Risk Of Postsplenectomy Sepsis Research Articles

Partial splenectomy for a giant epidermoid cyst of the spleen

Key Clinical MessageThe splenic epidermoid cysts are rare benign tumors, and a definitive treatment remains unclear. Although some spleen‐preserving approaches have been reportedly used, splenic cyst recurrence usually occurs in true cyst cases, wherein the cyst is incompletely removed. In our case, partial splenectomy was performed and the giant cyst was completely removed.

Acute splenic torsion in children: which is the best treatment? A case report

Wandering spleen is a clinical entity which rarely affects children and adolescents. This condition can be asymptomatic or responsible of chronic pain, but it appears as a surgical emergency when an acute twisting occurs. The risk of post-splenectomy sepsis in the pediatric population suggests a conservative approach whenever possible, and also in case of acute torsion, most authors prefer to preserve the spleen and perform a splenopexy. The Authors describe a case of a child with acute splenic torsion, in whom a conservative surgical approach was initially adopted. The conservative option has to be balanced with the risk of prolonged thrombocytopenia, multiple transfusions and a possible second procedure to remove the spleen.

Comments on 'clinical course of 63 children with hereditary spherocytosis: a retrospective study'

Comments on 'clinical course of 63 children with hereditary spherocytosis: a retrospective study'

Surgical Treatment of Patients with Wandering Spleen: Report of Six Cases with a review of the literature

Wandering spleen, which is defined as a spleen without peritoneal attachments, is a rare disease and a delay in the clinical and/or radiological diagnosis may lead to splenic torsion, infarction, and necrosis. Owing to the physiologic importance of the spleen, especially in children, and the risk of postsplenectomy sepsis, early diagnosis and splenopexy are recommended. In the present article, we describe the results of our management of this rare problem on six patients, and we review all available literature from 1895 to 2005. Briefly, our technique includes flap creation from parietal peritoneum and settlement of spleen in the fossa splenica. Free edges of this flap are stitched to the stomach and the left end of transverse colon and the beginning of the descending colon. The body of the stomach was stitched to the abdominal wall to prevent gastric volvulus, while the fundus region was fixed to the diaphragm to support the spleen. Finally, an omental patch was stitched to the intact abdominal wall above the flap. In conclusion, the procedure of splenopexy without using mesh is considered to be a safe and curative modality for wandering spleen without imposing any undue risk of infection or foreign material reaction.

Laparoscopic Splenopexy for the Wandering Spleen Syndrome

Purpose: Wandering spleen syndrome is an uncommon condition characterized by the absence of the normal suspensory ligaments of the spleen. The wandering spleen is highly mobile, suspended only by its vascular pedicle, and may cause significant morbidity, including hypersplenism, splenic torsion and infarction, pancreatitis, intestinal obstruction, and bleeding from gastric varices. Splenectomy has been the traditional method of treatment; however, splenopexy has recently been advocated to avoid the risk for post-splenectomy sepsis. We present a novel, minimally invasive method of splenopexy for the treatment of a wandering spleen and associated hypersplenism in a pediatric patient. Methods: A 15-year-old girl presented with a 3-week history of intermittent severe lower abdominal pain and was found to have anemia, thrombocytopenia, and a palpable lower abdominal mass. Ultrasonography demonstrated an enlarged wandering spleen and cholelithiasis. Laparoscopic splenopexy and cholecystectomy were performed wit...

Multiple trauma: liver and spleen injury

The management of hepatic and splenic injuries in childhood has evolved over the past 30 years from prompt operation upon recognition of injury to nonoperative management in the large majority of children. Many aspects of nonoperative management have become increasingly standardized and efforts continue to further refine this strategy. The appropriate intensive care unit and acute care unit length of stay, the number of laboratory draws, the length of activity restriction and the need for radiographic evidence of healing prior to release from activity restriction remain areas of study. Previously demonstrated variation in the management and outcome of injured children between adult and pediatric surgeons has led to debate over which type of facility should best care for injured children. The Pennsylvania Trauma Systems Foundation dataset was used to derive a series of children with severe liver injuries. Finally, the risk of post-splenectomy sepsis, a stimulus for the initial development of nonoperative management, has been further clarified by a literature review. While falls from a low height may infrequently lead to a significant injury, falls from greater heights are more likely to induce a solid organ injury.

Preparation of patients with hematologic diseases for splenectomy

Splenectomy in haematological patients is usually performed as an elective surgery. These patients may have thrombocytopenia or coagulation abnormalities which have to be corrected as much as possible before surgery. The increase of number of platelets may be achieved by increase of dose of steroids, with immunoglobulins, with danazol or by transfusion of platelets. The coagulation abnormalities are to be corrected by appropriate treatment. The risk of postsplenectomy sepsis may be reduced by proper preoperative vaccination and/or by antibiotics.

