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Surgery_Schwartz_10102 | Surgery_Schwartz | has been tried as a second line agent in refractory Felty’s syndrome.106,107Overall response to splenectomy is excellent, with >80% of patients showing a durable increase in white blood cell count. More than one-half of patients who had infections before surgery may clear their infections after surgery.108 Besides symptomatic neutropenia, other indications for sple-nectomy include transfusion-dependent anemia and profound thrombocytopenia.Wandering Spleen A very uncommon anatomic abnormality is the “wandering spleen.” In this condition, the spleen “floats” inside the abdominal cavity due to an anomaly during embryo-genesis and may present itself in a variety of ways includ-ing acute abdomen.109 The wandering spleen is not normally attached to adjacent viscera in the splenic fossa. This may lead to splenic torsion and infarction. Splenopexy or splenectomy may be required.110Partial Splenectomy and Splenic Salvage. The increased awareness of asplenia-related life-threatening | Surgery_Schwartz. has been tried as a second line agent in refractory Felty’s syndrome.106,107Overall response to splenectomy is excellent, with >80% of patients showing a durable increase in white blood cell count. More than one-half of patients who had infections before surgery may clear their infections after surgery.108 Besides symptomatic neutropenia, other indications for sple-nectomy include transfusion-dependent anemia and profound thrombocytopenia.Wandering Spleen A very uncommon anatomic abnormality is the “wandering spleen.” In this condition, the spleen “floats” inside the abdominal cavity due to an anomaly during embryo-genesis and may present itself in a variety of ways includ-ing acute abdomen.109 The wandering spleen is not normally attached to adjacent viscera in the splenic fossa. This may lead to splenic torsion and infarction. Splenopexy or splenectomy may be required.110Partial Splenectomy and Splenic Salvage. The increased awareness of asplenia-related life-threatening |
Surgery_Schwartz_10103 | Surgery_Schwartz | This may lead to splenic torsion and infarction. Splenopexy or splenectomy may be required.110Partial Splenectomy and Splenic Salvage. The increased awareness of asplenia-related life-threatening complications such as overwhelming postsplenectomy infection (OPSI) has led to the development of parenchyma sparing splenic resec-tions for select patients and disorders. The first successful partial splenectomy was reported in 1979 by Shapiro and was followed by Uranus who would perform the first laparoscopic partial splenectomy in 1995.111,112 Previously, many surgeons had been reluctant to perform partial splenectomy because of the technical difficulties and bleeding risk. However, with a better understanding of the segmental vascular anatomy of the spleen and the development of improved laparoscopic skills and technologies, laparoscopic partial splenectomy has been used successfully in patients with hematologic diseases such as hereditary spherocytosis in children, who may benefit the | Surgery_Schwartz. This may lead to splenic torsion and infarction. Splenopexy or splenectomy may be required.110Partial Splenectomy and Splenic Salvage. The increased awareness of asplenia-related life-threatening complications such as overwhelming postsplenectomy infection (OPSI) has led to the development of parenchyma sparing splenic resec-tions for select patients and disorders. The first successful partial splenectomy was reported in 1979 by Shapiro and was followed by Uranus who would perform the first laparoscopic partial splenectomy in 1995.111,112 Previously, many surgeons had been reluctant to perform partial splenectomy because of the technical difficulties and bleeding risk. However, with a better understanding of the segmental vascular anatomy of the spleen and the development of improved laparoscopic skills and technologies, laparoscopic partial splenectomy has been used successfully in patients with hematologic diseases such as hereditary spherocytosis in children, who may benefit the |
Surgery_Schwartz_10104 | Surgery_Schwartz | skills and technologies, laparoscopic partial splenectomy has been used successfully in patients with hematologic diseases such as hereditary spherocytosis in children, who may benefit the most from splenic preservation, as well as for benign splenic cysts.113-119 The technique of partial splenectomy will be dis-cussed later in this chapter.IMAGING FOR EVALUATION OF SIZE AND PATHOLOGYThorough assessment of anatomic detail and functional status of the spleen are essential for proper surgical planning. Spe-cial preoperative consideration needs to be given to patients with splenomegaly because minimally invasive methods of resection may be fraught with additional difficulty in patients with very large spleens, even in skilled hands. Other indica-tions for splenic imaging include trauma, investigations of left upper quadrant pain, characterization of splenic lesions such as tumors, cysts, and abscesses, and guidance for percutaneous procedures.165,166Preoperative imaging of the spleen is | Surgery_Schwartz. skills and technologies, laparoscopic partial splenectomy has been used successfully in patients with hematologic diseases such as hereditary spherocytosis in children, who may benefit the most from splenic preservation, as well as for benign splenic cysts.113-119 The technique of partial splenectomy will be dis-cussed later in this chapter.IMAGING FOR EVALUATION OF SIZE AND PATHOLOGYThorough assessment of anatomic detail and functional status of the spleen are essential for proper surgical planning. Spe-cial preoperative consideration needs to be given to patients with splenomegaly because minimally invasive methods of resection may be fraught with additional difficulty in patients with very large spleens, even in skilled hands. Other indica-tions for splenic imaging include trauma, investigations of left upper quadrant pain, characterization of splenic lesions such as tumors, cysts, and abscesses, and guidance for percutaneous procedures.165,166Preoperative imaging of the spleen is |
Surgery_Schwartz_10105 | Surgery_Schwartz | of left upper quadrant pain, characterization of splenic lesions such as tumors, cysts, and abscesses, and guidance for percutaneous procedures.165,166Preoperative imaging of the spleen is primarily performed to obtain an accurate assessment of the splenic volume in order to confirm and document splenomegaly as well as to exclude any large splenic lesion that could affect the surgical resection plane. Identification of the presence of accessory spleens in the preoperative setting is also important, although lack of acces-sory tissue on the imaging should not preclude a thorough intra-operative search.The guidelines of the European Association for Endo-scopic Surgery suggest that for all patients in whom splenec-tomy is indicated, preoperative imaging should be obtained.24 Two of the most commonly used imaging modalities include ultrasound and CT, both enabling measurement of splenic size and volume. When desired, the splenic volume may be calcu-lated using a formula for the volume of | Surgery_Schwartz. of left upper quadrant pain, characterization of splenic lesions such as tumors, cysts, and abscesses, and guidance for percutaneous procedures.165,166Preoperative imaging of the spleen is primarily performed to obtain an accurate assessment of the splenic volume in order to confirm and document splenomegaly as well as to exclude any large splenic lesion that could affect the surgical resection plane. Identification of the presence of accessory spleens in the preoperative setting is also important, although lack of acces-sory tissue on the imaging should not preclude a thorough intra-operative search.The guidelines of the European Association for Endo-scopic Surgery suggest that for all patients in whom splenec-tomy is indicated, preoperative imaging should be obtained.24 Two of the most commonly used imaging modalities include ultrasound and CT, both enabling measurement of splenic size and volume. When desired, the splenic volume may be calcu-lated using a formula for the volume of |
Surgery_Schwartz_10106 | Surgery_Schwartz | commonly used imaging modalities include ultrasound and CT, both enabling measurement of splenic size and volume. When desired, the splenic volume may be calcu-lated using a formula for the volume of a prolate ellipsoid:Volume (cc) = length (cm) × width (cm) × height (cm) × 0.52.64Other imaging modalities, although not as commonly used, include nuclear medicine studies and magnetic resonance imaging (MRI).PREOPERATIVE CONSIDERATIONSAs part of preoperative discussion prior to splenectomy, patients should be consulted on potential complications associated with this procedure, including overwhelming postsplenectomy sepsis, splenic vein thrombosis, bleeding, arterial thrombosis (myocardial infarction, stroke), deep vein thrombosis, and pul-monary hypertension.Vaccination and Patient EducationConsidering that infection is the most common complication, patient education and vaccinations against encapsulated pathogens are the mainstay of preventive therapy.52,120 Although rare, the most | Surgery_Schwartz. commonly used imaging modalities include ultrasound and CT, both enabling measurement of splenic size and volume. When desired, the splenic volume may be calcu-lated using a formula for the volume of a prolate ellipsoid:Volume (cc) = length (cm) × width (cm) × height (cm) × 0.52.64Other imaging modalities, although not as commonly used, include nuclear medicine studies and magnetic resonance imaging (MRI).PREOPERATIVE CONSIDERATIONSAs part of preoperative discussion prior to splenectomy, patients should be consulted on potential complications associated with this procedure, including overwhelming postsplenectomy sepsis, splenic vein thrombosis, bleeding, arterial thrombosis (myocardial infarction, stroke), deep vein thrombosis, and pul-monary hypertension.Vaccination and Patient EducationConsidering that infection is the most common complication, patient education and vaccinations against encapsulated pathogens are the mainstay of preventive therapy.52,120 Although rare, the most |
Surgery_Schwartz_10107 | Surgery_Schwartz | that infection is the most common complication, patient education and vaccinations against encapsulated pathogens are the mainstay of preventive therapy.52,120 Although rare, the most feared and extreme infectious complica-tion is overwhelming postsplenectomy sepsis (OPSI). (See later section, “Overwhelming Postsplenectomy Infection,” for detailed discussion.) Patients undergoing splenectomy for hematologic or malignant indications have the greatest risk, whereas patients who undergo splenectomy for trauma or iatro-genic injury have the lowest risk. OPSI is more common in the pediatric population, with 4.4% of children less than 16 years of age versus 0.9% of adults developing this life-threatening condi-tion. The risk has been observed to be the greatest in the first 2 years after splenectomy; however, asplenic patients remain at lifelong risk.121-123 Considering that the spleen is the site for spe-cial adaptation of macrophages that target encapsulated organ-isms, asplenic patients | Surgery_Schwartz. that infection is the most common complication, patient education and vaccinations against encapsulated pathogens are the mainstay of preventive therapy.52,120 Although rare, the most feared and extreme infectious complica-tion is overwhelming postsplenectomy sepsis (OPSI). (See later section, “Overwhelming Postsplenectomy Infection,” for detailed discussion.) Patients undergoing splenectomy for hematologic or malignant indications have the greatest risk, whereas patients who undergo splenectomy for trauma or iatro-genic injury have the lowest risk. OPSI is more common in the pediatric population, with 4.4% of children less than 16 years of age versus 0.9% of adults developing this life-threatening condi-tion. The risk has been observed to be the greatest in the first 2 years after splenectomy; however, asplenic patients remain at lifelong risk.121-123 Considering that the spleen is the site for spe-cial adaptation of macrophages that target encapsulated organ-isms, asplenic patients |
Surgery_Schwartz_10108 | Surgery_Schwartz | however, asplenic patients remain at lifelong risk.121-123 Considering that the spleen is the site for spe-cial adaptation of macrophages that target encapsulated organ-isms, asplenic patients are at higher risk of infection caused by Streptococcus pneumoniae (responsible for >50% of OPSI), H influenzae type b, Neisseria meningitidis, and Capnocytoph-aga canimorsus (transmitted by dog bites).124In the setting of elective splenectomy, patients should be vaccinated two weeks prior to surgery to optimize anti-gen recognition and processing. If splenectomy is performed emergently, vaccinations can be administered postoperatively and consideration should be given to delaying administration 7Brunicardi_Ch34_p1517-p1548.indd 153223/02/19 2:37 PM 1533THE SPLEENCHAPTER 34for 2 weeks to avoid the transient immunosuppression asso-ciated with surgery. International guidelines also recommend annual influenza vaccine for asplenic patients. The influenza vaccination provides protection from | Surgery_Schwartz. however, asplenic patients remain at lifelong risk.121-123 Considering that the spleen is the site for spe-cial adaptation of macrophages that target encapsulated organ-isms, asplenic patients are at higher risk of infection caused by Streptococcus pneumoniae (responsible for >50% of OPSI), H influenzae type b, Neisseria meningitidis, and Capnocytoph-aga canimorsus (transmitted by dog bites).124In the setting of elective splenectomy, patients should be vaccinated two weeks prior to surgery to optimize anti-gen recognition and processing. If splenectomy is performed emergently, vaccinations can be administered postoperatively and consideration should be given to delaying administration 7Brunicardi_Ch34_p1517-p1548.indd 153223/02/19 2:37 PM 1533THE SPLEENCHAPTER 34for 2 weeks to avoid the transient immunosuppression asso-ciated with surgery. International guidelines also recommend annual influenza vaccine for asplenic patients. The influenza vaccination provides protection from |
Surgery_Schwartz_10109 | Surgery_Schwartz | the transient immunosuppression asso-ciated with surgery. International guidelines also recommend annual influenza vaccine for asplenic patients. The influenza vaccination provides protection from influenza syndrome and secondary bacterial infection. This immunization is associated with a 54% reduced risk of death compared with unimmunized asplenic persons.125Preoperative and postoperative patient education regard-ing OPSI is paramount because patients with OPSI may rap-idly progress from a febrile illness to circulatory collapse and death within a matter of hours. In one study, 28% of asplenic patients were unaware of the potential infection risks, and the main reasons for this lack of awareness were that correct advice was not given or that that advice was forgotten.121,126 The use of currently available vaccines against pneumococcus and other encapsulated organisms has led to a drop in the overall inci-dence of OPSI to <1%. The mechanism by which vaccination protects asplenic | Surgery_Schwartz. the transient immunosuppression asso-ciated with surgery. International guidelines also recommend annual influenza vaccine for asplenic patients. The influenza vaccination provides protection from influenza syndrome and secondary bacterial infection. This immunization is associated with a 54% reduced risk of death compared with unimmunized asplenic persons.125Preoperative and postoperative patient education regard-ing OPSI is paramount because patients with OPSI may rap-idly progress from a febrile illness to circulatory collapse and death within a matter of hours. In one study, 28% of asplenic patients were unaware of the potential infection risks, and the main reasons for this lack of awareness were that correct advice was not given or that that advice was forgotten.121,126 The use of currently available vaccines against pneumococcus and other encapsulated organisms has led to a drop in the overall inci-dence of OPSI to <1%. The mechanism by which vaccination protects asplenic |
Surgery_Schwartz_10110 | Surgery_Schwartz | of currently available vaccines against pneumococcus and other encapsulated organisms has led to a drop in the overall inci-dence of OPSI to <1%. The mechanism by which vaccination protects asplenic patients is not entirely understood. Serum anti-body titers do not necessarily correspond to clinical immunity. Moreover, antibody levels after pneumococcus vaccination decline steadily within 5 to 10 years. Revaccination is reason-ably recommended for these patients, although the efficacy of this measure is not proven.121-124,126Deep Vein Thrombosis ProphylaxisDeep vein thrombosis (DVT) after splenectomy is not infre-quent, especially in cases involving splenomegaly and myelo-proliferative disorders.76 Risk of portal vein thrombosis (PVT) may reach 50% for patients presenting with both splenomegaly and myeloproliferative disorders.127,128Postsplenectomy PVT typically presents with anorexia, abdominal pain, leukocytosis, and thrombocytosis. Effective PVT treatment is possible by | Surgery_Schwartz. of currently available vaccines against pneumococcus and other encapsulated organisms has led to a drop in the overall inci-dence of OPSI to <1%. The mechanism by which vaccination protects asplenic patients is not entirely understood. Serum anti-body titers do not necessarily correspond to clinical immunity. Moreover, antibody levels after pneumococcus vaccination decline steadily within 5 to 10 years. Revaccination is reason-ably recommended for these patients, although the efficacy of this measure is not proven.121-124,126Deep Vein Thrombosis ProphylaxisDeep vein thrombosis (DVT) after splenectomy is not infre-quent, especially in cases involving splenomegaly and myelo-proliferative disorders.76 Risk of portal vein thrombosis (PVT) may reach 50% for patients presenting with both splenomegaly and myeloproliferative disorders.127,128Postsplenectomy PVT typically presents with anorexia, abdominal pain, leukocytosis, and thrombocytosis. Effective PVT treatment is possible by |
