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Tivadar BM, Dumitrascu T, Vasilescu C. A Glimpse into the Role and Effectiveness of Splenectomy for Isolated Metachronous Spleen Metastasis of Colorectal Cancer Origin: Long-Term Survivals Can Be Achieved. J Clin Med 2024; 13:2362. [PMID: 38673636 PMCID: PMC11050850 DOI: 10.3390/jcm13082362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 04/15/2024] [Accepted: 04/15/2024] [Indexed: 04/28/2024] Open
Abstract
Background: Many papers exploring the role of resectioning metastases in colorectal cancer (CRC) have focused mainly on liver and lung sites, showing improved survival compared with non-resectional therapies. However, data about exceptional metastatic sites such as splenic metastases (SMs) are scarce. This paper aims to assess the role and effectiveness of splenectomy in the case of isolated metachronous SM of CRC origin. Methods: The patients' data were extracted after a comprehensive literature search through public databases for articles reporting patients with splenectomies for isolated metachronous SM of CRC origin. Potential predictors of survival were explored, along with demographic, diagnostic, pathology, and treatment data for each patient. Results: A total of 83 patients with splenectomies for isolated metachronous SM of CRC origin were identified. The primary CRC was at an advanced stage (Duke's C-70.3%) and on the left colon (45.5%) for most patients, while the median interval between CRC resection and SM was 24 months. The median overall survival after splenectomy was 84 months, and patients younger than 62 years presented statistically significantly worse overall survival rates than those ≥62 years old (p = 0.011). There was no significant impact on the long-term outcomes for factors including primary tumor location or adjuvant chemotherapy (p values ≥ 0.070, ns). Laparoscopic splenectomy was increasingly used in the last 20 years from 2002 (33.3% vs. 0%, p < 0.001). Conclusions: Splenectomy is the optimal treatment for patients with isolated metachronous SM of CRC, with the laparoscopic approach being increasingly used and having the potential to become a standard of care. Encouraging long-term survival rates were reported in the context of a multidisciplinary approach. Younger ages are associated with worse survival. Perioperative chemotherapy in the context of a patient diagnosed with SM of CRC origin appears to be a reasonable option, although the present study failed to show any significant impact on long-term survival.
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Affiliation(s)
| | - Traian Dumitrascu
- Department of General Surgery, Fundeni Clinical Institute, Carol Davila University of Medicine and Pharmacy, Fundeni Street No. 258, 022328 Bucharest, Romania; (B.M.T.); (C.V.)
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Carrano FM, Spinelli A. Management of intraoperative complications during laparoscopic left colectomy. Minerva Surg 2021; 76:316-323. [PMID: 33855373 DOI: 10.23736/s2724-5691.21.08644-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Minimally invasive surgery has gained a major role in the current management of colorectal disease since the introduction of laparoscopy in the early 1990s for colorectal procedures. The laparoscopic approach, in fact, is not exempt from the risk of intraoperative complications, some of which can occur outside the field of view. Aim of this chapter is to review the different types of complications that can happen during left colectomy, analyzing the causes, how to prevent them and what to do in case they occur. EVIDENCE ACQUISITION A literature search was carried out using the MEDLINE and PubMed databases for studies published between January 1980 and October 2020. The following terms were used for the search: complications, risk factors, colorectal surgery, colorectal resection, laparoscopy, left colectomy, intraoperative complications, splenic injury, intraoperative bleeding. EVIDENCE SYNTHESIS From our literature search we identified twenty-four studies, including two systematic reviews and metanalyses, that were the most pertinent to the subject. CONCLUSIONS Many different complications can occur during laparoscopic left colectomy. Maintaining control of the situation is important to provide a prompt solution to the occurred injury. Increasing the reporting rate of complications may help, in the future, to analyze the causes and improve management strategies, keeping in mind that the only surgeon who does not have complications is the one who does not operate.
