3.3.04 Spleen Teaching Presentation - dartmouth- .Tail of Pancreas • Splenocolic...

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Transcript of 3.3.04 Spleen Teaching Presentation - dartmouth- .Tail of Pancreas • Splenocolic...

SpleenSpleen

March 3, 2004Resident Teaching Conference

SplenectomySplenectomy

15491549 First reported by Zacarello in Italy

18161816 First in North America, OBrien

Victim stabbed in LUQ while committing a rape

18261826 Quittenbaum, 1stelective splenectomy

Portal HTN

SplenectomySplenectomy

18661866 Bryant, 1st splenectomyfor leukemia

19081908 Johnson reports mortality of 87.7% in 49 patients with leukemia

19161916 Kaznelson reports good results for thrombocytopenic purpura

SplenectomySplenectomy

19521952 OPSS reported

19621962 Christo in Brazil: Splenic salvage prevents OPSS

19911991 Laparoscopic splenectomy reported by four different groups

Tail of Pancreas

-Direct contact with spleen in 30%

-Otherwise within 1 cm

AnatomyAnatomy

SuspensorySuspensory LigamentsLigaments

Gastrosplenic LigamentShort Gastric VesselsGastroepiploic Vessels

Splenorenal LigamentSplenic VesselsTail of Pancreas

Splenocolic Ligament

Phrenicocolic LigamentPhrenicosplenicligament

-Superior Polar Artery may arise directly from Celiac trunk (Duplicate artery)

-Splenic artery may arise directly from Aorta, SMA, MCA

Blood SupplyBlood Supply

70% 70% -- DistributedDistributed

30% 30% -- MagistralMagistral

-Branches originate 3-13cm from hilum

-Transverse Anastomoses why embolization / clipping may fail

- Pancreatica Magna embolic debris from angio may cause pancreatitis

-Branches originate within 3.5 cm of hilum

-L Gastroepiploic artery Most varied of splenic branches (72% arise several cm from splenic artery proximal to terminal branching)

SplenicSplenic blood flow accounts for what percentage of blood flow accounts for what percentage of total portal total portal blood flowblood flow in normal subjects?in normal subjects?

A. 10%B. 20%C. 30%D. 40%E. 50%F. Beats the Fick out of me

Vascular anatomy of the spleen is:Vascular anatomy of the spleen is:

A. Segmental end arteries with somewhat discrete segments

B. An open system of sinusoids without segments

PseudoPseudo--Segmental Blood SupplySegmental Blood Supply

End Arterioles White PulpT-CellsB-Cells

No true capillaries Red PulpVenous SinusoidsSplenic Cords of Billroth

Macrophages Dendritic Cells

The spleen is an important storage site for:The spleen is an important storage site for:

A. RBCsB. WBCsC. PlateletsD. All of the Above

White PulpWhite Pulp--OpsoninsOpsonins IgMIgM, , IgGIgG, , tuftsintuftsin, , properdinproperdin

--TT--CellsCells

Red Pulp Red Pulp (75% of parenchyma)(75% of parenchyma)--PhagocytosisPhagocytosis

--Pitting damaged Pitting damaged RBCsRBCs, , WBCsWBCs

--OpsonizedOpsonized Pathogen ClearancePathogen Clearance

Immunologic AnatomyImmunologic Anatomy

The spleen is usually enlarged in all EXCEPT:The spleen is usually enlarged in all EXCEPT:

A. ITPB. Hemolytic AnemiasC. Gauchers DiseaseD. Chronic Lymphocytic Leukemia (CLL)E. Spleen is enlarged in all the above

HypersplenismHypersplenism

Hematologic effects of splenomegaly

Enhanced capacity of the enlarged spleen:Pooling,Sequestering, andDestroying blood cells

Results in reduction of blood cell countsBone marrow function usually normalSometimes by sequestration aloneCytopenia corrected following splenectomy

HypersplenismHypersplenism

Platelet SequestrationPlatelet Sequestration

Healthy Hypersplenism

Palpable spleen is at least twice its normal size

HypersplenismHypersplenism Many EtiologiesMany Etiologies

HypersplenismHypersplenism

Why Splenectomy in Hypersplenism?Treat Splenomegaly

Compressive symptoms Risk for splenic injury if active

Improve blood counts RBCs, PlateletsTemporize underlying condition

Rarely curative, but an adjunctive therapy Failed medical management Reduce number of required transfusions Pain or abcess secondary to splenic infarction

(sickle cell, thalassemia)

Staging Procedure

SplenectomySplenectomy is the treatment of choice for is the treatment of choice for hydatidhydatid cysts of the spleen:cysts of the spleen:

A. TrueB. FalseC. BothD. None of the above except maybe C

- Typically unilocular cyst in the spleen < 5% in USA

- Serology confirms Dx

- Open splenectomy

SplenicSplenic NeoplasmsNeoplasms and Cystsand Cysts

NHLNHL - Most common 1 and 2 splenic tumor

True Cysts (20%)Epidermoid (15-20%)

