Robot-assisted partial splenectomy for benign splenic tumors:Four case reports

BACKGROUND Robotic-assisted partial splenectomy(RAPS)is a superior approach for treating splenic cysts and splenic hemangiomas,as it preserves the immune function of the spleen and reduces the risk of overwhelming post splenectomy infection.Curren-tly,there are no standardized guidelines for performing a partial splenectomy.CASE SUMMARY Four patients with splenic cysts or splenic hemangiomas were treated by RAPS.Critical aspects with RAPS include carefully dissecting the splenic pedicle,accurately identifying and ligating the supplying vessels of the targeted segment,and ensuring precise hemostasis during splenic parenchymal transection.Four successful RAPS cases are presented,where the tumors were removed by pret-reating the splenic artery,dissecting and ligating the corresponding segmental vessels of the splenic pedicle,transecting the ischemic segment of the spleen,and using electrocautery for optimal hemostasis.Four patients underwent successful surgeries with minimal bleeding during the procedure,and there were no signs of bleeding or recurrence postoperatively.CONCLUSION Four cases confirm the feasibility and superiority of RAPS for the treatment of benign splenic tumors.

Predictors of portal vein thrombosis after splenectomy in patients with cirrhosis

BACKGROUND Portal vein thrombosis(PVT)is a commonthsn complication after splenectomy in patients with cirrhosis.However,the predictors of postoperative PVT are not known.AIM To investigate the predictors of PVT after splenectomy in patient with cirrhosis.METHODS A total of 45 patients with cirrhosis who underwent splenectomy were consecutively enrolled from January 2017 to December 2018.The incidence of PVT at 1 months,3 months,and 12 months after splenectomy in patients with cirrhosis was observed.The hematological indicators,biochemical and coagulation parameters,and imaging features were recorded at baseline and at each observation point.The univariable,multivariable,receiver operating characteristic curve and timedependent curve analyses were performed.RESULTS The cumulative incidence of PVT was 40.0%,46.6%,and 48.9%at 1 months,3 months,and 12 months after splenectomy.Multivariable analysis showed that portal vein diameter(PVD)≥14.5 mm and monthsdel end-stage liver disease(MELD)score>10 were independent predictors of PVT at 1 months,3 months,and 12 months after splenectomy(P<0.05).Time-dependent curve showed that the cumulative incidence of PVT was significantly different between patients with MELD score≤10 and>10(P<0.05).In addition,the cumulative incidence of PVT in the PVD≥14.5 mm group was significantly higher than that in the PVD<14.5 mm group(P<0.05).CONCLUSION Wider PVD and MELD score>10 were independent predictors of PVT at 1 months,3 months,and 12 months after splenectomy in patient with cirrhosis.

Will partial splenic embolization followed by splenectomy increase intraoperative bleeding?

BACKGROUND Partial splenic embolization(PSE)has been suggested as an alternative to splenectomy in the treatment of hypersplenism.However,some patients may experience recurrence of hypersplenism after PSE and require splenectomy.Currently,there is a lack of evidence-based medical support regarding whether preoperative PSE followed by splenectomy can reduce the incidence of complications.AIM To investigate the safety and therapeutic efficacy of preoperative PSE followed by splenectomy in patients with cirrhosis and hypersplenism.METHODS Between January 2010 and December 2021,321 consecutive patients with cirrhosis and hypersplenism underwent splenectomy at our department.Based on whether PSE was performed prior to splenectomy,the patients were divided into two groups:PSE group(n=40)and non-PSE group(n=281).Patient characteristics,postoperative complications,and follow-up data were compared between groups.Propensity score matching(PSM)was conducted,and univariable and multivariable analyses were used to establish a nomogram predictive model for intraoperative bleeding(IB).The receiver operating characteristic curve,Hosmer-Lemeshow goodness-of-fit test,and decision curve analysis(DCA)were employed to evaluate the differentiation,calibration,and clinical performance of the model.RESULTS After PSM,the non-PSE group showed significant reductions in hospital stay,intraoperative blood loss,and operation time(all P=0.00).Multivariate analysis revealed that spleen length,portal vein diameter,splenic vein diameter,and history of PSE were independent predictive factors for IB.A nomogram predictive model of IB was constructed,and DCA demonstrated the clinical utility of this model.Both groups exhibited similar results in terms of overall survival during the follow-up period.CONCLUSION Preoperative PSE followed by splenectomy may increase the incidence of IB and a nomogram-based prediction model can predict the occurrence of IB.

