Partial splenectomy for hereditary spherocytosis: a multi-institutional review

COVID-19 in patients with anemia and haematological malignancies: risk factors, clinical guidelines, and emerging therapeutic approaches

Extensive research in countries with high sociodemographic indices (SDIs) to date has shown that coronavirus disease 2019 (COVID-19) may be directly associated with more severe outcomes among patients living with haematological disorders and malignancies (HDMs). Because individuals with moderate to severe immunodeficiency are likely to undergo persistent infections, shed virus particles for prolonged periods, and lack an inflammatory or abortive phase, this represents an overall risk of morbidity and mortality from COVID-19. In cases suffering from HDMs, further investigation is needed to achieve a better understanding of triviruses and a group of related variants in patients with anemia and HDMs, as well as their treatment through vaccines, drugs, and other methods. Against this background, the present study aimed to delineate the relationship between HDMs and the novel COVID-19, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Besides, effective treatment options for HDM cases were further explored to address this epidemic and its variants. Therefore, learning about how COVID-19 manifests in these patients, along with exploiting the most appropriate treatments, may lead to the development of treatment and care strategies by clinicians and researchers to help patients recover faster. Video Abstract.

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.

Role of Partial Splenectomy in Hematologic Childhood Disorders

The spleen is a secondary lymphoid organ that belongs to the reticular-endothelial system, directly connected to blood circulation. The spleen is greatly involved in the immune response, especially against capsulated bacteria. Splenectomy plays a fundamental role in the treatment of numerous pediatric hematologic disorders. Taking into account all the possible complications (especially infections) linked to this procedure, alternatives to total splenectomy have been sought. Partial splenectomy has been proposed as a treatment that allows the reduction of infectious risk. This approach has proven safe and feasible in most patients, but multicentric and prospective studies are necessary to more accurately define the indications for performing partial splenectomy. However, vaccinations and antibiotic prophylaxis remain fundamental for preventing serious infections, even in the case of partial splenectomy. We review anatomical and functional properties of the spleen, with a focus on medical or surgical indications to splenectomy, aiming to give practical educational information to patients and their families after splenectomy. Furthermore, we discuss the feasibility of partial splenectomy in children with hematologic diseases who require splenectomy.

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.

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.

How I approach hereditary hemolytic anemia and splenectomy

Hereditary hemolytic anemias (HHA) are a heterogeneous group of anemias associated with decreased red cell survival. While there can be clinical benefit of splenectomy in many cases, splenectomy is not appropriate for all types of HHA. Additionally, there are significant risks during and following splenectomy including surgical risks, postsplenectomy sepsis, and thrombotic complications. This review discusses the diagnostic approach to HHA as well as the role of splenectomy in the management. Surgical approaches and outcomes for total and partial splenectomy are discussed.

Long‐term hematologic and clinical outcomes of splenectomy in children with hereditary spherocytosis and sickle cell disease

Background

Total splenectomy (TS) and partial splenectomy (PS) are used for children with congenital hemolytic anemia (CHA), although the long-term outcomes of these procedures are poorly defined. This report describes long-term outcomes of children with CHA requiring TS or PS.

Procedure

We collected data from children ages 2-17 with hereditary spherocytosis (HS) or sickle cell disease (SCD) requiring TS or PS from 1996 to 2016 from 14 sites in the Splenectomy in Congenital Hemolytic Anemia (SICHA) consortium using a prospective, observational patient registry. We summarized hematologic outcomes, clinical outcomes, and adverse events to 5 years after surgery. Hematologic outcomes were compared using mixed effects modeling.

Results

Over the study period, 110 children with HS and 97 children with SCD underwent TS or PS. From preoperatively compared to postoperatively, children with HS increased their mean hemoglobin level by 3.4 g/dL, decreased their mean reticulocyte percentage by 6.7%, and decreased their mean bilirubin by 2.4mg/dL. Hematologic improvements and improved clinical outcomes were sustained over 5 years of follow-up. For children with SCD, there was no change in hemoglobin after PS or TS following surgery, although all clinical outcomes were improved. Over 5 years, there was one child with HS and 5 children with SCD who developed post-splenectomy sepsis.

