Institutional experience with laparoscopic partial splenectomy for hereditary spherocytosis

Long-term haematological response and maintained immunological function after laparoscopic subtotal splenectomy in patients with hereditary spherocytosis

INTRODUCTION

Subtotal or total splenectomy are recommended in severe and should be considered in intermediate forms of hereditary spherocytosis (HS). Data on laparoscopic subtotal splenectomy (LSTS) in HS patients are sparse.

METHODS

Thirty three patients with HS (median age 10.7 years (yrs), range 1.8-15.5) underwent LSTS. Baseline and follow-up investigation included haematological parameters, microscopic analysis of pitted erythrocytes (pitE), and B-cell subpopulations assessed by flow cytometry. Results were compared to those of non-splenectomised HS patients, HS patients after total splenectomy (TS), and healthy individuals.

RESULTS

After LSTS, haemoglobin levels were normalised in all patients. During median long-term follow-up of 3.9 yrs (range 1.1-14.9), only four patients presented mild anaemia. Despite re-growing of the remnant spleen none of the patients required a second surgical intervention. As compared to TS, PitE in LSTS patients were significantly lower and indicated normal to only moderately decreased spleen function. Relative but not absolute IgM memory B-cell counts were reduced in both LSTS and TS patients.

CONCLUSIONS

LSTS is effective for the treatment of patients with HS. A small remnant spleen is sufficient to provide adequate phagocytic function and to induce a pool of IgM memory B-cells.

Clinical effect of laparoscopic partial splenectomy for both benign tumours and trauma-10 years of experience at a single institution

BACKGROUND

This retrospective study aimed to present our surgical experience in patients with benign tumour or trauma in spleen who underwent laparoscopic partial splenectomy (LPS) and to compare the results with those of patients who underwent an open partial splenectomy (OPS).

METHODS

We analysed the medical data of patients who underwent LPS or OPS between January 2010 and January 2020.

RESULTS

In total, 41 patients were enrolled. Nine patients underwent open surgery, 32 patients underwent laparoscopic surgery. The proportion of patients with tumours in the upper pole in LPS group was more than patients in OPS group. No difference was observed in estimated blood loss, allogeneic transfusion, postoperative stay, pathology and complications between LPS and OPS groups. The operation time in the LPS group (137.5 ± 30.8 min) was longer than that in the OPS group (88.3 ± 30.1 min) for patients with splenic traumatic rupture (P = 0.019).

CONCLUSIONS

LPS is an effective and safe spleen-preserving surgery as OPS. The advantages are small trauma, light pain and quick recovery. It is suitable for patients with benign tumours or trauma confined to one side of the spleen.

Minimally Invasive Partial Spleen Resection Preserving the Lower Pole in Children: A Technical Report on Feasibility and Safety

Background: Laparoscopic partial splenectomy is a surgical option for removing part of the spleen with a pathological mass in a way that ensures preservation of the spleen's physiological functions. We aimed to evaluate the efficacy and feasibility of this procedure, performed while preserving the blood supply from the left gastroepiploic artery, in children. Materials and Methods: Following institutional review board approval, this retrospective study was conducted on patients who, between January 2015 and December 2019, underwent laparoscopic partial splenectomy with preservation of blood supply from the left gastroepiploic vessels. In the article, we described patient indications for surgery, surgical technique, surgery time, complications, and follow-up outcomes. Results: Eleven patients (mean age: 12.3 ± 3.4 years) underwent laparoscopic partial splenectomy. Indications for surgery included nonparasitic cysts (n = 8), pseudocysts (n = 2), and hamartomas (n = 1). The mean benign mass diameter was 60 ± 22 mm. The mean operative time was 193.2 ± 55.1 minutes. The mean size of the retained lower pole was 31.1% ± 3.8%. There was no conversion to open splenectomy or any significant complication. The mean postoperative stay was 9 ± 0.7 days. No thrombosis of the splenic and portal veins was noted in the follow-up period, and no splenic remnant infarction occurred. Conclusions: Laparoscopic partial splenectomy with preservation of blood supply arising from the left gastroepiploic vessels seems to be safe in children. However, a larger study is needed to confirm our results.

