Postoperative outcomes after laparoscopic splenectomy compared with open splenectomy

Selection of surgical modality for massive splenomegaly in children

BACKGROUND

Laparoscopic splenectomy (LS), a treatment for both benign and malignant splenic diseases, can prove technically challenging in patients with massive splenomegaly. In particular, the optimal surgical modality for treating massive splenomegaly in children remains controversial.

METHODS

The clinicopathologic data of 289 pediatric patients undergoing splenectomy for massive splenomegaly were studied in a retrospective analysis. Accordingly, the patients were classified into the LS surgery group and open splenectomy (OS) surgery group. In the laparoscopy cohort, they were separated into two subgroups according to the method of surgery: the multi-incision laparoscopic splenectomy (MILS) and the single-incision laparoscopic splenectomy (SILS) surgery groups, respectively. Patient demographics, clinical data, surgery, complications, and postoperative recovery underwent analysis. Concurrently, we compared the risk of adverse laparoscopic splenectomy outcomes utilizing univariable and multivariable logistic regression.

RESULTS

The total operation time proved remarkably shorter in the OS group in contrast to the LS group (149.87 ± 61.44 versus 188.20 ± 52.51 min, P < 0.001). Relative to the OS group, the LS group exhibited lowered postoperative pain scores, bowel recovery time, and postoperative hospitalization time (P < 0.001). No remarkable difference existed in post-operation complications or mortality (P > 0.05). Nevertheless, the operation duration was remarkably longer in the SILS surgery group than in the MILS surgery group (200 ± 46.11 versus 171.39 ± 40.30 min, P = 0.02). Meanwhile, the operative duration of MILS and SILS displayed a remarkable positive association with splenic length. Moreover, the operative duration of SILS displayed a remarkable positive association with the age, weight, and height of the sick children. Splenic length proved an independent risk factor of adverse outcomes (P < 0.001, OR 1.378).

CONCLUSIONS

For pediatric patients with massive splenomegaly who can tolerate prolonged anesthesia and operative procedures, LS surgery proves the optimal treatment regimen. SILS remains a novel surgery therapy which may be deemed a substitutional surgery approach for treating massive splenomegaly.

Long-term Results of Splenectomy in Transfusion-dependent Thalassemia

Splenectomy is indicated in transfusion-dependent thalassemia (TDT) only in certain situations. This study aimed to present the effectiveness, complications, and long-term follow-up results of splenectomy in children with TDT. We performed a 30-year single-institution analysis of cases of splenectomy for TDT between 1987 and 2017 and their follow-up until 2021. A total of 39 children (female/male: 24/15) were included. The mean age at splenectomy was 11.2±3.2 years, and their mean follow-up duration after splenectomy was 21.5±6.4 years. Response was defined according to the patient's annual transfusion requirement in the first year postsplenectomy and on the last follow-up year. Complete response was not seen in any of the cases; partial response was observed in 32.3% and no response in 67.6%. Thrombocytosis was seen in 87% of the patients. The platelet counts of 7 (17.9%) patients were >1000 (10 9 /L), and aspirin prophylaxis was given to 22 (56.4%) patients. Complications were thrombosis in 2 (5.1%) patients, infections in 11 (28.2%) patients, and pulmonary hypertension in 4 (10.2%) patients. Our study showed that after splenectomy, the need for transfusion only partially decreased in a small number of TDT patients. We think splenectomy can be delayed with appropriate chelation therapy up to higher annual transfusion requirement values.

The Diagnostic Utility of Splenectomy in Idiopathic Splenomegaly

INTRODUCTION

With increasing frequency, patients with idiopathic splenomegaly are referred to surgeons for splenectomy. We evaluated the diagnostic utility of splenectomy and feasibility of a minimally invasive approach in the face of idiopathic splenomegaly.

METHODS

We retrospectively reviewed 68 patients who underwent splenectomy for idiopathic splenomegaly. The primary endpoint was the rate of definitive diagnosis based on final surgical pathology of the removed spleen.

