Splenectomy for massive splenomegaly. Apropos of 36 cases

Thirty-six splenectomies for splenomegaly exceeding 1000 grams are reported. The enlargement of the spleen most often was related with a malignant disease (n = 32). Cytopenia was the main indication in 14 cases, and splenectomy was contemplated for diagnosis (n = 12), initial treatment (n = 6), or due to pain (n = 3) or spontaneous rupture (n = 1). Ten patients (27.8%) had an associated surgical treatment. One patient died postoperatively (2.8%) and 12 patients presented with 14 complications (33%) usually with a rapidly favorable evolution. In 11 of 12 cases (91.6%), the operation allowed establishing the diagnosis in cases of splenomegaly with an unknown origin. Lastly, it was always effective to relieve pain and in most cases improved cytopenia. The authors conclude that the patients with massive splenomegaly are improved by splenectomy, although it most often is merely a palliative treatment in cases of malignant hemopathy.     

Splenectomy for massive splenomegaly

The technique, and short and long term results, of splenectomy for massive splenomegaly are presented. The latter was defined as a spleen weighing in excess of 1.5 kg. Thirty-five of the 38 patients had a serious haematological disorder as the indication for the operation, usually non-Hodgkin's lymphoma or myelofibrosis. All operations were carried out through abdominal incisions. Accessible splenic attachments were divided, and the splenic artery was ligated in continuity, prior to posterior mobilization. Two patients (5.3%) died as a result of the operation, both deaths being due to sepsis. Septic and thrombo-embolic complications were common, and occurred both early and late after the operation. Overall, eight of the 12 deaths during the first postoperative year were due to the primary disease, whereas all of the five deaths after that time were due to causes other than the primary disease. Twenty-four patients lived at least 1 year, and 10 patients are alive for more than 5 years.     

Splenectomy for massive splenomegaly

Twenty-four patients who underwent resection of giant spleen (spleen weight greater than 1.5 kg) have been reviewed to determine the difficulties and benefits of the procedure and, in particular, whether the use of adrenaline injection into the splenic artery could safely reduce technical difficulty. Although morbidity was higher in patients with giant spleens compared with those undergoing resection of smaller spleens the incidence of serious complications was small, and there were no operative or in-hospital deaths. In addition, virtually all patients benefited either on the basis of minimized haematological defect, or palliation of symptoms. Further, the injection of 1 ml of 1:10,000 adrenaline into the splenic artery before splenic mobilization reduced the splenic volume by approximately 40 per cent on average, and resulted in improved exposure, thereby facilitating the procedure.     

Splenectomy for massive splenomegaly

Removal of a massively enlarged spleen is a challenging surgical problem that is associated with higher death and complication rates than the removal of smaller spleens. Older age, serious and chronic primary diseases, and associated cardiopulmonary abnormalities contribute to the morbidity and mortality. Most patients with massive splenomegaly have been treated with corticosteroid and/or antineoplastic drugs, which impair wound healing, hemostatic function, and host resistance. Precise surgical technic is especially important in these cases because of the susceptibility to postoperative hemorrhage. Ligation of the splenic artery via the lesser peritoneal sac before mobilization of the spleen is associated with lower intraoperative transfusion requirements than when the spleen is mobilized before the splenic artery is ligated.     

Splenectomy for massive splenomegaly

Splenectomy was performed on 47 patients with massive splenomegaly (spleen weight greater than 1.5 kg). With one exception, all patients had a haematological malignancy. The indications for splenectomy were for the diagnosis of unknown cause (n = 5), for the relief of pain (n = 8), as the initial treatment of hairy cell or prolymphocytic leukaemia (n = 8), and for the correction of a haematological cytopenia (n = 26). Splenectomy was completely successful in relieving pain and in establishing a diagnosis, and provided effective palliation in patients with hairy cell and prolymphocytic leukaemia. An immediate correction of a haematological cytopenia was achieved in 24 patients, and the correction was maintained for over 1 year in 11 patients. There were no postoperative deaths and morbidity was acceptably low. We conclude that patients with massive splenomegaly can derive considerable benefit from splenectomy and that massive splenomegaly should not be regarded as a contra-indication to splenectomy.     