Partial splenectomy in children: Long-term reoperative outcomes☆

PURPOSE

Partial, or subtotal, splenectomy (PS) has become an accepted alternative to total splenectomy (TS) for management of hematologic disorders in children, but little is known about its long-term outcomes. Here, we present our institutional experience with partial splenectomy, to determine rate of subsequent TS or cholecystectomy and identify if any factors affected this need.

METHODS

All patients who underwent partial splenectomy at a single tertiary children's hospital were retrospectively reviewed from 2002 through 2019 after IRB approval. Primary outcome of interest was rate of reoperation to completion splenectomy (CS) and rate of cholecystectomy. Secondary outcome were positive predictor(s) for these subsequent procedures.

RESULTS

Twenty-four patients underwent PS, at median age 6.0 years, with preoperative spleen size of 12.7 cm by ultrasound. At median follow up time of 8.0 years, 29% of all patients and 24% of hereditary spherocytosis (HS) patients underwent completion splenectomy at median 34 months and 45 months, respectively. Amongst HS patients who did not have a cholecystectomy with or prior to PS, 39% underwent a delayed cholecystectomy following PS. There were no significant differences in age at index procedure, preoperative splenic volume, weight of splenic specimen removed, transfusion requirements, preoperative or postoperative hematologic parameters (including hemoglobin, hematocrit, total bilirubin, and reticulocyte count) amongst patients of all diagnoses and HS only who underwent PS alone compared to those who went on to CS. There were no cases of OPSS or deaths.

CONCLUSION

Partial splenectomy is a safe alternative to total splenectomy in children with hematologic disease with theoretical decreased susceptibility to OPSS. However, families should be counseled of a 29% chance of reoperation to completion splenectomy, and, in HS patients, a 39% chance of delayed cholecystectomy if not performed prior to or with PS. Further studies are needed to understand predictors of these outcomes.

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 using the harmonic scalpel for parenchymal transection: two case reports and review of the literature

Laparoscopic splenectomy is nowadays widely performed for the treatment of benign and malignant diseases of the spleen. However, removing the spleen increases the risk of postoperative infections, therefore patients need long-life antibiotics. Advancement in surgical technique and instrumentation have led to the development of partial splenectomy, which is mainly indicated to treat localized lesions of the spleen. The main advantage is the preservation of the immune function, so that long-life prescription of antibiotics is no longer needed. The introduction of the laparoscopic approach to laparoscopic splenectomy seems to add further benefits, namely a faster recovery. We report two cases of benign splenic cysts, which were treated by laparoscopic partial splenectomy. Technical aspects on the parenchymal transection and data from the most recent literature are discussed as well.

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.

Laparoscopic Partial Splenectomy: A Safe and Feasible Treatment for Splenic Benign Lesions

PURPOSE

The purpose of this study was to explore the safety and feasibility of laparoscopic partial splenectomy in treating splenic benign lesions (SBL).

MATERIALS AND METHODS

A total of 16 SBL patients clearly diagnosed before surgery (8 cases of splenic cysts, 5 cases of splenic lymphangioma, and 3 cases of splenic hemangioma) underwent 2D or 3D laparoscopic partial splenectomy from October 2013 to August 2016. The diameters of the SBL were 5 to 17 cm with an average of 8.7 cm; 12 cases were located in the upper pole of the spleen, and 4 cases were located in the lower pole of the spleen.

RESULTS

All 16 patients successfully completed laparoscopic partial splenectomy, and no patients required conversion to an open operation. There were 3 cases of resection using the 3D laparoscope. There were 14 cases of resection of half of the spleen and 2 cases of partial resection of the lower spleen. The operation time was 110 to 195 minutes with an average time of 157 minutes. The amount of intraoperative blood loss was 80 to 200 mL, and no patients required blood transfusion. The postoperative abdominal drainage time was 3 to 5 days, and no abdominal bleeding, pancreatic leakage, subphrenic infection, or other complications occurred; the postoperative hospital stay lasted 5 to 6 days.

CONCLUSIONS

Laparoscopic partial splenectomy is safe and feasible for the treatment of splenic benign lesions.

A long-term follow-up study of subtotal splenectomy in children with hereditary spherocytosis

BACKGROUND

Hereditary spherocytosis (HS) is a heterogeneous hemolytic anemia treated with splenectomy in patients suffering from severe or moderate disease. Total splenectomy, however, renders patients vulnerable to overwhelming postsplenectomy infection despite preventive measures. Although subtotal splenectomy has been advocated as an alternative to total splenectomy, long-term follow-up data are scarce. We investigated how often hematologic recurrences requiring secondary total splenectomy occurred.

