JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES Volume 00, Number 00, 2017 ª Mary Ann Liebert, Inc. DOI: 10.1089/lap.2017.0478
Full Report
Downloaded by Gothenburg University Library from online.liebertpub.com at 10/12/17. For personal use only.
Validation of a Difficulty Grading Score in Laparoscopic Splenectomy Diana Gonc¸alves, MD,1,2,* Marina Morais, MD,1,2,* Andre´ Costa-Pinho, MD,1,2 Renato Bessa-Melo, MD,1,2 Luı´s Grac¸a, MD,1 and J. Costa-Maia, MD1
Abstract
Introduction: Laparoscopic splenectomy (LS) is the gold standard for the treatment of many spleen-related disorders. However, in the presence of splenomegaly, the rate of conversion to open surgery can be as high as 33.9% and is associated with longer operative times and higher costs. In an attempt to improve risk stratification and patient selection for LS, a score that includes four preoperative parameters (age, gender, diagnosis, and spleen size) has been developed. The aim was the validation of a difficulty grading score, in predicting conversion and poorer outcomes. Methods: Retrospective analysis of 153 consecutive patients subjected to LS from January 2006 through December 2016 was performed. Several parameters were reviewed and correlation with evaluated outcomes was analyzed. Results: Conversion to open surgery occurred in 13 (8.50%) patients and was highly associated with serious intraoperative complications. Spearman correlation showed a significant association between the score and risk of conversion, operative time, and postoperative complications, but not with intraoperative bleeding. Discussion: Patient and disease features, incorporated in a difficulty grading score, can reliably determine the difficulty of LS and predict risk of conversion, intraoperative, and postoperative complications. This simple and reproducible score improves risk stratification for LS and could be practical in daily clinical activities. Keywords: laparoscopic splenectomy, conversion, difficulty grading score advanced laparoscopic procedures (colectomy, sleeve gastrectomy, Roux-en-Y bypass, and adrenalectomy), suggesting that LS requires advanced laparoscopic skills.2,8 Similar to other laparoscopic procedures, conversion to open surgery should not be regarded as a complication but rather as a wise decision to prevent major morbidity or even mortality. When conversion to open surgery is needed, it is associated with increased length of stay and higher costs,9 which could be avoided by a correct patient selection for LS. In the literature, many variables such as indication for splenectomy, individual patient factors, intraoperative findings (namely hemorrhage),8 and learning curve have been related to conversion to open surgery.10 In an attempt to improve risk stratification for surgery, Rodriguez-Otero Luppi et al. developed and validated a predictive model of technical difficulty in LS for nontraumatic diseases.9 They evaluated its association with operative time, operative bleeding, and conversion to open surgery. This score with three levels of difficulty was
Introduction
L
aparoscopic splenectomy (LS) was first described by Delaitre and Maignien in 1992.1 Owing to the advantages of minimally invasive surgery, namely less postoperative pain, faster recovery, shorter hospital stay, and better cosmetic results,2 it has been considered the gold standard for the treatment of benign and malignant spleen-related diseases.3 Splenomegaly was initially considered a relative contraindication for LS, due to inadequate exposure of the upper left quadrant, increased tissue vascularity, and difficulties in specimen retrieval.4 In the past two decades, this contraindication has been obviated5 due to accumulating experience, innovative instruments,6 and hybrid techniques, such as handassisted LS.7 The rate of conversion of LS to open surgery can be as high as 33.9% which is one of the highest rates among other 1
Department of Surgery, Sao Joao Medical Center, Porto, Portugal. Faculty of Medicine of the University of Porto, Porto, Portugal. *Both these authors contributed equally to this work.
2
1
GONCxALVES ET AL.
2
then developed based on four preoperative parameters: age, gender, diagnosis, and spleen size based on final spleen weight. This study aims to independently evaluate the performance of this scoring tool in the selection of patients for LS.
Downloaded by Gothenburg University Library from online.liebertpub.com at 10/12/17. For personal use only.
