Laparoscopic splenectomy as a definitive management option for high-grade traumatic splenic injury when non operative management is not feasible or failed: a 5-year experience from a level one trauma center with minimally invasive surgery expertise

The safety and feasibility of laparoscopic partial splenectomy: analysis of perioperative indications from different vascular subtypes and improvement of surgical approach

INTRODUCTION

While laparoscopic splenectomy (LS) has been widely used in benign splenic tumor, more concerns have been raised for postoperatively short-term and long-term complications. Laparoscopic partial splenectomy (LPS) is a surgical option, to preserve splenic function, and reduce postoperative complications. The aim of our study was to retrospectively identify the safety and feasibility of LPS compared with LS in patients with splenic benign tumor.

MATERIALS AND METHODS

From 2014 to 2024, a total of 165 patients diagnosed with occupational splenic lesions underwent splenectomy, of whom 87 underwent LPS and 78 underwent LS. We compare the perioperative parameters and long term follow up between these two groups.

RESULTS

The etiology of splenic space-occupying lesions was nonparasitic splenic cysts, followed by splenic lymphangioma and splenic hemangioma. Of the patients with LPS, 55 underwent conventional surgery with blockage of the splenic arterial branch and resection along the ischemic line (RAIL), and 32 underwent with our modified total splenic blood supply blockade followed by resection alone the tumor edge (RATE). The tumor size, the operative time and estimated blood loss were comparable between the LPS and LS groups. One patient developed abnormal signs during the LPS procedure and was promptly referred for LS. The LPS group had fewer pancreatic leakage, incision infection, and pulmonary infection. As for different vascular types, patients with LS under all branches of the splenic artery had a longer time to resume postoperative feeding. As for the comparison of RAIL and RATE, estimated blood and operative time were significantly reduced in patients receiving RATE. Postoperative complications were the same in patients underwent each surgical procedures.

CONCLUSION

LPS is a viable approach for patients with splenic benign tumor. We introduce the tumor artery supply types to indicate the resection region. Our RATE technique has proven to be clinically effective and safety.

Current use of artificial intelligence in the diagnosis and management of acute appendicitis

INTRODUCTION

Acute appendicitis is a common and time-sensitive surgical emergency, requiring rapid and accurate diagnosis and management to prevent complications. Artificial intelligence (AI) has emerged as a transformative tool in healthcare, offering significant potential to improve the diagnosis and management of acute appendicitis. This review provides an overview of the evolving role of AI in the diagnosis and management of acute appendicitis, highlighting its benefits, challenges, and future perspectives.

EVIDENCE ACQUISITION

We performed a literature search on articles published from 2018 to September 2023. We included only original articles.

EVIDENCE SYNTHESIS

Overall, 121 studies were examined. We included 32 studies: 23 studies addressed the diagnosis, five the differentiation between complicated and uncomplicated appendicitis, and 4 studies the management of acute appendicitis.

CONCLUSIONS

AI is poised to revolutionize the diagnosis and management of acute appendicitis by improving accuracy, speed and consistency. It could potentially reduce healthcare costs. As AI technologies continue to evolve, further research and collaboration are needed to fully realize their potential in the diagnosis and management of acute appendicitis.

To the point: Utility of laparoscopy for operative management of stabbing abdominal trauma

BACKGROUND

Algorithms for managing penetrating abdominal trauma are conflicting or vague regarding the role of laparoscopy. We hypothesized that laparoscopy is underutilized among hemodynamically stable patients with abdominal stab wounds.

METHODS

Trauma Quality Improvement Program data (2016-2019) were used to identify stable (SBP ≥110 and GCS ≥13) patients ≥16yrs with stab wounds and an abdominal procedure within 24hr of admission. Patients with a non-abdominal AIS ≥3 or missing outcome information were excluded. Patients were analyzed based on index procedure approach: open, therapeutic laparoscopy (LAP), or LAP-conversion to open (LCO). Center, clinical characteristics and outcomes were compared according to surgical approach and abdominal AIS using non-parametric analysis.

