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Acta Cirurgica Brasileira

Print version ISSN 0102-8650On-line version ISSN 1678-2674

Acta Cir. Bras. vol. 13 n. 4 São Paulo Oct./Nov./Dec. 1994

http://dx.doi.org/10.1590/S0102-86501998000400002 

AUTOTRANSPLANTATION OF SPLEEN TISSUE IN CHILDREN WITH MANSONIC SCHSTOSOMIASIS WHO UNDERWENT SPLENECTOMY: EVALUATION OF SPLENIC RESIDUAL FUNCTIONS.1

 

Carlos Teixeira Brandt2
Lenisio Bragante de Araújo3
Célia Maria Barbosa4

 

 

BRANDT, C.T.; ARAÚJO, L.B.; BARBOSA, M.C. - Autotransplant of spleen tissue in children with mansonic schistosomiasis who underwent splenectomy: evaluation of splenic residual functions. Acta Cir. Bras.,13(4):212-6, 1998.

SUMMARY: Autotransplantation of spleen tissue is an attempt for maintenance of splenic functions when splenectomy is indicated in children. It minimizes the risks of overwhelming postsplenectomy infection and it has been done in children with severe portal hypertension due to hepatosplenic mansonic schistosomiasis that underwent splenectomy. The purposes of this investigation were to study the morphology of the residual splenic tissue; to evaluate the residual filtration function of this splenosis; and to assess the immune response to polyvalent pneumococcal vaccine of these patients. Twenty-three children with portal hypertension from mansonic schistosomiasis who underwent splenectomy, ligature of the left gastric vein, autotransplantation of spleen tissue into an omental pouch were evaluated for residual splenic parenchyma and functions. Tc-99m sulfur colloid liver-spleen scans were used for detection of splenic nodules. The search for Howell Jolly bodies were used for assessing the filtration function and Enzyme-linked immunosorbent assay was used for measuring the relative rise in titter of specific pneumococcal antibodies. Splenosis was evident in all children; however, in two 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 immune response was adequate in 15 patients; it was intermediate in 4 patients and inadequate in 4 patients. Autotransplantation of spleen tissue into an omental pouch is efficient in maintaining the filtration splenic function in more than 90% of the cases and the immune response to pneumococcal vaccination in approximately 65% of the children.
SUBJECT HEADINGS:
Autotransplantation of spleen tissue. Autologous splenic implantation. Hepatosplenic mansonic schistosomiasis. Filtration splenic function. Immune splenic function. Pneumococcal vaccination.

 

 

INTRODUCTION

Mansonic schistosomiasis is hyperendemic in Northeastern, Brazil, and it represents the main cause of portal hypertension in children1,2. Splenectomy, ligature of the left gastric vein and sclerosis of the esophageal varices is one of the most frequent approach of surgical treatment for the variceal hemorrhage associated with portal hypertension from hepatosplenic mansonic schistosomiasis2. In children, autotransplantation of spleen tissue into an omental pouch of the greater omentum has been added to this protocol as a measure of protecting against overwhelming postsplenectomy sepsis (OPSI). However decreasing the portal inflow to the liver, this surgical approach has proved to decrease the portal hypertension, to improve the development of these children as well as to maintain the hepatic functional reserve3, 4.

King and Schumacker, in 1952, draw attention to the risks of OPSI after splenectomy in children5. Subsequent reports have confirmed these observations and have changed the concept of the spleen as an expendable organ. Without the filtering function of the spleen, pneumococcus and other organisms may rapidly multiply in the bloodstream causing OPSI6-18.

Immunization with pneumococal, meningococcal, and hemophilus vaccines are efficacious in the prevention of OPSI if they are given two weeks before splenectomy. Prophylaxis with oral penicillin V should be considered in splenectomized patients without splenosis. In patients who had undergone splenectomy, due to trauma, without previous vaccination but develop natural splenosis or had received autologous splenic implantation, the immunization with pneumococal polysaccharides appears to produce good specific antibody response19-21. The asplenic patients, on the other hand, have a diminished response22,23.

