Esplenectomía laparoscópica en esplenomegalia masiva por linfoma no Hodgkin de zona marginal / Massive laparoscopic splenectomy for marginal zone non-Hodgkin lymphoma / Esplenectomia laparoscópica em esplenomegalia maciça devido a linfoma não-Hodgkin de zona marginal

Resumen: Introducción: si bien la esplenectomía laparoscópica en esplenomegalias masivas y supramasivas constituye un desafío técnico, su realización es factible y segura en centros con equipos con experiencia en cirugía laparoscópica. Objetivo: presentar el primer caso de esplenectomía laparoscópica en esplenomegalia masiva realizada en Uruguay. Caso clínico: se trata de una paciente de 70 años portadora de una pancitopenia periférica, esplenomegalia masiva y diagnóstico realizado por punción de médula ósea de neoplasia linfoproliferativa tipo B de bajo grado, a quien se le indicó la esplenectomía con fines diagnósticos y terapéuticos. La paciente se operó en decúbito lateral derecho a 15 grados, los trócares se colocaron bajo visión directa adaptados al tamaño del bazo que se extendía desde el diafragma hasta el estrecho superior de la pelvis. Se realizó la esplenectomía en un tiempo de 220 minutos, extrayéndose la pieza íntegra y sin haberla colocado en bolsa a través de un hemi Pfannenstiel, protegiendo la pared con un retractor de heridas quirúrgicas. No presentó complicaciones, fue dada de alta a las 48 horas. El hemograma realizado a las 24 horas demostró un aumento de las cifras de todas las series celulares y el informe anatomopatológico diagnosticó un linfoma no Hodgkin de zona marginal. Discusión: la esplenectomía laparoscópica en esplenomegalias masivas requiere de un mayor tiempo quirúrgico, aunque las pérdidas sanguíneas y la estadía hospitalaria son menores en comparación a los procedimientos convencionales, presentando una morbilidad similar. En la experiencia inicial de los equipos quirúrgicos se reporta un porcentaje de conversiones y reingresos cercanos al 30%.

Abstract: Introduction: despite the fact that laparoscopic splenectomy for massive and supramassive splenomegaly constitutes a technical challenge, it is a feasible and safe procedure in the context of institutions with experienced teams in laparoscopic surgery. Objective: to present the first case of laparoscopic splenectomy for massive splenomegaly in Uruguay. Clinical case: the study presents the case of a 70-year-old patient carrier of peripheral pancytopenia, massive splenomegaly and a diagnosis of type B lymphoproliferative neoplasm based on bone marrow aspiration and biopsy, who underwent diagnostic and therapeutic splenectomy. The patient was operated in supine position with a 15-degree tilt, the trocars were placed under direct view, adapted to the size of the spleen which went from the diaphragm until the superior pelvic outlet. Splenectomy was performed in 220 minutes, the entire piece was removed through a hemi Pfannenstiel incision, without placing it in a bag, the wall being protected with a surgical wound retractor. There were no complications and the patient was discharged from hospital 48 hours. The blood count performed after 24 hours evidenced increase in all cell series and the pathology report confirmed diagnosis of marginal zone non- Hodgkin lymphoma. Discussion: laparoscoppic splenectomy in massive splenomegaly requires of a greater surgical time, although blood loss and hospital star are lower when compared to conventional procedures and evidence similar morbility. The initial experience of surgical teams reports 30% of conversions and readmissions.

Resumo: Introdução: embora a esplenectomia laparoscópica em esplenomegalias massivas e supremassivas seja um desafio técnico, sua realização é viável e segura em centros com equipes com experiência em cirurgia laparoscópica. Objetivo: apresentar o primeiro caso de esplenectomia laparoscópica em esplenomegalia maciça realizada no Uruguai. Caso clínico: paciente de 70 anos com pancitopenia periférica, esplenomegalia maciça e diagnóstico feito por punção de medula óssea de neoplasia linfoproliferativa tipo B de baixo grau, com indicação de esplenectomia para fins diagnósticos e terapêuticos. A paciente foi operada em decúbito lateral direito a 15 graus, os trocartes foram colocados sob visão direta adaptados ao tamanho do baço que se estendia do diafragma ao estreito superior da pelve. A esplenectomia foi realizada em um tempo de 220 minutos, retirando-se toda a peça e sem colocá-la em bolsa por meio de uma hemi Pfannenstiel, protegendo a parede com afastador de ferida operatória. Sem apresentar complicações a paciente teve alta após 48 horas. O hemograma realizado 24 horas depois da cirurgia mostrou um aumento no número de todas as séries de células e o laudo anatomopatológico diagnosticou linfoma não Hodgkin de zona marginal. Discussão: a esplenectomia laparoscópica nas esplenomegalias maciças requer um tempo cirúrgico maior, embora as perdas sanguíneas e a permanência hospitalar sejam menores em comparação aos procedimentos convencionais, apresentando morbidade semelhante. Na experiência inicial das equipes cirúrgicas, é relatado um percentual de conversões e readmissões próximo a 30%.

