The learning curve of laparoscopic splenectomy and esophagogastric devascularization for portal hypertension with 10-year follow-up.

INTRODUCTION AND OBJECTIVES: Laparoscopic splenectomy and esophagogastric devascularization (LSED) are minimally invasive, effective, and safe in treating esophageal-fundic variceal bleeding with portal hypertension (PHT). The study aimed to assess the learning curve of LSED by cumulative summation (CUSUM) analysis. The 10-year follow-up data for LSED and open surgery were also examined. PATIENTS AND METHODS: Five hundred and ninety-four patients were retrospectively analyzed. Operation time, intraoperative blood loss, open operation conversion, and postoperative complications were selected as the evaluation indicators of surgical ability. The learning curve of LESD was assessed by the CUSUM approach. Patient features, perioperative indices, and 10-year follow-up data were examined. RESULTS: Totally 236 patients underwent open surgery, and 358 underwent LSED. Patient characteristics were similar between groups. The LSED patients experienced less intraoperative blood loss, fewer complications, and faster recovery compared to the open surgery cohort. The learning curve of LESD was maximal for a case number of 50. Preoperative general characteristics were comparable for both stages. But the skilled stage had decreased operation time, reduced blood loss, less postoperative complications, and better recovery compared to the learning stage. The LSED group had higher recurrent hemorrhage-free survival rate and increased overall survival in comparison with cases administered open surgery in the 10-year follow-up. Free-liver cancer rates were similar between two groups. CONCLUSIONS: About 50 cases are needed to master the LSED procedure. Compared to open surgery, LSED is a safer, feasible, and safe procedure for PHT patients, correlating with decreased rebleeding rate and better overall survival.

Elective splenectomy for hematological diseases: a vanishing indication.

INTRODUCTION: Splenectomy has been used as a diagnostic and therapeutic tool in the management of hematological diseases for many years. However, the emergence of new medical therapies has modified guidelines for many hematological diseases for which splenectomy was previously considered. We aimed to evaluate the evidence of a decrease in the hematological indications for splenectomy and the reasons and justifications for this change. MATERIAL AND METHODS: We conducted a single-center, retrospective analysis of patients who underwent laparoscopic splenectomy for hematological disease between January 2010 and December 2023. Patients were classified into four groups: 1 autoimmune and hemolytic diseases (HAD), (2) lymphomas, (3) myeloproliferative diseases (MPN), and (4) other splenic diseases. We recorded the annual incidence of splenectomy and the ratio of new medical cases, demographic and clinical data and surgical outcomes. RESULTS: During the study period, 98 patients were referred for splenectomy. There was a significant progressive decrease in this surgical indication, particularly regarding HAD (p < 0.001). The indication for splenectomy for immune thrombocytopenic purpura (ITP) declined to zero despite an increase in the number of patients diagnosed with this disorder (p < 0.001). The pattern of decrease in AHAI and Evans syndrome was similar to that in ITP. The group of splenectomies due to lymphoma persisted consistently during the study period, as did the indication for splenectomy in the context of lymphoma treatment. Splenectomy due to massive splenomegaly secondary to MPN was indicated only in one patient. Splenectomies due to other causes were similarly distributed over the years. CONCLUSIONS: Our findings confirm a significant decrease in the indication for elective surgery for hematological diseases, mainly regarding autoimmune disease. The surgical community and surgical departments should be aware of this situation yet maintain the skills to adopt this technique both safely and efficiently.

Prognosis of LSPD versus TIPS for the treatment of esophagogastric variceal bleeding in cirrhosis.

