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Costi R, Castro Ruiz C, Romboli A, Wind P, Violi V, Zarzavadjian Le Bian A. Partial splenectomy: Who, when and how. A systematic review of the 2130 published cases. J Pediatr Surg 2019; 54:1527-1538. [PMID: 30665627 DOI: 10.1016/j.jpedsurg.2018.11.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 11/05/2018] [Accepted: 11/25/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND/PURPOSE In order to avoid consequences of total splenectomy (including severe postsplenectomy sepsis), partial splenectomy (PS) is increasingly reported. Without guidelines and indications concerning a rarely-indicated procedure, a review of literature should be an asset. METHODS A systematic review of all PSs from 1960 to December 2017 was performed, with special focus on surgical indications, sites of resection, approaches and techniques of vascular dissection and parenchymal section/hemostasis of the spleen, perioperative morbidity/mortality, including complications compelling to perform total splenectomy. RESULTS Among 2130 PSs, indications for resection were hematological disease in 1013 cases and nonhematological conditions in 1078, including various tumors in 142 and trauma in 184. Parenchymal transection was performed using several techniques through the years, most frequently after having induced partial ischemia by splenic hilum vascular dissection/ligation. 371 laparoscopic/robotic PSs were reported. Rescue total splenectomy was required in 75 patients. CONCLUSIONS Although good results are probably overestimated by such a retrospective review, PS should be considered as a procedure associated with a low morbidity/mortality. Nevertheless, severe complications are also reported, and the need of total splenectomy should not to be minimized. Laparoscopic/robotic procedures are increasingly performed, with good results and rare conversions. TYPE OF STUDY Systematic review. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Renato Costi
- Unità di Scienze Chirurgiche, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italia; Unità Operativa di Chirurgia Generale, Dipartimento Chirurgico, Ospedale di Vaio, Fidenza, Italia.
| | | | - Andrea Romboli
- Unità di Scienze Chirurgiche, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italia
| | - Philippe Wind
- Service de Chirurgie Générale Digestive, Cancerologique, Bariatrique et Métabolique, Hôpital Avicenne, Bobigny, France
| | - Vincenzo Violi
- Unità di Scienze Chirurgiche, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italia; Unità Operativa di Chirurgia Generale, Dipartimento Chirurgico, Ospedale di Vaio, Fidenza, Italia
| | - Alban Zarzavadjian Le Bian
- Service de Chirurgie Générale Digestive, Cancerologique, Bariatrique et Métabolique, Hôpital Avicenne, Bobigny, France; Laboratoire d'Ethique Médicale et de Médecine Légale, Université Paris "Descartes", Paris, France
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Tian AG, Hintz SR, Cohen RS, Edwards MSB. Ventricular access devices are safe and effective in the treatment of posthemorrhagic ventricular dilatation prior to shunt placement. Pediatr Neurosurg 2012; 48:13-20. [PMID: 22832699 DOI: 10.1159/000337876] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2011] [Accepted: 03/02/2012] [Indexed: 11/19/2022]
Abstract
Intraventricular hemorrhage of prematurity (IVH) is a diagnosis that has become more frequent in recent years. Advances in medical care have led to survival of increasingly premature infants, as well as infants with more complex medical conditions. Treatment with a ventricular access device (VAD) was reported almost 3 decades ago; however, it is unclear how effective this treatment is in the current population of premature infants. At our institution (from 2004 to present), we treat posthemorrhagic hydrocephalus (PHH) with a VAD. In order to look at safety and efficacy, we retrospectively combed the medical records of premature children, admitted to Lucile Packard Children's Hospital from January 2005 to December 2009, and identified 310 premature children with IVH. Of these, 28 children required treatment for PHH with a VAD. There were no infections associated with placement of these devices and a very low rate of other complications, such as need for repositioning (7.41%) or replacement (3.75%). Our data show that treatment with a VAD is very safe, with few complications and can be used to treat PHH in this very complex infant population.
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Affiliation(s)
- Ashley G Tian
- Department of Neurosurgery, Lucile Salter Packard Children's Hospital, Stanford University, Stanford, Calif. 94305-5327, USA.
