Laparoscopic spleen-preserving distal pancreatectomy with and without splenic vessel preservation: The role of the Warshaw procedure

Background/objectivesLaparoscopic spleen-preserving distal pancreatectomy (LSPDP) for low-grade malignant pancreas tumors was recently demonstrated. Although the procedure with splenic vessel preservation (SVP) is optimal for LSPDP, SVP is not always possible in patients with a large tumor or a tumor attached to splenic vessels. This study aimed to analyze the safety of two procedures: LSPDP without SVP, known as the Warshaw technique (lap-WT), and LSPDP with SVP (lap-SVP).MethodsSeventeen patients who underwent a lap-WT and seven patients who underwent a lap-SVP were investigated retrospectively.ResultsThe median follow-up duration was 45 (range 17–105) months. In the lap-WT and lap-SVP patients, the sizes of the tumors were 5 (1.3–12) and 1.5 (1–4) cm; the operative times were 304 (168–512) and 319 (238–387) min; the blood loss was 210 (5–3250) and 60 (9–210) gr; the length of the postoperative hospital stay was 15 (8–29) and 18 (5–24) days; the peak platelet counts were 37.2 (14.6–65.2) and 26.4 (18.8–41) × 10⁴/μL, and splenomegaly was observed in 10 (59%) and three (43%) patients, respectively. In both procedures, there was no local recurrence. In the lap-WT group, splenic infarctions were seen in four (24%) patients and perigastric varices were seen in two (12%) patients. All of these patients were observed conservatively.ConclusionsBoth the lap-WT and lap-SVP were found to be safe and effective, and in cases in which the tumor is relatively large or close to the splenic vessels, lap-WT can be used as the more appropriate procedure.     

Hypersplenism and thrombocytopenia after exposure to ustekinumab in a patient with Crohn’s disease

Crohn’s disease can be characterized as a chronic inflammatory state causing various clinical presentations and long-term risks that should be considered when determining the optimal therapeutic strategy. To date, while a few case reports have been available regarding ustekinumab-induced thrombocytopenia, none are available regarding hypersplenism. We describe a 33-year-old woman who developed only Ileocolonic Crohn’s disease on ustekinumab due to failure of anti-TNF with septic shock and thrombocytopenia. Abdominal computed tomography revealed hepatosplenomegaly, parasacral collection, and fistulization. The patient was transferred to the intensive care unit and managed accordingly. Various treatment modalities were attempted, but none of them improved her platelet count. Our case report demonstrates that ustekinumab may induce hypersplenism and subsequently thrombocytopenia and should be considered a potential cause of low platelet count.     

原发性骨髓纤维化伴巨脾患者脾切除术前后血常规动态观察

目的探讨原发性骨髓纤维化(PMF)伴巨脾患者脾切除术对血常规的影响。 方法对1例PMF伴巨脾患者脾切除术前后的血常规等指标进行动态观察,并对切除的巨脾进行组织学检查。 结果患者术后呼吸困难、腹胀、纳差等症状明显好转。血常规结果示：白细胞明显升高,中性粒细胞百分比下降,淋巴细胞百分比升高,红细胞数变化相对较小,血红蛋白术后早期由于自体脾血回输升高,继之基本平稳,血小板变化最显著,术后明显减少,第5天最低仅10×10⁹/L,后逐渐恢复正常。组织学检查可见脾脏出现骨髓化倾向。 结论PMF伴巨脾行脾切除后血常规改变明显,脾脏出现了部分代替骨髓造血的组织学改变,脾切除后机体血细胞计数逐渐恢复正常。对PMF伴脾脏巨大导致影响呼吸和消化功能的患者应予以切除脾脏。     

Laparoscopic splenectomy for histiocytic sarcoma of the spleen

Primary histiocytic sarcoma of the spleen is a rare but potentially lethal condition. It can remain asymptomatic or only mildly symptomatic for a long time. An 81-year-old woman presented with an extremely enlarged spleen. She suffered from progressive anemia and required a red blood cell transfusion once a month. Although computed tomography, ultrasonography, and magnetic resonance imaging were performed for diagnosis, a confirmed diagnosis was not obtained. Her enlarged spleen compressed her stomach, and she suffered from gastritis and a sense of gastric fullness just after meals. She underwent laparoscopic splenectomy for therapeutic and diagnostic purposes. Her post-operative course was uneventful. After surgery, her red blood cell and platelet counts increased markedly. The tumor was diagnosed as splenic histiocytic sarcoma. Post-surgical chemotherapy was not performed, and the patient died of liver failure due to liver metastasis 5 mo after surgery. Laparoscopic splenectomy is minimally invasive and useful for the relief of symptoms related to hematological disorders. However, in cases of an enlarged spleen, optimal views and working space are limited. In such cases, splenic artery ligation can markedly reduce the size of the spleen, thus facilitating the procedure. The case reported herein suggests that laparoscopic splenectomy may be useful for the treatment of splenic malignancy.     

