Elective Splenectomy Research Articles

Transjugular intrahepatic portosystemic shunt (TIPS) versus laparoscopic splenectomy (LS) plus preoperative endoscopic varices ligation (EVL) in the treatment of recurrent variceal bleeding

The aim of the present study was to compare elective transjugular intrahepatic portosystemic shunt (TIPS) and laparoscopic splenectomy (LS) plus preoperative endoscopic varices ligation (EVL) in their efficacy in preventing recurrent bleeding and improving the long-term liver function in patients with liver cirrhosis and portal hypertension. Between January 2009 and March 2012, we enrolled 83 patients (55 with TIPS, defined as the TIPS group, and 28 with LS plus preoperative EVL, defined as the LS group) with portal hypertension and a history of gastroesophageal variceal bleeding resulting from liver cirrhosis. The clinical characteristics, perioperative outcomes, and follow-up were recorded. No significant differences were observed between the two treatment groups with respect to the patients' characteristics and preoperative variables. Within 30 days after surgery, one patient in the TIPS group died of multiple organ dysfunction syndrome, whereas no patient in the LS group died. Complications occurred in 14 patients in the TIPS group, which included rebleeding, encephalopathy, ascites, bleeding from a pseudoaneurysm of the thoracoabdominal aorta, and pulmonary infection, compared with 5 patients in the LS group, which included pulmonary effusion, pancreatic leakage, and portal vein thrombosis. During a mean follow-up of 13.6 months in the TIPS group and 12.3 months in the LS group, the actuarial survival was 85.5 % in the TIPS group versus 100 % in the LS group. The long-term complications included rebleeding and encephalopathy in the TIPS group. LS plus EVL was superior to TIPS in the prevention of gastroesophageal variceal rebleeding in cirrhotic patients. This treatment was associated with a low rate of portosystemic encephalopathy and improvements in the long-term liver function.

Hepatic vein waveform and splenomegaly predict improvement of prothrombin time after splenectomy in hepatitis C virus‐related cirrhotic patients

Whether hepatic function can recover in cirrhotic patients after splenectomy remains controversial. All consecutive Japanese patients with hepatic cirrhosis due to hepatitis C who had undergone elective splenectomy in Kyushu University Hospital between January 2008 and December 2009 were included in this retrospective study. Prothrombin time, serum albumin and total bilirubin concentrations were reviewed before and after splenectomy and analyzed to clarify whether splenectomy improves hepatic function in patients with cirrhosis and to determine the factors predictive of improvement in hepatic function. Prothrombin time and total serum bilirubin concentration improved after splenectomy; however, serum albumin concentrations did not increase significantly. Twelve months after splenectomy, total serum bilirubin had decreased by over 0.3 mg/dL in 52.3% of patients and prothrombin time had improved by over 10% in 52.3% of patients. Multiple linear regression analysis identified hepatic vein waveform (HVWF) type I (P = 0.0174) and spleen weight (P = 0.0394) as independent predictors of improvement in prothrombin time and preoperative total serum bilirubin (P = 0.0002) as the only independent predictor of decrease in total bilirubin. Total bilirubin and prothrombin time were significantly improved after splenectomy in patients with HVWF type I, however, they were not improved in patients with HVWF type II. Prothrombin time and total bilirubin improve in approximately half of cirrhotic patients within a year after splenectomy. HVWF type I and splenomegaly may be predictive factors for improvement in prothrombin time after splenectomy in patients with cirrhosis due to hepatitis C.

Anterior Versus Posterolateral Approach for Total Laparoscopic Splenectomy: A Comparative Study

