全胃切除联合脾脏切除术根治进展期贲门癌的适应证选择

目的:探讨进展期贲门癌根治术联合脾脏切除术的适应证及意义。方法:分析26例进展期贲门癌行全胃切除患者的临床资料,根据脾脏是否切除分为切脾组(n=10)和保脾组(n=16),比较两组患者手术时间、住院时间、术后并发症以及脾门淋巴结转移情况。结果:切脾组手术时间、住院时间和膈下感染发生率均明显高于保脾组(P<0.05)。切脾组与保脾组术后病理检查出的第10、11组淋巴结转移率的差异无统计学意义(P>0.05)。结论:贲门癌根治术时,脾脏和脾血管受侵是联合脾脏切除的合理适应证。

延迟性脾破裂27例诊治体会

目的:探讨延迟性脾破裂(DRS)的诊断和治疗。方法:回顾分析27例DRS患者的临床资料。结果:该组DRS患者中,手术治疗26例,非手术治疗1例,27例全部治愈。结论:及时明确诊断,延迟性脾破裂的治疗以急诊脾切除术为主。

断流联合脾腔分流术治疗门脉高压症29例

目的:探讨脾切除贲门周围血管离断联合脾腔分流术治疗门脉高压症的安全性和临床疗效。方法:回顾性分析29例行断流联合脾腔分流术治疗的门脉高压症患者的临床资料。结果:所有患者均成功手术,无围手术期死亡病例,术后发生肺部感染1例,腹水短期增多2例。随访期间发生食管静脉曲张破裂再出血2例(6.88%),肝性脑病1例(3.44%),因肝功能衰竭死亡1例(3.44%)。结论:脾切除贲门周围血管离断加脾腔分流术治疗门脉高压症,具有再出血率低,近远期治疗效果满意等优点,是目前治疗门脉高压症的较佳术式。掌握好手术适应证,在基层医院也可开展应用。

A case of successful management with splenectomy of intractable ascites due to congenital dyserythropoietic anemia type II-induced cirrhosis

The congenital dyserythropoietic anemias comprise a group of rare hereditary disorders of erythropoiesis, characterized by ineffective erythropoiesis as the predominant mechanism of anemia and by characteristic morphological aberrations of the majority of erythroblasts in the bone marrow. Congenital dyserythropoietic anemia type II is the most frequent type. All types of congenital dyserythropoietic anemias distinctly share a high incidence of iron loading. Iron accumulation occurs even in untransfused patients and can result in heart failure and liver cirrhosis. We have reported about a patient who presented with liver cirrhosis and intractable ascites caused by congenital dyserythropoietic anemia type II. Her clinical course was further complicated by the development of autoimmune hemolytic anemia. Splenectomy was eventually performed which achieved complete resolution of ascites, increase of hemoglobin concentration and abrogation of transfusion requirements.

Predictive value of D-dimer for portal vein thrombosis after portal hypertension surgery in hepatitis B virus-related cirrhosis

AIM: To evaluate the predictive value of D-dimer as a predictive indicator of portal vein thrombosis (PVT) after portal hypertension surgery in hepatitis B virus-related cirrhosis. METHODS: A prospective study was carried out in 52 patients who had undergone surgery for portal hypertension in hepatitis B virus-related cirrhosis. Changes in perioperative dynamic D-dimer were observed. The sensitivity, specifi city, positive predictive values and negative predictive values of D-dimer were calculated, and ROC curves were analyzed. RESULTS: The D-dimer levels in the group developing postoperative PVT was signifi cantly higher than those in the group not developing PVT (P = 0.001), and the ROC semi-quantitative and qualitative analysis of D-dimer showed a moderate predictive value in PVT (semi- quantitative value Az = 0.794, P = 0.000; qualitative analysis: Az = 0.739, P = 0.001). CONCLUSION: Dynamic monitoring of D-dimer levels in patients with portal hypertension after surgery can help early diagnosis of PVT, as in cases where the D-dimer levels steadily increase and exceed 16 μg/mL, the possibility of PVT is very high.

