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PubMed2003

T cell receptor VB repertoire diversity in patients with immune thrombocytopenia following splenectomy.

In recent years, a pathophysiological role for T cells in immune thrombocytopenia (ITP) has been established. We applied cDNA size distribution analysis of the T cell receptor (TCR) beta-variable (VB) complementarity-determining region 3 (CDR3) in order to investigate T cell repertoire diversity among immune thrombocytopenia patients who had either responded or not responded to splenectomy, and compared them to normal controls. ITP patients who had had a durable platelet response to splenectomy showed a mean 2.8 +/- 2.1 abnormal CDR3 size patterns per patient, similar to healthy volunteers (2.9 +/- 2.0 abnormal CDR3 size patterns). In contrast, patients unresponsive to splenectomy demonstrated evidence of significantly more clonal T cell expansions than patients who had responded to splenectomy or controls (11.3 +/- 3.3 abnormal CDR3 size patterns per patient; P < 0.001). Of the VB subfamilies analysed, VB3 and VB15 correlated with response or non-response to splenectomy, each demonstrating oligoclonality in non-responding patients (P < 0.05). These findings suggest that removal of the spleen may lead directly or indirectly to reductions in T cell clonal expansions in responders, or that the extent of T cell clonality impacts responsiveness to splenectomy in patients with ITP.

Adult↗

PubMed2002

Technical developments and a team approach leads to an improved outcome: lessons learnt implementing laparoscopic splenectomy.

BACKGROUND: To document the technical aspects, outcome and lessons learnt during the learning curve phase of implementing laparoscopic splenectomy, by comparing the results before and after the introduction of a standardized technique. METHODS: We present a retrospective and prospective review of laparoscopic splenectomies over a 4-year period. Two chronological periods were studied, before and after the implementation of a standardized technique of a laparoscopic splenectomy involving: (i) hilar dissection with ultrasonic shears; (ii) two experienced laparoscopic surgeons; and (iii) trained dedicated equipment and staff using a checklist approach in the preparation and conduct of the operation. Two groups of patients were studied relating to the periods before and after the implementation of a standardized technique. Statistical methods used were the Wilcoxon's rank sum test and the two-sample test. RESULTS: Thirty-one laparoscopic splenectomies were attempted. The most common indication was for idiopathic thrombocytopenic purpura. When comparing the early phase (n = 15) with the standardized technique phase (n = 16), there was a significant reduction in conversion rates (40% vs 6%), operating times (218 min vs 171 min), complication rates (6 cases including 1 death vs none) and length of stay (11 days vs 4 days). The results were significant for reduction in hospital stay, conversion rates and complications rates. CONCLUSIONS: A reduction in conversion rates, operating time, morbidity and length of stay was realized during the learning curve of implementing laparoscopic splenectomy by adopting a standardized technique. This technique involved hilar dissection using the ultrasonic shears, two experienced laparoscopic surgeons performing the surgery, dedicated equipment and trained staff using the checklist approach. We recommend such a standardized technique in performing laparoscopic splenectomy.

Adult↗

PubMed2001

[Laparoscopic splenectomy in thrombotic thrombocytopenic purpura. Surgical and hematological results in 2 patients].

HISTORY: Case 1. Thrombotic-thrombocytopenic purpura (TTP, Moschkowitz' disease) in a 57-year-old woman had for one year been treated conservatively. But when daily plasmapheresis was temporarily discontinued she developed behavioural changes and impaired speech, providing an indication for splenectomy. Case 2. A 53-year-old woman with TTP had been similarly treated for one month. Splenectomy was indicated when neurological symptoms rapidly developed. INVESTIGATIONS: At admission, creatinine 110 mg/d, white cell count (WBC) 12.4 G/l haemoglobin 10.1 g/dl, haematocrit 0.29, platelets 91 G/l. Prothrombin time (PTT) and thromboplastin time were normal. Patient 2. At admission, platelet count was below 10 G/l and she had various neurological abnormalities. Haemoglobin was 9.0 f/dl, haematocrit 0.27. Platelet count, PTT, thromboplastin time and renal functions were normal. TREATMENT AND COURSE: Case 1. After plasmapheresis and administration of cryoprecipitate-free fresh frozen plasma (FFP) excess, laparoscopic splenectomy was performed. On the third postoperative day WBC count was 11.5 G/l, haemoglobin level was unchanged, but platelet count was now normal, as were PTT and thromboplastin time and renal functions. 8 and 32 months after the operation WBC count, haemoglobin, haematocrit and platelets were all normal. There were no neurological abnormalities postoperatively. Case 2. Laparoscopic splenectomy was performed after intensive haematological preparation. The pre- and postoperative course was uneventful and she was discharged on the 8th postoperative day, at which time her haemoglobin was 8.4 g/dl, haematocrit 0.25, while platelets, PTT, thromboplastin time and renal functions were all normal and remained so at follow-up 11 months later. There have been no neurological symptoms after the splenectomy. CONCLUSION: Laparoscopic splenectomy is a haematologically and surgically safe treatment of TTP and should be considered for all cases of TTP that fail to respond to conservative management.

