Splenectomy

Last updated
Splenectomy
ICD-9-CM 41.43, 41.5
MeSH D013156
OPS-301 code 5-413

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

Surgery Medical specialty

Surgery is a medical specialty that uses operative manual and instrumental techniques on a patient to investigate or treat a pathological condition such as a disease or injury, to help improve bodily function or appearance or to repair unwanted ruptured areas.

Spleen internal organ in most vertebrate animals

The spleen is an organ found in virtually all vertebrates. Similar in structure to a large lymph node, it acts primarily as a blood filter. The word spleen comes from Ancient Greek σπλήν (splḗn).

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 is also known to function as a site for the development of new red blood cells from their hematopoietic stem cell precursors, and particularly in situations in which the bone marrow, the normal site for this process, has been compromised by a disorder such as leukemia. 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.

Lymph node organ of the lymphatic system

A lymph node or lymph gland is an ovoid or kidney-shaped organ of the lymphatic system and the adaptive immune system. Lymph nodes are widely present throughout the body and are linked by the lymphatic vessels as a part of the circulatory system. They are major sites of B and T lymphocytes and other white blood cells. Lymph nodes are important for the proper functioning of the immune system, acting as filters for foreign particles and cancer cells, but they do not have a detoxification function.

Red blood cell most common type of blood cell

Red blood cells, also known as RBCs, red cells, red blood corpuscles, haematids, erythroid cells or erythrocytes (from Greek erythros for "red" and kytos for "hollow vessel", with -cyte translated as "cell" in modern usage), are the most common type of blood cell and the vertebrate's principal means of delivering oxygen (O2) to the body tissues—via blood flow through the circulatory system. RBCs take up oxygen in the lungs, or gills of fish, and release it into tissues while squeezing through the body's capillaries.

Platelet component of blood

Platelets, also called thrombocytes, are a component of blood whose function is to react to bleeding from blood vessel injury by clumping, thereby initiating a blood clot. Platelets have no cell nucleus: they are fragments of cytoplasm that are derived from the megakaryocytes of the bone marrow, and then enter the circulation. Circulating unactivated platelets are biconvex discoid (lens-shaped) structures, 2–3 µm in greatest diameter. Activated platelets have cell membrane projections covering their surface. Platelets are found only in mammals, whereas in other animals thrombocytes circulate as intact mononuclear cells.

It is removed under the following circumstances:

  1. When it becomes very large such that it becomes destructive to platelets/red blood cells
  2. For diagnosing certain lymphomas
  3. Certain cases of splenic abscess
  4. Certain cases of wandering spleen
  5. Splenic vein thrombosis with bleeding Gastric varices
  6. When platelets are destroyed in the spleen as a result of an auto-immune condition, such as idiopathic thrombocytopenic purpura.
  7. When the spleen bleeds following physical trauma
  8. Following spontaneous rupture
  9. For long-term treatment of congenital erythropoietic porphyria (CEP) if severe hemolytic anemia develops [1]
  10. The spread of gastric cancer to splenic tissue
  11. When using the splenic artery for kidney revascularisation in renovascular hypertension.
  12. For long-term treatment of congenital pyruvate kinase (PK) deficiency

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), trivial activities, such as leaning over a counter or straining while defecating, can cause a rupture.

Procedure

Laparoscopy is the preferred procedure in cases where the spleen is not too large and when the procedure is elective. Open surgery is performed in trauma cases or if the spleen is enlarged. Either method is major surgery and is performed under general anesthesia. Vaccination for pneumococcus, H. influenza and meningococcus should be given pre-operatively if possible to minimize the chance of overwhelming post-splenectomy infection (OPSI), a rapid-developing and potentially fatal type of septicaemia. The spleen is located and disconnected from its arteries. The ligaments holding the spleen in place are dissected and the organ is removed. In some cases, one or more accessory spleens are discovered and also removed during surgery. The incisions are closed and when indicated, a drain is left. If necessary, tissue samples are sent to a laboratory for analysis.

Laparoscopy

Laparoscopy invented by George Kelling in 1901, in Germany, is an operation performed in the abdomen or pelvis using small incisions with the aid of a camera. The laparoscope aids diagnosis or therapeutic interventions with a few small cuts in the abdomen.

An overwhelming post-splenectomy infection (OPSI) or overwhelming post-splenectomy sepsis (OPSS) is a rare but rapidly fatal infection occurring in individuals following removal of the spleen. The infections are typically characterized by either meningitis or sepsis, and are caused by encapsulated organisms including Streptococcus pneumoniae.

