FRCA Notes

Splenectomy

The curriculum asks us to know 'the principles of the peri-operative management of the commoner complex cases including... splenectomy'.

The topic appeared as an SAQ back in 2017, where the indication for splenectomy was ITP.

The marks from that question relating to splenectomy included knowing post-splenectomy vaccinations, and conservative management of traumatic splenic injury.

Resources


Condition Notes
ITP If refractory to medical treatment
Hereditary spherocytosis Treatment of choice
Hereditary elliptocytosis If symptomatic
Thalassaemias and sickle-cell disease For splenomegaly
Hypersplenism from other diseases E.g. Felty's syndrome, myelofibrosis, lymphoma
Traumatic splenic injury Spleen-preserving strategies may be employed
As part of other surgical procedure E.g. distal pancreatectomy


Perioperative considerations in the patient undergoing splenectomy


Investigation and optimisation

  • Depending on the aetiology/indication for surgery, patients may have haematological issues such as:
    • Anaemia
    • Thrombocytopaenia
    • Coagulopathies

  • Close liaison with Haematology to ensure optimised pre-operatively, and plan accordingly for intra- and post-operative care, is necessary
  • Ensure blood (either valid group and saves or cross-match 2 units) and platelets available

Medicines management

  • Patients may be on long-term steroids and so suitable perioperative planning is required
  • Patients may require short-term therapy to raise the platelet count to a safe level for surgery (i.e. at the very least 50 x 109/L)
    • Steroids
    • IVIg
    • Romiplostim (TPO receptor agonist)

Monitoring and access

  • Standard AAGBI monitoring

  • Wide-bore IV access as risk of brisk haemorrhage although average blood loss only 50-100ml with laparoscopic techniques
  • Arterial line not absolutely required unless other indication

Anaesthetic technique

  • Neuraxial techniques are unlikely to be used for such a surgery, but if so need to ensure adequate platelet count and coagulation profile normal
  • Splenomegaly can cause left lower lobe atelectasis, with consequent reductions in FRC and raised alveolar-arterial oxygen gradient

Other aspects of intra-operative care

  • If intra-operative platelet transfusion is required, consider waiting until after the splenic vessels have been ligated to reduce the risk of further splenic sequestration
  • Perioperative steroids management as per pre-operative plan/local guidelines

  • Rebound thrombocytosis
  • Left subphrenic abscess
  • Left lower lobe atelectasis

Vaccination requirements

  • From 2 weeks post-traumatic splenectomy:
    • Pneumococcal vaccine
    • Haemophilus influenzae B vaccine
    • Meningococcal C vaccine
  • Lifelong penicillin V (or clarithromycin if penicillin allergic)

Overwhelming Post-Splenectomy Infection (OPSI)

  • A rare, potentially lethal complication (up to 70% mortality)
  • Incidence highest in first 3yrs post-splenectomy, lifetime risk 5%
  • Routine prophylaxis against encapsulated Gram positive reduces the long-term risk to ~1%

  • Typical microbiological culprits:
    • Strep. pneumoniae
    • Neisseria menigitidis
    • Haemophilus influenza

  • More common if splenectomy in paediatric patient or for haematological malignancy
  • Characterised by massive encapsulated organism bacteraemia and sepsis without an obvious primary source of infection

    • Clinical features of OPSI
    Short non-specific prodrome e.g. URTI
    Septic shock
    Multi-organ failure
    DIC
    Bilateral adrenal haemorrhage (Waterhouse-Friedrichsen syndrome)
  • Management is as for any septic patient