Splenorrhaphy: changing concepts for the traumatized spleen.

Established doctrine dictating splenectomy for the traumatized spleen has come under considerable critism since the report of fatal postsplenectomy sepsis by King and Shumacher in 1952. With expanding knowledge of immunologic and physiologic function, splenectomized persons have been proven at risk in different areas, but the most important impetus for splenic preservation has been the observation of overwhelming postsplenectomy sepsis. Several reports have confirmed this concern, with a documented increase in morbidity and death of splenectomized patients of 50 to 200 times the normal. Successful results with surgical repair of traumatized spleens have been reported, experimentally and clinically proving excellent healing capabilities. It is not uncommon to frequently find little if any active bleeding with such injuries; in fact, even significant bleeding can be controlled with splenic salvage. Several different techniques to accomplish this have been reported. These are reviewed, two new successful and previously unreported techniques are outlined in detail, and statistical information supporting the use of these techniques is presented.     

The risk of splenorrhaphy

The main reason for splenorrhaphy is to prevent the occurrence of overwhelming postsplenectomy sepsis. This fear of postsplenectomy sepsis has led to an enthusiasm for splenic salvage to the extent that it may be felt that the injured spleen must be saved at all costs. However, if that is valid, the complications that result from splenic salvage must not exceed the risk incurred by loss of this organ. To assess this, 119 splenic injuries treated by splenorrhaphy were reviewed. These were major splenic injuries that were actively hemorrhaging at laparotomy and, therefore, required specific operative intervention for hemostasis. There were 14 complications in 11 patients (11.8%) directly attributed to the splenorrhaphy. In one patient, the repaired spleen rebled 17 days postoperatively, necessitating splenectomy. Ten patients had persistent or recurrent bleeding, requiring blood transfusions. Three of these underwent reexploration for additional hemostasis. Blood transfusion in association with splenorrhaphy has not previously been considered a complication. However, the literature clearly documents that the risk of blood transfusion heavily outweighs the risk of postsplenectomy sepsis. Therefore, if blood transfusion becomes a necessary adjunct for successful splenorrhaphy, then splenectomy without transfusion is the safer treatment.     

Incidental splenic injury during abdominal vascular surgery: a case-controlled analysis

BACKGROUND: The small but finite risk of postsplenectomy sepsis is generally regarded as a firm indication for splenic preservation after iatrogenic injury, especially in the young. But splenectomy may be preferable in patients who sustain splenic injuries during vascular operations because of the potential for continued bleeding associated with anticoagulation. The purpose of this study was to determine the perioperative morbidity of incidental splenectomy among patients undergoing abdominal vascular operations. STUDY DESIGN: We studied 17 patients who underwent incidental splenectomy at the time of abdominal vascular operations. Complete data collected on each subject included preoperative and postoperative blood counts, operative indications and details, transfusion requirements, length of hospital stay, and outcomes. Using age- and gender-matched case controls undergoing identical vascular operations from the same period, we evaluated the complication rate and outcomes of patients who underwent splenectomy for iatrogenic injuries of the spleen, versus those who did not sustain splenic injuries. RESULTS: The estimated prevalence of iatrogenic splenic injury during the study period was 0.5%. Mean operative time, estimated blood loss, and duration of mechanical ventilation tended to be greater in the splenectomy patients, but the differences did not achieve statistical significance. Splenorrhaphy was attempted in seven patients, but continued bleeding mandated spleen removal in all cases. Splenectomy patients had a higher transfusion requirement (p = 0.03) and a longer mean length of stay (p = 0.03) than controls. Compared with controls, there was a higher prevalence of infectious complications in the splenectomy patients (p = 0.015), but there was no difference in the prevalence of thromboembolic complications between groups. Two of the splenectomy patients died in the postoperative period from multisystem organ failure, and one died of a missed splenic injury. CONCLUSIONS: These data suggest that incidental splenectomy during abdominal vascular operations is associated with increased postoperative infectious complications and prolonged hospitalization.     

