Paolo Torelli

Laparoscopic splenectomy: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES)

BackgroundAlthough laparoscopic splenectomy (LS) has become the standard approach for most splenectomy cases, some areas still remain controversial. To date, the indications that preclude laparoscopic splenectomy are not clearly defined. In view of this, the European Association for Endoscopic Surgery (EAES) has developed clinical practice guidelines for LS.MethodsAn international expert panel was invited to appraise the current literature and to develop evidence-based recommendations. A consensus development conference using a nominal group process convened in May 2007. Its recommendations were presented at the annual EAES congress in Athens, Greece, on 5 July 2007 for discussion and further input. After a further Delphi process between the experts, the final recommendations were agreed upon.ResultsLaparoscopic splenectomy is indicated for most benign and malignant hematologic diseases independently of the patient’s age and body weight. Preoperative investigation is recommended for obtaining information on spleen size and volume as well as the presence of accessory splenic tissue. Preoperative vaccination against meningococcal, pneumococcal, and Haemophilus influenzae type B infections is recommended in elective cases. Perioperative anticoagulant prophylaxis with subcutaneous heparin should be administered to all patients and prolonged anticoagulant prophylaxis to high-risk patients. The choice of approach (supine [anterior], semilateral or lateral) is left to the surgeon’s preference and concomitant conditions. In cases of massive splenomegaly, the hand-assisted technique should be considered to avoid conversion to open surgery and to reduce complication rates. The expert panel still considered portal hypertension and major medical comorbidities as contraindications to LS.ConclusionDespite a lack of level 1 evidence, LS is a safe and advantageous procedure in experienced hands that has displaced open surgery for almost all indications. To support the clinical evidence, further randomized controlled trials on different issues are mandatory.

Laparoscopic splenectomy for hematologic diseases: a preliminary analysis performed on the Italian Registry of Laparoscopic Surgery of the Spleen (IRLSS).

BackgroundThe Italian Registry of Laparoscopic Surgery of the Spleen (IRLSS) was developed to provide at the national level an informative tool useful for performing multicenter studies in the field of spleen laparoscopic surgery. In this first study analyzing the IRLSS data, a cohort of patients with hematologic diseases was retrospectively investigated for potential predictive parameters that could affect the outcome of laparoscopic splenectomy.MethodsA total of 309 patients who underwent laparoscopic splenectomy for hematologic diseases in 17 Italian centers (between February 1, 1993, and September 30, 2004) were entered in the IRLSS. Their records were analyzed retrospectively by the Student’s t-test, chi-square, and logistic regression.ResultsThe mean operative time was 141 min (range, 30–420 min). Conversion was necessary in 21 cases (7%), and approximately 1 accessory spleen in 25 patients (9%) was found. The mean spleen weight was 1191 g (range, 85–4,500 g). Perioperative death occurred in two cases (0.6%). No complications were experienced by 253 patients (81.9%), who had a mean hospital stay of 5.4 days (range, 2–30 days). Overall morbidity occurred in 56 patients (18.1%), mainly associated with transient fever (n = 22), pleural effusion (n = 13), and actual or suspected hemorrhage (n = 12), requiring a reintervention for 7 patients. Multivariate analysis found that body mass index (p = 0.024) and clinical indication (p = 0.004) were independent predictors for surgical conversion. The clinical indication was almost significant as an independent predictor for the occurrence of postoperative complication (p = 0.05).ConclusionsThis first study analyzing the IRLSS data shows that laparoscopic splenectomy may represent the gold standard treatment for hematologic diseases with normal-size spleen. The low morbidity and mortality rate suggests that laparoscopic splenectomy can be successfully proposed also for splenomegaly in hematologic malignancies.

