A laparoscopic approach to partial splenectomy for children with hereditary spherocytosis

Comparison of perioperative outcomes between laparoscopic and open partial splenectomy in children and adolescents

BACKGROUND

In order to avoid consequences of total splenectomy, partial splenectomy (PS) is increasingly reported. The purpose of this study was to compare perioperative outcomes of laparoscopic PS (LPS) and open PS (OPS) in children and adolescents.

AIM

To compare perioperative outcomes of patients with LPS and OPS.

METHODS

After institutional review board approval, a total of 26 patients that underwent LPS or OPS between January 2008 and July 2018 were identified from the database of our tertiary referral center. In total, 10 patients had LPS, and 16 patients underwent OPS. Blood loss was calculated by Mercuriali’s formula. Pain scores, analgesic requirements and complications were assessed. The Wilcoxon rank sum test was used for comparison. To compare categorical variables, Fisher’s exact test was applied.

RESULTS

LPS was performed in 10 patients; 16 patients had OPS. Demographics (except for body mass index and duration of follow-up), indicating primary disease, preoperative spleen size and postoperative spleen volume, perioperative hematological parameters, postoperative pain scores, analgesic requirements, adverse events according to the Clavien-Dindo classification and the comprehensive complication index, median time from operation to initiation of feeds, median time from operation to full feeds, median time from operation to mobilization and median length of hospital stay did not differ between LPS and OPS. Median (range) operative time (min) was longer in LPS compared to the OPS group [185 (135-298) vs 144 (112-270), respectively; P = 0.048]. Calculated perioperative blood loss (mL of red blood cell count) was higher in the LPS group compared to OPS [87 (-45-777) vs -37 (-114-553), respectively; P = 0.039].

CONCLUSION

This is the first study that compared outcomes of LPS and OPS. Both operative approaches had comparable perioperative outcomes. LPS appears to be a viable alternative to OPS.

Laparoscopic Partial Splenectomy: A Critical Appraisal of an Emerging Technique. A Review of the First 457 Published Cases

Background: Laparoscopic partial splenectomy (LPS) may allow avoiding total splenectomy (TS) complications and maximizing the advantages of mini-invasive approach. The objective of this review is to assess feasibility and safety of LPS, to compare this approach with alternative options. Materials and Methods: A literature review of articles reporting LPS is performed. Several parameters, including age, indication, surgical technique, devices used for splenic section/hemostasis, adverse outcomes, including morbidity/mortality, conversions to open surgery, conversions to TS, operative time (OT), and hospital stay (HS), are analyzed. Articles comparing LPS' results with those of open partial splenectomy and laparoscopic TS are also analyzed. Results: Fifty-nine articles reporting 457 LPS were included. Patients' characteristics varied widely, concerning age and indications, including hematological disease (hereditary spherocytosis, drepanocytosis), splenic focal masses, and trauma. Several technical options are reported. Mean OT and HS are 128 ± 43.7 minutes and 4.9 ± 3.8 days, respectively. No mortality and 5.7% morbidity are reported. Conversion rates to open surgery and to TS are 3.9% and 3.7%, respectively. Conclusions: In conclusion LPS is feasible and safe, with no mortality, low morbidity, and low conversion rates to laparotomy and to TS. LPS may be accomplished by various techniques and tools. Major complications are sporadically reported, thus potential risks should not be underestimated.

Feasibility and Safety of Laparoscopic Partial Splenectomy: A Systematic Review

BACKGROUND

Laparoscopic partial splenectomy (LPS) is a challenging procedure. The aim of this review was to evaluate its feasibility, safety, and potential benefits.

METHODS

We conducted a comprehensive review for the years 1995-2018 to retrieve all relevant articles.