BACKGROUND: This study aimed to compare postoperative complications in patients with esophagogastric variceal bleeding (EVB) who underwent laparoscopic splenectomy combined with pericardial devascularization (LSPD) versus transjugular intrahepatic portosystemic shunt (TIPS) procedures. METHODS: A retrospective collection of medical records was conducted from January 2014 to May 2020 at Union Hospital, Tongji Medical College, Huazhong University of Science and Technology. The study included patients from the departments of trauma surgery, interventional radiology, and general surgery who were diagnosed with EVB caused by portal hypertension and treated with LSPD or TIPS. Follow-up data were obtained to assess the occurrence of postoperative complications in both groups. RESULTS: A total of 201 patients were included in the study, with 104 cases in the LSPD group and 97 cases in the TIPS group. There was no significant difference in the 1-year and 3-year post-surgery survival rates between the TIPS and LSPD groups (P = 0.669, 0.066). The 3-year survival rate of Child-Pugh B patients in the LSPD group was higher than TIPS group (P = 0.041). The LSPD group also had a significantly higher rate of freedom from rebleeding at 3-year post-surgery compared to the TIPS group (P = 0.038). Stratified analysis showed no statistically significant difference in the rebleeding rate between the two groups. Furthermore, the LSPD group had a higher rate of freedom from overt hepatic encephalopathy at 1-year and 3-year post-surgery compared to the TIPS group (P = 0.007, < 0.001). The LSPD group also had a lower rate of severe complications at 3-year post-surgery compared to the TIPS group (P = 0.020). CONCLUSION: Compared to TIPS, LSPD does not increase the risk of mortality and rebleeding, while demonstrating fewer complications. In patients classified as Child-Pugh A and B, the use of LSPD for treating EVB is both safe and effective.

Effects of laparoscopic splenectomy on surgical site wound infection in patients with spleen rupture: A meta-analysis.

A meta-analysis was performed to compare the effects of laparoscopic splenectomy (LS) and open splenectomy (OS) for splenic rupture on postoperative surgical site wound infections and postoperative complications. A comprehensive computerised search was conducted for studies comparing LS with OS for the treatment of splenic rupture in the PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI), VIP, and Wanfang databases, with the search including studies published in any language between the creation of the databases and August 2023. Two researchers independently screened the literature and extracted the data. Literature quality was assessed using the Newcastle-Ottawa Scale, and the included data were collated and analysed using Stata 17.0 software for meta-analysis. Twenty-two studies involving 1545 patients were included. LS was superior to OS in the following aspects: reduced risk of postoperative surgical site wound infection (OR = 0.19, 95% CI: 0.11-0.34, p = 0.000), shortened hospital stay (standardised mean difference = -1.73, 95% CI: -2.05 to -1.40, p = 0.000), and reduced postoperative complication rate (OR = 0.22, 95% CI: 0.16-0.31, p = 0.000). Compared with OS, LS has a lower rate of postoperative wound infection, shorter hospital stay, and reduced rate of postoperative complications. LS is safe and effective for the treatment of splenic rupture and can be promoted clinically.

Clinical effects of cluster technology optimization and innovations on laparoscopic splenectomy and azygoportal disconnection: a single-center retrospective study with 500 consecutive cases.

BACKGROUND: In Asia, laparoscopic splenectomy and azygoportal disconnection (LSD) has been widely regarded as a preferential treatment modality for cirrhotic portal hypertension (PH). However, LSD involves high surgical risk, technical challenges, and many potential postoperative complications. Technology optimization and innovation in LSD aiming to solve to these difficulties has scarcely been reported. In this retrospective study, we aimed to evaluate the clinical therapeutic effect of our cluster technology optimization and innovation on LSD for PH. METHODS: From February 2012 to January 2020, 500 patients with cirrhosis who had esophagogastric variceal bleeding and hypersplenism underwent LSD in our department. According to different operation periods, patients were divided into the early-, intermediate-, and late-period groups. We collected information regarding clinical characteristics of all patients as well as their preoperative and postoperative follow-up data. RESULTS: Compared with the early-period group, operation time and postoperative hospital stay were all significantly different and gradually declined from the intermediate- and late-period groups, respectively (all P < 0.05). Intraoperative blood loss of these three groups was gradually decreased, with significant differences (P < 0.05). The incidences of delayed gastric emptying and diarrhea in the late-period group were all significantly lower than those in the early- and intermediate-period groups, respectively (all P < 0.05). Compared with the early-period group, the incidence of variceal re-bleeding was significantly lower in the intermediate- and late-period groups (all P < 0.05). CONCLUSION: Our cluster technology optimization and innovation of LSD not only contributed to faster recovery and fewer complications but also enhanced surgical safety for patients. It is worth promoting this approach among patients with EVB and hypersplenism secondary to cirrhotic PH.

The usefulness of modified splenic hilum hanging maneuver in laparoscopic splenectomy, especially for patients with huge spleen: a case-control study with propensity score matching.

