Indications of splenectomy and effects on body after splenectomy (DRAFT)

Training material IV

Indications of splenectomy
and effects on body after splenectomy

一、脾切除术指征

() 血液病

血液病与脾外科的关系甚为密切,1887 Spencer 首先为遗传性球形细胞增多症作脾切除术。从此为外科脾切除治疗血液病揭开了新的一页。但对血液病患者进行选择性脾切除或急症脾切除术、以及术前准备、手术时机等,与一般疾病所行脾切除不同,有其特殊性。

1、遗传性球形红细胞增多症 (Hereditary Spherocytosis, HS) 又称家族性溶血性贫血或先天性溶血性黄疸。本病属常染色体显性遗传。凡是确诊HS者临床有贫血与脾大,都应行脾切除治疗。WilliamsSchwartz 等均指出,确诊为HS后即使轻型患者,都是脾切除指征,脾切除作为HS的主要治疗方法,并有显著疗效,已被国内外学者公认。由于幼儿手术后易发生感染,故在4岁以下儿童不宜施行脾切除。

2、遗传性椭圆形红细胞增多症 (Hereditary Elliptocytosis, HE) 亦属常染色体显性遗传疾病,临床上无任何症状者可不予治疗,如有贫血、脾大与溶血性黄疸的重型病例,应行脾切除治疗。

3、地中海贫血为遗传性血红蛋白合成障碍性疾病,脾切除对减轻溶血和减少输血量有帮助。脾切除对 α 型地中海贫血有较好疗效,HbE-β 型则差,中科院血研所对29 α 地中海贫血患者行脾切除术,术后 Hb 明显升高,但术前Hb 80g/L 以上者,术后 Hb 上升不显,提出因 Hb 80g/L 以下者适合手术治疗。同时对11 β 型地中海贫血患者行脾切除术,其疗效均不如α型。α型地中海贫血脾切除手术指征: (1) 年龄在3岁以上; (2) Hb 80g/L 以下; (3) 脾亢伴全血细胞减少; (4) 51Cr 红细胞寿命缩短,脾肝比值 >2,脾定位指数增高者。

4、自体免疫性溶血性贫血 (Autoimmune Hemolytic Anemia, AHA) 是一种后天获得性溶血性贫血,系机体免疫功能紊乱,而产生了能破坏自身正常的红细胞的抗体所致。???原理主要是去除了产生破坏自身红细胞或血小板抗体的主要场所,故温抗体型原发性 AHA 适合于脾切除治疗,而冷抗体型 AIHA 的溶血主要发生在血循环或肝脏中,故不适合脾切除治疗。脾切除指征: (1) 药物治疗无效或长期用药,停药后复发者;(2) 合并血小板减少的 Evans 综合症,皮质激素等治疗效果不满意者; (3) 51Cr 同位素体表测定,红细胞主要在脾脏潴留破坏者;(4) 单纯 IgG Coombs 试验阳性脾切除效果佳。国内外报道脾切除疗效一般在 60% 左右。

5. 原发性血小板减少性紫癜 (Idiopathic Thrombocytopenic Purpura, ITP)   
本病的发生与自体免疫有关,血小板上均吸附有免疫球蛋白 G,这种带有免疫球蛋白的血小板在胆及肝内被巨噬细胞提前破坏,破坏的部位 2/3 病人在脾。故而多数病例脾切除后血小板计数可迅速上升,关于 ITP 脾切除的疗效报道甚多,有效率在 80% 左右,对于急性 ITP 患者是否行急症脾切除术,意见不甚一致。一般认为,急性 ITP 患者用强的松、大剂量静脉输注丙种球蛋白等无效,出血危及生命时,可进行紧急脾切除术; 慢性 ITP 患者的脾切除指征: (1) 在病程达6个月以上,经用激素或免疫抑制等治疗而未缓解者; (2) 血小板计数低于 25×103/L, 有颅内出血或其他脏器大出血者: (3) 激素或免疫抑制剂等药物治疗效果不佳或长期需用较大剂量激素维持者;(4) 对激素或免疫抑制剂应用有禁忌者;(5) 51Cr 标准检查血小板主要在脾脏??破坏者。

