[Spleen injuries during colorectal carcinoma surgery. Effect on the early postoperative result]

Splenectomy during cytoreductive surgery in epithelial ovarian cancer

Background

The aim of the study was to analyze the underlying causes and application of splenectomy in patients with epithelial ovarian cancer (EOC) and assess its effect on the surgical satisfaction and prognosis of these patients.

Materials and methods

Clinical data of patients with ovarian epithelial cancer treated with cytoreductive surgery were collected from 2000 to 2015 at Peking Union Medical College Hospital.

Results

A total of 2,882 patients underwent ovarian cancer cytoreductive surgery at Peking Union Medical College Hospital between 2000 and 2015, of whom 38 (1.3%) also underwent spleen resections. Of these 38 patients, one underwent splenectomy due to intraoperative trauma, whereas the remaining 37 patients underwent splenectomy due to splenic metastasis. Among these 37 patients, 27 underwent resection due to direct tumor spread in the spleen and 10 underwent resection due to hematogenous metastasis. For subsequent first-line chemotherapy, 22 patients were platinum sensitive and 15 were platinum resistant. Overall median survival and the postsplenectomy median survival time were 106 and 75 months, respectively. The overall median survival in secondary cytoreduction was 101 months compared with 20.3–56 months in literature reviews. Univariate analysis revealed that platinum resistance to first-line chemotherapy, suboptimal surgery, and hematogenous metastasis influenced survival. Chemosensitivity and residual disease were identified as independent risk factors by multivariate analysis. We also report a literature review concerning the efficacy and safety of splenectomy during cytoreductive surgery in EOC.

Conclusion

Approximately 1.3% of patients with EOC underwent spleen resection during initial cytoreductive surgery and more often during recytoreductive surgery. Tumor involvement was the most common indication for splenectomy, and rare patients underwent splenectomy due to intraoperative trauma. Most patients achieved optimal surgery, and thus their overall survival and postsplenectomy survival rates were longer. The prognosis of patients was closely related to chemosensitivity and presence of residual tumors. Splenectomy should be attempted in all patients with splenic involvement in whom optimal cytoreductive surgery was achievable, no matter in primary or secondary cytoreduction.

Iatrogenic spleen injury risk during robotic left colonic and rectal resections by routine left flexure mobilization technique: a retrospective study

BACKGROUND

The routine mobilization of the left colonic flexure as a standard procedure during left colonic/rectal resection is a controversial topic in open and minimally invasive surgery. According to some authors, this maneuver may increase the risk of iatrogenic spleen damage; for others this does not change the odds. Ligaments over-traction is the most frequent injury mechanism. Some documented risk factors are reported: laparotomic approach, male gender, vascular disease, cancer, diverticulitis, surgery performed in emergency-setting. The type of procedure influences the associated risk: transverse colectomy is the riskiest, followed by left colonic resection and pancolectomy.

METHODS

Retrospective original paper. Sample size - a total of 125 patients have been considered. 75 robotic left colonic resections (60%), 40 robotic rectal resections (32%) and 10 robotic pancolectomy (8%). Primary outcomes - 1) percentage of iatrogenic splenic injuries; 2) conversion rate. Secondary outcomes - 1) intra-/postoperative complications; 2) anastomotic leakage rate; 3) mortality. In order to avoid potential confounding factors and technical/expertise heterogeneity, all the procedures included have been performed using the same standardized operative technique and by the same experienced surgeon (P.C.G.).

RESULTS

We retrospectively analyzed 125 procedures. Primary outcomes - 1) iatrogenic splenic injuries: 0%; 2) conversion rate: 1.6%. Secondary outcomes - 1) intraoperative complications: 0%; 2) anastomotic leakage rate: 1 case of leakage out of 125 cases (1.3% of the left colectomy sub-sample); in this case the leakage was probably due to an infectious process rather than a vascular deficit; 3) mortality: 0%; 4) miscellanea postoperatory complications (small bowel obstructions, wound infection, pelvic collections, pneumonia and acute kidney injury) are detailed in the manuscript.