BACKGROUND: Although Laparoscopic splenectomy (LS) have been proven to the standard operation for removal of spleen, the rate of conversion to open surgery is still higher than those of other laparoscopic surgeries, especially for huge spleen. In order to reduce the rate of conversion to open surgery, we had developed LS using modified splenic hilum hanging (MSHH) maneuver: the splenic pedicle was transected en bloc using a surgical stapler after hanging splenic hilum with an atraumatic penrose drain tube. METHODS: Between January 2005 and December 2019, we retrospectively assessed 94 patients who underwent LS. MSHH maneuver was performed in 37 patients (39.4%). We compared the intra- and postoperative outcomes between patients with or without MSHH maneuver. To adjust for differences in preoperative characteristics and blood examination, propensity score matching was used at a 1:1 ratio, resulting in a comparison of 29 patients per group. Predictive factors of conversion from LS to open surgery were elucidated using the uni- and multi-variate analyses. RESULTS: After the propensity score matching, blood loss (268 ml vs. 50 ml), the rate of conversion to open surgery (27.6% vs. 0%), and postoperative hospital stays (15 days vs. 10 days) were significantly decreased in patients with MSHH maneuver, respectively. Among 94 patients, 19 patients (20.2%) underwent conversion to open surgery. In multivariate analysis, spleen volume (SV) and LS without MSHH maneuver were independent predictive factors of conversion to open surgery, respectively. Additionally, cut-off value of SV for conversion to open surgery was 802 ml (sensitivity: 0.684, specificity: 0.827, p < 0.001). CONCLUSIONS: LS using MSHH maneuver seems to be useful surgical technique to improve intraoperative outcomes and reduce the rate of conversion from LS to open surgery resulting in shorten postoperative hospital stay.

Portal vein thrombosis following elective laparoscopic splenectomy: incidence and analysis of risk factors.

BACKGROUND: Minimally invasive splenectomy is now well established for a wide range of pathologies. Portal vein thrombosis (PVT) is increasingly being recognised as a complication of splenectomy. The aim was to determine the incidence and risk factors for PVT after laparoscopic splenectomy. METHODS: All cases of elective laparoscopic splenectomy performed from 1993 to 2020 were reviewed. Parameters recorded included demographics, diagnostic criterion and post-operative outcomes. Data were analysed using Minitab V18 with a p < 0.05 considered significant. RESULTS: 210 patients (103 female, 107 male) underwent laparoscopic splenectomy (14 to 85 years). A major proportion of cases were performed for ITP (n = 77, p = 0.012) followed by lymphoma (n = 28), indeterminate lesions (n = 21) and myelofibrosis (n = 19). Ten patients developed symptomatic portal vein thrombosis (4.8%). Patients presented most commonly with pain and fever and diagnosis was confirmed by computed tomography (CT) or ultrasonography (USS). There were 10 conversions (4.8%) to open and two postoperative deaths, one from PVT and one from pneumonia. The remaining nine patients were successfully treated with anticoagulation. Of 19 patients with myelofibrosis, six patients developed PVT (p = 0.0002). Patients who developed PVT had significantly greater specimen weights (1773 g vs 348 g, p < 0.001). Forty-three patients had a specimen weight of 1 kg or greater, and of these 9 developed portal vein thrombosis (21%), versus one with PVT of 155 with a specimen weight of less than 1 kg (p < 0.0001). Myelofibrosis (p = 0.0039), specimen weight (p < 0.001) and mean platelet count (p = 0.0049) were predictive of PVT. CONCLUSION: A high index of suspicion for this complication should be maintained and prompt treatment with anticoagulation. High-risk patients should be considered for prophylactic anticoagulation and routine imaging of the portal vein.

Splenic infarction after Epstein-Barr virus infection in a patient with hereditary spherocytosis: a case report and literature review.

BACKGROUND: Hereditary spherocytosis (HS) complicated by splenic infarction is very rare, and it is even rarer to develop splenic infarction after infectious mononucleosis (IM) as a result of Epstein-Barr virus (EBV) infection. Therefore, misdiagnosis or missed diagnosis is prone to occur. CASE PRESENTATION: A 19-year-old Chinese female previously diagnosed with HS was admitted to our institution with persistent high fever and icterus. On admission, the physical examination showed anemia, jaundice, marked splenomegaly, obvious tenderness in the left upper abdomen (LUA). Peripheral blood film shows that spherical red blood cells accounted for about 6%, and Immunoglobulin M (IgM) antibodies specific to Epstein-Barr virus (EBV) viral capsid antigen were detected. An abdominal CT scan revealed a splenic infarction. The patient was diagnosed with HS with splenic infarction following EBV infection and underwent an emergency laparoscopic splenectomy (LS). Pathological analysis showed a splenic infarction with red pulp expansion, white pulp atrophy and a splenic sinus filled with red blood cells. After two months of follow-up visits, the patient showed no signs of relapse. CONCLUSIONS: HS complicated by splenic infarction is very rare and mostly occurs in men under 20 years of age and is often accompanied by other diseases, such as sickle cell traits (SCT) or IM. Although symptomatic management may be sufficient, emergency laparoscopic splenectomy may be safe and effective when conservative treatment is ineffective.

