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ANNALS Of ANATOMY
Anatomical and surgical aspects of splenic segmentectomies Marcelo Campos Christo* and Liberato J. A. DiDio
* Department of Surgery, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Rua Dias Toledo, 76 (Vila Paris), 30380-670, Belo Horizonte, MG, Brasil, and Department of Anatomy and Surgery, Faculty of Medicine, University of Santo Amaro, Rua Prof. Eneas Siqueira Neto 340, 04829-300 Sao Paulo, SP, Brasil
Summary. Based upon the anatomicosurgical segments of the spleen, suggested by DiDio and demonstrated in cadavers, classified and named by Neder (1958) and Zappahi (1958, 1959, 1963), the normal segmental organization was anatomically and radiologically confirmed in 51 human spleens, after studying corrosion casts and radiograms of intraparenchymal vessels (Christo, 1959 a, b, 1960, 1962, 1963, 1993). From 1958 to 1965, pioneer segmental resections were performed successfully in 34 dogs and in 9 patients to safely remove traumatic injured splenic segments. At the same time, the overwhelming postsplenectomy infection (OPSI) became well identified. Consequently, to save normally functioning splenic parenchyma became the most important issue in the management of splenic injuries. The anatomical basis for partial splenectomy and splenic segmentectomy is discussed. The term "splenorrhaphy" was employed to designate all conservative or parenchyma saving operations of spleen based upon its vascular supply: from topical packings to splenic sutures including "cappings" and partial splenectomies. From analysis of 38 consecutive reports in 20 years, covering 4,076 patients, it was concluded that "splenorrhaphies" had been electively employed in 46% of the injuries and partial splenectomies were identified in 8.6% of these surgical interventions. However, the critical minimal mass of splenic tissue to be preserved after partial splenectomies is still to be defined. Postoperative complications directly related to "splenorrhaphies" are rare. Uncommonly performed after splenectomies, the heterotopical splenic autotransplantation has presented dubious results. Trials with nonoperaCorrespondence to: Liberato 1. A. DiDio
Ann Anat (1997) 179: 461-474 © Gustav Fischer Verlag
tive management of splenic blunt trauma injuries have been safer among children, whose spleens are predominantly transversally disrupted and have a higher relationship "capsular resistance/parenchymal bulk" .Splenectomies have been most frequently the ultimate result of delayed laparotomy and underlying risks of growing blood requirements may surpass the advantages of preventing OPSI. Key words: Splenic anatomy - Anatomicosurgical segments - Splenic segmentation - Trauma - Autotransplantation - Splenorrhaphies - Segmentectomy
Introduction and literature Anatomical investigations on the angioarchitecture of parenchymatous organs showed a "segmental organization", in which each parenchymal segment is provided with a pedicle for its own independent blood supply and drainage. The segments are separated, one from the other, anatomically and/or surgically, by paucivascular limiting planes, justifying the name "anatomicosurgical segments" (DiDio 1982, 1988, 1989, 1993, 1994; DiDio and Lopes 1995). Such a background made possible to apply reliable surgical procedures. Techniques of partial resections or segmentectomies were developed initially for the lungs (Boyden 1945), liver (Couinaud 1954) and kidneys (Graves 1954; DiDio 1956). Based upon anatomical and experimental studies, suggested by and under the supervision of DiDio, performed by a surgeon (Neder 1958), and an anatomist (Zappala 1958, 1959, 1963), splenic segmentectomy was first performed in humans by Christo (1959 a).
The spleen, traditionally assumed to be an expendable organ, remained for long time as surgically indivisible. The immediate removal of the entire injured spleen was considered a safe, efficient and, above all, a complicationfree elective operation. Saving spleen procedures were hardly justifiable, "regardless of type and extent of splenic injury" (Schwartz et al. 1974), a belief that had begun to be challenged since the report of a clinical observation by King and Schumacker (1952). In this landmark paper, medical attention was called by an "extraordinary association of splenectomy in infancy and subsequent susceptibility to severe infection", in a group of five children operated on under the age of six months. Several reports on post-splenectomy severe bacterial infections appeared in the following years (Cole et al. 1955; Gofstein et al. 1956; Smith et al. 1957 and Huntley
Fig. 1. Radiogram of a human spleen after injection of mercury and radiopaque substance in the splenic artery. The arterial branches supplying the superior segment and the mid-inferior segment were not injected (male, adult, Brazilian).
et al. 1958). These evidences convinced us that to save splenic viable parenchyma, after traumatic injuries, should be advantageous. Toward this goal safe rational, anatomically and experimentally-based surgical techniques for partial splenectomies could be established. In a few words, the final result of our investigations was the successful direct application to surgery of pure and simple knowledge of macroscopic anatomy of the spleen.
Material and methods Anatomical studies The intrasplenic distribution of the hilar splenic vessels were studied in 51 spleens of human individuals of either sex, 47 of which were removed during necroscopy and 4 during surgical interventions, sparing their hilar arterial and venous vessels. Vynil acetate colored casts of the intraparenchymatous arteries and veins were obtained in 40 spleens, by injection of the solution through the hilar vessels followed by parenchymal corrosion in a hydrochloric acid bath. Radiograms were obtained in 11 spleens after selective injections of live mercury or radiopaque pharmaceutical substance in hilar arterial rami Fig. 1). Such techniques demonstrated that the spleen consists of segments or "parenchymatous units", each one with its own hilar arterial blood supply and venous drainage, separated, one from the other, by paucivascular planes. The segments were named superior, midsuperior, middle, mid-inferior and inferior (Christo 1963). The intersegmental divisional planes are transversally superposed, at higher and higher angles, on a supero-inferior direction. The division of the spleen into superior and inferior hemispleens occurs at a 90 degree dihedral angle (Fig. 2).
