Indications for splenectomy


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Indications for splenectomy

  1. 1. INDICATIONS FOR SPLENECTOMY (NON-TRAUMA)Size of spleen ~12 x 7 x 3 to 4 cm in thickness. The average weight 150 g, (80 to 300 g).Spleen: major hematopoietic functions until 5th month of gestation ⇒ bone marrow assumesfunction. No significant hematopoietic function left in the spleen except in hematologicdisorders: Myelodysplastic syndrome, hemoglobinopathies.The functions: closely linked its unique circulatory system. The arteries the white pulp(lymphoid tissues) endothelial cell-lined capillaries into the venous system ("closed"theory). Most of the blood flow, however, enters the macrophage-lined reticular meshwork,and the blood flows slowly back to the venous circulation through the venous sinuses ("open"theory). Abnormal blood component will be trapped in the spleen and ingested by splenicphagocytes.The most important function: mechanical filtration, which removes senescent RBC andcontrol of infection.The spleen is a major site of production for the opsonins, properdin and tuftsin. Properdin:alternative pathway of complement activation ⇒ destruction of bacteria, foreign andabnormal cells. Tuftsin: peptides that enhances the phagocytic activity of both PMN andphagocytes. Decreased neutrophil function in asplenic patients: result from the absence of acirculating mediator.Immune Thrombocytopenic Purpura(idiopathic thrombocytopenic purpura): Low platelet count, a normal bone marrow, and theabsence of other causes of thrombocytopenia.Increased platelet destruction: autoantibodies to platelet membrane antigens ⇒ phagocytosisby the reticuloendothelial system. Bone marrow megakaryocytes are present in normal orsometimes increased numbers.The initial treatment: prednisone (1 mg/kg) 26-30% complete response.Indication for splenectomy in ITP: • refractory severe thrombocytopenia • toxic doses of steroids • relapse after initial steroids • >6 weeks and continue to have a platelet < 10,000/mm 3 • >3 months with incomplete response to primary therapy platelet < 30,000/mm 3 • 2nd trimester of pregnancy with medical refractory platelet <10,000/mm 3 or who have platelet <30,000/mm 3 and bleeding problems.The success rate (complete and permanent response) ~65% 316
  2. 2. Preoperative indium-111-labeled platelet scintigraphy could be predictive of the efficacy ofsplenectomy. The best long-term cure rates have been when predominantly splenicsequestration is present (87 to 93%). hepatic sequestration ~7 to 30%Increase platelet count usually seen within the first 10 days post op. Durable plateletresponses if platelet > 150,000/mm 3 by the 3rd day post op with relapse rates of 4 to 12%Failure to respond to splenectomy or relapse after an initial response : Accessory spleen upto10% the absence of asplenic red blood cell morphologic features and may also be identifiedby radionuclide imaging. If accessory spleen found in a patient who remains severelythrombocytopenic surgical excision of the accessory spleen.Hereditary Spherocytosis• autosomal dominant disease that results from a deficiency of spectrin, a red blood cell cytoskeletal protein.• This defect causes membrane abnormality in the red blood cells that are small, spherical, and rigid.• These cells have increased osmotic fragility.• These. spherocytes are more susceptible to becoming trapped in the spleen and destroyed.• Hemolytic anemia, occasionally jaundice, and splenomegaly.• The diagnosis is made by identification of spherocytes on the peripheral blood smear, an increased reticulocyte count, increased osmotic fragility, and a negative Coombs test.• Splenectomy decreases the rate of hemolysis and usually leads to resolution of the anemia.• Splenectomy is usually performed in childhood shortly after diagnosis but is delayed until after the 4th year of life to preserve immunologic function of the spleen in young children (risk for OPSI).• Cholecystectomy: recommended at time of splenectomy if gallstones are present.Hemoglobinopathies• Indications for splenectomy in patients with sickle cell disease include: ○ acute splenic sequestration crisis (rapid enlargement of spleen, anemia pain, blood transfusion) ○ hypersplenism (reduces transfusions improve cytopenia) ○ splenic abscess. Splenic abscesses (not uncommon): fever, abdominal pain, and a tender, enlarged spleen. Many patients with splenic abscess have leukocytosis; thrombocytosis and Howell-Jolly bodies also occur in these patients, indicating functional asplenia. Common organisms in sickle cell anemia are salmonella, enterobacteria. 317
  3. 3. Splenectomy for Malignancy• Lymphomas ○ HODGKINS DISEASE Most patients have asymptomatic lymphadenopathy (cervical node) at the time of diagnosis (20s-30s), and most present with enlargement. The improved non-operative staging has led to a decrease in the numbers of patients requiring staging laparotomy. Staging laparotomy and splenectomy for selected patients with an early clinical stage of disease (Stage IA or IIA) in whom pathologic staging of the abdomen will significantly influence the therapeutic management. ○ NON-HODGKINS LYMPHOMAS Splenomegaly or hypersplenism is a common occurrence during the course of NHL. Splenectomy is indicated for patients with NHL for treatment of massive splenomegaly (abdominal pain, fullness, and early satiety) and hypersplenism Splenectomy: diagnosis and staging of patients who present with isolated splenic disease. The most common primary splenic neoplasm is NHL (50 to 80% of NHL) There is frequent involvement of the splenic hilar lymph nodes, extra-hilar nodes, bone marrow, and liver in these patients. About 75% exhibit clinical evidence of hypersplenism. ○ Hairy cell leukemia, CML, CLL: splenectomy only for palliation of symptoms or complications of splenomegaly (hypersplenism, abscess, rupture)• Nonlymphoid Tumors of the Spleen ○ Metastatic tumor in up to 7% of autopsies of cancer patients. ○ Breast, lung, and melanoma; however, virtually any primary malignancy may metastasize to the spleen. ○ Often asymptomatic but may be associated with symptomatic splenomegaly or even spontaneous splenic rupture. ○ Splenectomy may provide effective palliation in carefully selected symptomatic patients with splenic metastasis.