Laparoscopic splenectomy for massive splenomegaly

BACKGROUND: Laparoscopic splenectomy (LS) is the preferred operative approach for diseases involving normal-sized spleens. Our experience with laparoscopic splenectomy in the setting of massive splenomegaly is presented. METHODS: A prospective review of patients undergoing LS for massive splenomegaly was conducted. Massive splenomegaly (MS) in adults was defined as a craniocaudal length >or=17 cm or a morcellated weight >or=600 g. In children, spleens measuring fourfold larger than normal for age were considered massive. RESULTS: Forty-nine patients with MS were treated with LS. The most common primary diagnoses were lymphoma and leukemia. Mean splenic length was 20 cm (15 to 27 cm), with weights ranging from 600 to 4,750 g. Twelve patients with supermassive splenomegaly (length >22 cm) required a hand-assisted laparoscopic approach. There were no conversions to open surgery. Mean operating time was 171 minutes (90 to 369). Mean blood loss was 114 cc (<30 to 600 cc). Average length of stay was 2.3 days (1 to 16). Minor postoperative complications occurred in 3 patients. CONCLUSIONS: Laparoscopic splenectomy in the setting of splenomegaly is safe and appears to minimize perioperative morbidity. In patients with supermassive splenomegaly, a hand-assisted laparoscopic approach may be required.     

Handport-assisted laparoscopic splenectomy in massive splenomegaly

Background: Laparoscopic splenectomy of normal-sized spleens is performed with increasing frequency. By using a handport, which allows the intraperitoneal introduction of one surgeon's hand, massively enlarged spleens may also be extirpated via a laparopscopy-assisted technique. Methods: Seven patients (54–80 years) with massive splenomegaly (3.5–5.8 kg) underwent handport-assisted laparoscopic splenectomy. All patients had spleens that extended beyond the umbilicus, hypersplenism, and discomfort in the upper left quadrant due to intractable hematological malignancy. Results: Both the operation and recovery were uneventful in five of the patients, but one patient had to be converted to an open procedure due to splenic damage and bleeding, and another was reoperated for hemorrhage from a trocar. The handport allowed splenic protection while the trocars were introduced and instruments changed. It also enabled splenic mobilization, particularly prior to stapling of the hilar structures and dissection of the upper splenic pole. Conclusions: Handport-assisted laparoscopic splenectomy seems to be a viable alternative for massive splenomegaly, but it requires further evaluation with respect to safety, efficacy, and indication. Received: 7 September 1999/Accepted: 12 March 2000/Online publication: 20 July 2000     

腹腔镜巨脾切除术治疗小儿遗传性球形红细胞增多症(附7例报告)

目的探讨腹腔镜巨脾切除术在小儿遗传性球形红细胞增多症治疗中的可行性及效果评价.方法实施腹腔镜巨脾切除术7例,年龄1～14岁,平均8.8岁;体重10～57 kg,平均33.8kg.其中3例合并胆石症,2例同时行胆囊切除术和1例行胆囊切开取石术.结果手术均获成功,1例脾静脉出血小切口辅助完成.手术时间50～150 min,平均90 min;术中出血量30～500 ml,平均117 ml;住院时间4～10 d,平均5.5 d;术后3 d红细胞计数较术前显著增高(t=2.652,P＜0.05).7例随访2个月～1年,平均7.8月.术前症状完全消失,无明显并发症发生.结论腹腔镜巨脾切除术是治疗小儿遗传性球形红细胞增多症的一种安全有效的方法.     

巨脾切除术的技术要点

The spleen whose size reaches or exceeds third degree should be regarded as massive splenomegaly.Splenectomy for massive splenomegaly demands precise procedures.First,median incision on upper abdomen(or vertical rectus muscle splitting incision)and incision under left costal arch are preferred.Second,the spleen was freed and then 0.33 mg of epinephrine was injected via the splenic artery before splenic artery ligation.During the process,a cell saver helps to minimize blood loss and makes autoinfusion possible for patients with benign lesions.Third,preoperative administration of fibrinogen,platelet and essential styptieum combined with the cooperation between surgeons and anesthesi010gists are the key points of bloodless surgery which is important for the recovery of patients.Four common problems of splenectomy for massive splenomegaly should also be addressed,including operation discontinuance,perioperative hemorrhage,accessory injury and postoperative intractable fever.     