Objective: Although the anterior approach is normally used for elective laparoscopic splenectomy (LS), the posterolateral approach may be superior. We have retrospectively compared the effectiveness and safety of these approaches in patients with non-severe splenomegaly scheduled for elective total LS.Methods: Patients with surgical spleen disorders scheduled for elective LS between March 2005 and June 2011 underwent laparoscopic splenic mobilization via the posterolateral or anterior approach. Main outcome measures included operation time, intraoperative blood loss, frequency of postoperative pancreatic leakage, and length of hospital stay.Results: During the study period, 203 patients underwent LS, 58 (28.6%) via the posterolateral and 145 (71.4%) via the anterior approach. Three patients (1.5%) required conversion to laparotomy due to extensive perisplenic adhesions. The posterolateral approach was associated with significantly shorter operation time (65.0 ± 12.3 min vs. 95.0 ± 21.3 min, P < 0.01), reduced intraoperative blood loss (200.0 ± 23.4 mL vs. 350.0 ± 45.2 mL, P < 0.01), and shorter hospital stay (5.0 ± 2.0 d vs. 9.0 ± 3.0 d, P < 0.01) than the anterior approach. The frequency of pancreatic leakage was slightly lower in patients undergoing LS via the posterolateral than the anterior approach (0.0% vs. 3.4%, P > 0.05)Conclusions: The posterolateral approach is more effective and safer than the anterior approach in patients without severe splenomegaly (< 30 cm).

Natural killer and natural killer T-like cells in splenectomised patients

ENWEndNote BIBJabRef, Mendeley RISPapers, Reference Manager, RefWorks, Zotero AMA Grywalska E, Markowicz J, Siwicka D, et al. Natural killer and natural killer T-like cells in splenectomised patients. Central European Journal of Immunology. 2013;38(3):372-379. doi:10.5114/ceji.2013.37759. APA Grywalska, E., Markowicz, J., Siwicka, D., Pasiarski, M., Surdacka, A., & Grafka, A. et al. (2013). Natural killer and natural killer T-like cells in splenectomised patients. Central European Journal of Immunology, 38(3), 372-379. https://doi.org/10.5114/ceji.2013.37759 Chicago Grywalska, Ewelina, Justyna Markowicz, Dorota Siwicka, Marcin Pasiarski, Agata Surdacka, Agnieszka Grafka, and Agnieszka Malec et al. 2013. "Natural killer and natural killer T-like cells in splenectomised patients". Central European Journal of Immunology 38 (3): 372-379. doi:10.5114/ceji.2013.37759. Harvard Grywalska, E., Markowicz, J., Siwicka, D., Pasiarski, M., Surdacka, A., Grafka, A., Malec, A., Bilski, M., Roman, T., and Roliński, J. (2013). Natural killer and natural killer T-like cells in splenectomised patients. Central European Journal of Immunology, 38(3), pp.372-379. https://doi.org/10.5114/ceji.2013.37759 MLA Grywalska, Ewelina et al. "Natural killer and natural killer T-like cells in splenectomised patients." Central European Journal of Immunology, vol. 38, no. 3, 2013, pp. 372-379. doi:10.5114/ceji.2013.37759. Vancouver Grywalska E, Markowicz J, Siwicka D, Pasiarski M, Surdacka A, Grafka A et al. Natural killer and natural killer T-like cells in splenectomised patients. Central European Journal of Immunology. 2013;38(3):372-379. doi:10.5114/ceji.2013.37759.

Three‐Dimensional CT Volumetry Predicts Outcome of Laparoscopic Splenectomy for Splenomegaly: Retrospective Clinical Study

The aim of this study was to determine the predictive value of the preoperative three-dimensional reconstructed volume (3D volumetry) for outcomes of laparoscopic splenectomy. The impact of splenomegaly on the feasibility of laparoscopic splenectomy is still debated. We hypothesized that splenic volumetry may accurately estimate splenic volume preoperatively and be used by surgeons to select patients for laparoscopic splenectomy. We performed a retrospective review of 88 patients seen at a tertiary referral center undergoing laparoscopic or open splenectomy between 2001 and 2010. Patients included in the study underwent elective splenectomy without associated procedures and had preoperative imaging available at our institution. We evaluated clinical, demographic characteristics and perioperative imaging as predictors of outcome. Study endpoints included conversion to open splenectomy, operating time, estimated blood loss (EBL), length of stay (LOS), postoperative complications, and mortality. In all, 53 procedures were started laparoscopically. Among them, 7 (13.2 %) were converted to open splenectomy and 7 (13.2 %) to hand-assisted laparoscopic splenectomy. The conversion group was matched with 35 patients who underwent open splenectomy to determine differences in outcomes between these groups. There were no conversions in spleens measuring <1100 cc, whereas spleens of 1100 to 2700 cc had a conversion rate of 41 %. Spleen volume >2700 cc was associated with an 87.5 % conversion rate. Spleen 3D volumetry >2700 cc was the only independent predictor of surgical conversion on multivariate analysis (odds ratio 38.0, confidence interval 4.02-358.75, p = 0.001). Patients who underwent open splenectomy had shorter operating times (160.3 vs. 253.0 min, p = 0.001) than those converted from laparoscopic to open splenectomy. A 3D reconstructed splenic volume of >2700 cc is a predictor of conversion from laparoscopic to open splenectomy. For spleens measuring <2700 cc, laparoscopic splenectomy may be performed by experienced surgeons with low to moderate rates of conversion. For spleens with a 3D reconstructed volume >2700 cc, laparoscopic splenectomy is associated with high rates of conversion to open surgery.