Female↗

PubMed1998

The role of partial splenectomy in children with thalassemia.

Partial splenectomy was performed on 12 patients with thalassemia (9 beta-thalassemia major and 3 Hb H disease) to reduce blood transfusion requirements. The indication for partial splenectomy was the presence of splenomegaly and increased blood transfusion requirements (i.e. Hb drop > 0.5 g per week). Their ages ranged from 3 to 10 years (mean 6.9 years). On follow-up, ranging from 1.1-5.5 years (mean 2.6 years), two of the three patients with Hb H disease required no more blood transfusions while the third continued to receive blood transfusions, but at a lower frequency. For those with beta-thalassemia major, the transfusion requirements and Hb drop per week decreased in the majority of patients. This is specially so during the first 1-2 years following partial splenectomy. In all, about 1/3 of the size of the normal spleen was preserved (either upper or lower pole) which was judged functional as there has been no significant infection in any of the patients, no change in IgM level, no Howell-Jolly bodies and visualization on scintigraphy. Partial splenectomy is recommended to start with for those with Hb H disease. For patients with beta-thalassemia major, partial splenectomy is beneficial as a temporary measure and in those children who are less than 5 years of age, as they are at greater risk of post splenectomy sepsis.

Blood Transfusion↗

PubMed1980

Splenectomy in the management of the thrombocytopenia of the Wiskott-Aldrich syndrome.

The Wiskott-Aldrich syndrome is an X-linked immunodeficiency disorder consisting of the triad of frequent infections, eczema, and profound thrombocytopenia. We evaluated the effects of splenectomy on hemostatic improvement and subsequent clinical course in 16 patients with the Wiskott-Aldrich syndrome. All 16 had an increase in platelet counts to at least 100,000 per cubic millimeter after splenectomy, with the mean increasing from 19,900 per cubic millimeter preoperatively to 262,700 per cubic millimeter after splenectomy. In addition, platelet size, which is characteristically small in this disease, also became normal. Survival after splenectomy correlated with the prophylactic use of antibiotics. Five of seven patients not taking prophylactic antibiotics died of sepis within 33 months of surgery. The mean survival of the nine patients maintained with prophylactic antibiotics, however, was at least 91.4 months, with six of these patients still alive an average of 11.0 years or more after splenectomy. Thus, splenectomy is a useful therapy for a major cause of morbidity and mortality in this complex syndrome.

Adolescent↗

PubMed1987

Splenic reticuloendothelial function after splenectomy, spleen repair, and spleen autotransplantation.

Overwhelming infection after splenectomy remains a problem despite the introduction of vaccine and antimicrobial prophylaxis. To evaluate prospectively various procedures proposed for salvage of the spleen, we measured reticuloendothelial function for two to five years in 51 patients who had initially presented with abdominal trauma and suspected splenic rupture. The mean percentage of pocked erythrocytes and the clearance of antibody-coated autologous erythrocytes in 8 patients who had splenic repair and in 6 who had partial splenectomy were the same as in 11 controls with intraabdominal injury that did not involve the spleen. The mean percentage of pocked erythrocytes remained significantly elevated in 19 patients who had undergone total splenectomy without autotransplantation of splenic tissue. One of seven patients who underwent splenic autotransplantation had a normal level of pocked erythrocytes 18 months after surgery, and a second patient had only a slight elevation at 24 months. The mean (+/- SEM) half-time clearance of labeled erythrocytes was significantly longer in the group that had total splenectomy without autotransplantation (421.1 +/- 74.5 hours) than in the autotransplantation group (91.6 +/- 20.0) or in the controls (5.4 +/- 2.0). We conclude that reticuloendothelial function was better preserved after partial splenectomy and splenic repair than after splenic autotransplantation, but that autotransplantation was superior to total splenectomy and appeared to be safe. Splenic autotransplantation deserves further study in patients who have had splenic trauma when other surgical maneuvers to save the spleen are not possible.

