Spleen surgical aspects Masoud Amini M.D. G.S. Laparoscopist & Bariatric Surgeon.

Spleen surgical aspects Masoud Amini M.D. G.S. Laparoscopist & Bariatric Surgeon

AMINI MD

???????????????????????????????????????????? largest reticuloendothelial organ(?) fromderm(?) ligaments of spleen(?) Vascular most of spleens blood derives from(?) three main branches of the celiac artery(?) accessory spleen Present in up to (?%) Spleen size & weight (?) Splenomegaly,Hypersplenism erythrocyte's, neutrophil & Platelets, life span (?) splenectomy should be delayed if possible to at least ??? age AMINI MD

Embryology & anatomy Spleen is the largest reticuloendothelial organ in the body From the primitive mesoderm Evident in the fifth week of gestation in an 8 mm embryo The most common variation of splenic embryology is the accessory spleen. Present in up to 20% of the population AMINI MD

Ligaments of the spleen (splenocolic ligament), to the colon (phrenosplenic ligament),to the diaphragm (splenorenal ligament) to the kidney, adrenal, and tail of the pancreas (gastrosplenic ligament),to the stomach The gastrosplenic ligament contains the short gastric vessels; the remaining ligaments are avascular AMINI MD

Anatomy cont. the tail of the pancreas has been demonstrated to lie within one cm of the splenic hilum 75% of the time and in 25% of patients actually to abut the spleen AMINI MD

ligaments

The spleen derives most of its blood from the splenic artery, the longest and most tortuous of the three main branches of the celiac artery AMINI MD

Accessory spleens Accessory spleens Present in up to 20% of the population Over 80% in the hilum and vascular pedicle Other locations in descending order gastrocolic ligament, greater omentum, stomach's greater curve, splenocolic ligament, small and large bowel mesentery, left broad ligament in women, and the left spermatic cord in men AMINI MD

Locations of accessory spleens AMINI MD

splenic artery & vein The distributed type :is the most common (70%) and is distinguished by a short trunk with many long branches. The less common magistral type of splenic artery (30%) has a long main trunk dividing near the hilum into short terminal branches. The splenic vein joins the superior mesenteric vein to form the portal vein and accommodates the major venous drainage of the spleen. AMINI MD

Spleen size The average adult spleen is 7 to 11cm in length and weighs 150 g (range 70 to 250 g). palpable below the left costal margin are at least double normal size, with an estimated weight of 750 g Spleen size and weight both diminishing in the elderly AMINI MD

Definitions, function The spleen can cause significant hematologic disturbance if it becomes hyper functioning ( hypersplenism) or hypertrophied ( splenomegaly) AMINI MD

Definitions Splenomegaly:( ?>1 kg or a pole-to-pole length of ?>15 cm) Hypersplenism :the presence of one or more cytopenias with normally functioning bone marrow.(e.g., hemolytic anemia ) AMINI MD

Massive splenomegalySplenomegalyNL SpleenSpleen >1 kg500 g70250(150) gmWt >22 cm and / or 15 cm.711 cmLength AMINI MD

immunologic role spleen plays a key immunologic role in defense against a number of organisms, particularly encapsulated bacteria AMINI MD

physiology The red pulp dynamic filtration system, enabling macrophages to remove microorganisms, cellular debris, antigen- antibody complexes, and senescent erythrocytes from the circulation. white pulp nodules that are 9 mg/dL, with intensive parenteral chelation therapy with deferoxa">

Thalassemia treatment Thalassemia Treatment involves transfusions to maintain a Hb >9 mg/dL, with intensive parenteral chelation therapy with deferoxamine. AMINI MD

Thalassemia major Other characteristics are intractable leg ulcers, head enlargement, frequent infections, the need for periodic blood transfusions. Untreated individuals usually die in late infancy or early childhood from severe anemia. Splenectomy is indicated for patients with excessive transfusion (>200 mL/kg per year) AMINI MD

Thalassemia patients are at high risk for pulmonary hypertension after splenectomy AMINI MD

INDICATIONS FOR SPLENECTOMY Splenic rupture (trauma) Red blood cell disorders and hemoglobino- pathies. White blood cell disorders, Platelet disorders, Bone marrow disorders (myeloproliferative disorders), Cysts and tumors, Infections and abscesses, Storage diseases and infiltrative disorders, miscellaneous disorders and lesions AMINI MD

Lymphomas Hodgkins Disease: Hodgkins disease is a malignant lymphoma that usually affects young adults in their 20s and 30s. Rarely, patients present with constitutional symptoms such as night sweats, weight loss, and pruritus but, more typically, asymptomatic lymphadenopathy usually involving the cervical nodes

staging Hodgkins disease Staging methods have evolved to include imaging techniques computed tomography (CT), 18F-fluorodeoxyglucose positron emission tomography (FDG-PET), and lymphangiography

staging laparotomy Hodgkins disease Historically, included splenectomy liver biopsy splenic hilar lymphadenectomy retroperitoneal node biopsy biopsy of a hepatoduodenal node and oophoropexy in premenopausal women common in stages I and II disease to rule out splenic or subdiaphragmatic involvement.

