Risk Of Overwhelming Postsplenectomy Sepsis Research Articles

A retrospective comparative study of robotic distal pancreatectomy with or without splenic vessel and spleen preservation

BackgroundRobotic distal pancreatectomy has been accepted to be safe and effective for pancreatic tail lesion. Whether spleen preservation by preserving the splenic vessels with robot assistance is feasible and beneficial remains controversial. Here we would like to compare the operative outcomes of robotic distal pancreatectomy and splenectomy (DPS) with robotic spleen preserving distal pancreatectomy by means of splenic vessel preservation (SVP). MethodsBetween March 2011 and September 2019, 56 consecutive patients undergoing robotic distal pancreatectomy were identified, with 28 patients in each group. Patient demographics, histopathology findings and operative outcomes were prospectively collected and compared between the two groups. A subgroup analysis was made after excluding malignant and pancreatic lesions >6 cm in the DPS group. ResultsThe two groups had similar conversion rate, blood loss, morbidity and pancreatic fistula rate. There was no operative mortality. The SVP group had shorter median operative time (245 vs 303.5 min, P = 0.019) and shorter median hospital stay (5 vs 6 days, P = 0.019) than the DPS group. However, all malignant lesions occurred in the DPS group and lesion size in DPS group was significantly larger. After matching, there were 28 SVP and 15 DPS. The histopathology findings and lesion size became comparable. The SVP group still had shorter operative time (245 vs 290 min, P = 0.022) and shorter hospital stay (5 vs 7 days, P = 0.014) than the DPS group. ConclusionApart from avoiding risk of overwhelming postsplenectomy sepsis, robotic SVP had additional advantage of shorter operative time and shorter hospital stay than robotic DPS.

Spleen and splenic vessel preserving distal pancreatectomy for bifocal PNET in a young patient with MEN1

MEN1 patients requiring resection of neuroendocrine tumors (pNET) are frequently young, active patients in whom a minimal access approach minimizes perioperative morbidity and splenic preservation decreases the risk of post-splenectomy sepsis. Laparoscopic spleen preserving distal pancreatectomy can be performed with removal (Warshaw's technique) or preservation of the splenic vessels, the later having a higher rate of successful splenic preservation. This is an active, 16-year-old Jehovah's Witness with trifocal nonfunctioning neuroendocrine tumor in the proximal body and tail of the pancreas as part of MEN1 syndrome. A spleen preserving distal pancreatectomy was performed with the final pathology showing three pNET with low mitotic count and three lymph nodes free of cancer (final stage pT2pN0). This video demonstrates patient and trocar positioning as well as operative tactics for a laparoscopic distal pancreatectomy with preservation of splenic vessels. Intraoperative ultrasound is crucial in assessing pNETs' relation to critical vessels, pancreatic duct, and to exclude synchronous lesions. The video focuses on safe laparoscopic creation of the retropancreatic tunnel and dissecting the pancreas off the splenic vessels using novel energy devises to control direct splenic venous branches into the pancreas. Improvements in laparoscopic techniques and technology have enabled surgeons to preserve the major splenic vessels to avoid splenic infarcts, abscesses and re-operations, and minimize the risk of left-sided portal hypertension. Splenic preservation is particularly important in young MEN1 patients undergoing laparoscopic pancreatectomy for pNET due to the increased risk of overwhelming post-splenectomy sepsis.

21st Century Approach to Splenic Injury

ABSTRACTRecent trends of splenic injury management in the 21st century emphasizes nonoperative treatment in children and adults. The clinician must base his treatment on clinical criteria on hemodynamic stability and associated injuries. The risk of overwhelming post-splenectomy sepsis is very low and should not influence the decision to operate, if the clinical condition demands it.How to cite this articleLucas CE. 21st Century Approach to Splenic Injury. J Trauma Critical Care Emerg Surg 2013;2(3): 116-125.

Overwhelming Post-Splenectomy Sepsis Eleven Years after Distal Pancreatectomy for Pancreatic Cancer

Context Overwhelming post-splenectomy sepsis (OPSI) is defined as septicemia and/or meningitis, usually fulminant, occurring days to several years after removal of the spleen. The risk of OPSI is estimated to be 0.23-0.42% per year with a lifetime risk of 5%. The highest risk of developing OPSI is within the first few years after splenectomy, particularly in children younger than 2 years and elderly patients. The incidence of sepsis is also associated with the underlying disease, with higher incidence for patients splenectomized for hematologic disease rather than for trauma. We report a case of a fulminant pneumococcal sepsis with a fatal outcome, occurring 11 years after distal pancreatectomy and splenectomy for pancreatic adenocarcinoma. Case report A 58-year-old woman presented to the emergency room in December 2011 with a 2-day history of mild fever and diarrhea, followed by hypotension, dyspnea, and peripheral cyanosis. Past medical history revealed a left breast quadrantectomy for lobular carcinoma (pT1N1M0G2) and distal pancreatectomy with splenectomy for ductal pancreatic adenocarcinoma (pT3N1M0G2) in October 2000. The patient was not aware of the need for prophylactic antibiotics and vaccination. Two years after surgery, she underwent excision of paraaortic lymph node, site of pancreatic cancer recurrence. Adjuvant therapy and oncological follow-up was planned. At admission, blood tests revealed abnormal coagulation screen, abnormal liver and kidney function, and metabolic acidosis. Despite the administration of intravenous fluid, vasopressor agents, antibiotics and mechanical ventilatory support, the patient died for multiorgan failure 7 hours after admission in intensive care unit. Blood culture showed the growth of Streotococcus Pneumoniae . Necropsy showed multiorgan failure with adrenal necrotic hemorrhage due to pneumococcal septicemia. No recurrence of pancreatic cancer was noted. Conclusions Although rare , OPSI is a well-known fatal complication which can occur to asplenic patients. The role of vaccination and antibiotics in preventing such complication is well-defined, but cases of fatal post-splenectomy sepsis are still reporting, also in vaccinated patients. There is a need of practical guidelines for patients and physicians, and a high index of suspicion must be maintained for any febrile illness in asplenic patients.

