Laparoscopic splenectomy for Immune thrombocytopenic purpura (ITP)

Laparoscopic splenectomy for Immune thrombocytopenic purpura (ITP)

Ahmed H.Ali, FRCS; Ahmed Nafei,MD; Tarek Youssef Ahmed,MD, MRCS Department of Surgery, Ain Shams University, Cairo, Egypt.

Background: In recent years laparoscopic  splenectomy (LS) has gained acceptance  as a viable alternative to open splenectomy. Laparoscopic splenectomy is evolving and may become the standard operative method for the treatment of the problem spleen.

Patients and methods: From July 2012 till December 2013, 20 patients with clinical immune thrombocytopenic purpura (ITP) were referred as surgical candidates. Two ofthem (10%) were converted to open, and the other 18 underwent successful LS. The operative approach was performed with the patient in the right lateral decubitus position, with extensive use of the ultrasonic dissecting shears.

Results:  There were 20 patients in the study, twelve women and eight men with a mean age of28 years (18-38). Immune thrombocytopenic  purpura (ITP) was the indication for surgery. Laparoscopic splenectomy was intended in all patients and successfully completed in 18 patients (90%). Two cases (10%) required conversion to open splenectomy, due to intraoperative hemorrhage  which could not be controlled laparoscopically.   Length  of hospital stay (LOS) was 2.3 ± 0.8 days. The two major complications (10%) were intraoperative hemorrhage which required conversion to open splenectomy The two minor complications were trocar site infection and hernia. The average operative times (150 ± 48 min) improved as the study progressed. This improvement was believed to be due to the learning curve.

Conclusion: Laparoscopic  splenectomy (LS)  may be considered  the standard of care for patients who require splenectomy  for ITP  Laparoscopic  splenectomy  results in less  patient disability, shorter hospitalization, and probably less perioperative morbidity

Key words: Spleen, splenectomy, laparoscopy, ITP, thrombocytopenic purpura.

Introduction:

Laparoscopic splenectomy was first successfully performed and published by Delaitre   and   Maignien   in   199I.l  Since then, laparoscopic splenectomy has become acceptedassafeandeffectiveforbenignsplenic disorders such as immune thrombocytopenic purpura  (ITP).2  Laparoscopic   splenectomy is a safe procedure and can provide less postoperative     morbidity     in    experienced hand  as  open splenectomy,  and  most  cases that require splenectomy can be treated laparosopically.   Laparoscopic   splenectomy is a useful method for reducing hospital stay, complications and early return to normal activity. With bettertraininginminimal access surgery now available,  the time  has arrived for  it to take  its  place  in modem  surgery.3

Several studies from centers dedicated to laparoscopy have shown the well-known advantages  of  minimally   invasive  surgery, e.g., decreased postoperative pain, shorter hospital  stay,  and  reduced  recovery  time.4

A recently  published meta-analysis  revealed a significantly  lower complication  rate after laparoscopic     versus      open      splenectomy in         particular;                     pulmonary        complications, wound   infections,  and  systemic  infectious complications were decreased.5 Laparoscopic splenectomy  (LS) rapidly gained widespread acceptance for the treatment of nontraumatic diseases  of  the  spleen  during  the  last  10 years. Increased technical skills and technical developments  have extended the indications for the laparoscopic  removal of the spleen.6

Hematologic   diseases   such   as   idiopathic thrombocytopenic   purpura            (ITP)     and thrombotic thrombocytopenic  purpura (TIP) with  normal  or  only  moderately   enlarged spleens are still the most common indications for  a laparoscopic  splenectomy.7  Massively enlarged spleens are often difficult to handle intraoperatively,  and there  is concern  about higher conversion rates and higher morbidity also retrieving a large specimen may require a long incision so that the benefits of minimally invasive access of LS are wasted.8  However, the spleen can be morcellated  and removed in  a  bag,  with  minimal  risk  of spleen  cell spreading. Hence, patients with a bulky spleen revealing a long axis of more than 20 em are commonly   excluded   from   a  laparoscopic approach.9     Other   authors   advocate   open splenectomy  (OS)  in patients with a spleen larger than 1 kg or a splenic axis greater than 15 cm.lO