Fig. 2. Drawing of intersegmental planes (paucivascular planes) and of a plane corresponding to the visceral aspect in a five-segment human spleen. The 90° angle corresponds to the division of the organ in superior and inferior hemispleens.
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Experimental Studies Knowing the segmental organization of the spleen in dogs (Zappala 1959, 1963), we undertook an experimental surgical investigation. In 24 dogs we performed every type of partial splenic resection, with selective ligature of the segmental vessels, followed by the removal of the parenchyma within pauci-vascular intersegmental planes. The necroscopy of each animal did not detect any hemorrhagic accidents, from the 1st to the 62nd postoperative day.
Results Based upon anatomical, radiological and experimental findings (Figs. 1- 5), we developed surgical techniques for partial splenectomies and segmentectomies to treat traumatic localized injuries in the spleen. These operations include two steps, as follows: I. Isolation and selective ligation of hilar vessels corresponding to the injured parenchymal segment. II. Cutting off the resulting ischemic injured splenic territory. Fig. 3. Drawing of the venous drainage in a four-segmented spleen, of an adult human individual. The segments and their segmental veins are named from top to bottom as superior, midsuperior, mid-inferior and inferior. (From Neder, 1958).
Fig. 4. Drawing of the arterial supply in a four-segmented spleen, of an adult human individual. From top to bottom: superior, midsuperior, mid-inferior and inferior segments. (From Zappala 1958, 1959).
Fig. 5. Diagram of the segmental arteries and veins and their distribution in the spleen of the case illustrated in Fig. 4. The segmental vessels have the same name of the corresponding splenic segment: artery (or vein) of the superior segment, a. (v.) of the midsuperior segment, a. (v.) of the mid-inferior segment, a. (v.) of the inferior segment. (From Zappala 1958, 1959).
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Such surgical interventions were carried out in 9 patients, aged from 6 to 48 years, with localized parenchymal injuries, distributed as follows: 4 segmentectomies of the superior segment, 1 segmentectomy of the mid-inferior segment, 3 superior bisegmentectomies or superior and midsuperior segmentectomies (resection of the superior and midsuperior segments or superior hemisplenectomies) and 1 segmentectomy of the inferior segment (Fig. 6 and Table 1). One postoperative death occurred on the 26th day after drainage of a left subphrenic abscess, related to gastric perforation, in a patient submitted to a segmentectomy of the superior segment of the spleen, injured by a bullet. The post-mortem examination revealed a normal residual spleen as a result of a successful surgical procedure. No postoperative complication was registered among the remaining 8 patients. In these initial cases, the cut surface of the spleen was left sutureless, covered with "Gelfoam" or omentum (epiploon). After a resection of a medium segment, the residual surfaces were joined together.
Discussion When King and Schumacker (1952) first suggested the necessity of research "to substantiate or refute the causeeffect relationship" between splenectomy and postoperative infection, the spleen "began to come out of hiding" (Morgenstern 1986). In the following years, studies dealing with pediatric and adult patients, ranging from case reports to large serial analysis, defined a clear relationship between splenectomies for diverse indications and severe late infections, as a lifelong risk (Cullingford et al. 1991). Consequently, splenic tissue salvage moved from a controversial issue to a mandatory procedure and the anatomy-based partial splenectomies (Christo 1959, 1962, Morgenstern et al. 1966) became "the historical most significant milestone" of this change (Derisi et al. 1982), a reversed turning point on the surgical respectability of the spleen. A prejudice-free safe way to the development of saving spleen techniques was opened and we felt rewarded by Sherman (1980) recognition: "The first report of successful partial splenectomy in modern times was a publication in 1962 by Campos-Christo".
Case 9
Case 2
Cases: 1, 3, 4, 8
Cases: 5, 6, 7 Fig. 6. Drawings of segmentectomies or segmental splenectomies (see table 1). x -ligated segmental arteries. Case 9: Splenic inferior segmentectomy (resection of the inferior segment of the spleen). Case 2: Splenic mid-superior segmentectomy (resection of the midinferior segment). Cases 1, 3, 4, 8: Splenic superior segmentectomy (resection of the superior segment). Cases, 5, 6, 7: Splenic superior and mid-superior segmentectomies (resection of the superior and mid-superior segments or splenic double segmentectomy). The top three drawings show unisegmentectomies and the bottom one shows a bisegmentectomy.
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Table 1. Segmentectomies and Hemisplenectomies for Trauma. The First 9 Cases Date
1959
1960
1965
Type of Partial Splenectomy
Case
Result
Age (years) Sex
Type of Trauma
40/M
knife wound
superior segmentectomy
1
cured
61F
bullet wound
mid-inferior segmentectomy
2
cured
231F
bullet wound
superior segmentectomy
3
cured
481F
bullet wound
superior segmentectomy
4
cured
171M
knife wound
superior bisegmentectomy or hemisplenectomy
5
died (infection)
271M
blunt
superior bisegmentectomy or hemisplenectomy
6
cured
101M
blunt
superior bisegmentectomy or hemisplenectomy
7
cured
221M
bullet wound
superior segmentectomy
8
cured
301M
bullet wound
inferior segmentectomy
9
cured
nr.
