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Introduction: This study aims to compare the outcomes of splenic artery embolization (SAE) versus splenectomy in adult trauma patients with high-grade blunt splenic injuries., Methods: This retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program database (2017-2021) compared SAE versus splenectomy in adults with blunt high-grade splenic injuries (grade ≥ IV). Patients were stratified first by hemodynamic status then splenic injury grade. Outcomes included in-hospital mortality, intensive care unit length of stay (ICU-LOS), and transfusion requirements at four and 24 h from arrival., Results: Three thousand one hundred nine hemodynamically stable patients were analyzed, with 2975 (95.7%) undergoing splenectomy and 134 (4.3%) with SAE. One thousand eight hundred sixty five patients had grade IV splenic injuries, and 1244 had grade V. Patients managed with SAE had 72% lower odds of in-hospital mortality (odds ratio [OR] 0.28; P = 0.002), significantly shorter ICU-LOS (7 versus 9 d, 95%, P = 0.028), and received a mean of 1606 mL less packed red blood cells at four h compared to those undergoing splenectomy. Patients with grade IV or V injuries both had significantly lower odds of mortality (IV: OR 0.153, P < 0.001; V: OR 0.365, P = 0.041) and were given less packed red blood cells within four h when treated with SAE (2056 mL versus 405 mL, P < 0.001)., Conclusions: SAE may be a safer and more effective management approach for hemodynamically stable adult trauma patients with high-grade blunt splenic injuries, as demonstrated by its association with significantly lower rates of in-hospital mortality, shorter ICU-LOS, and lower transfusion requirements compared to splenectomy., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Importance: The spleen is often removed in laparotomy after traumatic abdominal injury, with little effort made to preserve the spleen., Objective: To explore the association of surgical management (splenic repair vs splenectomy) with outcomes in patients with traumatic splenic injuries undergoing laparotomy and to determine whether splenic repair is associated with lower mortality compared with splenectomy., Design, Setting, and Participants: This is a trauma registry-based cohort study using the American College of Surgeons Trauma Quality Improvement Program database from January 2013 to December 2019. Participants included adult patients with severe splenic injuries (Abbreviated Injury Scale [AIS] grades 3-5) undergoing laparotomy after traumatic injury within 6 hours of admission. Data analysis was performed from April to August 2023., Exposures: Splenic repair vs splenectomy in patients with severe traumatic splenic injury., Main Outcomes and Measures: The primary outcome was in-hospital mortality. Outcomes were compared using different statistical approaches, including 1:1 exact matching with consecutive conditional logistic regression analysis as the primary analysis and multivariable logistic regression, propensity score matching, and inverse-probability weighting as sensitivity analyses., Results: A total of 11 247 patients (median [IQR] age, 35 [24-52] years; 8179 men [72.7%]) with a severe traumatic splenic injury undergoing laparotomy were identified. Of these, 10 820 patients (96.2%) underwent splenectomy, and 427 (3.8%) underwent splenic repair. Among patients who underwent an initial splenic salvage procedure, 23 (5.3%) required a splenectomy during the subsequent hospital stay; 400 patients with splenic preservation were matched with 400 patients who underwent splenectomy (matched for age, sex, hypotension, trauma mechanism, AIS spleen grade, and AIS groups [0-2, 3, and 4-5] for head, face, neck, thorax, spine, and lower and upper extremity). Mortality was significantly lower in the splenic repair group vs the splenectomy group (26 patients [6.5%] vs 51 patients [12.8%]). The association of splenic repair with lower mortality was subsequently verified by conditional regression analysis (adjusted odds ratio, 0.4; 95% CI, 0.2-0.9; P = .03). Multivariable logistic regression, propensity score matching, and inverse-probability weighting confirmed this association., Conclusions and Relevance: In this retrospective cohort study, splenic repair was independently associated with lower mortality compared with splenectomy during laparotomy after traumatic splenic injury. These findings suggest that efforts to preserve the spleen might be indicated in selected cases of severe splenic injuries.

Background/aim: The aim of this study was to investigate surgical and oncological outcomes of minimally invasive (MI) and open radical antegrade modular pancreatosplenectomy (RAMPS) for the treatment of left-sided pancreatic cancer., Materials and Methods: A systematic literature search and meta-analyses were performed focusing on short-term surgical oncology of MI- and open-RAMPS., Results: A total of seven studies with 423 patients were included in this review. The equivalent short-term and long-term outcomes of the groups were confirmed. The results of meta-analyses found no significant difference in R0 resection rates (OR=1.78, 95%CI=0.76-4.15, p=0.18), although MI-RAMPS was associated with a smaller number of dissected lymph nodes (MD=-3.14, 95%CI=-4.75 - -1.53, p<0.001) and lymph node metastases (OR=0.55, 95%CI=0.31-0.97, p=0.04)., Conclusion: MI-RAMPS could provide surgically and oncologically feasible outcomes for well-selected left-sided pancreatic cancer as compared to open-RAMPS. However, further high-level evidence should be needed to confirm survival benefits following MI-RAMPS., (Copyright © 2022 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Objective: Splenectomy is often performed during open thoracoabdominal aortic aneurysm (TAAA) repair, because capsular tears are common and can be associated with significant bleeding. It is unknown whether splenectomy affects the short- or long-term outcomes after TAAA repair., Methods: All open type I to IV TAAA repairs performed from 1987 to June 2015 were evaluated using a single institutional database. The primary endpoints were in-hospital death, major adverse events (MAE) and long-term survival. The secondary endpoint was hospital length of stay (LOS). All repairs performed for aneurysm rupture were excluded. Univariate analysis was conducted using the Fisher's exact test for categorical variables and the Wilcoxon rank sum test for continuous variables. Logistic and linear multivariable regression were used for the in-hospital endpoints, and survival analyses were performed using Cox proportional hazards modeling and Kaplan-Meier techniques., Results: A total of 649 patients met the study inclusion criteria. Of the 649 patients, 150 (23%) underwent concurrent splenectomy (CS) and six required emergency splenectomy secondary to bleeding postoperatively, leading to 156 cases of total in-hospital splenectomy. The perioperative mortality rate was 5.2% in the CS group and 5.2% in the non-CS group (P = 1.0). MAE were experienced by 48% of the CS patients compared with 34% of the non-CS patients (P = .003). Multivariable analysis revealed splenectomy was not independently predictive of perioperative death (adjusted odds ratio, 0.95; 95% confidence interval [CI], 0.41-2.23; P = .9). However, splenectomy was independently associated with any MAE (adjusted odds ratio, 1.78; 95% CI, 1.19-2.65; P = .005). Splenectomy was also associated with a longer length of stay (+5.39 days; 95% CI, 1.86-8.92; P = .003). No survival difference was found between the cohorts in the total splenectomy cohort in the unadjusted (log-rank P = 1.0) or adjusted (splenectomy adjusted hazard ratio, 1.02; 95% confidence interval, 0.78-1.35; P = .9)., Conclusions: CS during open TAAA repair did not lead to increased perioperative mortality but did lead to significantly increased perioperative morbidity and longer hospital lengths of stay. We found no difference in long-term survival outcomes when CS was performed. Splenectomy during TAAA repair did not affect long-term survival., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Two European phase III trials comparing D1 and D2 demonstrated that D2 did not improve the overall survival and was associated with a high mortality related to splenectomy. However, a long-term follow-up study showed that the gastric cancer-related death rate was significantly higher in D1 than D2. Based on these findings, the standard surgery in Europe became D2 without pancreatico-splenectomy to prevent mortality. In contrast, the JCOG9501 phase III comparing D2 and D2 plus para-aortic nodal dissection did not showed a survival efficacy of extended lymphadenectomy, but the mortality rate was quite low in both surgeries. Subsequently, the JCOG0110 phase III study comparing D2 and spleen-preserving D2 for upper gastric cancer not invading the greater curvature clearly showed the non-inferiority of spleen preservation. Thus, spleen-preserving D2 was made the standard surgery for these tumors in Japan. However, splenectomy is often selected for complete dissection of the splenic-hilar nodes, a frequent metastatic site for upper gastric tumors invading the greater curvature. Recently, an approach involving splenic hilar nodal dissection without splenectomy has been developed., (Copyright © 2021. Published by Elsevier Ltd.)