Patients and  methods:

Patients:  From  July  2012  till  December 2013, 20 patients with clinical ITP underwent laparoscopic splenectomy (LS) at Ain Shams University hospitals. The decision to perform splenectomy  was made by both the surgeon and       hematologist/oncologist.        Standard preoperative laboratory studies and other tests were obtained, including a type and screen or cross  match for blood  products.  Ultrasound examination  was obtained  preoperatively  to assess  spleen  size  (maximum  pole  length), measured  as  the  joining  line  between  the two  organ poles and was divided into three categories:  (a) normal  spleen  (<11  em), (b) moderate  splenomegaly  (11-20  em),  or (c) severe splenomegaly (>20 em). Laparoscopic splenectomy (LS) was performed for patients with  category  a and  b  while  patients  with severe  splenomegaly   were  excluded  from this  study. A radiologist  was  also  asked  to try to identify accessory spleens in all cases. Absolute  contraindications  for  laparoscopic splenectomy   in  this  series  included  portal hypertension,       severe       cardiopulmonary disease,         and   uncorrectable             coagulopathy. Operative  time,  platelet  count,  conversion rate and length of hospital stay were recorded

Operative techniques:

Preoperative preparation: All patients received polyvalent pneumococcal and Haemophilus  influenza type  b vaccines  two weeks before surgery. Perioperative antibiotic coverage  in the form  of a single  dose  of a third-generation cephalosporin was given routinely.

Surgical         technique         Figures (1-4):

Informed  consent for  surgery  was obtained with  the  understanding  that  conversion  to open splenectomy may occur. After induction of        general anesthesia        and         endotracheal intubation,  a nasogastric  or  orogastric  tube was   placed,   a  urinary   drainage   catheter was  inserted,   and  pneumatic  compression stockings       were     applied.                        The              operative approach      for    LS   was      performed             with the   patient   in  the  right   lateral   decubitus position, with extensive use of the ultrasonic dissecting shears, late division of the splenic hilum, and extraction  bag of the spleen at a subcostal trocar site. The left upper quadrant, splenocolic   ligament,   splenic   hilum,   and lesser           sac   were           routinely        explored      for accessory    spleens.  Ultrasonic   dissection of                 retrosplenic       peritoneal     attachments, splenophrenic  ligament, and the short gastric vessels allowed anteromedial mobilization of the spleen. Once elevated, the splenic hilum was divided by linear cutting stapler, and the organ was placed in the extraction bag, with emphasis on minimal parenchymal handling. The  specimen   was  mechanically   fracture­ morcellated  via  the  exteriorized  extraction bag. Care  was taken  not to spill  any tissue fragments.   After  adequate   hemostasis,  the fascia  and wounds  were closed.  The lateral position was clearlythe best. And most studies support  the  use  of  lateral  and  semilateral position.  The  spleen  was  located  deep  in the left hypochondrium  and a key maneuver for  splenectomy   was  the  mobilization   of the  organ.  Lateral  and  semilateral  position took  the  advantage  of gravity  and  avoided spleen   grasping   and   stretching.   The  full lateral approach with adequate fixation of the patient to the table allowed  exaggerating  of the lateral tilt of the table and better access to the posterior or anterior face of the spleen. A minor drawback of this position was in case of conversion to open and the need to change the position to supine but the advantages were outweighing these disadvantages.

Adequate   pain   relief   was   successfully achieved  with  local  anesthetics  injected around trocar sites, and with oral and intravenous analgesic agents. All patients tolerated clear oral liquid on the evening of surgery. The majority ofthe patients returned to unrestricted activity within a week. 

Statistics:

All  data  collected  were  analyzed  using SPSS 11. for Windows statistical software.

Results:

There were 20 patients in the study, twelve women and eight men with a mean age of 28 years (18-38). Immune thrombocytopenic purpura (ITP) was the indication for surgery Table (1).

The presence of purpura and/or petechial rash was the most common presentation, and recurrent episodes of ITP were the primary indication for surgery Table (2).

The majorities of patients responded to preoperative treatment and were able to attain platelet counts >25,000/mm3 at the time of surgery. LS were uniformly successful in inducing  clinical  remission   in  this  group. In two  patients  with  counts  that  remained<25,000/mm3 in spite of aggressive  medical treatment, the effectiveness of LS fell to 50%Table (3).