Laparoscopic splenic artery aneurysmectomy with ICG guided partial splenectomy: alternative approach.

We herein report the case of a voluminous splenic artery aneurysm (SAA) diagnosed in a 48 year-old Caucasian male patient. After endovascular treatment failure, considering the volumetric aneurysm increase and recurrent symptoms, a laparoscopic splenic artery aneurysmectomy with partial splenectomy guided by indocyanine green fluorescence (ICG) was performed. This conservative strategy leads to save a spleen volume of about 10 cm3 to avoid postsplenectomy thrombocytosis and infections, potential immunodeficiency and overwhelming postsplenectomy infection syndrome (OPSS) and to preserve pancreatic vascularization preventing distal pancreas injuries.

Efficacy and safety of laparoscopic splenectomy for hypersplenism secondary to portal hypertension after transjugular intrahepatic portosystemic shunt.

BACKGROUND: Laparoscopic splenectomy (LS) being used after Transjugular intrahepatic portosystemic shunt (TIPS) has not been reported. This report aims to explore the feasibility, safety, and potential efficacy of LS after TIPS hypersplenism secondary to portal hypertension (PHT). METHODS: We retrospectively reviewed a series of six patients who underwent LS after TIPS for hypersplenism secondary to PHT between 2014 and 2020. The perioperative data and patients' clinical outcomes were recorded. RESULTS: LS was successfully performed in all patients. Hypersplenism was corrected after LS in all six patients. Postoperative prothrombin time, prothrombin activity, international normalized ratio, and total bilirubin showed a trend toward improvement. The preoperative and 1-month postoperative albumin and activated partial thromboplastin levels showed no significant difference. Plasma ammonia level and thromboelastography indicators were ameliorated in two limited recorded patients. No postoperative complications such as subphrenic abscess, portal vein thrombosis, variceal bleeding, hepatic encephalopathy, and liver failure occurred during the 1-month follow-up period. CONCLUSION: LS following TIPS is feasible, safe, and beneficial for patients with hypersplenism secondary to PHT. The following LS not only corrects the hypersplenism, but also has the potential to improve liver function.

Guidelines for the performance of minimally invasive splenectomy.

BACKGROUND: Minimally invasive splenectomy (MIS) is increasingly favored for the treatment of benign and malignant diseases of the spleen over open access approaches. While many studies cite the superiority of MIS in terms of decreased morbidity and length of stay over a traditional open approach, the comparative effectiveness of specific technical and peri-operative approaches to MIS is unclear. OBJECTIVE: To develop evidence-based guidelines that support clinicians, patients, and others in decisions on the peri-operative performance of MIS. METHODS: A guidelines committee panel of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) including methodologists used the Grading of Recommendations Assessment, Development and Evaluation approach to grade the certainty of evidence and formulate recommendations. RESULTS: Informed by a systematic review of the evidence, the panel agreed on eight recommendations for the peri-operative performance of MIS for adults and children in elective situations addressing six key questions. CONCLUSIONS: Conditional recommendations were made in favor of lateral positioning for non-hematologic disease, intra-operative platelet administration for patients with idiopathic thrombocytopenic purpura instead of preoperative administration, and the use of mechanical devices to control the splenic hilum. Further, a conditional recommendation was made against routine intra-operative drain placement.

Laparoscopic surgery for splenic injuries in the era of non-operative management: current status and future perspectives.

The spleen is one of the organs most commonly injured by blunt abdominal trauma. It plays an important role in immune response to infections, especially those sustained by encapsulated bacteria. Nonoperative management (NOM), comprising clinical and radiological observation with or without angioembolization, is the treatment of choice for traumatic splenic injury in patients who are hemodynamically stable. However, this strategy carries a risk of failure, especially for high-grade injuries. No clear predictors of failure have been identified, but minimally invasive surgery for splenic injury is gaining popularity. Laparoscopic surgery has been proposed as an alternative to open surgery for hemodynamically stable patients who require surgery, such as after failed NOM. We reviewed research articles on laparoscopic surgery for hemodynamically stable patients with splenic trauma to explore the current knowledge about this topic. After presenting an overview of the treatments for splenic trauma and the immunological function of the spleen, we try to identify the future indications for laparoscopic surgery in the era of NOM.

