estrogens, from a renovascular cause or from pheo- usefulness of clinical work-up forms based on this chromocytoma. recommendation. * Physical examination should include (a) deterDAVID L. SACKETr, MD, M sc Departments of clinical epidemiology mination of the first-phase (appearance of Korotkoff and biostatistics, and medicine sounds) and fifth-phase (disappearance of sounds) blood McMaster University pressures in the arm and the position that will be used Hamilton, Ont. to monitor therapy; (b) a search for target organ damage by funduscopy, lung auscultation, cardiac examina- References tion and a check for ankle edema; and (c) a search for GIFFORD RW .Ja: Evaluation of the hypertensive patient. secondary hypertension from renovascular, aortic or 1. Chest 64: 336, 1973 endocrine causes. 2. MELBY JC: Extensive hypertensive work-up: pro. JAMA 231: 399, 1975 0 Laboratory evaluation should include (a) urinalysis by dipstick; (b) determination of the serum potas- 3. GIFFORD RW JR: Evaluation of the hypertensive patient with emphasis on detecting curable causes. Milbank Mem sium concentration; and (c) determination of the serum Fund Q 47 (3) (part 2): 170, 1969 creatinine concentration. 4. RUDNICK KV, SACKETT DL, HIRsT S, et al: Hypertension in * Although the work-up will usually be performed a family practice. Can Med Assoc J 117: 492, 1977 by physicians, it can also be performed by specially 5. BERGLUND G, ANDERSSON 0, WILHELMSEN L: Prevalence of primary and secondary hypertension: studies in a random trained and appropriately supervised nurses. sample. Br Med J 2: 554, 1976 * The detailed recommendation for the work-up 6. population LOGAN AG, CAMPBELL WP, HAYNES RB, et al: Clinical should be provided to every primary-care clinician in effectiveness of specially trained nurses to control hypertension at the work site (abstr). Clin Res 25: 329, 1977 Canada; priority should be given to evaluation of the
Splenectomy for rupture of the spleen: a reappraisal Until recently the management of splenic injuries, both operative and traumatic, has been simple - splenectomy. It has been surgical dogma that injuries to the spleen in persons of all ages could be safely and effectively managed by splenectomy as bleeding from the spleen could not be simply controlled. Why should this straightforward and apparently effective approach be changed? Splenectomy is not without its complications, whether it is incorporated with another operation or included as part of the management of the patient. However, of more interest is the increasingly understood role of the spleen in immune function. The spleen functions as a filter for bacteria, effete blood cells and other particulate matter. Its role in antibody production is significant in the control of infection. The loss of the spleen leads to depressed circulating 1gM concentrations1 and reduced antibody response without the normal switch from 1gM to IgG production following immunization.2 The studies leading to these conclusions were stimulated by clinical reports published in 1952' that indicated that, following splenectomy, infants less than 2 years of age had a marked risk of overwhelming sepsis. Further observations in 1967 showed that children of all ages were at risk of sepsis, although the risk was less in those more than 5 years of age.4 The nature of the underlying disease was
related to the frequency of sepsis. Splenectomy for trauma appeared to be safe. The infecting organisms in children and adults are encapsulated bacteria (pneumococci, Hernophilus in!luenzae and meningococci) that require specific antibody for phagocytosis. In this issue of the Journal (starting on page 57) Kingston and MacKenzie describe the successful management of pneumococcemia in an asplenic 53-year-old man who, 18 years previously, had undergone splenectomy for idiopathic thrombocytopenia. They also document 25 other cases of pneumococcemia, disseminated intravascular coagulation and asplenia. Of the 25 patients 8 had undergone splenectomy for trauma, 2 had undergone incidental splenectomy during another operation and 2 had had congenital asplenia; therefore, 12 of the patients had had no underlying disease. Only 1 of the 25 patients survived. The septic episodes developed between 8 months and 25 years following the splenectomy. The syndrome documented is rare; the frequency of septicemia with disseminated intravascular coagulation in the splenectomized population cannot be clearly determined. The severity of these sequelae suggests that in all age groups new approaches to the management of the injured spleen are needed. Ratner and colleagues5 have reported on the successful operative repair of injured spleens in 17 children. The members of the surgical CMA JOURNAL/JULY 7, 1979/VOL. 121
*-For prescribing information see page 71