Autoimmune thrombocytopenia in response to splenectomy in cirrhotic patients with accompanying hepatitis C

AIM： To estimate the contribution of autoimmune thrombocytopenia to hepatitis C virus-related liver cirrhosis （type C cirrhosis）, we evaluated the influence of splenectomy upon platelet-associated immunoglobulin G （PAIgG） levels and platelet numbers. METHODS： PAIgG titers and immune markers were determined in 24 type C cirrhotic patients with an intact spleen, 17 type C cirrhotic patients submitted to splenectomy, and 21 non-C cirrhosis with an intact spleen. RESULTS： Thrombocytopenia （PLT〈15×10^4/μL） in type C cirrhosis was diagnosed in all patients with an intact spleen, 8 patients submitted to splenectomy, and in 19 non-C cirrhosis with intact spleen. Elevated titers of PAIgG at more than 25.0 ng/107cells were detected in all cirrhotic patients except for one splenectomized patient. PAIgG titers （ng/10^7cells） were significantly higher in the type C cirrhosis with an intact spleen （247.9 ± 197.0） compared with the splenectomized patients （125.6±87.8） or non-C cirrhosis （152.4± 127.4）. PAIgG titers were negatively correlated with platelet counts in type C cirrhotic patients with an intact spleen. In comparison with the type C cirrhosis with an intact spleen, the splenectomized patients had a reduced CD4/CD8 ratio and serum neopterin levels. The spleen index （cm^2） was negatively correlated with platelet counts in the non-C cirrhosis, but not in the type C cirrhosis. CONCLUSION： Our data indicate that the autoimmune mechanism plays an important role in thrombocytosis complicated by HCV-positive cirrhosis. In addition, splenectomy may impair T cells function through, at least in part, a reduction of CD4/CD8 ratio, consequently suppressing PAIgG production.

Pre-and postoperative systemic hemodynamic evaluation in patients subjected to esophagogastric devascularization plus splenectomy and distal splenorenal shunt:A comparative study in schistomomal portal hypertension

AIM: To investigate the systemic hemodynamic effects of two surgical procedures largely employed for treatment of schistosomal portal hypertension. METHODS: Thirty-six patients undergoing elective surgical treatment of portal hypertension due to hepatosplenic mansonic schistosomiasis were prospectively evaluated. All patients were subjected to preoperative pulmonary artery catheterization; 17 were submitted to esophagogastric devascularization and splenectomy (EGDS) and 19 to distal splenorenal shunt (DSRS). The systemic hemodynamic assessment was repeated 4 d after the surgical procedure. RESULTS: Preoperative evaluation revealed (mean ± SD) an increased cardiac index (4.78 ± 1.13 L/min per m2),associated with a reduction in systemic vascular resistance index (1457 ± 380.7 dynes.s/cm5.m2). The mean pulmonary artery pressure (18 ± 5.1 mmHg) as well as the right atrial pressure (7.9 ± 2.5 mmHg) were increased,while the pulmonary vascular resistance index (133 ± 62 dynes.s/cm5.m2) was decreased. Four days after EGDS,a significant reduction in cardiac index (3.80 ± 0.4 L/min per m2,P < 0.001) and increase in systemic vascular resistance index (1901.4 ± 330.2 dynes.s/cm5. m2,P < 0.001) toward normal levels were observed. There was also a significant reduction in pulmonary artery pressure (12.65 ± 4.7 mmHg,P < 0.001) and no significant changes in the pulmonary vascular resistance index (141.6 ± 102.9 dynes.s/cm5.m2). Four days after DSRS,a non-significant increase in cardiac index (5.2 ± 0.76 L/min per m2) and systemic vascular resistance index (1389 ± 311 dynes.s/cm5.m2) was observed. There was also a non-significant increase in pulmonary artery pressure (19.84 ± 5.2 mmHg),right cardiac work index (1.38 ± 0.4 kg.m/m2) and right ventricular systolic work index (16.3 ± 6.3 g.m/m2),without significant changes in the pulmonary vascular resistance index (139.7 ± 67.8 dynes.s/cm5.m2). CONCLUSION: The hyperdynamic circulatory state observed in mansonic schistosomiasis was corrected by EGDS,but was maintained in patients who underwent DSRS. Similarly,the elevated mean pulmonary artery pressure was corrected after EGDS and maintained after DSRS. EGDS seems to be the most physiologic surgery for patients with schistosomal portal hypertension.

