Laparoscopic splenectomy for idiopathic thrombocytopenic purpura (ITP)

Laparoscopic splenectomy in malignancies: is safe and feasible?

BACKGROUND

Laparoscopic splenectomy (LS) is considered the treatment of choice for benign hematologic diseases of the spleen. However, the role of LS in malignancies is still controversial. Technical difficulties, hemorrhagic risk, the need of pathological characterization of malignant disease, may be considered contraindications to LS in malignancies. This study aims to verify the efficacy and feasibility of LS for hematologic malignancies.

METHODS

One hundred and forty-five patients underwent LS for hematologic disease and were retrospectively shared in two groups: Group A (N.=83) patients with preoperative diagnosis of benign hematologic disease and Group B (N.=62) with malignancies. Bipolar spleen diameter, mean operative time, conversion rate and causes, complications and need of transfusion were evaluated.

RESULTS

Median splenic diameter was greater in Group B than in Group A with a statistically significant difference (P<0.005), and the number of accessory mini-laparotomies (P<0.005) and the conversion rate (P=0.024) in the group of patients with a diagnosis of malignancy were also higher. The mean operative time was 117.6 minutes in group A and 148.1 minutes in Group B (P<0.005). Besides, there were no significant differences relative to intraoperative and postoperative transfusions and the incidence of postoperative complications. No perioperative mortality occurred.

CONCLUSIONS

The analysis of our data highlights that LS for hematologic malignancies is effective and feasible even if it associated with higher conversion rate due to splenomegaly and difficult hilum dissection. Besides, no differences in the patient outcome were highlighted. LS may be considered a safe procedure in the treatment of haematological malignancies of the spleen.

Corticosteroid response predicts success of laparoscopic splenectomy in treating immune thrombocytopenia

BACKGROUND

Laparoscopic splenectomy is a second-line therapy for immune thrombocytopenia with a sustained success rate of 66%. In a climate of new available medical therapies for immune thrombocytopenia, the comparative safety and efficacy of laparoscopic splenectomy are worthy of attention. The purpose of this study is to identify factors predictive of laparoscopic splenectomy success that will enable preoperative prognostication.

METHODS

A retrospective cohort study was conducted of patients undergoing laparoscopic splenectomy for immune thrombocytopenia. The data collected evaluated response to medical and surgical therapy, which was defined on a platelet level of 50 × 109/L with no bleeding events. Univariate and multivariate analyses were conducted to evaluate factors predictive of laparoscopic splenectomy success, with an additional subanalysis planned to assess for laparoscopic splenectomy safety in individuals ≥65 years.

RESULTS

One hundred forty-one patients were reviewed. Operative outcomes showed a 3.6% conversion rate and 8.5% complication rate. Disease remission was achieved in 78.7% of patients. Response to initial corticosteroid therapy was associated with a laparoscopic splenectomy success rate of 90% and increased odds of surgical success by 5.58 over individuals with no response to corticosteroids. Age did not confer an increased risk of failure or complications.

CONCLUSION

Laparoscopic splenectomy is a safe and effective intervention for immune thrombocytopenia regardless of age. Initial response to corticosteroids is associated with laparoscopic splenectomy success rate of 90% and improved odds of surgical success. Laparoscopic splenectomy should be the standard second-line therapy for immune thrombocytopenia, especially in patients responding to corticosteroids.

Role of Laparoscopic Splenectomy in Elderly Immune Thrombocytopenia

The management of older patients with chronic primary immune thrombocytopenia (ITP) is still very challenging because of the fragility of older patients who frequently have severe comorbidities and/or disabilities. Corticosteroid-based first-line therapies fail in most of the cases and patients require a second-line treatment, choosing between rituximab, thrombopoietin-receptor agonists and splenectomy. The choice of the best treatment in elderly patients is a compromise between effectiveness and safety and laparoscopic splenectomy may be a good option with a complete remission rate of 67% at 60 months. But relapse and complication rates remain higher than in younger splenectomized ITP patients because elderly patients undergo splenectomy with unfavorable conditions (age >60 year-old, presence of comorbidities, or multiple previous treatments) which negatively influence the outcome, regardless the hematological response. For these reasons, a good management of concomitant diseases and the option to not use the splenectomy as the last possible treatment could improve the outcome of old splenectomized patients.

Postsplenectomy recurrence of idiopathic thrombocitopenic purpura: role of laparoscopic splenectomy in the treatment of accessory spleen

AIM

Idiopatic thrombocytopenic purpura (ITP) is the most common indication for splenectomy. The failure rate of surgery is about 8% and the failure rate after splenectomy is approximately 28% for all patients. When the presence of an accessory spleen is diagnosed, splenectomy is recommended. Laparoscopic approach is considered the first choice.

PATIENTS AND METHODS

At our Department, between July and November 2011 two patients underwent laparoscopic accessory splenectomy for recurrence of ITP. Both patients had a previously laparoscopic splenectomy. Preoperative Magnetic Resonance (MR) was performed in both the cases revealing the presence of an accessory spleen.

RESULTS

The operative time was 105 and 100 minutes respectively. No perioperative complications occured. Hospital stay was four days in both cases. The first patient had a disease free period of two months; the second one of one month. Both patients restarted immunosuppressive therapy.