CONCLUSIONS

In our experience, and according to some of the literature data as well, during robotic left colonic/rectal resections the routine mobilization of the left flexure as a standard procedure is not a risk factor in terms of iatrogenic spleen injury rate. Conversely, this technique may be beneficial as it does not excessively extend the operative time, increases the surgical skills acquirement, and reduces the tension-related anastomotic ischemia. It also allows a better oncological dissection. Standard laparoscopic approach reduces the rate of spleen by almost 3.5 times in comparison to open surgery. The improved technical accuracy provided by the robotic platform may decrease the rate of splenic injury. More studies are needed on the topic to confirm our findings.

Splenectomy is an independent risk factor for poorer perioperative outcomes after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: an analysis of 936 procedures

BACKGROUND

There is a paucity of data on the impact of splenectomy on peri-operative outcomes after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC). We report the largest series to date which addresses this topic.

METHODS

Nine hundred and thirty six consecutive patients underwent CRS/HIPEC from 1996 to 2016 at a high-volume institution in Sydney, Australia. Of these, 418 (45%) underwent splenectomy. Peri-operative complications were graded according to the Clavien-Dindo Classification. The association of splenectomy with 19 peri-operative outcomes was assessed using univariate and multivariate analyses.

RESULTS

In-hospital mortality was 1.8%. Patients undergoing splenectomy had a higher disease burden (peritoneal cancer index ≥17) (71% vs. 22%, P<0.001) and underwent a longer operation (≥9 hours) (73% vs. 34%, P<0.001). Even after accounting for confounding factors, splenectomy was independently associated with an increased risk of grade III/IV morbidity [relative risk (RR), 1.94; 95% confidence interval (CI), 1.29-2.91; P=0.01], infective complications (RR, 1.63; 95% CI, 1.09-2.44; P=0.018), pancreatic leak (RR, 5.2; 95% CI, 1.81-14.89, P=0.002) and intra-abdominal collection (RR, 1.86; 95% CI, 1.23-2.84, P=0.004). It was also an independent risk factor for long hospital stay (≥28 days) (RR, 1.98; 95% CI, 1.25-3.11; P=0.003). Splenectomy was not associated with in-hospital mortality (RR, 1.68; 95% CI, 0.32-9.32, P=0.556).

CONCLUSIONS

Splenectomy is an independent risk factor for poorer peri-operative outcomes. Minimizing the likelihood of inadvertent splenic injury through careful dissection and routine vaccination can improve outcomes.

A solution to the negative effects of splenectomy during colorectal trauma and surgery: an experimental study on splenic autotransplantation to the groin area

BACKGROUND

Splenectomy after combined colosplenic trauma or iatrogenic splenic injury during colorectal surgery associates with worse short- and long-term outcomes, including reduced survival in patients with colorectal cancer. Splenic autotransplantation may improve the outcomes of such patients. Omental splenic transplantation is the standard procedure but may be difficult when performing laparoscopic colorectal surgery or when total or subtotal omentectomy is required. This animal model study was performed to evaluate the impact of splenic autotransplantation to the groin area on colonic wound healing.

METHODS

Thirty rats were divided into three groups of ten animals. One group underwent colon anastomosis and sham splenectomy, the second underwent colon anastomosis and splenectomy, and the third underwent colon anastomosis, splenectomy, and intramuscular autotransplantation of the spleen. On postoperative day 7, anastomotic healing was evaluated by measuring bursting pressure and hydroxyproline levels. The third group was subjected to scintigraphy before sacrifice to assess whether the transplant was functional.

RESULTS

The mortality rates of the sham, splenectomized, and transplanted animals were 0 %, 30 %, and 20 %, respectively: the splenectomized animals had significantly lower mean bursting pressures than the other two groups (p = 0.002). The mean hydroxyproline levels of the three groups were 467.4, 335.3, and 412.7 mg hydroxyproline/g protein, respectively (p = 0.0856). Nine of the ten transplanted animals (90 %) had splenic activity on scintigraphy.

CONCLUSIONS

Splenectomy impaired the healing of the colonic anastomosis. This effect was largely reversed by splenic autotransplantation. Intramuscular autotransplantation to the groin area appears to be feasible and effective.

