Laparoscopic splenectomy for second-line treatment of immune thrombocytopenia – analysis of 53 patients and current perspectives

Evaluating the Effectiveness of Laparoscopic Removal of an Accessory Spleen After a Failed Splenectomy for Immune Thrombocytopenia

Immune thrombocytopenic purpura (ITP) is a challenging condition to manage especially when conventional treatment methods, including splenectomy, fail. This report evaluates the effectiveness of laparoscopic removal of accessory spleen for chronic refractory ITP after an initial splenectomy. A 73-year-old African American male with a history of ITP, previously treated with laparoscopic splenectomy nine years ago, presented with severe thrombocytopenia that was found to be refractory to medical therapies. Platelet counts were monitored, and the absence of Howell-Jolly bodies was noted in the peripheral blood smear. Imaging studies over the past eight years indicated the growth of a mass in the left upper abdomen, suggesting a possible accessory spleen. Given the overwhelming evidence of a splenule in refractory thrombocytopenia, laparoscopic exploration and mass removal were conducted. Histologic analysis of the removed mass confirmed a splenule. Despite the complete removal of the mass, postoperative platelet counts remained consistently low and unresponsive to the resumption of medical therapies. This study emphasizes the limitations of accessory splenectomy for refractory ITP and highlights the need for further research to clarify the long-term effectiveness of this surgical procedure in these patients.

Laparoscopic Resection of a Left Upper Quadrant Mass Leading to a Surprise Diagnosis

Background. Resplenectomy is most commonly done for the treatment of recurrent idiopathic thrombocytopenic purpura (ITP) refractory to medical management due to the regrowth of a missed accessory spleen. Case Report. A 66-year-old male had undergone open splenectomy for traumatic rupture 40 years ago. He presented with a leiomyosarcoma of his leg, which was surgically removed. When he developed metastatic disease, chemotherapy was started. He developed left upper quadrant pain, and on CT scan, a 5 cm mass compatible with a sarcoma was found between the tail of the pancreas and the left adrenal gland. During laparoscopy, dense adhesion of the omentum to the abdominal wall and the stomach from his previous splenectomy was divided. The lesser sac was opened through the gastrocolic ligament, and the splenic flexure was taken down. Superior and dorsal to the tail of the pancreas next to the left adrenal gland, the mass was identified and carefully dissected out. The vascular pedicle, which originated from a side branch of the splenic vessels at the tail of the pancreas, was stapled. The gastric fundus showed multiple nodules, and therefore, a modified sleeve gastrectomy was done; also, a 2 cm nodule in segment 5 of the liver and an omental nodule were removed. The tumors and gastrectomy specimen were placed in an endobag and removed through a periumbilical mini-incision. The patient recovered without any complications from the procedure and his LUQ pain resolved. Pathology revealed no sarcoma metastases but accessory spleens in all specimens. Discussion. Splenosis with multiple implants within the abdomen after splenectomy for trauma is a rare condition. In our patient, this seems to have been triggered by chemotherapy for his sarcoma resulting in extramedullary hemopoiesis. Laparoscopic removal of accessory spleens can be safely done.

Validation of a Difficulty Grading Score in Laparoscopic Splenectomy

INTRODUCTION

Laparoscopic splenectomy (LS) is the gold standard for the treatment of many spleen-related disorders. However, in the presence of splenomegaly, the rate of conversion to open surgery can be as high as 33.9% and is associated with longer operative times and higher costs. In an attempt to improve risk stratification and patient selection for LS, a score that includes four preoperative parameters (age, gender, diagnosis, and spleen size) has been developed. The aim was the validation of a difficulty grading score, in predicting conversion and poorer outcomes.

METHODS

Retrospective analysis of 153 consecutive patients subjected to LS from January 2006 through December 2016 was performed. Several parameters were reviewed and correlation with evaluated outcomes was analyzed.

RESULTS

Conversion to open surgery occurred in 13 (8.50%) patients and was highly associated with serious intraoperative complications. Spearman correlation showed a significant association between the score and risk of conversion, operative time, and postoperative complications, but not with intraoperative bleeding.

DISCUSSION

Patient and disease features, incorporated in a difficulty grading score, can reliably determine the difficulty of LS and predict risk of conversion, intraoperative, and postoperative complications. This simple and reproducible score improves risk stratification for LS and could be practical in daily clinical activities.