Thrombocytopenia after autologous bone marrow transplantation in in acute lymphatic leukemia]

There is reported about the treatment of refractory thrombocytopenia in a 9 years old boy following the autologous bone marrow transplantation for acute lymphoblastic leukaemia. The megakaryocytes were found diminished in the bone marrow smears. Controls of the thrombocyte count and the kinetics with radioactively labeled platelets of a donor spoke in favour of immunothrombocytopenia. Threatening bleeding complications challenged the use of all treatment possibilities. The irradiation of the spleen was without any success. After the splenectomy the thrombocyte count increased slowly, but after a remarkable lag phase, however. A diminished reproduction capacity of the bone marrow graft for special cell sorts has to be taken into account in such cases. The usual cytodynamics after splenectomy cannot be expected at all.     

Changes in immune status in patients undergoing splenectomy for the staging of Hodgkin's disease.

The immune status of 17 patients with Hodgkin''s disease was studied before and after splenectomy (undertaken in staging laparotomy) and during chemotherapy or after radiotherapy. The findings were compared with those in 19 patients not selected for splenectomy. Serum IgA and IgM levels became significantly lower after treatment in the splenectomy group. Cell-mediated immunity was depressed mainly in patients receiving quadruple cytotoxic chemotherapy. Neutrophil function was normal or enhanced and was unchanged after splenectomy and treatment despite changes in neutrophil counts. Three patients who underwent splenectomy suffered fatal septicaemia. These results suggest that humoral immunity is depressed by treatment in patients who have undergon splenectomy, and the benefits of early accurate staging must be weighed against the likelihood of infective complications.     

脾动脉栓塞术后出现严重粘连的脾切除手术体会

目的:探讨脾动脉栓塞术后严重脾粘连脾切除手术技巧,为临床实践提供可借鉴的方法。方法:收集我院2005年4月-2013年6月收治的18例脾动脉栓塞术后严重脾粘连行脾切除术的患者临床资料,分析手术时间、术中出血、术中特殊处理及术后恢复情况等。结果:18例患者均顺利恢复出院,无围手术期死亡,开腹后到脾切除完成平均耗时55 min、出血550 mL。术后并发症为腹水(8例)、肺部感染(1例)、胰瘘(1例)及腹腔内出血(1例)。结论:脾动脉栓塞术后出现严重脾粘连行脾切除术,手术风险较大,手术时间、术中出血较常规脾切除术明显延长、增多。规范手术操作,细致分离脾周粘连,合理处理脾蒂,是安全、有效完成此类脾切除术的关键。     

2200例门静脉高压症患者行脾切除贲门周围血管离断术的近期疗效观察

目的:总结脾切除贲门周围血管离断术治疗门静脉高压症的近期疗效。方法:回顾性分析我院1999年6月-2013年6月收治的2200例择期行脾切除贲门周围血管离断术的肝硬化门静脉高压症患者的临床资料。统计并分析手术前后的止血率、并发症及肝功能指标等。结果:近期随访率78%(1716/2200);其中,上消化道出血史88.3%(1515例),手术止血率为99.1%(1701例),围术期病死率为1.3%(22例),主要死亡原因为感染和肝肾功能衰竭;并发症情况:发热39.8%(683例)、腹腔内出血2%(34例)、门静脉系统血栓51%(875例)、胸腹腔感染3.7%(63例)、肝脓肿0.7%(12例)、胃瘘0.3%(5例)及胰瘘0.3%(5例)。丙肝肝硬化脾切除抗病毒103例,预防手术112例,丙肝切脾抗病毒、预防手术围手术期无死亡;肝功能Child分级:术前85%为A级,术后94%为A级;ALB、TBil、PT及腹水消失率均明显好转。结论:脾切除贲门周围血管离断术对门静脉高压症引起的上消化道出血具有积极的作用,可获得较好的近期疗效,并发症经对症处理可消除或缓解,但如何有效降低术后门静脉系统血栓的形成仍需在今后的临床实践中深入研究。     

Successful Splenectomy for Hypersplenism in Wilson’s Disease: A Single Center Experience from China

