Late results after splenectomy in adult idiopathic thrombocytopenic purpura

Hemocoagulative post-operative changes after laparoscopic surgery compared to open surgery: the role of lupus anticoagulant

Although still debated, post-operative modification of hemostasis seems to be less pronounced after laparoscopy compared to open surgery. Antiphospholipid antibodies might play a role in the post-operative thromboembolic risk, although their evaluation in surgical patients has never been performed. Post-operative modification of antiphospholipid antibodies could be related to the surgical approach (laparoscopic or open). In this prospective study, the authors statistically compared the pre-operative values and post-operative modification of antiphospholipid antibodies in two homogeneous groups of patients operated on by laparoscopic and open surgery. No statistical differences within each group and between the two groups were shown comparing mean values of pre-operative and post-operative antiphospholipid antibodies. In the open group, there was a significant difference between pre-operative and post-operative LAC means (P < 0.01). In the laparoscopic group, on the contrary, no significant change in LAC values between pre- and post-operative tests (P = 0.55) was observed. Since LAC could be related to coagulation disorders, this study seems to support that laparoscopic surgery might induce a less risk of post-operative thromboembolic disease.

Combined subtotal gastrectomy and splenectomy after partial splenic embolization for a patient with gastric cancer and immune thrombocytopenic purpura: A case report

•

Immune thrombocytopenic purpura (ITP) is an autoimmune disease characterized by thrombocytopenia.

•

Gastric cancer complicated by ITP can result in gastrointestinal bleeding.

•

Partial splenic embolization effectively treats thrombocytopenia.

•

Preserving blood flow to the remnant stomach is important when performing combined subtotal gastrectomy and splenectomy.

Introduction

Immune thrombocytopenic purpura is an acquired thrombocytopenia. Preoperative management of thrombocytopenia is important in patients with gastric cancer. Partial splenic embolization can be effective for patients with thrombocytopenia, but could lead to ischemic necrosis of the remnant stomach when performing subtotal gastrectomy with splenectomy.

Presentation of case

The patient is an 84-year old woman evaluated for anemia. Endoscopy revealed an advanced gastric cancer with bleeding. The patient also had immune thrombocytopenic purpura with a platelet count <50,000/μL. Administration of platelets did not increase the platelet count. Partial splenic embolization was performed followed by administration of high-dose immunoglobulin. The platelet count was over 50,000/μL preoperatively. The patient underwent combined subtotal gastrectomy and splenectomy, followed by an uneventful course.

Discussion

Patients with immune thrombocytopenic purpura and advanced gastric cancer can have anemia. Partial splenic embolization has been used to treat patients with refractory immune thrombocytopenic purpura as an alternative to splenectomy. Preoperative partial splenic embolization and high-dose immunoglobulin therapy resulted an increased platelet count in this patient. Elderly patients with gastric cancer have a high risk of postoperative complications. Patients with gastric cancer undergoing total gastrectomy have an impaired postoperative quality of life compared to those who undergo subtotal gastrectomy. We performed a subtotal gastrectomy and splenectomy as a function-preserving operation, completed safely by maintaining blood flow to the remnant stomach.

Conclusion

Partial splenic embolization is effective for patients with immune thrombocytopenic purpura and gastric cancer. Combined subtotal gastrectomy and splenectomy is achieved by preserving blood flow to the remnant stomach.

Predictive Factors for Success of Laparoscopic Splenectomy for ITP

Background and Objectives:

Therapy-resistant immune thrombocytopenia (ITP) is the most frequent indication of laparoscopic splenectomy (LS). It ensures the best results for this disease compared with possible second-line pharmacologic therapies. Therefore, learning about the safety of the surgical method and its long-term efficacy is important, as is selecting patients who respond to surgical treatment. Our purpose was to analyze the safety of LS and the short-and long-term prognostic significance of known perioperative parameters.

Methods:

We performed 40 LSs for ITP from January 1, 2000, to January 1, 2015. We analyzed the roles of the perioperative parameters by using evidence-based guidelines.

Results:

Complete response (CR; platelet count over 100 × 10⁹/L) occurred in 28 cases (70%) and partial response (PR; platelet count between 30 and 100 × 10⁹/L) in 5 cases (12.5%). Below the age of 50, 9% (2/22) of the patients had no response (NR; platelet count not increasing over 30 × 10⁹/L), 28% (5/18) over the age of 50 (P = .023) had no response. In the steroid-refractory group, 30% did not respond, whereas 100% of the steroid-dependent patients had a CR (NR: 7/23 steroid refractory vs 0/17 steroid dependent; P = .027). The patients were followed up for a mean of 10.9 ± 6.9 years, and a long-term response (LTR) was detected in 21 of the responders (n = 33). Of the patients who originally had a CR, 71% also achieved LTR, whereas only 20% of the PR patients did.

Conclusion:

LS is safe and remains the most effective second-line treatment for ITP. In our study, younger age and response to preoperative steroids were predictive factors for the long-term success of splenectomy.

Preoperative Predictive Factors of Conversions in Laparoscopic Splenectomies

PURPOSE

Presently, laparoscopic splenectomy (LS) is being performed for several indications in clinical practice. However, conversion to open surgery is occasionally required in some patients. We analyzed the intraoperative indications and potential preoperative predictors associated with conversion to open surgery in those presenting for LS.

METHODS

We reviewed 107 patients who underwent LS. We analyzed the surgical indications, spleen size, surgical procedure performed, operative time, rate of and indications for conversions, as well as postoperative complications.

