Subtotal Splenectomy Research Articles

Late Results of a Modified New Surgical Procedure for the Treatment of Portal Hypertension

The aim of this study is to report on the late results of the modified surgical procedure "subtotal splenectomy with omentopexy and partial splenic attachment to the parietal peritoneum" for the treatment of portal hypertension in children. Over a period of twenty years (1984 - 2004), two modifications have been performed of the procedure of "partial splenectomy and partial splenic attachment for the treatment of portal hypertension", which were reported in the Zeitschrift für Kinderchirurgie [ ], in 1990. The modifications were due to the recurrence of splenomegaly in five cases, with signs of hypersplenism in three of them after ten years. The follow-up ranges between one and fourteen years. All the patients are in good health, with good growth and development, except for one case with liver failure due to liver cirrhosis. No mortality occurred in this group of patients. Severe bleeding occurred in only one case after four years. Treatment consisted of sclerotherapy and ligation of the splenic artery. Splenomegaly was found in five cases, with hypersplenism in three of them. Splenic artery embolisation in two cases and ligation in one case produced good results. Howell-Jolly bodies were negative in all cases and radionuclide scan showed satisfactory to good results in most cases. Good results were also obtained in the studies of immunoglobulins and complements in most cases, with two exceptions of reduced IGM in one case and C4 in the other. Subtotal splenectomy with omentopexy and partial splenic attachment is a good alternative to other operative procedures for the treatment of portal hypertension. With this method, the precipitation and increase in collateral circulation leads to rapid improvement.

Synchronous isolated splenic metastasis from colon carcinoma and concomitant splenic abscess: A case report and review of the literature

This study aimed to describe a case in which an isolated splenic metastasis was synchronous with the colonic primary and a concomitant splenic abscess was associated. A wide review of the literature was also performed. A 54-year-old woman with abdominal pain and fever was admitted to our department. Abdominal CT revealed two low-density areas in the spleen and wall-thickening of the left colonic flexure, which was indistinguishable from the spleen parenchyma. The patient underwent emergency celiotomy, with the presumptive diagnosis of obstructing colon carcinoma of the splenic flexure, and concomitant splenic abscess. Subtotal colectomy and splenectomy were performed. Pathological findings were consistent with mucinous colonic carcinoma, synchronous isolated splenic metastasis and concomitant splenic abscess. This paper is also a review of the existing literature on the association between colorectal cancer and splenic metastasis. Only 41 cases of isolated splenic metastasis from colon carcinoma have been reported in the literature. This report is the third described case of synchronous isolated splenic metastasis from colon carcinoma. Only one case with concomitant splenic abscess has been previously reported. When obstructing left-sided colorectal cancer is suspected, careful CT examination can allow early diagnosis of splenic involvement by the tumor. The literature review suggests that there might be a significant improvement in survival following splenectomy for a metachronous isolated splenic metastasis from colon carcinoma. Prognosis for synchronous splenic metastasis seems to be related to the advanced stage of the disease. Nevertheless, no definitive conclusions can be drawn because of the small number of cases.

Preservative spleen surgery and hyperbaric oxygen therapy

To assess functional and morphological aspects of spleen auto-implants and of the splenic inferior pole of rats, post-operatively treated or not with hyperbaric oxygen, as well as the survival of these animals, were studied. Seventy-eight male Wistar rats, weighing between 192 and 283 g ( 238,3 +/- 9,6g), were randomly distributed into three groups: Group 1--(n=20), spleen manipulation; group 2--(n=36), spleen auto-implantation; group 3--(n= 22), subtotal splenectomy preserving the inferior pole. Each group was subdivided as follows: subgroup a, not submitted to hyperbaric oxygen therapy: 1a(n=10), 2a(n=21), 3a(n= 13); subgroup b, submitted to the therapy: 1b(n=10), 2b(n=15), 3b(n=9). Blood was collected pre-operatively and 11 days after surgery, for the estimation of lipids and immunoglobulins and the counting of platelets and Howell-Jolly corpuscles. The spleen and remains were taken for histological study. The number of surviving animals was significantly higher in groups 1(p<0,01) and 3(p<0,05) relative to those of subgroup 2a. Total cholesterol and the LDL fraction increased significantly in subgroup 2a (p<0,01) and 3a (p<0,05), and remained unaltered in subgroups 2b e 3b. IgM decreased more significantly in subgroup 2 than in subgroup 3 (p<0,001 vs p<0,01). The increase of platelet numbers and the appearance of Howell Jolly corpuscles was smaller in subgroup 2b compared to subgroup 2a , and in group 3 compared to group aqui-> 2. The macro and microscopic appearance in subgroup 2b were more viable than in subgroup 2a, and that of group 3 more viable than in group 2. The survival of the animals carrying their whole spleen or its inferior pole was more frequent than that of the auto-implanted animals. Functionality and viability of the whole spleen or of its inferior pole, were better than in the auto-implanted animals. Hyperbaric oxygen-therapy contributed to increased survival frequency of auto-implanted animals, and to improve the functionality and viability of the auto-implants and the function of the inferior splenic pole, and did not interfere in animals carrying their whole spleen.

