Present status of laparoscopic splenectomy for hematologic diseases: certitudes and unresolved issues

Laparoscopic splenectomy is considered to be the "gold-standard" treatment of benign hematologic diseases, with normal or slightly enlarged spleens. Laparoscopic treatment of malignant diseases and splenomegalies remains more controversial. The procedure requires a great surgeon's laparoscopic expertise, appropriate positioning of the patient and trocar insertion, and gentle and meticulous dissection of the spleen. The technique is feasible in 91% of the patients with a 0.9% operative mortality and a postoperative complications rate of 12%. When compared with open splenectomy in retrospective case-controlled studies, the laparoscopic approach includes a longer operative time and higher operative room costs. However, advantages include reduced postoperative hospital stay and faster return to normal activities. Despite scarce reported data, long-term hematologic cure rate seems to be equivalent in patients with idiopathic thrombocytopenic purpura. The accuracy of laparoscopic exploration to detect all accessory spleens is however questioned, and residual postoperative accessory splenic tissues have been observed. Prospective randomized controlled trials comparing short- and long-term results of open and laparoscopic splenectomies are required to confirm definitely the role of laparoscopy in the management of hematologic disorders.     

Hand-assisted laparoscopic splenectomy for hydatid cyst

Splenic hydatidosis is a rare condition. We performed a hand-assisted laparoscopic splenectomy for a large hydatid cyst localized in the center of the spleen. We discuss the advantages of the "helping hand."     

A new technique for laparoscopic splenectomy with massively enlarged spleens

Splenectomy is indicated in several hematological disorders and it can be particularly challenging in children with sickle cell disease, splenomegaly, and recurrent sequestration. Over the last 6 months, we have developed a new technique for laparoscopic splenectomy (LS) for hypersplenism and splenomegaly in five children with sickle cell disease. The average age of our patients was 6 years (range, 2-11), and the average weight was 18.7 kg (range, 13.2-30.1). On preoperative ultrasound, spleen size index ranged from 0.42 to 0.76. For the LS, four trochars were placed. One patient, who also underwent a laparoscopic cholecystectomy, had six trochars placed, two of which were used for both cholecystectomy and splenectomy. After laparoscopic mobilization of the spleen and hilar vascular stapling, a Steiner electromechanical morcellator was inserted through the 12-mm port to extract cores of splenic tissue until complete splenectomy was achieved. No patient required conversion to an open procedure or creation of a larger incision to remove the massively enlarged spleen. Operative time averaged 190 minutes; the combined LS and cholecystectomy took 245 minutes. Postoperative length of stay was <2 days for all patients. There were no complications, and no patient required postoperative transfusion. Based on these early findings, we conclude that intracorporeal coring of splenic tissue allows for safe and complete laparoscopic removal of very large spleens in small children. It provides expedient recovery and minimal postoperative pain and scarring. This new technique should enable surgeons to perform LS even in patients with massive splenomegaly, eliminating the need for large and cumbersome intracorporeal bags or the creation of additional incisions to remove the spleen.     

A learning curve for laparoscopic splenectomy at an academic institution

Variceal hemorrhage continues to be a major cause of morbidity and mortality in cirrhotic patients. Transjugular intrahepatic portosystemic shunt (TIPS) is gaining wide acceptance as a treatment for several complications of portal hypertension. The aim of the current randomized study was to compare the transjugular shunt and endoscopic sclerotherapy (ES) for the prevention of variceal rebleeding (VB) in cirrhotic patients. Forty-six consecutive cirrhotic patients with variceal bleeding were randomly allocated to receive either transjugular shunt (22 patients) or ES (24 patients) 24 hours after control of bleeding. VB (50% vs. 9%) and early (first 6 weeks) VB (33% vs. 5%) were significantly more frequent in sclerotherapy patients; the actuarial probability of being free of VB was higher in the shunt group (P <.002). Eight patients (33%) of the sclerotherapy group and 3 patients (15%) of the shunt group died; the actuarial probability of survival was higher for the shunted patients (P <.05); 6 patients in the sclerotherapy group and none in the shunt group died from VB (P <.05). No difference was found in the proportion of patients with clinically evident hepatic encephalopathy (HE). These results show that the transjugular shunt is more effective than sclerotherapy in the prevention of both early and long-term VB. Moreover, a significant improvement in survival was found in the shunt group.     

