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PubMed1996

Unresolved issues in laparoscopic splenectomy.

BACKGROUND: Laparoscopy is now expanding to surgery of intra-abdominal solid organs such as splenectomy for hematologic diseases. The purpose of this study is to further demonstrate that laparoscopic splenectomy is feasible for the surgeon, teachable for the resident, and beneficial to the patient and to revise prior contraindications to this minimally invasive approach. METHODS: Thirty-three consecutive cases of laparoscopic splenectomy were performed between May 1992 and March 1996. The series included 21 females and 12 males with a median age of 42 years (range 19-79) and a median weight of 73 kg (range 36-115). Indications included: immune thrombocytopenic purpura (20), hemolytic anemia (5), hereditary spherocytosis (4), infarction with abscess (1), Hodgkin's lymphoma (1), Gaucher's disease (1), and AIDS-related thrombocytopenia (1). Dissection was predominately performed with a new surgical instrument, the harmonic shears, and main vessels were controlled with clips. RESULTS: Thirty-two (97%) of the cases were completed laparoscopically, with 1 (3%) conversion to control hilar bleeding. Four patients underwent simultaneous cholecystectomy. The median spleen size was 13 cm (range 8-28) and median weight was 256 g (range 40-2100). Median operating time was 242 minutes (range 85-515). Morbidity occurred in 2 (6%) patients: ileus and small bowel obstruction. Median hospital stay was 4 days (range 2-14). There was no mortality in our series. Median follow-up was 20 months (range 1-46) with no evidence of late surgical complication or recurrent disease. CONCLUSION: Laparoscopic splenectomy may be successful in cases previously considered contraindicated, particularly splenomegaly and splenic infarct with abscess. It is a procedure that can be learned under appropriate guidance in academic centers.

Adult↗
PubMed1997

The lateral approach to laparoscopic splenectomy.

BACKGROUND: Laparoscopic splenectomy has been shown to result in shorter hospital stays and a quicker return to work than conventional splenectomy. Having tried the anterior 5 trocar approach, we developed a 4 trocar lateral approach and now present our experience with 22 cases. METHODS: All patients were placed in the right lateral decubitus position. A 10-mm trocar was inserted in the left subcostal region, 2 in the flank, and a 5-mm trocar dorsally. A 30 degrees laparoscope was used. Splenectomy was performed for varying pathologies. RESULTS: Operating room (OR) time averaged 169 minutes, spleen weight 513 grams, and postoperative (post-op) stays 5.4 days (median 3 days). One patient was converted to laparotomy. There were no deaths, post-op abscesses, pancreatic injuries, or bleeding complications. CONCLUSIONS: The lateral approach affords superior exposure, allowing easier dissection of splenic hilar structures. Over varying patient habitus and spleen size it has been demonstrated to be the approach of choice for laparoscopic splenectomy.

Adolescent↗
PubMed1995

Thrombotic thrombocytopenic purpura: indications for and results of splenectomy.

BACKGROUND: Thrombotic thrombocytopenic purpura (TTP) is a rare, life-threatening disorder of unknown pathophysiology. The role of splenectomy in the multimodality therapy of TTP is controversial. MATERIALS AND METHODS: All charts of patients with TTP at the University of Utah between 1984 and 1994 were reviewed to evaluate various treatment regimens, and specifically, the impact of splenectomy on morbidity and survival. RESULTS: Of the 15 patients identified, 14 underwent initial treatment with plasmapheresis and steroids. Nine patients were treated with medical therapy only, 6 of whom completely recovered, while 3 patients died. Six patients failed plasmapheresis and underwent splenectomy. There were no operative complications or postoperative deaths. All surgical patients had no active disease at last follow-up. CONCLUSION: Plasmapheresis and steroid administration remain the first-line therapy for TTP. This series documents that splenectomy offers excellent results with minimal morbidity and mortality in patients who do not respond to or who relapse after plasmapheresis.

Adult↗
PubMed1993

Decision analysis in children with blunt splenic trauma: the effects of observation, splenorrhaphy, or splenectomy on quality-adjusted life expectancy.

