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Splenectomy for massive splenomegaly
Splenectomy for Massive Splenomegaly Jerry Goldstone, MD, San Francisco, California
“The long course of the splenic artery along the upper edge of the pancreas . . . permits it to be exposed through the lesser peritoneal cavity some distance from the spleen. This is of considerable importance in dealing with very large spleens since it permits control of a major portion of the blood supply before attempting to mobilize the spleen.” LTC J.E. Dunphy, 1946[1]
The author of the above statement has maintained a keen interest in surgery of the spleen since the paper from which the quote was taken was published in this Journal in 1946. Although that paper was entitled, “Splenectomy for Trauma,” he has always been particularly interested and involved in the care of patients with massive spleens. Although there are few reports that deal specifically with removal of huge spleens [2], this procedure is commonly believed to be more dangerous and less beneficial than is removal of smaller spleens. The present study analyzes the morbidity, mortality, and efficacy of splenectomy for massive splenomegaly in order to substantiate these beliefs.
dionuclide scans performed in twenty-one patients confirmed massive splenomegaly in all cases and demonstrated associated hepatomegaly in ten cases. The scans indicated the eventual diagnosis in five patients: cysts were shown in two, and infiltrative processes suggestive of leukemia in three. Splenic arteriograms were performed in eight patients and were diagnostic in seven. All of the patients were symptomatic. The symptoms were of three types: physical-mechanical, related to the huge size of the spleen; hematologic, related to hypersplenism; and those related to splenic infarction. Abdominal fullness, the most common symptom, occurred in twenty-eight patients (82 per cent) and was often associated with a feeling of heaviness and discomfort. Moderate to severe abdominal and particularly left upper quadrant pain occurred in fifteen patients. Several patients with acute pain were thought on the basis of clinical findings to have splenic infarction. Four patients had left shoulder pain and only four had early satiety from gastrointestinal compression. The hypersplenic abnormalities determined the nature of the hematologic symptoms. Symptoms related to thrombocytopenia were common; bruising and/or petechiae were present in twelve patients, overt bleeding oc-
Material and Methods 8 The course of 300 consecutive patients undergoing splenectomy as a primary operation at the University of California, San Francisco was analyzed. Massive splenomegaly was defined as a spleen weighing 1,500gm or more. Thirty-four cases meeting this criterion were identified and form the basis for this analysis. Clinical Features. There were eighteen males and sixteen females ranging in age from five to seventy-nine years. Half of the patients were fifty years of age or older. (Figure 1.) Twenty-nine of the patients were Caucasian, two were black, and three were Oriental. All had massive, easily palpable spleens, that in many cases filled the entire left side of the abdomen and extended into the pelvis. In each case the spleen was clearly seen on plain abdominal x-ray, and twenty-four displaced the colon and/or gastric air bubble or elevated the left hemidiaphragm. Splenic raFrom the Department of Svgery. Universityof California School of Medicine, and Veterans Administration Hospital, San Francisco, California. This work was supported in part by Veterans Administration Research Service. Reprint requests should be addressed to Jerry Goldstone, MD, Department of Sugery, University of California School of Medicine, 4150 Clement Street, San Francisco, California 9412 1.
volume 135, March 1978
7 1
Cl0
II-20
21.30 Age
31.40 41.50 in Years
51.60
61-70
71.80
1
Figure 1. Age dhdribufti of thtriy-fourpatianta wtth maadve sptenomegaty. Monr than haff the pattents were older than tiny years.
385
Goldstone
curred in four (epistaxis or monorrhagia), and occult bleeding in seven. Sixteen patients with marked anemia complained of fatigue, weakness, and pallor. Leukopenia led to recurrent infections in four patients, two of whom had white blood cell counts of less than 1,000/mm3. Hypersplenism involving one or more of the formed elements of the blood was present in twenty-eight of the thirty-four patients (82 per cent). Three patients had thrombocytopenia alone (platelet count of less than 150,000/mms). Six patients had anemia only (hematocrit less than 34). Eight patients had thrombocytopenia and anemia; two had thrombocytopenia and leukopenia; and two anemia and leukopenia. Seven patients had pancytopenia. Pathology. The weight of the resected spleens ranged from 1,500 to 6,100 gm and averaged 2,814 gm. (Figure 2.) The pathologic findings in the spleen were diagnostic in themselves or compatible with the clinical diagnosis in twenty-two patients. Among these were myeloid metaplasia (13 patients), leukemia (4 patients), lymphoma (2 patients), benign cysts (2 patients), and Gaucher’s disease (1 patient). Splenic congestion was the most significant abnormality in five other cases. In nine spleens nonspecific findings such as lymphoid and/or reticuloendothelial hyperplasia (4 patients) were described. Indication for Splenectomy. The most frequent reason for operation (15 patients) was to relieve symptoms from the massively enlarged spleen; other indications for splenectomy were symptomatic anemia (6 patients), thrombocytopenia (6 patients), and leukopenia (2 patients). In four patients splenectomy was performed principally to establish a diagnosis. One patient was operated on for spontaneous rupture of a leukemic spleen.
