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.

Splenic lymphangioma masquerading as splenic abscess managed by laparoscopic splenectomy: A case report

BACKGROUND Primary benign splenic tumours are unique and account for<0.007%of all tumours identified during surgery and autopsy.Splenic lymphangiomas are rarely seen in adults.Splenic lymphangiomas may be asymptomatic,or may present with upper left abdominal pain,splenomegaly,hypersplenism,or splenic rupture with haemorrhagic shock.The clinical and radiological features of these lesions are not specific.This case report serves to remind the clinician to consider the rare but important differential diagnosis of splenic lymphangioma while treating splenic lesions.CASE SUMMARY We report a case of splenic lymphangioma in a 22-year-old woman who presented with left upper quadrant abdominal pain for three months.Initial investigations were unremarkable;however,computed tomography later revealed multiple splenic micro-abscesses.The patient underwent laparoscopic splenectomy,and histopathological examination revealed splenic lymphangioma.The patient was discharged on postoperative day three.One month after surgery,the abdominal pain resolved completely,with no new complaints.Splenic lymphangiomas present clinically as splenomegaly or left upper quadrant abdominal pain;prompt intervention is necessary for avoiding complications.CONCLUSION This case report concludes that splenic lymphangiomas should be considered in the differential diagnosis of splenomegaly or left upper quadrant pain,even in adults,because they are amenable to curative treatment.Delays in surgical intervention may lead to severe complications,such as infection,rupture,and hemorrhage.Such lesions can be safely managed with laparoscopy,involving less postoperative pain and early patient discharge with excellent cosmetic outcomes.

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.

Reaching proficiency in laparoscopic splenectomy

AIM:To investigate the proficiency level reached in laparoscopic splenectomy using the learning curve method.METHODS:All patients in need of splenectomy for benign causes in whom laparoscopic splenectomy was attempted by a single surgeon during a time period of 6 years were included in the study (n=33). Besides demographics, operation-related variables and the response to surgery were recorded. The patients were allocated to groups of five, ranked according to the date of the operation. Operation duration, complications, postoperative length of stay, conversion to laparotomy and splenic weight were then compared between these groups.RESULTS: There was a significant difference regarding operation times between the groups (P = 0.001). An improvement was observed after the first 5 cases. The learning curve was flat up to the 25th case. Following the 25th case the operation times decreased still further. There was no difference between the groups regarding the other parameters.CONCLUSION: Unlike the widely accepted "L" shape, the learning curve for laparoscopic splenectomy is a horizontal lazy "S" with two distinct slopes. Privileges may be granted after the first 5 cases. However proficiency seems to require 25 cases.

Laparoscopic splenectomy for immune thrombocytopenic purpura at a teaching institution

Background High anatomic location, fragility, and generous blood supply of the spleen makes laparoscopic splenectomy （LS） difficult to master, and few patients need splenectomy for benign disorders. The aim of this research was to assess operative outcomes and hematological results of a large series of patients treated with LS for chronic immune thrombocytopenic purpura （ITP） and to determine which clinical variables predict favorable hematological outcome.Methods LS was successfully performed for 154 patients with chronic ITP from September 1999 to April 2009 at the First Affiliated Hospital of Sun Yat-sen University. Operative outcomes were assessed retrospectively. Long-term follow-up data were obtained from outpatient medical records and phone interviews. Clinical and laboratory variables （including gender, age, disease duration before surgery, previous response to steroids, preoperative platelet count, and postoperative peak platelet count） were evaluated by univariate analysis to identify potential predictors of hematological outcome. Multivariate Logistic regression model was used to determine independent predictors of hematological outcome.Results One patient died from subphrenic abscess and postoperative sepsis. The overall major morbidity rate was 8.4%. None of the patients required a second surgery for complications. Of the 127 patients available for a mean follow-up of 43.6 months （range 9-114 months）, the overall initial response （i.e., at two months after LS） and long-term response to LS were achieved in 89.0% and 80.3%, respectively. Five patients （3.9%） developed pneumonia 3-35 months after LS. Univariate analysis showed a significant difference in mean age between responders （29.1 years） and nonresponders （38.8 years; P ＜0.05）. Patients who responded to steroid therapy had better hematological outcome than those who did not respond （P ＜0.05）. Compared to nonresponders, responders to LS had a significantly higher postoperative peak platelet count （404x109/L versus 213×109/L, P ＜0.001）. Multivariate Logistic regression analysis identified postoperative peak platelet count as the only independent predictor of favorable response to LS （P＜0.001）.Conclusiona LS is a safe and effective treatment for chronic ITP. Postoperative peak platelet count may serve as a major predictor of long-term response.

Laparoscopic versus Traditional Open Splenectomy for Hepatocellular Carcinoma with Hypersplenism

This study aimed to examine the efficacy of the laparoscopic vs. traditional open splenectomy for hepatocellular carcinoma（HCC） with hypersplenism. Between 2002 and 2013, 51 Chinese HCC patients with hypersplenism underwent either simultaneous laparoscopic splenectomy plus anticancer therapies（Lap-S＆A）（n=25） or traditional open splenectomy plus anti-cancer therapies（TOS＆A）（n=26）. The outcomes were reviewed during and after the operation. Anti-cancer therapies for HCC included laparoscopic hepatectomy（LH） and laparoscopic microwave ablation（LMA）. The results showed that there was no significant difference in the operating time between the two groups, but the blood loss and blood transfusion were less, pain intensity after surgery was weaker, the time to first bowel movement, time to the first flatus and postoperative hospital stay were shorter, and the postoperative complication rate and the readmission rate were lower in the Lap-S＆A group than in the TO-S＆A group. Two patients in the Lap-S＆A group and one patient in the TO-S＆A group died 30 days after surgery. However, no significant difference in the mortality rate was noted between the two groups. It was concluded that simultaneous Lap-S＆A holds the advantages of more extensive indications, lower complication incidence and less operative expenditure than conventional open approach and it is a feasible and safe approach for HCC with hypersplenism.

