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Introduction: Laparoscopic splenectomy (LS) has become the standard treatment for benign hematological disorders and hypersplenism. However, serious complications such as pancreatic fistula and portal venous thrombosis (PVT) sometimes occur. We investigated the clinical significance of splenic vessels and anatomical features in LS. Methods: Patient data were collected from 32 patients who underwent LS. The indications for LS were hypersplenism due to liver cirrhosis, idiopathic thrombocytopenic purpura, hereditary spherocytosis, and others. Close contact of pancreatic tail with splenic hilum, spleen volume, and diameters of splenic vessels were evaluated on computed tomography images. Results: Close contact of pancreatic tail with splenic hilum was recognized in 15 of the patients. The close contact was significantly associated with operation time ( P  = .038), spleen volume ( P  = .021), and spleen volume/body surface area (BSA) ratio ( P  = .001). In multivariate analysis, spleen volume/BSA ratio was an independent factor for close contact ( P  = .022). PVT occurred in 3 cirrhosis patients, and the diameter of the splenic vein (SV) was significantly associated with PVT as a result of multivariate analysis ( P  = .027). Conclusion: Close contact of the pancreatic tail with the splenic hilum may cause a longer operation time at LS and be associated with spleen volume/BSA ratio. A larger SV diameter in cirrhosis patients may be related to PVT after LS.

Innate lymphoid cells (ILCs) have been characterized as innate immune cells capable to modulate the immune response in the mucosae. Human ILCs have been rarely described in secondary lymphoid organs except in tonsils. Moreover, their function and phenotype in human secondary lymphoid organs during autoimmune diseases have never been studied. We took advantage of splenectomy as a treatment of immune thrombocytopenia (ITP) to describe and compare splenic ILC from 18 ITP patients to 11 controls. We first confirmed that ILC3 represented the most abundant ILC subset in human non-inflamed spleens, accounting for 90% of total ILC, and that they were mostly constituted of NKp44 - cells. On the contrary, proportions of ILC1 and ILC2 in spleens were lower than in blood. Splenic IL-2- and IFN-γ-producing ILC1 were increased in ITP. While the frequencies of total splenic ILC3 were similar in the two groups, splenic GM-CSF-producing ILC3 were increased in ITP. This is the first description of human ILC in a major secondary lymphoid organ during an autoimmune disease, ITP. We observed an expansion of splenic ILC1 that could participate to the Th1 skewing, while the increased production of GM-CSF by splenic ILC3 could stimulate splenic macrophages which play a key role in ITP pathophysiology., (Copyright © 2018. Published by Elsevier Ltd.)

Background: An accessory spleen (AS) is a lobule of splenic tissue found in ectopic locations. Identification of AS is particularly important in patients with immune thrombocytopenia (ITP) requiring splenectomy as unrecognized AS can later cause refractory symptoms. The AS can also be a source of significant intraabdominal hemorrhage. The aim of this meta-analysis was to systematically analyze the data on the prevalence, number, location, and morphometry of AS., Materials and Methods: An extensive search of the major electronic databases was conducted to identify all studies that reported relevant data on the AS. No date or language restrictions were applied. Data on the study type, the prevalence of AS, location, morphometry and number of AS per patient were extracted from the eligible studies and pooled into a meta-analysis., Results: A total of 81 studies (n = 22,487 subjects) were included into the quantitative analysis. The overall pooled prevalence of AS was 14.5% (95%CI: 12.4-16.7), while the pooled prevalence of AS in ITP patients was 16.7% (95%CI: 12.1-21.7). The majority of accessory spleens were located in the splenic hilum (62.1% [95%CI:51.5-76.3]). Moreover, 26% of ITP patients with an AS have more than one., Conclusions: The findings of this study provide an evidence-based foundation of anatomical knowledge about the AS. Surgeons should take particular caution in identifying an AS, as unnoticed AS during splenectomy can lead to recurrence of hematological diseases or can be a potential source of bleeding in the future., (Copyright © 2017. Published by Elsevier Ltd.)

Aim: Idiopatic thrombocytopenic purpura (ITP) is the most common indication for splenectomy. The failure rate of surgery is about 8% and the failure rate after splenectomy is approximately 28% for all patients. When the presence of an accessory spleen is diagnosed, splenectomy is recommended. Laparoscopic approach is considered the first choice., Patients and Methods: At our Department, between July and November 2011 two patients underwent laparoscopic accessory splenectomy for recurrence of ITP. Both patients had a previously laparoscopic splenectomy. Preoperative Magnetic Resonance (MR) was performed in both the cases revealing the presence of an accessory spleen., Results: The operative time was 105 and 100 minutes respectively. No perioperative complications occured. Hospital stay was four days in both cases. The first patient had a disease free period of two months; the second one of one month. Both patients restarted immunosuppressive therapy., Conclusions: The relapse of thrombocytopenia post-splenectomy can be associated with the presence of an accessory spleen. The laparoscopic accessory splenectomy should be considered the first choice approach. Surgical accessory splenectomy allows a transitory remission of the disease.

