Post-traumatic Splenectomy Research Articles

Erythema Migrans in Patients with Post-Traumatic Splenectomy.

Information on asplenic Lyme borreliosis (LB) patients with erythema migrans (EM) is lacking. We compared the course and outcome of 26 EM episodes in 24 post-trauma splenectomized patients (median age 51 years) diagnosed at a single clinical center in Slovenia during 1994-2023 with those of 52 age- and sex-matched patients with EM but with no history of splenectomy. All patients were followed for one year. A comparison of pre-treatment characteristics revealed that EM in splenectomized patients was of shorter duration before diagnosis (4 vs. 8 days, p = 0.034) with a smaller EM diameter (10.5 vs. 14 cm, p = 0.046), and more frequently fulfilled criteria for disseminated LB (3/26, 11.5% vs. 0%, p = 0.034). Treatment failure occurred in 5/26 (19.2%) EM episodes in splenectomized patients versus 0/52 in non-splenectomized patients (p = 0.003). The five treatment failure cases were retreated with antibiotic regimens used to treat EM and had complete resolution of all symptoms/signs. In conclusion, our study showed that splenectomized adult patients with EM differ somewhat in presentation and more often have treatment failure compared with non-splenectomized patients with EM.

INCIDENTALLY IDENTIFIED JAK2 MUTATION -POST TRAUMATIC SPLENECTOMY

Reactive thrombocytosis post splenectomy is usually self-limiting. Hence in patients with raising platelet count after splenectomy detailed evaluation may be required to rule out other causes of thrombocytosis. Extreme thrombocytosis(>10 lakhs/cmm) leading to thrombotic or hemorrhagic complications can be multifactorial i.e., Infection, iron deficiency, Myeloproliferative disorders - CML, Polycythemia vera, essential thrombocytosis. Timely treatment of patients with thrombocytosis can prevent the development of life-threatening complications like splenic, mesenteric, and portal vein(PST-SMPv) has an incidence of 8%-10%, splenic size and myeloproliferative disorders are the main risk factors. Here we index an unusual case of reactive thrombocytosis post-traumatic splenectomy in which extreme thrombocytosis had to be controlled with systemic anticoagulation

Subcutaneous Splenosis Presenting 37 years post-traumatic splenectomy; A Case Report.

IntroductionThe term splenosis refers to autotransplantation of splenic tissue in ectopic sites. Ectopic splenic tissue may be found in the liver, thorax, pelvis and subcutaneous tissues following traumatic splenectomy. Although clinically insignificant, local symptoms such as abdominal pain may arise. In this paper we report a case of subcutaneous splenosis presenting 37 years post-traumatic splenectomy.Case presentationA 40-year-old medically free lady presented to our institution with a surgical history of post-traumatic splenectomy at the age of three and two cesarean sections. She complained for nonpainful right upper quadrant soft mass that has been stable in size over the years. Her laboratory results, including peripheral blood smear, were all within normal limits and no asplenic changes were detected. SPECT scan confirmed extraperitoneal splenosis in right upper quadrant.DiscussionSplenosis is an acquired form of ectopic splenic tissue that is defined as an auto-transplantation of a viable splenic tissue. It commonly occurs after traumatic rupture of the spleen.5 Splenosis has been widely reported around the world with an incidence of 16–67% after traumatic splenic rupture or splenectomy. Subcutaneous splenosis is an extremely rare condition, mostly observed in abdominal surgical scars. It is believed to follow laparotomy for splenectomy where splenic cells auto-implant or spread hematogenously at different locations.ConclusionSubcutaneous splenosis is a rare consequence of post-traumatic splenectomy that can manifest itself up to three decades after. Although concerning to the patient and alarming to the surgeon as it may resemble more serious entities such as abdominal wall sarcoma, surgical removal of asymptomatic splenosis is subject to the location of mass and patients' wishes.

Omphalocaval shunt post traumatic splenectomy in a cirrhotic patient.

Omphalocaval shunt post traumatic splenectomy in a cirrhotic patient.

Intraomental Splenic Implant - An Attempt of Reassessment.

The permanent risk of splenectomized patients to infectious complications, the most severe being overwhelming post splenectomy infection (OPSI), determined the search for solutions in order to diminish these evolutionary possibilities. Therefore, intraomental developsplenic autotransplantation seems to be a viable option which, according to some authors, would have beneficial effects by restoring (at least partially) the functions of the spleen. The article presents the current experience related to this procedure (principles of surgical technique, implant location, complications, post-procedural evaluation) in an attempt to bring it back to the attention of trauma / general surgery surgeons. The procedure is simple, fast and with minimal or no complications and should be applied after any post-traumatic splenectomy.

