Fatal overwhelming postsplenectomy infection

A total of 776 patients underwent splenectomy at the Massachusetts General Hospital between 1962 and 1972. Follow-up information was obtained on 637 patients (82 percent), including 584 adults and 53 children. There was a total of 4,837 person-years of follow-up with a mean observation interval of 8.4 years. Four cases of fatal overwhelming postsplenectomy infection were identified. In our pediatric population, the incidence of fatal overwhelming postsplenectomy infection was 3.77 percent, which was significantly higher than the incidence of 0.34 percent in our asplenic adults. Overwhelming postsplenectomy infection is a unique clinical entity distinguishable from other infections. It may occur during the lifetime of any asplenic patient and especially in those patients who have had a splenectomy in childhood. In asplenic adults, the incidence is low. The aggressive approach to splenic preservation in the adult should be tempered by these results.     

Heterotopic splenic autotransplantation in prevention of overwhelming postsplenectomy infection.

An experimental study was undertaken to evaluate the protective effect of heterotopic splenic autotransplantation in weanling rats. Rats were divided into three experimental groups: splenectomy, control, and splenic autotransplantation. Rats were challenged with i.v. type I pneumococcus. Bacterial bloodstream clearance and survival were determined. Splenic bacterial uptake was measured by determining the isotopic activity of technetium-99m-labeled pneumococci. Autoradiographs and material stained with hematoxylin and eosin and Gram strains were examined for histologic features. All autografts survived and were histologically compatible with normal splenic tissue. Bloodstream clearance of pneumococci was significantly greater in rats with splenic autotransplantation. Splenic autografts had 10 to 30 times greater uptake of pneumocci than did the liver. Rats with autotransplantation had a prolonged survival time. Heterotopic splenic autotransplantation may prove to be an important adjunctive surgical measure in the treatment of children undergoing splenectomy.     

The overwhelming postsplenectomy sepsis problem

Postsplenectomy vulnerability to infection is not limited to age or disease process. Postsplenectomy infection is an emergency problem that requires immediate and accurate treatment because death is potential within a few hours of onset. Although the pathogenesis of overwhelming postsplenectomy sepsis is not completely understood, experimental evidence suggests that loss of mechanical filtration is more important than immunologic deficiences resulting from splenectomy. Certainly, a combination of both may be present. While no single measure seems to completely protect against overwhelming postsplenectomy sepsis, experimental evidence suggests that by reducing or minimizing the amount of spleen removed by newer surgical techniques, and by the addition of pneumococcal vaccine and prophylactic penicillin, the incidence of overwhelming sepsis can be reduced. Further evaluation of splenic function is necessary to assess the role of autotransplantation in the prevention of postsplenectomy sepsis (Fig. 1).     

Fulminant sepsis following posttraumatic splenectomy--OPSI (overwhelming postsplenectomy infection) syndrome

We report a case of fulminant sepsis 10 years after posttraumatic splenectomy. The low-cardiac-output stage of the septic shock with disseminated intravascular coagulation (DIC), which was already marked on admission to the intensive care unit, could not be overcome despite appropriate shock treatment. The pathogenetic spectrum includes more than 70% pneumococci, but any pathogen can trigger an overwhelming postsplenectomy infection (OPSI) syndrome. Pathogenetically, the OPSI syndrome is primarily due to distinctly reduced bacterial clearance from loss of the reticuloendothelial tissue in the spleen. Appropriate treatment of the septic shock is of prime therapeutic importance. In summary, the following recommendations can be made: 1. Nonspecific symptoms of infection in splenectomized patients, such as fever, call for immediate clarification with respect to the onset of a septic process. Immediate admission to a hospital, close monitoring, including blood cultures, and immediate antibiotic therapy are unavoidable. 2. The aim of treatment is to prevent DIC by aggressive therapy of the septic shock with prevention of the low-output stage. 3. Splenectomized patients must be informed of the possibility of a serious, potentially fatal infection and its premonitory symptoms. An emergency passport is appropriate. 4. In view of the few side effects of the vaccine, all splenectomized patients should be immunized against pneumococci. Children under 2 years of age should furthermore receive prophylactic oral penicillin up to the age of 5.     