Background and Objectives: The single-incision approach in laparoscopic surgery is a relatively new concept. This systematic review of the literature was performed to appraise the existing clinical evidence concerning the use of the single-incision technique for spleen resection., Methods: We performed a systematic search of the PubMed and Scopus databases, and the studies retrieved were included in our review. The references of the included studies were also hand searched., Results: Thirty-one relevant studies were found in the field including 81 patients with an age range from 0.6 to 90 years and a body mass index range from 18 to 36.7 kg/m2. Splenomegaly (44.6%), idiopathic thrombocytopenic purpura (31%), and immune thrombocytopenic purpura (6.8%) were the most common indications for the procedure. Concerning the applied port system, multiple single ports (5 to 12 mm) were used in 54.4% of patients, the SILS port (Covidien, Mansfield, Massachusetts) was used in 26.6%, the TriPort (Advanced Surgical Concepts, Wicklow, Ireland) was used in 7.6%, glove ports were used in 6.3%, and the GelPort (Applied Medical, Rancho Santa Margarita, California) was used in 5.1%. The median operative time was 125 minutes (range, 45-420 minutes), and the median quantity of blood loss was 50 mL (range, 10-450 mL). No conversion to open surgery and no transfusion were needed. The length of hospital stay was between 1 and 9 days. Low rates of complications and no patient deaths were found. The existing evidence on cosmesis is limited., Conclusion: Single-site/single-port laparoscopic surgery is a minimally invasive procedure that seems to be a challenging alternative in the management of spleen resection.

Background: Obesity is still considered a relative contraindication to laparoscopic splenectomy (LS)., Methods: All patients undergoing LS at our institution were classified as obese or nonobese (group A, body mass index [BMI] >30; group B, BMI <30). Primary end points included conversion rate, operative complications, length of stay, operative time, and estimated blood loss (EBL)., Results: Three hundred seventy patients who underwent LS were included. Baseline characteristics were similar in groups A (n = 127; mean BMI, 36.2 ± 6.9 kg/m²) and B (n = 243; mean BMI, 24.6 ± 2.9 kg/m²). Conversion rates and overall morbidity were similar in both groups (9% vs 11% for conversion to open procedures, P = .621; 16% vs 16% for morbidity rates, P = .940). Length of hospital stay and EBL were also comparable (P = .643 and P = .544, respectively). Mean operative time was significantly increased in the obese group on multivariate analysis (170 vs 151 minutes, P = .021)., Conclusions: Obesity does not adversely affect outcomes after LS. The laparoscopic approach is the optimal technique for splenectomy regardless of the patient's weight., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Platelets are targeted by autoantibodies and destroyed in the reticuloendothelial system in the spleen, liver and bone marrow in patients with immune thrombocytopenia (ITP). Other mechanisms such as destruction by cytotoxic T-cells and defective production of platelets in the bone marrow also exist. Splenectomy normalizes the platelet count in 70% of ITP patients, however, precious little is known about the spleen in this disease. Our aim was therefore to investigate the splenic morphology and especially the number and localization of splenic leukocytes in patients with ITP and controls and to evaluate factors predicting outcome of splenectomy. Spleen sections from 29 ITP patients and 11 individuals splenectomized due to trauma were analyzed by immunohistochemistry. All except one of the ITP patients had a normalized platelet count 12 months after splenectomy and the platelet count was inversely correlated with age. ITP patients had an increased number of B-cells in the red pulp. The number of white pulp B-cells and number of T-cells in both compartments was unchanged. In conclusion, B-cells are increased in the red pulp of the spleen and together with cytotoxic T-cells, helper T-cells and macrophages line the sinusoids enabling the immunological attack on platelets in ITP.

Based on the earlier published data this article describes the role of the spleen in the development of some hematological diseases, the main of which is idiopathic thrombocytopenic purpura (ITP). The authors emphasize the role of splenectomy in the treatment of this disease. At 178 splenectomies performed at the clinic, 23,6 % of operations were carried out for hematological diseases, and among them 42,8 %--for ITP. The authors share their immediate and remote results of the treatment.

Background: Some one-fifth of patients may have accessory spleens (AcS) and require their removal at the time of splenectomy to achieve and maintain hematological response. The purpose of this study was to evaluate the benefit of computed tomography (CT) in patients undergoing laparoscopic splenectomy (LS)., Methods: All patients who required splenectomy were offered LS and underwent preoperative contrast-enhanced CT scan to detect and locate AcS. The surgeon was not blinded to the result of the CT scan. Patients were followed up to determine if there was recurrent disease., Results: Between 2000 and 2007, 58 consecutive patients (31 men) were referred for splenectomy and all underwent LS. Preoperative CT scan detected 11 AcS in 11 patients (19%), of which 9 were confirmed during LS; the remaining 2 patients suffered with ITP preoperatively and had a good hematologic response to LS. At LS, 14 AcS were found in 13 patients (22%), of which 4 patients had negative preoperative CT scan; those additional AcS were readily found and were located close to the lower pole or hilum of the spleen. All removed AcS were confirmed histologically. In one patient who had LS and removal of AcS for ITP a further AcS within the tail of the pancreas was detected 1 year postoperatively on CT after thrombocytopenia relapsed. The sensitivity and specificity of CT scan for the detection of AcS were 60% and 95.6%, and the corresponding values for laparoscopy were 93.3% and 100%, respectively. Pairwise comparison of the ROC curves identified laparoscopy to be associated with a significantly higher area under the curve compared with CT scan (0.967 vs. 0.673; P = 0.004)., Conclusions: Accessory spleens can be readily detected at laparoscopy in the vicinity of the spleen; preoperative CT scan for their detection and localization may not be necessary.