The management of blunt splenic trauma in children has remained controversial, with different physicians advocating observation, splenorrhaphy, and splenectomy. Proponents for each position have debated the relative importance of rebleeding (delayed splenic rupture), posttransfusion hepatitis with its sequelae, and overwhelming postsplenectomy sepsis. In an attempt to guide the clinician, a decision analysis was performed. Variables evaluated included the incidence of transfusion, postsplenectomy sepsis, posttransfusion hepatitis, chronic active hepatitis, cirrhosis, and rebleeding. The quality-adjusted life expectancies (QALEs) when the average incidence of the variables were used in the decision analysis were 62.69 years for observation, 62.32 years for splenorrhaphy, and 61.14 years for splenectomy. Sensitivity analysis showed that there was very little difference between observation and splenorrhaphy when the transfusion rate and hepatitis rate were varied. But these treatment options produced longer QALEs than splenectomy. Therefore, in appropriately selected patients, observation is a safe and effective therapeutic option. If an operation is necessary, every effort should be made to preserve the spleen. Splenectomy may still be required in those cases of complete devascularization, persistent hemorrhage, or other associated significant injuries.

Blood Transfusion↗
PubMed1989

Experience of splenectomy and cholecystectomy in children with chronic haemolytic anaemia.

Since 1973, 419 children (233 boys, 186 girls) with chronic haemolytic anaemia (mean age, 10.2 +/- 3.5 years) have been splenectomised. Fifty-three (12.6%) have also been cholecystectomised because of cholelithiasis. Between 1973 and 1982, cholecystectomy and splenectomy were performed at the same time in symptomatic patients. Later, between 1983 and 1987, cholecystectomy was also performed in clinically asymptomatic patients with positive sonographic findings. In the first period, 11 thalassaemic patients (45.8%) were cholecystectomised a short period after splenectomy (in two cases, only 2 and 3 weeks later). Between 1983 and 1987, when asymptomatic patients with cholelithiasis were screened by sonography, simultaneous cholecystectomy and splenectomy were performed in 13.6% of the patients with thalassaemia, in 41% of the patients with sickle cell or microdrepanocytic disease, and in 22.2% of the patients with spherocytosis. As there is a high incidence of asymptomatic cholelithiasis and hypersplenism in patients with chronic haemolytic anaemia, screening for gallstones should precede splenectomy. Simultaneous cholecystectomy should be performed in patients with cholelithiasis.

Adolescent↗
PubMed1989

Gaucher disease: fate of the splenic remnant after partial splenectomy--a case of rapid enlargement.

In Gaucher disease, partial splenectomy has been suggested for alleviating the complications of splenomegaly as well as for avoiding the immunologic compromise and potential acceleration of bony and hepatic involvement that may follow total splenic resection. However, the fate of the splenic remnant has been reported rarely. A subtotal splenectomy (85%) was performed in a 19-month-old girl with rapidly progressing Gaucher disease and massive splenomegaly (12% of body weight). Within 3 months, the splenic remnant had increased four-fold in size. Previous reports indicated only three Gaucher patients had significant enlargement of the splenic remnant after partial splenectomy. These findings indicate that splenomegaly may recur rapidly in Gaucher disease following partial splenectomy.

Female↗
PubMed1999

The morbidity and mortality of pediatric splenectomy: does prophylaxis make a difference?

PURPOSE: The aim of this study was to analyze the incidence of postsplenectomy sepsis morbidity and mortality after prophylaxis, in comparison with our previous 13-year study (1958 to 1970, inclusive). METHODS: All patients who had splenectomy at the Hospital for Sick Children, Toronto, between 1971 and 1995, inclusive (to give a minimum of 2 years for follow-up), were reviewed for infection and mortality. The criterion for classifying a patient as "infected" was the recovery of an invading encapsulated organism from the blood culture in a patient admitted to the hospital. RESULTS: Of the 264 patients studied, 10 had a postsplenectomy infection (3.8%); nine occurred in patients who underwent splenectomy between the ages of 0 and 5 years. Infection took place within 2 +/- 3 years (mean +/- SD) after splenectomy for the immunized patients and 11 +/- 5 days (mean +/- SD) for the nonimmunized children. A significant number of patients were admitted for an apparent respiratory infection, but no serum organisms were isolated. One died of overwhelming sepsis, but the responsible organism was not identified. CONCLUSION: Although there has not been a decrease in the number of splenectomies performed per year, the incidence of infection and mortality has decreased by 47% and 88%, respectively, with prophylaxis.

Adolescent↗
PubMed1995

Outcome of partial splenectomy for type I Gaucher disease.

Partial splenectomy was introduced to achieve the benefits of splenectomy and to avoid the risk of overwhelming infection in patients with symptomatic Gaucher disease. We observed regrowth of the splenic remnant, reemergence of preoperative symptoms, and new bone involvement among most of our patients who had undergone partial splenectomy. Enzyme replacement therapy has markedly limited indications for splenectomy, partial or total, for Gaucher disease.

