Autologous replantation of spleen particles--an established procedure? An opinion

Autologous splenic replantation after splenectomy for trauma is generally recommended in order to prevent postsplenectomy sepsis. Several aspects, however, make this method uncertain: The extent of splenosis induced is not to be predicted. Even if the whole spleen is replanted, the resulting mass may not exceed splenosis, which sometimes develops spontaneously after sole splenectomy. But patients with extended splenic regenerates do not differ from those without any splenosis, considering various immunologic parameters. Postoperative complications after splenic replantation (abscess, intestinal occlusion) are possible, although they may be rare. Fatal cases of postsplenectomy sepsis despite massive splenosis are known. The most important reasons apparently are the altered vascularity and scarring in splenic regenerates. There is no specific test for immunological splenic function. Therefore there is no test to judge the success of replantation, too. Overall, the preservation of the spleen and the vaccination of splenectomized individuals are the most important surgical intentions.     

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.     

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.     

Minimally invasive surgery in the treatment of splenosis

Splenosis has been serious etiologic reason in the recurrence of benign hematologic diseases after elective open or laparoscopic splenectomy. Although, the incidence of splenosis in patients splenectomized for trauma is high, as long as they are asymptomatic, they do not require surgical treatment. Herein, we report a case of idiopathic thrombocytopenic purpura recurrence due to splenosis 5 years after the initial laparoscopic splenectomy. Laparoscopic treatment of splenosis was performed successfully.     

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.     

Splenic function after splenectomy for trauma. Role of autotransplantation and splenosis

Follow-up of patients treated for severe trauma to the spleen, with autotransplantation (20 cases) or splenectomy (21 cases) included hepatic and splenic scintigraphy, intracutaneous skin testing with seven recall antigens and hematologic studies (red and white blood count, Howell-Jolly bodies, erythrocyte morphology, immunoglobulins, complements). In all reimplantation cases splenic tissue was scintigraphically demonstrated. After removal of the spleen due to severe traumatic ruptures the incidence of splenosis was 66%. Good clearance function in all reimplantation and splenosis cases was demonstrated by Howell-Jolly bodies and erythrocyte morphology. Autotransplantation of splenic tissue is a simple and safe procedure, without serious complications. As yet, however, there is no proof that it provides adequate resistance to infections. Reimplantation, therefore, should be performed only if spleen-preserving procedures are not feasible.     

Immune response capacity after human splenic autotransplantation: restoration of response to individual pneumococcal vaccine subtypes

OBJECTIVE: To evaluate features of general immune function, in particular the restoration of the humoral immune response to pneumococcal capsular polysaccharides, in humans undergoing a spleen autotransplantation after splenectomy because of trauma. SUMMARY BACKGROUND DATA: After splenectomy, patients have an increased risk of overwhelming infection or sepsis involving encapsulated bacteria such as pneumococci. The value of human spleen autotransplantation after splenectomy because of trauma has long been questioned. Mononuclear phagocyte system function appeared to be similar to that in splenectomized persons. The presence of specific antipneumococcal antibodies would allow other parts of the mononuclear phagocyte system, such as those in the liver, to phagocytose opsonized bacteria. METHODS: Ten consecutive patients undergoing splenectomy followed by autotransplantation were compared with the next 14 consecutive patients undergoing splenectomy alone. After a minimum of 6 months, the patients were vaccinated with 23-valent pneumococcal vaccine. Blood samples were taken at the time of vaccination and after 3 and 6 weeks for antipneumococcal capsular polysaccharides IgM and IgG enzyme-linked immunosorbent assay against types 3, 4, 6, 9, 14, and 23. Splenic regrowth was evaluated by scintigraphy. RESULTS: Surprisingly, several of the nonautotransplanted patients showed scintigraphic activity, indicating the presence of either accessory spleens or traumatic seeding (splenosis). Significant antibody titer increases (more than twofold) were found for both IgM and IgG in the autotransplanted patients. Splenectomized-only patients showed no significant increase in Ig levels in patients without splenic regrowth and partial improvement in patients with splenosis/accessory spleens. CONCLUSIONS: Considering this significant antipneumococcal antibody increase, spleen autotransplants can be expected to permit an adequate humoral response to pneumococcal infections and presumably also to other TI-2 antigens, and to protect against overwhelming postsplenectomy infection or sepsis.     

Splenosis. A cause of massive gastrointestinal hemorrhage

Splenosis is the autotransplantation of splenic tissue following surgery or trauma. While it has been reported to cause a number of complications, splenosis is most commonly an incidental finding at laparotomy or on imaging studies. In our study, a case of massive, acute gastrointestinal hemorrhage occurred secondary to splenosis involving the small bowel. While there are several reports of self-limited gastrointestinal hemorrhage secondary to splenosis involving the gastric fundus, we are aware of no reports of massive, acute intestinal bleeding caused by this condition. Splenosis should be considered in the differential diagnosis of gastrointestinal hemorrhage in patients who have experienced prior splenic trauma or splenectomy.     

