Alterations in the immune system and tumor growth in laparoscopy

Background: The explosion in the use of therapeutic laparoscopy during the past decade has focused much research interest on finding a basic scientific support for the clinically apparent attenuation of the stress response to surgery. In particular, the potential impact that attenuation of the immune response to surgery may have on laparoscopy for the cure of malignancy has attracted much attention. Methods: A review of the published literature on the stress response to laparoscopic surgery and the impact of laparoscopy on tumor growth was performed. Results: Evidence favors an attenuation of the immune response to surgery with laparoscopic cholecystectomy. Whether this is true also of more major procedures such as laparoscopically assisted colectomy for malignancy is currently unclear. In animal models, tumor growth after laparoscopic surgery is less than after laparotomy and depends on the insufflation agent used. Conclusions: Laparoscopic cholecystectomy appears to be associated with attenuation of the immune response to surgery. The implications of these findings for the future use of laparoscopic surgical techniques for malignant disease remain unclear.     

The immune status of children with extrahepatic portal hypertension following splenectomy]

The purpose of the work was to study the immune status and some nonspecific defense factors in children with extrarenal portal hypertension after splenectomy. Seventy-one children were examined. It was found that the T-lymphocyte count before and in the early periods after the operation in children with extrahepatic portal hypertension did not differ from that in the control group. At the same time, the changes in serum immunoglobulins depended on the stage of the examination. Study of other links of immunity also revealed the time course of changes in their values.     

Intra-abdominal splenosis following laparoscopic splenectomy causing recurrence in a child with chronic immune thrombocytopenic purpura

In this paper, we present the case of a 12-year-old boy with refractory, symptomatic immune thrombocytopenic purpura (ITP) who underwent a laparoscopic splenectomy (LS). During morcellation of the spleen the retrieval bag ruptured. Thirteen (13) months postoperatively, the patient developed further symptoms and was found to be thrombocytopenic. Tc-99m heat-damaged red blood cell scintigraphy showed an accumulation of heat-damaged red cells in the upper left quadrant, raising the possibility of missed accessory spleen. Laparoscopic exploration revealed widespread intra-abdominal splenosis, and a therapeutic omentectomy was carried out. Fourteen (14) months post-surgery, platelet counts improved and the patient remains well. Following an elective splenectomy, a relapse in ITP may be the result of missed accessory spleen or splenosis; in others, it may the result of ongoing platelet consumption in non-splenic, reticulo-endothelial tissue. During LS, consideration must therefore be given to the risk of not only leaving additional splenic tissue behind, but also to the possibility of accidental autotransplantation, such as that from laparoscopic bag rupture. The risk of rupture can be minimized by using blunt instruments and stronger bag materials. If a rupture does occur, immediate suction and a thorough search for splenic fragments must be undertaken. Further development is needed into new techniques for organ retrieval and stronger bag materials.     

Changes in morbidity following traumatologically-induced splenectomy

12 patients were followed up who had been splenectomised between 1978 and 1985 after traumatic injury of the spleen. Analysis of late morbidity after loss of the spleen was performed besides physical examination and a study of clinical pathology findings, the analysis being based on the individual anamnesis and history of previous diseases of each patient. It was not possible to establish a clear rise in general an infection-conditioned morbidity. We believe that the simple method of comparing preoperative and postoperative disease periods on the basis of the individual list of previous diseases represents a new objective parameter for assessing the late sequelae following splenectomy.     

Immunodeficiency following splenectomy in the early postimmunization period

Splenectomy is associated with an increased risk of serious infection with encapsulated micro-organisms in a small number of individuals. The immunological defects in this state are unclear. We have investigated in rabbits the effect of splenectomy, before and after primary immunization with a specific antigen (sheep erythrocytes) similar in structure to the pneumococcal capsular antigen, on the organ localization of antibody forming cells and the long-lived memory cells. Antibody forming cell and memory cell assays were performed at intervals up to day 270 after primary immunization. Antibody titres following secondary immunization were also measured. The results show that the major site of antibody forming cells is in the spleen following primary immunization of the untreated rabbit and that antibody forming cells subsequently migrate to the lymph nodes and thymus. On the other hand, in rabbits splenectomized before primary immunization the major site of the antibody forming cells is the peripheral lymph nodes. These rabbits also gave good secondary immune responses. However, splenectomy 40 days after primary immunization results in a poor secondary immune response, indicating that essentially all the antibody forming cells following primary immunization were localized in the spleen at the time of splenectomy.     

The morbidity and mortality of splenectomy in childhood.

One hundred and eighty-two patients undergoing splenectomy in infancy and childhood were followed for periods of 2 to 15 years. Serious infections occurred in 11 patients (6%) with death in 6 (3.3%). In 10 patients the infection was sepsis, and in all but one patient the infection occurred within 2 years of splenectomy. Among children over 2 years of age the risk of infection was still appreciable except when the spleen was removed incidentally or for traumatic rupture. Splenectomy for thalassemia and portal hypertension resulted in an increased risk of serious infections when compared with removal of the spleen for hereditary spherocytosis, idiopathic thrombocytopenic purpura, trauma, or for technical reasons in the course of another operation. Post-splenectomy infections tended to follow a characteristic pattern. The infecting organism was predominantly pneumococcus, the course was fulminating and the mortality high.     