Esplenomegalia gigante en la leucemia linfocítica crónica / Giant splenomegaly in chronic lymphocytic leukemia

La leucemia linfocítica crónica constituye la forma de leucemia más frecuente en el mundo occidental; sus síntomas más frecuentes son la aparición de adenopatías, el cansancio, la pérdida de peso y aquellos derivados de las infecciones y del síndrome anémico. Aunque es una de las enfermedades que rara vez son tributarias de una esplenectomía por hiperesplenismo, es una entidad frecuente en hematología y debe ser del dominio y conocimiento del cirujano general. Presentamos un paciente con una esplenomegalia de proporciones gigantes, de inusual aparición(AU)

Chronic lymphocytic leukemia is the most frequent in the Western hemisphere; their symptoms usually include adenopathy, fatigue, loss weight and those derived from infection and anemic syndrome. Although it is one of the diseases rarely in need of splenectomy for hyperesplenism, it is a common pathology in hematology and they and general surgeon should have thorough knowledge about it. We introduced a patient with a splenomegaly of giant proportions and unusual presentation(AU)

Splenectomy in a patient with treatment-resistant visceral leishmaniasis: a case report / A esplenectomia na leishmaniose visceral refratária ao tratamento clínico: relato de caso

Visceral leishmaniasis (VL), also known as Kala-azar, is a systemic infection caused by a protozoan (Leishmania) and, in its classic form, is a serious illness associated with malnutrition, anemia, hepatosplenomegaly, infectious processes and coagulopathies. The effect of splenectomy in patients with visceral leishmaniasis is not well defined; however, it is known that the spleen is the largest reservoir of infected cells belonging to the reticulo endothelial system. Therefore, the surgical procedure is an option for the debulking of parasites, providing a cure for refractory VL and minimizing the complications of hypersplenism.

A leishmaniose visceral (LV) ou calazar é uma infecção sistêmica causada por um protozoário (Leishmania) e na sua forma clássica é uma doença grave. Cursa com desnutrição, anemia, hepatoesplenomegalia, processos infecciosos e coagulopatias. O papel da esplenectomia em pacientes com leishmaniose visceral não é bem definido; entretanto, sabe-se que o baço é o maior reservatório de células parasitadas do sistema reticulo endotelial e o procedimento cirúrgico é, dessa forma, uma opção para debulking de parasitas, propiciando a cura da LV refratária e minimizando as complicações do hiperesplenismo.

Leucemia de células velludas en el embarazo: Caso clínico / Hairy cell leukemia during pregnancy: Report of one case

Hairy cell leukemia (HCL) is a rare chronic B cell lymphoproliferative disorder that affects mostly men. It usually presents with pancytopenia, splenomegaly and bone marrow infiltration, without lymphadenopathy. Diagnosis is based on the presence of mononuclear cells with cytoplasmic projections in a blood smear, the typical bone marrow infiltration pattern and the immunophenotypic profile. HCL occurs seldom in young women and even more exceptionally during pregnancy. We report a 31-year-old woman in whom a splenomegaly was detected during routine prenatal care. Pancytopenia with 25 percent of hairy cells was found in her blood count. The patient was subjected to an open splenectomy and had an uneventful pregnancy. After two years of follow up, she has a normal blood count and has not required chemotherapy.

