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Year : 2002  |  Volume : 12  |  Issue : 3  |  Page : 371-374
Efficacy of partial splenic embolisation in the management of hypersplenism


Dept of Radiodiagnosis JLNH & RC Bhilai Nagar, Chattishgarh 490009, India

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   Abstract 

Objective: To assess the efficacy of partial splenic embolisation in the management of hypersplenism Material and Method: Eleven partial splenic embolisations were performed in nine children suffering from portal hypertension, aged 10 to 15 yrs (mean 12.5 years). All patients had splenomegaly with thrombocytopenia (platelet count less than 60x10, 9/ lit) and leucopenia at the time of the procedure. Portal hypertension was investigated in all patients with endoscopy, liver biopsy & abdominal sonography. Particles of polyvinyl alcohol were used to achieve embolisation of at least 75 percent of the splenic artery thereby causing embolisation of the peripheral splenic branches. Post embolisation arteriogram and ct were obtained to document the extent of devascularisation. Results: Peripheral count had improved significantly after partial splenic embolisation (PSE) and platelet count of more than 450 x 10 9 lit was present in nine of the eleven patients by the end of the seventh day. Leucocyte count rose significantly by day one and seven after PSE compared with counts before the procedure. Reduction in size of the spleen was noticed in all patients. Six out of eight patients showed considerable reduction in size of the oesophageal and gastric varices. All patients had a moderate rise in temperature up to 38.5 degree C along with pain in the left hypochondrium. Segmental atelectasis was seen in three patients. Conclusion: Partial splenic artery embolisation is an effective procedure for the control of Hypersplenism.

Keywords: Embolisation, Hypersplenism, Splenic artery

How to cite this article:
Dwivedi M K, Pal R K, Dewanga L, Nag P. Efficacy of partial splenic embolisation in the management of hypersplenism. Indian J Radiol Imaging 2002;12:371-4

How to cite this URL:
Dwivedi M K, Pal R K, Dewanga L, Nag P. Efficacy of partial splenic embolisation in the management of hypersplenism. Indian J Radiol Imaging [serial online] 2002 [cited 2014 Dec 20];12:371-4. Available from: http://www.ijri.org/text.asp?2002/12/3/371/28487

   Introduction Top


Hypersplenism is one of the important complications of portal hypertension. It is manifested by anaemia, thrombocytopenia and neutropenia and may compound the risk of gastrointestinal bleeding. In the past hypersplenism was treated by splenectomy which increases the risk of overwhelming infection. The present study was conducted to evaluate the alternative technique of partial splenic embolisation(PSE). The procedure helps to occlude the arterial supply more peripherally i.e. in the splenic parenchyma, which results in ischemic necrosis of much of the functional spleen followed by a decrease in splenic size and hypersplenism. It allows the preservation of adequate splenic tissue and thereby prevents the overwhelming infection. The study was done to describe the outcome of partial splenic embolisation to encourage more wide spread use of the technique in appropriate situation.


   Material and Methods Top


Between Feb. 1996 to April 1999 eleven partial splenic embolisations were performed in nine patients aged 10 to 15 yrs (mean 12.5). Splenomegaly was seen in all patients with the spleen palpable up to 6 to 15 cms (mean 10 cms) below the left costal margin. All patients had portal hypertension, which was investigated with endoscopy, liver biopsy and abdominal sonography. Portal hypertension with oesophageal varices were present in eight patients. Four patients had portal vein obstruction and three had hepatic cirrosis, two patients had chronic active hepatitis with hypersplenism. All patients had thrombocytopenia (platelet count less than 60x109 lit), which was a prerequisite for including them in this study. Eight of the nine patients were treated with sclerotherapy before partial splenic embolisation. All patients were treated with intravenous systemic antibiotic Gentamicin 10 mg /kg/day, Cefoxitin sodium 100mg/kg/day beginning two hours before PSE and continuing for at least five days after PSE. The splenic artery was selectively catheterized through the transfemoral route using a 4F catheter. After a preliminary angiogram the catheter was moved forward so that its tip lay distal to the last pancreatic artery. Controlled embolisation of the peripheral splenic branches was performed by use of polyvinyl alcohol particles 250 to 355 micro mm size which had been soaked in antibiotic solutions containing 1,00,000 units of penicillin and 40 mg of gentamicin. The entire procedure was closely monitored under the image intensifier, the embolisation is considered to be complete when moderate slowing of splenic blood flow was established which correlates with embolisation of 75% of the splenic artery. Post embolisation angiogram and CT scan were performed for documentation


   Results Top


Post embolisation course and complication are shown in [Table1] and [Table - 2].

Influence on peripheral count is demonstrated in [Table - 1]. Leukocyte count rose significantly between day one and seven after PSE, compared with counts before the procedure. The platelet count rose significantly after PSE, platelet counts were more than 100x109 /lit on day one in all patients and by day seven platelet counts were more than 450x109 lit in all patients. The platelet count remained elevated at more than 200x10; 9/lit during the follow up period of six months to 5 yrs. Peripheral counts and hemoglobin had improved significantly after PSE in all patients

Clinical examination after six months of PSE shows the spleen to be minimally palpable in two patients and in seven patients it was palpable about 2-3 cms below the costal margin.

Eight patients had significant hematemesis before partial splenic embolisation out of which seven patients had sclerotherapy for oesophageal varices. Endoscopy after PSE revealed resolution of the oesophageal and gastric cardia varices in six patients. Blood transfusion after PSE was not required in any patients.