Pilot study using ambroxol as a pharmacological chaperone in type 1 Gaucher disease

The purpose of this pilot was to assess the tolerability and efficacy of ambroxol as a pharmacological chaperone in patients with symptomatic, type 1 Gaucher disease who present with measurable disease parameters but are not receiving enzyme replacement therapy (ERT) in order to provide proof of concept and/or ascertain the suitability of ambroxol for a larger clinical trial. The Israeli Ministry of Health Form 29c was employed to prescribe ambroxol for off-label use. Twelve patients were dispensed 2 capsules of 75 mg of ambroxol daily for 6 months. There were 8 females (66.7%). Mean age at entry was 41.1 (range: 24-63) years. Mean body weight at entry was 66.4 (range: 46.5-100) kg. One patient withdrew because of a hypersensitivity reaction, one because of elective splenectomy. No patient experienced clinically relevant deterioration in disease parameters measured. One patient achieved a robust response relative to baseline: +16.2% hemoglobin; +32.9% platelets; -2.8% liver volume; and -14.4% spleen volume. Three patients, including the above one, elected to continue on ambroxol for a further 6 months: hemoglobin levels and liver volumes were relatively stable, but platelet counts further increased in the above patient (+52.6% from baseline) and spleen volumes decreased further in all three patients (-6.4%, -18.6%, and -23.4% from baseline). Thus, ambroxol may be a safe option for Gaucher disease patients with potential disease-specific efficacy and should be expanded into a clinical trial using higher doses and placebo-controlled design.

The Impact of Operative Approach in Elective Splenectomy

Laparoscopy is an increasingly prevalent choice for elective splenectomy but it carries an inconsistent documentation of complications. This study examines 30-day postoperative outcomes after open (OS) and laparoscopic (LS) splenectomy. Elective splenectomies were extracted from the National Surgical Quality Improvement Program database. Multivariate analysis determined factors associated with complications and an increased postoperative length of stay (LOS). There were a total of 1583 splenectomies with 991 (63.0%) laparoscopic cases. On univariate analysis, the LS group had fewer major (10.6% vs. 18.8%, P<0.0001) and minor complications (2.6% vs. 7.1%, P<0.0001). Adjusting for baseline differences, LS was not associated with an increase in major complications [odds ratio (OR), 0.76; 95% confidence interval, 0.54-1.08; P = 0.1255] but offered a decrease in minor complications (OR, 0.41; 95% confidence interval, 0.24-0.69; P = 0.0010) coupled with a decrease in postoperative LOS of 1.89 ± 0.30 days (P<0.0001) compared with OS. After accounting for comorbidities and intraoperative factors, laparoscopy remains a safe choice for elective splenectomy with fewer complications and shorter LOS.

Reducing the risk of infection in a patient who will undergo splenectomy

A 28-year-old woman with steroid-refractory immune thrombocytopenia (platelet count 16 × 109/L, with associated epistaxis) recently saw her hematologist, who recommended elective splenectomy for the management of her condition.[1][1] After a discussion with her hematologist, the patient has ongoing

Elective Splenectomy for Haematological Disorders: One Centre Experience

The spleen plays an important role in immune-surveillance and haematopoiesis. Its role in the fight against infection, especially infection of encapsulated organisms, is particularly significant. It also removes intracellular inclusions (pitting) and filters aged blood cellular elements from circulation. Although the spleen has important immune functions, elective splenectomy is sometimes indicated for excessive cellular destruction (hypersplenism) or sequestration, lymphomatous or myeloid disease or tumours. We present a sixteen year experience of elective splenectomy from a tertiary care surgery and haematology centre in Northern Ireland with a literature review. doi:10.4021/jcs42w