Surgery_Schwartz_10111 | Surgery_Schwartz | splenomegaly and myeloproliferative disorders.127,128Postsplenectomy PVT typically presents with anorexia, abdominal pain, leukocytosis, and thrombocytosis. Effective PVT treatment is possible by maintaining a high index of sus-picion, achieving early diagnosis with contrast enhanced CT, and starting anticoagulation immediately. DVT prophylaxis, including use of sequential compression devices and subcu-taneous administration of heparin (5000 U), should be initi-ated for patients undergoing splenectomy.16,77 Each patient’s risk factors for DVT should be evaluated, and when elevated risk exists (obesity, history of prior venous thromboembolism, known hypercoagulable state, older age), a postoperative anti-thrombotic regimen of up to two weeks of low molecular weight heparin should be maintained.SPLENECTOMY TECHNIQUESPatient PreparationAssessment of the potential need for transfusion of blood products and optimization of preoperative coagulation status are necessary. It is the authors’ | Surgery_Schwartz. splenomegaly and myeloproliferative disorders.127,128Postsplenectomy PVT typically presents with anorexia, abdominal pain, leukocytosis, and thrombocytosis. Effective PVT treatment is possible by maintaining a high index of sus-picion, achieving early diagnosis with contrast enhanced CT, and starting anticoagulation immediately. DVT prophylaxis, including use of sequential compression devices and subcu-taneous administration of heparin (5000 U), should be initi-ated for patients undergoing splenectomy.16,77 Each patient’s risk factors for DVT should be evaluated, and when elevated risk exists (obesity, history of prior venous thromboembolism, known hypercoagulable state, older age), a postoperative anti-thrombotic regimen of up to two weeks of low molecular weight heparin should be maintained.SPLENECTOMY TECHNIQUESPatient PreparationAssessment of the potential need for transfusion of blood products and optimization of preoperative coagulation status are necessary. It is the authors’ |
Surgery_Schwartz_10112 | Surgery_Schwartz | TECHNIQUESPatient PreparationAssessment of the potential need for transfusion of blood products and optimization of preoperative coagulation status are necessary. It is the authors’ practice to order blood typing and antibody screening tests for normosplenic patients under-going elective splenectomy. Anemic patients should be trans-fused before surgery to a hemoglobin level of 10 g/dL. In more complex cases, including patients with splenomegaly, at least 2 to 4 units of cross-matched blood should be available at the time of surgery. Thrombocytopenia may be transiently cor-rected with platelet transfusions. Thrombocytopenic patients preferably should not undergo transfusion before the day of surgery and ideally not before the intraoperative ligation of the splenic artery. Several authors recommended a platelet count of 30 × 109 / L before the surgery; this may require treatment with IV immunoglobulin or oral corticosteroids if the platelets are below this number. Pooled normal human | Surgery_Schwartz. TECHNIQUESPatient PreparationAssessment of the potential need for transfusion of blood products and optimization of preoperative coagulation status are necessary. It is the authors’ practice to order blood typing and antibody screening tests for normosplenic patients under-going elective splenectomy. Anemic patients should be trans-fused before surgery to a hemoglobin level of 10 g/dL. In more complex cases, including patients with splenomegaly, at least 2 to 4 units of cross-matched blood should be available at the time of surgery. Thrombocytopenia may be transiently cor-rected with platelet transfusions. Thrombocytopenic patients preferably should not undergo transfusion before the day of surgery and ideally not before the intraoperative ligation of the splenic artery. Several authors recommended a platelet count of 30 × 109 / L before the surgery; this may require treatment with IV immunoglobulin or oral corticosteroids if the platelets are below this number. Pooled normal human |
Surgery_Schwartz_10113 | Surgery_Schwartz | recommended a platelet count of 30 × 109 / L before the surgery; this may require treatment with IV immunoglobulin or oral corticosteroids if the platelets are below this number. Pooled normal human immunoglobulin is effective in elevating the platelet count in approximately 75% of patients.129-131Patients who have been maintained on corticosteroid therapy preoperatively should receive parenteral corticosteroid therapy perioperatively. Bowel preparation is not routinely performed for patients undergoing elective splenectomy. All splenectomy patients do receive DVT prophylaxis, as discussed previously. After endotracheal intubation, a nasogastric (NG) tube is inserted for stomach decompression.Open SplenectomyAlthough laparoscopic surgery increasingly has achieved acceptance as the standard approach for normosplenic patients requiring splenectomy, open splenectomy (OS) is still widely practiced. The largest published series is a report of the Nationwide Inpatient Sample (NIS), where of | Surgery_Schwartz. recommended a platelet count of 30 × 109 / L before the surgery; this may require treatment with IV immunoglobulin or oral corticosteroids if the platelets are below this number. Pooled normal human immunoglobulin is effective in elevating the platelet count in approximately 75% of patients.129-131Patients who have been maintained on corticosteroid therapy preoperatively should receive parenteral corticosteroid therapy perioperatively. Bowel preparation is not routinely performed for patients undergoing elective splenectomy. All splenectomy patients do receive DVT prophylaxis, as discussed previously. After endotracheal intubation, a nasogastric (NG) tube is inserted for stomach decompression.Open SplenectomyAlthough laparoscopic surgery increasingly has achieved acceptance as the standard approach for normosplenic patients requiring splenectomy, open splenectomy (OS) is still widely practiced. The largest published series is a report of the Nationwide Inpatient Sample (NIS), where of |
Surgery_Schwartz_10114 | Surgery_Schwartz | approach for normosplenic patients requiring splenectomy, open splenectomy (OS) is still widely practiced. The largest published series is a report of the Nationwide Inpatient Sample (NIS), where of 37,006 nontrau-matic splenectomies identified during a 6-year study period (2005–2010), 81.4% of those cases were approached by open surgery.132Traumatic rupture of the spleen continues as the most common indication for OS. Several other clinical scenarios favor an OS approach, including massive splenomegaly, ascites, portal hypertension, multiple prior operations, extensive splenic irradiation, and possible splenic abscess.During OS, the patient is placed in the supine position with the surgeon situated at the patient’s right. A left subcostal incision paralleling the left costal margin and lying two finger-breadths below it is preferred for most elective splenectomies. A midline incision is optimal for exposure when the spleen is ruptured or massively enlarged. The spleen is mobilized by | Surgery_Schwartz. approach for normosplenic patients requiring splenectomy, open splenectomy (OS) is still widely practiced. The largest published series is a report of the Nationwide Inpatient Sample (NIS), where of 37,006 nontrau-matic splenectomies identified during a 6-year study period (2005–2010), 81.4% of those cases were approached by open surgery.132Traumatic rupture of the spleen continues as the most common indication for OS. Several other clinical scenarios favor an OS approach, including massive splenomegaly, ascites, portal hypertension, multiple prior operations, extensive splenic irradiation, and possible splenic abscess.During OS, the patient is placed in the supine position with the surgeon situated at the patient’s right. A left subcostal incision paralleling the left costal margin and lying two finger-breadths below it is preferred for most elective splenectomies. A midline incision is optimal for exposure when the spleen is ruptured or massively enlarged. The spleen is mobilized by |
Surgery_Schwartz_10115 | Surgery_Schwartz | two finger-breadths below it is preferred for most elective splenectomies. A midline incision is optimal for exposure when the spleen is ruptured or massively enlarged. The spleen is mobilized by dividing ligamentous attachments, usually beginning with the splenocolic ligament (Fig. 34-6). In patients with signifi-cant splenomegaly, once lesser sac access has been achieved through either the gastrosplenic or gastrohepatic attachments, ligating the splenic artery in continuity along the superior bor-der of the pancreas may be preferable. This maneuver may serve several purposes: allowing safer manipulation of the Figure 34-6. Splenocolic ligament is divided at the beginning of open splenectomy.Brunicardi_Ch34_p1517-p1548.indd 153323/02/19 2:37 PM 1534SPECIFIC CONSIDERATIONSPART II5-mm cephalad working port5-mm camera port with 30’ scope2-mm accessory port (flank)10/12-mm caudad working portFigure 34-7. Patient positioning and trocar placement for laparoscopic splenectomy.spleen and | Surgery_Schwartz. two finger-breadths below it is preferred for most elective splenectomies. A midline incision is optimal for exposure when the spleen is ruptured or massively enlarged. The spleen is mobilized by dividing ligamentous attachments, usually beginning with the splenocolic ligament (Fig. 34-6). In patients with signifi-cant splenomegaly, once lesser sac access has been achieved through either the gastrosplenic or gastrohepatic attachments, ligating the splenic artery in continuity along the superior bor-der of the pancreas may be preferable. This maneuver may serve several purposes: allowing safer manipulation of the Figure 34-6. Splenocolic ligament is divided at the beginning of open splenectomy.Brunicardi_Ch34_p1517-p1548.indd 153323/02/19 2:37 PM 1534SPECIFIC CONSIDERATIONSPART II5-mm cephalad working port5-mm camera port with 30’ scope2-mm accessory port (flank)10/12-mm caudad working portFigure 34-7. Patient positioning and trocar placement for laparoscopic splenectomy.spleen and |
Surgery_Schwartz_10116 | Surgery_Schwartz | working port5-mm camera port with 30’ scope2-mm accessory port (flank)10/12-mm caudad working portFigure 34-7. Patient positioning and trocar placement for laparoscopic splenectomy.spleen and dissection of the splenic hilum, facilitating some shrinkage of the spleen, and providing an autotransfusion of erythrocytes and platelets. Further medial mobilization of the spleen is achieved by incising its lateral peritoneal attachments, most notably the splenophrenic ligament. Then follows indi-vidual ligation and sequential division of the short gastric ves-sels, steps that if carefully executed reduce the risk of these vessels’ retracting and bleeding. Splenic hilar dissection then takes place. Whenever possible, care should be taken to dis-sect and individually ligate the splenic artery and vein (in that order) before dividing them. As noted in the discussion of splenic anatomy, the tail of the pancreas lies within 1 cm of the splenic hilum in 75% of patients; therefore, during hilar | Surgery_Schwartz. working port5-mm camera port with 30’ scope2-mm accessory port (flank)10/12-mm caudad working portFigure 34-7. Patient positioning and trocar placement for laparoscopic splenectomy.spleen and dissection of the splenic hilum, facilitating some shrinkage of the spleen, and providing an autotransfusion of erythrocytes and platelets. Further medial mobilization of the spleen is achieved by incising its lateral peritoneal attachments, most notably the splenophrenic ligament. Then follows indi-vidual ligation and sequential division of the short gastric ves-sels, steps that if carefully executed reduce the risk of these vessels’ retracting and bleeding. Splenic hilar dissection then takes place. Whenever possible, care should be taken to dis-sect and individually ligate the splenic artery and vein (in that order) before dividing them. As noted in the discussion of splenic anatomy, the tail of the pancreas lies within 1 cm of the splenic hilum in 75% of patients; therefore, during hilar |
Surgery_Schwartz_10117 | Surgery_Schwartz | vein (in that order) before dividing them. As noted in the discussion of splenic anatomy, the tail of the pancreas lies within 1 cm of the splenic hilum in 75% of patients; therefore, during hilar dissec-tion, great care must be taken to avoid injuring the pancreas. Once the spleen is excised, hemostasis is secured by irrigating, suctioning, and scrupulously inspecting the bed of dissection. The splenic bed is not routinely drained. A thorough search for accessory spleens must be undertaken when a hematologic disorder has occasioned splenectomy. At the completion of sur-gery, the nasogastric tube is removed.Laparoscopic SplenectomyLaparoscopic splenectomy (LS) has become the procedure of choice over the last two decades, since it has been first described Delaitre and Maignien in 1991.133 In fact, LS is now the gold standard for elective splenectomy in patients with normal-sized spleens. In experienced hands, LS is associated with decreased intraoperative blood loss, shorter hospital | Surgery_Schwartz. vein (in that order) before dividing them. As noted in the discussion of splenic anatomy, the tail of the pancreas lies within 1 cm of the splenic hilum in 75% of patients; therefore, during hilar dissec-tion, great care must be taken to avoid injuring the pancreas. Once the spleen is excised, hemostasis is secured by irrigating, suctioning, and scrupulously inspecting the bed of dissection. The splenic bed is not routinely drained. A thorough search for accessory spleens must be undertaken when a hematologic disorder has occasioned splenectomy. At the completion of sur-gery, the nasogastric tube is removed.Laparoscopic SplenectomyLaparoscopic splenectomy (LS) has become the procedure of choice over the last two decades, since it has been first described Delaitre and Maignien in 1991.133 In fact, LS is now the gold standard for elective splenectomy in patients with normal-sized spleens. In experienced hands, LS is associated with decreased intraoperative blood loss, shorter hospital |
Surgery_Schwartz_10118 | Surgery_Schwartz | In fact, LS is now the gold standard for elective splenectomy in patients with normal-sized spleens. In experienced hands, LS is associated with decreased intraoperative blood loss, shorter hospital length of stay, and lower morbidity rates when compared to OS.134,135 Since the introduction of the lateral approach, most LS proce-dures are now performed with the patient in the right lateral decubitus position (Fig. 34-7).136 A midway “double-access” technique in which the patient is in a 45° right lateral decubitus position has also been advocated. This positioning permits con-comitant surgery, such as laparoscopic cholecystectomy, more easily than does the lateral approach. The double-access 8technique requires the placement of five or six trocars. The lateral approach routinely involves the use of three or four trocars posi-tioned as shown in Fig. 34-7. Use of an angled (30° or 45°) lapa-roscope (2, 5, or 10 mm) greatly facilitates the procedure. Exposure of the vital anatomy in a | Surgery_Schwartz. In fact, LS is now the gold standard for elective splenectomy in patients with normal-sized spleens. In experienced hands, LS is associated with decreased intraoperative blood loss, shorter hospital length of stay, and lower morbidity rates when compared to OS.134,135 Since the introduction of the lateral approach, most LS proce-dures are now performed with the patient in the right lateral decubitus position (Fig. 34-7).136 A midway “double-access” technique in which the patient is in a 45° right lateral decubitus position has also been advocated. This positioning permits con-comitant surgery, such as laparoscopic cholecystectomy, more easily than does the lateral approach. The double-access 8technique requires the placement of five or six trocars. The lateral approach routinely involves the use of three or four trocars posi-tioned as shown in Fig. 34-7. Use of an angled (30° or 45°) lapa-roscope (2, 5, or 10 mm) greatly facilitates the procedure. Exposure of the vital anatomy in a |
Surgery_Schwartz_10119 | Surgery_Schwartz | the use of three or four trocars posi-tioned as shown in Fig. 34-7. Use of an angled (30° or 45°) lapa-roscope (2, 5, or 10 mm) greatly facilitates the procedure. Exposure of the vital anatomy in a manner that allows for a more intuitive sequence of dissection, paralleling that of OS, may be considered an additional advantage of the lateral approach.Placement of trocars in the left upper quadrant should be performed under laparoscopic visualization, particularly if any degree of splenomegaly exists, because the latter can sig-nificantly reduce the available operating space. As with OS, the splenocolic ligament and the lateral peritoneal attachments are divided with resultant medial mobilization of the spleen. The short gastric vessels may be divided usually with hemo-static energy sources such as ultrasonic dissection, diathermy, or radiofrequency ablation. With the lower pole of the spleen gently retracted, the splenic hilum is accessible to further appli-cations of clips or an | Surgery_Schwartz. the use of three or four trocars posi-tioned as shown in Fig. 34-7. Use of an angled (30° or 45°) lapa-roscope (2, 5, or 10 mm) greatly facilitates the procedure. Exposure of the vital anatomy in a manner that allows for a more intuitive sequence of dissection, paralleling that of OS, may be considered an additional advantage of the lateral approach.Placement of trocars in the left upper quadrant should be performed under laparoscopic visualization, particularly if any degree of splenomegaly exists, because the latter can sig-nificantly reduce the available operating space. As with OS, the splenocolic ligament and the lateral peritoneal attachments are divided with resultant medial mobilization of the spleen. The short gastric vessels may be divided usually with hemo-static energy sources such as ultrasonic dissection, diathermy, or radiofrequency ablation. With the lower pole of the spleen gently retracted, the splenic hilum is accessible to further appli-cations of clips or an |
Surgery_Schwartz_10120 | Surgery_Schwartz | such as ultrasonic dissection, diathermy, or radiofrequency ablation. With the lower pole of the spleen gently retracted, the splenic hilum is accessible to further appli-cations of clips or an endovascular stapling device. The splenic artery and vein are divided separately when possible. Good long-term outcomes, however, are increasingly being achieved with mass hilar stapling (Fig. 34-8). Using the lateral approach with the spleen thus elevated, the surgeon can easily visualize the tail of the pancreas and avoid injury when placing the endo-vascular stapler within the sack and allows piecemeal extrac-tion; a blunt instrument should be used to disrupt and remove the spleen to avoid the risk of sack rupture, spillage of contents, and subsequent splenosis (Fig. 34-9 and Fig. 34-10).Hand-Assisted SplenectomyWhen LS is performed in patients with splenomegaly, there have been reports of high rates of both complications and con-version to open splenectomy.137 Hand-assisted laparoscopic | Surgery_Schwartz. such as ultrasonic dissection, diathermy, or radiofrequency ablation. With the lower pole of the spleen gently retracted, the splenic hilum is accessible to further appli-cations of clips or an endovascular stapling device. The splenic artery and vein are divided separately when possible. Good long-term outcomes, however, are increasingly being achieved with mass hilar stapling (Fig. 34-8). Using the lateral approach with the spleen thus elevated, the surgeon can easily visualize the tail of the pancreas and avoid injury when placing the endo-vascular stapler within the sack and allows piecemeal extrac-tion; a blunt instrument should be used to disrupt and remove the spleen to avoid the risk of sack rupture, spillage of contents, and subsequent splenosis (Fig. 34-9 and Fig. 34-10).Hand-Assisted SplenectomyWhen LS is performed in patients with splenomegaly, there have been reports of high rates of both complications and con-version to open splenectomy.137 Hand-assisted laparoscopic |