LEUCOCYTOSIS AFTER POST TRAUMATIC SPLENECTOMY- A PHYSIOLOGICAL EVENT OR INDICATOR OF SEPSIS.

Background: Blunt injury abdomen causes a variety of injuries, the commonest being solid organ injury. Among the solid organs, the spleen is most commonly injured. Operative management plays a major role in treatment of blunt injury abdomen. Various postoperative complications can occur following emergency laparotomy including surgical site infection, abdominal abscess, urinary tract infection and lower respiratory tract infection. Diagnosing these infections becomes particularly challenging following splenectomy because of the unusual physiological response to leucocyte count and platelet count. The aim of this study is to assess the three risk factors i.e Total Leucocyte Count, Platelet count/Total Leucocyte Count Ratio and Injury Severity Score in patients undergoing splenectomy and to compare them with other patients undergoing laparotomies other than splenectomy for blunt injury abdomen in order to achieve a cut off value beyond which persistence of leucocytosis may denote infection. Aim and objectives: To study the WBC Count and Platelet Count(PC)/WBC Count ratio in infected and non infected individuals who have undergone post traumatic splenectomy compared to other blunt abdomen trauma patients who have undergone laparotomy. To study the relationship of three prognostic factors : WBC count, PC/WBC count ratio and Injury Severity Score in individuals who have undergone emergency laparotomy after trauma and their role in post operative infection. Materials and Methods: This Observational study (Prospective) was conducted in Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai from June 2017 to October 2018. All patients undergoing splenectomy after trauma and other blunt trauma patients who underwent laparotomy were included in the study. Sample size is 30 cases of splenectomy. Parameters assessed were WBC count, platelet count, injury severity score, presence of post operative infections like pneumonia, abdominal abscess, septicaemia, urinary tract and wound infections. Results: The following are the results of the study.Injury severity score >21 is a signicant risk factor. Post operative day 5 WBC count more than 15000 indicates infection. PC/TC ratio < 20 on the 5th post operative day indicates infection. Patients who underwent laparotomies other than splenectomy showed elevated Total count and Decreased platelet/total count ratio only if infected . Presence of more than 1 risk factor is associated with 72% chance of infection. Conclusion: Post operative day 5 is the earliest time that infected and non infected patients can be distinguished on the basis of total count and PC/TC ratio.Risk factors for infection includes Total count >15,000 on 5th post operative day,PC/TC ratio< 20 on 5th post operative day, ISS > 21. Presence of more than one risk factor carries 72% increased chance of infection and these patients should be monitored with high degree of suspicion.

Tubal splenosis: unusual location of the spleen

Introduction: Splenosis is defined as the autotransplantation of splenic tissue to abnormal locations after splenic injury. Heterotopic spleen can be found within the abdominal and pelvic cavities. We report a tubal splenosis case in a 48 year old woman who underwent splenectomy following a blunt trauma 41 years prior to presentation. Case report: A 48 years old gravida 3, para 3, was admitted to our gynecology clinic for pelvic pain, menstrual irregularities and abnormal bleeding. The patient had a six months history of sonographically detected 40 x 20 mm pelvic mass. She also had a blunt trauma and splenectomy history from 41 years ago. Total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed. Intraoperative exploration revealed a 40 mm sized suspicious mass immediately adjacent to the right fallopian tube. The histopathologic examination of the specimen reported normal splenic tissue with polymorphous small lymphocytes, granulocytes, and frequent hemosiderin laden macrophages. Discussion: Posttraumatic pelvic splenosis is a rare condition. Splenosis should be kept in mind as a differential diagnosis especially for patients with a history of posttraumatic splenectomy who are scheduled for pelvic mass surgery. Although most of the patients are diagnosed postoperatively, if preoperative diagnosis could be made, there is no medical indication for this normally functioning tissue to be resected.

An alternative imaging modality to scintigraphy in noninvasive diagnosis of splenosis in patients with post-traumatic splenectomy: Diffusion weighted imaging

An alternative imaging modality to scintigraphy in noninvasive diagnosis of splenosis in patients with post-traumatic splenectomy: Diffusion weighted imaging

