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SSAT Patient Care Guidelines

Surgical Treatment of Disease and Injuries of the Spleen

Introduction
Our evolving understanding of the spleen's role in the immune surveillance system has markedly altered the indications for splenectomy. Newer treatment modalities for hematologic neoplasms and benign disorders, innovative techniques for achieving hemostasis and splenic salvage, and the accuracy of intra-abdominal imaging techniques have also had a profound effect. Laparoscopic splenectomy, which is becoming increasingly common, appears to be safe and associated with less pain, shorter hospital stay, and more rapid convalescence.

Indications for Splenectomy
Traumatic injury to the spleen is no longer an immediate or mandatory indication for operation or splenectomy. CT scanning or ultrasound can accurately characterize splenic injury in patients with blunt trauma. Non-operative support with in-hospital observation for up to 5 days is indicated in children and adults with splenic injury and hemodynamic stability, provided there is no evidence of other intra-abdominal injuries that might require laparotomy. CTscan demonstrating contrast extravasation (“blush”) from the spleen may be an indication for splenic artery embolization as part of the non-operative algorithm. Accepted indications for operation in adults include: hemodynamic instability, bleeding > 1000 mL, transfusion of more than 2 units of blood, or other evidence of ongoing blood loss. In children under 14 years old, more aggressive non-operative support is justified. When operative intervention is necessary, preservation of the spleen should be considered if bleeding can be controlled quickly and when there are no other life-threatening intra- abdominal injuries. Again, in children under 14 years of age, more aggressive attempts at intraoperative splenic salvage are justified. Splenic autotransplantation with a free-graft for maintenance of specific splenic immunity is of no proven value.

Iatrogenic (Intraoperative) Splenic Injury
The spleen may be injured during the performance of intraperitoneal procedures, especially those involving the distal esophagus, stomach, distal pancreas, or splenic flexure of the colon. These injuries may occur directly from operative retractors or, by traction on capsular adhesions leading to persistent bleeding. To avoid splenectomy, hemostasis should be attempted using suture plication, topical hemostatic agents (including absorbable mesh), electrocautery, or argon beam coagulation. However, if secure hemostasis is not possible before blood loss is sufficient to require blood transfusion, the patient is better managed by splenectomy than by repeated attempts at splenic salvage.

Hematologic Diseases
The decision for elective splenectomy in hematologic disease should be reached in a multi-disciplinary fashion with the patient’s hematologist/oncologist. Common indications include immune thrombocytopenic purpura (ITP), hereditary spherocytosis, thalassemia major, and certain forms of autoimmune hemolytic anemia unresponsive to medical management. Thrombotic thrombocytopenic purpura (TTP) and hairy-cell leukemia unresponsive to other treatment strategies are occasional indications for splenectomy. Routine splenectomy as part of the staging for Hodgkin’s Lymphoma is of historical note only. More common now, the enlarged spleen harboring non-Hodgkin’s (Large B-Cell) Lymphoma may be a diagnostic indication for splenectomy.

Myeloproliferative disorders may lead to massive splenomegaly. Related symptoms may be best relieved by splenectomy although it does not usually alter overall survival. This information should be clearly discussed with the patient prior to operation, and they should be aware of the frequent requirement for blood or blood products when splenectomy is carried out for very large spleens. Massive splenomegaly may preclude a laparoscopic approach. In these circumstances an open or "hand-assisted" laparoscopic technique may be used. The operative morbidity and mortality rates are higher in these patients due to the hematologic co-morbidity.

Other Indications for Splenectomy
Less common indications for splenectomy include splenic abscesses, cysts, sinistral portal hypertension secondary to isolated splenic vein thrombosis or obstruction, or splenic mass presumed to be a neoplasm. Splenectomy is occasionally included in en bloc resection for malignancy in an adjacent organ. Distal pancreatectomy usually includes splenectomy if preservation of the splenic artery and vein is either contraindicated (malignancy) or technically impossible.

