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surgical removal of the spleen

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出典(authority):フリー百科事典『ウィキペディア（Wikipedia）』「2012/05/12 15:02:39」(JST)

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A splenectomy is a surgical procedure that partially or completely removes the spleen.

Indications

The spleen, similar in structure to a large lymph node, acts as a blood filter. Current knowledge of its purpose includes the removal of old red blood cells and platelets, and the detection and fight against certain bacteria. It is also known to function as a site for the development of new red blood cells from their hematopoietic stem cell precursors, and particularly in situations in which the bone marrow, the normal site for this process, has been compromised by a disorder such as leukemia. The spleen is enlarged in a variety of conditions such as malaria, mononucleosis and most commonly in "cancers" of the lymphatics, such as lymphomas or leukemia.

It is removed under the following circumstances:

When it becomes very large such that it becomes destructive to platelets/red blood cells
For diagnosing certain lymphomas
Certain cases of wandering spleen
When platelets are destroyed in the spleen as a result of an auto-immune process (see also idiopathic thrombocytopenic purpura)
When the spleen bleeds following physical trauma
Following spontaneous rupture
For long-term treatment of congenital erythropoietic porphyria (CEP) if severe hemolytic anemia develops^[1]
The spread of gastric cancer to splenic tissue
When using the splenic artery for kidney revascularisation in renovascular hypertension.
For long-term treatment of congenital pyruvate kinase (PK) deficiency
As a treatment for idiopathic thrombocytopenic purpura (ITP) when steroids and other medication have proven ineffective.^{[citation needed]}

The classical cause of traumatic damage to the spleen is a blow to the abdomen during a sporting event. In cases where the spleen is enlarged due to illness (mononucleosis), trivial activities, such as leaning over a counter or straining while defecating, can cause a rupture.

Procedure

Laparoscopy is the preferred procedure in cases where the spleen is not too large and when the procedure is elective. Open surgery is performed in trauma cases or if the spleen is enlarged. Either method is major surgery and is performed under general anesthesia. Vaccination for pneumococcus, H. influenza and meningococcus should be given pre-operatively if possible to minimize the chance of overwhelming post-splenectomy infection (OPSI), a rapid-developing and potentially fatal type of septicaemia. The spleen is located and disconnected from its arteries. The ligaments holding the spleen in place are dissected and the organ is removed. In some cases, one or more accessory spleens are discovered and also removed during surgery. The incisions are closed and when indicated, a drain is left. If necessary, tissue samples are sent to a laboratory for analysis.

Side effects

As splenectomy causes an increased risk of sepsis due to encapsulated organisms (such as S. pneumoniae and Haemophilus influenzae) the patient should receive the pneumococcal conjugate vaccine (Prevnar), Hib vaccine, and the meningococcal vaccine; see asplenia. These bacteria often cause a sore throat under normal circumstances but after splenectomy, when infecting bacteria cannot be adequately opsonized, the infection becomes more severe.

An increase in blood leukocytes can occur following a splenectomy.^[2]^[3] The post-splenectomy platelet count may rise to abnormally high levels (thrombocytosis), leading to an increased risk of potentially fatal clot formation. There also is some conjecture that post-splenectomy patients may be at elevated risk of subsequently developing diabetes.^[4] Splenectomy may also lead to chronic neutrophilia. Splenectomy patients typically have Howell-Jolly bodies^[5]^[6] and less commonly Heinz bodies in their blood smears^[7]. Heinz bodies are usually found in cases of G6PD (Glucose-6-Phosphate Dehydrogenase) and chronic liver disease^[8].

Partial splenectomy

Much of the spleen's protective roles can be maintained if a small amount of spleen can be left behind.^[9] Where clinically appropriate, attempts are now often made to perform either surgical subtotal (partial) splenectomy,^[10] or partial splenic embolization.^[11] In particular, whilst vaccination and antibiotics provide good protection against the risks of asplenia, this is not always available in poorer countries.^[12] However as it may take some time for the preserved splenic tissue to provide the full protection, it has been advised that preoperative vaccination still be given.^[13]

