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Splenectomy: An old topic revisited

Joint Hospital Surgical Grand Round 24 Oct 2009 Dr Tiffany Wong Department of Surgery Prince of Wales Hospital. Splenectomy: An old topic revisited. Indications for splenectomy. ELECTIVE. EMERGENCY. Trauma Iatrogenic injury. Benign Idiopathic thrombocytopenic purpura

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Splenectomy: An old topic revisited

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  1. Joint Hospital Surgical Grand Round24 Oct 2009 Dr Tiffany Wong Department of Surgery Prince of Wales Hospital Splenectomy:An old topic revisited

  2. Indications for splenectomy ELECTIVE EMERGENCY Trauma Iatrogenic injury • Benign Idiopathic thrombocytopenic purpura Hereditary spherocytosis Idiopathic autoimmune hemolytic anaemia • Malingnant Primary: Lymphoma/Leukaemia/Sarcoma Secondary

  3. What is the current standard? Laparoscopic Vs Open Splenectomy

  4. Lap Vs Open for normal size spleen

  5. Laparoscopic Vs Open Laparoscopic approach is preferable for normal size spleen due to • Less blood loss • Lower complication rate • Shorter hospital stay

  6. Is splenomegaly a limitation? Laparoscopic Vs Open Splenectomy

  7. Lap Vs Open for splenomegaly

  8. For splenomegaly • Laparoscopic approach still superior to open for mild to moderate splenomegaly

  9. For massive splenomegaly • Technically challenging due to limited working space and difficult manipulation in case of massive splenomegaly ie >23cm or weight > 2000g Terrosu G, Surg Endosc 2002 • Hand assisted laparoscopic or open splenectomy might be better (no good evidence as support) EAES consensus statement 2008

  10. Is malignant disease a limitation? Laparoscopic Vs Open Splenectomy

  11. Lap splenectomy for benign vs malignant disease

  12. For malignant disease • Laparoscopic approach is still preferable • Need to avoid tumor spillage • En bloc retrieval for histopathological examination

  13. Approach to splenectomy • Laparoscopic approach is in general preferred except in massive splenomegaly • Less blood loss • Lower complication rate • Shorter hospital stay

  14. Positioning Sharma D, Surg Laparosc Endosc Percutan Tech 2009

  15. Vascular control • Ultrasonic coagulating device Rothenberg SS, J Laparoendosc Surg 1996 • Advanced bipolar device Romano F, Pediatr Surg Int 2003 Yuney E, Laparosc Endosc Percutan Tech 2005 Romano F, J Laparoendosc Adv Surg Tech A 2007 • Surgical stapling device Miles WF, Br J Surg 1996 Romano F, J Laparoendosc Adv Surg Tech A 2007 • No RCT comparing different techniques • All shown to be safe and effective

  16. Accessory spleen • 10% in autopsy study • Most common site at hilum, retroperitoneum, greater omentum, small bowel etc Halpert B, Arch pathol 1964 • Not detected, might be responsible for relapsing disease • Computer tomography is the preferred choice 100% sensitivity for number and site of accessory spleen Napoli, Radiology 2004 Gigot JF, Pro Gen Surg 2002 • Thorough search for splenic tissue during surgery is essential

  17. Prevention of sepsis

  18. History • 1919: First recognition of importance of splenic function in resistance to infection Morris DH, Ann Surg 1919 • 1929: First report of postsplenectomy sepsis O’Donnel, BMJ 1929 • 1952: 5 case reports of severe sepsis in postsplenectomy children King, Ann Surg 1952 • 1973: “Postsplenectomy sepsis” as septicaemia, meningitis or pneumonia that is fulminant and occurs after splenectomy Singer, Perspective Paediatr Pathol 1973

  19. Overwhelming Post Splenectomy Sepsis • Highest risk at first 2 years after surgery Bisharat N, J Infect 2001 • Incidence 5% in children and 0.9% in adult Lynch AM, Infect Dis Clin North Am 1996 Cullingford GL, Br J Surg 1991 • 38-69% mortality Aavitsland P, Lancet 1994 Waghorn DJ, J Clin Pathol 2001

  20. Overwhelming Post Splenectomy Sepsis • At risk group: Children Those for hematological malignancy Those with immunosuppressive treatment Those with previous history of OPSS • The lowest risk with trauma Singer, Perspective Paediatr Pathol 1973 Mourtzoukou EG, Br J Surg 2008

  21. Microbiology • Classically by encapsulated organisms Streptococcus pneumoniae Haemophilus influenzae type b Neisseria meningitidis Others: Salmonella/ Capnocytophaga canimorsus/ Babesia/ Malaria • Review of 349 episodes 57% streptococcal infection & mortality 59% 22% haemophilus & mortality 32% Holdsworth R, Br J Surg 1991

  22. Vaccination Strategy

  23. 2

  24. Vaccination Timing • Elective 2 weeks before splenectomy • Emergency 2 weeks after splenectomy Based on 59 trauma patients vs 12 control 1st/7th/14th days after splenectomy Opsonophagocytic function was diminished for those vaccinated before day 14 Shatz DV, J Trauma 1998

  25. Antibiotic Prophylaxis

  26. Daily Prophylaxis • No evidence in adult population • Only one RCT Infection rate 13/110 vs 2/105, p= 0.0025 No mortality in antibiotic group Gaston MH, N Eng J Med 1986 • 1971-1995 > daily penicillin 1958-1970> no prophylaxis Reduced incidence of infection 47% & 88% reduction in mortality Jugenburg M, J Pediatr Surg 1999

  27. Daily prophylaxis • Not adequately evaluated in adult • At risk of selection of resistance strain • Poor compliance • Penicillin resistant pneuomococci • Possible reduction in mortality • Based on efficacy from pediatric population • Most guidelines recommend prophylaxis for 3-5 years for adult Melles DC, Neth J Med 2004

  28. Prevention of infection • Vaccination • Antibiotic prophylaxis • Early recognition & treatment of sepsis in asplenic patients • Patient education

  29. Conclusion • Laparoscopic splenectomy is the preferred approach • Beware of accessory spleen • Importance of post splenectomy sepsis

  30. Thank You

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