Surgery_Schwartz_10121 | Surgery_Schwartz | SplenectomyWhen LS is performed in patients with splenomegaly, there have been reports of high rates of both complications and con-version to open splenectomy.137 Hand-assisted laparoscopic surgery (HALS) has been described as an alternative to the LS approach.24,138,139 Spleens greater than 22 cm in craniocau-dal length or 19 cm in width may benefit from HALS over a purely laparoscopic approach.139 It has been reported that the Brunicardi_Ch34_p1517-p1548.indd 153423/02/19 2:37 PM 1535THE SPLEENCHAPTER 34Figure 34-8. Splenic hilum can be divided laparoscopically en masse once the spleen has been rotated medially having been mobi-lized from its lateral attachments.ABFigure 34-9. Spleen extraction. A. Spleen is placed into a ripstop nylon bag before morcellation. B. Splenic morcellation.use of this technique has resulted in a marked reduction in aver-age operative time for patients with massive splenomegaly (146 vs. 295 minutes). Although HALS does require a small incision (7–8 cm) | Surgery_Schwartz. SplenectomyWhen LS is performed in patients with splenomegaly, there have been reports of high rates of both complications and con-version to open splenectomy.137 Hand-assisted laparoscopic surgery (HALS) has been described as an alternative to the LS approach.24,138,139 Spleens greater than 22 cm in craniocau-dal length or 19 cm in width may benefit from HALS over a purely laparoscopic approach.139 It has been reported that the Brunicardi_Ch34_p1517-p1548.indd 153423/02/19 2:37 PM 1535THE SPLEENCHAPTER 34Figure 34-8. Splenic hilum can be divided laparoscopically en masse once the spleen has been rotated medially having been mobi-lized from its lateral attachments.ABFigure 34-9. Spleen extraction. A. Spleen is placed into a ripstop nylon bag before morcellation. B. Splenic morcellation.use of this technique has resulted in a marked reduction in aver-age operative time for patients with massive splenomegaly (146 vs. 295 minutes). Although HALS does require a small incision (7–8 cm) |
Surgery_Schwartz_10122 | Surgery_Schwartz | of this technique has resulted in a marked reduction in aver-age operative time for patients with massive splenomegaly (146 vs. 295 minutes). Although HALS does require a small incision (7–8 cm) for hand insertion and specimen extraction, no differences in length of stay were observed when comparing these patients to those managed purely laparoscopically.139When performing HALS splenectomy, patient position-ing is similar to that of LS (Fig. 34-11). For patients with mas-sive spleens, lateral positioning is altered slightly, such that the patient is placed supine with the left side elevated at 45°. Depending on the hand dominance of the surgeon, the hand-assist device can be placed in either a midline position for right-hand dominant or a subcostal position for left-hand dominant surgeons. A 7to 8-cm incision should be made 2 to 4 cm caudal to the inferior pole of the enlarged spleen. The hand-assisted technique allows for a tactile feedback and atraumatic manipu-lation of the | Surgery_Schwartz. of this technique has resulted in a marked reduction in aver-age operative time for patients with massive splenomegaly (146 vs. 295 minutes). Although HALS does require a small incision (7–8 cm) for hand insertion and specimen extraction, no differences in length of stay were observed when comparing these patients to those managed purely laparoscopically.139When performing HALS splenectomy, patient position-ing is similar to that of LS (Fig. 34-11). For patients with mas-sive spleens, lateral positioning is altered slightly, such that the patient is placed supine with the left side elevated at 45°. Depending on the hand dominance of the surgeon, the hand-assist device can be placed in either a midline position for right-hand dominant or a subcostal position for left-hand dominant surgeons. A 7to 8-cm incision should be made 2 to 4 cm caudal to the inferior pole of the enlarged spleen. The hand-assisted technique allows for a tactile feedback and atraumatic manipu-lation of the |
Surgery_Schwartz_10123 | Surgery_Schwartz | A 7to 8-cm incision should be made 2 to 4 cm caudal to the inferior pole of the enlarged spleen. The hand-assisted technique allows for a tactile feedback and atraumatic manipu-lation of the enlarged spleen.The nondominant hand provides medial retraction and rotation of the spleen through a hand-assist port, while the domi-nant hand carries out the dissection using laparoscopic instru-ments. The anterior and posterior attachments of the spleen are taken down as in the laparoscopic approach, and the hilar pedicle is ligated using an endoscopic vascular stapler.Single-Incision Laparoscopic Surgery SplenectomySingle-incision laparoscopic surgery (SILS) splenectomy emphasizes the concept of surgery through one small transab-dominal incision rather than the standard multiple trocar sites, with theoretical benefits of less pain and better cosmetics. The incision can be hidden periumbilically and is used as the specimen extraction site at the end of the case. This approach for solid organs | Surgery_Schwartz. A 7to 8-cm incision should be made 2 to 4 cm caudal to the inferior pole of the enlarged spleen. The hand-assisted technique allows for a tactile feedback and atraumatic manipu-lation of the enlarged spleen.The nondominant hand provides medial retraction and rotation of the spleen through a hand-assist port, while the domi-nant hand carries out the dissection using laparoscopic instru-ments. The anterior and posterior attachments of the spleen are taken down as in the laparoscopic approach, and the hilar pedicle is ligated using an endoscopic vascular stapler.Single-Incision Laparoscopic Surgery SplenectomySingle-incision laparoscopic surgery (SILS) splenectomy emphasizes the concept of surgery through one small transab-dominal incision rather than the standard multiple trocar sites, with theoretical benefits of less pain and better cosmetics. The incision can be hidden periumbilically and is used as the specimen extraction site at the end of the case. This approach for solid organs |
Surgery_Schwartz_10124 | Surgery_Schwartz | theoretical benefits of less pain and better cosmetics. The incision can be hidden periumbilically and is used as the specimen extraction site at the end of the case. This approach for solid organs poses several technical challenges. Since all instruments are closely aligned together, “fencing” of instru-ments and the laparoscope and limited degrees of movement are commonly encountered. The spleen, being a solid organ, cannot be grasped, and thus retraction may be more challeng-ing in these cases. Furthermore, it has been reported that peri-umbilical port position may result in technical challenges when dealing with high body mass index or tall patients, precluding Brunicardi_Ch34_p1517-p1548.indd 153523/02/19 2:37 PM 1536SPECIFIC CONSIDERATIONSPART IIFigure 34-10. Morcellation and extraction of the spleen within nylon sac extending through the 10-mm trocar site. (Reproduced with per-mission from Park A, Marcaccio M, Sternbach M, et al: Laparoscopic vs open splenectomy, Arch Surg. | Surgery_Schwartz. theoretical benefits of less pain and better cosmetics. The incision can be hidden periumbilically and is used as the specimen extraction site at the end of the case. This approach for solid organs poses several technical challenges. Since all instruments are closely aligned together, “fencing” of instru-ments and the laparoscope and limited degrees of movement are commonly encountered. The spleen, being a solid organ, cannot be grasped, and thus retraction may be more challeng-ing in these cases. Furthermore, it has been reported that peri-umbilical port position may result in technical challenges when dealing with high body mass index or tall patients, precluding Brunicardi_Ch34_p1517-p1548.indd 153523/02/19 2:37 PM 1536SPECIFIC CONSIDERATIONSPART IIFigure 34-10. Morcellation and extraction of the spleen within nylon sac extending through the 10-mm trocar site. (Reproduced with per-mission from Park A, Marcaccio M, Sternbach M, et al: Laparoscopic vs open splenectomy, Arch Surg. |
Surgery_Schwartz_10125 | Surgery_Schwartz | of the spleen within nylon sac extending through the 10-mm trocar site. (Reproduced with per-mission from Park A, Marcaccio M, Sternbach M, et al: Laparoscopic vs open splenectomy, Arch Surg. 1999 Nov;134(11):1263-1269.)the surgeon from adequately reaching the spleen. Other alter-natives to single port placements have been reported, although to date, no proven benefits of SILS splenectomy have been demonstrated.140-142Robotic SplenectomyThe da Vinci surgical robot (Intuitive Surgical, Sunnyvale, CA) was cleared by the U.S. Food and Drug Administration (FDA) for use in humans in the year 2000 and has been applied to clinical practice in a variety of abdominal procedures includ-ing splenectomy since 2002.143,144 The term robotic surgery, referencing the da Vinci device should more accurately be described as computer assisted surgery (CAS), as it requires a surgeon sitting at a console controlling distant end effectors. A truly robotic, automated system has not yet been devised nor | Surgery_Schwartz. of the spleen within nylon sac extending through the 10-mm trocar site. (Reproduced with per-mission from Park A, Marcaccio M, Sternbach M, et al: Laparoscopic vs open splenectomy, Arch Surg. 1999 Nov;134(11):1263-1269.)the surgeon from adequately reaching the spleen. Other alter-natives to single port placements have been reported, although to date, no proven benefits of SILS splenectomy have been demonstrated.140-142Robotic SplenectomyThe da Vinci surgical robot (Intuitive Surgical, Sunnyvale, CA) was cleared by the U.S. Food and Drug Administration (FDA) for use in humans in the year 2000 and has been applied to clinical practice in a variety of abdominal procedures includ-ing splenectomy since 2002.143,144 The term robotic surgery, referencing the da Vinci device should more accurately be described as computer assisted surgery (CAS), as it requires a surgeon sitting at a console controlling distant end effectors. A truly robotic, automated system has not yet been devised nor |
Surgery_Schwartz_10126 | Surgery_Schwartz | be described as computer assisted surgery (CAS), as it requires a surgeon sitting at a console controlling distant end effectors. A truly robotic, automated system has not yet been devised nor deployed to perform splenectomy. The reported advantages of CAS have inspired many surgeons to investigate its potential and to broaden its application in the minimally invasive surgery armamentarium. Some of these advantages include increased degrees of freedom as compared to standard “straight-stick” lap-aroscopy, improved optics including three-dimensional imag-ing of the operative field, improved instrument stabilization and reduction in hand tremor, and finally purported enhanced ergonomic and comfort factors for the operating surgeon.145-147 However, detractors of this emerging technology cite high capi-tal expenses as well as on-going disposable costs and the loss of haptic feedback as major downsides of CAS such that the benefits of the robotic platform are still not fully clear in the | Surgery_Schwartz. be described as computer assisted surgery (CAS), as it requires a surgeon sitting at a console controlling distant end effectors. A truly robotic, automated system has not yet been devised nor deployed to perform splenectomy. The reported advantages of CAS have inspired many surgeons to investigate its potential and to broaden its application in the minimally invasive surgery armamentarium. Some of these advantages include increased degrees of freedom as compared to standard “straight-stick” lap-aroscopy, improved optics including three-dimensional imag-ing of the operative field, improved instrument stabilization and reduction in hand tremor, and finally purported enhanced ergonomic and comfort factors for the operating surgeon.145-147 However, detractors of this emerging technology cite high capi-tal expenses as well as on-going disposable costs and the loss of haptic feedback as major downsides of CAS such that the benefits of the robotic platform are still not fully clear in the |
Surgery_Schwartz_10127 | Surgery_Schwartz | high capi-tal expenses as well as on-going disposable costs and the loss of haptic feedback as major downsides of CAS such that the benefits of the robotic platform are still not fully clear in the extant literature. Recent studies suggest that ergonomic ben-efits of robotic surgery may not be as pronounced as previously thought, as “robotic surgeons” still manifested chronic pain related to poor ergonomics.148There have been few published works comparing conven-tional laparoscopic splenectomy to CAS splenectomy. In one recent retrospective case-matched analysis, the authors com-pared hospital length of stay, operating room times and cost between these two groups. Although they were able to conclude that the application of CAS was feasible and safe for splenec-tomy, they cited a nearly 30-minute increase in operative time and over $4000 increase in cost of the procedures.149 This is consistent with a prior study supporting the notion that robotic-assisted splenectomy takes longer and | Surgery_Schwartz. high capi-tal expenses as well as on-going disposable costs and the loss of haptic feedback as major downsides of CAS such that the benefits of the robotic platform are still not fully clear in the extant literature. Recent studies suggest that ergonomic ben-efits of robotic surgery may not be as pronounced as previously thought, as “robotic surgeons” still manifested chronic pain related to poor ergonomics.148There have been few published works comparing conven-tional laparoscopic splenectomy to CAS splenectomy. In one recent retrospective case-matched analysis, the authors com-pared hospital length of stay, operating room times and cost between these two groups. Although they were able to conclude that the application of CAS was feasible and safe for splenec-tomy, they cited a nearly 30-minute increase in operative time and over $4000 increase in cost of the procedures.149 This is consistent with a prior study supporting the notion that robotic-assisted splenectomy takes longer and |
Surgery_Schwartz_10128 | Surgery_Schwartz | increase in operative time and over $4000 increase in cost of the procedures.149 This is consistent with a prior study supporting the notion that robotic-assisted splenectomy takes longer and is more costly than con-ventional laparoscopic surgery.150Splenectomy has also been reported using a single-incision CAS approach.151 However, this procedure is likely associated with an even steeper learning curve than traditional multiport robotic-assisted splenectomy, which calls into question the util-ity of this technique.Robotic splenectomy has been performed in the pediatric population, also proving feasibility and safety, but much like the adult population, larger series are needed to determine the true benefits of this procedure as compared to conventional laparo-scopic splenectomy in children.152The role of CAS in the patient requiring more complex surgery, for example, partial splenectomy or resection of a mas-sive spleen, is yet to be determined. At present there appears to be no | Surgery_Schwartz. increase in operative time and over $4000 increase in cost of the procedures.149 This is consistent with a prior study supporting the notion that robotic-assisted splenectomy takes longer and is more costly than con-ventional laparoscopic surgery.150Splenectomy has also been reported using a single-incision CAS approach.151 However, this procedure is likely associated with an even steeper learning curve than traditional multiport robotic-assisted splenectomy, which calls into question the util-ity of this technique.Robotic splenectomy has been performed in the pediatric population, also proving feasibility and safety, but much like the adult population, larger series are needed to determine the true benefits of this procedure as compared to conventional laparo-scopic splenectomy in children.152The role of CAS in the patient requiring more complex surgery, for example, partial splenectomy or resection of a mas-sive spleen, is yet to be determined. At present there appears to be no |
Surgery_Schwartz_10129 | Surgery_Schwartz | role of CAS in the patient requiring more complex surgery, for example, partial splenectomy or resection of a mas-sive spleen, is yet to be determined. At present there appears to be no argument supporting the application of CAS over standard laparoscopy for routine splenectomy in terms of clinical or cost advantage. The entry into the market of competing devices is likely to favorably alter these considerations.Partial SplenectomyThe past few decades have witnessed ever-widening endorse-ment for and practice of partial splenectomy. This technique, initially reported in the early 18th century, is particularly indi-cated to minimize the risk of postsplenectomy sepsis in children. Certain lipid storage disorders leading to splenomegaly (e.g., Gaucher’s disease), some forms of traumatic splenic injury (blunt and penetrating), spherocytosis in children, and focal benign splenic lesions are amenable to treatment with partial splenectomy.153 Both the laparoscopic and open approaches for | Surgery_Schwartz. role of CAS in the patient requiring more complex surgery, for example, partial splenectomy or resection of a mas-sive spleen, is yet to be determined. At present there appears to be no argument supporting the application of CAS over standard laparoscopy for routine splenectomy in terms of clinical or cost advantage. The entry into the market of competing devices is likely to favorably alter these considerations.Partial SplenectomyThe past few decades have witnessed ever-widening endorse-ment for and practice of partial splenectomy. This technique, initially reported in the early 18th century, is particularly indi-cated to minimize the risk of postsplenectomy sepsis in children. Certain lipid storage disorders leading to splenomegaly (e.g., Gaucher’s disease), some forms of traumatic splenic injury (blunt and penetrating), spherocytosis in children, and focal benign splenic lesions are amenable to treatment with partial splenectomy.153 Both the laparoscopic and open approaches for |