Band 3 Courcouronne: Homozygous Mutation Ser667Phe Causes Severe Hereditary Spherocytosis and Incomplete Distal Renal Tubular Acidosis.

We describe the second case of a homozygous mutation in band 3 (anion exchanger 1 (AE1), SLC4A1) causing both hereditary spherocytosis (HS) and distal renal tubular acidosis (dRTA). This new variant differed from the previous homozygous variant (Band 3 Coimbra, Ribeiro et al, Blood 2000: 96, 1602) in that a significant amount of band 3 was present in the red cell membrane and the dRTA was incomplete. In the proband, an Algerian male baby, a severe hemolytic anemia rapidly developed following birth. Low hemoglobin (3.5 g Hb/dL) at D12 demanded a first transfusion. Hepato-splenomegaly, marked palor and jaundice were noted. Eight transfusions were administered in the following months. Subtotal splenectomy, performed at the age of 9 months, cancelled the transfusional needs. Veinous blood examined after splenectomy showed band 3 to be reduced to ~35% of normal, as shown by immunoblotting. The other known proteins of the band 3/Rh macrocomplex were also found to be reduced. The parents were first cousins. Both showed mild spherocytosis associated with a mild band 3 deficiency. DNA sequence analysis revealed a novel homozygous mutation: TCC to TTC at codon 667 in exon 16, leading to an amino acid substitution: Ser667Phe, located in proposed transmembrane helix 8. Both parents were heterozygous for the same mutation. Anion transport (sulphate uptake) in the patient's red cells was ~40% normal, showing that transport specific activity of the mutant band 3 was not affected. The mutant red cell band 3 and kidney band 3 were expressed in Xenopus oocytes, with and without co-expression of glycophorin A (GPA). There was very little chloride transport detected in oocytes expressing either mutant red cell or kidney protein alone, but transport was partially rescued by co-expression of GPA. After birth the child showed a temporary acidosis which spontaneously receded. No nephrocalcinosis has been noted to date. At 2 years of age, an ammonium chloride challenge suggested that the child has incomplete dRTA; over the seven hours of the test the blood bicarbonates decreased down to 15.6 mmoles/L, but urinary pH remained above 5.90. Stable expression of mutant kidney band 3 in non-polarised Madin-Darby canine kidney (MDCK) cells showed that the mutant protein was retained in the endoplasmic reticulum. We are currently investigating the effects of this mutant in polarized MDCK cells. Overall our results suggest that the Ser667Phe does not affect the anion transport function of band 3 but causes a trafficking defect in both red blood cells and kidney cells. The trafficking defect may be less severe in red blood cells where it is probably attenuated by the chaperone-like effect of GPA, which is not expressed in kidney cells. The fact that the hematological manifestations are far more conspicuous than their nephrologic counterpart will be discussed.