Evaluation of risk of splenosis during laparoscopic splenectomy in rat model

Laparoscopic splenectomy (LS) is an alternative to open surgery. However, there is a theoretic risk of splenosis and abdominal cavity dissemination of splenic cells if the splenic capsule is broken, as seen by experimental evidence of tumoral cell mobilization by the pneumoperitoneum. We evaluated the features of splenosis after splenectomy operated via an open approach or under laparoscopic control in an experimental model in the rat. A total of 65 Sprague-Dawley rats were distributed in seven groups that included the open approach, CO₂ pneumoperitoneum LS, or wall lift LS with or without a splenic graft. Splenic function was evaluated 90 day later through (1) scintigraphy with Tc-labeled heat-damaged erythrocytes; (2) determination of circulating “pitted” cells; and (3) analysis of the distribution of splenic pulp in the peritoneal cavity. Scintigraphy did not show viable residual tissue in any group after splenectomy; splenic activity in the splenic fossa was observed in 40% of the animals with grafts. Splenectomy increased the “pit” cell count, but it was reduced to normal values with a splenic graft. Necropsy showed normal splenic tissue in the splenic fossa in 100% of animals with a graft. Abdominal implants were observed significantly more frequently after CO₂ LS than after the open surgery or a wall lift LS (80% vs. 20% vs. 30%; p < 0.05). In addition, trocar site implants were observed with CO₂ LS (n= 3) or wall lift LS (n= 2), whereas there were no implants in the wound in the open group. We conclude that in an experimental rat model the pneumoperitoneum may facilitate abdominal splenosis after LS if the splenic capsule is ruptured or if splenic tissue spills compared with surgery without gas (open or laparoscopic).     

Splenosis. A diagnosis to be considered

The term splenosis applies to the autotransplanted splenic tissue resulting from seeding in the context of past splenic trauma or surgery. We report a 42-year-old man with a history of splenectomy observed for an incidentally found retrovesical mass thought to be an ectopic testicle. The abdominal laparotomy revealed multiple focuses of pelvic splenosis. As splenosis can be diagnosed through specific imaging studies one should always consider it in differential diagnosis of a mass discovered years after splenic surgery or trauma.     

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.     

Assessment of post-splenectomy residual splenic function. Splenic autotransplants

Splenectomy increases the risk of fulminant sepsis. The present study assesses residual splenic function in patients splenectomized due to traumatic rupture of the spleen; and six cases with splenic autotransplants. Splenic tissue was observed in only 48% of the splenectomized patients and 100% of the autotransplant cases. The two most reliable analytical parameters to assess the presence of functional splenic tissue, were the absence of Howell-Jolly bodies and normal IgM blood levels. In cases where total splenectomy is indicated, it has proved useful to perform autotransplantation of splenic tissue at omentum major level.     

Immune consequences of nonoperative treatment of splenic trauma in the rat model

To investigate the immunologic consequences of non-operative management of splenic injury, three parameters were studied: survival following pneumococcal sepsis, clearance of blood-borne bacteria, following Hemophilus influenzae challenge, and antibody response to type III pneumococcal capsular polysaccharide. Two hundred twenty-five Sprague-Dawley rats were divided into three groups and subjected either to a splenectomy, a sham operation, or standard blunt trauma. A significant increase in mortality was noted in the splenectomized group as compared with both the traumatized and control groups when challenged with Streptococcus pneumoniae. In both the control and trauma groups, H influenzae cleared significantly within 18 hours. Blood-borne bacteria persisted at the same level for 72 hours in the splenectomized animals. Four and 11 days later, the antibody level in both traumatized and control groups was higher than in the splenectomized subjects (P less than .001). There was no difference in the serum antibody level between the control and trauma groups at four days. However, at 11 days the trauma group showed a significant decrease in the antibody level (P less than .05). It can be concluded that following spontaneously-healing splenic trauma in the rat model, survival, bacterial clearance, and antibody response were all superior to that observed in the splenectomized subjects. In addition, the healed splenic disruption did not impair clearance of blood-borne encapsulated bacteria.     

Post-splenectomy splenosis presenting as hepatocellular carcinoma in the left lateral section of the liver: A case report

INTRODUCTION

Defined as heterotrophic autotransplantation of splenic tissue after splenic trauma or surgery.

PRESENTATION OF CASE

We present a case of 45 years old female patient with past history of splenectomy for haemolyticanaemia. Complaining of abdominal pain the patient was investigated by abdominal CT scan which revealed a focal lesion in the left lateral section of the liver suspicious to be hepatocellular carcinoma and gall bladder stones. Serum α-fetoprotein was within normal range. Exploration revealed a well encapsulated lesion completely separable from the liver and the diaphragm. Histopathological examination confirmed the diagnosis of splenosis. Although it is a rare condition, we recommend that the diagnosis of splenosis should be put in consideration in every patient with past history of splenectomy for proper management.