6. 慢性再生障碍性贫血 (Chronic Aplastic Anemia, CCA)   Mitchell指出对 CCA 选择性脾切除是有益的,可以减轻溶血,延长血小板寿命和减少输血。CAA 选择脾切除手术指征: (1) 骨髓增生较好,红系偏高,合并溶血而内科治疗无效者;51Cr 测定红细胞或/和血小板寿命缩短,脾脏破坏为主的。中科院血研所对28 CAA 患者行脾切除治疗,有效率为 65.2%

7. 慢性粒细胞性白血病 (Chronic Myeloid Leukemid, CML)    70年代,一些学者认为急变细胞在脾脏较多,脾切除可以防止 CML 急性变。但近年来研究,脾切除不能防止 CML 急变,也无何益处。目前对 CML 患者除非巨脾引起机械压追症状、脾亢,龙其是伴有血小板减少者,一般不再主张脾切除术,因为脾切除并不能延长生存或延缓急变的发生。

8. 毛细胞性白血病 (Hairy Cell, HCL)   当伴有脾肿大和脾功能亢进时,是外科脾切除指征。Jansen 认为在以下情况,手术效果较好:(1) 脾在肋缘大于等于4cm; (2) 脾在助缘下 1-3cm,但 Hb<85g/L Hb85-120g/L, pt≤50×109/L; (3 ) 脾摸不到,但Hb<85g/Lpt≤50×109/L. 

9. 戈谢病 (Gaucher )    多见于幼儿,属常染色体隐性遗传。Mitchell 指出伴脾肿大,脾功亢进是脾切除指征,但脾切除对此病仅是一种对症治疗,可以缓解由于脾功能亢进引起的全血细胞减少等症状,并非能解决先天性家族性类脂代谢的紊乱。

10. 骨髓纤维化症 (Myelofibrasis, MF)     原发性MF的脾切除指征为: (1) 疼痛性脾肿大;(2) 巨脾引起机械性压追症状; (3) 脾功能亢进全血细胞明显减少和难以控制的溶血; (4) 需经常输血或用皮质激素治疗,骨髓涂片尚见部分造血灶,特别是年轻病人。Benbasat 收集了英、法、德文中 321 MF 患者脾切除资料,约 64% 患者手术有治标作用,输血量减少,出血倾向和腹痛减轻。但病人于术后可出现代偿性肝肿大,对于合并活动性肝病和 pt 计数偏高者,不适宜脾切除术。

11. 何杰金氏病 (Hodgkin’s Disease, HD)     某些脾脏受累伴脾亢者可以行脾切除术。Mitchell 提出临床分期 IAIB A 的病例可考虑脾切除或作为剖腹探查的一部分手术,剖腹探查进行肝脏和淋巴结活检并切除脾脏,可以查明腹腔淋巴结受累程度及病变累及范围,便于提出针对性的治疗方案; 同时脾切除还可使患者发热、乏力等全身症状获得缓解,并可解决脾亢和增强对放疗或化疗的耐受性。

T his is the traditional viewpoint of spleen cutting which has lasted for two to three hundred years: “The spleen is not necessary for life. The spleen can be removed at will.”   With the development of modern medicine, as well as the in-depth exploration and research on the function of the spleen, it has been gradually found that the spleen has non-negligible immune functions such as anti-infection and anti-cancer. Therefore, selective and effective splenectomy has become a trend of the times. However, to systematically understand the general view of spleen function and the adverse effects on the body after splenectomy, and to correctly grasp the indications of splenectomy are the key to ensure the quality of splenic surgery.