However controversial in adults, natural splenosis or autologous splenic implantation, at least in children, has been used to explain the lesser risk of OPSI in the normal splenectomized host24-31.

The purpose of this investigation was three fold: 1 - To investigate the results of splenic tissue implantation in the greater omentum in children with portal hypertension due to schistosomiasis after undergoing splenectomy and ligature of the left gastric vein; 2 - To evaluate the residual filtration splenic function; and 3 - To assess the immune response to polyvalent pneumococcal vaccine of these patients.

 

METHOD

Twenty-three children, from 11 to 18 years of age, seventeen males and six females, suffering from recurrent gatroesophageal bleeding associated with severe portal hypertension due to hepatosplenic mansonic schistosomiasis were included in this investigation. They had undergone splenectomy, ligature of the left gastric vein and autotransplantation of spleen tissue into an omental pouch in the greater omentum. The patients who presented with recurrent variceal hemorrhage in the follow up were included in the protocol for endoscopic sclerosis of esophageal varices. All patients were cared for at The University Hospital - Federal University of Pernambuco, Brazil, from 1990 to 1995.

All patients were treated, 30 days before surgery, with oxamniquine for the schistosomiasis. Liver function tests and serum investigation for hepatitis B antigenemia were done in all patients. The Child’s criteria for assessment of hepatic functional reserve were used. Liver biopsy from all patients was sent for histopathology. Follow-up varied from one to six years, with average of three years. The patients were assessed for splenic nodules (splenosis) using the hepatosplenic nuclear scan employing sulfur colloidal technetium 99m. The filtration function was evaluated using the search, in the peripheral blood, for erythrocyte abnormalities such as Howell-Jolly bodies.

All patients received 0.5ml of intramuscular polyvalent pneumoccocal vaccine (Pneumo 23-Pasteur Mérieux – France). Before vaccination and after six weeks blood samples were collected. Pre and post immunization serum samples were used for Enzyme-linked Immunosorbent assay, in the same plates, of pneumoccocal type-specific polysaccharide antibody responses. The results were expressed in fold increase of titer antibody immune response, defined as: FI = post-immunization titter over pre-immunization titter20,21.

The patients who presented with FI greater than two were considered normal as regard to their immune response. Patients with FI between one and two were accepted as presenting intermediate response, and the ones with FI smaller than one were considered with impaired immune response. Paired Student "t" test was used for measuring the difference between the sample means of pneumoccocal type-specific polysaccharide antibodies. P < 0.001 rejected the null hypothesis.

 

RESULTS

Hepatosplenic Tc - 99m scan demonstrated five or more splenic nodules in the great omentum in 21 (91.3%) out of the 23 patients. (Fig. 1). They were considered as having sufficient residual spleen tissue. However, in two patients (8.7%) less than five splenic nodules were identified. In these two patients splenosis was considered inadequate, correspondingly Howell-Jolly bodies were found only in their peripheral blood smears. Splenic filtration function was then considered satisfactory in more than 90% of the patients Fig.I.

 

Image1683.gif (40406 bytes)

Fig. I - Tc-99 sulfur colloid captation of the splenosis

 

The post-immunization mean serum concentrations of pneumoccocal antibodies was greater than the pre-immunization. (P < 0.001). Fifteen patients (65.2%) presented with FI greater than two. In four patients (17.4%) the FI were between one and two and in another four patients (17.4%) the FI remained bellow one. Table 1.

 

Table I - Ratios between the post-immunization titer over pre-immunization titer.

FI

PATIENTS

> 2

7.0

6.1

5.0

4.3

3.7

3.4

3.1

3.0

2.7

2.3

2.2

2.1

2.0

2.0

2.0

>1<2

1.4

1.3

1.3

1.2

>1

0.9

0.8

0.8

0.7

 

DISCUSSION

Severe sepsis occurs more commonly in children who have undergone total splenectomy. The overall incidence of OPSI in these patients is about 4.25% but varies with age and underlying disease. Partial splenectomy, splenorraphy, partial splenic embolization, and autologous splenic implantation in the great omentum have been used for minimizing the risks of OPSI. Prophylactic penicillin is routinely employed after splenectomy to protect against pneumococcal infection. On the other hand, preventive vaccination against pneumococcos and other pathogens have been used more frequently in asplenic patients 32.

