Laparoscopic splenectomy: outcome and efficacy for massive and supramassive spleens

Selection of surgical modality for massive splenomegaly in children

BACKGROUND

Laparoscopic splenectomy (LS), a treatment for both benign and malignant splenic diseases, can prove technically challenging in patients with massive splenomegaly. In particular, the optimal surgical modality for treating massive splenomegaly in children remains controversial.

METHODS

The clinicopathologic data of 289 pediatric patients undergoing splenectomy for massive splenomegaly were studied in a retrospective analysis. Accordingly, the patients were classified into the LS surgery group and open splenectomy (OS) surgery group. In the laparoscopy cohort, they were separated into two subgroups according to the method of surgery: the multi-incision laparoscopic splenectomy (MILS) and the single-incision laparoscopic splenectomy (SILS) surgery groups, respectively. Patient demographics, clinical data, surgery, complications, and postoperative recovery underwent analysis. Concurrently, we compared the risk of adverse laparoscopic splenectomy outcomes utilizing univariable and multivariable logistic regression.

RESULTS

The total operation time proved remarkably shorter in the OS group in contrast to the LS group (149.87 ± 61.44 versus 188.20 ± 52.51 min, P < 0.001). Relative to the OS group, the LS group exhibited lowered postoperative pain scores, bowel recovery time, and postoperative hospitalization time (P < 0.001). No remarkable difference existed in post-operation complications or mortality (P > 0.05). Nevertheless, the operation duration was remarkably longer in the SILS surgery group than in the MILS surgery group (200 ± 46.11 versus 171.39 ± 40.30 min, P = 0.02). Meanwhile, the operative duration of MILS and SILS displayed a remarkable positive association with splenic length. Moreover, the operative duration of SILS displayed a remarkable positive association with the age, weight, and height of the sick children. Splenic length proved an independent risk factor of adverse outcomes (P < 0.001, OR 1.378).

CONCLUSIONS

For pediatric patients with massive splenomegaly who can tolerate prolonged anesthesia and operative procedures, LS surgery proves the optimal treatment regimen. SILS remains a novel surgery therapy which may be deemed a substitutional surgery approach for treating massive splenomegaly.

Long-term Results of Splenectomy in Transfusion-dependent Thalassemia

Splenectomy is indicated in transfusion-dependent thalassemia (TDT) only in certain situations. This study aimed to present the effectiveness, complications, and long-term follow-up results of splenectomy in children with TDT. We performed a 30-year single-institution analysis of cases of splenectomy for TDT between 1987 and 2017 and their follow-up until 2021. A total of 39 children (female/male: 24/15) were included. The mean age at splenectomy was 11.2±3.2 years, and their mean follow-up duration after splenectomy was 21.5±6.4 years. Response was defined according to the patient's annual transfusion requirement in the first year postsplenectomy and on the last follow-up year. Complete response was not seen in any of the cases; partial response was observed in 32.3% and no response in 67.6%. Thrombocytosis was seen in 87% of the patients. The platelet counts of 7 (17.9%) patients were >1000 (10 9 /L), and aspirin prophylaxis was given to 22 (56.4%) patients. Complications were thrombosis in 2 (5.1%) patients, infections in 11 (28.2%) patients, and pulmonary hypertension in 4 (10.2%) patients. Our study showed that after splenectomy, the need for transfusion only partially decreased in a small number of TDT patients. We think splenectomy can be delayed with appropriate chelation therapy up to higher annual transfusion requirement values.

Laparoscopic splenectomy for massive splenomegaly: the "splenic no-touch" technique for hilar control by anterior lienorenal approach

PURPOSE

Laparoscopic splenectomy is challenging in patients with massive splenomegaly. The paper describes a technique that overcomes the difficulties one faces while dealing with a massive spleen laparoscopically.

METHODS

We describe our splenic no-touch technique through the anterior lienorenal approach in patients undergoing laparoscopic splenectomy for massive splenomegaly during a 10-year period from January 2010 to January 2020.

RESULTS

During the study period, 14 patients underwent laparoscopic splenectomy for massive splenomegaly. Of these, 13 patients had successful laparoscopic completion of the procedure. One patient required conversion for bleed. There were no pancreatic tail injuries during splenic hilar stapling in any patient. The median operative time was 170 minutes (140-225). The median blood loss was 50 mL (20-600). Two patients required blood transfusions. There was no other morbidity or mortality. The median postoperative stay was 2 days.

CONCLUSION

The splenic no-touch technique using the anterior lienorenal approach for laparoscopic splenectomy is safe and feasible in patients with massive splenomegaly. Preoperative imaging enables optimal port placement and procedure ergonomics.

Primary splenic lymphoma discovered on massive splenomegaly: A case report

INTRODUCTION AND IMPORTANCE

Malignant lymphoma occurs in all the systemic organs. Rarely, large B-cell lymphoma is located in the spleen, making the diagnosis difficult. Herein, we report a patient presenting with massive splenomegaly due to LBCL. Splenectomy was essential to assess the diagnosis and to guide postoperative therapeutics.