Spontaneous splenic rupture following infectious mononucleosis

Four cases of spontaneous splenic rupture after infectious mononucleosis (IM) have been treated at this institution since 1978. The condition is rare, occurring in 0.1-0.5 per cent of patients with proven infectious mononucleosis. Splenectomy is considered the treatment of choice for these patients. However, because recent trends in the management of traumatic splenic rupture are moving towards nonoperative treatment with selected patients, a similar approach has been considered for the patient with spontaneous splenic rupture following IM. The major reason for avoiding splenectomy is the increased incidence of sepsis in splenectomized patients. Yet, splenic rupture is accompanied by hemorrhage and the risks associated with blood transfusion for ongoing hemorrhage are of similar magnitude as those of sepsis following splenectomy. In addition, the grossly abnormal spleens seen at operation tend to include large, contained hematomas that may also be prone to rupture. Therefore, operative management still appears to be the preferred treatment for spontaneous splenic rupture following IM. Splenectomy is curative, safe, and obviates the need for transfusion, extended hospitalization, and activity restriction.     

Postsplenectomy complications

Postsplenectomy complications were reviewed among 420 patients with simple splenic injury, splenic plus multisystem trauma, elective splenectomy, incidental or accidental splenectomy, and those having splenectomy prior to renal transplantation. Complications not specifically related to splenectomy occurred postoperatively in 52 per cent and 41 per cent, respectively, in the complex trauma and incidental-accidental splenectomy groups. Nonfatal complications specifically related to splenectomy occurred in 15 per cent of patients with multi-organ injury and in 18 per cent of patients with incidental-accidental splenic removal. Morbidity was infrequent when simple splenic trauma prompted splenectomy or in elective splenectomy. Mortality related to splenectomy occurred most often following renal transplantation, but also appeared high when the spleen was removed for multiple trauma or incidental to other surgery. The latter category is at risk for morbidity and mortality when splenectomy is incidental to a planned procedure (e.g., radical gastrectomy) or accidental as when injured by the surgeon. These splenectomies and those planned prior to transplantation may be unnecessary in many instances. The postsplenectomy sepsis syndrome was encountered late only once in this entire series; nonetheless, sound indications for splenectomy must prevail before splenic removal since significant early morbidity and mortality follows splenectomy.     

Splenorrhaphy in the management of splenic injury

A retrospective study of 301 adult splenic injuries presenting to the Princess Alexandra Hospital during a 15 year period, from 1970 to 1984, was conducted. Particular attention was paid to the last 5 years during which 25% of the ruptured spleens were preserved. The details of the preserved spleens are discussed. Respiratory infections were the only complications in this same selected group of patients; the complication rate being higher in the splenectomy group (15.8%) than the splenorrhaphy group (6.25%). None of the cases of splenorrhaphy required re-operation for continued haemorrhage. Twenty-five per cent of all cases of splenic injury had associated intra-abdominal injury which, of its own nature, would require laparotomy. A policy of operative management for splenic injury in adults with major trauma is therefore proposed because of the rate of associated intra-abdominal injuries. When laparotomy is performed, splenorrhaphy should be considered because of the now widely acknowledged risks of diminished immunological competence and overwhelming sepsis in asplenic individuals.     

Autologous replantation of spleen particles--an established procedure? An opinion

Autologous splenic replantation after splenectomy for trauma is generally recommended in order to prevent postsplenectomy sepsis. Several aspects, however, make this method uncertain: The extent of splenosis induced is not to be predicted. Even if the whole spleen is replanted, the resulting mass may not exceed splenosis, which sometimes develops spontaneously after sole splenectomy. But patients with extended splenic regenerates do not differ from those without any splenosis, considering various immunologic parameters. Postoperative complications after splenic replantation (abscess, intestinal occlusion) are possible, although they may be rare. Fatal cases of postsplenectomy sepsis despite massive splenosis are known. The most important reasons apparently are the altered vascularity and scarring in splenic regenerates. There is no specific test for immunological splenic function. Therefore there is no test to judge the success of replantation, too. Overall, the preservation of the spleen and the vaccination of splenectomized individuals are the most important surgical intentions.     

Intra-abdominal infection following combined spleen-colon trauma

The reality of late overwhelming post-splenectomy sepsis in adults as well as children has led to more frequent attempts at splenic salvage following splenic trauma. Less attention has been paid to early septic postoperative complications in the splenectomized patient. Associated colon injury has been believed to be a relative contraindication to splenic conservation. If splenectomy enhances the chance of early postoperative infection, then associated colon injury should be an indication for splenic salvage One hundred sixty one patients who had either splenic trauma (58), colon trauma (90), or combined spleen-colon trauma (13) were studied. All patients with splenic trauma had a splenectomy. There was a significantly higher incidence of intra-abdominal sepsis requiring reoperation in the spleen-colon patients (46.7%) than in either of the other groups (spleen = 5.7%, colon = 8.9%, P less than .002 for both comparisons). It is concluded that splenectomy enhances infection in the early postoperative period. When possible, combined spleen-colon trauma should be an indication rather than a contraindication for splenic salvage.     