Laparoscopic splenectomy for hematological diseases

BackgroundWe reviewed retrospectively the records of all patients who underwent laparoscopic splenectomy (LS) at our institution for a wide range of hematological disorders. We compared our experience to those reported in the literature and analyzed various aspects of the treatment that are still under discussion and in need of confirmation, such as the treatment of malignant blood diseases, the indication in case of splenomegaly, and the adequacy of the detection of accessory spleens.MethodsBetween June 1997 and June 2001, we performed 43 LS. The patients were classified into three groups according to clinical diagnosis: idiopathic thrombocytopenic purpura (ITP) (n=23), hemolytic anemia (HA) (n=5) and hematological malignancy (HM) (n=15). Statistical analyses were done to compare the three groups.ResultsLS was completed in 41 patients, with a conversion rate of 5%. Splenomegaly was present in 37% of all patients (73% of HM). Mean operative time was 128 min. The incidence of accessory spleens was 20%. A concomitant laparoscopic procedure was done in three cases (cholecystectomy). Postoperative complications occurred in eight patients (18%). Duration of surgery, length of hospital stay, transfusions rate, and some demographics features, such as age and spleen weight and length, were significantly different in each group. No deaths were attributed to the procedure.ConclusionsThe statistical analysis of our series shows that, the laparoscopic approach reliable even in the management of malignant and nonmalignant blood diseases.

Putative predictive parameters for the outcome of laparoscopic splenectomy: a multicenter analysis performed on the Italian Registry of Laparoscopic Surgery of the Spleen.

Objective:To identify predictive risk factors for conversion to open splenectomy and postoperative complications in patients undergoing elective laparoscopic splenectomy. Background:The laparoscopic approach represents the “gold standard” for splenectomy, but its use in the treatment of splenomegaly and malignant disease is controversial. Factors that influence immediate outcome are clinical, anatomic, and pathologic. Methods:Univariate and multivariate analyses of data from the Italian Registry of Laparoscopic Surgery of the Spleen, a multicenter database supported by 25 referral centers. Analysis of data (1993–2007) was performed on a series of patients (n = 676) undergoing elective laparoscopic splenectomy. Demographic data, the operative indications, the surgical technique applied, and any intra- and/or postoperative complications with respect to the patients were assessed. Records were analyzed retrospectively using the Student t test, the &khgr;2 test, and logistic regression. Results:Conversion to open splenectomy was necessary in 39 cases (5.8%). Perioperative deaths occurred in 3 cases (0.4%). There were no complications in 560 patients (82.8%), with a mean hospital stay of 5 days (range, 2–54). Overall, morbidity occurred in 116 patients (17.2%). Multivariate analysis found that the body mass index (P = 0.01) and the presence of hematologic malignancy (P < 0.001) were independent predictors for intraoperative complications and surgical conversion. Spleen longitudinal diameter (P = 0.001) and surgical conversion (P = 0.001) were independent predictors for the occurrence of postoperative complications. Conclusions:This large multicenter study provides evidence for the significance of predictive risk factors for intra- and postoperative complications in laparoscopic splenic surgery. Besides splenic dimensions, other factors like the patients habitus and the specific underlying hematologic pathology should be recognized by the surgeon to reduce complications and initiate adequate treatment.

Laparoscopic lymph node biopsy in intra-abdominal lymphoma: high diagnostic accuracy achieved with a minimally invasive procedure.

Ultrasound or computed tomography-guided percutaneous lymph nodes biopsy often do not supply sufficient tissue for the histopathologic diagnosis of a lymphoma. Laparoscopic lymph node biopsy (LLB) has the advantage of obtaining the entire lymph node and avoiding the invasivity and all the possible complications of a laparotomy. The aim of the present study is to assess the safety and diagnostic accuracy of the LLB in intra-abdominal lymphoma. Between April 1999 and October 2005, 36 LLB were performed in 35 patients to rule out or to follow the progression of a lymphoma. The clinical outcome and the pathology reports were analyzed retrospectively. A conversion to laparotomy was necessary in 2 cases due to intraoperative difficulties (5.8%). No major postoperative complications or mortality occurred. Mean hospital stay was 2.1 days. In 9 patients, LLB was performed to follow a possible progression of the lymphoma, whereas in 26 patients it was used to establish a diagnosis. Two repeated LLB were necessary to achieve a correct diagnosis in 1 patient. Fourteen patients had non-Hodgkin lymphoma, 6 patients had Hodgkin lymphoma, 9 patients presented an infiltration by primitive or metastatic tumors, and 7 patients had benign lymphadenopathy. In 97% of the cases, LLB supplied the necessary information for the correct diagnosis, classification, and subsequent therapeutic decisions. In conclusion, LLB is a safe and effective procedure. Its diagnostic accuracy is superior to percutaneous techniques. LLB can be proposed as the procedure of choice to sample deep lymphatic tissues in patients with intra-abdominal lymphadenopathy at a very low morbidity rate and as an outpatient procedure in selected cases.

