General Gastroenterological Surgery: Spleen.

Abstract

Asian Journal of Endoscopic SurgeryVolume 8, Issue 3 p. 242-245 JSES guidelineFree Access General Gastroenterological Surgery: Spleen First published: 25 August 2015 https://doi.org/10.1111/ases.12221_2Citations: 1AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat For references, please see the pages exclusive to the members of the Japan Society for Endoscopic Surgery. Clinical question 1: Is laparoscopic surgery recommended for splenectomy? Laparoscopic splenectomy (LS) is recommended when the indications are appropriate and if the procedure is performed by a skilled and experienced surgeon. Strength of recommendation: B 1-1 Are malignancies and a large spleen indications for LS? Although there is insufficient comparative evidence, malignancies and a large spleen may be indications for LS depending on the surgeon's skill level and experience. ■ Explanation LS is recommended for both benign and malignant lesions 1. Patients with hematologic malignancy are more likely to have splenomegaly or massive splenomegaly than those with benign disease 1, 2. LS in patients with splenomegaly is associated with increased surgical difficulty owing to the limited surgical space in the abdominal cavity. However, in patients with mild splenomegaly, the rate of conversion to open surgery, length of hospitalization, and complication rate with LS do not significantly differ from those in patients with normal spleen, although increased surgical time and blood loss have been noted 3. There is currently no clear evidence indicating whether malignancy or splenomegaly of different sizes is an indication for LS. The LS guidelines established by the European Association for Endoscopic Surgery (EAES) in 2008 describe the normal size and weight of the adult spleen as being 11 × 7 × 4 cm and 100–250 g, respectively 4; they define a longitudinal diameter ≥15 cm as splenomegaly and ≥20 cm as massive splenomegaly. The guidelines state that for splenomegaly, LS is safe and should be recommended over open splenectomy (OS) (EAES strength of recommendation: B). In contrast, for massive splenomegaly, the use of HALS or OS should be considered (EAES strength of recommendation: C), as supported by studies of evidence level II or less. A multicenter case–control study identified patient physique and the presence of hematological malignancy as independent risk factors for intraoperative complications and conversion to OS during LS; it also identified the longitudinal diameter of the spleen and conversion to OS as independent risk factors for postoperative complications 2. Meanwhile, an RCT demonstrated the efficacy of HALS over OS for treating splenomegaly and massive splenomegaly 5. However, no study of evidence level I is available. Therefore, although it is unclear whether malignancy or splenomegaly of different sizes is an indication for LS, LS should be selected as the first-line treatment for treatable cases of malignancy and splenomegaly depending on the surgeon's skills and experience. At a lower level of recommendation, HALS or OS should be used for complicated cases. 1-2 Is LS superior to laparotomy with respect to short-term outcomes, recovery, and cost? LS is superior to laparotomy but not substantially so. ■ Explanation A meta-analysis and two RCT have compared the perioperative outcomes of LS and OS 5-7. The meta-analysis shows that LS is associated with a significantly shorter length of postoperative hospitalization and lower incidence of postoperative pain and complications (mainly respiratory complications and wound infection). However, it also indicates that LS is significantly associated with longer surgical time and increased blood loss 6. An RCT also demonstrates a shorter length of postoperative hospitalization and less postoperative pain with HALS than with laparotomy in patients with splenomegaly 5. The costs of LS have only been discussed in case–control studies 8, 9, with no study of evidence level I having been reported. (Herein, “cost” includes the costs of surgery, hospitalization, and outpatient visits as well as social costs such as loss of income due to absence from work.) One of these studies reports that LS is associated with higher surgical costs than OS, as it requires relatively expensive medical instruments, more disposable items, and longer surgical time; however, the overall cost is not significantly different from that of OS because of the shorter length of hospitalization after LS 8. Another study reports that the cost of splenectomy in patients with hematological disease is related to the size of spleen and complications, not the surgical technique used 9. Given these reports, further studies with higher evidence levels and that consider disease type and other factors are required to conclude if there is any significant difference between LS and OS with respect to cost. Therefore, although no