Trends in laparoscopic splenectomy for massive splenomegaly

HYPOTHESIS: During the past 10 years, expertise with minimally invasive techniques has grown, leading to an increase in successful laparoscopic splenectomy (LS) even in the setting of massive and supramassive spleens. DESIGN: Retrospective series of patients who underwent splenectomy from November 1, 1995, to August 31, 2005. SETTING: Academic tertiary care center. PATIENTS: Adult patients who underwent elective splenectomy as their primary procedure (n = 111). MAIN OUTCOME MEASURES: Demographics, spleen size and weight, conversion from LS to open splenectomy, postoperative length of stay, and perioperative complications and mortality. Massive splenomegaly was defined as the spleen having a craniocaudal length greater than 17 cm or weight more than 600 g, and supramassive splenomegaly was defined as the spleen having a craniocaudal length greater than 22 cm or weight more than 1600 g. RESULTS: Eighty-five (77%) of the 111 patients underwent LS. Of these 85 patients, 25 (29%) had massive or supramassive spleens. These accounted for 40% of LSs performed in 2004 and 50% in 2005. Despite this increase in giant spleens, the conversion rate for massive or supramassive spleens has declined from 33% prior to 1999 to 0% in 2004 and 2005. Since January 2004 at our institution, all of the massive or supramassive spleens have been removed with a laparoscopic approach. Patients with massive or supramassive spleens who underwent LS had no reoperations for bleeding or deaths and had a significantly shorter postoperative length of stay (mean postoperative length of stay, 3.8 days for patients who underwent LS vs 9.0 days for patients who underwent open splenectomy; P<.001). CONCLUSIONS: Despite conflicting reports regarding the safety of LS for massive splenomegaly, our data indicate that with increasing institutional experience, the laparoscopic approach is safe, shortens the length of stay, and improves mortality.     

手助腹腔镜及开腹脾切除巨脾的临床疗效比较

目的比较手助腹腔镜(HALS)和开腹切除(OP)巨脾的临床效果。方法回顾性分析2004年—2010年行脾切除术患者的临床资料,比较其中大于20 cm脾脏行HALS和OP的临床疗效。结果大于20 cm的巨脾切除术患者41例,21例为HALS手术,20例为开腹脾切除手术。HALS组的中转开腹率4.7%。HALS和OP组的平均出血量为227 mL和887 mL(P=0.01),平均输血为0和0.6单位(P<0.05)。HALS组的住院时间比OP显著为短(4.3 d vs.8.4 d)(P=0.001)。并发症发生率两者相比无统计学差异(P>0.05)。结论 HALS是一项安全和有效的巨脾(大于20 cm)切除技术。相比开腹脾切除其住院时间更短,出血及输血更少,是一种行之有效的替代方法。     

Laparoscopic versus open pediatric splenectomy for massive splenomegaly

Laparoscopic splenectomy (LS) has rapidly evolved into the technique of choice compared with open splenectomy (OS) because of the advantages of the minimally invasive approach. Splenomegaly increases the technical difficulties of LS. LS for massive splenomegaly has generally been found to fail in adults and children. With improvements in laparoscopic technique and accumulation of laparoscopic experience, however, concerns about completing the procedure in pediatric cases with even massive splenomegaly have been lowered. A retrospective review (April 1997-October 2009) of databases at 2 institutions identified 145 children undergoing splenectomy, 79 laparoscopic and 66 open. We defined splenic margin below the umbilicus or anteriorly extending over the midline as massive splenomegaly. By this definition, 22 cases of pediatric laparoscopic and 17 cases of open splenectomies for massive splenomegaly were performed. Perioperative and follow-up data of laparoscopic pediatric splenectomies were compared with those of open splenectomies, including operative time, bleeding, spleen size, complications, and hospital stay. There were no deaths, wound infections, or instances of pancreatitis. No accessory spleen was missed by laparoscopic; accessory spleens were missed in 2 patients in open splenectomies. The complication rate of laparoscopic versus open was 13.6% versus 41.2%. No subsequent surgery was necessary for dealing with complications both in laparoscopic and open series. Laparoscopic pediatric splenectomy for massive splenomegaly is a feasible, effective, and safe procedure and is associated with low morbidity and a short hospital stay.     