Partial Splenectomy for Hereditary Spherocytosis

Partial Splenectomy for Hereditary Spherocytosis

A Novel Technique of Partial Splenectomy Using Radiofrequency Ablation

IntroductionPartial splenectomy has frequently been advocated to avoid the risk of overwhelming postsplenectomy sepsis. Concerns over adequate haemostasis during partial splenectomy, however, have limited its widespread use. We have previously reported our experience of using radiofrequency (RF) ablation to minimise blood loss during hepatic and splenic resections. MethodsIn this video, we illustrate the technique of partial splenectomy assisted by RF energy to minimise blood loss.

Institutional experience with laparoscopic partial splenectomy for hereditary spherocytosis

Background/Purpose Moderate to severe hereditary spherocytosis (HS) is treated with splenectomy. However, total splenectomy leads to decreased immunologic function with the risk of overwhelming postsplenectomy sepsis. Splenic preservation is postulated as a method to avoid this potentially fatal complication. Although mainly performed through laparotomy, we report our experience with a laparoscopic approach to partial splenectomy for HS. Methods A retrospective review was conducted on 9 laparoscopic partial splenectomies performed for HS at our institution. Follow-up was from 1 to 3.5 years. Data included preoperative and postoperative hemoglobin, absolute reticulocyte count, splenic size, operative time, complications, and length of stay. Results All patients successfully underwent laparoscopic partial splenectomy with a radiologically determined upper-pole remnant of 10% to 30% and preservation of the blood supply through the upper short gastric arteries. The mean preoperative spleen length was 13 cm. Mean hospital stay was 3.6 days (range, 1-6 days). There was 1 intraoperative complication (a small bowel tear during spleen extraction) and 2 minor postoperative complications (ileus and wound infection). One patient underwent completion total splenectomy 2 years after partial splenectomy. Conclusion Laparoscopic partial splenectomy is a feasible and effective procedure that addresses the hematologic consequences of HS while retaining a portion of functional spleen, in addition to conferring the advantages of laparoscopy.

Laparoscopic Distal Pancreatectomy in Children: Four Cases and Review of the Literature

Laparoscopy has been utilized for children with pancreatic masses and blunt transection. In this article, we report our technique and experience. With supine positioning, an umbilical trocar and three 5-mm trocars are positioned across the epigastrium. The gastrocolic ligament is opened completely and the stomach is retracted superiorly. A vessel-sealing electrosurgical device is used to dissect along the inferior margin of the pancreas. Dissection proceeds proximally or distally, depending on the location of the pathology. The proximal pancreatic duct is oversewn or stapled closed. The distal pancreas is mobilized from the splenic vessels. If the vessels cannot be mobilized from the pancreas, they are divided and a laparoscopic splenectomy is performed. The specimen is removed through the umbilical trocar by using a retrieval bag. Drains are placed prior to closure. CASE EXPERIENCE: We report 4 cases: 2 with pseudopapillary tumors and 2 with traumatic injuries. One patient was male; the mean age was 13.0 +/- 1.4 years. Two spleens were removed due to pathology. Mean operative time was 256 +/- 46.6 minutes, with no open conversion or mortality. Patients initiated oral intake 2.0 +/- 1.4 days postoperatively. Hospital stay was 6.2 +/- 3.9 days. One patient required 15 days of total parenteral nutrition to resolve a pancreatic fistula. Laparoscopic pancreatic resection in children is feasible, safe, and leads to rapid recovery without significant morbidity. The spleen can often be spared, minimizing the risk of overwhelming postsplenectomy sepsis. This initial experience should encourage wider use of laparoscopy for pancreatic resection in children.

Hereditary spherocytosis. Recent experience and current concepts of pathophysiology.

Hereditary spherocytosis is a clinically heterogeneous, genetically determined red blood cell membrane disorder resulting in hemolytic anemia. A deficiency of spectrin, the largest and most abundant structural protein of the erythrocyte membrane skeleton, results in the formation of spherocytes which lack the strength, durability, and flexibility to withstand the stresses of the circulation. Clinical manifestations of the disease are primarily dependent on the severity of hemolysis, which additionally results in an increased incidence of pigment gallstones. The likelihood of cholelithiasis is directly related to patient age and is uncommon before 10 years of age. Splenectomy is indicated in virtually every patient. When the disease is diagnosed in early childhood, the risk of overwhelming postsplenectomy sepsis makes it advisable to delay splenectomy until after 6 years of age if possible. At the time of splenectomy, it is important to identify and remove any accessory spleens. If gallstones are present, cholecystectomy should be performed. Although spherocytosis persists following splenectomy, hemolysis is alleviated and clinical cure of the anemia is achieved for most patients. Patients with recessively inherited spherocytosis are exceptions. Although they are significantly benefited by splenectomy, their anemia is not completely corrected. Splenectomy reduces hemolysis in all patients and thereby decreases the risk for development of pigment gallstones. Excision of an enlarged spleen removes the danger of traumatic rupture.