Esquistossomose hepato-esplênica em crianças: avaliaçao morfológica e funcional após esplenectomia e auto-implante esplênico

Brandt, Carlos Teixeira; Oliveira, Bruno Santos; Nogueira, Janaína de Brito M.; Neves, Juliana Rodrigues; Lopes, Tércio Limongi

doi:10.1590/S0100-69911998000600008

Resumos

A esquistossomose mansônica hepato-esplênica com varizes sangrantes do esôfago é infreqüente em crianças, entretanto, determina morbidade atingindo a produtividade desses futuros adultos. Uma das opções para o tratamento cirúrgico é a esplenectomia associada à ligadura da veia gástrica esquerda e esclerose endoscópica das varizes, nos casos de recidiva hemorrágica. Auto-implante esplênico tem sido adicionado em crianças. Há evidências de que a esplenose pós-esplenectomia por trauma mantém, de forma parcial, as funções imunológica e de filtração esplênicas. Todavia, estudos semelhantes não foram realizados em pacientes esquistossomóticos. Foram analisados 23 pacientes, de 9 a 18 anos, com esquistossomose hepato-esplênica submetidos à esplenectomia, ligadura de veia gástrica esquerda e auto-implante esplênico no omento maior. Avaliou-se a função de filtração através da pesquisa de corpúsculos de Howell-Jolly em esfregaços de sangue periférico, cuja presença indica ausência ou insuficiência de função de filtração esplênica. Foi realizada análise morfológica da esplenose através de exame cintilográfico, usando enxofre coloidal, marcado com Tecnécio 99m. Observou-se captação dos implantes esplênicos em todos os pacientes, entretanto, em dois (8,7%), o número de nódulos esplênicos observados foi inferior a cinco, sendo considerado insuficiente. Em correspondência, esses dois pacientes foram os únicos que apresentaram positividade para corpúsculos de Howell-Jolly. Os dados confirmam o auto-implante esplênico no omento maior como método eficaz de produção de esplenose e manutenção da função de filtração esplênica em mais de 90% dos pacientes.

Esplenectomia; Auto-implante esplênico; Esplenose; Esquistossomose mansônica

The hepatosplenic form of schistosomiasis mansoni with bleeding esophageal varices is not common in children. However when it occurs, it may determine severe implications of their whole productive life. Splenectomy ligature of the left gastric vein and endoscopic sclerosis of the varices in the cases of recurrent bleeding has been one of the surgical approaches. Autologous implantation of spleen tissue in the greater omentum has been added in children. There are evidences that immunologic and filtration splenic functions persist, at least in part, after splenectomy and splenic autologous implantation induced by trauma. However similar studies were not conducted in children with schistosomiasis who underwent splenectomy, ligature of the left gastric vein and autologous implantation of spleen tissue into an omental pouch of the greater omentum. Blood smears were repeatedly studied for evidence of Howell-Jolly bodies, which indicate insufficiency of filtration splenic junction. The splenosis was proved by hepatosplenic scintigraphic sulfur colloid 99m Technetium scan. Splenosis was evident in all children, however in two patients there were less than five splenic nodules in the greater omentum, which was considered insufficient. Howell-Jolly bodies were found in the peripheral blood only in these two patients with less evident splenosis. The results seem to indicate that splenic autologous implantation in the greater omentum is an effective method for producing splenosis and maintaining the filtration splenic function.

Schistosomiasis mansoni; Splenectomy; Spleen tissue implantation; Splenosis

ARTIGOS ORIGINAIS

Esquistossomose hepato-esplênica em crianças: avaliaçao morfológica e funcional após esplenectomia e auto-implante esplênico

Hepatosplenic schistosomiasis in children: morphologic and functional evaluation after splenectomy and autologous splenic implantation

Carlos Teixeira Brandt, TCBC - PE^I; Bruno Santos Oliveira^II; Janaína de Brito M. Nogueira^II; Juliana Rodrigues Neves^II; Tércio Limongi Lopes^II

^IProfessor Titular de Clínica Pediátrica Cirúrgica UFPE

^IIAcadêmicos da Faculdade de Ciências Médicas da Universidade de Pernambuco - UPE