Background: Laparoscopic splenectomy is an effective treatment for many patients with immune thrombocytopenic purpura (ITP) who fail or relapse after treatment with steroids. Patients with an incomplete response to splenectomy and those who experience recurrence of symptoms should be evaluated for the presence of an accessory spleen. The clinical effectiveness of laparoscopic excision of an accessory spleen after a previous splenectomy for ITP has varied in different studies. Laparoscopic intraoperative identification of an accessory spleen can be difficult. The authors report their experience with laparoscopic accessory splenectomy (LAS) and the use of perioperative localization methods for this procedure., Methods: This study reviewed seven consecutive patients who underwent LAS, after initial splenectomy failed to cure ITP, at a tertiary care center between April 9, 2003 and March 31, 2008. Demographics, diagnostic and localization studies, technical success, and the effect on thrombocytopenia were examined. The location of the accessory spleen also was recorded. A novel method for localizing accessory spleen was used. It consisted of preoperative computed tomography (CT)-guided injection of methylene blue at the accessory spleen's site, preoperative intravenous injection of 99m-technetium-labeled, heat-damaged red blood cells, or both. Intraoperatively, the dye was used for visual identification, and the gamma probe was used to aid in locating and confirming the presence of the accessory spleen in the excised specimen., Results: Seven patients with recurrent ITP after initial failed splenectomy underwent LAS during the study period. Five of these patients had the initial splenectomy performed laparoscopically. All seven patients had successful laparoscopic removal of the accessory spleen based on a final pathologic examination. One patient required the second laparoscopic exploration with perioperative localization after a failed attempt without it. These perioperative localization methods were used in subsequent operations on other patients. These methods were found to be helpful in the intraoperative identification of the accessory spleens. The accessory spleens missed at initial splenectomy were found in unusual locations. Five of the seven patients had sustained improvement in platelet counts after LAS. One patient had a postoperative ileus that resolved with nonoperative management. No other complications or mortality was observed., Conclusion: The LAS procedure after previous splenectomy is feasible and safe. Perioperative localization methods aid in the intraoperative identification of an accessory spleen. Accessory spleens missed at initial splenectomy are generally found in unusual locations. Treatment of recurrent or unresolved ITP with LAS can be effective for some patients.

Severe thrombocytopenia in idiopathic thrombocytopenic purpura may recur owing to retained accessory spleens. Accessory spleen may hide in unusual and difficult locations. We present an interesting case in which we used a handheld gamma probe intraoperatively to localize two accessory spleens. The two accessory spleens were successfully retrieved and removed. A handheld gamma probe is used as a valuable tool in localizing residual splenic tissue following splenectomy.

Primary hypersplenism may affect any of the figurative elements of blood, simultaneously or in successive sequences. In function the answers, the therapy may be necessary splenectomy. The authors present the case of a 50-year-old patient what suffered one splenectomy, admitted to the 1st Surgical Clinic for purpuric cutaneous phenomena. 32 years ago, the patient suffered the splenectomy, from a severe autoimmune hemolytic anemia. After 29 years the biologic exam realized for a generalized purple, relieved a severe thrombocytopenia (2,500/mm3) being necessary the administration of thrombocytes transfusion and high doses of corticosteroids in emergency. The spleen sequestration test, ultrasound exam and CT showed the existence of accessory spleens. We practice the surgical intervention for ablation of the accessory spleens. The splenectomy cure disease in 65-80% of cases and the partial remission of manifestation is obtained in 15-20% of cases. The recurrence risk is possible by omission of the accessory spleens. The ablation of these accessory spleens induced recovery in 98-99% of cases.

Idiopathic thrombocytopenic purpura is an autoimmune disease in which macrophages of reticuloendothelial system, mainly in the spleen, remove platelets coated by autoantibodies from the circulation. By removing the spleen, 60-80% of patients can be cured. Partial remission is achieved in 10-20% cases. This case is a typical example of partial remission of idiopathic thrombocytopenia (ITP) when a patient developed a splenunculus years after removal of the spleen. MRI is the investigation of choice for the detection of a splenunculus.

Aim: The preoperative detection of accessory spleen (AS) is still a very important and serious problem. The aim of the study was to assess the reasons for failure and the long-term results of laparoscopic splenectomy (LS) in patients with idiopathic thrombocytopenic purpura (ITP)., Method: Fifty-eight ITP patients underwent LS between June 1998 and December 2002. There were 42 women and 16 men. Preoperatively, we performed computed tomography (CT) and sonography to evaluate the size of the spleen and possibly to recognize the presence of the accessory spleens, which were found preoperatively in three cases., Results: Intraoperatively, ASs were found in the course of laparoscopy in six cases overall, three preoperatively false negative. During follow-up (median time 31 months), in three patients the low platelet count was recognized, respectively after 5 months and 1.5 and 1.8 years. In all those cases scintigraphy was performed and in one case the residual accessory spleen, missed both in preoperative examination and during laparoscopy, was revealed. In two other patients, in spite of thrombocytopenia, no residual spleens were found., Conclusion: We conclude that the problem of accessory spleens can be managed by careful videoscopic examination of the abdominal cavity during splenectomy, while the use of preoperative imaging techniques in detection of accessory spleens is still limited by the insufficient sensitivity of the examination.

Autoimmune thrombocytopenic purpura (AITP) is an autoimmune disorder that results from antiplatelet autoantibodies; these autoantibodies cause platelet destruction in the reticluoendothelial system. Oral corticosteroid therapy is the first line treatment. Splenectomy is the major treatment modality after the failure of more conservative medical therapy. Approximately 15% of the patients will relapse either soon after splenectomy or, as is less common, many years later. The presence of an accessory spleen should be sought. We experienced a patient with a known diagnosis of autoimmune thrombocytopenic purpura who had a worsening thrombocytopenia 11 years after splenectomy. This patient was diagnosed with an accessory spleen. Accessory splenectomy was performed with only a transient elevation of the platelets. We report here on this case with a review of the literature.