Splenectomy: Indications in the General Surgery Department of Ignace Deen Hospital

Introduction: Splenectomy is the surgical removal of the spleen. It can be performed during various pathologies, ranging from abdominal trauma to hemoglobinopathies. The progress made in the knowledge of the immune functions of the spleen and the fear of post-splenectomy infectious complications have favored the development of surgical or non-surgical splenic preservation techniques calling into question the dogma of splenectomy. The aim of this study was to determine the indications for splenectomy. Methodology: This was a retrospective, descriptive study lasting 5 years in the general surgery department of the Ignace Deen National Hospital. All files of splenectomized patients were included, our variables were clinical, therapeutic and progressive. Results: We collected 42 cases of splenectomies out of the 2478 surgical procedures performed, representing 1.7% of the department’s surgical activities. The average age was 44 years. The age group of 41 to 50 years was the most represented, i.e. 26% (n = 11) of cases. Sex ratio = 1. Abdominal pain was the reason for consultation in patients, i.e. 100% (n = 42) of cases. The antecedents were dominated by recurrent malaria with 52.3% (n = 22) of cases, then recurrent anemia in 21% (n = 9), and 16.7% (n = 7) had sickle cell disease. Splenomegaly was found in 31 patients, or 73.6%. Ultrasound was performed in all patients. The indications for splenectomy were: isolated splenomegaly with risk of rupture (38%, n = 16), hypersplenism (26%, n = 11) and trauma to the spleen (19.04%, n = 8). Total splenectomy was performed in all cases. The surgical consequences were favorable in 85.7%, (n = 36) with morbidity of 14% (n = 6) and mortality of 9.52% (n = 4). The average length of hospitalization was 10.4 days with extremes of 1 and 22 days. Conclusion: Splenectomy constitutes a relatively common surgical procedure in our context. The indications for splenectomy were isolated splenomegaly with risk of rupture, hypersplenism and trauma to the spleen and total splenectomy was the rule.

Postoperative outcomes after open splenectomy versus laparoscopic splenectomy in cirrhotic patients:a meta-analysis

BACKGROUND： Laparoscopic splenectomy is considered the gold standard for resecting normal-to-moderately bigger spleens in benign conditions, and in addition could be tried for patients with malignant splenic disorders. However, the safety of laparoscopic splenectomy in patients with hyper- splenism is not well-known. This study aimed to investigate the efficacy and safety of laparoscopic splenectomy for pa- tients with hypersplenism secondary to liver cirrhosis by com- paring with the open splenectomy.

Laparoscopic splenectomy:Current concepts

Since early 1990's,when it was inaugurally introduced,laparoscopic splenectomy has been performed with excellent results in terms of intraoperative and postoperative complications.Nowadays laparoscopic splenectomy is the approach of choice for both benign and malignant diseases of the spleen.However some contraindications still apply.The evolution of the technology has allowed though,cases which were considered to be absolute contraindications for performing a minimal invasive procedure to be treated with modified laparoscopic approaches.Moreover,the introduction of advanced laparoscopic tools for ligation resulted in less intraoperative complications.Today,laparoscopic splenectomy is considered safe,with better outcomes in comparison to open splenectomy,and the increased experience of surgeons allows operative times comparable to those of an open splenectomy.In this review we discuss the indications and the contraindications of laparoscopic splenectomy.Moreover we analyze the standard and modified surgical approaches,and we evaluate the short-term and long-term outcomes.

Transumbilical single-incision endoscopic splenectomy:Report of ten cases

AIM: To investigate the feasibility and clinical application of transumbilical single-incision endoscopic splenectomy using conventional laparoscopic instruments.

