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Kashiwagi R, Ishida M, Onodera K, Aoki S, Iseki M, Miura T, Ohtsuka H, Mizuma M, Nakagawa K, Kamei T, Unno M. Laparoscopic excision of accessory spleen for recurrent autoimmune hemolytic anemia after splenectomy: a case report. Surg Case Rep 2024; 10:110. [PMID: 38700738 PMCID: PMC11068696 DOI: 10.1186/s40792-024-01884-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 04/01/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND Splenectomy is indicated in cases of autoimmune hemolytic anemia (AIHA), which are refractory to medical management. In post-splenectomy, there exists a theoretical risk of AIHA recurrence, especially if an accessory spleen undergoes compensatory hypertrophy. In this context, we present a unique case of recurrent AIHA managed through laparoscopic excision of the accessory spleen (LEAS). CASE PRESENTATION A 60-year-old male underwent laparoscopic splenectomy (LS) for AIHA refractory to standard medical therapies. Following the surgery, there was a marked improvement in hemolytic anemia symptoms, and oral steroid therapy was terminated 7 months post-LS. Nonetheless, a year after the LS, the patient exhibited a marked decline in hemoglobin levels, dropping to a concerning 5.8 g/dl, necessitating the reintroduction of oral steroids. A subsequent contrast-enhanced computed tomography (CT) scan unveiled an enlarged accessory spleen. The patient then underwent LEAS, during which the accessory spleen, obscured within adipose tissue, proved challenging to visualize laparoscopically. This obstacle was surmounted utilizing intraoperative ultrasonography (US), enabling successful excision of the accessory spleen. The post-surgical period progressed without complications, and the steroid dosage was reduced to one-twelfth of its initial preoperative quantity. CONCLUSIONS Recurrent AIHA can be instigated by post-splenectomy compensatory hypertrophy of the accessory spleen. Ensuring comprehensive splenic tissue excision is crucial in AIHA management to obviate recurrent stemming from hypertrophic remnants. In scenarios of AIHA recurrence tied to an enlarged accessory spleen, LEAS stands as a viable and effective therapeutic modality.
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Affiliation(s)
- Ryosuke Kashiwagi
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryomachi, Aobaku, Sendai, Miyagi, 980-8574, Japan
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Masaharu Ishida
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryomachi, Aobaku, Sendai, Miyagi, 980-8574, Japan
| | - Koichi Onodera
- Department of Hematology, Tohoku University Hospital, 1-1 Seiryomachi, Aobaku, Sendai, Miyagi, 980-8574, Japan
| | - Shuichi Aoki
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryomachi, Aobaku, Sendai, Miyagi, 980-8574, Japan
| | - Masahiro Iseki
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryomachi, Aobaku, Sendai, Miyagi, 980-8574, Japan
| | - Takayuki Miura
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryomachi, Aobaku, Sendai, Miyagi, 980-8574, Japan
| | - Hideo Ohtsuka
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryomachi, Aobaku, Sendai, Miyagi, 980-8574, Japan
| | - Masamichi Mizuma
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryomachi, Aobaku, Sendai, Miyagi, 980-8574, Japan
| | - Kei Nakagawa
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryomachi, Aobaku, Sendai, Miyagi, 980-8574, Japan
| | - Takashi Kamei
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryomachi, Aobaku, Sendai, Miyagi, 980-8574, Japan
| | - Michiaki Unno
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryomachi, Aobaku, Sendai, Miyagi, 980-8574, Japan.
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Bhattacharya P, Phelan L, Fisher S, Hajibandeh S, Hajibandeh S. Robotic vs. Laparoscopic Splenectomy in Management of Non-traumatic Splenic Pathologies: A Systematic Review and Meta-Analysis. Am Surg 2021; 88:38-47. [PMID: 33596106 DOI: 10.1177/0003134821995057] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
We aimed to evaluate comparative outcomes of robotic and laparoscopic splenectomy in patients with non-traumatic splenic pathologies. A systematic search of electronic databases and bibliographic reference lists were conducted, and a combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators and limits in electronic databases were applied. Intraoperative and post-operative complications, wound infection, haematoma, conversion to open procedure, return to theatre, volume of blood loss, procedure time and length of hospital stay were the evaluated outcome parameters. We identified 8 comparative studies reporting a total of 560 patients comparing outcomes of robotic (n = 202) and laparoscopic (n = 258) splenectomies. The robotic approach was associated with significantly lower volume of blood loss (MD: -82.53 mls, 95% CI -161.91 to -3.16, P = .04) than the laparoscopic approach. There was no significant difference in intraoperative complications (OR: 0.68, 95% CI .21-2.01, P = .51), post-operative complications (OR: .91, 95% CI .40-2.06, P = .82), wound infection (RD: -.01, 95% CI -.04-.03, P = .78), haematoma (OR: 0.40, 95% CI .04-4.03, P = .44), conversion to open (OR: 0.63; 95% CI, .24-1.70, P = .36), return to theatre (RD: -.04, 95% CI -.09-.02, P = .16), procedure time (MD: 3.63; 95% CI -16.99-24.25, P = .73) and length of hospital stay (MD: -.21; 95% CI -1.17 - .75, P = .67) between 2 groups. In conclusion, robotic and laparoscopic splenectomies seem to have comparable perioperative outcomes with similar rate of conversion to an open procedure, procedure time and length of hospital stay. The former may potentially reduce the volume of intraoperative blood loss. Future higher level research is required to evaluate the cost-effectiveness and clinical outcomes.