11
team at the Hospital for Sick Children in Toronto have pioneered a nonoperative approach to the management of splenic injuries in children. They have demonstrated that, with the use of radionuclide scanning, the presence of rupture of the spleen can be determined. Therefore, patients can be managed in an aggressive nonoperative manner rather than with the conservative approach of surgical removal of the spleen. There have been sporadic but increasingly supportive reports of nonoperative or reparative approaches to splenic injuries in children.5 In adults the nonoperative or nonresectional approach to the management of splenic injuries has not been popular. The efficacy of microfibrillar collagen, a hemostatic agent, in controlling bleeding from a surgically torn splenic capsule has been clearly documented.6 At the 1978 meeting of the American Association for the Surgery of Trauma, Virgilio reported good results of splenorrhaphy in 17 patients with niptured spleens. At the San Francisco General Hospital Medical Center 12 spleens were salvaged in 1977 and 1978 (D.D. Trunkey: personal communication, 1978), and at Downstate Medical Center in New York 19 spleens were salvaged between September 1976 and December 1978 (G.W. Shaftan: personal communication, 1978). Pooling these data we see that 35 spleens were salvaged in adults and 13 in prepubescent children. A common observation among trauma surgeons is that only 15% to 30% of injured spleens are bleeding at the time of laparotomy. With the data on splenorrhaphy it appears that about 80% of all injured spleens can be saved with the use of these approaches. Some technical points regarding operative repair are important. It is not possible to repair the spleen in the depths of the abdomen. It must be carefully and adequately mobilized so that it rests comfortably on the abdominal wall, or at least within the surgeon's view. The mobilization of the spleen must be done carefully and anatomically or further damage may occur. It is no longer adequate to mobilize the spleen rapidly with a deft hand in the left upper quadrant. Useful techniques include the use of topical microfibrillar collagen, figureof-eight sutures in the capsule, suti.re ligature and clips. Splenic injuries tend to be transverse and therefore parallel to a compartmentalized vasculature, such that the spleen tends to rupture between vessels, thereby facilitating hemostasis and making splenorrhaphy or hemisplenectomy possible. Pearson and associates7 recently described the "bornagain spleen" - the apparent return of splenic function following splenectomy for trauma in children. They demonstrated an absence or a small number of abnormal erythrocytes, suggesting clearance, and in all the patients they examined the uptake of radionuclide by the spleen was normal. Studies with mice have indicated that half a spleen with portal vasculature is
12 OMA JOURNAL/JULY 7, 1979/VOL. 121
immunologically equivalent to a whole spleen, and have suggested that splenic tissue outside the portal vasculature does not function adequately from an immunologic point of view. The "born-again spleen", or splenosis, may therefore not protect the host against overwhelming septicemia from the encapsulated organisms for which they are at risk. Unresolved issues in the management of the asplenic patient are whether all patients should receive the polyvalent vaccine against Diplococcus pneumoniae, and whether they should all be receiving penicillin prophylaxis. Data on the value of the vaccine are unclear, but administration seems reasonable. There are no data available on penicillin prophylaxis in healthy asplenic adults, and such a study would be difficult; I do not envisage persuading a healthy adult to take penicillin daily or to have monthly injections. The Medical Letter (Jan. 14, 1977) presented a divided opinion. The reasonable solution seems to be for the patient to take ampicillin at the first sign of an infection. At the very least the patient and his or her family should be carefully informed of the risk of sepsis and instructed to seek medical attention promptly when there is any evidence of bacterial infection. Despite the low frequency of overwhelming septicemia following splenectomy for trauma, it is apparent that the operative management of splenic injuries requires examination. The conservative approach of splenectomy in all patients with splenic injuries is no longer reasonable. More progressive attitudes incorporating either nonoperative treatment in children or an operative-reparative approach in adults seem appropriate. In particular, the incidental splenectomy following a capsular tear associated with another procedure should no longer be "de rigueur". Aggressive attempts should be made to salvage the spleen. JONATHAN L. MEAKINS, MD, D SC, FRCS[C], FACS
