Splenectomy - SUNY Downstate Medical · PDF fileINDICATIONS FOR SPLENECTOMY EXCLUDING TRAUMATRAUMA downstatesurgery.org. HISTORYHISTORY

SplenectomySplenectomySplenectomySplenectomy

Jason Levine MDJason Levine MD

Long Island College HospitalLong Island College Hospitalg g pg g p

January 7, 2010 January 7, 2010

downstatesurgery.org

CASE PRESENTATIONCASE PRESENTATIONCASE PRESENTATIONCASE PRESENTATION

58 YO AAM

No PMH

2005: Aphasia, Fevers, Generalized Purpurap p


CASE PRESENTATIONCASE PRESENTATIONCASE PRESENTATIONCASE PRESENTATION

HospitalizedHospitalized HospitalizedHospitalized

H d CT N iH d CT N i Head CT NegativeHead CT Negative

Routine Labs: platelet count <20,000 Routine Labs: platelet count <20,000 Peripheral smear Peripheral smear pp

SchistocytesSchistocytes

Coombs NegativeCoombs Negative


HOSPITAL COURSEHOSPITAL COURSEHOSPITAL COURSEHOSPITAL COURSE

Diagnosis: TTPDiagnosis: TTP Diagnosis: TTPDiagnosis: TTP

Pl h iPl h i PlasmapheresisPlasmapheresis

RituximabRituximab

Surgery ConsultSurgery Consult


HOSPITAL COURSEHOSPITAL COURSEHOSPITAL COURSEHOSPITAL COURSE

Immunized Immunized H. flu Pneumovax Meningococcus

Laparoscopic Splenectomy Discharged POD#4 Discharged POD#4

Pathology: 133 gms 10 x 8 x 5 cm Congested sinusoids

Platelet count: 274,000


INDICATIONS FOR INDICATIONS FOR SPLENECTOMYSPLENECTOMY

EXCLUDING TRAUMATRAUMA


HISTORYHISTORYHISTORYHISTORY

1549 11549 1stst reported splenectomyreported splenectomy1549 11549 1 reported splenectomyreported splenectomy Zaccarella Zaccarella ItalyItalyyy

1865 11865 1stst sucessful splenectomysucessful splenectomy PaenPaenPaenPaen FranceFrance Splenic cystSplenic cystp yp y

1991 1991 11stst laparoscopic splenectomylaparoscopic splenectomy11 laparoscopic splenectomylaparoscopic splenectomy


HISTOLOGYHISTOLOGYHISTOLOGYHISTOLOGY

Spleen: white pulp, p p pmarginal zone and red pulp

White pulp: surrounding the arteries

Marginal zone: lymphatics and macrophages

Red pulp: mature macrophages erythrocytesmacrophages, erythrocytes


PHYSIOLOGYPHYSIOLOGYPHYSIOLOGYPHYSIOLOGY

H l i d I l i F i Hematologic and Immunologic Functions

Destroys Senescent or Deformed Red Blood Cells

Stores Platelets Stores Platelets


PHYSIOLOGYPHYSIOLOGYPHYSIOLOGYPHYSIOLOGY

Produces Red Blood CellsProduces Red Blood Cells

Filters AntigensFilters Antigens

Opsonization of Encapsulated BacteriaOpsonization of Encapsulated Bacteria


ANATOMYANATOMYANATOMYANATOMY

LUQLUQ

9th-11th ribs 9 -11 ribs

Size: 13 x 7 x 4cm Size: 13 x 7 x 4cm

W i ht: 150 m Weight: 150 gms


HEMATOLOGIC DISORDERSHEMATOLOGIC DISORDERSHEMATOLOGIC DISORDERSHEMATOLOGIC DISORDERS

ITPITP Failure Medical Tx, Failure Medical Tx, 7575--85% Response85% Response,,Recurrent DxRecurrent Dx

% p% p

TTPTTP Excessive Plasma Excessive Plasma ExchangeExchange

40 % Response Rate40 % Response RateExchangeExchange

Hereditary Hereditary SpherocytosisSpherocytosis

Hemolytic Anemia, Hemolytic Anemia, transfusions, Leg transfusions, Leg UlcersUlcers

Improves / Eliminates AnemiaImproves / Eliminates Anemia

UlcersUlcers

Felty’s SyndromeFelty’s Syndrome NeutropeniaNeutropenia 80% Response80% Response

Sickle Cell DxSickle Cell Dx Crisis, InfarctionCrisis, Infarction VariableVariable