• Vascular neoplasms: ○ commonly found incidentally. ○ Hemangiomas are usually incidental findings identified in spleens removed for other reasons. ○ Angiosarcomas (or hemangiosarcomas) of the spleen have been associated with environmental exposure to thorium dioxide or monomeric vinyl chloride May present with splenomegaly, hemolytic anemia, ascites, and pleural effusions or with spontaneous splenic rupture poor prognosis. ○ Lymphangiomas are usually benign endothelium-lined cysts that may become symptomatic by causing splenomegaly. ○ Lymphangiosarcoma within a cystic lymphangioma has been reported. 318
  4. 4. Splenectomy is appropriate for diagnosis, treatment, or palliation of the conditions citedpreviously.• Splenic Abscess ○ Splenic abscess is an uncommon and potentially fatal illness. ○ The mortality for splenic abscess ranges from about 80% in immunocompromised patients to about 15 to 20% in previously healthy patients with solitary unilocular lesions. ○ Predisposing illnesses include: Malignancies polycythemia vera endocarditis previous trauma hemoglobinopathy (such as sickle cell disease) urinary tract infection intravenous drug abuse AIDS ○ ~70% from hematogenous spread (endocarditis, osteomyelitis, and IVDA). but may also occur as the result of infection of a nearby structure, such as the colon, kidney, or pancreas. Gram-positive cocci, such as Staph, Strep, or Enterococcus, and gram-negative enteric organisms. Less common: M. tuberculosis, M. avium, and Actinomyces species. Immunosuppressed patients may develop multiple fungal abscesses, typically from Candida species infection. ○ Presentation is often nonspecific and insidious, including LUQ abdominal pain, fever, peritonitis, and pleuritic chest pain. ○ Splenomegaly is present in a minority of patients. ○ Diagnosis: most accurately by CT; however, it may also be made with ultrasonography. ○ Two thirds of splenic abscesses in adults are solitary, one third are multiple. These ratios are reversed in children. ○ Unilocular abscesses are amenable to CT-guided drainage, along with systemic antibiotic has a success rate of 75%-90%. ○ Failure of a prompt clinical response to percutaneous drainage should lead to splenectomy without delay. ○ Multilocular abscesses should usually be treated by splenectomy, with drainage.• Splenic Cysts ○ Most are incidental findings. ○ Primary true cysts of the spleen account for about 10% of all nonparasitic cysts of the spleen. ○ Most nonparasitic cysts are pseudocysts and are secondary to trauma. ○ Focal calcifications up to half of cases. ○ Most are unilocular, and the cysts are smooth and thick-walled. 319
  5. 5. ○ Small asymptomatic splenic pseudocysts (less than 4 cm) do not require treatment and may undergo involution over time. ○ Symptomatic pseudocyst percutaneous drainage: up to 90% success rate or partial splenectomy. ○ True splenic cyst found the second and third decades of life squamous epithelial lining often + for CA 19-9 and CEA many are considered congenital. ○ The presence of symptoms is often related to the size of the cysts > 8cm ○ may present with acute symptoms related to rupture, hemorrhage, or infection. ○ The diagnosis of splenic cyst is best made with CT imaging. ○ Operative intervention is indicated for symptomatic cysts and for large cysts. ○ Either total or partial splenectomy may provide successful treatment. ○ Preservation of at least 25% of the spleen protect appears sufficient to protect against pneumococcal pneumonia ○ Most true splenic cysts are parasitic cysts in areas of endemic hydatid disease (Echinococcus species). Imaging studies: cyst wall calcifications or daughter cysts. Serologic tests for Echinococcus species are often helpful in verifying the presence of parasites. Spillage of cyst contents may precipitate an anaphylactic shock and risks intraperitoneal dissemination of infective scolices. Splenectomy is the treatment of choice. The cysts may be sterilized by injection of a 3% sodium chloride solution, alcohol, or 0.5% silver nitrate, as has been recommended for hydatid cysts of the liver.• Splenic vein thrombosis (SVT) ○ UGI bleeding from esophageal or gastric varicies without presence of cirrhosis. ○ Splenomegaly without cirrhosis, portal HTN or hematologic disease. ○ Most common cause: pancreatitis (acute, chronic, pseudocyst). Pancreatic neoplasms Adenopathy metastatic cancer post partial gastrectomy. ○ 17% of SVT has varicies, ○ 23% progressed to PV thrombosis. ○ EUS may be more sensitive than regular sonogram. ○ Venous phase angiogram is gold standard. ○ Splenectomy is treatment of choice in SVT sclerotherapy has high success rate embolization in acute bleed effective, but splenic infarct up to (25%) and abscess may follow. 320
  6. 6. References• Townsend: Sabiston Textbook of Surgery, 16th ed., Copyright © 2001 W. B. Saunders Company• George JN, Woolf SH, Raskob GE, et al: Idiopathic thrombocytopenic purpura: A practice guideline developed by explicit methods for the American Society of Hematology. Blood 88:3-40, 1996.• Sharon M. Weber, M.D., Layton F. Rikkers, M.D. Splenic Vein Thrombosis and Gastrointestinal Bleeding in Chronic Pancreatitis World J. Surg 2003:; 27: 1271–1274, Naris Nilubol, M.D. May 17, 2004 321