脾脏并非生命所必需,脾可以随便切除。这便是历时二、三百年的传统切脾观点。随着现代医学的发展,以及对脾脏功能深入探索和研究,已陆续发现脾脏具有不可忽视的抗感染、抗癌等免疫功能。因此,选择性有效保脾手术已成为一种时代的倾向。但系统地了解脾脏功能的全貌及去脾后对机体有哪些不利的影响,正确地掌握脾切除的指征,这便是保证脾外科质量的关键之关键。

A, splenectomy indications 

(1) Hematopathy

Hematological diseases are closely related to splenic surgery. In 1887, Spencer first performed splenectomy for hereditary spherocytosis. A new page was opened for surgical splenectomy to treat hematological diseases. However, selective splenectomy or emergency splenectomy for patients with hematological diseases, as well as preoperative preparation and operation timing, are different from splenectomy for general diseases and have their own particularities. 

  1. Hereditary Spherocytosis, HS) is also known as familial hemolytic anemia or congenital hemolytic jaundice. The disease is autosomal dominant. Splenectomy should be performed for all patients diagnosed with HS who have anemia and splenomegaly in clinic. Williams and Schwartz et al. pointed out that even mild patients after the diagnosis of HS were indications of splenectomy. Splenectomy as the main treatment of HS, with significant efficacy, has been recognized by scholars both in China and abroad. Splenectomy is not recommended for children under 4 years of age due to the susceptibility of infants to infection after surgery. 
  2. Hereditary elliptic erythrocytosis (HE) is also an autosomal dominant disease, and it can be treated without any clinical symptoms. In case of severe anemia, splenomegaly and hemolytic jaundice, splenectomy should be performed. 
  3. thalassemia for hereditary hemoglobin synthesis disorder, splenectomy to reduce hemolysis and reduce the amount of blood transfusion. Splenectomy had good curative effect on α thalassemia, while HbE-β type was worse. The Institute of Blood Research of Chinese Academy of Sciences performed splenectomy on 29 patients with α thalassemia. The Hb post-surgery increased significantly. However, for the patients with Hb above 80g/L before surgery, the Hb post-surgery did not increase significantly. It was proposed that the patients with Hb below 80g/L were suitable for surgical treatment. At the same time, splenectomy was performed on 11 patients with β -thalassemia, and the curative effects were not as good as those of α-thalassemia. Indications of splenectomy for α -thalassemia: (1) Aged over 3 years old; (2) Hb is below 80g/L; (3) Hyperactivity of spleen with pancytopenia; (4) 51Cr shortened red blood cell life, spleen-liver ratio > 2, and increased spleen positioning index. 
  4. Autoimmune Hemolytic Anemia, AHA) is an acquired hemolytic anemia caused by the production of antibodies against red blood cells that can destroy the body's normal function due to the body's immune dysfunction. ? ? ? The principle is to remove the main place where the antibodies that destroy your red blood cells or platelets are produced. Therefore, warm antibody type primary AHA is suitable for splenectomy, while cold antibody type AIHA hemolysis occurs mainly in the blood circulation or liver, so it is not suitable for splenectomy. Indications of splenectomy: (1) patients who failed to respond to medication or took medication for a long time, and relapsed after drug discontinuation; (2) Patients with Evans syndrome complicated with thrombocytopenia, and patients with unsatisfactory therapeutic effects such as corticosteroids; (3) 51Cr isotope body surface measurement shows that red blood cells are mainly in the spleen retention destroyer; (4) Splenectomy with positive IgG-type Coombs test was effective. It has been reported in China and abroad that the curative effect of splenectomy is generally about 60%. 