An extremely rare case of Rosai-Dorfman disease in the spleen.

BACKGROUND: Rosai-Dorfman disease (RDD) is a rare, multisystemic histiocytic disorder, and commonly manifesting as lymphadenopathy in the young male. Abdominal manifestations of RDD are extremely rare. CASE PRESENTATION: In August 2018, a 42-year-old man underwent an abdominal ultrasonography examination due to his weight loss of 10 kg in only three months and found a giant solid tumor was found in his spleen. Then, he was admitted to our hospital and diagnosed as a splenic mass via abdominal enhanced CT and MRI. Laparoscopic splenectomy was administrated within six days of admission due to the clear surgical indications. The pathogenesis of RDD remained poorly understood and the disease should be diagnosed based on histopathology and immunohistochemistry (IHC). The mutations in ATM and NFKBIA were observed using next generation sequencing (NGS). CONCLUSION: We reported a case of splenic involvement of RDD with NGS genetic testing, indicating the difficulty of making a diagnosis before surgery. This extremely rare case offers new references for the understanding of abdominal viscera RDD.

Safety and Efficacy of Using Staplers and Vessel Sealing Devices for Laparoscopic Splenectomy: A Randomized Controlled Trial.

Background. Laparoscopic splenectomy (LS) is considered the operation of choice on elective basis for managing patients with certain hematological disorders. Hemostatic control of the splenic pedicle is one of the crucial steps in LS. This study compares the safety and efficacy of using endoscopic staplers and vessel sealing devices to control the splenic pedicle in patients with nonsevere splenomegaly. Methods. Fifty-one consecutive patients with different blood disorders including idiopathic thrombocytopenic purpura (ITP), hypersplenism, and lymphoma were randomized for elective LS. Traditional steps of LS, via lateral approach, were followed, and pedicle control was done with either endovascular gastrointestinal anastomosis stapler (n = 26) or vessel sealing device (Ligasure) (n = 25). Results. No difference was noted with different splenic spans when using either methods of pedicle control (P = .145). The volume of blood loss was higher in the Ligasure group compared to the staplers group (182 mL vs 131 mL, respectively), but was not statistically significant (P = .249). Conversion to open was notably higher in the Ligasure group (P = .034), but the intraoperative complications were comparable in both groups (P = .357). Conclusion. The use of vessel sealing devices for splenic pedicle control has comparable surgical outcomes compared with the use of endoscopic staplers for LS, but with higher rate of conversion to open surgery.

A novel preoperative scoring system to predict technical difficulty in laparoscopic splenectomy for non-traumatic diseases.

BACKGROUND: Laparoscopic splenectomy (LS) has been proven to be a safe and advantageous procedure. To ensure that resections of appropriate difficulty are selected, an objective preoperative grading of difficulty is required. We aimed to develop a predictive difficulty grading of LS based on intraoperative complications. METHODS: A total of 272 non-traumatic patients who underwent LS were identified from a regional medical center. Patients were randomized into a training cohort (n = 222) and a validation cohort (n = 50). Data on demographics, medical and surgical history, operative and pathological characteristics, and postoperative outcome details were collected. Univariate and multivariate analyses of risk factors for intraoperative complications were performed to develop a difficulty scoring system. The Spearman correlation coefficient was used to evaluate the relationship between the difficulty grading score and intraoperative outcomes. Receiver operating characteristic (ROC) curve was used to evaluate the discriminatory power of this scoring system. RESULTS: Three preoperative factors (spleen weight, esophagogastric varices, and INR) had a significant effect on operative time, bleeding, and conversion to open surgery. We created a difficulty grading score with three levels of difficulty: low (≤ 4 points), medium (5-6 points), and high (≥ 7 points), based on the three preoperative parameters. The correlation was highly significant (P < 0.01) according to Spearman's correlation. The area under the ROC curve was 0.695 (95% CI 0.630-0.755). The external validation showed significant correlations with the present model, with an AUC of 0.725 (95% CI 0.580-0.842). The comparison between our difficulty score and the previous grading system in the 272-patient cohort presented a significant difference in the AUC (0.701, 95% CI 0.643-0.755 vs. 0.644, 95% CI 0.584-0.701, P = 0.0452). CONCLUSION: The present difficulty scoring system, based on preoperative factors, has good performance in predicting the risk of intraoperative complications of LS and could be helpful for enabling appropriate case selection with respect to the current experience of a surgeon.

