Changing role of splenectomy for hematologic disease

Splenectomy in a General Hospital

Splenectomy is often performed in patients with malignant disease or trauma who are at a high risk of complications. In the long term, it increases the risk of infection by encapsulated bacteria. An audit was performed to determine the reasons for splenectomy in a district general hospital, to review the results and complications of surgery, and to see how often the patients were prescribed antibacterial prophylaxis. Twenty-eight patients underwent splenectomy in 3 years. The indication was haematological disease in 13 and trauma in four. In the remaining nine the spleen was removed either as part of a radical gastrectomy or during some other abdominal procedure. Six of the 28 patients had died, one within 30 days from disseminated intravascular coagulopathy following an emergency gastrectomy and splenectomy for haematemesis, two from progressive haematological malignant disease, two from non-haematological malignancy, and one from bronchopneumonia. Of the nine patients (32%) with complications, three required a further laparotomy. Most patients had been prescribed pneumococcal vaccine (85%) and prophylactic antibiotics (93%).

Laparoscopic versus open splenectomy in children: a systematic review and meta-analysis

PURPOSE

We conducted a systematic review and meta-analysis to compare the clinical outcomes between laparoscopic splenectomy and the traditional open splenectomy in children.

METHODS

Literature searches were conducted to identify studies having compared the laparoscopic splenectomy (LS) and open splenectomy (OS) for children. Parameters such as operative time, blood loss, length of postoperative stay, the removal of accessory spleens and postoperative complications including postoperative high fever, acute chest syndrome (ACS), and ileus were pooled and compared by meta-analysis.

RESULTS

Among the 922 pediatric participants included in the 10 studies, 508 had received LS and 414 OS. There were shorter length of hospital stays, less blood loss, and longer operative times with the LS approach compared with OS. However, no significant difference was found between LS and OS in the secondary outcome, such as the removal of accessory spleens or postoperative complications including postoperative high fever, ACS, and ileus.

CONCLUSION

LS is a feasible, safe, and effective surgical procedure alternative to OS for pediatric patients. Compared with OS, LS has the advantage of shorter hospital stay and less blood loss. Besides, total postoperative complications may be slightly lower in LS. We conclude that LS should be considered an acceptable option for children.

Pattern of splenectomy indications in kashan shahid-beheshti hospital: a 5-year study

BACKGROUND

The spleen is amongst the most vulnerable organs which are easily injured in abdominal trauma. Nowadays, blunt trauma is the most prevalent indication of splenectomy.

OBJECTIVES

We conducted this study to determine the pattern of indications for open splenectomies carried out during the past five years in Shahid-Beheshti hospital, a central hospital in Kashan, Iran.

PATIENTS AND METHODS

Demographic data of all patients who had undergone an open splenectomy in Kashan Shahid-Beheshti hospital during the past five years (2007-2012), indications for this type of surgery and outcome of patients were collected and entered into the study.

RESULTS

During the study period, the data from a total of 99 open splenectomies were entered in our study. Sixty-eight (68.7%) patients were male and 31 (31.1%) female. The mean age was 31.64 years, 75.8% of the cases had indications of trauma and 24.2% were elective. The most prevalent indication for trauma was motor-bike rider accidents and for elective ones portal hypertension.

CONCLUSIONS

Most cases of splenectomy in our center caused by trauma, and among the different types of trauma, blunt trauma is the dominant cause. Road traffic accidents, in particular motor vehicle accidents, especially motorbike injures, are the most frequent cause of splenectomy. Due to the instability of trauma patients, a mortality rate of 8% seems to be reasonable for splenectomy. We recommend that more research be conducted in this area and more cases enrolled with a reasonable follow-up period for splenectomy complications in this study.

[Splenectomy for thrombocytopenic purpura. Retrospective analysis of the postoperative course]

BACKGROUND

Idiopathic thrombocytopenic purpura (ITP) comprises approximately 8% of all haemorrhagic diseases. Typical findings are a very low platelet count which manifests as petechial bleeding. Therapy consists of medication and removal of the spleen if conservative therapy fails.

PATIENTS AND METHODS

Between 1988 and 1999, 47 patients with ITP were splenectomized in our surgical department. We examine the postoperative development of platelet counts and long-term results in 33 of these patients.