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Affiliation(s)
- Pratik Bhattacharya
- Department of General Surgery, 1731Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Liam Phelan
- Department of General Surgery, 156631Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Simon Fisher
- Department of General Surgery, 8947Wye Valley NHS Trust, Hereford County Hospital, Hereford, UK
| | | | - Shahin Hajibandeh
- Department of General Surgery, 8947Wye Valley NHS Trust, Hereford County Hospital, Hereford, UK
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Laparoscopic Splenectomy Versus Open Splenectomy In Massive and Giant Spleens: Should we Update the 2008 EAES Guidelines? Surg Laparosc Endosc Percutan Tech 2019; 29:178-181. [PMID: 30720696 DOI: 10.1097/sle.0000000000000637] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The objective of this study was to derive some useful parameters to define the feasibility of laparoscopic splenectomy (LS) in massive [spleen longitudinal diameter (SLD)>20 cm] and giant spleens (SLD>25 cm). Between December 1996 and May 2017, 175 patients underwent an elective splenectomy. A laparoscopic approach was used in 133 (76%) patients. Massive spleens were treated in 65 (37.1%) patients, of which 24 were treated laparoscopically. In this subset of massive spleens, the results of laparoscopic splenectomy in massive spleens (LSM) and open splenectomy in massive spleens (OSM) were compared. The clinical outcome of a subgroup of patients with giant spleens was also analyzed. The LSM group resulted in significant longer operative times (143±31 vs. 112±40 min; P=0.001), less blood loss (278±302 vs. 575±583 mL; P=0.007), and shorter hospital stay (6±3 vs. 9±4 d; P=0.004). No conversions were experienced in the LSM group, and the morbidity rate was similar in both the LSM and OSM groups (16.6% vs. 20%; P=0.75). When considering the subset of 9 LSM patients and 26 OSM patients with giant spleens, the same favorable tendency of the laparoscopic group as regards surgical conversion, blood loss, and hospital stay was maintained. The laparoscopic approach can be successfully proposed in the presence of massive splenomegaly also after a careful preoperative evaluation of the expected abdominal "working space." In experienced hands, LS is safe, feasible, and associated with better outcomes than open splenectomy for the treatment of massive and giant spleen, with a maximum SLD limit of 31 cm.
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Challenges and Results of Laparoscopic Splenectomy for Hematological Diseases in a Developing Country. Minim Invasive Surg 2018; 2018:4256570. [PMID: 30155296 PMCID: PMC6093075 DOI: 10.1155/2018/4256570] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 07/03/2018] [Accepted: 07/15/2018] [Indexed: 12/16/2022] Open
Abstract
Introduction Though, in developed countries, laparoscopy is now a gold standard for splenectomy, we are lacking in this aspect in the eastern world. Splenectomy has mostly been performed by open surgery in our region. This is our effort to introduce laparoscopic splenectomy in our country. Methods This is a retrospective cohort study done in patients presenting to hematology and surgery department of our hospital who underwent laparoscopic splenectomy for hematological diseases from January 2013 to December 2016. Results There were 50 patients (38 females, 12 males). The diagnoses were idiopathic thrombocytopenic purpura in 31, (steroid/azathioprine-resistant, steroid dependent), hereditary spherocytosis in 9, alpha-thalassemia in 3, beta-thalassemia in 2, autoimmune hemolytic anemia in 4, and isolated splenic tuberculosis in 1. Average platelet counts preoperatively were 62000 ± 11000/mm3 (range 52000-325000/mm3). The mean operative time was 130 ± 49 minutes (range 108-224 min). The mean postoperative stay was 4 ± 2.11 days (range 3-9 days). Laparoscopic splenectomy could be completed in 45 (90%) patients. Conclusion Laparoscopic splenectomy could be successfully contemplated in patients with hematological diseases, especially if spleen is normal or only mildly enlarged, and is an advantageous alternative to open splenectomy. Absence of ideal resources has not limited our progress in minimal access approach.
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Moris D, Dimitriou N, Griniatsos J. Laparoscopic Splenectomy for Benign Hematological Disorders in Adults: A Systematic Review. ACTA ACUST UNITED AC 2018; 31:291-302. [PMID: 28438854 DOI: 10.21873/invivo.11058] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 03/10/2017] [Accepted: 03/13/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Since its introduction in the early 1990s, laparoscopic splenectomy (LS) has gained worldwide acceptance for spleen removal, especially in hematological patients. AIM The present review summarizes the current knowledge and results of LS for the treatment of benign hematological diseases in adults. MATERIALS AND METHODS A MEDLINE/PubMed database research was performed using the terms: "laparoscopic splenectomy" OR "laparoscopy" OR "splenectomy" AND "hematological disorders" OR "hematological disease" OR "hematology" AND "adults" as key words. We set our analysis starting date as January 1st 2010 and the end date as December 31st 2016. We identified 247 relative articles. All the references from the identified articles were searched for relevant information. RESULTS Twenty-seven articles were deemed appropriate for our analysis. LS was found to be feasible and safe in the majority of patients with benign hematological disorders, with a mortality rate ranging from 0% to less than 4% and the postoperative complications rate from 0% to 35.7%. The conversion rate was also very low (4%) and response (complete or partial) was achieved in more than 80% of patients. Lateral approach with four trocars was the most commonly used approach with concommitant cholecystectomy being correlated with increased operative time and morbidity. CONCLUSION Current literature holds that whenever splenectomy is required for the treatment of hematological disorders in adults, a laparoscopic approach should be offered as the gold standard. However, to strengthen the clinical evidence in favor of LS, more high-quality clinical trials on several issues of the procedure are necessary.
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Affiliation(s)
- Demetrios Moris
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, U.S.A.
| | - Nikoletta Dimitriou
- First Department of Surgery, National and Kapodistrian University of Athens, Medical School, Laikon General Hospital, Athens, Greece
| | - John Griniatsos
- First Department of Surgery, National and Kapodistrian University of Athens, Medical School, Laikon General Hospital, Athens, Greece
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Illuminati G, Prezioso G, Pizzardi G, Pasqua R, Perotti B, Amatucci C, De Vincentiis L. Splenic hamartoma associated with abdominal discomfort and pain: Case report. INTERNATIONAL JOURNAL OF SURGERY OPEN 2018. [DOI: 10.1016/j.ijso.2018.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Misiakos EP, Bagias G, Liakakos T, Machairas A. Laparoscopic splenectomy: Current concepts. World J Gastrointest Endosc 2017; 9:428-437. [PMID: 28979707 PMCID: PMC5605342 DOI: 10.4253/wjge.v9.i9.428] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 05/21/2017] [Accepted: 07/24/2017] [Indexed: 02/06/2023] Open
Abstract
Since early 1990’s, when it was inaugurally introduced, laparoscopic splenectomy has been performed with excellent results in terms of intraoperative and postoperative complications. Nowadays laparoscopic splenectomy is the approach of choice for both benign and malignant diseases of the spleen. However some contraindications still apply. The evolution of the technology has allowed though, cases which were considered to be absolute contraindications for performing a minimal invasive procedure to be treated with modified laparoscopic approaches. Moreover, the introduction of advanced laparoscopic tools for ligation resulted in less intraoperative complications. Today, laparoscopic splenectomy is considered safe, with better outcomes in comparison to open splenectomy, and the increased experience of surgeons allows operative times comparable to those of an open splenectomy. In this review we discuss the indications and the contraindications of laparoscopic splenectomy. Moreover we analyze the standard and modified surgical approaches, and we evaluate the short-term and long-term outcomes.
