Research
Original Investigation
Morbidity and Mortality Following Elective Splenectomy for Benign and Malignant Hematologic Conditions Analysis of the American College of Surgeons National Surgical Quality Improvement Program Data Naina Bagrodia, MD; Anna M. Button, MS; Philip M. Spanheimer, MD; Mary E. Belding-Schmitt, MS; Lori J. Rosenstein, MD; James J. Mezhir, MD
IMPORTANCE Splenectomy is a commonly performed operation; however, data from large
Invited Commentary page 1030
series regarding operative outcomes to help guide decision making and informed consent are lacking.
CME Quiz at jamanetworkcme.com
OBJECTIVE To evaluate clinical and pathologic variables associated with morbidity and mortality following elective splenectomy for benign and malignant hematologic conditions in the United States. DESIGN, SETTING, AND PARTICIPANTS A review of the American College of Surgeons National Surgical Quality Improvement Program data for elective splenectomy between January 1, 2005, and December 31, 2011, was performed, and 1715 eligible individuals were identified. INTERVENTION Elective splenectomy for hematologic conditions. MAIN OUTCOMES AND MEASURES Complications and operative mortality were evaluated for the entire cohort and compared between patients with benign vs malignant diseases. Multivariable logistic regression was used to evaluate factors predictive of operative complications and death. RESULTS Splenectomy was performed in 1344 patients (78.4%) for benign disease and in 371 patients (21.6%) for malignant disease. Two hundred ninety-one patients (17.0%) had a complication, and operative mortality occurred in 27 patients (mortality rate, 1.6%). Patients treated for malignant disease had a higher rate of overall complications (27.2%) compared with patients treated for benign disease (14.1%) (P < .001). Several variables were independent predictors of complications, including malignant disease (vs benign) (Odds Ratio [OR], 1.86; 95% CI, 1.23-2.80; P = .003), independent performance status (vs dependent) (OR, 0.33; 95% CI, 0.07-1.52; P = .02), and increasing albumin level (OR, 0.75; 95% CI, 0.66-0.86; P < .001). Increasing age (OR, 1.03; 95% CI, 1.00-1.06; P = .05) was an independent predictor of mortality while increasing albumin level (OR, 0.63; 95% CI, 0.46-0.86; P = .003) predicted lower risk of operative death. From these data, a patient older than 60 years with a low preoperative albumin level has a predicted probability for operative death as high as 10.0%. CONCLUSIONS AND RELEVANCE Preoperative performance and nutritional status are significant risk factors for complications and mortality following elective splenectomy. Although operative mortality continues to decrease over time, specific preoperative variables may help with patient selection before elective splenectomy for certain patients.
JAMA Surg. 2014;149(10):1022-1029. doi:10.1001/jamasurg.2014.285 Published online August 20, 2014. 1022
Author Affiliations: Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City (Bagrodia, Spanheimer, Belding-Schmitt, Mezhir); Department of Epidemiology and Biostatistics, University of Iowa Hospitals and Clinics, Iowa City (Button); Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City (Rosenstein). Corresponding Author: James J. Mezhir, MD, Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, University of Iowa Hospitals and Clinics, 200 Hawkins Dr, 4642 JCP, Iowa City, IA 52242 ([email protected]). jamasurgery.com
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/22/2015
Morbidity and Mortality Following Elective Splenectomy
S
plenectomy is a commonly performed operation for various conditions, including trauma and benign and malignant hematologic disorders.1,2 The operation is frequently performed laparoscopically; however, some patients still undergo open splenectomy depending on patient-specific factors and surgeon preference.3 Many hematologic conditions such as hemolytic anemia and idiopathic thrombocytopenic purpura are treated with splenectomy following failure of medical management.4,5 Malignant conditions such as leukemia and lymphoma are treated selectively with splenectomy when the spleen is primarily involved, with the potential to improve survival over that of chemotherapy alone.6 In addition, splenectomy may be performed palliatively to help control pain or to decrease transfusion needs in certain patients. Not all patients may benefit from removal of the spleen irrespective of the approach; therefore, careful consideration of the risks and benefits of the operation need to be considered when offering the procedure to treat a given hematologic disease.7 Splenectomy has been shown to be a safe and effective treatment option for select hematologic conditions, with low complication rates and mortality.8,9 However, operative mortality from splenectomy for some hematologic disorders has been reported to be as high as 6.3%.9,10 It has also been demonstrated in large retrospective investigations that laparoscopic splenectomy, when feasible, is associated with fewer complications, less blood transfusion, shorter hospital stay, and faster return to work.11 However, data are limited on the operative morbidity and mortality associated with elective splenectomy from large multi-institutional series.12,13 Many studies published are from single institutions and do not compare the results between patients treated for benign vs malignant hematologic conditions, who may have different outcomes for numerous reasons. The objective of this study was to evaluate the variables predictive of complications and mortality following elective splenectomy using a large national data set. This analysis will provide information to guide clinical decision making and informed consent for this commonly performed procedure.
