surgical ppt

1. Wednesday,
April 12, 2023
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Post-splenectomy
recommendations
DR. HIWA OMER AHMED
PROFESSOR IN GENERAL AND BARIATRIC SURGERY
UNIVERSITY OF SULAIMANI
COLLEGE OF MEDICINE – SULAIMANI CITY-
KURDISTAN

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April 12, 2023
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Indications of splenectomy
1. Trauma (accidents)
2. Cancer
3. Blood diseases

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April 12, 2023
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 The spleen is the largest lymphatic organ and
plays a crucial role in linking
1. innate first line against infection
2. adaptive immunity memorizing immunity.
 As a result, the absence of the spleen is
associated with significant morbidity and
mortality

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April 12, 2023
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Functions
1. filtration of blood
 The spleen is a large secondary lymphoid organ located in the blood-
stream, primarily functioning as a massive blood filter.
 It filtered
1. effete red blood cells
2. antigen-antibody complexes
3. apoptotic bodies
4. damaged cells

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April 12, 2023
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2. Immunity
 As a specialized immune organ
 the spleen immune system plays a significant role in innate and
adaptive immunity.
1. Specialized innate immune, which is line of resonse to pathogen and
tissue injury
With cells like B cells, natural killer (NK) cells, and macrophages
populate locations within the spleen.

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April 12, 2023
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2. the spleen is a crucial organ for peripheral immune tolerance,
complementing central immune tolerance.
Spleen remains the only organ in the body capable of mounting an
appropriate immune response to encapsulated bacteria.
3. Spleen houses tolerogenic immune cells like CD8+ Treg cells,
F4/80+ macrophages, CD68+F4/80+ red pulp macrophages,
CD169+ metallophillic macrophages, CD8+CD205+ splenic dendritic
cells (DCs), splenic CD8α+CD103+CD207+ DCs,
CD43+veCD19hiCD5+veIgMhiIgDlo B cells, and splenic NKT cells
that express regulated on activation normal T cell expressed and
secreted (RANTES/CCL5) chemokine.

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April 12, 2023
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4. Splenocytes are extra-thymic autoimmune regulator gene
(AIRE) expressing cells that regulate tissue-specific antigens'
expression to confer peripheral immune tolerance.
As such, the spleen provides the right site for
counteracting autoimmunity. Splenectomy in both study
animals and humans results in overwhelming infections with,
especially encapsulated bacteria.
5. The anterior chamber-associated immune deviation (ACAID) is
closely related to the spleen that related to transplant
survival.
6. The role of the spleen in anti-tumor immunity yields an
inconclusive result.

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April 12, 2023
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7. Opsonized pathogens are mopped up from blood by the spleen and
liver, but poorly opsonized microbes like Streptococcus
pneumoniae are only removed from circulation by the spleen.
Upon splenectomy follows the massive loss of immunoglobulin (Ig)-M
memory B cells, loss of splenic clearance of opsonized bacteria due
to loss of marginal zone monocytes. Henceforth, a higher prevalence
of severe infections within the first year after splenectomy, with half of
the cases occurring within the first month

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April 12, 2023
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Dangerous omplication
 The mortality of post-splenectomy sepsis (PSS, also called overwhelming
post-splenectomy infection [OPSI]), the most dangerous complication,
reaches 30–50%.
 Studies report incidence rates of 7–8 infections requiring hospitalization
per 100 patient-years and a post-splenectomy sepsis incidence of 1 per
100 patient-years. Compared to the general population, patients with
asplenia have an approximately 6-fold increased risk of sepsis-related
hospitalization.

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April 12, 2023
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Recommendations
 These recommendations include
1. patient education
2. Vaccinations
3. prophylactic and stand-by antibiotics
4. medical alert cards
5. travel advice and early treatment of animal bites.
 Patients without a functioning spleen and their physicians should be
educated about the everyday risk of overwhelming infections and the need
of prompt recognition and treatment of infections.

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April 12, 2023
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Steps
 Asplenic patients should
1. receive sequential pneumococcal vaccination (13-valent conjugate
followed by 23-valent polysaccharide vaccine),
2. meningococcal vaccination (tetravalent ACWY and serotype B
vaccine), Haemophilus influenza type b conjugate vaccine
3. yearly influenza vaccination.
4. antibiotic prophylaxis
5. A stand-by antibiotic

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April 12, 2023
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Vaccination
 Elective Splenectomy Ideally start immunisation course at least TWO
(ideally four to six) weeks prior to surgery.
 Emergency Splenectomy Ideally start immunisation course at least TWO
weeks post surgery.

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April 12, 2023
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April 12, 2023
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ANTIBIOTIC PROPHYLAXIS
 All patients should be offered lifelong antibiotic prophylaxis.
 Needs rebust doses when
1. Inadequate serological response to pneumococcal vaccination
2. A history of previous invasive pneumococcal disease
3. Splenectomy for underlying haematological malignancy, particularly those
who have received splenic irradiation
4. Patients with active ongoing graft-versus-host disease

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April 12, 2023
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April 12, 2023
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Pregnancy/Breast-feeding
 All of the vaccines may be given during pregnancy and breast-feeding
when protection is required without delay

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April 12, 2023
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Travel
 Patients should be educated as to the potential risks of overseas
travel, particularly with regards malaria and unusual infections, for
example those resulting from animal bites and tick bites.
 Animal Bites
Human, dog or other bites may be fatal if untreated due to infection
with Capnocytophagia canimorsus and other virulent organisms. All
animal bites need to be treated quickly with antibiotics.
 Tick bites :Babesiosis is a rare tick borne infection that can cause
moderate to severe disease, to take precautions against being bitten
in endemic areas. North and South America, Europe, Asia and
Africa.