Evaluation of the effects of combined endoscopic variceal ligation and splenectomy with pericardial devascularization on esophageal varices

AIM: To detect the hemodynamic alterations in collateral circulation before and after combined endoscopic variceal ligation (EVL) and splenectomy with pericardial devascularization by ultrasonography, and to evaluate their effect using hemodynamic parameters. METHODS: Forty-three patients with esophageal varices received combined EVL and splenectomy with pericardial devascularization for variceal eradication. The esophageal vein structures and azygos blood flow (AZBF) were detected by endoscopic ultrasonography and color Doppler ultrasound. The recurrence and rebleeding of esophageal varices were followed up. RESULTS: Patients with moderate or severe varices in the esophageal wall and those with severe peri- esophageal collateral vein varices had improvements after treatment, while the percentage of patients with severe para-esophageal collateral vein varices decreased from 54.49% to 2.33%, and the percentage of patients with detectable perforating veins decreased from 79.07% to 4.65% (P < 0.01). Color Doppler flowmetry showed a significant decrease both in AZBF (43.00%, P < 0.05) and in diameter of the azygos vein (28.85%, P < 0.05), while the blood flow rate was unchanged. The recurrence rate of esophageal varices was 2.5% (1/40, mild), while no re-bleeding cases were recorded. CONCLUSION: EVL in combination with splenectomy with pericardial devascularization can block the collateral veins both inside and outside of the esophageal wall, and is more advantagious over splenectomy in combination with pericardial devascularization or EVL in preventing recurrence and re-bleeding of varices.

Spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein

PreservaUon of the spleen at distal pancreatectomy has recently attracted considerable attention. Since our first successful trial, spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein for tumors of the pancreas and chronic pancreatitis has been performed more frequently. The technique for spleenpreserving distal pancreatectomy with conservation of the splenic artery and vein are outlined. The splenic vein is identified behind the pancreas and within the thin connective tissue membrane. The connective tissue membrane is cut longitudinally above the splenic vein. An important issue is to remove the splenic vein from the body of the pancreas toward the spleen, since a different approach may be very difficult. The pancreas is preferably removed from the splenic artery toward the head of the pancreas itself. This procedure is much easier than removing the pancreas from the vein side. One patient had undergone distal gastrectomy for duodenal ulcer, with reconstruction by Billroth Ⅱ tehcnique. If distal pancreatectomy with splenectomy had been performed for the lesion of the distal pancreas at the time, the residual stomach would also have to be resected. The potential damage done to the patient by reconstruction of the gastrointestinal tract in combination with distal pancreatectomy and splenectomy would have been much greater than with distal pancreatectomy only with preservation of the spleen and residual stomach. Benign lesions as well as low-grade malignancy of the body and tail of the pancreas may be a possible indication for this procedure.

Successful laparoscopic splenectomy after living-donor liver transplantation for thrombocytopenia caused by antiviral therapy

Although interferon (IFN) based therapy for recurrent hepatitis C virus (HCV) infection after liver transplantation has been widely accepted, it induces various adverse effects such as thrombocytopenia, resulting in its interruption. Recently, concomitant splenectomy at the time of living donor liver transplantation (LDLT) has been tried to overcome this problem, but this procedure leads to several complications such as excessive intraoperative bleeding and serious infection. A 60-year-old female received LDLT using a left lobe graft from her second son for liver failure caused by hepatitis C-related cirrhosis. Six months after LDLT, she was diagnosed as recurrent HCV infection by liver biopsy. IFN monotherapy was started from 7 mo after LDLT and her platelet count decreased to less than 50 000/μL, which thus made it necessary to discontinue the treatment. We decided to attempt laparoscopic splenectomy (LS) under general anesthesia. Since intra-abdominal findings did not show any adhesion formations around the spleen, LS could be successfully performed. After LS, since her platelet count immediately increased to 225 000/μL 14 d after operation, IFN therapy was restarted and we could convert the combination therapy of IFN and ribavirin, resulting in no detectable viral marker. Inconclusion, LS can be performed safely even after LDLT, and LS after LDLT is a feasible and less invasive modality for thrombocytopenia caused by antiviral therapy.