PROCEDURE

With a follow-up of at least 5 years, we analyzed the data of 12 patients, aged 11 years maximum (median 6.5 years), who had undergone intended subtotal splenectomy, and 9 patients (median age 11.9 years), who had undergone total splenectomy. We compared their hematologic results and searched for factors associated with secondary spleen surgery.

RESULTS

Hemolysis was reduced after subtotal splenectomy and absent after total splenectomy. Subtotal splenectomy was not successful in three children because no functional splenic remnant remained after 6 months (one conversion at surgery; one necrosis of splenic remnant; one early secondary splenectomy). Four children required secondary splenectomy after a median of 5 years for hematologic recurrence. In the remaining five patients, a functional splenic remnant was present for at least 5.5 years. The median time to secondary total splenectomy after intended subtotal splenectomy was 5.2 years. In all patients requiring secondary total splenectomy, increased reticulocyte levels within 2 years indicated hematologic recurrence.

CONCLUSIONS

Subtotal splenectomy can be an alternative for total splenectomy in young patients with HS. It allows for hematologic improvement and may preserve splenic immune function for as many as 5 years.

Indications and outcome of splenectomy in hematologic disease

Splenectomy is part of the therapeutic arsenal for benign or malignant hematological disorders that constitute the main indication for elective splenectomy. With the development of minimally invasive approaches, and in particular, laparoscopy, as well as the advent of monoclonal antibody therapy, the indications and the outcomes of splenectomy for hematologic disease have changed in recent years. Nonetheless, splenectomy has its place in hemoglobinopathies and hemolytic diseases, improves thrombocytopenia in refractory immune thrombocytopenic purpura, can reverse sequelae linked to voluminous splenomegaly secondary to myelofibrosis, or can be used for diagnostic purposes or for splenomegaly in lymphoproliferative syndromes.

Recommendations regarding splenectomy in hereditary hemolytic anemias

Hereditary hemolytic anemias are a group of disorders with a variety of causes, including red cell membrane defects, red blood cell enzyme disorders, congenital dyserythropoietic anemias, thalassemia syndromes and hemoglobinopathies. As damaged red blood cells passing through the red pulp of the spleen are removed by splenic macrophages, splenectomy is one possible therapeutic approach to the management of severely affected patients. However, except for hereditary spherocytosis for which the effectiveness of splenectomy has been well documented, the efficacy of splenectomy in other anemias within this group has yet to be determined and there are concerns regarding short- and long-term infectious and thrombotic complications. In light of the priorities identified by the European Hematology Association Roadmap we generated specific recommendations for each disorder, except thalassemia syndromes for which there are other, recent guidelines. Our recommendations are intended to enable clinicians to achieve better informed decisions on disease management by splenectomy, on the type of splenectomy and the possible consequences. As no randomized clinical trials, case control or cohort studies regarding splenectomy in these disorders were found in the literature, recommendations for each disease were based on expert opinion and were subsequently critically revised and modified by the Splenectomy in Rare Anemias Study Group, which includes hematologists caring for both adults and children.

Feasibility and safety of emergency laparoscopic partial splenectomy: A retrospective analysis

The increased awareness of asplenia-related life-threatening complications has led to the development of parenchyma sparing splenic resections in past few years. The aim of this study is to retrospectively analyze the feasibility and safety of laparoscopic partial splenectomy (LPS) in selected emergency patients.From January 2013 to December 2015, there were 46 emergency patients, diagnosed with splenic rupture, admitted in our department. Selection criteria for LPS: (1) Preoperative CT scan revealed single pole rupture without spleen pedicle injury; (2) BP>90/60 mm Hg and heart rates <120 bpm; (3) No sigh of multiple organ injury. Eventually, LPS was performed in 21 patients (Group LPS), while laparoscopic splenectomy (LS) was performed in 20 patients (Group LS).The main cause of splenic rupture was traffic accident, followed by blunt injury and high falling injury. Abdominal CT scan showed the mean longitudinal diameter of spleen of group LPS was 14.2 ± 1.8 cm (range 12-17 cm), while the size of remnant spleen was 5.5 ± 1.2 cm. Between 2 groups, operation time (LPS: 122.6 ± 17.2 min vs LS: 110.5 ± 18.7 minutes, P = .117), and intraoperative blood loss (LPS: 174 ± 22 mL vs LS: 169 ± 29 mL, P = .331) were similar. There were 2 patients suffered subsequent unstable vital sign altering during mobilization when performing LPS. Conversion to LS (2/21, 9.52%) was decided and successfully completed. Although there was no patient suffered postoperative OPSI or thrombocytosis events in both groups after 6-month follow-up, the mean platelets and leukocyte count were significantly lower in group LPS. Splenic regrowth was evaluated in 20 patients of group LPS. And the mean regrowth of splenic volume reached 19% (10%-26%).Due to its minimal invasive effect and functional splenic tissue preservation, LPS may be a safe and feasible approach for emergency patients. And prospective trials with clear inclusion criteria are needed to proof the benefit of LPS.