RESULTS

Preoperative workup included a bone marrow biopsy and peripheral blood smear in 93% and 100% of patients, respectively, with none having lymphadenopathy warranting biopsy. Splenectomy provided a definitive diagnosis for 44 (64.7%) patients. Of these, 34 (50%) patients had an underlying malignancy, of which more than half were splenic marginal zone lymphoma. There were 33 (48.5%) laparoscopic, 23 (33.8%) open, 10 (14.7%) laparoscopic converted to open, and two (2.9%) laparoscopic hand-assist cases. Conversion to open was due to splenic size [median craniocaudal length 21.8 cm (cm)] in eight and staple line bleeding at the splenic hilum in two patients. Overall, the laparoscopic approach was completed in patients with a smaller splenic size compared to open (median craniocaudal length 15.2 vs. 26.0 cm, p < 0.0001). The open group had one (1.5%) intra-operative mortality due to uncontrollable hemorrhage. Thirty-day complication rates were similar for laparoscopic and open approaches (p = 0.10).

CONCLUSION

Splenectomy is an effective diagnostic modality in determining a pathologic cause for splenomegaly in this patient population. Laparoscopic splenectomy can be performed safely in appropriate cases with craniocaudal splenic size having the largest influence on surgical approach.

Clinical Significance of Splenic Vessels and Anatomical Features in Laparoscopic Splenectomy

Introduction: Laparoscopic splenectomy (LS) has become the standard treatment for benign hematological disorders and hypersplenism. However, serious complications such as pancreatic fistula and portal venous thrombosis (PVT) sometimes occur. We investigated the clinical significance of splenic vessels and anatomical features in LS. Methods: Patient data were collected from 32 patients who underwent LS. The indications for LS were hypersplenism due to liver cirrhosis, idiopathic thrombocytopenic purpura, hereditary spherocytosis, and others. Close contact of pancreatic tail with splenic hilum, spleen volume, and diameters of splenic vessels were evaluated on computed tomography images. Results: Close contact of pancreatic tail with splenic hilum was recognized in 15 of the patients. The close contact was significantly associated with operation time (P = .038), spleen volume (P = .021), and spleen volume/body surface area (BSA) ratio (P = .001). In multivariate analysis, spleen volume/BSA ratio was an independent factor for close contact (P = .022). PVT occurred in 3 cirrhosis patients, and the diameter of the splenic vein (SV) was significantly associated with PVT as a result of multivariate analysis (P = .027). Conclusion: Close contact of the pancreatic tail with the splenic hilum may cause a longer operation time at LS and be associated with spleen volume/BSA ratio. A larger SV diameter in cirrhosis patients may be related to PVT after LS.

Modern management of splenomegaly in patients with myelofibrosis

Myelofibrosis (MF) is a chronic myeloproliferative neoplasm which can lead to massive splenomegaly secondary to extramedullary hematopoiesis. Patients frequently exhibit debilitating symptoms including pain and early satiety, in addition to cellular sequestration causing severe cytopenias. JAK 1/2 inhibitors, such as ruxolitinib and fedratinib, are the mainstay of therapy and produce significant and durable reductions in spleen volume. However, many patients are not eligible for JAK 2 inhibitor therapy or become refractory to treatment over time. Novel therapies are in development that can reduce the degree of splenomegaly for some of these patients. However, splenectomy, splenic irradiation, and partial splenic artery embolization remain valuable therapeutic options in select patients. In this review, we will discuss currently available pharmacologic therapies and describe promising drugs currently in development. We will also delve into the efficacy and safety concerns of splenectomy, splenic irradiation, and partial splenic artery embolization. Finally, we will propose a treatment algorithm to help guide clinicians in the management of symptomatic splenomegaly in patients with MF.

Predicting venous thrombosis in patients undergoing elective splenectomy

BACKGROUND

Venous thrombosis (VT) is an ongoing problem for patients undergoing elective splenectomy. There is limited data evaluating risk factors for VTs. An increase in platelet counts is commonly seen after splenectomy; however, there is a paucity of literature evaluating post-operative platelet counts as a risk factor for VTs in this patient cohort. The objective of this study was to determine the incidence of VT events and to use the platelet count as a predictor for VT development.

METHODS

A retrospective review was undertaken at Brigham Women's Hospital, evaluating elective splenectomy patients between 1997 and 2018. Descriptive statistics were utilized to determine the incidence of VTs. Receiver operator characteristic (ROC) curves were utilized to identify platelet counts that could predict VTs.