Adolescent↗

PubMed2002

Laparoscopic splenectomy for hematologic diseases.

BACKGROUND: Laparoscopic splenectomy has been demonstrated to be technically feasible and safe for the treatment of hematologic diseases. METHODS: The study comprised 64 consecutive patients with chronic immune thrombocytopenia purpura (ITP) who were admitted to our hospital from 1992 to 2000 and underwent laparoscopic splenectomy. Forty-one consecutive patients with ITP who underwent open splenectomy performed at the same hospital by the same surgical team between 1986 and 2000 were selected as the control group. RESULTS: We performed laparoscopic splenectomies for ITP, hereditary spherocytosis (HS), malignant lymphoma, autoimmune hemolytic anemia, and cryoglobulinemia. Laparoscopic surgery as compared with open surgery in ITP revealed a significantly lower pain medication requirement, an earlier resumption of oral intake, and a shorter hospital stay, but a longer operative time. During the present study (range: 3.8-80 months), the cumulative rate of nonrecurrence was 67.9% at 5 years after surgery, which was similar to the rate for the previous open splenectomy. CONCLUSIONS: Laparoscopic splenectomy is considered to be a suitable alternative therapeutic modality in the treatment of hematologic diseases.

Anemia, Hemolytic↗

PubMed1999

Early postoperative complications of splenectomy for hematologic disease.

Splenectomy may be indicated in a variety of hematologic diseases for diagnostic reasons, therapeutic reasons, or both. Most reviews reveal a high proportion of procedures performed as part of the staging process for Hodgkin disease. Splenectomy for myelofibrosis has been associated with an increased postoperative complication rate. Other determinants of morbidity have been splenic weight and operative blood loss. The authors reviewed a series of 83 adult patients from a prospective database established in 1991 to determine the incidence of early postoperative complications associated with splenectomy for hematologic disease and to analyze patient characteristics that may predict their occurrence. Morbidity that occurred within 30 days of splenectomy was considered to be an early postoperative complication. Operative estimated blood loss and incidence of postoperative complications were correlated with patient age, preoperative platelet count, splenic weight, and diagnosis of myelofibrosis as regression covariates. Indications for splenectomy were therapeutic in 76 patients (92%). Median splenic weight was 760 g, and 22 patients had massive splenomegaly. Patients with splenic weight more than 1,500 g had a significantly higher median estimated blood loss (300 ml; p = 0.02). Splenic weight was the main determinant of estimated blood loss in a multiple linear regression analysis (p = 0.02). Twenty-two patients (27%) experienced postoperative complications and five of those patients died (6%). Patients with myelofibrosis had the highest incidence of complications (50%) and the highest postoperative mortality (21%; p = 0.04). In a logistic regression model, estimated blood loss was the only variable significantly correlated with postoperative complications (p = 0.02). Splenectomy for hematologic disease is associated with an acceptable early postoperative complication rate, even when the indication is predominantly therapeutic. Patients at particularly high risk include those with elevated operative blood loss, massive splenomegaly, and myelofibrosis.

Adult↗

PubMed1986

Increased low-density lipoprotein levels after splenectomy: a role for the spleen in cholesterol metabolism in myeloproliferative disorders.