Particularly in the management of traumatic injuries a number of splenic tissue saving procedures, surgical and nonsurgical, to preserve the non-injured, normal splenic parenchyma, has been developed and successfully employed: I) topical hemostatic techniques. II) rhaphy techniques, partial splenectomy and segmentectomy, III) heterotopic autotransplantation of splenic tissue, and IV) non operative management. 1. Splenic topical hemostatic techniques
Fully accepted as a relevant surgical practice by Morgenstern et al. (1965, 1979) and Scheele et al. (1984, 1993), the local packing with topical hemostatic agents has been electively employed for incidental iatrogenic peri-operative splenic capsular avulsion injuries or, eventually, as an adjuvant to splenic sutures and/or partial splenectomies. As a primary isolated treatment for splenic traumatic injuries, it has been generally prevented as an elective practice. Exceptions to this rule are the series by Giuliano and Lim (1981) and Beal et Spisso (1988), when topical hemostatic techniques were electively employed to treat external traumatic splenic injuries. According to the topical employed agent, two operative procedures are distinguished: I) topical applications of tissue adhesives, among which the fibrin tissue adhesives have proven to be the most efficient; II) local coagulation with electrocautery or alternate special devices employing infrared light contact, argon beam and laser system, under experimental trial. 2. Rhaphy techniques and partial splenectomies It was demonstrated by Upadhyaya and Simpson (1968)
in children with traumatic splenic rupture, that the blunt
ruptures are predominantly transversally oriented and less bleeding. In contrast, penetrating injuries, cutting across the transverse planes, produce more intrasplenic damage and more profuse bleeding. These views were confirmed by an experimental investigation in monkeys, when splenic sutures were successfully performed (Upadhyaya et al. 1971). Splenic splenorrhaphy, as an alternative to splenectomy, in traumatic injuries, was first described at the turn of the century (Zikoff 1895). Successful splenorrhaphy of a transverse blunt splenic tear, involving the hilum, in a child, was reported by Mishalany (1974). Referring to the studies of Upadhyaya et aI., he proposed the practice of the suture of the spleen in traumatic lesions, "no matter what plane the injuries assume". It is well recognized since Dretzka (1930), that splenic parenchymal "circumscribed wounds" can be successfully repaired. In complex lacerations, the surgical conservative management is controversial and frequently derived from surgeons own experience (Shackford et al. 1981). Technical problems, involving debridment and hemostasis of complex lacerations, eventually extended into the splenic hilum, have been managed through different procedures: I) by ligation of the main splenic artery (Shermann and Ausch 1978) II) by intermittent ischemia, drawing taut a selective loop around the splenic artery (Morgenstern and Shapiro 1979) III) individual ligation of bleeding deep points, preventing hilar vessels (Schackford et al. 1981) IV) by temporary clamping of the splenic hilar vessels (Witte et al. 1992)
465
Under the same circumstances, for Barrett et al. (1983), a partial splenectomy must be electively carried out, while Moore et al. (1984), reporting their experience, warn that "nonsegmental" debridment and suture had enhanced the incidence of bleeding complications. Contemporarily with the growing acceptance of the spleen saving surgical practice, the significance of the term splenorrhaphy gained diverse technical connotations (Buntain et al. 1979, 1985, 1988). In a series of papers on surgical spleen salvage, poorly defined "rhaphies" repairing injuries techniques or technically well defined partial splenectomies became less and less distinguished as surgical circumstantial alternatives.
At present, splenorrhaphy has been indifferently employed as a title to enlist a number of surgical tissue saving operations on the spleen. Such conservative techniques range from the topical usage of hemostatic agents to various types of splenic suture repairing techniques, including also an unspecified number of undeclared formal partial splenectomies. This current practice constitutes a difficulty for the evaluation of the exact proportion among different saving spleen operations and their outcomes. To determine the proportion between "total" splenectomies and saving techniques and, particularly, between sutures repairing techniques and partial splenectomies in
Table 2. List of Reported Splenic Saving Operations Author
Year
Mishalany Burrington La Mura Ratner Shushpanov Mishalany Sherman Strauch Welch Morgenstern Weinstein Grosfeld Kaiser King Patcher Shackford Fekete Habeler Traub Barrett Moore Bongard Feliciano Spencer Nunes* Buyukunal Buntain Cogbill Pickhardt Patcher Andrade Daher Rabelo* Saudemont Witte lavolec Tricarico Abrantes*
1974 1977
TOTAL
*
1978 1979
1981
1982
1983 1984 1985
1986 1987 1988 1989 1990 1991
1992 1993 1994
Total Splenic Trauma 10 10 1 17 238 4 6 9 8 30 24 68 27 85 12 172 272 36 200 75 190 103 62 81 30 720 170 167 54 65 488 95 20 211 177 139 4076 (100%)
Total Surgical Repai! 8 8 1 15 103 2 3 4 5 44 18 15 36 16 24 43 9 65 41 18 85 44 136 83 34 59 18 302 107 111 17 7 215 34 9 39 32 91 1891 (46%)
From the institution where we formerly performed our first segmentectomies and partial splenectomies
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Identified Partial Splenectomies 0 2 0 0 0 1 3 2 3 6 6 2 0 0 3 7 3 0 5 7 19 0 3 0 3 7 0 1 13 11 4 1 22 2 2 0 16 10 164 (8.6%)
traumatic InJunes, we analyzed 30 consecutive reports, covering 4076 patients (table 2), from various hospitals in different countries, including 689 ones (16.9%) from the institutions where we formerly performed our first partial splenectomies (Nunes et al. 1986, Rabelo et al. 1991 and Abrantes et al. 1994). In these series, the splenic salvage surgical techniques were electively employed in 1891 patients, corresponding to 46% of splenic injuries. Partial splenectomies were identified as 8.6% of these saving splenic procedures, corresponding to 164 patients operated on. "Sutural" (rhaphy) techniques are fairly embodied in analyses of Buntain et al. (1979, 1985, 1988) and Feliciano et al. (1990). Besides the so-called "sutural" conventional techniques, parenchymal sutures through "splenic capping" of absorbable mesh of polyglycolic acid or polyglactin are being more and more accepted. Experimentally proposed by Delany et al. (1982) to permit parenchymal sutures with "splenic tamponade", this technique has received widespread clinical attention. Good initial results were reported, when this device was applied to save badly fractured spleens with preserved hi-