^{Endereço para correspondência} Endereço para correspondência: Dr. Carlos Teixeira Brandt Ed. Porta d'Água Rua 19 de Abril, 30/602 52031-332 - Recife-PE

RESUMO

A esquistossomose mansônica hepato-esplênica com varizes sangrantes do esôfago é infreqüente em crianças, entretanto, determina morbidade atingindo a produtividade desses futuros adultos. Uma das opções para o tratamento cirúrgico é a esplenectomia associada à ligadura da veia gástrica esquerda e esclerose endoscópica das varizes, nos casos de recidiva hemorrágica. Auto-implante esplênico tem sido adicionado em crianças. Há evidências de que a esplenose pós-esplenectomia por trauma mantém, de forma parcial, as funções imunológica e de filtração esplênicas. Todavia, estudos semelhantes não foram realizados em pacientes esquistossomóticos. Foram analisados 23 pacientes, de 9 a 18 anos, com esquistossomose hepato-esplênica submetidos à esplenectomia, ligadura de veia gástrica esquerda e auto-implante esplênico no omento maior. Avaliou-se a função de filtração através da pesquisa de corpúsculos de Howell-Jolly em esfregaços de sangue periférico, cuja presença indica ausência ou insuficiência de função de filtração esplênica. Foi realizada análise morfológica da esplenose através de exame cintilográfico, usando enxofre coloidal, marcado com Tecnécio 99m. Observou-se captação dos implantes esplênicos em todos os pacientes, entretanto, em dois (8,7%), o número de nódulos esplênicos observados foi inferior a cinco, sendo considerado insuficiente. Em correspondência, esses dois pacientes foram os únicos que apresentaram positividade para corpúsculos de Howell-Jolly. Os dados confirmam o auto-implante esplênico no omento maior como método eficaz de produção de esplenose e manutenção da função de filtração esplênica em mais de 90% dos pacientes.

Unitermos: Esplenectomia; Auto-implante esplênico; Esplenose; Esquistossomose mansônica.

ABSTRACT

The hepatosplenic form of schistosomiasis mansoni with bleeding esophageal varices is not common in children. However when it occurs, it may determine severe implications of their whole productive life. Splenectomy ligature of the left gastric vein and endoscopic sclerosis of the varices in the cases of recurrent bleeding has been one of the surgical approaches. Autologous implantation of spleen tissue in the greater omentum has been added in children. There are evidences that immunologic and filtration splenic functions persist, at least in part, after splenectomy and splenic autologous implantation induced by trauma. However similar studies were not conducted in children with schistosomiasis who underwent splenectomy, ligature of the left gastric vein and autologous implantation of spleen tissue into an omental pouch of the greater omentum. Blood smears were repeatedly studied for evidence of Howell-Jolly bodies, which indicate insufficiency of filtration splenic junction. The splenosis was proved by hepatosplenic scintigraphic sulfur colloid 99^m Technetium scan. Splenosis was evident in all children, however in two patients there were less than five splenic nodules in the greater omentum, which was considered insufficient. Howell-Jolly bodies were found in the peripheral blood only in these two patients with less evident splenosis. The results seem to indicate that splenic autologous implantation in the greater omentum is an effective method for producing splenosis and maintaining the filtration splenic function.

Key words: Schistosomiasis mansoni; Splenectomy; Spleen tissue implantation; Splenosis.

Texto completo disponível apenas em PDF.

Full text available only in PDF format.

Recebido em 20/3/98

Aceito para publicação em 23/7/98

Trabalho realizado no Departamento de Cirurgia do Centro de Ciências da Saúde - UFPE - Apoio da FACEPE.