Total versus partial splenectomy in pediatric hereditary spherocytosis: A systematic review and meta-analysis

To compare the clinical effectiveness of total splenectomy (TS) or partial splenectomy (PS) in pediatric hereditary spherocytosis, a systematic review and meta-analysis was performed (PROSPERO registration CRD42015030056). There were 14 observational studies comparing pre- and postoperative hematologic parameters. Secondary outcomes include in-hospital infections, surgical complications, symptomatic recurrence, and biliary disease. TS is more effective than PS to increase hemoglobin (3.6 g/dl vs. 2.2 g/dl) and reduce reticulocytes (12.5% vs. 6.5%) after 1 year; outcomes following PS are stable for at least 6 years. There were no cases of overwhelming postsplenectomy sepsis. A population-based patient registry is needed for long-term follow-up.

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.

Spleen hydatidosis treated by hemi-splenectomy: A low-morbidity, cost-effective management by a recently improved surgical technique

BACKGROUND

Splenic hydatidosis is a rare condition and is usually managed by total splenectomy, which is associated to various complications, including overwhelming post-splenectomy sepsis and thrombosis. Probably due to supposed technical difficulties, the partial splenectomy is rarely performed being often unknown to physicians, infectious disease specialists and surgeons.

METHODS

Demographic, clinical and surgical data were collected of four consecutive patients undergoing partial (or hemi-) splenectomy using an original, recently improved technique as a treatment for polar splenic hydatid cyst. The procedure implies a selective vascular ligation, a mechanical stapler-assisted section and haemostatic agents (Surgicel(®)) application on the cutting surface. Three patients were treated by laparotomy (including one affected by both liver and spleen localizations) whereas the last one was approached laparoscopically.

RESULTS

Partial splenectomy operative time reached 74 min (range: 60-94 min) and blood loss was 8 ml (range: 5-10 ml). Hospital stay was 5.6 days (range: 5-7 days). At a mean follow-up of 20 months (range: 12-36 months), outcomes were uneventful.

CONCLUSIONS

Partial splenectomy for hydatidosis is effective and safe. Physicians and surgeons should be aware of such an easy-to-catch option when dealing with benign splenic conditions, such as parasitic cysts. Cost-effectiveness, low morbidity and the possible prevention of splenectomy-related infectious complications should plead in favor of this technique in developing countries, where hydatidosis is endemic and post-splenectomy drugs and vaccines may be lacking.

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.

Peter S, Sharma M, Davidoff AM, Nottage K, Bernabe K, Wilson DB, Dutta S, Glader B, Crary SE, Dassinger MS, Dunbar L, Islam S, Kumar M, Rescorla F, Bruch S, Campbell A, Austin M, Sidonio R, Blakely ML. Clinical outcomes of splenectomy in children: report of the splenectomy in congenital hemolytic anemia registry

The outcomes of children with congenital hemolytic anemia (CHA) undergoing total splenectomy (TS) or partial splenectomy (PS) remain unclear. In this study, we collected data from 100 children with CHA who underwent TS or PS from 2005 to 2013 at 16 sites in the Splenectomy in Congenital Hemolytic Anemia (SICHA) consortium using a patient registry. We analyzed demographics and baseline clinical status, operative details, and outcomes at 4, 24, and 52 weeks after surgery. Results were summarized as hematologic outcomes, short-term adverse events (AEs) (≤30 days after surgery), and long-term AEs (31-365 days after surgery). For children with hereditary spherocytosis, after surgery there was an increase in hemoglobin (baseline 10.1 ± 1.8 g/dl, 52 week 12.8 ± 1.6 g/dl; mean ± SD), decrease in reticulocyte and bilirubin as well as control of symptoms. Children with sickle cell disease had control of clinical symptoms after surgery, but had no change in hematologic parameters. There was an 11% rate of short-term AEs and 11% rate of long-term AEs. As we accumulate more subjects and longer follow-up, use of a patient registry should enhance our capacity for clinical trials and engage all stakeholders in the decision-making process.