CONCLUSIONS

The relapse of thrombocytopenia post-splenectomy can be associated with the presence of an accessory spleen. The laparoscopic accessory splenectomy should be considered the first choice approach. Surgical accessory splenectomy allows a transitory remission of the disease.

Long-term outcomes of laparoscopic splenectomy versus open splenectomy for idiopathic thrombocytopenic purpura

The long-term outcomes of laparoscopic splenectomy (LS) versus open splenectomy (OS) in patients with idiopathic thrombocytopenic purpura (ITP) are not known. A retrospective analysis of 73 patients who underwent splenectomy (32 LS and 41 OS) for refractory ITP between April 2003 and June 2012 was conducted. LS was associated with shorter hospital stay (P = 0.01), less blood loss and blood transfusion during surgery, quicker resumption of oral diet (P < 0.0001), and earlier drain removal (P < 0.01). Conversion to OS was required in 4 patients (12.5%). Operation time was significantly longer in LS (P < 0.0001). Deep venous thrombosis (DVT) was observed in 1 patient after LS and in 4 patients after OS (P = 0.52). One patient died from intraperitoneal bleeding after OS, another patient developed pulmonary embolism. Median follow-up of 36 months was performed in LS group (29 of 32, 91%) and of 46 months in OS group (35 of 41, 85%), 25 patients (86%) in LS group and 32 (91%) in OS group reached sustained complete response (P = 0.792). Kaplan-Meier analysis showed that there was no significant difference in the relapse-free survival rate between the groups (P = 0.777). In conclusion, the long-term outcome of laparoscopic splenectomy is not different from that of open splenectomy for patients with ITP.

Long-term outcomes of laparoscopic splenectomy versus open splenectomy for idiopathic thrombocytopenic purpura

The long-term outcomes of laparoscopic splenectomy (LS) versus open splenectomy (OS) in patients with idiopathic thrombocytopenic purpura (ITP) are not known. A retrospective analysis of 73 patients who underwent splenectomy (32 LS and 41 OS) for refractory ITP between April 2003 and June 2012 was conducted. LS was associated with shorter hospital stay (P = 0.01), less blood loss and blood transfusion during surgery, quicker resumption of oral diet (P < 0.0001), and earlier drain removal (P < 0.01). Conversion to OS was required in 4 patients (12.5%). Operation time was significantly longer in LS (P < 0.0001). Deep venous thrombosis (DVT) was observed in 1 patient after LS and in 4 patients after OS (P = 0.52). One patient died from intraperitoneal bleeding after OS, another patient developed pulmonary embolism. Median follow-up of 36 months was performed in LS group (29 of 32, 91%) and of 46 months in OS group (35 of 41, 85%), 25 patients (86%) in LS group and 32 (91%) in OS group reached sustained complete response (P = 0.792). Kaplan-Meier analysis showed that there was no significant difference in the relapse-free survival rate between the groups (P = 0.777). In conclusion, the long-term outcome of laparoscopic splenectomy is not different from that of open splenectomy for patients with ITP.

CT and MRI characteristics of special types of accessory spleen

AIM: To explore the computed tomography (CT) and magnetic resonance imaging (MRI) imaging features of accessory spleen in special location.

METHODS: CT and MRI imaging data for five patients diagnosed pathologically with accessory spleen were analyzed retrospectively.

RESULTS: Accessory spleen was located in the pancreas in 3 cases, in the peripancreatic in 1 case, and around the left kidney in 1 case. Three accessory spleens in the pancreas showed round-like soft tissue nodules at the tail of the pancreas, which were similar to the main spleen in non-enhanced CT and MRI scans, and consistent with the main spleen in enhanced scans. Of these three cases, one had unclear boundary on plain CT and enhanced CT, but had clear boundary on MRI. CT density and MRI sequence of accessory spleens around the pancreas and left kidney were similar to the main spleen, and their blood supply was provided by the small branch of the splenic artery and the left renal artery. Enhanced CT and MRI showed heterogeneous enhancement in the arterial phase, whose degree was weaker than that of the main spleen, and homogeneous enhancement in the venous and delayed phase, whose degree was consistent with that of the main spleen.

CONCLUSION: A definite diagnosis of accessory spleen can be made in most cases, because most of them have typical imaging findings and locations. Accessory spleens that are located in special sites or have special blood supply are easily misdiagnosed, although they have typical CT and MRI imaging features.

Adverse postoperative outcomes in surgical patients with immune thrombocytopenia

Background

Patients with immune thrombocytopenia (ITP) are likely to have various medical co-morbidities, yet their global features regarding adverse postoperative outcomes and use of medical resources when undergoing major surgery are unknown. The objective of this study was to validate whether ITP is an independent risk factor for adverse postoperative outcomes, and to explore the potential clinical predictors of outcomes after major surgery among patients with ITP.

Methods

A retrospective population-based cohort study was conducted using Taiwan's National Health Insurance Research Database, controlling for preoperative co-morbidities by means of multiple logistic regression. Major postoperative complication and mortality rates, and in-hospital medical costs were analysed.

