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Peritoneal reflection of spleen?
- Splenophrenic, gastrosplenic, splenorenal, and splenocolic ligaments
- In patients without portal hypertension, the splenophrenic and splenocolic ligaments are relatively avascular.
- The gastrosplenic ligament carries the short gastric vessels in its superior aspect and the left gastroepiploic in its inferior aspect.
- The splenorenal ligament houses the splenic artery and vein as well as the tail of the pancreas.
Variations of the splenic artery?
Magistral type (30% cases) - branches into terminal and polar arteries near the hilum of the spleen
Distributed type (70% cases) - gives off its branches early and distant from the hilum.
Indications of splenectomy? [TU 2064/5]
- Benign Hematologic Conditions
- Immune Thrombocytopenic Purpura
- Hereditary Spherocytosis
- Hemolytic Anemia Caused by Erythrocyte Enzyme Deficiency
- Hemoglobinopathies - Sickle cell disease and thalassemia
Miscellaneous Benign Conditions
- Malignant Disease
- Lymphomas - Hodgkin disease and Non-Hodgkin lymphomas
- Leukemia - Hairy cell leukemia, Chronic lymphocytic leukemia, Chronic myelogenous leukemia
- Splenic Cysts, Splenic Abscess
What are the treatment modalities for splenic abscess? Discuss their indications. [TU 2070]
Steps of splenectomy?
1. Incision - In emergency or trauma situations - upper midline incision, for a hematologic disorders - left subcostal incision.
2. Incision of avascular peritoneal attachments.
- Splenophrenic ligament - at the superior pole.
- Splenocolic and splenorenal ligaments - at the inferior pole.
- These suspensory ligaments are avascular except for the gastrosplenic ligament, which contains the short gastric vessels.
3. Clamp the artery, which is typically anterior to the splenic vein, and then squeeze the spleen in order to promote autotransfusion of splenic blood prior to clamping the vein.
4. Before closing, a thorough search for accessory spleens should be conducted, especially if the indication for splenectomy is hematological.
What are the possible postoperative complications and measures to prevent them. [TU 2064/7]
What is OPSI? Enumerate the complications of splenectomy? [TU 2059]
Postoperative bleeding - Common sources of bleeding following splenectomy include the raw edges of the divided splenic attachments, and short gastric or hilar vessel remnants.
Gastric perforation - can result from necrosis of the gastric wall from the effects of the initial trauma, or ligation of the short gastric vessels where gastric wall tissue is incorporated into the suture ligature.
Pancreatic fistula - due to injury of the tail of the pancreas
Perioperative infection – Pneumonia, Intra-abdominal abscess
Risk for malignancy — A few studies have suggested that there is possibly an increased risk for malignancy following splenectomy (traumatic or nontraumatic), but in others, the association with malignancy following traumatic splenectomy has not been found
Venous thromboembolism - prophylaxis can be initiated within 24 hours after splenectomy unless contraindicated by other associated injuries.
Late morbidity after splenectomy?
- 1. Postsplenectomy thrombocytosis
- - occurs particularly in patients with myeloproliferative disorders (e.g., CML, polycythemia vera, essential thrombocytosis)
- - can result in thrombosis of the mesenteric, portal, and renal veins and can be life-threatening because it can lead to hemorrhage and thromboembolism
- - Aspirin may be instituted when the platelet count exceeds 1,000,000/microL, if not contraindicated (eg, cerebral trauma).
- 2. Overwhelming postsplenectomy infection (OPSI)
- - most infections occurred more than 2 years after splenectomy
- - OPSI typically begins with a prodromal phase characterized by fever, rigors, and chills and other nonspecific symptoms, including sore throat, malaise, myalgias, diarrhea, and vomiting. Pneumonia and meningitis may be present. Many patients have no identifiable focal site of infection and present only with high-grade primary bacteremia. Progression of the illness is rapid, with the development of hypotension, disseminated intravascular coagulation, respiratory distress, coma, and death within hours of presentation. Despite antibiotics and intensive care, the mortality rate is between 50% and 70% for florid OPSI. Survivors also often have a long and complicated hospital course with multiple sequelae, such as peripheral gangrene requiring amputation, deafness from meningitis, mastoid osteomyelitis, bacterial endocarditis, and cardiac valvular destruction.
— Autotransplantation of splenic tissue at the time of the injury (ie, splenosis) may provide a critical mass of splenic tissue to confer some degree of splenic immunocompetence to the patient, although this is not reliably established.
Vaccine recommendation in splenectomy patients?
- ● Pneumococcal, meningococcal, and Haemophilus influenzae vaccines be administered at least 14 days prior to surgery.
- ● If it is not possible to administer these vaccines prior to splenectomy, they can be given after the 14th postoperative day.