Natural splenosis, reported after splenectomy due to trauma in about 34% of the patients, or intentional splenosis, seem to reduce the adverse effects caused in the immune system. However controversial, the maintenance, at least in part, of the phagocitic activity in the neoformed splenic tissue and the preservation of immune memory may recommend autologous splenic implantation after an inevitable splenectomy 28,29,33-37. Nevertheless, the effective ability of the splenosis to protect the host against encapsulated microorganisms is still challenged 13-16,26,38.

In children with huge splenomegaly, portal hypertension and bleeding esophageal varices due to mansonic schistosomiasis, autologous implantation of spleen tissue from the upper pole into an omental pouch of the greater omentum after splenectomy and ligature of the left gastric vein is still under investigation. The clinical observations of 57 children with this condition who entered in this protocol, from January 1990 to July 1997, cared for at The University Hospital - Federal University of Pernambuco, Brazil, are very encouraging. There has been no increase in the rate of infection and it was not observed any case of OPSI 4.

The radioisotope evidence on over one year follow-up Tc-99m sulfur colloid scanning in 21 out of 23 patients of more than five splenic nodules shows that autologous splenic implantation into an omental pouch in the greater omentum is more effective than natural splenosis for maintaining functioning splenic parenchyma. However, in two patients (8,7%) there were less than five splenic nodules both of them were positive for Howell-Jolly bodies. This seems to indicate that the splenic filtration function is associated with the amount of remaining splenic tissue. Previous study on partial splenic embolization in children with portal hypertension due to congenital abnormalities showed that the remaining 15% to 25% of pre-treatment splenomegaly was sufficient to maintain normal hemocatheretic splenic function 39. Normal specific anti-pneumococcal antibody response in 65% of the patients in this series may represent the efficacy of the residual splenic tissue in maintaining the immune humoral defense. This may be the result of the preservation of B lymphocyte memory. We have already demonstrated an increase in B lymphocytes after splenectomy and autologous splenic implantation in the greater omentum in children with surgical schistosomiasis 40. Among the eight patients with intermediate and impaired immune response two had inefficient splenosis, other two had pre-immunization high levels of antipneumoccocal antibodies and four were positive for hepatitis B with signs of cirrhosis on liver histology. All of them were considered as moderate risk (B) for the hepatic functional reserve. The patients with normal immune response had sufficient splenosis, were negative for hepatitis B, with pure Symmers fibrosis on liver biopsy and were considered as good risk (A) for the hepatic functional reserve.

From the results the following conclusions can be drawn: splenic filtration and immuneresponse to pneumoccocal vaccination can be achieved, in the majority of the children with severe portal hypertension due to hepatosplenic mansonic schistosomiasis, who have undergone splenectomy followed by efficient autologous splenic implantation in the greater omentum. Inefficient splenosis, association with hepatitis and/or cirrhosis, and poor hepatic functional reserve may impair these residual splenic functions.

 

REFERENCES

1. AMARAL, R.S.; PORTO, A.S. - Evolução e situação atual do controle da esquistossomose no Brasil. Rev Soc Bras Med Trop 27: 73-89, 1994.        [ Links ]

2. KELNER, S. - Critical evaluation of surgical treatment of schistosomotic portal hypertension. Memórias do Instituto Oswaldo Cruz 87(4): 357-368, 1992.        [ Links ]

3. BRANDT, C.T.; FREI CANECA, O.A.; TAVARES, D.J.S.; ÁVILA, J.R. - Surgical hepatosplenic mansonic schistosomiasis in children: a Doppler Duplex study of the portal vein and hepatic artery. Trans R Soc Trop Med Hyg 89: 70-71, 1995.        [ Links ]

4. BRANDT, C.T.; TAVARES, D.J.S.; FREI CANECA, A.O. - Splenectomy associated with ligature of the left gastric vein in children with surgical schistosomiasis: analysis of the hepatic functional reserve. Acta Cir Bras 8: 150-153, 1997.        [ Links ]