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Louis D, Duc MLP, Reix P, Chazalette JP, Durieu I, Feigelson J, Bellon G. Partial splenectomy for portal hypertension in cystic fibrosis related liver disease. Pediatr Pulmonol 2007; 42:1173-80. [PMID: 17968998 DOI: 10.1002/ppul.20713] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
AIMS To review the middle- and long-term effects of partial splenectomy (PS) on portal hypertension (PHT) and its complications in patients with cystic fibrosis (CF) related liver disease risky PHT. METHOD Over a 20 years period, 19 patients aged 7-23 years underwent partial PS for massive splenomegaly, hypersplenism, and/ or severe PHT. RESULTS In all but three cases, PHT and hypersplenism have improved for long periods. Noticeable improvement of hepatic tests occurred simultaneously. In all patients PS resolved abdominal discomfort. Fifteen patients are alive and a stabilization of the liver disease occurred with a follow-up of 1-20 years (mean 7.9). One patient died following respiratory insufficiency 10 years after PS although PHT was stable. Manifestations recurred in 2 patients 5 and 6 years after PS. In two patients, the course of the disease evolved to hepatic insufficiency without recurrence of PHT 3 and 8 years after PS. PS did not give the expected results in three cases only, in which PHT was not modified or reoccurred during the following year. No severe complication was observed. Early (three patients) or late (one patient) eventration required surgical procedure. CONCLUSIONS Our results show that PS is a reliable and well-tolerated technique. Therefore, it is a therapeutic option for the management of PHT in CF patients with a preserved liver function. It can prevent and significantly delay a liver transplantation and its constraints.
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Affiliation(s)
- Dominique Louis
- Pediatric Cystic Fibrosis Centre, Hospices Civilis de Lyon, Université Claude Bernard Lyon 1, Hôpital Debrousse, Lyon, France
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Linnane B, Oliver MR, Robinson PJ. Does splenectomy in cystic fibrosis related liver disease improve lung function and nutritional status? A case series. Arch Dis Child 2006; 91:771-3. [PMID: 16737995 PMCID: PMC2082902 DOI: 10.1136/adc.2006.093773] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
AIMS To review the effect of total splenectomy on lung function and nutrition in children with cystic fibrosis related liver disease (CFLD) and associated portal hypertension. The stated indications for surgery and the short and long term risks of the procedure were also documented. METHOD Over a 25 year period from January 1980 to June 2005, approximately 650 patients with cystic fibrosis (CF) were treated at the Royal Children's Hospital, Melbourne, Australia. Nine patients with CFLD who underwent a splenectomy during that time were identified and their medical records were reviewed. RESULTS FEV1% predicted dropped by -16+/-11% in the two years pre-splenectomy. This contrasts with the increase in FEV1% predicted of 2+/-16% in the two years post-splenectomy (p = 0.05). The cumulative gain in WAZ score (DeltaWAZ pre) over the two years prior to splenectomy of 0.045+/-0.69 was not significantly different from the cumulative gain in WAZ score (DeltaWAZ post) for the two years after splenectomy of 0.15+/-0.36 (p = 0.65). The average age at splenectomy was 14.8 years (SD = 3 years). The average weight of an excised spleen was 983 g (SD = 414 g). There were no deaths associated with splenectomy. The median length of follow up post-splenectomy was 6.0 years (range 0.7-15.8). There were no episodes of bacterial peritonitis or overwhelming sepsis. CONCLUSIONS Splenectomy may have a beneficial effect on lung function although this may not manifest itself until the second year post-splenectomy. Splenectomy in patients with CFLD appears to be a safe procedure.
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Affiliation(s)
- B Linnane
- Department of Respiratory Medicine, Royal Children's Hospital, Melbourne, Australia.
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Abstract
Extra-hepatic portal hypertension (EHPH) defined as non cirrhotic, presinusoidal and prehepatic portal hypertension, with obstruction and cavernomatous transformation of the main portal vein, entails a high, early and prolonged risk of gastro-intestinal bleeding (GIB) mainly from esophageal and/or gastric varices, and less often a risk of cholangiopathy or protein-losing enteropathy. Diagnosis of EHPH may be done with non invasive imaging techniques. Assessment of bleeding risk is based on results of endoscopic examination. Occurence of a bleeding episode or onset during follow-up of endoscopic signs of high risk of GIB require radical eradication of varices. Radical cure of EHPH is achieved at best by bypass surgery restoring a physiological portal flow, and as a second choice by shunt surgery. Endoscopic therapy has a place as first line treatment of GIB episodes, and also in a few cases with poor extrahepatic portal network contra-indicating efficient vascular surgery.
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Affiliation(s)
- Frédéric Gauthier
- Service de Chirurgie Pédiatrique, Centre Hospitalier Universitaire Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin Bicêtre, France.
