EHA Library - The official digital education library of European Hematology Association (EHA)

Surgical resection of large spleens may eliminate a significant amount of tumor, allow definite diagnosis of malignant disorder, ameliorate abdominal symptoms and resolve cytopenia. However, because of short term perioperative events (25%) and long term immunosuppression (increased risk of infections caused by encapsulated bacteria) physicians can be reluctant to choose splenectomy, especially in older patients or patients with comorbidities. The role of laparoscopic splenectomy (LS) in patients with hematological malignancies is still unclear. Nevertheless, the ageing of the world's population and the increased incidence of Non-Hodgkin’s Lymphoma are increasing the indications for splenectomy, requiring a well-tolerated and less invasive procedure.

The aim of this review is to analyze our single-center experience of LS performed for malignant Hemopathies. Results are compared with LS for benign splenomegaly and the risk of locoregional dissemination or inadequacy of fragmented histological sample were analyzed.

We retrospectively analyzed 50 patients who underwent LS between 2005 and 2016 at Saint-Pierre Hospital. Anterior approach was used in 12 patients whereas in the remaining 38 cases, a semi-lateral position was chosen. All the patients received the triple vaccination (Streptococcus pneumoniae, type B Haemophilus influenzae, and Neisseria meningitidis). Patients characteristics, safety data such as early (< 30 days) and late (> 30 days) morbidities and mortality and efficacy (hematological recovery, accuracy of histological diagnosis) were analyzed.

19 patients underwent splenectomy for benign hemopathies (SBH) and 31 patients for malignant hemopathies (SMH). Non-Hodgkin’s lymphomas (12) and idiopathic myelofibrosis (10) were the most common causes of splenectomy followed by chronic lymphocytic leukemia (7), hairy cell leukemia (1) and hodgkin's lymphoma (1). Patients' age (67 +/- 12 years, ranging from 36 to 87 in SHM, and from 11 to 71 in SBH), prior abdominal surgery (18/31) and spleen volume (1515 +/- 662 mL, ranging from 220 to 3000ml in SMH, and from 90 to 1500ml in SBH) were significantly higher in the SMH group (p <0.05). There was no significant difference in surgical time (150 vs 146 min, p = 0.8), blood losses (243 vs 402 mL, p = 0.26) and duration of hospitalization (5.4 vs 7.5 days, p = 0.19) between SMH and SBH. No case of locoregional dissemination was experienced. The early morbidity of the SBH group was 10% and 13% for the SMH group (p = 1). Late morbidity was 0% in the SBH group and 13% in the SMH group (p = 0.28). This could be explained by a combination of underlying disease and immunosuppression (2 sepsis and 2 deep vein thrombosis). There was one conversion to open surgery and perioperative mortality in each group (p = 1). There was no significant difference in efficacy of splenectomy, with respectively 83% and 79% (p = 0.91) or quality of histological sample for pathological report between SBH and SMH. In the SMH group, 4 out of 31 patients received a pre-surgical corticosteroid treatment, with a pre-surgical platelets level of 156 +/- 108 x 10³/mL, white blood cell level of 15696 +/- 18950/mL and Hemoglobin level of 10.1 +/- 1.6 g/dL. Regarding the efficacy of LS in correcting hypersplenism in the SMH, a significant difference in term of platelets recovery after 1 month from the surgery was shown in patients efficiently Vs inefficiently operated (respectively 387 +/- 125 Vs 138+/- 90 x 10³/ml, p < 0,05). The median follow up is 39 +/- 37 months and 80% achieved a hematological recovery.

LS is a safe and less-invasive procedure in patients affected by Malignant Hemopathies. This approach is also well tolerated in older patients (median 67yrs) and in patients with large spleen (1515+/-660 ml), extending the indication for laparoscopic SHM even in older patient and in patients with high volume spleen. Compared to historical data, LSy for Malignant Hemopathies shows better early and late morbidities. Our data shows however a trend for higher late morbidity in the SMH group, warranting a careful long term follow-up in this subset of patients.