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Affiliation(s)
- Francesco M Carrano
- Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy.,University of Rome Tor Vergata, Rome, Italy
| | - Antonino Spinelli
- Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy - .,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
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Chatterjee S, LeMaire SA, Green SY, Price MD, Amarasekara HS, Zhang Q, Pirko CJ, Preventza O, de la Cruz KI, Todd SR, Coselli JS. Is incidental splenectomy during thoracoabdominal aortic aneurysm repair associated with reduced survival? J Thorac Cardiovasc Surg 2020; 160:641-652.e2. [DOI: 10.1016/j.jtcvs.2019.07.133] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 06/27/2019] [Accepted: 07/03/2019] [Indexed: 01/06/2023]
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Damin DC, Betanzo LN, Ziegelmann PK. Splenic flexure mobilization in sigmoid and rectal cancer resections: a meta-analysis of surgical outcomes. ACTA ACUST UNITED AC 2019; 46:e20192171. [PMID: 31644719 DOI: 10.1590/0100-6991e-20192171] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 07/10/2019] [Indexed: 12/18/2022]
Abstract
OBJECTIVE to evaluate the influence of the splenic flexure mobilization for the main surgical outcomes of patients submitted to resection of sigmoid and rectal cancer. METHODS we searched the MEDLINE, Cochrane Central Register of Controlled Trials and LILACS, using the terms "splenic flexure mobilization", "colorectal surgery", "rectal cancer", "anterior resection", "sigmoid colon cancer", and "sigmoid resection". The main outcome was anastomotic dehiscence. Other outcomes analyzed were mortality, bleeding, infection and general complications. We estimated the effect sizes by grouping data from six case-control studies (1,433 patients) published until January 2018. RESULTS our meta-analysis showed that patients undergoing complete mobilization of the splenic flexure had a higher risk of anastomotic dehiscence (RR=2.27, 95%CI: 1.22-4.23) compared with those not submitted to this procedure. There was no difference between the groups in terms of mortality, bleeding, infection and general complications. CONCLUSION splenic flexure mobilization is associated with a higher risk of anastomotic dehiscence in resections of sigmoid and rectal cancer. This surgical maneuver should be used with caution in the surgical management of sigmoid or rectal cancers.
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Affiliation(s)
- Daniel C Damin
- Universidade Federal do Rio Grande do Sul, Faculdade de Medicina, Departamento de Cirurgia, Programa de Pós-Graduação em Medicina (Ciências Cirúrgicas), Porto Alegre, RS, Brasil.,Universidade Federal do Rio Grande do Sul, Faculdade de Medicina, Hospital de Clinicas de Porto Alegre, Serviço de Coloproctologia, Porto alegre, RS, Brasil
| | - Luize N Betanzo
- Universidade Federal do Rio Grande do Sul, Faculdade de Medicina, Departamento de Cirurgia, Programa de Pós-Graduação em Medicina (Ciências Cirúrgicas), Porto Alegre, RS, Brasil.,Universidade Federal do Rio Grande do Sul, Faculdade de Medicina, Hospital de Clinicas de Porto Alegre, Serviço de Coloproctologia, Porto alegre, RS, Brasil
| | - Patrícia K Ziegelmann
- Universidade Federal do Rio Grande do Sul, Faculdade de Medicina, Programa de Pós-Graduação em Epidemiologia e Departamento de Estatística, Porto Alegre, RS, Brasil
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Effect of splenic flexure mobilization performed via medial-to-lateral and superior-to-inferior approach on early clinical outcomes in elective laparoscopic resection of rectal cancer. Wideochir Inne Tech Maloinwazyjne 2019; 14:509-515. [PMID: 31908696 PMCID: PMC6939205 DOI: 10.5114/wiitm.2019.85224] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 04/17/2019] [Indexed: 11/17/2022] Open
Abstract
Introduction Whether complete splenic flexure mobilization (SFM) is required remains a controversial issue and there are numerous approaches regarding the performance of this procedure. Aim To investigate the effect of SFM performed with a medial-to-lateral and superior-to-inferior approach on early clinical outcomes in laparoscopic resection of rectal cancer. Material and methods The SFM procedure was initiated by the ligation of the inferior mesenteric vein followed by dissection extending from the upper border of the pancreas to the splenic hilum through the gastrocolic space. The mesocolon was dissected in a superior-to-inferior and medial-to-lateral fashion and the presacral space was entered by dividing the inferior mesenteric artery. The procedure was completed by dividing all the splenocolic, phrenicocolic, gastrocolic, and pancreaticomesocolic ligaments. Results A total of 43 patients were included in the study, comprising 26 (60.5%) men and 17 (39.5%) women with a mean age of 58.2 ±13.9 (range: 30–87) years. Of the 43 patients, 21 (48.8%) underwent neoadjuvant chemotherapy and a diversion stoma was performed in 37 (86%) patients. No adjacent organ injury occurred intraoperatively. Mean operative time was 271 ±50 min and mean blood loss was 144 ±83 ml. One (2.3%) patient might have developed anastomotic leakage secondary to bevacizumab therapy postoperatively and developed no anastomotic stenosis in the follow-up period. Mean length of hospital stay was 9.3 ±4.3 days and no mortality occurred in any patient. Conclusions Splenic flexure mobilization performed via the superior-to-inferior and medial-to-lateral approach appears to be a safe and feasible procedure.
