The spleen and splenectomy.

After 1940, the number of splenectomies performed in the United States and elsewhere increased rapidly. Splenectomy for Banti's disease and malaria decreased gradually into disrepute. Removal of the spleen for idiopathic thrombocytopenic purpura, congenital spherocytic anemia and acquired hemolytic anemia became accepted practice. However, debate still continues regarding the proper indications for splenectomy in Gaucher's disease, Felty's syndrome and leukemia.

Iatrogenic splenic injury.

In a previous report from this institution, 21% of splenectomies performed between 1957 and 1967 were for iatrogenic injury to the spleen. In the present study, encompassing the years 1971 to 1987, the frequency of iatrogenic splenic injury was reduced to 9% (134 of 1,557 splenectomies). However, there has been no evidence of a progressive decrease in accidental splenic injury from 1971 to 1987. Although the number of injuries related to operations on the stomach or repair of hiatus hernia have declined somewhat in the past decade, the incidence of splenic injuries secondary to colectomy and nephrectomy has not changed appreciably, and injuries linked to complex operations on the aorta and its branches (19 cases) have increased. No evidence could be found that morbidity was increased if the splenic injury is promptly recognized and managed by splenectomy. However, 13 of these 134 patients required reoperation for control of continued bleeding from unrecognized iatrogenic splenic trauma. Constant awareness of the continued prevalence of this operative complication and the mechanisms by which it is produced should enable surgeons to lessen its frequency and potential sequelae.

Splenectomy for massive splenomegaly.

Several groups of authors have recently reported that removal of the massively enlarged spleen (1,500 grams or greater) is associated with a greater morbidity than that encountered in patients with spleens of smaller sizes. In our experience, 46 of 51 patients with massively enlarged spleens had a myeloproliferative disorder (leukemia, lymphoma or agnogenic myeloid metaplasia) and usually had a limited life expectancy. When morbidity in these patients was compared with that in patients with the same diagnosis but spleens of smaller size, no increase in complications or death was found other than a greater operative blood loss in patients with non-Hodgkin's lymphoma. Limitation of operative morbidity in patients with very large spleens depends on careful selection and appropriate operative and perioperative management.

Some factors affecting phencyclidine biotransformation by human liver and placenta.

Samples of human liver and placenta microsomes were analyzed for their in vitro hydroxylation capabilities using phencyclidine, [PCP, 1-(1-phenylcyclohexyl)piperidine] as substrate. Microsomes were prepared from full-term placentas (cesarean deliveries under epidural anesthesia) and from histologically normal liver specimens (staging laparotomies for Hodgkin's disease). Three different hydroxylated PCP metabolites were assayed including 1-(1-phenyl-3-hydroxycyclohexyl)piperidine (3-OH-cyclo-PCP), 1-(1-phenyl-4-hydroxycyclohexyl)piperidine (3-OH-cyclo-PCP), 1-(1-phenyl-4-hydroxycyclohexyl)piperidine (4-OH-cyclo-PCP), and 1-(1-phenylcyclohexyl)-4-hydroxypiperidine (4-OH-pip-PCP). The mean amounts of in vitro microsomal hydroxylation of PCP at the three different positions of the PCP ring varied considerably between individual samples of both liver and placenta. The placenta hydroxylated PCP but not as effectively as liver. Evidence for independent hydroxylation of PCP to 3-OH-cyclo-PCP was comparable to 4-OH-cyclo-PCP and 4-OH-pip-PCP. The formation of 3-OH-cyclo-PCP by the liver was enhanced in tobacco smokers. The formation of 4-OH-cyclo-PCP by the liver was negatively correlated with the stage of Hodgkin's disease even though the liver was free of disease in 11 of 12 subjects.

Splenectomy for cytopenias associated with systemic lupus erythematosus.

Splenectomy was performed in 20 patients with refractory cytopenias associated with systemic lupus erythematosus. An immediate and sustained increase in platelet count (greater than 150,000 cells/mm3) was achieved in 12 of 18 patients whose principal indication for operation was thrombocytopenia. Of seven patients with hemolytic anemia, which was linked with thrombocytopenia in five, six had an increase in the hematocrit value of 20 percent or more after operation. The white blood count increased to normal values in three leukopenic patients. We believe that although removal of the spleen is not uniformly successful in correcting cytopenias in patients with systemic lupus erythematosus, splenectomy should be considered in patients refractory to other modalities of treatment.