Background: Severe acute respiratory syndrome due to coronavirus 2 has rapidly spread worldwide in an unprecedented pandemic. Patients with an ongoing COVID-19 infection requiring surgery have higher risk of mortality and complications. This study describes the mortality and morbidity in patients with perioperative COVID-19 infection undergoing elective and emergency surgeries., Methods: Prospective cohort of consecutive patients who required a general, gastroesophageal, hepatobiliary, colorectal, or emergency surgery during COVID-19 pandemic at an academic teaching hospital. The primary outcome was 30-day mortality and major complications. Secondary outcomes were specific respiratory mortality and complications., Results: A total of 701 patients underwent surgery, 39 (5.6%) with a perioperative COVID-19 infection. 30-day mortality was 12.8% and 1.4% in patients with and without COVID-19 infection, respectively (p < 0.001). Major surgical complications occurred in 25.6% and 6.8% in patients with and without COVID-19 infection, respectively (p < 0.001). Respiratory complications occurred in 30.8% and 1.4% in patients with and without COVID-19 infection, respectively (p < 0.001). Mortality due to a respiratory complication was 100% and 11.1% in patients with and without COVID-19 infection, respectively (p < 0.006)., Conclusions: 30-day mortality and surgical complications are higher in patients with perioperative COVID-19 infection. Indications for elective surgery need to be reserved for non-deferrable procedures in order to avoid unnecessary risks of non-urgent procedures.

Purpose: To quantify changes in the management of pediatric patients with isolated splenic injury from 2007 to 2015., Materials and Methods: Patients under 18 years old with registered splenic injury in the National Trauma Data Bank (2007-2015) were identified. Splenic injuries were categorized into 5 management types: nonoperative management (NOM), embolization, splenic repair, splenectomy, or a combination therapy. Linear mixed models accounting for confounding variables were used to examine the direct impact of management on length of stay (LOS), intensive care unit (ICU) days, and ventilator days., Results: Of included patients (n = 24,128), 90.3% (n = 21,789), 5.6% (n = 1,361), and 2.7% (n = 640) had NOM, splenectomy, and embolization, respectively. From 2007 to 2015, the rate of embolization increased from 1.5% to 3.5%, and the rate of splenectomy decreased from 6.9% to 4.4%. Combining injury grades, NOM was associated with the shortest LOS (5.1 days), ICU days (1.9 days), and ventilator days (0.5 day). Moreover, splenectomy was associated with longer LOS (10.1 days), ICU days (4.5 days), and ventilator days (2.1 days) than NOM. The average failure rate of NOM was 1.5% (180 failures/12,378 cases). Average embolization failure was 1.3% (6 failures/456 cases). Splenic artery embolization was associated with lower mortality than splenectomy (OR: 0.10, P <.001). No statistically significant difference was observed in mortality between embolization and NOM (OR: 0.96, P = 1.0)., Conclusions: In pediatric splenic injury, NOM is the most utilized and associated with favorable outcomes, most notably in grades III to V pediatric splenic injury. If intervention is needed, embolization is effective and increasingly utilized most significantly in lower grade injuries., (Copyright © 2021 SIR. Published by Elsevier Inc. All rights reserved.)

Abstract: The spleen plays an important role in tumor progression and the curative effects of splenectomy before hepatectomy for hypersplenism and hepatocellular carcinoma (HCC) are not clear. We investigated whether splenectomy before hepatectomy increases survival rate among patients with HCC and hypersplenism compared with that of patients who underwent synchronous hepatectomy and splenectomy or hepatectomy alone.Between January 2011 and December 2016, 266 patients who underwent hepatectomy as a result of HCC and portal hypertension secondary to hepatitis were retrospectively analyzed. Their perioperative complications and survival outcome were evaluated.Patients underwent synchronous hepatectomy and splenectomy (H-S group) and underwent splenectomy before hepatectomy (H-preS group) exhibited significantly higher disease-free survival (DFS) rates than those of patients underwent hepatectomy alone (H-O group). The DFS rates for patients in the H-S group, H-preS group, and H-O group were 74.6%, 48.4%, 39.8%, and 80.1%, 54.2%, 40.1%, and 60.5%, 30.3%, 13.3%, at 1, 3, and 5 years after surgery, respectively. Tumor size, tumors number, and levels of alpha fetoprotein (AFP) were independent risk factors for DFS. Gender and tumor size were independent prognostic factor for overall survival (OS). The preoperative white blood cell (WBC) and platelet (PLT) counts were significantly higher in the H-preS group than in those of the H-S group and the H-O group. After operation, the WBC and PLT counts in the H-S group and H-preS groups were significantly higher compared to those of the H-O group.No matter splenectomy before hepatectomy or synchronous hepatectomy and splenectomy, hepatectomy with splenectomy may improve DFS rates in patients with HCC and hypersplenism, and splenectomy before hepatectomy alleviates hypersplenism without an increased surgical risk., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: Complex procedures such as distal pancreatectomy and splenectomy (DPS) may be required for R0 resection in patients with ovarian cancer (OC). These procedures can increase survival and cause serious morbidity. We aimed to present our experience in this field., Materials and Methods: Thirteen patients who underwent DPS for OC between January 2004 and July 2018 in two centers (Hacettepe University Hospital, Etlik Hospital) were evaluated. Statistical analysis was performed using SPSS., Results: The mean operative time was 310 min (220-570 min). None of the patients required transfusion. No perioperative mortality was observed. The mean postoperative hospital stay was 12 days (ranging from 8 to 33 days). The number of patients with early postoperative complications was four (30.7%). One of these patients was complicated by intestinal perforation, one with pancreatic fistula, one with pneumonia and the other with atelectasis. Other complications were observed conservatively. Ten patients underwent 6 cycles of platinum-based chemotherapy postoperatively. The median value of the postoperative chemotherapy period was 20 days (range 11-47 days). The median follow-up period was 46 months (2-144 months). Ten patients had recurrence. Eleven patients died of disease. Two patients are stil alive. Disease-free (DFS) and overall (OS) survival were 16 and 63 months, respectively., Conclusion: DPS for cytoreductive surgery is a procedure that increases morbidity, but most of the complications can be treated conservatively. Considering the increase in survival, it is considered to be a valuable procedure in upper abdominal disease., Competing Interests: Declaration of competing interest Authors declare that they have no conflict of interest., (Copyright © 2020. Published by Elsevier B.V.)

Purpose of Review: Myelofibrosis is a chronic myeloproliferative neoplasm which can lead to massive splenomegaly. Currently approved medical therapies do not improve splenomegaly in all patients and effects are not sustained. Thus, spleen-directed therapies (i.e., splenectomy and splenic irradiation) have been used in some cases to palliate the signs and symptoms of the disease. Here, we critically review the literature regarding palliative splenectomy and splenic irradiation in myelofibrosis, and discuss their position in the current treatment landscape., Recent Findings: Retrospective studies have demonstrated that splenectomy improves symptoms of splenomegaly, decreases complications of portal hypertension, and decreases transfusion dependence. However, it carries a significant peri-operative and long-term morbidity and mortality rate. Splenic irradiation reduces splenic size but is limited by duration of response and myelosuppression. Spleen-directed therapies in myelofibrosis may be considered for refractory symptoms and complications of massive splenomegaly after carefully weighing the associated risks, though overall survival may not be impacted. Development of medical therapies that target and reverse the underlying disease pathophysiology is required in order to have a significant impact on the natural history of the disease process.

Objective: The effect of incidental splenectomy during thoracoabdominal aortic aneurysm repair is unknown. We hypothesized incidental splenectomy was associated with decreased late survival., Methods: We studied 1056 thoracoabdominal aortic aneurysm repairs from 2006 to 2016. Exclusion criteria were age less than 18 years (n = 9), prior splenectomy (n = 2), and intraoperative death (n = 3). This left 1042 thoracoabdominal aortic aneurysm repairs for analysis (median age, 65 years; interquartile range, 56-72), including 221 (21%) that were reoperations. Multivariable modeling identified predictors of operative mortality in the total cohort. Moreover, to adjust for baseline differences, propensity score matching was performed to examine the frequency of these outcomes in the total cohort (n = 132 pairs) and the early survivors (n = 110 pairs). Late survival was estimated by the Kaplan-Meier method, and risk of late mortality was assessed by Cox proportional hazards regression., Results: Incidental splenectomy was performed in 135 patients (13%), 36% of whom underwent reoperation. Operative mortality rates of the incidental splenectomy and nonincidental splenectomy groups were 16% versus 8% in both the overall study (P = .005) and the propensity score-matched (P = .07) cohorts. In multivariable analysis, incidental splenectomy independently predicted operative mortality (odds ratio, 2.2; 95% confidence interval, 1.21-3.94; P = .008). For early survivors, incidental splenectomy did not increase the risk of late mortality. Survival estimates of matched early survivors did not differ between the incidental splenectomy and nonincidental splenectomy groups (P = .29)., Conclusions: Incidental splenectomy during thoracoabdominal aortic aneurysm repair was associated with increased operative mortality but not reduced late survival. Splenic preservation is encouraged when feasible., (Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Splenectomy for dissecting splenic hilar lymph nodes (#10) should be avoided for most gastric cancer, considering the high morbidity and lack of any survival benefit, but it is often selected for scirrhous gastric cancer because this type frequently invades the whole stomach and lymph nodes. Splenectomy is necessary for dissecting #10; however, the survival benefit of dissecting #10 is unclear., Methods: Patients who had scirrhous gastric cancer and underwent D2 total gastrectomy with splenectomy at National Cancer Center Hospital, Japan, between 2000 and 2011 were retrospectively analyzed. The therapeutic value index was calculated by multiplying the metastatic rate of each nodal station and the 5-year survival of patients who had metastasis to each node., Results: In total, 137 patients were eligible for the present study. The most frequent metastatic node was #3(58%), followed by #4d(46%), #1(35%), #4sb(23%), #6(22%), #7(21%), #4sa(18%), #10(15%), #2(14%), #11p(14%), #11d(13%), #9(13%), and #8a(11%). These lymph nodes had a metastatic rate of more than 10%. The node station with the highest index was #3(18.9), followed by #4d(14.1), #1(10.8), #4sa(6.11), #4sb(6.06), #10(5.09), #7(4.39), #11d(4.36), #11p(4.06), #2(2.93), #8a(2.18), and #9(1.45). The index of #10 exceeded that of #2, #7, #8a, and #9, which are the key nodes dissected in D2., Conclusion: The metastatic rate of the splenic hilar lymph nodes was relatively high, and the therapeutic index was the sixth highest among the 15 regional lymph nodes included in D2 dissection. Splenectomy for dissecting splenic hilar lymph nodes would be justified for scirrhous gastric cancer.