12 -
10 v) z CUB._ 5 a 6> t -D4E 3 =2-
0
152.0 Spleen
2.1-3.03.1-4.04.1-5.0 5.1-6.0 >6.0
Weight
(Kilograms)
Figure 2. Weight distribution of the removed spleens. A verage weight was 2,8 14 gm.
366
All of the patients were deemed refractory to maximum medical treatment, which included blood transfusions, corticosteroids, busulfan, hydroxyurea, immunosuppression, and splenic irradiation. Most of the patients were seriously and chronically ill and were referred for splenectomy in a last effort to relieve bothersome or life-threatening symptoms and to improve the quality of life.
Operative Technic
All of the patients were operated on under general endotracheal anesthesia using a variety of anesthetic agents and technics. A midline incision was employed in twenty patients; left rectus muscle-splitting or retracting incisions were used in twelve, and a left subcostal incision in one. A left upper quadrant transverse incision was used in the one child in the series. All of the incisions were described in the operative reports as long or generous. In twenty-four patients the splenic artery was ligated along the upper border of the pancreas before the spleen was mobilized from its ligamentous attachments. Access to the artery was through the lesser peritoneal sac after a sufficient number of short gastric vessels were divided to obtain adequate exposure. In a few cases, epinephrine solution (1 cc of l:lO,OOO)was injected into the splenic artery before it was ligated. Both maneuvers promptly decreased the size of the spleen. In the other ten cases, the splenic attachments to the parieties were divided, and the spleen was delivered into the wound, before the major splenic vessels were divided and sutureligated. The average blood loss was 1.3 units (range, 0 to 6) when the splenic artery was ligated as a first step compared to 2.5 units (range, 0 to 9) when the artery was ligated after the spleen had been mobilized (p
The American Journal of Surgery
Massive
Results
Of the fifteen patients in whom splenectomy was performed for mechanical symptoms due to the size of the spleen, twelve (80 per cent) were relieved postoperatively. The other three patients died. The hematocrit increased, symptoms were alleviated, and transfusion requirements decreased in five of the six patients operated on for hypersplenic anemia. One patient improved only slightly. Five of the six patients operated on for thrombocytopenia had moderate to complete resolution of low platelet counts and complete relief of bleeding symptoms. One patient had no response and subsequently died. Both patients with leukopenia had return of their white blood cell counts to normal. The patient with splenic rupture had an uneventful recovery. All four patients in whom the splenectomy was done for diagnosis had a diagnosis established. It is of interest that of the thirteen patients with agnogenic myeloid metaplasia, all but one received substantial symptomatic or hematologic benefit from splenectomy. None of the patients became hematologically worse due to splenectomy, but one patient was unimproved and died postoperatively. There were five deaths within thirty days of surgery (14.7 per cent). One was due to postoperative bleeding from a branch of the splenic vein in a patient with primary splenic pancytopenia. Another, in a patient with leukemia reticuloendotheliosis, followed cardiac arrest caused by postoperative hemorrhage. Aspiration pneumonia led to the death of one patient with chronic myelocytic leukemia. This patient also required reoperation for diffuse bleeding due to defective primary hemostasis. Another death was due to blast crisis and sepsis in a patient with chronic myelocytic leukemia and myeloid metaplasia who had no hematologic improvement from splenectomy. One death was due to sepsis in a patient with myeloid metaplasia and pancytopenia who was on high dose steroids and had no hematologic improvement from splenectomy. Complications developed in nineteen of the thirty-four patients (56 per cent). Postoperative hemorrhage, which occurred in nine patients, required transfusions only in three and reoperation in six. The average blood loss during splenectomy in these nine patients was 3 units, but none of these patients received intraoperative platelet transfusions. Three of the six patients reoperated on died; two of the deaths were directly attributed to bleeding.