Surgery_Schwartz_10130 | Surgery_Schwartz | injury (blunt and penetrating), spherocytosis in children, and focal benign splenic lesions are amenable to treatment with partial splenectomy.153 Both the laparoscopic and open approaches for partial splenectomy have been well described.153 The spleen must be adequately mobilized, and the splenic hilar vessels attached to the targeted segment, ligated, and divided. The devascularized segment of spleen is transected along an obvi-ous line of demarcation.A useful technical tip is to transect the parenchyma 1 cm inside the ischemic demarcation line to minimize blood loss.154 Bleeding from the cut surface of the spleen usually is limited and can be controlled by various methods, including cauter-ization, argon coagulation, or application of direct hemostatic agents such as cellulose gauze and fibrin glue.Inadvertent Intraoperative Splenic InjuryInadvertent intraoperative injury to the spleen is a noted occur-rence in the surgical literature, familiar to and dreaded by the abdominal | Surgery_Schwartz. injury (blunt and penetrating), spherocytosis in children, and focal benign splenic lesions are amenable to treatment with partial splenectomy.153 Both the laparoscopic and open approaches for partial splenectomy have been well described.153 The spleen must be adequately mobilized, and the splenic hilar vessels attached to the targeted segment, ligated, and divided. The devascularized segment of spleen is transected along an obvi-ous line of demarcation.A useful technical tip is to transect the parenchyma 1 cm inside the ischemic demarcation line to minimize blood loss.154 Bleeding from the cut surface of the spleen usually is limited and can be controlled by various methods, including cauter-ization, argon coagulation, or application of direct hemostatic agents such as cellulose gauze and fibrin glue.Inadvertent Intraoperative Splenic InjuryInadvertent intraoperative injury to the spleen is a noted occur-rence in the surgical literature, familiar to and dreaded by the abdominal |
Surgery_Schwartz_10131 | Surgery_Schwartz | and fibrin glue.Inadvertent Intraoperative Splenic InjuryInadvertent intraoperative injury to the spleen is a noted occur-rence in the surgical literature, familiar to and dreaded by the abdominal surgeon. The true incidence is unknown. The gravity of such injury is not to be underestimated. Significant short-term morbidity is associated with injury to the spleen, including increased blood loss, need for transfusion, and pro-longed hospital stay.155Intraoperative injury to the spleen has been linked with numerous operations, such as gastric fundoplication, colectomy, Brunicardi_Ch34_p1517-p1548.indd 153623/02/19 2:37 PM 1537THE SPLEENCHAPTER 34BCAFigure 34-11. A. Patient table placement for hand-assisted laparoscopic splenectomy (HALS) in case of splenomegaly. B and C. Intraopera-tive images of HALS.Brunicardi_Ch34_p1517-p1548.indd 153723/02/19 2:37 PM 1538SPECIFIC CONSIDERATIONSPART IIparaesophageal hernia repair, nephrectomy, and abdominal and pelvic vascular surgery. There | Surgery_Schwartz. and fibrin glue.Inadvertent Intraoperative Splenic InjuryInadvertent intraoperative injury to the spleen is a noted occur-rence in the surgical literature, familiar to and dreaded by the abdominal surgeon. The true incidence is unknown. The gravity of such injury is not to be underestimated. Significant short-term morbidity is associated with injury to the spleen, including increased blood loss, need for transfusion, and pro-longed hospital stay.155Intraoperative injury to the spleen has been linked with numerous operations, such as gastric fundoplication, colectomy, Brunicardi_Ch34_p1517-p1548.indd 153623/02/19 2:37 PM 1537THE SPLEENCHAPTER 34BCAFigure 34-11. A. Patient table placement for hand-assisted laparoscopic splenectomy (HALS) in case of splenomegaly. B and C. Intraopera-tive images of HALS.Brunicardi_Ch34_p1517-p1548.indd 153723/02/19 2:37 PM 1538SPECIFIC CONSIDERATIONSPART IIparaesophageal hernia repair, nephrectomy, and abdominal and pelvic vascular surgery. There |
Surgery_Schwartz_10132 | Surgery_Schwartz | images of HALS.Brunicardi_Ch34_p1517-p1548.indd 153723/02/19 2:37 PM 1538SPECIFIC CONSIDERATIONSPART IIparaesophageal hernia repair, nephrectomy, and abdominal and pelvic vascular surgery. There are also reports of splenic injuries after endoscopic procedures, such as colonoscopy.Improper traction on the spleen against its peritoneal attachments is the most common mechanism of intraopera-tive injury. Capsular tears are the most common type of injury, but parenchymal lacerations and subcapsular hematomas also occur. The lower pole is more commonly injured, owing to its orientation and the greater concentration of peritoneal attach-ments found here.As with all hemorrhage, prompt temporary control of bleeding should be obtained by direct compression of the spleen itself, packing of the left upper quadrant, compression of the vessels at the splenic hilum, or pressure on the splenic artery at the superior pancreatic margin. The spleen should then be mobi-lized from its peritoneal | Surgery_Schwartz. images of HALS.Brunicardi_Ch34_p1517-p1548.indd 153723/02/19 2:37 PM 1538SPECIFIC CONSIDERATIONSPART IIparaesophageal hernia repair, nephrectomy, and abdominal and pelvic vascular surgery. There are also reports of splenic injuries after endoscopic procedures, such as colonoscopy.Improper traction on the spleen against its peritoneal attachments is the most common mechanism of intraopera-tive injury. Capsular tears are the most common type of injury, but parenchymal lacerations and subcapsular hematomas also occur. The lower pole is more commonly injured, owing to its orientation and the greater concentration of peritoneal attach-ments found here.As with all hemorrhage, prompt temporary control of bleeding should be obtained by direct compression of the spleen itself, packing of the left upper quadrant, compression of the vessels at the splenic hilum, or pressure on the splenic artery at the superior pancreatic margin. The spleen should then be mobi-lized from its peritoneal |
Surgery_Schwartz_10133 | Surgery_Schwartz | the left upper quadrant, compression of the vessels at the splenic hilum, or pressure on the splenic artery at the superior pancreatic margin. The spleen should then be mobi-lized from its peritoneal attachments and the nature of the injury assessed. Overall, the patient’s condition is the primary deter-minant of whether splenic salvage can be attempted, although hilar injury is best managed by splenectomy. When dealing with capsular tears (most common injury), strong consideration should be given to splenorrhaphy techniques: application of topical hemostatics, suture plication of disrupted parenchyma with or without omental buttress, and the use of bioabsorbable mesh sheets.The time-honored surgical tenets of liberal exposure and visualization are particularly germane to the avoidance of splenic injury. Incisions and approaches must be tailored to both patient circumstances and surgeon experience. There is some evidence to support the assertion that use of the lapa-roscopic approach | Surgery_Schwartz. the left upper quadrant, compression of the vessels at the splenic hilum, or pressure on the splenic artery at the superior pancreatic margin. The spleen should then be mobi-lized from its peritoneal attachments and the nature of the injury assessed. Overall, the patient’s condition is the primary deter-minant of whether splenic salvage can be attempted, although hilar injury is best managed by splenectomy. When dealing with capsular tears (most common injury), strong consideration should be given to splenorrhaphy techniques: application of topical hemostatics, suture plication of disrupted parenchyma with or without omental buttress, and the use of bioabsorbable mesh sheets.The time-honored surgical tenets of liberal exposure and visualization are particularly germane to the avoidance of splenic injury. Incisions and approaches must be tailored to both patient circumstances and surgeon experience. There is some evidence to support the assertion that use of the lapa-roscopic approach |
Surgery_Schwartz_10134 | Surgery_Schwartz | splenic injury. Incisions and approaches must be tailored to both patient circumstances and surgeon experience. There is some evidence to support the assertion that use of the lapa-roscopic approach may reduce the incidence of splenic injury for certain operations. As with all hemorrhage, prompt tempo-rary control of bleeding is required. Direct compression of the spleen itself, packing of the left upper quadrant, compression of the vessels at the splenic hilum, or pressure on the splenic artery at the superior pancreatic margin can slow or stop hem-orrhage and allow more deliberate consideration of manage-ment options.The type of injury plays a role as well; it has been sug-gested that hilar injury is best managed by splenectomy.80 Bar-ring these unfavorable circumstances, however, and recalling that the majority of intraoperative splenic injuries are capsular tears, it is reasonable to expect that splenic preservation can be achieved in many appropriately selected situations. | Surgery_Schwartz. splenic injury. Incisions and approaches must be tailored to both patient circumstances and surgeon experience. There is some evidence to support the assertion that use of the lapa-roscopic approach may reduce the incidence of splenic injury for certain operations. As with all hemorrhage, prompt tempo-rary control of bleeding is required. Direct compression of the spleen itself, packing of the left upper quadrant, compression of the vessels at the splenic hilum, or pressure on the splenic artery at the superior pancreatic margin can slow or stop hem-orrhage and allow more deliberate consideration of manage-ment options.The type of injury plays a role as well; it has been sug-gested that hilar injury is best managed by splenectomy.80 Bar-ring these unfavorable circumstances, however, and recalling that the majority of intraoperative splenic injuries are capsular tears, it is reasonable to expect that splenic preservation can be achieved in many appropriately selected situations. |
Surgery_Schwartz_10135 | Surgery_Schwartz | and recalling that the majority of intraoperative splenic injuries are capsular tears, it is reasonable to expect that splenic preservation can be achieved in many appropriately selected situations. Presented with one of these situations, the surgeon has at his or her dis-posal a number of useful and well-described splenorrhaphy techniques: application of topical hemostatics, suture plication of disrupted parenchyma with or without omental buttress, and the use of bioabsorbable mesh sheets.Currently, incidental splenectomies during laparoscopic procedures such as colorectal resections are rare events, but they are associated with worse short-term outcomes.156Preoperative Grading Score to Predict Technical Difficulty in Laparoscopic SplenectomyA splenectomy grading system based on preoperative parame-ters was developed to predict the surgical difficulty and morbid-ity for elective laparoscopic splenectomies.157,158 Preoperative data concerning demographic, clinical, pathological, | Surgery_Schwartz. and recalling that the majority of intraoperative splenic injuries are capsular tears, it is reasonable to expect that splenic preservation can be achieved in many appropriately selected situations. Presented with one of these situations, the surgeon has at his or her dis-posal a number of useful and well-described splenorrhaphy techniques: application of topical hemostatics, suture plication of disrupted parenchyma with or without omental buttress, and the use of bioabsorbable mesh sheets.Currently, incidental splenectomies during laparoscopic procedures such as colorectal resections are rare events, but they are associated with worse short-term outcomes.156Preoperative Grading Score to Predict Technical Difficulty in Laparoscopic SplenectomyA splenectomy grading system based on preoperative parame-ters was developed to predict the surgical difficulty and morbid-ity for elective laparoscopic splenectomies.157,158 Preoperative data concerning demographic, clinical, pathological, |
Surgery_Schwartz_10136 | Surgery_Schwartz | parame-ters was developed to predict the surgical difficulty and morbid-ity for elective laparoscopic splenectomies.157,158 Preoperative data concerning demographic, clinical, pathological, anatomi-cal, laboratory and radiological factors were compared with three surgical outcomes: operative time, intraoperative bleeding, and surgical conversion. Four preoperative parameters (male Table 34-3Difficulty ScoreAge≤40 years040–60 years1≥60 years2GenderFemale0.5Male1Pathology groupITP0.5Other benign1Malignant2Spleen weighta<400 gr1400–1000 gr3>1000 gr5Difficulty gradeLow≤4Medium4–6High≥6Note: Minimum possible score: 2 points; maximum possible score: 10 points.aSpleen weight formula: width (cm) × length (cm) × height (cm) × 0.6 = splenic weight in grams.gender, age, type of pathology, and spleen weight) were found to be associated with a difficult splenectomy (Table 34-3). This grading score is simple to calculate from the physical examina-tion, laboratory tests, and US or CT images and | Surgery_Schwartz. parame-ters was developed to predict the surgical difficulty and morbid-ity for elective laparoscopic splenectomies.157,158 Preoperative data concerning demographic, clinical, pathological, anatomi-cal, laboratory and radiological factors were compared with three surgical outcomes: operative time, intraoperative bleeding, and surgical conversion. Four preoperative parameters (male Table 34-3Difficulty ScoreAge≤40 years040–60 years1≥60 years2GenderFemale0.5Male1Pathology groupITP0.5Other benign1Malignant2Spleen weighta<400 gr1400–1000 gr3>1000 gr5Difficulty gradeLow≤4Medium4–6High≥6Note: Minimum possible score: 2 points; maximum possible score: 10 points.aSpleen weight formula: width (cm) × length (cm) × height (cm) × 0.6 = splenic weight in grams.gender, age, type of pathology, and spleen weight) were found to be associated with a difficult splenectomy (Table 34-3). This grading score is simple to calculate from the physical examina-tion, laboratory tests, and US or CT images and |
Surgery_Schwartz_10137 | Surgery_Schwartz | weight) were found to be associated with a difficult splenectomy (Table 34-3). This grading score is simple to calculate from the physical examina-tion, laboratory tests, and US or CT images and could be highly practical in a daily clinical setting. It could facilitate training and development of skills while simultaneously fostering dissemina-tion of laparoscopic procedures.SPLENECTOMY OUTCOMESChanges in blood composition resulting from splenectomy include the appearance of Howell-Jolly bodies and siderocytes. After splenectomy, leukocytosis and increased platelet counts are common as well. Although platelet counts most often rise within 2 days, they may not peak for several weeks in patients with preoperative thrombocytopenia (see “Hematologic Out-comes” later). Similarly, within 1 day after splenectomy, the white blood cell count typically rises, and such elevation may continue for several months.Overwhelming Postsplenectomy InfectionThe prevalence of asplenia in the United States | Surgery_Schwartz. weight) were found to be associated with a difficult splenectomy (Table 34-3). This grading score is simple to calculate from the physical examina-tion, laboratory tests, and US or CT images and could be highly practical in a daily clinical setting. It could facilitate training and development of skills while simultaneously fostering dissemina-tion of laparoscopic procedures.SPLENECTOMY OUTCOMESChanges in blood composition resulting from splenectomy include the appearance of Howell-Jolly bodies and siderocytes. After splenectomy, leukocytosis and increased platelet counts are common as well. Although platelet counts most often rise within 2 days, they may not peak for several weeks in patients with preoperative thrombocytopenia (see “Hematologic Out-comes” later). Similarly, within 1 day after splenectomy, the white blood cell count typically rises, and such elevation may continue for several months.Overwhelming Postsplenectomy InfectionThe prevalence of asplenia in the United States |
Surgery_Schwartz_10138 | Surgery_Schwartz | after splenectomy, the white blood cell count typically rises, and such elevation may continue for several months.Overwhelming Postsplenectomy InfectionThe prevalence of asplenia in the United States is estimated to be 1 million; which is comparable to the number of patients carrying the human immunodeficiency virus (HIV).185,186 As with other forms of immunodeficiency, asplenic patients bear an increased susceptibility to specific types of infections for the remainder of their lives. Asplenic patients are at highest risk for infection with encapsulated organisms, most commonly Streptococcus pneumoniae, but also Haemophilus influenza Brunicardi_Ch34_p1517-p1548.indd 153823/02/19 2:37 PM 1539THE SPLEENCHAPTER 34(in particular subtype B) and Neisseria meningitides.21,185-192 Although the overwhelming majority of splenectomized patients experience no ill consequence from the absence of their spleen, the potentially catastrophic consequences of overwhelming postsplenectomy infection | Surgery_Schwartz. after splenectomy, the white blood cell count typically rises, and such elevation may continue for several months.Overwhelming Postsplenectomy InfectionThe prevalence of asplenia in the United States is estimated to be 1 million; which is comparable to the number of patients carrying the human immunodeficiency virus (HIV).185,186 As with other forms of immunodeficiency, asplenic patients bear an increased susceptibility to specific types of infections for the remainder of their lives. Asplenic patients are at highest risk for infection with encapsulated organisms, most commonly Streptococcus pneumoniae, but also Haemophilus influenza Brunicardi_Ch34_p1517-p1548.indd 153823/02/19 2:37 PM 1539THE SPLEENCHAPTER 34(in particular subtype B) and Neisseria meningitides.21,185-192 Although the overwhelming majority of splenectomized patients experience no ill consequence from the absence of their spleen, the potentially catastrophic consequences of overwhelming postsplenectomy infection |
Surgery_Schwartz_10139 | Surgery_Schwartz | overwhelming majority of splenectomized patients experience no ill consequence from the absence of their spleen, the potentially catastrophic consequences of overwhelming postsplenectomy infection (OPSI) demand lifelong vigilance and intimate knowledge of appropriate precautions and preven-tative measures.ComplicationsComplications of splenectomy may be classified as pulmonary, hemorrhagic, infectious, pancreatic, and thromboembolic.12,159 Left lower lobe atelectasis is the most common complication after OS; pleural effusion and pneumonia also can occur. Hem-orrhage can occur intraoperatively or postoperatively, present-ing as subphrenic hematoma. Transfusions have become less common since the advent of LS, although the indication for operation influences the likelihood of transfusion as well. Sub-phrenic abscess and wound infection are among the periopera-tive infectious complications. The placement of a drain in the left upper quadrant may be associated with postoperative | Surgery_Schwartz. overwhelming majority of splenectomized patients experience no ill consequence from the absence of their spleen, the potentially catastrophic consequences of overwhelming postsplenectomy infection (OPSI) demand lifelong vigilance and intimate knowledge of appropriate precautions and preven-tative measures.ComplicationsComplications of splenectomy may be classified as pulmonary, hemorrhagic, infectious, pancreatic, and thromboembolic.12,159 Left lower lobe atelectasis is the most common complication after OS; pleural effusion and pneumonia also can occur. Hem-orrhage can occur intraoperatively or postoperatively, present-ing as subphrenic hematoma. Transfusions have become less common since the advent of LS, although the indication for operation influences the likelihood of transfusion as well. Sub-phrenic abscess and wound infection are among the periopera-tive infectious complications. The placement of a drain in the left upper quadrant may be associated with postoperative |