Conclusions

For children with HS, there are excellent long-term hematologic and clinical outcomes following either PS or TS. Although hemoglobin levels do not change after TS or PS in SCD, the long-term clinical outcomes for children with SCD are favorable.

Clinical and laboratory outcomes following total or partial splenectomy in patients with hereditary spherocytosis

This study compared outcomes following total (TS) or partial splenectomy (PS) among patients with hereditary spherocytosis. Seventy-nine patients (TS = 33, PS = 46) were identified. The follow-up period was longer after PS (59.6 vs. 24.9 months, p < .001). Long-term adverse events occurred more frequently following PS (50% vs. 29%, p = .001). Anemia, jaundice, and fatigue recurred in six patients with PS, leading to five completion splenectomies. Hemoglobin was not different between PS and TS by 5 years post-procedure (12.3 vs. 13.4 g/dL, p = .25). Both PS and TS ameliorate symptoms and improve hematologic parameters. The rate of secondary surgery following PS should be considered when planning the initial surgical procedure.

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.

Mild Hereditary Spherocytosis without Accompanying Hereditary Haemochromatosis: An Unrecognised Cause of Iron Overload

Hereditary spherocytosis (HS) is a common inherited haemolytic anaemia and has great variability in its presentation. Non-transfusion iron overload in HS has only been reported with co-inheritance of hereditary haemochromatosis (HHC). We present 4 unrelated patients of East Asian ethnicity with mild HS and significant non-transfusion iron overload in the absence of known disease-causing mutations in HHC genes. We hypothesise that, in patients with mild HS, life-long chronic haemolysis and erythropoietic drive may promote iron absorption. This suggests that mild HS may not be entirely benign, and that patients with mild HS should be monitored for iron overload.

Blood cell parameters for screening and diagnosis of hereditary spherocytosis

Background

There is currently no single index for the diagnostic screening of hereditary spherocytosis (HS). However, hematology analyzers are widely used in hospital laboratories because of their highly automated performance and quality control procedure, and detection of some blood cell parameters may be useful for the early screening of HS.

Methods

We investigated the values of blood cell parameters for the screening and differential diagnosis of HS. We performed a descriptive study of 482 samples (67 cases of HS, 59 cases of G6PD deficiency, 57 cases of AIHA, 199 cases of thalassemia, and 100 cases of healthy controls) that were run on Beckman Coulter LH780 Hematology Analyzer.

Results

HS was characterized by increased MCHC, decreased MRV, MSCV‐MCV < 0, and increased Ret with no concomitant increase in IRF. The areas under the ROC curves were MSCV‐MCV (0.97; 95% CI 0.95‐1.0) > MRV (0.94; 95% CI 0.91‐0.97) > MCHC (0.92; 95% CI 0.88‐0.97) > Ret/IRF (0.77; 95% CI 0.7‐0.84). MSCV‐MCV ≤ 0.6 fl was valuable parameter for the diagnostic screening of HS, with a sensitivity of 95.5% and specificity of 94.9%.

Conclusion

These indices have high reference values for differentiating HS from thalassemia, AIHA, and G6PD deficiency.

Whole-exome sequencing enables correct diagnosis and surgical management of rare inherited childhood anemia

Correct diagnosis of inherited bone marrow failure syndromes is a challenge because of the significant overlap in clinical presentation of these disorders. Establishing right genetic diagnosis is crucial for patients’ optimal clinical management and family counseling. A nondysmorphic infant reported here developed severe transfusion-dependent anemia and met clinical criteria for diagnosis of Diamond–Blackfan anemia (DBA). However, whole-exome sequencing demonstrated that the child was a compound heterozygote for a paternally inherited pathogenic truncating variant (SPTA1^{c.4975 C>T)} and a novel maternally inherited missense variant of uncertain significance (SPTA1^{c.5029 G>A}) within the spectrin gene, consistent with hereditary hemolytic anemia due to disruption of red blood cell (RBC) cytoskeleton. Ektacytometry demonstrated abnormal membrane flexibility of the child's RBCs. Scanning electron microscopy revealed morphological aberrations of the patient's RBCs. Both parents were found to have mild hereditary elliptocytosis. Importantly, patients with severe RBC membrane defects may be successfully managed with splenectomy to minimize peripheral destruction of misshapen RBCs, whereas patients with DBA require lifelong transfusions, steroid therapy, or hematopoietic stem cell transplantation. As suggested by the WES findings, splenectomy rendered our patient transfusion-independent, improving the family's quality of life and preventing transfusion-related iron overload. This case illustrates the utility of whole-exome sequencing in clinical care of children with genetic disorders of unclear presentation.