Simultaneous radiofrequency ablation combined with laparoscopic splenectomy: a safe and effective way for patients with hepatocellular carcinoma complicated with cirrhosis and hypersplenism.

Purpose: This study aimed to evaluate the safety and effectiveness of simultaneous radiofrequency ablation (RFA) combined with laparoscopic splenectomy (Lap-Sp) for patients with hepatocellular carcinoma (HCC) complicated with cirrhosis and hypersplenism.Material and methods: Between January 2013 and June 2014, 42 patients with primary HCC complicated with cirrhosis and hypersplenism who underwent simultaneous RFA combined with Lap-Sp were enrolled at the Department of General Surgery, Beijing Di Tan Hospital. The median number of tumors ablated using RFA was one (range 1-3), and the median sum of the maximum diameter of tumors was 2.5 cm (range 1.2-5.4 cm). The related indicators before and after surgery, complications, and long-term effects were retrospectively analyzed.Results: The median operative time for 42 patients undergoing simultaneous RFA combined with Lap-Sp was 4.5 h (range 2.5-8.5 h), and the median blood loss was 120 mL (range 5-2200 mL). The incidence of moderate-to-severe postoperative complications and the perioperative mortality after surgery were 31.0 and 0%, respectively. The disease-free survival rate for one, three, and five years was 73.8, 19.7, and 16.4%, respectively. The overall survival rate was 90.5, 73.3, and 60.4%, respectively.Conclusion: Simultaneous RFA combined with Lap-Sp was safe and effective for patients with HCC complicated with cirrhosis and hypersplenism.

Laparoscopic splenectomy for immune thrombocytopenia (ITP): long-term outcomes of a modern cohort.

BACKGROUND: The advent of newer second-line medical therapies (SLMT) for immune thrombocytopenia (ITP) has contributed to decreased rates of splenectomy, following a trend to avoid or delay surgery. We aimed to characterize the long-term outcomes of laparoscopic splenectomy (LS) for ITP at our institution, examining differences in LS efficiency when performed before or after SLMTs. METHODS: Adults with primary ITP who underwent LS between 2002 and 2016 were identified. Retrospective review of electronic medical records was supplemented with telephone interviews. Treatment response was defined according to current guidelines as complete responders (CR), responders (R), and non-responders (NR). Kaplan-Meier estimates assessed relapse-free rates, and predictors of long-term response were investigated using logistic regression. RESULTS: 109 patients met inclusion criteria, from which 42% were treated with an SLMT before referral to LS. LS was completed in all cases, with no conversions or intraoperative complications. The perioperative morbidity was 7.3%, including 3 deep vein and 2 portal vein thrombosis, one reoperation for bleeding, and no mortalities. Splenectomy was initially effective in 99 patients (CR + R = 90.8%), and 10 patients were NR. At a median 62-month follow-up, 25 patients relapsed, resulting in a 68% CR + R rate. Proportion of CR + R was similar in patients who previously received SLMT and those who did not (61 vs. 76.7%, p = 0.08). CR + R patients were younger (45 vs. 53, p = 0.03), had higher preoperative platelet counts (36 vs. 19, p = 0.01), and experienced a higher increment in platelet counts during hospital stay (117 vs. 38, p < 0.001) as well as 30-days postoperatively (329 vs. 124, p < 0.001). Only a robust response in platelet count at 30-days postoperatively was independently associated with long-term response (OR 1.005, p = 0.006). CONCLUSION: LS was curative in 68% of patients, with no statistically significant difference when performed before or after SLMTs. Outcomes remain challenging to predict preoperatively, with only a robust increase in platelet counts on short term being associated with long-term response.

Laparoscopic versus open splenectomy for splenomegaly: the verdict is unclear.