门静脉高压症183例脾切除的治疗体会

目的总结门静脉高压症脾切除的治疗经验。方法回顾性分析我院2006年1月至2009年12月门静脉高压症脾切除的183例患者的临床资料。结果无手术死亡病例,无术后脾蒂血管出血,无胰漏、胃底及结肠损伤等严重并发症。术后主要并发症包括左膈下脓肿1例、肺部感染5例、左侧胸腔积液7例、大量腹水9例、门静脉系统血栓形成21例,均经保守治疗后治愈。结论脾动脉的妥善处理、脾周韧带及粘连的解剖分离、脾蒂血管的正确处理以及脾窝创面的彻底止血是门静脉高压症脾脏切除的关键。     

多层螺旋CT对活体人脾体积的评估

目的 运用16层螺旋CT测量成人正常脾体积及容积相关参数,探讨脾体积与年龄、身高和体重等参数的关系,提供一个脾体积的简易估测方法。 方法 对无明确脾疾病的510例患者进行16层螺旋CT腹部增强扫描,针对1mm层厚、0.5mm重建间隔的门脉期图像进行分析。采用东芝公司Volume体积测量软件测定脾的体积、脾上下径、左右径、前后径、厚度和最大截面积,并对测量结果进行统计分析。 结果 510例患者的平均脾体积为(203±79)cm³。平均脾上下径、左右径、前后径、厚度和最大截面积分别为(9.0±1.7)cm、(9.1±1.0)cm、(9.5±1.9)cm、(3.8±0.7)cm及(35.6±9.5)cm²。体积与身高、体重存在较弱的正相关关系,与年龄间存在较弱的负相关关系。消除了体重因素的影响后,两性间脾体积无显著差异。脾体积与脾上下径及脾最大截面积均具有很好的正相关性(r=0.787 6, P<0.01;r=0.865 1, P<0.01)。简化的回归方程为：脾体积＝0.616×脾上下径×脾最大截面积(t=109.7, r²=0.990 6, P<0.01)。诊断脾肿大的标准是:脾体积大于358cm³为脾增大。 结论 本研究与传统的脾体积估算方法相比,可简单、迅速而较准确地估测脾体积,操作方法便于掌握,有较好的临床应用价值。     

Spleen size of live donors for liver transplantation

BACKGROUND: Normal spleen size is not well defined for the adult population. METHODS: Abdominal computed tomography (CT) scans of 238 consecutive living donors for liver transplantation were studied. Two methods for determining splenomegaly were applied. In Method N, a horizontal line was drawn to the left side from the most ventral point of the spleen. A perpendicular line was drawn from the central point of the aorta of the CT slice. The height of the cross point of the two lines was compared with the diameter of the aorta. In Method C, a perpendicular line was drawn from the most ventral point of the spleen. The distance between the posterior and anterior abdominal walls was partitioned in three parts, from dorsal to ventral and defined of Zones 1, 2, and 3, respectively. Donors were divided into two groups, those under age 40 and those over age 40. RESULTS: The mean volume of the spleen was 123 +/- 45 cm(3). Spleen volume was negatively correlated with age (R = -0.32, p < 0.001) and positively correlated with body mass (R = 0.24, p < 0.001). In donors under age 40, the most ventral point of the 96% of the spleens was below four times the diameter of the aorta (Method N). In Method C, 52% of the spleens were located in Zones 1 and 2. In donors over age 40, the most ventral point of the 96% of the spleens was below three times the diameter of the aorta (Method N). Totally 82% of the spleens were located in Zones 1 and 2 (Method C). CONCLUSIONS: Splenomegaly can be evaluated by the simple method on CT although the threshold must be changed by the age of the subject.     

The anatomy and pathology of the porta hepatis demonstrated by gray scale ultrasonography

Gray scale ultrasound has proved to be a simple, rapid, and reliable means for the investigation of cholestatic jaundice. The distended biliary tree has a characteristic but sometimes confusing appearance on ultrasonic tomography. Gray scale ultrasound can diagnose portal hypertension by visualizing an enlarged, tortuous portal vein. This can be differentiated from the typical shape of the dilated common bile duct by the condition of the intrahepatic biliary canaliculi and by examination of the spleen.     

101 laparoscopic splenectomies for the treatment of benign and malignant hematologic disorders

BACKGROUND: Laparoscopic splenectomy (LS) is the surgical approach of choice for patients with hematologic disorders requiring splenectomy. Patients with idiopathic thrombocytopenic purpura (ITP) have normal to slightly enlarged spleens and benefit the most from LS. METHODS: We reviewed the perioperative outcomes in 101 patients who underwent LS between May 1996 and December 2002. Patients were divided into three groups--ITP, other benign, and malignant hematologic disorders--and compared. RESULTS: The ITP patients (n = 48) had significantly smaller spleens and operative times compared with the other groups. Splenomegaly in the other benign (n = 23) and malignant hematologic disorders (n = 30) groups was responsible for higher open conversion rates and greater need for hand-assisted laparoscopic splenectomy (HALS). CONCLUSIONS: Laparoscopic splenectomy and HALS can be performed with good results for benign and malignant hematologic disorders. The benefits of HALS are similar to LS, so there should be a low threshold for HALS in patients with large spleens.     

Patients with severe schistosomiasis mansoni in Ituri Province,Democratic Republic of the Congo

Background::Severe hepatosplenic complications arise in patients with chronic Schistosoma mansoni infection after heavy exposure to disease agents in end...