RESULTS

Five hundred and twenty splenectomies were included in the study of which 344 were completed in an open manner and 176 were done laparoscopically. The overall incidence of VT events was 6.7% (35/520), 6.1% (21/344) for open, and 8.0% (14/176) for laparoscopic approaches (p = 0.43). ROC curves demonstrated platelet counts to be a good predictor for the development of VTs with an area under the curve (AUC) of 0.77 (95% CI 0.69-0.86; p < 0.001) for all splenectomy patients, 0.70 (95% CI 0.59-0.81; p < 0.001) for those completed in an open manner, and 0.88 (95% CI 0.77-0.99; p < 0.001) for those done laparoscopically. The optimal platelet cutoff was found to be 545 for the overall splenectomy cohort, 457 for the open, and 659 for the laparoscopic cohorts. These platelet counts had a diagnostic accuracy that ranged from 61 to 86% and a negative predictive value (NPV) that ranged from 97 to 99%.

CONCLUSION

These results suggest platelet cutoffs that predict VTs. This information can be used to individualize prophylactic strategies.

Prediction of Technical Difficulties in Laparoscopic Splenectomy and Analysis of Risk Factors for Postoperative Complications in 468 Cases

Prediction of intraoperative difficulties may be helpful in planning surgery; however, few studies explored this issue in laparoscopic splenectomy (LS). We performed retrospective analysis of consecutive 468 patients undergoing LS from 1998 to 2017 (295 women; median age 47 years). The patients were divided into difficult LS and control groups. The inclusion criteria for difficult LS were operative time ≥mean + 2SD; intraoperative blood loss ≥500 mL, intraoperative adverse events (IAE), conversion. Primary outcomes were risk factors for difficult splenectomy and secondary outcomes for perioperative morbidity. Fifty-six patients were included in the difficult LS group (12%). Spleens ≥19 cm and higher participation of younger surgeons in consecutive years were predictive for difficult splenectomy. Age ≥53 years and diagnosis other than idiopathic thrombocytopenic purpura (ITP) were independent risk factors of spleen ≥19 cm. The perioperative morbidity was 8.33%; its OR was increased only by blood loss and IAEs. Only blood loss significantly increased serious morbidity. Male sex, spleens ≥19 cm, and IAEs were independent risk factors for intraoperative hemorrhage. Spleen length ≥19 cm was a risk factor for difficult LS and intraoperative hemorrhage. Diagnoses other than ITP in patients aged ≥53 years with ≥19 cm spleens are predictive for intraoperative difficulties and perioperative complications.

Laparoscopic versus open splenectomy for splenomegaly: the verdict is unclear

BACKGROUND

The benefits of laparoscopic splenectomy (LS) over open splenectomy (OS) for normal-sized spleens have been well documented. However, the role of laparoscopy for moderate and massive splenomegaly is debated.

METHODS

A retrospective review of patients undergoing elective splenectomy at one institution from 1997 to 2017 was conducted. Moderate and massive splenomegaly was defined as splenic weight of 500-1000 g and greater than 1000 g, respectively. We performed a 1:2 matching of laparoscopic to open splenectomy to control for differences in splenic weight. Differences in perioperative morbidity (infection, thromboembolism, reoperation, readmission), intraoperative factors (blood loss, operative time), length of stay, and mortality were examined.

RESULTS

A total of 491 elective splenectomies were identified. 268 cases were for splenic weights greater than 500 g. After a 1:2 matching of LS:OS, we identified 22 LS and 44 matched OS for moderate splenomegaly. The LS group had longer mean operative times (178 vs. 107 min, p < 0.01), with similar length of stay and blood loss. For massive splenomegaly, 26 LS were identified and matched to 52 OS. LS had longer mean operative times (171 vs. 112 min, p < 0.01) and higher readmission rates (27% vs. 6%, p < 0.05). Other factors and outcomes did not differ between LS and OS for moderate or massive splenomegaly. The conversion rate for LS was higher for massive versus moderate splenomegaly, but was not statistically significant (35% vs. 14%, p = 0.09).

CONCLUSIONS

LS for moderate and massive splenomegaly is associated with longer operative times. Other perioperative outcomes were comparable to OS, with no demonstrated benefits for LS. Although LS may be a feasible approach to moderate and massive splenomegaly, its benefits require further clarification in this patient population.