Pediatric laparoscopic splenectomy using the lateral approach

Laparoscopic splenectomy in children has been shown to be safe, to reduce postoperative pain and hospital stay, and to accelerate return to full activities. We describe our experience with a four-port "lateral" approach in 18 patients. Patients were placed in the lateral decubitus position and the table was flexed to separate the left subcostal margin and iliac crest. The camera port was inserted at the umbilicus and additional ports were placed in the epigastrium and left lower quadrant. After mobilization of the splenic flexure a port was inserted in the left flank below the 12th rib for elevation of the spleen. A 30 degrees laparoscope was used and the splenic vessels were controlled with an endo-GIA and/or clips. The spleens were placed in a bag, morcellated, and extracted through a port site. Eight females and 10 males with a median age of 12.5 years (5-17 years) and weight of 55.5 kg (17-124 kg) underwent splenectomy of idiopathic thrombocytopenia purpora (10), spherocytosis (6), elliptocytosis (1), and Hodgkin's disease (1). The median operating time was 160 min (90-300 min) and median blood loss was 105 ml (5-350 ml). Accessory spleens were removed in four cases. Three patients required extensions of a port site to remove large spleens which could not be placed in a bag. The sole complication was a transient pancreatitis with associated pleural effusion. The median postoperative hospital stay was 2 days (1-11 days) and time to full activities was 8 days (3-25 days). The lateral approach affords excellent visualization of the splenic vessels, pancreas, and accessory spleens. This approach is safe and reliable and is our preferred approach for laparoscopic splenectomy in children.     

Mycobacterial infection in patients with hematologic disorders

In patients with hematologic disorders, cellular immunity may be suppressed by the disease itself or by treatment with adrenal corticosteroids, immunosuppressants, or anticancer agents. Miliary tuberculosis developing in such compromised hosts is cryptic, and thus its diagnosis is difficult to make. Miliary tuberculosis will be fatal if it cannot be detected. Therefore, the possibility of mycobacterial infection should always be kept in mind when treating patients with hematologic disorders. However, such patients often have a poor prognosis, even if they have already been diagnosed with miliary tuberculosis. Prophylactic medication has been proved to be effective against mycobacterial infection with hematologic disorders. Thus, the importance of prophylactic medication should be emphasized.     

Elective conventional colectomy in the era of laparoscopic surgery

Laparoscopic surgery, since its introduction into the general surgery, has reduced hospital stay. Can lessons learned from laparoscopic surgery about aggressive postoperative care be applied to elective conventional colectomy? Between August 1994 and February 1995, a prospective study was conducted on 24 consecutive patients undergoing elective conventional colectomy with primary anastomosis. A comparison of 30 consecutive patients in the 7 months immediately before this study were used as a historical control group. Both groups were comparable in age, indications for operation, type of operation, and operative time. The protocol consisted of an outpatient bowel prep, hospital admission on day of surgery, and intravenous metoclopramide starting before the operation and continued every 6 hours with diet started at 24 hours. Patients were discharged on regular diet after a bowel movement and were continued on oral metoclopramide for a total of 7 days. Hospital stay was reduced from 8 days (range 4-19 days) to 4 days (range 2-7 days) on the protocol P < 0.001). Hospital charges were also reduced by 20 per cent (from $18,450 to $14,586) (P = 0.066). Complication rate and postoperative emergency room visits as a measure of quality of care did not differ between the two groups. By implementing this protocol, hospital costs and length of stay for elective conventional colectomy were reduced without compromising patient care.     

Posterolateral approach. An alternative strategy in laparoscopic splenectomy

Laparoscopic splenectomy (LS) is effective and technically feasible for treating various hematological diseases, especially idiopathic thrombocytopenic purpura (ITP). An anterior approach to the vascular pedicle is usually described. However, in this approach to the splenic hilum, the dissection of the splenic artery is often difficult. A total of 13 patients with ITP underwent elective laparoscopic splenectomy. We utilized a laparoscopic posterolateral approach involving dissection of the suspensory ligaments at the lower pole, then dissection and division of the posterolateral attachments, followed by the dissection and ligation of all splenic branches near the splenic parenchyma. This procedure was completed in 11 of our 13 patients and converted to open surgery in the other two patients. Mean operative time was 3 h; mean postoperative stay was 3 days. No blood transfusion was required, and no complications were noted in the postoperative period. The posterolateral approach provides better visualization and control of branches of the splenic vein and artery in the splenic hilum. It also permits visualization and control of surgical hemorrhage through the operating ports.     

