Laparoscopic splenectomy in adults and children: experience with 31 patients

BACKGROUND: Open surgery is the standard approach for splenectomy in hematologic disorders, but a few cases of successful laparoscopic splenectomy have been reported. METHODS: Thirty-one patients (18 adults, group 1; and 13 children, group 2) underwent laparoscopic splenectomy. Indications for surgery included idiopathic thrombocytopenic purpura (25 patients), congenital spherocytosis (4 patients), and hemolytic anemia (2 patients). In 97% of the patients the diameter of the spleen was less than 15 cm. RESULTS: Laparoscopic splenectomy was successful in 94% of the patients; conversion to open surgery was mainly related to hemorrhage. Accessory spleen was found in 39% in group 1 and 8% in group 2. Two adults received intraoperative autotransfusion. Postoperative morbidity was minimal. The median postoperative stay was 3 days (range, 2 to 12 days) in group 1 and 2 days (range, 2 to 5 days) in group 2. CONCLUSIONS: Laparoscopic splenectomy is safe in both adults and children. Adequate selection of patients (small-size spleen, splenic destruction on preoperative scanning of platelets), appropriate preparation in patients with idiopathic thrombocytopenic purpura (immunoglobulin G), and meticulous surgical technique (with routine opening of the gastrocolic ligament to search for accessory spleen) are key factors in obtaining the same long-term results as with open surgery.     

Association of oligodendroglioma-like cell proliferation and angiomatous vasculature--coincidence or pathogenetically related lesions?

Iatrogenic injuries of spleen complicating left transperitoneal nephrectomy are the third reason of the injury of the spleen during abdominal surgery. This article deals with procedure of surgical freeing of file spleen from its fixing system with aim to avoid of its injury. Authors revalue all cases of left nephrectomy which was complicated with splenectomy, on their urology department during last ten years.     

Eicosanoids and fat emulsions in acute respiratory distress syndrome patients

Laparoscopic splenectomy has been accepted as a feasible extension of minimally invasive surgery, which has undergone dramatic improvements in both technology and instrumentation. We performed a laparoscopic splenectomy in a 7-year-old girl with hereditary spherocytosis. The patient recovered rapidly and returned to unrestricted activities quickly. The appropriate positioning of each laparoscopic port is essential for a good operative view and smooth access. It is also important to dissect the hilum of the spleen meticulously. Laparoscopic splenectomy in the pediatric age group appears to be another promising extension of laparoscopic surgery.     

Ipsilateral adrenalectomy in the surgical treatment of renal carcinoma

OBJECTIVES: To assess the value of ipsilateral adrenalectomy during radical nephrectomy for the treatment of renal cell carcinoma as a function of preoperative computed tomography findings. METHODS: Between May 1985 and June 1994, 194 patients underwent radical nephrectomy for renal cell carcinoma in our institution. Preoperative radiological reports and postoperative pathological reports were reviewed for 185 patients. RESULTS: 148 patients underwent abdominal computed tomography before surgery. 94 adrenalectomies were performed in this group of patients. None of the 77 patients in whom computed tomography showed a normal adrenal gland had adrenal metastasis on the definitive histological examination. 17 patients had an adrenal mass on computed tomography, 3 of which proved to be neoplastic. Preoperative CT had a sensitivity of 100%, a specificity of 82%, a positive predictive value of 18% and a negative predictive value of 100%. The 185 files reviewed included 114 adrenalectomies, including 4 adrenal glands invaded by renal cell carcinoma (3.5%). In these 4 cases, the smallest diameter of the renal tumour was 4 cm and the minimum pathological stage was T3. CONCLUSIONS: It therefore appears justified not to perform adrenalectomy during nephrectomy, in the presence of a renal tumour and negative adrenal computed tomography.     

Splenectomy in Hodgkin''s disease--indication and results (author''s transl)

The spleen is involved in 20-30 percent of patients with Hodgkin's disease. Involvement of the spleen cannot be excluded with reliability by radiological procedures or clinical chemistry. Therefore laparotomy and splenectomy are recommended as staging and therapeutic measures. In the authors's material, splenectomy showed splenic lesions in 9 out of 21 patients, mostly unexpected. Splenectomy is always indicated in stage II and should be taken into consideration in individual cases of stages I and III, too.     