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Affiliation(s)
- Evangelos P Misiakos
- 3rd Department of Surgery, Attikon University Hospital, University of Athens School of Medicine, Attica, 12462 Athens, Greece
| | - George Bagias
- Clinic for General, Visceral and Transplant Surgery, Hannover Medical School, 30625 Hannover, Germany
| | - Theodore Liakakos
- 1st Department of Surgery, National and Kapodistrian University of Athens, Medical School, Laikon General Hospital, 11527 Athens, Greece
| | - Anastasios Machairas
- 3rd Department of Surgery, Attikon University Hospital, University of Athens School of Medicine, Attica, 12462 Athens, Greece
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Vikse J, Sanna B, Henry BM, Taterra D, Sanna S, Pękala PA, Walocha JA, Tomaszewski KA. The prevalence and morphometry of an accessory spleen: A meta-analysis and systematic review of 22,487 patients. Int J Surg 2017; 45:18-28. [DOI: 10.1016/j.ijsu.2017.07.045] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Accepted: 07/07/2017] [Indexed: 12/14/2022]
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Komo T, Hihara J, Kanou M, Kohashi T, Ohmori I, Yoshimitsu M, Ikeda T, Nakashima A, Miguchi M, Yamakita I, Mukaida H, Hirabayashi N, Kaneko M. Splenic hamartoma associated with thrombocytopenia: A case report. Int J Surg Case Rep 2017; 39:172-175. [PMID: 28846949 PMCID: PMC5573780 DOI: 10.1016/j.ijscr.2017.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 08/04/2017] [Accepted: 08/08/2017] [Indexed: 02/06/2023] Open
Abstract
Few cases of splenic hamartomas associated with thrombocytopenia have been reported. Imaging findings in splenic hamartomas are non-specific, variable, and making definitive preoperative diagnosis difficult. Surgery is necessary for diagnosis when malignancy cannot be ruled out. Surgery may also improve symptoms of hypersplenism, including thrombocytopenia.
Introduction Hamartomas are rare, benign tumors of the spleen. Few cases of splenic hamartomas associated with thrombocytopenia have been reported. Presentation of case An asymptomatic 64-year-old man with myelodysplastic syndrome was found to have a splenic tumor. Laboratory tests were significant for thrombocytopenia, with a platelet count of 7.8 × 104/μL. Ultrasonography showed splenomegaly (10.8 × 6.6 cm), and a hypoechoic splenic mass (8.0 × 7.0 cm). Color doppler ultrasound revealed blood flow within the mass, and the mass density was homogeneous on abdominal computed tomography (CT). Contrast-enhanced CT showed heterogeneous enhancement of the splenic mass during the arterial phase. Positron emission tomography (PET)-CT showed no significant fludeoxyglucose (FDG) accumulation within the mass. The differential diagnosis included splenic hamartoma, splenic hemangioma, splenomegaly associated with extramedullary hematopoiesis, and malignant tumor, including solitary splenic metastasis. A laparoscopic splenectomy was performed due to the possibility of malignancy, the presence of thrombocytopenia, and the risk of splenic rupture. The resected specimen showed a localized, well-demarcated, 8.0 × 7.0 cm splenic mass. Histological examination revealed abnormal red pulp proliferation and the absence of normal splenic structures. The patient’s post-operative course was uneventful. His platelet count improved on post-operative day 1 and he was discharged on post-operative day 9. He remained in good health with a normal platelet count one month after surgery. Discussion Making definitive preoperative diagnosis is difficult in splenic hamartomas. Surgery is necessary for diagnosis when malignancy cannot be ruled out. Conclusions Surgery may also improve symptoms of hypersplenism, including thrombocytopenia.
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Affiliation(s)
- Toshiaki Komo
- Department of Gastroenterological Surgery, Hiroshima City Asa Citizens Hospital, Japan
| | - Jun Hihara
- Department of Gastroenterological Surgery, Hiroshima City Asa Citizens Hospital, Japan.
| | - Mikihiro Kanou
- Department of Gastroenterological Surgery, Hiroshima City Asa Citizens Hospital, Japan
| | - Toshihiko Kohashi
- Department of Gastroenterological Surgery, Hiroshima City Asa Citizens Hospital, Japan; Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute Biomedical & Health Sciences, Hiroshima University, Japan
| | - Ichiro Ohmori
- Department of Gastroenterological Surgery, Hiroshima City Asa Citizens Hospital, Japan; Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute Biomedical & Health Sciences, Hiroshima University, Japan
| | - Masanori Yoshimitsu
- Department of Gastroenterological Surgery, Hiroshima City Asa Citizens Hospital, Japan; Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute Biomedical & Health Sciences, Hiroshima University, Japan
| | - Takuhiro Ikeda
- Department of Gastroenterological Surgery, Hiroshima City Asa Citizens Hospital, Japan
| | - Akira Nakashima
- Department of Gastroenterological Surgery, Hiroshima City Asa Citizens Hospital, Japan
| | - Masashi Miguchi
- Department of Gastroenterological Surgery, Hiroshima City Asa Citizens Hospital, Japan; Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute Biomedical & Health Sciences, Hiroshima University, Japan
| | - Ichiko Yamakita
- Department of Gastroenterological Surgery, Hiroshima City Asa Citizens Hospital, Japan
| | - Hidenori Mukaida
- Department of Gastroenterological Surgery, Hiroshima City Asa Citizens Hospital, Japan
| | - Naoki Hirabayashi
- Department of Gastroenterological Surgery, Hiroshima City Asa Citizens Hospital, Japan
| | - Mayumi Kaneko
- Department of Pathology, Hiroshima City Asa Citizens Hospital, Japan
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Abstract
Primary Evans syndrome (ES) is defined by the concurrent or sequential occurrence of immune thrombocytopenia and autoimmune hemolytic anemia in the absence of an underlying etiology. The syndrome is characterized by a chronic, relapsing, and potentially fatal course requiring long-term immunosuppressive therapy. Treatment of ES is hardly evidence-based. Corticosteroids are the mainstay of therapy. Rituximab has emerged as the most widely used second-line treatment, as it can safely achieve high response rates and postpone splenectomy. An increasing number of new genetic defects involving critical pathways of immune regulation identify specific disorders, which explain cases of ES previously reported as "idiopathic".