1. Pereira G, Santos RP, Alexandre Neto J, et al. Formas graves da Esquistossomose Mansônica: Dados de internação hospitalar em Pernambuco. Ann da Fac de Med de Pernamb 1993;38:12-18.
2. Amaral RS, Porto AS. Evolução e situação atual do controle da esquistossomose no Brasil. Rev Soc Bras Med Trop 1994;27:73-89.
3. Kelner S. Critical evaluation of surgical treatment of schistosomotic portal hypertension. Mem Inst Oswaldo Cruz 1992;87(Supl 4): 357-368.
4. Kelner S, Ferreira PR, Dantas S, et al. Ligadura de varizes esôfago-gástricas na hipertensão portal esquistossomótica: avaliação de 25 anos. Rev Col Bras Cir 1982;9:140-146.
5. King H, Schumacker HB. Splenic studies: Susceptibility to infection after splenectomy performed in infancy. Ann Surg 1952;136: 239-242.
6. Smith CH, Erlandson M, Schulman I. Hazards of severe infections in splenectomized infants and children. Am J Med 1957;22: 390-404.
7. Huntley CC. Infection folIowing splenectomy in infants and children. J Dis Child 1958;95:477-480.
8. Horan M, Colebatch JH. Relation between splenectomy and subsequent infection: A clinical study. Arch Dis Child 1962; 37: 398-411.
9. Singer DB. Postsplenectomy sepsis. Perspect Pediatr Pathol 1965; 1:285-311.
10. Eraklis AJ, Kevy SV, Diamond LK, et al. Hazard of overwhelming infection after splenectomy in childhood. N Engl 1 Med 1967; 276:1225-1229.
11. Krivit W, Giebink GS, Leonard A. Overwhelming postsplenectomy infection. Surg Clin North Am 1979;59:223-233.
12. Tesluk GC, Thomas CG, Benjamin JT, et al. Fatal overwhelming postsplenectomy sepsis following autologous splenic transplantation in severe congenital osteopetrosis. J Pediatr Surg 1984; 19:269-272.
13. Hays DM, Ternberg JL, Chen TT, et al. Postsplenectomy sepsis and other complications following staging laparotomy for Hodgkin's disease in childhood. J Pediatr Surg 1986;21:628-632.
14. Green JB, Shackford SR, Sise MJ, et al. Postsplenectomy sepsis in pediatric patients following splenectomy for trauma: a proposal for a multi-institutional study. J Pediatr Surg 1986;21:1.084-1.086.
15. Aagerge IS, Heier HE, Hem E, et al. IgM and IgG response to pneumococcal capsular polysaccharides in splenectomized children. Acta Path Microbiol Immunol Scand 1984;92: 11-16.
16. Hathaway 1M, Harley RA, Sally S, et al. Immunological function in post-traumatic splenosis. Clin Immunol Immunopathol 1995;74: 143-150.
17. Weibel RE, Vella PP, McLaren AA, et al. Studies in human subjects of polyvalent pneumoooccal vaccines. Proc Soc Exp Biol Med 1977; 156:144-150.
18. Traub A, Giebink GS, Smith C, et al. Splenic reticuloendothelial function after splenectomy, spleen repair and spleen autotransplantation. N Engl Med 1987.;317:1.559-1.564.
19. Shokouh-amiri MH, Kharazmi A, Rahimi-saber S, et al. Phagocyte function after splenic autotransplantation. Arch Surg 1990;125: , 595-597.
20. Bargmann L, Buttcher W, Seufert RM. Quantitative and functional restaurations and alterations of peripheral lymphocytes in patients with autologous spleen implantation. Arch Orthop Trauma Surg 1990;109:102-105.
21. Annexton M. Autotransplantation of spleen tissue after trauma: encouraging evidence. JAMA 1979;24:437-438.
22. MülIer U, Rothlin M. Splenic neoforrnation following trauma-induced splenectomy diagnosis and function. Swiss Surg 1995;5:230-235.
23. Rice HM, James PD. Ectopic splenic tissue failed to prevent fatal Pneumococcal septicemia after splenectomy for trauma. Lancet 1980;15:565-566.
24. Schwartz AD, Goldthorn JF. Born-again spleens: and resistance to infection. N Engl J Med 1978;12:832.
25. Patel J, Williams JS, Shijel B, et al. Preservation of splenic function by autotransplantation of traumatized spleen in man. Surgery 1981; 90:683-685.
26. Patel J, Williams JS, Naim JO, et al. The effect of site and technique of splenic tissue reimplantation on pneumococcal clearence from the blood. J Pediatr Surg 1986;2:877-880.
27. Ldtke FE, Mack SC, Schuff-Wemer P, et al. Splenic function after splenectomy for trauma. Role of auto-transplantation and splenosis. Acta Chir Scand 1989;155:533-539.
28. Cooney DR, Dearth JC, Swanson SE, et al. Relative merits of partial splenectomy, splenic reimplantation, and immunization in preventing postsplenectomy infection. Surgery 1979;86:561-569.
29. Wolf BC, Neiman RS. Functions of the spleen. In: Wolf BC, Neiman RS Disorders of the spleen. W.B. Saunders Company. Harcout Brace Jovanovich. Philadelphia, London, Toronto, Montreal, Sydney, Tokyo. 1989, pp.20-29.
30. Domingues ALC, Domingues LAW. Forma intestinal, hepatointestinal e hepato-esplênica. In: Malta J - Esquistossomose mansônica. Editora Universitária. Recife. 1994, pp.91-109.
31. Kays MA, Stolar CJH. The spleen and splenectomy: implication for the pediatric population. In: Fonkalsrud EW, Krummel TM - Infection and immunological disorders in pediatric surgey. W.B. Saunders Company. Harcout Brace Jovanovich. Philadelphia, London, Toronto, Montreal, Sydney, Tokyo. 1993, pp.91-100.
32. Corazza GR, Ginaldi L, Zoli G, et al. Howell-Jolly body counting as measure of splenic function. A reassesment. Clin Lab Haematol 1990;12: 269-275.