Patients with myeloproliferative disorders demonstrate decreased plasma cholesterol and apolipoprotein B concentrations, and this has been related to the presence of a large spleen. Patients that underwent splenectomy in the past demonstrated normal plasma cholesterol levels. Plasma high-density lipoprotein (HDL) cholesterol and apolipoprotein A-I were also reduced in these patients, but were normal after splenectomy. To study the immediate effect of splenectomy on the plasma lipid pattern, three patients with myeloproliferative disease and a large spleen who were undergoing splenectomy were compared with two control groups, one undergoing orthopedic operations and the second, cholecystectomy. In the control groups, plasma lipids tended to decrease for the first 2 days after surgery and then returned to preoperative levels. After splenectomy, however, plasma cholesterol, low-density lipoprotein (LDL), and apolipoprotein B significantly increased, reaching maximum levels after 4 days. Plasma HDL as well as apolipoprotein A-I decreased 1 day after splenectomy, but then increased over and above their preoperative concentrations. These results suggest an important role for the spleen in cholesterol metabolism in these patients. The spleen appears to be an important site for LDL catabolism in these patients.

Adult↗

PubMed1988

Splenectomy in hematologic disorders. The ever-changing indications.

A comparison between a series of splenectomies performed at the University of Virginia Medical Center for hematologic disorders between 1946 and 1962 (Series I) and 1963 and 1982 (Series II) is presented. Four hundred splenectomies (20 per year) were performed between 1963 and 1982 compared with 94 (5.5 per year) between 1946 and 1962. Also noted in Series II was a sharp decline in the number performed each year between 1974 and 1983. The major factor responsible for these observations was the evolution of the staging laparotomy for malignant lymphomas, particularly Hodgkin's disease, and the decline in the average annual incidence of staging laparotomies since 1974. Staging laparotomy currently is rarely done for non-Hodgkin's lymphomas. Also contributing to the changes noted was an increase in the total number but subsequent fall in the annual incidence of splenectomy for hereditary spherocytosis, idiopathic hypersplenism, and myeloproliferative disorders in Series II. The average number of splenectomies for idiopathic thrombocytopenic purpura increased from 1.1 per year in Series I to 3.6 per year in Series II; the annual incidence during the study period of Series II, however, remained constant. The total number of splenectomies for hairy cell leukemia and Felty's syndrome increased from zero in Series I to 12 and 17, respectively, in Series II, whereas the number of miscellaneous reasons dropped from 29 (1.7 per year) in Series I to 15 (0.75 per year) in Series II. The mortality rate in Series I was 6.3% compared with 4.0% in Series II. No deaths occurred in Series II after 1979. Indications for splenectomy in Series II were for diagnostic purposes in 3.2%, therapeutic in 56.5%, staging in 39.5%, and restaging in 0.8%. Accessory spleens were found in 49 (12.5%) in Series II.

Hematologic Diseases↗

PubMedDate not supplied

Portal system thrombosis after splenectomy for neoplasm or chronic hematologic disorder: is routine surveillance imaging necessary?

PURPOSE: This study was undertaken to assess the frequency and sequelae of portal system thrombosis (PST) after splenectomy in patients with cancer or chronic hematologic disorders and to determine whether routine surveillance imaging for this potential complication is warranted. METHOD: The radiology reports of 203 consecutive patients with cancer or chronic hematologic disorders who underwent splenectomy between January 1990 and January 1997 were reviewed. Imaging examinations and medical records were reviewed for those in whom PST was found after splenectomy. RESULTS: One hundred twenty-three patients (60.6%) underwent CT (n = 88), sonography (n = 10), or both (n = 24) after splenectomy; one other patient underwent MRI. Twelve of these patients (9.8%) had thrombosis of the splenic, portal, and/or superior mesenteric veins. Their underlying diseases were myelofibrosis/ myelodysplastic syndrome (n = 8), lymphoma (n = 3), and leukemia (n = 1). At follow-up imaging (obtained in 10 of the 12 patients), PST had resolved (n = 5), worsened (n = 2), improved (n = 1), remained unchanged (n = 1), or resulted in cavernous transformation of the portal vein (n = 1). Nine of 12 patients were symptomatic. No patient died of PST. CONCLUSION: PST was an uncommon and typically unsuspected finding after splenectomy in this patient population, and no serious sequelae of PST were found. Routine surveillance imaging for PST after splenectomy does not seem warranted, but in symptomatic patients (particularly those with myelofibrosis/myelodysplastic syndrome), a high clinical suspicion and a low threshold for obtaining imaging examinations are needed.