Background: Whether splenectomy for splenic hilar lymph node (No. 10) dissection in type 4 gastric cancer involving the greater curvature is necessary is not established. Patients with type 4 gastric cancer often experience peritoneal relapse, despite curative surgery, and total gastrectomy with splenectomy is frequently associated with infectious complications., Method: Patients with cT2-T4 gastric cancer in the upper or middle third of the stomach, or both, involving the greater curvature who underwent R0 total gastrectomy with splenectomy between 2006 and 2016 were selected. Clinicopathological findings, postoperative complications, the incidence of lymph node metastasis, and the therapeutic value index of each station were compared between type 4 and non-type 4 gastric cancer., Results: We enrolled 50 patients with type 4 and 60 with non-type 4. The former had a significantly higher proportion of the undifferentiated type and larger and deeper tumors. The overall incidence of Grade III or higher complications was 20.9%. The incidence of No. 10 metastasis was 26.0% in type 4 and 31.7% in non-type 4. Although the therapeutic value index of the No. 10 was 13.7 in type 4 and 15.0 in non-type 4, the index of type 4 ranked just below several peri-gastric stations and seventh, while that in non-type 4 ranked second., Conclusion: Splenectomy for No. 10 dissection may be oncologically valid for type 4 gastric cancer involving the greater curvature. A safer procedure for No. 10 dissection should be established.

Introduction: This study was undertaken to examine 100 consecutive robotic distal pancreatectomies with splenectomies, and to compare our outcomes to predicted outcomes as calculated using the American college of surgeons national surgical quality improvement program (ACS NSQIP) Surgical Risk Calculator and to the outcomes contained within NSQIP., Methods: Outcomes were compared with predicted outcomes, calculated using the ACS NSQIP Surgical Risk Calculator, and with outcomes documented in NSQIP for distal pancreatectomy. For illustrative purposes, data are presented as median (mean ± SD)., Results: Patients who underwent robotic distal pancreatectomy were of age 67 (63 ± 13.4) years with a BMI of 29 (29 ± 6.3) kg/m 2 , with 49% being women. Operative duration was 242 (265 ± 112.2) minutes and estimated blood loss was 110 (211 ± 233.9) mL. Predicted outcomes were similar to those reported in NSQIP. Our actual outcomes were significantly superior to the predicted outcomes for serious complication, any complication, surgical site infection, sepsis, and length of stay. Compared to NSQIP outcomes, our actual outcomes for serious complication, any complication, surgical site infection, sepsis, and delayed gastric emptying were significantly superior. Twelve percent of operations were converted to "open." There were 3 deaths within 30 days, similar to predicted outcomes. Deaths were due to sepsis (2) and respiratory failure (1)., Conclusion: Our patients' predicted outcomes were the same as national outcomes; our patients were not a select group. However, their actual outcomes were like or significantly superior than those predicted by NSQIP or reported in NSQIP. We believe that the robot has the future of distal pancreatectomy with or without splenectomy.

Despite the publication in 2009 of a paper on 'terms and definitions of immune thrombocytopenia' (ITP), some unresolved issues remain and are reflected by the disagreement in the treatment suggested for primary ITP in adults. Considering that these disagreements could be ascribed to non-shared goals, we generated a 'consensus' on some terms, definitions, and assertions useful for classifying the different lines of treatment for primary ITP in adults according to their indications and goals. Agreement on the appropriateness of the single assertions was obtained by consensus for the following indicators: 1 . classification of four 'lines of therapy'; 2 . acceptance of the expression 'sequences of disease' for the indications of the respective four lines of treatment; 3 I . practicability of splenectomy; 3 Ib . acceptance, with only some exceptions, of a 'timing for elective splenectomy of 12 months'; and 4 a-d . 'goals of the four lines of therapy.' On the basis of the consensus, a classification of four lines of treatment for primary ITP in adults was produced. In our opinion, this classification, whose validity is not influenced by the recently published new guidelines of the American Society of Hematology (ASH) and reviews, could reduce the disagreement that still exists regarding the treatment of the disease.

Although the consequences of splenectomy are well understood in mice, much less is known about the immunologic changes that occur following splenectomy in humans. We sought to characterize the circulating immune cell populations of patients before and after elective splenectomy to determine if these changes are related to postsplenectomy survival outcomes. Retrospective clinical information was collected from 95 patients undergoing elective splenectomy compared with 91 patients undergoing pancreaticoduodenectomy (Whipple procedure). We further analyzed peripheral blood from five patients in the splenectomy group, collected before and after surgery, using single-cell cytometry by time-of-flight mass spectrometry. We compared pre- and postsplenectomy data to characterize both the major and minor immune cell populations in significantly greater detail. Compared with patients undergoing a Whipple procedure, splenectomized patients had significant and long-lasting elevated counts of lymphocytes, monocytes, and basophils. Cytometry by time-of-flight mass spectroscopy analysis demonstrated that the elevated lymphocytes primarily consisted of naive CD4 + T cells and a population of activated CD25 + CD56 + CD4 + T cells, whereas the elevated monocyte counts were mainly mature, activated monocytes. We also observed a significant increase in the expression of the chemokine receptors CCR6 and CCR4 on several cellular populations. Taken together, these data indicate that significant immunological changes take place following splenectomy. Whereas other groups have compared splenectomized patients to healthy controls, this study compared patients undergoing elective splenectomy to those undergoing a similar major abdominal surgery. Overall, we found that splenectomy results in significant long-lasting changes in circulating immune cell populations and function., (Copyright © 2020 The Authors.)

Background: Despite advances in the treatment of patients with gastric cancer, the debate over the optimal extent of lymphadenectomy continues., Method: A review of the classification, rationale for, and boundaries of lymphadenectomy is presented. A review of the available literature comparing D1 versus D2 versus D3 lymphadenectomy was performed and included randomized controlled trials, and prospective and retrospective comparative and non-comparative studies., Results: Earlier studies demonstrated increased morbidity with D2 compared with D1 lymphadenectomy, with no significant survival benefit. More recent studies have demonstrated survival benefit of a pancreas and spleen-sparing D2 lymphadenectomy in patients with advanced, node-positive tumors. Para-aortic/D3 dissections contribute to increased morbidity, with no survival benefit., Conclusions: In patients with resectable gastric adenocarcinoma, a D2 lymph node dissection preserving the pancreas and spleen should be considered standard for optimal staging and treatment, provided it is performed by surgeons with sufficient expertise. Extended lymph node dissections beyond D2 should not be routinely performed as it has been shown to have increased morbidity, with no improvement in outcomes. While systemic chemotherapy should be considered standard in patients undergoing D2 lymphadenectomy, the role of adjuvant radiation continues to evolve.