Treatment of hemangioma of the spleen by preoperative partial splenic embolization plus laparoscopic partial splenectomy: A case report

RATIONALE

Complete loss of splenic function increases infection and cardiovascular disease risks, so there is growing emphasis on spleen-preserving treatments, such as laproscopic partial splenectomy (LPS). However, LPS carries higher risk for hemorrhage. Sequential splenic embolization can obliterate the perilesional vascular bed while preserving flow through healthy tissue, substantially reducing risk of uncontrolled hemorrhage during LPS. Preoperative partial splenic embolization (PSE) may soften the spleen and reduce its size, which enhances space exposure for laparoscopic operation. Furthermore, immediate LPS guaranties these effects of PSE and prevents abscess, non-traumatic splenic rupture, post-embolization syndrome, and other complications. In light of these advantages, we conducted combined PSE and LPS for a case of hemangioma.

PATIENT CONCERNS

The patient presented with left abdominal discomfort of >1 year.

DIAGNOSES

Ultrasound examination at the outpatient clinic identified a space-occupying lesion in the spleen. Contrast-enhanced computed tomography scan of the upper abdomen revealed a hypodense lesion, approximately 33 × 21 mm in size, located in the upper pole of the spleen, suggesting possible hemangioma.

INTERVENTIONS

The patient was treated by preoperative PSE followed by LPS.

OUTCOMES

Treatment resulted in only mild intraoperative hemorrhage, fast postoperative recovery, and no recurrence during follow-up. And the postoperative histopathology confirmed splenic cavernous hemangioma.

LESSIONS

Preoperative PSE combined with LPS is an effective therapy for elective patients that minimizes intraoperative hemorrhage during laparoscopic surgery, reduces surgical risk, and enhances surgical safety.

Laparoscopic hemi-splenectomy

Laparoscopic splenectomy is now established as a safe and feasible procedure. However, it remains associated with some short- and long-term postoperative complications, especially infectious complications. To our knowledge, this is the first report (with video) focusing on the safety and feasibility of laparoscopic hemi-splenectomy and its surgical outcomes for the treatment of splenic abscesses causing septic emboli. This technique combines the immunological benefits of partial splenectomy and the postoperative benefits of a minimally invasive approach. Further studies are needed to standardize this technique and to assess its immunological and surgical benefits.

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.

Hereditary Spherocytosis in the Neonatal Period: A Case Report

Hereditary spherocytosis (HS) is the third most common yet most frequently underrecognized, congenitally acquired hemolytic disease of the neonate. Hereditary spherocytosis is caused by a defect of one or more erythrocyte membrane proteins, which leads to an increased rate of destruction of circulating red blood cells. The HS spectrum of symptoms is varied from asymptomatic to intrauterine hydrops. Diagnostic tests range from a complete blood count (CBC) analysis to deoxyribonucleic acid (DNA) sequencing. Management in the neonatal period focuses primarily on associated comorbidities, including the prevention of severe hyperbilirubinemia and anemia. Life span implications of HS include hemolysis, jaundice, anemia, splenomegaly, and periodic gallstones. Early identification and diagnosis of HS is essential to ensure proper monitoring and medical management throughout infancy, childhood, and adulthood.

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.

Hematologic outcomes after total splenectomy and partial splenectomy for congenital hemolytic anemia

PURPOSE

The purpose of this study was to define the hematologic response to total splenectomy (TS) or partial splenectomy (PS) in children with hereditary spherocytosis (HS) or sickle cell disease (SCD).