Splenic artery embolization before laparoscopic splenectomy. An update

Several studies have indicated that plasma viscosity contributes to cardiovascular risk in men. So far, a significant relationship between plasma viscosity and the severity of coronary heart disease has not been found. Thus, the present study is the first to report on the relationship of plasma viscosity and the severity of coronary heart disease. In a collective of 1142 male myocardial infarction patients, plasma viscosity and additional laboratory parameters were determined. Atherosclerotic changes were quantified by coronary angiography. Patients were divided into groups without any, and with one to three stenosed vessels. We found a positive relationship between plasma viscosity and the severity of coronary heart disease, even after adjusting groups for age, fibrinogen, and use of diuretics. Mean plasma viscosity ranged from 1.141+/-0.035 mPa s in patients without stenosed vessels to 1.162+/-0.044 mPa s in patients who had three coronary vessels with stenoses >50%. Differences between the groups were significant (P<0.001 to 0.05), with two exceptions: differences between patients without any and with one stenosed vessel, as well as between patients with one and two stenosed vessels, did not reach the significance level. On the whole, we can give further support to the hypothesis that cardiovascular risk factors and coronary heart disease may be linked by plasma viscosity.     

Portal thrombosis. A rare complication of laparoscopic splenectomy

Portal thrombosis is a rare complication of splenectomy. We performed 12 laparoscopic splenectomies and observed this complication only in one patient with idiopathic thrombocytopenia (ITP). The right branch of the portal vein presented a partial thrombosis, while the left branch was completely obstructed by thrombi. Abdominal ultrasonography and an ultrasound doppler exam allowed us to diagnose this event and a retrograde angiography performed afterward confirmed our diagnosis. A 48-h intravenous heparin treatment was promptly begun, followed by anticoagulant drugs (dicumarol). The patient was dismissed 5 days afterward, presenting a steady-state ultrasound doppler pattern and a complete normalization of liver parameters. An ultrasound doppler exam performed 1 month after anticoagulant therapy showed a complete resolution of portal thrombosis. We believe that early diagnosis of this rare complication, prompt beginning of anticoagulant therapy, and care in surgical procedures may reduce patient life-threatening risks and assure complete remission.     

Recent advances in laboratory approaches to hematologic disorders

During recent years, there has been substantial advance in our knowledge of the etiology, pathogenesis, laboratory diagnosis, and management of hematologic disorders. In this symposium, the discussion includes the following six topics: (1) some problems of automatic blood cell analyzer and flow cytometer for the diagnostic use of hematologic disorders, (2) usefulness of fluorescence in situ hybridization techniques for the diagnosis of leukemias, (3) recent advance in pathogenesis and management of multiple myeloma, (4) usefulness of the thrombin-antithrombin III complex, plasmin-antiplasmin complex, and tissue factor activity for the diagnosis of disseminated intravascular coagulation syndrome, (5) detection of activated platelets, and (6) molecular diagnosis of hereditary coagulation disorders.     

Optimizing laparoscopic splenectomy. Technical details and experience in 59 patients

BACKGROUND: Laparoscopic splenectomy (LS), like other advanced laparoscopic procedures, is still an evolving procedure. The indications for surgery, criteria for patient selection, and operative technique are not yet well defined. We have therefore modified the standard technique for performing LS in an attempt to optimize the procedure. METHODS: Over the past 2 years, we have performed LS in 59 patients. The last 43 patients were operated using a standardized technique that we believe to be optimal. It includes the routine use of the right lateral position, operating through three trocars, the mass transection of the splenic vasculature with a vascular endoscopic stapler, and the use of a self-retaining retrieval bag. RESULTS: The average operating time was 79 min. Average blood loss was 95 cc, and average postoperative hospitalization was 2.3 days. There was one intraoperative complication and one postoperative complication. These results are superior to those we achieved earlier in our own experience, as well as to similar series that have been published recently. CONCLUSIONS: In our experience, the use of this new technique resulted in relatively short procedures with low morbidity. We believe that these results justify the use of LS as the procedure of choice for elective splenectomy in patients with normal or moderately enlarged spleens.     