Volume 135, March 1979
Splenomegaly
There were six wound complications, three of which were superficial infections. None of these patients received prophylactic antibiotics. One patient was on chronic steroid therapy, and one patient required reoperation for postoperative hemorrhage. Three patients developed wound dehiscence. All three had midline incisions, two were on long-term steroid therapy, and two were more than sixty years old. A subphrenic infection requiring drainage developed in one patient. Thirteen patients manifested significant left-sided pleural effusions. Although six of these effusions were drained, this was most often done for diagnosis. Seven patients developed clinically significant atelectasis and one patient developed pneumonia. Thrombotic complications occurred in only two patients, one in the deep veins of the leg and one in the arm. Platelet counts were greater than l,OOO,OOO in both patients when the complication was discovered. Three patients were thought clinically to have had pulmonary embolism, one minor and two major. The platelet count was greater than l,OOO,OOO at the time of the event in one patient. Another patient developed mesenteric thrombosis two and a half months postoperatively at a time when her platelet count was greater than 2,000,OOO.There were no cases of postoperative pancreatitis in this series of patients. In the other 266 patients with spleens less than 1,500 gm who had splenectomy during the period of this study, there was an 11 per cent morbidity rate and 5.0 per cent operative mortality. Comments
Splenectomy for trauma has become an increasingly common surgical procedure even in civilian practice, as has splenectomy for hematologic disease and for the staging of Hodgkin’s disease and other lymphomas [3]. Most of these operations are not technically difficult and are associated with a low morbidity and mortality. Patients with massive spleens, however, present more challenging management problems, because most are elderly and have serious primary diseases that often render them prone to infection or hemorrhage. They also tend to have associated cardiopulmonary abnormalities [3]. Few reports deal specifically with surgery for massive splenomegaly, but there are several that contain a few such cases [4-8]. The available data, including our experience, indicate that splenectomy for massive splenomegaly is often performed late in the course of the disease after the patients have become re-
387
Goldstone
fractory to other therapeutic modalities [g-14]. Crosby [15,16], however, has advocated splenectomy in these patients. The 14.7 per cent operative mortality of this series compared with the 5 per cent mortality for other elective splenectomies in our institution supports this contention. With the exception of those performed for a diagnosis, our splenectomies were done to relieve severe symptoms or life-threatening cytopenias and were notably successful. However, when the desired hematologic response to splenectomy was not achieved the outcome was dismal. Two deaths were due to progression of the underlying disease in such circumstances. The technic of early ligation of the splenic artery results in less operative blood loss than early mobilization of the spleen. Dunphy [I] has stressed preliminary arterial ligation as a way to deal with uncontrollable bleeding during splenectomy, and the use of this technic in our patients has been an important adjunct. We differ with the opinion that early ligation of the splenic artery is not applicable when the splenomegaly is marked [4].
In most cases splenectomy for patients with massive splenomegaly relieves symptoms whether due to the huge spleen itself or to the associated hypersplenic cytopenias. Postoperative deaths are usually due to failure of splenectomy to achieve the desired hematologic response. Splenectomy earlier in the course of diseases associated with massive splenomegaly should be encouraged, because operation is safer at this stage. Acknowledgment: The assistance of Mrs Miriam Blaustein, Medical Records Librarian, in retrieving the charts for analysis is gratefully acknowledged. References
5. 6.
Summary
Removal of a massively enlarged spleen is a challenging surgical problem that is associated with higher death and complication rates than the removal of smaller spleens. Older age, serious and chronic primary diseases, and associated cardiopulmonary abnormalities contribute to the morbidity and mortality. Most patients with massive splenomegaly have been treated with corticosteroid and/or antineoplastic drugs, which impair wound healing, hemostatic function, and host resistance. Precise surgical technic is especially important in these cases because of the susceptibility to postoperative hemorrhage. Ligation of the splenic artery via the lesser peritoneal sac before mobilization of the spleen is associated with lower intraoperative transfusion requirements than when the spleen is mobilized before the splenic artery is ligated.
300
7.
8. 9.
10. 11. 12.
13. 14.
15. 16.