Coil embolization of splenic artery as an adjunctive therapeutic technique before splenectomy in patients with massive splenomegaly and secondary hypersplenism

Splenectomy for massive splenomegaly, [splenic weight 10 times usual weight of 150-200 gm], with secondary hypersplenism, has uncommonly high morbidity and mortality because of technical challenges and problems of hemostasis due to severe thrombocytopenia refractory to platelet transfusion. In an attempt to decrease intraoperative blood loss and to improve the preoperative general condition of the patients, preoperative splenic artery embolization is advised. To study the effects of preoperative coil embolization of the splenic artery in patients with massive splenomegaly and secondary hypersplenism and its impact on improvement of hypersplenism specially thrombocytopenia and subsequent Splenectomy. This study included 15 patients with massive splenomegaly and secondary hypersplenism. The causes of splenomegaly were liver cirrhosis with portal hypertension [5 patients], spherocytosis [5 patients], isolated splenic lymphoma [3 patients] and sickle cell-beta thalassemia [one patient] and one patient with unknown cause. All patients with liver cirrhosis were selected to be Child-Pough grade A. All patients were subjected to coil embolization of the splenic artery after infusion of one unit of fresh blood and another unit of platelet concentrates in some patients. Then subsequent splenectomy was done within 2 to 5 days. In patients with liver cirrhosis and portal hypertension, ligation of the left gastric vein was also done in conjunction to splenectomy. This study was done in Assiut University Hospital during the period between February 2001 to October 2006. This study was done on 15 patients with massive splenomegaly, 9 males [60%] and 6 females [40%] with their ages ranged between 15-48 years with the mean age of 29.2 years. The preembolization platelet count ranged between 19x10[9]/L to 78 x10[9]/L with a mean value 45x10[9]/L. One of the patients, known to have heterozygos sickle cell disease presented by acute splenic sequestration crisis. Splenic artery occlusion aided normalization of the thrombocytopenia within 2 to 5 days in all patients by fresh blood transfusion. The postembolization platelet count ranged from 143 to 210 x10[9]/L with a mean 168x10[9]/L. Successful splenectomy was subsequently done with no intraoperative significant blood loss and additional transfusion. No serious complications resulted from both procedures. Preoperative proximal coil embolization of the splenic artery is a safe technique and allows safe splenectomy in patients with massive splenomegaly with secondary hypersplenism that carries high risk splenectomy. It is a life saving technique in patients with acute splenic sequestration crisis. After proximal coil embolization, it is advisable to perform splenectomy before dilatation of the collateral and recurrence of hypersplenism

Complications associated with splenectomy in thalassemia

The study aims at investigating the complications associated with splenectomy in thalassemic patients It was a prospective clinical study. Sixty Splenectomies were preformed electively after pre-operative preparation in Sir Ganga Ram Hospital, Lahore during the year Jan 2003 to Sep 2005. Complications were categorized into per-operative, early post-operative and late complications. The frequency of per-operative complications was 3%, early post-operative complications were 10% and late complications were 1.6%. The rate of complications has decreased markedly as the patients are well prepared and improved post operative carp has also reduced the post-operative complications. With good perioperative management, splenectomy in children with massive splenomegaly is both safe and effective

Combined needlescopic cholecystectomy and laparoscopic splenectomy for the treatment of thalassaemic splenomegaly and cholelithiasis

Gallstone disease is a common association in patients with haematological splenomegaly. When indicated, simultaneous splenectomy and cholecystectomy should be performed and traditionally this is accomplished by open surgery. We report a 17 year old thalassaemic girl with splenomegaly complicated by gallstone pancreatitis. We treated her with a combination of needlescopic cholecystectomy and laparoscopic splenectomy as well as delivering the huge spleen via a pfannenstiel incision to hide the scar. We believe this technique is an acceptable alternative mainly for rapid delivery of the spleen and to minimize visible scars hence improving cosmesis.

Bone mineral density in children and adolescents with hepatosplenic mansonic schistosomiasis and esophageal varices who underwent splenectomy and ligature of the left gastric vein

Twenty eight children and adolescents from 7 to 19 years of age, suffering from hepatosplenic mansonic schistosomiasis and bleeding esophageal varices were evaluated for bone mineral density (BMD), before undergoing medical and surgical treatment. The surgical protocol was splenectomy, autoimplantation of spleen tissue into a pouch of the greater omentum and ligature of the left gastric vein. Twenty one patients were evaluated after a follow up from two to nine years post surgical treatment. The BMD was measured at the lumbar spine (L2 - L4) through the dual energy absorptionmetry X-ray (DEXA), using a LUNAR DPX-L densitometer. Preoperatively, all patients showed deficit of the BMD varying from 1 to 7.07 standard deviations (Mean +/- SEM - 2.64 +/- 0.28), considering the mean line of the control curve for healthy children accepted as normal. The BMD deficit was more evident among the females than the males. After treatment there was a significant increment (C2 = 9.19 - p =0.01) of the BMD and 29 percent of the patients (six out of twenty one) were considered without bone mineral deficit. It was concluded that the patients included in this series, who suffer from hepatosplenic mansonic schistosomiasis, showed an important BMD deficit, specially among the females which has had a significant improvement after medical and surgical treatment