Ius, but also to treat parenchymal lesions secondary to knife, gunshot and hilar involving wounds, eventually associated to partial splenectomies (Delany et al. 1985; Lange et al. 1988; Yvatury et al. 1993). In complex lacerations, the risk of including in sutures, area of necrosis, or inadequate hemostasis have been pointed out (Shackford et al. 1988 and Saudemont et al. 1992), as well as the high incidence of postoperative left pleural effusion (Shackford 1988 and Lange et al. 1988). Reoperation with loss of spleen was pointed out as a consequence of a tightly sutured splenic "capping" (Witte et al. 1992). To reassemble viable portions of injured spleens, it seems better indicated to save transversally lacerated parenchyma with preserved hilar vessels, more commonly seen after blunt trauma. Its usage in splenic injuries associated to enteric potentially contaminating lesions has not been clearly approached. Performing the role of an adjuvant for splenic reconstruction or partial resections, its seducing liberal usage may propitiate technical disregards. The safety in the conservative surgery of the splenic injuries is based upon the respect to well recognized princi-
Table 3. Splenic Tissue Transplantation: Technical Characteristics Author
Year
Tissue Quantity grams
Benjamin
1978
Aigner
1980
Patel
1981
20
Perry
1981
25
Boland
1981
50
Velcek
1983
Moore
1983/4
Corazza
1984
Traub
1987
Buyukunal
1987
Mizrahi
1987
Formal division
Graft Site
"slabs" 3x4 x 12cm
anterior rectus compartment
2
"homogenised"
subphrenic space and abdominal wall
1
"whole width of the middle" 2 slices of 3 mm
omental pouch
4
parietal peritoneum left upper quadrant
6
"spliced"
omental pouch
7
"waffers" 1.5 x 1.5 x 0.2 cm
omental rows
3
"five fragments" 10xlOx2 to 40x40x5mm
omental pouch
volume
51
113 spleen
20% spleen 2.0
30 cm3 splenic tissue (clinical approach) 25 to 30
50
Number
43
"splenosis"
"thinly sliced" single layer
extraperitoneal pocket (abdominal wall)
"Two to four decapsulate splenic slices" 3x5xO.5 cm
omental rows
16
"3 mm - thick slices"
between two layers of omentum
10
467
7
pIes. The necessity of careful evaluation of the damage of the injured spleen, achieved through a complete mobilization and close inspection of the organ. This inspection is generally prevented, when "local packing" is electively employed as an isolated procedure (Scheele et al. 1984). It is also fully recognized that without a complete hemostasis, splenic saving procedures cannot be considered acceptable. This is a very strong reason to prevent saving splenic procedures in patients with hemorrhagic shock. In fact, a performed splenic saving procedure cannot be accepted as complete before a careful checking out in hemostasis, with a hemodynamically stable patient. Descriptions of technical steps of partial splenectomy in cases of trauma have been unclear. It should be emphasized that to prevent per and postoperative bleeding complications, it is technically safer to undertake resections only after previous ligation of the corresponding (segmental) hilar vessels and that any after-resection persistent bleeding on the raw surface is a sure indication of a technical mistake. Despite the advantages of salvaging viable splenic tissue, the question of the critical minimal mass of normal splenic tissue capable of maintaining efficient immunity functions remains undefined. It was demonstrated that conservation of the splenic artery and a possession of "around one third" of the normal splenic mass provide a clearcut protective edge (Cooney et al. 1979; Van Wyck et al. 1980; Okinaga et al. 1981; Bradshaw and Thomas Jr. 1982; Pabst et al. 1984). On the other hand, a saved spleen, even after splenic artery ligation, can provide better results than autografts (Cooney et al. 1981). Results of the comparison between splenorrhaphies and partial splenectomies in human patients are not available and it seems improbable that the long-term follow-up could give sure information. As already mentioned, there are only a few technical reports of the various "splenorrhaphies" procedures after trauma and specially partial splenectomies. The growth of splenic stumps in normal human spleen, after subtotal splenectomies for trauma, will be hardly answered. We believe that the splenic stump of some pathologic spleens grows continuously thanks to pathologic stimulus after subtotal therapeutic resections (Christo 1993). But from traumatic patients, otherwise healthy people, information on the long-term evolution of their splenic stumps are scarce. According to a clinical report by Bowen and Gough (1994), no bulk increasing, as measured by scan, occurred after an eight-year evolution in a child, in a one third residual spleen, with saved hilar segmental vessels, thus, confirming the experimental findings of Hayari et al. (1994). On the other hand, an important late enlargement in a seven-year heterotopic autotransplantation, in a splenectomized adult, was recorded by Moore et al. (1993), as evaluated through laparotomy. Aside from their anatomical peculiarities, these findings are conflicting. Nevertheless, above appearances, it seems that after
splenic saving operations, the final outcome of every residual splenic tissue is dependent on splenic inhibiting growth factors and, consequently, buttressed on the presence or absence of hilar preserved vessels, as outlined by Soutter et a1. (1994). Under such an approach, these different behaviors seem clearly explained. Postoperative bleeding complications related to splenic saving procedures are uncommon. Among 884 cases of splenorrhaphies and partial splenectomies, 13 reoperations for postoperative bleeding (1.5%) have been reported by King et al. (1981), Traub et a1. (1982), Moore et a1. (1984), Bongard et al. (1985), Kreis et al. (1987), Pickhardt et al. (1989), Rabelo et al. (1991) and Abrantes et al. (1994). Late~rations for perisplenic hematoma are reported' by Stiegmann et al. (1979) and Saudemont et a1. (1992) after suture "capping" and isolated "packing" applications. A completely discordant result deserves to be analyzed: the incidence of 11.8% of bleeding complications among 119 splenic saving procedures reported by Beal and Spisso (1988). Based upon their data it is impossible to explain this disagreement. It seems possible, however, to conclude that the ligation of the splenic artery is not a sure way to prevent hemorrhagic postoperative complications and that is high the risk of treating electively by packing, although "selectively chosen", traumatic non-incidental splenic injuries. It is pertinent to remember that packing techniques, when primarily employed, inhibit a free inspective mobilization of the spleen (Scheele et a1. 1984) making difficult a clear evaluation of injuries. Postoperative abdominal infections have been specifically reported after salvage procedures by Shackford et at. (1981), Traub et at. (1982), Moore et al. (1984), Feliciano et al. (1985), Saudemont et al. (1992). In our first series of partial splenectomies, we reported a left subphrenic abscess related to a gastric perforation (Christo 1962). A solitary postoperative splenic abscess was reported by Shah et al. (1987), after a non-sutured non-bleeding splenic lesion, associated to a closely related colon perforation. In spite of these reports, there is a unanimous view on the fact that "the association of splenic injuries to hollow viscus perforation" does not constitute a determinant contraindication for splenic saving operations. In marked peritoneal contamination, risks and benefits must be weighed individually. In fact, after analysing six year data on surgery of splenic trauma, collected from hospital records of 252 patients, Duke et a1. (1993) concluded that infective perioperative complications are not related to the final surgical outcome splenectomy or splenic repair. "Total" splenectomies have been primarily indicated because of the magnitude of parenchymal or hilar compromise. Eventually, they have been imposed by the concomitant presence of life-threatening associated injuries, profound hemorrhagic shock or hemodynamic instability, commanding mandatory priorities. Finally, as an imme-