RESULTS

A total of 44 studies with 252 patients undergoing LPS were reviewed. Six studies described combined operations. Ranges of operative time and estimated blood loss were 50-225 min and 0-1200 ml, respectively. There are eight patients need blood transfusion in 231 patients with available data. The conversion rate was 3.6% (9/252). Overall, 27 patients (10.7%;27/252) developed postoperative or intraoperative complications. Overall mortality was 0% (0/252). The length of postoperative stay (POS) varied (1-11 days). Among four comparative studies, one showed LPS could reduce POS than laparoscopic total splenectomy (LTS) (LTS 5.4 ± 1.8 days, LPS 4.2 ± 0.8 days, p = 0.027) and complications (pleural effusion (LTS 9/22, LPS 0/15, p = 0.005), splenic vein thrombosis (LTS 10/22, LPS 0/15, p = 0.002)). Another comparative study showed LPS may benefit emergency patients. However, one comparative study showed LPS was associated with more pain, longer time to oral intake, and longer POS in children with hereditary spherocytosis. The fourth comparative study showed robotic subtotal splenectomy was comparable to laparoscopy in terms of POS and complication. The main benefits were lower blood loss, vascular dissection time, and a better evaluation of splenic remnant volume.

CONCLUSIONS

In early series of highly selected patients, LPS appears to be feasible and safe when performed by experienced laparoscopic surgeons.

Partial splenectomy: Who, when and how. A systematic review of the 2130 published cases

BACKGROUND/PURPOSE

In order to avoid consequences of total splenectomy (including severe postsplenectomy sepsis), partial splenectomy (PS) is increasingly reported. Without guidelines and indications concerning a rarely-indicated procedure, a review of literature should be an asset.

METHODS

A systematic review of all PSs from 1960 to December 2017 was performed, with special focus on surgical indications, sites of resection, approaches and techniques of vascular dissection and parenchymal section/hemostasis of the spleen, perioperative morbidity/mortality, including complications compelling to perform total splenectomy.

RESULTS

Among 2130 PSs, indications for resection were hematological disease in 1013 cases and nonhematological conditions in 1078, including various tumors in 142 and trauma in 184. Parenchymal transection was performed using several techniques through the years, most frequently after having induced partial ischemia by splenic hilum vascular dissection/ligation. 371 laparoscopic/robotic PSs were reported. Rescue total splenectomy was required in 75 patients.

CONCLUSIONS

Although good results are probably overestimated by such a retrospective review, PS should be considered as a procedure associated with a low morbidity/mortality. Nevertheless, severe complications are also reported, and the need of total splenectomy should not to be minimized. Laparoscopic/robotic procedures are increasingly performed, with good results and rare conversions.

TYPE OF STUDY

Systematic review.

LEVEL OF EVIDENCE

IV.

Results after laparoscopic partial splenectomy for children with hereditary spherocytosis: Are outcomes influenced by genetic mutation?

BACKGROUND

Laparoscopic partial splenectomy (LPS) theoretically maintains long-term splenic immune function for children with hereditary spherocytosis (HS). Our goal was to review our results after LPS and to determine if specific genetic mutations influence outcome.

METHODS

All children with HS undergoing LPS between 2005 and 2016 were reviewed.

RESULTS

Thirty-one children underwent LPS (16 male) at a median age of 9 (range 2-18) years. All experienced an increase in hemoglobin and decrease in reticulocyte count early after LPS and at last follow-up. Twenty-two were sent for genetic analysis. Mutations in α-spectrin, β-spectrin, and Ankyrin were identified in 6, 5, and 11 patients, respectively. Gene mutation was not correlated with complications, perioperative transfusion, length of hospital stay, or median hemoglobin, platelet, or reticulocyte counts. Three children required completion splenectomy at 10.9, 6.9, and 3.2years post-LPS, each with a different gene mutation.

CONCLUSIONS

LPS is effective in reversing anemia and reducing reticulocytosis. So far less than 10% have required completion splenectomy, and those children did benefit from delaying the risks of asplenia. In this preliminary analysis, genetic mutation did not influence outcome after LPS. A larger multicenter study is necessary to further investigate potential correlations with specific genetic mutations.

TYPE OF STUDY

Prognosis Study.

LEVEL OF EVIDENCE

IV.