RESULTS

After splenectomy, more then 75% of our patients had normal platelet counts. In long-term examination, 58% remained in stable condition with normal platelet counts. Retrospectively we tried to identify preoperative clinical features that could predict the long-term outcome of splenectomy in ITP but were unable to find reliable factors.

CONCLUSION

Idiopathic thrombocytopenic purpura can be treated by surgical means but should be considered only when conservative treatment has failed. The long-term outcome of splenectomy is not predictable. Reliable predictive factors have to be identified through further research.

The Incidence of Splenectomy is Decreasing: Lessons Learned from Trauma Experience

Over the past decade, splenic preservation has become a well-reported and accepted principle in trauma management. The reasons for splenic preservation may have influenced nontraumatic surgical management as well. To investigate the changing incidence and indications for splenectomy, we conducted a 10-year review of all splenectomies at our institution. During this time, between January 1, 1986, and December 31, 1995, 896 patients underwent splenectomy. Hospital charts and records were examined to determine the etiology and incidence of splenectomy. Indications were classified as: 1) trauma, i.e., performed for blunt or penetrating injury; 2) hematologic malignancy, i.e., therapy or staging of underlying leukemia, Hodgkin's lymphoma, or non-Hodgkin's lymphoma; 3) cytopenia, i.e., treatment of thrombocytopenia, anemia, or leukopenia; 4) iatrogenic, i.e., injury during another procedure; 5) incidental, i.e., required for adjacent organ resection; 6) portal hypertension, i.e., left-sided portal hypertension or during shunting procedure; 7) diagnostic, i.e., uncertainty excluding hematologic malignancy; or 8) other, i.e., miscellaneous indications. Trauma accounted for 41.5 per cent of all splenectomies during this time period, hematologic malignancy 15.4 per cent, cytopenia 15.6 per cent, incidental 12.3 per cent, iatrogenic 8.1 per cent, portal hypertension 2.3 per cent, diagnostic 2.0 per cent, and other 2.7 per cent. Comparing the first and second 5-year time periods, the following increases/decreases in average annual incidence were noted: splenectomy for all indications, -36.9 per cent; trauma, -32.9 per cent; hematologic malignancy, -51.4 per cent; cytopenia, 35.1 per cent; incidental, -35.9 per cent; iatrogenic, -30.2 per cent; diagnostic, +4.9 per cent, and other, -57 per cent. Traumatic injury to the spleen remains the most common indication for splenectomy, but the incidence has decreased dramatically over the past 10 years. Splenectomies for treatment of hematologic malignancies and cytopenia, as well as incidental and iatrogenic splenectomies, have also decreased significantly. Only the incidence of diagnostic splenectomy has remained stable. Although initiated within the field of trauma, the advantages of splenic preservation now appear to be well recognized beyond that field.

Early postoperative complications of splenectomy for hematologic disease

Splenectomy may be indicated in a variety of hematologic diseases for diagnostic reasons, therapeutic reasons, or both. Most reviews reveal a high proportion of procedures performed as part of the staging process for Hodgkin disease. Splenectomy for myelofibrosis has been associated with an increased postoperative complication rate. Other determinants of morbidity have been splenic weight and operative blood loss. The authors reviewed a series of 83 adult patients from a prospective database established in 1991 to determine the incidence of early postoperative complications associated with splenectomy for hematologic disease and to analyze patient characteristics that may predict their occurrence. Morbidity that occurred within 30 days of splenectomy was considered to be an early postoperative complication. Operative estimated blood loss and incidence of postoperative complications were correlated with patient age, preoperative platelet count, splenic weight, and diagnosis of myelofibrosis as regression covariates. Indications for splenectomy were therapeutic in 76 patients (92%). Median splenic weight was 760 g, and 22 patients had massive splenomegaly. Patients with splenic weight more than 1,500 g had a significantly higher median estimated blood loss (300 ml; p = 0.02). Splenic weight was the main determinant of estimated blood loss in a multiple linear regression analysis (p = 0.02). Twenty-two patients (27%) experienced postoperative complications and five of those patients died (6%). Patients with myelofibrosis had the highest incidence of complications (50%) and the highest postoperative mortality (21%; p = 0.04). In a logistic regression model, estimated blood loss was the only variable significantly correlated with postoperative complications (p = 0.02). Splenectomy for hematologic disease is associated with an acceptable early postoperative complication rate, even when the indication is predominantly therapeutic. Patients at particularly high risk include those with elevated operative blood loss, massive splenomegaly, and myelofibrosis.