  5. Idiopathic thrombocytopenic purpura (ITP) The occurrence of this disease is related to autoimmune. Immunoglobulin G is adsorbed on the platelets. The platelets with immunoglobulin G are damaged in advance by macrophages in the gallbladder and liver. The damage site is 2/3 in the spleen. Therefore, in most cases, the platelet count can rise rapidly after splenectomy. There are many reports on the efficacy of splenectomy for ITP, with the effective rate of about 80%. There are different opinions on whether to perform emergency splenectomy for patients with acute ITP. It is generally considered that prednisone and high-dose intravenous immunoglobulin are ineffective for patients with acute ITP, and emergency splenectomy can be performed when bleeding is life-threatening. Indications for splenectomy in patients with chronic ITP: (1) those who have been treated with hormones or immunosuppression for more than six months without remission; (2) Patients with platelet count less than 25×103/L and intracranial hemorrhage or massive hemorrhage of other organs: (3) patients who had unsatisfactory therapeutic effects of drugs such as hormones or immunosuppressants, or who needed to maintain a large dose of hormones for a long time; (4) the hormone or immunosuppressive agent application taboo; (5) Platelet detected by 51Cr standard is mainly in spleen? ? Saboteurs. 
  6. Chronic aplastic anemia (CCA) Mitchell pointed out that selective splenectomy for CCA was beneficial to reduce hemolysis, prolong platelet life and reduce blood transfusion. Indications for splenectomy for CAA: (1) patients with good bone marrow hyperplasia, high erythroid, and hemolysis, for which medical treatment was ineffective; 51Cr determination of red blood cells and/or platelets life expectancy, spleen damage. The Institute of Hematology of the Chinese Academy of Sciences performed splenectomy on 28 patients with CAA, and the effective rate was 65.2%. 
  7. Chronic myeloid leukemia (CML) In the 1970s, some scholars believed that there were more acute transformation cells in the spleen, and splenectomy could prevent acute transformation of CML. However, it has been proved in recent years that splenectomy cannot prevent CML from sudden change and is of no benefit. At present, for patients with CML unless the massive spleen causes symptoms of mechanical chase and hypersplenism, and the massive spleen is accompanied by thrombocytopenia, splenectomy is generally no longer advocated because splenectomy cannot prolong survival or delay the occurrence of sudden changes. 
  8. Hairy cell leukemia (HCl) is an indication for surgical splenectomy when accompanied by splenomegaly and hypersplenism. Jansen believed that the surgery had better effects under the following conditions: (1) The spleen was larger than or equal to 4cm at the costal margin; (2) The spleen is 1–3 cm below the synergic edge, but Hb<85g/L or HB85–120 g/L, Pt ≤ 50 × 109/L; (3) The spleen was not palpable, but Hb<85g/L, Pt ≤ 50 × 109/L. 
  9. Gaucher disease occurs more frequently in young children and is autosomal recessive. Mitchell pointed out that with splenomegaly, hypersplenism was the indication for splenectomy, but splenectomy was only a symptomatic treatment for the disease, which could alleviate the symptoms such as pancytopenia caused by hypersplenism, rather than solve the congenital disorder of familial lipid metabolism. 
  10. Myelofibrasis, MF) The indications of splenectomy for primary MF are as follows: (1) Painful splenomegaly; (2) Giant spleen causes mechanical chase after symptoms; (3) The pancytopenia of hypersplenism and uncontrolled hemolysis; (4) Regular blood transfusion or corticosteroid treatment is needed, and partial hematopoietic foci are still observed on bone marrow smear, especially for young patients. Benbasat collected 321 cases of MF patients with splenectomy data in English, French and German, about 64% of the patients have palliative effect, reduce the amount of blood transfusion, bleeding tendency and abdominal pain. However, the patient may develop compensated hepatomegaly postoperatively, and splenectomy is not appropriate for patients with combined active liver disease and high pt counts. 
  11. Hodgkin's Disease, HD): splenectomy can be performed for some patients with splenic involvement and hypersplenism. Mitchell proposed that for cases with clinical stages IA, IB and A, splenectomy or surgery as part of laparotomy could be considered, and laparotomy with liver and lymph node biopsy and splenectomy could be performed to identify the extent of abdominal lymph node involvement and the lesion involvement, so that targeted treatment could be proposed. At the same time, splenectomy can also relieve the patients' systemic symptoms such as fever and fatigue, solve the hypersplenism and enhance the tolerance to radiotherapy or chemotherapy.