Esplenectomia videolaparoscopica em paciente portador de esplenomegalia por esferocitose hereditaria: relato de dois casos / Laparoscopics splenectomy: report of two cases

Com os recentes avancos tecnologicos e a maior experiencia dos cirurgioes com o metodo laparoscopico, a esplenectomia videolaparoscopica tornou-se factivel. Embora esta tecnica seja mais comumente empregada na remocao de bacos de tamanho normal ou pouco aumentados, a sua utilizacao em pacientes com esplenomegalia vem sendo tentada com sucesso por alguns autores. Os autores apresentam dois pacientes portadores de esferocitose hereditaria que apresentaram crises hemoliticas. Desde entao fizeram acompanhamento hematologico, tendo sido indicada intervencao cirurgica para remocao do baco. A ultra-sonografia revelou esplenomegalia acentuada nos dois casos...

Complicaciones de la esplenectomía en la operación de Sugiura-Futagawa / Splenectomy complications in the Surgiura-Futagawa procedure

Evaluar las complicaciones de esplenectomía en la operación de Sugiura-Futagawa. Antecedentes. La esplenectomía en hipertensión portal tiene mayores dificultades y probablemente se asocia a una mayor morbimortalidad. Método. Se realizó un estudio observacional, retrospectivo, transversal y descriptivo para analizar las complicaciones secundaria a esplenectomía en pacientes con hipertensión porta hemorrágica, tratada con la operación de Sugiura-Futagawa. Resultados. Se revisaron 155 expedientes de pacientes operados, con edad promedio de 42 años, 81 del sexo masculino y 74 del femenino. En 87 casos se demostró cirrosis hepática, en 39 fibrosis portal, en 23 cirrosis biliar primaria y en 6 hipertensión portal idiopática (hígado normal). Estos pacientes no recibieron inmunización preoperatoria contra neumococo; sin embargo, recibieron profilaxis antibiótica con cefalosporinas de primera y segunda generación. Se encontraron complicaciones en 16 casos (10.3 por ciento), trece de ellas atribuibles al procedimiento quirúrgico (peritonitis 3.9 por ciento, colecciones subfrénicas 1.9 por ciento, pseudoquiste pancreático 1.9 por ciento y fístula pancreática 0.6 por ciento y tres atribuibles a la ausencia de bazo (1.9 por ciento, manifestadas como choque séptico. Conclusión. La frecuencia de complicaciones relacionadas con esplenectomía en la operación de Sugiura-Futagawa es baja. El índice de infección relacionado con la ausencia de bazo es también bajo. La esplenectomía en la operación se Sugiura.Futagawa no es un factor contribuyente de consideración a la morbilidad postoperatoria

Reavaliaçäo da autotransfusäo de órgäos extirpados / Re-evaluation of the autotransfusion of extirpated organs

Os autores realizaram uma reavaliaçäo da eficácia e da inocuidade do novo método de autotransfusäo proposto por L. Bogossian em 1989, que consiste na reinfusäo imediata no paciente do sangue recuperado de seu baço esplenomegálico recém-extirpado. Foram analisados cinco autotransfusäo de baços removidos no período de 01/01/93 a 31/12/94. Conclui-se que o método é eficaz, inócuo e recupera grandes volumes de sangue, concorrendo para a reduçäo da demanda de transfusöes homólogas e do número de complicaçöes

Role of splenectomy in splenic disorder

To study the haemoglobinopathies with their subsequent splenomegalic and hypersplenic symptoms and to assess the postoperative complications of splenectomy. There were 50 patients with splenic pathology operated upon in the Salmaniya Medical Centre. The symptomatology of splenomegaly and hypersplenism were evaluated in addition to the surgical indications for splenectomy; specific reference was made to splenic weight, its relation to morbidity and mortality and especially the occurrence of post-splenectomy sepsis. Haemoglobinopathies with their consequent splenomegalic and hypersplenic symptoms are a common indication for splenectomy in this part of the Arabian Gulf. Several studies have cautioned about post-splenectomy complications. The aim of this study was to assess these complications with specific reference to post-splenectomy sepsis and also to verify any relation between such complications and splenic size. Splenectomy was performed for splenomegaly and hypersplenism in 19 [38%] of the 50 patients; 17 [34%] had splenectomy because of splenic trauma and the remaining 14 [28%] because of lymphomas and/or adjuvant to other surgical procedures. The spleen weight was 840 g [range 185-2200 g]. The largest and heaviest spleens were found in patients with splenomegaly, and hypersplenism with sickle-cell disease. The mortality rate was 4% and postoperative complications were observed in 16%. There was no relation between the complication and splenic size. Our results show that these patients benefited from splenectomy, in terms of life-saving, haematological improvement and relief of discomfort and pain. These results were achieved with an acceptable mortality and morbidity

