[What does laparoscopy contribute to explaining fever of unknown origin?]

Patients with Fever of Unknown Origin and Splenomegaly: Diagnostic Value of Splenectomy and Preoperative Risk Factors Suggestive of Underlying Lymphomas

BACKGROUND

We reviewed patients with fever of unknown origin (FUO) and splenomegaly and assessed the diagnostic value of splenectomy and measured risk factors suggestive of an underlying lymphoma.

METHODS

FUO patients (n = 83) who had splenomegaly and underwent splenectomy were enrolled into this retrospective single-center study. Clinical presentations were documented and risk factors suggestive of an underlying lymphoma were tested.

RESULTS

Seventy-four patients (89.2%) had a diagnosis of lymphoma or not after splenectomy and follow-up. Of those (55.4%) diagnosed with lymphoma, 29 had B-cell non-Hodgkin lymphoma and 12 had T-cell non-Hodgkin lymphoma. The remaining 33 (44.6%) had diseases other than lymphoma. Using multivariate logistic analysis, the following 3 independent risk factors were found to be related to a final diagnosis of lymphoma: age (continuous) (HR 1.086; 95% CI 1.033-1.141; p = 0.001), massively enlarged spleen (HR 7.797; 95% CI 1.267-47.959; p = 0.027), and enlarged intra-abdominal lymph nodes (HR 63.925; 95% CI 7.962-513.219; p < 0.001). The calibration of the model was satisfactory (p = 0.248 using the Hosmer-Lemeshow test), and the discrimination power was good (area under the receiver operating characteristic curve 0.925; 95% CI 0.863-0.987).

CONCLUSIONS

Splenectomy is an effective diagnostic procedure for patients with FUO and splenomegaly and lymphoma is a common cause. Older age, a massively enlarged spleen, and enlarged intra-abdominal lymph nodes are risk factors suggesting an underlying lymphoma, and surgery for high-risk patients should be considered.

Diagnostic splenectomy in patients with fever of unknown origin and splenomegaly

OBJECTIVE

To review the diagnostic significance, safety and possible risk factors of splenectomy in fever of unknown origin (FUO) with splenomegaly.

METHODS

The records of 54 patients with FUO and splenomegaly who underwent splenectomy in our hospital in the past 20 years were reviewed retrospectively. Pathologic findings, morbidity, mortality and possible risk factors were analyzed.

RESULTS

Histologic findings included 29 cases of non-Hodgkin lymphoma, 4 cases of spleen tuberculosis, 3 cases of Hodgkin lymphoma, 1 case of Castleman disease and 2 cases of hemophagocytic syndrome. An etiologic diagnosis was made in 72.2% of the patients undergoing splenectomy. Surgical complications occurred in 25.9% of the patients and 1-month operative mortality was 16.7%. The mortality rate 1 month after surgery was significantly associated with serous cavity effusion (46.2 vs. 7.5%, p = 0.006) and spleen weight >1,500 g (50.0 vs. 9.1%, p = 0.007). There was no significant difference in the mortality rate of the patients with or without jaundice, pancytopenia, elevated serum alanine aminotransferase (ALT) or elevated LDH (p > 0.5). Multivariate analysis revealed serous cavity effusion (odds ratio 21.0; 95% confidence interval 2.2-212.8; p = 0.01) and spleen weight >1,500 g (odds ratio 18.0; 95% confidence interval 1.9-173.8; p = 0.01) as independent risk factors.

CONCLUSION

Splenectomy is an effective diagnostic modality for FUO presenting with splenomegaly. The presence of serous cavity effusions and spleen weight >1,500 g identifies patients with the greatest operative risk.

Laparoscopic surgery and its potential for medical complications

Laparoscopic surgery is very popular among physicians and patients because this technique is associated with safety, shorter hospital stay, early return to normal activity, and cosmetic acceptance of the operative scar. Although the procedure involves minimal invasion and tissue damage, it has potentially serious complications, including cardiopulmonary effects that result mainly from hypercarbia and raised intraabdominal pressure caused by pneumoperitoneum. Absorbed carbon dioxide from the peritoneal cavity tends to cause acidosis. Leakage of the gas into tissue spaces may induce subcutaneous emphysema, pneumothorax, pneumomediastinum and pneumopericardium. Cardiac effects include arrhythmias, hypotension, cardiac arrest, gas embolism, pulmonary edema, and myocardial ischemia or infarction. Some of these effects, though rare, are serious and potentially fatal. Physicians should anticipate these problems in their patients undergoing laparoscopic procedures. This review discusses the technique of and physiologic considerations in laparoscopic surgery as well as its potential complications.