Adult↗

PubMed1986

Late septic complications in adults following splenectomy for trauma: a prospective analysis in 144 patients.

One hundred forty-four patients were prospectively followed through our Asplenic Registry for the development of late septic complications following splenectomy for trauma. There were 114 males and 30 females with a mean age of 28.6 years. The total time of followup was 8,810 patient months with a mean followup of 61 months (range, 12-144 months). Indications for splenectomy were blunt trauma, 111 patients; penetrating trauma, six patients; and intra-operative injury, 27 patients. During the followup to date, 15 late major septic complications requiring hospitalization have occurred in 13 patients (9%). Fulminant pneumococcal sepsis resulted in the death of a 27-year-old male, 3 years after splenectomy. Septicemia occurred in four patients, pneumonia in five, abscess in two, infection of a prosthetic heart valve in one, meningitis in one, and fever of unknown origin in one. All but two of these infections were due to encapsulated organisms. Minor septic complications occurred in 44 patients (30%), and consisted of infections which required outpatient medical care. Major late septic complications occurred more frequently following incidental splenectomy than following splenectomy for blunt or penetrating trauma (18.5% and 5.9% respectively; p less than 0.05). The mortality from major septic complications in this series (7%) is lower than previously reported by other investigators (30-80%). Our data suggest that adults undergoing splenectomy for trauma are at an increased risk of developing late major septic complications. This risk is significant enough to warrant attempts at splenic salvage, especially when injury is incidental to an elective operative procedure.(ABSTRACT TRUNCATED AT 250 WORDS)

Abscess↗

PubMed2002

Continuous fluid resuscitation and splenectomy for treatment of uncontrolled hemorrhagic shock after massive splenic injury.

BACKGROUND: Using a standardized massive splenic injury (MSI) model of uncontrolled hemorrhagic shock, we studied the effect of continuous fluid resuscitation and splenectomy on the hemodynamic response and survival in rats. METHODS: The animals were randomized into seven groups: group 1 (n = 8), sham-operated; group 2 (n = 8), MSI untreated; group 3 (n = 8), MSI treated with 7.5 mL/kg/h of 7.5% NaCl (hypertonic saline [HTS]) for 1 hour; group 4 (n = 8), MSI treated with 7.5 mL/kg/h hydroxyethyl starch (HES-7.5) for 1 hour; group 5 (n = 8) MSI treated with 35 mL/kg/h Ringer's lactate (RL) solution (RL-35) for 1 hour; group 6 (n = 8) MSI treated with 70 mL/kg/h RL for 1 hour (RL-70); and group 7 (n = 8), MSI treated with 105 mL/kg/h RL for 1 hour (RL-105). In all MSI groups, splenectomy was performed 45 minutes after injury. RESULTS: MSI in untreated group 2 resulted in a fall of mean arterial pressure from 105.9 +/- 10.7 mm Hg to 27.0 +/- 6.7 mm Hg (p < 0.001) in 60 minutes. Mean survival time after splenectomy in this group was 160.7 +/- 29.7 minutes, and total blood loss was 34.8 +/- 4.7% of blood volume. Continuous HTS infusion with splenectomy in group 3 was followed by a total blood loss of 38.7 +/- 4.4% and mean survival time was 176.5 +/- 23.2 minutes. HES-7.5 infusion and splenectomy was followed by a total blood loss of 39.6 +/- 2.5% and survival time was 171.6 +/- 19.5 minutes. Continuous infusion of increasing volumes of RL in groups 5, 6, and 7 was followed by increase in blood loss to 29.0 +/- 4.1%, 50.2 +/- 3.1% (p < 0.001), and 62.7 +/- 7.1% (p < 0.002) of total blood volume, respectively. Mean survival time in groups 5, 6, and 7 was 233.5 +/- 6.5 minutes (p < 0.04), 207.6 +/- 17.0 minutes (p < 0.05), and 158 +/- 26 minutes, respectively. CONCLUSION: Continuous infusion of large-volume RL and splenectomy after massive splenic injury resulted in a significant increase in intra-abdominal bleeding and shortened survival time compared with small-volume RL infusion.

Animals↗

PubMedDate not supplied

Splenic complications of the sickling syndromes and the role of splenectomy.