() 脾功能亢进

主要由于肝硬变导致门静脉高压而引起充血性脾肿大,巨脾在血吸虫性肝硬变时尤为多见。周围血细胞减少是由于脾红髓增生时其正常滤过及储存功能呈病理性亢进时所致。脾切除可使周围血液恢复正常。我国大量晚期血吸虫病人行脾切除后 4-5 年的随访结果,生车率达94%。对肝炎后肝硬化或所谓的班替氏病患者的巨脾应根据脾功能亢进程度,静脉曲张有无及全身情况慎重考虑单纯脾切除或与其它分流及断流手术合用,若患者因任何原因造成显著脾肿大有压迫症状或有脾梗塞、脾破裂之危险者也可考虑脾切除。

B. hypersplenism 

Congestive splenomegaly is mainly caused by portal hypertension due to cirrhosis, and splenomegaly is particularly common in schistosomal cirrhosis. The decrease in peripheral blood cells is due to the pathological hyperfunction of the normal filtration and storage functions of the splenic red pulp when it proliferates. Splenectomy can normalize the surrounding blood. According to the 4–5 year follow-up results of a large number of people with advanced schistosomiasis in China after splenectomy, the car-bearing rate has reached 94%. Splenectomy alone or in combination with other shunting and devascularization procedures should be carefully considered in patients with post-hepatitis cirrhosis or so-called Banteay's disease whose massive spleen is in accordance with the degree of hypersplenism, the presence of varicose veins and the general condition. Splenectomy may also be considered in cases where the patient suffers from any cause of marked splenomegaly with symptoms of compression or a risk of splenic infarction or splenic rupture. 

() 脾破裂

脾切除曾一直是治疗损伤的唯一治疗方法。但自1952 King 报告了儿童脾切除术后发生爆发性感染 (Overwhelming postspleenectomy infection, OPSI) 引起了人们对脾切除术的重新认识。随着对脾脏生理功能研究的深入,各种脾手术兴起,诸如脾修补术、脾部分切除术等,这些手术保留了脾脏功能,但需要一定的技术水平、经验及术后严密观察。总的原则是抢救生命第一、保留脾脏第二,即在保证生命安全的前提下,尽可能保留脾脏或保存 (或保存一部分) 脾功能,既不要不管损伤程度如何,一律采用切脾治疗,又切忌不顾病人安危而强行保脾治疗。必须根据病情及本医院技术力量,制定适合于自己的单位的切脾适应证,切忌千篇一律,以保证疗效。一般来说,全切除术的适应证:(1) IV 度破裂伤,全脾破裂或广泛性脾实质破裂,脾脏血供完全中断;(2) 有威胁生命的多发伤;(3) 病情重、血压不稳定;(4) 脾缝合术不能有效的止血。

C. Spleen rupture 

Splenectomy has always been the only treatment for injury. However, the outbreak of fulminant infection (OPSI) after splenectomy in children reported by King in 1952 has aroused new understanding of splenectomy. With the deepening of research on the physiological function of the spleen, various splenic operations have arisen, such as splenic repair and partial splenectomy, which preserve the spleen function but require a certain technical level, experience and close observation after surgery. The general principle is to save life first and preserve the spleen second, that is, on the premise of ensuring the safety of life, to preserve the spleen or preserve (or preserve part of) the spleen function as much as possible. The spleen cutting treatment should be adopted regardless of the degree of injury, and the spleen conservation treatment should not be forced regardless of the safety of the patient. According to the condition and the technical strength of our hospital, an indication suitable for spleen resection in our unit must be formulated, and no one in common is required to ensure the curative effect. In general, the indications of total resection: (1) Degree IV rupture injury, whole spleen rupture or extensive splenic parenchyma rupture, and complete interruption of splenic blood supply; (2) There are multiple life-threatening injuries; (3) Severe illness and unstable blood pressure; (4) Spleen suture cannot effectively stop bleeding. 

二、脾切除术后对机体的影响

() 免疫功能低下

脾脏是一个重要的免疫器官,脾脏对机体提供的免疫保护作用是终生的,对婴幼儿和儿童尤其显得重要。脾脏有如一个滤器对侵入血流中的颗粒抗原如细菌首先可发挥机械清除及滤过作用。脾脏还可以产生具有强大调理作用的IgM,经过调理的抗原才易被脾内外吞噬细胞所吞噬。脾脏产生的 Tuftsin,能有效促进多形核细胞吞噬。实验证明半脾切除之后,脾清除能力下降 25%,脾动脉结扎后下降 50%,脾切除后脾清除作用消失。