Surgery_Schwartz_10140 | Surgery_Schwartz | as well. Sub-phrenic abscess and wound infection are among the periopera-tive infectious complications. The placement of a drain in the left upper quadrant may be associated with postoperative sub-phrenic abscess and is not routinely recommended. Pancreati-tis, pseudocyst, and pancreatic fistula are among the pancreatic complications that may result from intraoperative trauma to the pancreas during dissection of the splenic hilum.Hematologic OutcomesThe results of splenectomy may be appraised according to the level of hematologic response (e.g., rise in platelet and hemo-globin levels) in those disorders in which the spleen contributes to the hematologic problem. Hematologic responses may be divided into initial and long-term responses. For thrombocyto-penia, an initial response typically is defined as a rise in plate-let count within several days of splenectomy. Reported series demonstrate the effectiveness of LS in providing a long-term platelet response in approximately 80% of | Surgery_Schwartz. as well. Sub-phrenic abscess and wound infection are among the periopera-tive infectious complications. The placement of a drain in the left upper quadrant may be associated with postoperative sub-phrenic abscess and is not routinely recommended. Pancreati-tis, pseudocyst, and pancreatic fistula are among the pancreatic complications that may result from intraoperative trauma to the pancreas during dissection of the splenic hilum.Hematologic OutcomesThe results of splenectomy may be appraised according to the level of hematologic response (e.g., rise in platelet and hemo-globin levels) in those disorders in which the spleen contributes to the hematologic problem. Hematologic responses may be divided into initial and long-term responses. For thrombocyto-penia, an initial response typically is defined as a rise in plate-let count within several days of splenectomy. Reported series demonstrate the effectiveness of LS in providing a long-term platelet response in approximately 80% of |
Surgery_Schwartz_10141 | Surgery_Schwartz | is defined as a rise in plate-let count within several days of splenectomy. Reported series demonstrate the effectiveness of LS in providing a long-term platelet response in approximately 80% of individuals with ITP (Table 34-4). These results are consistent with the long-term success rate associated with OS.For chronic hemolytic anemias, a rise in hemoglobin levels to >10 g/dL without the need for transfusion signifies a successful response to splenectomy. By this criterion, splenec-tomy has been reported to be successful for the vast majority of patients with chronic hemolytic anemia. For hemolytic anemia due to spherocytosis, the success rate is usually higher, ranging from 90% to 100%.Splenectomy results also may be examined in terms of surgical and postsurgical characteristics, including operative time, recovery time, and morbidity and mortality rates, all of which tend to vary according to hematologic indication (see Tables 34-4 and 34-5).12Results of few prospective, randomized | Surgery_Schwartz. is defined as a rise in plate-let count within several days of splenectomy. Reported series demonstrate the effectiveness of LS in providing a long-term platelet response in approximately 80% of individuals with ITP (Table 34-4). These results are consistent with the long-term success rate associated with OS.For chronic hemolytic anemias, a rise in hemoglobin levels to >10 g/dL without the need for transfusion signifies a successful response to splenectomy. By this criterion, splenec-tomy has been reported to be successful for the vast majority of patients with chronic hemolytic anemia. For hemolytic anemia due to spherocytosis, the success rate is usually higher, ranging from 90% to 100%.Splenectomy results also may be examined in terms of surgical and postsurgical characteristics, including operative time, recovery time, and morbidity and mortality rates, all of which tend to vary according to hematologic indication (see Tables 34-4 and 34-5).12Results of few prospective, randomized |
Surgery_Schwartz_10142 | Surgery_Schwartz | operative time, recovery time, and morbidity and mortality rates, all of which tend to vary according to hematologic indication (see Tables 34-4 and 34-5).12Results of few prospective, randomized trials comparing LS and OS have been published. However, several recent meta-analyses of published comparative series including 38 papers with more than 2914 patients indicate that the laparoscopic approach typically results in longer operative times, shorter hos-pital stays, lower morbidity rates, similar blood loss, and similar mortality rates compared with OS.12,120,136 Questions of the cost effectiveness of LS persist, although analysis of this issue is hindered by a lack of universally accepted metrics as well as a paucity of recent objective data. Proponents of LS argue that the generally higher operating room charges are offset by the reduced hospital stay and presumably shorter time of lost productivity.160-162 For those institutions with experienced per-sonnel and technical | Surgery_Schwartz. operative time, recovery time, and morbidity and mortality rates, all of which tend to vary according to hematologic indication (see Tables 34-4 and 34-5).12Results of few prospective, randomized trials comparing LS and OS have been published. However, several recent meta-analyses of published comparative series including 38 papers with more than 2914 patients indicate that the laparoscopic approach typically results in longer operative times, shorter hos-pital stays, lower morbidity rates, similar blood loss, and similar mortality rates compared with OS.12,120,136 Questions of the cost effectiveness of LS persist, although analysis of this issue is hindered by a lack of universally accepted metrics as well as a paucity of recent objective data. Proponents of LS argue that the generally higher operating room charges are offset by the reduced hospital stay and presumably shorter time of lost productivity.160-162 For those institutions with experienced per-sonnel and technical |
Surgery_Schwartz_10143 | Surgery_Schwartz | higher operating room charges are offset by the reduced hospital stay and presumably shorter time of lost productivity.160-162 For those institutions with experienced per-sonnel and technical capability, the laparoscopic approach has emerged as the standard for elective, nontraumatic splenectomy.CancerA Taiwanese population-based study found that individuals who had splenectomy have higher risks of developing certain types of cancer (adjusted hazard ratios were 2.64 and 1.29 for nontraumatic and traumatic reasons, respectively). Splenectomy patients were found to have significantly higher risks in esopha-gus, stomach, liver, other head and neck, non-Hodgkin’s lym-phoma, and leukemia cancers. Although the exact mechanism for the possible association between splenectomy and cancer remains unclear, a plausible explanation is that the spleen is thought to be involved in immunological defenses and provides active response through humoral and cell-mediated pathways and that splenectomy may | Surgery_Schwartz. higher operating room charges are offset by the reduced hospital stay and presumably shorter time of lost productivity.160-162 For those institutions with experienced per-sonnel and technical capability, the laparoscopic approach has emerged as the standard for elective, nontraumatic splenectomy.CancerA Taiwanese population-based study found that individuals who had splenectomy have higher risks of developing certain types of cancer (adjusted hazard ratios were 2.64 and 1.29 for nontraumatic and traumatic reasons, respectively). Splenectomy patients were found to have significantly higher risks in esopha-gus, stomach, liver, other head and neck, non-Hodgkin’s lym-phoma, and leukemia cancers. Although the exact mechanism for the possible association between splenectomy and cancer remains unclear, a plausible explanation is that the spleen is thought to be involved in immunological defenses and provides active response through humoral and cell-mediated pathways and that splenectomy may |
Surgery_Schwartz_10144 | Surgery_Schwartz | a plausible explanation is that the spleen is thought to be involved in immunological defenses and provides active response through humoral and cell-mediated pathways and that splenectomy may impair immune surveillance in the host.163,164Table 34-4Outcome after splenectomyOUTCOME VARIABLESTUDIES (N)PATIENTS (N)POOLED RESULTS AND CIPMortality382914–0.01 (–0–02, 0)1Complications Pooled382914–0.11 (–0.16, –0.05)<.00001 Minor362914–0.03 (–0.05, –0.01).13 Severe362745–0.07 (–0.11, –0.03)<.00001 Thrombosis352695–0.01 (–0.02, 0.01)1 Organ injury3426390.01 (–0, 0.02)1Acces. spleen2921350.02 (–0.01, 0.05).87Operative time18137057.4 min (43.3, 71.4)<.00001Blood loss10759–41 mL (–87, 4.71)<.00001Length of stay201566–2.48 d (–2.89, –2.07)<.00001Reproduced with permission from Bai YN, Jiang H, Prasoon P. A meta-analysis of perioperative outcomes of laparoscopic splenectomy for hematological diseases, World J Surg. 2012 Oct;36(10):2349-2345.Brunicardi_Ch34_p1517-p1548.indd 153923/02/19 2:37 PM | Surgery_Schwartz. a plausible explanation is that the spleen is thought to be involved in immunological defenses and provides active response through humoral and cell-mediated pathways and that splenectomy may impair immune surveillance in the host.163,164Table 34-4Outcome after splenectomyOUTCOME VARIABLESTUDIES (N)PATIENTS (N)POOLED RESULTS AND CIPMortality382914–0.01 (–0–02, 0)1Complications Pooled382914–0.11 (–0.16, –0.05)<.00001 Minor362914–0.03 (–0.05, –0.01).13 Severe362745–0.07 (–0.11, –0.03)<.00001 Thrombosis352695–0.01 (–0.02, 0.01)1 Organ injury3426390.01 (–0, 0.02)1Acces. spleen2921350.02 (–0.01, 0.05).87Operative time18137057.4 min (43.3, 71.4)<.00001Blood loss10759–41 mL (–87, 4.71)<.00001Length of stay201566–2.48 d (–2.89, –2.07)<.00001Reproduced with permission from Bai YN, Jiang H, Prasoon P. A meta-analysis of perioperative outcomes of laparoscopic splenectomy for hematological diseases, World J Surg. 2012 Oct;36(10):2349-2345.Brunicardi_Ch34_p1517-p1548.indd 153923/02/19 2:37 PM |
Surgery_Schwartz_10145 | Surgery_Schwartz | P. A meta-analysis of perioperative outcomes of laparoscopic splenectomy for hematological diseases, World J Surg. 2012 Oct;36(10):2349-2345.Brunicardi_Ch34_p1517-p1548.indd 153923/02/19 2:37 PM 1540SPECIFIC CONSIDERATIONSPART IIUltrasoundUltrasound is the least invasive mode of splenic imaging. It is rapid, relatively easy to perform, and does not expose the patient to ionizing radiation. It is often the first imaging modality used to evaluate the spleen in a trauma patient, although questions of sensitivity and specificity remain.133,167 In the elective setting, such as for routine diagnostic purposes or for preoperative plan-ning, it is the least costly modality available, and the sensitivity of ultrasound for detecting textural lesions of the spleen can be quite good in experienced hands.168When examining a normal spleen, differentiation between red and white pulp is not possible, and a homogeneous acous-tic echotexture should be visualized. Splenic artery and vein patency may | Surgery_Schwartz. P. A meta-analysis of perioperative outcomes of laparoscopic splenectomy for hematological diseases, World J Surg. 2012 Oct;36(10):2349-2345.Brunicardi_Ch34_p1517-p1548.indd 153923/02/19 2:37 PM 1540SPECIFIC CONSIDERATIONSPART IIUltrasoundUltrasound is the least invasive mode of splenic imaging. It is rapid, relatively easy to perform, and does not expose the patient to ionizing radiation. It is often the first imaging modality used to evaluate the spleen in a trauma patient, although questions of sensitivity and specificity remain.133,167 In the elective setting, such as for routine diagnostic purposes or for preoperative plan-ning, it is the least costly modality available, and the sensitivity of ultrasound for detecting textural lesions of the spleen can be quite good in experienced hands.168When examining a normal spleen, differentiation between red and white pulp is not possible, and a homogeneous acous-tic echotexture should be visualized. Splenic artery and vein patency may |
Surgery_Schwartz_10146 | Surgery_Schwartz | hands.168When examining a normal spleen, differentiation between red and white pulp is not possible, and a homogeneous acous-tic echotexture should be visualized. Splenic artery and vein patency may be assessed using Doppler imaging. Splenic artery anatomy has been classified commonly into two patterns: dis-tributed and magistral. This variability in vascular distribution visualized by Doppler imaging becomes important when there is consideration of performing a partial splenectomy due to the possibility of segmental blood flow and its effect on area of resection.Percutaneous ultrasound-guided procedures for splenic disease (e.g., cyst aspiration, biopsy), historically avoided due to the risk of hemorrhage and other complications, are becom-ing more common as the safety of these procedures has become increasingly demonstrated.165,166Computed TomographyCT affords a high degree of resolution and detail of the splenic parenchyma, vasculature, and its relationship to neighboring | Surgery_Schwartz. hands.168When examining a normal spleen, differentiation between red and white pulp is not possible, and a homogeneous acous-tic echotexture should be visualized. Splenic artery and vein patency may be assessed using Doppler imaging. Splenic artery anatomy has been classified commonly into two patterns: dis-tributed and magistral. This variability in vascular distribution visualized by Doppler imaging becomes important when there is consideration of performing a partial splenectomy due to the possibility of segmental blood flow and its effect on area of resection.Percutaneous ultrasound-guided procedures for splenic disease (e.g., cyst aspiration, biopsy), historically avoided due to the risk of hemorrhage and other complications, are becom-ing more common as the safety of these procedures has become increasingly demonstrated.165,166Computed TomographyCT affords a high degree of resolution and detail of the splenic parenchyma, vasculature, and its relationship to neighboring |
Surgery_Schwartz_10147 | Surgery_Schwartz | procedures has become increasingly demonstrated.165,166Computed TomographyCT affords a high degree of resolution and detail of the splenic parenchyma, vasculature, and its relationship to neighboring structures, making it the preferred imaging modality for many surgeons. CT has become an invaluable tool in the evaluation and management of the blunt trauma patient, and standardized scoring systems for splenic trauma based on CT images now aid in management decisions.169 In the nontrauma setting, CT is extremely useful for assessment of splenomegaly, identification of solid and cystic lesions, and guidance of percutaneous pro-cedures.3 The use of iodinated contrast material adds diagnostic clarity to CT imaging of the spleen, although at the cost of, the small but real risks, possible renal impairment or allergic reac-tions. Three-dimensional reconstruction after CT scan may help to predict the difficulty of the procedure and to choose the best surgical approach.170,171The appearance of | Surgery_Schwartz. procedures has become increasingly demonstrated.165,166Computed TomographyCT affords a high degree of resolution and detail of the splenic parenchyma, vasculature, and its relationship to neighboring structures, making it the preferred imaging modality for many surgeons. CT has become an invaluable tool in the evaluation and management of the blunt trauma patient, and standardized scoring systems for splenic trauma based on CT images now aid in management decisions.169 In the nontrauma setting, CT is extremely useful for assessment of splenomegaly, identification of solid and cystic lesions, and guidance of percutaneous pro-cedures.3 The use of iodinated contrast material adds diagnostic clarity to CT imaging of the spleen, although at the cost of, the small but real risks, possible renal impairment or allergic reac-tions. Three-dimensional reconstruction after CT scan may help to predict the difficulty of the procedure and to choose the best surgical approach.170,171The appearance of |
Surgery_Schwartz_10148 | Surgery_Schwartz | impairment or allergic reac-tions. Three-dimensional reconstruction after CT scan may help to predict the difficulty of the procedure and to choose the best surgical approach.170,171The appearance of normal splenic tissue on a noncon-trast CT is uniform parenchymal attenuation with values ranging between 40 and 60 Hounsfield units (HU).172 On a contrast-enhanced CT, the appearance of the spleen depends largely on the timing of the intravenous bolus administration of contrast material. Due to the different rates of flow through the red and white pulp, the spleen appears heterogeneously enhanc-ing during the first minute after initiation of intravenous admin-istration of contrast material during the arterial and early portal venous phases.23 The frequency of these artifacts increases with advancing patient age. When evaluating for splenic abscess, a contrast-enhanced CT should be utilized.64,173Three-dimensional CT volumetry is a novel modality that measures the volume of the spleen. | Surgery_Schwartz. impairment or allergic reac-tions. Three-dimensional reconstruction after CT scan may help to predict the difficulty of the procedure and to choose the best surgical approach.170,171The appearance of normal splenic tissue on a noncon-trast CT is uniform parenchymal attenuation with values ranging between 40 and 60 Hounsfield units (HU).172 On a contrast-enhanced CT, the appearance of the spleen depends largely on the timing of the intravenous bolus administration of contrast material. Due to the different rates of flow through the red and white pulp, the spleen appears heterogeneously enhanc-ing during the first minute after initiation of intravenous admin-istration of contrast material during the arterial and early portal venous phases.23 The frequency of these artifacts increases with advancing patient age. When evaluating for splenic abscess, a contrast-enhanced CT should be utilized.64,173Three-dimensional CT volumetry is a novel modality that measures the volume of the spleen. |
