Impact of morbid obesity on outcome of laparoscopic splenectomy.

BACKGROUND: Because of the obesity epidemic, surgeons are operating on morbidly obese patients in increasing numbers. The aim of this study was to evaluate the impact of morbid obesity on the outcome of laparoscopic splenectomy. METHODS: The study group consisted of 120 consecutive patients who underwent laparoscopic splenectomy for benign and malignant disease from March 1996 to May 2005. These patients were retrospectively divided into three groups. Group 1 had a body mass index (BMI) < 30. Group 2 patients had a BMI > or = 30 and < 40 and were considered obese. Group 3 had a BMI > or = 40 and were considered morbidly obese. Data including surgical approach (laparoscopic vs. hand-assisted), operative time, conversion rate, estimated blood loss, splenic weight, length of stay, time to tolerate a diet, pathologic diagnosis, complications, and mortality were recorded. RESULTS: Complete data were available for evaluation of 112 patients of whom 73 (65%) had a BMI < 30, 32 (29%) had a BMI > or = 30 and < 40, and 7 (6%) had a BMI > or = 40. The most frequent indication for splenectomy in all three groups was idiopathic thrombocytopenic purpura (ITP). The operative times were significantly higher in patients with a BMI > 40. Conversion rates were also higher in this group, although this did not reach statistical significance. Patients with a BMI > 30 experienced similar complication rates when compared with patients with a BMI < 30. Only when patients had a BMI > 40 did they experience more complications. CONCLUSIONS: Laparoscopic splenectomy was performed safely in obese patients (BMI > 30) with similar results to those of nonobese patients. Only in morbidly obese patients (BMI > 40) do outcomes and complications appear to be affected. Obesity should not be a contraindication to laparoscopic splenectomy.

Defining the learning curve for laparoscopic splenectomy for immune thrombocytopenia purpura.

BACKGROUND: The current study was undertaken to define the learning curve for laparoscopic splenectomy (LS) in patients with immune thrombocytopenic purpura (ITP). METHODS: The data of 50 patients who underwent LS for ITP between March 1996 and February 2003 were reviewed. Patients were divided into sequential groups of 10. Operative time, estimated blood loss, conversion to open procedure, length of stay (LOS), time to oral intake, complications, and mortality rates were analyzed. RESULTS: The mean OR time in the 3rd, 4th, and 5th groups of 10 were significantly shorter than the 1st and 2nd groups of 10. There were no significant differences in estimated blood loss, LOS, or time to oral intake between the groups. Three conversions to open splenectomy occurred; one each in the 2nd, 3rd, and 4th groups of 10. Complications were evenly distributed between groups. There were no deaths. CONCLUSION: The learning curve for LS in patients with ITP is a minimum of 20 cases.

Mitotic rate and younger age are predictors of sentinel lymph node positivity: lessons learned from the generation of a probabilistic model.

BACKGROUND: Sentinel lymph node (SLN) biopsy allows surgeons to identify patients with subclinical nodal involvement who may benefit from lymphadenectomy and, possibly, adjuvant therapy. Several factors have been variably, and sometimes discordantly, reported to have predictive value for SLN metastasis to best select which patients require SLN biopsy. METHODS: We reviewed 419 patients who underwent SLN biopsy for melanoma from a prospectively collected melanoma database. To derive a probabilistic model for the occurrence of a positive SLN, a multivariate logistic model was fit by using a stepwise variable selection method. The accuracy of each model was evaluated by using receiver operator characteristic curves. RESULTS: On univariate analysis, the number of mitoses per square millimeter, increasing Breslow depth, decreasing age, ulceration, and melanoma on the trunk showed a significant relationship to a positive SLN. Multivariate analysis revealed that once age, mitotic rate, and Breslow thickness were included, no other factor, including ulceration, was significantly associated with a positive SLN. The data suggest that younger patients with tumors <1 mm may still have a substantial risk for a positive SLN, especially if the mitotic rate is high. CONCLUSIONS: In addition to Breslow depth, mitoses per square millimeter and younger age were factors identified as independent predictors of a positive SLN. This model may identify patients with thin melanoma at sufficient risk for metastases to justify SLN biopsy.