Background: As the experience grew with laparoscopic splenectomy (LS) more surgeons appreciate the advantages of lateral approach compared with conventional anterior approach. In view of this we aimed to compare anterior approach and lateral approach in LS., Methods: We conducted a search of electronic information sources to identify all randomized controlled trials (RCTs) and observational studies comparing anterior and lateral approach in patients undergoing LS. Primary outcomes included need for blood transfusion, intraoperative blood loss, and conversion to open surgery. The secondary outcomes included postoperative morbidity, operative time, time to oral intake, length of hospital stay, need for reoperation, and mortality. Random or fixed-effects modeling were applied to calculate pooled outcome data., Results: We identified 1 RCT and 4 retrospective observational studies, enrolling 728 patients. The baseline characteristics included populations in both groups were comparable. Anterior approach was associated with higher need for blood transfusion [odds ratio (OR), 4.83, 95% confidence interval (CI), 2.31-10.97; P=0.0001]; higher risks of intraoperative blood loss [mean difference (MD), 101.06, 95% CI, 52.05-150.06; P=0.0001], conversion to open surgery (OR, 3.33, 95% CI, -1.32 to 8.43; P=0.01), postoperative morbidity (OR, 3.86, 95% CI, -2.23 to 6.67; P=0.00001) and need for reoperation (OR, 6.91, 95% CI, -1.07 to 44.6; P=0.04); longer operative time (MD, 2.51, 95% CI, -1.43 to 3.59; P=0.00001), time to oral intake (MD, 0.60, 95% CI, -0.14 to -1.07; P=0.01), and length of stay (MD, 2.52, 95% CI, -1.43 to 3.59; P=0.00001) compared with lateral approach. There was no difference in the risk of mortality between the 2 groups (risk difference, 0.00, 95% CI, -0.01 to 0.02; P=0.61)., Conclusions: The best available evidence suggests that the lateral approach is superior to anterior approach in LS as indicated by better access, more secure hemostasis, less conversion to open surgery, less morbidity, earlier recovery, and shorter length of hospital stay. The quality of the available evidence is moderate; high-quality RCTs are required to provide more robust basis for definite conclusions.

Objective: At present, cholecystectomy is carried out for thalassaemia patients with gall stone disease only if they develop symptoms of cholecystitis, except in the rare instance where an un-inflammed gall bladder is removed simultaneously with splenectomy. We carried out this retrospective analysis of case records to examine if patients with thalassaemia have a higher rate of peri operative complications compared to non-thalassaemics with gall stone disease, warranting a change of policy to justify elective cholecystectomy., Results: Case records of 540 patients with thalassaemia were retrospectively analysed of which 98 were found to have gallstones. Records of 62 patients without thalassaemia with gall stone disease too were used for comparison. 19 of patients with thalassaemia and 52 of non-thalassaemic who had gallstones had undergone cholecystectomy. In all but 5 patients with thalassaemia cholecystectomy was done following attacks of acute cholecystitis as was the case in the non-thalassaemic controls. A significantly higher proportion of early and late complications had occurred in thalassaemia patients compared to non-thalassaemic patients post operatively. Six deaths related to sepsis following acute cholecystitis in the peri operative period were reported among 19 thalassaemia patients whereas no deaths were reported among 55 non-thalassaemic patients who underwent cholecystectomy for gallstones.

Background: The Japan Clinical Oncology Group phase 3 study confirmed the survival non-inferiority of spleen-preserving surgery against splenectomy for advanced proximal gastric cancer not invading the greater curvature. However, the efficacy of #10 lymph node (LN) dissection for tumors that involve the greater curvature remains unclear., Methods: Data from patients who underwent D2-total gastrectomy with splenectomy between January 2000 and December 2012 were retrospectively reviewed. The study included 593 patients. The patients were split into two groups, with 212 patients in the tumor invasion of the greater curvature (Gre) group and 381 patients in the non-Gre group. Survival curves and the state of LN metastasis and the index of estimated benefit from LN dissection of each station were evaluated., Results: The incidence of #10 LN metastasis was 8.1% (48/593): 15.1% in the Gre group and 4.2% in the non-Gre group. The 5-year overall survival rates for the patients with and without #10 metastasis were respectively 46.9 and 50.2% (P = 0.829) in the Gre group and 49.6 and 62.3% (P = 0.074) in the non-Gre group. The indices for #10 LN dissection were 7.1 in the Gre group and 2.3 in the non-Gre group. In the Gre group, the node station with the highest index was #3, followed by #4d, #1, #4sb, #4sa, #7, #2, #10 (index > 7)., Conclusion: The splenic hilar nodes should be prioritized as a component of D2 lymphadenectomy for advanced gastric cancer invading the greater curvature based on its high metastatic rate and index.

Objective: Splanchnic artery aneurysms (SAAs) are rare, and little is known about their natural history and management. We reviewed our single-center experience in managing this population of patients., Methods: A retrospective review of the Yale radiologic database from January 1999 to December 2016 was performed. Only patients with an SAA and a computed tomography scan of the abdomen were selected for review. Demographics of the patients, aneurysm characteristics, management, postoperative complications, and follow-up data were collected. Our primary outcomes included aneurysm growth rate and risk of rupture in those patients managed nonoperatively and morbidity and mortality of those SAA patients who underwent operative intervention., Results: There were 122 patients with 138 SAAs identified; 77 were male (62%), with a mean age of 66 years (range, 25-94 years). On computed tomography, 56 (45%) had previously diagnosed or concomitant aneurysms elsewhere. Of the patients managed nonoperatively, 101 patients (79%) had 108 SAAs; in the operative intervention group, 25 (21%) patients had 30 SAAs. The mean overall vessel diameter was 1.76 ± 0.83 cm. The diameter of observed and operatively repaired SAAs was 1.58 ± 0.56 cm and 2.41 ± 1.23 cm, respectively (P = .00001). Mean follow-up was 50 ± 42 months for nonoperative management without any adverse events related to SAA, including 10 patients with SAA >2.0 cm. The mean observed growth rate for SAA was 0.064 ± 0.18 cm/y. All symptomatic patients who presented with severe abdominal pain (n = 11 [44%]) underwent operative intervention. Five patients presented with a ruptured SAA (3.6%; range, 2.3-5.0 cm); all of them except one underwent operative intervention. Other indications for repair included large size in seven, rapid growth in two, other open abdominal surgical procedures in two, multiple aneurysms in one, and desire to pursue fertility treatment in one. Operative repair included 14 (56%) endovascular embolizations and 11 (44%) open abdominal operations. After endovascular embolization, two patients underwent abdominal operation for hemorrhage and splenectomy. Open repairs included bypasses in six, splenectomy in two, resection in two, and plication in one. Two patients had postoperative acute kidney injury that resolved and one died of multisystem organ failure. One bypass occluded without sequelae. On multivariable regression analysis, female sex (P = .02) was associated with faster growth rate, and a history of smoking (P = .04) was associated with slower growth rate., Conclusions: It seems reasonable to observe asymptomatic patients with an SAA <2.0 cm because of the slow growth rate (0.064 ± 0.18 cm/y) and benign behavior. When intervention is needed, both open and endovascular options should be considered., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Portal vein thrombosis (PVT) is a severe complication after liver transplantation that can result in increased morbidity and mortality. Few data are available regarding risk factors, classification, and treatment of PVT after living donor liver transplantation (LDLT). Between January 2004 and November 2014, 421 adult-to-adult LDLTs were performed at our institution, and they were included in the analysis. Perioperative characteristics and outcomes from patients with no-PVT (n = 393) were compared with those with de novo PVT (total portal vein thrombosis [t-PVT]; n = 28). Ten patients had early portal vein thrombosis (e-PVT) occurring within 1 month, and 18 patients had late portal vein thrombosis (l-PVT) appearing later than 1 month after LDLT. Analysis of perioperative variables determined that splenectomy was associated with t-PVT (hazard ratio [HR], 3.55; P = 0.01), e-PVT (HR, 4.96; P = 0.04), and l-PVT (HR, 3.84; P = 0.03). In contrast, donor age was only found as a risk factor for l-PVT (HR, 1.05; P = 0.01). Salvage rate for treatment in e-PVT and l-PVT was 100% and 50%, respectively, without having an early event of rethrombosis. Mortality within 30 days did not show a significant difference between groups (no-PVT, 2% versus e-PVT, 10%; P = 0.15). No significant differences were found regarding 1-year (89% versus 92%), 5-year (79% versus 82%), and 10-year (69% versus 79%) graft survival between the t-PVT and no-PVT groups, respectively (P = 0.24). The 1-year (89% versus 96%), 5-year (82% versus 86%), and 10-year (79% versus 83%) patient survival was similar for the patients in the no-PVT and t-PVT groups, respectively (P = 0.70). No cases of graft loss occurred as a direct consequence of PVT. In conclusion, the early diagnosis and management of PVT after LDLT can lead to acceptable early and longterm results without affecting patient and graft survival., (© 2018 by the American Association for the Study of Liver Diseases.)

Splenectomy is a well-recognised risk factor for life-threatening overwhelming post-splenectomy infection (OPSI). To prevent OPSI, immunisations against encapsulated bacteria (S. pneumoniae, N. meningitidis, H. influenzae) and influenza virus are recommended. However, there is still a lack of uniformity and poor compliance with these recommendations. Following a local physicians' awareness campaign regarding the importance of vaccine prophylaxis of splenectomised patients, we aimed to register vaccination coverage, mortality and infection rates in all patients who underwent splenectomy at our hospital, over a six-year time span. Reasons for splenectomy, patients' compliance with vaccinations, mortality and infectious events were recorded. The reasons for splenectomy in the 216 identified patients (mean age 58.2 ± 14; M:F ratio 1.4:1) were haematologic disorders (38.8%), solid tumours (28.7%), traumatic rupture (22.7%) and other causes (9.7%). A total of 146 patients (67.6%) received at least one of the four vaccines. Overall, the mortality rate was significantly greater in unvaccinated compared to vaccinated patients (p < 0.001), although after the adjustment for the cause of splenectomy the statistical significance was lost (p = 0.085) due to the burden of solid tumour-related mortality. Among the 21 reported cases of OPSI, eight were fatal and five were potentially vaccine-preventable. Our results show that two-thirds of splenectomised patients comply with vaccine prophylaxis. Future interventional studies or ad hoc registries might overcome barriers to vaccination or intentional non-compliance.