Accessory spleen Accessory spleen is usually found in the omentum

An accessory spleen is a small nodule of splenic tissue found apart from the main body of the spleen. Accessory spleens are found in approximately 10 percent of the population and are typically around 1 centimetre in diameter. They may resemble a lymph node or a small spleen. They form either by the result of developmental anomalies or trauma. They are medically significant in that they may result in interpretation errors in diagnostic imaging or continued symptoms after therapeutic splenectomy.

Side effects

Splenectomy causes an increased risk of sepsis due to encapsulated organisms (such as S. pneumoniae and Haemophilus influenzae ).It has been found that the risk of acquiring sepsis is 10 to 20 times higher in a splenectomized patient compared to a non-splenectomized patient, which can result in death, especially in young children. [2] Therefore, patients are administered the pneumococcal conjugate vaccine (Prevnar), Hib vaccine, and the meningococcal vaccine post-operatively (see asplenia). 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.

Sepsis life-threatening organ dysfunction triggered by infection

Sepsis is a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs. Common signs and symptoms include fever, increased heart rate, increased breathing rate, and confusion. There may also be symptoms related to a specific infection, such as a cough with pneumonia, or painful urination with a kidney infection. In the very young, old, and people with a weakened immune system, there may be no symptoms of a specific infection and the body temperature may be low or normal, rather than high. Severe sepsis is sepsis causing poor organ function or insufficient blood flow. Insufficient blood flow may be evident by low blood pressure, high blood lactate, or low urine output. Septic shock is low blood pressure due to sepsis that does not improve after fluid replacement.

<i>Haemophilus influenzae</i> Species of bacterium

Haemophilus influenzae is a Gram-negative, coccobacillary, facultatively anaerobic pathogenic bacterium belonging to the Pasteurellaceae family. H. influenzae was first described in 1892 by Richard Pfeiffer during an influenza pandemic.

Pneumococcal conjugate vaccine (PCV) is a pneumococcal vaccine and a conjugate vaccine used to protect infants, young children, and adults against disease caused by the bacterium Streptococcus pneumoniae. There are currently three types of PCV available on the global market, which go by the brand names: Prevnar, Synflorix and Prevnar 13.

An increase in blood leukocytes can occur following a splenectomy. [3] The post-splenectomy platelet count may rise to abnormally high levels (thrombocytosis), leading to an increased risk of potentially fatal clot formation. Mild thrombocytosis may be observed after a splenectomy due to the lack of sequestering and destruction of platelets that would normally be carried out by the spleen. In addition, the splenectomy may result in a slight increase in the production of platelets within the bone marrow. Normally, erythrocytes are stored and removed from the circulating blood by the spleen, including the removal of damaged erythrocytes. However, after a splenectomy the lack of presence of the spleen means this function cannot be carried out so damaged erythrocytes will continue to circulate in the blood and can release substances into the blood. If these damaged erythrocytes have a procoagulant activity then the substances they release can lead to the development of a procoagulant state and this can cause thromboembolic events e.g. pulmonary embolism, portal vein thrombosis and deep vein thrombosis. [2] 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 [5] [6] and less commonly Heinz bodies in their blood smears. [7] Heinz bodies are usually found in cases of G6PD (Glucose-6-Phosphate Dehydrogenase) and chronic liver disease. [8]

Diabetes a disease characterized by long-term high blood sugar

Diabetes mellitus (DM), commonly known as diabetes, is a group of metabolic disorders characterized by high blood sugar levels over a prolonged period. Symptoms of high blood sugar include frequent urination, increased thirst, and increased hunger. If left untreated, diabetes can cause many complications. Acute complications can include diabetic ketoacidosis, hyperosmolar hyperglycemic state, or death. Serious long-term complications include cardiovascular disease, stroke, chronic kidney disease, foot ulcers, and damage to the eyes.

Neutrophilia

Neutrophilia is leukocytosis of neutrophils, that is, a high number of neutrophils in the blood. Because neutrophils are the main type of granulocytes, mentions of granulocytosis often overlap in meaning with neutrophilia.

Chronic liver disease in the clinical context is a disease process of the liver that involves a process of progressive destruction and regeneration of the liver parenchyma leading to fibrosis and cirrhosis. "Chronic liver disease" refers to disease of the liver which lasts over a period of six months. It consists of a wide range of liver pathologies which include inflammation, liver cirrhosis, and hepatocellular carcinoma. The entire spectrum need not be experienced.

