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