Surgery_Schwartz_10149 | Surgery_Schwartz | advancing patient age. When evaluating for splenic abscess, a contrast-enhanced CT should be utilized.64,173Three-dimensional CT volumetry is a novel modality that measures the volume of the spleen. This tool may be of some benefit in planning technically challenging cases involving sple-nomegaly. A recent retrospective review of laparoscopic sple-nectomy patients who underwent CT volumetry preoperatively demonstrated a higher conversion rate when the spleen was measured to be greater than 2700 cc.170 This information may aid in proper informed consent as well as preoperative planning to assist in determination of which patients may benefit from a minimally invasive or open surgical approach.139Plain RadiographyRarely is plain radiography used for primary splenic imaging. Plain films can indirectly provide an outline of the spleen in the left upper quadrant or suggest splenomegaly by revealing dis-placement of adjacent air-filled structures (e.g., the stomach or splenic flexure of the | Surgery_Schwartz. advancing patient age. When evaluating for splenic abscess, a contrast-enhanced CT should be utilized.64,173Three-dimensional CT volumetry is a novel modality that measures the volume of the spleen. This tool may be of some benefit in planning technically challenging cases involving sple-nomegaly. A recent retrospective review of laparoscopic sple-nectomy patients who underwent CT volumetry preoperatively demonstrated a higher conversion rate when the spleen was measured to be greater than 2700 cc.170 This information may aid in proper informed consent as well as preoperative planning to assist in determination of which patients may benefit from a minimally invasive or open surgical approach.139Plain RadiographyRarely is plain radiography used for primary splenic imaging. Plain films can indirectly provide an outline of the spleen in the left upper quadrant or suggest splenomegaly by revealing dis-placement of adjacent air-filled structures (e.g., the stomach or splenic flexure of the |
Surgery_Schwartz_10150 | Surgery_Schwartz | provide an outline of the spleen in the left upper quadrant or suggest splenomegaly by revealing dis-placement of adjacent air-filled structures (e.g., the stomach or splenic flexure of the colon). Plain films may also demonstrate splenic calcifications. Splenic calcifications often are found in association with splenomegaly but are otherwise a nonspe-cific finding. Splenic calcifications can indicate a number of benign, neoplastic, or infectious processes, including phlebo-lith, splenic artery aneurysm, sickle cell changes, tumors (e.g., hemangioma, hemangiosarcoma, lymphoma), echinococcosis, or tuberculosis.168Magnetic Resonance ImagingAlthough MRI offers excellent detail and versatility in abdomi-nal imaging, it is more expensive than CT scan or ultrasound and offers no obvious advantage for primary imaging of the spleen. MRI can be a valuable adjunct to the more commonly used imaging techniques when splenic disease is suspected but not definitively diagnosed.168,173Magnetic | Surgery_Schwartz. provide an outline of the spleen in the left upper quadrant or suggest splenomegaly by revealing dis-placement of adjacent air-filled structures (e.g., the stomach or splenic flexure of the colon). Plain films may also demonstrate splenic calcifications. Splenic calcifications often are found in association with splenomegaly but are otherwise a nonspe-cific finding. Splenic calcifications can indicate a number of benign, neoplastic, or infectious processes, including phlebo-lith, splenic artery aneurysm, sickle cell changes, tumors (e.g., hemangioma, hemangiosarcoma, lymphoma), echinococcosis, or tuberculosis.168Magnetic Resonance ImagingAlthough MRI offers excellent detail and versatility in abdomi-nal imaging, it is more expensive than CT scan or ultrasound and offers no obvious advantage for primary imaging of the spleen. MRI can be a valuable adjunct to the more commonly used imaging techniques when splenic disease is suspected but not definitively diagnosed.168,173Magnetic |
Surgery_Schwartz_10151 | Surgery_Schwartz | for primary imaging of the spleen. MRI can be a valuable adjunct to the more commonly used imaging techniques when splenic disease is suspected but not definitively diagnosed.168,173Magnetic resonance (MR) signal characteristics of the spleen are related to the relative ratio of red and white pulp and the relationship of the timing of the intravenous (IV) contrast bolus and the time of image acquisition. The spleen will gener-ally have a homogeneous MR signal on noncontrast images. Table 34-5Laparoscopic splenectomy results by hematologic indicationITP (N = 151)TTP (N = 7)ANEMIA (N = 40)MALIGNANCY (N = 28)OR time (min)128146149165EBL (mL)13796116238LOS (days)2.23.02.22.6Conversions from LS to OS3 (2%)1 (14%)1 (3%)1 (4%)Complications14 (9%)01 (3%)3 (11%)EBL = estimated blood loss; ITP = idiopathic thrombocytopenic purpura; LOS = length of hospital stay; LS = laparoscopic splenectomy; OR = operating room; OS = open splenectomy; TTP = thrombotic thrombocytopenic purpura.Data from | Surgery_Schwartz. for primary imaging of the spleen. MRI can be a valuable adjunct to the more commonly used imaging techniques when splenic disease is suspected but not definitively diagnosed.168,173Magnetic resonance (MR) signal characteristics of the spleen are related to the relative ratio of red and white pulp and the relationship of the timing of the intravenous (IV) contrast bolus and the time of image acquisition. The spleen will gener-ally have a homogeneous MR signal on noncontrast images. Table 34-5Laparoscopic splenectomy results by hematologic indicationITP (N = 151)TTP (N = 7)ANEMIA (N = 40)MALIGNANCY (N = 28)OR time (min)128146149165EBL (mL)13796116238LOS (days)2.23.02.22.6Conversions from LS to OS3 (2%)1 (14%)1 (3%)1 (4%)Complications14 (9%)01 (3%)3 (11%)EBL = estimated blood loss; ITP = idiopathic thrombocytopenic purpura; LOS = length of hospital stay; LS = laparoscopic splenectomy; OR = operating room; OS = open splenectomy; TTP = thrombotic thrombocytopenic purpura.Data from |
Surgery_Schwartz_10152 | Surgery_Schwartz | = idiopathic thrombocytopenic purpura; LOS = length of hospital stay; LS = laparoscopic splenectomy; OR = operating room; OS = open splenectomy; TTP = thrombotic thrombocytopenic purpura.Data from Brunicardi FC, Andersen DK, Billiar TR, et al: Schwartz’s Principles of Surgery, 8th ed. New York, NY: McGraw-Hill; 2005.Brunicardi_Ch34_p1517-p1548.indd 154023/02/19 2:37 PM 1541THE SPLEENCHAPTER 34On contrast MRI, the spleen appears to have heterogeneous enhancement during the arterial phase of contrast enhancement.AngiographyAngiography of the spleen most commonly refers to inva-sive arterial imaging, and when it is combined with thera-peutic splenic arterial embolization (SAE), there are multiple applications for this procedure: localization and treatment of hemorrhage in select trauma patients; delivery of a variety of therapies in patients with cirrhosis or portal and sinistral hyper-tension and in transplant patients; and adjunct (or, more con-troversially, as an alternative) to | Surgery_Schwartz. = idiopathic thrombocytopenic purpura; LOS = length of hospital stay; LS = laparoscopic splenectomy; OR = operating room; OS = open splenectomy; TTP = thrombotic thrombocytopenic purpura.Data from Brunicardi FC, Andersen DK, Billiar TR, et al: Schwartz’s Principles of Surgery, 8th ed. New York, NY: McGraw-Hill; 2005.Brunicardi_Ch34_p1517-p1548.indd 154023/02/19 2:37 PM 1541THE SPLEENCHAPTER 34On contrast MRI, the spleen appears to have heterogeneous enhancement during the arterial phase of contrast enhancement.AngiographyAngiography of the spleen most commonly refers to inva-sive arterial imaging, and when it is combined with thera-peutic splenic arterial embolization (SAE), there are multiple applications for this procedure: localization and treatment of hemorrhage in select trauma patients; delivery of a variety of therapies in patients with cirrhosis or portal and sinistral hyper-tension and in transplant patients; and adjunct (or, more con-troversially, as an alternative) to |
Surgery_Schwartz_10153 | Surgery_Schwartz | patients; delivery of a variety of therapies in patients with cirrhosis or portal and sinistral hyper-tension and in transplant patients; and adjunct (or, more con-troversially, as an alternative) to splenectomy for treatment of hematologic disorders such as ITP or hypersplenism.174-176 Preoperative or intraoperative SAE for elective splenectomy is also a common, although not universal, practice. Few pro-spective data have been published in the last 5 years on pre-operative SAE.177 Preoperative SAE is purported not only to facilitate less intraoperative blood loss but also possibly to allow a laparoscopic approach in patients whose spleens had previ-ously been considered too large for, or otherwise not amenable to, safe laparoscopic resection. Limited success in using partial SAE as an alternative to therapeutic splenectomy in chronic ITP has been previously reported.178 Its detractors argue that the need for increased analgesics and occasional extended hospital stay preoperatively, | Surgery_Schwartz. patients; delivery of a variety of therapies in patients with cirrhosis or portal and sinistral hyper-tension and in transplant patients; and adjunct (or, more con-troversially, as an alternative) to splenectomy for treatment of hematologic disorders such as ITP or hypersplenism.174-176 Preoperative or intraoperative SAE for elective splenectomy is also a common, although not universal, practice. Few pro-spective data have been published in the last 5 years on pre-operative SAE.177 Preoperative SAE is purported not only to facilitate less intraoperative blood loss but also possibly to allow a laparoscopic approach in patients whose spleens had previ-ously been considered too large for, or otherwise not amenable to, safe laparoscopic resection. Limited success in using partial SAE as an alternative to therapeutic splenectomy in chronic ITP has been previously reported.178 Its detractors argue that the need for increased analgesics and occasional extended hospital stay preoperatively, |
Surgery_Schwartz_10154 | Surgery_Schwartz | to therapeutic splenectomy in chronic ITP has been previously reported.178 Its detractors argue that the need for increased analgesics and occasional extended hospital stay preoperatively, the possibility of pancreatitis, and the well-described risks of invasive arteriography associated with the passage of wires and catheters through the vasculature, may negate any presumed benefits of preoperative SAE.Nuclear ImagingRadioscintigraphy with technetium-99m sulfur colloid demon-strates splenic location and size. It may be especially helpful in locating accessory spleens after unsuccessful splenectomy for ITP and has recently proven useful in diagnosing splenosis.179,180 Unfortunately, no conclusive outcome benefit has been shown for preoperative technetium scanning before splenectomy.52,181 When dealing with diseases of platelet sequestration, indium-labeled autologous platelet scanning (ILAPS) demonstrates whether platelet sequestration is predominantly in the spleen, liver, or both. | Surgery_Schwartz. to therapeutic splenectomy in chronic ITP has been previously reported.178 Its detractors argue that the need for increased analgesics and occasional extended hospital stay preoperatively, the possibility of pancreatitis, and the well-described risks of invasive arteriography associated with the passage of wires and catheters through the vasculature, may negate any presumed benefits of preoperative SAE.Nuclear ImagingRadioscintigraphy with technetium-99m sulfur colloid demon-strates splenic location and size. It may be especially helpful in locating accessory spleens after unsuccessful splenectomy for ITP and has recently proven useful in diagnosing splenosis.179,180 Unfortunately, no conclusive outcome benefit has been shown for preoperative technetium scanning before splenectomy.52,181 When dealing with diseases of platelet sequestration, indium-labeled autologous platelet scanning (ILAPS) demonstrates whether platelet sequestration is predominantly in the spleen, liver, or both. |
Surgery_Schwartz_10155 | Surgery_Schwartz | When dealing with diseases of platelet sequestration, indium-labeled autologous platelet scanning (ILAPS) demonstrates whether platelet sequestration is predominantly in the spleen, liver, or both. This becomes important in deciding whether or not a patient will benefit from a splenectomy. ILAPS is a nuclear imaging modality in which autologous platelets are reinfused into the patient after ex vivo labeling. Subsequent scintigraphy demonstrates the site(s) of platelet sequestration and clearance. It has been proposed that patients with purely or predominantly splenic sequestration determined by ILAPS may be more likely to respond to splenectomy than those exhibiting hepatic, mixed, or diffuse patterns.176An emerging and novel application for spleen scintigraphy may be as a noninvasive method to diagnose nonalcoholic ste-atohepatitis (NASH). Conventional imaging methods are reli-able for the detection of moderate to severe fatty changes in the liver, though they are not reliable for | Surgery_Schwartz. When dealing with diseases of platelet sequestration, indium-labeled autologous platelet scanning (ILAPS) demonstrates whether platelet sequestration is predominantly in the spleen, liver, or both. This becomes important in deciding whether or not a patient will benefit from a splenectomy. ILAPS is a nuclear imaging modality in which autologous platelets are reinfused into the patient after ex vivo labeling. Subsequent scintigraphy demonstrates the site(s) of platelet sequestration and clearance. It has been proposed that patients with purely or predominantly splenic sequestration determined by ILAPS may be more likely to respond to splenectomy than those exhibiting hepatic, mixed, or diffuse patterns.176An emerging and novel application for spleen scintigraphy may be as a noninvasive method to diagnose nonalcoholic ste-atohepatitis (NASH). Conventional imaging methods are reli-able for the detection of moderate to severe fatty changes in the liver, though they are not reliable for |
Surgery_Schwartz_10156 | Surgery_Schwartz | to diagnose nonalcoholic ste-atohepatitis (NASH). Conventional imaging methods are reli-able for the detection of moderate to severe fatty changes in the liver, though they are not reliable for detecting NASH or hepatic fibrosis. NASH, which may lead to cirrhosis, can result from nonalcoholic fatty liver disease (NAFLD), the most common cause of steatosis. With the alarming rise of obesity worldwide, NAFLD is also increasingly common with prevalence rang-ing from 6.3% to 33%.15,182 The diagnosis of progression from NAFLD to NASH has been dependent on histologic assessment of tissue obtained from liver biopsy. Characteristics unique to NASH have been reported, among them the association of splenic enlargement, not seen to a similar degree in NAFLD.13In addition, the ratio of liver-to-spleen uptake determined by scintigraphy has been found to be predictably altered in NASH patients. The liver-to-spleen uptake ratio is significantly decreased in NASH patients, but not NAFLD patients, | Surgery_Schwartz. to diagnose nonalcoholic ste-atohepatitis (NASH). Conventional imaging methods are reli-able for the detection of moderate to severe fatty changes in the liver, though they are not reliable for detecting NASH or hepatic fibrosis. NASH, which may lead to cirrhosis, can result from nonalcoholic fatty liver disease (NAFLD), the most common cause of steatosis. With the alarming rise of obesity worldwide, NAFLD is also increasingly common with prevalence rang-ing from 6.3% to 33%.15,182 The diagnosis of progression from NAFLD to NASH has been dependent on histologic assessment of tissue obtained from liver biopsy. Characteristics unique to NASH have been reported, among them the association of splenic enlargement, not seen to a similar degree in NAFLD.13In addition, the ratio of liver-to-spleen uptake determined by scintigraphy has been found to be predictably altered in NASH patients. The liver-to-spleen uptake ratio is significantly decreased in NASH patients, but not NAFLD patients, |
Surgery_Schwartz_10157 | Surgery_Schwartz | uptake determined by scintigraphy has been found to be predictably altered in NASH patients. The liver-to-spleen uptake ratio is significantly decreased in NASH patients, but not NAFLD patients, leading some to conclude that technetium-99m-phytate scintigraphy is a reliable tool to differentiate NASH from NAFLD.183 Although additional studies are needed to identify the role of these nuclear medicine studies in prognostication and monitoring of those patients at high risk for the development of NASH, recent stud-ies show promise in this regard.184Microbiology and Pathogenesis. Life-threatening infec-tion in the asplenic patient is attributable to four main factors: loss of splenic macrophages, diminished tuftsin production, loss of the spleen’s reticuloendothelial screening function, and dysregulated coagulation.187 In the normal host, these factors work in concert to eliminate opsonized bacteria from the blood-stream. This system is particularly suited for the removal of encapsulated | Surgery_Schwartz. uptake determined by scintigraphy has been found to be predictably altered in NASH patients. The liver-to-spleen uptake ratio is significantly decreased in NASH patients, but not NAFLD patients, leading some to conclude that technetium-99m-phytate scintigraphy is a reliable tool to differentiate NASH from NAFLD.183 Although additional studies are needed to identify the role of these nuclear medicine studies in prognostication and monitoring of those patients at high risk for the development of NASH, recent stud-ies show promise in this regard.184Microbiology and Pathogenesis. Life-threatening infec-tion in the asplenic patient is attributable to four main factors: loss of splenic macrophages, diminished tuftsin production, loss of the spleen’s reticuloendothelial screening function, and dysregulated coagulation.187 In the normal host, these factors work in concert to eliminate opsonized bacteria from the blood-stream. This system is particularly suited for the removal of encapsulated |
Surgery_Schwartz_10158 | Surgery_Schwartz | coagulation.187 In the normal host, these factors work in concert to eliminate opsonized bacteria from the blood-stream. This system is particularly suited for the removal of encapsulated bacteria, whose polysaccharide coating is a natu-ral defense against opsonization (S pneumoniae, H influenzae, and N meningitidis are the classic examples). Infections with protozoa that invade the red blood cell, such as Babesia microti (transmitted by tick bites), Ehrlichia, and Plasmodium, occur more frequently in splenectomized individuals than in normal hosts. Other potential infectious bacterial sources include group A streptococci, C canimorsus (transmitted by dog bites), group B streptococci, Enterococcus species, Bacteroides species, Salmonella species, and Bartonella species.124 In the absence of the spleen, elimination of these pathogens from the bloodstream falls solely to the liver, a process that has been demonstrated to be less effective.12,126 Further, the pathophysiology of infection | Surgery_Schwartz. coagulation.187 In the normal host, these factors work in concert to eliminate opsonized bacteria from the blood-stream. This system is particularly suited for the removal of encapsulated bacteria, whose polysaccharide coating is a natu-ral defense against opsonization (S pneumoniae, H influenzae, and N meningitidis are the classic examples). Infections with protozoa that invade the red blood cell, such as Babesia microti (transmitted by tick bites), Ehrlichia, and Plasmodium, occur more frequently in splenectomized individuals than in normal hosts. Other potential infectious bacterial sources include group A streptococci, C canimorsus (transmitted by dog bites), group B streptococci, Enterococcus species, Bacteroides species, Salmonella species, and Bartonella species.124 In the absence of the spleen, elimination of these pathogens from the bloodstream falls solely to the liver, a process that has been demonstrated to be less effective.12,126 Further, the pathophysiology of infection |
