Validation of a Difficulty Grading Score in Laparoscopic Splenectomy

Prognostic scoring system of laparoscopic splenectomy in children with benign hematological diseases, a retrospective cohort study

Purpose

laparoscopic splenectomy (LS) gained popularity during the last years among pediatric surgeons. Benign hematological diseases represent the main indications of that procedure. There are some score systems of difficulty of the technique. Most of them are for adult patients. The aim is to develop a prognostic score system of LS in children with benign hematological diseases.

Methods

LS was performed in all children with benign hematological diseases. The children were operated in lateral decubitus position. The control of pedicle was achieved using bipolar sealing devices, polymer clips or endoscopic linear stablers. Preoperative, operative, and postoperative data were recorded and analyzed. Children were divided into two groups A and B according to the onset of complications.

Results

137 successive children were operated. The mean age of patients was 8.7 (4–15) years. The main indications of LS were thalassemia, spherocytosis, idiopathic thrombocytopenic purpura (ITP), and sickle cell anemia (SCA). The mean length of splenic axis in thalassemia and spherocytosis cases was15.6 ± 2.3 cm. The mean amount of estimated blood loss (EABL) was 149 ± 43.2 ml in group A while it was 185 ± 44.4 ml in group B. The mean operative time in group A was 75.5 ± 22.5 min while it was 89.2 ± 20.6 min in group B.

Conclusion

the development of prognostic score of LS in children with benign hematological diseases can predict children who are more susceptible for complications. It helps to minimize these complications and improve the outcome of LS.

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Laparoscopic splenectomy in children gained popularity during last years.

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The outcome of laparoscopic surgery is superior to conventional surgery.

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Benign hematological diseases represent the main indication of splenectomy in children.

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There is a need to develop a prognostic score of laparoscopic splenectomy in pediatric age group.

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Method of pedicle control represents one of main prognostic factors.

A novel preoperative scoring system to predict technical difficulty in laparoscopic splenectomy for non-traumatic diseases

BACKGROUND

Laparoscopic splenectomy (LS) has been proven to be a safe and advantageous procedure. To ensure that resections of appropriate difficulty are selected, an objective preoperative grading of difficulty is required. We aimed to develop a predictive difficulty grading of LS based on intraoperative complications.

METHODS

A total of 272 non-traumatic patients who underwent LS were identified from a regional medical center. Patients were randomized into a training cohort (n = 222) and a validation cohort (n = 50). Data on demographics, medical and surgical history, operative and pathological characteristics, and postoperative outcome details were collected. Univariate and multivariate analyses of risk factors for intraoperative complications were performed to develop a difficulty scoring system. The Spearman correlation coefficient was used to evaluate the relationship between the difficulty grading score and intraoperative outcomes. Receiver operating characteristic (ROC) curve was used to evaluate the discriminatory power of this scoring system.

RESULTS

Three preoperative factors (spleen weight, esophagogastric varices, and INR) had a significant effect on operative time, bleeding, and conversion to open surgery. We created a difficulty grading score with three levels of difficulty: low (≤ 4 points), medium (5-6 points), and high (≥ 7 points), based on the three preoperative parameters. The correlation was highly significant (P < 0.01) according to Spearman's correlation. The area under the ROC curve was 0.695 (95% CI 0.630-0.755). The external validation showed significant correlations with the present model, with an AUC of 0.725 (95% CI 0.580-0.842). The comparison between our difficulty score and the previous grading system in the 272-patient cohort presented a significant difference in the AUC (0.701, 95% CI 0.643-0.755 vs. 0.644, 95% CI 0.584-0.701, P = 0.0452).

CONCLUSION

The present difficulty scoring system, based on preoperative factors, has good performance in predicting the risk of intraoperative complications of LS and could be helpful for enabling appropriate case selection with respect to the current experience of a surgeon.

Laparoscopic Splenectomy Versus Open Splenectomy In Massive and Giant Spleens: Should we Update the 2008 EAES Guidelines?

The objective of this study was to derive some useful parameters to define the feasibility of laparoscopic splenectomy (LS) in massive [spleen longitudinal diameter (SLD)>20 cm] and giant spleens (SLD>25 cm). Between December 1996 and May 2017, 175 patients underwent an elective splenectomy. A laparoscopic approach was used in 133 (76%) patients. Massive spleens were treated in 65 (37.1%) patients, of which 24 were treated laparoscopically. In this subset of massive spleens, the results of laparoscopic splenectomy in massive spleens (LSM) and open splenectomy in massive spleens (OSM) were compared. The clinical outcome of a subgroup of patients with giant spleens was also analyzed. The LSM group resulted in significant longer operative times (143±31 vs. 112±40 min; P=0.001), less blood loss (278±302 vs. 575±583 mL; P=0.007), and shorter hospital stay (6±3 vs. 9±4 d; P=0.004). No conversions were experienced in the LSM group, and the morbidity rate was similar in both the LSM and OSM groups (16.6% vs. 20%; P=0.75). When considering the subset of 9 LSM patients and 26 OSM patients with giant spleens, the same favorable tendency of the laparoscopic group as regards surgical conversion, blood loss, and hospital stay was maintained. The laparoscopic approach can be successfully proposed in the presence of massive splenomegaly also after a careful preoperative evaluation of the expected abdominal "working space." In experienced hands, LS is safe, feasible, and associated with better outcomes than open splenectomy for the treatment of massive and giant spleen, with a maximum SLD limit of 31 cm.