Methods
Original Investigation Research
Benign hematologic conditions included hemolytic anemia, idiopathic thrombocytopenic purpura, thrombotic thrombocytopenic purpura, hereditary spherocytosis, polycythemia vera, thrombocytopenia, and Evans syndrome. Malignant hematologic conditions included leukemia and lymphoma. Excluded from analysis were patients who had a traumatic splenic injury, patients who received a resection for splenomegaly or hypersplenism, patients who underwent nonelective splenectomy (because of trauma or accidental intraoperative injury), and patients who had a splenectomy performed in addition to another major procedure (eg, cholecystectomy) or a multivisceral resection (eg, colectomy or pancreatectomy). Patients without an identifiable diagnosis were also excluded. Postoperative complications were recorded. These included renal failure, perioperative transfusion, deep venous thrombosis or pulmonary embolism, pulmonary complications (reintubation or failure to wean from the ventilator), and infectious complications (wound infection, pneumonia, urinary tract infection, or sepsis), as well as operative death within 30 days.
Statistical Analysis The variables were analyzed with comparative statistics using t test and χ2 test where appropriate. Univariate logistic regression models were fit for each of the predictor variables, and the results were reported for all of the operative complication outcome variables. For each end point, multivariable logistic models were built with the significantly associated predictors using stepwise selection. Estimated associations for the univariate and multivariable models are reported as odds ratios (95% CIs). A nomogram for risk estimation for operative complications was constructed to demonstrate the relative importance of each predictor in the multivariable logistic model. An effect plot for operative mortality was created using significant demographic and pathologic variables from the multivariable analysis to determine patients at highest risk for death following splenectomy. Statistical tests were 2-sided and were assessed for significance at the 5% level. Analyses were performed with a statistical software package (SAS 9.3; SAS Institute Inc).