Background: RAMPS is considered, in high volume centers, as the best treatment for adenocarcinoma of the body and tail of the pancreas. Methods: PubMed database was searched. The results of studies that compared RAMPS with SRPS were analyzed by meta-analytical methods. Results: Five studies, published between 2013 and 2016, were suitable for quantitative synthesis. 285 unique patients were included, 135 patients in the RAMPS group and 150 patients in the SRPS group. Regarding retrieved lymph nodes, the mean difference was 6.54. This difference was considered to be statistical significant, P 0.00001. A complete tumor resection was observed in 115 of 129 patients who underwent RAMPS and in the case of the standard procedure a R0 resection was obtained in 107 cases out of 137, the RR was 1.17 (95% CI, 1.04, 1.32). One-year overall survival was found to be 79.2% in the RAMPS groups compared with 64.29% in the SRPS group. This difference is considered statistically significant, with a P value of 0.02. Conclusions: RAMPS is a safe procedure for the treatment of adenocarcinomas of the body and tail of the pancreas. RAMPS procedure is superior to SRPS in terms of lymph node retrieval and R0 resections., (Celsius.)

Background: Splenic injury frequently occurs after blunt abdominal trauma; however, limited epidemiological data regarding mortality are available. We aimed to investigate mortality rate trends after blunt splenic injury in Japan., Methods: We retrospectively identified 1,721 adults with blunt splenic injury (American Association for the Surgery of Trauma splenic injury scale grades III-V) from the 2004-2014 Japan Trauma Data Bank. We grouped the records of these patients into 3 time phases: phase I (2004-2008), phase II (2009-2012), and phase III (2013-2014). Over the 3 phases, we analysed 30-day mortality rates and investigated their association with the prevalence of certain initial interventions (Mantel-Haenszel trend test). We further performed multiple imputation and multivariable analyses for comparing the characteristics and outcomes of patients who underwent TAE or splenectomy/splenorrhaphy, adjusting for known potential confounders and for within-hospital clustering using generalised estimating equation., Results: Over time, there was a significant decrease in 30-day mortality after splenic injury (p < 0.01). Logistic regression analysis revealed that mortality significantly decreased over time (from phase I to phase II, odds ratio: 0.39, 95% confidence interval: 0.22-0.67; from phase I to phase III, odds ratio: 0.34, 95% confidence interval: 0.19-0.62) for the overall cohort. While the 30-day mortality for splenectomy/splenorrhaphy diminished significantly over time (p = 0.01), there were no significant differences regarding mortality for non-operative management, with or without transcatheter arterial embolisation (p = 0.43, p = 0.29, respectively)., Conclusions: In Japan, in-hospital 30-day mortality rates decreased significantly after splenic injury between 2004 and 2014, even after adjustment for within-hospital clustering and other factors independently associated with mortality. Over time, mortality rates decreased significantly after splenectomy/splenorrhaphy, but not after non-operative management. This information is useful for clinicians when making decisions about treatments for patients with blunt splenic injury.

Background: Indications for splenectomy (SP) during whole liver transplantation (LT) remain controversial and SP is often avoided because of common complications. We aimed to evaluate specific complications of these combined procedures., Methods: Data were retrospectively analysed. Splenectomy was performed in patients with splenorenal shunt and/or splenic artery aneurysms or hypersplenism. Patients undergoing simultaneous transplantation and splenectomy (LTSP group) were matched to a non-splenectomy group (LT group)., Results: Between 1994 and 2013, we included 47 and 94 patients in LTSP and LT groups, respectively. The LTSP patients had a higher rate of pre-LT portal vein thrombosis (PVT). The LTSP group had a longer operative time and greater blood loss. Mean follow-up was 101 months and 5-year survivals were identical (LTSP 85% vs LT 88%, p = 0.831). Hospital morbidity and rejection incidence were comparable, whereas de novo PVT (34% vs 2%, p < 0.0001) and infection (47% vs 25%, p = 0.014) rates were higher after SP., Conclusion: Splenectomy during LT is technically demanding and exposes recipients to a higher thrombosis rate, therefore portal vein patency must be specifically assessed postoperatively. In selected recipients, SP can be performed without increased mortality but at the price of worsening outcome as evidenced by greater risk of infection and PVT., (Copyright © 2017 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Performing a pretransplantation splenectomy in patients with myelofibrosis (MF) is a matter of debate, as while the procedure improves hematological recovery, it may lead to severe morbidities. We retrospectively analyzed data from 85 consecutive patients who underwent transplantation in our center for MF, including 39 patients who underwent splenectomy before their transplantation. A majority of them had primary MF (78%), were considered high-risk patients (84% dynamic international prognostic scoring system intermediate-2 or higher), and had received transplants from HLA-matched sibling donors (56%) after a reduced-intensity conditioning regimen (82%). One-half of all splenectomized patients presented surgical or postsurgical morbidities, most frequently thrombosis and hemorrhage. After adjustment using Cox models, pretransplantation splenectomy was not associated with nonrelapse mortality or post-transplantation relapse but with an improved overall survival (OS) and event-free survival (EFS). We conclude that some patients with huge splenomegaly may undergo pretransplantation splenectomy without a deleterious impact on post-transplantation outcomes. OS and EFS improvement should in confirmed in controlled study., (Copyright © 2017 The American Society for Blood and Marrow Transplantation. Published by Elsevier Inc. All rights reserved.)

Introduction: Thrombocytosis is common following elective splenectomy and major trauma. However, little is known about the in-hospital course of platelet count (PC) and incidence of thrombocytosis after splenic trauma. Extreme thrombocytosis (PC>1000×10 9 ) is associated with increased risk of venous thromboembolism (VTE) in primary thrombocytosis leading to the use of acetylsalicylic acid (ASA) for risk reduction, but the need for this agent in splenic trauma is undefined., Methods: Retrospective cohort study of all patients with splenic trauma between April 1, 2010 and March 31, 2014. The in-hospital course of PC was assessed based on splenic injury management type. The association of management type with thrombocytosis was evaluated using a multivariable logistic regression model adjusting for potential confounders. The association of thrombocytosis, extreme thrombocytosis, and ASA use for the outcome of VTE was explored., Results: 156 patients were eligible, PC initially increased in all patients with the highest peak after total splenectomy. The incidence of thrombocytosis was 41.0% (64/156). Thrombocytosis was more likely following splenectomy compared with spleen preserving strategies independent of length of stay, injury grade, ISS, age and transfusion (OR 7.58, 95% CI: 2.26-25.45). Splenectomy was associated with extreme thrombocytosis (OR 10.39, 95% CI: 3.59-30.07)., Conclusions: Thrombocytosis in splenic trauma is more likely after splenectomy than with spleen preserving strategies. Splenectomy is associated with extreme thrombocytosis. There was insufficient data in our study to determine the use of ASA as primary prevention of VTE after splenic trauma., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Background: To assess the published evidence on clinical outcomes following radical antegrade modular pancreatosplenectomy (RAMPS) for adenocarcinoma in the body or tail of the pancreas., Method: PubMed and Chinese Biomedical Literature databases were searched. The results of comparisons between RAMPS and standard retrograde pancreatosplenectomy (SRPS) were analyzed by meta-analytical techniques., Results: The literature search identified 13 observational studies involving 354 patients undergoing RAMPS. The overall morbidity and 30-day mortality was 40% and 0% respectively. The R0 resection rate was 88%; the median number of retrieved lymph nodes was 21; and the median 5-year overall survival rate was 37%. The result of meta-analysis showed that RAMPS was associated with a significantly less intraoperative bleeding [weighted mean difference -195.2 (95% confidence interval (CI) -223.27 to -167.13); P < 0.001], a greater number of retrieved lymph nodes [odds ratio (OR) 6.19 (95% CI 3.72 to 8.67); P < 0.001] and a higher percentage of R0 resection [OR 2.46 (95% CI 1.13 to 5.35); P = 0.02] as compared with SRPS., Conclusion: The current literature provides supportive evidence that RAMPS is a safe and effective procedure for adenocarcinoma in the body or tail of the pancreas, and is oncologically superior to SRPS., (Copyright © 2016 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

