidities, indications, complications, and mortality. RESULTS: Twenty-three males and 16 females with a mean age of 54.2 years and a mean 12.8-day postoperative length of stay were reviewed. Sixteen patients (41%) had 23 major complications related to age (P = 0.047) and operative time (P = 0.01). Intraoperative transfusion was related to splenic size (P = 0.04), and estimated blood loss (P = 0.02) was inversely related to use of splenic artery preligation. Three perioperative deaths were secondary to sepsis and multi-organ system failure. CONCLUSION: Splenomegaly and comorbidities of the primary disease result in higher morbidity and mortality. Splenic artery preligation is valuable to limit intraoperative blood loss and facilitate splenectomy.