[Intraoperative complications of the lower gastrointestinal tract : Prevention, recognition and therapy]

Every surgical intervention is associated with the risk of intraoperative complications. These occur in approximately 2-12% of patients but significantly influence the postoperative outcome, overall complication and mortality rates. This article presents the treatment of typical intraoperative complications during surgery of the lower gastrointestinal tract with a focus on the prevention and identification of risk factors. Especially changes in the regular anatomy caused by previous surgery, inflammation, tumors and emergency situations carry the risk of iatrogenic injuries to the bowels, spleen, ureter and blood vessels. These risk factors must be considered when choosing a surgical procedure, a surgical approach or an appropriate surgeon. The early detection of complications with a definitive restoration is the essential step for a successful treatment without long-term sequelae. Every delay in therapy is associated with an increased morbidity and mortality and should be avoided.

Does laparoscopy reduce splenic injuries during colorectal resections? An assessment from the ACS-NSQIP database

BACKGROUND

Nearly half of all incidental splenectomies caused by iatrogenic splenic injury occur during colorectal surgery. This study evaluates factors associated with incidental splenic procedures during colorectal surgery and their impact on short-term outcomes using a nationwide database.

METHODS

Patients who underwent colorectal resections between 2005 and 2012 were identified from the American College of Surgeons National Surgical Quality Improvement Program database according to Current Procedural Terminology codes. Patients were classified into two groups based on whether they underwent a concurrent incidental splenic procedure at the time of the colorectal procedure. All splenic procedures except a preoperatively intended splenectomy performed in conjunction with colon or rectal resections were considered as incidental. Perioperative and short-term (30 day) outcomes were compared between the groups.

RESULTS

In total, 93633 patients who underwent colon and/or rectal resection were identified. Among these, 215 patients had incidental splenic procedures (153 open splenectomy, 17 laparoscopic splenectomy, 36 splenorraphy, and 9 partial splenectomy). Open colorectal resections were associated with a significantly increased likelihood of incidental splenic procedures (OR 6.58, p < 0.001) compared to laparoscopic surgery. Incidental splenic procedures were associated with increased length of total hospital stay (OR 1.25, p < 0.001), mechanical ventilation dependency (OR 1.62, p = 0.02), transfusion requirement (OR: 3.84, p < 0.001), re-operation requirement (OR 1.7, p = 0.005), and sepsis (OR: 2.03, p = 0.001). Short-term advantages of splenic salvage (splenorraphy or partial splenectomy) included shorter length of total hospital stay (p = 0.001) and decreased need for re-operation (p < 0.001).

CONCLUSIONS

Incidental splenic procedures during colorectal resections are associated with worse short-term outcomes. Use of the laparoscopic technique decreases the need for incidental splenic procedures.

[Iatrogenic splenic injuries in surgery of colorectal carcinoma: impact on the oncological long-term of outcome]

INTRODUCTION

Iatrogenic lesions of the spleen during surgery of colorectal carcinoma is considered a significant risk factor for a worse early postoperative outcome. With regard to the impact of iatrogenic splenic lesions particularly associated with splenectomy on the oncological long-term outcome, only limited valid data are available.

METHODS

Data obtained in a prospective multicenter observational study were analyzed. The study enrolled 45,265 patients with surgery for colorectal carcinoma in curative and palliative intentions during the study period from 01 January 2000 to 31 December 2004, with regard to the impact of iatrogenic splenic lesions on survival rates.

RESULTS AND CONCLUSION

Follow-up data with corresponding informed consent were obtained from 564 patients with iatrogenic splenic lesions, resulting in a follow-up rate of 99.8 %. The median follow-up period was 50.2 months. The median 5-year overall survival was 4.8 years in group I (splenic lesion with splenectomy) and in group II (splenic lesion with organ preservation) 8.0 years (p = 0.009). Between group II (splenic lesion with organ preservation) and group III (control group with no splenic lesion) there were no significant differences with regard to long-term survival. Using multivariate Cox regression analysis, iatrogenic splenic lesions with splenectomy were identified as an independent risk factor for a worse oncological long-term outcome.