Laparoscopic splenectomy. How to make it easier using an innovative atraumatic suction grasper

BACKGROUND: With the evolution of laparoscopic surgery comes the need for specific instruments that apply traction to parenchymal tissue, like the spleen, without exposing the organ to the associated high risk of bleeding. To meet this need, we designed and developed a suction-cup grasper that allows easy grasping and manipulation of the spleen. Some of the difficulties usually encountered during laparoscopic splenectomy may be overcome by using this device. MATERIALS: The instrument consists of a cone-shaped, silicone rubber suction cup designed with an antislip internal surface. The cup is connected to a support arm with a flexible distal end that can be rotated. Traction is exerted with a commonly available suction system. The device is inserted through a 12-mm-diameter guide sheath. RESULTS: The two interventions performed with the atraumatic device were completed with laparoscopic technique. No complications arose during or after the operations. The average operating time was 110 min. The patients were discharged after 4 and 5 days postoperative, respectively. CONCLUSIONS: As a device specifically designed for grasping parenchymal organs, the atraumatic suction grasper affords the operator a faster and safer technique in laparoscopic splenectomy.     

Effect of immunosuppression and splenectomy in transplantation sarcomas in mice

After spontaneous regression of transplanted tumours, marked reduction in number of tumours was found when challenged with isogenic tumour cells. The ALS abrogates this effect. Tumour removal by surgical excision of limb and subsequent time scheduled challenge by tumour cells maximally suppress on the 10th day and continues up to the 42nd day the tumorogenic effect. Splenectomy has no effect if done before a day or 3 days after challenge but marked decrease in tumour development was seen when challenged on the 8th day after splenectomy. Amputation and splenectomy together potentiates tumour formation. Only in tumour extrication, does resistance develop up to the 42nd day from surgery. Challenging at a different site in mice with tumours, resulted in prolongation of the intervals of tumour formation. Challenge after surgical removal of tumour after a time lapse, results in marked reduction in number and size of tumours. Surgical tumour extrication after splenectomy and subsequent challenge on 11th day inhibited tumour formation. Whereas splenectomized tumour bearing mice when challenged at a heterosite did not develop resistance.     

Spontaneous rupture of renal tumours presenting as surgical emergency

A study of renal tumours filed in the pathology department of a regional hospital in Hong Kong during 1971-1990 showed 6 cases of surgical emergency due to spontaneous rupture of the kidney by tumour. All occurred as a complication of renal angiomyolipoma, a rare tumour or hamartoma. A literature review showed that the renal tumour most frequently reported to cause spontaneous rupture was renal carcinoma. Chinese patients appear to have more renal ruptures due to angiomyolipoma than to renal carcinoma. It is proposed that intra-operative frozen section diagnosis should be sought, when this can be safely performed, in cases of rupture of the kidney by tumour. Surgery aiming at conserving functional renal parenchyma is appropriate for benign lesions such as angiomyolipoma.     

Repair of splenic lesions with video-laparoscopy

Conservative therapy of spleen injuries (non-operative treatment, partial splenectomy, autotransplantation, etc.) makes it possible to avoid the risk related to post-splenectomy hyposplenism. The videolaparoscopic approach makes the performance of such treatment possible achieving a clear reduction in surgical stress. The authors report two multiple injured patients showing spleen lesions, treated conservatively through videocoelioscopic procedure. Both patients (a 42-year-old woman and a 26-year-old man) presented hemorrhagic shock in hemodynamic compensation and hemoperitoneum. Abdominal ultrasonographic scanning proved the presence of spleen injuries. Both patients underwent a conservative surgical videolaparoscopic treatment using fibrin glue and omentoplasty. The resolution of the hemorrhagic shock and the restoration of the spleen lesions were achieved in both cases. The authors have already used the videocoelioparoscopic approach both in elective (biliary lithiasis, inguinal hernia, appendicitis, etc.) and in emergency surgery (acute cholecistitis, perforated ulcer, intestinal obstruction, etc.). They note the effectiveness of the method, also in the field of the mini-invasive conservative treatment of parenchymatous organ lesions (mainly in the case of spleen injuries, when the splenic function has to be preserved). So, it's possible to add the advantages of a conservative treatment to those of the minimal invasivity, provided by the videolaparoscopic procedure.     