Adolescent↗
PubMed1994

Laparoscopic assisted splenectomy for treatment of presumed immune thrombocytopenic purpura: initial results.

OBJECTIVE: To present the initial results of performance of laparoscopic splenectomy in two patients at Mayo Clinic Scottsdale. DESIGN: We describe two 18-year-old patients with idiopathic immune thrombocytopenic purpura and the technique of laparoscopic splenectomy used for treatment. MATERIAL AND METHODS: For adequate visualization of the spleen and exposure of the upper midline area should urgent laparotomy become necessary, we position the patient supine with a sandbag under the left lower costal margin. Insertion of five 10-mm trocars facilitates placement of instruments. Dissection of the spleen is begun inferiorly. The splenic flexure of the colon is reflected inferiorly, and the spleen is rotated anterolaterally to allow division of the gastrosplenic ligament and the splenic hilum. Individual vessels are divided between clips, as are the short gastric vessels. Cautery is used for dividing the splenophrenic ligament. The spleen is placed in a plastic bag, and the open end of the bag is delivered through the umbilical incision, after which the spleen is morcellated and then removed. Considerable care must be exercised to ensure that the plastic bag is not punctured and that no ectopic splenic tissue is present. RESULTS: Both laparoscopic splenectomies were successful, and no intraoperative or postoperative complications occurred. After dismissal on postoperative day 3, the patients quickly resumed all activities. The platelet counts returned to normal. CONCLUSIONS: These encouraging results support the use of laparoscopic splenectomy for immune thrombocytopenic purpura and suggest that this procedure may have a role in patients with other conditions of the spleen.

Adolescent↗
PubMed2003

Perioperative outcomes of laparoscopic versus open splenectomy: a meta-analysis with an emphasis on complications.

BACKGROUND: The purpose of this study was to analyze the published perioperative results of laparoscopic splenectomy (LS) compared to open splenectomy (OS), and to determine the impact of LS on the incidence and type of splenectomy-related complications. METHODS: Perioperative results and complications were tabulated from all English-language reports of LS from 1991 through 2002, and complications were analyzed further by type. Data were taken from 26 series that compared OS to LS within an institution (paired analysis) and from an additional 25 series of only LS (unpaired analysis), and a meta-analysis was performed. RESULTS: A total of 2940 patients from 51 published series were included (LS, 2119 patients; OS, 821 patients). Age, gender, and American Society of Anesthesiologists class were similar. In the analysis of paired OS and LS studies, the mean operative time for LS was significantly longer (LS, 180 minutes; OS, 114 minutes; P<.0001,) but the postoperative hospital stay was shorter (LS, 3.6 days; OS, 7.2 days; P<.001). Accessory spleens were identified in 11% of cases in both groups. The total complication rate for LS was 15.5%, compared with 26.6% for OS (P<.0001). LS was associated with significantly fewer pulmonary, wound, and infectious complications (P<.001 for all) but with more hemorrhagic complications, when conversions for bleeding were included. Mortality rates for LS and OS were similar (OS, 1.1%; LS, 0.6%; P=not significant). Comparable results were obtained when the unpaired LS series were added to the analysis. CONCLUSIONS: Although operative times are longer for LS than OS, LS is associated with a significant reduction in splenectomy-related morbidity, primarily as a function of fewer pulmonary, wound, and infectious complications.

Adult↗
PubMed1975

Splenectomy for complications of chronic granulocytic leukaemia.

13 patients with chronic granulocytic leukaemia (C.G.L.) which was unsatisfactorily controlled underwent splenectomy. 3 out of 4 patients with hypersplenism did well, as did 5 out of 8 patients in whom the C.G.L. had undergone metamorphosis to a refractory phase. In a case of C.G.L. complicated by severe myelofibrosis the need for transfusion was reduced but survival was short. Splenectomy should be considered when C.G.L. in its chronic phase is complicated by hypersplenism, and may be considered as a part of the treatment after C.G.L. has undergone metamorphosis to a refractory phase. However, a favourable outcome is unlikely for patients over 65 years, and in the presence of coexistent illnesses, rapidly progressive metamorphosis to an acute phase, or severe bone-marrow failure from any cause. In C.G.L., elective splenectomy early in the chronic phase must be clearly distinguished from splenectomy performed at a later stage when the disease is not well controlled.

Adolescent↗
PubMed1975

Splenectomy for haematological cytopenias in patients with malignant lymphomas.