468
diate consequence, after unsuccessful splenic saving surgical attempt. Total primary splenectomy has been circumstantially performed on injured pathologic spleens (Sushpanov 1977; Fekete et al. 1982; Saudemont et al. 1982); in the presence of massive peritoneal contamination (Patcher et al. 1981; King et al. 1981); in patients aged above 60 years or under anticoagulant therapy (Fekete et al. 1982). According to Wisner et al. (1992), if hemoperitoneum is less than 500 ml, attempts on splenic salvage are reasonable, but if there are more than 1000 ml in the peritoneal cavity the splenic salvage should not be attempted. Heterotopic autotransplantation
Splenic autotransplantation has been considered as a valuable alternative to preserve splenic function after splenectomy for trauma (Pisters and Patcher 1994). Experimentally optimized, but seldom clinically performed, the surgical heterotopical autotransplantation of splenic tissue was recorded in only 5.5% of the after trauma "total" splenectomies, with the final outcome of 54% of the injured spleens surgically managed (table 2). Frequent occurrence of a "born-again spleen" in intraperitoneal splenosis after splenectomy for trauma was pointed out by Pearson et al. (1978) in 13 out of 22 children, from one to eight years postoperatively. They admitted that this finding could explain the lower incidence of OPSI in patients splenectomized for trauma. But the reported clinical experience does not seem to confirm such a view. Probably, the mere presence of functioning splenic tissue after splenectomy does not correspond to a guarantee against OPSI. Splenic remnant tissue after death for OPSI has been reported as a necropsy finding by Singer (1973), Scully (1975), Balfanz et al. (1976), Gopal and Bisno (1977), Rice and James (1980), Moore et al. (1983) and Sab et al. (1983). On the other hand, the subphrenic and abdominal wall reimplanted "one third of homogenised splenic volume", after splenectomy for trauma in a newborn infant, seemed clinically and laboratorially efficient, five months postoperatively (Aigner et al. 1980). With less evidence, but very suggestive of efficient immunofunctional activity was the result reported by Benjamin et al. (1978), in a four year old child, late followed-up, with a rectus sheath autotransplantation, after an hematologically indicated splenectomy. Better results in children are to be expected, confirming experimental findings (Kovacs et al. 1981, Westermann et al. 1988). The late excellent evolution of a child, autotransplanted in the rectus sheath (Benjamin et al. 1978), however, seems not to confirm the view of being the extraperitoneal, systemic drained implants, "an inappropriate alternative" for splenic autotransplantation (Livingstone et al. 1983). Notwithstanding some controversies, probably these and other pediatric reports (Velcek et al. 1982; Buyukunal et al. 1987) are the strongest clinical supports of a
definite role of the autotransplanted splenic tissue in restoring immunity performance in children. But this outcome became undecided after the fatal OPSI recorded by Michalski et al. (1991), on a five year old boy, eleven months after splenic tissue reimplantation. Among adults, active splenic auto transplanted tissue has been clearly demonstrated postoperatively (Patel et al. 1981; Millikan et al. 1982). An eventual immunity failure, however, had been evidenced by a fatal OPSI, recorded five months postoperatively (Moore et al. 1983). On the other hand, in a late follow-up report, the same surgical group (Moore et al. 1993) showed a very significant late growth of splenic autotransplanted tissue in an adult, seven years postoperatively. It is unlikely that in current splenic clinical autotransplantation practice, the experimentally determined "critical mass" of 1/4 to 1/3 of the total splenic tissue (Van Wick et al. 1980; Greco et al. 1981; Bradshaw et al. 1982) has been preserved, so as the blood flow rate competent to support the filtering effect to clear-up blood-born bacteria (Okinaga et al. 1981; Horton et al. 1982; Pabst et al. 1984; Scher et al. 1985; Westermann et al. 1988). In the successful clinical case of splenic autotransplantation reported by Aigner et al. (1980), this critical amount of splenic tissue seems to have been reached, but the corresponding critical functional blood flow remained a conjectural matter. Characteristic of the reports on splenic autotransplantation is the great difference of opinions concerning the quantity, size and formal division of splenic tissue to be transplanted (table 3). The indicated quantity, expressed in grams, oscillated from 2 grams (Moore at al. 1983) to 20 grams (Patel el at. 1981), to 25 grams (Perry et al. 1981), to 30 grams (Traub et al. 1987), to 50 grams (Boland 1981; Mizrahi et al. 1989). Expressed in volume, this quantity varied from 30 cm3 (Corazza et al. 1984) to 1/3 of the splenic volume (Aigner et al. 1980). As far as the mode of division is concerned, the splenic tissue, before transplantation, was cut "in slabs" of 3 x 4 x 12 cm (Benjamin et al. 1978); "homogenised" (Aigner et al. 1980), "spliced" (Boland 1981); reduced to "fragments" or "wafers" of 10 to 15 x 20 mm (Veleek et al. 1982; Moore et al. 1983); cut "thinly sliced in a single layer" (Traub et al. 1987), reduced to "two thin slices of the whole width of the middle of the spleen" (Patel et al. 1981). Despite these technical diversities (table 3), infection related complications have not been reported. It was experimentally demonstrated (Pabst et al. 1986), that it is a misconception to expect a harmonic correlation between the quantity of normal tranplanted spleen and the amount of regenerated splenic tissue. On the other hand, a sure evaluation test for immunofunctional activity of the splenic autotransplantation was not adequately developed so far (Timens and Leemans 1992). It seems clear that the most efficient measure to prevent OPSI is, whenever possible, to save spleen and its vascular supply.