PRESENTATION OF A CASE

A 47-year-old woman, with no comorbidities, complained of weight loss and abdominal pain. She had a palpable spleen that extended below the navel. CT scan revealed massive splenomegaly and lymph nodes in the spleen hilum. Splenectomy was performed. Histopathological examination confirmed the diagnosis of large B-cell lymphoma. The postoperative course was uneventful. Three courses of chemotherapy were given. The patient was in remission after a follow-up of 8 months.

DISCUSSION

Massive splenomegaly can be one of the circumstances of the discovery of large B-cell lymphoma. Splenectomy was then essential to confirm the diagnosis and to guide postoperative therapeutics. It also permits reducing hypersplenism and preventing spleen rupture. In patients with high operative risk, splenic needle biopsy should be taken into consideration. Splenic artery embolization before surgery can also be performed in patients having massive splenomegaly to reduce the spleen volume. We highlight the importance of splenectomy to confirm the diagnosis and to relieve the symptoms. Postoperative chemotherapy is essential to prevent relapses.

CONCLUSION

Splenectomy is essential in spleen localized large B-cell lymphoma. It permits to confirm the diagnosis, relieve symptoms, and treatment of underlying hematologic malignancies. Postoperative chemotherapy is essential to prevent relapses.

Application of Real-Time Augmented Reality Laparoscopic Navigation in Splenectomy for Massive Splenomegaly

OBJECTIVES

To evaluate the clinical impact and technical feasibility of augmented reality laparoscopic navigation (ARLN) system in laparoscopic splenectomy for massive splenomegaly.

METHODS

The clinical data of 17 consecutive patients who underwent laparoscopic splenectomy using ARLN (ARLN group) and 26 patients without ARLN guidance (Non-ARLN group) between January 2018 and April 2020 were enrolled. Propensity score matching (PSM) analysis was performed between the patients with and without ARLN guidance at a ratio of 1:1.

RESULTS

Mean intraoperative blood loss was significantly lower in the ARLN-group than in the Non-ARLN group (306.6 ml vs. 462.6 ml, p = 0.047). All the patients in the ARLN-group achieved successful splenic artery dissection, while surgical success was achieved in 12 patients in the Non-ARLN group (p = 0.044). Postoperative hospital stay was significantly longer in the Non-ARLN group (3.8 days vs. 4.5 days, p = 0.040).

CONCLUSIONS

ARLN can provide feasible and accurate intraoperative image guidance, and it could be helpful in the performance of laparoscopic splenectomy for massive splenomegaly.

Efficacy and safety of laparoscopic splenectomy for hypersplenism secondary to portal hypertension after transjugular intrahepatic portosystemic shunt

Background

Laparoscopic splenectomy (LS) being used after Transjugular intrahepatic portosystemic shunt (TIPS) has not been reported. This report aims to explore the feasibility, safety, and potential efficacy of LS after TIPS hypersplenism secondary to portal hypertension (PHT).

Methods

We retrospectively reviewed a series of six patients who underwent LS after TIPS for hypersplenism secondary to PHT between 2014 and 2020. The perioperative data and patients’ clinical outcomes were recorded.

Results

LS was successfully performed in all patients. Hypersplenism was corrected after LS in all six patients. Postoperative prothrombin time, prothrombin activity, international normalized ratio, and total bilirubin showed a trend toward improvement. The preoperative and 1-month postoperative albumin and activated partial thromboplastin levels showed no significant difference. Plasma ammonia level and thromboelastography indicators were ameliorated in two limited recorded patients. No postoperative complications such as subphrenic abscess, portal vein thrombosis, variceal bleeding, hepatic encephalopathy, and liver failure occurred during the 1-month follow-up period.

Conclusion

LS following TIPS is feasible, safe, and beneficial for patients with hypersplenism secondary to PHT. The following LS not only corrects the hypersplenism, but also has the potential to improve liver function.

The Diagnostic Utility of Splenectomy in Idiopathic Splenomegaly

INTRODUCTION

With increasing frequency, patients with idiopathic splenomegaly are referred to surgeons for splenectomy. We evaluated the diagnostic utility of splenectomy and feasibility of a minimally invasive approach in the face of idiopathic splenomegaly.

METHODS

We retrospectively reviewed 68 patients who underwent splenectomy for idiopathic splenomegaly. The primary endpoint was the rate of definitive diagnosis based on final surgical pathology of the removed spleen.

RESULTS

Preoperative workup included a bone marrow biopsy and peripheral blood smear in 93% and 100% of patients, respectively, with none having lymphadenopathy warranting biopsy. Splenectomy provided a definitive diagnosis for 44 (64.7%) patients. Of these, 34 (50%) patients had an underlying malignancy, of which more than half were splenic marginal zone lymphoma. There were 33 (48.5%) laparoscopic, 23 (33.8%) open, 10 (14.7%) laparoscopic converted to open, and two (2.9%) laparoscopic hand-assist cases. Conversion to open was due to splenic size [median craniocaudal length 21.8 cm (cm)] in eight and staple line bleeding at the splenic hilum in two patients. Overall, the laparoscopic approach was completed in patients with a smaller splenic size compared to open (median craniocaudal length 15.2 vs. 26.0 cm, p < 0.0001). The open group had one (1.5%) intra-operative mortality due to uncontrollable hemorrhage. Thirty-day complication rates were similar for laparoscopic and open approaches (p = 0.10).