Haematological cytopenias caused by increased splenic activity occurred in 86 patients with malignant lymphomas (50 patients with stage III or IV Hodgkin disease [H.D.] and 36 with non-Hodgkin lymphomas). Splenectomy was performed in 84 of these 86 patients. There was complete or partial correction of the haematological defect in 90% of the H.D. patients and 89% of the non-Hodgkin patients. Chemotherapy or radiotherapy was started after the haematological defect had been corrected by splenectomy, and as a result 79% of the H.D. patients and 75% of the non-Hodgkin patients had a complete or partial remission of their disease. Increased splenic activity should be considered as a cause of a haematological cytopenia in patients with malignant lymphomas even in those with bone-marrow involvement, since splenectomy is accompanied by excellent results in terms of disease remission with subsequent therapy. 2 patients with H.D. (4%) and 5 with non-Hodgkin lymphomas (14%) died in hospital after splenectomy. Thus the operation was associated with acceptable mortality and morbidity despite the advanced stage of disease in most cases.

Anemia↗
PubMed1997

A study of 42 episodes of overwhelming post-splenectomy infection: is current guidance for asplenic individuals being followed?

Individuals without a spleen have an increased risk of overwhelming post-splenectomy infection (OPSI). Improved awareness in recent years has stimulated increased efforts to prevent OPSI. Published guidelines have described policies for immunization, chemoprophylaxis and other measures considered beneficial to asplenic patients, yet OPSI episodes continue to occur. In an attempt to investigate why serious infections are still being seen, we have conducted a nationally based survey of recent OPSI episodes, using mainly a network of medical microbiologists. Data including clinical background to both splenectomy and OPSI episode, immunization and chemoprophylaxis history have been collated. Forty-two cases of overwhelming infection were reported by June 1996. Patients of all ages were affected with OPSI occurring up to 59 years after splenectomy. A mortality rate of 45% was seen. Pneumococcal infection caused at least 37 of 42 episodes, but only 12 patients had received pneumococcal vaccine. Four cases were possible vaccine failures. Only 22% of individuals had taken any chemoprophylaxis since splenectomy, and only one carried a medical alert card. Much more needs to be done to ensure that asplenic patients are warned of the risks of infection, and given at least pneumococcal vaccine. The role of antibiotics for either continual prophylaxis or as a reserve supply for self-prescription at appropriate times also needs greater discussion. Further work on improving pneumococcal vaccine response together with suitable programmes for revaccination are required. Surveillance should continue until the incidence of OPSI reaches an irreducible minimum.

Adult↗
PubMed1999

Splenectomy attenuates superoxide anion release into the hepatic sinusoids after lipopolysaccharide challenge.

BACKGROUND/AIMS: The aim of this study was to determine whether the spleen contributes to superoxide anion release into the hepatic sinusoids and subsequent damage to endothelial cells of the hepatic sinusoids after lipopolysaccharide challenge. METHODS: Rats were given 2 mg/kg body weight lipopolysaccharide. Three hours after the treatment, superoxide anion release into the hepatic sinusoids was examined in a liver perfusion model using the cytochrome C method. Damage to endothelial cells of the hepatic sinusoids was assessed from the purine nucleoside phosphorylase/glutamic-pyruvic transaminase ratio in the liver perfusate. To further characterize the mechanisms behind these changes, these studies were done in rats given superoxide dismutase or an anti-TNFalpha antibody. To study whether the spleen plays a role in the mechanisms, experiments with splenectomized rats were performed. RESULTS: Lipopolysaccharide challenge resulted in superoxide anion release into the hepatic sinusoids and damage to endothelial cells of the hepatic sinusoids. These changes were significantly attenuated by the treatments with superoxide dismutase or an antibody against TNFalpha, as well as by splenectomy. The hepatic macrophage and Kupffer cell populations after lipopolysaccharide challenge were significantly smaller in the rats given splenectomy than in those given a sham operation. There were no significant differences in the neutrophil populations between the two groups. Levels of TNFalpha were significantly lower in the former than the latter, whereas there were no significant differences in levels of Interleukin-8 between the two groups. CONCLUSIONS: Splenectomy reduced the superoxide anion release into the hepatic sinusoids caused by the lipopolysaccharide challenge and subsequent damage to endothelial cells of the hepatic sinusoids. This supports the view that splenectomy has a protective effect in lipopolysaccharide-induced liver injury.

Animals↗
PubMed1993

Immune restoration in children after partial splenectomy.