TROMBOCYTOSIS FOLLOWING SPLENECTOMY IN PEDIATRIC PATIENTS

Thrombocytosis represents a platelet count over 500.000/mm³. Objective. The aim of this study is to evaluate the frequency and gravity of reactive thrombocytosis in pediatric patients who underwent splenectomy. Material and method. We performed a retrospective study including 20 patients (4-16 years old) who underwent splenectomy between 2006-2015. The inclusion criteria in the study were: patients with the age under 18 years, who underwent splenectomy independently by the cause, and who developed afterwards thrombocytosis. Results. In the studied group 64% of the splenectomised patients (16) developed a form of thrombocytosis. In 4 cases – severe form (Platelets > 1 million/mm3) and in 7 cases a mild form. There were not noticed any significant differences regarding the gender repartition of the patients (9 were females, and 11 were males). In 13 patients, thrombocytosis disappeared after 30 days, and only in 3 cases, the episode lasted more than 360 days. Thrombotic phenomena were noticed only in one patient from our study group. All the patients benefited from thromboprophylaxis and hydration measures, and 2 cases needed associated treatment with Hydroxyurea. Conclusions. Our study reveals an increased frequency of thrombocytosis after splenectomy (80%), with a maximum peak of incidence in 2-10 days following the intervention, thrombocytosis being generally benign and self-limited; still one of the cases experienced thrombotic complications and severe thrombocytosis was more frequent after post-traumatic splenectomy.

Advances in research of prevention and treatment of thrombosis after posttraumatic splenectomy

Advances in research of prevention and treatment of thrombosis after posttraumatic splenectomy

Pelvic Nodules in a Gynecologic Patient

A 27-year-old female presented with severe dysmenorrhea and primary infertility. She had past history of post-traumatic splenectomy but was otherwise healthy. Her pelvic ultrasound was normal. She had a diagnostic hysteroscopy, laparoscopy, and a tubal patency dye test. On laparoscopy, there were multiple fleshy looking, red with blue hue nodules. In between, there were few scattered dark blue nodules on the anterior surface of the uterus, the visceral peritoneum, uterosacral ligaments, left ovarian fossa, and sigmoid colon. There were no significant adhesions. Some of those nodules were excised. The ones left behind were those in tricky anatomical locations like on the sigmoid colon and the ovarian fossa. The excised nodules were sent for histopathological confirmation. The patient made unremarkable recovery.

An Uncommon Cause of a Focal Liver Lesion

Question: A 62-year-old man with a chronic hepatitis C and liver cirrhosis Child A was referred for abdominal computed tomography (CT) after a nodular liver lesion in segment V was found on ultrasonography. His medical history included esophageal varices grade I, reflux esophagitis grade III, and a posttraumatic splenectomy 50 years ago. The physical examination was unremarkable and the laboratory values were normal (alpha-fetoprotein, 1.9 g/L). Abdominal CT scan revealed a homogenous, smoothly outlined, round lesion measuring 15 18 mm located between the gallbladder and the liver (segment V). During the arterial phase the lesion seemed to be enhanced (Figure A) and during the venous phase the lesion’s density was similar to the surrounding liver parenchyma (Figure B). To rule out small hepatocellular carcinoma, diagnostic laparoscopy was performed. The nodule could be visualized at the Calot’s triangle of the gallbladder (Figure C). We found unexpected, multiple nodules of different sizes throughout the entire left upper abdominal quadrant. These nodules were located within the greater omentum and the mesentery as well as at the peritoneal surface including the left-sided diaphragm (Figure D). Laparoscopic cholecystectomy and resection of the suspicious nodule at the Calot’s triangle was performed. The specimen was sent for histology (Figure E). The postoperative course was uneventful. What is the diagnosis? Look on page 659 for the answer and see the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Diagnostic et traitement de splénose pelvienne au cours d’un bilan d’infertilité

Splenosis is the heterotopic autotransplantation of splenic tissue that usually follows traumatic splenectomy. Rare pelvic localizations are reported. We report here a case of a 36-year-old woman, followed for secondary infertility. On transvaginal ultrasound pelvic scanning hypervascular paracervical nodules were demonstrated. Pelvic splenosis was suspected regarding the patient's medical past (post-traumatic splenectomy). Surgical exploration and resection were decided considering the nodule localization, the risk during ovarian ponction for IVF, and the hypothetical risk of bleeding at delivery. Generally, it is recommended to leave in place the splenic tissue, which may be immunologically functional.