- ● Inactivated influenza vaccination annually, as well as other routine vaccines according to age-based recommendations
- Tetanus (Td/Tdap) - One dose every 10 years
- Human papillomavirus - Three doses for women through age 26 years (0, 2, 6 months)
- Measles, mumps, rubella - One or two doses
- Varicella Two doses (0, 4-8 weeks)
- Zoster - One dose
- Influenza - One dose annually
- Pneumococcal polysaccharide - One or two doses
- Hepatitis A - Two doses (0, 6-12 months or 0, 6-18 months)
- Hepatitis B - Three doses (0, 1-2 months, 4-6 months)
- Meningococcal - One dose
Antibiotic prophylaxis in splenectomy cases?
- Asplenic children receive daily prophylaxis with oral penicillin VK or amoxicillin until at least age five and for at least one year following splenectomy.
- Routine prophylaxis is not recommended in asplenic adults, since sepsis is less common in asplenic adults than in asplenic children.
- Highly immunocompromised individuals and survivors of pneumococcal sepsis may be considered for prophylaxis until age 18 or even for life. Amoxicillin suspension offers enhanced palatability and coverage of some H. influenzae type b strains.
Management of fever in post-splenectomy cases?
- Immediate initiation of antibiotics at the onset of fever or rigors for coverage of S. pneumoniae and H. influenzae.
- Antibiotics include amoxicillin-clavulanate, cefuroxime or, for adults/hypersenity to penicillin with fluoroquinolone (levofloxacin, moxifloxacin, or gemifloxacin).
- If a patient is suspected of having bacteremia, empiric antibiotics such as ceftriaxone should be administered immediately.
Pneumococcal vaccine in Splenectomy patients?
PPV23 replaced the l4-valent vaccine. PPV23 is composed of purified preparations of pneumococcal capsular polysaccharide antigens of 23 types of S. pneumoniae (25 mg each) that cause 88% of the bacteremic pneumococcal disease in the United States.
Short note on ITP. [TU 2056]
What is Immune Thrombocytopenic.
ITP is characterized by a low platelet count despite normal bone marrow and the absence of other causes of thrombocytopenia that could be responsible for the finding. Autoantibodies are responsible for the disordered platelet destruction mediated by the overactivated platelet phagocytosis within the reticuloendothelial system. Within the bone marrow, normal (or sometimes increased) amounts of megakaryocytes are present.
Clinical features of ITP?
- Purpura, epistaxis, and gingival bleeding, gastrointestinal bleeding and hematuria
- Intracerebral hemorrhage is a rare but sometimes fatal presentation.
Diagnosis of ITP?
Exclusion of other relatively common causes of thrombocytopenia
Common causes of thrombocytopenia?
- Pregnancy – normal pregnancies or with preeclampsia.
- Drug-induced thrombocytopenia (e.g., heparin, quinidine, quinine, sulfonamides)
- Viral infections - hepatitis C, HIV infection, rarely Epstein-Barr virus infection
- Bacterial infection - Helicobacter pylori, has also been linked to infection-related thrombocytopenia that improves with eradication.
Management of ITP?
- Asymptomatic patients
- - Platelet >50,000/mm3 - observe without further intervention.
- - Platelet counts, between 30,000 and 50,000/mm3 - observed but with more routine follow.
- Symptomatic patients (mucous membrane bleeding) or high risk conditions (active lifestyle, hypertension, peptic ulcer disease) or platelet count < 20,000 to 30,000/mm3, even without symptoms
- - Initial medication is glucocorticoid administration (typically, prednisone, 1 mg/kg body weight/day).
- - Hospitalization for patients whose platelets counts remain below 20,000/mm3 with significant mucous membrane bleeding, life-threatening hemorrhage.
- - Platelet transfusion is indicated only for those who experience severe hemorrhage.
- - Intravenous immune globulin is important for the treatment of acute bleeding, in pregnancy, or for patients being prepared for operation, including splenectomy. The usual dose is 1 g/kg body weight/day for 2 days.
- - Medical options for refractory ITP include oral prednisone, oral dexamethasone (40 mg/ day for 4 days), rituximab (375 mg/m2/wk intravenously for 4 weeks), and thrombopoietin receptor antagonists (eltrombopag, romiplostim).
- - Indications of Splenectomy - patients with severe thrombocytopenia with counts below 10,000/mm3 for 6 weeks or longer, for those with thrombocytopenia refractory to glucocorticoid treatment, and for those who require toxic doses of steroid to achieve remission.
- - It is not necessary to proceed to splenectomy for patients who have platelet counts higher than 50,000/mm3, who have had ITP for longer than 6 months, who are not experiencing bleeding symptoms, and who are not engaged in high-risk activities.
- - Patients with chronic ITP in whom an accessory spleen is identified should have this removed, as long as the patient can withstand the surgical risk.