Reduction of virus burden-induced splenectomy in patients with liver cirrhosis related to hepatitis C virus infection

AIM： To examine the hepatitis C virus （HCV） levels and immunological markers in cirrhotic patients after splenectomy. METHODS： HCV RNA titers as well as cellular and humoral immune markers were determined in 20 cirrhotic patients after splenectomy and in 32 cirrhotic controls with an intact spleen. RESULTS： Serum HCV RNA titers were lower in the splenectomized patients than in the controls （186 ± 225 × 10^3 copies/mL vs 541 ± 417×10^3 copies/mL, P〈0.01）. HCV RNA was judged to have been spontaneously eradicated in 4 splenectomized patients, but in none of the controls. Natural killer cell activity was higher in the splenectomized patients than in the controls （41.2 ± 19.3% vs 24.7 ± 15.3%, P〈 0.01）, and natural killer cell activity was negatively correlated to HCV RNA titers in the splenectomized patients except in those with serotype 2-related infection. The CEH/CD8 ratio was significantly lower in the splenectomized patients than in the controls. CONCLUSION： The findings suggest that splenectomy may diminish virus burden in cirrhotic patients with HCV infection at least in part, through augmentation of natural killer cell activity.

Splenectomy with endoscopic variceal ligation is superior to splenectomy with pericardial devascularization in treatment of portal hypertension

AIM: To investigate the therapeutic efficacy and complications of splenectomy with endoscopic variceal ligation (EVL) and splenectomy with pericardial devascularization (i.e. Hassab’s operation) in patients with portal hypertension. METHODS: A total of 103 patients with liver cirrhosis and portal hypertension were randomly selected to receive either splenectomy with EVL (n = 53, group A) or Hassab’s operation (n = 50, group B). RESULTS: The portal blood flow volume, the presence of portal vein thrombosis, gastric emptying time and free portal venous pressure (FPP) before and after the operation were determined. Patients were followed up for up to 64 mo with an average of 45 mo, and the Dagradi classification of variceal veins and the grading of portal hypertension gastropathy (PHG) were evaluated. It was found that all esophageal varices were occluded or decreased to grade Ⅱ or less in both groups. There was little difference in the recurrence rate of esophageal varices (11.9% vs 13.2%) and the re-bleeding rate (7.1% vs 5.3%) between groups A and B. The incidence of complications and the percentage of patients with severe PHG after the operation were significantly higher in group B (60.0% and 52.0%) than in group A (32.1% and 20.8%, P < 0.05). No patients died of operation-related complications. There was no significant difference in gastric emptying time, FPP and portal blood flow volume between the two groups. CONCLUSION: The results suggest that splenectomy with EVL achieves similar therapeutic efficacy to that of Hassab’s operation in terms of the recurrence rate of esophageal varices and the re-bleeding rate, but theformer results in fewer and milder complications.

Abscesses of the spleen:Report of three cases

Abscess of the spleen is a rare discovery, with about 600 cases in the international literature so far. Although it may have various causes, it is most usually associated with trauma and infections of the spleen. The latter are more common in the presence of a different primary site of infection, especially endocarditis or in cases of ischemic infarcts that are secondarily infected. Moreover, immunosuppression is a major risk factor. Clinical examination usually reveals a combination of fever, left-upper-quadrant abdominal pain and vomiting. Laboratory findings are not constant. Imaging is a necessary tool for establishing the diagnosis, with a choice between ultrasound and computed tomography. Treatment includes conservative measures, and surgical intervention. In children and in cases of solitary abscesses with a thick wall, percutaneous catheter drainage may be attempted. Otherwise, splenectomy is the preferred approach in most centers. Here, we present three cases of splenic abscess. In all three, splenectomy was performed, followed by rapid clinical improvement. These cases emphasize that current understanding of spleen abscess etiology is still limited, and a study for additional risk factors may be necessary.

Non-invasive evaluation of liver stiffness after splenectomy in rabbits with CCl_4-induced liver fibrosis

AIM To investigate the diagnostic performance of liver stiffness measurement(LSM) by elastography point quantification(Elast PQ) in animal models and determine the longitudinal changes in liver stiffness by Elast PQ after splenectomy at different stages of fibrosis.METHODS Liver stiffness was measured in sixty-eight rabbits with CCl4-induced liver fibrosis at different stages and eight healthy control rabbits by Elast PQ. Liver biopsies and blood samples were obtained at scheduled time points to assess liver function and degree of fibrosis. Thirty-one rabbits with complete data that underwent splenectomy at different stages of liver fibrosis were then included for dynamic monitoring of changes in liver stiffness by Elast PQ and liver function according to blood tests.RESULTS LSM by Elast PQ was significantly correlated with histologic fibrosis stage(r = 0.85, P < 0.001). The optimal cutoff values by Elast PQ were 11.27, 14.89, and 18.21 k Pa for predicting minimal fibrosis, moderate fibrosis, and cirrhosis, respectively. Longitudinalmonitoring of the changes in liver stiffness by Elast PQ showed that early splenectomy(especially F1) may delay liver fibrosis progression.CONCLUSION Elast PQ is an available, convenient, objective and non-invasive technique for assessing liver stiffness in rabbits with CCl4-induced liver fibrosis. In addition, liver stiffness measurements using Elast PQ can dynamically monitor the changes in liver stiffness in rabbit models, and in patients, after splenectomy.