DISCUSSION

Although several cases of hepatic splenosis have been reported in the literature, supra-hepatic splenosis as our case has been rarely described.

CONCLUSION

Considering patients past history of splenectomy or splenic trauma should add splenosis to the list of possible differential diagnosis to avoid unnecessary surgical intervention.     

Recurrent Ruptured Spleen

Regrowth of splenic tissue after splenectomy for trauma and splenectomy for idiopathic thrombocytopenia purpura have been reported. However, rupture of splenic tissue, either spontaneous or traumatic, that requires a second surgical intervention for hemoperitoneum caused by a ruptured splenic nodule or splenosis has rarely been reported. We report the case of a 43-year-old man in whom hemoperitoneum developed 25 years after he underwent an open splenectomy, after a motor vehicle accident, that required removal of a recurrent ruptured splenotic nodule.     

Thoracic splenosis twenty-nine years after traumatic splenectomy mimicking intrathoracic neoplasm

Thoracic splenosis refers to a condition of ectopic splenic tissue in the thoracic cavity. It is usually a consequence of splenic tissue seeding in the pleural cavity after thoracoabdominal trauma. A rare case of thoracic splenosis, in a 62-year-old man who had had a traumatic splenectomy due to thoracoabdominal trauma 29 years earlier, is reported. The patient, a heavy smoker, was admitted for evaluation of a left-side thoracic lesion discovered on a plain chest film. Bronchoscopy, CT scan and needle biopsy proved inconclusive for the diagnosis. Exploratory thoracotomy was necessary to establish the diagnosis. During the operation, a thoracic splenosis was confirmed. To date, only 28 cases of thoracic splenosis have been reported in the literature. The purpose of this report is to present a new case of splenosis of the thoracic cavity simulating intrathoracic neoplasm.     

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.     

Splenorrhaphy for splenic trauma.

Thirty consecutive patients sustaining splenic injury from blunt abdominal trauma were evaluated as to the feasibility of performing splenorrhaphy rather than splenectomy. Twenty-four patients were over 14 years of age. The procedure to be performed was decided intraoperatively. Twelve patients required a splenectomy, and 18 patients had all or a portion of the injured spleen salvaged. The two groups were similar in age, mechanism of injury, and associated injuries. Nine of the 18 salvaged spleens required only debridement and the topical application of Avitene for hemostasis. The remaining nine patients required more extensive procedures including hemisplenectomy (three) and partial splenectomy (three); three patient patients required oversewing of bleeding splenic surfaces and the ligation of vessels without removal of splenic tissue. There were no differences in the number of blood transfusions required by the two groups. There were no postoperative complications resulting from the splenorrhaphy. Sixteen of the 18 who underwent splenorrhaphy were studied postoperatively by spleen scan. In all cases functioning splenic tissue was found consistent with the operative findings and procedure.     

Management of splenic trauma: the Durban experience

In a retrospective survey of splenic trauma managed at a teaching hospital, the data of 127 patients during a 2 year period have been analysed. Splenic conservation was achieved in 47 laparotomies (38.8 per cent). Six patients with blunt abdominal trauma (4.7 per cent of all patients) were managed non-operatively. Splenic conservation by suture with or without packing with omentum or oxidized cellulose was successful in 27 out of 37 attempts. Failure of this technique was easily recognized during laparotomy and no patient required re-operation for continued splenic bleeding after splenorrhaphy. There was no significant difference between successful conservation of the spleen at laparotomy of patients below the median age (28 years) and older patients. Wound sepsis was increased after splenectomy (P less than 0.05). Splenic conservation is not appropriate for all types of splenic injury. Where conservation is not possible splenectomy and re-implantation is recommended.     

Advances in management of splenic injuries.

Because there is no such thing as "minor splenic injury", the diagnosis of splenic rupture is a major problem after abdominal trauma. Since it is our policy to explore all penetrating abdominal injuries, the problem of early recognition arises in patients with blunt trauma. When abdominal evaluation is difficult because of associated injuries, we increasingly use peritoneal dialysis. This has been particularly helpful in patients with head injury or drug intoxication and has also contributed to earlier operation in patients with signs of hypovolemia but minimal abdominal findings. Angiography has been useful in doubtful cases. Review of our experience in the last five years with splenectomy (298 cases) has revealed complications, particularly thromboembolic, that have changed our management of these patients. The incidence of clinical pulmonary embolism was 4 per cent in patients having splenectomy for trauma as contrasted with 0.5 per cent in patients having laparotomy for trauma without splenectomy. Postoperative platelet evaluations in patients after splenectomy for trauma revealed thrombocytosis. Detailed follow-up platelet studies showed a peak thrombocytosis at about two weeks, averaging 976,000/mm3. In contrast, similar studies in other patients having laparotomy for trauma showed counts of about 200,000/mm3. Because of the high incidence of thromboembolic complications, a low-dose heparin regimen was initiated. There was a 30 per cent incidence of infection postoperatively.