Surgery for massive splenomegaly

Abstract

Background: Splenectomy for massive splenomegaly (spleen weight more than 1·5 kg) is commonly believed to be hazardous and to provide poor palliation. The aim of this cohort study was to investigate these issues and examine the many definitions of massive splenomegaly to see whether a better tool might be proposed for preoperative evaluation of these patients.

Methods: Morbidity and long-term outcomes were assessed in consecutive patients. Relief of pressure-volume-related symptoms and sustainable independence from transfusion in patients were used to ascertain the impact of splenectomy.

Results: Splenectomy was performed in 56 patients, mainly for non-Hodgkin's lymphoma and myeloproliferative diseases. Median spleen weight was 2·3 (range 1·5-6·0) kg. Mortality at 180 days was zero, and the postoperative complication rate was 25 per cent (17 complications in 14 patients). At 2 years, relief of pain was maintained in 33 of 34 patients, with sustained independence from transfusion in 15 of 19 patients with anaemia and nine of 11 with thrombocytopenia. Spleen weight correlated negatively with BMI (P = 0·036).

Conclusion: Splenectomy for massive splenomegaly is safe and provides effective palliation. Provisional cut-off points relating to spleen size and BMI help to identify patients benefiting from a splenectomy, even those in a critical state.

Figure 1

a CT images of a 6·0‐kg splenomegaly extending down to the pelvis in a cachectic female patient (bodyweight 36 kg, BMI 12 kg/m²) presenting with myelofibrosis. b The patient was placed in the supine position, turned slightly to the right. c Intraoperative view after oblique subcostal incision. d A 15‐cm scar seen 2 months after surgery

Figure 2

Dry weight distribution of the 56 removed spleens. Hatched areas indicate the 32 patients operated on by the left oblique incision

Figure 3

Scatter plot of bodyweight/spleen weight ratio against BMI in 56 patients with massive splenomegaly. The left lower quadrant delineated by dotted lines (BMI less than 24 kg/m² and bodyweight/spleen weight ratio below 40) includes 35 of the 42 patients who had excellent pain relief after splenectomy (Karnofsky performance score increased from 20–50 to a postoperative score of 70–90). The regression line with its 95 per cent c.i. is shown. R = 0·69, P < 0·001

Figure 4

Kaplan–Meier survival estimate with 95 per cent c.i. for 56 severely compromised patients with massive splenomegaly

Figure 5

Comparison of spleen weights with BMI, performed to eliminate the possibility of superimposed mathematical coupling. In the left upper quadrant delineated by dotted lines (BMI less than 24 kg/m² and spleen weight above 2·0 kg) are the 25 patients who had excellent pain relief after splenectomy, as assessed by the Karnofsky performance score. The regression line with its 95 per cent c.i. is shown. R = −0·28, P = 0·036