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Background: Obesity is still considered a relative contraindication to laparoscopic splenectomy (LS)., Methods: All patients undergoing LS at our institution were classified as obese or nonobese (group A, body mass index [BMI] >30; group B, BMI <30). Primary end points included conversion rate, operative complications, length of stay, operative time, and estimated blood loss (EBL)., Results: Three hundred seventy patients who underwent LS were included. Baseline characteristics were similar in groups A (n = 127; mean BMI, 36.2 ± 6.9 kg/m²) and B (n = 243; mean BMI, 24.6 ± 2.9 kg/m²). Conversion rates and overall morbidity were similar in both groups (9% vs 11% for conversion to open procedures, P = .621; 16% vs 16% for morbidity rates, P = .940). Length of hospital stay and EBL were also comparable (P = .643 and P = .544, respectively). Mean operative time was significantly increased in the obese group on multivariate analysis (170 vs 151 minutes, P = .021)., Conclusions: Obesity does not adversely affect outcomes after LS. The laparoscopic approach is the optimal technique for splenectomy regardless of the patient's weight., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Splenectomy in patients with massive splenomegaly and hematologic malignancy results in higher morbidity and mortality with primarily palliative benefit., Methods: From a 14-year experience with 172 splenectomies, the perioperative course of 39 high-risk patients with splenomegaly was reviewed for comorbidities, indications, complications, and mortality., Results: Twenty-three males and 16 females with a mean age of 54.2 years and a mean 12.8-day postoperative length of stay were reviewed. Sixteen patients (41%) had 23 major complications related to age (P = 0.047) and operative time (P = 0.01). Intraoperative transfusion was related to splenic size (P = 0.04), and estimated blood loss (P = 0.02) was inversely related to use of splenic artery preligation. Three perioperative deaths were secondary to sepsis and multi-organ system failure., Conclusion: Splenomegaly and comorbidities of the primary disease result in higher morbidity and mortality. Splenic artery preligation is valuable to limit intraoperative blood loss and facilitate splenectomy.

Background: To assess the mortality (mostly long-term sequelae) of patients undergoing splenectomy, we carried out a population-based study in Sweden., Methods: Using the unique personal identification number assigned to each Swedish resident, we linked centralized hospitalization records with nationwide mortality data. After initially assessing risks within the first 12 months after splenectomy, we excluded deaths during the first year and computed standardized mortality ratios (SMRs) for 1,297 patients splenectomized for external trauma and 991 surgically treated for nonmalignant conditions of adjacent organs who were alive at 12 months following surgery. The general Swedish population was used as the comparison., Results: Both men and women undergoing splenectomy for external trauma had a 1.6-fold (SMR = 1.6) significantly elevated mortality risk, due mainly to circulatory diseases (particularly thromboembolism), alcoholism, digestive disorders, and external causes. Men also had a 28-fold increased mortality from septicemia and an excess of liver cirrhosis (mostly alcohol-related). Patients of both genders splenectomized for nonmalignant conditions had small but significantly elevated mortality overall (SMR = 1.4 to 1.5) reflecting excess risks for malignancies, diseases of blood-forming organs, external causes, and circulatory, respiratory, and digestive disorders. In addition, men had increased mortality from thromboembolism and pneumonia while women experienced elevated risks from septicemia., Conclusion: The excess mortality resulted from functional postsplenectomy defects (including sepsis and thromboembolism), behaviors increasing risk of traumatic splenic injury (eg, alcoholism), damage to other organs from the external trauma (eg, traumatic injury to the central nervous system/spinal cord), or the same or recurrent nonmalignant conditions for which surgery was performed (eg, gastric and duodenal ulcers).

Since 1987, we have used the TA-stapler for 15 partial resections of the spleen. The cases included 5 second- to third-degree traumatic ruptures, 4 splenic cysts, 3 injuries resulting from accidents during upper-abdominal surgery, 2 diagnostic resections, and 1 intralienal pancreatic cyst. The TA-55 stapler was used 14 times and the TA-90 once. No patient developed postoperative bleeding or required further surgery. Postoperative laboratory chemistry and scintigraphy findings were within the limits indicative of normal function in all cases. The TA-stapler expands the technical possibilities for organ-conserving splenic surgery.

A 10-year experience with the devascularization operation described by Sugiura is reported here. The operation was performed electively in 100 patients in whom it was not possible to place a shunt, all of whom had different kinds of hepatopathies (63 Child's A, 32 Child's B, and 5 Child's C). In 15 patients, the procedure was done in one stage (6% operative mortality, 1 patient), and, in 51, it was performed in two stages. Eight deaths were recorded in the 63 patients of the Child's A group, with a total of 111 operations. The operative mortality rate for this group was 12% and, as related to the number of operative procedures, 7% (8 of 111 operations). Seventeen patients were not considered for a second stage. Rebleeding in the early postoperative period was 4% and at long-term 6%. Incapacitating encephalopathy was found in 2 of the 71 surviving patients (3%). Survival (as determined by Kaplan-Meier tests) was 75% (1 year), 70% (5 years), and 69.2% (10 years). Six esophageal fistulas were observed secondary to transection. The Sugiura operation is an excellent complement to the therapeutic armamentarium used to treat portal hypertension, with low rebleeding and encephalopathy rates.