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Mangano A, Gheza F, Giulianotti PC. Iatrogenic spleen injury during minimally invasive left colonic flexure mobilization: the quest for evidence-based results. MINERVA CHIR 2018; 73:512-519. [DOI: 10.23736/s0026-4733.18.07737-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Mangano A, Fernandes E, Valle V, Bustos R, Gheza F, Giulianotti PC. Iatrogenic spleen injury risk during robotic left colonic and rectal resections by routine left flexure mobilization technique: a retrospective study. MINERVA CHIR 2018; 73:451-459. [PMID: 29806761 DOI: 10.23736/s0026-4733.18.07806-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
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.
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Affiliation(s)
- Alberto Mangano
- Division of General, Minimally Invasive, and Robotic Surgery, University of Illinois at Chicago, Chicago, IL, USA -
| | - Eduardo Fernandes
- Division of General, Minimally Invasive, and Robotic Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Valentina Valle
- Division of General, Minimally Invasive, and Robotic Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Roberto Bustos
- Division of General, Minimally Invasive, and Robotic Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Federico Gheza
- Division of General, Minimally Invasive, and Robotic Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Pier Cristoforo Giulianotti
- Division of General, Minimally Invasive, and Robotic Surgery, University of Illinois at Chicago, Chicago, IL, USA
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Saxena A, Liauw W, Morris DL. Splenectomy is an independent risk factor for poorer perioperative outcomes after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: an analysis of 936 procedures. J Gastrointest Oncol 2017; 8:737-746. [PMID: 28890825 DOI: 10.21037/jgo.2017.07.09] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
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.
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Affiliation(s)
- Akshat Saxena
- UNSW Department of Surgery, St George Hospital, Kogarah, New South Wales, Australia
| | - Winston Liauw
- UNSW Department of Surgery, St George Hospital, Kogarah, New South Wales, Australia
| | - David L Morris
- UNSW Department of Surgery, St George Hospital, Kogarah, New South Wales, Australia
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Inadvertent Splenectomy During Resection for Colorectal Cancer Does Not Increase Long-term Mortality in a Propensity Score Model: A Nationwide Cohort Study. Dis Colon Rectum 2016; 59:1150-1159. [PMID: 27824700 DOI: 10.1097/dcr.0000000000000712] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Previous studies suggest that long-term mortality is increased in patients who undergo splenectomy during surgery for colorectal cancer. The reason for this association remains unclear. OBJECTIVE The purpose of this study was to investigate the association between inadvertent splenectomy attributed to iatrogenic lesion to the spleen during colorectal cancer resections and long-term mortality in a national cohort of unselected patients. DESIGN This was a retrospective, nationwide cohort study. SETTINGS Data were collected from the database of the Danish Colorectal Cancer Group and merged with data from the National Patient Registry and the National Pathology Databank. PATIENTS Danish patients with colorectal cancer undergoing curatively intended resection between 2001 and 2011 were included in the study. MAIN OUTCOME MEASURES The primary outcome was long-term mortality for patients surviving 30 days after surgery. Secondary outcomes were 30-day mortality and risk factors for inadvertent splenectomy. Multivariable and propensity-score matched Cox regression analyses were used to adjust for potential confounding. RESULTS In total, 23,727 patients were included, of which 277 (1.2%) underwent inadvertent splenectomy. There was no association between inadvertent splenectomy and long-term mortality (adjusted HR = 1.15 (95% CI, 0.95-1.40); p = 0.16) in the propensity score-matched model, whereas 30-day mortality was significantly increased (adjusted HR = 2.31 (95% CI, 1.71-3.11); p < 0.001). Inadvertent splenectomy was most often seen during left hemicolectomy (left hemicolectomy vs right hemicolectomy: OR = 24.76 (95% CI, 15.30-40.06); p < 0.001). LIMITATIONS This study was limited by its retrospective study design and lack of detailed information on postoperative complications. CONCLUSIONS Inadvertent splenectomy during resection for colorectal cancer does not seem to increase long-term mortality. The previously reported reduced overall survival after inadvertent splenectomy may be explained by excess mortality in the immediate postoperative period.