5. KING, H.; SCHUMACKER, H.B. - Splenic studies: susceptibility to infection after splenectomy performed in infancy. Ann Surg 136: 239-242, 1952.        [ Links ]

6. SMITH, C.H.; ERLANDSON, M.; SCHULMAN, I. - Hazards of severe infections in splenectomized infants and children. Am J Med 22: 390-404, 1957.        [ Links ]

7. HUNTLEY, C.C. - Infection following splenectomy in infants and children. J Dis Child 95: 477-480,1958.        [ Links ]

8. HORAN, M.; COLEBATCH, J.H. - Relation between splenectomy and subsequent infection: a clinical study. Arch Dis Child 37: 398-411, 1962.        [ Links ]

9. SINGER, D.B. - Postsplenectomy sepsis. Perspect Pediatr Pathol 1: 285-311,1965.        [ Links ]

10. ERAKLIS, A.J.; KEVY, S.V.; DIAMOND, L.K.; GROSS, R.E. - Hazard of overwhelming infection after splenectomy in childhood. N Engl J Med 259: 1164-1169, 1967.        [ Links ]

11. KRIVIT, W.; GIEBINK, G.S.; LEONARD, A. - Overwhelming postsplenectomy infection. Surg Clin North Am 59: 223-233,1979.        [ Links ]

12. VEJA, A.; HOWELL, C.; KRASNA, I.; CAMPOS, J.; HEYAMN, S.; ZIEGLER, M.; KOOP, E. - Splenic autotransplantion: optimal functional factors. J Pediatr Surg 16: 898-904, 1981.        [ Links ]

13. TESLUK, G.C.; THOMAS, C.G.; BENJAMIN, J.T.; McMILLAN, C. - Fatal overwhelming postsplenectomy sepsis following autologous splenic transplantation in severe congenital osteopetrosis. J Pediatr Surg 19: 269-272, 1984.        [ Links ]

14. LOGGIE, B.W.; HINCHEY, J. - Does splenectomy predispose to meningococcal sepsis? An experimental study and clinical review. J Pediatr Surg 21: 326-330, 1986.        [ Links ]

15. GREEN, J.B.; SHACKFORD, S.R.; SISE, M.J., POWELL, R.W. - Postsplenectomy sepsis in pediatric patients following splenectomy for trauma: a proposal for a multi-institutional study. J Pediatr Surg 21: 1084-1086, 1986.        [ Links ]

16. HAYS, D.M.; TERNBERG, J.L.; CHEN, T.T.; SULLIVAN, M.P.; TEFFT, M.; FUNG, F.; GILCHRIST, G.; FRYER, C.; GEHAN, E.A. - Postsplenectomy sepsis and other complications following staging laparotomy for Hodgkin’s disease in childhood. J Pediatr Surg 21: 628-632,1986.        [ Links ]

17. TRAUB, A.; GIEBINK, G.S.; SMITH, C.; KUNI, C.C.; BREKKE, M.L.; EDLUND, D., PERRY, J.F. - Splenic reticuloendothelial function after splenectomy, spleen repair and spleen autotransplantation. N Engl J Med 317: 1559-1564,1987.        [ Links ]

18. STEELY, W.M.; SATAVA, R.M.; BRIGHAM, R.A.; SETSER, E.R.; DAVIES, R.S. - Splenic autotransplantation: determination of the optimum amount required for maximum survival. J Surg Res 45: 327-332, 1988.        [ Links ]

19. HATHAWAY, J.M.; HARLEY, R.A.; SALLY, S.; SCHIFFMAN, G.; VIRELLA, G. - Immunological function in post-traumatic splenosis. Clinical Immunology and Immunopathology 74: 143-50, 1995.        [ Links ]

20. WEIBEL, R.E.; VELLA, P.P.; McLAREN, A.A.; WOODHOUR, A.F.; DAVIDSON, W.L.; HILLEMAN, M.R. - Studies in human subjects of polyvalent pneumococcal vaccines. Proc Soc Exp Biol Med 156: 144-150, 1977.        [ Links ]