The surgical management of colorectal complications from irradiation for carcinoma of the cervix

Rapid evaluation of the hypotensive patient in the emergency department is essential. The availability of ultrasonography in the ED, performed by emergency physicians and surgeons, has made it easier to evaluate the hypotensive trauma patient. We describe a 44-year-old man transferred to our institution from a community hospital for evaluation of syncope and hypotension with no obvious cause. On arrival the patient began to complain of slight lower abdominal pain. The patient's physical examination revealed minimal abdominal tenderness. A rapid ultrasound examination performed at bedside revealed the presence of intraperitoneal fluid. Examination of the spleen suggested likely rupture. The patient was promptly taken to surgery for splenectomy and discharged home in 4 days.     

Late results of the complex treatment of primary kidney neoplasm in children

88 children with primary renal tumours (85 with nephroblastoma and 3 with renal cell carcinoma) were treated between 1973 and 1990 in the paediatric urology department of Institute "Pirogov" and the paediatric haematological oncology department in Sofia. Combined therapy includes early surgery (nephrectomy + lymphadenectomy) and combination chemotherapy (Dactinomycin, Vincristine + Adriamycin, Endoxan). Stage II (with lymph node in involvement), III and IV disease was treated by radiotherapy. Chemotherapy and preoperative radiotherapy were administered in the case of very large tumours. In this series of 88 children, 64 (72.2%) are alive and 21 (23.8%) have died, while no information was available for 3 cases (3.5%). Survival was related to clinical stage, histological type and the child's age. One of the 2 cases with bilateral tumours survived for more than 2 years after the operation and combined therapy. One girl with liver and spleen metastases survived in remission for 11 years after the operation. Two children with pulmonary metastases, discovered one year after surgery for the primary tumour survived in remission for 4 and 14 years, respectively. The authors discuss the good results obtained with early combined therapy in this type of tumour.     

Splenunculus mimicking late local recurrence of renal cell carcinoma

We report on a case of a splenunculus found in the renal fossa 14 years after left transperitoneal radical nephrectomy and splenectomy for renal cell carcinoma. The significance of splenunculi in differential diagnosis of space occupying lesions in the left renal bed is discussed.     

Overwhelming postsplenectomy infection with vaccine-type Streptococcus pneumoniae in a 12-year-old girl despite vaccination and antibiotic prophylaxis

This report describes a 12-year-old girl who developed vaccine-type pneumococcal septicemia (type 4, Danish nomenclature) 2 years after splenectomy for recurrent idiopathic thrombocytopenia despite vaccination with the 23-valent vaccine 4 weeks before surgery and antibiotic prophylaxis with penicillin V. The disease presented as high fever with shivering and vomiting followed by disseminated petechiae and a deteriorated general condition. Initial laboratory studies showed severe sepsis with leucocytopenia and thrombocytopenia, a markedly elevated CRP, and disseminated intravascular coagulation. Despite antibiotic treatment, which was initiated with clindamycin, cefotaxime and trimethoprim/sulfamethoxazole and was switched to cefotaxime and penicillin after the result of the blood culture had been obtained, the patient had to be ventilated, and hemofiltration became necessary because of acute renal insufficiency. Furthermore, she required amputation of all her toes because of severe necrosis. No type-specific pneumococcal antibody titers were detected during and after infection. It remains unclear whether the susceptibility to Streptococcus pneumoniae was due to primary failure of antibody production or a decline in antibody levels after vaccination. Patients and/or their relatives should be informed that neither vaccination nor continuous antibiotic prophylaxis can guarantee full protection against infection with S. pneumoniae in patients after splenectomy.     

bcl-2 protein is strongly expressed in post-transplant lymphoproliferative disorders

