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Intervention:
Splenectomy
ICD-10 code:
ICD-9 code: 41.43 41.5
MeSH D013156
Other codes:

A splenectomy is a surgical procedure that partially or completely removes the spleen.

Contents

Indications

The spleen, similar in structure to a large lymph node, acts as a blood filter. Current knowledge of its purpose includes the removal of old red blood cells and platelets, and the detection and fight against certain bacteria. It's also known to create new blood cells. The spleen is enlarged in a variety of conditions such as malaria, mononucleosis and most commonly in "cancers" of the lymphatics, such as lymphomas or leukemia.

It is removed under the following circumstances:

  1. When it becomes very large such that it becomes destructive to platelets/red cells
  2. For diagnosing certain lymphomas
  3. Certain cases of wandering spleen
  4. When platelets are destroyed in the spleen as a result of an auto-immune process (see also idiopathic thrombocytopenic purpura)
  5. When the spleen bleeds following physical trauma
  6. Following spontaneous rupture
  7. For long-term treatment of congenital erythropoietic porphyria (CEP) if severe hemolytic anemia develops[1]

- Spleen is also removed if gastric cancer has spread in any of its area.

The classical cause of traumatic damage to the spleen is a blow to the abdomen during a sporting event. In cases where the spleen is enlarged due to illness (mononucleosis), the smallest things such as leaning over a counter or straining at stool can cause it to rupture.

Procedure

Vaccination for pneumococcus, H. influenza and meningococcus should be given pre-operatively if possible. In general, spleens are removed by laparoscopy (minimal access surgery) when the spleen is not too large and when the procedure is elective. It is performed by open surgery for trauma or large spleens. Both methods are major surgeries, and are performed under general anesthesia. The spleen is located and disconnected from its arteries. The ligaments holding the spleen in place are dissected and the spleen is removed. When indicated a drain is left in place and the incision(s) is closed. If necessary, tissue samples are sent to a laboratory for analysis.

Side effects

As splenectomy causes an increased risk of overwhelming sepsis due to encapsulated organisms (such as S. pneumoniae and Haemophilus influenzae) the patient should receive the pneumococcal conjugate vaccine (Prevnar), Hib vaccine, and the meningococcal vaccine; see asplenia. Failure to do so later puts the patient at risk of overwhelming post-splenectomy infection (OPSI), a rapid-developing and potentially fatal type of septicaemia. These bacteria often cause a sore throat under normal circumstances but after splenectomy, when infecting bacteria cannot be adequately opsonized, the infection becomes more severe.

An increase in blood leukocytes can occur following a splenectomy.[2][3]

The post-splenectomy platelet count may rise to high levels, leading to an increased risk of potentially fatal clot formation. There also is some conjecture that post-splenectomy patients may be at elevated risk of subsequently developing diabetes.[4] Splenectomy may also lead to chronic neutrophilia. Splenectomy patients typically have Howell-Jolly bodies in their blood smears.

Partial splenectomy

Much of the spleen's protective roles can be maintained if a small amount of spleen can be left behind.[5] Where clinically appropriate, attempts are now often made to perform either surgical subtotal (partial) splenectomy,[6] or partial splenic embolization.[7] In particular, whilst vaccination and antibiotics provide good protection against the risks of asplenia, this is not always available in poorer countries.[8] However as it may take some time for the preserved splenic tissue to provide the full protection, it has been advised that preoperative vaccination still be given.[9]

References

  1. ^ Frye R. (2006-03-02). "Porphyria, Cutaneous". eMedicine. http://www.emedicine.com/ped/topic1871.htm.  
  2. ^ "Guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen. Working Party of the British Committee for Standards in Haematology Clinical Haematology Task Force". BMJ 312 (7028): 430–4. 1996. PMID [http://bmj.bmjjournals.com/cgi/content/full/312/7028/430 Full text 8601117 Full text].  
  3. ^ J M Davies et al. (2001-06-02). "The Prevention And Treatment Of Infection In Patients With An Absent Or Dysfunctional Spleen - British Committee for Standards in Haematology Guideline up-date". BMJ. Full text.  
  4. ^ http://www.nytimes.com/2004/11/09/health/09diab.html?pagewanted=print&position= New York Times article
  5. ^ Grosfeld JL, Ranochak JE (1976). "Are hemisplenectomy and/or primary splenic repair feasible?". J. Pediatr. Surg. 11 (3): 419–24. doi:10.1016/S0022-3468(76)80198-4. PMID 957066.  
  6. ^ Bader-Meunier B, Gauthier F, Archambaud F, et al. (2001). "Long-term evaluation of the beneficial effect of subtotal splenectomy for management of hereditary spherocytosis". Blood 97 (2): 399–403. doi:10.1182/blood.V97.2.399. PMID 11154215.  
  7. ^ Pratl B, Benesch M, Lackner H, et al. (2007). "Partial splenic embolization in children with hereditary spherocytosis". Eur J Haematol 0: 071119202650002. doi:10.1111/j.1600-0609.2007.00979.x. PMID 18028435.  
  8. ^ Sheikha AK, Salih ZT, Kasnazan KH, et al. (October 2007). "Prevention of overwhelming postsplenectomy infection in thalassemia patients by partial rather than total splenectomy". Can J Surg 50 (5): 382–6. PMID 18031639.  
  9. ^ Kimber C, Spitz L, Drake D, et al. (1998). "Elective partial splenectomy in childhood". J. Pediatr. Surg. 33 (6): 826–9. doi:10.1016/S0022-3468(98)90651-0. PMID 9660206.  
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