Indications for and efficacy of splenectomy for haematological disorders

Elective splenectomy in patients with non-Hodgkin lymphoma: Does the size of the spleen affect surgical outcomes?

Backgrounds/Aims

Splenectomy in patients with non-Hodgkin lymphoma (NHL) is performed to relieve abdominal symptoms, treat hypersplenism or confirm diagnosis. Excision of a very large spleen is technically challenging and data on outcomes of surgery in patients with NHL are scanty. The aim of study was to evaluate the impact of spleen size on the surgical outcome of splenectomy in patients with NHL.

Methods

Patients with NHL who underwent splenectomy, between 2006 and 2017, were included and divided into two groups: group 1, spleen ≤ 20 cm; group 2, spleen > 20 cm. Surgical approach, operative time, postoperative morbidity, mortality, hospital stay and re-admission rates were retrospectively compared between groups. Non-parametric data were evaluated with the Mann-Whitney U test. Differences in frequencies were analyzed with Fisher's exact test.

Results

Sixteen patients were included (group 1, 6; group 2, 10). Laparoscopy was successful in three patients of group 1, none of group 2 (p = 0.035), the intraoperative time did not differ significantly between groups. One patient in each group developed postoperative complications. The patient in group 1 died of pneumonia. Median length of stay was 8 days (range, 3-16 days) for group 1, 5.5 days (range, 3-10 days) for group 2, showing no significant difference between the two groups. No patient was readmitted to hospital.

Conclusions

Spleen size does not affect the outcome of splenectomy in patients with NHL. If a mini-invasive approach is to be chosen, laparoscopy may not be feasible when the spleen size is > 20 cm.

Role of Partial Splenectomy in Hematologic Childhood Disorders

The spleen is a secondary lymphoid organ that belongs to the reticular-endothelial system, directly connected to blood circulation. The spleen is greatly involved in the immune response, especially against capsulated bacteria. Splenectomy plays a fundamental role in the treatment of numerous pediatric hematologic disorders. Taking into account all the possible complications (especially infections) linked to this procedure, alternatives to total splenectomy have been sought. Partial splenectomy has been proposed as a treatment that allows the reduction of infectious risk. This approach has proven safe and feasible in most patients, but multicentric and prospective studies are necessary to more accurately define the indications for performing partial splenectomy. However, vaccinations and antibiotic prophylaxis remain fundamental for preventing serious infections, even in the case of partial splenectomy. We review anatomical and functional properties of the spleen, with a focus on medical or surgical indications to splenectomy, aiming to give practical educational information to patients and their families after splenectomy. Furthermore, we discuss the feasibility of partial splenectomy in children with hematologic diseases who require splenectomy.

Indications for Surgery in Non-Traumatic Spleen Disease

The spleen is the largest lymphatic organ that acts as a site for filtration of foreign particles from the blood, erythropoiesis and hematopoiesis. Splenectomy represents the first line of treatment for spontaneous splenic rupture, abscesses, cysts, tumours. It is also used to control hereditary, autoimmune, and myeloproliferative disorders alternatively. Numerous diseases have been indicated for surgery in non-traumatic spleen diseases such as non-traumatic spleen rupture, immune thrombocytopenic purpura (ITP), haemolytic anaemias, Felty’s syndrome, Hodgkin’s and non-Hodgkin’s lymphoma among others. This result because the spleen is the most affected lymphoid organ following its overactivity that occurs during sequestration of dead or disrupted RBCs and lymphocytes. Abdominal pain is one of the major manifestations of splenomegaly, and can also designate other associated complications such as liver cirrhosis or bacterial endocarditis. As a secondary lymphoid organ, the spleen is more often an organ for lymphomas. Although splenectomy is a curative alternative in a few diseases, it is a complementary means of treating several other diseases. Splenectomy is a salvage therapy used when other therapeutic alternatives fail. Despite its indication in numerous diseases, controversies are still inbound of its use.