Early-stage Hodgkins disease is often cured with radiation therapy alone. Laparotomy is no longer indicated for patients likely to relapse, those with evidence of intra-abdominal involvement on imaging, and those with B symptoms. These patients should receive systemic chemotherapy

Non-Hodgkins Lymphoma (NHL) Splenomegaly or hypersplenism is common Splenectomy is indicated for NHL patients with massive splenomegaly leading to abdominal pain, early satiety, and Fullness also indicated in hypersplenism (anemia, neutropenia, and thrombocytopenia)

NHL Splenectomy may also be instrumental in the diagnosis and staging of patients with isolated splenic disease. The most common primary splenic neoplasm is NHL 50% to 80% of patients with NHL have involvement of the spleen but less than 1% of patients present with splenomegaly without lymphadenopathy Most patients have low-grade NHL, with frequent involvement of the splenic hilar lymph nodes, extrahilar nodes, bone marrow, or liver.Approximately 75% of these patients have clinically apparent hypersplenism

NHL In patients with spleen-predominant features, survival is significantly improved after splenectomy compared with similar patients who did not undergo splenectomy

Hairy Cell Leukemia Hairy cell leukemia, a rare disease that approximately 2% of adult leukemias This disease affects older men who presents with palpable splenomegaly. Approximately 10% of patients require no treatment because of the indolent course Treatment for cytopenias or splenomegaly typically begins with purine analogue chemotherapy. For more refractory cancers, a second-line immunotherapy may be instituted

splenectomy in hairy cell leukemia splenectomy in hairy cell leukemia If chemotherapy or immunotherapy failed in symptomatic anemia, infections from neutropenia, or hemorrhage from thrombocytopenia can lead to splenectomy. Patients with diffusely involved bone marrow without massive splenomegaly are less responsive to splenectomy. Patients with hairy cell leukemia are also at a two- to threefold risk for developing other malignancies (solid tumors)

Chronic lymphocytic leukemia (CLL) is disease of B lymphocytes characterized by the progressive accumulation of relatively mature but functionally incompetent lymphocytes. CLL is seen mainly after the age of 50 Medical treatment is indicated for symptomatic patients or those exhibiting evidence of rapid disease progression. Monoclonal antibodies are also used in the treatment of CLL. Bone marrow transplantation currently offers the only known cure for CLL. Splenectomy is indicated for patients with refractory splenomegaly and pancytopenia, which results in improvements in blood counts in 60% to 70% of patients

Chronic myelogenous leukemia (CML) is a myeloproliferative disorder & may occur in patients from childhood to old age characterized by the progressive replacement of normal diploid elements of the bone marrow with mature-appearing neoplastic myeloid cells Although CML can be asymptomatic at presentation, patients commonly present with fever, fatigue, malaise, effects of pancytopenia (infections, anemia, easy bruising), and occasionally splenomegaly

CML Bone marrow transplantation is an option but prognosis has improved dramatically with the advent of recent therapies, making transplantation less common Symptomatic splenomegaly and hypersplenism in CML can be effectively treated with splenectomy, but there does not appear to be a survival benefit when performed during the early chronic phase. Surgery is therefore reserved for patients with significant symptoms.

CML the Philadelphia chromosome, is highly associated with CML

Non-Hematologic Tumors of the Spleen The spleen can also be the site of metastatic disease, seen in up to 7% of autopsies of cancer patients. most frequently spread to the spleen are carcinomas of the breast, lung, and melanoma. Any primary malignancy, however, can metastasize to the spleen splenectomy may provide palliation for carefully chosen patients with symptomatic splenic metastases

white blood cell disorders Splenectomy for white blood cell disorders can be effective therapy for symptomatic splenomegaly and hypersplenism, improving some clinical parameters but generally not altering the course of the underlying disease. Splenectomy is indicated to improve cytopenias and was shown to be 75% effective in a combined group of patients who had either CLL or nonmalignant Hodgkin's disease. AMINI MD

INDICATIONS FOR SPLENECTOMY Splenic rupture (trauma) Red blood cell disorders and hemoglobino- pathies. White blood cell disorders, Platelet disorders, Bone marrow disorders (myeloproliferative disorders), Cysts and tumors, Infections and abscesses, Storage diseases and infiltrative disorders, miscellaneous disorders and lesions AMINI MD

Splenectomy in Benign Hematologic Conditions Aged red blood cells with decreased plasticity (>120 days) become trapped and destroyed in the spleen. SPLENECTOMY in Benign Hematologic Conditions Immune (idiopathic) Thrombocytopenic Purpura (ITP), is characterized by a low platelet count despite normal bone marrow and the absence of other causes of thrombocytopenia. Autoantibodies are responsible for the disordered platelet destruction mediated by the overactivated platelet phagocytosis within the reticuloendothelial system.