21. AAGERGE, I.S.; HEIER, H.E.; HEM, E.; GIERCKSKY; GRONG, E.C. - IgM and IgG response to pneumococcal polysaccharide vaccine in normal individuals and individuals splenectomyzed due to trauma. Acte Path Microbiol Immunol Scand Sect 92: 11-16. 1984.        [ Links ]

22. HOSEA, S.W.; BURCH, C.G.; BROWON, E.J.; BERG, R.A.; FRANK, M.M. - Impaired immune response of splenectomized patients to polyvalent pneumococcal vaccine. Lancet 1: 804-807, 1981.        [ Links ]

23.PEDERSEN, K.F.; HENRICHSEN, J.; SCHIFFMAN, G. - Antibody response to vaccination with pneumococcal capsular polysaccharides in splenectomized children. Acta Pediatr Scand 71: 451-455, 1982.        [ Links ]

24. SCHWARTZ, A.D.; GOLDTHORN, J.F. - Born-again spleens: and resistance to infection. N Engl J Med 12: 832, 1978.        [ Links ]

25. ANNEXTON, M. - Autotransplantation of spleen tissue after trauma: encouraging evidence. JAMA 24: 437-438, 1979.        [ Links ]

26. COONEY, D.R.; DEARTH, J.C.; SWANSON, S.E.; DEWANJEE, M.K.; TELANDER, R.C. - Relative merits of partial splenectomy, splenic reimplantation, and immunization in preventing postsplenectomy infection. Surg 86: 561-569, 1979.        [ Links ]

27. PATEL, J.; WILLIAMS, J.S.; SHIJEL, B.; HINSHAW, J.R. - Preservation of splenic function by autotransplantation of traumatized spleen in man. Surg 90: 683-688, 1981.        [ Links ]

28. PATEL, J.; WILLIAMS, J.S.; NAIM, J.O.; HINSHAW, J.R. - Protection against pneumococcal sepsis in splenectomized rats by implantation of splenic tissue into an omental pouch. Surg 91: 683-641, 1982.        [ Links ]

29. PATEL, J.M.; WILLIAMS, J.S.; NAIM, J.O.; HINSHAW, J.R. - The effect of site and technique of splenic tissue reimplantation on pneumococcal clearence from the blood. J Pediatr Surg 2: 877-880, 1986.        [ Links ]

30. HARDING, B.; KENNY, F.; GIVEN, F.; MURPHY, B.; LAVELLE, S. - Autotransplantation of splenic tissue after splenectomy in rats offers partial protection against intravenous pneumococal challenge. Eur Surg Res 19: 135-139, 1987.        [ Links ]

31. LDTKE, F.E.; MACK, S.C.; SCHUFF-WERNER, P.; NOTH, E. - Splenic function after splenectomy for trauma. Role of autotransplantation and splenosis. Acta Chi Scand 155: 533-539, 1989.        [ Links ]

32. KAYS, M.A.; STOLAR, C.J.H. - The spleen and splenectomy: implications for pediatric population. In: FONKALSRUD EW, KRUMMEL TM. - Infections and immunologic disorders in Pediatric Surgery. W. B. Saunders Company, 1993,. pp 91-100.        [ Links ]

33. VELCEK, F.F.; JONGCO, B.; SHAFTAN, G.W.; KLOTZ, D.H.; RAO, S.P.; SCHIFFMAN, G.; KOTTMEIER, P.K. - Posttraumatic splenic reimplantation in children. J Pediatr Surg 12: 879-883, 1982.        [ Links ]

34.WESTERMANN, J.; PABST, R. - Autotransplantation of splenic fragments: lymphocyte subset in blood, lymphonodes and splenic tissue. Clin Exp Immunol 64: 188-194, 1986.        [ Links ]

35. SHOKOUH-AMIRI, M.H.; KHARAZMI, A.; RAHIMI-SABER, S.; HANSEN, C.P.; JENSEN, S.L. - Phagocyte function after splenic autotransplantation. Arch Surg 125: 595-597, 1990.        [ Links ]