Subtotal splenectomy preserving the lower pole in rats: technical, morphological and functional aspects

To assess the possibility of preserving the lower pole of the spleen, supplied by the inferior lobar vessels and segmental vessels, or by vessels of the gastrosplenic ligament, in subtotal splenectomy; to study the viability and function of the lower pole of the spleen. Thirty-six male Wistar rats were used in this study. Said animals weighed 273-390 g ( 355.2 +/- 30.5 g ), and were randomly distributed into three groups. Group 1 comprised ten animals which were submitted to exploratory laparotomy with spleen manipulation (sham operation). Group 2 comprised 16 animals which were submitted to total splenectomy. Group 3 comprised ten animals which were submitted to subtotal splenectomy, preserving the lower pole of the spleen. Blood was collected from all animals before and 90 days after surgery to measure the levels of cholesterol and triglycerides. The animals were sacrificed 90 days after surgery. Spleens and remaining spleens were removed for macroscopic and microscopic examination. Surgery was performed with no complications in all groups. Six animals died in group 2. Spleens of groups 1 and 2, and lower poles of group 3 were macroscopically viable. Apparent white pulp hyperplasia was observed in group 1. In group 3, slight inflammation and capsular fibrosis were observed at the incision site, as well as diffuse hemosiderosis in the red pulp. Average mass of remaining spleen was 35.84% +/- 4.31%. No significant difference was observed between preoperative and late postoperative lipid levels in groups 1 and 3 (p > 0.05). Late postoperative lipid levels significantly increased in group 2. Preservation of the lower pole of the spleen (supplied by gastrosplenic vessels or inferior lobar vessels and segmental vessels) was possible with subtotal splenectomy. The lower pole was macroscopically and microscopically viable in all cases. Subtotal splenectomy preserving the lower pole prevented changes in lipid levels, which were observed in rats submitted to total splenectomy. Plasma lipid levels in rats submitted to subtotal splenectomy were similar to those observed in sham operated rats.

Esplenectomia subtotal por via laparoscópica em cães

OBJETIVO: O objetivo deste trabalho foi determinar a exeqüibilidade, reprodutibilidade e segurança da esplenectomia subtotal por via laparoscópica e suas repercussões morfológicas, hematológicas, imunitárias e de depuração sangüínea, comparando esses dados com os obtidos na esplenectomia laparotómica. MÉTODO: Este estudo experimental foi conduzido de acordo com os princípios éticos de pesquisa experimental, propostos pelo Comitê de Ética em Experimentação Animal da UFMG. Quatorze cães adultos mestiços de ambos os sexos foram distribuídos em dois grupos (n = 7): Grupo 1 - Esplenectomia subtotal laparoscópica, preservando o polo superior suprido exclusivamente pelos vasos esplenogástricos; a secção esplênica e hemostasia foram realizadas utilizando um grampeador linear cortante laparoscópico com carga de 45 mm de extensão. Grupo 2 - Esplenectomia total, realizada por meio de laparotomia mediana. Depois de três meses, foram analisadas as alterações nos exames hematológico, imunitário e cintilográfico em todos os animais. Secções dos remanescentes esplênicos, fígado e linfonodos foram avaliadas histologicamente. RESULTADOS: Todos os procedimentos transcorreram sem complicações, não havendo morte operatória e com perda sangüínea mínima. Todos os animais sobreviveram à operação durante os três meses de acompanhamento. Após esse período, houve redução da contagem de plaquetas (p &lt; 0,05) no Grupo 1. O restante dos exames hematológicos permaneceu normal. Os remanescentes esplênicos apresentaram arquitetura semelhante ao baço normal. Não houve alterações histológicas nos linfonodos e fragmentos hepáticos. CONCLUSÕES: É possível e segura a realização da esplenectomia subtotal por via laparoscópica no cão.