Laparoscopic splenectomy for splenic rupture secondary to metastatic choriocarcinoma

Gestational choriocarcinoma is a rare and aggressive type of gestational trophoblastic neoplasia, which is characterized by early vascular invasion and widespread metastases. Choriocarcinoma metastasizes hematogenously, and bleeding from metastases is common. Splenic rupture from a metastatic tumour is exceedingly rare, with only a few reports. We report a case of a 41-year-old female presenting with acute abdomen and haemorrhagic shock secondary to splenic rupture from metastatic choriocarcinoma, which was managed with emergency laparoscopic splenectomy.

Reemergence of Splenectomy for ITP Second-line Treatment?

INTRODUCTION

Corticosteroids are still the standard first-line treatment for immune thrombocytopenic purpura (ITP). As second-line therapy, splenectomy and Rituximab are both recommended. The aim of our study was to compare the efficacy of Rituximab to splenectomy in persistent or chronic ITP patients.

METHODS

Between January 1999 and March 2015, we retrospectively selected all consecutive patients who underwent an ITP second-line treatment: Rituximab or splenectomy. The distinction between open (OS) and laparoscopic splenectomy (LS) was analyzed. Primary outcome was composite: hospitalization for bleeding and/or thrombocytopenia and death from hemorrhage or infection. Secondary outcomes were based on response (R) and complete response (CR) rates as defined by the American Society of Hematology.

RESULTS

Ninety-six patients were included: 30 patients received Rituximab, 37 underwent OS, and 29 underwent LS. The follow-up was 30, 60, and 120 months in Rituximab, LS, and OS groups, respectively. At 30 month, the primary outcome-free survival rate was higher in splenectomy groups (84% for OS, 86% for LS) than Rituximab group (47%) (P = 0.0002). Similarly, at 30 month, R and CR rates were higher for OS (86.5% and 75.7%, respectively) and LS groups (93.1% and 89.7%) than Rituximab (46.7% and 30%) (P = 0.0001). Moreover, R rates remained elevated at 60 month for OS and LS groups (83.7% and 89.6% respectively) and 78.4% at 120 month for OS group.

CONCLUSION

We observed that splenectomy for ITP second-line treatment was more effective than Rituximab regarding maintenance of R, CR, and overall response rates. OS and LS had similar efficacy.

Laparoscopic versus traditional open splenectomy for hepatocellular carcinoma with hypersplenism

This study aimed to examine the efficacy of the laparoscopic vs. traditional open splenectomy for hepatocellular carcinoma (HCC) with hypersplenism. Between 2002 and 2013, 51 Chinese HCC patients with hypersplenism underwent either simultaneous laparoscopic splenectomy plus anticancer therapies (Lap-S&A) (n=25) or traditional open splenectomy plus anti-cancer therapies (TOS&A) (n=26). The outcomes were reviewed during and after the operation. Anti-cancer therapies for HCC included laparoscopic hepatectomy (LH) and laparoscopic microwave ablation (LMA). The results showed that there was no significant difference in the operating time between the two groups, but the blood loss and blood transfusion were less, pain intensity after surgery was weaker, the time to first bowel movement, time to the first flatus and postoperative hospital stay were shorter, and the postoperative complication rate and the readmission rate were lower in the Lap-S&A group than in the TO-S&A group. Two patients in the Lap-S&A group and one patient in the TO-S&A group died 30 days after surgery. However, no significant difference in the mortality rate was noted between the two groups. It was concluded that simultaneous Lap-S&A holds the advantages of more extensive indications, lower complication incidence and less operative expenditure than conventional open approach and it is a feasible and safe approach for HCC with hypersplenism.

Pancreatic fistula after laparoscopic splenectomy in patients with hypersplenism due to liver cirrhosis: effect of fibrin glue and polyglycolic acid felt on prophylaxis of postoperative complications

BACKGROUND

This study aimed to determine the effect of fibrin glue and polyglycolic acid (PGA) felt on prevention of pancreatic fistula (PF) after laparoscopic splenectomy in patients with hypersplenism due to liver cirrhosis.

METHODS

Fifty consecutive patients were enrolled in this prospective study. Twenty-three patients underwent laparoscopic splenectomy with a fibrin sheet (fibrin sheet group). The sealing ability of each treatment was evaluated by an ex vivo pressure test model. Based on the results from ex vivo experiments, 27 patients received prophylaxis using fibrin glue and PGA felt (PGA with fibrin group). The primary endpoint was the incidence of PF.

