Splenectomy for massive splenomegaly

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.

Does open surgery continue to have a role in elective splenectomy?

BACKGROUND

Since it was first reported in 1991, laparoscopic splenectomy has become the procedure of choice for elective splenectomy. However, doubts have been raised regarding the suitability of patients with splenomegaly (>1 kg) for laparoscopic resection because there have been reports of greater morbidity and higher conversion rates in this group of patients. Since 2000, patients referred to the authors' center for splenectomy with an estimated spleen weight exceeding 1 kg have undergone splenectomy by the open approach.

METHODS

Between September 1995 and April 2005, 95 elective splenectomies were performed by a single surgeon. Operative data were collected prospectively.

RESULTS

A comparison between the operations that took place before 2001 (n = 47) and those performed after 2000 (n = 48) for all sizes of spleen showed significant reductions in conversion rate, operative time, and hospital stay in the later group. As compared with laparoscopic splenectomy (n = 11), open splenectomy (n = 18) for cases of splenomegaly resulted in a significantly shorter operative time, less operative blood loss, and no significant difference in hospital stay.

CONCLUSION

Although laparoscopic splenectomy is the treatment of choice for the majority of patients requiring elective splenectomy, the procedure for patients with significant splenomegaly requires caution and common sense. This study shows that an open splenectomy for these patients significantly reduces operative time and blood loss without increasing morbidity or hospital stay.

Massive splenomegaly is associated with significant morbidity after laparoscopic splenectomy

OBJECTIVE

To evaluate the impact of spleen weight on operative and clinical outcome in a series of 108 consecutive laparoscopic splenectomies.

BACKGROUND

Laparoscopic splenectomy as an alternative to open splenectomy for splenomegaly is regarded as controversial.

METHODS

Patients underwent laparoscopic splenectomy for a range of hematological disorders between November 1992 and February 2000. Multiple linear and logistic regression analysis were used to assess the effect of massive splenomegaly (>1000 g) on perioperative mortality and morbidity, after adjusting for the joint effects of patient age, weight, pre- and postoperative full blood counts, operating time, estimated blood loss, conversion rate, reoperation rate, and duration of hospital stay.

RESULTS

Massive splenomegaly was recorded in 27 of 108 (25%) cases. In this group, splenic weight ranged from 1000 to 4750 g (median, 2500 g). Patients with splenic weight >1000 g had a significantly longer median operating time (170 vs. 102 minutes, P < 0.01), conversion rate (5/27 vs. 4/81, P < 0.05), postoperative morbidity (15/27 vs. 4/81, P < 0.01), and median postoperative stay (5 vs. 3 days, P < 0.01). Multivariate analysis found splenic weight to be the most powerful predictor of morbidity (P < 0.01). Patients with splenomegaly (>1000 g) were 14 times likely to have post operative complications. One patient died 3 days after surgery, following a pulmonary embolus (spleen weight 500 g, mortality 1/108, 0.9%).

CONCLUSIONS

Laparoscopic splenectomy is feasible in patients with giant spleens. However, it is associated with greater morbidity, and the advantages of minimal access surgery in this subgroup of patients are not so clear.

The spleen as a diagnostic specimen: a review of 10 years' experience at two tertiary care institutions

BACKGROUND

Few studies have examined the yield of the diagnostic splenectomy, and the relevance of these studies to the management of patients with unexplained splenomegaly or a splenic mass are limited by low number of cases, the use of selection criteria, and the lack of modern terminology and modern ancillary studies. The current study correlates clinical intent with preoperative clinical and radiologic studies and histologic findings in an assessment of the diagnostic yield of splenectomy.

METHODS

The medical charts, laboratory data, radiologic studies, and pertinent preoperative biopsies on all patients who underwent splenectomy between the years 1986 and 1995 were reviewed, and the clinical intent behind the procedure was correlated with histologic findings.

RESULTS

One hundred twenty-two of the 1280 patients underwent splenectomy for diagnosis, and in 116 patients a specific disease was identified histologically that explained the splenomegaly/splenic mass; malignancy was the most common cause of unexplained splenomegaly or splenic mass, though benign neoplasms and reactive disorders were documented in 25% of the cases. Primary splenic lymphomas were most commonly of large cell B-cell type.

CONCLUSIONS

In the setting of splenomegaly or splenic mass, splenectomy has a high diagnostic yield and usually discloses a malignancy. The clinical category of "primary splenic lymphoma" is biologically heterogeneous, and the diagnosis is usually an intermediate grade (not low grade) lymphoma. The range of conditions associated with splenic masses were quite commonly associated with diseases that are amenable to fine-needle aspiration (FNA) diagnosis, whereas those disorders associated only with splenomegaly included a large fraction of diseases for which FNA may yield either incomplete or misleading results.

Splenectomy in high-risk patients with splenomegaly

BACKGROUND

Splenectomy in patients with massive splenomegaly and hematologic malignancy results in higher morbidity and mortality with primarily palliative benefit.

METHODS

From a 14-year experience with 172 splenectomies, the perioperative course of 39 high-risk patients with splenomegaly was reviewed for comorbidities, indications, complications, and mortality.

RESULTS

Twenty-three males and 16 females with a mean age of 54.2 years and a mean 12.8-day postoperative length of stay were reviewed. Sixteen patients (41%) had 23 major complications related to age (P = 0.047) and operative time (P = 0.01). Intraoperative transfusion was related to splenic size (P = 0.04), and estimated blood loss (P = 0.02) was inversely related to use of splenic artery preligation. Three perioperative deaths were secondary to sepsis and multi-organ system failure.

CONCLUSION

Splenomegaly and comorbidities of the primary disease result in higher morbidity and mortality. Splenic artery preligation is valuable to limit intraoperative blood loss and facilitate splenectomy.

Is splenectomy for massive splenomegaly safe in children?

PURPOSE

To study and analyze the causes, etiology, morbidity, mortality and therapeutic value of splenectomy performed for massive splenomegaly in children.

METHODS

The medical records of 115 children less than 18 years old who had splenectomy for various hematological disorders were reviewed. Twenty of them had splenectomy for massive splenomegaly (spleen weight > or =1,000 g). The records of these were reviewed for age at operation, gender, hematological diagnosis, indication for splenectomy, operative procedures, postoperative complications, and outcome.

RESULTS

Twenty children had splenectomy for massive splenomegaly. There were 16 males and 4 females. Their ages ranged from 4 to 15 years (mean 11.2). Twelve had sickle cell disease, 5 had sickle-beta-thalassemia, 1 had beta-thalassemia major, 1 had thalassemia intermediate, and 1 had chronic myeloid leukemia. The indications for splenectomy were hypersplenism in 11, recurrent splenic sequestration crisis in 8, and splenic abscess in 1. The transfusion requirements in the patient with beta-thalassemia major decreased markedly postoperatively from 18 transfusions/year to only 4 transfusions/year; and for those with hypersplenism, there was a marked improvement in their blood parameters following splenectomy. The patient with thalassemia intermediate required no more blood transfusions. There was no mortality. The immediate postoperative morbidity was 10% for those with massive splenomegaly compared with 6.3% for those with splenomegaly <1,000 g.

CONCLUSIONS

With good perioperative management, splenectomy in children with massive splenomegaly is both safe and effective.

Splenomegaly should not be considered a contraindication for laparoscopic splenectomy

OBJECTIVE

To analyze the impact of spleen size on operative and immediate clinical outcome in a series of 74 laparoscopic splenectomies (LS).

SUMMARY BACKGROUND DATA

LS is gaining acceptance as an alternative to open splenectomy. However, splenomegaly hinders LS, and massive splenomegaly has been considered a contraindication.

METHODS

Between February 1993 and September 1997, 74 patients with a wide range of splenic disorders were treated by laparoscopy and prospectively recorded. They were classified into three groups according to spleen weight: group I, <400 g (n = 52); group II, 400 to 1000 g (n = 9); and group III, >1000 g (n = 13). Age, operative time, number of trocars required, need for perioperative transfusion, spleen weight, conversion rate, mode of spleen retrieval (bag or accessory incision), postoperative analgesia requirements, length of hospital stay, and morbidity rates were recorded.

RESULTS

LS was completed in 69 patients, and the conversion rate was thus 6.7%. Operative time was significantly longer in patients with larger spleens, and an accessory incision was more frequently required. However, there were no significant differences in transfusion rate, length of stay, severe morbidity, or conversion rate.

CONCLUSIONS

Preliminary evaluation of LS for patients with large spleens suggests that it requires a longer operative time, but it is feasible and may potentially offer the same advantages (shorter stay and faster recovery) as it does to those with smaller spleens.

Is splenectomy more dangerous for massive spleens?

BACKGROUND

Reports vary about whether risks are greater for removal of massive (> or = 1500 g) spleens than for smaller (< 1500 g) spleens. We sought to determine the hazards of splenectomy.

METHODS

We reviewed 223 consecutive adults with elective splenectomies for hematologic diseases. Morbidity and mortality rates were combined with published data to create a meta-analysis.

RESULTS

Patients with massive spleens are more likely to have postoperative complications (relative risk [RR] 2.1, 95% confidence interval [CI] 1.3 to 3.4; P = 0.003) and death (RR 4.7, 95% CI, 1.5 to 15.1; P = 0.01). However, when the investigation is restricted to comparable diagnoses, patients with massive spleens do not differ from those with smaller spleens regarding complications (RR 1.4, 95% CI, 0.8 to 2.7; P = 0.3) or mortality (RR 2.1, 95% CI, 0.5 to 9.7; P = 0.4). These observations are confirmed by metaanalysis. Furthermore, multivariate analysis indicts age as a critical risk of complications and death.

CONCLUSIONS

Increased age and underlying illness are the predominant factors associated with morbidity and mortality following splenectomy for hematologic disease. Adjusting for age and diagnosis, spleen size is not a hazard.

A 10-year experience with splenectomy in patients with malignant non-Hodgkin's lymphoma at the Norwegian Radium Hospital

BACKGROUND

Splenectomy is a major surgical intervention that has many implications for patients with malignant non-Hodgkin's lymphoma. As debated during the last few decades, the therapeutic benefit must outweigh the surgical risk and the loss of cellular immunity. A more liberal attitude toward splenectomy developed during the years 1980-1990 at the Norwegian Radium Hospital, as illustrated by the higher number of operations performed in the last 5 years (21 patients) compared to the first 5 years (14 patients).

METHODS

A 10-year retrospective review of the effects and side effects of splenectomy in 35 patients with malignant non-Hodgkin's lymphoma was performed, based on information obtained from the patient files at the authors' institution.

RESULTS

Clinical Stage IV disease was found in 29 patients (83%), and B symptoms in 15 patients (43%). At diagnosis, 26 patients (74%) had splenomegaly, and 8 patients (23%) had primary splenic lymphoma. The surgical mortality was 2.9%, and the morbidity was 37%. Infection was the most common complication, occurring in seven patients (20%). Pneumococcal vaccination had been performed in 13 patients, and the frequency of septicemia and pneumonia tended to be higher during follow-up in unvaccinated patients (not significant). Blood counts returned to normal during the first postoperative month in 18 of 25 patients (72%) who had cytopenia. After splenectomy, a durable remission was achieved in five patients (14%) who did not receive subsequent treatment.

CONCLUSIONS

Splenectomy has the potential to relieve local symptoms, correct cytopenias, and modify the disease course in patients with malignant non-Hodgkin's lymphomas, even in advanced stages, at the cost of an acceptable operative risk.

Splenectomy in patients with undiagnosed splenomegaly

Of splenectomies performed in the Cork Regional Hospital over an 11 year period, ten were undertaken primarily for diagnostic purposes. A definitive histological diagnosis was established in nine patients, seven of whom had lymphoma, two with Hodgkin's disease and five with non-Hodgkin's lymphoma. The weight of the excised spleen in all patients with lymphoma exceeded 1 kg; in all those with a diagnosis other than lymphoma, the spleen weighed less than 1 kg. A majority of patients also had symptomatic improvement from reversal of hypersplenism and from relief of the mechanical pressure effects of an enlarged spleen. Operative mortality was zero. Diagnostic splenectomy is a worthwhile procedure. Most patients will have lymphoma.

Splenectomy for splenomegaly exceeding 1000 grams: analysis of 47 patients

Forty-seven patients who underwent splenectomy for splenomegaly > or = 1000 g were studied retrospectively. There were 29 men and 18 women of mean age 56 (range 19-87) years. Haematological malignancy was the most common disorder (42 patients). The main indications for splenectomy were cytopenia (20 patients), diagnosis (14), initial treatment of leukaemia (eight), pain (four) and spontaneous rupture (one). Thirteen patients underwent an associated surgical procedure. One patient died (mortality rate 2 per cent) and 12 (26 per cent) had postoperative complications. The advantages of splenectomy included histopathological diagnosis in 13 of 14 patients with splenomegaly of unknown origin, effective initial treatment in prolymphocytic and hairy cell leukaemia, definitive relief of pain in all affected patients, and long-term improvement of cytopenia in most.

Splenectomy for hypersplenism in chronic lymphocytic leukaemia and malignant non-Hodgkin's lymphoma

Between 1 January 1980 and 31 July 1988, 62 patients with chronic lymphocytic leukaemia (CLL) or malignant non-Hodgkin's lymphoma (NHL) were splenectomized for splenomegaly and presumed hypersplenism. All patients except one had splenomegaly (mean (s.d.) weight 1585(872) g, range 150-4300 g) and 34 had massive splenomegaly (greater than 1500 g). Forty-nine patients had platelet counts less than 100 x 10(9)/l and 16 patients had anaemia with haemoglobin levels less than 10 g/dl. White cell counts were less than 3 x 10(9)/l in six NHL patients. Fifteen patients had bicytopenia, and three NHL patients had tricytopenia. The selected group of 62 patients underwent splenectomy largely because of failure to respond to medical therapy (39 patients) or inability to tolerate or start adequate chemotherapy because of very low blood counts (11 patients). There was one postoperative death, and a 29 per cent morbidity rate. The response rate was 89 per cent in the first month after splenectomy and 39 patients (63 per cent) had a continuing complete response with a median follow-up of 26 months (range 3-96 months). Twelve patients (10 with CLL) received no further therapy after splenectomy. Seven patients failed to respond and 15 relapsed after splenectomy. These 22 patients could be distinguished on the basis of: (1) lower average preoperative platelet counts (P less than 0.007), postoperative platelet counts (P less than 0.001), and postoperative rise in platelets (P less than 0.004); (2) lower average spleen weight (P less than 0.052); (3) preoperative chemotherapy (P less than 0.044). However preoperative and postoperative platelet counts were the only two variables selected by stepwise regression analysis (P less than 0.05 and P less than 0.01, respectively). Bone marrow failure did not preclude complete response after splenectomy. Long-term survivors emerged from the group of patients with continuing complete response. Of the seven patients who failed to respond, five died with a median survival of 4 months, and of the 15 patients who relapsed after splenectomy, 13 died, with a median survival of 6 months after relapse and 18 months after splenectomy. Thus, splenectomy may be an effective palliation for both CLL and NHL patients with splenomegaly and hypersplenism.