References

^ Frye R. (2006-03-02). "Porphyria, Cutaneous". eMedicine. http://www.emedicine.com/ped/topic1871.htm. Retrieved 2006-03-28.
^ "Guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen. Working Party of the British Committee for Standards in Haematology Clinical Haematology Task Force". BMJ 312 (7028): 430–4. 1996. doi:10.1136/bmj.312.7028.430. PMC 2350106. PMID 8601117. http://bmj.bmjjournals.com/cgi/content/full/312/7028/430.
^ J M Davies et al. (2001-06-02). "The Prevention And Treatment Of Infection In Patients With An Absent Or Dysfunctional Spleen - British Committee for Standards in Haematology Guideline up-date". BMJ. Full text.
^ http://www.nytimes.com/2004/11/09/health/09diab.html?pagewanted=print&position= New York Times article
^ synd/1596 at Who Named It?
^ Katcher AL. Familial asplenia, other malformations, and sudden death. Pediatrics. 1980 Mar;65(3):633-5.
^ Hematology: Clinical Principles and Applications. Rodak B, Fritsma, G and Doig, K.
^ "Anemia in Children - October 15, 2001 - American Family Physician". http://www.aafp.org/afp/20011015/1379.html.
^ Grosfeld JL, Ranochak JE (1976). "Are hemisplenectomy and/or primary splenic repair feasible?". J. Pediatr. Surg. 11 (3): 419–24. doi:10.1016/S0022-3468(76)80198-4. PMID 957066.
^ Bader-Meunier B, Gauthier F, Archambaud F, et al. (2001). "Long-term evaluation of the beneficial effect of subtotal splenectomy for management of hereditary spherocytosis". Blood 97 (2): 399–403. doi:10.1182/blood.V97.2.399. PMID 11154215.
^ Pratl B, Benesch M, Lackner H, et al. (2007). "Partial splenic embolization in children with hereditary spherocytosis". Eur J Haematol 80 (1): 76–80. doi:10.1111/j.1600-0609.2007.00979.x. PMID 18028435.
^ Sheikha AK, Salih ZT, Kasnazan KH, et al. (October 2007). "Prevention of overwhelming postsplenectomy infection in thalassemia patients by partial rather than total splenectomy". Can J Surg 50 (5): 382–6. PMC 2386178. PMID 18031639. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=2386178.
^ Kimber C, Spitz L, Drake D, et al. (1998). "Elective partial splenectomy in childhood". J. Pediatr. Surg. 33 (6): 826–9. doi:10.1016/S0022-3468(98)90651-0. PMID 9660206.

UpToDate Contents

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2. 脾腫およびその他の脾疾患を有する成人患者に対するアプローチ approach to the adult patient with splenomegaly and other splenic disorders
3. 成人外傷患者における脾臓損傷の外科的マネージメント surgical management of splenic injury in the adult trauma patient
4. 患者情報：脾摘後の重症感染症の予防（詳細） preventing severe infection after splenectomy beyond the basics
5. フェルティ症候群における脾臓摘出術の適応 indications for splenectomy in feltys syndrome

English Journal

A case report of bacteremia manifesting as an overwhelming postsplenectomy infection due to Streptococcus pneumoniae post vaccination.

Hirose K1, Okabe H1,2, Yoshizumi T3, Uchiyama H1, Ikegami T1, Harimoto N1, Itoh S1, Kimura K1, Baba H2, Maehara Y1.
Surgical case reports.Surg Case Rep.2016 Dec;2(1):48. doi: 10.1186/s40792-016-0173-2. Epub 2016 May 25.
A 62-year-old woman was admitted for acute epigastralgia and high-grade fever of over 39 °C. The patient had undergone splenectomy for idiopathic portal hypertension 1 year ago and vaccination against Streptococcus pneumoniae immediately post operation. She developed localized peritoneal irritati
PMID 27221131

A case of splenic metastasis of ovarian cancer treated with complete laparoscopic splenectomy and transvaginal specimen extraction.

Takase Y1,2, Tomizawa N3,4, Enokida Y1,2, Shiraishi T1, Katoh R1,2, Suto Y1,2, Sato H1,2, Muroya K1,2, Kurosaki R1,2, Kobayashi K1,2, Arakawa K1,2, Ando T1,2, Takesyohi I2.
Surgical case reports.Surg Case Rep.2016 Dec;2(1):26. doi: 10.1186/s40792-016-0150-9. Epub 2016 Mar 14.
A 61-year-old woman was diagnosed with right inguinal lymph node and splenic metastasis of ovarian serous cystadenocarcinoma. We performed right inguinal lymph node dissection and total laparoscopic splenectomy in the supine position followed by transvaginal specimen extraction (TVSE). First, using
PMID 26976616

Splenic Pregnancy: A New Minimally Invasive Approach to Treatment.

Klang E1, Keddel N2, Inbar Y2, Rimon U2, Amitai M2.
Cardiovascular and interventional radiology.Cardiovasc Intervent Radiol.2016 Sep;39(9):1339-42. doi: 10.1007/s00270-016-1403-5. Epub 2016 Jun 29.
The spleen is a rare site of abdominal ectopic pregnancy. In a review of the literature, we found 16 published cases of primary splenic pregnancies. Of the cases identified, all received surgical intervention, with one case successfully treated with laparoscopic methotrexate injection, and the rest
PMID 27358040

Japanese Journal

がんの最新治療各論(11)卵巣がんの治療

野村秀高,松井英雄
東京女子医科大学雑誌 83(5), 328-333, 2013-10-25
… Recently, primary and interval debulking surgeries for pelvic and paraaortic lymphadenectomy, bowel resection, splenectomy and resection of peritoneum and diaphragm are performed in patients with advanced stage. …
NAID 110009631870

臨床編各種デバイスを応用した脾手術 (特集各種デバイスを応用した私の手術 : 使用法と工夫)

瀬下明良,亀岡信悟
外科 75(9), 965-969, 2013-09
NAID 40019790061

症例報告迅速な治療開始で劇症化を防いだ脾摘後遺伝性球状赤血球症の1例

大木庸子,七野浩之,谷ヶ崎博 [他]
日大医学雑誌 = Journal of Nihon University Medical Association 72(4), 236-239, 2013-08
NAID 40019798612

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