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Nonoperative management
The non operative management of splenic injuries after blunt trauma has been electively accepted in hemodynamically stable pediatric patients, under careful observation and follow-up facilities. The good pioneering results, reported by Douglas and Simpson (1971) and Ein et al. (1978), have supported this conservative attitude. About this successful management, involving electively pediatric patients, some anatomical, pathological and clinical facts must be pointed out. Sharp anatomicopathological differences have been demonstrated between splenic blunt injuries in children and adults. As emphasized by Mazel (1945), the elastic rib cage of children is less prone to fracture, but acting as a compressive wave on splenic parenchyma causes transversal disruptions, less bleeding, and permits safe splenorrhaphies. In adults, the compression commonly associated to injuring fractured ribs resulted in more complex parenchymal lesions. In a different experimental approach on cadavers, Gieseler (1965) confirmed the bias for transverse lacerations in spleens after blunt trauma in children. On another line of investigation, Gross (1964) demonstrated that proportionally the parenchyma of the spleen in children has a stronger capsular support than in adults. According to Morgenstern and Uyeda (1983), the hemostatic control is favored in children's spleens by active functional smooth muscle and elastic tissue in the capsule, septa and vessels. In a landmark clinical paper, Upadhyaya and Simpson (1968) confirmed that in children the splenic rupture after blunt trauma is "governed" by the internal architecture of the organ, which is arranged in a transverse plane causing minimal vascular trauma. They pointed out that in the majority of their 32 operated on children for blunt trauma, the bleeding from the splenic lacerations had stopped by the time of laparotomy. The good results in children have encouraged the trial of nonoperative management on adult patients and the first results began to be reported. From a group of 77 adult patients with splenic blunt trauma, Malangoni et al. (1984) reported the evolution, from 30 hours to 21 days, in 10 of them, with stable vital signs, who were selected for conservative management: seven of them required late operation. Six of the latter 7 patients had fresh intra-abdominal blood and one, an infected hematoma. Total splenectomies became a mandatory indication in six of them, while, in one, the spleen could be partially saved by hemisplenectomy. Analysing their own results, the authors recommended early operation in adults. Better supported with routine usage of computerized tomography in 46 patients, Buntain et al. (1988) created an image grading for splenic blunt injuries, pointing out a high correlation to anatomic findings and recommending early operation to patients with severe scores. In a multicenter cooperative paper of Cogbill et al. (1989), involving 112 patients (children 36%, adults 64%)
selected clinically and through computerized tomography images, nuclear scan, ultrasound and arteriography, were reported 13 failures (11.6%), followed by exploratory laparotomy in one child (2%) and 12 adults (17%), from one to 36 days after the hospital admission. These laparotomies resulted in 5 splenectomies, one hemisplenectomy, 6 splenorrhaphies, one distal pancreatectomy. The authors concluded that splenic preservation was attained in 98% of the children and 83% of the adults. In successive surveys, involving 59 adult patients, Mahon and Sutton (1985) and Nallathambi (1988) emphasized a longer hospital stay and a significantly higher requirement of blood transfusions, among adult patients submitted to nonoperative management when compared to patients submitted to early laparotomy. In a comparative study, Rescinitti et al. (1988), managing 87 patients, pediatric and adults, demonstrated that the nonoperative management is safer in children than in adults, regardless of the clinical and CT score selection. Evaluating 76 adult and pediatric patients, managed nonsurgically, using previous published criteria, Kohn et al. (1994) demonstrated that the degree of failures among adults is high and that the CT images are frequently not trustworthy in predicting clinical outcomes. Analyzing morbidity and mortality related to blood transfusions and OPSI risk, Luna and Dellinger (1987) estimated that late death risk for posttransfusion hepatitis per unit of blood transfusion is 0.140%, while the late death risk for OPSI is 0.026% for adults and 0.052% for children, respectively. In a theoretical approach to the late death combining risk possibilities for OPSI and for posttransfusion hepatitis, comparing the recorded requirements for blood transfusions in nonoperative management and in early laparotomy, they concluded that in non operative management hepatitis became a higher late death risk than OPSI. This would continue to be true, if assumed that every early laparotomy would result in splenectomy. In an updating suggestion, Witte et al. (1992) advocate early laparotomy, emphasizing the risk of hepatitis and human immunodeficiency virus infections through blood transfusion and the availability of automated cell salvage devices, capable of reinfusing shed autologous blood at the time of the laparotomy, preventing the hazards of exogenous blood. In spite of some recognized risks, reports on nonoperative management in splenic blunt trauma are growing. Serial analysis of Elmore (1989) and Smith (1992) involved 467 predominantly adult patients with a success rate of about 70%. It has been generally recognized that a longer hospital stay, enhanced requirements for blood transfusions and heightened mandatory indication of total splenectomies after delayed laparotomy, are calculated inherent risks of the procedure. It is undeniable that the non operative management of splenic blunt injuries in children and adults came as a consequence of surgical research and progressed with
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technological diagnostic facilities. It must advance with them, preventing non therapeutic laparotomies. Last but not least, it should be emphasized that so much progress in modern surgery of the spleen is due to the practical application of the simple knowledge of macroscopic anatomy. A new application of the old anatomy. Meminisse juvabit ...