Haematological studies using radioactive iodine

This study evaluated the hematological changes in 20 bilharzial patients without esophageal varices who underwent segmental splenectomy, by using radioactive 1131. It was found that bilharzial hepatosplenomegaly associated with anemia, shortened red cell life span. 45 days after segmental splenectomy, anemia corrected and the red cell life span is lengthened. It has been concluded that segmental splenectomy improves the anemia present in bilharzial splenomegaly as it decreases the site of red cell destruction

Esplenectomía parcial en esplenopatias hematológicas usando los rayos laser de CO2 / Partial splenectomy in hematologic splenopathies using CO2 laser rays

Se presentan 7 niños, que padecían de esplenopatías hematológicas necesitadas de esplenectomía, en edades comprendidas entre 15 meses y 15 años, con una media de 7,2 años. Se señala que las indicaciones de esplenectomía estuvieron dadas por: esplenomegalia gigante y marcados signos de hiperesplenismo. Dos niños presentaron enfermedad de Gaucher, 3 mostraron drepanocitemia, uno Sß talasanemia y otro, una leucemia mieloide crónica variedad infantil. Se informa que a todos se les practicó esplenectomía parcial, resecando de dos tercios a cuatro quintos del bazo , al que se le dejó solo un polo inferior, irrigado por arteria y vena polar. Un solo niño tuvo que ser reintervenido a las 2 horas de operado. A todos se les realizó gammagrafía con tecnetio 99m pre y posoperatorio. Se resume que hasta la fecha todos los niños se encuentran bien; se han normalizado las cifras de hematíes, leucocitos y plaquetas

Esplenomegalia idiopática no tropical e hiperesplenismos:informe de un caso / Non-tropical idiopathic splenomegaly with hypersplenism: report of a case

Aunque esplenomegalia e hiperesplenismo pueden se causados por una gran variedad de enfermedades, se han descrito casos en los cuales no es posible identificar la causa, entidad que ha sido descrita como esplenomegalia idiopática no tropical o Síndrome de Dacie. Esta es una enfermedad rara, caracterizada por explenomegalia masiva, hiperesplenismo y crecimiento hepático. Informamos los hallazgos en el estudio de un paciente que fue admitido en el hospital por esplenomegalia masiva. Hepatopatías, así como anormalidades hematológicas u otras enfermedades fueron descartadas, y se realizó esplenectomía. En el estudio histopatológico no pudieron demostrarse anormalidades. El paciente ha tenido una buena evolución en el postoperatorio inmediato y el diagnóstico final fue Síndrome de Dacie

Enfermedad de Gaucher / Gaucher's disease

El diagnóstico anatomopatológico de la Enfermedad de Gaucher se ha acomplejado como consecuencia de reiteradas descripciones de la presencia de células características en casos de enfermedades hematológicas, em particular relacionadas con el linfocito B. En estos casos, de acuerdo a la sustancia atesorada las células de Gaucher pueden ser falsas o verdaderas. El caso de una niña de 5 años con severa esplenomegalia, discreta hepatomegalia y compromiso medular óseo (no detectado radiológicamente), nos ha permitido un adecuado estudio morfológico, tanto con Microscopía Fotónica como Electrónica, complementado con estudio bioquímico del parénquima esplénico. Se concluye que, en la Microscopía Fotónica las técnicas morfológicas sólo pueden discernir como falsas aquellas células que muestran en forma sistemática núcleos picnóticos. Que de las técnicas histoquímicas, la presencia de hierro parece significativa que otras, que sólo demuestran que las células son macrófagos activados. La técncia de PAS es totalmente inútil. En todos los casos, la Microscopía Electrónica o la determinación bioquímica, resuelven el problema. Sin embargo,el diagnóstico diferencial definitivo entre la verdadera enfermedad de Gaucher, de la cual posseemos una definición molecular y las diversas asociaciones entre enfermedades hematológicas y células de Gaucher, exige uma adecuada correlación clínico patológica