Benign, Young Compression Sxs Hemorrhage, rupture,

infectionEchinococcal Cysts (

All are associated with congenital All are associated with congenital spherocytosisspherocytosis EXCEPT:EXCEPT:

A. Leg UlcersB. Pigment gallstonesC. JaundiceD. Increased osmotic fragility of RBCsE. SplenomegalyF. Cholesterol gallstones

Hereditary Hereditary SperocytosisSperocytosis

Autosomal DominantMost common hemolytic anemia in North Europeans

Defect in Spectrin

Shortened RBC LifeUnable to pass through splenic sinusoidsSplenomegalyPigmented Gallstones

Anemic Crisis following viral Sx

GauchersGauchers DiseaseDisease

SplenicSplenic AbcessAbcess

UncommonMale > Female 2:1

Bimodal Distribution for Primary Abcess

< 40 years Imunosuppressed IV Drug Abuse Multiloculated

> 70 years DM, Septic Focus Unilocular

Secondary AbcessInfected hematoma (trauma)Infected splenic infarctContiguous infection (pancreatitis, perinephric)

TreatmentBroad-spectrum Abx

GPC, GNB, Anaerobes May be complicated by

recurrent abcessPercutaneous Drainage

Thin fluidDrainage in OR / Splenectomy

Platelet count following Platelet count following splenectomysplenectomy for ITP for ITP will rise significantly within:will rise significantly within:

A. 1-2 DaysB. 1-2 WeeksC. 1 MonthD. 1 Year

s/p Splenectomy for trauma platelets rise within 7-10 days

Immune Thrombocytopenic Immune Thrombocytopenic PurpuraPurpura (ITP)(ITP)

Highest incidence in women aged 15-50 Usually Idiopathic May be seen in conjunction with:

SLE, HIV, CLL, Hodgkins Dz, or autoimmune hemolytic anemia

Normal platelet lifespan from 7-10 days to 5 hrsTotal platelet turnover 5x normal

May remit and relapse over timeAutoantibodies directed against platelet surface Ag

Immune Thrombocytopenic Immune Thrombocytopenic PurpuraPurpura (ITP)(ITP)

Medical treatment successful in only about 15% of patients

Splenectomy successful in:66% of patients initially with full responseAdditional 15% with partial response15% of these will relapse with 1 year, can relapse years later

Indications for Splenectomy in ITP:Persistent platelet count < 80,000/mm3 despite therapyRecurrence of thrombocytopenia after tapering or discontinuation of steroidsEmergent splenectomy only if evidence of ICHChildren: Indicated if no remission after 1 year

All the following can help reduce All the following can help reduce intraoperativeintraoperativebleeding during bleeding during splenectomysplenectomy for ITP, EXCEPT:for ITP, EXCEPT:

A. Preop Steroid AdministrationB. Preop use of IV IgG (gamma-globulin)C. Intraop administration of Platelets before

splenic hilum is controlledD. It doesnt matter because

If you aint wreckin, you aint racin - Preop steroids only depending on the patient either for stress dose if on steroids or to help increase platelet levels

- Preop IV IgG to help boost Platelet levels in thrombocytopenic patients

Mechanism and Treatment of ITPMechanism and Treatment of ITP

IV IV IgGIgG

SteroidsSteroids

AntimitoticsAntimitotics, , ColchicineColchicine

SplenectomySplenectomy for ITPfor ITP

HyposplenismHyposplenism -- Peripheral Blood SmearPeripheral Blood Smear

Incidence of overwhelming postIncidence of overwhelming post--splenectomysplenectomysepsis is LEAST following sepsis is LEAST following splenectomysplenectomy for:for:

A. ITPB. Congenital Hemolytic AnemiaC. Acquired Hemolytic AnemiaD. Trauma

Trauma - 20% of patients with capsule disruption develop splenosis

SplenosisSplenosis

Accessory spleens are found in about:Accessory spleens are found in about:

A. 2% of casesB. 20% of casesC. 80% of casesD. 100% of cases when really searched forE. All cases of Splenosis

-Hypersplenism / ITP Searching for and resectingany accessory spleens part of the procedure

Accessory SpleensAccessory Spleens

- Usually on Left side

- Never below Left _Ovary or Testicle

Immunizations should be given:Immunizations should be given:

A. Prior to splenectomyB. Intraop, before clamping splenic arteryC. Prior to dischargeD. Within 2-4 weeks following splenectomy

- Best to give before splenectomy better immune response

- Immune suppressed on steroids for ITP - BEFORE

- Prior to trauma lap if possible - otherwise ASAP

- Definitely before D/C on Trauma patient poor followup

PostPost--SplenectomySplenectomy SepsisSepsis

Overwhelming Post-Splenectomy Sepsisa.k.a. OPSS, OPSI

Caused by encapsulated bacteriaStreptococcus pneumoniaeHaemophilus influenzaeNeisseria meningitidis

80% of cases occur within 2 years of splenectomy

PostPost--SplenectomySplenectomy SepsisS