CONCLUSION

Splenectomy is an effective diagnostic modality in determining a pathologic cause for splenomegaly in this patient population. Laparoscopic splenectomy can be performed safely in appropriate cases with craniocaudal splenic size having the largest influence on surgical approach.

Outcomes of Laparoscopic Splenectomy for Treatment of Splenomegaly: A Systematic Review and Meta-analysis

OBJECTIVES

To review the evidence regarding the outcomes of laparoscopic techniques in cases of splenomegaly.

BACKGROUND

Endoscopic approaches such as laparoscopic, hand-assisted laparoscopic, and robotic surgery are commonly used for splenectomy, but the advantages in cases of splenomegaly are controversial.

REVIEW METHODS

We conducted a systematic review using PRISMA guidelines. PubMed/MEDLINE, ScienceDirect, Scopus, Cochrane Library, and Web of Science were searched up to February 2020.

RESULTS

Nineteen studies were included for meta-analysis. In relation to laparoscopic splenectomy (LS) versus open splenectomy (OS), 12 studies revealed a significant reduction in length of hospital stay (LOS) of 3.3 days (p = <0.01) in the LS subgroup. Operative time was higher by 44.4 min (p < 0.01) in the LS group. Blood loss was higher in OS 146.2 cc (p = <0.01). No differences were found regarding morbimortality. The global conversion rate was 19.56%. Five studies compared LS and hand-assisted laparosocpic splenectomy (HALS), but no differences were observed in LOS, blood loss, or complications. HALS had a significantly reduced conversion rate (p < 0.01). In two studies that compared HALS and OS (n = 66), HALS showed a decrease in LOS of 4.5 days (p < 0.01) and increase of 44 min in operative time (p < 0.01), while OS had a significantly higher blood loss of 448 cc (p = 0.01). No differences were found in the complication rate.

CONCLUSION

LS is a safe approach for splenomegaly, with clear clinical benefits. HALS has a lower conversion rate. Higher-quality confirmatory trials with standardized splenomegaly grading are needed before definitive recommendations can be provided. Prospero registration number: CRD42019125251.

A novel preoperative scoring system to predict technical difficulty in laparoscopic splenectomy for non-traumatic diseases

BACKGROUND

Laparoscopic splenectomy (LS) has been proven to be a safe and advantageous procedure. To ensure that resections of appropriate difficulty are selected, an objective preoperative grading of difficulty is required. We aimed to develop a predictive difficulty grading of LS based on intraoperative complications.

METHODS

A total of 272 non-traumatic patients who underwent LS were identified from a regional medical center. Patients were randomized into a training cohort (n = 222) and a validation cohort (n = 50). Data on demographics, medical and surgical history, operative and pathological characteristics, and postoperative outcome details were collected. Univariate and multivariate analyses of risk factors for intraoperative complications were performed to develop a difficulty scoring system. The Spearman correlation coefficient was used to evaluate the relationship between the difficulty grading score and intraoperative outcomes. Receiver operating characteristic (ROC) curve was used to evaluate the discriminatory power of this scoring system.

RESULTS

Three preoperative factors (spleen weight, esophagogastric varices, and INR) had a significant effect on operative time, bleeding, and conversion to open surgery. We created a difficulty grading score with three levels of difficulty: low (≤ 4 points), medium (5-6 points), and high (≥ 7 points), based on the three preoperative parameters. The correlation was highly significant (P < 0.01) according to Spearman's correlation. The area under the ROC curve was 0.695 (95% CI 0.630-0.755). The external validation showed significant correlations with the present model, with an AUC of 0.725 (95% CI 0.580-0.842). The comparison between our difficulty score and the previous grading system in the 272-patient cohort presented a significant difference in the AUC (0.701, 95% CI 0.643-0.755 vs. 0.644, 95% CI 0.584-0.701, P = 0.0452).

CONCLUSION

The present difficulty scoring system, based on preoperative factors, has good performance in predicting the risk of intraoperative complications of LS and could be helpful for enabling appropriate case selection with respect to the current experience of a surgeon.

Laparoscopic Splenectomy Versus Open Splenectomy In Massive and Giant Spleens: Should we Update the 2008 EAES Guidelines?

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.

Is ITP really a desirable indication for teaching laparoscopic splenectomy? Cohort study

Background: We aimed to evaluate the outcomes of laparoscopic splenectomy (LS) in patients with immune thrombocytopenic purpura (ITP) compared with operated for other indications. Methods: Retrospective cohort study of patients who underwent LS in 1998-2017. Group 1 consisted of 256 patients operated for ITP, and Group 2 of 231 operated for other indications. Primary outcome was procedure difficulty. Secondary was perioperative course (30 days of surgery). Results: Patients in Group 1 were younger (p < .001) with lower ASA (p < .001). The spleen was larger in Group 2 (p < .001). Operative time was longer in Group 2 [110 (80-150) vs. 90 (65-115) min; p < .001)]. Intraoperative blood loss was greater in Group 2 (p < .001). Conversions were higher in Group 2 (4.76 vs. 6.93%, p = .037), as were intraoperative complications (7.79 vs. 3.91%, p = .048). Morbidity, reoperations and mortality did not differ between groups (respectively, p = .899, .697, and .999). Median length of stay was similar (p = .211). Among the first 10 LSs performed by trainees, 63.66% were done for ITP. Later (after 11+ procedures) this dropped to 48.12% (p = .002). Conclusions: ITP may be a preferred indication for surgeons training for LS. Patients' characteristics and intraoperative factors allow an expectation for a relatively easy and hassle-free operation in those patients.