Efeitos de operações sobre o baço no lipidograma de ratas

Although the occurrence of spleen alterations in the various forms of dyslipidemia, such as Gaucher's disease, has been well established, the relation between the spleen and lipid metabolism has not been properly studied. In order to contribute to the filling of this gap, in the present investigation we assessed experimentally the lipidogram of rats in the presence of the spleen, in asplenia, and after conservative spleen surgeries. Forty female Wistar rats of similar weight and age were divided into 4 groups submitted to the following procedures: Group 1--control, with an intact spleen; Group 2--total splenectomy; Group 3--subtotal splenectomy, and Group 4--total splenectomy complemented with autogenous spleen tissue implants. Four months after the interventions, serum triglycerides, total cholesterol and fractions (VLDL, LDL, HDL) were determined. The results for the four groups were compared by analysis of variance followed by the Tukey-Kramer test, with the level of significance set at p < 0.05. There were no differences between groups 1, 3 and 4. In the animals submitted to total splenectomy, total cholesterol (p = 0.0093) and LDL fraction concentrations (p < 0.0001) were higher, whereas HDL fraction concentrations were lower (p = 0.05) than those detected in the other groups. There was no difference in triglycerides (p = 0.1882) or VLDL (p = 0.2030) between groups. The spleen probably plays an important role in the lipid metabolism of female rats and total splenectomy may be related to changes in cholesterol control. It is possible that preservation of spleen tissue prevents such metabolic disorders.

Late follow-up of patients submitted to subtotal splenectomy

Background Over the past 21 years, we have performed more than 200 subtotal splenectomies, in which the upper splenic pole vascularized only by the gastrosplenic pole vascularized only by the gastrosplenic vessels is preserved, to treat different pathologic conditions. A meticulous follow-up of the postoperative results of this procedure is of fundamental importance. Methods All patients undergoing subtotal splenectomy were invited to be reviewed. A total of 86 patients who had undergone surgery 1–20 years ago were gathered; the surgical procedure was performed for one of the following conditions: portal hypertension due to schistosomiasis ( n = 43), trauma ( n = 31), Gaucher's disease ( n = 4), myeloid hepatosplenomegaly due to myelofibrosis ( n = 3), splenomegalic retarded growth and sexual development ( n = 2), severe pain due to splenic ischemia ( n = 2) and pancreatic cystadenoma ( n = 1). Patients underwent a hematological examination, an immunological assessment, abdominal ultrasonography, computed tomography, scintigraphy and endoscopy. Results Increased white blood cell count and platelets were the only hematological abnormalities. No immunological deficit was found. Esophageal varices were still present in patients who underwent surgery because of portal hypertension although without rebleeding. The ultrasound, tomography and scintigraphy examinations confirmed the presence of functional splenic remnants without significant size alteration. Conclusions Subtotal splenectomy seems to be a safe procedure that can be useful in treating conditions involving the spleen. The functions of the splenic remnants are preserved during long periods of time.

Subtotal splenectomy in Gaucher's disease: towards a definition of critical splenic mass.

Partial splenectomy is currently the favoured surgical approach for Gaucher's disease. Preservation of splenic tissue is indicated to prevent susceptibility to overwhelming postsplenectomy sepsis, to delay the massive deposition of glucocerebroside in the liver and bones, and to relieve symptoms of hypersplenism. Controversial issues and technical problems related to partial splenectomy for Gaucher's disease are discussed and a definition of critical splenic mass considered.

Subtotal splenectomy with a microwave coagulator.

A microwave coagulator (Heiwa Electronic, Osaka, Japan) with a frequency of 2450 MHz has been used to perform hepatectomy 1,2 and may also have some application in splenic surgery 2,3 . Use of the coagulator in 17 patients undergoing splenic surgery is reported

LATE POSTOPERATIVE FOLLOW-UP OF PATIENTS UNDERGOING SUBTOTAL SPLENECTOMY

Over the past 21 years, we have performed more than 200 subtotal splenectomies, in which the upper splenic pole vascularized only by the gastrosplenic pole vascularized only by the gastrosplenic vessels is preserved, to treat different pathologic conditions. A meticulous follow-up of the postoperative results of this procedure is of fundamental importance. All patients undergoing subtotal splenectomy were invited to be reviewed. A total of 86 patients who had undergone surgery 1 to 20 years ago were gathered; the surgical procedure was performed for one of the following conditions: portal hypertension due to schistosomiasis (n = 43), trauma (n = 31), Gaucher's disease (n = 4), myeloid hepatosplenomegaly due to myelofibrosis (n = 3), splenomegalic retarded growth and sexual development (n = 2), severe pain due to splenic ischemia (n = 2) and pancreatic cystadenoma (n = 1). Patients underwent a hematologic exam, an immunologic assessment, abdominal ultrasonography, computed tomography, scintigraphy and endoscopy. Increased white blood cell count and platelets were the only hematological abnormalities. No immunologic deficit was found. Esophageal varices were still present in patients who underwent surgery because of portal hypertension although without rebleeding. The ultrasound, tomography and scintigraphy exams confirmed the presence of functional splenic remnants without significant size alteration. Subtotal splenectomy seems to be a safe procedure that can be useful in treating conditions involving the spleen. The functions of the splenic remnants are preserved during long periods of time.