Results

The study included 11 085 surgical patients with ITP and 44 340 controls without ITP matched for sex, age, and type of surgery and anaesthesia. Surgical patients with ITP had a higher risk of postoperative death (odds ratio (OR) 1·89, 95 per cent confidence interval 1·57 to 2·27), and overall postoperative complications (OR 1·47, 1·39 to 1·56), and increased hospital stay (OR 1·90, 1·80 to 2·01), admission to the intensive care unit (OR 1·73, 1·63 to 1·83) and medical costs (OR 1·89, 1·79 to 1·99). Amount of preoperative platelet and/or red blood cell transfusion, emergency visits and admission to hospital for ITP care were identified as risk factors for adverse postoperative outcomes.

Conclusion

Patients with ITP undergoing surgery are at increased risk of adverse perioperative events, particularly if blood or blood product transfusion are required preoperatively, or the procedure is done as an emergency.

The feasibility and safety of laparoscopic splenectomy for massive splenomegaly: a comparative study

BACKGROUND

Laparoscopic splenectomy used for massive splenomegaly is still controversial. The purpose of our current study was to identify the feasibility and safety of laparoscopic splenectomy for massive splenomegaly.

METHODS

From January 2006 to January 2010, laparoscopic splenectomy was performed on 33 patients with massive splenomegaly in our hospital, compared with 29 patients who received open splenectomy (group 2) and 48 patients with normal-size spleens who underwent laparoscopic splenectomy (group 3). Perioperative outcomes of these patients were compared.

RESULTS

Compared with patients in group 2, the patients in group 1 required more operative time, less blood transfusion, and a shorter postoperative hospital stay; furthermore, patients in group 1 had less estimated blood loss and fewer complications. No statistically significant difference was found in the patients' spleen volume and spleen weight. Group 1 had statistically significant differences in operative time, estimated blood loss, postoperative hospital stay, spleen volume, and spleen weight compared with patients in group 3. No significant differences were found in the conversion, blood transfusion, or complication rate.

CONCLUSIONS

Laparoscopic splenectomy is a technically feasible and safe procedure for splenomegaly.

Laparoscopic splenectomy: learning curve comparison between benign and malignant disease

BACKGROUND

New surgical techniques should be formally evaluated for feasibility and safety. As a model for this evaluation, this study examines the authors' institution's experience with splenectomy for benign and malignant hematologic disease since the introduction of laparoscopic splenectomy (LS) in 1996. The authors present the evaluation of the recognized surgeon/institutional learning curve using CUSUM (cumulative sum) analysis.

METHODS

This is a single institution retrospective chart review of consecutive splenectomies for hematologic disease performed between 1996 and 2008. The primary outcome was conversion to open splenectomy. The learning curve for LS was evaluated using CUSUM analysis.

RESULTS

A total of 123 splenectomies were performed for benign (51.2%) or malignant (48.7%) hematologic disease. 58% of patients underwent planned LS, with a 21% conversion rate. The surgeon's overall learning curves for LS, as well as that for malignant disease, were maintained within acceptable conversion thresholds. However, the learning curve for benign disease did cross the unacceptable conversion threshold at case 29. With additional experience, the curve again approached the acceptable conversion threshold. Patients with malignant disease were significantly older (P = .0004), had larger spleens (P = .0004), were more likely to undergo open splenectomy (P = .001), and had longer lengths of stay (P = .01). However, there was no significant difference in operative time, transfusion requirements, morbidity rates, or mortality rates between patients with benign and malignant disease.

CONCLUSION

LS, for benign or for malignant hematologic disease, is associated with a significant learning curve. This evaluation model illustrates that careful patient selection and ongoing quality assessment is essential when introducing a new technique.

Long-term outcomes of a 5-year follow up of patients with immune thrombocytopenic purpura after splenectomy

Background

The long-term outcomes of adult patients with immune thrombocytopenic purpura (ITP) after splenectomy are not clear.

Methods

We retrospectively analyzed 31 patients who underwent splenectomy after diagnosis of ITP at our institution between 1990 and 2009. Long-term follow-up was defined as a follow-up that lasted 1 year or more from splenectomy to the last follow-up.

Results

The overall response rate to splenectomy was 84%. However, the response rate at 6 and 12 months decreased to 77% and 68%, respectively. During the 6 years of median follow-up after splenectomy, 11 patients (35%) relapsed. The long-term response rate was 55%. The long-term follow-up of 26 patients after responding to splenectomy showed that the median time from splenectomy to relapse was 19 months in the partial response (PR) group; however, there was no relapse after 9 months in the complete response (CR) group. Variables, including age, were not predictive of the long-term response after splenectomy. Additional treatment in patients who did not respond or relapsed after splenectomy was mostly effective. After a median follow-up of 7 years (range: 1-25 years) from the diagnosis, there were 2 deaths, including one due to spontaneous bleeding after repair of duodenal ulcer perforation.

Conclusion

Although splenectomy is safe and effective, the response rate after splenectomy continuously decreases over time. The duration of response is different between the patients that achieved CR and those that achieved PR. Factors, including age, were not predictors of a response to splenectomy.