Dunphy JE: Splenectomy for trauma. Am J Surg 71: 450, 1946. Henry AK: The removal of large spleens. i3r J Surg 27: 464, 1940. Fabri PJ, Metz EN, Nick WV, Zollinger RM: A quarter century with splenectomy. Arch Surg 108: 569. 1974. Schwartz SI, Adams JT, Bauman AW: Splenectomy for hematologic disorders. Curr Probl Surg Chicago, Year Book Medical, 197 1. Schwartz SI, Bernard RP. Adams JT, Bauman AW: Splenectomy for hematologic disorders. Arch Surg 101: 338, 1970. Skarin AT, Davey FR, Moloney WC: Lymphosarcoma of the spleen. Arch intern h&d 127: 259, 1971. McBride CM. Hester JP: Chronic myelogenous leukemia: management of splenectomy in a high-risk population. Cancer 39: 653, 1977. Crosby WH, Whelan TJ, Heaton LD: Splenectomy in the elderly. Med C/in Norfh Am 50: 1533, 1966. Lowenbraun S, Ramsey HE, Serpick. AA: Splenectomy in Hodgkin’s disease for splenomegaly, cytopenias and intolerance to myelosuppressive chemotherapy. Am J Med.50: 49, 1971. Ahmann DL. Kiely JM, Harrison EG Jr, Payne WS: Malignant lymphoma of the spleen. Cancer 19: 481, 1986. Yam LT, Li C-Y, Finkel HE: Leukemic reticuloendotheliosis. Arch Intern A&d 130: 248, 1972. Gomes MR, Silverstein MN, ReMine WH: Splenectomy for agnogenic myeloid metaplasia. Surg Gyneco/ Ubstet 125: 106, 1967. Silverstein MN, ReMine WH: Sex, splenectomy and myeloid metaplasia. JAMA 227: 424, 1974. Gomes MM, Silverstein MN, ReMine WH: Indications for splenectomy in hematologic diseases. Swg Gynecol Obstet 129: 129, 1969. _ Editorial: Splenectomy in chronic myelocytic leukaemia. Acta A&d Stand 197: 145, 1975. Crosby WH: Hematologic indications for splenectomy, Nfng/ J Med286: 1252, 1972.
The American Journal of Surgery
“The long course of the splenic artery along the upper edge of the pancreas . . . permits it to be exposed through the lesser peritoneal cavity some distance from the spleen. This is of considerable importance in dealing with very large spleens since it permits control of a major portion of the blood supply before attempting to mobilize the spleen.” LTC J.E. Dunphy, 1946[1]
The author of the above statement has maintained a keen interest in surgery of the spleen since the paper from which the quote was taken was published in this Journal in 1946. Although that paper was entitled, “Splenectomy for Trauma,” he has always been particularly interested and involved in the care of patients with massive spleens. Although there are few reports that deal specifically with removal of huge spleens [2], this procedure is commonly believed to be more dangerous and less beneficial than is removal of smaller spleens. The present study analyzes the morbidity, mortality, and efficacy of splenectomy for massive splenomegaly in order to substantiate these beliefs.
dionuclide scans performed in twenty-one patients confirmed massive splenomegaly in all cases and demonstrated associated hepatomegaly in ten cases. The scans indicated the eventual diagnosis in five patients: cysts were shown in two, and infiltrative processes suggestive of leukemia in three. Splenic arteriograms were performed in eight patients and were diagnostic in seven. All of the patients were symptomatic. The symptoms were of three types: physical-mechanical, related to the huge size of the spleen; hematologic, related to hypersplenism; and those related to splenic infarction. Abdominal fullness, the most common symptom, occurred in twenty-eight patients (82 per cent) and was often associated with a feeling of heaviness and discomfort. Moderate to severe abdominal and particularly left upper quadrant pain occurred in fifteen patients. Several patients with acute pain were thought on the basis of clinical findings to have splenic infarction. Four patients had left shoulder pain and only four had early satiety from gastrointestinal compression. The hypersplenic abnormalities determined the nature of the hematologic symptoms. Symptoms related to thrombocytopenia were common; bruising and/or petechiae were present in twelve patients, overt bleeding oc-
Material and Methods 8 The course of 300 consecutive patients undergoing splenectomy as a primary operation at the University of California, San Francisco was analyzed. Massive splenomegaly was defined as a spleen weighing 1,500gm or more. Thirty-four cases meeting this criterion were identified and form the basis for this analysis. Clinical Features. There were eighteen males and sixteen females ranging in age from five to seventy-nine years. Half of the patients were fifty years of age or older. (Figure 1.) Twenty-nine of the patients were Caucasian, two were black, and three were Oriental. All had massive, easily palpable spleens, that in many cases filled the entire left side of the abdomen and extended into the pelvis. In each case the spleen was clearly seen on plain abdominal x-ray, and twenty-four displaced the colon and/or gastric air bubble or elevated the left hemidiaphragm. Splenic raFrom the Department of Svgery. Universityof California School of Medicine, and Veterans Administration Hospital, San Francisco, California. This work was supported in part by Veterans Administration Research Service. Reprint requests should be addressed to Jerry Goldstone, MD, Department of Sugery, University of California School of Medicine, 4150 Clement Street, San Francisco, California 9412 1.