Splenic rupture following colonoscopy

Colonoscopy is a safe and routinely performed diagnostic and therapeutic procedure for different colorectal diseases. Although the most common complications are bleeding and perforation, extracolonic or visceral injuries have also been described. Splenic rupture is a rare complication following colonoscopy, with few cases reported. We report a 60-year-old female who presented to surgical consultation 8 h after a diagnostic colonoscopy. Clinical, laboratory and imaging findings were suggestive for a massive hemoperitoneum. At surgery, an almost complete splenic disruption was evident, and an urgent splenectomy was performed. After an uneventful postoperative period, she was discharged home. Splenic injury following colonoscopy is considered infrequent. Direct trauma and excessive traction of the splenocolic ligament can explain the occurrence of this complication. Many times the diagnosis is delayed because the symptoms are due to colonic insuffl ation, so the most frequent treatment is an urgent splenectomy. A high index of suspicion needs an early diagnosis and adequate therapy.

Reaching proficiency in laparoscopic splenectomy

AIM:To investigate the proficiency level reached in laparoscopic splenectomy using the learning curve method.METHODS:All patients in need of splenectomy for benign causes in whom laparoscopic splenectomy was attempted by a single surgeon during a time period of 6 years were included in the study (n=33). Besides demographics, operation-related variables and the response to surgery were recorded. The patients were allocated to groups of five, ranked according to the date of the operation. Operation duration, complications, postoperative length of stay, conversion to laparotomy and splenic weight were then compared between these groups.RESULTS: There was a significant difference regarding operation times between the groups (P = 0.001). An improvement was observed after the first 5 cases. The learning curve was flat up to the 25th case. Following the 25th case the operation times decreased still further. There was no difference between the groups regarding the other parameters.CONCLUSION: Unlike the widely accepted "L" shape, the learning curve for laparoscopic splenectomy is a horizontal lazy "S" with two distinct slopes. Privileges may be granted after the first 5 cases. However proficiency seems to require 25 cases.

RESECTION OF THE BODY AND TAIL OF THE PANCREAS WITH PRESERVATION OF SPLEEN

A total of 19 cases were performed the resection of the body and tail of the pancreas with preservation of spleen in our department since it was first successfully carried out in the late 1980′s The indications of operation were pancreatic cystadenoma(n=8),pseudocyst(n=2),insulioma(n=3),pancreatic injury(n=6) All but one went well intraoperatively and postoperatively with the normal appearance and function of the spleen The main observation items of postoperation were leukocyte phagocytosis test, splenic CT scan,ultrasonography and Technetium 99m spleen scan The exceptional one showed transient insufficiency of splenic blood supply after the operation Considering the regional conditions in the operations, the procedure could be classified into the resection of the body and tail of pancreas with and without conservation of the splenic artery and vein

Case Report:Wernicke encephalopathy following splenectomy in a patient with liver cirrhosis:a case report and review of the literature

Objective:To report a case of Wernicke encephalopathy in the early stage after surgery.Methods:A nonalcoholic female patient with hepatitis B-related cirrhosis and hypersplenism underwent splenectomy in a local hospital.No surgical complications occurred and the patient recovered well.However,on the eighth postoperative day she developed psychiatric and neurological disturbance without an obvious cause.She was then admitted to our hospital.Brain magnetic resonance imaging(MRI) with FLAIR T2 showed symmetric high-signal intensities in the periaqueductal area of the midbrain,which were consistent with Wernicke encephalopathy.She was thus given in-tramuscular thiamine immediately.Results:After the administration of thiamine,the patient's confused mental state resolved within 3 d,and her dystaxia gradually improved over the next 5 d.The brain MRI with FLAIR T2 was re-examined one month after the episode,and showed nearly complete resolution of the previously abnormal signal intensities in the periaqueductal area of the midbrain.Conclusion:Physicians should be aware of the possibility of acute Wernicke encephalopathy,especially in patients with liver dysfunction.