INTRODUCTION The spleen remains one of the most frequently injured organs following blunt abdominal trauma. In 2012, regional trauma networks were launched across England and Wales with the aim of improving outcomes following trauma. This retrospective cohort study investigated the management and outcomes of blunt splenic injuries before and after the establishment of regional trauma networks. METHODS A dataset was drawn from the Trauma Audit Research Network database of all splenic injuries admitted to English and Welsh hospitals from 1 April 2010 to 31 March 2014. Demographic data, injury severity, treatment modalities and outcomes were collected. Management and outcomes were compared before and after the launch of regional trauma networks. RESULTS There were 1457 blunt splenic injuries: 575 between 2010 and 2012 and 882 in 2012-14. Following the introduction of the regional trauma networks, use of splenic artery embolotherapy increased from 3.5% to 7.6% (P = 0.001) and splenectomy rates decreased from 20% to 14.85% (P = 0.012). Significantly more patients with polytrauma and blunt splenic injury were treated with splenic embolotherapy following 2012 (61.2% vs. 30%, P < 0.0001). Increasing age, injury severity score, polytrauma and Charlson Comorbidity Index above 10 were predictors of increased mortality (P < 0.001). Increasing systolic blood pressure (odds ratio, OR, 0.757, 95% confidence interval, CI, 0.716-0.8) and Glasgow Coma Scale (OR 0.988, 95% CI 0.982-0.995) were protective. CONCLUSIONS This study demonstrates a reduction in splenectomy rate and an increased use of splenic artery embolotherapy since the introduction of the regional trauma networks. This may have resulted from improved access to specialist services and reduced practice variation since the establishment of these networks.

The recent large decrease in splenectomy use for chronic immune thrombocytopenia (ITP) is partly due to still-unsolved questions about long-term safety. We performed the first single-center exposed/unexposed cohort study evaluating the long-term incidence of splenectomy complications in patients with primary ITP. Overall, 83 patients who underwent splenectomy more than 10 years ago (exposed) were matched with 83 nonsplenectomized patients (unexposed) on the date of ITP diagnosis ±5 years, age and gender. After a median follow-up of 192 months (range 0.5-528), 43 patients (52%) achieved overall response after splenectomy. Splenectomized patients experienced more venous thromboembolism (VTE) than controls (n = 13 vs n = 2, P = 0.005). On multivariate analysis, splenectomy was an independent risk factor of VTE (hazard ratio = 4.006, P = 0.032 [95% confidence interval: 1.13-14.21]). Splenectomized patients presented more severe infections on long-term follow-up: all required hospitalization, and 5/26 (19%) infections led to severe sepsis or septic shock and to death for 3 cases (none in controls). However, the incidence of malignancy was similar in both groups, as was cardiovascular risk, which appeared to be related more to ITP than splenectomy. Finally, splenectomy did not significantly decrease overall survival. Despite the risk of thrombosis and severe sepsis, splenectomy remains an effective and curative treatment for ITP., Competing Interests: M. Michel has served as a consultant for Amgen and Glaxo-Smith Kline and received research support from Roche, participated on advisory boards and/or as a speaker at medical education events supported by Amgen and declares no competing financial interests. B. Godeau has served as a consultant for Amgen and GSK and received research support from Roche, participated on advisory boards and/or as a speaker at medical education events supported by Amgen, Roche, and GSK and declares no competing financial interests. The other authors declare no competing financial interests.

The study aimed to investigate the long-term outcomes of laparoscopic splenectomy (LS) in Chinese patients with chronic idiopathic thrombocytopenic purpura (ITP). This was a retrospective analysis of 114 patients with ITP who underwent LS from 2001 to 2013. Patients were classified according to response at last contact: complete response (CR), partial response (PR), and no response (NR). Patients with CR had the highest platelet levels and patients with NR had the lowest. A correlation was observed between postoperative peak platelet count and platelet count on 2-month postoperative (r=0.829, P<0.01). In total, 27 patients showed NR to LS. Ten patients recurred within 3 years. The 140-month response rate to LS was 68%. Multivariate analysis showed that age and postoperative platelet count were independently associated with CR/PR. In conclusion, LS achieved good outcomes in Chinese patients with ITP. Age and postoperative peak platelet were independently associated with response.

Background: Splenectomy is indicated for selected patients with lymphoid neoplasms. We examined surgical morbidity and mortality in this high-risk patient population using a contemporary national cohort, with attention to hospitalization status before surgery., Materials and Methods: The American College of Surgeons National Surgical Quality Improvement Program database (2005-2013) was queried for patients with lymphoid malignancies undergoing splenectomy. Stepwise statistical analyses were performed to identify factors associated with increased risk of death and serious morbidity (DSM). A risk scoring system was developed to predict DSM., Results: In 456 patients, morbidity rate was 24.1%, and mortality rate was 2.4%. Albumin <3 g/dL (odds ratio [OR] = 2.6, P = 0.005), hematocrit <30% (OR = 2.8, P < 0.0001), and a history of chronic obstructive pulmonary disease (OR = 3.4 P = 0.009) were independent predictors of DSM. Rates of DSM were stratified by these risk factors (RFs): 13.5% (0 RF), 34.4% (1 RF), and 58.5% (2-3 RF), P < 0.0001. Patients admitted before surgery (IP) were more likely to have RF compared with those undergoing surgery on the day of admission (SDS); 74.6 versus 26.4%, P < 0.001. Morbidity (39.7% versus 18.2%, P < 0.0001) and mortality (7.1% versus 0.6%, P < 0.0001) were significantly increased in the IP group., Conclusions: Splenectomy for lymphoid neoplasm in hospitalized patients is associated with substantial morbidity and mortality. Risk stratification in this group may aid in perioperative management to mitigate DSM., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: The purpose of this report is to present results of the radical antegrade modular pancreatosplenectomy (RAMPS) procedure in 78 patients from a single center., Methods: Seventy-eight patients had RAMPS procedure over 13 years. A database dealing with RAMPS for adenocarcinoma of the pancreas was constructed so that it could be converted into a set of tables. Each table covered one element of the subject. The database was populated from clinical records of patients who had a RAMPS procedure from 1999 to 2013., Results: Fifty-six patients had anterior RAMPS and 22 had posterior RAMPS. Negative tangential margins were obtained in 94% of specimens. Overall the R0 rate was 85%. Mean lymph node count was 20. There were no 30-day or in-hospital mortalities but two patients died within 90 days. Pancreatic fistula and need for postoperative transfusion were the most common complications. Median survival was 24.6 months and 5-year overall actuarial survival was 25.1%., Conclusions: The RAMPS technique resulted in high negative tangential margin rates and good lymph node retrieval. The long-term survival result in 78 patients is probably an accurate reflection of what is possible with this tumor using this technique at this time., (© 2016 Japanese Society of Hepato-Biliary-Pancreatic Surgery.)

Splenic marginal zone lymphoma (SMZL) is an indolent lymphoma in which watch and wait (W&W) approach as well as splenectomy and chemo-immunotherapy are usually recommended. The role of the different approaches in relation to risk factors was evaluated. One hundred patients with SMZL were retrospectively studied. Median age was 65 years. HCV positivity was 3.1%. The 10-year overall-survival was 95.1% (CI: 90-100%). Sixty-two asymptomatic, low tumour burden patients were submitted to W&W. A low-risk group not requiring treatment was identified. Patients requiring treatment received splenectomy (36), chemotherapy-alone (27) and rituximab ± chemotherapy (16). In multivariate analysis, negative predictors for starting treatment were female-sex, splenomegaly, ECOG ≥ 1. Patients with low IIL-Score had a better 5-year TFT (24%). The median TFT of the W&W cohort was 58.5 months; at 10 years, 17% of patients were still on W&W. Splenectomy and rituximab ± chemotherapy showed similar results, while chemotherapy alone proved inferior. This real-life single-centre study of SMZL confirmed its very good prognosis with a survival likelihood overlapping that of general population. The prognostic role of IIL-Score was confirmed. The W&W approach allowed a median PFS longer than in follicular lymphoma. Finally, our data confirm the inferiority of chemotherapy compared to splenectomy and rituximab±chemotherapy., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Background: Significance of splenic hilar node dissection with splenectomy is now denied for advanced gastric cancer of upper one-third of the stomach without invasion to the greater curvature by the Japan Clinical Oncology Group 0110, a pivotal randomized study from Japan. However, a question remains for tumors which involve the greater curvature, as this study excluded such tumors., Methods: We retrospectively analyzed 421 consecutive patients with gastric cancer who underwent curative total gastrectomy with splenectomy from 1992 to 2009. The survival curves, state of lymph node (LN) metastasis, and index of the estimated benefit from LN dissection of each station were evaluated according to the tumor location., Results: The incidence of No. 10 metastasis was 9.3 % (39/421), with 15.9 % in patients with tumors involving the greater curvature (Gre group, n = 132) and 6.2 % in those without (non-Gre group, n = 289) (P = 0.032). The 5-year overall survival (OS) of patients with and without No. 10 metastasis was 35.4 and 43.1 % (P = 0.135) in the Gre group and 32.8 and 66.5 % (P = 0.0006) in the non-Gre group, respectively. The index of No. 10 LN dissection was 5.6 and 2.0 in the Gre and non-Gre groups, respectively. In the Gre group, the index was relatively higher in patients aged < 65 years, within pT3, and with Borrmann type 4 tumors., Conclusions: Splenectomy may have a survival benefit when a tumor shows involvement with the greater curvature, especially in relatively young patients and those without serosal exposure.

