The Spleen
Lecture Conference
Steven J. Binenbaum, MD
SLR
September 12th, 2007
Splenectomy for Hematologic Diseases
Rarely cures the disease
Alleviates symptoms
Corrects hematologic abnormalities
Staging & Diagnosis
Splenectomy for Hematologic Diseases
Red Cell-Related Indications
Hereditary Spherocytosis (HS)
Most common type of hemolytic anemia
Autosomal dominant
Spectrin deficiency (RBC membrane) → Loss of osmotic stability
Osmotic fragility testing
Splenomegaly & Gall stones
Dx by (+) spherocytes in the blood
TOC is Splenectomy in the 4th year of life
+/- cholecystectomy if (+) cholelithiasis
Splenectomy for Hematologic Diseases
Autoimmune Hemolytic Anemia (AIHA)
Warm-antibody autoimmune HA
Autoantibody opsonization and phagocytosis
Intravascular destruction or by spleen macrophages
Treatment Of Choice
#1 is Corticosteroids 1-2 mg/kg/day
PRBC’s for severe anemia
Splenectomy (80% favorable clinical response) if:
medical tx fails
Intolerance to steroids or its side-effects
Splenectomy for Hematologic Diseases
Pyruvate kinase Deficiency
Autosomal-recessive disease
Splenomegaly
TOC
Splenectomy
Reduces PRBC’s requirements
G6PD Deficiency
Splenomegaly is rare
Splenectomy is not indicated!
Splenectomy for Hematologic Diseases
Sickle Cell Disease (SCD)
B-globin gene A→T substitution (Hb S/SS)
autosomal dominant
Sickling of RBCs in tissues with low O2 tension
Red & White pulps
Splenic microinfarcts
Painful
Abscess
Infections
Anemia
Splenectomy (palliative)
Acute sequestration crises (recurrence = 40%-50% with 20% Mortality rate)
Rapid hypersplenism
Abscess formation
Splenectomy for Hematologic Diseases
Thalassemia
Thalassemia major (homozygous B)
autosomal-dominant disease
Decreased expression of beta-chains
Pallor, Growth retardation, head enlargement
Splenectomy indicated if:
Symptomatic splenomegaly
Anemia
Pain due to infarctions
increased PRBC’s requirements (>200 ml/kg/year)
↑ rate of infections after splenectomy
Risk vs. Benefit
Splenectomy for Hematologic Diseases
Platelet Related Indications
ITP TTP
Spleen is not enlarged Splenomegaly
Microvascular thrombosis
♀ > ♂; Renal insufficiency
Petechiae, fever, neurologic changes
children vs. adults
#1 TOC
Self-limited in children (70%)
Plasmaphoresis
Splenectomy is for rare cases
Splenectomy is #2
Insidious onset in adults
Durable remission?
↓ Plts 10 cm or
symptomatic
Splenic Abscess
Uncommon, but fatal
Erode into adjacent structures
Most are secondary in etiology
Bacterial endocarditis
Intrabdominal infections (pyelo-, etc)
IVDA
Infected splenic hematoma
Infected splenic infarctions (embolizations, ischemia, etc)
S/S: fever, WBC;
50% (+) blood cultures
Dx by CT scan + IV contrast
Staphylococcus & Streptococcus
E.coli, Salmonella, anaerobes
Tx:
Splenectomy + IV Abx
Percutaneous drainage
Splenic Salvage Procedures:
Therapeutic Options
SLR
September 12th, 2007
Nonoperative Management of Splenic
Trauma
Indications for initial nonoperative management
hemodynamic stability
absence of peritonitis
CT scan
No contrast extravasation
absence of other injuries
Transfusions - >2 PRBC’s
Protocol for Nonoperative Management
Grade I & II
Awake + alert, isolated injury
monitored observation
BR, H/H q6h, serial abdominal exams
Regular floor in 48º
If remain stable and asymptomatic – D/C in 5 days
F/U CT scan in 4 wks
Avoid prophylactic and therapeutic heparinization
Grade III, IV, & V
Monitored observation x5 days
Repeat CT scan
Transfer to floor if stable
F/U CT scan in 6-8 wks after discharge
Splenorrhaphy
Topical Hemostasis
Small injuries (I & II)
Bovie electrocautery
Argon beam
Gelfoam
Surgicel
Avitene
Suture Repair & Partial Resection
Segmental blood supply
Monofilament sutures
Pledgeted horizontal mattress sutures
Splenorrhaphy
Mesh Splenorrhaphy
Delaney (1982)
Autotransplantation
controversial