36. BERGMANN, L.; BTTCHER, W.; SEUFERT, R.M.; MITROU, P.S. - Quantitative and function restorations and alterations of peripheral lymphocytes in patients with autologous spleen implantation. Arch Orthop Trauma Surg 109: 102-105, 1990.        [ Links ]

37. MULLER, U.; ROTHLIN, M. - Splenic neoformation following trauma-induced after splenectomy: diagnosis and function. Swiss-Surgery 5: 230-235, 1995.        [ Links ]

38. RICE, H.M.; JAMES, P.D. - Ectopic splenic tissue failed to prevent fatal pneumococcal septicemia after splenectomy for trauma. The Lancet 15: 565-566, 1980.        [ Links ]

39. BRANDT, C.T.; ROTHBARTH, L.J.; KUMPE, D.; KARRER, F.M.; LILLY J.R. - Splenic embolization in children: Long-term efficacy. J Pediatr Surg 24: 642-645, 1989.         [ Links ]

40.BRANDT, C.T.; MORAES FILHO, J.L.; MIRANDA, C.J.C. - Hepatosplenic mansonic   schistosomiasis in children: Lymphocite subsets after splenectomy and autologous                         splenic transplantation. Acta Cir Bras 10: 112-116, 1995.

 

 

BRANDT, C.T.; ARAÚJO, L.B.; BARBOSA, M.C. - Transplante autólogo de tecido esplênico em crianças esquistossomóticas que se submeteram à esplenectomia: Avaliação da função esplênica residual. Acta Cir. Bras.,13(4):212-6, 1998.

RESUMO: Transplante autólogo de tecido esplênico é uma tentativa de manter as funções esplênicas quando esplenectomia está indicado em crianças. Ele minimiza os riscos de septicemia fulminante após esplenectomia e tem sido feito em crianças com hipertensão porta severa, devido a hepato-esplenomegalia esquistossomótica, que se submeteram à esplenectomia. Os objetivos da presente investigação foram: estudar a morfologia do tecido esplênico residual; avaliar a função de filtração da esplenose; e avaliar a resposta imune à vacinação polivalente contra pneumococos destes pacientes. Vinte e três crianças com hipertensão porta, devido a esquistossomose mansônica, que se submeteram à esplenectomia, ligadura da veia gástrica esquerda, autotransplante de tecido esplênico em bolsa no omento maior foram avaliadas para as funções esplênicas residuais. Cintilografia hepatoesplênica com enxofre coloidal marcado com Tc-99m foi usado para detecção dos nódulos esplênicos. A pesquisa de corpúsculos de Howell Jolly foi usada para avaliar a função de filtração. A avaliação da resposta de anticorpos contra pneumococos foi medida pelo método de Elisa. Esplenose foi evidente em todas as crianças, contudo, em dois, foi identificado menos de cinco nódulos esplênicos no omento maior, a qual foi considerada insuficiente. Corpúsculos de Howell Jolly foram encontrados no sangue periférico somente nesses dois pacientes com esplenose menos evidente. A resposta imune foi adequada em quinze pacientes; foi intermediária em quatro pacientes e inadequada em outros quatro. Transplante autólogo de tecido esplênico em bolsa do omento maior foi considerado eficiente na manutenção da função esplênica em mais de 90% dos pacientes e da resposta imune à vacinação contra pneumococos em aproximadamente 65% das crianças.
DESCRITORES: Autotransplante de tecido esplênico. Transplante autólogo de tecido esplênico. Esquistossomose mansônica hepatoesplênica. Função de filtração esplênica. Função imunológica esplênica. Vacinação pneumocócica.

 

 

 

Address reprint request:
Carlos Teixeira Brandt
R 19 de abril, 30/602
52071-332 Recife - PE

Accepted for publication september 1998.

 

 

1 – Article from Pediatric Surgical Service of the University Hospital, Pernambuco - Brazil
2 – Head Professor of Pediatric Surgery – Federal University of Pernambuco – Brazil.
3 - Master of Science (M.Ch.)
4 - Assistant Professor of Tropical Diseases

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