Primary Splenic Hydatidosis: A Case Report

Hydatid disease is a zoonotic parasitic infection caused mainly by Echinococcus granulosus and is a common disease in this part of the world. However, primary splenic hydatidosis is rare. A case is described in a 45 year old female who presented with left upper quadrant swelling and pain. Ultrasonography revealed a hydatid cyst towards upper pole of spleen. A Computed Tomography confirmed the primary splenic hydatid cyst of 7.5cm × 7cm without internal septations and calcification. Serological tests were positive for hydatid disease. An elective splenectomy was performed successfully.

Single-port laparoscopic splenectomy for idiopathic thrombocytopenic purpura

Laparoscopic splenectomy has been performed with an average of 4 trocars since the early 1990s, and it has become the gold standard for elective splenectomy. Recently, single-port laparoscopic (SPL) surgery has emerged as an alternative to multiport laparoscopy, but SPL splenectomy in a patient with idiopathic thrombocytopenic purpura (ITP) has not been reported to date in Saudi Arabia or the region. A case report of SPL splenectomy in a patient with ITP is briefly described along with the surgical technique needed for such a procedure. The patient was an otherwise healthy 24-year-old female woman with medically refractory ITP and a platelet count of 2200. A standard splenectomy was performed using a SPL technique. The patient did well intraoperatively and postoperatively, was happy with her incision, and was discharged home with no complications 3 days after the procedure. In conclusion, SPL splenectomy is feasible in select patients and may provide a less painful, cosmetically better alternative.

Childhood Immune Thrombocytopenia: A Changing Therapeutic Landscape

Childhood immune thrombocytopenia (ITP) is generally a benign self-limiting disorder of young children with <10% of cases requiring regular platelet enhancing therapy at 1 year following diagnosis. Increasingly, children with newly diagnosed ITP, who have isolated thrombocytopenia and no atypical features in the history or physical examination, are managed with minimal investigation and observation alone. The role of up-front, short-course corticosteroid therapy without bone marrow aspiration in this subgroup of cases merits further investigation. For children with clinically significant chronic ITP, the timing of elective splenectomy and the role of splenectomy-sparing strategies such as rituximab continues to be debated. Management of children with combined autoimmune cytopenias secondary to systemic lupus erythematosus, common variable immunodeficiency, and the autoimmune lymphoproliferative syndrome is often a challenge. Splenectomy should be avoided in cases with documented immunodeficiencies because of the increased risk of overwhelming sepsis postsplenectomy. For these cases, as well as for children with resistant primary chronic ITP who have failed splenectomy, the role of therapies such as mycophenolate mofetil, sirolimus, and the thrombopoietins remains to be determined.

Valmiltistökur á Landspítala 1993-2004. Árangur og langtímaeftirfylgd

To evaluate the long-term outcome of elective splenectomy, with emphasis on the incidence of complications, vaccine immunization and patient´s knowledge about asplenia. Medical reports of all patients, who underwent elective splenectomy during the time period of 1993-2004, were reviewed. Questionnaire was sent to 96% (44/46) patients alive. The average age was 50 (8-83) years. Thirty-five patients were male and 32 were female. Eighty percent responded to the questionnaire. Most of the patients (31) had idiopathic thrombocytopenic purpura (ITP). Complete response was obtained in 60% (18/30) and partial response in 23% (7/30). Five patients had spherocytosis and all of them had complete response. None of the three patients with autoimmune hemolytic anemia had any response to the splenectomy. Patients were vaccinated against pneumococci in 92% of the cases. In 44% of the cases revaccination was done. Only 41% of those who answered experienced that they had got a good education about the consequences of asplenia. Sixteen percent of the patients (10/64) had major postoperative complications. One patient with metastatic cancer and thrombocytopenia died within 30 days of surgery. Five patients had long-term complications. Two had pneumococcal sepsis, one of them was unvaccinated and the other had not been revaccinated. Splenectomy has a good long-term outcome for spherocytosis and ITP patients. The incidence of complications is high. It is possible that better guidelines and better patient´s education can lower the complication rate and improve the outcome.

