Gemma Cerdán

Effect of spleen size on splenectomy outcome. A comparison of open and laparoscopic surgery.

AbstractBackground: Laparoscopic splenectomy (LS) is gaining acceptance as an alternative to open splenectomy (OS). However, splenomegaly presents an obstacle to LS, and massive splenomegaly has been considered a contraindication. Analyses comparing the procedure with the open approach are lacking. The purpose of this study was to analyze the effect of spleen size on operative and immediate clinical outcome in a series of 105 LS compared with a series of 81 cases surgically treated by an open approach. Methods: Between January 1990 and November 1998, 186 patients underwent a splenectomy for a wide range of splenic disorders. Of these patients, 105 were treated by laparoscopy (group I, LS; data prospectively recorded) and 81 were treated by an open approach (group II, OS analyzed retrospectively). Patients also were classified into three groups according to spleen weight: group A, <400 g; group B, 400–1000 g; and group C, >1000 g. Age, gender, operative time, perioperative transfusion, spleen weight, conversion rate, mode of spleen retrieval (bag or accessory incision), postoperative analgesia, length of stay, and morbidity were recorded in both main groups. Results: Operative time was significantly longer for LS than for OS. However, LS morbidity, mortality, and postoperative stay were all lower at similar spleen weights. Spleens weighing more than 3,200 g required conversion to open surgery in all cases. When LS outcome for hematologic malignant diagnosis was compared with LS outcome for a benign diagnosis, malignancy did not increase conversion rate, morbidity, and transfusion, even though malignant spleens were larger and accessory incisions were required more frequently. Postoperative hospital stay was significantly longer in malignant than in benign diagnosis (5 ± 2.4 days vs. 4 ± 2.3 days; p < 0.05). Conclusions: In patients with enlarged spleens, LS is feasible and followed by lower morbidity, transfusion rate, and shorter hospital stay than when the open approach is used. For the treatment of this subset of patients, who usually present with more severe hematologic diseases related to greater morbidity, LS presents potential advantages.

Hand-assisted laparoscopic splenectomy (HALS) in cases of splenomegaly

Background: Laparoscopic splenectomy (LS) is considerably more difficult to perform when the spleen is enlarged. The new technique of hand-assisted designed technique aimed to assist laparoscopic surgery allows the surgeon to insert his or her hand into the abdomen while maintaining the pneumoperitoneum, thus recovering the tactile sensation lost in conventional laparoscopic surgery. Object: In this study, we compared the immediate results of conventional LS and hand-assisted LS (HALS) in cases of splenomegaly. Methods: Between February 1993 and August 2001, 200 LS were attempted at two university hospitals. In 56 cases, splenomegaly (final spleen weight >700 g) was observed clinically or detected on radiological examination. We compared the first 36 patients operated on by conventional LS (group I) with the last consecutive 20 patients, who underwent HALS (group II). The study parameters were operative time, conversion rate, transfusion rate, morbidity and length of hospital stay. Results: The groups were comparable in terms of age (58 ± 13 [ranges, l9–82] vs 58 ± 16 years [range, 44–84] (ns), diagnosis, and spleen weight (1425 ± 884 [range, 700–3400]) vs 1753 ± 1124 g [range, 720–4500] (ns). HALS was associated with less morbidity (36% vs 10%) (ns), a shorter operative time (177 ± 52 [range, 95–300]) vs 135 ± 53 min [range, 85–270] (p <0.009), and a shorter hospital stay (6.3 ± 3.3 [range, 3–14]) vs 4 ± 1.2 [range, 2–7] days (p <0.05). Conclusion: In cases of splenomegaly, HALS assisted laparoscopic surgery significantly facilitates the surgical maneuvers during LS while maintaining the advantages of a purely laparoscopic approach.

Impact of hematological diagnosis on early and late outcome after laparoscopic splenectomyrid

AbstractBackground: Laparoscopic splenectomy (LS) is now regarded as the treatment of choice for autoimmune thrombopenia (ITP). However, there have been few reports describing the application of LS to other splenic diseases, such as malignant entities and conditions associated with splenomegaly. Hematological diseases have specific clinical features that can influence immediate outcome after LS. Although the long-term effects of LS are unknown, a risk of splenosis has been suggested. Therefore, we designed a study to analyze the impact of primary hematological disease on immediate and late outcome in a prospective series of LS patients. Methods: We performed a prospective analysis of 111 LS done between February 1993 and March 1999. The patients were classified by hematological indications into the following four groups: (a) group 1, low platelet count. This group was further subdivided into group 1A, idiopathic thrombocytopenic purpura (ITP) (n= 48) and group 1B, HIV-related ITP (n= 8); (b) group 2, anemia. This group was further subdivided into group 2A, autoimmune hemolytic anemia (n= 8), and group 2B, spherocytosis (n= 11); (c) group 3, malignancy (n= 28); and (d) group 4, others (n= 8). Immediate outcomes were recorded prospectively. Hematological status and late complications were reviewed after a mean follow-up of 24 ± 18 months. Results: There were no significant differences between the groups in terms of conversion, transfusion requirements, and morbidity, although transfusion and morbidity were slightly higher in group 3. However, hospital stay was significantly longer in groups 3 and 4 than in groups 1 and 2. Long-term follow-up showed satisfactory hematological results in ≥75% of patients (group 1A, 82%; group 1B, 88%; group 2A, 88%; group 2B, 100%; group 3, 75%; group 4, 88%). Overall, late morbidity was 8.3% and mortality was 6.2%, mainly due to deaths in group 4 (six of 22 patients). Conclusion: LS is a safe and reproducible procedure for most hematological indications, with a similar immediate outcome for benign diseases and a long-term hematological response comparable to the standard results that have been observed in open series.