Partial splenectomy for children with congenital hemolytic anemia and massive splenomegaly

Partial splenectomy is an alternative to total splenectomy for the treatment of congenital hemolytic anemias (CHAs) in children, although the feasibility of this technique in the setting of massive splenomegaly is unknown. This study was designed to evaluate the safety and efficacy of partial splenectomy in children with CHAs and massive splenomegaly. This retrospective study examined 29 children with CHAs who underwent partial splenectomy. Children were divided into 2 groups based on splenic size: 8 children had splenic volumes greater than 500 mL, whereas 21 children had splenic volumes less than 500 mL. Outcome variables included perioperative complications, transfusion requirements, hematocrits, reticulocyte counts, bilirubin levels, splenic sequestration, and splenic regrowth. All 29 children underwent successful partial splenectomy with 0.02 to 10 years of follow-up. After partial splenectomy, children overall had decreased transfusion requirements, increased hematocrits, decreased bilirubin levels, decreased reticulocyte counts, and elimination of splenic sequestration. Children with massive splenomegaly had similar outcomes compared with children without massive splenomegaly. Long-term complications included 3 mild infections, 4 cases of gallstones requiring cholecystectomy, and 1 child who required completion splenectomy. Partial splenectomy is a safe, effective, and technically feasible option for children with various CHAs, even in the setting of massive splenomegaly.     

Splenectomy for massive splenomegaly due to myeloid metaplasia

From an analysis of these cases and those reported in the recent literature, earlier splenectomy is advocated for patients with myeloid metaplasia. Careful attention to preoperative preparation and “safe” operative technic has reduced the mortality to acceptable levels. Although postoperative mortality and morbidity in this series were high, they reflect primarily the advanced stage of the disease in patients finally referred for surgery. No patient should be denied operation on the basis of risk of operative mortality or on the basis of the spleen being the primary site of hematopoiesis.     

Outcome of laparoscopic splenectomy with preoperative splenic artery embolization for massive splenomegaly

Background  

Laparoscopic splenectomy (LS) has become a safe and feasible procedure for cases involving spleens of normal size. Only a few publications report on the outcome of LS with preoperative splenic artery embolization (SAE) for massive splenomegaly. The authors present their experience in patients with massive splenomegaly who underwent laparoscopic-assisted splenectomy (LAS) or hand-assisted laparoscopic splenectomy (HALS) following SAE.     

改良脾脏后外侧入路在腹腔镜巨脾切除术中的应用评价

目的:探讨改良脾脏后外侧入路在腹腔镜巨脾切除术中的临床应用价值。方法:回顾性分析2016年1月至2019年7月在江南大学附属医院接受腹腔镜脾切除术(LS)的巨脾患者临床资料。共入组48例患者,其中男性29例,女性19例,平均年龄55.8岁。根据手术分离脾脏入路分为研究组( n＝26)：采用改良脾脏后外侧入路...     

Is splenectomy for massive splenomegaly safe in children?

PURPOSE: To study and analyze the causes, etiology, morbidity, mortality and therapeutic value of splenectomy performed for massive splenomegaly in children. METHODS: The medical records of 115 children less than 18 years old who had splenectomy for various hematological disorders were reviewed. Twenty of them had splenectomy for massive splenomegaly (spleen weight > or =1,000 g). The records of these were reviewed for age at operation, gender, hematological diagnosis, indication for splenectomy, operative procedures, postoperative complications, and outcome. RESULTS: Twenty children had splenectomy for massive splenomegaly. There were 16 males and 4 females. Their ages ranged from 4 to 15 years (mean 11.2). Twelve had sickle cell disease, 5 had sickle-beta-thalassemia, 1 had beta-thalassemia major, 1 had thalassemia intermediate, and 1 had chronic myeloid leukemia. The indications for splenectomy were hypersplenism in 11, recurrent splenic sequestration crisis in 8, and splenic abscess in 1. The transfusion requirements in the patient with beta-thalassemia major decreased markedly postoperatively from 18 transfusions/year to only 4 transfusions/year; and for those with hypersplenism, there was a marked improvement in their blood parameters following splenectomy. The patient with thalassemia intermediate required no more blood transfusions. There was no mortality. The immediate postoperative morbidity was 10% for those with massive splenomegaly compared with 6.3% for those with splenomegaly <1,000 g. CONCLUSIONS: With good perioperative management, splenectomy in children with massive splenomegaly is both safe and effective.