Laparoscopic  splenectomy  was  intended in all patients and successfully completed  in 18 patients (90%). Two cases (10%) required conversion to open splenectomy, due to intraoperative  hemorrhage  which  could  not be controlled laparoscopically. Length of hospital stay (LOS) was 2.3 ± 0.8 days. There were no deaths. The two major complications (10%) were intraoperative hemorrhage which required  conversion  to  open  splenectomy. The two minor complications were trocar site infection and hernia. The average operative times  (150  ± 48 min)  and  estimated  blood loss (175 ± 135) were improved as the study progressed.  This improvement  was believed to be due to the learning curve and to the use of the ultrasonic dissecting shears Table (4).

Discussion:

By   Deltaire   laparoscopic    splenectomy was first reported at the end of 1991. There are  now  quite   a  number   of  large  series from  around  the  world  which  confirm that the  laparoscopic  approach  to  splenectomy is the  treatment  of choice  for  the  majority of   patients.ll     Laparoscopic    splenectomy has become a definitive alternative to open surgery  for  removal  of  the  non  enlarged spleen and mild to moderate enlarged spleen. This  particularly  in ITP, the  most  frequent indication for splenectomy in a general hospital.l2 In this study ITP was the only indication for laparoscopic splenectomy. The precise size limit for attempting laparoscopic splenectomy is still under evaluation, but it would appear that spleens 28 to 30 em or greater  in longitudinal  dimension  and 3000 gm or more  in weight  are  best approached in open fashion  because  of the  low success rate with the laparoscopic approach.l3 This is comparable  with this study as LS was done to spleen size less than 20 em. Another study showed that most patients with moderately enlarged  spleens (15-20 em  in longitudinal dimension or <1000 gin weight) can usually be resected laparoscopically.ll  Considerable expenence  should be developed with laparoscopic splenectomy in non enlarged spleens   before   attempting   this   procedure in  patients   with   marked   splenomegaly.l4

Splenectomy is indicated in adult patient who failed  steroid therapy.  In this  study  patients with preoperative platelet count >25,000 showed remission rate (100%)16/16 while patients   with   preoperative   platelet   count <25,000  showed  remission  rate  (50%)  2/4which  is  comparable  to  ronald  and  Alfons study which showed permanent improvement of platelet count in about 80% ofpatients.l5

Lee and Kim, 1997 performed  a total  of 53 laparoscopic splenectomeis.  Among them 40 patients had immune thrombocytopenic purpura 35 were females and 5 patients were males. The mean age was 34, varying from 17 to 56. The mean hospital stay was 5 days. There was no perioperative mortality; but in 2 cases they had postoperative subpherenic abscesses which were successfully  drained by catheter drainage.      Since   undergoing       laparoscopic splenectomy, 28 patients (70%) were weaned effectively  from their steroid medications.  8 patients (20%) have been on small doses of steroid,  and 4 patients  (10%)  have been on the same doses of steroid with no response. The  patient  group  with  rapidly  increasing platelet   count   after   splenectomy   showed a  statistically   significant  relation  with  the complete response group. Their opinion were that  laparoscopic  splenectomy  is a safe and reasonable  operative  procedure  for  patients with  immune  thrombocytopenic   purpura.l6

In this study the average  age was 28 (range 18-38),  length  of  hospital  stay  (LOS)  was 2.3 ± 0.8 days. The two major complications (10%) were intraoperative hemorrhage which required  conversion  to  open  splenectomy. The two minor complications were trocar site infection and hernia.