Splenomegaly and pancytopenia are common in Wilson’s disease (WD) and splenectomy is one of the conventional treatments for splenomegaly and the associated pancytopenia. However, splenectomy remained controversial for hypersplenism in WD as it was reported that splenectomy leaded to serious emotional and neurological deterioration in WD patients with hypersplenism. In the current study, we present our experiences in 70 WD patients with hypersplenism who had undergone splenectomy, outlining the safety and efficacy of splenectomy in WD. The clinical database of 70 WD patients with hypersplenism who had undergone splenectomy in our hospital between 2009 and 2013 were reviewed and followed-up regularly. Before splenectomy, all the patients accepted a short period of anti-copper treatment with intravenous sodium 2, 3-dimercapto-1-propane sulfonate (DMPS). All the patients demonstrated a marked improvement in platelet and leucocyte counts after splenectomy. No severe postoperative complication was observed. In particular, none of the 37 patients with mixed neurologic and hepatic presentations experienced neurological deterioration after splenectomy, and none of the patients with only hepatic presentations newly developed neurological symptoms. During the one year follow-up period, no patient presented hepatic failure or hepatic encephalopathy, no hepatic patient newly developed neurological presentations, and only 3 patients with mixed neurologic and hepatic presentations suffered neurological deterioration and these 3 patients had poor compliance of anti-copper treatment. Quantative analysis of the neurological symptoms in the 37 patients using the Unified Wilson’s Disease Rating Scale (UWDRS) showed that the neurological symptoms were not changed in a short-term of one week after splenectomy but significantly improved in a long-term of one year after splenectomy. Additionally, compared to that before splenectomy, the esophageal gastric varices in most patients significantly improved one year after splenectomy. Thus, we may conclude that splenectomy is a safe and effective therapeutic measure for hypersplenism in WD patients who had been preoperatively treated with DMPS for powerful anti-copper therapy.     

The syndrome of pneumococcemia,disseminated intravascular coagulation and asplenia.

A 58-year-old man who survived an episode of fulminant pneumococcal septicemia with disseminated intravascular coagulation had undergone splenectomy 23 years previously. In the literature there are 25 reported cases of fulminant septicemia and disseminated intravascular coagulation associated with asplenia in adults (excluding cases in which corticosteroid or immunosuppressive therapy was given). The pneumococcus was responsible for all of these cases as well. The mortality in this series was more than 90%, and death occurred within 24 hours of presentation at hospital in almost 70% of the fatal cases and was associated with high-density bacteremia and adrenal hemorrhage. Gram-staining of the buffy coat of the peripheral blood or the exudate from purpuric skin lesions was carried out in only 6 of the 26 cases but yielded positive results in all but 1. It is concluded that a diagnosis of septicemia in asplenic adults can be established within a short time of presentation on the basis of statistical probability and the results of Gram-staining of the peripheral blood and exudate from the skin lesions. Prevention appears to be the cornerstone of management because of the variable interval from splenectomy to the onset of the syndrome and the high mortality.     

部分脾栓塞术对肝硬化脾功能亢进的介入治疗

目的:探讨和评价部分脾栓塞术(PSE)治疗肝硬化脾功能亢进的临床应用价值。方法:采用Seldinger技术对28例乙肝后肝硬化伴脾功能亢进患者用高压消毒明胶海绵颗粒共进行31次PSE。结果:28例手术中27例获得成功,栓塞范围为30％-60％,25位患者术后1周以内、1-2周及2周以上WBC和PLT均有不同程度的上升(P<0.01),临床有效率为92.6％。手术前后肝功能变化不大。全部病例均未发生严重并发症。结论:部分脾栓塞术对治疗肝硬化脾亢有明显疗效,可替代脾切除术。对肝功能的改善,近期疗效不明显。     

Planned splenectomy in treatment of idiopathic thrombocytopenic purpura.

The results of a policy of treatment in idiopathic thrombocytopenic purpura based on previous observations on the natural history of the disease and its response to corticosteroids are described. The results of splenectomy were better when the history was less than 100 days. Three patterns of response to splenectomy were observed: complete remission, symptomatic remission, and relapse. The prognosis can be determined by the level of the platelet count six weeks after splenectomy. Corticosteroid treatment for more than three weeks before splenectomy noticeably increased the incidence of complications after operation. Splenectomy can safely be performed in pregnancy. The decision to operate should be made on the maternal condition and its response to corticosteroids.     

Regenerative capacity of the spleen in a splenectomized fish, Channa punctatus Bloch, with related investigations into changes in peripheral blood and haematopoiesis

The present investigation has provided evidence by a simultaneous study of the regenerating spleen, peripheral blood and the kidney of the haematopoietic tissue to establish the role of the spleen in the development of circulating blood cells in Channa ( Ophiocephalus ) punctatus Bloch. Regeneration of the spleen after eight to nine weeks of splenectomy was shown to be complete. Weekly observations a fortnight after splenectomy are recorded with reference to spleen morphology and weight, erythrocyte and differential leucocyte counts, haemoglobin content, haematocrit value and related red cell indices (MCV, MCH, MCHC). The results show that splenectomy leads to a macrocytic hypochromic anaemia and leucopenia, resulting in 25% reduction in haemoglobin content and a decrease in leucocyte numbers in five weeks following splenectomy. Thrombocytes and neutrophils show a relative ( P < 0·01) increase. The leucopenia is caused by large and small lymphocytes, eosinophils and basophils whose number was reduced from 50% to 67%.     