References
Royal Victoria Hospital Montreal, PQ
1. CHAIMOFF C, DOUER D, PICK IA, et al: Serum immunoglobulin changes after accidental splenectomy in adults. Am I Surg 136: 332, 1978 2. SULLIVAN JL, OcHs HD, SCHIFFMAN G, et al: Immune
response after splenectomy. Lancet 1: 178, 1978 3. KING H, SHUMAKER HB .ni: Splenic studies: susceptibility to infection after splenectomy performed in infancy. Ann Surg 136: 239, 1952 4. ERAKLIS AJ, KEVY SV, DIAMOND LK, et al: Hazard of overwhelming infection after splenectomy in childhood. N Engi I Med 276: 1225, 1967 5. RATNER MH, GARROw E, VALDA V, et al: Surgical repair of the injured spleen. I Pediatr Surg 12: 1019, 1977 6. MORGENSTERN L: The avoidable complications of splenectomy. Surg Gynecol Obstet 145: 525, 1977 7. PEARSON HA, JOHNSTON MT, SMITH KA, et al: The bornagain spleen. Return of splenic function after splenectomy for trauma. N Engi I Med 298: 1389, 1978
Splenectomy for rupture of the spleen: a reappraisal Until recently the management of splenic injuries, both operative and traumatic, has been simple - splenectomy. It has been surgical dogma that injuries to the spleen in persons of all ages could be safely and effectively managed by splenectomy as bleeding from the spleen could not be simply controlled. Why should this straightforward and apparently effective approach be changed? Splenectomy is not without its complications, whether it is incorporated with another operation or included as part of the management of the patient. However, of more interest is the increasingly understood role of the spleen in immune function. The spleen functions as a filter for bacteria, effete blood cells and other particulate matter. Its role in antibody production is significant in the control of infection. The loss of the spleen leads to depressed circulating 1gM concentrations1 and reduced antibody response without the normal switch from 1gM to IgG production following immunization.2 The studies leading to these conclusions were stimulated by clinical reports published in 1952' that indicated that, following splenectomy, infants less than 2 years of age had a marked risk of overwhelming sepsis. Further observations in 1967 showed that children of all ages were at risk of sepsis, although the risk was less in those more than 5 years of age.4 The nature of the underlying disease was
related to the frequency of sepsis. Splenectomy for trauma appeared to be safe. The infecting organisms in children and adults are encapsulated bacteria (pneumococci, Hernophilus in!luenzae and meningococci) that require specific antibody for phagocytosis. In this issue of the Journal (starting on page 57) Kingston and MacKenzie describe the successful management of pneumococcemia in an asplenic 53-year-old man who, 18 years previously, had undergone splenectomy for idiopathic thrombocytopenia. They also document 25 other cases of pneumococcemia, disseminated intravascular coagulation and asplenia. Of the 25 patients 8 had undergone splenectomy for trauma, 2 had undergone incidental splenectomy during another operation and 2 had had congenital asplenia; therefore, 12 of the patients had had no underlying disease. Only 1 of the 25 patients survived. The septic episodes developed between 8 months and 25 years following the splenectomy. The syndrome documented is rare; the frequency of septicemia with disseminated intravascular coagulation in the splenectomized population cannot be clearly determined. The severity of these sequelae suggests that in all age groups new approaches to the management of the injured spleen are needed. Ratner and colleagues5 have reported on the successful operative repair of injured spleens in 17 children. The members of the surgical CMA JOURNAL/JULY 7, 1979/VOL. 121
*-For prescribing information see page 71
11
team at the Hospital for Sick Children in Toronto have pioneered a nonoperative approach to the management of splenic injuries in children. They have demonstrated that, with the use of radionuclide scanning, the presence of rupture of the spleen can be determined. Therefore, patients can be managed in an aggressive nonoperative manner rather than with the conservative approach of surgical removal of the spleen. There have been sporadic but increasingly supportive reports of nonoperative or reparative approaches to splenic injuries in children.5 In adults the nonoperative or nonresectional approach to the management of splenic injuries has not been popular. The efficacy of microfibrillar collagen, a hemostatic agent, in controlling bleeding from a surgically torn splenic capsule has been clearly documented.6 At the 1978 meeting of the American Association for the Surgery of Trauma, Virgilio reported good results of splenorrhaphy in 