Splenectomy for thrombocytopenia due to secondary hypersplenism.

The response to splenectomy of patients with thrombocytopenia due to secondary hypersplenism is frequently unpredictable. Our experience indicated that splenectomy is seldom justified for this indication in patients with chronic myelogenous or chronic granulocytic leukemia. Since patients with chronic lymphocytic leukemia, hairy-cell leukemia, and stage IV lymphoma may have a more prolonged life expectancy, removal of the spleen brings about a satisfactory response of thrombocytopenia in some instances. Elevation of platelet counts after splenectomy in patients with agnogenic myeloid metaplasia is most likely to occur in women with the primary form of the disease. In other nonmalignant conditions, splenectomy has resulted in a satisfactory response in the majority of patients.

Splenectomy for idiopathic thrombocytopenic purpura.

Over a period of 20 years, splenectomy has been performed upon 216 patients with idiopathic thrombocytopenic purpura. Splenectomy resulted in an immediate and sustained platelet response in 72 per cent of these patients. An additional 7.4 per cent of the patients had a sustained platelet count of 150,000 per cubic millimeter develop while off all drug therapy within the first postoperative year. Of the remaining patients who failed to meet these criteria, only one died of subsequent thrombocytopenic bleeding and only eight remained on any therapy with steroids or other immunosuppressive agents at last follow-up examination.

Enteric intussusception presenting as a rapidly enlarging mass.

Enteric intussusception is unusual in adults and frequently presents in a confusing manner. A case of jejunojejunal intussusception is presented in which a 15-cm abdominal mass developed in 24 h. The plain film, barium, and ultrasound findings in enteric intussusception are stressed.

Anticoagulant therapy.

This is a brief review of some of the more important aspects of pharmacology and clinical management of anticoagulant therapy for venous thromboembolism. Some controversial aspects of treatment with respect to drug dosage, laboratory monitoring, and intensity and duration of therapy have been discussed. Thromboembolic complications can be reduced by extending the duration of anticoagulant therapy to a minimum period of 4 months after hospital discharge. Longer periods of treatment may be necessary in patients with recurrent deep venous thrombosis or pulmonary embolism. Hemorrhagic complications can be minimized by proper attention to laboratory monitoring and awareness of drug interactions and side effects.

Splenectomy in the treatment of hemolytic anemia.

In 113 patients with hemolytic anemia splenectomy was performed, without mortality and with minimal morbidity. Fifty-three patients with congenital spherocytosis and two with congenital elliptocytosis had postoperative increases in hematocrit to normal or near-normal levels. Three patients with pyruvate kinase deficiency and three with thalassemia variants were improved. Splenectomy in 52 patients with autoimmune hemolytic anemia resulted in an excellent response in 64% (no further steroid therapy) and an improved status in another 21% (prednisone requirements, 15 mg/day or less). For conditions other than congenital spherocytosis, in which splenectomy is uniformly of value, a decision to remove the spleen should be based on severity of the hemolytic process, failure to respond to other therapies, and the potential for achieving significant improvement in anemia and other associated cytopenias.

The limited role of splenectomy in patients with leukemia.

Splenectomy is a valuable method of management of approximately 80 per cent of patients with hairy cell leukemia who have hypersplenic complications develop; operation can be performed with minimal morality and morbidity. Removal of the spleen also provides useful palliation in patients with chronic lymphocytic leukemia who have symptomatic splenomegaly or autoimmune hemolytic anemia; success is less predictable when operation is performed for thrombocytopenia. Splenectomy is linked with a high mortality and is of little benefit in patients with chronic granulocytic leukemia except when operation is performed as a prerequisite to bone marrow transplantation. Several patients with acute leukemia who have signs of splenic infarction and intra-abdominal bleeding develop had a short survival period after splenectomy.

Felty's syndrome: when is splenectomy indicated?

The spectrum of disease was assessed in 43 patients with Felty's syndrome. Twenty-three underwent splenectomy. Although complete remission of neutropenia occurred in only two nonoperated patients, most of the patients had no serious infections during the subsequent period of observation. Operative morbidity was minimal in the splenectomized patients. On the basis of natural history of this condition, splenectomy should probably be restricted to neutropenic patients with serious or recurrent infections, patients with severe anemia requiring transfusions, those with the rare circumstance of profound thrombocytopenia, and those with non-healing leg ulcers.

