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Joint Hospital Surgical Grand Round24 Oct 2009
Dr Tiffany WongDepartment of SurgeryPrince of Wales Hospital
ELECTIVE Benign
Idiopathic thrombocytopenic purpuraHereditary spherocytosisIdiopathic autoimmune hemolytic anaemia
MalingnantPrimary: Lymphoma/Leukaemia/SarcomaSecondary
EMERGENCY
TraumaIatrogenic
injury
What is the current standard?
Author/ Year
No OT time (min)
Blood loss
Complications
Conversion
Hospital stay
Sampath2007
OS 54LS 51
103156
NA 3117
-14
103
Kucuk 2005
OS 38LS 30
81 ± 31148 ± 64
188 ± 94216 ± 129
1613
-7
5.1 ± 2.32.8 ± 1.2
Berends 2004
OS 31LS 50
103 159
725615
2614
-22
8.95.5
Tanoue2002
OS 41LS 49
100 ± 35198 ± 93
511 ± 375187 ± 243
4611
-0
20.1 ± 12.59.6 ± 3.2
Park 1999
OS 63LS 147
77145
381162
3510
-3
9.2 2.4
Targarona 1999
OS 43LS 66
102 ± 18143 ± 50
20% 17%
2511
-0
8 ± 2.98 ± 3
Watson 1997
OS 47LS 13
8788
13%0%
190
-0
10 2.1
Laparoscopic approach is preferable for normal
size spleen due to
Less blood lossLower complication rate Shorter hospital stay
Is splenomegaly a limitation?
Author/ Year
No SizeWeight g
OT time
Blood loss
Cx %
Conversion
Hospital Stay
Watanabe 2007
OS 28LS 25
460 ± 200525 ± 300
205 ±60 173±53
750±600359 ±280
3628
-16
NA
Konstadoulakis 2006
OS 14LS 14
631±353685±274
135±23188±42
14%64%
1421
-21
6.5±1.25.0 ±2.4
Owera 2006
OS 13LS 15
11001300
90175
NA 3113
-7
31
Donini 1999
OS 56LS 44
732±1112773±1184
133±42130±62
347±511295±279
237
-2
3.6±0.81.7±0.8
Targarona1999
OS 18LS 18
642±160670±184
103±60170±77
33%22%
4027
-Excluded
12±65±2
Targarona 1999
OS 20LS 21
2713±10971762±1150
111±19176±56
40%33%
5527
-Excluded
12±56±3
Laparoscopic approach still superior to open for mild to moderate splenomegaly
Technically challenging due to limited working space and difficult manipulation in case of massive splenomegaly ie >23cm or weight > 2000g
Terrosu G, Surg Endosc 2002
Hand assisted laparoscopic or open splenectomy might be better (no good evidence as support)
EAES consensus statement 2008
Is malignant disease a limitation?
Author/ Year
No Size Weight g
OT time
Blood loss
Cx %
Conversion
Hospital stay
Casaccia 2006
M 144B 235
1844±1185676±522
151±52134±55
35%25%
1822
134
6.1±2.24.9±2.7
Walsh 2004
M 73B 86
680 162
148126
200100
88
151
32
Knauer 2003
M 30B 101
1295±859191±176
190±43139±42
1060±1293382±593
2010
406
6.3±5.73.5±5
Berman1999
M 22B 31
930164
203155
600125
329
143
42
Targarona 1999
M 28B 77
1441±1000 331±458
170±59150±50
32%20%
2514
145
5±2.44±2.3
Decker 1998
M 13B 22
1420±850160±387
235±67173±67
NA1415
230
4.55
Laparoscopic approach is still preferable
Need to avoid tumor spillageEn bloc retrieval for histopathological
examination
Laparoscopic approach is in general preferred except in massive splenomegaly
Less blood lossLower complication rateShorter hospital stay
Anterior/ Supine Semi lateral / Full lateral
Pros Good access to splenic hilum > early control of vascular supply
Feasible for concomitant procedure e.g. cholecystectomy
Uses gravity to expose splenic attachment and splenic hilum
Good visualization to pancreatic tail
Better access to perisplenic ligaments
Cons Difficult in exposing and dissecting ligamental structures especially at posterior part
Lack of wide visual view, may miss accessory spleen
Sharma D, Surg Laparosc Endosc Percutan Tech 2009
Ultrasonic coagulating deviceRothenberg SS, J Laparoendosc Surg 1996
Advanced bipolar deviceRomano F, Pediatr Surg Int 2003
Yuney E, Laparosc Endosc Percutan Tech 2005Romano F, J Laparoendosc Adv Surg Tech A 2007