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Abstract
Autoimmune hemolytic anemia is an acquired autoimmune disorder resulting in the production of antibodies directed against red blood cell antigens causing shortened erythrocyte survival. The disorders can present as a primary disorder (idiopathic) or secondary to other autoimmune disorders, malignancies, or infections. Treatment involves immune modulation with corticosteroids and other agents.
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Affiliation(s)
- Howard A Liebman
- Jane Anne Nohl Division of Hematology, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
| | - Ilene C Weitz
- Jane Anne Nohl Division of Hematology, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Affiliation(s)
- Maurizio Miano
- Clinical and Experimental Haematology Unit; Department of Haematology/Oncology; IRCCS Istituto Giannina Gaslini; Genoa Italy
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Kawanaka H, Akahoshi T, Kinjo N, Harimoto N, Itoh S, Tsutsumi N, Matsumoto Y, Yoshizumi T, Shirabe K, Maehara Y. Laparoscopic Splenectomy with Technical Standardization and Selection Criteria for Standard or Hand-Assisted Approach in 390 Patients with Liver Cirrhosis and Portal Hypertension. J Am Coll Surg 2015. [PMID: 26206637 DOI: 10.1016/j.jamcollsurg.2015.04.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Laparoscopic splenectomy (LS) is still challenging in patients with liver cirrhosis and portal hypertension. This study was designed to establish safe and less invasive LS in patients with liver cirrhosis and portal hypertension. STUDY DESIGN We analyzed 390 patients with liver cirrhosis and portal hypertension, who underwent LS between 1993 and 2013. Patients were divided into 3 time periods; early (1993 to 2004, n = 106); middle (2005 to 2008, n = 159); and late (2008 to 2013, n = 125). During the middle time period, standardized technique for LS and selection criteria for hand-assisted LS were adopted. Patients with spleen volume ≥ 1,000 mL by CT volumetry, large perisplenic collateral vessels, and/or Child-Pugh score ≥ 9, underwent hand-assisted LS. During the late time period, the selection criteria were refined and patients with spleen volume ≥ 600 mL underwent hand-assisted LS. RESULTS Conversion to open splenectomy decreased (10.4% in the early time period, 1.9% in the middle time period, and 3.2% in the late time period, p = 0.004), median blood loss decreased (300g, 87g, and 98g, respectively, p < 0.001), and the success rate of pure LS tended to improve (87.2%, 89.5%, and 98.0%, respectively, p = 0.110). Mortality was 0% in each time period, Clavien-Dindo grade IIIb or more complications tended to decrease (5.7%, 2.5%, and 0.8%, respectively, p = 0.081), and technique-related complications decreased significantly (10.4%, 3.8%, and 2.4%, respectively, p = 0.014). CONCLUSIONS Laparoscopic splenectomy is now a safe and less invasive approach, even in patients with liver cirrhosis and portal hypertension, because of its technical standardization with the refined selection criteria for pure or hand-assisted LS.
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Affiliation(s)
- Hirofumi Kawanaka
- Department of Surgery and Multidisciplinary Treatment, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Clinical Research Institute, National Hospital Organization, Beppu Medical Center, Beppu, Japan.
| | - Tomohiko Akahoshi
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Nao Kinjo
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Norifumi Harimoto
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shinji Itoh
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Norifumi Tsutsumi
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshihiro Matsumoto
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tomoharu Yoshizumi
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ken Shirabe
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshihiko Maehara
- Department of Surgery and Multidisciplinary Treatment, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Bayraktar B, Bayraktar O, Ozemir IA, Kizilkilic E, Ozturk E, Yigitbasi R. Comparison of two minimal invasive techniques of splenectomy: Standard laparoscopy versus transumbilical multiport single-site laparoscopy with conventional instruments. J Minim Access Surg 2015; 11:143-8. [PMID: 25883456 PMCID: PMC4392489 DOI: 10.4103/0972-9941.137756] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Accepted: 12/25/2013] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Laparoendoscopic single-site (LESS) splenectomy which is performed on small number of patients, has been introduced with better cosmetic outcome, less postoperative pain, greater patient satisfaction and faster recovery compared to standard laparoscopy. MATERIALS AND METHODS Thirty six patients were included in the study comparing standard laparoscopic splenectomy (LS, 17 patients) transumbilical multiport splenectomy performed with conventional laparoscopic instruments (TUMP-LS, 19 patients). Two groups of patients were compared retrospectively by means of operation time, intra- and postoperative blood loss, perioperative complications, packed red cell and platelet requirements, lenght of hospitalization, pain scores and patient satisfaction. RESULTS There was no mortality in any of the groups, and no significant differences determined in operative time (P = 0,069), intraoperative blood loss (P = 0,641), patient satisfaction (P = 0,506), pain scores (P = 0,173) and the average length of hospital stay (P = 0,257). Umbilical incisions healed uneventfully and no hernia formation or wound infection was observed during follow-up period (2-34 months). There were no conversions to open surgery. CONCLUSIONS Transumbilical multiport splenectomy performed with the conventional laparoscopic instruments is feasible and could be a logical alternative to classical laparoscopic splenectomy by combining the advantages of single access techniques and standard laparoscopy.