Short-term and long-term failure of laparoscopic splenectomy in adult immune thrombocytopenic purpura patients: a systematic review

Splenectomy is a common therapy for adults with chronic idiopathic thrombocytopenic purpura (ITP). Thisstudy was designed to estimate both the short-term surgical non-response rate and the long-term relapse rate after laparoscopic splenectomy. A systematic review was conducted of articles published between January 1, 1991 and January 1, 2008. Selection criteria included: chronic ITP, study enrollment in 1990 or later, > or =12 months of follow-up, > or =15 patients with ITP, > or =75% of patients at least 14 years of age, not HIV positive, not undergoing a second splenectomy, and type of performed splenectomy clearly reported. Data were pooled across studies to estimate rates. We identified 170 articles, of which 23 met our inclusion criteria (all observational studies). These studies represent 1,223 laparoscopic splenectomies (71 or 5.6% were converted to open splenectomy during surgery). The pooled short-term surgical non-response rate among the 18 studies reporting data was 8.2% (95% CI 5.4-11.0). The pooled long-term relapse rate across all 23 studies was 43.6 per 1,000 patient years (95% CI 28.2-67.2). This translates to an approximate failure rate of 28% at 5 years for all patients undergoing splenectomy. Studies with shorter durations of follow-up had significantly higher pooled relapse rates than studies with longer follow-up (P = 0.04). Laparoscopicsplenectomy is effective for most patients. Splenectomy may have higher initial relapse rates, particularly, in the first 2 years after surgery, and the rate may decline over time. Am. J. Hematol. 2009. (c) 2009 Wiley-Liss, Inc.

Laparoscopic versus open splenectomy for hypersplenism secondary to liver cirrhosis

BACKGROUND

Since the first laparoscopic splenectomy (LS) in 1991, LS has become the gold standard for the removal of normal-to-moderately enlarged spleens in benign conditions. Compared with open splenectomy (OS), fewer postsurgical complications and better postoperative recovery were observed, but it is contraindicated for hypersplenism secondary to liver cirrhosis owing to technical difficulties associated with splenomegaly, well-developed collateral circulation, and increased risk of bleeding. With the improvements of laparoscopic technique, the concept is changing.

METHODS

OS and LS performed for hypersplenism secondary to liver cirrhosis at our institution were analyzed. Relationships between postoperative increases in platelet counts, white blood cell counts, hemoglobin, and liver function were examined. Perioperative data of LSs were compared with those of OSs, including operative time, blood loss, excised spleen weight, complications, and hospital stays.

RESULTS

A total of 216 splenectomies (135 OS and 81 LS) were performed from April 1999 to March 2007. Five laparoscopic cases were converted to open surgery owing to operative bleeding or bleeding of splenic fossa. The other 76 patients were performed LSs successfully. No major operative complications occurred. There was no operative death. Excised spleen weight >400 g was present in 56% of cases in this series. At 7 days postoperatively, the platelet counts, white blood cell counts, and hemoglobin significantly increased after open and laparoscopic surgeries, and increase of alanine aminotransferase, aspartate aminotransferase, total bilirubin, and directed bilirubin of LS were significantly different with open cases. Operation times of LS and OS were 2.9+/-0.7 hours and 2.6+/-0.6 hours, respectively. Blood losses were 150.6+/-135.4 mL and 633.8+/-340.3 mL (P<0.01), excised spleen weights were 585.7+/-184.6 g and 591.1+/-153.4 g (P>0.05), and hospital stay were 8.2+/-2.0 days and 11.9+/-3.8 days (P<0.01). Operative associated complications were noted in both LS and OS. Less blood loss, shorter hospital stay, and less impairment of liver function were observed in LS than OS.

CONCLUSIONS

LS is feasible, effective, and safe procedures for hypersplenism secondary to liver cirrhosis and contributes to less impairment of liver function, less blood loss, and shorter hospital stay.

Laparoscopic splenectomy: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES)

BACKGROUND

Although laparoscopic splenectomy (LS) has become the standard approach for most splenectomy cases, some areas still remain controversial. To date, the indications that preclude laparoscopic splenectomy are not clearly defined. In view of this, the European Association for Endoscopic Surgery (EAES) has developed clinical practice guidelines for LS.

METHODS

An international expert panel was invited to appraise the current literature and to develop evidence-based recommendations. A consensus development conference using a nominal group process convened in May 2007. Its recommendations were presented at the annual EAES congress in Athens, Greece, on 5 July 2007 for discussion and further input. After a further Delphi process between the experts, the final recommendations were agreed upon.

RESULTS

Laparoscopic splenectomy is indicated for most benign and malignant hematologic diseases independently of the patient's age and body weight. Preoperative investigation is recommended for obtaining information on spleen size and volume as well as the presence of accessory splenic tissue. Preoperative vaccination against meningococcal, pneumococcal, and Haemophilus influenzae type B infections is recommended in elective cases. Perioperative anticoagulant prophylaxis with subcutaneous heparin should be administered to all patients and prolonged anticoagulant prophylaxis to high-risk patients. The choice of approach (supine [anterior], semilateral or lateral) is left to the surgeon's preference and concomitant conditions. In cases of massive splenomegaly, the hand-assisted technique should be considered to avoid conversion to open surgery and to reduce complication rates. The expert panel still considered portal hypertension and major medical comorbidities as contraindications to LS.