Splenectomy and the sick asplenic patient

The sick asplenic patient bears risk to infectious complications and mortality. That risk is not widely accepted since no specific syndrome is applicable to all asplenic patients who are ill. In order to determine outcome following splenectomy, 624 patients having simple splenic injury, splenic plus multisystem trauma, elective splenectomy, incidental or accidental splenectomy, or splenectomy associated with transplantation were studied. Nonfatal complications specifically related to splenectomy occurred in 23 per cent of patients with multiorgan injury and 18 per cent with incidental-accidental splenic removal; splenectomy associated with transplantation had the highest mortality. The classic postsplenectomy sepsis syndrome was encountered late only twice. In the already sick patient rendered asplenic, conditions heralding susceptibility to progressive and sometimes fatal infection must be considered at all times. Sound indications for splenectomy must prevail before splenic removal since morbidity and mortality follow splenectomy, especially in the sick asplenic patient.     

Preservation of splenic function in adults and children with injured spleens.

Mounting evidence supports efforts to preserve splenic function. This evidence indicates (1) that the problem of postsplenectomy sepsis warrants splenic preservation whenever possible, and (2) that the spleen, as a whole or in part, and its function, can be preserved in cirmustances which formerly seemed to necessitate removal of the entire spleen. Nine patients with splenic injuries in whom splenic function was preserved successfully are presented. Approaches to management of the splenic injuries included (1) nonoperative management, (2) hemostasis by application of microfibrillar collagen (Avitene), (3) partial splenic resection, and (4) preservation of accessory spleen. Since reliable prevention and treatment of postsplenectomy sepsis do not seem attainable in the near future, continuing efforts to preserve function of the spleen whenever possible, in patients with injured spleens, seem justified and desirable.     

Operative risk of splenic repair for isolated but complex splenic injuries due to blunt abdominal trauma]

Surgical repair for complex splenic trauma is often controversial, because the operative risk of splenic salvage may exceed the risk of overwhelming postsplenectomy infection (OPSI). To determine the operative risk of splenic salvage for such injuries, 19 cases of isolated but complex injuries among 73 cases of blunt splenic trauma were examined retrospectively. Shattered spleens were excluded from the study. Splenic repair was accomplished successfully in all 10 attempted cases. Prior to the repair, vascular isolation and temporal occlusion of splenic artery was done to control the bleeding from injured spleen. In another 9 cases, splenectomy was immediately performed after laparotomy. Total amount of blood loss and operative morbidity in each group were not different, and no death occurred in both groups. Operative time was longer in group of splenic repair (112 +/- 20 min) in comparison to splenectomy group (71 +/- 23 min). Postoperative peripheral platelet count, serum IgM level, and finding of RBC scan showed adequate functional activity of the repaired spleen. In conclusion, it is felt that surgical repair should be attempted for isolated but complex splenic injury, and that the spleen should be preferably repaired even with associated injuries, unless prolonged operative time does not increase operative risk to more than that of OPSI.     

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.     

Postsplenectomy sepsis and its mortality rate: actual versus perceived risks

A collective critical review of the literature on postsplenectomy sepsis from 1952 to 1987 has been undertaken. The reports cover a cohort of 12,514 patients undergoing splenectomy but of these only 5902 reports were sufficiently detailed to allow a useful analysis. The incidence of infection after splenectomy in children under 16 years old was 4.4 per cent with a mortality rate of 2.2 per cent. The corresponding figures for adults were 0.9 per cent and 0.8 per cent respectively. The present analysis of well documented patients has shown that severe infection after splenectomy for benign disease is very uncommon except in infants (infection rate 15.7 per cent) and children below the age of 5 years (infection rate 10.4 per cent). Many of these reported postsplenectomy infections may have been coincidental. It is also apparent that children contract a different type of infection after splenectomy than adults, predominantly a meningitis which is less frequently fatal. Adults, in contrast, appear to develop a septicaemic type of illness associated with a higher mortality rate. This survey has also shown that children are reported to be more susceptible to pneumococcal sepsis than to infection caused by any other organism. Although the removal of the spleen in otherwise normal people does not appear to be associated with an increased frequency of infection, the presence of a coexistent disorder, notably hepatic disease, can increase the risk substantially.     

