Laparoscopic splenectomy for immune thrombocytopenic purpura--long-term result of 40 laparoscopic splenectomies

Splenectomy in haematology–A 5-year single centre experience

OBJECTIVE

To define indications and outcome in haematologic cases undergoing splenectomy.

STUDY DESIGN

A retrospective review of clinical records from consecutive patients having open or laparoscopic removal of the spleen in an academic centre in the private sector. Endpoints were survival, operating time, spleen size, histopathology, requirements for blood or related products complications and average costs.

RESULTS

In the total group (n = 69) there were two deaths. Referrals were for immune thrombocytopaenia (41%), acquired haemolytic anaemia (10%), myeloproliferative syndrome (9%), acute or chronic leukaemia (19%), lymphoma (13%) and a miscellaneous group (8%), comprising cholelithiasis, aplasia or as a diagnostic procedure for otherwise unexplained splenomegaly. An open midline approach was predicated by spleens greater than twice normal size and a history of any bleeding disorder. Here the mean operating time was 83 min (range 40-295) whereas for laparoscopy this was 251 min (range 181-272).

SUMMARY

Careful stratification between the two options facilitated optimum haemostasis and consequently reduced requirement for packed red cells and platelets. Neither underlying pathology nor the choice of treatment influenced morbidity or mortality. Overall local experience is consistent with published international standards of surgical practice. Outcome is directly proportional to the number of each procedure carried out by a single team, observance of consistent protocols for preoperative evaluation and standardized proactive management through the recovery period.

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

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

Laparoscopic accessory splenectomy: the value of perioperative localization studies

BACKGROUND

Laparoscopic splenectomy is an effective treatment for many patients with immune thrombocytopenic purpura (ITP) who fail or relapse after treatment with steroids. Patients with an incomplete response to splenectomy and those who experience recurrence of symptoms should be evaluated for the presence of an accessory spleen. The clinical effectiveness of laparoscopic excision of an accessory spleen after a previous splenectomy for ITP has varied in different studies. Laparoscopic intraoperative identification of an accessory spleen can be difficult. The authors report their experience with laparoscopic accessory splenectomy (LAS) and the use of perioperative localization methods for this procedure.

METHODS

This study reviewed seven consecutive patients who underwent LAS, after initial splenectomy failed to cure ITP, at a tertiary care center between April 9, 2003 and March 31, 2008. Demographics, diagnostic and localization studies, technical success, and the effect on thrombocytopenia were examined. The location of the accessory spleen also was recorded. A novel method for localizing accessory spleen was used. It consisted of preoperative computed tomography (CT)-guided injection of methylene blue at the accessory spleen's site, preoperative intravenous injection of 99m-technetium-labeled, heat-damaged red blood cells, or both. Intraoperatively, the dye was used for visual identification, and the gamma probe was used to aid in locating and confirming the presence of the accessory spleen in the excised specimen.

RESULTS

Seven patients with recurrent ITP after initial failed splenectomy underwent LAS during the study period. Five of these patients had the initial splenectomy performed laparoscopically. All seven patients had successful laparoscopic removal of the accessory spleen based on a final pathologic examination. One patient required the second laparoscopic exploration with perioperative localization after a failed attempt without it. These perioperative localization methods were used in subsequent operations on other patients. These methods were found to be helpful in the intraoperative identification of the accessory spleens. The accessory spleens missed at initial splenectomy were found in unusual locations. Five of the seven patients had sustained improvement in platelet counts after LAS. One patient had a postoperative ileus that resolved with nonoperative management. No other complications or mortality was observed.

CONCLUSION

The LAS procedure after previous splenectomy is feasible and safe. Perioperative localization methods aid in the intraoperative identification of an accessory spleen. Accessory spleens missed at initial splenectomy are generally found in unusual locations. Treatment of recurrent or unresolved ITP with LAS can be effective for some patients.