ThalassemiaThalassemia Transfusions, Transfusions, InfarctionInfarction

Less Transfusions, PainLess Transfusions, Pain


IDIOPATHIC IDIOPATHIC THROMBOCYTOPENIC PURPURATHROMBOCYTOPENIC PURPURATHROMBOCYTOPENIC PURPURATHROMBOCYTOPENIC PURPURA

SplenectomyEl ti I di ti Elective Indication Thrombocytopenia

Ecchymoses

P Purpura

Abnormal Bleeding

Antiplatelet IgG AutoABs

Childr n lf limitin Children, self limiting symptomatic

thrombocytopenia present f > 1for > 1 year


IDIOPATHIC IDIOPATHIC THROMBOCYTOPENIC PURPURATHROMBOCYTOPENIC PURPURATHROMBOCYTOPENIC PURPURATHROMBOCYTOPENIC PURPURA

Adults: 1-2% risk intracranial

hemorrhageO l t id Oral steroids

IV Immunoglobin

Splenectomy Splenectomy Failure medical therapy

no improvement 8 weeksl l l recurrence low platelets

intracranial hemorrhage

75-85% cure rate


IDIOPATHIC IDIOPATHIC T O OC TO C AT O OC TO C ATHROMBOCYTOPENIC PURPURATHROMBOCYTOPENIC PURPURA

No Platelets: Splenic Artery Ligation 1st. No Platelets: Splenic Artery Ligation 1 30% patients accessory spleen

MUST search Intra - op MUST search Intra - op gastrosplenic

gastrocolic

lienorenal ligaments

Recurrent symptoms Recurrent symptoms indium scan


THROMBOTIC THROMBOTIC THROMBOCYTOPENIC PURPURATHROMBOCYTOPENIC PURPURATHROMBOCYTOPENIC PURPURATHROMBOCYTOPENIC PURPURA

Abnormal Plt Clumping p g Arterioles & Capillaries

Hemolysis

Classic Pentad Purpura

Fe er Fever

Microangiopathic hemolytic anemia

N l i d fi i Neurologic deficits

Renal dysfunction


THROMBOTIC THROMBOTIC THROMBOCYTOPENIC PURPURATHROMBOCYTOPENIC PURPURATHROMBOCYTOPENIC PURPURATHROMBOCYTOPENIC PURPURA

Plasma Exchange

Indication for splenectomy F il f di l hFailure of medical therapy

Approximately 40% cure rate


Laproscopic Splenectomy in Patients with Laproscopic Splenectomy in Patients with R f R l i TTPR f R l i TTPRefractory or Relapsing TTPRefractory or Relapsing TTP

8 laproscopic splenectomies for refractory TTP Patients followed 32 months post operatively

7 patients remaining relapse free

S h J MD l A h S 2001 V l 136 1236 1238Schwartz, J MD; et.al. Arch Surgery 2001 Vol 136 p1236-1238


FELTY SYNDROMEFELTY SYNDROMEFELTY SYNDROMEFELTY SYNDROME

Triad Triad Rheumatoid arthritis

Neutropenia Neutropenia

Splenomegaly

1% of RA patients

Antineutrophil IgG

Recurrent infections & chronic leg ulcersg


HEREDITARY SPHEROCYTOSISHEREDITARY SPHEROCYTOSISHEREDITARY SPHEROCYTOSISHEREDITARY SPHEROCYTOSIS

AD Erythrocyte membrane

protein dysfunction Anemia Anemia Jaundice

Splenomegaly

Splenectomy Age >5yo

Spherocytes persistSpherocytes persist Anemia & Jaundice

improve


THALASSEMIATHALASSEMIATHALASSEMIATHALASSEMIA

AD: premature destruction of RBCsp Pallor Ulcers Gallstones Head Enlargement Splenomegaly

Peripheral smear : target cells Peripheral smear : target cells Splenectomy

> 1 blood transfusion per month i severe pain

severe thrombocytopenia (<20,000)