Venous thromboembolism. Prevalence, risk factors, and prevention.

Venous thromboembolism is a major source of morbidity in hospitalized patients. A knowledge of the factors that increase the risk of development of this condition can be utilized to plan appropriate and cost-effective preventive management.

Diagnostic celiotomy for fever of undetermined origin.

In 38 patients with FUO, celiotomy provided a definitive or tentative diagnosis for which specific therapy could be prescribed in 19. No pattern of signs, symptoms or laboratory findings could be defined which might improve the diagnostic yield. In evaluating the outcome in nonoperated upon patients with FUO, prolonged observation or therapeutic trials have been no more successful in reaching a definitive diagnosis. The current process of selection of patients with FUO for celiotomy, although imperfect, has brought about a diagnosis in almost all patients with treatable malignant neoplasms and has not resulted in excessive morbidity or mortality in those who did not undergo operation.

Diagnosis of isolated small bowel injury following blunt abdominal trauma.

A review of the case histories of 29 patients with isolated rupture of the small bowel was undertaken to determine which diagnostic tests were most sensitive in the early diagnosis of this notoriously occult injury. Results indicate that peritoneal lavage was the most useful test for this purpose, clearly more sensitive than standard clinical or radiographic signs. All patients in this series had indications for peritoneal lavage, and 85% of the patients who underwent peritoneal lavage in the emergency department had positive results and prompt operation. Reliance on the development of clinical peritonitis or the detection of pneumoperitoneum leads to long delays before operation.

Splenectomy for agnogenic myeloid metaplasia.

Only a fraction of the patients with myeloid metaplasia have indications for splenectomy develop. Palliation for symptomatic splenomegaly is highly successful. Significant relief from hypersplenism, anemia or thrombocytopenia was achieved, however, in less than half of the patients. Since patients with severe thrombocytopenia are at continuing risk of spontaneous hemorrhage and of bleeding after minor trauma, splenectomy appears to be justified in these patients, provided that studies of peripheral blood and bone marrow have excluded those with leukemic conversion. The benefit obtained from splenectomy in patients with chronic anemia requiring frequent transfusions in less certain, particularly in men and in patients converting to myeloid metaplasia from polycythemia vera. In some instances, the continuation of transfusions may result in less morbidity and better palliation than operation. Although the course of this myeloproliferative disorder from first symptoms to death frequently extends for more than a decade, the manifestations which may provide an indication for splenectomy usually occur late in the course of the disease. The element as well as the morbidity of the operation makes a thorough evaluation of each patients essential before splenectomy is considered.

Indications for and morbidity associated with operative staging in patients with lymphoma.

Operative staging of patients with lymphoma has made an important contribution to the more accurate planning of treatment of this disease. Concomitant improvements in therapy have led to an increase in 5 year survival, particularly in patients with Hodgkin's disease. Nevertheless, considering risk versus benefit, several groups of patients might be spared increased morbidity from postoperative infection by restricting the operation to patients with stage I non-Hodgkin's lymphoma and to patients with Hodgkin's disease, stages I to III, without B symptoms. Groups having a greater risk of infection include all patients with non-Hodgkin's lymphoma and patients with Hodgkin's disease and B symptoms in whom operation is indicated. These exclusions from operative staging may not apply if accurate definition of the extent of disease is essential to evaluation of a new therapeutic program being assessed by a prospective randomized clinical trial.

Management of abdominal hemophilic pseudotumor.

The abdominal hemophilic pseudotumor is a rare but frequently disabling and life-threatening complication in patients with severe hemophilia. Our patients were observed for a considerable period of time to document progressive enlargement of the pseudotumor and increasing disability from severe pain, nerve compression, or leg swelling. The decision to operate was made on the basis of incapacitating symptomatology or fear of impending rupture. Although the complications resulting from operation may be major, with the current availability of large amounts of factor VIII and activated prothrombin complex concentrate, excision of this lesion can be performed without concern for the hazard of uncontrollable hemorrhage. Late recurrence of the pseudotumor may necessitate further operative management.