Splenectomy for Massive Splenomegaly Jerry Goldstone, MD, San Francisco, California

“The long course of the splenic artery along the upper edge of the pancreas . . . permits it to be exposed through the lesser peritoneal cavity some distance from the spleen. This is of considerable importance in dealing with very large spleens since it permits control of a major portion of the blood supply before attempting to mobilize the spleen.” LTC J.E. Dunphy, 1946[1]

The author of the above statement has maintained a keen interest in surgery of the spleen since the paper from which the quote was taken was published in this Journal in 1946. Although that paper was entitled, “Splenectomy for Trauma,” he has always been particularly interested and involved in the care of patients with massive spleens. Although there are few reports that deal specifically with removal of huge spleens [2], this procedure is commonly believed to be more dangerous and less beneficial than is removal of smaller spleens. The present study analyzes the morbidity, mortality, and efficacy of splenectomy for massive splenomegaly in order to substantiate these beliefs.

dionuclide scans performed in twenty-one patients confirmed massive splenomegaly in all cases and demonstrated associated hepatomegaly in ten cases. The scans indicated the eventual diagnosis in five patients: cysts were shown in two, and infiltrative processes suggestive of leukemia in three. Splenic arteriograms were performed in eight patients and were diagnostic in seven. All of the patients were symptomatic. The symptoms were of three types: physical-mechanical, related to the huge size of the spleen; hematologic, related to hypersplenism; and those related to splenic infarction. Abdominal fullness, the most common symptom, occurred in twenty-eight patients (82 per cent) and was often associated with a feeling of heaviness and discomfort. Moderate to severe abdominal and particularly left upper quadrant pain occurred in fifteen patients. Several patients with acute pain were thought on the basis of clinical findings to have splenic infarction. Four patients had left shoulder pain and only four had early satiety from gastrointestinal compression. The hypersplenic abnormalities determined the nature of the hematologic symptoms. Symptoms related to thrombocytopenia were common; bruising and/or petechiae were present in twelve patients, overt bleeding oc-

Material and Methods 8 The course of 300 consecutive patients undergoing splenectomy as a primary operation at the University of California, San Francisco was analyzed. Massive splenomegaly was defined as a spleen weighing 1,500gm or more. Thirty-four cases meeting this criterion were identified and form the basis for this analysis. Clinical Features. There were eighteen males and sixteen females ranging in age from five to seventy-nine years. Half of the patients were fifty years of age or older. (Figure 1.) Twenty-nine of the patients were Caucasian, two were black, and three were Oriental. All had massive, easily palpable spleens, that in many cases filled the entire left side of the abdomen and extended into the pelvis. In each case the spleen was clearly seen on plain abdominal x-ray, and twenty-four displaced the colon and/or gastric air bubble or elevated the left hemidiaphragm. Splenic raFrom the Department of Svgery. Universityof California School of Medicine, and Veterans Administration Hospital, San Francisco, California. This work was supported in part by Veterans Administration Research Service. Reprint requests should be addressed to Jerry Goldstone, MD, Department of Sugery, University of California School of Medicine, 4150 Clement Street, San Francisco, California 9412 1.

volume 135, March 1978

7 1

Cl0

II-20

21.30 Age

31.40 41.50 in Years

51.60

61-70

71.80

1

Figure 1. Age dhdribufti of thtriy-fourpatianta wtth maadve sptenomegaty. Monr than haff the pattents were older than tiny years.

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curred in four (epistaxis or monorrhagia), and occult bleeding in seven. Sixteen patients with marked anemia complained of fatigue, weakness, and pallor. Leukopenia led to recurrent infections in four patients, two of whom had white blood cell counts of less than 1,000/mm3. Hypersplenism involving one or more of the formed elements of the blood was present in twenty-eight of the thirty-four patients (82 per cent). Three patients had thrombocytopenia alone (platelet count of less than 150,000/mms). Six patients had anemia only (hematocrit less than 34). Eight patients had thrombocytopenia and anemia; two had thrombocytopenia and leukopenia; and two anemia and leukopenia. Seven patients had pancytopenia. Pathology. The weight of the resected spleens ranged from 1,500 to 6,100 gm and averaged 2,814 gm. (Figure 2.) The pathologic findings in the spleen were diagnostic in themselves or compatible with the clinical diagnosis in twenty-two patients. Among these were myeloid metaplasia (13 patients), leukemia (4 patients), lymphoma (2 patients), benign cysts (2 patients), and Gaucher’s disease (1 patient). Splenic congestion was the most significant abnormality in five other cases. In nine spleens nonspecific findings such as lymphoid and/or reticuloendothelial hyperplasia (4 patients) were described. Indication for Splenectomy. The most frequent reason for operation (15 patients) was to relieve symptoms from the massively enlarged spleen; other indications for splenectomy were symptomatic anemia (6 patients), thrombocytopenia (6 patients), and leukopenia (2 patients). In four patients splenectomy was performed principally to establish a diagnosis. One patient was operated on for spontaneous rupture of a leukemic spleen.

12 -

10 v) z CUB._ 5 a 6> t -D4E 3 =2-

0

152.0 Spleen

2.1-3.03.1-4.04.1-5.0 5.1-6.0 >6.0

Weight

(Kilograms)

Figure 2. Weight distribution of the removed spleens. A verage weight was 2,8 14 gm.

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All of the patients were deemed refractory to maximum medical treatment, which included blood transfusions, corticosteroids, busulfan, hydroxyurea, immunosuppression, and splenic irradiation. Most of the patients were seriously and chronically ill and were referred for splenectomy in a last effort to relieve bothersome or life-threatening symptoms and to improve the quality of life.

Operative Technic

All of the patients were operated on under general endotracheal anesthesia using a variety of anesthetic agents and technics. A midline incision was employed in twenty patients; left rectus muscle-splitting or retracting incisions were used in twelve, and a left subcostal incision in one. A left upper quadrant transverse incision was used in the one child in the series. All of the incisions were described in the operative reports as long or generous. In twenty-four patients the splenic artery was ligated along the upper border of the pancreas before the spleen was mobilized from its ligamentous attachments. Access to the artery was through the lesser peritoneal sac after a sufficient number of short gastric vessels were divided to obtain adequate exposure. In a few cases, epinephrine solution (1 cc of l:lO,OOO)was injected into the splenic artery before it was ligated. Both maneuvers promptly decreased the size of the spleen. In the other ten cases, the splenic attachments to the parieties were divided, and the spleen was delivered into the wound, before the major splenic vessels were divided and sutureligated. The average blood loss was 1.3 units (range, 0 to 6) when the splenic artery was ligated as a first step compared to 2.5 units (range, 0 to 9) when the artery was ligated after the spleen had been mobilized (p

Splenectomy for massive splenomegaly.

Splenectomy for Massive Splenomegaly Jerry Goldstone, MD, San Francisco, California “The long course of the splenic artery along the upper edge of th...
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