volume 135, March 1978
7 1
Cl0
II-20
21.30 Age
31.40 41.50 in Years
51.60
61-70
71.80
1
Figure 1. Age dhdribufti of thtriy-fourpatianta wtth maadve sptenomegaty. Monr than haff the pattents were older than tiny years.
385
Goldstone
curred in four (epistaxis or monorrhagia), and occult bleeding in seven. Sixteen patients with marked anemia complained of fatigue, weakness, and pallor. Leukopenia led to recurrent infections in four patients, two of whom had white blood cell counts of less than 1,000/mm3. Hypersplenism involving one or more of the formed elements of the blood was present in twenty-eight of the thirty-four patients (82 per cent). Three patients had thrombocytopenia alone (platelet count of less than 150,000/mms). Six patients had anemia only (hematocrit less than 34). Eight patients had thrombocytopenia and anemia; two had thrombocytopenia and leukopenia; and two anemia and leukopenia. Seven patients had pancytopenia. Pathology. The weight of the resected spleens ranged from 1,500 to 6,100 gm and averaged 2,814 gm. (Figure 2.) The pathologic findings in the spleen were diagnostic in themselves or compatible with the clinical diagnosis in twenty-two patients. Among these were myeloid metaplasia (13 patients), leukemia (4 patients), lymphoma (2 patients), benign cysts (2 patients), and Gaucher’s disease (1 patient). Splenic congestion was the most significant abnormality in five other cases. In nine spleens nonspecific findings such as lymphoid and/or reticuloendothelial hyperplasia (4 patients) were described. Indication for Splenectomy. The most frequent reason for operation (15 patients) was to relieve symptoms from the massively enlarged spleen; other indications for splenectomy were symptomatic anemia (6 patients), thrombocytopenia (6 patients), and leukopenia (2 patients). In four patients splenectomy was performed principally to establish a diagnosis. One patient was operated on for spontaneous rupture of a leukemic spleen.
12 -
10 v) z CUB._ 5 a 6> t -D4E 3 =2-
0
152.0 Spleen
2.1-3.03.1-4.04.1-5.0 5.1-6.0 >6.0
Weight
(Kilograms)
Figure 2. Weight distribution of the removed spleens. A verage weight was 2,8 14 gm.
366
All of the patients were deemed refractory to maximum medical treatment, which included blood transfusions, corticosteroids, busulfan, hydroxyurea, immunosuppression, and splenic irradiation. Most of the patients were seriously and chronically ill and were referred for splenectomy in a last effort to relieve bothersome or life-threatening symptoms and to improve the quality of life.