Objective: To determine the percentage of dogs surviving to hospital discharge and identify factors associated with death prior to hospital discharge among dogs undergoing surgery because of primary splenic torsion (PST)., Design: Retrospective case series., Animals: 102 client-owned dogs., Procedures: Medical records of dogs with a confirmed diagnosis of PST that underwent surgery between August 1992 and May 2014 were reviewed. History, signalment, results of physical examination and preoperative bloodwork, method of splenectomy, concurrent surgical procedures, perioperative complications, duration of hospital stay, splenic histopathologic findings, and details of follow-up were recorded. Best-fit multivariate logistic regression was performed to identify perioperative factors associated with survival to hospital discharge., Results: 93 of the 102 (91.2%) dogs survived to hospital discharge. German Shepherd Dogs (24/102 [23.5%]), Great Danes (15/102 [14.7%]), and English Bulldogs (12/102 [11.8%]) accounted for 50% of cases. Risk factors significantly associated with death prior to hospital discharge included septic peritonitis at initial examination (OR, 32.4; 95% confidence interval [CI], 2.1 to 502.0), intraoperative hemorrhage (OR, 22.6; 95% CI, 1.8 to 289.8), and postoperative development of respiratory distress (OR, 35.7; 95% CI, 2.7 to 466.0). Histopathologic evidence of splenic neoplasia was not found in any case., Conclusions and Clinical Relevance: Results suggested that the prognosis for dogs undergoing splenectomy because of PST was favorable. Several risk factors for death prior to discharge were identified, including preexisting septic peritonitis, intraoperative hemorrhage, and postoperative development of respiratory distress.

The spleen is a crucial organ in humans. However, little is known about the association of venous thromboembolism (VTE) with splenic injury and splenectomy in trauma patients. The aim of this study was to determine the subsequent risk of VTE following splenic injury and splenectomy. A nationwide retrospective cohort study was conducted by analysing data from the National Health Insurance Research Database in Taiwan. We included 6,162 splenic injury patients (3,033 splenectomised and 3,129 nonsplenectomised patients) and 24,648 comparison patients who were selected by frequency match based on sex, age, and the index year during 2000-2006. All patients were followed until the occurrence of VTE, 31 December, 2011, death, or withdrawal from the insurance program. The age of patients with splenic injury was 41.93 ± 16.44 years. The incidence rates of VTE were 11.81, 8.46, and 5.21 per 10,000 person-years in the splenic injury patients with splenectomy, splenic injury patients without splenectomy, and comparison patients, respectively. Compared with the comparison cohort, splenic injury patients with splenectomy exhibited a 2.21-fold risk of VTE (95% confidence interval [CI], 1.43-3.43), whereas those without splenectomy exhibited a 1.71-fold risk of VTE (95% CI, 1.05-2.80). The overall incidence rate of VTE was 1.97-fold higher in the splenic injury cohort than the comparison cohort (95% CI, 1.38-2.81). Although splenectomy increased the risk of VTE 1.35-fold compared with no splenectomy, the difference was not statistically significant (95% CI, 0.74-2.45). These results may alert physicians and patients to the complications of splenic injury and splenectomy.

Background: The aim of this study was to evaluate the treatment reality for outpatients with immune thrombocytopenia (ITP) managed by hematologists in routine care., Patients and Methods: All patients with ITP diagnosed between 06/1995 and 12/2014 in a community-based oncology group practice in Germany were retrospectively analyzed., Results: 422 patients with a median age of 55 years (range 7-91 years) were evaluated. 57% were female and 43% male. Only 198 (47%) patients needed therapy. First-line therapy (n = 198) consisted of steroids in 81%, intravenous immunoglobulins (IVIG) in 12%, and IVIG plus steroids in 6%. Patients received a median of 2 (range 1-10) lines of therapy. The most frequently used treatment modalities were steroids in 93%, IVIG in 55%, splenectomy in 21%, and other immunosuppressive agents (OISA) in 23% of patients. Rituximab and thrombopoietin receptor agonists (TRAs) were used in 10% and 6% only. 9 (2%) patients needed hospitalization due to bleeding complications. 72% of patients achieved a durable remission after their last line of therapy. 1 (0.2%) patient died due to bleeding complications., Conclusion: The treatment modalities most frequently used are steroids, immunoglobulins, splenectomy, and OISA. Rituximab and TRAs are only used infrequently. 72% of ITP patients achieve durable remissions. The rate of hospital admissions due to bleeding complications and the ITP-related mortality are low. The majority of ITP patients can be safely managed by hematologists on an outpatient basis., (© 2015 S. Karger GmbH, Freiburg.)

Background: Despite all improvements in tumor diagnostics and treatment, pancreatic cancer is still the fourth leading cause of cancer-related death in the Western world. It is mostly diagnosed at a locally advanced or metastasized stage because of the lack of early symptoms. A radical margin-free surgical resection offers the only potential cure for locoregional disease. Over the last decades, several surgical strategies and techniques have evolved to optimize oncologic radical resections and thus to improve long-term outcome of patients., Purpose: The purpose of this review was to describe the various surgical strategies and techniques for locally advanced pancreatic cancer and to evaluate their influence on long-term outcome., Conclusions: Locally advanced pancreatic cancer should not generally be deemed unresectable. Various surgical techniques offer a good chance of margin-free tumor resection, even if surrounding organs or vessels are involved. Because of potentially higher peri- and postoperative morbidity rates, patients should be selected properly and are best treated in specialized high-volume centers.

This was a multi-institutional retrospective study evaluating the outcome and clinical parameters associated with the postoperative prognosis of 36 cats with splenic mast cell tumors treated with splenectomy. Clinical parameters reviewed included signalment, clinical history, results of staging tests, surgical variables, administration of blood products, presence of metastasis, postoperative complications, administration of chemotherapy postoperatively, chemotherapy protocol, and response to chemotherapy. Overall median survival time was 390 days (range, 2-1737 days). Administration of a blood product (P < .0001), metastasis to a regional lymph node (P = .022), and evidence of either concurrent or historical neoplasia (P = .037) were negatively associated with survival. Response to chemotherapy (P = .0008) was associated with an improved median survival time. Larger-scale prospective studies evaluating different chemotherapy protocols are required to elucidate the discrepancy between lack of survival benefit with administration of chemotherapy and improvement in survival time with positive response to chemotherapy.

Aim: To investigate whether the use of synchronous hepatectomy 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, 84 consecutive 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 long-term 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.

Objective: Esophageal cancer surgery carries a risk of splenic injury, which may require splenectomy, but predictors of such events remain uncertain. Moreover, the hypothesis that incidental splenectomy carries a worse prognosis deserves attention., Design: A population-based, nationwide cohort study was conducted on 1679 patients who underwent resection for esophageal cancer in Sweden in 1987 to 2010, with follow-up until February 2012. Predictors of splenic injury and incidental splenectomy were analyzed using multivariable logistic regression, providing odds ratios (ORs) with 95% confidence intervals (CIs). Associations between incidental splenectomy and risk of mortality and severe infections were analyzed using multivariable Cox regression, providing hazard ratios (HRs) with 95% CIs., Results: Higher surgeon volume of esophageal cancer resection decreased the risk of splenic injury and incidental splenectomy (OR: 0.58; 95% CI: 0.41-0.80; and OR: 0.41; 95% CI: 0.25-0.66, respectively, comparing the highest to lowest category). In patients with splenic injury, progression to incidental splenectomy decreased by 92% during the study period. Sex, age, tumor stage, previous abdominal surgery, neoadjuvant therapy, and surgical radicality did not influence these risks. Incidental accidental splenectomy increased the overall risk of mortality (HR: 1.29; 95% CI: 1.03-1.61) and severe infections (HR: 2.79; 95% CI: 1.35-5.79)., Conclusion: The inverse association between surgeon volume and splenic injury supports centralization of esophageal cancer surgery. The increased risk of mortality and severe infections after incidental splenectomy should be kept in mind during surgery, and we should encourage efforts to preserve an injured spleen and stress the relevance of vaccination after splenectomy.