Lefor  et  al.,  1993  reviewed  their  initial experience   with  laparoscopic   splenectomy in patients with hematologic diseases. They found that laparoscopic splenectomy was attempted in 43 patients and successfully completed  in 35 (81%).  Therapeutic platelet response  to  splenectomy  occurred  in  82% of patients with immune thrombocytopenic purpura undergoing successful laparoscopic splenectomy. The morbidity rate was 11.6% (5 of  43 patients).  Mean length of stay was 2.7   days   after   laparoscopic   splenectomy. Their opmwn were that laparoscopic splenectomy may be performed with efficacy and morbidity rates comparable to those of open splenectomy for hematologic diseases, and it appears to retain other patient benefits of laparoscopic surgery.l7

Katkhouda, et al., 1998 studied the safety and  efficacy  of  laparoscopic   splenectomy (LS)  in patients  with predominantly  benign hematologic  disorders  in one hundred  three consecutive   patients   who   underwent   LS. They found  that indications  were idiopathic thrombocytopenic  purpura  (ITP),  hereditary spherocytosis,    autoimmune    hemolytic anemia, and thrombotic thrombocytopenic purpura.   Mean   spleen   size   was   14  em and  mean  weight  was  263  g.  There  were no deaths. Complications occurred in six patients,  one  requiring  a  second  procedure for small bowel obstruction. Six patients received  transfusions,  and  four  procedures were converted to open splenectomy for bleeding. Meansurgicaltimewas 161 minutes and was greater in the first 10 cases than the last.lO Mean postsurgical  stay was 2.5 days. Thrombocytopenia resolved  after surgery in 84% of patients with ITP, and hematocrit levels increased  significantly  in  70%  of  patients with  chronic  hemolytic  anemias. A positive response was noted in 92% of patients with hereditary spherocytosis,  without relapse for the duration of the observation. ITP relapsed in   four   patients   during   follow-up,   three within  12 months.  Their opinions  were that LS can be performed  safely  and effectively in a teaching  institution.  LS should become the  technique   of  choice  for  treatment   of intractable  benign  hematologic  disease.l8  In this   study   laparoscopic   splenectomy   (LS) was  performed   for   patients   with   splenic s1ze  <11   em.   Laparoscopic   splenectomy was  successfully  completed  in  18  patients (90%). Two cases (10%) required conversion to  open  splenectomy,  due to  intraoperative hemorrhage  which  could  not  be  controlled laparoscopically.   Length   of   hospital   stay (LOS)   was    2.3   ± 0.8   days.   A   positive response  was  noted  in  16/16  patients  with platelet counts  >25,000/mm3  at the time  of surgery and LS was uniformly successful  in inducing  clinical remission.  In two  patients with  counts  that  remained  <25,000/mm3  in spite  of  aggressive  medical  treatment,  the effectiveness  of LS fell to 50%. There were no   deaths.  The  two   major   complications (10%) were intraoperative hemorrhage which required  conversion  to  open  splenectomy. The two minor complications were trocar site infection  and hernia.  The average  operative times  (150 ± 48 min) were improved as the study   progressed.   This   improvement   was believed to be due to the learning curve and to the use of the ultrasonic dissecting shears.

Figure (1): Division of the short gastric vessels with hannonic  scalpel.

Figure (2): Division of splenic hilum by linear cutting stapler.

Figure (3): Division of splenic hilum by linear cutting stapler.

Figure (4): Spleen in retrieval bag.

Table 1: Patient demographics.

Misawa et al., 2009 studied and evaluated the outcome of patients undergoing laparoscopic splenectomy (LS) on 52 patients undergoing LS compared to 28 concunently treated  open  splenectomy  patients  (OS). These  patients did not differ  with regard  to age, gender, body, or splenic weights. The operative time was longer in the LS patients

Table 2: Indications for surgery.

Table 3: Surgical results related to platelet count.

Table 4: Surgical results and complications.

 (mean 196 vs. 156 min), but the length of stay were shorter in the LS group. Six patients required   conversion to  OS,  four   occurring in the  first  11 patients  treated  (overall conversion rate of 11%).  Three  patients  died from complications related to their underlying disease.l9 In this study the average  operative time  was (150  ± 48 min).  Length  of hospital stay  (LOS)  was  2.3 ± 0.8  days.  There  were no   deaths.   The  two   major   complications (10%) were intraoperative hemorrhage which required   conversion  to   open   splenectomy. The two minor  complications were trocar site infection and hernia.

Conclusion :

Laparoscopic splenectomy could be considered the  standard of  care for  patients who  require  splenectomy for  ITP, with primary splenic manifestations. Laparoscopic splenectomy results  in less patient  disability, shorter  hospitalization, and probably  less perioperative morbidity.  

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