Predicting venous thrombosis in patients undergoing elective splenectomy

BACKGROUND

Venous thrombosis (VT) is an ongoing problem for patients undergoing elective splenectomy. There is limited data evaluating risk factors for VTs. An increase in platelet counts is commonly seen after splenectomy; however, there is a paucity of literature evaluating post-operative platelet counts as a risk factor for VTs in this patient cohort. The objective of this study was to determine the incidence of VT events and to use the platelet count as a predictor for VT development.

METHODS

A retrospective review was undertaken at Brigham Women's Hospital, evaluating elective splenectomy patients between 1997 and 2018. Descriptive statistics were utilized to determine the incidence of VTs. Receiver operator characteristic (ROC) curves were utilized to identify platelet counts that could predict VTs.

RESULTS

Five hundred and twenty splenectomies were included in the study of which 344 were completed in an open manner and 176 were done laparoscopically. The overall incidence of VT events was 6.7% (35/520), 6.1% (21/344) for open, and 8.0% (14/176) for laparoscopic approaches (p = 0.43). ROC curves demonstrated platelet counts to be a good predictor for the development of VTs with an area under the curve (AUC) of 0.77 (95% CI 0.69-0.86; p < 0.001) for all splenectomy patients, 0.70 (95% CI 0.59-0.81; p < 0.001) for those completed in an open manner, and 0.88 (95% CI 0.77-0.99; p < 0.001) for those done laparoscopically. The optimal platelet cutoff was found to be 545 for the overall splenectomy cohort, 457 for the open, and 659 for the laparoscopic cohorts. These platelet counts had a diagnostic accuracy that ranged from 61 to 86% and a negative predictive value (NPV) that ranged from 97 to 99%.

CONCLUSION

These results suggest platelet cutoffs that predict VTs. This information can be used to individualize prophylactic strategies.

Quest for the optimal technique of laparoscopic splenectomy - vessels first or hilar transection?

Introduction

Throughout our 20 years of experience, we have used several different techniques for laparoscopic splenectomy (LS). However, two methods have been used most frequently: "vessels first" and "hilar transection".

Aim

To evaluate the outcomes of LS performed with these two different approaches.

Material and methods

It was an observational study based on retrospective analysis of consecutive patients undergoing LS in a tertiary referral surgical center in the period 1998-2017. We excluded patients with splenic trauma, initially submitted to open surgery, stapled transection of splenic hilum, partial resections of the spleen and other spleen-preserving procedures. Patients were divided into two groups: group 1 ("vessels first") with 188 patients, and group 2 ("hilar transection") with 287 patients.

Results

Mean operative time was shorter (p < 0.001) and blood loss was lower (p < 0.001) in group 2. The need for blood transfusions and the conversion rate were higher in group 1 (p = 0.044 and p = 0.003 respectively). There was no difference in intraoperative adverse events (p = 0.179). Overall postoperative morbidity did not differ between groups (p = 0.081) and we noted mortality of 0.21% (1 patient of group 2). The morbidity rate associated with accidental injury of the pancreatic parenchyma was significantly higher in group 1 (p = 0.028). Median length of hospital stay was 4 days (range: 1-99) and did not differ between groups (p = 0.175).

Conclusions

The "vessels first" technique is associated with longer operative time, higher blood loss and increased risk of conversion. "Hilar transection" is associated with lower incidence of local complications related most likely to accidental injury of the pancreatic tail. In the case of a large caliber of splenic vessels the "vessels first" approach remains the technique of choice.

Laparoscopic versus open splenectomy for splenomegaly: the verdict is unclear

BACKGROUND

The benefits of laparoscopic splenectomy (LS) over open splenectomy (OS) for normal-sized spleens have been well documented. However, the role of laparoscopy for moderate and massive splenomegaly is debated.

METHODS

A retrospective review of patients undergoing elective splenectomy at one institution from 1997 to 2017 was conducted. Moderate and massive splenomegaly was defined as splenic weight of 500-1000 g and greater than 1000 g, respectively. We performed a 1:2 matching of laparoscopic to open splenectomy to control for differences in splenic weight. Differences in perioperative morbidity (infection, thromboembolism, reoperation, readmission), intraoperative factors (blood loss, operative time), length of stay, and mortality were examined.

RESULTS

A total of 491 elective splenectomies were identified. 268 cases were for splenic weights greater than 500 g. After a 1:2 matching of LS:OS, we identified 22 LS and 44 matched OS for moderate splenomegaly. The LS group had longer mean operative times (178 vs. 107 min, p < 0.01), with similar length of stay and blood loss. For massive splenomegaly, 26 LS were identified and matched to 52 OS. LS had longer mean operative times (171 vs. 112 min, p < 0.01) and higher readmission rates (27% vs. 6%, p < 0.05). Other factors and outcomes did not differ between LS and OS for moderate or massive splenomegaly. The conversion rate for LS was higher for massive versus moderate splenomegaly, but was not statistically significant (35% vs. 14%, p = 0.09).

