SPLENECTOMY FOR DISEASE
AND MANAGEMENT OF
CONDITIONS OTHER THAN
TRAUMA
Douglas Slakey 2015
Outline
 This lecture will focus on the management
of diseases that may require surgical
treatment, including splenectomy.
1. Cysts and Tumors of the Spleen
2. Splenic Abscess
3. Indications for Splenectomy (other than
trauma)
Cysts and Tumors of the Spleen

Splenic masses are rare compared to other abdominal
organs

History and Physical
 Patients are often asymtpomatic (30-45%)– masses
discovered incidentally
 May have RUQ pain
 Most common 10-30 years of age, but can occur at any
age.

Imaging
 Ultrasound – differentiate cystic from solid
 CT or MRI
Cysts and Tumors of the Spleen
Solid Masses
 Lymphoid
 Hodgkin
 Non-Hodgkin
 Nonlymphoid
 Benign
 Malignant
Cysts and Tumors of the Spleen
 Cystic Masses
 Primary (True)
 Parasitic (Echinococcus granulosus most common)
 Congenital (10% of all cysts)
 Neoplastic

Include endodermoid, dermoid, epidermoid
 Pseudocysts (75% of all cysts)
 Post-traumatic – patients often cannot recall
specific traumatic even
 May be related to silent splenic infarct
 Other
Cysts of the Spleen
 Risk of Cyst rupture is 25% if >5cm
 CA 19-9 and CEA may be elevated
 Treatment
 Aspiration may be considered, but risk of
bleeding and recurrance – spread of
malignant cells if present
 Partial splenectomy or fenestration if certain
pseudocyst
 Precautions as for liver cysts if parasitic
 Total most common treatment
Prior to any splenic Surgery
 Immunization
 Streptococcus pneumoniae
 Neisseria meningitidis
 Meningococcus
 Post splenectomy sepsis
 Incidence is 0.2% to 4.3%
 Lifetime risk 5%
Solid Tumors of Spleen
 Uncommon
 Tumors may be diffuse or localized within
spleen
 Lymphoid tumors first arise in white pulp
 Splenectomy indicated for
 staging protocols (not common today)
 Hypersplenism, pain
Solid Tumors of Spleen
 Primary
 Hemangiomas
 Most common benign tumor
 Usually asymptomatic
 May cause unexplained consumptive
coagulopathy
 Lymphangiomas, hemangioendotheliomas
 May cause symptoms from mass effect
 Rare tumors: hamartomas, lipomas,
fibrosacroma, and others
Solid Tumors of Spleen
 Metastatic, secondary
 Uncommon
 Primary may be: melanoma, breast, lung
 Primary hemangiosarcoma
 Rare, but most common primary splenic
malignancy
 Grow rapidly and metasize early
 May rupture spontaneously
Management of Splenic Abscess
 Symptoms highly variable, may be
asymptomatic
 May be associated with left pleural
thickening, pneumonia
 Ultrasound 75-90% sensitive
 Irregular thickened wall, look for internal
septations, debris
 Can be found in immunosuppressed
patients
Management of Splenic Abscess
 Many potential organisms, aerobic and
anaerobic
 Polymicrobial in up to 36%
 Fungal in 25%
 Most common candida
 Mycobacterium in 4 – 7%
Management of Splenic Abscess
 If untreated, uniformly fatal
 Medical treatment alone – 80% mortality
 First-line treatment percutaneous
drainage
 Lowest initial mortality, but 30% recurrence
rate
 Allows for culture
 Monitor with repeat US / CT
 Complications – bleeding, hemothorax,
pneumothorax
Management of Splenic Abscess
 Laparoscopic drainage
 If percutaneous not feasible
 Antibiotic therapy 10-14 days with
drainage
 If recurrence, or persistent abscess then
total splenectomy
Splenectomy for other Conditions
 Typically for cytopenia and/or
splenomegaly
 Failure of medical treatment if applicable
 Weigh risk vs. benefit
 Indivdualize treatment
 Risk of splenectomy is low for experienced
surgeons
 Normal spleen weight: 90-150g.
Splenomegaly defined as weight more
than 175 g.
Splenectomy for other Conditions
 Thromocytopenia
 Platelet count < 150,000 / microL
 Idiopathic Thrombocytopenic Purpura (ITP)
 Most common indication
 Splenic macrophages clear platelets coated
with IgG autoantibodies
 Test for autoantibodies
 Sensitivity 49-66%
 Specificity 78-92%
Splenectomy for other Conditions
 ITP


Response to splenectomy 67% (range 37% - 100%)
Younger age (<30) at time of splenectomy - better
outcome
Accessory splenic tissue in up to 30%



Possible locations: splenic hilum, gastrocolic ligament, greater
omentum, mesentary, pre-sacral space
Splenectomy usually avoided during pregnancy

If necessary, 2nd trimester preferred
Splenectomy for other Conditions
 Thrombotic Thrombocytopenia Purpura (TTP)
 Can be lethal
 Pentad: thrombocytopenia, hemolytic anemia,
fever, renal dysfunction, neurologic impairment
 Peripheral schistocytes (fragmented
erythrocytes)
 Microvascular thrombosis
 Total plasma exchange is preferred treatment
 Splenectomy for relapse or refractory patients
 Significant surgical morbidity for these patients
Splenectomy for other Conditions
 Systemic Lupus Erythematosus
 Antiplatelet antibodies in 78%, severe
thrombocytopenia in 8-20%
 For refractory patients splenectomy has
response rate similar for ITP
 HIV
 Subset of patients with thrombocytopenia
refractory to medical treatment have
favorable response (80+%) to splenectomy
Splenectomy for other Conditions
 Wiskott-Aldrich Syndrome
 X-linked immunodeficiency disorder
 Thrombocytopenia most common
manifestation
 Splenectomy indicated for patients who fail
medical management, or who are ineligible
for bone marrow transplant
Disorders Causing Anemia
 Hereditary Anemia
 Hereditary spherocytosis
 For moderate to severe disease splenectomy is
indicated. Typically between 6 yo – to puberty
 Other disorders where splenectomy
indicated if medical manamgnet not
effective:




Glucose-6-phosphate dehydrogenase deficiency
Sickle cell anemia
Thalassemia major
Acquired hemolytic anemia
Splenectomy for other Conditions
 Splenic artery aneursym
 Third most common abdominal aneurysm
 After aortic and iliac
 Most common in multiparous women
 Mortality if rupture while pregnant – 70% for
mother, nearly 100% for fetus
 Splenectomy may be necessary, but not
always – depends upon anatomy
 All symptomatic aneursyms need surgery
 If > 2.5 cm
Splenectomy for other Conditions
 Portal hypertension, splenic vein thrombosis
 If severe, symptomatic thrombocytopenia and no
contraindications, may consider
 If bleeding from gastric varices (unusual
indication)
 Wandering spleen
 When spleen is attached by long, loose vascular
pedicle
 May cause torsion, abdominal pain.
 Children – splenopexy to diaphragm
 Adults - splenectomy
The End