Children (esp. <4yo) Highest risk for OPSI


SICKLE CELL DISEASESICKLE CELL DISEASESICKLE CELL DISEASESICKLE CELL DISEASE

Single amino acid gsubstitution B chain of hemoglobin

R d Mi l Repeated Microvascular

Infarcts

Splenomegaly Splenomegaly Autosplenectomy

Splenectomy Acute Sequestration Crisis

Hypersplenism

Splenic abscesses Splenic abscesses


SPLENIC CYSTSSPLENIC CYSTSSPLENIC CYSTSSPLENIC CYSTS

True (parasitic or (pnonparasitic) Parasitic cysts

E hi Echinococcus

Nonparasitic cysts Congenital Neoplastic

Epidermoid cysts

PseudocystsPseudocysts Trauma

Remove if Symptomatic


TUMORSTUMORSTUMORSTUMORS

Non Hodgkin’s lymphoma Non Hodgkin s lymphoma Most common malignancy

Splenectomy Splenectomy

Hodgkin’s Hodgkin s Splenectomy for staging

Leukemias: Symptomatic


SPLENIC ABSCESSSPLENIC ABSCESSSPLENIC ABSCESSSPLENIC ABSCESS

Hematogenous Seeding Organisms

Staph

Strep

Salmonella

Splenectomy

IV ABx


VASCULAR DISEASESVASCULAR DISEASESVASCULAR DISEASESVASCULAR DISEASES

Splenic vein thrombosisSplenic vein thrombosis Pancreatitis

Pancreatic Carcinoma

Trauma

Gastric Varices

Splenic artery aneurysm Young Women

Pain

Nausea / Vomiting


SPLENECTOMYSPLENECTOMYSPLENECTOMYSPLENECTOMY

Laproscopicp p standard

Open splenectomy


LAPAROSCOPIC APPROACHLAPAROSCOPIC APPROACHLAPAROSCOPIC APPROACHLAPAROSCOPIC APPROACH

Mobilization splenic flexure

Free lateral attachments

Ligate short gastric vessels

Divide Splenic Hilum


OPEN SPLENECTOMYOPEN SPLENECTOMYOPEN SPLENECTOMYOPEN SPLENECTOMY

Mobilization of ligaments Mobilization of ligaments

Sh i l Short gastric vessels

Hilar Dissection Ligation of splenic arteryg p y

Ligation of splenic vein


COMPLICATIONSCOMPLICATIONSCOMPLICATIONSCOMPLICATIONS

Hemorrhage Atelectasisg

Pneumonia

P titi

Pleural Effusion

S b h i Ab Pancreatitis

Pancreatic fistula

Subphrenic Abscess

Portal Vein Thrombosis


Overwhelming Post Splenectomy InfectionOverwhelming Post Splenectomy InfectionOverwhelming Post Splenectomy InfectionOverwhelming Post Splenectomy Infection

Lifetime risk of 1-5% Emergency SurgeryLifetime risk of 1 5% URI:

Rapid decompensation Sh k

g y g y Vaccinate before

discharge

Shock

Highest risk: Children

Medical Bracelet

Underlying hematologic conditions

Vaccinated 10-14 days prior

Booster every 5 yrs

Strep. pneumo H. influenza Meningococcus

Yearly vaccination influenza


Perioperative outcomes of Laparoscopic vs. Open splenectomyPerioperative outcomes of Laparoscopic vs. Open splenectomyA tA t l i ith h i li til i ith h i li tiA metaA meta--analysis with an emphasis on complicationsanalysis with an emphasis on complications

51 series (2940 pts) of Splenectomy from 199151 series (2940 pts) of Splenectomy from 1991--20022002( p ) p y( p ) p y Laparoscopic Splenectomy (2119 pts)Laparoscopic Splenectomy (2119 pts)

Longer to perform Longer to perform Hi h i k f bl diHi h i k f bl di Higher risk of bleeding Higher risk of bleeding Superior to open Superior to open

Decreased length of stayDecreased length of stayL l li iL l li i Less pulmonary complicationsLess pulmonary complications

Less wound complicationsLess wound complications

Emily R. Winslow MD and L. Michael Brunt MD Surgery 2003 Vol134 Issue 4Surgery 2003 Vol134 Issue 4Department of Surgery and the Institute for Minimally Invasive Surgery, WashingtonUniversity School of Medicine, St. Louis, Mo, USA


THE ENDTHE END


Documents

Splenectomy - SUNY Downstate Medical · PDF fileINDICATIONS FOR SPLENECTOMY EXCLUDING TRAUMATRAUMA downstatesurgery.org. HISTORYHISTORY