CONCLUSIONS

LS for moderate and massive splenomegaly is associated with longer operative times. Other perioperative outcomes were comparable to OS, with no demonstrated benefits for LS. Although LS may be a feasible approach to moderate and massive splenomegaly, its benefits require further clarification in this patient population.

Preoperative Predictive Factors of Conversions in Laparoscopic Splenectomies

PURPOSE

Presently, laparoscopic splenectomy (LS) is being performed for several indications in clinical practice. However, conversion to open surgery is occasionally required in some patients. We analyzed the intraoperative indications and potential preoperative predictors associated with conversion to open surgery in those presenting for LS.

METHODS

We reviewed 107 patients who underwent LS. We analyzed the surgical indications, spleen size, surgical procedure performed, operative time, rate of and indications for conversions, as well as postoperative complications.

RESULTS

Among the 15 patients (14.0%) who underwent conversion, the conversion was related to the occurrence of a splenic lymphoma in 10, severe bleeding in 3, a lack of anatomic definition in 1, and splenic candidiasis in 1 patient. A comparison between the results obtained in the initial 30 patients (LS performed during the learning curve) and those obtained in the remaining 77 patients, showed that conversions appeared to be related to the experience/expertise of the surgical team excluding patients with splenic malignancies. Conversion was not associated with a higher morbidity-mortality rate, but only a longer length of hospitalization.

CONCLUSIONS

LS is a gold standard procedure when performed by experienced and competent surgeons. However, careful patient selection is recommended before using the laparoscopic approach in those presenting with splenic malignancies.

Laparoscopic Splenectomy for Massive Splenomegaly: Does Size Matter?

BACKGROUND

Laparoscopic splenectomy (LS) has become the most common approach for elective splenectomy, but use of LS for patients with massive splenomegaly (MS) remains controversial. By the 2008 European guidelines, LS for MS (spleen size >20 cm) is generally not recommended.

METHODS

We performed a retrospective analysis of 229 consecutive patients undergoing LS, hand-assist (HALS), and open splenectomy (OS) at our institution from January 1, 1995 to December 2016. Eighty-six (38%) had MS. Patient demographics, comorbidities, operative details, and outcomes were analyzed.

RESULTS

Of 86 patients with MS, 27 (31%) underwent LS, 12 (14%) HALS, and 47 (55%) OS. No significant difference was revealed in patient demographics, comorbidities, American Society of Anesthesiologists class, and spleen size (24.2 cm vs. 23.7 cm vs. 26.6 cm, P = .06). Benign spleen diseases (23), malignancy (57%), and miscellaneous (20%) were indications for surgery. The mean operative time and estimated blood loss in LS, HALS, and OS were 153, 168, and 131 minutes (P = .17) and 100, 162, and 278 mL (P = .24), respectively. Three patients (11.1%) with LS and 1 (8.3%) with HALS required conversion to OS for different reasons (spleen size, technical difficulties, bleeding). Morbidity was similar in all three groups (P = .99). One mortality (1.1%) was noted after OS. Six (7%) patients in the LS group and three (3.5%) in the OS group developed postsplenectomy thrombosis of splenic, mesenteric, and portal veins. Length of stay was shorter in patients with LS and almost reached clinical significance (3.2 vs. 4.9 vs. 5.2 days; P = .06).

CONCLUSION

LS is safe, feasible, and associated with shorter hospital stay than HALS and OS for MS.

Surgery for massive splenomegaly

BACKGROUND

Splenectomy for massive splenomegaly (spleen weight more than 1·5 kg) is commonly believed to be hazardous and to provide poor palliation. The aim of this cohort study was to investigate these issues and examine the many definitions of massive splenomegaly to see whether a better tool might be proposed for preoperative evaluation of these patients.

METHODS

Morbidity and long-term outcomes were assessed in consecutive patients. Relief of pressure-volume-related symptoms and sustainable independence from transfusion in patients were used to ascertain the impact of splenectomy.

RESULTS

Splenectomy was performed in 56 patients, mainly for non-Hodgkin's lymphoma and myeloproliferative diseases. Median spleen weight was 2·3 (range 1·5-6·0) kg. Mortality at 180 days was zero, and the postoperative complication rate was 25 per cent (17 complications in 14 patients). At 2 years, relief of pain was maintained in 33 of 34 patients, with sustained independence from transfusion in 15 of 19 patients with anaemia and nine of 11 with thrombocytopenia. Spleen weight correlated negatively with BMI (P = 0·036).

CONCLUSION

Splenectomy for massive splenomegaly is safe and provides effective palliation. Provisional cut-off points relating to spleen size and BMI help to identify patients benefiting from a splenectomy, even those in a critical state.

Laparoscopic splenectomy is emerging 'gold standard' treatment even for massive spleens

INTRODUCTION

Since its first description by Delaitre and Maignien in 1991, laparoscopic splenectomy (LS) has evolved as treatment of choice for mild-to-moderately-enlarged spleens and for benign haematological disorders. LS is a challenge if massive spleens or malignant conditions necessitate treatment, but we report our method and its feasibility in this study.