PURPOSE: To analyze the authors' experience with splenectomy for sickling disorders and evaluate the indications, complications, and outcome. PATIENTS AND METHODS: Over a period of 10 years (1987-1997), 113 patients with sickling disorders (100 with sickle cell disease and 13 with sickle-beta-thalassemia) had splenectomy at the authors' hospital as part of their management. The indications for splenectomy were hypersplenism (26 patients), major splenic sequestration crisis (MSSC) (23 patients), minor recurrent splenic sequestration crisis (MRSSC) (50 patients), splenic abscess (12 patients), and massive splenic infarction (2 patients). RESULTS: Splenectomy in patients with sickle cell disease (SCD) and sickle-beta-thalassemia (S-beta-Thal) was beneficial in reducing their transfusion requirements and its attendant risks, eliminating the discomfort from mechanical pressure of the enlarged spleen, and avoiding the risks of acute splenic sequestration crisis. It also was curative for patients with splenic abscess and massive splenic infarction. Twenty-four patients with SCD (24%) had splenectomy and cholecystectomy caused by concomitant gallstones. There was no mortality, and the postoperative morbidity was 7%. CONCLUSIONS: With careful perioperative management, splenectomy is both safe and beneficial in a select group of patients with SCD and S-beta-Thal.

Abdominal Abscess↗

PubMed2005

High incidence of thrombosis of the portal venous system after laparoscopic splenectomy: a prospective study with contrast-enhanced CT scan.

OBJECTIVE: The aims of this prospective study were to investigate the true incidence of portal or splenic vein thrombosis (PSVT) after elective laparoscopic splenectomy using contrast-enhanced computed tomography (CT) scan, and outcome of anticoagulant therapy for PSVT. SUMMARY BACKGROUND DATA: Although rare, thrombosis of the portal venous system is considered a possible cause of death after splenectomy. The reported incidence of ultrasonographically detected PSVT after elective open splenectomy ranges from 6.3% to 10%. METHODS: Twenty-two patients underwent laparoscopic splenectomy (LS group), and 21 patients underwent open splenectomy (OS group). Preoperative and postoperative helical CT with contrast were obtained in all patients, and the extent of thrombosis was investigated. Prothrombotic disorder was also determined. RESULTS: PSVT occurred in 12 (55%) patients of the LS group, but in only 4 (19%) of the OS group. The difference was significant (P = 0.03). Clinical symptoms appeared in 4 of the 12 LS patients. Thrombosis occurred in the intrahepatic portal vein (n = 9), extrahepatic portal vein (n = 2), mesenteric veins (n = 1), proximal splenic vein (n = 4), and distal splenic vein (n = 8). Prothrombotic disorder was diagnosed in 1 patient. Anticoagulant therapy was initiated once the diagnosis was established, and complete recanalization, except for distal splenic vein, was observed without any adverse event. Patients with splenomegaly were at high risk of PSVT. CONCLUSIONS: PSVT is a more frequent complication of laparoscopic splenectomy than previously reported but can be treated safely following early detection by CT with contrast.

Aged↗

PubMed2004

Hospital factors associated with splenectomy for splenic injury: a national perspective.

BACKGROUND: The management of patients with splenic injury has shifted from routine splenectomy to attempts at splenic salvage. Using the Healthcare Cost and Utilization Project's National Inpatient Sample (HCUP-NIS), we assessed the patterns of care for splenic trauma. We hypothesized that the processes of care in urban and rural hospitals would differ. METHODS: Generalized estimating equations were used to identify predictor variables associated with laparotomy and splenectomy from a national, population-based sample of inpatients (HCUP-NIS). Fourteen thousand nine hundred one patients with an International Classification of Diseases, Ninth Revision, Clinical Modification discharge diagnosis code of 865 were selected from the 1998 to 2000 HCUP-NIS data. Exclusion criteria included age greater than 80 years. Analyses were compared using all patients and excluding patients who died during the first 2 hospital days. RESULTS: Eight thousand five hundred fifty-three patients were treated in urban teaching hospitals. Forty percent underwent a laparotomy and 28% underwent a splenectomy at that time. Another 4,461 patients were cared for in urban nonteaching hospitals. Of these, 46% had a laparotomy and 35% underwent a splenectomy. The remaining 1,887 patients were seen in rural hospitals. Forty-six percent had a laparotomy and 36% had a splenectomy. Patients in urban teaching hospitals had lower risk-adjusted odds of splenectomy in multivariate models controlling for confounders including overall injury severity. Overall splenic salvage increased from 1998 to 2000, primarily because of increased salvage rates among urban teaching hospitals. CONCLUSION: The management of patients with splenic injury differs among urban teaching, urban nonteaching, and rural hospitals. Surgeons at urban teaching hospitals appear more willing to attempt splenic salvage by means of nonoperative management.