Study Design The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data set was used to identify patients who underwent elective splenectomy for benign and malignant hematologic diseases between January 1, 2005, and December 31, 2011. The ACS NSQIP collects data on patients being treated with surgical procedures in the United States from university and private medical centers. Patient clinicopathologic and treatment-related variables are collected in addition to 30-day outcomes, including operative complications and mortality. The ACS NSQIP now collects 252 case variables and has been the focus of publications focused on operative outcomes and quality assessment.14-16 The University of Iowa Institutional Review Board deemed this study to be exempt from review due to the retrospective nature of the analysis of deidentified data. jamasurgery.com
Results Patient Characteristics Among the Entire Cohort In total, 4907 patients were identified by the ACS NSQIP who had a splenectomy between 2005 and 2011, and 1715 patients met criteria for analysis. Clinicopathologic variables for the entire cohort are listed in Table 1. Overall, 1344 patients (78.4%) were treated for benign hematologic disorders, including 988 (57.6%) with idiopathic thrombocytopenic purpura and 153 (8.9%) with hemolytic anemia. In total, 371 patients (21.6%) were treated for malignant hematologic conditions, including 59 (3.4%) with leukemia and 312 (18.2%) with lymphoma. Eighty-four patients (4.9%) had impaired functional status before surgery. JAMA Surgery October 2014 Volume 149, Number 10
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/22/2015
1023
Research Original Investigation
Morbidity and Mortality Following Elective Splenectomy
Table 1. Clinicopathologic, Treatment, and Outcome Variables Among 1715 Patients Treated With Elective Splenectomy Variable
Figure 1. Operative Morbidity and Mortality Following Elective Splenectomy Between 2005 and 2011
Value
30
Clinicopathologic Variables Male sex, No. (%)
737 (43.0)
25 P =.01
53 (16-90)
Benign, No. (%)
1344 (78.4)
Polycythemia vera
12 (1.0)
Evans syndrome
13 (1.0)
Thrombotic thrombocytopenic purpura
10 (1.0)
Hereditary spherocytosis
53 (3.1)
Thrombocytopenia
115 (6.7)
Hemolytic anemia
153 (8.9)
Idiopathic thrombocytopenic purpura
988 (57.6)
15
10
5
0 2005
2006
Leukemia
59 (3.4)
Lymphoma
312 (18.2)
BMI, mean (range)
29.1 (12.5-76.6)
Diabetes mellitus, No. (%)
250 (14.6)
Smoking
284 (16.6)
COPD or asthma, No. (%)
65 (3.8)
Renal disease, No. (%)
20 (1.2)
Chronic corticosteroid use, No. (%)
852 (49.7)
Preoperative functional status, No. (%)
2007
2008
2009
2010
2011
Treatment Year
371 (21.6)
3.5 3.0 P =.10 2.5
Mortality, %
Malignant, No. (%)
20
Morbidity, %
Age, mean (range), y
2.0 1.5 1.0
Independent
1630 (95.0)
Partially or totally dependent
84 (4.9)
5.0
Preoperative weight loss, No. (%)
62 (3.6)
0.0
Preoperative transfusion, No. (%)
36 (2.1)
2005
2006
2007
2008
2009
2010
2011
Treatment Year
Patients treated, No. (%) 2005-2007
561 (32.7)
2008-2009
656 (38.3)
2010-2011
498 (29.0)
A significant increase was observed in operative complications over time during the study period, consisting mostly of an increase in bleeding and transfusion. Operative mortality remained less than 1% in 2010 and 2011.
Treatment and Outcome Variables Splenectomy approach, No. (%) Open
457 (26.6)
Laparoscopic
1258 (73.4)
Operative time, mean (range), min
122 (5-440)
Hospital stay, mean (range), d
6.3 (0-125)
Need for reoperation, No. (%)
53 (3.1)
Mortality, No. (%)
27 (1.6)
Complication by system, No. (%)
291 (17.0)
DVT or PE
41 (2.4)
Pulmonary
45 (2.6)
Renal
13 (0.8)
Infectious
144 (8.4)
Postoperative bleeding and transfusion
87 (5.1)
Abbreviations: BMI, body mass index (calculated as weight in kilograms divided by height in meters squared); COPD, chronic obstructive pulmonary disease; DVT, deep venous thrombosis; PE, pulmonary embolism.
