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Laparoscopic Splenectomy for Hematologic Disorders In Children- Long-Term Outcomes

Saturday, October 20, 2012: 1:36 PM
Napoleon Ballroom (Hilton Riverside)
Govardhana Yannam, MD1, Stephanie Heidemann, MD2, Russell L. Griffin, PhD3, Benjamin Tuanama4, Jeffrey Lebensburger, MD2 and Carroll M. Harmon, MD, PhD1, (1)Pediatric Surgery, The Children's Hospital of Alabama, University of Alabama at Birmingham, Birmingham, AL, (2)Department of Pediatrics, Children's Hospital of Alabama, Birmingham, AL, (3)Epidemiology; Center for Clinical Translational Science, University of Alabama at Birmingham, School of Public Health, Birmingham, AL, (4)Pediatric Surgery, The Children's Hospital of Alabama, Birmingham, AL

Purpose: Laparoscopic splenectomy (LS) has become the treatment of choice in the management of several hematological disorders in children. Though several studies have reported safety and early efficacy after LS for hematologic disorders, few studies have analyzed long-term hematologic outcomes comprehensively after splenectomy in children. The present study is a large retrospective review of a single institute experience of splenectomy  to evaluate the efficacy and long-term benefit of splenectomy in treating various hematological disorders in children.

Methods: After IRB approval, a database search was performed using Current Procedural Terminology codes for splenectomy for all consecutive patients who underwent splenectomy for various hematologic diseases between January 1999 and July 2011.  Demographic features, indications for splenectomy, type of procedure, operative outcome, postoperative complications and hematologic outcomes were analyzed. Chi-square test and t-test were used for categorical and continuous variables respectively and p<0.05 was considered significant.

Results: A total of 204 patients underwent splenectomy for various hematologic diseases; 84 with hereditary spherocytosis (HS), 65 with sickle cell disease (SCD), 40 with idiopathic thrombocytopenic purpura (ITP) and 15 with other hematologic diseases.  Mean follow-up was 7.9 +10.5 years. Two hundred one patients underwent an elective procedure and 3 patients required emergency splenectomy. LS was attempted in 190 (93%) patients, successful in 178 (94%) patients and 14 patients underwent open splenectomy during the study period. Concomitant procedures included cholecystectomy in 45 (22%) children and liver biopsy in 17 (8%). One ITP patient died due to an intracranial bleed.  The postoperative morbidity was low (13%).  Intraoperative bleeding occurred in 8 patients, 2 patients required relaparotomy and 3 SCD patients developed acute chest syndrome.    In addition one patient had streptococcal pneumoniae bacteremia and another had meningococcal meningitis in the follow-up period and responded well to aggressive medical management. All except 3 patients [concomitant enzyme deficiencies detected during work-up for relapse (2) and Moyamoya diseases (1)] with HS had an excellent outcome with normalization of hemoglobin, hematocrit and reticulocyte counts. For ITP patients, 83% had remission; age at diagnosis, gender, race, age at surgery, time from diagnosis to splenectomy and response to steroids/IVIG prior to surgery could not predict a favorable response. None of the patients with relapse are found to have had accessory spleens. As shown in our prior study on SCD patients, significantly improved hematocrit (p<0.01) and decreased transfusion requirements (p<0.001) were noted after splenectomy in SCD patients.

Conclusion: Laparoscopic splenectomy has long term benefit in several childhood hematological diseases with a low complication rates. Further studies are warranted to assess post splenectomy thrombotic and infectious complications.