Splenectomy in children with sickle cell disease and thalassemia

A number of Saudi children (31) with sickle cell disease and thalassemia underwent splenectomy: 12 for frequent blood transfusions, 15 for chronic hypersplenism (most of whom were also the recipients of periodic blood transfusion) and 4 for splenic abscess. The mean age of splenectomy was 8.8 years (8 months-18 years). Eight patients had sickle cell disease, 14 beta-thalassemia and 9 had sickle cell thalassemia. All patients received prophylaxis against pneumococcal infection. There was one postoperative death most probably due to sepsis. Sixteen of those who required frequent preoperative blood transfusions needed no more transfusions, while in 7 the need for transfusions decreased significantly (p less than 0.05). For those with hypersplenism, there was a significant postoperative increase in total hemoglobin (P less than 0.001), RBC (P less than 0.001) and platelet counts (p less than 0.02); and a substantial decrease in reticulocyte counts (p less than 0.05). The common post splenectomy complications were chest infection and a brief episode of pyrexia, but without undue morbidity. The study establishes a definite place for splenectomy in a selected population of children with sickle cell disease and thalassemia.

Splenectomy for massive splenomegaly

Twenty-four patients who underwent resection of giant spleen (spleen weight greater than 1.5 kg) have been reviewed to determine the difficulties and benefits of the procedure and, in particular, whether the use of adrenaline injection into the splenic artery could safely reduce technical difficulty. Although morbidity was higher in patients with giant spleens compared with those undergoing resection of smaller spleens the incidence of serious complications was small, and there were no operative or in-hospital deaths. In addition, virtually all patients benefited either on the basis of minimized haematological defect, or palliation of symptoms. Further, the injection of 1 ml of 1:10,000 adrenaline into the splenic artery before splenic mobilization reduced the splenic volume by approximately 40 per cent on average, and resulted in improved exposure, thereby facilitating the procedure.

Metabolism in hematologic malignancy

The authors used isotopic infusions of 6-3H-glucose, U-14C-glucose, and 14C-urea and calorimetry to investigate energy expenditure and metabolic profiles in 19 patients with hematologic malignancy. The average age of these patients was 62 years. Eleven patients had either leukemia or myeloproliferative disorders (LEMP). The rest had lymphoma (LYMPH). The Resting Energy Expenditure (REE) in the LYMPH patients was 1015 +/- 115 kcal/24 hr. This value in the LEMP group was significantly elevated at 2083 +/- 270 kcal/24 hr (P less than 0.025) despite similar weights and ages between the two groups. Net Protein Catabolism (NPC) in the LYMPH group was 82 +/- 29 mg/kg.hr. In contrast the value in the LEMP group was more than doubled at 174 +/- 30 mg/kg.hr (P less than 0.05). Glucose production in the LYMPH group was 14.1 +/- 2.7 mumol/kg.min, and the percent of glucose uptake oxidized in the LYMPH group was 37% +/- 9%. In contrast, glucose production in the LEMP group was significantly elevated (P less than 0.025) at 41.0 +/- 8.1 mumol/kg.min, and the percent of glucose uptake oxidized was significantly depressed (P less than 0.05) at 20% +/- 4% compared with the value in the LYMPH group. Glucose recycling in the LYMPH group was 9.0% +/- 6%. In the LEMP group the rate of recycling was significantly elevated at 60.3% +/- 4.8% (P less than 0.005). The percent suppression of endogenous glucose turnover during glucose infusion in the LYMPH group was 96% +/- 4%. The value for the LEMP patients was significantly less at 30.2% +/- 5% (P less than 0.0005). The serum cortisol concentration in the LYMPH patients was 285 +/- 74 nmol/l. The value in the LEMP patients was significantly higher (P less than 0.005) at 579 +/- 22 nmol/l. The authors concluded that hematologic malignancy is not a homogeneous group when evaluated metabolically. Lymphoma patients are similar metabolically to normal volunteers, but LEMP patients form a distinct group with major abnormalities in both glucose and protein kinetics and energy expenditure.