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Polat D, Rizalar R, Tander B, Yildiz L, Aritürk E, Bernay F. Effects of splenohepatopexy and omentopexy in experimentally induced infrahepatic portal hypertension in rats. Pediatr Surg Int 2004; 20:434-8. [PMID: 15098132 DOI: 10.1007/s00383-004-1171-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/20/2003] [Indexed: 02/06/2023]
Abstract
The purpose of this study was to determine whether splenohepatopexy (SHP) or omental transposition (OP) could reverse the portal hypertension (PH) induced by portal vein ligation (PVL). Fifty-eight Wistar rats divided into four groups: in group A (22 rats) PH was produced by calibrated PVL. In group B (8 rats), SHP was performed. Group C animals (13 rats) underwent SHP and PVL. In group D (15 rats) both PVL and OP were done. In all of the rats, the portal pressures (PP) were measured before and after the production of PVL. For SHP, small areas on the spleen and liver capsula were stripped off, and these two areas were placed together. In group D, an omentum patch was tied on the prepared liver surface. Twelve weeks after surgery, the PP were measured again and portal angiography was done. The liver, omentum and spleen were histopathologically examined. In all of the groups, the PP after PVL were significantly higher than before PVL. Twelve weeks after surgery, the PP of SHP and OP groups were significantly lower than those with PVL alone. Angiographic study showed many collaterals between transposed tissue and liver. Histopathologically, the collaterals of animals with SHP or OP were found to be well developed to allow sufficient flow for PP reduction. Both SHP and OP may reverse the increased PP in PVL model of PH. In the future; these methods may be alternative techniques for PP reduction in human beings as well.
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Affiliation(s)
- Dilek Polat
- Department of Pediatric Surgery, Ondokuzmayis University, Samsun, Turkey
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Debray D. Question 5 Quelle prise en charge de l'átteinte hepatobiliaire au cours de la mucoviscidose? Stratégie thérapeutique spécifique de 1' atteinte hépatobiliaire au cours de la mucoviscidose. Arch Pediatr 2003; 10 Suppl 3:490s-494s. [PMID: 14671965 DOI: 10.1016/s0929-693x(03)90016-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- D Debray
- Service d'hépatologie pédiatrique, hôpital de Bicêtre, 78, rue du Général Leclerc, 94275 Le Kremlin-Bicêtre, France
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Thalhammer GH, Eber E, Uranüs S, Pfeifer J, Zach MS. Partial splenectomy in cystic fibrosis patients with hypersplenism. Arch Dis Child 2003; 88:143-6. [PMID: 12538318 PMCID: PMC1719430 DOI: 10.1136/adc.88.2.143] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
We report three cystic fibrosis (CF) patients with hypersplenism who underwent partial splenectomy. The postoperative course was uneventful in two patients; one patient developed a complication necessitating resection of the rest of the spleen. Haematological parameters improved and oesophageal varices regressed in all patients. On follow up, one patient showed a normal spleen, the other a normally functioning accessory spleen; the third patient again developed splenomegaly with hypersplenism. Partial splenectomy is a promising therapeutic option for CF patients with hypersplenism.
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Affiliation(s)
- G H Thalhammer
- Respiratory and Allergic Disease Division, Paediatric Department, University of Graz, Austria
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Affiliation(s)
- A Munck
- Service de gastro-entérologie pédiatrique, hôpital Robert-Debré, 75019 Paris, France
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Abstract
Liver disease is the second most common cause of death in patients with cystic fibrosis (CF). Improvement in surgical techniques, medical management, and imaging modalities has broadened the range of options for treatment of these patients. Medical management with ursodeoxycholic acid and nutritional support may help decelerate the progression of liver disease. A timely evaluation of CF patients with liver involvement for transplantation is important. Such evaluation should not be delayed until signs of hepatic decompensation occur. Combined lung-liver transplant can be considered for patients with advanced pulmonary disease. Pretransplant management of portal hypertension with a portosystemic shunt procedure is an option for patients with well-preserved synthetic liver function. Improvement in lung function after liver transplantation and no significant risk of pulmonary infection with immunosuppressive therapy have been reported. Review of individual center experiences have shown satisfactory survival and improved quality of life for CF patients undergoing liver transplant.
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Affiliation(s)
- Y S Genyk
- Division of Pediatric Gastroenterology and Pediatric Liver Transplant Program, Childrens Hospital Los Angeles, University of Southern California, Los Angeles, California 90027, USA.
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Affiliation(s)
- C Colombo
- Department of Pediatrics, University of Sassari, Italy.