METHODS

We undertook a retrospective study of prospectively collected data of all elective splenectomies carried out in our firm of upper gastrointestinal surgeons from June 2003 to June 2012. Only patients opting for elective LS were included in this study.

RESULTS

From June 2003 to June 2012, elective splenectomy was carried out in 80 patients. Sixty-seven patients underwent LS and 13 underwent open splenectomy (OS). In the LS group, there were 38 males and 29 females. Age ranged from 6 years to 82 years. Spleen size in the LS group ranged from ≤11 cm to 27.6 cm. Twelve patients had a spleen size of >20 cm. Weight ranged from 35 g to 2,400 g. Eighteen patients had a spleen weight of 600-1,600 g and eight had a spleen weight >1,600 g. Operating times were available for 56 patients. Mean operating time for massive spleens was 129.73 min. There was no conversion to OS. There were no major complications.

CONCLUSIONS

With improved laparoscopic expertise and advancing technology, LS is safe and feasible even for massive spleens and splenic malignancies. It is the emerging 'gold standard' for all elective splenectomies and has very few contraindications.

Outcomes of Open Splenectomy for Hematologic Malignancy with Splenomegaly: A Contemporary Perspective

Splenectomy for hematologic malignancy (HM) is considered a high-risk procedure, especially in cases of splenomegaly. We analyzed the postoperative course of 82 patients undergoing open splenectomy for HM-related splenomegaly (splenic craniocaudal length 15 cm or greater) in a high-volume center. Primary outcome measures were: perioperative clinical course, rate and severity of postoperative complications (Clavien-Dindo classification), and length of hospital stay. Risk factors analyzed for morbidity and mortality by logistic regression analysis were: gender, age, American Society of Anesthesiologists (ASA)grade, body mass index (BMI), steroidal treatment, preoperative white blood cell count, spleen size, spleen weight, and operative time. The postoperative mortality rate was 1.2 per cent. Only 15.9 per cent of patients required surgical, endoscopic, or radiological intervention after splenectomy (Grade 3 or greater complication). Overall postoperative morbidity rate (as Grade 2 or greater complication) was 52.4 per cent. Surgical complications, mainly bleeding, occurred in 40.2 per cent of patients and 32.9 per cent of patients required blood transfusion. Medical complication rate was 24.4 per cent. Pulmonary disorders were prevalent among medical complications. At multivariate analysis, only ASA score was an independent risk factor for postoperative complications. Open splenectomy can be performed in high-volume centers with low mortality and acceptable morbidity in patients with HM-related splenomegaly, provided that patients at highest risk of postoperative complication (ASA greater than 3) are carefully evaluated.

Hand-assisted versus conventional laparoscopic splenectomy: a systematic review and meta-analysis

BACKGROUND

Hand-assisted laparoscopic splenectomy (HALS) has been widely applied for the resection of larger spleens. We conducted a systematic review and meta-analysis to evaluate the safety and feasibility of HALS compared with conventional laparoscopic splenectomy (CLS).

METHODS

A comprehensive literature search in MEDLINE, EMBASE and Cochrane Library databases was performed to compare clinical outcomes of CLS and HALS. Data were extracted by two independent reviewers. Pooled odds ratios and weighted mean differences with 95% confidence intervals were calculated by meta-analytic software.

RESULTS

Nine non-randomized controlled studies for a total of 463 patients were selected to satisfy the inclusion criteria (HALS versus CLS: 170 versus 293, respectively). The groups were similar in operative time, estimated operative blood loss, length of hospital stay, mortality and intraoperative and post-operative complications. There was a significantly reduced conversion rate in the HALS versus CLS group (odds ratio: 2.98; 95% confidence interval 1.28 to 6.93; P = 0.01). Splenic weights in the HALS group were higher than in the CLS group (weighted mean differences: -0.93; 95% confidence interval -1.74 to -0.11; P = 0.03).

CONCLUSION

HALS may be preferable to CLS for the treatment of patients with enlarged spleens. The result needs to be certified by further random controlled trials.

Hand-assisted laparoscopic splenectomy for a huge splenic vascular lesion with aneurysms in a patient with impending Kasabach-Merritt syndrome-like phenomenon

Splenic vascular lesions are relatively rare and are usually found incidentally. However, the vascular lesions associated with Kasabach-Merritt syndrome, such as hemangioma, can be life-threatening. We herein describe the case of a young adult female patient with a huge splenic vascular lesion, aneurysms of the splenic artery, and increased plasma levels of fibrin/fibrinogen degradation products and D-dimers. Hand-assisted laparoscopic splenectomy was performed, after which the coagulopathy was drastically improved. Minimally invasive surgical intervention such as hand-assisted laparoscopic splenectomy should be considered as the first treatment choice in such a case.

Postoperative outcomes after laparoscopic splenectomy compared with open splenectomy

OBJECTIVE

To evaluate 30-day postoperative outcomes in laparoscopic (LS) versus open splenectomy (OS).

SUMMARY BACKGROUND DATA

LS has generally been associated with lower rates of postoperative complications than OS. However, evidence mainly comes from small studies that failed to adjust for the confounding effects of the underlying indication or clinical condition that may have favored the use of one technique over the other.