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Kreis DJ Jr, Montero N, Saltz R, Echenique M, Plasencia G, Santisban R, Gomez GA, Vopal JJ and Civetta JM (1987) The role of splenorrhaphy in splenic trauma. Am Surgeon 53: 307-309 LaMura J, Chung-Fat SP and San Fillipo JA (1977) Splenorrhaphy for treatment of splenic rupture in infants and children. Surgery 81: 497-500 Lange DA, Zaret P, Merlotti GJ, Robin AP, Sheaf G and Barret JA (1988) The use of absorbable mesh in splenic trauma. J Trauma 28: 269-275 Livingstone CD, Levine BA and Sirinek KB (1983) Site of splenic autotransplantation affects protection from sepsis. Am J Surg 146: 734-737 Luna GK and Dellinger EP (1987) Nonoperative observation for splenic injuries: a safe therapeutic option? Am J Surg 153: 462-468 Mahon PA and Sutton Jr JE (1985) Nonoperative management of adult splenic injury due to blunt trauma: a warning. Am J Surg 149: 716-721 Malangoni MA, Levine AW, Droege EA, Aprahamian C and Condon RE (1984) Management of injury to the spleen in adults. Results of early operation and observation. Ann Surg 200: 702-705 Michalski S, Blankenhorn P, Lepsien G und Ludtke FE (1991) Letale Sepsis nach Splenektomie trotz Reimplantation von Milzgewebe. Klin Wochenschr 69: 375-378 Mazel Ms (1945) Traumatic rupture of the spleen. With special reference to its characteristics in young children. J Pediatrics 26: 82-88 Millikan JS, Moore EE, Moore GE and Stevens RE (1982) Alternatives to splenectomy in adults after trauma repair partial resection and reimplantation of splenic tissue. Am J Surg 144: 711-716 Mishalany H (1974) Repair of the ruptured spleen. J Pediatr Surg 9: 175-178 Mishalany HG, Mahour GH, Andrassy RJ, Harrison MR and Wooley MM (1978) Modalities of preservation of traumatized spleen. Am J Surg 136: 697-700 Mizrahi S, Bickel A, Hai M, Lunski I, Shtamler B (1989) Postraumatic autotransplantation of spleen tissue. Arch Surg 124: 863-865 Moore FA, Moore EE, Moore GE and Erdoes L (1993) Fivefold enlargement of implants in a splenic autotransplant recipient. Surgery 113: 462-465 Moore FA, Moore EE, Moore GE and Millikan JS (1984) Risk of splenic salvage after trauma Analysis of 200 adults. Am J Surg 148: 800-805 Moore GE, Stevens RE, Moore EE and Aragon GE (1983) Failure of splenic implants to protect against fatal postsplenectomy infection. Am J Surg 146: 413-414 Morgenstern L (1965) Experimental partial splenectomy: Application of cyanoacrylate monomer tissue adhesive for hemostasis. Am Surgeon 31: 709-712 Morgenstern L (1974) Microcrystalline collagen used in experimental splenic injury. A new surface hemostatic agent. Arch Surg 109: 47-55 Morgenstern L (1986) Evolution of splenic surgery from mythology to modernity. Contemporary Surgery 29: 15-18 Morgenstern L, Kahn FG, Weinstein 1M (1966) Subtotal splenectomy in myelofibrosis. Surgery 60: 336-339 Morgenstern L and Shapiro SJ (1979) Techniques of splenic conservation. Arch Surg 114: 449-454 Morgenstern L and Uyeda RY (1983) Nonoperative management of injuries of the spleen in adults. Surg Gynecol Obst 157: 513-518
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Neder AM (1958) [Anatomical study of the splenic venous segments and of their drainage in man] (In Portuguese). Anais Fac Med Univ Fed Minas Gerais Belo Horizonte 18: 265310 Nallathambi MN, Yvatury RR, Wapnir I and Rohman M (1988) Nonoperative management versus early operation for blunt trauma in adults. Surg Gynecol Obst 166: 252-258 Nunes ML, Figueiredo HB and Abrantes WL (1986) Abdominal trauma in children. Rev Col Bras Cir 13: 206-210 Okinaga K, Giebink GS, Rick RH, Baesl TJ, Krishnanaik D and Leonard AS (1981) The effect of partial splenectomy on experimental pneumococcal bacteremia in animal model. J Pediatr Surg 16: 717-724 Pabst R, Kamran D (1986) Autotransplantation of splenic tissue. J Pediatr Surg 21: 120-124 Pabst R, Kamran D and Creutzig H (1984) Splenic regeneration and blood flow after ligation of the splenic artety or partial splenectomy. Am J Surg 147: 383-386 Patcher HL, Hofstetter SR and Spencer FC (1981) Evolving concepts in splenic surgery: splenorrhaphy versus splenectomy and postsplenectomy drainage. Experience in 105 patients. Ann Surg 194: 262-269 Patcher HL, Spencer FC, Hofstetter SR, Liang HG, Hoballah J and Coppa GF (1990) Experience with selective operative and nonoperative treatment of splenic injuries in 193 patients. Ann Surg 583-591 Patel JA, Williams JS, Shmigel B and Hinshaw JR (1981) Preservation of splenic function by autotransplantation of traumatized spleen in man. Surgery 90: 683-88 Pearson HA, Johnston D, Smith KA and Touloukian RJ (1978) The bornagain spleen. Return of splenic function after splenectomy for trauma. N Engl J Med 298: 1389-1392 Perry JF (1981) in Patel et al (1981) Discussion of cases Pickhardt B, Moore EE, Moore FA, McCroskey BL and Moore GE (1989) Operative splenic salvage in adults a decade perspective. J