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Affiliation(s)
- Baris Bayraktar
- Department of General Surgery, Istanbul Medeniyet University Goztepe Training and Research Hospital, Kadikoy, Turkey
| | - Onur Bayraktar
- Department of General Surgery, Acibadem Atakent Hospital, Halkali, Turkey
| | - Ibrahim Ali Ozemir
- Department of General Surgery, Istanbul Medeniyet University Goztepe Training and Research Hospital, Kadikoy, Turkey
| | - Ebru Kizilkilic
- Department of Haematology, Maltepe University, Maltepe, Turkey
| | - Erman Ozturk
- Department of Haematology, Istanbul Medeniyet University Goztepe Training and Research Hospital, Kadikoy, Istanbul, Turkey
| | - Rafet Yigitbasi
- Department of General Surgery, Istanbul Medeniyet University Goztepe Training and Research Hospital, Kadikoy, Turkey
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Abstract
Autoimmune hemolytic anemia (AIHA) is a relatively uncommon disorder caused by autoantibodies directed against self red blood cells. It can be idiopathic or secondary, and classified as warm, cold (cold hemagglutinin disease (CAD) and paroxysmal cold hemoglobinuria) or mixed, according to the thermal range of the autoantibody. AIHA may develop gradually, or have a fulminant onset with life-threatening anemia. The treatment of AIHA is still not evidence-based. The first-line therapy for warm AIHA are corticosteroids, which are effective in 70-85% of patients and should be slowly tapered over a time period of 6-12 months. For refractory/relapsed cases, the current sequence of second-line therapy is splenectomy (effective approx. in 2 out of 3 cases but with a presumed cure rate of up to 20%), rituximab (effective in approx. 80-90% of cases), and thereafter any of the immunosuppressive drugs (azathioprine, cyclophosphamide, cyclosporin, mycophenolate mofetil). Additional therapies are intravenous immunoglobulins, danazol, plasma-exchange, and alemtuzumab and high-dose cyclophosphamide as last resort option. As the experience with rituximab evolves, it is likely that this drug will be located at an earlier point in therapy of warm AIHA, before more toxic immunosuppressants, and in place of splenectomy in some cases. In CAD, rituximab is now recommended as first-line treatment.
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Affiliation(s)
- Alberto Zanella
- U.O. Ematologia, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Wilma Barcellini
- U.O. Ematologia, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
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Nyilas R, Székely B, Váróczy L, Simon Z, Árokszállási A, Illés Á, Gergely L. Autoimmune haemolytic anaemia: a review and report of four cases. Orv Hetil 2015; 156:449-56. [DOI: 10.1556/oh.2015.30105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Treatment of autoimmune haemolytic anaemia is still a challenge to clinicians. Even today it may be lethal. Half of the cases are secondary due to an underlying disease, and the others are primary or idiopathic cases. According to the specificity and type of autoantibodies there are warm and cold type forms of autoimmune haemolytic anaemia. The hallmark of the diagnosis is to detect the presence of haemolysis by clinical and laboratory signs and detect the underlying autoantibodies. Treatment of autoimmune haemolytic anaemia is still a challenge to clinicians. We still loose patients due to excessive haemolysis or severe infections caused by immunosuppression. First line treatment is corticosteroids. Other immunosuppressive agents like: cyclophosphamide, azathioprine, cyclosporine or the off label rituximab can be used in case of corticosteroid refractoriness. Splenectomy is a considerable option in selective cases. The authors discuss treatment options and highlight difficulties by presenting 4 cases. Orv. Hetil., 2015, 156(11), 449–456.
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Affiliation(s)
- Renáta Nyilas
- Debreceni Egyetem, Klinikai Központ, Általános Orvostudományi Kar Belgyógyászati Intézet, Hematológiai Tanszék Debrecen Nagyerdei krt. 98. 4032
| | - Borbála Székely
- Debreceni Egyetem, Klinikai Központ, Általános Orvostudományi Kar Belgyógyászati Intézet, Hematológiai Tanszék Debrecen Nagyerdei krt. 98. 4032
| | - László Váróczy
- Debreceni Egyetem, Klinikai Központ, Általános Orvostudományi Kar Belgyógyászati Intézet, Hematológiai Tanszék Debrecen Nagyerdei krt. 98. 4032
| | - Zsófia Simon
- Debreceni Egyetem, Klinikai Központ, Általános Orvostudományi Kar Belgyógyászati Intézet, Hematológiai Tanszék Debrecen Nagyerdei krt. 98. 4032
| | - Anita Árokszállási
- Debreceni Egyetem, Klinikai Központ, Általános Orvostudományi Kar Belgyógyászati Intézet, Hematológiai Tanszék Debrecen Nagyerdei krt. 98. 4032
| | - Árpád Illés
- Debreceni Egyetem, Klinikai Központ, Általános Orvostudományi Kar Belgyógyászati Intézet, Hematológiai Tanszék Debrecen Nagyerdei krt. 98. 4032
| | - Lajos Gergely
- Debreceni Egyetem, Klinikai Központ, Általános Orvostudományi Kar Belgyógyászati Intézet, Hematológiai Tanszék Debrecen Nagyerdei krt. 98. 4032
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Casaccia M, Stabilini C, Gianetta E, Ibatici A, Santori G. Current concepts of laparoscopic splenectomy in elective patients. World J Surg Proced 2014; 4:33-47. [DOI: 10.5412/wjsp.v4.i2.33] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Revised: 05/13/2014] [Accepted: 06/20/2014] [Indexed: 02/06/2023] Open
Abstract
Formerly, open splenectomy represented the conventional surgical treatment for many hematologic diseases. Currently, thanks to permanent technical development and improved skills, also laparoscopic splenectomy (LS) has become a recognized procedure in the treatment of spleen diseases, even in case of splenomegaly. A systematic review was performed with the aim of recalling the proved concepts of this surgical treatment and to browse new devices and techniques and their impact on the surgical outcome. The literature search was initially conducted in PubMed by entering general queries related to LS. The record identified through PubMed searching (n = 1599) was then screened by applying several criteria (study published in English from 1991 to 2013 with abstract available, by excluding systematic/non-systematic reviews, meta-analysis, practice guidelines, case reports, and study involving animals). The articles assessed for eligibility (n = 160) were primarily evaluated by excluding studies that did not report operative time and conversion to open surgery. For articles that treated multiport LS we included only clinical trials with patients > 20. The studies included in qualitative synthesis were 23. The search strategy carried out in PubMed does not allow to obtain an overview of the items returned by the main queries. With this aim we replicated the search in the Web of ScienceTM database, only including the studies published in English in the period 1991-2013 with no other filter/selection criteria. The full records (n = 1141) and cited references returned by Web of ScienceTM were analyzed with the visualization of similarities (VOS) mapping technique. Maps of title/abstract text corpus and bibliographic coupling of authors obtained by applying the VOS approach were presented. If in normal-size or moderately enlarged spleens the laparoscopic approach is unquestionable, in massive splenomegaly the optimal technique remain to be determined. In this setting, prospective randomized trials to compare open vs LS are needed. Between the new techniques of LS the robotic single port splenectomy has the ability to join all the positive aspects of both techniques. Data about this topic are too initial and need to be confirmed with further studies.