Intrathoracic splenosis: evaluation by superparamagnetic iron oxide-enhanced magnetic resonance imaging and radionuclide scintigraphy

Splenosis represents the heterotopic autotransplantation of splenic tissue after either splenic trauma or surgery. Intrathoracic splenosis is a rare condition resulting from concomitant rupture of the spleen and the left hemidiaphragm. We report a case of splenosis in a 41-year-old male patient who had experienced severe thoracoabdominal injury including rupture of the spleen and left hemidiaphragm and post-traumatic splenectomy 20 years previously. Abnormal opacities in the cardiac region were noted on a chest radiograph at an annual checkup. Computed tomography (CT) of the chest demonstrated multiple, well-circumscribed pleura-based nodules at the posterior base of the left hemithorax and the left subdiaphragmatic area. On magnetic resonance imaging (MRI), the lesions were hypointense on T1-weighted images and hyperintense on T2-weighted images. After administration of superparamagnetic iron oxide (SPIO), the lesions showed decreased signal intensity but remained slightly hyperintense relative to liver parenchyma on T2-weighted images. (99m)Tc-labeled Sn colloid scintigraphy revealed multiple areas of increased activity consistent with the lesions on the CT and MRI scans. In addition to the history of splenic trauma and left hemothorax, SPIO-enhanced MRI and radionuclide scintigraphy, which can demonstrate phagocytic ability in the ectopic splenic tissue, were useful for confirming the diagnosis.

QS393. Vaccination for Post-Traumatic Splenectomy: Are We Doing it Right?

QS393. Vaccination for Post-Traumatic Splenectomy: Are We Doing it Right?

Purpura fulminans due to imported falciparum malaria

Sir, Purpura fulminans (PF) is usually associated with meningococcemia or invasive pneumococcal infection. Here, we report a case of PF due to imported Plasmodium falciparum malaria in an asplenic patient. A 51-year-old Caucasian man was admitted to the Emergency Department because of fever and confusion. He had just returned 13 days earlier after a long stay in Madagascar. He had a history of posttraumatic splenectomy in his childhood. He had no antimalarial chemoprophylaxis. He had fever and asthenia 4 days before the admission, and took one dose of dirithromycin orally. Once in the Emergency Department, he was confused, his blood pressure was 100/ 60 mmHg, and his temperature 38.7 C. A peripheral blood smear revealed erythrocytes infected by P. falciparum. A treatment with intravenous quinine was initiated without loading dose. The patient was transferred to the ICU where he presented generalized tonic–clonic seizure and coma, leading to intubation for mechanical ventilation and sedation with midazolam and fentanyl. At this point, he was severely shocked (blood pressure 60/40 mmHg) and anuric. A physical examination showed cold extremities and extensive necrotic and purpuric skin lesions on his hands and legs. There was no focal neurological deficit or neck stiffness. All peripheral pulses were palpable. The rest of the examination showed no abnormalities. Parasitemia was 12%. Arterial blood gas measurements showed: pH 7.21; pCO2 31 mmHg; bicarbonate level 12 mmol/L and PaO2/FiO2 ratio 315. Laboratory studies revealed the following values: blood urea nitrogen 24 mmol/L; serum creatinine 437 lmol/L; lactates 6.5 mmol/L; serum bilirubin166 lmol/L; normal glycemia. Other laboratory test results are displayed in Table 1. He received intravenous fluid, norepinephrin, low dose hydrocortisone, intravenous quinine, ceftriaxone after blood cultures, and renal replacement by continuous venovenous hemofiltration (ultrafiltration rate at 33 mL/kg per h). CT scan of the brain showed a subarachnoid hemorrhage. An electroencephalogram revealed no ongoing seizure activity. Vitamin K and platelets transfusion were given for 3 days, and fibrinogen and antithrombin concentrates on day 5. All blood cultures remained negative. The purpura progressed to skin necrosis of the two forefeet. The patient’s condition improved progressively, but his two forefeet were amputated 2 months later and the patient was discharged to a rehabilitation unit. Secondary hematological explorations revealed no deficiency of protein C, protein S, and antithrombin. The most likely diagnosis was falciparum malaria complicated by disseminated intravascular

Antibody responses to pneumococcal and hemophilus vaccinations in splenectomized patients with hematological malignancies or trauma