Hypersplenism in Schistosomatic Portal Hypertension

For many years, the hematologic changes occurring in hepatosplenic Manson's schistosomiasis have been defined as hypersplenism. Initially, the belief was that removal of the spleen would normalize the hematologic values. However, hematimetric normalization was observed in surgeries for the treatment of portal hypertension in which the spleen was preserved. In view of these findings, it is necessary to verify the clinical and laboratory profile of these patients in order to define the real presence of hypersplenism. This study was conducted on 51 patients with schistosomatic portal hypertension divided into five groups: group 1, non-operated patients under clinical control; group 2, patients submitted to distal splenorenal shunt; group 3, patients with subtotal splenectomy and central splenorenal shunt; group 4, patients with total splenectomy and central splenorenal shunt; and group 5, patients with total splenectomy and portal-variceal disconnection. Clinical signs of hypersplenism were assessed in all patients. Hematologic values of the pre- and postoperative period were compared. Immunoglobulin counts of the patients were verified in the late postoperative period. In all operated groups, hematimetric values, leukocyte counts, platelet number and prothrombin time were higher during the postoperative period. With respect to the immunoglobulins, the postoperative values of IgM, IgG and IgA were normal. Patients with schistosomatic portal hypertension and peripheral cytopenia cannot be classified as having hypersplenism but rather as having pancytopenia due to splenomegaly caused by difficulty on portal blood drainage.

Oclusión intestinal secundaria a pancreatitis que mimetiza una neoplasia estenosante del ángulo esplénico del colon

Colonic involvement in patients with severe acute pancreatitis or chronic pancreatitis is common and complications such as paralytic ileus, segmental necrosis and pancreatic-colonic fistulae have been described. However, mechanical occlusion of the colon due to pancreatitis is infrequent. We present the case of a 45-year-old man with occlusion of the colon secondary to asymptomatic pancreatitis mimicking a locally advanced stenosing neoplasm of the splenic angle. Ten years prior to the present episode the patient had presented acute alcoholic pancreatitis complicated by a pseudocyst requiring surgery. The current reason for admission was abdominal colic pain and constipation with onset 5 days previously. Contrast enema was administered showing colonic occlusion caused by stenosis at the splenic flexure, suggesting the presence of a neoplasm. Urgent laparotomy showed the presence of a tumor originating in the colon that infiltrated the splenic hilum. Subtotal colectomy and en-bloc splenectomy were performed. Histopathological analysis showed pericolonic inflammation and fibrosis secondary to pancreatitis; the colonic mucosa showed no tumoral infiltration. To date, fewer than 30 cases of this infrequent complication have been published.

Primary Malignant Melanoma of the Stomach

We report a 54-year-old patient with a complaint of weakness, abdominal pain and weight loss. During the clinical examination a palpable tumor resistance in the abdomen was found as well as iron deficiency anemia. Gastroscopy showed an exulcerated, dark brown, fungiform tumor about 4 cm in diameter at the great curve of stomach. Endoscopic biopsy revealed the diagnosis of malignant melanoma by demonstrating the presence of melanin containing tumor cells in gastric mucosa. The patient underwent subtotal gastrectomy, appendectomy and splenectomy. The diagnosis of gastric melanoma with regional lymph node metastases, as well as metastases in appendix adjacent tissue was confirmed by histology and immunohistochemistry. In three years follow up period patient developed cerebral and retroauricular subcutaneous metastases that were treated by surgery, adjuvant chemotherapy and radiotherapy. Finally, an explorative laparatomy was revealed advanced intraabdominal tumor dissemination with dark pigmented ascites. Concerning that all available diagnostic procedures failed to prove other site of melanoma, presented case was considered as primary gastric melanoma as a possible rare site of tumor.