Laparoscopic splenectomy for hereditary spherocytosis-preliminary report

Splenectomy is considered standard surgical therapy in hereditary spherocytosis. The procedure is indicated in patients with severe anemia, recurrent hemolytic, and aplastic crises. The aim of the study was to assess treatment outcomes in patients with hereditary spherocytosis who underwent total or partial laparoscopic splenectomy. Fifteen patients aged 4-17 yr underwent laparoscopic splenectomy from 2009 to 2012. Partial and total splenectomies were performed (five and 10 children, respectively). Hematologic parameters, liver function tests, and splenic volume before and after the surgery were analyzed retrospectively. Total follow-up was 1-30 months. Hospitalization and operating time were similar in both groups. In partial splenectomy group, branches of splenic arteries gave better blood supply than short gastric vessels. In both groups, hematologic parameters were improved. Postoperative markedly elevated platelet count was maintained up to 6 months, and after that, platelet count gradually decreased to normal values. Bilirubin level was decreased in early postoperative period; however, it increased later to achieve levels lower than in preoperative period. No severe general infections were observed in both groups. Laboratory parameters (hemoglobin and bilirubin concentrations and RBC) after the surgery improved in all patients, and the effect was maintained during 12 months of follow-up. Platelet count increased significantly after the surgery and was maintained at high levels during the next 6 months. However, it returned to preoperative levels within a year after the surgery. Our study showed that partial splenectomy was not inferior to total splenectomy. However, full assessment requires longer follow-up and larger group of patients.

Role of laparoscopic partial splenectomy for tumorous lesions of the spleen

BACKGROUND

Laparoscopic partial splenectomy (LPS) is a surgical option for splenic masses, with the goal of reducing postoperative complications while preserving splenic function.

METHODS

Thirty-seven patients who underwent laparoscopic splenectomy for tumorous lesions of the spleen at two affiliated hospitals were enrolled. Among them, 22 patients underwent laparoscopic total splenectomy (LTS) and 15 patients underwent LPS.

RESULTS

The tumorous lesions of the spleen in both groups, in order of decreasing frequency, consisted of epithelial cysts, hemangiomas, lymphangiomas, abscesses, metastatic tumors, and hamartomas. All procedures were completed by laparoscopy, and the pathologic lesions in the spleen were completely removed in both groups. There were no significant differences between the groups in terms of the operative time (LTS 151.5 ± 98.5 min, LPS 168.6 ± 46.8 min, p = 0.483), intraoperative blood loss (LTS 337.3 ± 188.4 ml, LPS 422.6 ± 187.4 ml, p = 0.185), and transfusion rate (LTS 3/22 [13.6 %], LPS 3/15 [20.0 %], p = 0.606). However, there were significant differences in postoperative complications such as pleural effusion (LTS 9/22 [40.9 %], LPS 0/15 [0 %], p = 0.005), splenic vein thrombosis (LTS 10/22 [45.5 %], LPS 0/15 [0 %], p = 0.002), and postoperative hospital stay (LTS 5.4 ± 1.8 days, LPS 4.2 ± 0.8 days, p = 0.027).

CONCLUSIONS

LPS is a feasible, safe surgical procedure in patients with tumorous lesions of the spleen, and it represents an effective approach to reduce postoperative hospital stay and complications.

[Partial splenectomy in sickle cell disease]

INTRODUCTION

Total splenectomy in sickle cell disease is related to a high risk of fulminant sepsis and increased incidence of other events, which have not been reported in patients with partial splenectomy. In this study we examined the patients with sickle cell disease and partial splenectomy and compared the clinical and laboratory results with non-splenectomized patients.

MATERIAL AND METHODS

We studied 54 patients with sickle cell disease who underwent partial splenectomy in childhood from 1986 until 2011 at the Institute of Hematology and Immunology. They were compared with 54 non-splenectomized patients selected by random sampling with similar characteristics.

RESULTS

Partial splenectomy was performed at a mean age of 4.1 years, with a higher frequency in homozygous hemoglobin S (70.4%), and the most common cause was recurrent splenic sequestration crisis. The most common postoperative complications were fever of unknown origin (14.8%) and acute chest syndrome (11.1%). After splenectomy there was a significant increase in leukocytes, neutrophils, and platelets, the latter two parameters remained significantly elevated when compared with non-splenectomized patients. There was no difference in the incidence of clinical events, except hepatic sequestration, which was more common in splenectomized patients.