A splenectomy also results in a greatly diminished frequency of memory B cells. [9] A 28-year follow-up of 740 World War II veterans who had their spleens removed on the battlefield showed a significant increase in the usual death from pneumonia (6 deaths rather than the expected 1.74) and an increase in the deaths from ischemic heart disease (41 deaths rather than the expected 30.26) but not from other conditions. [10]

World War II 1939–1945 global war

World War II, also known as the Second World War, was a global war that lasted from 1939 to 1945. The vast majority of the world's countries—including all the great powers—eventually formed two opposing military alliances: the Allies and the Axis. A state of total war emerged, directly involving more than 100 million people from over 30 countries. The major participants threw their entire economic, industrial, and scientific capabilities behind the war effort, blurring the distinction between civilian and military resources. World War II was the deadliest conflict in human history, marked by 50 to 85 million fatalities, most of whom were civilians in the Soviet Union and China. It included massacres, the genocide of the Holocaust, strategic bombing, premeditated death from starvation and disease, and the only use of nuclear weapons in war.

Pneumonia Infection of the lungs

Pneumonia is an inflammatory condition of the lung affecting primarily the small air sacs known as alveoli. Typically symptoms include some combination of productive or dry cough, chest pain, fever, and trouble breathing. Severity is variable.

Partial splenectomy

Much of the spleen's protective roles can be maintained if a small amount of spleen can be left behind. [11] Where clinically appropriate, attempts are now often made to perform either surgical subtotal (partial) splenectomy, [12] or partial splenic embolization. [13] In particular, whilst vaccination and antibiotics provide good protection against the risks of asplenia, this is not always available in poorer countries. [14] 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. [15]

History

The Austrian surgeon Hermann Schloffer performed the first splenectomy in 1916.

See also

Related Research Articles

Hemolysis or haemolysis, also known by several other names, is the rupturing (lysis) of red blood cells (erythrocytes) and the release of their contents (cytoplasm) into surrounding fluid. Hemolysis may occur in vivo or in vitro.

Spherocytosis

Spherocytosis is the presence in the blood of spherocytes, i.e erythrocytes that are sphere-shaped rather than bi-concave disk shaped as normal. Spherocytes are found in all hemolytic anemias to some degree. Hereditary spherocytosis and autoimmune hemolytic anemia are characterized by having only spherocytes.

Lymphocytosis

Lymphocytosis is an increase in the number of lymphocytes in the blood. In adults, lymphocytosis is present when the lymphocyte count is greater than 4000 per microliter (4.0 x 109/L), in older children greater than 7000 per microliter and in infants greater than 9000 per microliter. Lymphocytes normally represent 20 to 40% of circulating white blood cells.

Immune thrombocytopenic purpura primary thrombocytopenia that involves relatively few platelets in blood as a result of autoantibodies

Immune thrombocytopenia purpura (ITP), also known as idiopathic thrombocytopenic purpura, is a type of thrombocytopenic purpura defined as isolated low platelet count with normal bone marrow and the absence of other causes of low platelets. It causes a characteristic purpuric rash and an increased tendency to bleed. Two distinct clinical syndromes manifest as an acute condition in children and a chronic condition in adults. The acute form often follows an infection and has a spontaneous resolution within two months. Chronic immune thrombocytopenia persists longer than six months with a specific cause being unknown.

Polycythemia vera human disease

Polycythemia vera is an uncommon neoplasm in which the bone marrow makes too many red blood cells. It may also result in the overproduction of white blood cells and platelets.

Hereditary spherocytosis congenital hemolytic anemia characterized by the production of red blood cells with a sphere shape, rather than the normal biconcave disk shape

Hereditary spherocytosis is an abnormality of red blood cells, or erythrocytes. The disorder is caused by mutations in genes relating to membrane proteins that allow for the erythrocytes to change shape. The abnormal erythrocytes are sphere-shaped (spherocytosis) rather than the normal biconcave disk shaped. Dysfunctional membrane proteins interfere with the cell's ability to be flexible to travel from the arteries to the smaller capillaries. This difference in shape also makes the red blood cells more prone to rupture. Cells with these dysfunctional proteins are degraded in the spleen. This shortage of erythrocytes results in hemolytic anemia.

Thrombocytopenia A blood platelet disease characterized by a low platelet count in the blood.

Thrombocytopenia is a condition characterized by abnormally low levels of thrombocytes, also known as platelets, in the blood.

Thrombocythemia is the presence of high platelet (thrombocyte) counts in the blood, and can be either primary or secondary. Although often symptomless, it can predispose to thrombosis in some patients. Thrombocytosis can be contrasted with thrombocytopenia, a loss of platelets in the blood.