Purpose: To prospectively evaluate multi-detector row spiral computed tomography (CT) for determination of splenic volume, splenic vascular anatomy, and presence of accessory spleens and parenchymal lesions in patients who were undergoing laparoscopic splenectomy., Materials and Methods: Twenty-two patients who were candidates for laparoscopic splenectomy underwent multiphasic multi-detector row CT. Two observers evaluated splenic volume with two hand-tracing editing modalities. Variability between the two observers was calculated with a reliability coefficient (Cronbach alpha). A linear regression equation for each modality was generated to identify the correlation between the two observers. Multi-detector row CT angiography was evaluated for assessment of splenic vascular anatomy. Presence and number of both accessory spleens and parenchymal lesions were recorded., Results: Mean splenic volume was 1,050 and 1,046 mL, respectively, for observers A and B by using each-section editing (technique 1) and 1,067 and 1,068 mL for observers A and B by using distanced editing (technique 2). For each editing modality, alpha reliability coefficient was higher than 0.99. Both techniques 1 and 2 were very highly predictive of specimen weight and had R2 values of greater than 0.99 (P <.001). CT angiograms correctly showed polar arteries in all cases and the presence of the arteria pancreatica magna in one case. Multi-detector row CT demonstrated the presence, number, and size of all accessory spleens and of focal parenchymal lesions., Conclusion: Multi-detector row CT volumetric and anatomic evaluation provided accurate and reproducible information., (Copyright RSNA, 2004)

Objective: Radionuclide imaging specific for functioning splenic tissue is considered the method of choice to detect an accessory spleen in patients of chronic idiopathic thrombocytopenia purpura (ITP), who present with relapse after splenectomy. Radioimmunospleen scintigraphy with Tc-99m-labeled autologous RBC opsonized with anti-D IgG (RIS) is claimed to be more sensitive and specific than Tc-99m heat-denatured RBC spleen scintigraphy (HDRS) in the detection of an accessory spleen. We compared the efficacy of RIS with HDRBC for the detection of accessory spleens, Methods: A total of 45 patients (male:female = 17:28, age range: 6-58 years) who presented with relapse of ITP after splenectomy underwent scintigraphy with both methods. An average of 3 years had passed since surgery. All patients were imaged by a dual-head gamma camera with high-resolution collimators; planar static images and SPECT of abdomen were acquired., Results: Accessory spleens were detected in 31% (14 of 45) of patients, 6 had 1 each and 8 had more than 1 (including 1 patient who had 13 accessory spleens). Both methods were concordant in all the patients. There was no difference in the scintigraphic picture (planar and SPECT) or in the size and number of accessory spleens detected., Conclusion: Tc-99m-labeled anti-D IgG opsonized autologous RBC spleen scintigraphy provides no additional diagnostic information over heat-denatured RBC spleen scintigraphy. Heat-denatured RBC scintigraphy thus remains the procedure of choice in the detection of accessory spleens.

Background: The use of a laparoscopic hand-assist device may aid in the identification of accessory spleens (ASs) and provide similar benefits to a conventional laparoscopic procedure. A patient with previous splenectomy for immune thrombocytopenic pupusa (ITP) and recurrent thrombocytopenia is reported., Method: A computed tomography scan and RBC scan identified several nodules consistent with ASs. Initial laparoscopic exploration could not identify all the ASs seen on preoperative imaging. A hand-assist device was placed and a total of five nodules of splenic tissue were identified without conversion to laparotomy., Results: The patient had a brief and uncomplicated postoperative course with a return of platelet counts to 350,000 at 1-month follow-up., Conclusion: We propose that in the scenario of recurrent ITP following laparoscopic splenectomy, repeat laparoscopy is the first step once an AS is identified by preoperative imaging. If the AS is not identified at laparoscopy, the insertion of a hand-assist device is an alternative to a full laparotomy.

Objectives: The aim of this prospective study was to evaluate the safety and feasibility of laparoscopic splenectomy (LS) in patients with hematological disorders of the spleen., Subjects and Methods: Between 1999 and 2001, 15 patients (11 female and 4 male), with a mean age of 30 years, underwent LS after preoperative evaluation. If difficulties were encountered in LS, one trocar site incision was enlarged to 7-8 cm to engage the left hand for hand-assisted laparoscopic splenectomy (HALS) and the procedure was completed. Various parameters were reported, including spleen size as assessed by ultrasound scan, postoperative mortality and morbidity rates, accessory spleen removal, conversion rate, operative times and length of hospital stay. LS was successfully completed in 9 patients (60%) and HALS was performed in 4 patients (26.6%). Two patients required conversion to open splenectomy., Results: The mean operative time was 209 min and the mean hospital stay was 8.1 days. The hospital stay was significantly longer among HALS patients than LS patients. The mean age of patients and splenic size were associated with a significantly higher conversion rate. No deaths were attributed to the procedure. Complications occurred in 2 of 15 patients. Accessory spleens were identified in 2 patients., Conclusions: LS is both a safe and feasible procedure, but it requires great technical care to avoid serious complications., (Copyright 2004 S. Karger AG, Basel)

The preoperative detection of accessory spleens (AS) is essential in ITP patients. The aim of this study was to evaluate the reasons of failure and long-term results of laparoscopic splenectomy (LS) in patients with idiopathic thrombocytopenic purpura (ITP). Thirty-four ITP patients (27 females and 7 males) underwent LS between June 1998 and January 2001. Computed Tomography (CT) and sonography (US) were performed preoperatively to evaluate the size of the spleen and to detect the presence of possible accessory spleens which were found in two cases. AS were seen during laparoscopy in three cases. During follow-up (median time = 23 months), in three patients a low platelet count was seen after 5 months, 1.5 and 1.8 years pop. In all these cases scintigraphy was performed, which revealed in one case the residual accessory spleen. In the two other patients, inspite of thrombocytopenia no residual spleens were found. The authors conclude that laparoscopic splenectomy is a safe and effective procedure in patients with ITP. The problem of accessory spleens can be managed by careful videoscopic examination of the abdominal cavity during splenectomy. The use of the preoperative imaging techniques for detection of accessory spleens is limited by the insufficient sensitivity of the examination.

