Fujitani R M, Johs S M, Cobb S R, Mehringer C M, White R A, Klein S R
Department of Surgery, Los Angeles County-Harbor-UCLA Medical Center, Torrence 90509.
Am Surg. 1988 Oct;54(10):602-8.
High risk splenectomy is often encountered in cases of hypersplenism with massive splenomegaly (10 times usual weight of 150-200 g) resulting from myelophthisic processes. Intra-operative ligation of the splenic artery through the lesser sac is a technically useful method of gaining vascular control prior to mobilizing the challenging spleen. However, a massive or inaccessible spleen imposes mechanical limitations during surgery and may be complicated by torrential intra-operative hemorrhage in the setting of severe thrombocytopenia refractile to platelet transfusions. The authors describe pre-operative intravascular proximal splenic artery control in four adult patients (3 men, 1 woman) with extreme splenomegaly (2,250-10,000 g). The massive splenomegaly in this group resulted from chronic myelogenous leukemia (n = 2), isolated splenic lymphoma (n = 1), and agnogenic myeloid metaplasia (n = 1). Chief symptom manifestations included left upper quadrant abdominal pain, early satiety, post-prandial emesis, dyspnea, petechiae, and associated easy bruising. Prior to surgery, all the patients were taken to the radiology suite where either detachable silastic balloons or stainless steel coils were placed selectively into the splenic artery under fluoroscopic guidance requiring approximately 35 minutes. Splenic artery occlusion aided normalization of thrombocytopenia (average increases 19,000/microliter to 215,000/microliter) with prolongation in survival of platelets. Successful splenectomy was subsequently performed with no additional transfusion requirements and was made technically easier by reducing splenic bulk. There were no adverse consequences of intravascular occlusion and no peri-operative morbidity or mortality. Preoperative intravascular selective splenic artery occlusion, used as an important potential adjunct to anticipated high risk splenectomy, is recommended.(ABSTRACT TRUNCATED AT 250 WORDS)
高风险脾切除术常见于骨髓痨性病变导致脾肿大（重达150 - 200克的正常脾脏重量的10倍）的脾功能亢进病例中。通过小网膜囊进行脾动脉术中结扎，是在处理具有挑战性的脾脏之前获得血管控制的一种技术上有用的方法。然而，巨大或难以触及的脾脏在手术中会带来机械限制，并且在严重血小板减少且对血小板输注无效的情况下，可能会并发术中大出血。作者描述了对4例成年患者（3男1女）进行术前血管内近端脾动脉控制的情况，这些患者均有极度脾肿大（2250 - 10000克）。该组患者的巨大脾肿大是由慢性粒细胞白血病（n = 2）、孤立性脾淋巴瘤（n = 1）和原发性骨髓化生（n = 1）引起的。主要症状表现包括左上腹疼痛、早饱、餐后呕吐、呼吸困难、瘀点以及相关的易瘀伤。手术前，所有患者被送往放射科，在透视引导下将可分离的硅橡胶球囊或不锈钢线圈选择性地置入脾动脉，这一过程大约需要35分钟。脾动脉闭塞有助于血小板减少症正常化（平均从19000/微升增加到215000/微升），并延长血小板存活时间。随后成功进行了脾切除术，无需额外输血，且通过减少脾脏体积使手术在技术上变得更容易。血管内闭塞没有不良后果，也没有围手术期发病率或死亡率。术前血管内选择性脾动脉闭塞作为预期高风险脾切除术的重要潜在辅助手段，值得推荐。（摘要截短于250字）