RESULTS

Among the 15 patients (14.0%) who underwent conversion, the conversion was related to the occurrence of a splenic lymphoma in 10, severe bleeding in 3, a lack of anatomic definition in 1, and splenic candidiasis in 1 patient. A comparison between the results obtained in the initial 30 patients (LS performed during the learning curve) and those obtained in the remaining 77 patients, showed that conversions appeared to be related to the experience/expertise of the surgical team excluding patients with splenic malignancies. Conversion was not associated with a higher morbidity-mortality rate, but only a longer length of hospitalization.

CONCLUSIONS

LS is a gold standard procedure when performed by experienced and competent surgeons. However, careful patient selection is recommended before using the laparoscopic approach in those presenting with splenic malignancies.

Laparoscopic Splenectomy for Benign Hematological Disorders in Adults: A Systematic Review

BACKGROUND

Since its introduction in the early 1990s, laparoscopic splenectomy (LS) has gained worldwide acceptance for spleen removal, especially in hematological patients.

AIM

The present review summarizes the current knowledge and results of LS for the treatment of benign hematological diseases in adults.

MATERIALS AND METHODS

A MEDLINE/PubMed database research was performed using the terms: "laparoscopic splenectomy" OR "laparoscopy" OR "splenectomy" AND "hematological disorders" OR "hematological disease" OR "hematology" AND "adults" as key words. We set our analysis starting date as January 1st 2010 and the end date as December 31st 2016. We identified 247 relative articles. All the references from the identified articles were searched for relevant information.

RESULTS

Twenty-seven articles were deemed appropriate for our analysis. LS was found to be feasible and safe in the majority of patients with benign hematological disorders, with a mortality rate ranging from 0% to less than 4% and the postoperative complications rate from 0% to 35.7%. The conversion rate was also very low (4%) and response (complete or partial) was achieved in more than 80% of patients. Lateral approach with four trocars was the most commonly used approach with concommitant cholecystectomy being correlated with increased operative time and morbidity.

CONCLUSION

Current literature holds that whenever splenectomy is required for the treatment of hematological disorders in adults, a laparoscopic approach should be offered as the gold standard. However, to strengthen the clinical evidence in favor of LS, more high-quality clinical trials on several issues of the procedure are necessary.

Topical hemostasis in laparoscopic surgery

A major goal during any surgical intervention is minimization of blood loss, which reduces the need for blood transfusion. In open surgery, the possibility for the surgeon to use the hands directly in contact with the bleeding tissues for hemostasis, makes mechanical methods, such as compression, ligatures or sutures, important to achieve proper hemostasis. In laparoscopic surgery, where the intervention is performed by means of small incisions through which the surgeon's hand cannot directly achieve the tissues, the problem of hemostasis is critical and needs more attention. Either in open or in laparoscopic surgery, significant bleeding during surgery is controlled through vessel ligation, suturing, and electrocautery. Topical hemostatic agents are useful adjuncts to surgical hemostasis for controlling non-specific bleeding. The introduction of different devices and topical agents has made possible to perform more complex interventions also in laparoscopy. The Authors discuss about the type, the field of application, the side effects of the hemostatic devices and of the topical hemostatic agents.

Platelet count evolution as a predictor of outcome after splenectomy for immune thrombocytopenic purpura

Splenectomy is the definitive second-line therapy for refractory immune thrombocytopenic purpura (ITP), and has a reported response rate of 50-80%. Medical attention should be reconsidered when there is no evidence of accessory spleen in refractory ITP patients after splenectomy. The purpose of this study was to determine whether platelet count evolution differs between patients with a successful or unsuccessful result after splenectomy for ITP. Archived records of 104 consecutive patients that underwent splenectomy for ITP were reviewed. Patients were divided into two groups (failures and successes) using a final follow-up platelet count of 100,000/μL as a cut-off. Platelet count evolutions in these two groups were compared using the Student's t test. Successes and failures were found to have significantly different platelet counts from two days postoperatively (P = 0.016). The area under the receiver operating characteristic curve was 0.630 (95% confidence interval, 0.518-0.741, P = 0.030), and when a cut-off value of 100,000/μL was used, sensitivity and specificity were 68.2 and 51.2%, respectively. To obtain positive and negative predictive values exceeding 50%, additional platelet counts were required at one week and one month after splenectomy. We propose a protocol for ITP follow-up after splenectomy.

Subcutaneous cervical emphysema and pneumomediastinum due to a diastatic rupture of the cecum

Pneumomediastinum usually occurs after esophageal or chest trauma. Subcutaneous cervical emphysema as a presentation of non-traumatic colonic perforation following colorectal cancer or diverticulitis, is very rare. We report a case of a patient with rectal cancer who developed a diastatic cecum retroperitoneal perforation with a secondary pneumomediastinum and cervical emphysema. The patient was in treatment with a neoadjuvant chemo-radiotherapy for a low rectal cancer. Treatment consisted in an emergency right hemi-colectomy with ileostomy and performance of distal colonic fistula. The Authors discuss the occurrence of pneumomediastinum and cervical emphysema complicating rectal cancer, pointing out ethiopathogenesis, clinical presentation, diagnosis and treatment. The importance of performing a diverting colostomy when neoadjuvant chemotherapy is scheduled in patients with stenotic rectal cancer, although not clinically occluded.

A rare case of myeloid sarcoma presenting as anal fissure

Myeloid sarcoma is a tumor composed of myeloblasts occurring at an extramedullary site. It may develop in patients with acute myeloid leukemia, myeloproliferative or myelodysplastic syndrome, sometimes preceding onset of the systemic disease. Frequent sites of myeloid sarcoma are bones or various soft tissues. Gastrointestinal involvement is very rare. We report a unique case of myeloid sarcoma presenting as a painful anal fissure, in a patient with a history of acute myeloid leukemia. The diagnosis was achieved by a surgical excisional biopsy and immunoistochemical staining.