101 laparoscopic splenectomies for the treatment of benign and malignant hematologic disorders.

BACKGROUND: Laparoscopic splenectomy (LS) is the surgical approach of choice for patients with hematologic disorders requiring splenectomy. Patients with idiopathic thrombocytopenic purpura (ITP) have normal to slightly enlarged spleens and benefit the most from LS. METHODS: We reviewed the perioperative outcomes in 101 patients who underwent LS between May 1996 and December 2002. Patients were divided into three groups--ITP, other benign, and malignant hematologic disorders--and compared. RESULTS: The ITP patients (n = 48) had significantly smaller spleens and operative times compared with the other groups. Splenomegaly in the other benign (n = 23) and malignant hematologic disorders (n = 30) groups was responsible for higher open conversion rates and greater need for hand-assisted laparoscopic splenectomy (HALS). CONCLUSIONS: Laparoscopic splenectomy and HALS can be performed with good results for benign and malignant hematologic disorders. The benefits of HALS are similar to LS, so there should be a low threshold for HALS in patients with large spleens.

Hand-assisted laparoscopic splenectomy in patients with splenomegaly or prior upper abdominal operation.

BACKGROUND: Laparoscopic splenectomy (LS) in patients with significant splenomegaly or prior upper abdominal operation is technically challenging with a high conversion rate to open operation. We hypothesized that hand-assisted laparoscopic splenectomy (HLS) in this setting would improve operative (OR) outcomes without impacting post-OR ileus, length of stay, morbidity, or mortality, compared with LS. METHODS: All patients with splenomegaly (spleen weight > or = 500 g) or prior upper abdominal operation undergoing LS or HLS between March 1996 and June 2001 were reviewed. Nonparametric continuous variables were expressed as median and intraquartile range with statistical significance determined by Wilcoxon rank sum test. RESULTS: Of 41 patients reviewed, 22 underwent HLS, whereas 19 underwent LS. Median OR time for HLS was significantly less than for LS (161 minutes vs 212 minutes, P =.004). HLS was associated with a lower conversion rate (13.6% vs 36.8%, P =.08) and blood loss (325 mL vs 550 mL, P =.18) than LS, which approached statistical significance. HLS did not increase post-OR ileus, length of stay, morbidity, or mortality. CONCLUSIONS: HLS in patients with significant splenomegaly or prior upper abdominal operation significantly shortens OR time compared with LS without adversely impacting post-OR ileus, length of stay, morbidity, or mortality. In addition, HLS may be associated with a lower conversion rate and decreased blood loss.

Immunostaining for cytokeratin 20 improves detection of micrometastatic Merkel cell carcinoma in sentinel lymph nodes.

BACKGROUND: Sentinel lymph node biopsy (SLNBx) can identify Merkel cell carcinoma (MCC) micrometastasis. OBJECTIVE: We attempted to examine the effectiveness of immunostaining and identify antibodies most appropriate for evaluation of SLNBxs for MCC. METHODS: Histopathologic material from 10 patients with MCC who had SLNBx was reviewed. RESULTS: Twenty-three SLNBxs from 10 patients appeared tumor-free in routine hematoxylin-eosin (H&E)-stained sections. However, tumor cells were detected in immunostained sections from 5 (22%) of 23 SLNBxs in 4 (40%) of 10 patients. Immunostains with pancytokeratin (panCK), cytokeratin-20 (CK-20), neurofilament protein, and chromogranin A were used for all primary and SLNBx specimens. All 5 (100%) micrometastatic foci stained strongly for CK-20 and panCK. Background normal lymph node tissue also stained for panCK but not for CK-20. CONCLUSION: Examination of H&E sections alone is insufficient for excluding micrometastatic MCC in sentinel lymph nodes. We observed the greatest sensitivity and specificity with anti-CK-20 antibody in identifying micrometastatic MCC in sentinel lymph nodes.