METHODS

A retrospective cohort study of patients undergoing splenectomy in 2008 and 2009 using data from the American College of Surgeons National Surgical Quality Improvement Program database (n = 1781). Retrieved data included 30-day mortality and morbidity (cardiac, respiratory, central nervous system, renal, wound, sepsis, venous thromboembolism, and major bleeding outcomes), demographics, indication, and preoperative risk factors. We used multivariate logistic regression to assess the adjusted effect of the splenectomy technique on outcomes.

RESULTS

A total of 874 (49.1%) cases had LS and 907 (50.9%) had OS. After adjusting for all potential confounders including the indication and preoperative risk factors, LS was associated with decreased 30-day mortality [OR (odds ratio): 0.39, 95% CI: 0.18-0.84] and postoperative respiratory occurrences (OR: 0.46, 95% CI: 0.27-0.76), wound occurrences (OR: 0.37, 95% CI: 0.11-0.79), and sepsis (OR: 0.52, 95% CI: 0.26-0.89) when compared with OS. Patients who underwent LS also had a significantly shorter total length of hospital stay and were less likely to receive intraoperative transfusions compared with patients who underwent OS.

CONCLUSIONS

LS is associated with more favorable postoperative outcomes than OS, irrespective of the indication for splenectomy or the patient's clinical status.

Laparoscopic versus open splenectomy: the impact of spleen size on outcomes

BACKGROUND

Although laparoscopic splenectomy (Lap-Spleen) has become the standard surgical approach for normal-sized spleens, open splenectomy (Open-Spleen) is still recommended by many in the setting of splenomegaly. We set out to compare the impact of spleen size on Lap-Spleen and Open-Spleen outcomes using a national database.

STUDY DESIGN

We reviewed the American College of Surgeons' National Surgical Quality Improvement Program database to identify patients who had undergone non-emergency splenectomy during 2005-2010. To evaluate the impact of spleen size on outcomes, we considered patients with diagnoses of splenomegaly and hypersplenism as those having large spleens (Large-Sp group) and those with diagnoses of primary thrombocytopenia and immune thrombocytopenic purpura as having normal spleens (Normal-Sp group). Patients were also categorized based on surgical approach into Lap-Spleen and Open-Spleen groups.

RESULTS

We identified 639 patients in the Large-Sp group and 879 patients in the Normal-Sp group. During 2005-2010 laparoscopy was used in 84.2% of cases in the Normal-Sp group (annual range, 77.8%-90.8%). However, the rate of laparoscopy in the Large-Sp group remained consistently below 50% with an average of 41.8% (annual range, 20%-47%). In the Lap-Spleen group, those with Large-Sp had longer operative time and length of stay and higher blood transfusion and morbidity compared with the Normal-Sp group. However, when looking specifically at the Large-Sp group, patients with Open-Spleen had more transfusion requirements, longer length of stay, and higher morbidity, compared with those with Lap-Spleen.

CONCLUSIONS

Lap-Spleen leads to significant improvement in outcomes. These advantages were believed to be limited to normal-sized spleens, but this study demonstrates that laparoscopy can still be advantageous in patients with splenomegaly. We hope such data encourages wider utilization of laparoscopy in the setting of splenomegaly, especially among surgeons who are experienced with the technique.

A meta-analysis of perioperative outcomes of laparoscopic splenectomy for hematological disorders

BACKGROUND

Due to changes in surgical trends, laparoscopic splenectomy (LS) has become the standard approach for most splenectomies performed for hematological disorders, barring any contraindications. The perioperative outcomes of LS for this indication have not been updated for several years. Controversy still surrounds whether LS should be performed for massive splenomegaly. The purpose of this meta-analysis was to evaluate the perioperative outcomes of laparoscopic splenectomy for hematological disorders.

METHODS

Literature searches were conducted to identify studies comparing the perioperative outcomes of the laparoscopic and open approaches for hematological disorders. The results were pooled by using standard meta-analysis methods.

RESULTS

Thirty-eight studies with a total of 2,914 patients comparing LS to open splenectomy (OS) for hematological disorders were identified. Mortality was low in both groups. The pooled complications of the LS group were significantly fewer than those of the OS group (-0.11, p < 0.001), and the NNT was 9 (95 % confidence interval, 6-20). For massive spleens, a similar result was observed (-0.12, p = 0.009). Accessory spleen resection and blood loss also were comparable between the two approaches. Additionally, LS was associated with longer operative times (57.38 min, p < 0.00001) and shorter hospital stays (2.48 days, p < 0.00001).

CONCLUSIONS

LS is preferred compared to OS, based on lower complication rates and better handling of comorbid conditions. LS is associated with shorter hospital stays but longer operative times. We conclude that LS may be considered an acceptable option even in cases of a massive spleen. To strengthen the clinical evidence, more high-quality clinical trials on different issues are necessary.

True benefit or selection bias: an analysis of laparoscopic versus open splenectomy from the ACS-NSQIP

BACKGROUND

By virtue of the benefits associated with minimally invasive approaches, laparoscopic splenectomy (LS) is believed to have better patient-related outcomes compared to open splenectomy (OS). However, there are limited data directly comparing the two techniques.

