A meta-analysis of perioperative outcomes of laparoscopic splenectomy for hematological disorders

BACKGROUND

Due to changes in surgical trends, laparoscopic splenectomy (LS) has become the standard approach for most splenectomies performed for hematological disorders, barring any contraindications. The perioperative outcomes of LS for this indication have not been updated for several years. Controversy still surrounds whether LS should be performed for massive splenomegaly. The purpose of this meta-analysis was to evaluate the perioperative outcomes of laparoscopic splenectomy for hematological disorders.

METHODS

Literature searches were conducted to identify studies comparing the perioperative outcomes of the laparoscopic and open approaches for hematological disorders. The results were pooled by using standard meta-analysis methods.

RESULTS

Thirty-eight studies with a total of 2,914 patients comparing LS to open splenectomy (OS) for hematological disorders were identified. Mortality was low in both groups. The pooled complications of the LS group were significantly fewer than those of the OS group (-0.11, p < 0.001), and the NNT was 9 (95 % confidence interval, 6-20). For massive spleens, a similar result was observed (-0.12, p = 0.009). Accessory spleen resection and blood loss also were comparable between the two approaches. Additionally, LS was associated with longer operative times (57.38 min, p < 0.00001) and shorter hospital stays (2.48 days, p < 0.00001).

CONCLUSIONS

LS is preferred compared to OS, based on lower complication rates and better handling of comorbid conditions. LS is associated with shorter hospital stays but longer operative times. We conclude that LS may be considered an acceptable option even in cases of a massive spleen. To strengthen the clinical evidence, more high-quality clinical trials on different issues are necessary.

Laparoscopic splenectomy for massive splenomegaly: technical aspects of initial ligation of splenic artery and extraction without hand-assisted technique

A 37-year-old man was referred for massive splenomegaly. In November 2005, he was diagnosed with non-Hodgkin's B-cell lymphoma in the setting of splenomegaly and thrombocytopenia. His laboratory results showed a coagulopathy owing to lupus anticoagulant. A computed tomography scan showed a 36 x 26 x 11 cm spleen and a prominent and sinuous splenic artery. The authors performed a laparoscopic splenectomy with an initial ligation of the splenic artery. The patient tolerated the procedure well and was discharged home on the fourth postoperative day in stable condition. Discussed in this paper is the safety and feasibility of the minimally invasive approach in massive splenomegaly.

Laparoscopic splenectomy: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES)

BACKGROUND

Although laparoscopic splenectomy (LS) has become the standard approach for most splenectomy cases, some areas still remain controversial. To date, the indications that preclude laparoscopic splenectomy are not clearly defined. In view of this, the European Association for Endoscopic Surgery (EAES) has developed clinical practice guidelines for LS.

METHODS

An international expert panel was invited to appraise the current literature and to develop evidence-based recommendations. A consensus development conference using a nominal group process convened in May 2007. Its recommendations were presented at the annual EAES congress in Athens, Greece, on 5 July 2007 for discussion and further input. After a further Delphi process between the experts, the final recommendations were agreed upon.

RESULTS

Laparoscopic splenectomy is indicated for most benign and malignant hematologic diseases independently of the patient's age and body weight. Preoperative investigation is recommended for obtaining information on spleen size and volume as well as the presence of accessory splenic tissue. Preoperative vaccination against meningococcal, pneumococcal, and Haemophilus influenzae type B infections is recommended in elective cases. Perioperative anticoagulant prophylaxis with subcutaneous heparin should be administered to all patients and prolonged anticoagulant prophylaxis to high-risk patients. The choice of approach (supine [anterior], semilateral or lateral) is left to the surgeon's preference and concomitant conditions. In cases of massive splenomegaly, the hand-assisted technique should be considered to avoid conversion to open surgery and to reduce complication rates. The expert panel still considered portal hypertension and major medical comorbidities as contraindications to LS.

CONCLUSION

Despite a lack of level 1 evidence, LS is a safe and advantageous procedure in experienced hands that has displaced open surgery for almost all indications. To support the clinical evidence, further randomized controlled trials on different issues are mandatory.

Laparoscopic versus open splenectomy for massive splenomegaly: a comparative study

BACKGROUND

Despite the benefits of the laparoscopic approach to splenectomy, its application in patients with massive splenomegaly (splenic weight >or= 1000 g) remains controversial. In this study we evaluated the safety and feasibility of laparoscopic splenectomy for massive splenomegaly compared with open splenectomy.

MATERIALS AND METHODS

One surgeon applied the laparoscopic approach to splenectomy to all comers with massive splenomegaly, while other surgeons carried out the surgery through a laparotomy. The outcomes of the two approaches were compared on an intention-to-treat basis. Results of continuous variables are shown as medians.

RESULTS

Fifteen patients underwent laparoscopic splenectomy between 2000 and 2005, and 13 underwent open splenectomy between 1996 and 2003. The two groups were comparable for age, sex, American Society of Anesthesiologists score, and splenic weight (1.3 vs. 1.1 kg). There was one conversion (6.6%) to open surgery. Although laparoscopic splenectomy was associated with significantly longer operating time (175 vs. 90 minutes, P < 0.001), it carried lower postoperative morbidity and mortality (13.3 vs. 30.8% and 0 vs. 7.7%, respectively). Laparoscopic splenectomy was associated with significantly lower total dose (29 vs. 264 mg morphine-equivalent, P < 0.0001) and duration of opiate usage (1 vs. 4 days, P < 0.0001); duration of parenteral hydration (24 vs. 96 hours, P = 0.006) and more rapid resumption of oral diet (24 vs. 72 hours, P = 0.017); and a shorter postoperative hospital stay (3 vs. 10 days, P < 0.0001).