Combining these reported and estimated incidences of mortality from overwhelming postsplenectomy infection, splenic salvage with nonoperative observation therapy and operative therapy, and the incidence of posttransfusion hepatitis and related mortality provides a conditional probability estimation of the risks of death with nonoperative observation therapy and operative therapy (Figure 4). The combined mortality rates for nonoperative observation and operative therapies are based on the following measured and estimated statistics: The post-transfusion hepatitis death rate per unit of blood transfused is 0.14 percent. Forty percent of children and 20 percent of adults who have successful nonoperative observation therapy receive an average of 2 units of blood. One hundred percent of children and adults in whom nonoperative observation therapy is unsuccessful receive an average of 4 units of blood. Twenty percent of children and adults who undergo operation initially receive an average of 2 units of blood. Ten percent of observed children require laparotomy and 75 percent of these patients then undergo splenectomy. Forty percent of adults who have nonoperative observation initially later require laparotomy, 93 percent of whom also require splenectomy. Ten percent of children and adults treated with initial operation later require splenectomy. Death from overwhelming postsplenectomy infection occurs in 0.026 percent of adults who undergo splenectomy and 0.052 percent of children who undergo splenectomy. Given these assumptions, the conditional probability of death in a child who initially undergoes nonoperative observation therapy is 0.17 percent compared with 0.06 percent for initial operative therapy. In adults, 0.26 percent of the observed patients die compared with 0.06 percent for those operated on initially. As stated, many of the percentages or probabilities listed are estimations based on the best available clinical data. The inability to establish a mortality rate from overwhelming postsplenectomy infection remotely resembling that reported for otherwise healthy patients required an unsubstantiated estimate. However, even when mortality rates from overwhelming postsplenectomy infection of 0.43 percent and 0.6 percent were substituted, early laparotomy still produced lower mortality rates. This continues to be true if one assumes that early laparotomy will result in 50 percent or even 100 percent of patients undergoing splenectomy, although in these cases the statistical differences would be less. We acknowledge that these statistics may exceed or underestimate the true risk of either treatment plan.(ABSTRACT TRUNCATED AT 400 WORDS)

The results of splenectomy for hematologic disorders have been reviewed with special attention to problems possibly associated with massive spleens (1,500 g or more). The mortality rate in the group of patients with massive spleens did not differ from that in the group of patients with smaller spleens (2 percent and 3 percent, respectively). The complication rate, however, in the group of patients with massive spleens (43 percent) was twice that in the patients with smaller spleens (43 percent and 22 percent, respectively). The most frequent complication was postoperative hemorrhage in the splenic bed, usually caused by thrombocytopenia, perisplenitis , or both. Postoperative morbidity is seen as a function of the underlying disorder and of the general condition of the patient and not of the weight of the spleen per se.

Routine bilateral nephrectomy and splenectomy (BNS) in uremic patients before transplantation are relatively safe procedures except when there is pre-existing sepsis, diabetes, or severe hypertension. A review of 421 patients undergoing routine pretransplantation BNS reveals that death before transplantation occurs in two definable groups of patients. In our series, the first group, those with juvenile onset diabetes, have a 15.4 per cent pretransplantation mortality (9.6 per cent operative and 5.8 per cent nonoperative) while being maintained on hemodialysis and awaiting transplantation. The second group, nondiabetic patients with other preoperatively definable risk factors such as severe hypertension and infected kidneys, had a 3.25 per cent pretransplantation mortality (1.9 per cent operative and 1.25 per cent nonoperative) while on hemodialysis. Paradoxically, these same factors are used as absolute criteria for pretransplantation nephrectomy at institutions where this operation is not a routine part of the pretransplantation regimen.

Of 277 splenectomies performed over 10 years, 24.2 percent were incidental. Operative mortality in this group was 14.9 percent, which is higher than that encountered after splenectomy for any other indication. A majority of the deaths were from septic causes, and infectious complications accounted for most of the morbidity as well. This finding is in marked contrast to the paucity of infectious morbidity and mortality in patients with all other splenectomies. Of the 251 patients who survived these operations, follow-up was available on 175. Twenty-six had received Pneumovax, and 4 of these patients died, none from infectious causes. There were 20 septic deaths among the 149 unvaccinated patients, including 3 cases of fulminant pneumococcal sepsis.