Laparoscopic Splenectomy: Standardized Approach

Laparoscopic splenectomy was first reported in 1991-1992 by several groups. The impact and role of laparoscopy for splenectomy can be considered as significant as that for gallbladder disease, achalasia, esophageal reflux, and adrenal disease. In many centers, the laparoscopic approach is now routine for most cases of elective splenectomy. The laparoscopic approach is associated with reduced morbidity, especially pulmonary, wound, and infectious complications. This article reviews a standardized approach to laparoscopic and hand-assisted splenectomy and covers indications, operative strategy, and complications. Several special considerations, including massive splenomegaly, postsplenectomy thrombosis of the portosplenic venous system, and accessory spleens are also discussed.

The Role of Pre-emptive Control of Vascular Pedicle in Laparoscopic Splenectomy: An Experience with 19 Consecutive Patients

Laparoscopic splenectomy is an acceptable approach for elective splenectomy in Hematological conditions. Nevertheless, the anatomical location, several ligamentous attachments, friability of the splenic tissue and intra-operative bleeding are the major challenges faced by Laparoscopic surgeons. To meet these challenges, many approaches are in practice for splenic mobilization and control of vascular pedicle. Newer advances such as; ultracision, ligasure devices, endostaplers and hand assisted ports have all facilitated this complex operation. Intra-operative bleeding remains the main cause for conversions to open surgery. Several authors have shown that preoperative embolization or ligation of the splenic vessels reduces the intra-operative bleeding and conversion rate. The ligation of the splenic artery is a routine practice in conventional elective open splenectomy prior to mobilization of the spleen. We maintained the same general approach and ligated the splenic artery prior to mobilization of the spleen to avoid intra-operative bleeding. Intra-operative bleeding is the main cause of conversion in laparoscopic splenectomy. Several studies have shown that early ligation of the splenic artery before mobilization of the spleen decreases the likelihood of bleeding and the conversion rate. Furthermore, it also decreases the blood loss during surgery, reduces the size of spleen and makes dissection and manipulation of this fragile organ easy. This study aims to show that elective intracorporeal ligation of the splenic vessels is safe and by reducing the bleeding and blood loss during surgery, it can facilitate laparoscopic splenectomy.

Liver Transplantation for Massive Hepatic Lymphangiomatosis in a Child

Liver Transplantation for Massive Hepatic Lymphangiomatosis in a Child

Predictors for conversion in laparoscopic splenectomy: A prospective randomized study

Background & objectives: Laparoscopic splenectomy had become the golden standard for elective splenectomy, as it is feasible, safe and provides many advantages to the patients in comparison to open splenectomy, and the growing experience and the advances in equipment had made it feasible in situations that were thought to be contraindications in the past. However, some cases still require conversion to an open procedure. Identifying predictive factors for conversion carries crucial benefits for patients and health care providers. Methods: 24 patients underwent elective laparoscopic splenectomy for different indications in our hospital between January 2008 and February 2010. Patients' data whether preoperative, operative or postoperative were collected and assessed statistically to identify the risk factors for conversion to open splenectomy. Results: The study included 24 patients (13 ITP, 5 spherocytosis, 4 chronic lymphocytic leukemia (CLL) and 2 Lymphoma patients). The rate of conversion was 16.7% (4 patients). The mean operative time was 116.5 ± 23.9 minutes; the mean estimated intraoperative blood loss was 286.5 ± 165.7 ml. The mean period until passage of flatus was 2 ± 1.1 days, patients resumed oral food intake in 3.2 ± 1.4 days and were discharged from the hospital in 4.6 ± 1.9 days. 4 patients had post operative complications in their hospital stay, and one needed reexploration. The significant risk factors for conversion in the study was diagnosis, ASA score 3, presence of technical difficulty, preoperative platelet count 17 cm and intraoperative blood loss > 500 ml. Conclusions: Proper analysis of all factors affecting successful completion of laparoscopic splenectomy will lead to better implementation of the procedure in context with patient's needs and the technical expertise of the surgical team, both leading to better outcomes. This will also help to address the areas of potential improvements to be implemented.