Laparoscopic evaluation of lymphoma

Surgeons are involved in the diagnosis and staging of patients with lymphoma. Treatment requires accurate information about histologic classification and the extent of disease. While most patients with non-Hodgkin's lymphoma are treated with systemic chemotherapy, the exact stage of disease in patients with Hodgkin's lymphoma may determine the therapy to be used. The use of minimally invasive surgery in surgical staging of patients with Hodgkin's disease has the potential to decrease the morbidity and mortality of the staging procedure in these patients. All of the components of a staging procedure (liver biopsies, splenectomy, lymph node biopsies, and oophoropexy) can be performed laparoscopically. The procedure is performed with the patient in the supine position. After obtaining several liver biopsies, the splenectomy is completed. Lymph nodes are then sampled from the celiac, portal, iliac, and peri-aortic regions. Lymph nodes identified as abnormal on pre-operative imaging studies are identified and excised. While each of these procedures is technically challenging, the laparoscopic conduct of this diagnostic procedure may afford patients decreased post-operative morbidity and mortality.

Comparison of laparoscopic and open splenectomy in children with hematologic disorders

OBJECTIVE

To compare laparoscopic and traditional open splenectomy in children with nonmalignant hematologic disorders.

STUDY DESIGN

Retrospective review of 36 consecutive nonrandomized splenectomies (16 laparoscopic and 20 open) performed for hematologic disorders at a single pediatric institution during the past 3 years. The two-sided Mann-Whitney U test for non-parametric variables was used for statistical analysis.

RESULTS

An open procedure was performed on 20 patients (mean age, 9.7 years), five of whom had a concomitant cholecystectomy. A laparoscopic splenectomy was performed on 16 children (mean age, 10.3 years), seven of whom had a concomitant cholecystectomy. The mean anesthesia and operative times were longer in the laparoscopic than in the open group (p < 0.001). However, the mean number of hours of postoperative analgesia was less in the laparoscopic group (p < 0.005). Patients who had laparoscopic splenectomy were also discharged home earlier (p < 0.01) and resumed a regular diet sooner. Mean operating room charges were higher in the laparoscopic group (p < 0.001), but total hospitalization costs were not significantly different. Postoperative complication rates were similar. The hematologic response was comparable.

CONCLUSIONS

laparoscopic splenectomy is feasible and safe in children with hematologic disorders. Although it currently requires more operative time than the open approach, it is superior with regard to duration of postoperative analgesia, duration of hospital stay, and recovery of bowel function.

Postoperative complications after splenectomy for hematologic malignancies

OBJECTIVE

The authors analyzed the frequency and character of postoperative complications after splenectomy in patients with hematologic malignancies, and correlated these findings with preoperative conditions that could have predicted their outcome.

SUMMARY BACKGROUND DATA

Splenectomy is performed for hematologic malignancies for diagnostic and therapeutic indications. The role of splenectomy for lymphoproliferative and myeloproliferative malignancies is complex and sometimes controversial.

METHODS

The medical records of 135 patients undergoing splenectomies for hematologic malignancies at Roswell Park Cancer Institute from January 1, 1984 to December 31, 1993 were reviewed retrospectively. These included Hodgkin's disease (HD), hairy cell leukemia (HCL), non-Hodgkin's lymphoma (NHL), chronic lymphocytic leukemia (CLL), chronic myelogenous leukemia (CML), and a miscellaneous group.

RESULTS

The overall postoperative complication and mortality rates for all patients were 52% and 9%, respectively. The complication rate was 63% for patients whose spleens weighed greater than 2000 g, and 29% for patients whose spleens weighed less than 2000 g (p = 0.001). Seventy-three percent of the postoperative deaths were due to septic complications, only one of which was caused by an encapsulated organism. Complications occurred in less than 20% of patients with the diagnosis of HD and HCL; more than 50% of patients with NHL, CLL, and CML suffered postoperative complications.

CONCLUSIONS

Splenectomy performed in patients with hematologic malignancies is a potentially morbid procedure. Splenic size was the only preoperative factor found to be predictive of postoperative complications. The complication rate differed significantly between the different diagnostic subgroups.