Morbidity and Mortality
Operative mortality for elective splenectomy is less than 1% except in patients with myeloproliferative disorders, who are at increased risk for postoperative hemorrhage. In trauma patients, the mortality rate for splenectomy depends upon the extent of other injuries. Postoperative complications of open splenectomy include pneumonia, thrombotic complications, wound infection, hernia formation, hemorrhage, subphrenic abscess, pancreatic abscess/fistula, pancreatic pseudocyst, and, rarely, gastric fistula/perforation. These potential complications also exist when using the laparoscopic approach, although wound complications consist primarily of herniation at trocar sites.

Post-Splenectomy Sepsis
Late sequelae related to splenectomy are much more common in children, especially those under 6 years old. Overwhelming post-splenectomy sepsis is a rare (less than l%) but potentially fatal complication of splenectomy. It is much more common in children younger than age 6 who have not yet developed extra-splenic specific immunity to encapsulated organisms such as pneumococcus and meningococcus. Adults are susceptible to similar infections following splenectomy, but the incidence is likely much lower than in children.

Most pediatricians believe that children who have undergone splenectomy before the age of 5 years should be treated with a daily dose of penicillin until the age of 10 years. The benefit of prophylactic penicillin is less clear in children over 5 years old and in adults. All patients who have undergone non-elective splenectomy should be immunized with Pneumovax (a non-viable pneumococcal vaccine). When planning elective splenectomy, patients should be immunized with Pneumovax, and against H. influenza and meningococcus, preferably two or more weeks before operation.

Qualifications for Performing Operations on the Spleen
The qualifications of a surgeon performing any operative procedure should be based on training (education), experience, and outcomes. At a minimum, surgeons who are certified or eligible for certification by the American Board of Surgery, the Royal College of Physicians and Surgeons of Canada, or their equivalent should perform emergency and elective operations on the spleen. For laparoscopic splenic procedures, surgeons should have advanced laparosocpic training and expertise.

References
Glasgow RE, Mulvihill SJ. Laparoscopic splenectomy. World J Surg 1999;23:384-388.

Katkhouda N, Hurwitz MB, Rivera RT, et al. Laparoscopic splenectomy. Outcome and efficacy in 103 consecutive patients. Ann Surg 1998;228:568-578.

Lucas, CE. Splenic trauma. Choice of management. Ann Surg 1991;213:98-103.

Munser, G, Lazer G, Hocking W, Busuttil W. Splenectomy for hematological disease:
The UCLA experience with 306 patients. Ann Surg 1984;200:40-48.

Shackford SR, Molin MR. Management of splenic injuries. Surg Clin N Am 1990;70:595-620.

Board Approved October 8, 1996

Key Words - patient, guideline, hematologic diseases/surgery, spleen, splenectomy, surgical procedures/laparoscopic, trauma, ultrasound, CT scan, iatrogenic, Pneumovax.

Revised 9-27-96
Revised 10-20-96
Revised 2-5-97
Revised 5-8-97
Revised 5-11-97
Revised 8-21-97
Revised 9/28/99
Revised 11/1/99
Proofed 1/8/00
Revised 5/17/03
Revised 2/9/04
Board Approved 2/21/04
Revised 11/22/13
Board Approved 11/22/13

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Disclaimer
SSAT Patient Care Committee Guidelines

These patient care guidelines were written for the primary care physicians on a variety of digestive diseases to assist on when to refer the patient for surgical consultation.
Their goal is to guide PRIMARY CARE physicians to the appropriate utilization of surgical procedures on the alimentary tract or related organs and they are based on critical review of the literature and expert opinion. Both of the latter sources of information result in a consensus that is recorded in the form of these Guidelines. The consensus addressses the range of acceptable clinical practice and should not be construed as a standard of care. These Guidelines require periodic revision to ensure that clinicians utilize procedures appropriately but the reader must realize that clinical judgment may justify a course of action outside of the recommendations contained herein.

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