Evans syndrome: clinical perspectives, biological insights and treatment modalities

Evans syndrome (ES) is a rare and chronic autoimmune disease characterized by autoimmune hemolytic anemia and immune thrombocytopenic purpura with a positive direct anti-human globulin test. It is classified as primary and secondary, with the frequency in patients with autoimmune hemolytic anemia being 37%–73%. It predominates in children, mainly due to primary immunodeficiencies or autoimmune lymphoproliferative syndrome. ES during pregnancy is associated with high fetal morbidity, including severe hemolysis and intracranial bleeding with neurological sequelae and death. The clinical presentation can include fatigue, pallor, jaundice and mucosal bleeding, with remissions and exacerbations during the person’s lifetime, and acute manifestations as catastrophic bleeding and massive hemolysis. Recent molecular theories explaining the physiopathology of ES include deficiencies of CTLA-4, LRBA, TPP2 and a decreased CD4/CD8 ratio. As in other autoimmune cytopenias, there is no established evidence-based treatment and steroids are the first-line therapy, with intravenous immunoglobulin administered as a life-saving resource in cases of severe immune thrombocytopenic purpura manifestations. Second-line treatment for refractory ES includes rituximab, mofetil mycophenolate, cyclosporine, vincristine, azathioprine, sirolimus and thrombopoietin receptor agonists. In cases unresponsive to immunosuppressive agents, hematopoietic stem cell transplantation has been successful, although it is necessary to consider its potential serious adverse effects. In conclusion, ES is a disease with a heterogeneous course that remains challenging to patients and physicians, with prospective clinical trials needed to explore potential targeted therapy to achieve an improved long-term response or even a cure.

Clinical, Anatomical, and Pathological Grading Score to Predict Technical Difficulty in Laparoscopic Splenectomy for Non-traumatic Diseases

BACKGROUND

We aimed to develop a grading system based on preoperative parameters that would predict surgical difficulty and morbidity in elective laparoscopic splenectomy.

STUDY DESIGN

We retrospectively assessed morbidity in 439 patients who underwent laparoscopic splenectomy for benign and malignant disorders between 1993 and 2013. Medical and surgical records were reviewed and analyzed. We compared preoperative data concerning demographic, clinical, pathological, anatomical, laboratory, and radiological factors with three surgical outcomes: operative time, intraoperative bleeding, and surgical conversion. Univariate and multivariate analyses were performed to identify statistically significant variables. A logistic regression model was used to identify determinant variables and to compose a predictive score. External validation of the score was performed using an independent cohort of 353 patients.

RESULTS

Four preoperative parameters (age, male sex, type of pathology, and spleen size based on final spleen weight) were significantly related with operative time, operative bleeding, and conversion to open surgery. Using these results, we developed a classification system with three levels of difficulty: low (≤4 points), medium (4.5-5.5 points), and high (≥6 points), based on the four preoperative parameters. The correlation was highly significant (p = <0.001) according to Spearman's correlation. The area under the ROC curve was 0.671 (95 % CI 0.596-0.745). The external validation showed significant correlations with the present model.

CONCLUSIONS

The grading score described here is simple to calculate from the physical examination, laboratory tests, and US or CT images, and we believe it could be useful to preoperatively assess the technical complexity of laparoscopic splenectomy.

Surgical complications of extraspinal tumors in the cervical spine: a report of 110 cases and literature review

PURPOSE

To assess the safety of surgical intervention for extraspinal tumors in the cervical spine.

METHODS

110 consecutive patients were enrolled and followed-up at least 12 months or until death. The complication rates and risk factors were documented and analyzed.

RESULTS

The quality of life in the surviving patients was significantly improved. The overall local recurrence rate was 17.3%. Twenty percent of patients developed distant metastasis. The perioperative mortality rate (30 days after surgery) was 0.9%. The complication related mortality was 1.8%. The rates of overall complication and major complication were 41.8% and 20.9%, respectively. The independent predictors for overall complications were Karnofsky score <60, multisegmental resection, and operation time >3 h. The independent predictors of major complications were comorbidity, tumor location at C1-C2, and combined approach.

CONCLUSIONS

Surgery for cervical spine tumor could improve the quality of life, though it might be accompanied with high morbidity and mortality. It is a highly demanding procedure; however, it can be performed to an acceptable degree of safety.

Fatal pulmonary embolism following splenectomy in a patient with Evan's syndrome: case report and review of the literature

Background

Evans syndrome (ES) is a rare disease characterized by simultaneous or sequential development of autoimmune hemolytic anemia (AIHA) and immune thrombocytopenia (ITP) with or without immune neutropenia. Splenectomy is one of the treatment options for disease refractory to medical therapy. Venous thromboembolism (VTE) following splenectomy for hematological diseases has an incidence of 10%.