Treatment-related variables and operative outcomes are listed in Table 1. In total, 1258 patients (73.4%) were treated with laparoscopic splenectomy. Twenty-seven patients died (overall operative mortality rate, 1.6%), and 291 patients (17.0%) experienced at least 1 complication. Despite a slight increase in 1024
morbidity over time, a significant trend of decreased mortality was observed during the study period (Figure 1). No corresponding significant change over time was seen in the percentage of patients treated for malignant disease or in the incidence of infectious complications. Also, no significant change was observed in the percentage of patients who received laparoscopic splenectomy over time: the percentages were 74.9% (in 2005-2007), 71.8% (in 2008-2009), and 73.5% (in 2001-2011). The percentage of patients undergoing transfusion remained less than 2% from 2005 to 2008 and significantly increased in 2010 and 2011 (Figure 2). No significant change was observed in the percentage of patients requiring preoperative transfusion or in the preoperative international normalized ratio (INR) over time. Among 36 patients who had a preoperative transfusion, only 11 required an additional perioperative transfusion. To determine the effect of the preoperative INR on operative transfusion, the mean preoperative INRs were compared among patients who underwent a transfusion and patients who did not receive a transfusion. Patients who underwent a transfusion had a higher mean (SD) preoperative INR of 1.13 (0.17) compared with 1.07 (0.22) in patients who did not receive a transfusion (P = .02).
JAMA Surgery October 2014 Volume 149, Number 10
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/22/2015
jamasurgery.com
Morbidity and Mortality Following Elective Splenectomy
Original Investigation Research
Comparison of Splenectomy for Malignant vs Benign Diseases
functional status. A higher percentage of patients underwe nt a l a p a ro s c o p i c p ro c e d u re fo r b e n i g n d i s e a s e (P < .001) and had shorter operative time and hospital stay. The complic ation rate was signific antly higher for p a t i e nt s w i t h m a l i g n a nt d i s e a s e ( 2 7. 2 % v s 1 4 . 1% , P < .001). This was mostly reflected in infectious complications and bleeding requiring transfusion. Operative mortality was not significantly different, at 1.6% for both groups (P = .94).
Table 2 summarizes the clinical and treatment-related variables of patients treated for malignant vs benign hematologic conditions. Patients with malignant disease more often had preoperative weight loss and dependent Figure 2. Percentage of Patients Who Experienced Bleeding Requiring Transfusion Following Elective Splenectomy Between 2005 and 2011
Patients Undergoing Transfusion, %
20
Univariate Analysis of Operative Complications and Mortality
P
Original Investigation
Morbidity and Mortality Following Elective Splenectomy for Benign and Malignant Hematologic Conditions Analysis of the American College of Surgeons National Surgical Quality Improvement Program Data Naina Bagrodia, MD; Anna M. Button, MS; Philip M. Spanheimer, MD; Mary E. Belding-Schmitt, MS; Lori J. Rosenstein, MD; James J. Mezhir, MD
IMPORTANCE Splenectomy is a commonly performed operation; however, data from large
Invited Commentary page 1030
series regarding operative outcomes to help guide decision making and informed consent are lacking.
CME Quiz at jamanetworkcme.com
OBJECTIVE To evaluate clinical and pathologic variables associated with morbidity and mortality following elective splenectomy for benign and malignant hematologic conditions in the United States. DESIGN, SETTING, AND PARTICIPANTS A review of the American College of Surgeons National Surgical Quality Improvement Program data for elective splenectomy between January 1, 2005, and December 31, 2011, was performed, and 1715 eligible individuals were identified. INTERVENTION Elective splenectomy for hematologic conditions. MAIN OUTCOMES AND MEASURES Complications and operative mortality were evaluated for the entire cohort and compared between patients with benign vs malignant diseases. Multivariable logistic regression was used to evaluate factors predictive of operative complications and death. RESULTS Splenectomy was performed in 1344 patients (78.4%) for benign disease and in 371 patients (21.6%) for malignant disease. Two hundred ninety-one patients (17.0%) had a complication, and operative mortality occurred in 27 patients (mortality rate, 1.6%). Patients treated for malignant disease had a higher rate of overall complications (27.2%) compared with patients treated for benign disease (14.1%) (P < .001). Several variables were independent predictors of complications, including malignant disease (vs benign) (Odds Ratio [OR], 1.86; 95% CI, 1.23-2.80; P = .003), independent performance status (vs dependent) (OR, 0.33; 95% CI, 0.07-1.52; P = .02), and increasing albumin level (OR, 0.75; 95% CI, 0.66-0.86; P < .001). Increasing age (OR, 1.03; 95% CI, 1.00-1.06; P = .05) was an independent predictor of mortality while increasing albumin level (OR, 0.63; 95% CI, 0.46-0.86; P = .003) predicted lower risk of operative death. From these data, a patient older than 60 years with a low preoperative albumin level has a predicted probability for operative death as high as 10.0%. CONCLUSIONS AND RELEVANCE Preoperative performance and nutritional status are significant risk factors for complications and mortality following elective splenectomy. Although operative mortality continues to decrease over time, specific preoperative variables may help with patient selection before elective splenectomy for certain patients.