CONCLUSION

Partial splenectomy was a safe procedure in patients with sickle cell disease. There were no differences in the clinical picture in children splenectomized and non-splenectomized except the greater frequency of hepatic sequestration crisis in the first group.

Hereditary spherocytosis, elliptocytosis, and other red cell membrane disorders

Hereditary spherocytosis and elliptocytosis are the two most common inherited red cell membrane disorders resulting from mutations in genes encoding various red cell membrane and skeletal proteins. Red cell membrane, a composite structure composed of lipid bilayer linked to spectrin-based membrane skeleton is responsible for the unique features of flexibility and mechanical stability of the cell. Defects in various proteins involved in linking the lipid bilayer to membrane skeleton result in loss in membrane cohesion leading to surface area loss and hereditary spherocytosis while defects in proteins involved in lateral interactions of the spectrin-based skeleton lead to decreased mechanical stability, membrane fragmentation and hereditary elliptocytosis. The disease severity is primarily dependent on the extent of membrane surface area loss. Both these diseases can be readily diagnosed by various laboratory approaches that include red blood cell cytology, flow cytometry, ektacytometry, electrophoresis of the red cell membrane proteins, and mutational analysis of gene encoding red cell membrane proteins.

Laparoscopic versus robotic subtotal splenectomy in hereditary spherocytosis. Potential advantages and limits of an expensive approach

BACKGROUND

This study was designed to compare the laparoscopic subtotal splenectomy with the robotic approach in patients with hereditary spherocytosis.

METHODS

Thirty-two consecutive subtotal splenectomies by minimal approach in patients with hereditary spherocytosis were analyzed (10 robotic vs. 22 laparoscopic subtotal splenectomies).

RESULTS

A significant difference was found for the robotic approach regarding blood loss, vascular dissection duration, and splenic remnant size. Follow-up for 4-103 months was available.

CONCLUSIONS

Subtotal splenectomy seems to be a suitable candidate for robotic surgery, requiring a delicate dissection of the splenic vessels and a correct intraoperative evaluation of the splenic remnant. Robotic subtotal splenectomy is comparable to laparoscopy in terms of hospital stay and complication. The main benefits are lower blood loss rate, vascular dissection time, and a better evaluation of the splenic remnant volume.

Guidelines for the diagnosis and management of hereditary spherocytosis--2011 update

Guidelines on hereditary spherocytosis (HS) published in 2004 (Bolton-Maggs et al, 2004) are here replaced to reflect changes in current opinion on the surgical management, (particularly the indications for concomitant splenectomy with cholecystectomy in children with mild HS, and concomitant cholecystectomy with splenectomy in those with asymptomatic gallstones). Further potential long term hazards of splenectomy are now recognised. Advances have been made in our understanding of the biochemistry of the red cell membrane which underpins the choice of tests. Biochemical assays of membranes proteins and genetic analysis may be indicated (rarely) to diagnose atypical cases. The diagnostic value of the eosin-5-maleimide (EMA) binding test has been validated in a number of studies with understanding of its limitations.

Single-port laparoscopic partial splenectomy: a case report

With the better understanding of the importance of the spleen as a primary organ of the human immune system, there has been an increased interest in performing the partial splenectomy for a number of indications such as nonparasitic cysts, benign tumors, staging of lymphomas, etc. Moreover, laparoscopic partial splenectomy has been gaining more interest as the recommended approach for benign splenic disorders to preserve the splenic function with very low recurrence rates. Meanwhile, many surgeons have attempted to reduce the number and size of the ports in laparoscopic surgery with the aim of inducing less parietal trauma and fewer scars. One of these efforts is single-port laparoscopic surgery, which is a rapidly evolving field all over the world. Here, we describe a feasible method of single-port laparoscopic partial splenectomy for treating a benign splenic cyst that was located in the upper medial aspect of the spleen.