RESULTS

5984 patients met inclusion criteria with 7 ​% and 8 ​% receiving therapeutic LAP and LCO, respectively. The conversion rate for patients initially treated with LAP was 54 ​%. Compared to conversion or open, therapeutic LAP patients had better outcomes including shorter ICU and hospital stays and less infection complications, but were younger and less injured. Assessing by abdominal AIS eliminated ISS differences, meanwhile LAP patients still had shorter hospital stays. At time of admission, 45 ​% of open patients met criteria for initial LAP opportunity as indicated by comparable clinical presentation as therapeutic laparoscopy patients.

CONCLUSIONS

In hemodynamically stable patients, laparoscopy remains infrequently utilized despite its increasing inclusion in current guidelines. Additional opportunity exists for therapeutic laparoscopy in trauma, which appears to be a viable alternative to open surgery for select injuries from abdominal stab wounds.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

Cesena guidelines: WSES consensus statement on laparoscopic-first approach to general surgery emergencies and abdominal trauma

BACKGROUND

Laparoscopy is widely adopted across nearly all surgical subspecialties in the elective setting. Initially finding indication in minor abdominal emergencies, it has gradually become the standard approach in the majority of elective general surgery procedures. Despite many technological advances and increasing acceptance, the laparoscopic approach remains underutilized in emergency general surgery and in abdominal trauma. Emergency laparotomy continues to carry a high morbidity and mortality. In recent years, there has been a growing interest from emergency and trauma surgeons in adopting minimally invasive surgery approaches in the acute surgical setting. The present position paper, supported by the World Society of Emergency Surgery (WSES), aims to provide a review of the literature to reach a consensus on the indications and benefits of a laparoscopic-first approach in patients requiring emergency abdominal surgery for general surgery emergencies or abdominal trauma.

METHODS

This position paper was developed according to the WSES methodology. A steering committee performed the literature review and drafted the position paper. An international panel of 54 experts then critically revised the manuscript and discussed it in detail, to develop a consensus on a position statement.

RESULTS

A total of 323 studies (systematic review and meta-analysis, randomized clinical trial, retrospective comparative cohort studies, case series) have been selected from an initial pool of 7409 studies. Evidence demonstrates several benefits of the laparoscopic approach in stable patients undergoing emergency abdominal surgery for general surgical emergencies or abdominal trauma. The selection of a stable patient seems to be of paramount importance for a safe adoption of a laparoscopic approach. In hemodynamically stable patients, the laparoscopic approach was found to be safe, feasible and effective as a therapeutic tool or helpful to identify further management steps and needs, resulting in improved outcomes, regardless of conversion. Appropriate patient selection, surgeon experience and rigorous minimally invasive surgical training, remain crucial factors to increase the adoption of laparoscopy in emergency general surgery and abdominal trauma.

CONCLUSIONS

The WSES expert panel suggests laparoscopy as the first approach for stable patients undergoing emergency abdominal surgery for general surgery emergencies and abdominal trauma.

Pancreatic Ductal Adenocarcinoma: Update of CT-Based Radiomics Applications in the Pre-Surgical Prediction of the Risk of Post-Operative Fistula, Resectability Status and Prognosis

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) is the seventh leading cause of cancer-related deaths worldwide. Surgical resection is the main driver to improving survival in resectable tumors, while neoadjuvant treatment based on chemotherapy (and radiotherapy) is the best option-treatment for a non-primally resectable disease. CT-based imaging has a central role in detecting, staging, and managing PDAC. As several authors have proposed radiomics for risk stratification in patients undergoing surgery for PADC, in this narrative review, we have explored the actual fields of interest of radiomics tools in PDAC built on pre-surgical imaging and clinical variables, to obtain more objective and reliable predictors.

METHODS

The PubMed database was searched for papers published in the English language no earlier than January 2018.