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Dagbert F, Thievenaz R, Decullier E, Bakrin N, Cotte E, Rousset P, Vaudoyer D, Passot G, Glehen O. Splenectomy Increases Postoperative Complications Following Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy. Ann Surg Oncol 2016; 23:1980-5. [DOI: 10.1245/s10434-016-5147-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Indexed: 11/18/2022]
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Karip B, Mestan M, Işık Ö, Keskin M, Çelik K, İşcan Y, Memişoğlu K. A solution to the negative effects of splenectomy during colorectal trauma and surgery: an experimental study on splenic autotransplantation to the groin area. BMC Surg 2015; 15:129. [PMID: 26680368 PMCID: PMC4683765 DOI: 10.1186/s12893-015-0105-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Accepted: 10/19/2015] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Bora Karip
- Department of General Surgery, Fatih Sultan Mehmet Training and Research Hospital, Barajyolu Caddesi Flora Evleri, E-15 Yenisehir/Atasehir, PB, 34758, Istanbul, Turkey.
| | - Metin Mestan
- Department of General Surgery, Kütahya Evliya Çelebi Training and Research Hospital, Kütahya, Turkey.
| | - Özgen Işık
- Department of General Surgery, Özel Acıbadem Hospital, Bursa, Turkey.
| | - Metin Keskin
- Department of General Surgery, Istanbul University, Istanbul School of Medicine, Istanbul, Turkey.
| | - Kafkas Çelik
- Department of General Surgery, Fatih Sultan Mehmet Training and Research Hospital, Barajyolu Caddesi Flora Evleri, E-15 Yenisehir/Atasehir, PB, 34758, Istanbul, Turkey.
| | - Yalın İşcan
- Department of General Surgery, Fatih Sultan Mehmet Training and Research Hospital, Barajyolu Caddesi Flora Evleri, E-15 Yenisehir/Atasehir, PB, 34758, Istanbul, Turkey.
| | - Kemal Memişoğlu
- Department of General Surgery, Fatih Sultan Mehmet Training and Research Hospital, Barajyolu Caddesi Flora Evleri, E-15 Yenisehir/Atasehir, PB, 34758, Istanbul, Turkey.
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Liu XD, Chen ZY, Yang P, Huang WG, Jiang CF. Splenectomy attenuates severe thermal trauma-induced intestinal barrier breakdown in rats. ACTA ACUST UNITED AC 2015; 35:868-873. [PMID: 26670438 DOI: 10.1007/s11596-015-1520-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 10/23/2015] [Indexed: 01/24/2023]
Abstract
The severe local thermal trauma activates a number of systemic inflammatory mediators, such as TNF-α, NF-κB, resulting in a disruption of gut barrier. The gastrointestinal tight junction (TJ) is highly regulated by membrane-associated proteins including zonula occludens protein-1 (ZO-1) and occludin, which can be modulated by inflammatory cytokines. As splenectomy has been shown to reduce secretion of cytokines, we hypothesized that (1) severe scald injury up-regulates TNF-α and NF-κB, meanwhile down-regulates expression of ZO-1 and occludin, leading to the increased intestinal permeability, and (2) splenectomy can prevent the burn-induced decrease in ZO-1 and occludin expression, resulting in improved intestinal barrier. Wistar rats undergoing a 30% total body surface area (TBSA) thermal trauma were randomized to receive an accessorial splenectomy meanwhile or not. Intestinal injury was assessed by histological morphological analysis, and serum endotoxin levels, TNF-α, NF-κB, ZO-1 and occludin levels were detected by Western blotting in the terminal ileum mucosal tissue. 30% TBSA burn caused a significant increase in serum endotoxin levels, but NF-κB, and TNF-α, and the average intestinal villus height and mucosal thickness were decreased significantly. Burn injury could also markedly decrease the levels of ZO-1 and occludin in terminal ileum mucosal tissue (all P<0.01). Splenectomy at 7th day after burn significantly reversed the burn-induced breakdown of ZO-1 and occludin (all P<0.01). The results of this study suggest that severe thermal injury damages the intestinal mucosal barrier. Splenectomy may provide a therapeutic benefit in restoring burn-induced intestinal barrier by decreasing the release of inflammatory cytokines and recovering TJ proteins.