All patients experienced generalized abdominal pain for three to seven days, which was well controlled with analgesics. Moderate fever upto 38.5 degree C, lasting for two to seven days is seen in all patients. Other than fever and abdominal pain, small left sided atelectasis was seen in three patients, left sided pleural effusion seen in two patients, which resolved uneventfully and did not require any intervention. Complications of catheterization and splenic abscess did not develop in any of our patients.


   Discussion Top


It is known that the spleen represents one fourth of the total lymphatic mass and it serves as a biological filter for the clearance of bacteria. The spleen is essential for rapid antibody production after challenge with blood-borne particulate antigen in the absence of preexisting antibodies [1],[2]. In addition the spleen appears to be the site of production of a nonspecific leucophilic immunoglobin tuftsin that increases the phagocytic activity of polymorphonuclear leucocytes [2]. Thus the spleen has important functions and its removal is not to be taken lightly. Surgical splenectomy carries significant postoperative morbidity and a long-term risk of overwhelming infection in 1% to 2% of patients [3]. Total splenectomy should be avoided whenever possible in favor of conservative medical and surgical approaches [4],[5],[6]. Total occlusion of the splenic artery will also produce similar complications including death [7],[8]. The modified technique of partial splenic embolisation that leads to embolisation of 60 to 80% of the spleen with sterile technique and coverage with intravenous antibiotics before and after the procedure gives better results [2],[5],[7].

Apart from the expected immunological advantage, partial splenic embolisation might prevent the development of a splenic abscess by preservation of the normal direction of blood flow through the splenic circulation. In total splenic embolisation, the arterial blood flow to the spleen is completely disrupted and the direction of flow in the splenic vein in reversed [10],[11]. The phenomenon might cause contamination of the infarcted splenic parenchyma with bacteria that are carried from the gastrointestinal tract through the portal circulation. Complications in our patients like prolonged mild grade fever and abdominal pain after partial splenic embolisation were similar to those described by other authors(2). However serious complications like splenic abscess were not observed in our study, we attribute this lack of significant complication to partial splenic embolisation rather than total splenic embolisation, strict aseptic technique and antibiotic prophylaxis. We have used small embolic particles in our study (250 to 355 micro mm of polyvinyl alcohol), these smaller particles are better delivered to the peripheral small vessels in the spleen and causes uniform occlusion of these vessels. Careful aggressive management of pain after embolisation has helped us to reduce post procedure atelectasis (3 out of 9). The increase in platelet counts probably is due to the reduced trapping capacity of thrombocytes in the embolized spleen. The increased WBC counts in the first week after PSE is perhaps due to the activation of defense mechanism against the dead splenic tissue [1]. Whether PSE can help to decrease the incidence of variceal hemorrhage owing to portal hypertension and for how long is questionable [11]. Reduction in variceal hemorrhage is possibly because of reversal of thrombocytopenia and its contribution to haemostasis [1].

Since partial splenic embolisation causes permanent ablation of sufficient splenic parenchyma to allow subsequent improvement of hematological status, we believe that it will become an alternative to splenectomy in selected patients with hypersplenism. The procedure is simple to perform; however pediatric angiography expertise is a pre-requisite Thus, given the safety, efficacy and advantages of PSE, it has been found to be a good means of treatment of hypersplenism.

 
   References Top

1.Likhit VV. Immunological impairment and susceptibility to infection after spleenectomy, JAMA: 1978: 236: 1376-1377.  Back to cited text no. 1    
2.Spigos DG, Jonasson O, Mozes M, Capek V. Partial splenic embolisation in the treatment of hypersplenism. AJR: 1979:132:777-782.  Back to cited text no. 2    
3.Dickerman JD. Spleenectomy and sepsis A warning: Pediatrics: 1979:63:938-941.  Back to cited text no. 3    
4.Cooper M J, Williamson R C N. Spleenectomy: Indication, hazards and alternatives: BJS: 1984: 71: 173-80.  Back to cited text no. 4    
5.David MI, Hassall E, Gofdan J.A. Journal of pediatrics: 1994: 124: 95-100.  Back to cited text no. 5    
6.Shah R, Mathur GH, Ford EG. Partial splenic embolisation an effective alternative to spleenectomy for hypersplenism. Ann Surg: 1990:56:774-777  Back to cited text no. 6    
7.Maddison FE. Embolic therapy of hypersplenism. Inrest Radiology: 1973:8:280-300.  Back to cited text no. 7    
8.Zuniga WR, Hammer Schmidt DE, Sanchez R, Amplatz K, Non surgical spleenectomy. AJR:1977:129:801-811.  Back to cited text no. 8    
9.Witte CL, Witte MH, Renest W. Splenic artery ligation in selected patients with hepatic cirrhosis and in Sprague dawley rats. Surg. Gynecol/Obst. 1976: 142: 1-12.  Back to cited text no. 9    
10.Alwmark A, Bengmark S, Gullstrand P, Joelsson B, Landerquist A, Owman T. Evaluation of splenic embolisation in patients with portal hypertension and hypersplenism. Ann Surg: 1982:196-518-523.  Back to cited text no. 10    
11.Kumpe DA, Rumack CM, Pretorius DH etal. Partial splenic embolisation in children with hypersplenism. Radiology: 1985:155:357-362  Back to cited text no. 11    

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Correspondence Address:
M K Dwivedi
Dept of Radiodiagnosis JLNH & RC Bhilai Nagar, Chattishgarh 490009
India
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    Figures

[Figure - 1], [Figure - 2]

    Tables

[Table - 1], [Table - 2]

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