Partial splenectomy for hereditary spherocytosis: a multi-institutional review

BACKGROUND/PURPOSE

Partial splenectomy has emerged as a surgical option for selected children with hereditary spherocytosis, with the goal of reducing anemia while preserving splenic function. This multi-institutional study is the largest series to date examining outcomes data for partial splenectomy in patients with hereditary spherocytosis.

METHODS

Data were collected retrospectively from 5 North American pediatric hospitals. Sixty-two children underwent partial splenectomy for hereditary spherocytosis between 1990 and 2008.

RESULTS

At 1 year following partial splenectomy, mean hemoglobin significantly increased by 3.0 ± 1.4 g/dL (n = 52), reticulocyte count decreased by 6.6% ± 6.6% (n = 41), and bilirubin level decreased by 1.3 ± 0.9 mg/dL (n = 25). Patients with poor or transient hematologic response were found to have significantly more splenic regeneration postoperatively compared with patients with a durable clinical response (maximal spleen dimension, 9.0 ± 3.4 vs 6.3 ± 2.2 cm). Clinically significant recurrence of anemia or abdominal pain led to completion splenectomy in 4.84% of patients. No patients developed postsplenectomy sepsis.

CONCLUSIONS

Our multi-institutional review indicates that partial splenectomy for hereditary spherocytosis leads to sustained and clinically significant improvement in hematologic profiles and clinical symptoms in most patients. Our data support partial splenectomy as an alternative for selected children with hereditary spherocytosis.

Laparoscopic partial splenectomy using a detachable clamp with and without partial splenic embolisation

BACKGROUND

In many centres, the laparoscopic total splenectomy is a well-established routine procedure. However, the crucial immunological role of the spleen in combating bacterial infections, in particular pneumonias, has led to a search for splenic-preserving techniques whenever possible. Yet, laparoscopic partial splenectomies are still rarely described possibly due to difficulties in controlling intra-operative parenchymal bleeding during splenic transection.

METHODS

Here, we present a case series of laparoscopic partial splenectomies using a new technique. The main splenic artery and vein were temporarily clamped using a detachable clip. Transection of the spleen was possible working with the LigaSure™ instrument. After transection, the margin was sealed with a collagen fleece. In one case of a haemangioma, the patient underwent a radiological coil embolisation of the feeding arteries of the splenic pole in question. This was done 4 weeks prior to surgery and included embolisation of the tumour.

RESULTS

Three patients (2 males, 1 female, mean age 58.3 years) have been successfully treated using a detachable clamp. The pre-surgical mean size of the spleen was 8.0 × 16.7 cm (range 6 × 14-11 × 22 cm). The removed specimens had a mean size of 4.2 × 5.5 cm (range 2.5 × 4.0-5.0 × 6.5 cm). The time of surgery averaged 144 min (range 110-187 min). Blood loss was minimal thereby avoiding the need for blood transfusions. The post-surgical course was uneventful; patients were discharged 5 days following surgery. Histopathology showed a benign splenic haemangioma, a benign splenic hamartoma and the presence of Hodgkin's disease stage III.

CONCLUSIONS

The technique of laparoscopic partial splenectomy and, in certain patients, pre-surgical partial splenic embolisation is safe and effective for patients with localised diseases of the spleen. This approach combines the benefits of the minimal surgical access with saving a significant amount of splenic tissue, thereby preserving the immune function of the spleen.

Institutional experience with laparoscopic partial splenectomy for hereditary spherocytosis

BACKGROUND/PURPOSE

Moderate to severe hereditary spherocytosis (HS) is treated with splenectomy. However, total splenectomy leads to decreased immunologic function with the risk of overwhelming postsplenectomy sepsis. Splenic preservation is postulated as a method to avoid this potentially fatal complication. Although mainly performed through laparotomy, we report our experience with a laparoscopic approach to partial splenectomy for HS.

METHODS

A retrospective review was conducted on 9 laparoscopic partial splenectomies performed for HS at our institution. Follow-up was from 1 to 3.5 years. Data included preoperative and postoperative hemoglobin, absolute reticulocyte count, splenic size, operative time, complications, and length of stay.