Laparoscopic splenectomy is becoming the gold standard technique for the treatment of hematological disorders of the spleen. Hemostasis is a fundamental step during laparoscopic splenectomy leading some authors to develop several techniques to control splenic vessels such as hand assistance, preoperative splenic artery embolization, and the use of vascular linear staplers. However, intraoperative bleeding is usually due to inadequate exposure of the hilar splenic vessels itself. The authors describe a standardized technique for the exposure of splenic pedicle using an endoscopic triangular retractor. We have been used this technique in 16 consecutive laparoscopic splenectomies with minimal blood loss. The present technique may increase the safety of laparoscopic splenectomy with adequate exposure of the splenic hilum reducing the conversion rate and intraoperative blood loss.

The objective of the present study is to determine splenic B-cell subsets and the ability of splenic CD5(+) B and CD5(-) B cells to produce platelet glycoprotein-specific autoantibodies in chronic idiopathic thrombocytopenic purpura (ITP). Splenic CD5(+) B cells were identified by two-color flow cytometric analysis in eight ITP patients. Magnetic activated cell sorting (MACS) purified splenic CD5(+) B cells and CD5(-) B cells were cultured separately in vitro. Glycoprotein-specific autoantibodies in culture supernatants and plasma were measured by modified monoclonal antibody immobilization of platelet antigen (MAIPA) assay. The percentage of splenic CD5(+) B cells in ITP patients was slightly higher than that in controls, with no statistical significance. Four ITP patients displayed plasma IgG autoantibodies against both GPIIb/IIIa and GPIb. Moreover, splenic CD5(+) B cells and CD5(-) B cells from these four ITP patients also produced high level of IgG anti-GPII(b)/III(a) and anti-GPI(b) antibodies. However, we were unable to detect IgM GP-specific autoantibodies in culture supernatant and plasma in these ITP patients. It is concluded that both splenic CD5(+) B cells and CD5(-) B cells produce platelet IgG GP-specific autoantibodies, and may all play a role in the pathogenic process of ITP.

There are no hard indications for splenectomy in children. The single most generally accepted indication is the more severe form of congenital spherocytosis. Idiopathic thrombocytopenia purpura is only an indication if there is a severe bleeding tendency. Other than local conditions involving the spleen, there seem to be no good indications for partial splenectomy. Ablation by means of embolisation has not gained popularity. Laparoscopic splenectomy appears to be better than splenectomy via laparotomy, but sound scientific evidence for this is not yet available. There appears to be an increased incidence of portal vein thrombosis immediately after splenectomy. The value of thrombosis prophylaxis has not yet been investigated.

The clinical success of therapeutic splenectomy for idiopathic thrombocytopenic purpura depends on the complete removal of all functional splenic tissue. Among reasons for poor response to splenectomy, failure to remove accessory spleens is mentioned. We present our experience with laparoscopic removal of accessory spleen from retroperitoneal space in a patient with relapse of ITP 30 years after classical splenectomy. A 45-year-old female patient underwent in 1972 classical splenectomy for ITP. Progressive decline in thrombocyte count was observed 7 years ago. Scintigraphy, CT, and ultrasound revealed residual splenic tissue. A laparoscopic approach was proposed. Four trocars placed along left costal margin were used. After dissection of all the adhesions behind the pancreatic tail deep in the retroperitoneal space a round structure 4 cm in diameter, macroscopically resembling splenic tissue, was found. The accessory spleen was removed intact. The patient recovered well; 2 months later steroids were discontinued while the thrombocyte level was 251 x 10(9)/L. Identification of accessory spleen seems to be major intraoperative problem. We believe that accessory spleen can be safely removed laparoscopically, avoiding a major open procedure, and a satisfactory postoperative result could be expected.

Laparoscopic excision of retained splenic tissue has been described as a treatment of recurrent hematologic disease after formal splenectomy. It is associated with a shorter hospital stay, more rapid recovery, and lower or equivalent morbidity compared with open surgery. However, intraoperative identification of residual splenic tissue remains difficult, particularly when preoperative computed tomography or magnetic resonance imaging results are unremarkable. It has been suggested that the laparoscopic approach has a lower success rate due to the loss of tactile feedback. We report a case of successful laparoscopic excision of retained splenic tissue using technetium sulfur colloid injection and intraoperative gamma probe localization in a patient with recurrent idiopathic thrombocytopenic purpura, 12 years after open splenectomy. This represents the first report of this intraoperative adjunctive measure for the laparoscopic identification and excision of functional accessory splenic tissue.

The simultaneous occurrence of idiopathic thrombocytopenic purpura (ITP) and Hodgkin's disease in the same patient is uncommon. There have been only a limited number of reported cases of newly diagnosed ITP following Hodgkin's disease. Even more uncommon is the development of ITP after splenectomy for Hodgkin's disease. Of the reported cases of ITP following splenectomy for Hodgkin's disease, all have been successfully treated with medical therapy. We report an unusual case of an accessory spleen causing ITP in a patient who had undergone a splenectomy for Hodgkin's disease 10 years earlier. The patient underwent hand-held gamma-probe-assisted laparoscopic accessory splenectomy.