high evidence-level study on this subject is available, LS appears to be almost comparable to OS in terms of cost because it is associated with shorter length of postoperative hospitalization, lower incidences of postoperative pain, and fewer complications despite longer surgical time and increased blood loss. 1-3 Is LS associated with higher incidences of complications such as bleeding, pancreatic fistula, and portal vein thrombosis than laparotomy? The complication rate for LS is comparable to that for laparotomy, although there is no robust evidence. ■ Explanation Many reports suggest LS is associated with a lower or comparable incidence of complications compared to OS. A meta-analysis comparing the perioperative outcome of LS and OS shows a lower incidence of complications with LS 6. LS is associated with lower incidences of respiratory-, wound-, and infection-related complications and subphrenic abscess (i.e. pancreatic fistula) as well as comparable incidences of postoperative bleeding and portal vein thrombosis. The 2008 EAES LS guidelines recommend LS over OS on the basis of the lower rate of complications and earlier postoperative recovery (EAES strength of recommendation: B) 4. Nevertheless, the incidence of portal vein thrombosis remains controversial; some reports show a comparable incidence between LS and OS, while others suggest a higher incidence with OS owing to increased abdominal air pressure. An RCT involving patients with splenomegaly (median spleen weight: 1200–1800 g) shows a comparable rate of complications, lower incidence of postoperative pain, and shorter length of postoperative hospitalization with HALS than with OS 5. No high evidence-level study has compared the complication rate of LS with that of OS in patients with portal hypertension or hypersplenism. Therefore, the possibility of varying incidences of complications among patients with varying surgical indications should be taken into consideration. Therefore, despite the lack of robust evidence, LS is comparable to OS with respect to the incidence of complications such as bleeding, pancreatic fistula, and portal vein thrombosis. 1-4 Is portal hypertension or hepatic cirrhosis (including Child–Pugh classification cut-off) an indication for LS? LS may be indicated for portal hypertension or hepatic cirrhosis (including Child–Pugh classification cut-off) depending on the surgeon's skill level and experience, although there is no robust evidence. ■ Explanation No high evidence-level study has compared the perioperative outcomes of LS and OS in patients with portal hypertension or hepatic cirrhosis. Nonetheless, compared to OS, LS is associated with slightly longer surgical time, less blood loss, a lower incidence of complications, earlier resumption of oral intake, lower frequency of analgesic use, and shorter length of hospitalization. LS does not negatively affect 1-week postoperative liver function as much as OS 10, 11. The rate of conversion to open surgery is reported as 2.4%–6.2%, the major cause of which is bleeding. No surgery-related death has been reported. LS for patients with portal hypertension or hepatic cirrhosis is associated with significantly longer surgical time than LS for patients with benign hematological disorders such as idiopathic thrombocytopenic purpura. However, no significant difference has been observed in terms of the rate of conversion to open surgery, blood loss, or transfusion volume. Some reports show that the complication rate and length of hospitalization are greater with LS, while others show comparable results between LS and OS 10, 12. For patients with compensated cirrhosis type C with a platelet count < 50 000/μL, interferon therapy may be started following LS, taking into account patient response to therapy 13. Therefore, LS may be indicated for portal hypertension or hepatic cirrhosis (including Child–Pugh classification cut-off) depending on the surgeon's skill level and experience, although there is no robust evidence. 1-5 Can early splenic artery ligation/embolization be performed? Early splenic artery ligation/embolization can be performed, although there is no robust evidence. ■ Explanation LS is more technically difficult than OS owing to limited surgical space and manipulation. Moreover, especially in patients with splenomegaly (including massive splenomegaly), LS is associated with increased intraoperative blood loss and an increased rate of conversion to open surgery 14, 15. Therefore, some institutions perform early splenic artery ligation/embolization to reduce intraoperative blood loss and conversion to open surgery. LS with early splenic artery ligation/embolization is associated with significantly better outcomes, less blood loss, and a lower rate of conversion to open surgery than LS without such a technique, but there is no significant difference with respect to surgical time 14, 15. The differences are particularly