CONCLUSION

Despite a lack of level 1 evidence, LS is a safe and advantageous procedure in experienced hands that has displaced open surgery for almost all indications. To support the clinical evidence, further randomized controlled trials on different issues are mandatory.

An 18-year review of open and laparoscopic splenectomy for idiopathic thrombocytopenic purpura

BACKGROUND

Laparoscopic splenectomy has become the preferred surgical procedure for the management of idiopathic thrombocytopenic purpura (ITP). However, there studies have directly compared the incidence of recurrent ITP secondary to missed accessory spleens in open versus laparoscopic splenectomy.

METHODS

Open and laparoscopic splenectomies performed for ITP at 4 sites over 18 years were analyzed. The incidence of recurrent disease secondary to missed accessory spleens was compared between the open and laparoscopic splenectomy groups.

RESULTS

A total of 105 splenectomies (54 open/51 laparoscopic) were performed. Accessory spleens were identified in 6 laparoscopic and 6 open cases (P = .57). Recurrent disease occurred in 27.6% of open and 14.6% of laparoscopic cases (P = .222). There were no cases of recurrent ITP secondary to a missed accessory spleen in either group.

CONCLUSIONS

The incidence of missed accessory spleens causing recurrent disease is similar when splenectomy is performed either open or laparoscopically.

Laparoscopic splenectomy is a better treatment for adult ITP than steroids — it should be used earlier in patient management. Conclusions of a ten-year follow-up study

BACKGROUND

Laparoscopic splenectomy (LS) has rapidly become the preferred surgical treatment for immune thrombocytopaenic purpura (ITP). The aim of this study was to assess the long-term outcome of laparoscopic splenectomy for adult ITP performed in a single unit.

METHODS

Between 1992 and 2002, 55 patients underwent LS for ITP refractory to medical therapy. These were performed by one surgeon. Long-term outcome data was obtained by case note review and telephone-based questionnaire. Complete remission was defined as a sustained platelet count of >100 x 10(9)/L without further requirement for medical therapy.

RESULTS

Follow-up information was obtained for 40 (73%) out of 55 patients. Overall, 35 (88%) of 40 patients were in complete remission at five-year median follow-up. Five (13%) patients required continued steroid therapy despite LS. Seven (18%) patients reported bleeding problems, in particular bruising. Thirty-five (88%) of 40 patients considered their operation a success. Of these, 16 (46%) patients wished that the operation had been performed earlier in the course of their disease.

CONCLUSIONS

This ten-year experience demonstrates that LS is safe, effective, and yields excellent long-term results for adult ITP, equivalent to results after open splenectomy. Patients' views suggest that laparoscopic splenectomy should be considered sooner in the management of adult ITP, reducing the duration and morbidity of medical treatment.

Impact of morbid obesity on outcome of laparoscopic splenectomy

BACKGROUND

Because of the obesity epidemic, surgeons are operating on morbidly obese patients in increasing numbers. The aim of this study was to evaluate the impact of morbid obesity on the outcome of laparoscopic splenectomy.

METHODS

The study group consisted of 120 consecutive patients who underwent laparoscopic splenectomy for benign and malignant disease from March 1996 to May 2005. These patients were retrospectively divided into three groups. Group 1 had a body mass index (BMI) < 30. Group 2 patients had a BMI > or = 30 and < 40 and were considered obese. Group 3 had a BMI > or = 40 and were considered morbidly obese. Data including surgical approach (laparoscopic vs. hand-assisted), operative time, conversion rate, estimated blood loss, splenic weight, length of stay, time to tolerate a diet, pathologic diagnosis, complications, and mortality were recorded.

RESULTS

Complete data were available for evaluation of 112 patients of whom 73 (65%) had a BMI < 30, 32 (29%) had a BMI > or = 30 and < 40, and 7 (6%) had a BMI > or = 40. The most frequent indication for splenectomy in all three groups was idiopathic thrombocytopenic purpura (ITP). The operative times were significantly higher in patients with a BMI > 40. Conversion rates were also higher in this group, although this did not reach statistical significance. Patients with a BMI > 30 experienced similar complication rates when compared with patients with a BMI < 30. Only when patients had a BMI > 40 did they experience more complications.

CONCLUSIONS

Laparoscopic splenectomy was performed safely in obese patients (BMI > 30) with similar results to those of nonobese patients. Only in morbidly obese patients (BMI > 40) do outcomes and complications appear to be affected. Obesity should not be a contraindication to laparoscopic splenectomy.

Laparoscopic splenectomy: present status and future perspective

Laparoscopic splenectomy has become widely accepted as the approach of choice for the surgical treatment of benign and malignant hematologic diseases. Advances in technology have led to better outcomes for the procedure, and have allowed surgeons to apply the technique to disease processes that were at one time felt to be contraindications to laparoscopic splenectomy. However, challenges still remain. There is a steep learning curve associated with the procedure. The development of cost-effective laparoscopic simulators to target the skills required for laparoscopic splenectomy and other laparoscopic procedures is essential. The advent of devices which isolate and seal the large blood vessels that surround the spleen have reduced intra-operative bleeding and minimized conversions to open splenectomy. Improvements in optics and instrumentation, as well as robotic technology, will continue to define the frontier of minimally invasive surgery, and further facilitate the acceptance of laparoscopic splenectomy for the treatment of benign and malignant hematologic diseases.