Idiopathic thrombocytopenic purpura is an autoimmune disease in which macrophages of reticuloendothelial system, mainly in the spleen, remove platelets covered by autoantibodies from circulation. By removing the spleen 60-80% of patients are cured. Partial remission is achieved in 10-20% cases. Very few patients do not react on splenectomy. Recurrency of idiopathic thrombocytopenic purpura in a splenectomized patient after already achieved complete remission, may be caused by hypertrophy of one or more of the retained accessory spleens. We present 3 patients, 41, 23 and 44 year old, in whom splenectomy for ITP had been performed 10, 3 and 11 years earlier. After full remission which lasted 10, 2.5 and 10.5 years a full recurrency of ITP took place with signs of severe thrombocytopenia and haemorrhagic syndrome. Using ultrasonography, computed tomography and scintigraphy accessory spleen/s, were discovered. By their removal, a full remission was achieved in all 3 patients, but full favorable effect appeared approximately three months after surgery during which period additional steroid therapy was necessary.

Chronic idiopathic thrombocytopenia purpura is an immunologically mediated disorder resulting in disordered platelet kinetics and potentially life-threatening thrombocytopenia. Failure of medical therapy is an indication for splenectomy, and responses are seen in 70% of patients after this procedure. An important cause of relapse after splenectomy is the presence of accessory spleens. The authors describe a patient with chronic idiopathic thrombocytopenia purpura who had a relapse of symptoms 4.5 years after splenectomy. Tc-99m heat-denatured RBC planar and SPECT studies revealed the presence of multiple (more than 13) accessory spleens, but few of them were localized anatomically using computed tomography.

Background: Splenic irradiation (SI) is a fairly unknown treatment modality in autoimmune disorders like autoimmune thrombocytopenia (AIT) or autoimmune hemolytic anemia (AIHA), which may provide an effective, low toxic and cost-effective treatment for selected patients., Patients, Materials and Methods: This article reviews the limited experiences on splenic irradiation in autoimmune thrombocytopenia by analyzing the current studies including 71 patients and some preliminary reports on splenic irradiation in autoimmune hemolytic anemia., Results: In autoimmune thrombocytopenia between 40 and 90% of all patients responded, but most of them relapsed within 4 to 6 months after splenic irradiation. Between 10 and 20% of all patients had a sustained response. The efficacy of splenic irradiation in HIV-associated cases of thrombocytopenia is probably lower than in other forms of autoimmune thrombocytopenia, but especially in this group immunosuppressive drug treatment of autoimmune thrombocytopenia exposes some problems. In autoimmune hemolytic anemia there are some case reports about efficacy of splenic irradiation. Toxicity of splenic irradiation in both diseases was very moderate., Conclusions: For HIV patients, for elderly patients or patients at high risk for complications following splenectomy splenic irradiation might be a treatment option. Splenic irradiation as preoperative treatment in patients not responding to or not suitable for immunosuppressive drugs prior to splenectomy may be a promising new application of splenic irradiation to reduce adverse effects of splenectomy in thrombocytopenic patients. A further analysis of the biological mechanisms underlying splenic irradiation may help to improve patient selection, to optimize dose concepts and treatment schedules and will improve understanding of radiotherapy as an immunomodulatory treatment modality.

Background: Laparoscopic splenectomy is an effective treatment for idiopathic thrombocytopenic purpura (ITP) and hemolytic anemia that has a remission rate of 80-90%. In some patients in whom the disease persists or recurs, a diagnosis of accessory spleen is made. The long-term efficacy of laparoscopic accessory splenectomy is unknown., Methods: Patients who underwent laparoscopic accessory splenectomy were followed in the outpatient clinic. The perioperative course, blood counts, and need for medical therapy to maintain a normal count were recorded., Results: Eight patients underwent laparoscopic accessory splenectomy. All procedures were completed laparoscopically, and all patients were discharged on the 1st postoperative day. Patients were available for a follow-up period of 15 months range, (3-27). None of the ITP patients achieved a complete remission. Two of them had a partial remission, and five ITP patients are now being treated with chronic corticosteroids to maintain a platelet count of >100,000/ml., Conclusion: Laparoscopic accessory splenectomy is associated with a low rate of morbidity and a short hospital stay. Despite its success in removing all residual splenic tissue, most patients will probably not enjoy a complete remission.

Background: Laparoscopic splenectomy has become an accepted procedure in the management of several hematologic diseases. Less clear is the effectiveness of laparoscopic excision of accessory spleens after initial splenectomy in the management of recurrent hematologic disease. We report here our early experience of this technique., Methods: All patients who underwent laparoscopic excision of accessory spleens (LEAS) after initial splenectomy were reviewed for preoperative studies, technical success, and effects on either platelet count or hemoglobin level., Results: In 5 patients LEAS was attempted. Two patients had initial open splenectomies, and 3 had initial laparoscopic splenectomies. Hematologic diagnoses were immune thrombocytopenic purpura (3), chronic lymphocytic leukemia-induced thrombocytopenia (1), and autoimmune hemolytic anemia (1). All patients underwent preoperative damaged red blood cell scintigraphy, which demonstrated functioning splenic tissue, and abdominal computed tomography scans, which demonstrated a nodule in 4 of 5 patients. LEAS was technically successful in 4 patients, with the 1 failure also being the patient in whom the computed tomography scan could not demonstrate the accessory spleen. However, only 2 of the 4 patients after LEAS had durable hematologic responses to surgery, despite follow-up damaged red blood cell scintigraphy showing no residual functioning splenic tissue., Conclusion: LEAS can be technically successful when the accessory spleen is demonstrated on both damaged red blood cell scintigraphy and computed tomography scan; therefore, adequate visualization in both studies is required. However, hematologic response to excision may be less effective than with the initial splenectomy. Further study is needed to determine the causes of these outcomes.