Clinical efficacy of total laparoscopic splenectomy for portal hypertension and its influence on hepatic hemodynamics and liver function

BACKGROUND The liver hemodynamic changes caused by portal hypertension(PH)are closely related to various complications such as gastroesophageal varices and portosystemic shunts,which may lead to adverse clinical outcomes in these patients,so it is of great clinical significance to find treatment strategies with favorable clinical efficacy and low risk of complications.AIM To study the clinical efficacy of total laparoscopic splenectomy(TLS)for PH and its influence on hepatic hemodynamics and liver function.METHODS Among the 199 PH patients selected from October 2016 to October 2020,100 patients[observation group(OG)]were treated with TLS,while the remaining 99[reference group(RG)]were treated with open splenectomy(OS).We observed and compared the clinical efficacy,operation indexes[operative time(OT)and intraoperative bleeding volume],safety(intraperitoneal hemorrhage,ascitic fluid infection,eating disorders,liver insufficiency,and perioperative death),hepatic hemodynamics(diameter,velocity,and flow volume of the portal vein system),and liver function[serum alanine aminotransferase(ALT),serum aspartate aminotransferase(AST),and serum total bilirubin(TBil)]of the two groups.RESULTS The OT was significantly longer and intraoperative bleeding volume was significantly lesser in the OG than in the RG.Additionally,the overall response rate,postoperative complications rate,and liver function indexes(ALT,AST,and TBil)did not differ significantly between the OG and RG.The hepatic hemodynamics statistics showed that the pre-and postoperative blood vessel diameters in the two cohorts did not differ statistically.Although the postoperative blood velocity and flow volume reduced significantly when compared with the preoperative values,there were no significant inter-group differences.CONCLUSION TLS contributes to comparable clinical efficacy,safety,hepatic hemodynamics,and liver function as those of OS in treating PH,with a longer OT but lesser intraoperative blood loss.

Preoperative predictors of portal vein thrombosis after splenectomy with periesophagogastric devascularization

AIM:To evaluate the predictive value of preoperative predictors for portal vein thrombosis(PVT)after splenectomy with periesophagogastric devascularization.METHODS:In this prospective study,69 continuous patients with portal hypertension caused by hepatitis B cirrhosis underwent splenectomy with periesophagogastric devascularization in West China Hospital of Sichuan University from January 2007 to August 2010.The portal vein flow velocity and the diameter of portal vein were measured by Doppler sonography.The hepatic congestion index and the ratio of velocity and diameter were calculated before operation.The prothrombin time(PT)and platelet(PLT)levels were measured before and after operation.The patients'spleens were weighed postoperatively.RESULTS:The diameter of portal vein was negatively correlated with the portal vein flow velocity(P<0.05).Thirty-three cases(47.83%)suffered from postoperative PVT.There was no statistically significant difference in the Child-Pugh score,the spleen weights,the PT,or PLT levels between patients with PVT and without PVT.Receiver operating characteristic curves showed four variables(portal vein flow velocity,the ratio of velocity and diameter,hepatic congestion index and diameter of portal vein)could be used as preoperative predictors of postoperative portal vein thrombosis.The respective values of the area under the curve were 0.865,0.893,0.884 and 0.742,and the respective cut-off values(24.45 cm/s,19.4333/s,0.1138 cm/s-1 and 13.5 mm) were of diagnostically efficient,generating sensitivity values of 87.9%,93.9%,87.9%and 81.8%,respectively,specificities of 75%,77.8%,86.1%and 63.9%,respectively.CONCLUSION:The ratio of velocity and diameter was the most accurate preoperative predictor of portal vein thrombosis after splenectomy with periesophagogastric devascularization in hepatitis B cirrhosis-related portal hypertension.

Effectiveness and safety of splenectomy for gastric carcinoma:A meta-analysis

AIM： To evaluate the impact of splenectomy on longterm survival, postoperative morbidity and mortality of patients with gastric cancer by performing a metaanalysis METHODS： A search of electronic databases to identify randomized controlled trials in The Cochrane Library trials register, Mediine, CBMdisc （Chinese Biomedical Database） and J-STAGE, etc was performed. Data was extracted from the studies by 2 independent reviewers. Outcome measures were survival, postoperative morbidity and mortality and operation-related events. The meta-analyses were performed by RevMan 4.3. RESULTS： Three studies comprising 466 patients were available for analysis, with 231 patients treated by gastrectomy plus splenectomy. Splenectomy could not increase the 5-year overall survival rate [RR = 1.17, 95% confidence interval （CI） 0.97-1.41]. The postoperative morbidity （RR = 1.76, 95% CI 0.82-3.80） or mortality （RR = 1.58, 95% CI 0.45-5.50） did not suggest any significant differences between the 2 groups. No significant differences were noted in terms of number of harvested lymph nodes, operation time, length of hospital stay and reoperation rate. Subgroup analyses showed splenectomy did not increase the survival rate for proximal and whole gastric cancer. No obvious differences were observed between the 2 groups when stratified by stage. Sensitivity analyses indicated no significant differences regarding the survival rates （P 〉 0.05）. CONCLUSION： Splenectomy did not show a beneficial effect on survival rates compared to splenic preservation. Routinely performing splenectomy should not be recommended.