Surgical stapling deviceMiles WF, Br J Surg 1996
Romano F, J Laparoendosc Adv Surg Tech A 2007
No RCT comparing different techniques All shown to be safe and effective
10% in autopsy study Most common site at hilum, retroperitoneum,
greater omentum, small bowel etcHalpert B, Arch pathol 1964
Not detected, might be responsible for relapsing disease
Computer tomography is the preferred choice100% sensitivity for number and site of accessory spleen
Napoli, Radiology 2004Gigot JF, Pro Gen Surg 2002
Thorough search for splenic tissue during surgery is essential
1919: First recognition of importance of splenic function in resistance to infection
Morris DH, Ann Surg 1919
1929: First report of postsplenectomy sepsisO’Donnel, BMJ 1929
1952: 5 case reports of severe sepsis in postsplenectomy children
King, Ann Surg 1952
1973: “Postsplenectomy sepsis” as septicaemia, meningitis or pneumonia that is fulminant and occurs after splenectomy
Singer, Perspective Paediatr Pathol 1973
Highest risk at first 2 years after surgery
Bisharat N, J Infect 2001
Incidence 5% in children and 0.9% in adult
Lynch AM, Infect Dis Clin North Am 1996Cullingford GL, Br J Surg 1991
38-69% mortalityAavitsland P, Lancet 1994
Waghorn DJ, J Clin Pathol 2001
At risk group: ChildrenThose for hematological malignancyThose with immunosuppressive treatment Those with previous history of OPSS
The lowest risk with trauma Singer, Perspective Paediatr Pathol 1973
Mourtzoukou EG, Br J Surg 2008
Classically by encapsulated organismsStreptococcus pneumoniaeHaemophilus influenzae type bNeisseria meningitidis
Others: Salmonella/ Capnocytophaga canimorsus/ Babesia/ Malaria
Review of 349 episodes57% streptococcal infection & mortality 59%22% haemophilus & mortality 32%
Holdsworth R, Br J Surg 1991
Year
Pneumococcal
Meningococcal
Hemophilus influenza type b
Advisory Committee on Immunization Practices for CDC
2006
√ + RV 5 years
√ √
Society of Surgery for the Alimentary Tract
2004
√ √ √
Department of Surgical Education, Orlando Regional Medical Centre
2006
√ + RV 6 years
√ √
British Committee for Standards in Haematology
2002
√ + RV 5 years
√ RV not recommended
√
Cumbria and Lancashire Health Protection Unit
2002
√ + RV 5 years or more frequent
√ + RV 5 years
√
Public Health Agency of Canada
2006
√ + RV 5 years
√ + RV 3 years
√
National health institutes of 23 European countries
2005
√ + RV at 3-6 years
- √
Elective2 weeks before splenectomy
Emergency2 weeks after splenectomyBased on 59 trauma patients vs 12 control1st/7th/14th days after splenectomyOpsonophagocytic function was diminished for those vaccinated before day 14
Shatz DV, J Trauma 1998
No evidence in adult population Only one RCT
Infection rate 13/110 vs 2/105, p= 0.0025No mortality in antibiotic group
Gaston MH, N Eng J Med 1986 1971-1995 > daily penicillin
1958-1970> no prophylaxisReduced incidence of infection 47% & 88% reduction in mortality
Jugenburg M, J Pediatr Surg 1999
Not adequately evaluated in adult
At risk of selection of resistance strain
Poor compliance
Penicillin resistant pneuomococci
Possible reduction in mortality
Based on efficacy from pediatric population
Most guidelines recommend prophylaxis for 3-5 years for adult
Melles DC, Neth J Med 2004
VaccinationAntibiotic prophylaxisEarly recognition & treatment of
sepsis in asplenic patientsPatient education
Laparoscopic splenectomy is the preferred approach
Beware of accessory spleen Importance of post splenectomy
sepsis