Laparoscopic splenectomy and LigaSure

Laparoscopic splenectomy (LS) is a preferred choice, especially for hematologic diseases. We present the advantages of the use of LigaSure (energy-based equipment that works by applying a precise amount of bipolar energy and pressure to the tissue, achieving a permanent seal) for achieving a precise hemostasis, thus making the LS easier. We have performed LS using LigaSure on 10 patients (4 female, 6 male; mean age, 36 years [range, 16-58]) between December 2002 and August 2003. All patients had ITP. There were no conversion to open surgery. Mean dimensions of spleens were 99 x 49 mm (range, 85 x 36-118 x 60). Intraoperative blood loss was no more than 100 mL in any patients (range, 20-100; mean, 60). The average operative time was 93 minutes (range, 60-155). There were no complications in the postoperative period. The average postoperative stay was 4.3 days (range, 3-7). LS using LigaSure is a safe and time-sparing procedure with almost no complications in this small initial series.

Laparoscopic splenectomy: a selected retrospective review

Previous investigators have suggested that laparoscopic splenectomy should be the procedure of choice for the treatment of benign hematologic disorders unresponsive to medical therapy. To evaluate the safety and utility of laparoscopic splenectomy for a variety of splenic disorders, we reviewed our collective experience at 2 institutions. We studied our 8-year experience by retrospective chart review. Patient demographic data, splenic pathology, intraoperative events, concomitant procedures, and all adverse perioperative events were recorded. A total of 131 patients had laparoscopic splenectomy, and there were 8 conversions to open surgery. Pathology included 63 with idiopathic thrombocytopenic purpura (ITP), 23 malignancies, 12 thrombotic thrombocytopenic purpura (TTP), 10 autoimmune hemolytic anemia (AIHA), and 23 others. Accessory spleens were noted in 21 patients (16%). Concomitant surgical procedures included 12 hepatic biopsies, 4 distal pancreatectomies, 4 cholecystectomies, and 7 others. Mean operative time was 170 minutes. There were 16 major complications in 16 patients and 2 deaths. Median postoperative length of stay was 3 days. Conversions, due mostly to bleeding, are related to splenic pathology and medical comorbidity and are not temporally related to surgical experience (learning curve). The morbidity, mortality, and conversion rates were low. Laparoscopic splenectomy permits an appropriate abdominal exploration and is associated with a short hospital stay. It is the procedure of choice for most indications for splenectomy.

Laparoscopic versus open splenectomy in the management of benign and malign hematologic diseases: a ten-year single-center experience

OBJECTIVE

Laparoscopic splenectomy (LS) has gained wide acceptance as a safe, effective alternative to open splenectomy (OS) in the treatment of hematologic disorders. The aim of this study was to compare two cohorts of patients with similar characteristics, who underwent LS and OS in a single university teaching center.

METHODS

Records were reviewed from 30 patients who underwent LS for a hematologic disease and compared with a control group of 38 patients undergoing OS for hematologic disease. Demographics and outcomes were recorded.

RESULTS

There were no significant differences between the two groups with respect to accessory spleens, blood loss, or complication rates (P > 0.05). The operation time in the LS group was significantly longer than in the OS group (P < 0.01) and the length of hospital stay in the LS group was significantly shorter than in the OS group (P < 0.01).

CONCLUSION

Laparoscopic splenectomy is likely becoming the gold standard in the surgical treatment of hematologic diseases.

Laparoscopic splenectomy with the da Vinci robot

BACKGROUND

We report our first series of minimally invasive splenectomies with a robotic surgical system.

METHODS

From August 2001 to October 2003, laparoscopic splenectomies with the da Vinci operating robot were performed in 7 patients (five females and two males, ages 20 to 74 years).

RESULTS

Indications for splenectomy were hematologic disorders in four patients and hypersplenism in three patients. Median dimensions of the resected spleens were 140 +/- 34 mm x 80 +/- 11 mm x 50 +/- 17 mm and median weight was 307 +/- 193 g. Median total operative time was 147 +/- 58 minutes including 107 +/- 49 minutes for the robotic act. There were no intraoperative complications and no conversions to open surgery. The median postoperative hospital stay was 7 days.

CONCLUSION

This first series suggests that robotic splenectomy with the da Vinci surgical system is technically feasible and safe. It provides an alternative to the conventional laparoscopic procedure. Nevertheless, justification for this new technique will require a larger prospective series and longer follow-up.

