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Laparoscopic splenectomy underutilized in the U.S.

Key clinical point: American general surgeons lag far behind their foreign colleagues in their rate of laparoscopically completed splenectomies.

Major finding: Only 13.3% of elective splenectomies performed in the United States started out as laparoscopic procedures ­– and of those, 40% were converted to open splenectomy.

Data source: A retrospective study of the Nationwide Inpatient Sample for 2005-2010, during which 37,006 elective total splenectomies were performed.

Disclosures: The presenter reported having no relevant financial conflicts.


 

AT MINIMALLY INVASIVE SURGERY WEEK

References

LAS VEGAS – Laparoscopic splenectomy has become the preferred surgical approach in the literature, but the number of such procedures performed in the United States remains relatively low, according to Dr. John Afthinos.

National data for 2005-2010 showed a total of 37,006 elective total splenectomies were performed. Only 4,938 of them, or 13.3%, began as laparoscopic procedures, of which 40% had to be converted to open splenectomies, he reported at the annual Minimally Invasive Surgery Week.

Dr. John Afthinos

Dr. John Afthinos

“Laparoscopic splenectomy remains underutilized,” Dr. Afthinos commented. “This is one of the lowest recorded rates of laparoscopic completion of any advanced procedure that we know of.”

For example, other investigators have demonstrated that laparoscopic colectomies and bariatric surgical procedures are typically completed laparoscopically in 85%-95% of cases, noted Dr. Afthinos of Staten Island (N.Y.) University Hospital.

The laparoscopic approach has convincingly been shown to result in less pain, shorter hospital length of stay, faster recovery, and improved cosmetic results, compared with the open surgical versions of various operations.

“In the U.S., laparoscopic splenectomy is not well incorporated into the armamentarium of the average general surgeon. We can speculate that the underutilization of this approach around the country prevents development of the familiarity and skill that you need to perform the operation safely without conversion,” he said at the meeting, presented by the Society of Laparoscopic Surgeons and affiliated societies.

Dr. Afthinos’s data were drawn from the Nationwide Inpatient Sample maintained by the U.S. Agency for Healthcare Research and Quality. In this database, patients who had a laparoscopic splenectomy had the shortest average hospital length of stay: 5.6 days, compared with 7.5 in those who underwent open splenectomy and 7.1 for conversion procedures. The overall morbidity rate was significantly lower in the laparoscopic group, too: 7.4%, compared with 10.4% in the open splenectomy group.

In a multivariate analysis, he and his coworkers identified three independent risk factors for conversion from laparoscopic to open splenectomy: hemorrhage, with a 3.23-fold increased risk; splenomegaly, with a 1.3-fold increased risk; and autoimmune hemolytic anemia, with an associated 1.36-fold elevated risk of conversion.

Dr. Catalin Vasilescu of Carol Davila University in Bucharest, Romania, rose from the audience to voice his incredulity at the American data: “I am really surprised at your national conversion rate of well over 30%. That is really a problem. Earlier at this meeting, we presented 520 laparoscopic splenectomy patients with a conversion rate over 20 years of 4%-5%,” the Romanian general surgeon said.

“How do you explain this? I have a hypothesis: Perhaps there are so many surgeons each performing very few of these procedures, instead of referring patients to an experienced center,” he said.

“It was surprising to us, too,” Dr. Afthinos replied. “I mean, I was expecting the conversion rate to be high, but not that high.”

He said Dr. Vasilescu was right on the mark. In addition, he explained, it’s important to understand that there are vast rural areas of the United States, and some rural patients are reluctant to travel hundreds of miles to undergo laparoscopic splenectomy at a large experienced center, especially in the winter or if their family can’t come along for support. And a rural general surgeon is not going to risk a patient’s life if he or she isn’t comfortable with a laparoscopic approach.

There is hope that the situation will improve, however, as more fellowship-trained minimally invasive surgeons enter clinical practice, according to Dr. Afthinos. He cited a recent report from a Columbus, Ohio, general surgery practice that after a fellowship-trained minimally invasive surgeon joined the practice, the group – excluding their fellowship-trained recent hire – increased its rate of various advanced procedures being performed laparoscopically from 12% to 48%. The five established surgeons indicated they found mentoring by a colleague with minimally invasive surgery training was a better way to learn the procedures than via weekend courses, videos, traveling proctors, and other methods (Surg. Endosc. 2013;27:1267-72).

Dr. Afthinos reported having no relevant financial conflicts.

bjancin@frontlinemedcom.com

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