A case of successful management with splenectomy of intractable ascites due to congenital dyserythropoietic anemia type II-induced cirrhosis

The congenital dyserythropoietic anemias comprise a group of rare hereditary disorders of erythropoiesis, characterized by ineffective erythropoiesis as the predominant mechanism of anemia and by characteristic morphological aberrations of the majority of erythroblasts in the bone marrow. Congenital dyserythropoietic anemia type II is the most frequent type. All types of congenital dyserythropoietic anemias distinctly share a high incidence of iron loading. Iron accumulation occurs even in untransfused patients and can result in heart failure and liver cirrhosis. We have reported about a patient who presented with liver cirrhosis and intractable ascites caused by congenital dyserythropoietic anemia type II. Her clinical course was further complicated by the development of autoimmune hemolytic anemia. Splenectomy was eventually performed which achieved complete resolution of ascites, increase of hemoglobin concentration and abrogation of transfusion requirements.

Anticoagulation therapy prevents portal-splenic vein thrombosis after splenectomy with gastroesophageal devascularization

AIM:To compare the incidence of early portal or splenic vein thrombosis(PSVT) in patients treated with irregular and regular anticoagulantion after splenectomy with gastroesophageal devascularization.METHODS:We retrospectively analyzed 301 patients who underwent splenectomy with gastroesophageal devascularization for portal hypertension due to cirrhosis between April 2004 and July 2010.Patients were categorized into group A with irregular anticoagulation and group B with regular anticoagulation,respectively.Group A(153 patients) received anticoagulant monotherapy for an undesignated time period or with aspirin or warfarin without low-molecular-weight heparin(LMWH) irregularly.Group B(148 patients) received subcutaneous injection of LMWH routinely within the first 5 d after surgery,followed by oral warfarin and aspirin for one month regularly.The target prothrombin time/international normalized ratio(PT/INR) was 1.25-1.50.Platelet and PT/INR were monitored.Color Doppler imaging was performed to monitor PSVT as well as the effectiveness of thrombolytic therapy.RESULTS:The patients' data were collected and analyzed retrospectively.Among the patients,94 developed early postoperative mural PSVT,including 63 patients in group A(63/153,41.17%) and 31 patients in group B(31/148,20.94%).There were 50(32.67%) patients in group A and 27(18.24%) in group B with mural PSVT in the main trunk of portal vein.After the administration of thrombolytic,anticoagulant and antiaggregation therapy,complete or partial thrombus dissolution achieved in 50(79.37%) in group A and 26(83.87%) in group B.CONCLUSION:Regular anticoagulation therapy can reduce the incidence of PSVT in patients who undergo splenectomy with gastroesophageal devascularization,and regular anticoagulant therapy is safer and more effective than irregular anticoagulant therapy.Early and timely thrombolytic therapy is imperative and feasible for the prevention of PSVT.

Changes of immune function in patients with liver cirrhosis after splenectomy combined with resection of hepatocellular carcinoma