Prognostic factors of response to laparoscopic splenectomy in patients with idiopathic thrombocytopenic purpura

Laparoscopic splenectomy (LS) has become the treatment of choice for patients with idiopathic thrombocytopenic purpura (ITP) who do not respond to medical treatment. The aim of this study was to identify factors predictive of outcome after LS for ITP. From May 1997 to December 2002, we performed 30 LS on patients with ITP. A positive response was defined as a postoperative platelet count greater than 50,000/micro L and no requirement for maintenance therapy. Chi-square testing was performed to determine the predictive effects of the following variables: age, sex, preoperative response to steroids or immunoglobulin, duration of disease, antiplatelet antibody, platelet associated antibody, and antinuclear antibody. LS was successfully performed in all patients. For a mean follow-up interval of 24.3 months, response to LS was 73.3%. Splenectomy for steroid nonresponders resulted in an inferior complete response rate (10 of 18, 55.6%) as compared with those that experienced relapse after steroid treatment (11 of 12, 91.7%) (p=0.042). The other significant predictor of outcome by univariate analysis was the time between diagnosis and surgery (p=0.049). The other variables showed no significant correlation with successful splenectomy. We conclude that LS can be performed safely with a satisfactory remission rate in patients with ITP who do not respond to medical treatment, and that the factors most frequently associated with surgical success are a response to steroid and disease duration.

High incidence of thrombosis of the portal venous system after laparoscopic splenectomy: a prospective study with contrast-enhanced CT scan

OBJECTIVE

The aims of this prospective study were to investigate the true incidence of portal or splenic vein thrombosis (PSVT) after elective laparoscopic splenectomy using contrast-enhanced computed tomography (CT) scan, and outcome of anticoagulant therapy for PSVT.

SUMMARY BACKGROUND DATA

Although rare, thrombosis of the portal venous system is considered a possible cause of death after splenectomy. The reported incidence of ultrasonographically detected PSVT after elective open splenectomy ranges from 6.3% to 10%.

METHODS

Twenty-two patients underwent laparoscopic splenectomy (LS group), and 21 patients underwent open splenectomy (OS group). Preoperative and postoperative helical CT with contrast were obtained in all patients, and the extent of thrombosis was investigated. Prothrombotic disorder was also determined.

RESULTS

PSVT occurred in 12 (55%) patients of the LS group, but in only 4 (19%) of the OS group. The difference was significant (P = 0.03). Clinical symptoms appeared in 4 of the 12 LS patients. Thrombosis occurred in the intrahepatic portal vein (n = 9), extrahepatic portal vein (n = 2), mesenteric veins (n = 1), proximal splenic vein (n = 4), and distal splenic vein (n = 8). Prothrombotic disorder was diagnosed in 1 patient. Anticoagulant therapy was initiated once the diagnosis was established, and complete recanalization, except for distal splenic vein, was observed without any adverse event. Patients with splenomegaly were at high risk of PSVT.

CONCLUSIONS

PSVT is a more frequent complication of laparoscopic splenectomy than previously reported but can be treated safely following early detection by CT with contrast.

[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.

Defining the learning curve for laparoscopic splenectomy for immune thrombocytopenia purpura

BACKGROUND

The current study was undertaken to define the learning curve for laparoscopic splenectomy (LS) in patients with immune thrombocytopenic purpura (ITP).

METHODS

The data of 50 patients who underwent LS for ITP between March 1996 and February 2003 were reviewed. Patients were divided into sequential groups of 10. Operative time, estimated blood loss, conversion to open procedure, length of stay (LOS), time to oral intake, complications, and mortality rates were analyzed.

RESULTS

The mean OR time in the 3rd, 4th, and 5th groups of 10 were significantly shorter than the 1st and 2nd groups of 10. There were no significant differences in estimated blood loss, LOS, or time to oral intake between the groups. Three conversions to open splenectomy occurred; one each in the 2nd, 3rd, and 4th groups of 10. Complications were evenly distributed between groups. There were no deaths.

CONCLUSION

The learning curve for LS in patients with ITP is a minimum of 20 cases.

Splenectomy for adult patients with idiopathic thrombocytopenic purpura: a systematic review to assess long-term platelet count responses, prediction of response, and surgical complications

Splenectomy has been a standard treatment for adult patients with idiopathic thrombocytopenic purpura (ITP) for more than 50 years. However, the durability of responses, the ability to predict who will respond, and the frequency of surgical complications with splenectomy all remain uncertain. To better interpret current knowledge we systematically identified and reviewed all 135 case series, 1966 to 2004, that described 15 or more consecutive patients who had splenectomy for ITP and that had data for 1 of these 3 outcomes. Complete response was defined as a normal platelet count following splenectomy and for the duration of follow-up with no additional treatment. Forty-seven case series reported complete response in 1731 (66%) of 2623 adult patients with follow-up for 1 to 153 months; complete response rates did not correlate with duration of follow-up (r = -0.103, P = .49). None of 12 preoperative characteristics that have been reported consistently predicted response to splenectomy. Mortality was 1.0% (48 of 4955 patients) with laparotomy and 0.2% (3 of 1301 patients) with laparoscopy. Complication rates were 12.9% (318 of 2465) with laparotomy and 9.6% (88 of 921 patients) with laparoscopic splenectomy. Although the risk of surgery is an important consideration, splenectomy provides a high frequency of durable responses for adult patients with ITP. (Blood. 2004; 104:2623-2634)

Use of a laparoscopic hand-assist device for accessory splenectomy

BACKGROUND

The use of a laparoscopic hand-assist device may aid in the identification of accessory spleens (ASs) and provide similar benefits to a conventional laparoscopic procedure. A patient with previous splenectomy for immune thrombocytopenic pupusa (ITP) and recurrent thrombocytopenia is reported.