Trauma 29: 1386-1391 Pisters WP and Patcher HE (1994) Autologous transplantation for splenic trauma. Ann Surg 219: 225-235 Rabelo GD, Abrantes WL, Drumond DAF (1991) Splenectomy versus conservative surgery for splenic injury. Rev Col Bras Cir 18: 80-86 Ratner MH, Garrow E, Valda V, Shashikumar VL and Sommers LA (1977) Surgical repair of the injured spleen. J Pediatr Surg 12: 1019-1025 Rescinitti A, Fink WP, Raptopoulos V, Davidoff A and Silva WE (1988) Nonoperative treatment of adult splenic trauma: development of a computed tomographic scoring system that detects appropriate candidates for expectant management. J Trauma 28: 828-831 Rice HM and James PD (1980) Ectopic splenic tissue failed to prevent fatal pneumococcal septicaemia after splenectomy for trauma. Lancet 1: 565-566 Sab W, Bergholz M, Kehl A, Seifert J and Hamalmann H (1983) Overwhelming infection after splenectomy in spite of some spleen remainilng and splenosis. A case report. Klin Wochenschr 61: 1075-1079 Saudemont A, Chambon JP, Wurtz A, Quandalle P (1992) Le traitement conservateur dans Ie traumatismes de la rate chez I'adulte. Ann Chir 46: 324-329 Scheele J, Bocker D and Stangl R (1993) Chirurgische Methoden der Milzerhaltung. Chirurg Gastroenterol9 (suppI2): 98-106 Scheele J, Gentsch HH and Matteson E (1984) Splenic repair by fibrin tissue adhesive and collagen fleece. Surgery 95: 6-13 Scher KS, Scott-Conner C, Jones CW, Wroczynsky AF (1985)
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Westermann J, Willfuhr KU and Pabst R (1988) Influence of donor and host age on the regeneration and blood flow of splenic transplants. J Pediatr Surg 23: 835-838 Wisner DH and Blaisdell FW (1992) When to save the ruptured .spleen. Surgery 111: 121-122 Witte CL, Esser MJ and Rappaport WD (1992) Updating the management of salvageable splenic injury. Ann Surg 215: 261265 Yvatury RR, Simon RJ, Guignard J, Kazigo J, Gunduz Y and Stahl WM (1993) The spleen at risk after penetrating trauma. J Trauma 35: 409-414 Zappala A (1958) [Anatomical study of the terminal division of the arteria lienalis. Arterial segments of the spleen]. (In Portu-
guese) PhD dissertation University of Minas Gerais Belo Horizonte Brazil Zappala A (1959) [Contribution to the anatomy of the splenic vessels and segments. Anatomical data in man and experimental in dogs for partial splenectomy] (In Portuguese) Chairmanship thesis University of Recife Brazil Zappala A (1963) [The anatomical basis for segmental resection of the spleen] (In Portuguese) An Fac Med Univ Recife 23: 736 Zikoff V (1895) 0 Prishivanii Selezionki (on suturing spleen) Vrach 995-1000 Accepted June 9, 1997
Buchbesprechung Praktikum der mikroskopischeo Hiimatologie. Von Fritz Heckner und Mathias Freund. 9., neubearb. und erw. Auflage; 136 Seiten, 388 Einzelabbildungen, 23 Tabellen. Broschur. DM 42.-, oS 307,-, sFr 39,-. Urban & Schwarzenberg, Miinchen-Wien-Baltimore 1996. ISBN 3-541-01009-6
Die enorme morphologische Vielfalt der Zellen des blutbildenden Systems wird im voliegenden kleinen und tibersichtlichen Atlas praxisbezogen dargestellt. Neben den Reifestadien der normalen Blutbildung ermoglicht das Buch vor allem die Einordnung der verschiedensten pathologischen Formen von Blutzellen. 1m ersten Teil findet sich eine kurze Einftihrung in die Technik des Blut- und Knochenmarksausstriches, im zweiten Teil folgt eine umfangreich bebilderte Darstellung der normalen Hamatopoese, die durch einige Schemata bzw. Tabellen erganzt wird. In letzteren werden allgemeine morphologische Merkmale der einzelnen Zellreihen, die CD-Oberflachenmarker in der normalen Granulo- und Lyrnphopoese sowie die Zytochemie der normalen Blut- und Knochenmarkszellen zusammengestellt. 1m dritten und umfangreichsten Teil widmet sich das Buch den ver-
schiedenen StOrungen in der Bildung von roten und weiBen Blutzellen, wobei die Beschreibungen der Erkrankungen streng nach den einzelnen Zellreihen angeordnet sind. Hier wird die ausgezeichnete Bebilderung jeweils durch kurze Reifungsschemata sowie durch molekulargenetische Befunde und immunologische Typisierungen erganzt. Allerdings ist in diesem Teil die Zuordnung der Bildtafeln zum Begleittext nicht immer leicht, und manche Legenden hatten etwas ausftihrlicher ausfallen konnen. 1m letzten Teil werden schlieBlich einige zytochemische Fiirbemethoden kurz dargestellt. Das "Praktikum" ist ein sehr guter Leitfaden fiir die Beurteilung von Blut- und Knochenmarkausstrichen im Labor und damit fiir aIle mit der Pathologie der Hiimatopoese beschiiftigten Mediziner und technischen Assistenten empfehlenswert. Neben seiner Funktion als Atlas kann das Buch dabei auch durchaus als kleines Nachschlagewerk dienen. Dem Studierenden ermoglicht das Buch ein gutes Verstandnis der bunten morphologischen Palette im Knochenmark, setzt allerdings bereits gute Kenntnisse voraus. Matthias Klinger, LUbeck
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