Operative Technic
All of the patients were operated on under general endotracheal anesthesia using a variety of anesthetic agents and technics. A midline incision was employed in twenty patients; left rectus muscle-splitting or retracting incisions were used in twelve, and a left subcostal incision in one. A left upper quadrant transverse incision was used in the one child in the series. All of the incisions were described in the operative reports as long or generous. In twenty-four patients the splenic artery was ligated along the upper border of the pancreas before the spleen was mobilized from its ligamentous attachments. Access to the artery was through the lesser peritoneal sac after a sufficient number of short gastric vessels were divided to obtain adequate exposure. In a few cases, epinephrine solution (1 cc of l:lO,OOO)was injected into the splenic artery before it was ligated. Both maneuvers promptly decreased the size of the spleen. In the other ten cases, the splenic attachments to the parieties were divided, and the spleen was delivered into the wound, before the major splenic vessels were divided and sutureligated. The average blood loss was 1.3 units (range, 0 to 6) when the splenic artery was ligated as a first step compared to 2.5 units (range, 0 to 9) when the artery was ligated after the spleen had been mobilized (p
The American Journal of Surgery
Massive
Results
Of the fifteen patients in whom splenectomy was performed for mechanical symptoms due to the size of the spleen, twelve (80 per cent) were relieved postoperatively. The other three patients died. The hematocrit increased, symptoms were alleviated, and transfusion requirements decreased in five of the six patients operated on for hypersplenic anemia. One patient improved only slightly. Five of the six patients operated on for thrombocytopenia had moderate to complete resolution of low platelet counts and complete relief of bleeding symptoms. One patient had no response and subsequently died. Both patients with leukopenia had return of their white blood cell counts to normal. The patient with splenic rupture had an uneventful recovery. All four patients in whom the splenectomy was done for diagnosis had a diagnosis established. It is of interest that of the thirteen patients with agnogenic myeloid metaplasia, all but one received substantial symptomatic or hematologic benefit from splenectomy. None of the patients became hematologically worse due to splenectomy, but one patient was unimproved and died postoperatively. There were five deaths within thirty days of surgery (14.7 per cent). One was due to postoperative bleeding from a branch of the splenic vein in a patient with primary splenic pancytopenia. Another, in a patient with leukemia reticuloendotheliosis, followed cardiac arrest caused by postoperative hemorrhage. Aspiration pneumonia led to the death of one patient with chronic myelocytic leukemia. This patient also required reoperation for diffuse bleeding due to defective primary hemostasis. Another death was due to blast crisis and sepsis in a patient with chronic myelocytic leukemia and myeloid metaplasia who had no hematologic improvement from splenectomy. One death was due to sepsis in a patient with myeloid metaplasia and pancytopenia who was on high dose steroids and had no hematologic improvement from splenectomy. Complications developed in nineteen of the thirty-four patients (56 per cent). Postoperative hemorrhage, which occurred in nine patients, required transfusions only in three and reoperation in six. The average blood loss during splenectomy in these nine patients was 3 units, but none of these patients received intraoperative platelet transfusions. Three of the six patients reoperated on died; two of the deaths were directly attributed to bleeding.
Volume 135, March 1979
Splenomegaly
There were six wound complications, three of which were superficial infections. None of these patients received prophylactic antibiotics. One patient was on chronic steroid therapy, and one patient required reoperation for postoperative hemorrhage. Three patients developed wound dehiscence. All three had midline incisions, two were on long-term steroid therapy, and two were more than sixty years old. A subphrenic infection requiring drainage developed in one patient. Thirteen patients manifested significant left-sided pleural effusions. Although six of these effusions were drained, this was most often done for diagnosis. Seven patients developed clinically significant atelectasis and one patient developed pneumonia. Thrombotic complications occurred in only two patients, one in the deep veins of the leg and one in the arm. Platelet counts were greater than l,OOO,OOO in both patients when the complication was discovered. Three patients were thought clinically to have had pulmonary embolism, one minor and two major. The platelet count was greater than l,OOO,OOO at the time of the event in one patient. Another patient developed mesenteric thrombosis two and a half months postoperatively at a time when her platelet count was greater than 2,000,OOO.There were no cases of postoperative pancreatitis in this series of patients. In the other 266 patients with spleens less than 1,500 gm who had splenectomy during the period of this study, there was an 11 per cent morbidity rate and 5.0 per cent operative mortality. Comments
Splenectomy for trauma has become an increasingly common surgical procedure even in civilian practice, as has splenectomy for hematologic disease and for the staging of Hodgkin’s disease and other lymphomas [3]. Most of these operations are not technically difficult and are associated with a low morbidity and mortality. Patients with massive spleens, however, present more challenging management problems, because most are elderly and have serious primary diseases that often render them prone to infection or hemorrhage. They also tend to have associated cardiopulmonary abnormalities [3]. Few reports deal specifically with surgery for massive splenomegaly, but there are several that contain a few such cases [4-8]. The available data, including our experience, indicate that splenectomy for massive splenomegaly is often performed late in the course of the disease after the patients have become re-
387
Goldstone
fractory to other therapeutic modalities [g-14]. Crosby [15,16], however, has advocated splenectomy in these patients. The 14.7 per cent operative mortality of this series compared with the 5 per cent mortality for other elective splenectomies in our institution supports this contention. With the exception of those performed for a diagnosis, our splenectomies were done to relieve severe symptoms or life-threatening cytopenias and were notably successful. However, when the desired hematologic response to splenectomy was not achieved the outcome was dismal. Two deaths were due to progression of the underlying disease in such circumstances. The technic of early ligation of the splenic artery results in less operative blood loss than early mobilization of the spleen. Dunphy [I] has stressed preliminary arterial ligation as a way to deal with uncontrollable bleeding during splenectomy, and the use of this technic in our patients has been an important adjunct. We differ with the opinion that early ligation of the splenic artery is not applicable when the splenomegaly is marked [4].
