Indications for Splenectomy
Our evolved understanding of the spleen's role in the immune surveillance system has markedly altered the indications for splenectomy, as have newer treatment modalities for selected hematologic neoplasms and benign disorders, the development of hemostasis and splenic salvage, and the proliferation of intra-abdominal imaging techniques. Laparoscopic splenectomy, which is becoming increasingly common, appears to be safe and associated with less pain, lower hospital stay, and more rapid convalescence.
Traumatic injury to the spleen is no longer an immediate or mandatory indication for operation or splenectomy, either in the adult or child. CT scanning or emergent ultrasound can diagnose splenic injury in patients with blunt trauma to the abdomen or lower chest. 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. Accepted indications for operation in adults include the significant accumulation of intraperitoneal blood (over 1,000 ml), the requirement for more than 2 units of blood transfusion, a progressively decreasing hemoglobin concentration, or hemodynamic instability. More aggressive non-operative support is justified in children under 14 years old. When operative intervention is necessary, preservation of the spleen should be considered if bleeding can be controlled quickly and other life-threatening intra-abdominal injuries are absent. 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 still experimental and of unproven efficacy.
Indications for splenectomy should be determined with the close cooperation of a hematologist/oncologist. Common indications include hereditary spherocytosis, thalassemia major, and certain forms of immune thrombocytopenic purpura (ITP) unresponsive to medical management. Myeloproliferative disorders may lead to massive splenomegaly and can cause symptoms that are best relieved by splenectomy, primarily for symptomatic relief. Splenectomy does not usually alter overall survival, and this information should be clearly discussed with the patient prior to operation, again with a hematologist/oncologist, including the probable requirement for blood or blood products. In the presence of splenomegaly, the procedure is best performed using an open or "hand-assisted" laparoscopic technique. The operative morbidity and mortality rates are higher in these patients due to the hematologic co-morbidity. Thrombotic thrombocytopenic purpura (TTP) and hairy-cell leukemia unresponsive to other treatment strategies are occasional indications for splenectomy.
Selected patients with clinical Stage I-A or II-A Hodgkin's disease may be candidates for a staging laparotomy or laparoscopy. In the absence of obvious liver or intra-abdominal nodal disease, splenectomy is an integral part of the staging procedure to exclude splenic involvement, which would alter the method of treatment.
Iatrogenic (Intraoperative) Splenic Injury
The spleen may be injured inadvertently 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, more often, secondary to inadvertently avulsed capsular adhesions that can lead to persistent bleeding. Hemostasis should be attempted using suture plication, topical hemostatic agents (including absorbable mesh), electrocautery, or argon beam coagulation so that splenectomy is not required. However, if rapid hemostasis is not possible, hemorrhage severe enough to require blood transfusion is better managed by formal splenectomy than by repeated attempts at splenic salvage, especially in the adult patient.
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 primary or undiagnosed neoplasm. Splenectomy is occasionally included in en bloc resection for malignancy in an adjacent organ, such as the stomach, colon, adrenal gland, or pancreas. 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 wound infection, hernia formation, hemorrhage, subphrenic abscess, pancreatic pseudocyst (secondary to inadvertent injury to the tail of the pancreas), and gastric fistula/perforation (secondary to injury/necrosis of the gastric wall during ligation of the short gastric vessels). These potential complications also exist when using the laparoscopic approach, although wound complications consist primarily of herniation at trocar sites. Late sequela related to splenectomy are much more common in children, especially those under 6 years old. Overwhelming postsplenectomy sepsis secondary to encapsulated organisms such as pneumococcus and meningococcus is a rare (less than l%) possibility in children prior to spleen-specific immune function becoming established outside the spleen. Adults are susceptible to similar infections following splenectomy, but the incidence is likely much lower than in children. Prophylactic aspirin is recommended to prevent axillary or other venous thrombosis if the blood platelet count per milliliter exceeds one million.
Prophylaxis Against Post-Splenectomy Sepsis
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 use of prophylactic penicillin is less defined 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 containing the more common virulent strains of the pneumococcus family). If elective splenectomy is planned, patients should also be immunized with Pneumovax, preferably two or more weeks before operation. Children less than 10 years old and all patients with immunosuppression or an associated immunodeficiency should be vaccinated against pneumococcus, H. influenza, meningococcus, and Hepatitis B.
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.
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.
Key Words - patient, guideline, hematologic diseases/surgery, spleen, splenectomy, surgical procedures/laparoscopic, trauma, ultrasound, CT scan, iatrogenic, Pneumovax
Board Approved 10/8/96
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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