CHRONIC PANCREATITIS WITH PANCREATIC RHEUMATOID NODULES

Purpose: A 61 year old female nurse anesthetist with a long history of Rheumatoid Arthritis presented with unrelenting upper abdominal pain, intermittent diarrhea and 20 lb. weight loss of three months duration. Computerized tomography of the abdomen showed a very prominent tail of the pancreas. At ERCP, there was a tight stricture at the mid pancreatic duct. Endoscopic ultrasound-guided fine needle aspiration of the tail showed atypical ductal epithelial cells in a background of abundant necrosis and chronic inflammation. She underwent subtotal pancreatectomy, splenectomy and cholecystectomy. The final pathologic diagnosis revealed granulomatous inflammation with central fibrinoid necrosis and necrobiotic debris consistent with rheumatoid nodules. Rheumatoid Arthritis is a rare cause of chronic pancreatitis. This case illustrates the difficulties and challenges involved in the management. The presence of rheumatoid nodules in the pancreas has not been previously described.

Cirurgias conservadoras do baço para tratamento da doença de Gaucher

Complications of splenomegaly in Gaucher's disease, such as hypersplenism and mechanical compressions, have been treated by partial splenectomy. However, the splenic remnant, vascularized by the hilar vessels, may enlarge leading to recurrent splenomegaly and all its adverse effects. More than eighteen years of experience treating portal hypertension, splenic trauma, myeloid splenomegaly, splenomegalic somatic and sexual hypodevelopment, chronic lymphocytic lymphoma and cystadenoma of pancreatic tail by subtotal splenectomy, maintaining the upper pole supplied only by the splenogastric vessels showed that the splenic remnant does not increase its size. Based on evidence that the hilar vessels may contribute to the increase of the splenic remnant, we performed in five cases with Gaucher's disease subtotal splenectomy, maintaining the upper pole supplied only by the splenogastric vessels. The splenic remnant did not modify in size during a postoperative follow-up of more than twelve years, and the hematological parameters remained normal. Another patient whose splenogastric vessels were insufficient to maintain the upper splenic pole, was submitted to total splenectomy and autologous splenic tissue transplantation on the greater omentum. The autotransplant survived and presented with function. All six patients had uneventful postoperative follow-up in relation to the splenic conservative procedure. In conclusion, in presence of giant splenomegaly with severe hematologic and clinical symptoms the spleen must be resected in a conservative fashion such as subtotal splenectomy or total splenectomy followed by autotransplants of splenic tissue.

Functions of the splenic remnant after subtotal splenectomy for treatment of severe splenic injuries

Background To evaluate the clinical and laboratory characteristics of patients submitted to subtotal splenectomy during the immediate and late postoperative period. Methods The study was conducted on 34 patients, 25 of whom were submitted to subtotal splenectomy (group I), and 9 to total splenectomy without preservation of splenic tissue (group II), and on 22 patients with intact spleens (group III, control). The immediate and late postoperative complications were investigated. Hematological examinations were performed during the late postoperative period (red cell count, hemoglobin, platelets, total and segmented leukocytes, lymphocytes, and Howell-Jolly bodies). Immunoglobulins (IgA, IgM, and IgG) and total T lymphocytes (TTL), active T lymphocytes (ATL), and B lymphocytes were also determined. Splenic scintigraphy with 99mTc colloidal sulfur was performed. Results Groups I and III did not presented abnormal blood bodies and their hematological and immunological pattern were normal. None of the groups showed leukocytosis or thrombocytosis. Howell-Jolly bodies were observed only in group II, which also showed reduced IgM levels. Scintigraphy showed filtering splenic tissue in group I. Conclusions We conclude that subtotal splenectomy is a good surgical alternative for serious distal spleen lesion or when the main splenic pedicle is injured.