Vergleich der laparoskopischen Splenektomie in Steinschnittlage mit der Hanging-Spleen-Technik bei idiopathischer thrombozytopenischer Purpura

Laparoscopic splenectomy has become the gold standard intervention for elective splenectomy. Several techniques have been described, which differ in trocar localisations and patient positions. The hanging-spleen technique was examined in comparison to the conventional laparoscopic splenectomy in the supine position among the patient population in our institution over a period of 8 years. On the basis of a retrospective analysis, data were collected on all patients who underwent elective laparoscopic splenectomy for idiopathic thrombocytopenic purpura between May 1994 and April 2002 and were examined for operation time, blood loss and peri-operative complications. Two types of operation were compared, the conventional laparoscopic splenectomy in the supine position (group A) and the hanging-spleen technique (group B). Finally, the costs of materials of the two operation techniques were compared. For 51 patients (43.1 % men, 56.9 % women) (mean age: 45.5 ± 17.5 years) the mean operation times were 134.2 ± 47.3 min (group A) and 9.8 ± 39.9 min (group B). The mean blood losses were 691.3 ± 544.4 mL in group A and 638.3 ± 1050.6 mL in group B. The perioperative complications were 38.8 % in group A and 21.2 % in group B. There was no significant difference found for operation time, blood loss and perioperative complications in a multivariate analysis. The cost of materials was reduced in group B (use of Endo-GIA 42.4 % in group B, 100 % in group A). In group A 4 incisions, in group B 3 incisions were necessary. Regarding operation time, blood loss and perioperative complications the 2 laparoscopic techniques for splenectomy do not differ significantly. Merely reduced material costs and a reduction of incisions were found in patients -operated with the hanging-spleen technique. Whether the hanging-spleen technique is the method of choice will have to be shown by further prospective studies.

Evolving Connective Tissue Disease Influenced by Splenectomy

In years past, there was concern that splenectomy could lead to dissemination of occult systemic lupus erythematosus. Clinical studies subsequently effectively refuted that concept. However, there remains uncertainty regarding the role of the spleen in autoimmune diseases and the effect of splenectomy on their course. We present a case of a 56-year-old woman with autoimmune hepatitis and rheumatoid arthritis, without clinical or serologic features of lupus, who developed glomerulonephritis and antiphospholipid syndrome subsequent to an elective splenectomy. Literature review was performed to identify examples of the effect of splenectomy on other autoimmune diseases. Splenectomy has been linked with the development of new autoimmune phenomenon, alterations in the clinical course of patients with prior autoimmune disease, such as in our patient, and in a progressive redistribution of memory B cells that may influence autoimmune disease activity and may have been involved in the alteration in our patient's clinical course.

Laparoscopic splenectomy: consensus and debatable points.

The emergence of minimally invasive techniques has broadened interest in splenectomy for a variety of haematological illnesses. Laparoscopic splenectomy (LS) is currently considered the gold standard for the treatment of various haematological disorders. The literature was reviewed to highlight points of consensus and debatable points regarding best practice in LS, looking at issues such as bleeding and conversion, splenomegaly, splenic retrieval techniques, types of instruments used, hand-assisted LS (HALS), complications, approaches, accessory spleen and splenosis. Our goal was to share our experience with LS and compare it with other reports. LS has emerged as the standard of care for elective splenectomy for benign haematological diseases. However, doubts have been raised regarding the suitability of patients with splenomegaly for LS. There is also uncertainty about its efficacy in major trauma. HALS has emerged as an option for safe manipulation and splenic dissection. We performed 25 consecutive LSs at King Abdullah University Hospital (KAUH), Jordan, from 2001 to 2008. Patient demographics, operative time, intra- and postoperative complications, conversion rate, additional procedures and length of hospital stay were retrospectively reviewed. The mean age of the patients was 38.8 years (range 11-77 years), mean operative time was 132 minutes (90- 170 minutes), and length of hospital stay was 2.9 (standard deviation 2.7) days. One case was converted to open surgery (5%). There was 1 case of superficial wound infection in the series (5%), and no deaths. LS is a well- accepted minimally invasive procedure, but knowledge and skill are required to perform it with minimal morbidity and mortality.