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Malign Effects of Splenectomy-The Place of Conservative Treatment NAHUM WERBIN* KIRAN LODHA M.D

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Malign Effects of Splenectomy-The Place of Conservative Treatment NAHUM WERBIN* KIRAN LODHA M.D Postgrad Med J: first published as 10.1136/pgmj.58.676.65 on 1 February 1982. Downloaded from Postgraduate Medical Journal (February 1982) 58, 65-69 REVIEW ARTICLE Malign effects of splenectomy-the place of conservative treatment NAHUM WERBIN* KIRAN LODHA M.D. M.S. Surgical Unit, Westminster Hospital, London, S.W.l Summary to be confirmed later on), and after sexual maturity In this review article the incidence is discussed of is either unimportant or its functions may be overwhelming post-splenectomy infection (OPSI), assumed by other haemopoietic tissues'. which is especially likely to occur in children and With the exception of very few experimental when splenectomy is carried out for haematological studies (Motohashi, 1922; Perla and Marmorston- disorders. Long-term broad spectrum antibiotics or Gottesman, 1930; Perla, 1936) it was not until 30 the use of polyvalent pneumococcal vaccine are often years later that clinical reports appeared which advocated as prophylactic measures under these related fatal infections to splenectomy (King and circumstances. Schumacker, 1952). In recent years, owing to an After mild splenic trauma, conservative surgery or increase in road accidents, gunshot wounds, sporting in of elective operations partial splenectomy may be indicated in some cases. injuries, and the number by copyright. Where trauma is more severe and the spleen cannot during which incidental splenectomy is performed safely be preserved there may be a place for auto- for technical reasons or for surgical trauma (Klaue, transplantation of splenic slices, for example into a Eckert and Kern, 1979), splenectomy has become a pocket of omentum, and there is some experimental relatively common operation. Only when Singer support for this technique. (1973) collected several thousand cases of splenec- tomized patients and showed the very high incidence Overwhelming post-splenectomy infection of sepsis amongst them as compared to the general When splenectomy first became a routine proce- population was overwhelming post-splenectomy in- dure for trauma of the spleen little was known about fection (OPSI) recognized (Krivit, Giebink and the functions of this organ, except that its removal Leonard, 1979). This risk is considered to be 50-fold http://pmj.bmj.com/ resulted in some minor changes in the blood picture greater following splenectomy for trauma than in which were not considered important (Moynihan, the general population, and is even greater for 1921; Tarnuzi and Smiley, 1967). Morris and patients undergoing splenectomy for haemato- Bullock (1919) were among the few alert observers logical disorders. Although children are more who recognized that some caution should be prone to OPSI, adults are affected as well (Ein et al., exercised while removing the spleen. When ex- 1977; Robinette and Fraumeni, 1977). perimenting on rats infected with the bacillus of rat plague, mortality in the splenectomy group was 80 % Splenic function on September 24, 2021 by guest. Protected compared to 38 % in the control group of animals. There is now a revival of interest in the spleen and Their conclusion was that 'it is not improbable that its functions and this has led to accumulation of the human body deprived of its spleen, shows a experimental and clinical information. similar increased susceptibility to infection'. The spleen is the first line of defence in clearing Marine and Manley (1920) are considered to be small numbers of bacteria from the circulation the first to have suggested a method of protection after intravenous injection (Leung, Szal and Drach- against post-splenectomy infection by transplanting man, 1972; Smith and Johnston, 1979). It initiates fragments of spleen to subcutaneous pockets in immune responses against particulate antigens rabbits after splenectomy. They thought that 'the (bacteria) by producing IgG and IgM (Likhite, spleen is most important in early life (an observation 1975, 1978). Part of the IgG is a specific cell bound leucophilic gamma globulin fraction (leucokinin or *Address for reprints: Surgery "A", Ichilov Hospital, Tel- tuftsin) which is essential for maximal stimulation of Aviv, Israel. the phagocytic activity of neutrophilic leucocytes 0032-5473/82/0200-0065 $02.00 () 1982 The Fellowship of Postgraduate Medicine Postgrad Med J: first published as 10.1136/pgmj.58.676.65 on 1 February 1982. Downloaded from 66 N. Werbin and K. Lodha (Najjar and Nishioka, 1970). The splenic macro- the implant, consistent with connective tissue cells. phages act on an intravenous challenge of bacteria These cells differentiate later into splenic reticular after their opsonization (Smith