Prevention of overwhelming postsplenectomy infection in thalassemia patients by partial rather than total splenectomy

Objective

We aimed to evaluate the protective role of partial versus total splenectomy against sepsis in patients with thalassaemia when other preventive measures are not available. Overwhelming postsplenectomy infection is a serious complication of splenectomy in these patients, and most present with pneumococcal septicemia. Pneumococcal vaccine given before surgery is a well-established preventive measure.

Methods

In this study, we compared 2 populations of patients from Iraq and Saudi Arabia, both of whom underwent splenectomy for thalassaemia. All patients from Saudi Arabia were given a preoperative pneumococcal vaccine and underwent total splenectomy after about 4 weeks. Unfortunately, this vaccine was not available for the Iraqi patients. Partial splenectomy was offered to many of these patients as a protective measure against this fatal complication.

Results

A significant difference was found between the total splenectomy fatalities in the 2 groups. There were 5 deaths in the 30 enrolled Iraqi patients over 4 years. One death over a 12-year period was reported in the 22 patients from Saudi Arabia. Partial splenectomy was associated with a dramatic reduction of mortality in the Iraqi patients. None of the 12 patients died during a follow-up period of 4 years.

Conclusions

Pneumovax is a powerful prophylactic tool against overwhelming postsplenectomy infection in patients with thalassaemia and should be used whenever available. In poor or problematic countries with limited health resources, partial rather than total splenectomy could offer an alternative measure to avoid this fatal complication.     

Severe late postsplenectomy infection

In all, 1490 patients underwent splenectomy in Western Australia between 1971 and 1983, giving 7825 person years exposure. Thirty-three patients developed severe late postsplenectomy infection (septicaemia, meningitis or pneumococcal pneumonia requiring hospitalization) and three developed overwhelming postsplenectomy infection. The incidence and mortality rates of severe late postsplenectomy infection were 0.42 and 0.08 per 100 person years exposure respectively and for overwhelming postsplenectomy infection the incidence and mortality rates were 0.04 per 100 person years exposure. There were 628 splenectomies after trauma, giving 3922 person years exposure. Eight patients developed severe late postsplenectomy infection of whom one had overwhelming postsplenectomy infection. Following trauma, the incidence of severe late postsplenectomy infection was 0.21 per 100 person years exposure, with the incidence and mortality rates of overwhelming postsplenectomy infection being 0.03 per 100 person years exposure. Patients undergoing splenectomy have a 12.6-fold increased risk of developing late septicaemia compared with the general population. Splenectomy following trauma gives an 8.6-fold increased risk of late septicaemia. The majority of severe late postsplenectomy infections did not occur within the first 2 years and 42 per cent of severe late postsplenectomy infections occurred greater than 5 years after splenectomy. The low incidence of severe late postsplenectomy infection and overwhelming postsplenectomy infection makes statistical evaluation of the effectiveness of prophylactic antibiotics, vaccination and splenic repair most difficult.     

Prophylaxis against postsplenectomy pneumococcal infection

An excess risk of overwhelming sepsis following splenectomy is well established. In view of this, surgical responsibility must embrace the administration of pneumococcal prophylaxis. Current recommendations vary, but routine pneumococcal vaccination, together with penicillin prophylaxis in selected patients, is advocated widely. This retrospective review of 75 patients undergoing splenectomy was undertaken in order to evaluate the extent to which current practice complies with these recommendations. Among surviving patients, the incidence of vaccination with polyvalent pneumococcal vaccine (PPV) was found to vary according to operative indication. All haematological patients received pre-operative PPV. Two-thirds of multitrauma patients were vaccinated, while 42% of patients who required splenectomy following accidental intra-operative trauma received PPV. Only 11% of patients who underwent incidental splenectomy were vaccinated. Long-term antibiotic prophylaxis was commenced in 33% of surviving patients under 20 years of age, and in 8% with underlying malignancy. These results highlight a need for greater vigilance in the administration of pneumococcal prophylaxis, particularly following accidental or incidental splenectomy.     