The learning curve for laparoscopic splenectomy for massive splenomegaly： a single surgeon＇s experience

Background Laparoscopic splenectomy （LS） for massive splenomegaly is more technically challenging than for a normal-sized spleen. The purpose of this study was to determine the effect of operative experience on perioperative outcomes of LS for massive splenomegaly. Methods Between January 2008 and December 2010, 36 consecutive patients who were diagnosed with massive splenomegaly underwent LS in our department. The perioperative outcomes were evaluated for evidence of a learning curve effect. Patients were divided into three groups （1, 2, and 3） of 12 consecutive patients, and outcomes of each group were compared. Results The mean operative time decreased significantly from 252 minutes of Group 1 to 179 minutes of Group 3. The estimated blood loss and length of post-operative hospital stay showed a similar trend. No significant differences were found in the splenic length and weight, transfusion rate, or average amount of drainage. In this cohort, there were three cases with surgical complications and one conversion to open laparotomy. Conclusions The first 24 cases constitute the early stage of the learning curve for LS for massive splenomegaly. LS for massive splenomegaly is a technically challenging operation with a long learning curve, and strategies for developing training programs must address these challenges.

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）.

Consecutive laparoscopic gallbladder and spleen resections in cirrhotic patients

AIM:To evaluate the feasibility,safety,and effectiveness of consecutive laparoscopic cholecystectomy(LC)plus splenectomy(LS)in liver cirrhosis patients.METHODS:From 2003 to 2013,17(group 1)patients with liver cirrhosis complicated by hypersplenism and symptomatic gallstones were treated with combined LC and LS,while 58(group 2)patients with liver cirrhosis and hypersplenism received LS alone.An additional 14(group 3)patients who received traditional open procedures during the same period were included as controls.Data were retrospectively collected and reviewed in regard to demographic characteristics and preoperative,intraoperative and postoperative features.Differences between the three groups were assessed by statistical analysis.RESULTS:The three groups showed no significant differences in the demographic characteristics or preoperative status.However,the patients treated with LC and LS required significantly longer operative time,shorter postoperative stay as well as shorter time of return to the first oral intake,and suffered less intraoperative blood loss as well as fewer postoperative surgical infections than the patients treated with traditional open procedures(group 1 vs group 3,P<0.05 for all).The patients treated with LC and LS showed no significant differences in the intraoperative and postoperative variables from those treated with LS alone(group 1 vs group 2).All patients showed significant improvements in the haematological responses(preoperative period vs postoperative period,P<0.05 for all).None of the patients treated with LC and LS presented with any gallstone-associated symptoms following discharge,while the patients treated with the traditional open procedures expressed complaints of discomfort related to their surgical incisions.CONCLUSION:Consecutive LC and LS is an appropriate treatment option for liver cirrhosis patients with gallstones and hypersplenism,especially for those with Child-Pugh A and B.

Laparoscopic distal pancreatectomy: Up-to-date and literature review

Pancreatic surgery represents one of the most challenging areas in digestive surgery. In recent years, an increasing number of laparoscopic pancreatic procedures have been performed and laparoscopic distal pancreatectomy (LDP) has gained world-wide acceptance because it does not require anastomosis or other reconstruction. To date, English literature reports more than 300 papers focusing on LDP, but only 6% included more than 30 patients. Literature review confirms that LDP is a feasible and safe procedure in patients with benign or low grade malignancies. Decreased blood loss and morbidity, early recovery and shorter hospital stay may be the main advantages. Several concerns still exist for laparoscopic pancreatic adenocarcinoma excision. The individual surgeon determines the technical conduction of LDP, with or without spleen preservation; currently robotic pancreatic surgery has gained diffu- sion. Additional researches are necessary to determine the best technique to improve the procedure results.

Laparoscopic Partial Splenectomy for Splenic Hemangioma： Experience of a Single Center in Six Cases

INTRODUCTION Despite a higher incidence of postoperative complications, splenectomy is a commonly performed procedure for splenic space-occupying lesions. A retrospective analysis of 2796 splenectomy patients showed that 119 patients （4.25%） had postoperative bacterial infections,

Successful treatment of floating splenic volvulus:Two case reports and a literature review

BACKGROUND The floating spleen refers to the spleen moving away from the normal anatomical position to other parts of the abdominal cavity.CASE SUMMARY In this report,we describe two cases of torsion of floating spleen,which were successfully treated by laparoscopic partial splenectomy and retroperitoneal fixation of the residual spleen.The clinical characteristics of previously reported cases are also discussed.CONCLUSION In conclusion,laparoscopic partial resection of splenic volvulus infarction and extraperitoneal fixation of residual spleen are safe and reliable.