RESULTS

All patients successfully underwent laparoscopic partial splenectomy with a radiologically determined upper-pole remnant of 10% to 30% and preservation of the blood supply through the upper short gastric arteries. The mean preoperative spleen length was 13 cm. Mean hospital stay was 3.6 days (range, 1-6 days). There was 1 intraoperative complication (a small bowel tear during spleen extraction) and 2 minor postoperative complications (ileus and wound infection). One patient underwent completion total splenectomy 2 years after partial splenectomy.

CONCLUSION

Laparoscopic partial splenectomy is a feasible and effective procedure that addresses the hematologic consequences of HS while retaining a portion of functional spleen, in addition to conferring the advantages of laparoscopy.

Hereditary spherocytosis and partial splenectomy in children: review of surgical technique and the role of imaging

The risks associated with total splenectomy, including overwhelming postsplenectomy infection, have led to an interest in the use of partial splenectomy as an alternative surgical option for children with congenital hemolytic anemias and hypersplenism. Partial splenectomy, a procedure designed to remove enough spleen to improve anemia and avoid complications of splenic sequestration while preserving splenic function, has shown promise in children. Radiologic imaging is essential for the preoperative evaluation and postoperative care for children undergoing partial splenectomy and offers a broad range of critical clinical information essential for care of these complex children. It is imperative for radiologists involved in the care of these children to be familiar with the surgical technique and imaging options for these procedures. This article reviews the surgical technique as well as the current status of various diagnostic imaging options used for children undergoing partial splenectomy, highlighting technical aspects and specific clinical information obtained by each modality.

Partial splenectomy prevents splenic sequestration crises in sickle cell disease

PURPOSE

Acute splenic sequestrations (SSs) are potentially fatal complications in sickle cell disease (SCD). Total splenectomies in young patients may predispose them to a higher risk of overwhelming infections, whereas partial splenectomy may maintain immunocompetence. We present our series of partial splenectomies in patients with multiple SS episodes.

METHODS

We retrospectively reviewed the records of 6 patients who underwent open partial splenectomies for SS. Data on their clinical courses were collected and analyzed.

RESULTS

None of the 6 patients had SS postprocedure, down from 2.1 +/- 1.0 (P = .003) sequestrations per year and 3.5 +/- 1.4 (P = .002) total sequestrations per patient. The transfusion requirements were significantly reduced postoperatively (10.2 +/- 5.6 vs 2.0 +/- 3.1 per year; P = .002). There was no increase in the infection-related hospital admissions during the period of follow-up (1.5 +/- 1.8 vs 0.8 +/- 0.8 per year after partial splenectomy; P = .363). The upper pole was preserved in all cases with blood supply off the main splenic artery.

CONCLUSIONS

Partial splenectomy decreases the risk of SS in SCD and reduces the need for blood transfusions. Infection rates did not increase after the procedure during the follow-up period. Partial splenectomy should be considered for patients who experience multiple acute SS crises or have long-term transfusion requirements.

Splenectomy for haematological disorders: a single center study in 150 patients from Oman

BACKGROUND

Haematological disorders, in particular sickle cell disease (SCD) and thalassaemia, are relatively common in Oman. We report our experience of splenectomy for haematological disorders and review the literature on splenectomy role in their management.

OBJECTIVES

To review our experience in the management of 150 patients with haematological disorders undergoing splenectomy with emphasis on indications and outcome. To compare our experience with those reported from outside this region.

METHODS

The records of 150 patients who underwent splenectomy over a thirteen year period were reviewed retrospectively, analyzing the age and sex of the patients, indication for splenectomy, operative procedures, complications, peri-operative management and outcome.