RESULTS

We found 301 studies, and 11 satisfied our research criteria. Of those included, four were on resectability status prediction, three on preoperative pancreatic fistula (POPF) prediction, and four on survival prediction. Most of the studies were retrospective.

CONCLUSIONS

It is possible to conclude that many performing models have been developed to get predictive information in pre-surgical evaluation. However, all the studies were retrospective, lacking further external validation in prospective and multicentric cohorts. Furthermore, the radiomics models and the expression of results should be standardized and automatized to be applicable in clinical practice.

Revitalize splenic functions. Following a splenectomy for trauma, a small amount of splenic autotransplantation was performed

INTRODUCTION

The spleen is a responsible significant part of the immune system; after Splenectomy following trauma, the immune system changes; splenic autotransplantation can preserve the immune system after trauma and Splenectomy.

BACKGROUND

Patients can be protected from immune dysfunction by autotransplanting splenic tissues after splenectomy following trauma because their immune systems and spleens are changed. Patients can gain their immune function after splenic autotransplantation.

METHODS

Patient classification methods are into three categories, Group A, 6 cases with auto-translation; Group B, 6 cases without transplantation; Group C, seven regular people serving as the control.

AIM OF WORK

The aim of the work is not to compare outcome methods or compare types of autotransplantation; This work aims to document postoperative radiological, immunological, clinical, and hematological investigations. We concentrated on the results of investigations more than the types of operation or approach or types of autotransplantation.

RESULTS

We showed that, after comparing each group with normal individuals subjects, patients who did not undergo autotransplantation had significantly higher platelet counts, a more significant percentage of micronucleated reticulocytes, increased levels of naive B lymphocytes, changes in class-switched memory and class-unswitched memory B cells, and higher levels of PD1 on CD8 + T lymphocytes. Nevertheless, neither splenic autotransplant patients nor the average general population showed any appreciable variations in any of the parameters.

CONCLUSIONS

Spleen's activities with adequate hemocatheter activity and recovery of the immunological deficit after splenic autotransplantation.

[Blunt abdominal trauma in children and adolescents: treatment concepts in the acute phase]

Fatal accidents due to blunt force trauma are the leading cause of death in children and adolescents [1]. Abdominal trauma is the third most common cause of death after traumatic brain injury and thoracic injuries [2]. Abdominal injury is seen in approximately 2-5% of children involved in accidents [3]. Blunt abdominal injuries are common sequelae of traffic accidents (for example as seat belt injury), falls, and sports accidents. Penetrating abdominal injuries are rare in central Europe. Spleen, liver, and kidney lacerations are the most common injuries after blunt abdominal trauma [4]. In most situations, nonoperative management (NOM) has become the gold standard with the surgeon leading the multidisciplinary treatment [5].

The role of laparoscopic splenectomy in traumatic splenic injury: a narrative review

INTRODUCTION

Splenic injuries are one of the commonest occurrences in abdominal trauma. Nonoperative management (NOM) is the treatment of choice in hemodynamically stable patients with low grade injuries in the absence of vascular injury on CT; however, in some cases, NOM can fail and surgery is required. Traditionally, splenectomy is performed via laparotomy but, recently, the use of laparoscopy is rapidly increasing because the numerous advantages it offers for selected trauma patients.

EVIDENCE ACQUISITION

A systematic review of the literature was performed through Medline for papers on the laparoscopic splenectomy (LS) in trauma patients, published from January 2006 to July 2022. The inclusion criteria were the study population consisted of hemodynamically stable adult patients treated with LS, as primary treatment or in case of complication or failure of NOM. The data extracted included gender, patient age, type of trauma, ISS, indication for LS and if LS was performed primary or secondary to NOM. The considered outcomes were operative time, length of stay, morbidity and mortality.