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Giza DE, Tudor S, Purnichescu-Purtan RR, Vasilescu C. Robotic Splenectomy: What is the Real Benefit? World J Surg 2014; 38:3067-73. [DOI: 10.1007/s00268-014-2697-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Jaime-Pérez JC, Rodríguez-Martínez M, Gómez-de-León A, Tarín-Arzaga L, Gómez-Almaguer D. Current Approaches for the Treatment of Autoimmune Hemolytic Anemia. Arch Immunol Ther Exp (Warsz) 2013; 61:385-95. [DOI: 10.1007/s00005-013-0232-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2012] [Accepted: 04/26/2013] [Indexed: 11/28/2022]
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Laparoscopic splenectomy: a single center experience. Unusual cases and expanded inclusion criteria for laparoscopic approach. Updates Surg 2013; 65:115-9. [PMID: 23355349 DOI: 10.1007/s13304-013-0197-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Accepted: 01/11/2013] [Indexed: 12/15/2022]
Abstract
Laparoscopic splenectomy (LS) is nowadays considered as the gold standard for most hematological diseases where splenectomy is necessary, but many questions still remain. The aim of this study was to analyze our 5-years experiences consisting of 48 consecutive LS cases in order to assess the optimal approach and the feasibility of the procedure also in malignant diseases and unusual cases such as a primary spleen lymphoma, a big splenic artery aneurism, or a spleen infarct due to a huge pancreatic pseudo-cyst. Forty-eight consecutive patients underwent LS from January 2006 to January 2011 with at least 1-year follow-up. Clinical data and immediate outcome were retrospectively recorded; age, diagnosis, operation time, perioperative transfusion requirement, conversion rate, accessory incision, hospital stay, and complications were analyzed. We had 14 cases of malignant splenic disease, the most frequent malignant diagnosis was non-Hodgkin's lymphoma (12/14, 85.7 %). Splenomegaly (interpole diameter (ID) >20 cm) was observed in 12 cases (25 %) and massive splenomegaly (ID >25 cm) in 3 cases (6.25 %). Conversion to laparotomy occurred in two patients (4.16 %), both associated to uncontrollable bleeding in patients with splenomegaly. Mean operative time was 138 ± 22 min. Mean hospital stay was 4.5 days. Postoperative morbidity rate was 8.8 % for the benign group and 35.7 % in the malignant group. Mortality occurred in 1/48 patients (2.08 %), as a result of overwhelming post-splenectomy infection (OPSI). LS can be performed safely for malignant splenic disease and splenomegaly without any statistically significant increase of morbidity and mortality rate. Conversion rate is increased for massive splenomegaly. LS should be considered as the preferential approach even in patients with malignant disease, splenomegaly, or unusual cases. Massive splenomegaly should be considered as relative contraindication to LS even at experienced centers.
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Pisani Ceretti A, Bislenghi G, Virdis M, Maroni N, Gatti A, Opocher E. Laparoscopic splenectomy for splenic hamartoma: a case report. Case Rep Gastrointest Med 2012; 2012:435802. [PMID: 23125940 PMCID: PMC3485498 DOI: 10.1155/2012/435802] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Accepted: 09/30/2012] [Indexed: 12/11/2022] Open
Abstract
Hamartoma is a rare splenic benign tumor usually accidentally detected as a radiologic finding. Preoperative diagnosis poses a challenge and thus surgery becomes necessary to confirm the clinical suspicion. Laparoscopic splenectomy has gained consensus as a standard surgical procedure particularly for autoimmune hematological diseases. This former experience has allowed this technique to be extended to other splenic pathologies. Here we report a case of total laparoscopic splenectomy for a bulky splenic hamartoma in a young male patient.
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Affiliation(s)
| | - Gabriele Bislenghi
- Department of General Surgery, San Paolo Hospital, University of Milan, Via Cesariano 10, 20154 Milano, Italy
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Koshenkov VP, Pahuja AK, Németh ZH, Abkin A, Carter MS. Identification of accessory spleens during laparoscopic splenectomy is superior to preoperative computed tomography for detection of accessory spleens. JSLS 2012; 16:387-91. [PMID: 23318063 PMCID: PMC3535795 DOI: 10.4293/108680812x13427982377102] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Missed accessory spleen (AcS) can cause recurrence of hematologic disease after splenectomy. The objective of the study was to determine whether detection of AcS is more accurate with preoperative computed tomography (CT) scan or with exploration during laparoscopic splenectomy. METHODS A retrospective chart review was performed for 75 adult patients who underwent laparoscopic splenectomy for various hematologic disorders from 1999 to 2009. Preoperative CT scans were performed in all patients. Patients were followed for recurrence of disease, and a scintigraphy scan was performed in those with suspected missed AcS. RESULTS The most common diagnosis was idiopathic thrombocytopenic purpura in 29 patients (39%), followed by non-Hodgkin's lymphoma in 22 patients (29%). Sixteen AcSs were found during surgery in 15 patients (20%), and preoperative CT scan identified 2 of these. Twelve AcSs were located at the splenic hilum (75%). Nine patients experienced recurrence of their disease, and none had a missed AcS on subsequent scintigraphy. Sensitivity of exploratory laparoscopy for detection of AcS was 100%, and for preoperative CT scan was 12.5% (P = .005). CONCLUSION Exploratory laparoscopy during splenectomy is more accurate than preoperative imaging with CT scan for detection of AcS. Preoperative CT scan misses AcS frequently and should not be obtained for the purpose of its identification.
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Affiliation(s)
- Vadim P Koshenkov
- Department of Surgical Oncology, University of Miami/Jackson Memorial Hospital, Miami, FL 33136, USA.