Pneumococcal meningitis in community is frequent after craniocerebral trauma and in alcohol abusers

Aim of this short communication was to assess risk factors and outcome of community acquired pneumococcal meningitis and compare it to all cases of community acquired meningitis. Univariate analysis was used for comparison of 68 pneumococcal to 201 CBM within a Slovak nationwide database of CBM. Significant risk factors for pneumococcal meningitis were previous craniocerebral trauma within 7 days (39.7% vs. 14.9%, p=0.00002), splenectomy (10.3% vs. 3.5%, p=0.03) and alcohol abuse (36.8% vs. 15.4%, p=0.0001). Concerning outcome, mortality was similar (8,8% and 12,4%, NS), proportion of those with neurologic sequellae after CBM due to Str. pneumoniae was insignificantly higher (20.6% vs. 15.4%, NS) in comparison to all CBM. All but 2 strains Str. pneumoniae were susceptible to penicillin and macrolides (3.3% resistance).     

Clinical Study on the Relationship Between Hematocytopenia and Splenomegaly Caused by Cirrhotic Portal Hypertension

This clinical study was designed to evaluate the presence of hematocytopenia in patients with splenomegaly caused by non-alcoholic cirrhotic portal hypertension. For this purpose, we randomly selected 358 patients with splenomegaly caused by non-alcoholic cirrhotic portal hypertension and admitted to the clinical data in our hospital between January 1991 and June 2009. Among these 358 patients, 322 patients (90.0 %) showed hematocytopenia, including multi-hemocyte decrease in 206 patients (i.e., 89 patients with a decrease in white blood cell count (WBC) + red blood cell count (RBC) + platelets count (PLT)); 52 patients with WBC + PLT decrease; 29 patients with RBC + PLT decrease; and 36 patients with WBC + RBC decrease) and single-hemocyte decrease in 116 patients (i.e., 31 cases with single PLT decrease; 29 cases with single WBC decrease; and 56 patients with single RBC decrease). After splenectomy, 36 patients (10.0 %) with hematocytopenia presented a statistical improvement of blood cell to normal level (P < 0.05), while 32 patients did not have any change as compared to pre-operative one (P > 0.05). It has to be noted that 4 patients did not received any surgery. Hematocytopenia was not detected in all the patients with splenomegaly caused by cirrhotic portal hypertension, thus it is probably a complication of splenomegaly but not an inevitable manifestation. It was concluded that splenectomy could be an effective treatment for splenomegaly associated with hematocytopenia, but patients without hematocytopenia could choose a non-surgical alternative treatment.     

SPLENECTOMY IN BLOOD DYSCRASIA

The decision for splenectomy must be based on a knowledge of the three functions of the spleen: Hematopoiesis (usually ceasing during fetal life but sometimes resuming when bone marrow function fails); filtration of abnormal and senescent cells and control of bone marrow activity, most probably humoral.When bone marrow function fails, splenectomy is contraindicated since splenic hematopoiesis becomes a vital function. On the other hand, when a large proportion of erythrocytes are abnormally shaped (spherocytes), although otherwise adequate, the spleen may trap these cells in its filter and destroy large numbers. Splenectomy is beneficial in almost every case of congenital spherocytosis, but in only half the cases of the acquired defect.In panhematocytopenia, thrombocytopenia and neutropenia, all apparently due to depression of hematopoiesis by endocrine or other action of the spleen, splenectomy may be beneficial if medical therapy fails.A surgeon undertaking splenectomy should recognize two special problems: (1) The presence of accessory spleens, which if not removed may negate the effects of the operation, and (2) the apparently high rate of infection in infants and children who have undergone splenectomy.     