Outcome of laparoscopic splenectomy for malignant hematologic diseases

Aim The role of laparoscopic splenectomy in the treatment of hematological diseases is still controversial. The aim of this study was to assess whether the benign or malignant nature of hematological diseases may influence the outcome of laparoscopic splenectomy. Patients and methods Between August 1997 and March 2002, 63 unselected patients with hematologic diseases underwent a laparoscopic splenectomy. Patients were divided into two groups according to the benign (Group A, 38 patients) or malignant (Group B, 25 patients) nature of the hematological diseases. Results Patients in group B were significantly (a) older, (b) had larger spleens that more frequently needed accessory incisions for specimen retrieval, (c) had greater transfusion requirements, and (d) were fed later than patients in group A. There were no statistically significant differences among the two groups in terms of (a) body-mass index, (b) operative time, (c) conversion rate, (d) blood loss, (e) pain medication requirements, and (f) hospital stay. Two postoperative deaths occurred among patients in group B, but none of them was related to surgery. Conclusions The results of the study showed that: a) the nature of the disease does not influence the outcome of laparoscopic splenectomy, b) the size of the spleen might increase the risk of conversion, but it is no longer a contraindication to laparoscopic splenectomy, and c) laparoscopic splenectomy can be effectively performed in the treatment of malignant hematologic diseases.

Laparoscopic bilateral hand-assisted nephrectomy: End-stage renal disease from tuberculosis, an unusual indication for nephrectomy before transplantation

The purpose of the study was to sterilize renal tuberculous foci in a pretransplantation patient with a laparoscopic hand-assisted approach and to verify the feasibility of bilateral nephrectomy for this indication. This case report is the first description of hand-assisted laparoscopic bilateral nephrectomy for this pathologic condition. The 33-year-old patient had end-stage renal disease from renal tuberculosis. A commercially available hand-assistance device was used through a midline 8-cm supraumbilical incision and with four ports. The procedure was successfully completed. The total operative time was 3 hours and 40 minutes. Estimated blood loss was 250 mL. The postoperative course was uneventful, and clinical follow-up at 3 weeks revealed a successful outcome. Hand-assisted bilateral laparoscopic nephrectomy in patients with chronic renal failure from tuberculosis represents a viable option because it is feasible and effective. The hand-assisted approach increases the safety of the procedure while retaining all the advantages of minimally invasive surgery.

Italian registry of laparoscopic surgery of the spleen

The coming of laparoscopy has substantially modified the surgical approach to many pathologies involving changes in management and indications. These innovations are often not codified but left to the inclination of the surgical schools. But the basis of modern surgery is that each procedure should be standardized so that every action can be reproducible. For many pathologies, codifications are confirmed by a number of studies, so that they might become accepted procedures. In other cases, when a clinical trial is in its initial phase, only by collecting and analyzing as many data as possible can therapeutical procedures be formally standardized. The Italian Society of Mini-Invasive Surgery and New Technologies (SICE) some time ago founded national registries whose aim is to collect a great number of case histories in order to be able to outline new guidelines and prospective evaluations on the efficacy of the employed therapeutical procedures. There are currently four registries in Italy: