The Spleen and Spleen Surgery in the Elderly

Abstract

The spleen is a very important organ with many essential functions, not only in the defense of the organism, but also in its metabolic, immunological and haematological systems. The most common manifestations of the splenic disturbances include splenomegaly and a decrease in the number of blood elements. After the removal of the spleen, 2% of adults present severe sepsis, while more than 10% of the elderly are at risk of death due to septic conditions. Most splenic diseases can be treated conservatively. Operative procedures should be considered in special conditions, when all conservative options have been unsuccessfully depleted. Even in the presence of a severe trauma to the spleen or advanced haematological diseases, the best approach is a non-operative procedure. When the operation is unavoidable, partial and subtotal splenectomies or implants of autogenous splenic tissue onto the greater omentum should be performed. At least 25% of a normal spleen should be left with drainage to the portal system to preserve the complete efficacy of all splenic functions. The technological advances and the progressive development of new surgical devices are responsible for laparoscopy with or without robotic assistance. These surgical approaches lead to less pain, faster postoperative recovery and better cosmetic results, without decreasing the therapeutic efficacy. The conservative splenic approach, whether clinical or surgical, is the best way to prevent postsplenectomy infection, by preserving the spleen's role in immunity.

Wandering splenomegaly reduction after splenopexy

“…This abnormality is found more commonly in women of the reproductive age group, however, in pediatrics, this condition is more detected in boys [1] , [10] , [12] , [16] . The diagnosis is difficult due to nonspecific clinical or laboratory findings, except for occasional pancytopenia, and is defined only by imaging exams [1] , [2] , [7] , [11] , [12] , [15] . This condition is usually asymptomatic, but it may be responsible for chronic abdominal pain with or without gastrointestinal or urinary symptoms.…”

“…The treatment must consider the risk of post-splenectomy overwhelming sepsis, mainly in the pediatric and elderly population, as well as in patients with chronic diseases [1] , [2] , [15] . A conservative approach is the best management whenever possible.…”

“…Laparoscopic splenopexy has many advantages over open splenopexy or splenectomy, including preserving splenic function, minimal postoperative pain, early discharge from the hospital, and rapid recovery [1] , [2] , [5] , [12] , [16] . Spleen size must be taken into consideration, facing the frequent necessity of conversion to open surgery in the presence of splenomegaly [10] , [12] , [15] , [16] .…”

“…In such circumstances tissue implants from the removed spleen on the greater omentum, to preserve at least part of the splenic functions, should be considered [14] . In the case of WS with no complications, the first-line treatment is elective laparoscopic splenopexy, performed in different techniques, including or not the use of a mesh [1] , [6] , [9] , [10] , [15] , [16] . Elective splenectomy for complicated WS is recommended when the spleen parenchyma is too damaged to recover from several ischemic events, or for the spleen dimension [7] , [11] , [12] .…”

Dwarfism associated with wandering splenomegaly

“…This treatment has been successfully performed in many patients, but with subsequent asplenia, which is related to serious adverse effects. Metabolic disorders, infections and death due to overwhelming sepsis, as well as pulmonary embolism, have often been reported after total splenectomy [ 3 , 5 ].…”