OBJECTIVE: To study the changes of immune function in liver cirrhosis patients after splenectomy combined with resection of hepatocellular carcinoma (HCC). METHODS: Sixteen patients with HCC associated with liver cirrhosis were divided into two groups: splenectomy combined with hepatectomy (splenectomy group n=7) and hepatectomy (non-splenectomy group, n=9). T lymphocyte subsets such as CD4, CD8, CD4/CD8 and Th lymphocyte cytokines such as interferon γ (IFN-γ), IL-2, IL-10 in 7 ml peripheral venous blood before operation and 2 months after operation were examined and compared between the two groups. RESULTS: There was no significant difference in pre-operative CD4, CD8, CD4/CD8, IL-2, IFN-γ, IL-10 levels in the two groups. Two months after operation, the levels of CD4 (38.2%±3.7%), CD4/CD8 (1.7±0.3), IFN-γ (104.4±14.9 pg/ml), 1L-2 (98.6±18.6 pg/ml) were increased and those of CD8 (23.7±3.7 pg/ml), IL-10 (55.5±11.2 pg/ml) levels were decreased in the splenectomy group. The levels of CD4 (32.5%±4.0%), CD4/CD8 (1.1±0.1), IFN-γ(70.5±12.6 pg/ml), IL-2(80.9±13.5 pg/ml) in the non-splenectomy group were much lower than those in the splenectomy group, but the levels of CD8 (29.4%±4.0%), IL-10 (89.4±10.0 pg/ml) in the non-splenectomy group were significantly higher than those in the splenectomy group (P<0.05). CONCLUSIONS: Splenectomy combined with hepatectomy for HCC patients associated with liver cirrhosis does not decrease but promote the recovery of T lymphocyte subsets and Th1/Th2 cytokines from imbalance and improve anti-tumor immune function of the patients.

Laparoscopic splenectomy for hypersplenism secondary to liver cirrhosis and portal hypertension

Since the first laparoscopic splenectomy(LS)was reported in 1991,LS has become the gold standard for the removal of normal to moderately enlarged spleens in benign conditions.Compared with open splenectomy,fewer postsurgical complications and better postoperative recovery have been observed,but LS is contraindicated for hypersplenism secondary to liver cirrhosis in many institutions owing to technical difficulties associated with splenomegaly,well-developed collateral circulation,and increased risk of bleeding.With the improvements of laparoscopic technique,the concept is changing.This article aims to give an overview of the latest development in laparoscopic splenectomy for hypersplenism secondary to liver cirrhosis and portal hypertension.Despite a lack of randomized controlled trial,the publications obtained have shown that with meticulous surgical techniques and advanced instruments,LS is a technically feasible,safe,and effective procedure for hypersplenism secondary to cirrhosis and portal hypertension and contributes to decreased blood loss,shorter hospital stay,and less impairment of liver function.It is recommended that the dilated short gastric vessels and other enlarged collateral circulation surrounding the spleen be divided with the LigaSure vessel sealing equipment,and the splenic artery and vein be transected en bloc with the application of the endovascular stapler.To support the clinical evidence,further randomized controlled trials about this topic are necessary.

Prognosis of metastatic splenic hilum lymph node in patients with gastric cancer after total gastrectomy and splenectomy

AIM:To clarify the significance of combined resection of the spleen to dissect the No.10 lymph node(LN). METHODS:We studied 191 patients who had undergone total gastrectomy with splenectomy,excluding non-curative cases,resection of multiple gastric cancer, and those with remnant stomach cancer.Various clinico-pathological factors were evaluated for any independent contributions to No.10 LN metastasis,usingχ 2 test. Significant factors were extracted for further analysis, carried out using a logistic regression method.Furthermore,lymph node metastasis was evaluated for any independent contribution to No.10 LN metastasis,using the same methods.The cumulative survival rate was calculated using the Kaplan-Meier method.The significance of any difference between the survival curves was determined using the Cox-Mantel test,and any difference was considered significant at the 5%level. RESULTS:From the variables considered to be potentially associated with No.10 LN metastasis,age, depth,invasion of lymph vessel,N factor,the numberof lymph node metastasis,Stage,the number of sites, and location were found to differ significantly between those with metastasis(the Positive Group)and those without(the Negative Group).A logistic regression analysis showed that the localization and Stage were significant parameters for No.10 LN metastasis.There was no case located on the lesser curvature in the Posi-tive Group.The numbers of No.2,No.3,No.4sa,No. 4sb,No.4d,No.7,and No.11 LN metastasis were each found to differ significantly between the Positive Group and the Negative Group.A logistic regression analysis showed that No.4sa,No.4sb,and No.11 LN metastasis were each a significant parameter for No.10 LN metastasis.There was no significant difference in survival curves between the Positive Group and the Negative Group. CONCLUSION:Splenectomy should be performed to dissect No.10 LN for cases which have No.4sa,No. 4sb or No.11 LN metastasis.However,in cases where the tumor is located on the lesser curvature,splenectomy can be omitted.