Avaliação da função fagocitária em remanescentes de esplenectomia subtotal e auto-implante esplênico autógeno

Para diminuir os efeitos adversos da esplenectomia total, abordagens conservadoras devem ser tentadas, quando for possível. Esplenectomia subtotal e auto-implantes esplênicos são boas alternativas nessa situação. O objetivo do presente estudo foi comparar as funções fagocitárias do pólo superior remanescente de esplenectomia subtotal e de tecido esplênico implantado no omento maior. Esta investigação foi conduzida em 35 ratos Holtzman adultos de ambos os sexos. Todos os animais foram submetidos a esplenectomia subtotal preservando o pólo superior suprido pelos vasos esplenogástricos e a auto-implante do segmento esplênico removido, no omento maior. A função fagocitária foi verificada por dois métodos diferentes: cintilografia com enxofre coloidal marcado com 99mTc e contagem, ao microscópio, de macrófagos que continham carbono coloidal. Durante os três primeiros meses, a fagocitose foi maior no pólo superior remanescente. Após esse período, não houve diferença entre o pólo superior e o auto-implante. Concluindo, o remanescente de esplenectomia subtotal e o auto-implante esplênico mantêm a função de filtração do baço mediante remoção de partículas coloidais do sangue.

Aspectos imunológicos da esquistossomose mansoni hepatoesplênica após cirurgia terapêutica

A forma hepatoesplenica da esquistossomose mansoni pode apresentar complicacoes, como o sangramento de varizes esofagicas e gastricas, que requerem tratamento cirurgico. Apesar de a esplenectomia ser frequentemente necessaria, esses pacientes raramente desenvolvem os fenomenos septicos, que sao mais frequentemente encontrados em pessoas asplenicas do que na populacao em geral. Essa particularidade dos esquistossomoticos pode ser relacionada a alguma caracteristica particular do sistema imune nessa afeccao. Com o objetivo de investigar os aspectos imunologicos de pacientes com esquistossomose, foram estudados os linfocitos T e B alem das imunoglobulinas M, A, e G (IgM, IgA, e IgG) em pacientes esquistossomoticos submetidos ou nao a procedimentos cirurgicos para tratamento de complicacoes da hipertensao porta. Esses pacientes foram comparados com voluntarios normais sem afeccao sistemica aparente. Os pacientes operados por derivacao esplenorrenal distal com a preservacao do baco apresentaram aumento dos linfocitos T em comparacao com o grupo-controle, de pessoas normais. Os niveis de IgG e IgM foram mais elevados nos pacientes submetidos a esplenectomia total do que no grupo-controle. Esses resultados sugerem que a esquistossomose mansoni cronica pode influenciar o sistema imune, garantindo que, mesmo na ausencia do baco, os pacientes estejam protegidos de fenomenos infecciosos graves.

Cirurgias conservadoras do baço para tratamento da esplenomegalia por mielofibrose

A mielofibrose idiopatica e uma doenca mieloproliferativa cronica, que pode evoluir com hepatoesplenomegalia, tambem denominada metaplasia, e acometer varios orgaos. Ocasionalmente, o baco alcanca proporcoes gigantescas e precisa ser retirado. Entretanto, esse procedimento e seguido de elevada morbidade e mortalidade. As esplenectomias parciais, que preservam o pediculo esplenico, foram propostas para reduzir complicacoes pos-operatorias. Apos melhora transitoria do quadro clinico, surge a recorrencia da esplenomegalia e da sintomatologia. A presente comunicacao relata duas alternativas para tratamento de esplenomegalia: a esplenectomia subtotal, com preservacao do polo esplenico superior suprido apenas pelos vasos esplenogastricos, e a esplenectomia total, com auto-implantes de tecido esplenico. Realizamos a esplenectomia subtotal em cinco pacientes. O acompanhamento por ate dez anos e a melhora clinica dos doentes sugerem que essa operacao deva ser considerada para o tratamento de bacos gigantes devido a esplenomegalia decorrente de mielofibrose. Um outro paciente foi submetido a esplenectomia total e auto-implante esplenico no omento maior. No seguimento de tres anos deste ultimo paciente, nao foram registradas complicacoes relacionadas ao remanescente esplenico. Entretanto, o paciente necessitou de controle hematologico intensivo por causa da gravidade de sua doenca de base. Concluindo, se for indicada operacao para complementar a terapeutica hematologica da esplenomegalia, deve-se realizar um procedimento conservador do baco. A esplenectomia subtotal ou a esplenectomia total com auto-implantes de tecido esplenico sao duas boas escolhas em tais situacoes.