The benefits of surgical splenectomy in patients with immune (Idiopathic) thrombocytopenia purpura (ITP) probably reflect the combined effects of eliminating a source of antiplatelet antibody synthesis as well as the primary site of platelet destruction. The recent availability of intravenous Rho(D) Immune globulin (WinRho SDF; Nabi, Boca Raton, FL) presents an opportunity to extend the duration of nonsurgical (spleen-sparing) management of chronic ITP by inducing reversible Fc blockade. While new methods for laparoscopic splenectomy may offer improved surgical outcomes and reduced costs for ITP patients in the near-term, the long-term consequences of splenectomy remain to be determined. Partial splenectomy has been shown to be effective in the management of anemia in hereditary spherocytosis and elliptocytosis, while preserving vital splenic phagocytic and immune functions. The concept that cell destruction occurs in reticuloendothelial cells has been updated with recognition that the mononuclear phagocyte is neither a reticular nor an endothelial cell. Immune phagocytosis is now understood to be mediated by macrophage IgG Fc and complement receptors. A key factor for devising a strategy for selecting medical or surgical splenectomy, or postponing splenectomy, is an assessment of the relative importance of splenic immune versus phagocytic function in the pathogenesis of ITP.

Background: A disparity exists between the incidence of accessory spleens reported in the open (15-30%) versus the laparoscopic (0-12%) literature. This disparity implies that a percentage of laparoscopic patients will require a reoperation for accessory splenectomy. We present our experience with the laparoscopic management of accessory spleens discovered after primary splenectomy for idiopathic thrombocytopenic purpura (ITP)., Methods: Seventeen patients who underwent primary splenectomy for ITP were reviewed (1 open, 16 laparoscopic). In the laparoscopic group, the incidence of accessory spleens was 3 in 16 (19%). In 1 of these 3 patients, the accessory spleen was found and removed at the initial operation, whereas in 2 of the 16 patients (13%), the accessory spleens were missed. A third patient, whose initial operation was open, presented with recurrent thrombocytopenia after primary splenectomy. After recurrent thrombocytopenia developed, radio nuclide spleen scans were performed showing accessory spleens in all three patients. These three patients underwent accessory splenectomy using a four-port laparoscopic approach., Results: Laparoscopic accessory splenectomy was successfully performed in all three patients. Location of accessory spleens correlated with the spleen scan in each case. Mean operation time was 180 min. There were no conversions to open surgery and no complications. All patients were discharged from the hospital on postoperation day 1. The three patients had a good clinical response and were weaned effectively from their steroid medications., Conclusions: Patients undergoing a laparoscopic splenectomy for chronic ITP have a higher probability of requiring a reoperation for a missed accessory spleen. To minimize missing an accessory spleen, a systematic search should be made at the beginning of the laparoscopic operation. We have found that preoperation imaging with heat-treated erythrocyte scans is valuable for locating accessory spleens before reoperation. When reoperation for accessory splenectomy is necessary, a laparoscopic approach is safe and effective.

Although splenectomy for chronic immune thrombocytopenic purpura (ITP) is successful in the majority of patients, recurrence of thrombocytopenia may occur in association with a functional accessory spleen, sometimes years after operation. Identification and resection of the accessory spleen under these circumstances may result in a sustained remission. We describe a case of recurrent thrombocytopenia associated with an accessory spleen occurring 5 years after splenectomy in a young woman with chronic immune thrombocytopenic purpura. Accessory splenectomy was successful in producing a sustained remission.

Background: The ultimate goal of surgery for hematological disorders is the complete removal of both the spleen and accessory spleens in order to avoid recurrence of the disease. Whereas splenectomy by open surgery provides excellent results, the validity of laparoscopic splenectomy in this regard remains unknown., Objective: The purpose of this study was to evaluate the detection of accessory spleens during laparoscopic splenectomy for hematologic diseases., Methods: We therefore evaluated the pre-, intra-, and postoperative detection of accessory spleens in a consecutive series of 18 patients treated by elective laparoscopic splenectomy for hematological diseases by using computed tomography (CT) and denatured red blood cell scintigraphy (DRBCS)., Results: Preoperative CT, DRBCS, and laparoscopic exploration detected 25%, 25%, and 75% of accessory spleens, respectively. At time of laparoscopy, 16 accessory spleens were detected in seven of the 18 patients (41%). In two patients (11%), laparoscopic exploration failed to detect accessory spleens, whereas preoperative CT (one case) and DRBCS (one case) did reveal them. Postoperatively, during a mean follow-up of 28 months (median, 24; range, 12-44 months), nine patients (50%) showed persistence of splenic tissue by DRBCS, and three of them had signs of disease recurrence., Conclusions: This prospective clinical study suggests that elective laparoscopic surgery for hematological diseases does not allow complete detection of accessory spleens. Moreover, after such a laparoscopic approach, residual splenic tissue is detectable in half of the patients during the follow-up.

This report describes the use of laparoscopic accessory splenectomy in treating recurrent idiopathic thrombocytopenic purpura (ITP). The patient presented 36 months after initial splenectomy with a platelet count of 16,000 cells/microl and nontolerance of medical therapy. A technetium-99 labeled, heat-damaged red blood cell scan revealed two small foci in the upper left quadrant. This finding was confirmed by an abdominal computed tomography scan. After laparoscopic accessory splenectomy, the patient was discharged (23 h after surgery) and at 9 months showed a platelet count of 234,000 cells/microl with no medical therapy. A minimally invasive approach to accessory spleen removal can be beneficial to patients with recurrent ITP and documented accessory splenic tissue.

The indication for splenectomy in chronic idiopathic thrombocytopenic purpura (ITP) remains a controversial subject. The mortality rate of persistent thrombocytopenia is very low, except in severe cases. Conversely, the risks of splenectomy are significant (in the present series, morbidity: 4.1% mortality: 1.4%), with a success rate of only 60-75%. It is therefore useful to define a parameter able to predict the efficacy or failure of splenectomy. An analysis of 578 cases of chronic ITP, where the site of platelet destruction has been determined, is presented. 268 of these cases had been splenectomized. When platelet destruction was splenic, 96% of subjects aged 5-30 years and 91% of cases over the age of 30 years obtained a remission. Conversely, when platelet destruction was hepatic or diffuse, failure or incomplete results were observed in 92% of cases. The site of platelet destruction therefore constitutes a parameter which can help the clinician to make the decision to perform splenectomy.

