OPSI or spleen salvage
Some 15 years ago we had a severe Crohn’s patient with recurrent fistulae after multiple operations trying to close them. He was for a long period on home parenteral nutrition. Came in with overwhelming systemic pneumococcal infection and died in the classical fashion. It was at the time when OPSI was very much in vogue and we reasoned that perhaps the long-term parenteral nutrion had functionally destroyed his spleen.
Since then I have not encountered another case after splenectomy, but have seen several overwhelming pneumococcal infections due to community acquired pneumonia (in patients with preserved spleens). Dreadful disease.
It seems to me that every generation has its scaring infection. Previously, overwhelming pneumococcal pneumonia or rhematoid fever, then fulminant meningococcal infection, then OPSI, then legionella or staph toxic shock syndrome, and right now the flesh-eating bacteria.
Everybody knows about them, all have seen a few cases at the time when the particular infection is in vogue, then not many more. Who cares about TSS (tampong disease) today. These infections are capable of changing the way societies behave.
The streptococci (including the diplococci) are particularly dangerous because they are human pathogens with a tendency to suddenly express very aggressive pathogenetic factors in which case they invade and produce an overwhelming infection in susceptible individuals.
I have salvaged ruptured spleens after trauma with this net bag made from Vicryl on a few instances. There appears to be price in salvage of smashed spleens in this way as I can remeber two pts with protracted courses for no obvious reason but a badly damage spleen remaining inside the body together with a lot of foreign material. Does anyone have good experiences with the bags?
I make a bag for splenic salvageout of NuKnit, by suturing it around the spleen. This is a microvascular collagen product, which can hold vicyrl. It has the advantage of promoting hemostasis.
I think these bags are useless. I have not seen it stop the bleeding in badly ruptured spleens unless tied so tight that it blocks the blood supply, and most of their “success” were in spleens that could be left alone anyway.
I suspect that the reason for the protracted course in your cases were that the “bag” was tied so tight that the spleed necrosed.
I either suture the spleen between two pieces of gore-tex (about an inch wide and as long as needed) or I do a partial splenectomy with the stapler. If there is just a capsular tear, I usually leave it alone.
We have been routinely salvaging spleens for years– I’ve been using simply Vicryl mesh, sewing it in a bag- like fashion to tamponade the organ, and it works fine–unlike the fluky anecdotes I;ve been reading on this board, the patients do as well as any other post-op trauma laps, and are completely in sync with what’s reported in the literature–I’d suggest to some of you to do a few more before coming up with these aberrant opinions. As the old saying goes–Try it, you’ll like it! Simply take a square of vicryl mesh, cut a “keyhole” in it extending to the middle of the sheet, pull this keyhole around the hilum from laterally and posteriorly (the best results are after taking down the short gastrics and diaphragmatic attachments so the spleen is attached only on its vascular pedicle, using your fingers to occlude the hilar vessels during this time so bleeding should never be a problem in this process), then sewing the keyhole together from the hilum outward, and then around the top in such a way that the spleen is squeezed tight, in the same way as if you just manually squeezed it–for the post that was “afraid” this would necrose it and you might as well remove it–baloney! Numerous studies have followed up these spleens long term and they look perfectly normal within even just a few days of surgery. Again, we have been doing this for years without any major problem. Again, massive bleeding, significant associated injuries, hemodynamic instability, etc mandate the quicker route of splenectomy, so common sense patient selection is essential here . It would really help if those bringing up these vague and unfounded conjectures about how worthless this procedure is had some data to cite to refute the scads available showing this to be a perfectly sound procedure?
All I said was that I have not had any success with the vicryl bag, and those “successes” that I have seen, walking through the OR, were all spleens that I would have left alone.
I am talking about the Vicryl bag with the 3 strings that is commericially available. With this device, I have seen two cases were the spleen necrosed down. One was proven on relaparotomy. The other had protractected course develeped thrombocytosis to over 1 mil, and the CT was suggestive of necrosis. Eventaully settled down.
What you are improvising sounds may be more effective. for one thing, you cannot tie down too hard on the hilar vessels.
I want to make clear that we salavage most of our isolated splenic ruptures.
If I can do a hemisplenectomy with the stapeler, I do this also on unstable patients and patients with other injuries. Since it is just as fast as a splenectomy, and works every time.
I have one young patient who had a damage control operation for the liver with hemisplenectomy following a kick from a Camel. Segment 6 and part of 7 were detached. He had several trips to the OR, and the remanat spleen was functioning. 3 months ago, I fixed his ventral hernia, so I looked at the spleen and liver, both apeared normal.
I have no arguement about splenic salvage, I don’t like a particular commercial method of doing it.
In young patients when is not possible any salvage of the spleen, what do you think about insertion of a couple of slice of sleen in the epiploon? Like what happens in fragmentations they go on in tehyr immunogen work; I tried this metod some times but of course I don’t have enough cases to prove any degree of evidence one scanning for other reasons proved normal image.