A case controlled comparison of open and laparoscopic splenectomy in children

BACKGROUND: This case controlled study compares the efficacy, safety, and cost of laparoscopic splenectomy (LS) and open splenectomy (OS) for hematologic disorders in children. METHODS: The records of 82 consecutive children and adolescents undergoing splenectomy for hematologic disorders between August 1994 and September 1997 were reviewed retrospectively. RESULTS: Fifty patients underwent LS by a lateral approach and 32 underwent OS through a left subcostal incision. Mean age was 7.76 years for LS and 6.9 years for OS. Patient weights were similar: (LS, mean 30.5 kg; OS, mean 27.6 kg). Hematologic indications included hereditary spherocytosis in 43 children (LS 26, OS 17), sickle cell anemia with sequestration in 13 (LS 7, OS 6), immune thrombocytopenic purpura in 14 (LS 8, OS 6), and 12 with other disorders (LS 9, OS 3). Concomitant cholecystectomy was performed in 10 of 50 LS and 6 of 32 OS cases. Accessory spleens were identified in 8 of 32 (25%) OS and 9 of 50 (18%) LS cases (P = .578). No LS procedures required conversion to OS. The mean estimated blood loss was 54.4 mL for LS and 49.0 mL for OS (P = .233). LS required a longer operative time (115 vs 83 minutes, P = .002), less need for postoperative intravenous narcotic (51% vs 100%, P < .0001), lower total narcotic doses (0.239 vs 0.480 mg/kg morphine, P = .006), shorter length of hospital stay (1.4 +/- 0.97 vs 2.5 +/- 1.43 days, P = .0001), and lower average total hospital charges ($5713 vs $6564) than OS. There were no deaths or major complications in either group. CONCLUSIONS: Laparoscopic splenectomy is a safe and effective procedure in children with hematologic disorders resulting in longer operative times, less narcotic administration, shorter length of stay, and lower total hospital charge.     

Allogeneic peripheral blood stem cell transplantation in 30 patients with hematologic disorders

Thirty patients (median age of 32 years; range, 6-61) with hematologic disorders received unmanipulated peripheral blood stem cell transplants from HLA-matched or one-antigen-mismatched related donors following myeloablative therapy for acute lymphoblastic leukemia (7), acute myelogenous leukemia (6), chronic myelogenous leukemia (8), myelodysplastic syndrome (3), or other disorders (6). Granulocyte colony stimulating factor (G-CSF) mobilized peripheral blood stem cells were collected from donors in 1 to 3 aphereses. The apheresis products contained mean counts of 11.3 x 10(8) (range, 3.8-17.2) nucleated cells/kg and 6.7 x 10(6) (range, 1.3-16.7) CD34+ cells/kg. Graft-versus-host-disease (GVHD) prophylaxis consisted of cyclosporin A plus methotrexate, or FK506 plus methotrexate. All patients received G-CSF following their transplant. Although 1 patient died of pneumonia 6 days after transplantation, the others demonstrated rapid engraftment. Median days to recovery to 500/microliter neutrophils and 20,000/microliter platelets were 13 (range, 8-21) and 14 (range, 1-23) days, respectively. The incidence of acute GVHD grade II-IV was 33%; chronic GVHD developed in 57% of the assessable patients. There were no episodes of graft failure or rejection. Nineteen patients (63%) were alive and in complete remission from 147 to 839 days following their transplant (median follow-up of 560 days). Further follow-up study will be required to assess the incidence of chronic GVHD and graft-versus-leukemia (GVL) effects.     

Carboquone therapy for hematologic neoplasms

A daily oral dose of 1-2 mg of Carboquone was administered for remission induction to 38 patients with hematologic malignancy, and the following results were obtained: 2 of the 3 patients with malignant lymphoma, 1 of the 12 patients with multiple myeloma, 13 of the 14 patients with chronic myelogenous leukemia, and all 9 patients with polycythemia vera attained complete remission.     

三氧化二砷治疗血液病后合并带状疱疹的临床研究

目的 分析三氧化二砷(ATO)治疗血液病后合并带状疱疹感染患者的临床特征及其可能的发生机制.方法 将研究对象分为研究组(应用ATO)和对照组(未应用ATO),观察两组带状疱疹发病率,以及研究组中发生带状疱疹和未发生带状疱疹患者的平均化疗次数.结果 研究组带状疱疹发病率为23.95%(23/96),发生带状疱疹者平均化疗7.60次,未发生带状疱疹者平均化疗7.72次(Z=0.976,P=0.296);对照组带状疱疹发病率7.89%(3/38),两组间带状疱疹发病率差异有统计学意义(χ2=4.492,P=0.034).结论 ATO治疗血液疾病可以增加带状疱疹的发病率,可能与其激活水痘-带状疱疹病毒有关.