METHODS

Patients who underwent elective LS and OS between 2005 and 2010 were identified from the public use file of the ACS-NSQIP database using the Current Procedural Terminology codes 38120 and 38100. Patients who had concomitant procedures were excluded. Because of the nonrandom assignment of surgical techniques, a selection bias could have been responsible for the differences in patient outcomes. Therefore, patient characteristics and comorbidities that were available and could have been potential confounders were compared and regression analysis was performed to determine independent risk factors associated with serious and overall morbidity as well as mortality.

RESULTS

During the study period 1,644 and 851 patients underwent LS and OS, respectively. Compared to patients who underwent LS, patients who had OS had a longer median length of hospital stay (3 vs. 6 days, P < 0.0001) and higher incidences of serious (7 vs. 17 %, P < 0.0001) and overall morbidity (12 vs. 25 %, P < 0.0001) and mortality (1.4 vs. 3.3 %, P = 0.02). However, there were certain significant differences in the characteristics and comorbidities of the patients that could have confounded outcomes. On regression analysis, OS was not associated with higher mortality (OR = 1.43, 95 % CI 0.7-2.7, P = 0.28) but was associated with higher serious morbidity (OR = 1.8, 95 % CI 1.4-2.3, P = 0.001) and overall morbidity (OR = 2.0, 95 % CI 1.6-2.4, P = 0.0001).

CONCLUSION

After adjusting for available confounders, patients who underwent LS had lower morbidity and similar mortality rates. Although certain confounders such as previous surgical history, underlying pathology, and spleen size could still have potentially influenced outcomes, the data suggest that patient outcomes after LS are excellent and when technically possible a minimally invasive technique should be the preferred approach for splenectomy.

Primary versus secondary splenic pedicle dissection in laparoscopic splenectomy for splenic diseases

BACKGROUND

Some areas of laparoscopic splenectomy (LS), such as the approach to splenic pedicle dissection, remain controversial. Here we recommend a technique for dissecting the secondary splenic pedicle vessels on the basis of analysis of retrospective data.

STUDY DESIGN

A retrospective review (April 2006 to October 2011) of databases at 2 institutions identified 136 patients who had undergone LS. In 34 patients with massive splenomegaly, primary splenic pedicle dissection technique (PSPD) had been used in 19 patients and secondary splenic pedicle dissection technique (SSPD) had been used in 15 patients. In 102 patients with normal-sized spleen or moderate splenomegaly, PSPD had been used in 56 patients and SSPD in 46 patients. We compared perioperative and follow-up data.

RESULTS

Laparoscopic splenectomy was completed in 128 patients. In the massive splenomegaly group, the conversion rate was 5.3% for PSPD and 33.3% for SSPD, the complication rate was 42.1% vs 20%, hospital stay was 3.2 ± 2.0 days vs 7.5 ± 3.5 days, and transfusion requirement was 1.1 ± 1.2 U vs 3.2 ± 0.9 U, respectively. However, in the normal or moderate splenomegaly group, except for complications, there were no significant differences between PSPD and SSPD techniques in perioperative findings. In the 2 groups, there were significant differences between the PSPD and SSPD techniques in pancreatic leakage (15.8% vs 0 and 8.9% vs 0, respectively) and postoperative fever (15.8% vs 6.7% and 10.7% vs 2.2%, respectively).

CONCLUSIONS

Secondary splenic pedicle dissection can decrease the incidence of splenic fever and pancreatic leakage and is a valuable technique for LS for normal-sized spleen or moderate splenomegaly. It is not a safe procedure for massive splenomegaly because of the high conversion rate.

Hand-assisted laparoscopic splenectomy is a better choice for patients with supramassive splenomegaly due to liver cirrhosis

BACKGROUND

The current laparoscopic splenectomy (LS) procedure used for cirrhotic patients still has limitations. The aim of our study was to determine a standard according to the splenic size for hand-assisted LS (HALS) in patients with splenomegaly and hypersplenism due to cirrhosis.

PATIENTS AND METHODS

We conducted a retrospectively review of cirrhotic patients who underwent splenectomy between 2008 and 2011. All patients were divided into two groups: Group A (19 patients), in which patients' operations were conducted by HALS, and Group B (20 patients), in which patients were treated with LS. Then the patients in Group A were classified on the basis of the spleen size: massive splenomegaly (Group A1) and supramassive splenomegaly (Group A2). Likewise, so were patients in Group B: massive splenomegaly (Group B1) and supramassive splenomegaly (Group B2). Perioperative outcomes of these patients were compared.

RESULTS

The comparison of HALS and LS based on spleen size demonstrated that in the massive splenomegaly groups, Group A1 and Group B1 had similar estimated blood loss and morbidity, and no transfusion was required in these patients. In the supramassive splenomegaly groups, compared with Group A2, Group B2 had longer operative time, more estimated blood loss, more patients requiring transfusion, and more complications that needed surgical intervention. However, no significant differences were observed in the requirement of analgesia, time of returning to oral intake, and length of hospitalization in these paired groups.

CONCLUSIONS

In cirrhotic patients with supramassive splenomegaly, HALS should be considered because of its safety, feasibility, and effectiveness.