Splenic trauma and salvage

The traditional view of the spleen as an expendable organ is no longer tenable. In recent years the importance of the spleen in immunologic processes of bacterial clearance, phagocytosis, and antibody formation has been well established. Post-splenectomy sepsis, once only considered a threat in children, is now recognized in adults. Several techniques have evolved since the early 1930s in dealing with splenic injury. These techniques include observation, prevention of iatrogenic injury, auto transplantation, and suture repair in conjunction with hemostatic agents. A recent review of splenectomies done at our institution showed a salvage rate of 97 per cent in children and 6.3 per cent in adults. The preservation of splenic function should be the principal goal in the isolated injury to the spleen; especially for iatrogenic trauma, conservative surgical management is indicated, particularly in children, but also now in adults.     

Partial splenectomy and overwhelming infection in rats

Susceptibility to overwhelming sepsis in rats was measured by intravenous Streptococcus pneumoniae challenge 5 weeks after removal of 25, 50, or 75% of the spleen, with sham splenectomy and total splenectomy groups included for comparison. The LD₅₀ (given in organisms per animal) for total splenectomy was 1.02 × 10³, for 75% splenectomy, 1.79 × 10⁴, for 50% splenectomy, 4.69 × 10⁴, for 25% splenectomy, 4.90 × 10⁵, and for sham splenectomy, 8.04 × 10⁶. All differences were significant at P < 0.05 except for that between 50 and 75% splenectomy. Thus sham, 25, 50, and 75% splenectomy were all associated with a higher LD₅₀ than total splenectomy, and the LD₅₀ increased in proportion to the size of the splenic remnant. No threshold for protection against overwhelming infection was noted, but a rapid fall in LD₅₀ from 75% to total splenectomy may be indicative of a critical splenic mass within that range.     

Splenic repair for trauma

The risks of overwhelming post-splenectomy infection (OPSI) are now well documented both in children and adults. Although the incidence of OPSI is comparatively low following splenectomy for trauma, it has a high mortality. Splenectomy is no longer the treatment of choice for splenic injury and splenic salvage is recommended whenever feasible. Since 1982, in the Isle of Wight hospitals, 13 cases of splenic injury following trauma have been treated applying various salvage procedures and are reported here.     

脾切除术后凶险感染是否真的已经消失？

脾切除术后凶险感染（overwhelming post-splenectomy infection，OPSI）是一种发病突然、来势凶猛，又极具危险的无脾综合征。对其重要性的认识，国内外均有一个过程。1911年Kocher提出“切脾无害论”以后，这一观点长期占据脾脏外科医生的思维，直到20世纪50年代后OPSI才开始引起重视，此后，国内外有关报道不断增多，积累了不少临床经验。     

Splenic trauma. Conservative treatment

The spleen performs a wide range of important life functional at an hematological, immunological and hormonal level. The frequency of immediate and late complications following splenectomy suggest that the most conservative treatment possible must be adopted in cases of splenic trauma. The paper reports 180 cases observed during the period from January 1982 to August 1987. Conservative treatment was used to treat 92 patients. The real advantages of this methods are reviewed in relation to the stability of clinical conditions, the absence of associated abdominal lesions, and the availability of diagnostic equipment and intensive therapy units.     

Splenic trauma by ventriculoperitoneal shunt catheter

Ventriculoperitoneal shunt is used as a treatment of hydrocephalus. Although this procedure is usually safe, several abdominal complications have been reported in the literature. However, to our knowledge, a catheter-induced splenic trauma has not been previously described. We report here the case of a patient who presented with a spontaneous splenic trauma, 10 years after ventriculoperitoneal shunt insertion. A conservative treatment with careful monitoring was successful and the patient recovered without surgery.     

脾切除后凶险性感染的预防和处理

脾切除后凶险性感染（overwhelming postsplenectomy infection，OPSI）在上世纪60～70年代国内译名甚多，如译为脾切除后暴发性或不可逆性或超急性感染等。1985年在武汉召开的第一届全国脾脏功能与脾脏外科学术研讨会上（以下简称脾外科会），裘法祖和夏穗生两位教授认为上述译法均有不妥之处，OPSI发病突然、来势凶猛，又是极具危险的无脾综合征，故译为脾切除后凶险性感染为好，同时也便于全国准确统计OPSI的发生率。