JAMA Surg. 2014;149(10):1022-1029. doi:10.1001/jamasurg.2014.285 Published online August 20, 2014. 1022
Author Affiliations: Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City (Bagrodia, Spanheimer, Belding-Schmitt, Mezhir); Department of Epidemiology and Biostatistics, University of Iowa Hospitals and Clinics, Iowa City (Button); Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City (Rosenstein). Corresponding Author: James J. Mezhir, MD, Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, University of Iowa Hospitals and Clinics, 200 Hawkins Dr, 4642 JCP, Iowa City, IA 52242 ([email protected]). jamasurgery.com
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/22/2015
Morbidity and Mortality Following Elective Splenectomy
S
plenectomy is a commonly performed operation for various conditions, including trauma and benign and malignant hematologic disorders.1,2 The operation is frequently performed laparoscopically; however, some patients still undergo open splenectomy depending on patient-specific factors and surgeon preference.3 Many hematologic conditions such as hemolytic anemia and idiopathic thrombocytopenic purpura are treated with splenectomy following failure of medical management.4,5 Malignant conditions such as leukemia and lymphoma are treated selectively with splenectomy when the spleen is primarily involved, with the potential to improve survival over that of chemotherapy alone.6 In addition, splenectomy may be performed palliatively to help control pain or to decrease transfusion needs in certain patients. Not all patients may benefit from removal of the spleen irrespective of the approach; therefore, careful consideration of the risks and benefits of the operation need to be considered when offering the procedure to treat a given hematologic disease.7 Splenectomy has been shown to be a safe and effective treatment option for select hematologic conditions, with low complication rates and mortality.8,9 However, operative mortality from splenectomy for some hematologic disorders has been reported to be as high as 6.3%.9,10 It has also been demonstrated in large retrospective investigations that laparoscopic splenectomy, when feasible, is associated with fewer complications, less blood transfusion, shorter hospital stay, and faster return to work.11 However, data are limited on the operative morbidity and mortality associated with elective splenectomy from large multi-institutional series.12,13 Many studies published are from single institutions and do not compare the results between patients treated for benign vs malignant hematologic conditions, who may have different outcomes for numerous reasons. The objective of this study was to evaluate the variables predictive of complications and mortality following elective splenectomy using a large national data set. This analysis will provide information to guide clinical decision making and informed consent for this commonly performed procedure.
Methods
Original Investigation Research
Benign hematologic conditions included hemolytic anemia, idiopathic thrombocytopenic purpura, thrombotic thrombocytopenic purpura, hereditary spherocytosis, polycythemia vera, thrombocytopenia, and Evans syndrome. Malignant hematologic conditions included leukemia and lymphoma. Excluded from analysis were patients who had a traumatic splenic injury, patients who received a resection for splenomegaly or hypersplenism, patients who underwent nonelective splenectomy (because of trauma or accidental intraoperative injury), and patients who had a splenectomy performed in addition to another major procedure (eg, cholecystectomy) or a multivisceral resection (eg, colectomy or pancreatectomy). Patients without an identifiable diagnosis were also excluded. Postoperative complications were recorded. These included renal failure, perioperative transfusion, deep venous thrombosis or pulmonary embolism, pulmonary complications (reintubation or failure to wean from the ventilator), and infectious complications (wound infection, pneumonia, urinary tract infection, or sepsis), as well as operative death within 30 days.