Endereço para correspondência:

Dr. Carlos Teixeira Brandt Ed. Porta d'Água

Rua 19 de Abril, 30/602

52031-332 - Recife-PE

Datas de Publicação

Publicação nesta coleção
31 Maio 2010
Data do Fascículo
Dez 1998

Histórico

Aceito
23 Jul 1998
Recebido
20 Mar 1998

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

[1] 1. Pereira G, Santos RP, Alexandre Neto J, et al. Formas graves da Esquistossomose Mansônica: Dados de internação hospitalar em Pernambuco. Ann da Fac de Med de Pernamb 1993;38:12-18.

[2] 2. Amaral RS, Porto AS. Evolução e situação atual do controle da esquistossomose no Brasil. Rev Soc Bras Med Trop 1994;27:73-89.

[3] 3. Kelner S. Critical evaluation of surgical treatment of schistosomotic portal hypertension. Mem Inst Oswaldo Cruz 1992;87(Supl 4): 357-368.

[4] 4. Kelner S, Ferreira PR, Dantas S, et al. Ligadura de varizes esôfago-gástricas na hipertensão portal esquistossomótica: avaliação de 25 anos. Rev Col Bras Cir 1982;9:140-146.

[5] 5. King H, Schumacker HB. Splenic studies: Susceptibility to infection after splenectomy performed in infancy. Ann Surg 1952;136: 239-242.

[6] 6. Smith CH, Erlandson M, Schulman I. Hazards of severe infections in splenectomized infants and children. Am J Med 1957;22: 390-404.

[7] 7. Huntley CC. Infection folIowing splenectomy in infants and children. J Dis Child 1958;95:477-480.

[8] 8. Horan M, Colebatch JH. Relation between splenectomy and subsequent infection: A clinical study. Arch Dis Child 1962; 37: 398-411.

[9] 9. Singer DB. Postsplenectomy sepsis. Perspect Pediatr Pathol 1965; 1:285-311.

[10] 10. Eraklis AJ, Kevy SV, Diamond LK, et al. Hazard of overwhelming infection after splenectomy in childhood. N Engl 1 Med 1967; 276:1225-1229.

[11] 11. Krivit W, Giebink GS, Leonard A. Overwhelming postsplenectomy infection. Surg Clin North Am 1979;59:223-233.

[12] 12. Tesluk GC, Thomas CG, Benjamin JT, et al. Fatal overwhelming postsplenectomy sepsis following autologous splenic transplantation in severe congenital osteopetrosis. J Pediatr Surg 1984; 19:269-272.

[13] 13. Hays DM, Ternberg JL, Chen TT, et al. Postsplenectomy sepsis and other complications following staging laparotomy for Hodgkin's disease in childhood. J Pediatr Surg 1986;21:628-632.

[14] 14. Green JB, Shackford SR, Sise MJ, et al. Postsplenectomy sepsis in pediatric patients following splenectomy for trauma: a proposal for a multi-institutional study. J Pediatr Surg 1986;21:1.084-1.086.