CONCLUSIONS

The laparoscopic approach to splenectomy for massive splenomegaly is feasible and safe. Despite a longer operating time, the postoperative recovery following laparoscopic splenectomy is smoother, with lower morbidity and shorter postoperative hospital stay compared with open splenectomy.

Laparoscopic gastric bypass for gastric outlet obstruction is associated with smoother, faster recovery and shorter hospital stay compared with open surgery

BACKGROUND/PURPOSE

Laparoscopic gastric bypass for relief of gastric outlet obstruction (GOO) is feasible and safe. However, comparative data to confirm the benefits of the laparoscopic approach remain scarce.

METHODS

Between 1998 and 2003, 26 patients underwent 15 laparoscopic (surgeon A) and 12 open (surgeon B) gastrojejunostomies (GJs) for GOO. The indications for surgery included malignant (n = 17) and benign (n = 10) diseases.

RESULTS

There were no conversions to open surgery in the laparoscopic group, and no operative mortality occurred in either group. The groups were comparable for age, sex, American Society of Anesthesiology (ASA) score, frequencies of previous abdominal surgery and of malignant or benign disease, and type of GJ fashioned. There were no differences between the laparoscopic and open groups with regard to the operating time (median, 90 vs 111 min; P = 0.113), and patients receiving intraoperative blood transfusion. However, laparoscopic surgery was associated with significantly shorter durations of postoperative intravenous hydration (60 vs 234 h; P = 0.001), opiate analgesia (49 vs 128 h; P = 0.025), and hospital stay (3 vs 15 days; P = 0.005). Operative morbidity occurred more frequently following open surgery (33% vs 13%; P = 0.219).

CONCLUSIONS

Laparoscopic GJ for the relief of GOO is associated with a smoother and more rapid postoperative recovery and shorter hospital stay compared with open surgery. In experienced hands, the laparoscopic approach to GJ should become the new gold standard.

Laparoscopic splenectomy for metastatic squamous cell cancer of the neck

Squamous cell carcinoma (SCC) spreads through direct extension, lymphatic vessels, and, rarely, hematogenous routes. The most common malignancies to metastasize to the spleen include carcinomas of the breast, lung, and melanoma. We present an unusual case of SCC of the neck with splenic metastases. The patient presented with a primary solid tumor of the neck that extended into the surrounding soft tissues, including the internal jugular vein and regional lymph nodes. A metastatic work-up with a positron emission tomograph showed enhancement in the left upper quadrant. A computed tomograph (CT) was then performed. The CT revealed three distinct splenic lesions, the largest measuring 6x6.5x2.5 cm. Subsequently, the patient was scheduled for a splenectomy. At the time of operation, diagnostic laparoscopy revealed only the splenic lesions. A laparoscopic splenectomy was performed successfully and the patient was started on a regular diet on postoperative day 1. This paper describes the first documented case of SCC of the neck with splenic metastases. The lesion was diagnosed and treated laparoscopically. The case is described in detail along with the clinical implications of this rare finding.

Laparoscopic versus open splenectomy in the management of benign and malign hematologic diseases: a ten-year single-center experience

OBJECTIVE

Laparoscopic splenectomy (LS) has gained wide acceptance as a safe, effective alternative to open splenectomy (OS) in the treatment of hematologic disorders. The aim of this study was to compare two cohorts of patients with similar characteristics, who underwent LS and OS in a single university teaching center.

METHODS

Records were reviewed from 30 patients who underwent LS for a hematologic disease and compared with a control group of 38 patients undergoing OS for hematologic disease. Demographics and outcomes were recorded.

RESULTS

There were no significant differences between the two groups with respect to accessory spleens, blood loss, or complication rates (P > 0.05). The operation time in the LS group was significantly longer than in the OS group (P < 0.01) and the length of hospital stay in the LS group was significantly shorter than in the OS group (P < 0.01).

CONCLUSION

Laparoscopic splenectomy is likely becoming the gold standard in the surgical treatment of hematologic diseases.

Grasper-assisted versus traditional laparoscopic splenectomy in the management of hematologic disorders

OBJECTIVE

To compare the technical benefits of grasper-assisted laparoscopic splenectomy (LS) with traditional LS.

METHODS

The study comprised 27 consecutive patients who were admitted to our hospital from 1998 to 2002 and underwent LS: 13 patients underwent traditional LS (group 1), and 14 had grasper-assisted LS (group 2).

RESULTS

In both groups, the most common indication for LS was idiopathic thrombocytopenic purpura. There was no difference between the groups in the demographic characteristics of patients. All splenectomies were performed in the right semidecubitus position, using four or five trocars. Conversion to open surgery was required in one patient (7.7%) in group 1 and in one patient (7.1%) in group 2. Both conversions occurred during the initial 16 operations and no conversion occurred during the subsequent 11 operations. The mean operating time was significantly shorter for group 2 (132 minutes) than for group 1 (154 minutes) (P <.005). Mean estimated blood loss (201 vs. 282 mL) was also lower in group 2 than in group 1 (P <.05). The mean length of hospital stay was 3.3 days in group 1 and 2.4 days in group 2 (P >.05).

CONCLUSION

Grasper-assisted LS is both safe and feasible in patients with hematologic diseases. This technique can be preferred in order to grasp and position the spleen during the surgery.