Materials and Methods
Adult patients (q18 years old) subjected to LS as a primary elective procedure have been included in an electronic database from January 2006 through December 2016. This database was retrospectively reviewed. The Ethics Committee of Sao Joao Medical Center approved the study, and all participants signed informed consent. The following variables were analyzed: demographic data, body mass index (BMI), indication for splenectomy, previous abdominal surgeries, spleen size and weight, hematocrit, platelet count, surgeon experience, rate and causes of conversion, intraoperative bleeding, operative time, and intraoperative complications. The surgical technique has remained unchanged for the duration of the study and is described next. Patients were positioned in right lateral decubitus or dorsal decubitus with axial rotation (30) to the right and with trunk extension. In general, four trocars were used (15, 10 mm, and two of 5 mm). Splenic mobilization was achieved by sectioning the lienocolic, lienorenal, and lienophrenic ligaments. Short vessels and gastrosplenic ligament were ligated with a harmonic scalpel. The splenic vein and artery were isolated and individually ligated with clips or a stapler. The specimen was retrieved either through the 15 mm port or through a Pfannestiel incision. Operative time was recorded as skinto-skin time. Using the preoperative parameters, scores were assigned based on the difficulty grading score criteria (Table 1), de-
Table 1. Difficulty Grading Score Parameter Age p40 Years 40–60 Years q60 Years Gender Female Male Pathology group ITP Other benign Malignant Spleen weighta 1000 g Difficulty grade Low Medium High
scribed by Rodriguez-Otero Luppi et al.9 The minimum possible score was 2 and the maximum possible score was 10. The degree of surgical difficulty was low for patients with p4 points, medium for those with 4.5–5.5 points, and high for those with q6 points. The validation of this score was achieved by comparing the three grades of difficulty with operative time, conversion to open surgery, operative bleeding, and postoperative complications. Preoperative abdominal ultrasound and/or computed tomography (CT) scan was performed to measure the size of the spleen and to assess the presence of accessory spleens. Splenomegaly was defined as a splenic vertical diameter of >15 cm, according to the European Association for Endoscopic Surgery.4 Spleen weight was determined by pathological examination in all cases. As spleen weight was a variable in the difficulty grading score, we confirmed the accuracy of the preoperative weight calculation by a formula previously described11: length · width · thickness of the spleen in centimeters, multiplied by a correction factor (0.6). Statistical analysis was performed on IBM SPSS Statistics Version 20; significant differences were determined by a P value 500 mL, and prolonged operative time— defined as 1.5 times or more over the median). This power was assessed using receiver operating characteristic (ROC) curve analysis. Results
Score 0 1 2 0.5 1 0.5 1 2 1 3 5 p4 4.5–5.5 q6
Minimum possible score, 2; maximum possible score, 10. a Spleen weight formula: width (cm) · length (cm) · height (cm) · 0.6 = splenic weight in grams. Adapted from Rodriguez-Otero Luppi et al.9 ITP, idiopathic trombocitopenic purpura.
Baseline characteristics and outcomes of 153 patients subjected to consecutive LS are described on Table 2. Maleto-female ratio was 0.6, mean age of the patients was 49 years old (range 18–88), and median BMI was 27.6 kg/m2. The most common indication for LS was idiopathic trombocitopenic purpura (ITP) in 83 (54.2%) patients, 27 (17.6%) patients presented malignant diseases, such as myeloproliferative disorders or lymphomas, and 43 (28.1%) patients presented other benign diseases, including spherocytosis, autoimmune hemolytic anemia (AIHA), Evans syndrome, splenic artery aneurism, splenic cyst/abscess, among others. The difficulty grading score classified 40.5% of patients as low difficulty, 31.4% as medium difficulty, and 28.1% as high difficulty. Patients’ characteristics were compared according to the three score groups, as shown on Table 2. Patients on the high-difficulty group were older (P = .001), predominantly males (P = .001), and with malignant pathology (500 mL
n Age Gender Male Female BMI (kg/m2) Pathology ITP Other benign Malignant Spleen weight (g) Hematocrit (%) Platelet count · 1000/lL Operative time (minutes) Conversion to open surgery
Parameter
Table 2. Preoperative, Intraoperative, and Postoperative Results According to Difficulty Grading Score
Downloaded by Gothenburg University Library from online.liebertpub.com at 10/12/17. For personal use only.