Long-term follow-up of laparoscopic splenectomy in patients with immune thrombocytopenic purpura

Laparoscopic splenectomy (LS) has been reserved for intractable and relapsing immune thrombocytopenic purpura (ITP) despite medical treatment. With further experiences of LS in ITP, we investigated long term outcomes of LS, especially newly developed morbidities, and tried to find predictive factors for favorable outcomes. From August 1994 to December 2004, fifty-nine patients whose follow-up period was more than 12 months after LS were investigated. After a long-term follow-up (median 54 months, range 12.5-129 months), a complete response (CR) was found in 28 patients (47.5%), partial response in 24 (40.7%), and no response in 7 (11.9%). The relapse rate during follow-up periods was 15.2%. The rapid response group (p=0.017), in which the platelet count increased more than twice of the preoperative platelet count within 7 days after LS, relapsing after medical treatment (p=0.02), and the satisfactory group as the initial result of LS (p=0.001) were significant for predicting CR in univariate analysis, but only the initial satisfactory group was an independent predictive factor for CR in multivariate analysis (p=0.036, relative risk=6419; 95% CI, 1.171-35.190). Infections were the most frequent morbidities during the follow-up period, which were treated well without mortality. LS is a safe and effective treatment modality for ITP. Active referral to surgery might be required, considering complications and treatment results related to long-term use of steroid-based medications.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Handheld gamma probe used to detect accessory spleens during initial laparoscopic splenectomies

BACKGROUND

Preoperative determination of the accessory spleen still is a major factor in the failure of both laparoscopic and conventional techniques. This study aimed to evaluate the practicability and efficacy of a handheld gamma probe in identifying accessory spleens at the initial intervention.

METHODS

This study evaluated 17 patients undergoing laparoscopic splenectomy attributable to benign hematologic disorders. All the patients had preoperative ultrasonography, computed tomography (CT) scan, and nuclear scintigraphic examination of the abdominal cavity to assess the size of the spleen, and to determine the existence of the accessory spleen or spleens. For all the patients, a handheld gamma probe count was used intraoperatively as an adjuvant method to define the presence and location of the accessory splenic tissue. Control nuclear scintigraphic examinations of all the patients were performed 1 month after the surgical procedure.

RESULTS

In two cases, intraoperatively accessory splenic tissue was detected by gamma probe, confirming the preoperative CT findings for the patients. One of these patients had three accessory spleens, although preoperative CT scan showed only two of them. However, by the help of the gamma probe, a third spleen located retroperitoneally was defined. For two patients, laparoscopic exploration and handheld gamma probe count did not identify any accessory splenic tissue, although preoperative CT scan indicated accessory spleens. For detecting accessory splenic tissue, the sensitivities of the studied techniques were 0% for ultrasonography, 75% for CT scan, 0% for preoperative nuclear scintigraphy, 75% for laparoscopic exploration, and 100% for perioperative gamma probe examination.

CONCLUSION

Preoperative imaging methods for accessory spleen determination still have limited benefits because of their limited sensitivity. Thus, the handheld gamma probe technique may be an adjuvant method for laparoscopic exploration ensuring that no accessory splenic tissue is missed during the initial surgical treatment of benign hematologic disorders.

Laparoscopic splenectomy: present status and future perspective

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

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

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

Laparoscopic splenectomy for idiopathic thrombocytopenic purpura

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Determination of intact splenic weight based on morcellated weight

BACKGROUND

Comparisons of splenic size based on splenic weight are difficult after laparoscopic splenectomy, which results in a morcellated specimen. We report the results of a direct comparison between morcellated and intact splenic weights.

METHODS

Porcine spleens were harvested via a midline laparotomy, and an intact splenic weight was obtained, which served as the control. The spleen then was placed into an impermeable retrieval bag and returned to the peritoneal cavity. A separate 10-mm incision was made and the spleen mechanically morcellated with a uterine forceps. This design most faithfully recreates the morcellation process during laparoscopic splenectomy in humans. The aggregate weight of the fragments was compared with intact splenic weight.

RESULTS

Intact and morcellated weights were obtained from 58 porcine spleens. The mean intact splenic weight was 145 g, and the mean morcellated weight was 78 g. For a given morcellated weight achieved at laparoscopic splenectomy, an estimated intact weight can be determined by the following formula: intact weight (g) = morcellated weight (g) x 1.34 + 45.

CONCLUSIONS

On the basis of our calculations, a normal spleen weighing 150 g would have a mean morcellated weight of 78 g, and splenomegaly (intact spleen weighing 250 g or more) would be defined by a morcellated weight exceeding 153 g.

Laparoscopic Splenectomy Review of Five Cases

Laparascopic splenectomy is one of the advanced surgical procedures with indications gradually increasing in hematological diseases. This is a review of five cases operated upon over two years. All were female patients, three with ITP and two with thalassemia. In one with gall bladder stones, laparascopic cholecystectomy was done with splenectomy. The mean operative time was 3 hours and 30 minutes. No case was converted to open technique. There were no intra-operative or post-operative complications with optimum patient response over the six month follow up; no steroids were required for the ITP patients and no more blood transfusions for the thalassemia patients.