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Affiliation(s)
- Xiang-Dong Liu
- Department of Plastic Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiaotong University, Shanghai, 200233, China
| | - Zhen-Yong Chen
- Department of General Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
| | - Peng Yang
- Department of General Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Wen-Guang Huang
- Department of General Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Chun-Fang Jiang
- Department of General Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
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Isik O, Aytac E, Ashburn J, Ozuner G, Remzi F, Costedio M, Gorgun E. Does laparoscopy reduce splenic injuries during colorectal resections? An assessment from the ACS-NSQIP database. Surg Endosc 2014; 29:1039-44. [PMID: 25159632 DOI: 10.1007/s00464-014-3774-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 07/26/2014] [Indexed: 12/01/2022]
Abstract
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.
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Affiliation(s)
- Ozgen Isik
- Department of Colorectal Surgery, Digestive Disease Institute, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
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Riss S, Mittlböck M, Riss K, Chitsabesan P, Stift A. Intraoperative complications have a negative impact on postoperative outcomes after rectal cancer surgery. Int J Surg 2014; 12:833-6. [PMID: 25014647 DOI: 10.1016/j.ijsu.2014.07.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Revised: 05/16/2014] [Accepted: 07/05/2014] [Indexed: 12/14/2022]
Abstract
PURPOSE The impact of intraoperative complications on the postoperative outcome in rectal cancer surgery is only poorly studied in literature. Thus, the aim of the present study was to assess the frequency of intraoperative complications during rectal resections for malignancies and its influence on the short term outcome. MATERIAL AND METHODS We analyzed 605 consecutive patients, who had operations for rectal cancer at a single institution between 1995 and 2010. Retrospective data from the surgical procedure and postoperative course were obtained from the institutional colorectal database and individual chart reviews. Intraoperative complications were recorded and its influence on postoperative course was investigated. RESULTS Intraoperative complications occurred in 66 (10.9%) patients, with injury to the spleen (n = 35 of 66, 53%) being the most frequent complication. Patients with intraoperative complications had a significant longer hospital stay (median: 13 days, range 7-92) compared to patients without complications (median: 12 days, range 2-135; p = 0.0102). In addition, intraoperative complications showed a tendency towards an increased risk for postoperative surgical complications (p = 0.0536), whereas no impact on postoperative medical complications could be found (p = 0.8043). Pulmonary disorders were the only predictive marker for intraoperative complications (p = 0.0247) by univariate analysis. CONCLUSION We found that intraoperative complications during rectal cancer surgery significantly prolonged hospital length stay. The overall morbidity rate was not affected.
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Affiliation(s)
- Stefan Riss
- Medical University of Vienna, Austria, Department of General Surgery, Währinger Gürtel 18-20, A-1090 Vienna, Austria.
| | - Martina Mittlböck
- Center for Medical Statistics, Informatics, and Intelligent Systems, Austria
| | - Katharina Riss
- Medical University of Vienna, Austria, Department of General Surgery, Währinger Gürtel 18-20, A-1090 Vienna, Austria
| | | | - Anton Stift
- Medical University of Vienna, Austria, Department of General Surgery, Währinger Gürtel 18-20, A-1090 Vienna, Austria
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Is concomitant splenectomy beneficial for the long-term survival of patients with gastric cancer undergoing curative gastrectomy? A single-institution study. World J Surg Oncol 2014; 12:193. [PMID: 24969079 PMCID: PMC4226942 DOI: 10.1186/1477-7819-12-193] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Accepted: 08/07/2013] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Curative resection is the treatment of choice for gastric cancer, but it is unclear whether gastrectomy should also include splenectomy. We retrospectively analyzed long-term survival in patients in our hospital who underwent gastrectomy plus splenectomy (G+S) or gastrectomy alone (G-A) for gastric cancer. METHODS We identified 214 patients who underwent surgery with curative intent between 1980 and 2003. Of these, 100 underwent G+S, and 114 underwent G-A. The primary endpoint was 5-year overall survival (OS). RESULTS Median follow-up was 18 months in patients who underwent G+S, and 26.5 months in patients who underwent G-A. The 5-year OS rate was significantly higher in patients who underwent G-A (33.8%; 95% CI 24.2 to 43.4%) than in those who underwent G+S (28.8%; 95% CI 19.6 to 38.0%) (log-rank test, P=0.013). CONCLUSIONS Splenectomy does not benefit patients undergoing gastrectomy for gastric cancer. Routine splenectomy should be abandoned in patients undergoing radical resections for gastric cancer.
