Splenic injury during resection for esophageal cancer: risk factors and consequences.
OBJECTIVE
Esophageal cancer surgery carries a risk of splenic injury, which may require splenectomy, but predictors of such events remain uncertain. Moreover, the hypothesis that incidental splenectomy carries a worse prognosis deserves attention.


METHODS
A population-based, nationwide cohort study was conducted on 1679 patients who underwent resection for esophageal cancer in Sweden in 1987 to 2010, with follow-up until February 2012. Predictors of splenic injury and incidental splenectomy were analyzed using multivariable logistic regression, providing odds ratios (ORs) with 95% confidence intervals (CIs). Associations between incidental splenectomy and risk of mortality and severe infections were analyzed using multivariable Cox regression, providing hazard ratios (HRs) with 95% CIs.


RESULTS
Higher surgeon volume of esophageal cancer resection decreased the risk of splenic injury and incidental splenectomy (OR: 0.58; 95% CI: 0.41-0.80; and OR: 0.41; 95% CI: 0.25-0.66, respectively, comparing the highest to lowest category). In patients with splenic injury, progression to incidental splenectomy decreased by 92% during the study period. Sex, age, tumor stage, previous abdominal surgery, neoadjuvant therapy, and surgical radicality did not influence these risks. Incidental accidental splenectomy increased the overall risk of mortality (HR: 1.29; 95% CI: 1.03-1.61) and severe infections (HR: 2.79; 95% CI: 1.35-5.79).


CONCLUSIONS
The inverse association between surgeon volume and splenic injury supports centralization of esophageal cancer surgery. The increased risk of mortality and severe infections after incidental splenectomy should be kept in mind during surgery, and we should encourage efforts to preserve an injured spleen and stress the relevance of vaccination after splenectomy.
*Surgical Care Sciences, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden †Upper GI Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden ‡Division of Cancer Studies, King's College London, London, United Kingdom.
Maryam
M
Derogar
Omid
O
Sadr-Azodi
Pernilla
P
Lagergren
Jesper
J
Lagergren
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001424:Bacterial Infections / Q000453:epidemiology; D002983:Clinical Competence; D004938:Esophageal Neoplasms / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000453:epidemiology*; D012189:Retrospective Studies; D012307:Risk Factors; D013154:Spleen / Q000293:injuries*; D013156:Splenectomy / Q000401:mortality; D013548:Sweden / Q000453:epidemiology; D055815:Young Adult