Results of laparoscopic splenectomy for treatment of malignant conditions

BACKGROUND Laparoscopic splenectomy (LS) is widely accepted for treatment of benign diseases, but there are few reports of its use in cases of haematological malignancy. In addition, comparative studies with open operation are lacking. Malignant haematological diseases have specific clinical features-notably splenomegaly and impaired general health-which can impact on the immediate outcome after LS. The immediate outcome of LS comparing benign with malignant diagnoses has been analysed in a prospective series of 137 operations. PATIENTS AND METHODS Between February 1993 and April 2000, 137 patients with a wide range of splenic disorders received LS. Clinical data and immediate outcome were prospectively recorded,and age, diagnosis, operation time, perioperative transfusion requirement, spleen weight, conversion rate, accessory incision, hospital stay and complications were analysed. RESULTS The series included 100 benign cases and 37 suspected malignancies. In patients with malignant diseases the mean age was greater (37 years [3-85] vs 60 years [27-82], p<0.01), LS took longer (138 min [60-400] vs 161 min [75-300], p<0.05) and an accessory incision for spleen retrieval was required more frequently (18% vs 93%, p<0.01) because the spleen was larger (279 g [60-1640] vs 1210 g [248-3100], p <0.01). However, the rate of conversion to open operation (5% vs 14%), postoperative morbidity rate (13% vs 22%) and transfusion requirement (15% vs 26%) did not differ between benign and malignant cases. Hospital stay was longer in malignant cases (3.7 days [2-14] vs 5 days [2-14], p<0.05). CONCLUSION LS is a safe procedure in patients with malignant disease requiring splenectomy in spite of the longer operative time and the higher conversion rate.

Cirugía laparoscópica asistida con la mano

Resumen Introduccion El principal inconveniente de la cirugia laparoscopica convencional es la perdida de la sensacion tactil. En los ultimos meses se han desarrollado diversos dispositivos que han permitido reconsiderar el concepto de cirugia laparoscopica asistida con la mano (CLAM), que constituye un tipo hibrido de cirugia que mantiene las caracteristicas de la CL (mejor vision y mas detallada) con la recuperacion del tacto. Objetivo Revision del estado de conocimiento actual de la CLAM. Resultados La CLAM ha sido utilizada para efectuar la mayoria de las intervenciones laparoscopicas digestivas, asi como urologicas, ginecologicas y vasculares, con buenos resultados iniciales, aunque en la mayoria de los casos no existen datos comparativos basados en evidencias con la cirugia abierta convencional o la laparoscopica pura. Conclusion La cirugia laparoscopica asistida con la mano puede ser una interesante alternativa a la CL convencional o a la cirugia abierta, facilitando la realizacion de intervenciones complejas a cirujanos expertos o la iniciacion en CL avanzada de los cirujanos menos entrenados. Se requieren estudios comparativos con las tecnicas laparoscopicas bien establecidas para definir sus ventajas definitivas, pero puede ser un recurso antes de la conversion a cirugia abierta, ante la evidencia inicial de que mantiene las ventajas de la CL.

Complicaciones abdominales graves en los pacientes sometidos a trasplante cardíaco: el problema de la inexpresividad clínica

INTRODUCTION In transplanted patients, immunosuppressive drugs can mask habitual pathologies that impede their diagnoses and management. Abdominal pathology gives up to 2-20%, 50% of which is surgical, with a mortality of 10-40%. The most frequently detected pathologies are: acute pancreatitis, peptic ulceration and intestinal obstruction. OBJECTIVES To determine the alarm parameters, more adequate diagnostic procedures and the most frequent causes of morbidity and mortality in order to attempt to avoid them. METHODS In our center 225 heart transplantations were performed from May 1984 to October 1997. The severe abdominal complications, time of appearance, implication of immunosuppressive drugs and presence of rejection were studied in these patients. RESULTS 35 severe abdominal complications were detected (incidence 12.9%), with the majority differing (> 1 year following transplant). The most frequently detected pathologies were digestive hemorrhages and perforations. Acute pancreatitis was 11%. The immunosuppressive drugs used were prednisona, cyclosporin and azathioprine. In 12 out of 29 patients the abdominal complication was in the context of acute rejection. CONCLUSIONS Even with some non-specific abdominal symptoms in these group of patients it is important to rule out severe pathologies such as acute pancreatitis or empty viscera perforation. The detection of amylases and lypases in the blood and an echographic or tomographic abdominal study should be performed early with a digestive hemorrhage it is important to perform an endoscopy. If the surgical intervention seems imminent its better to perform it without any delay, because it has been demonstrated that the delay is worse than the probable rejection.