In this study we addressed the question of whether an underlying hematological malignancy may affect the immune response to vaccination against bacterial polysaccharide antigens (e.g. Haemophilus influenzae type b, Streptococcus pneumoniae) in splenectomized patients. Between 1993 and 2003, 44 splenectomized adults from the outpatient clinic for infectious diseases were prospectively included in the study: 23 patients suffered from hematological malignancies (HM) and had undergone splenectomy; 21 were splenectomized following trauma (T) and served as the control group. Each patient received an intradeltoid injection with 0.5 ml of a single lot of a 23-valent pneumococcal polysaccharide vaccine, and 0.5 ml of a polyribosyl ribitol phosphate capsular polysaccharide vaccine of H. influenzae type b (Hib) into the opposite arm. Blood samples for determination of pneumococcal and Hib antibodies were taken prior to vaccination and again 6-8 weeks later. In assessing responses to the 23-valent pneumococcal polysaccharide vaccine, we found significant differences in antibody titer increase between the HM and T groups (median IgG increase 1.27 [0.7; 2.39] vs. 3.9 [2.1; 15.3], P < 0.001; and median IgM increase 1.33 [1.0;2.67] vs. 5.25 [2.3; 7.78], P < 0.001). In the HM group, only 8/23 and 6/23 showed a titer increase of twice or more the base value for IgG and IgM respectively, whereas in the trauma group an adequate response was shown by 16/21 and 16/20 respectively. Patients with splenectomy and hematological malignancies responded poorly to the 23-valent polysaccharide vaccine. Response to the conjugated Hib vaccine was slightly better, but still significantly lower than in individuals with posttraumatic splenectomy. Data suggest that vaccination response to the polysaccharide vaccines should be evaluated at least in the high-risk group.

Time Lapse and Comorbidities Influence Patient Knowledge and Pursuit of Medical Care After Traumatic Splenectomy

There is insufficient knowledge of infectious risk in patients after splenectomy; minimal data exists specifically for trauma patients. This study evaluated patient knowledge and practices regarding infection risk after traumatic splenectomy. Our hypothesis was that patients with poor knowledge regarding their asplenic state would be less likely to pursue medical care in the event of an illness than those with good knowledge. Non-randomized, cohort study of all posttraumatic splenectomy patients < or =11 years after injury in 2 rural trauma centers. Patients received a validated questionnaire; weighted responses determined knowledge about infection risks and appropriate follow-up actions. Fifty-four percent of patients responded to the questionnaire. Overall, 47% of responders were identified as having adequate knowledge regarding infectious risk, and only 28% would pursue appropriate medical care. Of patients with adequate knowledge, 42% were more likely to pursue appropriate care versus 15% of patients with inadequate knowledge (p = 0.06). Patients with adequate knowledge were more likely to receive an annual influenza vaccine (p = 0.03) and contact their provider with fewer symptoms (p = 0.03). Logistic regression revealed significant interactions between knowledge and presence of comorbidities (p = 0.04). Focusing on patients with poor knowledge and absence of comorbidities, none would engage in appropriate action in the event of illness (p < 0.01). A longer time since injury, >3 years, was associated with a diminished likelihood of appropriate action (p = 0.03). The relationship between knowledge and action was not accounted for by other potential confounders. Trauma patients retain minimal knowledge about infection risk after splenectomy and are not likely to pursue appropriate medical care. Time since injury negatively influences patient actions. Healthcare providers must be more proactive to develop new strategies in educating these patients, particularly those without comorbidities and those greater than 3 years postsplenectomy.

Cœur pulmonaire chronique postembolique révélant une bêtathalassémie intermédiaire après splénectomie

Introduction The clinical expression of beta-thalassemia intermedia is variable and complications are more frequent than in the minor form. Thromboembolism risk increase after splenectomy. Few cases of the type of complications are reported. Case record A man was admitted for beta-thalassemia intermedia with moderate chronical hemolysis anemia, complicated by chronic pulmonary thromboembolism and liver iron overload. Post-traumatic splenectomy probably increase the risk of this two complications. The patient's respiratory status improved following bosentan therapy without worsening his hepatopathy. Conclusion The present study also notes that thromboembolism complications can be an indicator of beta thalassemia and interrogate about the risk and the benefit of splenectomy in the treatment of beta-thalassemia intermedia.

Spinal Cord Stimulation in Visceral Pathologies: Table 1

Spinal cord stimulation (SCS) has widely been applied for the treatment of neuropathic pain with excellent outcomes. However, there seems to be a general lack of consensus on the modalities and treatment approaches for the visceral component of nociceptive pain syndromes. There have recently been some interesting developments in the domain of visceral pain treatment by utilizing SCS. We have published case studies to exemplify the viscerotomal distribution of abdominal visceral pain pathways and the application of traditional SCS techniques for its treatment in another recent article. Spinal stimulation was successfully applied in patients experiencing abdominal visceral pain due to various conditions, including chronic nonalcoholic pancreatitis, post-traumatic splenectomy, and generalized abdominal pain secondary to laparotomies performed to relieve gastrointestinal adhesions. There was a significant reduction in the visual analog scale scores along with a substantial decrease in narcotic use. This article is meant to provide the anatomical basis and rationale for the clinical application of SCS in various abdominal visceral pain syndromes. SCS holds great promise as a highly effective, nondestructive, and reversible treatment modality for abdominal visceral pain disorders.