Modified laparoscopic splenectomy and azygoportal disconnection combined with cell salvage is feasible and might reduce the need for blood transfusion

AIM: To investigate perioperative outcomes in patients undergoing modified laparoscopic splenectomy and azygoportal disconnection (MLSD) with intraoperative autologous cell salvage.

Laparoscopic Partial Splenectomy for Giant Hemangioma Misdiagnosed as Splenic Cyst:a Case Report

ALTHOUGH unusual, hemangioma is the most common type of primary splenic neoplasm.1 Usually, splenic hemangioma appears as solid mass, but sometimes it presents cystic corn-ponent as well, which is difficult to discriminate from some other lesions, such as abscess, simple cyst, parasitic cyst, and lymphangioma.2 Preoperative diagnosis of splenic hemangioma mainly depends on imaging study （e.g. ultrasonography, CT, MRI）.

Synchronous splenectomy and hepatectomy for patients with hepatocellular carcinoma and hypersplenism:A casecontrol study

AIM:To investigate whether the use of synchronoushepatectomy and splenectomy(HS)is more effective than hepatectomy alone(HA)for patients with hepatocellular carcinoma(HCC)and hypersplenism.METHODS:From January 2007 to March 2013,84consecutive patients with HCC and hypersplenism who underwent synchronous hepatectomy and splenectomy in our center were compared with 84 well-matched patients from a pool of 268 patients who underwent hepatectomy alone.The short-term and longterm outcomes of the two groups were analyzed and compared.RESULTS:The mean time to recurrence was 21.11±12.04 mo in the HS group and 11.23±8.73 mo in the HA group,and these values were significantly different(P=0.001).The 1-,3-,5-,and 7-year disease-free survival rates for the patients in the HS group and the HA group were 86.7%,70.9%,52.7%,and 45.9%and 88.1%,59.4%,43.3%,and 39.5%,respectively(P=0.008).Platelet and white blood cell counts in the HS group were significantly increased compared with the HA group one day,one week,one month and one year postoperatively(P<0.001).Splenectomy and micro-vascular invasion were significant independent prognostic factors for disease-free survival.Gender,tumor number,and recurrence were independent prognostic factors for overall survival.CONCLUSION:Synchronous hepatectomy and hepatectomy potentially improves disease-free survival rates and alleviates hypersplenism without increasing the surgical risks for patients with HCC and hypersplenism.

Perioperative advantages of modified laparoscopic vs open splenectomy and azygoportal disconnection

AIM: To investigate perioperative outcomes in patients undergoing modified laparoscopic splenectomy or open splenectomy and azygoportal disconnection for portal hypertension.

Transjugular intrahepatic portosystemic shunt versus open splenectomy and esophagogastric devascularization for portal hypertension with recurrent variceal bleeding

BACKGROUND： Transjugular intrahepatic portosystemic shunt（TIPS） and open splenectomy and esophagogastric devascularization（OSED） are widely used to treat patients with portal hypertension and recurrent variceal bleeding（PHRVB）. This study aimed to compare the effectiveness between TIPS and OSED for the treatment of PHRVB.METHODS： The data were retrospectively retrieved from 479 cirrhotic patients（Child-Pugh A or B class） with PHRVB, who had undergone TIPS（TIPS group） or OSED（OSED group） between January 1, 2010 and October 31, 2014.RESULTS： A total of 196 patients received TIPS, whereas 283 underwent OSED. Within one month after TIPS and OSED, the rebleeding rates were 6.1% and 3.2%, respectively（P=0.122）. Significantly lower incidence of pleural effusion,splenic vein thrombosis, and pulmonary infection, as well as higher hepatic encephalopathy rate, shorter postoperative length of hospital stay, and higher hospital costs were observed in the TIPS group than those in the OSED group. During the follow-up periods（29 months）, significantly higher incidences of rebleeding（15.3% vs 4.6%, P=0.001） and hepatic encephalopathy（17.3% vs 3.9%, P=0.001） were observed in the TIPS group than in the OSED group. The incidence of instent stenosis was 18.9%. The survival rates were 91.3% in the TIPS group and 95.1% in the OSED group. The long-term liver function did not worsen after either TIPS or OSED.CONCLUSION： For the patients with liver function in the Child-Pugh A or B class, TIPS is not superior over OSED in terms of PHRVB treatment and rebleeding prevention.