EVIDENCE SYNTHESIS

Eight papers were considered suitable for the study and all the articles were retrospective studies and only one of them was multicentered. A total of 202 patients were included in the study and all of these suffered splenic trauma and all patients were hemodynamically stable or responding to fluid resuscitation. Trauma mechanism was blunt in 92.9% of cases and penetrating in 7%. Twenty-one patients underwent LS after failure of angioembolization. Operative time of LS was reported in 6 papers and the mean was 130.7 mins. Length of stay was reported in 7 papers and the mean was 8.12 days. Overall morbidity was 7.7% and the postoperative mortality was cited in 6 articles with an overall percentage of 2.5%.

CONCLUSIONS

Laparoscopy should be considered a valid alternative to open surgery, in hemodynamically stable patients and when performed by an experienced surgeon, such as the minimally invasive trauma surgeon.

Laparoscopy vs. Laparotomy for the Management of Abdominal Trauma: A Systematic Review and Meta-Analysis

Background

There is still no consensus regarding the role of laparoscopy in trauma cases. The purpose of this paper is to assess the value of diagnostic and therapeutic laparoscopy for patients with blunt or penetrating abdominal trauma by performing a systematic review and meta-analysis.

Methods

PubMed, Embase, and the Cochrane library were systemically searched for the randomized controlled trials (RCTs) and non-RCT comparative studies on effectiveness and safety of laparoscopy vs. laparotomy for the two authors independently performed the search, data extraction, and quality assessment.

Results

A total of 5,517 patients were enrolled in 23 eligible studies that were published in English. Meta-analysis results suggest that there is no significant difference in the incidence of missed injury and mortality between abdominal trauma patients receiving laparoscopy and those receiving laparotomy. Concerning postoperative complications, compared with patients in the open surgery group, those in the laparoscopy group are at a similar risk of intra-abdominal abscesses, thromboembolism, and ileus, while there is a decreased incidence of wound infection and pneumonia. Besides, patients in the laparoscopy group experience shorter hospitalization times and procedure times. For most outcomes, the sensitivity analysis yielded similar results to the primary analysis.

Conclusion

Laparoscopic surgery is a practical alternative to laparotomy for appropriate patients. The decision to perform laparoscopy should be based on the experience of the surgeon and the resources available.

Infectious outcomes after splenectomy for trauma, splenectomy for disease and splenectomy with distal pancreatectomy

Introduction

The spleen provides a unique immune function in its production of opsins directed against encapsulated bacteria. Splenectomy, therefore, increases the risk of infections in patients as well as post-operative complications. This study aims to assess the risk of post-operative complications within 5 years of splenectomy by indication for splenectomy: trauma, disease, or in association with a distal pancreatectomy for pancreatic disease. The relationship between vaccination and infectious outcomes was also investigated.

Methods

This study is a review of splenectomy cases between June 2005 and June 2015 at a single institution. Infection, splenectomy indication, and vaccination history were identified from electronic medical records and lab test confirmations. Data was analyzed using Student’s t test for continuous variables, the Mann–Whitney U test for ordinal variables, and a Chi-square/Fisher exact test for categorical variables.

Results

A total of 106 splenectomy patients were included: 35 traumatic (74% male) and 71 non-traumatic causes (42% male) with no significant difference in age. There were no statistical differences in complications during splenectomy and vaccination administration between the splenectomy indication groups: trauma, disease, and with distal pancreatectomy. There was a statistically significant higher infection rate within 5 years post-splenectomy in the non-traumatic vs traumatic group (42% vs 14.0%, p = 0.0040) with majority gastrointestinal (7/38) and respiratory (5/38) and surgical wound infections (3/38) observed in non-traumatic versus traumatic, respectively.

Conclusion

Results from data analysis show a statistically significant difference in rates of infection within 5 years post-operatively between traumatic versus non-traumatic indications for splenectomies, with the non-traumatic group experiencing a higher rate of infectious outcomes. The non-traumatic group included patients with disease and distal pancreatectomy indications. This suggests that patients who have non-traumatic causes may be at a higher risk of developing infections following splenectomy procedure. Additionally, vaccinations did not appear to have a protective effect.