Idiopathic Thrombocytopenic Purpura

Idiopathic Thrombocytopenic Purpura

The role of partial splenectomy in children with thalassemia.

Partial splenectomy was performed on 12 patients with thalassemia (9 beta-thalassemia major and 3 Hb H disease) to reduce blood transfusion requirements. The indication for partial splenectomy was the presence of splenomegaly and increased blood transfusion requirements (i.e. Hb drop > 0.5 g per week). Their ages ranged from 3 to 10 years (mean 6.9 years). On follow-up, ranging from 1.1-5.5 years (mean 2.6 years), two of the three patients with Hb H disease required no more blood transfusions while the third continued to receive blood transfusions, but at a lower frequency. For those with beta-thalassemia major, the transfusion requirements and Hb drop per week decreased in the majority of patients. This is specially so during the first 1-2 years following partial splenectomy. In all, about 1/3 of the size of the normal spleen was preserved (either upper or lower pole) which was judged functional as there has been no significant infection in any of the patients, no change in IgM level, no Howell-Jolly bodies and visualization on scintigraphy. Partial splenectomy is recommended to start with for those with Hb H disease. For patients with beta-thalassemia major, partial splenectomy is beneficial as a temporary measure and in those children who are less than 5 years of age, as they are at greater risk of post splenectomy sepsis.

Nonoperative Management of the Adult Ruptured Spleen

The risk of postsplenectomy sepsis has led to increased enthusiasm for preservation of the spleen. From January 1984 to December 1988, 51 consecutive adult patients with ruptured spleen sustained from blunt trauma were examined. Thirty-four patients (67%) had their conditions hemodynamically stabilized at the time of hospital admission and were placed on a regimen of strict bed rest with intensive monitoring. The average hemoglobin value at hospital admission in this group was 126 +/- 18 g/L, with an average drop of 17 +/- 14 g/L during their hospitalization; 14 patients required transfusions averaging 3 U each. Nonoperative treatment was successful in 33 (97%) of 34 patients; one patient whose condition deteriorated clinically underwent splenectomy on the fifth hospital day. These patients have been followed up for an average of 28 months with no sequelae from their splenic injury. We conclude that a nonoperative approach is a viable alternative in stable adult patients with splenic injuries due to blunt trauma when intensive monitoring is available.

SPLENECTOMY IN SPHEROCYTOSIS: IS IT WORTH THE RISK?

Splenectomy reduces the incidence of gallstone formation in patients with hereditary spherocytosis (HS). However, this surgical procedure carries an operative risk as well as the risk of postsplenectomy sepsis (PSS). Furthermore, gallstones do not always cause symptomatic biliary tract disease. Using decision analysis, a quantitative approach to problem solving under conditions of uncertainty, we have examined the relative merits of two approaches to patients with mild HS: (1) routine splenectomy in childhood or (2) cholecystectomy for symptomatic gallstones in adulthood. Probability values for critical events were obtained from the medical literature; final outcome is recovery or death. The analysis shows the risk of death associated with the choice of splenectomy to be 40 times greater than the risk of cholecystectomy for symptomatic gallstones (.0245 vs .0006). Sensitivity and threshold analyses show that the decision to avoid splenectomy remains unaltered even if the risk of death from PSS (.022) is reduced four-fold or if the risk of developing gallstones (including symptomatic and silent stones) is increased from .43 to 1.0. The choices become equivalent only if the risk of developing symptomatic gallstones increases from .08 to .50 while the risk of PSS falls from .022 to .001. On the basis of the best data currently available, the preferable course for patients with HS and mild anemia is careful surveillance for symptomatic biliary tract disease rather than routine splenectomy to prevent gallstones.

