Xin Wang, MD, Yongbin Li, MD, Mingjun Wang, MD, Zhengguo Yang, MD, Bing Peng, MD, PhD, Shuangchen Ke
West China Hospital, Sichuan University, Chengdu, China
Instruction: The aim of this study was to evaluate the operative and clinical outcome in a series of 302 consecutive laparoscopic splenectomies and to analyze the risk factors of postoperative complications.
Methods and Procedures: We retrospectively reviewed 302 consecutive patients who underwent laparoscopic splenectomy by a single surgeon between 2003 and 2012. The patients were classified into three groups according to clinical diagnosis: benign spleen-related disease (Group1, n=196), malignant spleen-related disease (Group2, n=42) and splenomegaly secondary to portal hypertension (Group3, n=64). Hand-assisted technique was selectively applied in a number of patients with supramassive splenomegaly (spleen size>22cm) and patients with splenomegaly secondary to portal hypertension at the discretion of the surgeon. Comparisons were conducted among the three groups in terms of perioperative data. Postoperative complications were classified into three groups according to the Clavien-Dindo Classification of Surgical Complications and our previous experience: no complications, mild complications (grade I and grade II in Clavien-Dindo classification) and severe complications (grade III and above in Clavien-Dindo classification). Multivariate logistic regression was used to analyze the independent risk factors of postoperative complications. Other statistical methods applied in our study included Analysis of Variance, Chi-square test and Fisher’s exact test.
Results: In these comparisons among the three groups, patients in Group1 were younger and had higher BMI, lower ASA score and smaller spleen than the other two groups with statistical significance. There were fewer patients in Group1 requiring hand-port than the other two groups: 5 out of 196 patients in Group1; 20 out of 42 patients in Group2; 25 out of 64 patients in Group3. Group1 had significantly lower operative times (117±52 vs 142±59, 181±58), required fewer transfusions (5.1% vs 19%, 23%), had lower incidence of complications (15% vs 38%, 39%) and shorter postoperative stays (7.2±2.8 vs 10.2±5.6, 8.4±2.9) than Group2 and Group3. Compared to Group1, Group3 had significantly more blood loss (196±272 vs 93±103) during the surgery. In the analysis of complications, high ASA score was an independent risk factor for occurrence of complications. Both high ASA score and larger spleen size were independent risk factors for occurrence of severe complications. Compared with total laparoscopic splenectomy, data including the hand-assisted cases showed a reduction in OR (odds ratio) of both occurrence of complications and occurrence of severe complications. In patients who underwent total laparoscopic splenectomy (n=252), patients with supramassive splenomegaly were 22 times (OR) more likely to suffer from severe complications than patients with normal spleen size (<15cm). However, with the help of hand-assisted technique (n=302), the OR (supramassive splenomegaly/normal spleen) decreased to 6.713.
Conclusions: Although the treatment of malignant spleen-related disease and portal hypertension with laparoscopic splenectomy is more challenging than for benign disease, it is still safe and effective for these patients. High ASA scores is an independent risk factor for occurrence of complications while high ASA scores and larger spleen size are both independent risk factors for occurrence of severe complications. The appropriate introduction of hand-assisted technique may facilitate the laparoscopic procedure and reduce postoperative complications.
Session: Podium Presentation
Program Number: S092