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Debray D, Lykavieris P, Gauthier F, Dousset B, Sardet A, Munck A, Laselve H, Bernard O. Outcome of cystic fibrosis-associated liver cirrhosis: management of portal hypertension. J Hepatol 1999; 31:77-83. [PMID: 10424286 DOI: 10.1016/s0168-8278(99)80166-4] [Citation(s) in RCA: 104] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND/AIM Variceal bleeding is the most severe complication in patients with cystic fibrosis-associated liver cirrhosis, who often do not have severe respiratory failure. The advent of liver transplantation has broadened the treatment options. The purpose of this study was to report our experience with the management of portal hypertension. METHODS Clinical and biochemical features, outcome of liver disease and management of portal hypertension were analyzed retrospectively in 44 children with cystic fibrosis-associated liver cirrhosis. RESULTS The mean age at diagnosis of liver cirrhosis was 9 years. Eighty-six per cent of the children developed esophageal varices, 50% of whom bled early in their second decade. Injection sclerotherapy of esophageal varices did not prevent recurrence of bleeding in five of seven children. Elective surgical portosystemic shunting was successfully performed in nine of 11 patients considered being at high risk of bleeding or with recurrent bleeding episodes but without severe pulmonary failure and liver dysfunction, allowing prolonged post-operative survival up to 15 years. Two of three children who underwent isolated liver transplantation for severe portal hypertension died post-operatively. CONCLUSIONS Management emphasis in cystic fibrosis patients with liver cirrhosis should be on control of bleeding and variceal decompression. These results suggest that surgical portosystemic shunting may be considered to relieve portal hypertension in patients without progressive liver failure and severe lung disease as an alternative to liver transplantation. With this policy, patients may be stabilized for many years until progression of liver or lung diseases indicates liver or lung-liver transplantation.
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Affiliation(s)
- D Debray
- Service d'Hépatologie Pédiatrique, Hôpital de Bicêtre, Le Kremlin-Bicêtre, France
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Freud E, Cohen IJ, Neuman M, Mor C, Zer M. Should repeated partial splenectomy be attempted in patients with hematological diseases? Technical pitfalls and causes of failure in Gaucher's disease. J Pediatr Surg 1997; 32:1272-6. [PMID: 9314241 DOI: 10.1016/s0022-3468(97)90300-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND/PURPOSE The awareness of the risk of overwhelming sepsis after splenectomy prompted surgeons to attempt splenic preservation in patients who had hematologic diseases for which splenectomy was the conventional treatment. Partial splenectomy for Gaucher's disease was widely performed before the introduction of alglucerase. In sporadic cases a second partial splenectomy had also been attempted. METHODS The authors present three cases of failed repeated partial splenectomy attempted before alglucerase was available. The role of angiography in planning operative strategy and the surgical pitfalls of this unusual reintervention are discussed. CONCLUSION New indications for partial splenectomy in other hematologic diseases makes the experience gained with Gaucher's disease valuable for management decisions.
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Affiliation(s)
- E Freud
- Department of Pediatric Surgery, Schneider Children's Medical Center of Israel, Beilinson Medical Campus, Petah Tiqva
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Mack DR, Traystman MD, Colombo JL, Sammut PH, Kaufman SS, Vanderhoof JA, Antonson DL, Markin RS, Shaw BW, Langnas AN. Clinical denouement and mutation analysis of patients with cystic fibrosis undergoing liver transplantation for biliary cirrhosis. J Pediatr 1995; 127:881-7. [PMID: 8523183 DOI: 10.1016/s0022-3476(95)70022-6] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To describe the clinical characteristics of patients with cystic fibrosis considered for liver transplantation and the clinical outcome after transplantation. METHODS Patient charts were reviewed. Mutation analysis was performed on blood or liver tissue samples with a panel of 17 mutations. RESULTS Eight patients (five girls) with cystic fibrosis have undergone orthotopic liver transplantation for biliary cirrhosis. Mean age at transplantation was 12.0 years +/- 7.7 years (range, 9 months to 23 years). Preoperatively, seven patients had mild to moderate pulmonary dysfunction and one moderate to severe pulmonary dysfunction. All patients required pancreatic enzyme replacement, and four patients required insulin for diabetes mellitus. The 1-year survival rate was 75%, with no deaths related to septic events. Mean time of follow-up the six operative survivors was 4.1 years +/- 1.9 years. Pulmonary function testing, in those serially tested, showed that forced expiratory volume in 1 second was maintained or improved and that forced vital capacity improved after transplantation. Mutation analysis showed the following genotypes: four patients, delta F508/delta F508; one patient, delta F508/N1303K; and three patients, delta F508/unknown. CONCLUSIONS Despite the high risk of transplantation, these encouraging results indicate that liver transplantation should be considered for patients with cystic fibrosis and complications of end-stage liver disease. We could not demonstrate an unusual pattern of CF gene mutations in these patients with severe liver disease. It appeared that immunosuppressive agents did not have a deleterious effect on pulmonary function.
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Affiliation(s)
- D R Mack
- Department of Pediatrics, University of Nebraska Medical Center, Omaha 68198-5160, USA
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