RESULTS

Significantly more (5, 22%) patients developed PF in the fibrin sheet group than in the PGA with fibrin group (0%, P = .037).

CONCLUSIONS

Our new application of fibrin glue and PGA felt is an effective prophylactic procedure for preventing development of PF after laparoscopic splenectomy.

Laparoscopic liver resection for hepatocellular carcinoma in patients with cirrhosis

Liver resection for patients with cirrhosis remains a challenging operation. The presence of thrombocytopenia and portal hypertension could lead to severe bleeding during hepatectomy. The enthusiasm of laparoscopic hepatectomy has been growing and many studies have reported their initial favorable results for patients with hepatocellular carcinoma (HCC). The advancement in technology, better understanding of the use of pneumoperitoneum pressure and more experience accumulated make laparoscopic liver resection for patients with cirrhosis possible. Favorable outcome may be achieved if the patients are carefully selected and carried out in high volume centers.

Short-term outcomes following elective transcatheter arterial embolization for splenic artery aneurysms: data from a nationwide administrative database

Background

Splenic artery aneurysm (SAA) rupture is life-threatening. Although elective transcatheter arterial embolization (TAE) suggested low in-hospital death in previous studies, there has been no large multi-center study of elective TAE for SAA.

Purpose

To examine the short-term outcomes of TAE for splenic artery aneurysm (SAA) and analyze the factors associated with the outcomes, including liver cirrhosis, using a nationwide administrative inpatient database.

Material and Methods

We identified patients who received elective TAE with a principal diagnosis of SAA. We assessed the patient background characteristics, comprising age, sex, and specific co-morbidities, including liver cirrhosis. The outcomes included the rate of TAE-related complications (acute pancreatitis, splenic infarction, splenic abscess, or intraperitoneal hematoma), length of stay, and in-hospital mortality.

Results

Among 18.3 million inpatients in the database between July 2010 and March 2013, we identified 534 patients who received elective TAE for SAA at 229 participating hospitals. Fifty-four (10.1%) patients had liver cirrhosis. No in-hospital deaths were observed. Thirty-two (6.0%) patients had at least one TAE-related complication. A multivariate linear regression analysis revealed that liver cirrhosis was significantly associated with longer length of stay (9.5 days; 95% confidence interval [CI], 7.0–12.0 days; P < 0.001). A logistic regression analysis showed that liver cirrhosis was not significantly associated with TAE-related complications (odds ratio, 0.99; 95% CI, 0.29–3.39; P = 0.980).

Conclusion

The results revealed no in-hospital mortality and a low complication rate associated with elective TAE for SAA including liver cirrhosis patients.

Single incision laparoscopic splenectomy, technical aspects and feasibility considerations

Minimally invasive techniques have been introduced to reduce morbidity related to standard laparoscopic procedures. One such approach is laparoendoscopic single-site surgery. The aim of the study was to present our initial clinical experience of using this technique for elective splenectomy. We carried out single access laparoscopic splenectomy (SALS) for an 8 cm cystic lesion of the spleen, involving the hilum, on a 38-year-old woman. The procedure was performed with a single-port device (4-channel) via a 2.5-cm umbilical incision. A flexible 5-mm optic and straight laparoscopic instruments were used. The operative time was 75 min. There was no blood loss. No complications were observed. The postoperative period was uneventful. Although substantial development of the instruments and skills is needed, this SALS technique appears to be feasible and safe. Nevertheless, further experience and observations are necessary.

Robotic single-access splenectomy using the Da Vinci Single-Site® platform: a case report

BACKGROUND

Single-access laparoscopic splenectomy can offer patients some advantages. It has many difficulties, such as instrument clashing, lack of triangulation, odd angles and lack of space. The Da Vinci Single-Site® robotic surgery platform could decrease these difficulties. We present a case of single-access robotic splenectomy using this device.

METHODS

A 37 year-old female with idiopathic thrombocytopenic purpura was operated on with a single-site approach, using the Da Vinci Single-Site robotic surgery device.

RESULTS

The procedure was successfully completed in 140 min. No intraoperative and postoperative complications occurred. The patient was discharged from hospital on day 3.

CONCLUSIONS

Single-access robotic splenectomy seems to be feasible and safe using the new robotic single-access platform, which seems to overcome certain limits of previous robotic or conventional single-access laparoscopy. We think that additional studies should also be performed to explore the real cost-effectiveness of the platform.