Resultados a medio plazo y calidad de vida del tratamiento laparoscópico de la hernia de hiato paraesofágica

Resumen Introduccion La reparacion laparoscopica de las hernias paraesofagicas (HPE) y mixtas es factible, con excelentes resultados inmediatos y a corto plazo. De todas formas, se han observado tasas de recidiva de hasta el 40% en el seguimiento a medio plazo. La utilizacion de escalas de calidad de vida permite evaluar con mas exactitud el impacto del tratamiento quirurgico en el estado de salud global de los pacientes, pero no se dispone de informacion sobre la calidad de vida postoperatoria en relacion con el tratamiento laparoscopico de las HPE y sus recidivas. Objetivo Evaluar prospectivamente la presencia de recidivas anatomicas y/o sintomaticas y su correlacion con la calidad de vida en pacientes intervenidos de HPE o mixtas. Material y metodo Se revaluo a todos los pacientes intervenidos por laparoscopia de una HPE o mixta entre febrero de 1998 y marzo del 2003. A todos ellos se les practico un esofagograma, se analizaron sus sintomas y se les efectuo una entrevista en la que respondieron a varios tests de calidad de vida: Short Form-36 (SF-36), Glasgow Dyspepsia Severity Score (GDSS) y Gastrointestinal Quality of Life Score (GIQLI). Resultados Durante el periodo de estudio se intervino a 46 pacientes, con una media de edad 68 anos (rango, 22-81). En 37 fue posible realizar un seguimiento minimo de 6 meses. Ocho pacientes (8/37, 21%) refirieron sintomas postoperatorios de origen gastrointestinal. Se practico un esofagograma en 30 pacientes (30/37, 81%), que mostro una recidiva en 6 (20%). Los tests de calidad de vida tipo SF-36 y GDSS no mostraron diferencias significativas con los valores estandar de la poblacion espanola con una edad y comorbilidad similares. Los pacientes sin recidiva alcanzaron valores con la escala GIQLI comparables a los de la poblacion general. Los pacientes con recidiva clinica mostraron valores significativamente inferiores a los del grupo no recidivado o a los del grupo con recidiva solo radiologica. Conclusion El tratamiento laparoscopico de la HPE y mixta es factible, seguro y ofrece una buena calidad de vida a medio plazo. Sin embargo, la incidencia de recidivas anatomicas y funcionales es elevada, por lo que es necesario identificar el subgrupo de pacientes con riesgo de fracaso y las tecnicas alternativas para garantizar la durabilidad de la reparacion quirurgica.

Complicaciones abdominales graves en los pacientes sometidos a trasplante cardíaco: el problema de la inexpresividad clínicaSevere Abdominal Complications in Patients Subjected to Cardiac Transplantation: The Problem of Clinical Inexpressiveness

Introduccion. En pacientes trasplantados, los farmacos inmunodepresores provocan un enmascaramiento de enfermedades habituales, lo que hace dificil su diagnostico y tratamiento. La enfermedad abdominal tiene lugar en un 2-20%, siendo quirurgica en un 50%, con una mortalidad de 10-40%. Las enfermedades mas frecuentemente detectadas son: pancreatitis aguda, ulcus peptico y obstruccion intestinal. Objetivos. Determinar los parametros de alarma, los procesos diagnosticos mas adecuados y las causas de morbimortalidad mas frecuentes para intentar evitarlas. Metodos. En nuestro centro se practicaron 225 trasplantes cardiacos entre mayo 1984 y octubre 1997. Se valoraron las complicaciones abdominales graves en estos pacientes, momento de aparicion, implicacion de farmacos inmunodepresores y presencia de rechazo agudo. Resultados. Se detectaron 35 complicaciones abdominales graves (incidencia del 12,9%), siendo la mayoria diferidas (> 1 ano postrasplante). Las enfermedades mas frecuentemente detectadas fueron las hemorragias digestivas y las perforaciones. Las pancreatitis ocurrieron en un 11% de los casos. Los farmacos inmunodepresores usados fueron prednisona, ciclosporina y azatioprina. En 12 de 29 pacientes la complicacion abdominal tuvo lugar en el contexto de rechazo agudo. Conclusiones. Ante la aparicion de una clinica abdominal inespecifica en estos pacientes es obligatorio descartar enfermedades graves, como pancreatitis o perforacion de viscera hueca. La deteccion de amilasas y lipasas en sangre y una ecografia o tomografia abdominal deben practicarse de forma temprana. Ante una hemorragia digestiva es obligatorio practicar una endoscopia. Si la intervencion quirurgica parece inminente, no se debe dudar, ya que se ha demostrado que es peor la demora que el probable rechazo.