METHOD

A computed tomography scan and RBC scan identified several nodules consistent with ASs. Initial laparoscopic exploration could not identify all the ASs seen on preoperative imaging. A hand-assist device was placed and a total of five nodules of splenic tissue were identified without conversion to laparotomy.

RESULTS

The patient had a brief and uncomplicated postoperative course with a return of platelet counts to 350,000 at 1-month follow-up.

CONCLUSION

We propose that in the scenario of recurrent ITP following laparoscopic splenectomy, repeat laparoscopy is the first step once an AS is identified by preoperative imaging. If the AS is not identified at laparoscopy, the insertion of a hand-assist device is an alternative to a full laparotomy.

Laparoscopic splenectomy for idiopathic thrombocytopenic purpura

BACKGROUND

Laparoscopic splenectomy (LS) has become the treatment of choice for patients with idiopathic thrombocytopenic purpura (ITP) who do not respond to medical treatment. Long-term follow-up data of LS for ITP are scarce.

METHODS

From May 1997 to December 2002, we performed 67 LS for patients with ITP. Data were assessed retrospectively.

RESULTS

LS was successfully attempted in all 67 patients. There was no surgical mortality. Three postoperative complications (5%) were encountered. The mean operative time decreased significantly from 176.2 minutes in the first 41 cases to 125.2 minutes in the last 26 cases. The mean postoperative hospital stay was 3.2 days. Accessory spleens were found in 3 patients (5%) during the LS. The mean follow-up interval was 23.3 months. The initial response to LS was 83%, and overall remission of ITP was 74%. The preoperative effect of steroid therapy had no significant influence on postoperative remission rate. More significant indicators of LS effectiveness were either an immediate postoperative platelet count surge or an immediate postoperative platelet count >or=100000/microL.

CONCLUSIONS

LS can be performed safely with a satisfactory remission rate for patients with ITP who do not respond to medical treatment. Our results indicated that an immediate postoperative platelet count surge and/or an immediate postoperative platelet count >or=100000/microL were positive predictors of long-term remission after LS for ITP.

Management of immune thrombocytopenic purpura in adults

Primary immune thrombocytopenic purpura (ITP), also referred to as idiopathic thrombocytopenic purpura, is an organ-specific autoimmune disorder in which antibody-coated or immune complex-coated platelets are destroyed prematurely by the reticuloendothelial system, resulting in peripheral blood thrombocytopenia. The disease is heterogeneous with regard to its severity and clinical course and is unpredictable in its response to therapy. Although the basic underlying pathophysiology of ITP has been known for more than 50 years, current treatment guidelines are based on expert opinion rather than on evidence because of a lack of high-quality clinical trials and research. The only patients for whom treatment is clearly required are those with severe bleeding and/or extremely low platelet counts (< 10 x 10(9)/L). Treatment of patients with ITP refractory to corticosteroids and splenectomy requires careful evaluation of disease severity, patient characteristics related to risk of bleeding, and adverse effects associated with treatment. Clinical trials with numerous new agents are under way, which we hope will add more effective and targeted strategies to our therapeutic armamentarium. We describe a logical and structured approach to the clinical management of ITP in adults, based on a literature review and our personal experience.

Perioperative outcomes of laparoscopic versus open splenectomy: a meta-analysis with an emphasis on complications

BACKGROUND

The purpose of this study was to analyze the published perioperative results of laparoscopic splenectomy (LS) compared to open splenectomy (OS), and to determine the impact of LS on the incidence and type of splenectomy-related complications.

METHODS

Perioperative results and complications were tabulated from all English-language reports of LS from 1991 through 2002, and complications were analyzed further by type. Data were taken from 26 series that compared OS to LS within an institution (paired analysis) and from an additional 25 series of only LS (unpaired analysis), and a meta-analysis was performed.

RESULTS

A total of 2940 patients from 51 published series were included (LS, 2119 patients; OS, 821 patients). Age, gender, and American Society of Anesthesiologists class were similar. In the analysis of paired OS and LS studies, the mean operative time for LS was significantly longer (LS, 180 minutes; OS, 114 minutes; P<.0001,) but the postoperative hospital stay was shorter (LS, 3.6 days; OS, 7.2 days; P<.001). Accessory spleens were identified in 11% of cases in both groups. The total complication rate for LS was 15.5%, compared with 26.6% for OS (P<.0001). LS was associated with significantly fewer pulmonary, wound, and infectious complications (P<.001 for all) but with more hemorrhagic complications, when conversions for bleeding were included. Mortality rates for LS and OS were similar (OS, 1.1%; LS, 0.6%; P=not significant). Comparable results were obtained when the unpaired LS series were added to the analysis.

CONCLUSIONS

Although operative times are longer for LS than OS, LS is associated with a significant reduction in splenectomy-related morbidity, primarily as a function of fewer pulmonary, wound, and infectious complications.