RESULTS

Of the 150 patients, 96 (64%) had SCD and 34 (22.6%) had beta-thalassaemia; the rest comprised patients with refractory idiopathic thrombocytopenic purpura (ITP) n=12, hereditary spherocytosis (HS) n=6, and auto-immune haemolytic anaemia (AHA) n=2. In SCD patients, the main indications for splenectomy were recurrent splenic sequestration (60.4%) and hypersplenism (36.4%), whereas in thalassaemic patients it was increased requirement of packed red blood cells (PRBC) transfusion (mean 310 ml, range 242-372 of PRBC/kg/year). All patients received prophylactic antibiotics and vaccination against pneumococcal infection and when the vaccine was available for Haemophilus influenzae. PRBC and platelet concentrates as well as intravenous fluids were infused preoperatively as per protocol. Concomitant procedures at laparotomy included liver biopsy (14.6%) and cholecystectomy (8.6%). The postoperative morbidity was low (8.6%) and there was no mortality. All patients were maintained on long term penicillin and proguanil, and the mean follow-up was 4.6 years. In SCD patients splenectomy eliminated the risks of life threatening acute splenic sequestration and improved significantly the blood counts of the hypersplenic cases, while in thalassaemic patients it reduced significantly the mean transfusion requirement by 100ml PRBC/kg/year (p<0.0001). Of the patients with refractory ITP, two thirds had a good response to splenectomy (p<0.0001). All HS and AHA patients benefited from splenectomy.

CONCLUSION

The predominant indications for splenectomy were recurrent acute splenic sequestration and hypersplenism in SCD patients, and increased transfusion demand in the thalassaemics. Overall, splenectomy proved beneficial in eliminating the risk of splenic sequestration in SCD patients, in improving the blood counts in SCD with hypersplenism and in reducing transfusion requirement in thalassaemic patients, while in ITP group two thirds of the patients benefited.

Splenectomy in hereditary spherocytosis: Review of 1,657 patients and application of the pediatric quality indicators

OBJECTIVE

The objective of the present study is to profile the outcome and safety of pediatric patients undergoing splenectomy with hereditary spherocytosis (HS) using a nationwide sample and the Agency for Healthcare Research and Quality (AHRQ) Pediatric Quality Indicators (PDIs).

PATIENTS AND METHODS

A retrospective cross-sectional descriptive analysis of a non-overlapping combination of the National Inpatient Sample (NIS), and Kids' Inpatient Database (KID) databases (1988-2004) were performed. These combined databases contain information from nearly 93 million discharges in the United States. Children with an age at admission of <18 years of age and HS (ICD-9 diagnosis code of 282.0) who underwent total splenectomy (ICD-9 procedure code of 41.5) were identified. Variables of gender, race, co-existing diagnoses, hospital type, and charges adjusted to 2006 dollars, length of stay, inpatient mortality, and complications were collected. PDIs were identified for each patient by linking the data obtained from the NIS and KID databases with the PDIs using the AHRQ Quality Indicators Wizard.

RESULTS

Splenectomy for HS was associated with low morbidity and mortality. Accompanying cholecystectomy and/or appendectomy appeared to be safely performed at the same operation. Of the 13 PDIs identified by AHRQ as potentially avoidable adverse events, none were observed to occur in more than 1% of the patients.

CONCLUSIONS

Based on the results of this study, splenectomy in patients with HS appears safe and to result in a minimal number of potentially preventable complications as identified by the AHRQ PDIs. We have successfully demonstrated use of the indicators to aid in the analysis of a specific surgical procedure within a subset of the pediatric population.

Laparoscopic partial vs total splenectomy in children with hereditary spherocytosis

BACKGROUND

Open partial splenectomy provides reversal of anemia and relief of symptomatic splenomegaly while theoretically retaining splenic immune function for hereditary spherocytosis. We recently developed a laparoscopic approach for partial splenectomy. The purpose of the present study is to compare the outcomes in a group of patients undergoing laparoscopic partial splenectomy (LPS) with those in a group of children undergoing laparoscopic total splenectomy (LTS) over the same period.

METHODS

Systematic chart review was conducted of all children with hereditary spherocytosis who had LTS or LPS from 2000 to 2006 at the Hospital for Sick Children, Toronto, Ontario, Canada. T tests were used for continuous data, and chi(2) for proportional data; P value of less than .05 was considered significant.