Splenectomy associated changes in IgM memory B cells in an adult spleen registry cohort

Asplenic patients have a lifelong risk of overwhelming post-splenectomy infection and have been reported to have low numbers of peripheral blood IgM memory B cells. The clinical value of quantitation of memory B cells as an indicator of splenic abnormality or risk of infection has been unclear. To assess changes in B cell sub-populations after splenectomy we studied patients recruited to a spleen registry (n = 591). A subset of 209 adult asplenic or hyposplenic subjects, and normal controls (n = 140) were tested for IgM memory B cells. We also determined a) changes in IgM memory B cells with time after splenectomy using the cross-sectional data from patients on the registry and b) the kinetics of changes in haematological markers associated with splenectomy(n = 45). Total B cells in splenectomy patients did not differ from controls, but memory B cells, IgM memory B cells and switched B cells were significantly (p<0.001) reduced. The reduction was similar for different indications for splenectomy. Changes of asplenia in routine blood films including presence of Howell-Jolly bodies (HJB), occurred early (median 25 days) and splenectomy associated thrombocytosis and lymphocytosis peaked by 50 days. There was a more gradual decrease in IgM memory B cells reaching a stable level within 6 months after splenectomy. IgM memory B cells as proportion of B cells was the best discriminator between splenectomized patients and normal controls and at the optimal cut-off of 4.53, showed a true positive rate of 95% and false positive rate of 20%. In a survey of 152 registry patients stratified by IgM memory B cells around this cut-off there was no association with minor infections and no registry patients experienced OPSI during the study. Despite significant changes after splenectomy, conventional measures of IgM memory cells have limited clinical utility in this population.     

Hem-o-lok结扎锁在腹腔镜脾切除术中的应用

目的:探讨Hem-o-lok结扎锁在腹腔镜脾切除术中的可行性及安全性。方法:选取2012年1月-2013年6月在我院接受腹腔镜脾切除术的患者97例,随机分为观察组(49例)和对照组(48例)。观察组患者采用Hem-o-lok结扎锁双重夹闭脾动脉,对照组则采用ENDOLOOP结扎圈套器双重结扎脾动脉。对比两组患者的手术时间、术中出血量、术后切口感染、残余脓肿、粘连性腹痛及门静脉血栓等并发症的发生率、住院时间及手术费用。结果:采用Hem-o-lok结扎锁的观察组患者手术时间、术中出血量、并发症的发生率、住院时间及手术费用均优于采用ENDOLOOP结扎圈套的对照组,差异显著且具有统计学意义(P0.05)。结论:Hem-o-lok结扎锁用于腹腔镜脾切除术具有很好的手术效果,不仅操作简单、安全有效,而且缩短了手术时间及术后并发症的发生率,值得临床推广应用。     

Operations for portal hypertension due to extrahepatic obstruction: results and 10 year follow up.

Between 1976 and 1984, 136 patients with portal hypertension due to extrahepatic obstruction were operated on. Twenty two patients had emergency and 114 elective operations. The operative mortality was 9% and 1%, respectively. Altogether 117 patients (86%) were followed up for from two to 10 years: 17 rebled, none developed encephalopathy or sepsis after splenectomy, and 90% and 75% were alive at five and 10 years respectively. Unlike endoscopic sclerotherapy and treatment with propranolol, operative treatment of variceal bleeding can usually be completed during one admission and carries a low mortality and a fairly low morbidity. Operation seems to be the best form of treatment for poor patients living far from medical facilities in developing countries and may be the treatment of choice in developed countries as well.     

New trends in CLL treatment

We review here results obtained from the various treatment modalities that have been used in CLL patients: chemotherapy; radiotherapy; splenectomy; leukapheresis; monoclonal antibodies and other immunomodulating agents. We conclude that it is still unclear whether patients in stage A (good prognosis) should be treated; intermediate forms of the disease (stage B) should, in most cases, be treated, but a better treatment than chlorambucil has not emerged; results from the Cooperative Group on CLL of Société Fran?aise d'Hématologie indicate that significant progress in the therapy of the advanced stage (stage C) has been achieved with the introduction of the CHOP regimen, using low doses of adriamycin; radiotherapy, splenectomy and immunomodulators such as levamizol, interleukins or interferons, and possibly monoclonal antibodies, are now being actively tested; the results are not yet conclusive.     

Bacteremic meningitis is associated with inferior outcome in comparison to community acquired meningitis without bacteremia

Meningitis associated with bacteremia is rare. Bacteremic form of meningitis occurred in 28 of 201 cases of community acquired meningitis (14%) in Slovakia within last 17 years. Bacteremic meningitis was associated with diabetes (21.4% vs. 7.5%, p=0.02) and with higher treatment failures (32.1% vs. 9.5%, p=0.01) and higher mortality (25% vs. 12.4%, NS). In univariate analysis comparing 28 cases of bacteremic community acquired bacterial meningitis (BCBM) to all CBM, no significant risk factor concerning underlying disease (cancer, ENT infection, alcohol abuses, trauma, splenectomy, etc.) or etiology was observed apart of diabetes mellitus, which was more common among bacteremic meningitis (21.4% vs. 7.5%, p=0.02). Mortality (25% vs. 12.4%, NS) insignificantly but therapy failure (32.1% vs. 9.5%, p=0.01) was significantly more frequently observed among meningitis with bacteremia. N. meningitis was the commonest causative agent (8 of 28 cases) followed by Str. pneumoniae (6), gram-negative bacteria (6), S. aureus (4) and H. influenzae (2).     