Surgery_Schwartz_10159 | Surgery_Schwartz | the spleen, elimination of these pathogens from the bloodstream falls solely to the liver, a process that has been demonstrated to be less effective.12,126 Further, the pathophysiology of infection in asplenic patients has also been implicated in their increased risk of thrombosis and pulmonary hypertension.187More recently, the bacterial patterns of splenectomy sepsis have been changing. After the introduction of vaccinations and new oral antibiotics, postsplenectomy patients can suffer from diverse strains of bacterial infection, which are not strictly cor-related with the splenic function. In recent cohort series, gram negative bacteria are prevalent, representing 45% to 50% of infections in asplenic patients.193,194 In vaccinated patients, the rate of sepsis by pneumococcus is very low. In fact, encapsulated bacteria, such as S pneumoniae, N meningitidis, and H influenzae, were rarely encountered in those series in whom vaccination was routinely adopted.193-196Sepsis by uncommon | Surgery_Schwartz. the spleen, elimination of these pathogens from the bloodstream falls solely to the liver, a process that has been demonstrated to be less effective.12,126 Further, the pathophysiology of infection in asplenic patients has also been implicated in their increased risk of thrombosis and pulmonary hypertension.187More recently, the bacterial patterns of splenectomy sepsis have been changing. After the introduction of vaccinations and new oral antibiotics, postsplenectomy patients can suffer from diverse strains of bacterial infection, which are not strictly cor-related with the splenic function. In recent cohort series, gram negative bacteria are prevalent, representing 45% to 50% of infections in asplenic patients.193,194 In vaccinated patients, the rate of sepsis by pneumococcus is very low. In fact, encapsulated bacteria, such as S pneumoniae, N meningitidis, and H influenzae, were rarely encountered in those series in whom vaccination was routinely adopted.193-196Sepsis by uncommon |
Surgery_Schwartz_10160 | Surgery_Schwartz | In fact, encapsulated bacteria, such as S pneumoniae, N meningitidis, and H influenzae, were rarely encountered in those series in whom vaccination was routinely adopted.193-196Sepsis by uncommon bacteria as well by protozoa infec-tions such as malaria and babesiosis are also known to affect asplenic patients.196-200Clinical Features. OPSI is uniformly fatal without treat-ment, and thus sepsis in a splenectomized patient is a medical emergency.21,187,192 Therefore, any clinical suggestion of infec-tion, including seemingly isolated fevers, must be viewed with a high index of suspicion and treated empirically as thorough investigation proceeds. OPSI may begin with a relatively mild-appearing prodrome of symptoms. In addition to fever, nonspe-cific symptoms such as malaise, myalgias, headache, vomiting, diarrhea, abdominal pain, and others should be viewed with alarm in the asplenic patient. This process can progress rapidly to fulminant bacteremic septic shock, with hypotension, | Surgery_Schwartz. In fact, encapsulated bacteria, such as S pneumoniae, N meningitidis, and H influenzae, were rarely encountered in those series in whom vaccination was routinely adopted.193-196Sepsis by uncommon bacteria as well by protozoa infec-tions such as malaria and babesiosis are also known to affect asplenic patients.196-200Clinical Features. OPSI is uniformly fatal without treat-ment, and thus sepsis in a splenectomized patient is a medical emergency.21,187,192 Therefore, any clinical suggestion of infec-tion, including seemingly isolated fevers, must be viewed with a high index of suspicion and treated empirically as thorough investigation proceeds. OPSI may begin with a relatively mild-appearing prodrome of symptoms. In addition to fever, nonspe-cific symptoms such as malaise, myalgias, headache, vomiting, diarrhea, abdominal pain, and others should be viewed with alarm in the asplenic patient. This process can progress rapidly to fulminant bacteremic septic shock, with hypotension, |
Surgery_Schwartz_10161 | Surgery_Schwartz | headache, vomiting, diarrhea, abdominal pain, and others should be viewed with alarm in the asplenic patient. This process can progress rapidly to fulminant bacteremic septic shock, with hypotension, anuria, and disseminated intravascular coagulation.The true incidence of OPSI is not precisely known because defining criteria vary among published series. Overall lifetime risk remains low, ranging from <1% to 5%.12,21,126,201 Among 9Brunicardi_Ch34_p1517-p1548.indd 154123/02/19 2:37 PM 1542SPECIFIC CONSIDERATIONSPART IIthose who develop OPSI, some characteristics can be identified that impart greater risk. Reason for splenectomy is the single most influential determinant of OPSI risk. Case series demon-strate that those who undergo splenectomy for hematologic dis-ease (malignancy, myelodysplasia, or hemoglobinopathy) are far more susceptible to OPSI than patients who undergo sple-nectomy for trauma or iatrogenic reasons. Age is also an impor-tant consideration, with children 5 years | Surgery_Schwartz. headache, vomiting, diarrhea, abdominal pain, and others should be viewed with alarm in the asplenic patient. This process can progress rapidly to fulminant bacteremic septic shock, with hypotension, anuria, and disseminated intravascular coagulation.The true incidence of OPSI is not precisely known because defining criteria vary among published series. Overall lifetime risk remains low, ranging from <1% to 5%.12,21,126,201 Among 9Brunicardi_Ch34_p1517-p1548.indd 154123/02/19 2:37 PM 1542SPECIFIC CONSIDERATIONSPART IIthose who develop OPSI, some characteristics can be identified that impart greater risk. Reason for splenectomy is the single most influential determinant of OPSI risk. Case series demon-strate that those who undergo splenectomy for hematologic dis-ease (malignancy, myelodysplasia, or hemoglobinopathy) are far more susceptible to OPSI than patients who undergo sple-nectomy for trauma or iatrogenic reasons. Age is also an impor-tant consideration, with children 5 years |
Surgery_Schwartz_10162 | Surgery_Schwartz | or hemoglobinopathy) are far more susceptible to OPSI than patients who undergo sple-nectomy for trauma or iatrogenic reasons. Age is also an impor-tant consideration, with children 5 years of age or less and adults 50 years or older being at elevated risk. Finally, time interval from spleen removal must be considered. A large number of OPSI cases occur many years to decades after splenectomy.186,189 This observation underscores both the threat of this lethal dis-ease and the need for lifelong vigilance.Antibiotics and the Asplenic Patient. Antibiotic therapy for the asplenic patient can be considered in three contexts: therapy for established or presumed infections, prophylaxis in anticipation of invasive procedures (e.g., dental procedures), and general prophylaxis. The most critical action in the treat-ment of established or presumed OPSI is the immediate use of broad-spectrum intravenous antibiotics, ideally after the collec-tion of blood cultures. Vancomycin provides | Surgery_Schwartz. or hemoglobinopathy) are far more susceptible to OPSI than patients who undergo sple-nectomy for trauma or iatrogenic reasons. Age is also an impor-tant consideration, with children 5 years of age or less and adults 50 years or older being at elevated risk. Finally, time interval from spleen removal must be considered. A large number of OPSI cases occur many years to decades after splenectomy.186,189 This observation underscores both the threat of this lethal dis-ease and the need for lifelong vigilance.Antibiotics and the Asplenic Patient. Antibiotic therapy for the asplenic patient can be considered in three contexts: therapy for established or presumed infections, prophylaxis in anticipation of invasive procedures (e.g., dental procedures), and general prophylaxis. The most critical action in the treat-ment of established or presumed OPSI is the immediate use of broad-spectrum intravenous antibiotics, ideally after the collec-tion of blood cultures. Vancomycin provides |
Surgery_Schwartz_10163 | Surgery_Schwartz | critical action in the treat-ment of established or presumed OPSI is the immediate use of broad-spectrum intravenous antibiotics, ideally after the collec-tion of blood cultures. Vancomycin provides broad-spectrum Gram-positive coverage, including coverage against penicillin-resistant S pneumonia.190 Ceftriaxone should be added to include Gram-negative coverage for N meningitidis and H influenza.190 Early implementation of antibiotics and goal-directed therapy for sepsis can significant reduce mortality rates.21,191 For the lat-ter two indications, unfortunately, evidence supporting efficacy is scant, and guidelines for antibiotic prophylaxis are not uni-form. Optimal duration of chemoprophylaxis in children also remains unclear; however, a daily dose of antibiotics until 5 years of age or at least 5 years after splenectomy are commonly recommended, although some advocate continuation into at least early adulthood.121,122,192 Concerns regarding compliance and bacterial resistance have | Surgery_Schwartz. critical action in the treat-ment of established or presumed OPSI is the immediate use of broad-spectrum intravenous antibiotics, ideally after the collec-tion of blood cultures. Vancomycin provides broad-spectrum Gram-positive coverage, including coverage against penicillin-resistant S pneumonia.190 Ceftriaxone should be added to include Gram-negative coverage for N meningitidis and H influenza.190 Early implementation of antibiotics and goal-directed therapy for sepsis can significant reduce mortality rates.21,191 For the lat-ter two indications, unfortunately, evidence supporting efficacy is scant, and guidelines for antibiotic prophylaxis are not uni-form. Optimal duration of chemoprophylaxis in children also remains unclear; however, a daily dose of antibiotics until 5 years of age or at least 5 years after splenectomy are commonly recommended, although some advocate continuation into at least early adulthood.121,122,192 Concerns regarding compliance and bacterial resistance have |
Surgery_Schwartz_10164 | Surgery_Schwartz | at least 5 years after splenectomy are commonly recommended, although some advocate continuation into at least early adulthood.121,122,192 Concerns regarding compliance and bacterial resistance have been raised, which have led some authors to suggest that lifelong daily antibiotic prophylaxis be recommended only for those patients whose antibody titers fail to respond appropriately to vaccination or, alternately, that asplenic patients be advised to carry at all times a reserve sup-ply of antibiotic to be self-administered at the earliest sign of infection.122 Considering the grave consequences of OPSI and its relatively low incidence, controlled trials resulting in mean-ingful data on this issue seem unlikely to be performed.Education. Several risk management strategies are com-monly recommended to patients following splenectomy, including wearing a medical bracelet, carrying a laminated medical alert card, possessing a medical letter with specific empiric therapy instructions | Surgery_Schwartz. at least 5 years after splenectomy are commonly recommended, although some advocate continuation into at least early adulthood.121,122,192 Concerns regarding compliance and bacterial resistance have been raised, which have led some authors to suggest that lifelong daily antibiotic prophylaxis be recommended only for those patients whose antibody titers fail to respond appropriately to vaccination or, alternately, that asplenic patients be advised to carry at all times a reserve sup-ply of antibiotic to be self-administered at the earliest sign of infection.122 Considering the grave consequences of OPSI and its relatively low incidence, controlled trials resulting in mean-ingful data on this issue seem unlikely to be performed.Education. Several risk management strategies are com-monly recommended to patients following splenectomy, including wearing a medical bracelet, carrying a laminated medical alert card, possessing a medical letter with specific empiric therapy instructions |
Surgery_Schwartz_10165 | Surgery_Schwartz | recommended to patients following splenectomy, including wearing a medical bracelet, carrying a laminated medical alert card, possessing a medical letter with specific empiric therapy instructions (including drug names and dos-ages), and keeping a 5-day supply of standby antibiotics, par-ticularly when travel is anticipated.187,189 The need for a high index of suspicion, prompt action, and aggressive education of the patient, family, and medical providers cannot be overstated in asplenic patients.REFERENCESEntries highlighted in bright blue are key references. 1. Moynihan B. The surgery of the spleen. Br J Surg. 1921 Jan 22; 1(3134):114-6. 2. McClusky DA, 3rd, Skandalakis LJ, Colborn GL, Skandalakis JE. Tribute to a triad: history of splenic anatomy, physiology, and surgery—part 1. World J Surg. 1999;23(3):311-325. 3. McClusky DA, 3rd, Skandalakis LJ, Colborn GL, Skandalakis JE. Tribute to a triad: history of splenic anatomy, physiology, and surgery-part 2. World J Surg. | Surgery_Schwartz. recommended to patients following splenectomy, including wearing a medical bracelet, carrying a laminated medical alert card, possessing a medical letter with specific empiric therapy instructions (including drug names and dos-ages), and keeping a 5-day supply of standby antibiotics, par-ticularly when travel is anticipated.187,189 The need for a high index of suspicion, prompt action, and aggressive education of the patient, family, and medical providers cannot be overstated in asplenic patients.REFERENCESEntries highlighted in bright blue are key references. 1. Moynihan B. The surgery of the spleen. Br J Surg. 1921 Jan 22; 1(3134):114-6. 2. McClusky DA, 3rd, Skandalakis LJ, Colborn GL, Skandalakis JE. Tribute to a triad: history of splenic anatomy, physiology, and surgery—part 1. World J Surg. 1999;23(3):311-325. 3. McClusky DA, 3rd, Skandalakis LJ, Colborn GL, Skandalakis JE. Tribute to a triad: history of splenic anatomy, physiology, and surgery-part 2. World J Surg. |
Surgery_Schwartz_10166 | Surgery_Schwartz | 1. World J Surg. 1999;23(3):311-325. 3. McClusky DA, 3rd, Skandalakis LJ, Colborn GL, Skandalakis JE. Tribute to a triad: history of splenic anatomy, physiology, and surgery-part 2. World J Surg. 1999;23(5):514-526. 4. Aristotle. De Paribus Animalium [On the Parts of Animals]. Cambridge: Harvard University Press; 1961. 5. Garfield E. Citation indexes for science; a new dimension in documentation through association of ideas. Science. 1955;122(3159):108-111. 6. Cameron BD. Trends in the usage of ISI bibliometric data: uses, abuses, and implications. Libraries and the Academy. 2005;5(1):105-125. 7. Foster M. Lectures on the History of Physiology During the Sixteenth, Seventeenth, and Eighteenth Centuries. Vol 164. Cambridge: Cambridge University Press; 1901. 8. Wilkins BS. The spleen. Br J Haematol. 2002;117(2):265-274. 9. Morgenstern L. A history of splenectomy. In: Hiatt JR, Phillips EH, Morgenstern L, eds. Surgical Disease of the Spleen. New York: Springer; 1997. 10. Gray H. On the | Surgery_Schwartz. 1. World J Surg. 1999;23(3):311-325. 3. McClusky DA, 3rd, Skandalakis LJ, Colborn GL, Skandalakis JE. Tribute to a triad: history of splenic anatomy, physiology, and surgery-part 2. World J Surg. 1999;23(5):514-526. 4. Aristotle. De Paribus Animalium [On the Parts of Animals]. Cambridge: Harvard University Press; 1961. 5. Garfield E. Citation indexes for science; a new dimension in documentation through association of ideas. Science. 1955;122(3159):108-111. 6. Cameron BD. Trends in the usage of ISI bibliometric data: uses, abuses, and implications. Libraries and the Academy. 2005;5(1):105-125. 7. Foster M. Lectures on the History of Physiology During the Sixteenth, Seventeenth, and Eighteenth Centuries. Vol 164. Cambridge: Cambridge University Press; 1901. 8. Wilkins BS. The spleen. Br J Haematol. 2002;117(2):265-274. 9. Morgenstern L. A history of splenectomy. In: Hiatt JR, Phillips EH, Morgenstern L, eds. Surgical Disease of the Spleen. New York: Springer; 1997. 10. Gray H. On the |
Surgery_Schwartz_10167 | Surgery_Schwartz | Haematol. 2002;117(2):265-274. 9. Morgenstern L. A history of splenectomy. In: Hiatt JR, Phillips EH, Morgenstern L, eds. Surgical Disease of the Spleen. New York: Springer; 1997. 10. Gray H. On the Structure and Use of the Spleen. London: J.W. Parker and Son; 1854. 11. Bryant T. Case of excision of the spleen for an enlargement of the organ, attended with leucocythaemia, with remarks. Guys Hosp Rep. 1867;13(412). 12. Bickenbach KA, Gonen M, Labow DM, et al. Indications for and efficacy of splenectomy for haematological disorders. Br J Surg. 2013;100(6):794-800. 13. Musallam KM, Khalife M, Sfeir PM, et al. Postoperative out-comes after laparoscopic splenectomy compared with open splenectomy. Ann Surg. 2013;257(6):1116-1123. 14. Mebius RE, Kraal G. Structure and function of the spleen. Nat Rev Immunol. 2005;5(8):606-616. 15. Tarantino G, Savastano S, Capone D, Colao A. Spleen: a new role for an old player? World J Gastroenterol. 2011;17(33):3776-3784. 16. Morgenstern L, Skandalakis | Surgery_Schwartz. Haematol. 2002;117(2):265-274. 9. Morgenstern L. A history of splenectomy. In: Hiatt JR, Phillips EH, Morgenstern L, eds. Surgical Disease of the Spleen. New York: Springer; 1997. 10. Gray H. On the Structure and Use of the Spleen. London: J.W. Parker and Son; 1854. 11. Bryant T. Case of excision of the spleen for an enlargement of the organ, attended with leucocythaemia, with remarks. Guys Hosp Rep. 1867;13(412). 12. Bickenbach KA, Gonen M, Labow DM, et al. Indications for and efficacy of splenectomy for haematological disorders. Br J Surg. 2013;100(6):794-800. 13. Musallam KM, Khalife M, Sfeir PM, et al. Postoperative out-comes after laparoscopic splenectomy compared with open splenectomy. Ann Surg. 2013;257(6):1116-1123. 14. Mebius RE, Kraal G. Structure and function of the spleen. Nat Rev Immunol. 2005;5(8):606-616. 15. Tarantino G, Savastano S, Capone D, Colao A. Spleen: a new role for an old player? World J Gastroenterol. 2011;17(33):3776-3784. 16. Morgenstern L, Skandalakis |
