Laparoscopic Splenectomy for Massive Splenomegaly in Older Adults

Jonathan G Bailey, MD, Dennis Klassen, MD, FRCSC

Department of Surgery, Division of General Surgery, Dalhousie University

Introduction: In the United States, the proportion of people over the age of 60 is projected to increase from 18% in 2009 to 27% by 2050. In the setting of massive splenomegaly authors initially raised concerns about laparoscopic splenectomy, however more recent studies have shown positive results in adults. Studies have found that laparoscopic splenectomy in older adults is associated with low rates of morbidity and mortality, but it is unclear if that is true for older adults with massive splenomegaly. The primary objective of this study is to compare rates of complications and mortality between older adult patients (>65 years) with massive splenomegaly versus older adults without massive splenomegaly undergoing laparoscopic splenectomy (conventional or hand assisted).

Methods: Patients (>65 years) undergoing laparoscopic splenectomy (conventional or hand assisted) at a tertiary care center between January 1, 2003 and July 31, 2011 were included. Patients who underwent urgent or emergent splenectomy were excluded. A retrospective chart review was utilized to extract demographic information and postoperative outcomes. Baseline characteristics and clinical outcomes were compared between those patients with and those without massive splenomegaly (defined as a splenic mass of >1000gm as reported by pathology). Independent t-tests were used for continuous data and chi-squared tests for binary and ordinal data.

Results: Fifty eight patients were included for analysis. Mean age, BMI and Charlson comorbidity index (CCI) for the cohort were 74.5 (range 65.0-88.6) years, 27.2 (range 17.0-39.0) kg/m2 and 1.9 (range 0.0-6.0) CCI, respectively. 33 of 58 patients, (56.9%) were male, 53 (91.4%) had at least one comorbidity and 44 (75.9%) had two or more comorbidities. Mean follow up length for the cohort was 858.0 (+/-761.1) days. There were 19 patients with and 39 without massive splenomegaly (>1000gm). Mean splenic mass was 2497.4 (+/-1382.0)gm and 316.5 (+/-286.6)gm for the two groups. There was no statistical difference for baseline characteristics or follow up period between the two groups, except for splenic mass. Patients with massive splenomegaly were more likely to undergo hand assisted splenectomy (94.7%) compared to those without massive splenomegaly (10.3%; p<0.0001). Older adults with massive splenomegaly had longer operative times (172.8+/-33.7 versus 128.0+/-62.9min, p=0.0008) and longer lengths of stay (11.5+/-11.3 versus 3.5+/-3.3 days, p=0.0066). Patients with massive splenomegaly were more likely to be transfused (7(58.3%) versus 5(41.7%), p=0.0390) and to experience a complication (17(89.5%) versus 17(43.6%), p=0.0004). However, only 7(12.1%) patients experienced a major complication, with no statistical difference between groups. The one year mortality rate was higher among patients with massive splenomegaly (4(21.1%) versus 1(2.6%), p=0.0225). There were no conversions to open surgery in either group.

Conclusion: Older adult patients with massive splenomegaly experience longer operative times, longer hospital stays and more complications. Older patients undergoing splenectomy for massive splenomegaly should be made aware of the high rate of morbidity and mortality. However, few major complications occurred and the high one year mortality rate is likely a reflection of the underlying disease process. Additional studies need to examine changes in quality of life after laparoscopic splenectomy in this population.

Session: Poster Presentation

Program Number: P663

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