Case presentation

Here we describe a case report of a young patient hospitalized with severe hemolytic anemia with Hgb 4.8 g/dl. He developed thrombocytopenia with platelet nadir of 52,000/mm³, thus formally diagnosed with ES. He failed standard medical therapy. He underwent splenectomy and had a fatal outcome. Autopsy confirmed the cause of death as pulmonary embolism (PE).

Conclusions

This case report and review of the literature highlight important aspects of the association between VTE, splenectomy, and hemolytic syndromes including the presence of thrombocytopenia. The burden of the disease is reviewed as well as various pathophysiologic mechanisms contributing to thromboembolic events in these patients and current perioperative prophylactic anticoagulation strategies. Despite an advancing body of literature increasing awareness of VTE following splenectomy, morbidity and mortality remains high. Identifying high risk individuals for thromboembolic complications from splenectomy remains a challenge. There are no consensus guidelines for proper perioperative and post-operative anti-coagulation. We encourage future research to determine which factors might be playing a role in increasing the risk for VTE in real time with hope of forming a consensus to guide management.

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.

Splenic irradiation for splenomegaly: A systematic review

Splenic irradiation (SI) is a palliative treatment option for symptomatic splenomegaly (i.e. for pain, early satiety, pancytopenia from sequestration) secondary to hematologic malignancies and disorders. The purpose of the current article is to review the literature on SI for hematologic malignancies and disorders, including: (1) patient selection and optimal technique; (2) efficacy of SI; and (3) toxicities of SI. PICOS/PRISMA methods are used to select 27 articles including 766 courses of SI for 486 patients from 1960 to 2016. The most common cancers treated included chronic lymphocytic leukemia and myeloproliferative disorders; the most common regimen was 10Gy in 1Gy fractions over two weeks, and 27% of patients received retreatment. A partial or complete response (for symptoms, lab abnormalities) was obtained in 85-90% of treated patients, and 30% were retreated within 6-12months. There was no correlation between biologically equivalent dose of radiation therapy and response duration, pain relief, spleen reduction, or cytopenia improvement (r2 all <0.4); therefore, lower doses (e.g. 5Gy in 5 fractions) may be as effective as higher doses. Grade 3-4 toxicity (typically leukopenia, infection) was noted in 22% of courses, with grade 5 toxicity in 0.7% of courses. All grade 5 toxicities were due to either thrombocytopenia with hemorrhage or leukopenia with sepsis (or a combination of both); they were sequelae of cancer and not directly caused by SI. In summary, SI is generally a safe and efficacious method for treating patients with symptomatic splenomegaly.

Bacterial Infections Following Splenectomy for Malignant and Nonmalignant Hematologic Diseases

Splenectomy, while often necessary in otherwise healthy patients after major trauma, finds its primary indication for patients with underlying malignant or nonmalignant hematologic diseases. Indications of splenectomy for hematologic diseases have been reducing in the last few years, due to improved diagnostic and therapeutic tools. In high-income countries, there is a clear decrease over calendar time in the incidence of all indication splenectomy except nonmalignant hematologic diseases. However, splenectomy, even if with different modalities including laparoscopic splenectomy and partial splenectomy, continue to be a current surgical practice both in nonmalignant hematologic diseases, such as Immune Thrombocytopenic Purpura (ITP), Autoimmune Hemolytic Anemia (AIHA), Congenital Hemolytic Anemia such as Spherocytosis, Sickle Cell Anemia and Thalassemia and Malignant Hematological Disease, such as lymphoma. Today millions of people in the world are splenectomized. Splenectomy, independently of its cause, induces an early and late increase in the incidence of venous thromboembolism and infections. Infections remain the most dangerous complication of splenectomy. After splenectomy, the levels of antibody are preserved but there is a loss of memory B cells against pneumococcus and tetanus, and the loss of marginal zone monocytes deputed to immunological defense from capsulated bacteria. Commonly, the infections strictly correlated to the absence of the spleen or a decreased or absent splenic function are due to encapsulated bacteria that are the most virulent pathogens in this set of patients. Vaccination with polysaccharide and conjugate vaccines again Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis should be performed before the splenectomy. This practice reduces but does not eliminate the occurrence of overwhelming infections due to capsulated bacteria. At present, most of infections found in splenectomized patients are due to Gram-negative (G-) bacteria. The underlying disease is the most important factor in determining the frequency and severity of infections. So, splenectomy for malignant diseases has the major risk of infections.