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Steinert R, Depel M, Schmidt A, Ptok H, Meyer F, Wolff S, Otto R, Gastinger I. [Iatrogenic splenic injuries in surgery of colorectal carcinoma: impact on the oncological long-term of outcome]. Chirurg 2014; 85:812-7. [PMID: 24519612 DOI: 10.1007/s00104-013-2697-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- R Steinert
- An-Institut für Qualitätssicherung in der operativen Medizin gGmbH an der Otto-von-Guericke-Universität, Leipziger Str. 44, 39120, Magdeburg, Deutschland
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Kosuta M, Cosola D, de Manzini N. Intraoperative Accidents. Updates Surg 2013. [DOI: 10.1007/978-88-470-2670-4_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Merchea A, Dozois EJ, Wang JK, Larson DW. Anatomic mechanisms for splenic injury during colorectal surgery. Clin Anat 2011; 25:212-7. [PMID: 21800366 DOI: 10.1002/ca.21221] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2011] [Revised: 05/19/2011] [Accepted: 05/23/2011] [Indexed: 11/08/2022]
Abstract
Intraoperative iatrogenic splenic injury during colorectal surgery is rare but may cause significant morbidity. We aimed to describe the anatomic mechanisms of iatrogenic injury to the spleen during colonic surgery. All adult surgical patients who sustained a splenic injury during colectomy at our institution from 1992 to 2007 were retrospectively identified. The operative and pathologic reports were reviewed, and anatomic details of the injuries were collected. Results are reported as a proportion or median, with range reported in brackets. Of 13,897 colectomies, 71 splenic injuries among 58 patients were identified. Splenic flexure colonic mobilization occurred in 53 (91%) of these patients. The median number of tears was 1 (1-3). The average length of tear was 4.59 cm. The distribution of injury location on the spleen was 24 (34%) inferior, 14 (20%) hilar, 3 (4%) posterior, 2 (3%) lateral, and 1 (1%) superior. Three (4%) patients suffered from splenic rupture. The location of 24 (34%) injuries was not described. Capsular tears were the cause of splenic injury in 55 (95%) patients. Intraoperative splenic injury ultimately resulted in splenectomy in 44 (76%) patients. Splenic injury was a delayed finding requiring reoperation in 4 (7%) patients. The primary mechanism of intraoperative splenic injury during colectomy is capsular tears and lacerations secondary to misplaced traction and tension on the spleen during colonic mobilization. Techniques to lessen these forces may decrease the number of injuries and subsequent splenectomy.
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Affiliation(s)
- Amit Merchea
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Kirchhoff P, Clavien PA, Hahnloser D. Complications in colorectal surgery: risk factors and preventive strategies. Patient Saf Surg 2010; 4:5. [PMID: 20338045 PMCID: PMC2852382 DOI: 10.1186/1754-9493-4-5] [Citation(s) in RCA: 247] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2009] [Accepted: 03/25/2010] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Open or laparoscopic colorectal surgery comprises of many different types of procedures for various diseases. Depending upon the operation and modifiable and non-modifiable risk factors the intra- and postoperative morbidity and mortality rate vary. In general, surgical complications can be divided into intraoperative and postoperative complications and usually occur while the patient is still in the hospital. METHODS A literature search (1980-2009) was carried out, using MEDLINE, PubMed and the Cochrane library. RESULTS This review provides an overview how to identify and minimize intra- and postoperative complications. The improvement of different treatment strategies and technical inventions in the recent decade has been enormous. This is mainly attributable to the increase in the laparoscopic approach, which is now well accepted for many procedures. Training of the surgeon, hospital volume and learning curves are becoming increasingly more important to maximize patient safety, surgeon expertise and cost effectiveness. In addition, standardization of perioperative care is essential to minimize postoperative complications. CONCLUSION This review summarizes the main perioperative complications of colorectal surgery and influencable and non-influencable risk factors which are important to the general surgeon and the relevant specialist as well. In order to minimize or even avoid complications it is crucial to know these risk factors and strategies to prevent, treat or reduce intra- and postoperative complications.
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Affiliation(s)
- Philipp Kirchhoff
- Department of Visceral and Transplantation Surgery, University Hospital of Zürich, Switzerland.
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Cahill R, Leroy J, Marescaux J. Localized resection for colon cancer. Surg Oncol 2009; 18:334-42. [DOI: 10.1016/j.suronc.2008.08.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2008] [Revised: 07/28/2008] [Accepted: 08/20/2008] [Indexed: 12/12/2022]
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Fujita T. Why does splenectomy adversely affect the outcomes of colorectal cancer surgery? Dis Colon Rectum 2008; 51:1440; author reply 1441-2. [PMID: 18521672 DOI: 10.1007/s10350-008-9387-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2008] [Accepted: 03/24/2008] [Indexed: 02/08/2023]
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