[15] 15. Aagerge IS, Heier HE, Hem E, et al. IgM and IgG response to pneumococcal capsular polysaccharides in splenectomized children. Acta Path Microbiol Immunol Scand 1984;92: 11-16.

[16] 16. Hathaway 1M, Harley RA, Sally S, et al. Immunological function in post-traumatic splenosis. Clin Immunol Immunopathol 1995;74: 143-150.

[17] 17. Weibel RE, Vella PP, McLaren AA, et al. Studies in human subjects of polyvalent pneumoooccal vaccines. Proc Soc Exp Biol Med 1977; 156:144-150.

[18] 18. Traub A, Giebink GS, Smith C, et al. Splenic reticuloendothelial function after splenectomy, spleen repair and spleen autotransplantation. N Engl Med 1987.;317:1.559-1.564.

[19] 19. Shokouh-amiri MH, Kharazmi A, Rahimi-saber S, et al. Phagocyte function after splenic autotransplantation. Arch Surg 1990;125: , 595-597.

[20] 20. Bargmann L, Buttcher W, Seufert RM. Quantitative and functional restaurations and alterations of peripheral lymphocytes in patients with autologous spleen implantation. Arch Orthop Trauma Surg 1990;109:102-105.

[21] 21. Annexton M. Autotransplantation of spleen tissue after trauma: encouraging evidence. JAMA 1979;24:437-438.

[22] 22. MülIer U, Rothlin M. Splenic neoforrnation following trauma-induced splenectomy diagnosis and function. Swiss Surg 1995;5:230-235.

[23] 23. Rice HM, James PD. Ectopic splenic tissue failed to prevent fatal Pneumococcal septicemia after splenectomy for trauma. Lancet 1980;15:565-566.

[24] 24. Schwartz AD, Goldthorn JF. Born-again spleens: and resistance to infection. N Engl J Med 1978;12:832.

[25] 25. Patel J, Williams JS, Shijel B, et al. Preservation of splenic function by autotransplantation of traumatized spleen in man. Surgery 1981; 90:683-685.

[26] 26. Patel J, Williams JS, Naim JO, et al. The effect of site and technique of splenic tissue reimplantation on pneumococcal clearence from the blood. J Pediatr Surg 1986;2:877-880.

[27] 27. Ldtke FE, Mack SC, Schuff-Wemer P, et al. Splenic function after splenectomy for trauma. Role of auto-transplantation and splenosis. Acta Chir Scand 1989;155:533-539.

[28] 28. Cooney DR, Dearth JC, Swanson SE, et al. Relative merits of partial splenectomy, splenic reimplantation, and immunization in preventing postsplenectomy infection. Surgery 1979;86:561-569.

[29] 29. Wolf BC, Neiman RS. Functions of the spleen. In: Wolf BC, Neiman RS Disorders of the spleen. W.B. Saunders Company. Harcout Brace Jovanovich. Philadelphia, London, Toronto, Montreal, Sydney, Tokyo. 1989, pp.20-29.

[30] 30. Domingues ALC, Domingues LAW. Forma intestinal, hepatointestinal e hepato-esplênica. In: Malta J - Esquistossomose mansônica. Editora Universitária. Recife. 1994, pp.91-109.

[31] 31. Kays MA, Stolar CJH. The spleen and splenectomy: implication for the pediatric population. In: Fonkalsrud EW, Krummel TM - Infection and immunological disorders in pediatric surgey. W.B. Saunders Company. Harcout Brace Jovanovich. Philadelphia, London, Toronto, Montreal, Sydney, Tokyo. 1993, pp.91-100.

[32] 32. Corazza GR, Ginaldi L, Zoli G, et al. Howell-Jolly body counting as measure of splenic function. A reassesment. Clin Lab Haematol 1990;12: 269-275.

Brasil

Brasil

Esquistossomose hepato-esplênica em crianças: avaliaçao morfológica e funcional após esplenectomia e auto-implante esplênico

Hepatosplenic schistosomiasis in children: morphologic and functional evaluation after splenectomy and autologous splenic implantation

Resumos

Endereço para correspondência:

Datas de Publicação

Histórico