Laparoscopic partial splenectomy performed by monopolar saline-cooled radiofrequency coagulation

BACKGROUND

Partial splenectomy is preferred to total splenectomy when possible to reduce the risk of life-threatening infection. Several techniques have been described, each with its merits. Laparoscopic transection with monopolar saline-cooled radiofrequency coagulation has not been previously described.

PATIENTS AND METHODS

Two patients with enlarging cystic splenic lesions consented to laparoscopic partial splenectomy. In 1 case, high-power saline-cooled monopolar radiofrequency transection was performed with a laparoscopic sealing hook; the procedure was performed with a rigid resectoscope and ball diathermy in the other.

RESULTS

Both cases were performed without complications. Transection with the resectoscope and ball diathermy was combined with selective clamping of the splenic hilar vessels and was performed in 100 minutes with estimated blood loss of 250 mL. Transection with the sealing hook was performed in 80 minutes without hilar vessel clamping, with an estimated blood loss of 100 mL. No additional hemostatic agents were required for either case.

CONCLUSIONS

Laparoscopic partial splenectomy can be performed with monopolar saline-cooled radiofrequency for parenchymal transection and hemostasis in a simple and effective manner.

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.

Evaluation of partial and total splenectomy in children with sickle cell disease using an Internet-based registry

BACKGROUND

Clinical outcomes of children with sickle cell disease (SCD) who undergo total or partial splenectomy (PS) are poorly defined. The purpose of this retrospective study was to initiate an Internet-based registry to facilitate analysis of clinical outcomes for these children. We hypothesized that both surgical procedures would be well tolerated and would eliminate risk of splenic sequestration.

METHODS

We developed a web-based registry using the Research Electronic Data Capture (REDCap) platform. Children were included if they had SCD and underwent total splenectomy (TS) or PS between 2003 and 2010. Clinical outcomes were compared between cohorts, with follow-up to 1 year.

RESULTS

Twenty-four children were included, TS (n = 15) and PS (n = 9). There were no differences in surgical time or intraoperative blood loss. The length of stay was longer after PS (4.1 ± 1.7 days) compared to TS, (2.4 ± 1.2 days, P = 0.02). Within 30 days of surgery, 2 (20%) patients had acute chest syndrome (ACS) following TS and 2 (15%) patients had ACS after PS. During 1-year follow-up, no patient in either cohort had recurrent splenic sequestration, venous thrombosis or overwhelming postsplenectomy sepsis. All children who were transfused preoperatively to prevent recurrent splenic sequestration successfully discontinued transfusions.

CONCLUSIONS

Both TS and PS result in favorable hematologic outcomes and low risk of adverse events for children with SCD. A REDCap-based registry may facilitate data entry and analysis of clinical outcomes to allow for comparison between different types of splenectomy.

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.

Comparative effectiveness of different types of splenectomy for children with congenital hemolytic anemias

OBJECTIVE

To compare the effectiveness of different types of splenectomy in children with congenital hemolytic anemias.

STUDY DESIGN

We constructed key questions that addressed outcomes relevant to clinicians and families on effects of partial or total splenectomy, including hematologic effect, splenic function, and the risk of adverse events. We identified from Pubmed and Embase 703 studies that evaluated different types of splenectomy and accepted 93 studies that satisfied entry criteria. We graded the quality of each report and summarized the overall strength of research evidence for each key question.

RESULTS

We did not identify any randomized clinical trials. All types of splenectomy have favorable clinical outcomes in most diseases. We did not identify any hematologic advantage of laparoscopy compared with laparotomy. Adverse events are uncommon in most studies and are minimized with use of laparoscopy.

CONCLUSIONS

There is a need for randomized clinical trials and improved data collection of different types of splenectomy in congenital hemolytic anemias. Outcomes studied should address the concerns of families and clinicians to assess the risks and benefits of various treatments.