Surgery_Schwartz_10168 | Surgery_Schwartz | Nat Rev Immunol. 2005;5(8):606-616. 15. Tarantino G, Savastano S, Capone D, Colao A. Spleen: a new role for an old player? World J Gastroenterol. 2011;17(33):3776-3784. 16. Morgenstern L, Skandalakis JE. Anatomy and embryology of the spleen. In: Hiatt JR, Phillips EH, Morgenstern L, eds. Surgical Diseases of the Spleen. Vol 15. Berlin/Heidelberg: Springer-Verlag; 1997. 17. Magowska A. Wandering spleen: a medical enigma, its natural history and rationalization. World J Surg. 2013;37(3):545-550. 18. Bratosin D, Mazurier J, Tissier JP, et al. Cellular and molecular mechanisms of senescent erythrocyte phagocytosis by macro-phages. A review. Biochimie. 1998;80(2):173-195. 19. Knutson M, Wessling-Resnick M. Iron metabolism in the reticuloendothelial system. Crit Rev Biochem Mol Biol. 2003;38(1):61-88. 20. Nolte MA, Belien JA, Schadee-Eestermans I, et al. A con-duit system distributes chemokines and small blood-borne molecules through the splenic white pulp. J Exp Med. | Surgery_Schwartz. Nat Rev Immunol. 2005;5(8):606-616. 15. Tarantino G, Savastano S, Capone D, Colao A. Spleen: a new role for an old player? World J Gastroenterol. 2011;17(33):3776-3784. 16. Morgenstern L, Skandalakis JE. Anatomy and embryology of the spleen. In: Hiatt JR, Phillips EH, Morgenstern L, eds. Surgical Diseases of the Spleen. Vol 15. Berlin/Heidelberg: Springer-Verlag; 1997. 17. Magowska A. Wandering spleen: a medical enigma, its natural history and rationalization. World J Surg. 2013;37(3):545-550. 18. Bratosin D, Mazurier J, Tissier JP, et al. Cellular and molecular mechanisms of senescent erythrocyte phagocytosis by macro-phages. A review. Biochimie. 1998;80(2):173-195. 19. Knutson M, Wessling-Resnick M. Iron metabolism in the reticuloendothelial system. Crit Rev Biochem Mol Biol. 2003;38(1):61-88. 20. Nolte MA, Belien JA, Schadee-Eestermans I, et al. A con-duit system distributes chemokines and small blood-borne molecules through the splenic white pulp. J Exp Med. |
Surgery_Schwartz_10169 | Surgery_Schwartz | Mol Biol. 2003;38(1):61-88. 20. Nolte MA, Belien JA, Schadee-Eestermans I, et al. A con-duit system distributes chemokines and small blood-borne molecules through the splenic white pulp. J Exp Med. 2003;198(3):505-512. 21. Di Sabatino A, Carsetti R, Corazza GR. Post-splenectomy and hyposplenic states. Lancet. 2011;378(9785):86-97. 22. Spelman D, Buttery J, Daley A, et al. Guidelines for the pre-vention of sepsis in asplenic and hyposplenic patients. Intern Med J. 2008;38(5):349-356. 23. Davies JM, Lewis MP, Wimperis J, et al. Review of guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen: prepared on behalf of the British Committee for Standards in Haematology by a work-ing party of the Haemato-Oncology task force. Br J Haematol. 2011;155(3):308-317. 24. Habermalz B, Sauerland S, Decker G, et al. Laparoscopic splenectomy: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES). Surg Endosc. | Surgery_Schwartz. Mol Biol. 2003;38(1):61-88. 20. Nolte MA, Belien JA, Schadee-Eestermans I, et al. A con-duit system distributes chemokines and small blood-borne molecules through the splenic white pulp. J Exp Med. 2003;198(3):505-512. 21. Di Sabatino A, Carsetti R, Corazza GR. Post-splenectomy and hyposplenic states. Lancet. 2011;378(9785):86-97. 22. Spelman D, Buttery J, Daley A, et al. Guidelines for the pre-vention of sepsis in asplenic and hyposplenic patients. Intern Med J. 2008;38(5):349-356. 23. Davies JM, Lewis MP, Wimperis J, et al. Review of guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen: prepared on behalf of the British Committee for Standards in Haematology by a work-ing party of the Haemato-Oncology task force. Br J Haematol. 2011;155(3):308-317. 24. Habermalz B, Sauerland S, Decker G, et al. Laparoscopic splenectomy: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES). Surg Endosc. |
Surgery_Schwartz_10170 | Surgery_Schwartz | 2011;155(3):308-317. 24. Habermalz B, Sauerland S, Decker G, et al. Laparoscopic splenectomy: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES). Surg Endosc. 2008;22(4):821-848. 25. Pozo AL, Godfrey EM, Bowles KM. Splenomegaly: investigation, diagnosis and management. Blood Rev. 2009;23(3):105-111.Brunicardi_Ch34_p1517-p1548.indd 154223/02/19 2:37 PM 1543THE SPLEENCHAPTER 34 26. Iolascon A, Andolfo I, Barcellini W, et al. Recommendations regarding splenectomy in hereditary hemolytic anemias. Haematologica. 2017;102(8):1304-1313. 27. Schilling RF. Risks and benefits of splenectomy versus no splenectomy for hereditary spherocytosis—a personal view. Br J Haematol. 2009;145(6):728-732. 28. Barcellini W, Bianchi P, Fermo E, et al. Hereditary red cell membrane defects: diagnostic and clinical aspects. Blood Transfus. 2011;9(3):274-277. 29. Casale M, Perrotta S. Splenectomy for hereditary spherocy-tosis: complete, partial or not at all? Expert Rev | Surgery_Schwartz. 2011;155(3):308-317. 24. Habermalz B, Sauerland S, Decker G, et al. Laparoscopic splenectomy: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES). Surg Endosc. 2008;22(4):821-848. 25. Pozo AL, Godfrey EM, Bowles KM. Splenomegaly: investigation, diagnosis and management. Blood Rev. 2009;23(3):105-111.Brunicardi_Ch34_p1517-p1548.indd 154223/02/19 2:37 PM 1543THE SPLEENCHAPTER 34 26. Iolascon A, Andolfo I, Barcellini W, et al. Recommendations regarding splenectomy in hereditary hemolytic anemias. Haematologica. 2017;102(8):1304-1313. 27. Schilling RF. Risks and benefits of splenectomy versus no splenectomy for hereditary spherocytosis—a personal view. Br J Haematol. 2009;145(6):728-732. 28. Barcellini W, Bianchi P, Fermo E, et al. Hereditary red cell membrane defects: diagnostic and clinical aspects. Blood Transfus. 2011;9(3):274-277. 29. Casale M, Perrotta S. Splenectomy for hereditary spherocy-tosis: complete, partial or not at all? Expert Rev |
Surgery_Schwartz_10171 | Surgery_Schwartz | membrane defects: diagnostic and clinical aspects. Blood Transfus. 2011;9(3):274-277. 29. Casale M, Perrotta S. Splenectomy for hereditary spherocy-tosis: complete, partial or not at all? Expert Rev Hematol. 2011;4(6):627-635. 30. Prchal JT, Gregg XT. Red cell enzymopathies. In: Hoffman R, ed. Hematology: Basic Principles and Practice. Vol 561. 3rd ed. New York: Churchill Livingstone; 2001. 31. Grace RF, Zanella A, Neufeld EJ, et al. Erythrocyte pyru-vate kinase deficiency: 2015 status report. Am J Hematol. 2015;90(9):825-830. 32. Beutler E, Gelbart T. Estimating the prevalence of pyruvate kinase deficiency from the gene frequency in the general white population. Blood. 2000;95(11):3585-3588. 33. Carey PJ, Chandler J, Hendrick A, et al. Prevalence of pyru-vate kinase deficiency in northern European population in the north of England. Northern Region Haematologists Group. Blood. 2000;96(12):4005-4006. 34. Hamilton JW, Jones FG, McMullin MF. Glucose-6phosphate dehydrogenase | Surgery_Schwartz. membrane defects: diagnostic and clinical aspects. Blood Transfus. 2011;9(3):274-277. 29. Casale M, Perrotta S. Splenectomy for hereditary spherocy-tosis: complete, partial or not at all? Expert Rev Hematol. 2011;4(6):627-635. 30. Prchal JT, Gregg XT. Red cell enzymopathies. In: Hoffman R, ed. Hematology: Basic Principles and Practice. Vol 561. 3rd ed. New York: Churchill Livingstone; 2001. 31. Grace RF, Zanella A, Neufeld EJ, et al. Erythrocyte pyru-vate kinase deficiency: 2015 status report. Am J Hematol. 2015;90(9):825-830. 32. Beutler E, Gelbart T. Estimating the prevalence of pyruvate kinase deficiency from the gene frequency in the general white population. Blood. 2000;95(11):3585-3588. 33. Carey PJ, Chandler J, Hendrick A, et al. Prevalence of pyru-vate kinase deficiency in northern European population in the north of England. Northern Region Haematologists Group. Blood. 2000;96(12):4005-4006. 34. Hamilton JW, Jones FG, McMullin MF. Glucose-6phosphate dehydrogenase |
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Surgery_Schwartz_10174 | Surgery_Schwartz | J Pediatr Surg. 2006;41(11):1909-1915. 43. Rachmilewitz EA, Giardina PJ. How I treat thalassemia. Blood. 2011;118(13):3479-3488. 44. Phrommintikul A, Sukonthasarn A, Kanjanavanit R, Nawarawong W. Splenectomy: a strong risk factor for pul-monary hypertension in patients with thalassaemia. Heart. 2006;92(10):1467-1472. 45. Sheikha AK, Salih ZT, Kasnazan KH, et al. Prevention of overwhelming postsplenectomy infection in thalassemia patients by partial rather than total splenectomy. Can J Surg. 2007;50(5):382-386. 46. Dedeoglu S, Bornaun H. Pulmonary hypertension in chil-dren with beta thalassemia major, are splenectomy and high-ferritin levels related or not? J Pediatr Hematol Oncol. 2017;39(4):259-265. 47. Cines DB, Blanchette VS. Immune thrombocytopenic purpura. N Engl J Med. 2002;346(13):995-1008. 48. George JN. Sequence of treatments for adults with primary immune thrombocytopenia. Am J Hematol. 2012;87(suppl 1): S12-S15. 49. Rodeghiero F, Besalduch J, Michel M, Provan D, Grotzinger | Surgery_Schwartz. J Pediatr Surg. 2006;41(11):1909-1915. 43. Rachmilewitz EA, Giardina PJ. How I treat thalassemia. Blood. 2011;118(13):3479-3488. 44. Phrommintikul A, Sukonthasarn A, Kanjanavanit R, Nawarawong W. Splenectomy: a strong risk factor for pul-monary hypertension in patients with thalassaemia. Heart. 2006;92(10):1467-1472. 45. Sheikha AK, Salih ZT, Kasnazan KH, et al. Prevention of overwhelming postsplenectomy infection in thalassemia patients by partial rather than total splenectomy. Can J Surg. 2007;50(5):382-386. 46. Dedeoglu S, Bornaun H. Pulmonary hypertension in chil-dren with beta thalassemia major, are splenectomy and high-ferritin levels related or not? J Pediatr Hematol Oncol. 2017;39(4):259-265. 47. Cines DB, Blanchette VS. Immune thrombocytopenic purpura. N Engl J Med. 2002;346(13):995-1008. 48. George JN. Sequence of treatments for adults with primary immune thrombocytopenia. Am J Hematol. 2012;87(suppl 1): S12-S15. 49. Rodeghiero F, Besalduch J, Michel M, Provan D, Grotzinger |
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Surgery_Schwartz_10197 | Surgery_Schwartz | Surg Endosc. 2014;28(12):3273-3278. 154. de la Villeon B, Zarzavadjian Le Bian A, Vuarnesson H, et al. Laparoscopic partial splenectomy: a technical tip. Surg Endosc. 2015;29(1):94-99. 155. Cadili A, de Gara C. Complications of splenectomy. Am J Med. 2008;121(5):371-375. 156. Isik O, Aytac E, Ashburn J, et al. Does laparoscopy reduce splenic injuries during colorectal resections? An assess-ment from the ACS-NSQIP database. Surg Endosc. 2015;29(5):1039-1044. 157. Rodriguez-Otero Luppi C, Targarona Soler EM, Balague Ponz C, et al. Clinical, anatomical, and pathological grading score to predict technical difficulty in laparoscopic splenectomy for non-traumatic diseases. World J Surg. 2017;41(2):439-448. 158. Gonçalves D, Morais M, Costa-Pinho A, Bessa-Melo R, Graca L, Costa-Maia J. Validation of a difficulty grading score in laparoscopic splenectomy. J Laparoendosc Adv Surg Tech A. 2018;28(3):242-247. 159. James AW, Rabl C, Westphalen AC, Fogarty PF, Posselt AM, Campos GM. | Surgery_Schwartz. Surg Endosc. 2014;28(12):3273-3278. 154. de la Villeon B, Zarzavadjian Le Bian A, Vuarnesson H, et al. Laparoscopic partial splenectomy: a technical tip. Surg Endosc. 2015;29(1):94-99. 155. Cadili A, de Gara C. Complications of splenectomy. Am J Med. 2008;121(5):371-375. 156. Isik O, Aytac E, Ashburn J, et al. Does laparoscopy reduce splenic injuries during colorectal resections? An assess-ment from the ACS-NSQIP database. Surg Endosc. 2015;29(5):1039-1044. 157. Rodriguez-Otero Luppi C, Targarona Soler EM, Balague Ponz C, et al. Clinical, anatomical, and pathological grading score to predict technical difficulty in laparoscopic splenectomy for non-traumatic diseases. World J Surg. 2017;41(2):439-448. 158. Gonçalves D, Morais M, Costa-Pinho A, Bessa-Melo R, Graca L, Costa-Maia J. Validation of a difficulty grading score in laparoscopic splenectomy. J Laparoendosc Adv Surg Tech A. 2018;28(3):242-247. 159. James AW, Rabl C, Westphalen AC, Fogarty PF, Posselt AM, Campos GM. |
Surgery_Schwartz_10198 | Surgery_Schwartz | J. Validation of a difficulty grading score in laparoscopic splenectomy. J Laparoendosc Adv Surg Tech A. 2018;28(3):242-247. 159. James AW, Rabl C, Westphalen AC, Fogarty PF, Posselt AM, Campos GM. Portomesenteric venous thrombosis after lapa-roscopic surgery: a systematic literature review. Arch Surg. 2009;144(6):520-526. 160. Li B, Liu J, Shangguan Y, Liu B, Qi Y. Laparoscopy-assisted small incision splenectomy and open splenectomy in the treatment of hematologic diseases: a single-institution com-parative experience. Surg Laparosc Endosc Percutan Tech. 2013;23(3):309-311. 161. Zhou J, Liu P, Yin Z, Zhao Y, Wang X. Safety and cost-effectiveness analysis of laparoscopic splenectomy by secondary pedicle division using monopolar electrocautery. Hepatogastroenterology. 2013;60(126):1302-1306. 162. Cordera F, Long KH, Nagorney DM, et al. Open versus laparoscopic splenectomy for idiopathic thrombocytope-nic purpura: clinical and economic analysis. Surgery. 2003; 134(1):45-52. 163. Sun LM, | Surgery_Schwartz. J. Validation of a difficulty grading score in laparoscopic splenectomy. J Laparoendosc Adv Surg Tech A. 2018;28(3):242-247. 159. James AW, Rabl C, Westphalen AC, Fogarty PF, Posselt AM, Campos GM. Portomesenteric venous thrombosis after lapa-roscopic surgery: a systematic literature review. Arch Surg. 2009;144(6):520-526. 160. Li B, Liu J, Shangguan Y, Liu B, Qi Y. Laparoscopy-assisted small incision splenectomy and open splenectomy in the treatment of hematologic diseases: a single-institution com-parative experience. Surg Laparosc Endosc Percutan Tech. 2013;23(3):309-311. 161. Zhou J, Liu P, Yin Z, Zhao Y, Wang X. Safety and cost-effectiveness analysis of laparoscopic splenectomy by secondary pedicle division using monopolar electrocautery. Hepatogastroenterology. 2013;60(126):1302-1306. 162. Cordera F, Long KH, Nagorney DM, et al. Open versus laparoscopic splenectomy for idiopathic thrombocytope-nic purpura: clinical and economic analysis. Surgery. 2003; 134(1):45-52. 163. Sun LM, |
Surgery_Schwartz_10199 | Surgery_Schwartz | F, Long KH, Nagorney DM, et al. Open versus laparoscopic splenectomy for idiopathic thrombocytope-nic purpura: clinical and economic analysis. Surgery. 2003; 134(1):45-52. 163. Sun LM, Chen HJ, Jeng LB, Li TC, Wu SC, Kao CH. Sple-nectomy and increased subsequent cancer risk: a nationwide population-based cohort study. Am J Surg. 2015;210(2): 243-251. 164. Kristinsson SY, Gridley G, Hoover RN, Check D, Landgren O. Long-term risks after splenectomy among 8,149 cancer-free American veterans: a cohort study with up to 27 years follow-up. Haematologica. 2014;99(2):392-398. 165. McInnes MD, Kielar AZ, Macdonald DB. Percutaneous image-guided biopsy of the spleen: systematic review and meta-analysis of the complication rate and diagnostic accu-racy. Radiology. 2011;260(3):699-708. 166. Singh AK, Shankar S, Gervais DA, Hahn PF, Mueller PR. Image-guided percutaneous splenic interventions. Radio-graphics. 2012;32(2):523-534. 167. Zarzaur BL, Kozar RA, Fabian TC, Coimbra R. A survey of American | Surgery_Schwartz. F, Long KH, Nagorney DM, et al. Open versus laparoscopic splenectomy for idiopathic thrombocytope-nic purpura: clinical and economic analysis. Surgery. 2003; 134(1):45-52. 163. Sun LM, Chen HJ, Jeng LB, Li TC, Wu SC, Kao CH. Sple-nectomy and increased subsequent cancer risk: a nationwide population-based cohort study. Am J Surg. 2015;210(2): 243-251. 164. Kristinsson SY, Gridley G, Hoover RN, Check D, Landgren O. Long-term risks after splenectomy among 8,149 cancer-free American veterans: a cohort study with up to 27 years follow-up. Haematologica. 2014;99(2):392-398. 165. McInnes MD, Kielar AZ, Macdonald DB. Percutaneous image-guided biopsy of the spleen: systematic review and meta-analysis of the complication rate and diagnostic accu-racy. Radiology. 2011;260(3):699-708. 166. Singh AK, Shankar S, Gervais DA, Hahn PF, Mueller PR. Image-guided percutaneous splenic interventions. Radio-graphics. 2012;32(2):523-534. 167. Zarzaur BL, Kozar RA, Fabian TC, Coimbra R. A survey of American |
Surgery_Schwartz_10200 | Surgery_Schwartz | Shankar S, Gervais DA, Hahn PF, Mueller PR. Image-guided percutaneous splenic interventions. Radio-graphics. 2012;32(2):523-534. 167. Zarzaur BL, Kozar RA, Fabian TC, Coimbra R. A survey of American Association for the Surgery of Trauma member practices in the management of blunt splenic injury. J Trauma. 2011;70(5):1026-1031. 168. Kamaya A, Weinstein S, Desser TS. Multiple lesions of the spleen: differential diagnosis of cystic and solid lesions. Semin Ultrasound CT MR. 2006;27(5):389-403. 169. Thompson BE, Munera F, Cohn SM, et al. Novel computed tomography scan scoring system predicts the need for inter-vention after splenic injury. J Trauma. 2006;60(5):1083-1086. 170. Filicori F, Stock C, Schweitzer AD, et al. Three-dimensional CT volumetry predicts outcome of laparoscopic splenectomy for splenomegaly: retrospective clinical study. World J Surg. 2013;37(1):52-58. 171. Berindoague R, Targarona EM, Balague C, et al. Can we pre-dict immediate outcome after laparoscopic splenectomy | Surgery_Schwartz. Shankar S, Gervais DA, Hahn PF, Mueller PR. Image-guided percutaneous splenic interventions. Radio-graphics. 2012;32(2):523-534. 167. Zarzaur BL, Kozar RA, Fabian TC, Coimbra R. A survey of American Association for the Surgery of Trauma member practices in the management of blunt splenic injury. J Trauma. 2011;70(5):1026-1031. 168. Kamaya A, Weinstein S, Desser TS. Multiple lesions of the spleen: differential diagnosis of cystic and solid lesions. Semin Ultrasound CT MR. 2006;27(5):389-403. 169. Thompson BE, Munera F, Cohn SM, et al. Novel computed tomography scan scoring system predicts the need for inter-vention after splenic injury. J Trauma. 2006;60(5):1083-1086. 170. Filicori F, Stock C, Schweitzer AD, et al. Three-dimensional CT volumetry predicts outcome of laparoscopic splenectomy for splenomegaly: retrospective clinical study. World J Surg. 2013;37(1):52-58. 171. Berindoague R, Targarona EM, Balague C, et al. Can we pre-dict immediate outcome after laparoscopic splenectomy |
Surgery_Schwartz_10201 | Surgery_Schwartz | for splenomegaly: retrospective clinical study. World J Surg. 2013;37(1):52-58. 171. Berindoague R, Targarona EM, Balague C, et al. Can we pre-dict immediate outcome after laparoscopic splenectomy for splenomegaly? Multivariate analysis of clinical, anatomic, and pathologic features after 3D reconstruction of the spleen. Surgical innovation. 2007;14(4):243-251. 172. Vancauwenberghe T, Snoeckx A, Vanbeckevoort D, Dymarkowski S, Vanhoenacker FM. Imaging of the spleen: what the clinician needs to know. Singapore Med J. 2015;56(3):133-144. 173. Karakas HM, Tuncbilek N, Okten OO. Splenic abnormali-ties: an overview on sectional images. Diagn Interv Radiol. 2005;11(3):152-158. 174. Dent D, Alsabrook G, Erickson BA, et al. Blunt splenic injuries: high nonoperative management rate can be achieved with selective embolization. J Trauma. 2004;56(5): 1063-1067. 175. Koconis KG, Singh H, Soares G. Partial splenic emboliza-tion in the treatment of patients with portal hypertension: a review of the | Surgery_Schwartz. for splenomegaly: retrospective clinical study. World J Surg. 2013;37(1):52-58. 171. Berindoague R, Targarona EM, Balague C, et al. Can we pre-dict immediate outcome after laparoscopic splenectomy for splenomegaly? Multivariate analysis of clinical, anatomic, and pathologic features after 3D reconstruction of the spleen. Surgical innovation. 2007;14(4):243-251. 172. Vancauwenberghe T, Snoeckx A, Vanbeckevoort D, Dymarkowski S, Vanhoenacker FM. Imaging of the spleen: what the clinician needs to know. Singapore Med J. 2015;56(3):133-144. 173. Karakas HM, Tuncbilek N, Okten OO. Splenic abnormali-ties: an overview on sectional images. Diagn Interv Radiol. 2005;11(3):152-158. 174. Dent D, Alsabrook G, Erickson BA, et al. Blunt splenic injuries: high nonoperative management rate can be achieved with selective embolization. J Trauma. 2004;56(5): 1063-1067. 175. Koconis KG, Singh H, Soares G. Partial splenic emboliza-tion in the treatment of patients with portal hypertension: a review of the |
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