Outcomes following splenectomy in patients with myeloid neoplasms

BACKGROUND AND OBJECTIVES

Myeloid neoplasms are classified into five major categories. These patients may develop splenomegaly and require splenectomy to alleviate mechanical symptoms, to ameliorate transfusion-dependent cytopenias, or to enhance stem cell transplantation. The objective of this study was to determine which clinical variables significantly impacted morbidity, mortality, and survival in patients with myeloid neoplasms undergoing splenectomy, and to determine if operative outcomes have improved over time.

METHODS

The records of all patients with myeloid neoplasms undergoing splenectomy from 1993 to 2010 were retrospectively reviewed.

RESULTS

Eighty-nine patients (n = 89) underwent splenectomy for myeloid neoplasms. Over half of patients who had symptoms preoperatively had resolution of their symptoms post-splenectomy. The morbidity rate was 38%, with the most common complications being bleeding (14%) or infection (20%). Thirty-day mortality rate was 18% and median survival after splenectomy was 278 days. Decreased survival was associated with a diagnosis of myelodysplastic syndrome/myeloproliferative neoplasm, anemia, abnormal white blood cell count, and hypoalbuminemia. Patients who underwent stem cell transplantation did not show an increased risk for morbidity or mortality.

CONCLUSIONS

Patients with myeloid neoplasms have a poor prognosis after splenectomy and the decision to operate is a difficult one, associated with high morbidity and mortality.

Splenectomy results from an 18-year single centre experience

INTRODUCTION

Splenectomy is performed both as an emergency procedure following trauma and electively when indicated for haematological disease. Postsplenectomy patients receive immunotherapy vaccines and continuous antibiotic prophylaxis. Despite well documented concerns regarding complications and overwhelming postsplenectomy infection (OPSI) risk, there appears to be only a small amount of consistent data on long-term outcomes. The authors therefore present their postsplenectomy patient outcomes over an 18-year follow-up period.

METHODS

One hundred and five postsplenectomy patients operated on between 1991 and 2011 were identified from pathology codes and their case notes were reviewed. Eighty-eight patients (83.8%) were followed up for at least five years or until death.

RESULTS

Of the 105 splenectomy patients (58 were male), the median age was 54 years (range: 10-87 years) and the median survival was 80 months. Operative morbidity and mortality rates were 21.0% (n=22) and 8.6% (n=9) respectively. Thirty-seven patients (27 males) underwent an emergency splenectomy with a median age, operative morbidity and operative mortality of 51 years, 13.5% and 21.6% (n=8) respectively. This compares with 68 patients (35 males) undergoing an elective splenectomy with the same parameters respectively of 55 years, 25.0% and 1.5% (n=1). Excluding operative deaths, multivariate analysis revealed age (p=0.002) as the only significant and independent prognostic indicator. Immunotherapy and antibiotic prophylaxis rates for the emergency cohort were 92.6% and 88.9% respectively, compared with 90.2% and 93.4% for the elective cohort. At follow-up, no patients were readmitted with OPSI.

CONCLUSIONS

Over an 18-year period and a diverse indication for splenectomy, we have identified no evidence of OPSI. However, a significant operative mortality was associated with traumatic splenic rupture.

Laparoscopic splenectomy: perioperative management, surgical technique, and results

Since their introduction in the early 1990s, minimally invasive techniques have gained widespread acceptance because of the significant benefits that patients are able to experience. Some of these benefits include reduced postoperative pain, earlier return to normal activity, and improved cosmesis when compared with open surgery. For these reasons, since its first description by Delaitre and Maignien in 1991, laparoscopic splenectomy (LS) has been increasingly utilized for a safe surgical removal of the spleen with nearly equivalent or superior short- and long-term outcomes when compared with the open approach. In this technical report, we aim to describe our preoperative and postoperative management of patients undergoing LS and to illustrate our preferred surgical technique, its rationale, and our results.