Splenectomy is the definitive treatment for most cases of idiopathic thrombocytopenic purpura (ITP). We present the case of a patient who was discovered to have ITP at age 5 and was treated medically for 3 years with decreasing response to medication. At age 8, he underwent splenectomy, after which the platelet count stabilized at approximately 200,000/mm3. Two years later he again had symptoms of thrombocytopenia and was treated medically with moderate success. At age 12, during hospitalization for bleeding, his liver/spleen scan gave negative results. Symptoms persisted, and when the patient was 13 a second scan found two small areas of uptake in the area of the splenic bed suggestive of secondary accessory splenic activity. The platelet count at that time was 6,000/mm3. Laparoscopy was performed, and after careful dissection of the left-upper quadrant, two globular masses, the larger of which was 3 x 2 x 2 cm, were removed without incident. The latest platelet count, 3 months after laparoscopic secondary accessory splenectomy, was 169,000/mm3, and a follow-up scan shows no uptake in the area of the spleen.

In two patients with relapsed thrombocytopenia, the authors used SPECT with In-111 labeled autologous platelets to identify residual splenic tissue after splenectomy. One case involved a previously splenectomized patient with idiopathic portal hypertension, while the other had relapsed chronic idiopathic thrombocytopenic purpura (ITP). In both patients, SPECT showed a higher In-111 uptake in the splenic tissues compared with planar images. In the patient with ITP, a small accessory spleen had been overlooked on abdominal CT because of post-operative changes, but it was identified by superimposition of SPECT/CT images. These cases indicate that In-111 platelet SPECT is useful in detecting and localizing residual accessory splenic tissue associated with relapsed thrombocytopenia.

Routine identification and resection of accessory splenic tissue, an integral part of splenectomy for immune thrombocytopenic purpura (ITP), is not necessarily a "blind spot" of the laparoscopic technique. This case report of laparoscopic resection of accessory spleen for recurrent ITP 19 yr after splenectomy supports this view.

A case of persistent thrombocytopenia after open splenectomy for immune thrombocytopenic purpura is presented. The accessory splenic tissue found by CT preoperatively was successfully treated using a laparoscopic technique. The management of this first case in the world literature of accessory splenic tissue is reviewed.

Twenty spleens of steroid resistant cases of idiopathic thrombocytopenic purpuras were studied by light and electron microscopy. Weights of the spleen were within normal range and were unremarkable grossly. On light microscopy reactive lymphoid follicles were seen in the five of the cases. Prominent and dirty looking sinusal histiocytes contain phagocytosed materials. Prominence of plasma cells were seen in the red pulp and also in the marginal zone. The three cases which failed to respond to splenectomy did not show any morphological variation from the others who had responded.

Destruction of platelets by the reticuloendothelial system in immune thrombocytopenia purpura (ITP) is enhanced by platelet-associated IgG. Relapse after splenectomy may result from IgG produced in the accessory spleen. These structures may be located at any site between Gerota's fascia and the left ovary or testicle as well as adjacent to the spleen. The heat-damaged red cell scan (HDRCS) has been demonstrated to be an accurate method for identifying accessory spleens. HDRCS using semi-in vitro labeling of the patient's red blood cells with technetium 99m pertechnetate delineated accessory splenic tissue as the etiology of post-splenectomy relapse three times in two patients 3 to 9 months postoperatively. A labeled intraabdominal probe and HDRCS were subsequently used by the surgical team for identification and excision of the accessory spleen. Four additional patients underwent splenectomy for ITP between 1989 and 1992; heat-damaged red blood cells were injected after the major splenic tissue was removed. Accessory spleens were identified in two patients. All patients were discharged within 6 days, without perioperative complications. Two patients currently require steroids. The techniques of intraoperative HDRCS allow rapid localization and removal of the accessory spleen at the time of laparotomy. Evidence of growth of accessory splenic tissue postsplenectomy was demonstrated.

Unlabelled: The spleens of 100 patients (ITP 60 cases, hypersplenism 20 cases, traumatic rupture of spleen 20 cases) were examined histologically and by electron microscopy. Measurements of the spleens removed from ITP patients were taken and compared to those of the other two groups. Short and long term post operative results were compared., Results: 1. Spleens from the ITP group had characteristics different from those from the hypersplenism (hepatocirrhosis) and control groups; 2. the ITP patients whose spleen is twice the weight of average had better long term response to splenectomy; 3. the mean diameter of splenic follicles greater than 500 microns and the average diameter of germinal centers greater than 200 microns were the criteria for long term response to splenectomy. Therefore, histological examination of excised ITP spleen can predict the possible long term effect of splenectomy.

From 1969 to 1985 we discovered accessory spleens in 8 patients with chronic immune thrombocytopenic purpura (ITP) who relapsed or failed after splenectomy. Imaging of accessory spleen used a liver spleen scintigraphy with heat-treated RBC labeled with Tc-99m. Platelet kinetic studies with 51Cr or 111In, including sequestration index, were performed. Five patients had accessory splenectomy. Disappearance of bleeding symptoms was achieved in the 5 splenectomized patients but with only partial response of platelet counts. These results are discussed in the context of diagnosis and therapeutic management of accessory spleens in patients with chronic immune thrombocytopenic purpura who relapsed or failed after splenectomy.