Statistical Analysis The variables were analyzed with comparative statistics using t test and χ2 test where appropriate. Univariate logistic regression models were fit for each of the predictor variables, and the results were reported for all of the operative complication outcome variables. For each end point, multivariable logistic models were built with the significantly associated predictors using stepwise selection. Estimated associations for the univariate and multivariable models are reported as odds ratios (95% CIs). A nomogram for risk estimation for operative complications was constructed to demonstrate the relative importance of each predictor in the multivariable logistic model. An effect plot for operative mortality was created using significant demographic and pathologic variables from the multivariable analysis to determine patients at highest risk for death following splenectomy. Statistical tests were 2-sided and were assessed for significance at the 5% level. Analyses were performed with a statistical software package (SAS 9.3; SAS Institute Inc).
Study Design The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data set was used to identify patients who underwent elective splenectomy for benign and malignant hematologic diseases between January 1, 2005, and December 31, 2011. The ACS NSQIP collects data on patients being treated with surgical procedures in the United States from university and private medical centers. Patient clinicopathologic and treatment-related variables are collected in addition to 30-day outcomes, including operative complications and mortality. The ACS NSQIP now collects 252 case variables and has been the focus of publications focused on operative outcomes and quality assessment.14-16 The University of Iowa Institutional Review Board deemed this study to be exempt from review due to the retrospective nature of the analysis of deidentified data. jamasurgery.com
Results Patient Characteristics Among the Entire Cohort In total, 4907 patients were identified by the ACS NSQIP who had a splenectomy between 2005 and 2011, and 1715 patients met criteria for analysis. Clinicopathologic variables for the entire cohort are listed in Table 1. Overall, 1344 patients (78.4%) were treated for benign hematologic disorders, including 988 (57.6%) with idiopathic thrombocytopenic purpura and 153 (8.9%) with hemolytic anemia. In total, 371 patients (21.6%) were treated for malignant hematologic conditions, including 59 (3.4%) with leukemia and 312 (18.2%) with lymphoma. Eighty-four patients (4.9%) had impaired functional status before surgery. JAMA Surgery October 2014 Volume 149, Number 10
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/22/2015
1023
Research Original Investigation
Morbidity and Mortality Following Elective Splenectomy
Table 1. Clinicopathologic, Treatment, and Outcome Variables Among 1715 Patients Treated With Elective Splenectomy Variable
Figure 1. Operative Morbidity and Mortality Following Elective Splenectomy Between 2005 and 2011
Value
30
Clinicopathologic Variables Male sex, No. (%)
737 (43.0)
25 P =.01
53 (16-90)
Benign, No. (%)
1344 (78.4)
Polycythemia vera
12 (1.0)
Evans syndrome
13 (1.0)
Thrombotic thrombocytopenic purpura
10 (1.0)
Hereditary spherocytosis
53 (3.1)
Thrombocytopenia
115 (6.7)
Hemolytic anemia
153 (8.9)
Idiopathic thrombocytopenic purpura
988 (57.6)
15
10
5
0 2005
2006
Leukemia
59 (3.4)
Lymphoma
312 (18.2)
BMI, mean (range)
29.1 (12.5-76.6)
Diabetes mellitus, No. (%)
250 (14.6)
Smoking
284 (16.6)
COPD or asthma, No. (%)
65 (3.8)
Renal disease, No. (%)
20 (1.2)
Chronic corticosteroid use, No. (%)
852 (49.7)
Preoperative functional status, No. (%)
2007
2008
2009
2010
2011
Treatment Year
371 (21.6)
3.5 3.0 P =.10 2.5
Mortality, %
Malignant, No. (%)
20
Morbidity, %
Age, mean (range), y
2.0 1.5 1.0
Independent
1630 (95.0)
Partially or totally dependent
84 (4.9)
5.0
Preoperative weight loss, No. (%)
62 (3.6)
0.0
Preoperative transfusion, No. (%)
36 (2.1)
2005
2006
2007
2008
2009
2010
2011
Treatment Year
Patients treated, No. (%) 2005-2007
561 (32.7)
2008-2009
656 (38.3)
2010-2011
498 (29.0)
A significant increase was observed in operative complications over time during the study period, consisting mostly of an increase in bleeding and transfusion. Operative mortality remained less than 1% in 2010 and 2011.