Essential thrombocythemia Human disease

Essential thrombocythemia (ET) is a rare chronic blood condition characterised by the overproduction of platelets (thrombocytes) by megakaryocytes in the bone marrow. It may, albeit rarely, develop into acute myeloid leukemia or myelofibrosis. It is one of four myeloproliferative neoplasms.

Asplenia refers to the absence of normal spleen function and is associated with some serious infection risks. Hyposplenism is used to describe reduced ('hypo-') splenic functioning, but not as severely affected as with asplenism.

Splenomegaly Abnormal increased size of the spleen

Splenomegaly is an enlargement of the spleen. The spleen usually lies in the left upper quadrant (LUQ) of the human abdomen. Splenomegaly is one of the four cardinal signs of hypersplenism which include: some reduction in number of circulating blood cells affecting granulocytes, erythrocytes or platelets in any combination; a compensatory proliferative response in the bone marrow; and the potential for correction of these abnormalities by splenectomy. Splenomegaly is usually associated with increased workload, which suggests that it is a response to hyperfunction. It is therefore not surprising that splenomegaly is associated with any disease process that involves abnormal red blood cells being destroyed in the spleen. Other common causes include congestion due to portal hypertension and infiltration by leukemias and lymphomas. Thus, the finding of an enlarged spleen, along with caput medusae, is an important sign of portal hypertension.

An autosplenectomy is a negative outcome of disease and occurs when a disease damages the spleen to such an extent that it becomes shrunken and non-functional. The spleen is an important immunological organ that acts as a filter for red blood cells, triggers phagocytosis of invaders, and mounts an immunological response when necessary. Lack of a spleen, called asplenia, can occur by autosplenectomy or the surgical counterpart, splenectomy. Asplenia can increase susceptibility to infection. Autosplenectomy can occur in cases of sickle-cell disease where the misshapen cells block blood flow to the spleen, causing scarring and eventual atrophy of the organ. Autosplenectomy is a rare condition that is linked to certain diseases but is not a common occurrence. It is also seen in systemic lupus erythematosus (SLE).

Howell–Jolly body

A Howell–Jolly body is a cytopathological finding of basophilic nuclear remnants in circulating erythrocytes. During maturation in the bone marrow, late erythroblasts normally expel their nuclei; but, in some cases, a small portion of DNA remains. Its presence usually signifies a damaged or absent spleen, because a healthy spleen would normally filter this type of red blood cell.

Splenic injury

A splenic injury, which includes a ruptured spleen, is any injury to the spleen. The rupture of a normal spleen can be caused by trauma, such as a traffic collision.

Splenic infarction condition in which oxygen supply to the spleen is interrupted

Splenic infarction is a condition in which blood flow supply to the spleen is compromised, leading to partial or complete infarction in the organ.

Pappenheimer bodies

Pappenheimer bodies are abnormal basophilic granules of iron found inside red blood cells on routine blood stain. They are a type of inclusion body composed of ferritin aggregates, or mitochondria or phagosomes containing aggregated ferritin. They appear as dense, blue-purple granules within the red blood cell and there are usually only one or two, located in the cell periphery. They stain on a Romanowsky stain because clumps of ribosomes are co‐precipitated with the iron‐containing organelles.

Hematologic diseases are disorders which primarily affect the blood & blood-forming organs. Hematologic disease include rare genetic disoders, anemia, HIV, sickle cell disease & complications from chemotherapy or transfusions.

Cold autoimmune hemolytic anemia caused by cold-reacting antibodies. Autoantibodies that bind to the erythrocyte membrane leading to premature erythrocyte destruction (hemolysis) characterize autoimmune hemolytic anemia.

References

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  2. 1 2 Tarantino G, Scalera A, Finelli C (June 2013). "Liver-spleen axis: intersection between immunity, infections and metabolism". World Journal of Gastroenterology. 19 (23): 3534–42. doi:10.3748/wjg.v19.i23.3534. PMC   3691032 . PMID   23801854.
  3. Working Party of the British Committee for Standards in Haematology Clinical Haematology Task Force (February 1996). "Guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen". BMJ. 312 (7028): 430–4. doi:10.1136/bmj.312.7028.430. PMC   2350106 . PMID   8601117.
  4. Kolata G (9 November 2004). "A Diabetes Researcher Forges Her Own Path to a Cure". The New York Times.
  5. synd/1596 at Who Named It?
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