Abdominal Injuries↗

PubMed2005

White blood cell and platelet counts can be used to differentiate between infection and the normal response after splenectomy for trauma: prospective validation.

BACKGROUND: Transient elevations of the serum white blood cell count (WBC) and platelet count (PC) are normal physiologic responses after splenectomy. The clinician is often challenged to identify an infection in a postsplenectomy patient with an elevated WBC. A previous retrospective study found that a WBC greater than 15 x 10/microL and a PC/WBC ratio < 20 on postoperative day 5, in addition to an Injury Severity Score > 16, were highly associated with infection and should not be considered as part of the physiologic response to splenectomy. The current study intends to prospectively validate the WBC and PC/WBC ratio on postoperative day 5 as markers of infection after splenectomy for trauma. METHODS: Consecutive trauma patients admitted to an urban, Level I trauma center who underwent splenectomy from June 2002 to December 2004 were collected prospectively. In addition to admission demographics, variables collected included daily WBC, PC, and PC/WBC ratio during the first 10 postoperative days. Outcome was the presence of infection. Patients with infection (infected group) were compared with those without infection (noninfected group). Injury Severity Score > 16, postoperative day 5 WBC > 15 x 10/microL, and PC/WBC ratio < 20 were investigated as risk factors for postsplenectomy infection. RESULTS: There were 96 trauma patients who underwent splenectomy during the study period, and 44 (46%) developed a postoperative infection. Infectious complications included pneumonia (n = 30 [31%]), followed by septicemia (n = 20 [21%]), urinary tract infection (n = 12 [13), abdominal abscess (n = 9 [9%]), and wound infection (n = 4 [4%]). Postoperative day 5 was the first day that infected patients had a higher WBC (16 +/- 6 x 10/microL vs. 14 +/- 4 x 10/microL, p = 0.03) and a lower PC/WBC ratio (15 +/- 9 vs. 24 +/- 12, p = 0.002) than noninfected patients. The presence of two or more risk factors for infection was associated with a 79% rate of infection, and no patient developed an infection if all three risk factors were absent. CONCLUSION: On postoperative day 5 after splenectomy for trauma, a WBC greater than 15 x 10/microL and a PC/WBC ratio less than 20 are reliable markers of infection.

Adult↗

PubMed1975

Splenectomy in homozygous beta thalassaemia: a retrospective study of 30 patients.

In order to clarify the indications for splenectomy in patients with homozygous beta thalassaemia we studied, retrospectively, the basal pre-transfusion haemoglobin levels and blood transfusion requirements before and after splenectomy, in a series of patients with this disorder. Thirty-six patients, of whom 20 underwent splenectomy, were included in this study. Three groups of patients with homozygous beta thalassaemia were identified on the basis of clinical and laboratory findings. Two of the three groups consisted of 24 patients with beta thalassaemia major, subdivided retrospectively according to their response to splenectomy. The third group consisted of six patients with beta thalassaemia intermedia who had a comparably mild clinical course. In the first group of 16 patients with beta thalassemia major, monthly transfusions were required from the age of 6 months to 24 months and splenectomy resulted in temporary improvement for a period of 1-2 years. Thereafter, the transfusion requirements returned to pre-operative levels with no sustained improvements in base-line pretransfusion haemoglobin levels. Despite the fact that haematological improvement was temporary, it is felt that splenectomy is indicated in this group since the development and the general well-being of the children was significantly improved. In the second group of eight patients with beta thalassaemia major, transfusion requirements were relatively infrequent before 1-2 years, but after several years the transfusion requirement increased simultaneously with the development of 'hypersplenism'.

Adolescent↗