28.1
7.0
18.6
0 60.5 39.5
60.5 39.5
28.1
%
.543
Full Report
Downloaded by Gothenburg University Library from online.liebertpub.com at 10/12/17. For personal use only.
Validation of a Difficulty Grading Score in Laparoscopic Splenectomy Diana Gonc¸alves, MD,1,2,* Marina Morais, MD,1,2,* Andre´ Costa-Pinho, MD,1,2 Renato Bessa-Melo, MD,1,2 Luı´s Grac¸a, MD,1 and J. Costa-Maia, MD1
Abstract
Introduction: Laparoscopic splenectomy (LS) is the gold standard for the treatment of many spleen-related disorders. However, in the presence of splenomegaly, the rate of conversion to open surgery can be as high as 33.9% and is associated with longer operative times and higher costs. In an attempt to improve risk stratification and patient selection for LS, a score that includes four preoperative parameters (age, gender, diagnosis, and spleen size) has been developed. The aim was the validation of a difficulty grading score, in predicting conversion and poorer outcomes. Methods: Retrospective analysis of 153 consecutive patients subjected to LS from January 2006 through December 2016 was performed. Several parameters were reviewed and correlation with evaluated outcomes was analyzed. Results: Conversion to open surgery occurred in 13 (8.50%) patients and was highly associated with serious intraoperative complications. Spearman correlation showed a significant association between the score and risk of conversion, operative time, and postoperative complications, but not with intraoperative bleeding. Discussion: Patient and disease features, incorporated in a difficulty grading score, can reliably determine the difficulty of LS and predict risk of conversion, intraoperative, and postoperative complications. This simple and reproducible score improves risk stratification for LS and could be practical in daily clinical activities. Keywords: laparoscopic splenectomy, conversion, difficulty grading score advanced laparoscopic procedures (colectomy, sleeve gastrectomy, Roux-en-Y bypass, and adrenalectomy), suggesting that LS requires advanced laparoscopic skills.2,8 Similar to other laparoscopic procedures, conversion to open surgery should not be regarded as a complication but rather as a wise decision to prevent major morbidity or even mortality. When conversion to open surgery is needed, it is associated with increased length of stay and higher costs,9 which could be avoided by a correct patient selection for LS. In the literature, many variables such as indication for splenectomy, individual patient factors, intraoperative findings (namely hemorrhage),8 and learning curve have been related to conversion to open surgery.10 In an attempt to improve risk stratification for surgery, Rodriguez-Otero Luppi et al. developed and validated a predictive model of technical difficulty in LS for nontraumatic diseases.9 They evaluated its association with operative time, operative bleeding, and conversion to open surgery. This score with three levels of difficulty was
Introduction
L
aparoscopic splenectomy (LS) was first described by Delaitre and Maignien in 1992.1 Owing to the advantages of minimally invasive surgery, namely less postoperative pain, faster recovery, shorter hospital stay, and better cosmetic results,2 it has been considered the gold standard for the treatment of benign and malignant spleen-related diseases.3 Splenomegaly was initially considered a relative contraindication for LS, due to inadequate exposure of the upper left quadrant, increased tissue vascularity, and difficulties in specimen retrieval.4 In the past two decades, this contraindication has been obviated5 due to accumulating experience, innovative instruments,6 and hybrid techniques, such as handassisted LS.7 The rate of conversion of LS to open surgery can be as high as 33.9% which is one of the highest rates among other 1
Department of Surgery, Sao Joao Medical Center, Porto, Portugal. Faculty of Medicine of the University of Porto, Porto, Portugal. *Both these authors contributed equally to this work.
2
1
GONCxALVES ET AL.
2
then developed based on four preoperative parameters: age, gender, diagnosis, and spleen size based on final spleen weight. This study aims to independently evaluate the performance of this scoring tool in the selection of patients for LS.
Downloaded by Gothenburg University Library from online.liebertpub.com at 10/12/17. For personal use only.