Treatment and Outcome Variables Splenectomy approach, No. (%) Open
457 (26.6)
Laparoscopic
1258 (73.4)
Operative time, mean (range), min
122 (5-440)
Hospital stay, mean (range), d
6.3 (0-125)
Need for reoperation, No. (%)
53 (3.1)
Mortality, No. (%)
27 (1.6)
Complication by system, No. (%)
291 (17.0)
DVT or PE
41 (2.4)
Pulmonary
45 (2.6)
Renal
13 (0.8)
Infectious
144 (8.4)
Postoperative bleeding and transfusion
87 (5.1)
Abbreviations: BMI, body mass index (calculated as weight in kilograms divided by height in meters squared); COPD, chronic obstructive pulmonary disease; DVT, deep venous thrombosis; PE, pulmonary embolism.
Treatment-related variables and operative outcomes are listed in Table 1. In total, 1258 patients (73.4%) were treated with laparoscopic splenectomy. Twenty-seven patients died (overall operative mortality rate, 1.6%), and 291 patients (17.0%) experienced at least 1 complication. Despite a slight increase in 1024
morbidity over time, a significant trend of decreased mortality was observed during the study period (Figure 1). No corresponding significant change over time was seen in the percentage of patients treated for malignant disease or in the incidence of infectious complications. Also, no significant change was observed in the percentage of patients who received laparoscopic splenectomy over time: the percentages were 74.9% (in 2005-2007), 71.8% (in 2008-2009), and 73.5% (in 2001-2011). The percentage of patients undergoing transfusion remained less than 2% from 2005 to 2008 and significantly increased in 2010 and 2011 (Figure 2). No significant change was observed in the percentage of patients requiring preoperative transfusion or in the preoperative international normalized ratio (INR) over time. Among 36 patients who had a preoperative transfusion, only 11 required an additional perioperative transfusion. To determine the effect of the preoperative INR on operative transfusion, the mean preoperative INRs were compared among patients who underwent a transfusion and patients who did not receive a transfusion. Patients who underwent a transfusion had a higher mean (SD) preoperative INR of 1.13 (0.17) compared with 1.07 (0.22) in patients who did not receive a transfusion (P = .02).
JAMA Surgery October 2014 Volume 149, Number 10
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/22/2015
jamasurgery.com
Morbidity and Mortality Following Elective Splenectomy
Original Investigation Research
Comparison of Splenectomy for Malignant vs Benign Diseases
functional status. A higher percentage of patients underwe nt a l a p a ro s c o p i c p ro c e d u re fo r b e n i g n d i s e a s e (P < .001) and had shorter operative time and hospital stay. The complic ation rate was signific antly higher for p a t i e nt s w i t h m a l i g n a nt d i s e a s e ( 2 7. 2 % v s 1 4 . 1% , P < .001). This was mostly reflected in infectious complications and bleeding requiring transfusion. Operative mortality was not significantly different, at 1.6% for both groups (P = .94).
Table 2 summarizes the clinical and treatment-related variables of patients treated for malignant vs benign hematologic conditions. Patients with malignant disease more often had preoperative weight loss and dependent Figure 2. Percentage of Patients Who Experienced Bleeding Requiring Transfusion Following Elective Splenectomy Between 2005 and 2011
Patients Undergoing Transfusion, %
20
Univariate Analysis of Operative Complications and Mortality
P