BACKGROUND: The benefits of laparoscopic splenectomy (LS) over open splenectomy (OS) for normal-sized spleens have been well documented. However, the role of laparoscopy for moderate and massive splenomegaly is debated. METHODS: A retrospective review of patients undergoing elective splenectomy at one institution from 1997 to 2017 was conducted. Moderate and massive splenomegaly was defined as splenic weight of 500-1000 g and greater than 1000 g, respectively. We performed a 1:2 matching of laparoscopic to open splenectomy to control for differences in splenic weight. Differences in perioperative morbidity (infection, thromboembolism, reoperation, readmission), intraoperative factors (blood loss, operative time), length of stay, and mortality were examined. RESULTS: A total of 491 elective splenectomies were identified. 268 cases were for splenic weights greater than 500 g. After a 1:2 matching of LS:OS, we identified 22 LS and 44 matched OS for moderate splenomegaly. The LS group had longer mean operative times (178 vs. 107 min, p < 0.01), with similar length of stay and blood loss. For massive splenomegaly, 26 LS were identified and matched to 52 OS. LS had longer mean operative times (171 vs. 112 min, p < 0.01) and higher readmission rates (27% vs. 6%, p < 0.05). Other factors and outcomes did not differ between LS and OS for moderate or massive splenomegaly. The conversion rate for LS was higher for massive versus moderate splenomegaly, but was not statistically significant (35% vs. 14%, p = 0.09). CONCLUSIONS: LS for moderate and massive splenomegaly is associated with longer operative times. Other perioperative outcomes were comparable to OS, with no demonstrated benefits for LS. Although LS may be a feasible approach to moderate and massive splenomegaly, its benefits require further clarification in this patient population.

Effect of laparoscopic splenectomy on portal vein thrombosis and serum YKL-40 in patients with cirrhotic portal hypertension.

INTRODUCTION AND OBJECTIVES: Laparoscopic splenectomy (LS) is a supportive intervention for cirrhotic patients. However, its efficacy for patients with cirrhotic portal hypertension (CPH) still needs clarification. Studies indicated YKL-40 might be effective targets for treatment of splenomegaly, however deeper insights are unclear. The aim of this study was to investigate the effect of LS on the formation of portal vein thrombosis (PVT) and serum levels of a fibrosis marker, YKL-40, in patients with CPH. MATERIALS AND METHODS: A total of 80 patients who underwent LS and 30 healthy controls were investigated in this study. Serum levels of YKL-40 were measured by enzyme-linked immunosorbent assay (ELISA). Demographic characteristics including age and gender were recorded. Clinicopathological and laboratory examinations included the severity of esophageal varices and the presence of viral hepatitis. The liver function was assessed according to the Child-Pugh classification. The incidence of PVT before and after operation was also monitored. RESULTS: Serum YKL-40 was significantly increased in CPH patients, and was associated with Child-Pugh score and HBV infection. Furthermore, elderly patients had an increased risk for postoperative PVT. Higher serum YKL-40 was observed in patients with thrombus at postoperative 7, 14 and 21 days than those without thrombus. CONCLUSIONS: LS could reduce serum YKL-40 levels and PVT progression and was a useful treatment for patients <40 years of age with CPH.

Is ITP really a desirable indication for teaching laparoscopic splenectomy? Cohort study.

Background: We aimed to evaluate the outcomes of laparoscopic splenectomy (LS) in patients with immune thrombocytopenic purpura (ITP) compared with operated for other indications. Methods: Retrospective cohort study of patients who underwent LS in 1998-2017. Group 1 consisted of 256 patients operated for ITP, and Group 2 of 231 operated for other indications. Primary outcome was procedure difficulty. Secondary was perioperative course (30 days of surgery). Results: Patients in Group 1 were younger (p < .001) with lower ASA (p < .001). The spleen was larger in Group 2 (p < .001). Operative time was longer in Group 2 [110 (80-150) vs. 90 (65-115) min; p < .001)]. Intraoperative blood loss was greater in Group 2 (p < .001). Conversions were higher in Group 2 (4.76 vs. 6.93%, p = .037), as were intraoperative complications (7.79 vs. 3.91%, p = .048). Morbidity, reoperations and mortality did not differ between groups (respectively, p = .899, .697, and .999). Median length of stay was similar (p = .211). Among the first 10 LSs performed by trainees, 63.66% were done for ITP. Later (after 11+ procedures) this dropped to 48.12% (p = .002). Conclusions: ITP may be a preferred indication for surgeons training for LS. Patients' characteristics and intraoperative factors allow an expectation for a relatively easy and hassle-free operation in those patients.