Overwhelming postsplenectomy sepsis in childhood

Three hundred ninety-three splenectomies were performed within the Charity Hospital system during the decade from 1969 through 1979. This number included 56 operations in children under 16 years of age, which formed the basis of this report of the risk of infection in young splenectomized patients and provided guidelines for the role of splenectomy under emergency and elective conditions. Eight episodes of serious infection were documented in four patients. There was only one case of overwhelming postsplenectomy infection which resulted in death, for a mortality rate of 1.8 percent (1 of 56 children) for death due to overwhelming postsplenectomy sepsis. It is emphasized, however, that the development of serious postsplenectomy sepsis in our series resulted in a 25 percent mortality rate. The risk of postsplenectomy sepsis is much greater in those individuals who are immunologically compromised, such as those who undergo staging splenectomy for Hodgkin's disease. If splenectomy is indicated for a hematologic disorder, it is wise to defer operation for as long as possible, especially if the acute episodes are self-limiting or mild. Rather than the promiscuous use of polyvalent serum and antibiotic therapy after splenectomy in children, it is recommended that parents be advised to bring the child to the hospital anytime an illness or fever develops that might require an immediate loading dose of an appropriate antibiotic. The role of subtotal splenectomy or hemisplenectomy merits consideration in staging Hodgkin's disease. Preoperative study of certain immunologic parameters may provide guidelines as to the proportion of individuals who may be vulnerable to overwhelming sepsis after splenectomy.

The risk of sepsis in the asplenic adult.

The risk of postsplenectomy sepsis in children is well established. The risk of sepsis following splenectomy in the adult remains unknown. This study provides data on this important subject. All adults (ages 16--91) who underwent splenectomies in three hospitals of the Louisiana State University Medical Center between 1965 and 1975 were identified. There were 298 patients included in the study. Postsplenectomy information was collected on 256 patients. The mean period of observation was 45 months (960 patient years). There were seven deaths from fulminant sepsis (incidence rate: 2.7%). Data were collected on 250 patients who had either a gastrectomy or cholecystectomy without splenectomy. The mean period of observation was 61 months (1270 patient years). There were no deaths due to fulminant sepsis (p less than 0.05). When postsplenectomy sepsis was compared with the risk of sepsis in the population at large (0.001%), the difference is significant (p less than 0.001). In the subgroup of 69 patients with hematologic or malignant disease, there were three deaths from sepsis (4.3%). In 187 patients with no underlying diseases, four patients developed sepsis, which is an incidence of 2.2% (p less than 0.05 when compared with the population at large and control group). The risk of sepsis appears to be greater in patients with chronic disease, but has no relationship to age. These data speak for the conservation of splenic tissue when possible.

Use and Efficacy of Pneumococcal Vaccine in Patients With Hodgkin Disease

AbstractFulminant bacterial sepsis has been described in patients with Hodgkin disease who have undergone splenectomy for staging purposes. The organisms commonly associated with sepsis in this setting include Streptococcus pneumoniae and Haemophilus influenzae. Polyvalent pneumococcal vaccine (Merck) has recently been licensed and has been suggested for use in patients with Hodgkin disease who are at risk for postsplenectomy sepsis. We administered 14-valent pneumococcal vaccine to 24 patients with Hodgkin disease and 24 normal controls, and measured antibody response to 13 antigens at time of immunization and at 3 wk and 3 mo following immunization. Our results indicate that patients who have been previously treated for Hodgkin disease, with chemotherapy, radiotherapy, or both, have severe impairment of antibody response. Untreated patients, however, respond in a manner similar to normal controls.

Use and efficacy of pneumococcal vaccine in patients with Hodgkin disease

Fulminant bacterial sepsis has been described in patients with Hodgkin disease who have undergone splenectomy for staging purposes. The organisms commonly associated with sepsis in this setting include Streptococcus pneumoniae and Haemophilus influenzae. Polyvalent pneumococcal vaccine (Merck) has recently been licensed and has been suggested for use in patients with Hodgkin disease who are at risk for postsplenectomy sepsis. We administered 14-valent pneumococcal vaccine to 24 patients with Hodgkin disease and 24 normal controls, and measured antibody response to 13 antigens at time of immunization and at 3 wk and 3 mo following immunization. Our results indicate that patients who have been previously treated for Hodgkin disease, with chemotherapy, radiotherapy, or both, have severe impairment of antibody response. Untreated patients, however, respond in a manner similar to normal controls.

Accessory Spleen in Hodgkin's Disease

To the Editor.— The problem of dealing with accessory spleens in patients undergoing laparotomy for abdominal staging of Hodgkin's disease, addressed by Jacobson and Reynolds (240:2081, 1978), seems worthy of further comment in view of two recent developments. The first of these is the growing realization that the problem of postsplenectomy sepsis in patients with Hodgkin's disease who have undergone total splenic ablation is of such magnitude that reappraisal of the value of total splenectomy for some patients seems in order. An assessment of the literature published since the risk of postsplenectomy sepsis in these patients became manifest indicates that the risk may range from about 10% overall 1 to more than 20% in patients who require aggressive multimodal therapy for their disease. 2 Since the mortality of patients with postsplenectomy sepsis remains extremely high, regardless of therapy once sepsis occurs, and since measures for prevention of postsplenectomy sepsis have