Splenectomy (SE) is recognized to be a therapeutical approach in treating children with severe autoimmune diseases (chronic idiopathic thrombocytopenia; hemolytic anemia) or hypersplenism because of portal hypertension. Nevertheless, removal of a main immune organ results in elevated infection risk for these patients. Partial splenectomy (PSE) was developed as a therapeutical compromise to retain immunologically active spleen tissue. Here, we document the analysis of immune parameters obtained from children after both partial and total splenectomy, which have been followed up for a period of more than 6 years: (i) Lymphocytes from both groups of patients failed to produce IgG in response to pokeweed mitogen in vitro. This was observed in 11/20 splenectomized patients even 10 years after operation, whereas in PSE patients a restoration of this parameter after 1-2 years was seen. (ii) In patients after PSE, but not in splenectomized persons, an elevated number of HLA-class II positive cells had been detected suggesting a different situation of immune regulation following this operation. However, in parallel with an improvement of B cell in vitro activity this parameter was found to achieve normal values. Our findings indicate that partial splenectomy may be a therapeutical alternative, if the therapeutic goal can be achieved by this procedure.

Adolescent↗
PubMed2000

Splenectomy may improve the glomerulopathy of type II mixed cryoglobulinemia.

Many patients with type II mixed cryoglobulinemia have been shown to be infected with hapatitis C virus (HCV). Therefore, interferon-alfa has become the first choice of treatment for patients with HCV-associated cryoglobulinemia. However, the disease often relapses after the discontinuation of interferon therapy. The long-term effect of interferon therapy is controversial. Therefore, a more effective therapy needs to be developed. A 62-year-old Japanese woman was admitted to our hospital for the examination of abnormal liver function tests, severe edema, and purpura in her lower extremities. Glomerulopathy secondary to HCV-related cryoglobulinemia was suspected. Her serum creatinine was increased to 2.1 mg/dL. Interferon therapy was considered initially. However, because of pancytopenia caused by liver cirrhosis and splenomegaly, splenectomy was performed in February 1997, before the start of interferon therapy. Renal biopsy specimen taken at the time of the splenectomy showed typical cryoglobulinemic glomerulonephritis. Gradually, after surgery, the patient's thrombocytopenia and anemia improved, her proteinuria and hematuria were decreased, her cryocrit dropped from 15% to 5%, the Ccr increased from 21.1 mL/min to 48.8 mL/min, and the purpura in her lower extremities disappeared. A repeat renal biopsy performed in May 1998 showed marked histological improvement. Splenectomy is not widely accepted as a treatment for cryoglobulinemia. Our case suggests the possibility that the monoclonal-IgM component of the type II cryoglobulin may be formed in the spleen. In conclusion, splenectomy may be an effective therapy for cryoglobulinemia in patients with HCV-positive liver cirrhosis and pancytopenia secondary to splenomegaly.

Anemia↗
PubMed1998

Laparoscopic splenectomy.

Splenectomy in childhood usually is required for hematologic disorders such as hereditary spherocytosis, immune thrombocytopenic purpura, or sickle cell disease. The laparoscopic approach for splenectomy in children has been developed and advanced over the past 5 years. New techniques and equipment allow the procedure to be performed safely and effectively. This article details the technique and reports the results of 63 infants, children, and adolescents who underwent laparoscopic splenectomy for hematologic disorders. Although operating times were longer than for open splenectomy, the narcotic requirement was less and length of stay was shorter.

Adolescent↗
PubMed2000

Effectiveness of gastric devascularization and splenectomy for patients with gastric varices.

BACKGROUND: Bleeding from gastric varices is difficult to control and has a high mortality rate. Recently, newly developed treatments for this serious lesion have been used, but surgical intervention is still advocated by several studies. We report our experience with gastric devascularization and splenectomy and its effectiveness for patients with gastric varices. STUDY DESIGN: Gastric devascularization and splenectomy was successfully performed to treat patients with isolated gastric varices (n = 42). The patients included 27 men and 15 women who ranged from 29 to 73 years of age (average 53.7 years). We analyzed the findings of gastric varices using endoscopy, the results of gastric devascularization and splenectomy, and survival after the operation. RESULTS: No patient had tortuous varices (F1). Twenty-seven patients (64.3%) had nodular varices (F2) and 15 (35.7%) had tumorous varices (F3). Twenty-five patients (59.5%) had large varices that occupied two or more areas. Twenty-nine patients (69.0%) had varices with a positive red color sign. No major complications during or after the operation were observed, and peri-operative death did not occur. Gastric varices were eradicated in all 42 patients. Survival rates were 97.6% after 1 year, 88.1% after 3 years, 76.2% after 5 years (mean followup period, 46 months). CONCLUSIONS: This study showed that gastric devascularization and splenectomy provides satisfactory results for patients with gastric varices that are likely to bleed and that it can be performed even on patients who have had other treatments.

Adult↗