Management of splenic trauma.

This article examines the current management of trauma to the spleen. The incidence, mechanism, classification, diagnosis, treatment and complications of splenic trauma are reviewed. Modern radiological investigations are assessed in view of the recent vogue for non-operative management. The effects of splenectomy and particularly of overwhelming postsplenectomy sepsis are discussed. The role of non-operative management of splenic injuries in children and in adults without associated injuries is emphasized. Means of repairing and preserving the spleen are detailed. Prompt splenectomy is necessary in seriously traumatized patients, especially those with head or multiple injuries.     

Splenic autotransplantation provides protection against fatal sepsis in young but not in old rats.

Splenectomy increases the risk of contracting infections with high mortality. Thus, splenic tissue should be repaired orthotopically whenever possible. If all attempts fail, splenic autotransplantation might be a suitable method for splenic salvage. The protective function of such transplants in adults has been questioned, leading to a decreased frequency of splenic autotransplantations. However, the regeneration of splenic tissue is better in the young organism than in the old, suggesting that the protection provided by regenerated splenic tissue might be more reliable in children than in adults. In addition, children are at a higher risk in the case of overwhelming postsplenectomy sepsis. The protection warranted by regenerated splenic tissue after autotransplantation at different ages was examined using a highly standardized animal model. Sham operation, splenectomy, and splenic autotransplantation were performed on adult, weanling, and newborn rats, and Streptococcus pneumoniae was applied intranasally 9 months after the operation. After pneumococcal challenge about 80% of the splenectomized animals in the different age groups died of infection, whereas only 20% of the sham operated rats died. Regenerated splenic tissue resulting from splenic autotransplantation performed on adult or weanling rats demonstrated no protective function. However, in newborn rats with transplanted splenic tissue, both survival rate and survival time were increased significantly. Determination of lymphocyte subsets in the blood did not allow the protective role of splenic transplants to be predicted. This study indicates that disappointing results of splenic autotransplantation in adult patients should not lead to false pessimism about the role of this operation in children.     

Immune response capacity after human splenic autotransplantation: restoration of response to individual pneumococcal vaccine subtypes

OBJECTIVE: To evaluate features of general immune function, in particular the restoration of the humoral immune response to pneumococcal capsular polysaccharides, in humans undergoing a spleen autotransplantation after splenectomy because of trauma. SUMMARY BACKGROUND DATA: After splenectomy, patients have an increased risk of overwhelming infection or sepsis involving encapsulated bacteria such as pneumococci. The value of human spleen autotransplantation after splenectomy because of trauma has long been questioned. Mononuclear phagocyte system function appeared to be similar to that in splenectomized persons. The presence of specific antipneumococcal antibodies would allow other parts of the mononuclear phagocyte system, such as those in the liver, to phagocytose opsonized bacteria. METHODS: Ten consecutive patients undergoing splenectomy followed by autotransplantation were compared with the next 14 consecutive patients undergoing splenectomy alone. After a minimum of 6 months, the patients were vaccinated with 23-valent pneumococcal vaccine. Blood samples were taken at the time of vaccination and after 3 and 6 weeks for antipneumococcal capsular polysaccharides IgM and IgG enzyme-linked immunosorbent assay against types 3, 4, 6, 9, 14, and 23. Splenic regrowth was evaluated by scintigraphy. RESULTS: Surprisingly, several of the nonautotransplanted patients showed scintigraphic activity, indicating the presence of either accessory spleens or traumatic seeding (splenosis). Significant antibody titer increases (more than twofold) were found for both IgM and IgG in the autotransplanted patients. Splenectomized-only patients showed no significant increase in Ig levels in patients without splenic regrowth and partial improvement in patients with splenosis/accessory spleens. CONCLUSIONS: Considering this significant antipneumococcal antibody increase, spleen autotransplants can be expected to permit an adequate humoral response to pneumococcal infections and presumably also to other TI-2 antigens, and to protect against overwhelming postsplenectomy infection or sepsis.     