Predictors of inferior outcome in community acquired bacterial meningitis

The aim of this study was to assess mortality and sequellae within cases from Nationwide survey of community acquired meningitis and identify risk factors for inferior outcome. Risk factors such as underlying disease (diabetes mellitus, cancer, trauma, neonatal age, splenectomy, alcoholism, sepsis, other infections), etiology, clinical symptoms and outcome (death, improvement and cured after modifications of ATB therapy, cured without change of therapy, cured with neurologic sequellae) were recorded and analysed with univariate analysis (chi2 or t test for trends, CDC Atlanta 2004). Analysing risk factors for inferior outcome (death or cured with neurologic sequellae), we compared patients who died or survived with neurologic sequellae to all patients with community acquired bacterial meningitis. Univariate analysis showed that trauma (p<0.05), alcohol abuse (p<0.05), diabetes, S. aureus (p<0.05) and gram-negative etiology (A. baumannii, Ps. aeruginosa or Enterobacteriaceae) (36% vs. 11,9%, p<0.05) were predicting inferior outcome. Analysing risk factors for treatment failure (death or failed but cured after change of antibiotic treatment) prior sepsis (34.1% vs. 13.9%, p<0.01) and gram-negative etiology (25% vs. 11.9%, p<0.02) were statistically significant predictors of treatment failure. Neisseria meningitis had less failures (p<0.05). Concerning infection associated mortality again diabetes mellitus (p<0.05), alcoholism (p<0.05) staphylococcal and gram-negative etiology (p<0.05) were significant predictors of death. N. meningitis had surprisingly less treatment failures (appropriate and rapid initial therapy). Neurologic sequellae were more common in patients with alcohol abuse (p<0.05), craniocerbral trauma (p<0.05) and less common in meningitis with pneumococcal etiology (p<0.05).     

Ability of plasma from patients with immune thrombocytopenic purpura (ITP) to promote the growth of megakaryocyte progenitors from normal bone marrow.

The ability of plasma from ITP patients (before and after splenectomy) to support the growth of megakaryocyte progenitors was compared with that from healthy subjects. Plasma Factor Index-Megakaryocyte PFI-Mk (ITP) which expressed resultant colony growth was significantly lower before splenectomy, but it normalized after splenectomy. (PFI-Mk) (ITP) did not relate neither to megakaryocyte nor to platelet counts. A positive correlation has been observed between megakaryocyte and platelet numbers in healthy subjects and in ITP patients after splenectomy, but not before splenectomy. The proportion of immature megakaryocytes was markedly higher in ITP marrow before splenectomy. This study indicates, that in ITP apart from antibodies directed to platelets and megakarocytes a low plasma stimulatory activity affected megakaryocytopoiesis.     

脾脏保留手术对外伤性脾破裂患者免疫功能的影响

目的:探究脾脏保留手术对外伤性脾破裂患者免疫功能的影响。方法:选取2015年8月~2018年9月我院收治的外伤性脾破裂患者83例进行回顾性分析,根据手术方式不同分为两组,对照组(41例)患者给予脾脏切除术,观察组(42例)患者给予脾脏保留手术。比较两组患者的手术时间、术中出血量、下床活动时间、术后1d引流量、抢救成功率及治疗前后CD3~+、CD4~+、CD8~+和Tuftsin因子水平和并发症的发生情况。结果:治疗后,观察组患者的手术时间、术中出血量、术后下床时间和术后1d引流量均显著短于或低于对照组,而救治成功率显著高于对照组(P0.05)。两组患者治疗后的CD3~+、CD4~+和CD4~+/CD8~+水平均较治疗前显著下降,且观察组以上指标均显著高于对照组(P0.05)。对照组治疗后血清Tuftsin因子水平较治疗前显著下降,而观察组血清Tuftsin因子水平较治疗前显著升高,并显著高于对照组(P0.05)。观察组患者的总并发症发生率为7.14%,较对照组(24.39%)显著降低(P0.05)。结论:与脾脏切除术相比,脾脏保留手术可显著改善外伤性脾破裂患者的免疫功能,且手术效果更好,安全性更高。