METHODS

The Splenectomy in Congenital Hemolytic Anemia (SICHA) consortium registry collected hematologic outcomes of children with CHA undergoing TS or PS to 1 year after surgery. Using random effects mixed modeling, we evaluated the association of operative type with change in hemoglobin, reticulocyte counts, and bilirubin. We also compared laparoscopic to open splenectomy.

RESULTS

The analysis included 130 children, with 62.3% (n=81) undergoing TS. For children with HS, all hematologic measures improved after TS, including a 4.1g/dl increase in hemoglobin. Hematologic parameters also improved after PS, although the response was less robust (hemoglobin increase 2.4 g/dl, p<0.001). For children with SCD, there was no change in hemoglobin. Laparoscopy was not associated with differences in hematologic outcomes compared to open. TS and laparoscopy were associated with shorter length of stay.

CONCLUSION

Children with HS have an excellent hematologic response after TS or PS, although the hematologic response is more robust following TS. Children with SCD have smaller changes in their hematologic parameters. These data offer guidance to families and clinicians considering TS or PS.

[Robot-assisted and laparoscopic partial splenectomy for nonparasitic cysts]

21 patients with nonparasitic spleen cysts were operated. Robot-assisted (RA) interventions were applied in 10 cases, laparoscopic--in 11 patients. Men surgery duration was 124 minutes in case of RA-technique and 120 minutes if laparoscopy was used. Blood loss was significantly lower in the group of RA resection (p=0.035). There were no conversions of access in the group of RA-operations while in group of laparoscopy conversion has been required in 1 case. We did not observe complications in case of RA-surgeries. Laparoscopic method was associated with 2 complications (left-sided hydrothorax and fluid accumulation in resection area). Postoperative hospital-stay did not differ in both groups and was 7.1 and 6.4 room-nights in case of RA-interventions and laparoscopy respectively. There were no deaths. Indications for robot-assisted partial splenectomy for nonparasitic cysts include location of mass in upper pole or hilus of spleen, its diameter more than 8 cm, body mass index more than 30 and splenomegaly. Lower pole resection and splenectomy are more advisable using laparoscopic method.

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.

Abnormalities of the erythrocyte membrane

Primary abnormalities of the erythrocyte membrane are characterized by clinical, laboratory, and genetic heterogeneity. Among this group, hereditary spherocytosis patients are more likely to experience symptomatic anemia. Treatment of hereditary spherocytosis with splenectomy is curative in most patients. Growing recognition of the long-term risks of splenectomy has led to re-evaluation of the role of splenectomy. Management guidelines acknowledge these considerations and recommend discussion between health care providers, patient, and family. The hereditary elliptocytosis syndromes are the most common primary disorders of erythrocyte membrane proteins. However, most elliptocytosis patients are asymptomatic and do not require therapy.

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.

Quantitative assessment of sensing and sequestration of spherocytic erythrocytes by the human spleen

Splenic sequestration of RBCs with reduced surface area and cellular deformability has long been recognized as contributing to pathogenesis of several RBC disorders, including hereditary spherocytosis. However, the quantitative relationship between the extent of surface area loss and splenic entrapment remains to be defined. To address this issue, in the present study, we perfused ex vivo normal human spleens with RBCs displaying various degrees of surface area loss and monitored the kinetics of their splenic retention. Treatment with increasing concentrations of lysophosphatidylcholine resulted in a dose-dependent reduction of RBC surface area at constant volume, increased osmotic fragility, and decreased deformability. The degree of splenic retention of treated RBCs increased with increasing surface area loss. RBCs with a > 18% average surface area loss (> 27% reduced surface area-to-volume ratio) were rapidly and completely entrapped in the spleen. Surface-deficient RBCs appeared to undergo volume loss after repeated passages through the spleen and escape from splenic retention. The results of the present study for the first time define the critical extent of surface area loss leading to splenic entrapment and identify an adaptive volume regulation mechanism that allows spherocytic RBCs to prolong their life span in circulation. These results have significant implications for understanding the clinical heterogeneity of RBC membrane disorders.

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.

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

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