BACKGROUND: Splenic complications of sickle-cell disease (SCD) are associated with morbidity, and in some it may lead to mortality. This paper presents our experience with 43 patients with SCD who had splenectomy as part of their management. PATIENTS AND METHODS: The records of 43 patients with SCD who had splenectomy were examined for age at operation, sex, hemoglobin (Hb) electrophoresis, indication for splenectomy, pre- and postoperative medications, operative procedures, and postoperative complications. RESULTS: The indications for splenectomy were acute splenic sequestration crisis (ASSC) in 21 patients, hypersplenism in 15, and splenic abscess in 7. In 17 patients, the spleen was also found to be massively enlarged causing discomfort and intervening with everyday activity. For those with hypersplenism, there was a significant postoperative increase in total Hb (P < 0.0001), hematocrit (P < 0.0001), white blood cells (P < 0.0001), and platelet count (P < 0.0001). CONCLUSIONS: With careful perioperative management and proper follow-up, splenectomy in patients with SCD is beneficial in reducing their transfusion requirements and its attendant risks, eliminating the discomfort from mechanical pressure of the enlarged spleen, avoiding the risks of ASSC, and managing splenic abscess.     

Diverticula of the female urethra. Comparison of imaging techniques

Splenic epidermoid cysts are rare lesions traditionally treated by splenectomy. Concerns about overwhelming postsplenectomy sepsis have led to the development of splenic preservation procedures in the treatment of cystic diseases of the spleen. We present the first case report of successful laparoscopic complete excision of a splenic epidermoid cyst.     

Splenectomy: its place in operations for inflammatory disease of the pancreas

Involvement of the spleen or its vasculature in inflammatory disease of the pancreas may result in life-threatening hemorrhage. Retrospective analysis of six patients having direct splenic involvement and/or occlusion of the splenic vein secondary to pancreatitis or pseudocyst showed that removal of the spleen as a portion of an appropriately timed operation for complications of pancreatitis uniformly resulted in an uncomplicated course and survival (3 patients). Leaving the spleen in place when it was directly involved in a pseudocyst and/or when the splenic vein was occluded resulted in postoperative bleeding, the requirement for reoperation, and death from septic sequelae (2 patients). One patient died of progressive respiratory and renal failure because initial operation was inappropriately delayed. We recommend splenectomy as a portion of an appropriately timed operation for complications of pancreatitis when the splenic vessels are involved and/or when the spleen is directly involved in a pseudocyst or lesser sac collection.     

Trends in rates of occupational fatal injuries in the United States (1983-92)

Recent advancements in laparoscopic surgery have made laparoscopic splenectomy possible. We retrospectively compared the outcomes of laparoscopic versus open splenectomy in patients with idiopathic thrombocytopenic purpura (ITP) or beta-thalassemia. From July 1993 to July 1997, 52 patients (ITP, 43 cases; beta-thalassemia, 9 cases) underwent either laparoscopic (30 patients, 9 men, 21 women; average age, 36.9 years) or conventional open splenectomy (22 patients, 5 men, 17 women; average age, 34.3 years). The two groups were similar in terms of sex, age, diagnosis, duration of disease, preoperative platelet count, and spleen size. The mean surgical time, estimated amount of blood loss, duration of postoperative recovery, analgesic usage, and complications were compared between the two groups. Laparoscopic splenectomy was successful in 29 (97%) of the 30 patients. The mean surgical time in the laparoscopy group was longer than in the open splenectomy group (190.6 vs 113.9 minutes, p < 0.01). The laparoscopy group had earlier postoperative oral intake (15.2 vs 52.6 hours, p < 0.01), less usage of analgesics (meperidine 50 mg/unit, 1.1 vs 2.8 units, p < 0.01) and a shorter postoperative hospital stay (4.1 vs 6.8 days, p < 0.01). The estimated blood loss, incidence of accessory spleen, surgical complication rate, and recurrence rate of thrombocytopenia were similar in the two groups. Our findings show that laparoscopic splenectomy in patients with ITP or beta-thalassemia is as safe as the open approach. While laparoscopy required a longer surgical time, the recovery period was shorter, analgesic use was less, and physical discomfort was less severe.     