脾切除后最主要的并发症是由免疫功能低下引起的感染,因为: (1) 脾脏是制造 IgM 的重要场所,感染后首先是 IgM 的增高 (初级免疫反应)IgM的半衰期只有5天,脾切后 IgM 很快下降,故可发生对感染的免疫应答功能低下;(2) 丧失了脾的滤器功能; (3) 不能制造吞噬作用激素,备解素及非特异性调理素,吞噬细胞的吞噬及清除细菌的功能明显减退。据统计外伤而切除脾脏的病人出现凶险的脾切除术后感染 (OPSI) 的危险是正常人群的50倍。因特发性血小板减少症,后天性溶血性贫血,何杰金氏病和其他血液病而施行脾切除者,其出现 OPSI 的危险性更大。

II. Effects on body after splenectomy 

(a) low immune function 

The spleen is an important immune organ. The immune protection provided by the spleen is lifetime, especially important for infants and children. The spleen acts as a filter for the mechanical clearance and filtration of particulate antigens such as bacteria that invade the bloodstream. The spleen can also produce IgM with a strong conditioning effect, and the conditioned antigen is easily swallowed by the phagocytes inside and outside of the spleen. Tuftsin produced by the spleen can effectively promote the phagocytosis of polymorphonuclear cells. Experiments showed that after hemisplenectomy, the splenic clearance decreased by 25%, and that after splenic artery ligation it decreased by 50%. The splenic clearance disappeared after splenectomy. The most important complication after splenectomy is infection caused by low immune function because: (1) The spleen is an important place for the production of IgM, and the first complication after infection is the increase of IgM (primary immune response). IgM has a half-life of only five days, and it decreases rapidly after splenectomy, so a low immune response to infection may occur. (2) Loss of the "filter" function of the spleen; (3) Can't produce phagocytic hormone, properdin and non-specific opsonin; the phagocytosis of phagocytes and the function of removing bacteria are decreased obviously. The risk of a dangerous post-splenectomy infection (OPSI) is calculated to be 50 times higher in patients with traumatic splenectomy than in the normal population. Splenectomy for idiopathic thrombocytopenia, acquired hemolytic anemia, Hodgkin's disease, and other hematological disorders is associated with a greater risk of developing OPSI. 

() 血液流变学改变

脾切除后由于细胞碎片,Howell-Jolly小体,Heinz 小体及其他代谢产物无法清除,红细胞内粘度升高,红细胞变形能力降低,因而脾切除术后血液粘度升高。脾切除对血小板的影响包括数量的增加和聚集性的增强。脾切除后约13%的病人血小板可超过100万,持续数月甚至数年,造成血小板增多症。血液和血浆粘度升高,加之血小板数量增加和功能增强,使机体处于一种高凝状态,这是术后血栓和栓塞发生的基础。有报道脾切除后死于闭塞性血管疾病和缺血性心脏病的比例增高,如迁移性血栓性静脉炎,深静脉血栓形成,冠心病等。

任何手术创伤都可导致血液流变学改变,但一般手术后的改变主要在术后近期,而远期大多恢复至术前水平。脾切除术后的上述改变则是持续的,因此对脾切除术后血液流变学指标和血小板聚集性明显增强者,以及血小板数量大于 400×109/l 者要采取预防措施,对原有心、脑血管疾病者更应引起重视。

(b) The changes of blood rheology

After splenectomy, the blood viscosity increased due to the inability to remove cell debris, the Howell-Jolly bodies, the Heinz bodies, and other metabolites, as well as the increased intracellular viscosity of erythrocytes and the decreased deformability of erythrocytes. Effects of splenectomy on platelets include an increase in number and aggregation. In about 13% of patients after splenectomy, platelets can exceed 1 million and last for months or even years, causing thrombocytosis. The increased viscosity of blood and plasma, together with the increased number and function of platelets, places the body in a hypercoagulable state, which is the basis for postoperative thrombosis and embolism. It has been reported that the proportion of patients who die from occlusive vascular disease and ischemic heart disease after splenectomy is increased, such as migratory thrombophlebitis, deep vein thrombosis, and coronary heart disease.