The role of splenorrhaphy in splenic trauma

Eighty-five cases of splenic trauma that were treated surgically from 1981 to 1983 were reviewed to define the exact role of splenorrhaphy. There were 73 male and 12 female patients with a mean age of 34 years. The mechanism of injury was blunt trauma in 51 and penetrating trauma in 34. The incidence of associated intraabdominal injury was 31 per cent and 79 per cent in blunt and penetrating trauma, respectively. Splenectomy was performed in 43 (51%) and splenorrhaphy in 42 (49%). Splenorrhaphy was performed in 19 (37%) who had blunt trauma and 23 (67%) who had penetrating trauma (P less than 0.01). Overall six patients died, three in the splenorrhaphy group (7.1%). Only one patient who had splenorrhaphy required reoperation for splenic hemorrhage. The authors conclude that about 50 per cent of all injured spleens in the patient population studied can be salvaged during laparotomy for splenic trauma, the splenic salvage rate is higher in penetrating trauma, and splenorrhaphy is a safe operation.     

Penicillin and natural immunity protect against postsplenectomy sepsis

Prophylactic penicillin, splenic autotransplantation, and immunization using pneumococcal vaccine have all been shown to reduce the incidence and mortality of postsplenectomy sepsis. However, little is known regarding the effect of penicillin in established infection or the effect of prior infection in either asplenic controls or animals with autotransplanted splenic tissue. An animal model with bacterial introduction via the lungs was used to investigate the effect of penicillin, splenic autotransplantation, and previous exposure to the infecting organism on the mortality of postsplenectomy sepsis. One hundred fifty-nine rats underwent either sham celiotomy, intraperitoneal splenic autotransplantation, or splenectomy. Twelve weeks postoperatively all animals were challenged using Streptococcus pneumoniae delivered transtracheally. Half of each group received procaine penicillin by intramuscular injection for 5 days beginning 24 hr post bacterial inoculation and mortality was observed. Eight weeks later surviving rats that had received penicillin were reinoculated with the same organism and mortality was again observed. Splenic autotransplantation reduced the early mortality in postsplenectomy sepsis. Prior bacterial exposure reduced the mortality in postsplenectomy sepsis, even in splenectomized animals. Treatment with penicillin produced a marked reduction in mortality even when administration was postponed for 24 hr after bacterial inoculation.     

Partial splenectomy in Gaucher's disease

In 11 children with hypersplenism due to Gaucher's disease, partial splenectomy was planned with the aim to prevent the development of postsplenectomy sepsis and also to slow the advance of the disease in the rest of the reticuloendothelial system by permitting continuing accumulation of the beta-glucocerebroside in the remaining splenic tissue. In seven children, partial splenectomy was performed successfully, the weight of the splenic tissue removed ranging from 400 to 3,680 g. The postoperative course was uneventful and the average duration of hospitalization was 12 days. In subsequent follow-up, isotope scanning demonstrated continuing growth of the splenic remnant and there were no episodes of postsplenectomy sepsis nor evidence of increased accumulation of beta-glucocerebroside in the liver or bones. These children showed a marked improvement in the growth curve and dramatic improvement in the hematologic picture. Of the four remaining children, in two, partial splenectomy was followed by complete removal of the remaining spleen due to necrosis, whereas in two, total splenectomy was performed since the huge spleens were extensively infarcted. Our experience suggests that partial splenectomy is the treatment of choice in the management of young patients with hypersplenism due to Gaucher's disease.     

Pneumococcal vaccine improves pulmonary clearance of live pneumococci after splenectomy

The efficacy of pneumococcal capsular polysaccharide vaccines after splenectomy to decrease the incidence of postsplenectomy pneumococcal sepsis is controversial. We examined the effect of pneumococcal vaccine on clearance of live pneumococci from lungs of splenectomized and sham-operated mice following an aerosol challenge of pneumococci. Splenectomy impaired clearance of pneumococci from mouse lungs and allowed for increased translocation of pneumococci to tracheobronchial lymph nodes compared to shams (P less than 0.01). Pneumococcal vaccine improved lung clearance in both splenectomized and sham-operated mice compared to saline controls (P less than 0.01), but the number of live pneumococci recovered from lung pairs was greater in splenectomized mice compared to shams (P less than 0.01). Pneumococcal vaccination facilitated earlier translocation of pneumococci to tracheobronchial lymph nodes, and probably promoted bactericidal activity in these nodes, in both splenectomized and sham-operated mice. Survival in splenectomized mice was improved by vaccination, but remained significantly less than that in saline-treated sham-operated mice (P less than 0.0009). The data show that pneumococcal vaccine can improve lung antipneumococcal defenses in splenectomized mice, but not to the same degree as in mice retaining their spleens. Pneumococcal vaccine should be given after splenectomy, but surgeons should caution patients that it may be less effective than when given to individuals with intact spleens or before elective surgery.