RESULTS

There were 9 patients (14 males) in each group. Groups were similar in sex, age, concomitant cholecystectomy, and preoperative hospitalizations, transfusions, and spleen size. Estimated blood loss was greater in the LPS group (188 + 53 vs 67 + 17 mL; P = .02), but transfusion requirements were similar (1/9 vs 0/9). Complication rate was similar between groups. The LPS group had higher morphine use (4.1 + 0.6 vs 2.4 + 0.2 days; P = .03), greater time to oral intake (4.4 + 0.7 vs 2.0 + 0.2 days; P = .01), and longer hospital stay (6.3 + 1.0 vs 2.7 + 0.3 days; P = .005) than the LTS group. Nuclear scan 6 to 8 weeks postoperatively demonstrated residual perfused splenic tissue in all LPS patients. No completion splenectomy was necessary after a mean follow-up of 25 months.

CONCLUSION

These data suggest that LPS is as effective as LTS for control of symptoms. However, LPS is associated with more pain, longer time to oral intake, and longer hospital stay. These disadvantages may be balanced by retained splenic immune function, but further studies are required to assess long-term splenic function in these patients.

Partial splenectomy for hereditary spherocytosis

The significant risks associated with total splenectomy have led to interest in the use of partial splenectomy as an alternative surgical therapy for children who have congenital hemolytic anemia. Partial splenectomy is designed to remove enough spleen to gain desired hematologic outcomes while preserving splenic immune function. Although preliminary data demonstrate successful laboratory and clinical outcomes after partial splenectomy in various congenital hemolytic anemias, conclusive data comparing the efficacy of partial splenectomy to total splenectomy are not reported. Based on preliminary data, a definitive clinical trial of partial splenectomy in children who have severe congenital hemolytic anemia may be warranted.

Partial splenectomy for children with congenital hemolytic anemia and massive splenomegaly

Partial splenectomy is an alternative to total splenectomy for the treatment of congenital hemolytic anemias (CHAs) in children, although the feasibility of this technique in the setting of massive splenomegaly is unknown. This study was designed to evaluate the safety and efficacy of partial splenectomy in children with CHAs and massive splenomegaly. This retrospective study examined 29 children with CHAs who underwent partial splenectomy. Children were divided into 2 groups based on splenic size: 8 children had splenic volumes greater than 500 mL, whereas 21 children had splenic volumes less than 500 mL. Outcome variables included perioperative complications, transfusion requirements, hematocrits, reticulocyte counts, bilirubin levels, splenic sequestration, and splenic regrowth. All 29 children underwent successful partial splenectomy with 0.02 to 10 years of follow-up. After partial splenectomy, children overall had decreased transfusion requirements, increased hematocrits, decreased bilirubin levels, decreased reticulocyte counts, and elimination of splenic sequestration. Children with massive splenomegaly had similar outcomes compared with children without massive splenomegaly. Long-term complications included 3 mild infections, 4 cases of gallstones requiring cholecystectomy, and 1 child who required completion splenectomy. Partial splenectomy is a safe, effective, and technically feasible option for children with various CHAs, even in the setting of massive splenomegaly.

Partial splenectomy for benign splenic cysts with the aid of a Lin clamp: technical note

BACKGROUND

Spleen-preserving procedures deserve every effort by surgeons to reduce the risk of overwhelming postsplenectomy infection. Partial splenectomy at hospitals with restricted sources remains technically demanding. We describe our method of partial splenectomy for benign splenic cysts with the aid of a Lin clamp.

PATIENTS AND METHODS

Since April 2003 to August 2004, we have performed partial splenectomy with the aid of a Lin clamp on 5 suitable patients with symptomatic cysts. Detailed patient characteristics, operative variables, and outcomes were collected. Following surgery, they were regularly followed up every 6 months.

RESULTS

All five partial splenectomies were successfully executed without any complications. The mean operating time was 75 minutes, and a mean operative blood loss of 68 ml could be achieved. With a mean follow-up of 34.4 months, no cyst recurrences were detected to date. Postoperative laboratory data, imaging studies, and clinical situations proved that the preserved splenic parenchyma maintained adequate function.

CONCLUSIONS

Partial splenectomy with the aid of a Lin clamp for benign splenic cysts is a practical method with the advantages of easy application, rapid parenchymal dissection, secure hemostasis, and cost-effectiveness. With encouraging preliminary results, further application of this method to bleeding eccentric parenchymal injuries of the spleen may be warranted.