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23
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Guaglio M, Romano F, Garancini M, Degrate L, Luperto M, Uggeri F, Scotti M, Uggeri F. Is expertise in pediatric surgery necessary to perform laparoscopic splenectomy in children? An experience from a department of general surgery. Updates Surg 2012; 64:119-23. [PMID: 22241167 DOI: 10.1007/s13304-011-0130-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2011] [Accepted: 12/28/2011] [Indexed: 01/28/2023]
Abstract
Splenectomy is frequently required in children for various hematologic pathologic findings. Because of progress in minimally invasive techniques, laparoscopic splenectomy (LS) has become feasible. The objective of this report is to present a monocentric experience and to evaluate the efficacy of and complications observed after laparoscopic splenic procedures in a department of general surgery. 57 consecutive LSs have been performed in a pediatric population between January 2000 and October 2010. There were 33 females and 24 males with a median age of 12 years (range 4-17). Indications were: hereditary spherocytosis 38 cases, idiopathic thrombocytopenic purpura 10, sickle cell disease (SCD) 6, thrombocytopenic thrombotic purpura 2 and non-hodgkin lymphoma 1 case. Patients were operated on using right semilateral position, employing Atlas Ligasure vessel sealing system in 49 cases (86%) and Harmonic Scalpel + EndoGIA in 8. In 24 patients (42.1%), a cholecystectomy was associated. Two patients required conversion to open splenectomy (3.5%). In three cases, a minilaparotomy was performed for spleen removal (5.2%). Accessory spleens were identified in three patients (5.2%). Complications (8.8%) included bleeding (two), abdominal collection (one) and pleural effusion (two). There was no mortality. Average operative time was 128 min (range 80-220). Average length of stay was 3 days (range 2-7). Mean blood loss was 80 ml (range 30-500) with a transfusion rate of 1.7% (one patient). Laparoscopic spleen surgery is safe, reliable and effective in the pediatric population with hematologic disorders and is associated with minimal morbidity, zero mortality, and a short length of stay. Ligasure vessel sealing system shortened operative time and blood loss. On the basis of the results, we consider laparoscopic approach the gold standard for the treatment of these patients even in a department of general surgery.
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Affiliation(s)
- Marcello Guaglio
- Department of Surgery, University of Milan, Bicocca, Monza, Italy
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24
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Fraser SA, Bergman S, Garzon J. Laparoscopic splenectomy: learning curve comparison between benign and malignant disease. Surg Innov 2011; 19:27-32. [PMID: 21719436 DOI: 10.1177/1553350611410891] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
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.
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Affiliation(s)
- Shannon A Fraser
- Department of Surgery, Jewish General Hospital, McGill University, Montreal, Quebec, Canada.
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25
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Unver Dogan N, Uysal II, Demirci S, Dogan KH, Kolcu G. Accessory spleens at autopsy. Clin Anat 2011; 24:757-62. [DOI: 10.1002/ca.21146] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2010] [Revised: 12/05/2010] [Accepted: 01/10/2011] [Indexed: 02/06/2023]
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26
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Abstract
Autoimmune hemolytic anemia is a heterogeneous disease with respect to the type of the antibody involved and the absence or presence of an underlying condition. Treatment decisions should be based on careful diagnostic evaluation. Primary warm antibody autoimmune hemolytic anemias respond well to steroids, but most patients remain steroid-dependent, and many require second-line treatment. Currently, splenectomy can be regarded as the most effective and best-evaluated second-line therapy, but there are still only limited data on long-term efficacy and adverse effects. The monoclonal anti-CD20 antibody rituximab is another second-line therapy with documented short-term efficacy, but there is limited information on long-term efficacy and side effects. The efficacy of immunosuppressants is poorly evaluated. Primary cold antibody autoimmune hemolytic anemias respond well to rituximab but are resistant to steroids and splenectomy. The most common causes of secondary autoimmune hemolytic anemias are malignancies, immune diseases, or drugs. They may be treated in a way similar to primary autoimmune hemolytic anemias, by immunosuppressants or by treatment of the underlying disease.
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Putative predictive parameters for the outcome of laparoscopic splenectomy: a multicenter analysis performed on the Italian Registry of Laparoscopic Surgery of the Spleen. Ann Surg 2010; 251:287-91. [PMID: 20010087 DOI: 10.1097/sla.0b013e3181bfda59] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To identify predictive risk factors for conversion to open splenectomy and postoperative complications in patients undergoing elective laparoscopic splenectomy. BACKGROUND The laparoscopic approach represents the "gold standard" for splenectomy, but its use in the treatment of splenomegaly and malignant disease is controversial. Factors that influence immediate outcome are clinical, anatomic, and pathologic. METHODS Univariate and multivariate analyses of data from the Italian Registry of Laparoscopic Surgery of the Spleen, a multicenter database supported by 25 referral centers. Analysis of data (1993-2007) was performed on a series of patients (n = 676) undergoing elective laparoscopic splenectomy. Demographic data, the operative indications, the surgical technique applied, and any intra- and/or postoperative complications with respect to the patients were assessed. Records were analyzed retrospectively using the Student t test, the chi test, and logistic regression. RESULTS Conversion to open splenectomy was necessary in 39 cases (5.8%). Perioperative deaths occurred in 3 cases (0.4%). There were no complications in 560 patients (82.8%), with a mean hospital stay of 5 days (range, 2-54). Overall, morbidity occurred in 116 patients (17.2%). Multivariate analysis found that the body mass index (P = 0.01) and the presence of hematologic malignancy (P < 0.001) were independent predictors for intraoperative complications and surgical conversion. Spleen longitudinal diameter (P = 0.001) and surgical conversion (P = 0.001) were independent predictors for the occurrence of postoperative complications. CONCLUSIONS This large multicenter study provides evidence for the significance of predictive risk factors for intra- and postoperative complications in laparoscopic splenic surgery. Besides splenic dimensions, other factors like the patient's habitus and the specific underlying hematologic pathology should be recognized by the surgeon to reduce complications and initiate adequate treatment.
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Abstract
This report suggests that single-access laparoscopic splenectomy may be an opportunity to further refine minimally invasive approaches for general surgical disease. Background: Laparoscopic splenectomy has been performed in a standard fashion with 4 to 5 trocars since the early 1990s. Single access laparoscopy has recently gained interest, but single access laparoscopic splenectomy has not been reported to date. It has the possible benefits of less pain, faster recovery, better cosmesis, with theoretically similar costs to that of traditional trocars. Methods: A case is presented and the surgical technique of single access laparoscopic splenectomy is detailed. Results: The patient is an otherwise healthy 24-year-old male with medically refractory idiopathic thrombocytopenic purpura and a platelet count of 15 000. A splenectomy was performed using a single incision laparoscopic technique. The patient was placed in a right lateral decubitus position, and a 2.5-cm left upper quadrant incision was made. A multi-instrument flexible single incision port was used that held 3 trocars. A standard splenectomy was performed through this port. A linear stapler was used to transect the splenic hilum. The procedure time was just over 2 hours. The patient did well, was happy with his incision, and was discharged with a platelet count of 108 000. Conclusions: Single access laparoscopic splenectomy is feasible in select patients and may provide a less painful, better cosmetic result.