Materials and Methods
Adult patients (q18 years old) subjected to LS as a primary elective procedure have been included in an electronic database from January 2006 through December 2016. This database was retrospectively reviewed. The Ethics Committee of Sao Joao Medical Center approved the study, and all participants signed informed consent. The following variables were analyzed: demographic data, body mass index (BMI), indication for splenectomy, previous abdominal surgeries, spleen size and weight, hematocrit, platelet count, surgeon experience, rate and causes of conversion, intraoperative bleeding, operative time, and intraoperative complications. The surgical technique has remained unchanged for the duration of the study and is described next. Patients were positioned in right lateral decubitus or dorsal decubitus with axial rotation (30) to the right and with trunk extension. In general, four trocars were used (15, 10 mm, and two of 5 mm). Splenic mobilization was achieved by sectioning the lienocolic, lienorenal, and lienophrenic ligaments. Short vessels and gastrosplenic ligament were ligated with a harmonic scalpel. The splenic vein and artery were isolated and individually ligated with clips or a stapler. The specimen was retrieved either through the 15 mm port or through a Pfannestiel incision. Operative time was recorded as skinto-skin time. Using the preoperative parameters, scores were assigned based on the difficulty grading score criteria (Table 1), de-
Table 1. Difficulty Grading Score Parameter Age p40 Years 40–60 Years q60 Years Gender Female Male Pathology group ITP Other benign Malignant Spleen weighta 1000 g Difficulty grade Low Medium High
scribed by Rodriguez-Otero Luppi et al.9 The minimum possible score was 2 and the maximum possible score was 10. The degree of surgical difficulty was low for patients with p4 points, medium for those with 4.5–5.5 points, and high for those with q6 points. The validation of this score was achieved by comparing the three grades of difficulty with operative time, conversion to open surgery, operative bleeding, and postoperative complications. Preoperative abdominal ultrasound and/or computed tomography (CT) scan was performed to measure the size of the spleen and to assess the presence of accessory spleens. Splenomegaly was defined as a splenic vertical diameter of >15 cm, according to the European Association for Endoscopic Surgery.4 Spleen weight was determined by pathological examination in all cases. As spleen weight was a variable in the difficulty grading score, we confirmed the accuracy of the preoperative weight calculation by a formula previously described11: length · width · thickness of the spleen in centimeters, multiplied by a correction factor (0.6). Statistical analysis was performed on IBM SPSS Statistics Version 20; significant differences were determined by a P value 500 mL, and prolonged operative time— defined as 1.5 times or more over the median). This power was assessed using receiver operating characteristic (ROC) curve analysis. Results
Score 0 1 2 0.5 1 0.5 1 2 1 3 5 p4 4.5–5.5 q6
Minimum possible score, 2; maximum possible score, 10. a Spleen weight formula: width (cm) · length (cm) · height (cm) · 0.6 = splenic weight in grams. Adapted from Rodriguez-Otero Luppi et al.9 ITP, idiopathic trombocitopenic purpura.
Baseline characteristics and outcomes of 153 patients subjected to consecutive LS are described on Table 2. Maleto-female ratio was 0.6, mean age of the patients was 49 years old (range 18–88), and median BMI was 27.6 kg/m2. The most common indication for LS was idiopathic trombocitopenic purpura (ITP) in 83 (54.2%) patients, 27 (17.6%) patients presented malignant diseases, such as myeloproliferative disorders or lymphomas, and 43 (28.1%) patients presented other benign diseases, including spherocytosis, autoimmune hemolytic anemia (AIHA), Evans syndrome, splenic artery aneurism, splenic cyst/abscess, among others. The difficulty grading score classified 40.5% of patients as low difficulty, 31.4% as medium difficulty, and 28.1% as high difficulty. Patients’ characteristics were compared according to the three score groups, as shown on Table 2. Patients on the high-difficulty group were older (P = .001), predominantly males (P = .001), and with malignant pathology (500 mL
n Age Gender Male Female BMI (kg/m2) Pathology ITP Other benign Malignant Spleen weight (g) Hematocrit (%) Platelet count · 1000/lL Operative time (minutes) Conversion to open surgery
Parameter
Table 2. Preoperative, Intraoperative, and Postoperative Results According to Difficulty Grading Score
Downloaded by Gothenburg University Library from online.liebertpub.com at 10/12/17. For personal use only.
28.1
7.0
18.6
0 60.5 39.5
60.5 39.5
28.1
%
.543