Study on the combined therapy of DNA-methyltransferase inhibitor and interferon-alpha/beta for mouse spontaneously arose renal cell carcinoma, and immunological mechanism induced by the therapy

BACKGROUND: In order to change the immunological environment of T-helper2 (Th2) predominance, namely humoural immunity, in renal cell carcinoma, we tried to examine the efficacy of combined treatment with DNA-methyltransferase inhibitor (Procainamide) and interferon (IFN)-alpha/beta in basic experiments, and also examined the immunological mechanism induced by this treatment modality. MATERIALS AND METHODS: The monotherapy of Procainamide (10 mg/kg, 20 mg/kg, 30 mg/kg, everyday for 3 weeks, i.p.) and of natural murine IFN-alpha/beta (1 x 10(4) I.U./mouse, 3 times for a week, total 9 times, s.c.), and combined treatment with these 2 drugs for mouse spontaneously arose renal cell carcinoma (RC-2) were undertaken. Furthermore, we examined the expression of cytokine mRNA related to the Th-subset in murine spleen under the tumour burden by the RT-PCR methods. RESULTS: 1) Regarding the anti-tumour efficacy of two kinds of monotherapy (Procainamide and IFN-alpha/beta), no effective result was obtained. On the other hand, the combined treatment with these two drugs induced effective anti-tumour efficacy in the relative mean tumour weight ratio (TRW/CRW), mean tumour weight and the survival rate compared with the control and each monotherapy, especially in the administration of Procainamide dosed at 30 mg/kg. As to the histological degeneration induced by the combined therapy, there still remained the viable tumour cells (grade IIb). 2) In an effort to analyse the immunological changes induced by the administration of Procainamide, there observed the expression of Th1-derived cytokines mRNA such as IFN-gamma, IL-2 and tumour necrosis factor-beta, and except for interleukin (IL)-10, there also observed the disappearance of Th2-derived cytokines mRNA such as IL-4, IL-5 and IL-6 in the murine spleen. CONCLUSION: We draw the conclusion that the treatment with DNA-methyltransferase inhibitor may change the humoural immunological environment into the cellular immunological environment enabling the effective anti-tumour efficacy combined with IFN-alpha/beta in renal cell carcinoma.     

Improving in-training evaluation programs

OBJECTIVES: Radical vulvar surgery is associated with significant morbidity. DESIGN: The aim of the study was to assess retrospectively the feasibility of less extensive surgery in vulvar cancer patients operated in our institution with radical intent. The feasibility of less extensive surgical procedures was investigated, based on the retrospective analysis of preoperative assessment of tumour location and extent in a group of 162 patients. RESULTS: In the next step, the pathology reports of actually performed extensive operations were carefully reviewed in a search of microscopic evidence of tumour outside the limits of proposed conservative procedures. Conservative surgery was regarded technically possible in 127 patients (85.8%). Macro- or microscopic multifocality was detected in 22 patients (14.9%), of whom in 15 cases conservative surgery was regarded possible on the basis of clinical assessment. However, only in 11 cases tumour was found outside the limits of planned excision, in 9 of those cases--due to multifocal lesions. CONCLUSIONS: Less extensive surgery is technically feasible in a vast majority of vulvar cancer patients, however the selection for conservative procedures based only on clinical assessment of tumour extent is not sensitive enough to assure radical treatment in all patients and better methods of preoperative evaluation, such as vulvoscopy or random vulvar biopsies need to be investigated before the decision on routine use of conservative surgery is made.     

Treatment of hemoglobin Bart''s hydrops with bone marrow transplantation

OBJECTIVE: It is currently proposed to perform tumour enucleation in mono-orchid patients presenting with a small germ cell tumour, in order to preserve physiological endocrine function. However, this conservative surgery must be accompanied by treatment of any carcinoma in situ lesions present in the remaining testicular parenchyma. MATERIAL AND METHODS: The presence of carcinoma in situ was investigated in 35 patients with germ cell tumour of the testis on samples obtained from the presumably healthy pulp of the orchidectomy specimen, adjacent to and away from the tumour. Samples away from the tumour were performed according to principle of surgical testicular biopsy. Histological examination also concerned the tissue situated in contact with the tumour. RESULTS: 25 patients (74.22%) presented intratubular germ cell dysplasia in the testicular parenchyma presumed to be healthy. These lesions were always concomitantly observed on samples performed adjacent to and away from the tumour. It was observed more frequently in seminomas, but was also observed in other histological forms. CONCLUSION: Because of the diffuse nature of carcinoma in situ in germ cell tumours of the testis, pulp samples adjacent to the tumour are sufficient to ensure the diagnosis during conservative surgery. Carcinoma in situ is currently treated by local radiotherapy.