Any surgical trauma can lead to hemorheological changes, but generally the changes after surgery are mainly in the short term after surgery, and most of them return to the preoperative level in the long term. The above changes after splenectomy are persistent, so preventive measures should be taken for patients with significantly enhanced blood rheology indexes and platelet aggregation after splenectomy, and for patients with platelet number greater than 400×109/l, and more attention should be paid to patients with original cardiovascular and cerebrovascular diseases. 

三、脾切除术后并发症

脾切除术虽为一中等手术,但并发症却相当多,也有很高的死亡率,根据 Thaeton 统计一家医院 2417 例脾切除总的并发症为 39%,住院死亡率为 10%,危险性相当于或高于全胃切除术。脾切除术后合并发症可根据发生时间的不同分为早期合并症及晚期合井症。

III. Complications after splenectomy Splenectomy is a medium-sized operation, but it has many complications and a high mortality rate. According to Thaeton, the total complication rate of 2417 cases of splenectomy in a hospital is 39%, and the mortality rate in hospital is 10%. The risk is equal to or higher than that of total gastrectomy. The combined complications after splenectomy can be divided into early complications and late complications according to the time of occurrence. 

() 早期合井症

1、出血    术中及术后数内最常见的严重合并症是出血,由于脾上极与胃底距离很近,胃短血管处理不当断端出血是常见的。又如胰尾有时延伸直达脾门,因顾忌伤及胰腺,脾蒂缝扎不牢,或处理脾蒂伤及脾静脉可造成难以控制的出血,门脉高压症尤其是血吸虫性巨脾,周围粘连重且有大量侧支循环,切除脾后膈面及后腹膜常有大量出血和渗血 ,如止血不完善,不彻底常于术后井发出血。

2、膈下积液、膈下脓肿    脾床止血不彻底,导致小量积血,或有淋巴液积聚等原因继发细菌感染而成,胃底损伤可导致胃漏,膈下积液及脓肿,胰尾损伤可导致胰漏、脓肿、胰腺囊肿及胰腺炎。

3、血小板计数过高    少数脾切除后可发生严重血小板增高,甚至达 1000×109/L 以上,这种情况多为一过性。

4、左侧胸腔积液及肺炎    常见于巨脾尤其是伴有门静脉高压,隔下广泛静脉侧支形成及淋巴管扩张者,因局部创伤,低蛋白血症,术后长期卧床,呼吸运动锻炼不足者。

5、脾热问题    脾切除患者术后常出现较长时间发热,短者2周左右,长者可达数月之久。抗生素治疗效果不佳,可笼统称为脾热,其实不同患者的脾热应该有其具体原因,除局部感染外,切脾后免疫功能低下,及脾静脉血栓形成也是常见原因。当然有部分的病例查不出原因,且应用抗生素效果不明显,而经一时期后体温慢恢复正常,人们称之为不明原因发热。

(1) Early commingling of wells

  1. The most common serious complication of hemorrhage during and after operation is hemorrhage. Due to the close distance between the superior pole of the spleen and the fundus of the stomach, it is common to have terminal hemorrhage due to improper treatment of short gastric vessels. For another example, the tail of pancreas sometimes extends as far as the splenic hilus. For fear of hurting pancreas, the pedicle of spleen cannot be firmly sutured, or uncontrolled bleeding can be caused by treating the injury of splenic pedicle and splenic vein. Portal hypertension, especially schistosomiasis splenomegaly, has severe peripheral adhesion and a large number of collateral circulation. The resection of the posterior diaphragmatic surface and retroperitoneum of the spleen often results in massive bleeding and bleeding. For example, if the hemostasis is not perfect, the bleeding will not be completely released in the postoperative well. 
  2. The hemostasis of the spleen bed for subphrenic effusion and subphrenic abscess is not complete, resulting in a small amount of blood accumulation, or secondary bacterial infection caused by lymph accumulation. Gastric fundus injury can lead to gastric leakage, subphrenic effusion and abscess, and pancreatic tail injury can lead to pancreatic leakage, abscess, pancreatic cyst and pancreatitis. 
  3. Platelet count is excessively high. A few patients may suffer from severe thrombocytosis after splenectomy, even reaching more than 1000 × 109/L. This condition is mostly transient. 
  4. Left pleural effusion and pneumonia are common in splenomegaly, especially in patients with portal hypertension, extensive collateral formation of inferior septal veins and lymphangiectasia. Due to local trauma, hypoproteinemia, the patients stay in bed for a long time after operation and have insufficient respiratory exercise.