In most cases splenectomy for patients with massive splenomegaly relieves symptoms whether due to the huge spleen itself or to the associated hypersplenic cytopenias. Postoperative deaths are usually due to failure of splenectomy to achieve the desired hematologic response. Splenectomy earlier in the course of diseases associated with massive splenomegaly should be encouraged, because operation is safer at this stage. Acknowledgment: The assistance of Mrs Miriam Blaustein, Medical Records Librarian, in retrieving the charts for analysis is gratefully acknowledged. References
5. 6.
Summary
Removal of a massively enlarged spleen is a challenging surgical problem that is associated with higher death and complication rates than the removal of smaller spleens. Older age, serious and chronic primary diseases, and associated cardiopulmonary abnormalities contribute to the morbidity and mortality. Most patients with massive splenomegaly have been treated with corticosteroid and/or antineoplastic drugs, which impair wound healing, hemostatic function, and host resistance. Precise surgical technic is especially important in these cases because of the susceptibility to postoperative hemorrhage. Ligation of the splenic artery via the lesser peritoneal sac before mobilization of the spleen is associated with lower intraoperative transfusion requirements than when the spleen is mobilized before the splenic artery is ligated.
300
7.
8. 9.
10. 11. 12.
13. 14.
15. 16.
Dunphy JE: Splenectomy for trauma. Am J Surg 71: 450, 1946. Henry AK: The removal of large spleens. i3r J Surg 27: 464, 1940. Fabri PJ, Metz EN, Nick WV, Zollinger RM: A quarter century with splenectomy. Arch Surg 108: 569. 1974. Schwartz SI, Adams JT, Bauman AW: Splenectomy for hematologic disorders. Curr Probl Surg Chicago, Year Book Medical, 197 1. Schwartz SI, Bernard RP. Adams JT, Bauman AW: Splenectomy for hematologic disorders. Arch Surg 101: 338, 1970. Skarin AT, Davey FR, Moloney WC: Lymphosarcoma of the spleen. Arch intern h&d 127: 259, 1971. McBride CM. Hester JP: Chronic myelogenous leukemia: management of splenectomy in a high-risk population. Cancer 39: 653, 1977. Crosby WH, Whelan TJ, Heaton LD: Splenectomy in the elderly. Med C/in Norfh Am 50: 1533, 1966. Lowenbraun S, Ramsey HE, Serpick. AA: Splenectomy in Hodgkin’s disease for splenomegaly, cytopenias and intolerance to myelosuppressive chemotherapy. Am J Med.50: 49, 1971. Ahmann DL. Kiely JM, Harrison EG Jr, Payne WS: Malignant lymphoma of the spleen. Cancer 19: 481, 1986. Yam LT, Li C-Y, Finkel HE: Leukemic reticuloendotheliosis. Arch Intern A&d 130: 248, 1972. Gomes MR, Silverstein MN, ReMine WH: Splenectomy for agnogenic myeloid metaplasia. Surg Gyneco/ Ubstet 125: 106, 1967. Silverstein MN, ReMine WH: Sex, splenectomy and myeloid metaplasia. JAMA 227: 424, 1974. Gomes MM, Silverstein MN, ReMine WH: Indications for splenectomy in hematologic diseases. Swg Gynecol Obstet 129: 129, 1969. _ Editorial: Splenectomy in chronic myelocytic leukaemia. Acta A&d Stand 197: 145, 1975. Crosby WH: Hematologic indications for splenectomy, Nfng/ J Med286: 1252, 1972.
The American Journal of Surgery