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Affiliation(s)
- Preeti Malladi
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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30
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Abstract
Laparoscopic splenectomy (LS) has become the standard approach to splenectomy for benign and malignant hematologic diseases despite a paucity of high-level evidence. The procedure requires expertise in laparoscopic surgical techniques and meticulous dissection of the spleen. Management should include a preoperative radiologic assessment to measure splenic volume and to detect the presence of accessory splenic tissue; the patient should undergo preoperative vaccination against meningococcal, pneumococcal, and Haemophilus influenzae type B infections. Prophylactic antibiotics are used in the perioperative period as well as prophylactic anticoagulation therapy which may be continued long-term in high-risk patients. LS is associated with a low morbidity and mortality; when compared to laparotomy, it reduces the length of hospital stay and improves the quality of life by decreasing postoperative ileus and pain. There are a variety of laparoscopic approaches; the hand-assisted technique and newer coagulating devices have facilitated the operative technique leading to increasing acceptance of laparoscopy as the preferred approach - even in patients with malignant hematologic disease and/or massive splenomegaly.
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Affiliation(s)
- F Borie
- Service de chirurgie digestive B, CHU Carémeau, place de Pr-Debré, 30029 Nimes, France.
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Georgin-Lavialle S, Gossot D, Galicier L, Oksenhendler E, Fieschi C. [Accessory spleens after splenectomy in a patient with common variable immunodeficiency]. Rev Med Interne 2009; 31:41-5. [PMID: 19740575 DOI: 10.1016/j.revmed.2009.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2009] [Revised: 06/03/2009] [Accepted: 06/25/2009] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Blood cells are mainly destroyed in the spleen during autoimmune cytopenia. Amongst the various therapeutic strategies, splenectomy is sometimes necessary during the disease course. However, splenosis or accessory spleens can account for autoimmune cytopenia relapse after initial splenectomy in these patients. CASE REPORT We report an 18-year-old male with common variable immunodeficiency who presented with immunological thrombocytopenia. Splenectomy allowed remission of cytopenia, but a relapse was attributed to splenosis, because Jolly bodies were absent on blood smear. Laparoscopic splenectomy of accessory spleens induced long term remission. A literature review is performed. CONCLUSION Fifteen to 20% of relapses of autoimmune cytopenia treated by splenectomy are related to accessory spleens. Ablation of accessory spleens can cure again the patients, including patients with accompanying common variable immunodeficiency.
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Affiliation(s)
- S Georgin-Lavialle
- Département d'immunologie clinique, hôpital Saint-Louis, Paris cedex 10, France
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32
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Nursal TZ, Ezer A, Belli S, Parlakgumus A, Caliskan K, Noyan T. Reaching proficiency in laparoscopic splenectomy. World J Gastroenterol 2009; 15:4005-8. [PMID: 19705495 PMCID: PMC2731950 DOI: 10.3748/wjg.15.4005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the proficiency level reached in laparoscopic splenectomy using the learning curve method.
METHODS: All patients in need of splenectomy for benign causes in whom laparoscopic splenectomy was attempted by a single surgeon during a time period of 6 years were included in the study (n = 33). Besides demographics, operation-related variables and the response to surgery were recorded. The patients were allocated to groups of five, ranked according to the date of the operation. Operation duration, complications, postoperative length of stay, conversion to laparotomy and splenic weight were then compared between these groups.
RESULTS: There was a significant difference regarding operation times between the groups (P = 0.001). An improvement was observed after the first 5 cases. The learning curve was flat up to the 25th case. Following the 25th case the operation times decreased still further. There was no difference between the groups regarding the other parameters.
CONCLUSION: Unlike the widely accepted “L” shape, the learning curve for laparoscopic splenectomy is a horizontal lazy “S” with two distinct slopes. Privileges may be granted after the first 5 cases. However proficiency seems to require 25 cases.
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Aydin C, Kayaalp C, Olmez A, Tatli F, Kirimlioglu V. Laparoscopic splenectomy with a vessel sealing device. MINIM INVASIV THER 2009; 17:308-12. [DOI: 10.1080/13645700802274612] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Habermalz B, Sauerland S, Decker G, Delaitre B, Gigot JF, Leandros E, Lechner K, Rhodes M, Silecchia G, Szold A, Targarona E, Torelli P, Neugebauer E. Laparoscopic splenectomy: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES). Surg Endosc 2008; 22:821-48. [PMID: 18293036 DOI: 10.1007/s00464-007-9735-5] [Citation(s) in RCA: 167] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2007] [Accepted: 11/23/2007] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- B Habermalz
- Institute for Research in Operative Medicine, University Witten/Herdecke, Witten/Herdecke, IFOM, Ostmerheimer Strasse 200, 51109, Köln, Germany
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Romano F, Gelmini R, Caprotti R, Andreotti A, Guaglio M, Franzoni C, Uggeri F, Saviano M. Laparoscopic Splenectomy: Ligasure Versus EndoGIA: A Comparative Study. J Laparoendosc Adv Surg Tech A 2007; 17:763-7. [DOI: 10.1089/lap.2007.0005] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Fabrizio Romano
- Department of General Surgery, San Gerardo Hospital, University of Milan–Bicocca, Monza, Italy
| | - Roberta Gelmini
- Department of Surgery, Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Roberto Caprotti
- Department of General Surgery, San Gerardo Hospital, University of Milan–Bicocca, Monza, Italy
| | - Alessia Andreotti
- Department of Surgery, Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Marcello Guaglio
- Department of General Surgery, San Gerardo Hospital, University of Milan–Bicocca, Monza, Italy
| | - Chiara Franzoni
- Department of Surgery, Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Franco Uggeri
- Department of General Surgery, San Gerardo Hospital, University of Milan–Bicocca, Monza, Italy
| | - Massimo Saviano
- Department of Surgery, Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
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