() 晚期井发症

1、血栓栓塞性并发症    少数病人切除后发生迁移性血栓性静脉炎或严重的深静脉血栓形成及血栓栓塞后井发症,特别是溶血性贫血及骨髓增生异常的病人脾切除后容易发生危险的血小板计数过度上升,必须密切监视病人必要时尽早采用抗凝剂或抗血小板积聚药物治疗。

2、副脾问题    据国内外报道,14-30% 的切脾手术患者有副脾,全脾切除后,如遗留副脾在体内,可以完全取代脾脏的功能,甚至原来的溶血或血小板减少症等疾病的复发或疗效不佳,当再次手术切除副脾后症状便可消失。

3、脾切除术后暴发性感染 (OPSD)    早在1919 Morris 已指出脾切除后可增加感染的局感性,并对滥行脾切除提出警告,但当时未被其他学者所重视,直到 1952 King 报告100例儿童球状血球性贫血脾切除后5例发生严重败血症、2例死亡,才引起人们的注意,并命名为脾切除后暴发性感染(OPSD,也有人们称为脾切除后败血症OPSI 的发病年率是 1.45%, 为正常情况感染死亡的 200 倍,OPSI 可发生在切脾后几周至几年之间,而发生越早,死亡率越高,但多发生在切脾后两年内,而且在儿童及患血液病患者中发病幸则更高。

(2) Late onset of well logging 

  1. thromboembolic complications occurred in a small number of patients after resection of migratory thrombophlebitis or severe deep vein thrombosis and thromboembolism after well hair disease, especially hemolytic anemia and myelodysplastic patients after splenectomy is prone to dangerous platelet count excessive rise, must closely monitor the patient as soon as possible when necessary using anticoagulant or antiplatelet accumulation drug treatment. 
  2. The accessory spleen problem According to the reports in China and abroad, 14-30% of patients undergoing splenectomy have an accessory spleen. After total splenectomy, if the accessory spleen is left in the body, it can completely replace the function of the spleen. Even the original hemolysis, thrombocytopenia and other diseases recur or the curative effect is poor, and the symptoms can disappear after the accessory spleen is resected again. 
  3. Post-splenectomy fulminant infection (OPSD) As early as after 1919, Morris pointed out that splenectomy could increase the local sensitivity of infection and warned against indiscriminate splenectomy, but it was not noticed by other scholars at that time. It was not until 1952, when King reported that five of the 100 cases of children with globocytic anemia developed severe septicemia and two died after splenectomy, which was called "OPSD", or "septicemia after splenectomy". The annual incidence rate of OPSI is 1.45%, which is 200 times of the death caused by normal infection. OPSI can occur in weeks to years after splenectomy. The earlier it occurs, the higher the death rate will be. However, it mostly occurs within two years after splenectomy, and the incidence rate is even higher in children and patients with hematological diseases.

 

This article was originally published in Proceedings of Wuhu Annual Surgical Conference,1996;28-30
Changhang Hospital, Li Mingjie

【李名杰从医67年论文专辑】(电子版)

【李名杰从医67年论文专辑(英语电子版)】

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立委博士,问问副总裁,聚焦大模型及其应用。Netbase前首席科学家10年,期间指挥研发了18种语言的理解和应用系统,鲁棒、线速,scale up to 社会媒体大数据,语义落地到舆情挖掘产品,成为美国NLP工业落地的领跑者。Cymfony前研发副总八年,曾荣获第一届问答系统第一名(TREC-8 QA Track),并赢得17个小企业创新研究的信息抽取项目(PI for 17 SBIRs)。

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