17 patients with niptured spleens. At the San Francisco General Hospital Medical Center 12 spleens were salvaged in 1977 and 1978 (D.D. Trunkey: personal communication, 1978), and at Downstate Medical Center in New York 19 spleens were salvaged between September 1976 and December 1978 (G.W. Shaftan: personal communication, 1978). Pooling these data we see that 35 spleens were salvaged in adults and 13 in prepubescent children. A common observation among trauma surgeons is that only 15% to 30% of injured spleens are bleeding at the time of laparotomy. With the data on splenorrhaphy it appears that about 80% of all injured spleens can be saved with the use of these approaches. Some technical points regarding operative repair are important. It is not possible to repair the spleen in the depths of the abdomen. It must be carefully and adequately mobilized so that it rests comfortably on the abdominal wall, or at least within the surgeon's view. The mobilization of the spleen must be done carefully and anatomically or further damage may occur. It is no longer adequate to mobilize the spleen rapidly with a deft hand in the left upper quadrant. Useful techniques include the use of topical microfibrillar collagen, figureof-eight sutures in the capsule, suti.re ligature and clips. Splenic injuries tend to be transverse and therefore parallel to a compartmentalized vasculature, such that the spleen tends to rupture between vessels, thereby facilitating hemostasis and making splenorrhaphy or hemisplenectomy possible. Pearson and associates7 recently described the "bornagain spleen" - the apparent return of splenic function following splenectomy for trauma in children. They demonstrated an absence or a small number of abnormal erythrocytes, suggesting clearance, and in all the patients they examined the uptake of radionuclide by the spleen was normal. Studies with mice have indicated that half a spleen with portal vasculature is
12 OMA JOURNAL/JULY 7, 1979/VOL. 121
immunologically equivalent to a whole spleen, and have suggested that splenic tissue outside the portal vasculature does not function adequately from an immunologic point of view. The "born-again spleen", or splenosis, may therefore not protect the host against overwhelming septicemia from the encapsulated organisms for which they are at risk. Unresolved issues in the management of the asplenic patient are whether all patients should receive the polyvalent vaccine against Diplococcus pneumoniae, and whether they should all be receiving penicillin prophylaxis. Data on the value of the vaccine are unclear, but administration seems reasonable. There are no data available on penicillin prophylaxis in healthy asplenic adults, and such a study would be difficult; I do not envisage persuading a healthy adult to take penicillin daily or to have monthly injections. The Medical Letter (Jan. 14, 1977) presented a divided opinion. The reasonable solution seems to be for the patient to take ampicillin at the first sign of an infection. At the very least the patient and his or her family should be carefully informed of the risk of sepsis and instructed to seek medical attention promptly when there is any evidence of bacterial infection. Despite the low frequency of overwhelming septicemia following splenectomy for trauma, it is apparent that the operative management of splenic injuries requires examination. The conservative approach of splenectomy in all patients with splenic injuries is no longer reasonable. More progressive attitudes incorporating either nonoperative treatment in children or an operative-reparative approach in adults seem appropriate. In particular, the incidental splenectomy following a capsular tear associated with another procedure should no longer be "de rigueur". Aggressive attempts should be made to salvage the spleen. JONATHAN L. MEAKINS, MD, D SC, FRCS[C], FACS
References
Royal Victoria Hospital Montreal, PQ
1. CHAIMOFF C, DOUER D, PICK IA, et al: Serum immunoglobulin changes after accidental splenectomy in adults. Am I Surg 136: 332, 1978 2. SULLIVAN JL, OcHs HD, SCHIFFMAN G, et al: Immune
response after splenectomy. Lancet 1: 178, 1978 3. KING H, SHUMAKER HB .ni: Splenic studies: susceptibility to infection after splenectomy performed in infancy. Ann Surg 136: 239, 1952 4. ERAKLIS AJ, KEVY SV, DIAMOND LK, et al: Hazard of overwhelming infection after splenectomy in childhood. N Engi I Med 276: 1225, 1967 5. RATNER MH, GARROw E, VALDA V, et al: Surgical repair of the injured spleen. I Pediatr Surg 12: 1019, 1977 6. MORGENSTERN L: The avoidable complications of splenectomy. Surg Gynecol Obstet 145: 525, 1977 7. PEARSON HA, JOHNSTON MT, SMITH KA, et al: The bornagain spleen. Return of splenic function after splenectomy for trauma. N Engi I Med 298: 1389, 1978