marked in patients with massive splenomegaly 15. Early splenic artery ligation/embolization is reported to have no benefit in patients with a longitudinal spleen diameter ≤20 cm, suggesting the need for further investigations to establish the indications for the technique 16. Early splenic artery ligation/embolization must be performed carefully as it is associated with complications such as pulmonary atelectasis, pleural effusion, pancreatitis, and coil dislocation 16. Although no study has compared the efficacy of ligation and embolization, there seems to be no major difference. The use of an automatic suturing instrument on the hilum of the spleen after coil embolization has been shown to be safe in an animal study using pigs as well as in actual clinical settings 17. Therefore, although there is no robust evidence regarding the use of early splenic artery ligation/embolization in LS, the technique can be performed, especially in patients with massive splenomegaly, in order to reduce intraoperative blood loss and conversion to open surgery. 1-6 Does LS increase late postoperative complications compared to laparotomy? Is the preoperative use of a pneumococcal vaccine (e.g. Pneumovax) (Pneumovax 23(TR), Merck & Co., Inc., West Point, PA) necessary? LS does not increase the rate of late postoperative complications, although there is no robust evidence. There is fair evidence to recommend the use of a pneumococcal vaccine for patients in select age groups, but there is insufficient evidence to recommend it for all patients. ■ Explanation Several studies suggest that compared to OS, LS results in a lower incidence of early postoperative (within 30 days) complications. Only a few studies have examined late postoperative complications. Pancreatic fistula is a serious complication of LS that usually occurs immediately postoperatively but rarely occurs more than 1 month postoperatively. Therefore, the rate of pancreatic fistula as a late postoperative complication is likely to be similar between OS and LS. Portal vein thrombosis is another complication of splenectomy that is particularly common in patients with splenomegaly; its incidence as a late postoperative complication is reported to be similar between OS and LS 18. Other complications of splenectomy that likely differ between OS and LS include wound pain, abdominal incisional hernia, and ileus, although no study has specifically compared the incidences of these complications between OS and LS. Given that the incidence of overwhelming postsplenectomy infection (OPSI) in children aged ≤5 years exceeds 10% compared to ≤1% in adults, vaccination is recommended for pediatric patients 19. Adult patients on radiation or anticancer therapy are also at an increased risk of OPSI, which is associated with high mortality; vaccination reduces the risk of severe infection 20. Although no study has compared the incidence of OPSI between OS and LS, any difference is unlikely because both approaches involve the same intervention: splenectomy. Splenectomy is associated with a postoperative decrease in immunoglobulin M memory B cells 21, but the use of a pneumococcal vaccine (e.g. Pneumovax) against pneumococci, the most common cause of OPSI, produces effective antibody titers even after splenectomy, except in patients with non-Hodgkin's lymphoma with impaired B-cell function 22. Therefore, LS can be performed without increasing late postoperative complications, although there is no robust evidence. There is fair evidence to recommend the use of a pneumococcal vaccine for patients in select age groups, but there is insufficient evidence to recommend it for all patients. Appendix: Appendix: authors' affiliations Masao Tanaka, Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University; Morimasa Tomikawa, Fukuoka City; Masafumi Nakamura, Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University; Yoshiharu Nakamura, Department of Surgery, Nippon Medical School; Takeyuki Misawa, Department of Surgery, Jikei University Kashiwa Hospital; Tomohiko Akahoshi, Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University; Nao Kinjyo, Department of Gastroenterological Surgery, National Kyushu Cancer Center; Hiroki Sumiyoshi, Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School; Kosuke Tsutsumi, Department of Surgery, Japan Community Health Care Organization (JCHO) Kyushu Hospital; Norifumi Tsutsumi, Department of Surgery, Center for Gastroenterology, National Kyushu Medical Center; Hiroshi Nakashima, Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University; Masaharu Higashida, Department of Digestive Surgery, Kawasaki Medical School; Yuki Fujiwara, Department of Surgery, Jikei University Kashiwa Hospital; Akira Matsushita, Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School; Michinori Matsumoto, Department of Surgery,Jikei University School of Medicine. 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