Circulating cellular and humoral elements of immune function following splenic arterial embolisation or splenectomy in trauma patients

BackgroundSplenectomy impairs the ability to combat infection, especially with encapsulated organisms. However, there is limited understanding of the impact of splenic arterial embolisation on immune function. Our hypothesis was that embolisation would not impair systemic immune function. This study examines elements of cellular and humoral immunity in patients undergoing splenic embolisation or splenectomy for trauma.Patients and methodsSplenic embolisation (SE) and splenectomy patients (S) were compared to blunt trauma patients without splenic injury (NS). Lymphocyte counts, natural-killer cells, serum complement (C3, C4), and properdin levels were assayed.ResultsNo significant differences in total, helper, or suppressor T-lymphocytes, complement (C3, C4), or properdin were found. B-lymphocyte counts were higher in S (602 ± 445 cells/mm³) than SE (238 ± 114 cells/mm³) or NS (293 ± 153 cells/mm³) (p = .003 for pairwise comparisons). S also had more natural killer T-cells than NS (325 ± 170 cells/mm³ vs. 174 ± 116 cells/mm³, p = .004).ConclusionSplenic embolisation does not alter the measured immunologic parameters. The absence of sensitive markers for splenic immune function limits the ability to assess the impact of embolisation for trauma.     

脾切除术后原发性肝癌

目的　探讨切脾术后肝癌治疗的价值和方法。方法　根据患者肝功能情况与肿瘤类型与临床分期 ,给予几种治疗方式。结果　除 1例肿瘤根治术后给予免疫增强治疗的病人已生存 2年以上外 ,其余患者有 6例在 6月内死亡 ,最近 1例术后 3个月情况已很差。结论　早期诊断手术根治切脾后肝癌术后给予免疫增强剂疗效佳。     

Pancreatic complications following laparoscopic splenectomy

Background: Laparoscopic splenectomy (LS) has been widely accepted despite a paucity of outcome data. Therefore, we performed a review of LS to assess the pancreatic complications and outcomes associated with this procedure. Methods: Ninety-four splenectomies were performed for a variety of hematologic disorders. The patient was placed in the lateral position, and three or four trocars were used. Results: LS was completed successfully in 93 patients. One case was converted to an open splenectomy for suspected gastrotomy. Thirty of 32 patients with splenomegaly underwent successful LS. Fifteen patients (16%) had some evidence of pancreatic injury. Six patients had asymptomatic hyperamylasemia. An injury directly associated with an adverse outcome occurred in nine cases (9.5% overall); six patients had pancreatic collections, one had a pancreatic fistula, and two developed hyperamylasemia and pain altering the length of hospitalization. Four of these nine patients did not have elevated postoperative amylase levels and were readmitted with pancreatic complications. Conclusions: LS can be performed for most pathologic conditions. Pancreatic injury is the most common morbidity associated with LS. The detection of hyperamylasemia can alert the surgeon to a pancreatic injury and alter postoperative management.     

Mesenteric thrombosis following splenectomy.

Three cases of postsplenectomy mesenteric thrombosis, two associated with thrombocytosis, are presented. Experience has shown that persistent thrombocytosis, accompanied by abnormal platelet function, is not a benign condition and may be associated with thrombosis. When encountered, postsplenectomy thrombocytosis of greater than 800,000 per mm-3 must be evaluated by platelet function studies and anticoagulation begun. Post-prandial cramping abdominal pain may be an early symptom of thrombosis, demanding immediate anticoagulation. Low-dose heparin, ASA, and dipyridamole are three of the more commonly used treatment modalities. Small bowel resection is indicated if thrombosis occurs.     

Alterations in respiratory mechanics following thoracotomy

Major alteration in respiratory mechanics occur in all patients following anaesthesia and thoracotomy because of a decrease in the functional residual capacity with minimal change in the closing volume leading to airway closure during tidal breathing and atelectasis. Diminished pulmonary reserve, because of non-pulmonary and pulmonary risk factors before operation, and/or restrictive ventilation and abnormal pattern of breathing due to postoperative pain sustain and aggravate these changes. These can proceed to postoperative pulmonary complications in some normal, and in many high risk, patients. Detection and correction of pre-existing pulmonary disease, smoking, sepsis and obesity is essential to reduce postoperative morbidity and mortality. Effective postoperative regional analgesia minimizes impairment of pulmonary function, aids in its recovery, and prevents postoperative pulmonary complications. The adjuvant use of chest physiotherapy and incentive spirometry should also help in decreasing the adverse affects of anaesthesia and surgery on the chest and thereby reduce the frequency and severity of postoperative complications.     

Intraperitoneal low-pressure suction drainage following splenectomy

A consecutive series of 282 patients undergoing splenectomy on one surgical unit has been studied to ascertain the incidence of postoperative subphrenic abscess. Only two atypical subphrenic abscesses occurred (0.17 per cent), a rate of abscess formation much lower than that reported in other series. We believe that the use of low-pressure closed suction drainage to the splenic bed accounts for this low rate.     

Results of laparoscopic splenectomy for immune thrombocytopenic purpura

BACKGROUND: Laparoscopic splenectomy has been demonstrated to be technically feasible and safe for the treatment of immune thrombocytopenic purpura (ITP), hereditary spherocytosis, and Hodgkin's disease. PATIENTS AND METHODS: The study comprised 76 consecutive patients with chronic ITP who were admitted to our hospital from 1968 to 1997 and underwent splenectomy; 35 patients underwent a laparoscopic splenectomy, and 41 had open surgery. RESULTS: Laparoscopic splenectomy involved minimal incision, and a significantly lower frequency of analgesia was required for postoperative abdominal pain (1.4 versus 3.3); postoperative hospital stay was shorter (9.6 versus 20.1 days, P <0.05). Operative time was significantly longer for the laparoscopic surgery (204.5 versus 99.8 minutes, P <0.01), but blood loss was less (154.4 versus 511.7 g, P <0.01). During the present study (range 3.8 to 80 months), accumulative nonrecurrence rate was 67.9% in 5 years after surgery, which is similar to that of the previous open splenectomy. CONCLUSIONS: Laparoscopic splenectomy can become an alternative therapeutic modality in the treatment of ITP.