and Johnston, 1979; cells that evolve into red and white pulp as time Likhite, 1979). The spleen plays a major role in progresses. This regeneration is reminiscent of opsonization by synthesizing early antibody and splenic embryogenesis. By the end of 5 weeks the complement factors (properdin) (Krivit et al., 1979; implant has a rather thick capsule but is otherwise Smith and Johnston, 1979). The local and systemic similar to normal splenic tissue. The final weight of effects are combined and are dependent on splenic the implant is approximately equal to that of the tissue mass and adequate blood supply (Leung et al., original transplanted tissue. Blood supply to these 1972; Cooney et al., 1979). implants comes mainly from neo-vascularization by small arterioles from the surrounding tissues. It The need to conserve splenic tissue seems important to measure the blood flow through When the spleen is removed for medical indica- them, as the filtering effect of the spleen was shown tions, such as hereditary spherocytosis, for staging of to be important in clearing the circulation of bacteria Hodgkin's disease or during renal transplantation, (Whitaker, 1968). The fate of these implants is not no attempt will usually be made to conserve splenic known. tissue. It is after traumatic injury (accidental or Since this preliminary work, auto-transplantation iatrogenic) that efforts have been made to conserve of the spleen has been performed in various other the spleen or part of it or to transplant splenic tissue. laboratory animals and in different sites, such as in Previously, when confronted with a splenic subcutaneous pockets (Likhite, 1974), retroperitoneal rupture, the surgeon had no choice but to remove pockets (Cooney et al., 1979) and the peritoneal the bleeding organ. When overwhelming post- cavity (Crosby and Benjamin, 1961). The spleen has splenectomy infection was recognized to be a been macerated (Schwartz et al., 1978), cut into definite entity, the need to conserve the spleen was small pieces (Crosby and Benjamin, 1961) or frag- advocated (Dickerman, 1976; Leading Article, mented (Leung et al., 1972). These models served 1978) and an alternative line of management of to test resistance to bacterial contamination,by copyright. splenic trauma was sought. In view of changing usually using Streptococcus pneumoniae (Coil, concepts of the role of the spleen in host defence, Dickerman and Boulton, 1978; Schwartz et al., the idea of conserving the spleen should no longer 1978) and Haemophilus influenzae (Moxon, Gold- be regarded as an oddity. There is now better thorne and Schwartz, 1980), which are the most understanding of the splenic arterial vasculature frequent infecting organisms in splenectomized and it is possible to conserve part or the whole of the patients (Singer, 1973; Dickerman, 1976). Some of spleen in a number of cases following splenic the experiments (Cooney et al., 1979; Fasching and trauma. There is evidence that the spleen in man Cooney, 1980) prove that auto-transplanted spleens consists of separate compartments or segments, have immunological activity and this is proved by each supplied by one of the hilar branches of the lower mortality rates in infected auto-transplanted http://pmj.bmj.com/ splenic artery and drained by one of the hilar animals as compared to splenectomized ones. tributaries of the splenic vein. The zblood vessels There are, however, several reports (Crosby and enter and leave at the hilum. Although arterial distri- Benjamin, 1961; Schwartz et al., 1978) denying bution is variable, bifurcation almost always occurs these protective effects and showing, in fact, similar outside the spleen and therefore control of bleeding mortality rates in splenectomized and auto-trans- from a particular segment by ligation (Tsapogas planted animals after pneumococcal infection. et al., 1973) and/or partial splenectomy (Sherman These conflicting results could be explained by and Asch, 1978) are feasible procedures. the mass of transplanted spleen involved, as a mini- on September 24, 2021 by guest. Protected mum of one-third of the original weight has been Splenic transplantation studies shown to be effective (de Boer, Sumner-Smith and Following the pioneering work of Marine and Downie, 1972; Likhite, 1974), or it may be explained Manley (1920), Perla and Marmorston-Gottesman by the method of transplantation. Fragmentation of (1930) continued transplantation experiments in the spleen and maceration are less effective, pre- rats and found that at least 7 weeks have to elapse sumably because of poorer blood supply. before the transplant can protect these animals from Bartonella muris haemolytic anaemia. Detailed The spleen and wound healing histological studies in rats (Tavassoli, Ratzan and The authors have examined the role of the spleen Crosby, 1973) showed that splenic fragments, auto- in wound healing in rats
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