Objective: The influence of surgical approaches on patients with gastric cancer with portal hypertension is unknown. The aim of the study was to investigate the outcomes in such patients who had undergone curative surgery for gastric cancer., Patients and Methods: The clinical data of 60 patients with portal hypertension undergoing curative surgery for gastric cancer or simultaneous surgery for portal hypertension were retrospectively analyzed., Results: Radical gastrectomy alone had no tremendous impact on postoperative liver function, but simultaneous surgery for portal hypertension affected patients' liver function dramatically (P<0.001). For those who underwent surgery for portal hypertension simultaneously, the incidence of complications on patients with Child's B was much higher than that of patients with Child's A (P<0.001). However, the incidence of complications did not differ between Child's A and Child's B patients who underwent radical gastrectomy alone. In addition, patients undergoing simultaneous surgery for portal hypertension displayed more severe complications than did those who underwent radical gastrectomy alone (P<0.001). Age, tumor stage, and simultaneous surgery for portal hypertension were the independent risk factors for the deterioration of liver function (P<0.05), and the survival time of patients undergoing simultaneous surgery for portal hypertension was significantly shorter than that of patients undergoing radical gastrectomy alone (P<0.05)., Conclusion: Individualized selection of surgical approaches for the treatment of gastric cancer with portal hypertension should be decided by preoperative liver function. Simultaneous management of portal hypertension was not advocated.

Aim: To study the feasibility and efficiency of transumbilical single-incision laparoscopic surgery splenectomy (SILS-Sp) using conventional instruments in consecutive patients and to compare outcomes of the procedure with those of standard multiple-incision laparoscopic splenectomy (MLS)., Patients and Methods: A retrospective review was conducted to evaluate all SILS-Sp procedures performed by a single surgeon between March 2010 and January 2013. Additionally, patients who underwent MLS by other surgeons in the same surgical group during the same period were evaluated to serve as a control group. Demographic data, operative parameters, and postoperative outcomes were assessed., Results: Thirteen patients underwent successful SILS-Sp during the study period without conversion to an open procedure or requiring additional ports. The median operative time was 165 minutes. There was 7.7% morbidity and no mortality in the study group. Median length of stay was 8.8 days. Additionally, 12 patients who underwent MLS were evaluated for comparison. No significant differences were identified in the preoperative patient characteristics between the two groups. For MLS, the median operative time was 158 minutes. There was 8.3% morbidity and no mortality in the group. Median length of stay was 8.3 days. SILS-Sp using conventional instruments was associated with reduced postoperative pain scores, but this did not reach statistical significance. The operative time, conversion rate, and length of stay were equivalent. The mortality, morbidity, and cost were also similar in the two groups. The umbilical incision of the single-incision group can be easily hidden in the umbilical fold with ideal cosmetic result., Conclusions: SILS-Sp is feasible and efficient in an unselected patient population in the hands of an experienced laparoscopic surgeon. The single-incision technique is comparable to standard laparoscopic splenectomy in terms of operative time and perioperative outcomes. Ideal cosmetic effect may be its potential advantage.

Importance: Splenectomy is a commonly performed operation; however, data from large series regarding operative outcomes to help guide decision making and informed consent are lacking., Objective: To evaluate clinical and pathologic variables associated with morbidity and mortality following elective splenectomy for benign and malignant hematologic conditions in the United States., Design, Setting, and Participants: A review of the American College of Surgeons National Surgical Quality Improvement Program data for elective splenectomy between January 1, 2005, and December 31, 2011, was performed, and 1715 eligible individuals were identified., Intervention: Elective splenectomy for hematologic conditions., Main Outcomes and Measures: Complications and operative mortality were evaluated for the entire cohort and compared between patients with benign vs malignant diseases. Multivariable logistic regression was used to evaluate factors predictive of operative complications and death., Results: Splenectomy was performed in 1344 patients (78.4%) for benign disease and in 371 patients (21.6%) for malignant disease. Two hundred ninety-one patients (17.0%) had a complication, and operative mortality occurred in 27 patients (mortality rate, 1.6%). Patients treated for malignant disease had a higher rate of overall complications (27.2%) compared with patients treated for benign disease (14.1%) (P < .001). Several variables were independent predictors of complications, including malignant disease (vs benign) (Odds Ratio [OR], 1.86; 95% CI, 1.23-2.80; P = .003), independent performance status (vs dependent) (OR, 0.33; 95% CI, 0.07-1.52; P = .02), and increasing albumin level (OR, 0.75; 95% CI, 0.66-0.86; P < .001). Increasing age (OR, 1.03; 95% CI, 1.00-1.06; P = .05) was an independent predictor of mortality while increasing albumin level (OR, 0.63; 95% CI, 0.46-0.86; P = .003) predicted lower risk of operative death. From these data, a patient older than 60 years with a low preoperative albumin level has a predicted probability for operative death as high as 10.0%., Conclusions and Relevance: Preoperative performance and nutritional status are significant risk factors for complications and mortality following elective splenectomy. Although operative mortality continues to decrease over time, specific preoperative variables may help with patient selection before elective splenectomy for certain patients.

Background: Over the past 2 decades, laparoscopy has been established as a superior technique in many general surgery procedures. Few studies, however, have examined the impact of the use of a laparoscopic approach in patients with symptomatic congestive heart failure (CHF). Because pneumoperitoneum has known effects on cardiopulmonary physiology, patients with CHF may be at increased risk. This study examines current trends in approaches to patients with CHF and effects on perioperative outcomes., Methods: The 2005-2011 National Surgical Quality Improvement Program Participant User File was used to identify patients who underwent the following general surgery procedures: Appendectomy, segmental colectomy, small bowel resection, ventral hernia repair, and splenectomy. Included for analysis were those with newly diagnosed CHF or chronic CHF with new signs or symptoms. Trends of use of laparoscopy were assessed across procedure types. The primary endpoint was 30-day mortality. The independent effect of laparoscopy in CHF was estimated with a multiple logistic regression model., Results: A total of 265,198 patients were included for analysis, of whom 2,219 were identified as having new or recently worsened CHF. Of these patients, there were 1,300 (58.6%) colectomies, 486 (21.9%) small bowel resections, 216 (9.7%) ventral hernia repairs, 141 (6.4%) appendectomies, and 76 (3.4%) splenectomies. Laparoscopy was used less frequently in patients with CHF compared with their non-CHF counterparts, particularly for nonelective procedures. Baseline characteristics were similar for laparoscopy versus open procedures with the notable exception of urgent/emergent case status (36.4% vs 71.3%; P < .001). After multivariable adjustment, laparoscopy seemed to have a protective effect against mortality (adjusted odds ratio, 0.45; P = .04), but no differences in other secondary endpoints., Conclusion: For patients with CHF, an open operative approach seems to be utilized more frequently in general surgery procedures, particularly in urgent/emergent cases. Despite these patterns and apparent preferences, laparoscopy seems to offer a safe alternative in appropriately selected patients. Because morbidity and mortality were considerable regardless of approach, further understanding of appropriate management in this population is necessary., (Copyright © 2014 Mosby, Inc. All rights reserved.)

Background/aims: Hepatocellular carcinoma (HCC) mainly arises from underlying liver disease. Complicated liver cirrhosis and secondary hypersplenism are the most risk factors preventing surgical treatment of patients with HCC. The present study aimed at investigating the safety and long term outcome of patients with HCC and liver cirrhosis undergoing synchronous hepatectomy and splenectomy., Methodology: The clinical data of 306 cases of patients with HCC and liver cirrhosis undergoing curative hepatectomy were reviewed. 18 cases underwent synchronous hepatectomy and splenectomy. The rest 288 cases of HCC with hepatectomy only were compared in aspects of clinicopathological and surgical variables and surgical outcomes., Results: Preoperative hemoglobin and platelet count were significantly lower in splenectomy than non-splenectomy group (p<0.01, respectively). Patients undergoing combined splenectomy and hepatectomy needed longer surgery time and hospital stay time, and transfused much more blood intraoperatively (p=0.07, 0.03, and 0.02), and also experienced more portal vein thrombosis (p<0.01). The level of hemoglobin and platelet increased after splenectomy and finally to normal level one month postoperatively. There was no statistical difference of overall and disease-free survival of patients in splenectomy and non-splenectomy groups (p>0.05)., Conclusions: With strict selection, patients with HCC and hypersplenism could undergo combined splenectomy and hepatectomy safely.

Liver transplantation for autoimmune hepatitis (AIH) is usually successful with excellent long-term outcomes, but primary disease may recur. The recurrence of AIH is a significant cause of graft loss. This study was to analyze the effect of splenectomy in preventing AIH relapse. The clinical courses of 12 patients who had transplantation for AIH were analyzed retrospectively. All patients were subjected to transplantation for end-stage liver disease caused by chronic AIH. Based on the duration of immunosuppressive treatment before liver transplantation, simultaneous splenectomy was performed in ten patients. Two patients underwent liver transplantation without splenectomy, one of them developed recurrent AIH and died from graft failure caused by AIH relapse. However, no episode of AIH recurrence was observed in patients who had undergone simultaneous splenectomy. Splenectomy might be an option to prevent AIH relapse in some patients with high risk factors.