Platelet Disorders IDIOPATHIC (immune)THROMBOCYTOPENIC PURPURA (ITP) Is an autoimmune disorder Antiplatelet immunoglobulin G autoantibodies produced in the spleen premature removal of platelets opsonized by antiplatelet immunoglobulin G autoantibodies. Characterized by a low platelet count and mucocutaneous and petechial bleeding & .. AMINI MD

Dif. Dx. Of ITP

ITP presentation purpura Epistaxis gingival bleeding. Less commonly, gastrointestinal bleeding and hematuria are noted. Intracerebral hemorrhage is a rare but sometimes fatal presentation. The diagnosis of ITP involves the exclusion of other relatively common causes of thrombocytopeniapregnancy, drug-induced thrombocytopenia (e.g., heparin, quinidine, quinine, sulfonamides), viral infections, and hypersplenism

Management of ITP Asymptomatic patients with platelet counts higher than 50,000/mm3 may be observed without further intervention. Platelet counts of 50,000/mm3 and higher are rarely associated with clinical sequelae, even with invasive procedures. Patients with platelet counts, between 30,000 and 50,000/mm3, may always be observed but with more routine follow-up because they are at increased risk for progressing to severe thrombocytopenia.

Initial medical treatment is glucocorticoid prednisone, 1 mg/kg body weight/day) for patients with platelets counts

ITP Of patients treated with steroids, 25% will experience a complete response. Patients with platelet counts >20,000 /mm3 who remain symptom-free, or who experience minor purpura as their only symptom, do not require hospitalization

ITP Hospitalization may be required for patients whose platelets counts remain below 20,000/mm3 with significant mucous membrane bleeding and is required for those who have life-threatening hemorrhage. Platelet transfusion is indicated only for those who experience severe hemorrhage. IV immunoglobulin is important for the treatment of acute bleeding, in pregnancy, or for patients being prepared for operation, including splenectomy. The usual dose is 1 g/kg body weight/day for 2 days.

ITP This dose usually increases the platelet count within 3 days; it also increases the efficacy of platelet transfusions For patients with severe thrombocytopenia, with counts less than 10,000/mm3 for 6 weeks or longer, those with thrombocytopenia refractory to glucocorticoid treatment, or those who require toxic doses of steroid to achieve remission, the treatment of choice is to proceed to splenectomy

ITP Splenectomy is also the treatment of choice for patients with incomplete response to glucocorticoid treatment and for pregnant women in the second trimester of pregnancy who have also failed steroid treatment or IV Ig therapy with platelet counts less than 10,000/mm3 without symptoms or less than 30,000/mm3 with bleeding problems.

ITP It is not necessary to proceed to splenectomy for patients who have platelet counts higher than 50,000/mm3, have had ITP for longer than 6 months, are not experiencing bleeding symptoms, and who are not engaged in high-risk activities. A recent review of short-term and long-term failure of laparoscopic splenectomy has reported an overall approximate failure rate of 28% at 5 years after splenectomy

ITP A systematic review has showed that 72% of patients with ITP had a complete response to splenectomy. Relapse occurred in a median of 15% of patients (range, 1% to 51%), with a median follow-up of 33 months Younger patients had improved responses Preoperative indium-111 labeled platelet scintigraphy with platelets sequestered predominantly within the spleen had a significantly higher response rate than those noted to have hepatic sequestration

ITP Durable platelet responses are associated with patients who have platelet counts of 150,000/mm3 by postoperative day 3 or more than 500,000/mm3 by the postoperative day 10 the long-term failure rate of laparoscopic splenectomy at approximately 8% and approximately 44/1000 patient-years of follow-up. Another study has estimated the complete response of ITP patients postsplenectomy to be 66%

ITP evaluation for a missed accessory spleen must be undertaken in patients who experience a relapse. Other treatment options for these patients include observation of stable nonbleeding patients with platelet counts higher than 30,000/mm3, long-term glucocorticoid therapy, and treatment with azathioprine or cyclophosphamide. Recent evidence regarding thrombopoietin receptor agonists may offer a novel medical therapy for patients with no response to steroids, IV immunoglobulin therapy, or splenectomy.

ITP Gingival bleeding, epistaxis, menorrhagia, hematuria, or even melena. Platelet >50,000/cc present with incidental findings; 30,000

Spleen surgical aspects Masoud Amini M.D. G.S. Laparoscopist & Bariatric Surgeon.

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Transcript of Spleen surgical aspects Masoud Amini M.D. G.S. Laparoscopist & Bariatric Surgeon.