Dear Editor

The fear of overwhelming infection following splenectomy has had a profound and detremental effect upon the recent evolution of surgical practice. Extraordinary efforts to save the spleen are now the rule usually in the hands of trainees and inexperienced or inadequately trained surgeons. The methods include splenic repair, partial splenectomy, wrapping the spleen in a Dexon mesh, non-operative management, and saving the spleen in the course of performing a distal pancreatectomy.[1-4] These can be challenging operations for the most experienced of abdominal surgeons who as a rule like to avoid all unnecessary risks.

Splenic repair is neither simple nor safe. In one study of 200 adults who sustained splenic trauma and underwent laparotomy splenorrhaphy was accomplished in 85 patients (42 percent).[1] Methods of repair in this study included cautery and hemostatic agents in 24 patients (28 percent), debridement and suturing in 42 patients (50 percent), and partial resection in 19 patients (22 percent). Postoperative complications occurred in 14 patients. Four were intraabdominal. Three patients required reoperation for splenic hemorrhage; one (2 percent) after suture repair and two (11 percent) after partial resection. A left subphrenic abscess developed in another patient. There were 5 deaths.

The evidence base upon which these changes in practice have been based is not strong. The reality is the risk of overwhelming sepsis after splenectomy is very small certainly in adults and the development of pneumococcal septicaemia is not necessarily fatal.[5] What is more there are other causes for overwhelming sepsis in most of the patients. These include associated diseases with immunological impairmnt, including malignancies, and the immunological compromise caused by blood transfusions and/or accompanying development of shock.[6]

The commonest reason for a splenectomy in adults is incidental injury (7). The risk of splenic injury is highest during left hemicolectomy (1- 8%), open anti-reflux procedures (3-20%), left nephrectomy (4-13%) and during exposure and reconstruction of the proximal abdominal aorta and its branches (21-60%). [Risks of this magnitude are a serious indictment of the overall standard of surgery being practiced in the UK for thiscomplication is a rarity in the hands of properly trained and experienced abdominal surgeons].

Splenic injury results in prolonged operating time, increased blood loss and longer hospital stay. It is also associated with a two to ten- fold increase in post operative infection rate and up to a doubling of morbidity rates. Mortality is also reported to be higher in patients undergoing splenectomy for iatrogenic injury. [These too are a serious indictment of the overall standard of surgical practice in the UK].

Two complications of conservative management of splenic injuries are of particular concern, delayed rupture of the spleen with the development of haemorrhagic shock in unfavourable circumstances [8,9] and an intra- abdominal abscess.[10] Both are serious complications that can be difficult to manage satisfactorily and are often fatal. In earlier days the development of a subphrenic abscess had an associated mortality as high as 50%. Should patients develop one the these complicatios the sooner they are recognised the easier they are to resolve satisfctorily. Anyone one who has had a splenic salvage operation requires, therefore, careful follow-up with sequential CT scans, an option that is expensive and not available in all communities even in developed countries.

The complications of splenic salvage are infrequent. The risk increases with more complex salvage attempts especially in the hands of trainees and inadequately trained or inexperienced surgeons. Splenic reimplantation has been advocated as a safe alternative [1] but is not without risk and is of unproven benefit in preventing overwhelming sepsis. Even giving pneumovax [pneumococcal vaccine] is not without risk in the critically ill and, for this reason, is administered only when a patient is ready to be discharged. Iatrogenic splenic injuries are invariably the product of suboptmal technique. Trainees need to be taught how to perform a splenectomy for a bleeding spleen rapidly, effectively and safely. The more experience they get the better. The proliferation of splenic salvage has compromised the opportunity to acquire this experience, an opportunity that may be further compromised but the restriction in working hours being imposed upon trainees by the EU.

The claim that splenectomy per se increases the risk of overwhelming sepsis is an unproven hypothesis. In the absence of proof of this hypothesis splenectomy should be restored as the treatment of choice for all significant splenic injuries certainly in adults. I would define significant injury as any injury that bleeds significantly. These are circumstances in which delay in controlling the haemorhage can quickly make matters infinitely worse.

References

1. Moore FA, Moore EE, Moore GE, Millikan JS. Risk of splenic salvage after trauma. Analysis of 200 adults. Am J Surg. 1984 Dec;148(6):800-5.

2. Berry MF, Rosato EF, Williams NN. Dexon mesh splenorrhaphy for intraoperative splenic injuries. Am Surg. 2003 Feb;69(2):176-80.

3. Jacobs IA, Kelly K, Valenziano C, Pawar J, Jones C. Nonoperative management of blunt splenic and hepatic trauma in the pediatric population: significant differences between adult and pediatric surgeons? Am Surg. 2001 Feb;67(2):149-54.

4. Giulini SM, Portolani N, Bonardelli S, Baiocchi GL, Zampatti M, Coniglio A, Baronchelli C. Distal pancreatic resection with splenic preservation for metastasis of renal carcinoma diagnosed 24 years later from the nephrectomy] Ann Ital Chir. 2003;74(1):93-6.

5. van ST, Reardon CM, O'Donnell JA, Kirwan WO, Brady MP. "How safe is splenectomy?". Ir J Med Sci. 1994 Aug;163(8):374-8.

6. Fiddian-Green RG. Open versus laparoscopy assisted colectomy. Lancet. 2003 Jan 4;361(9351):74; author reply 75-6.

7. Cassar K, Munro A. Iatrogenic splenic injury. J R Coll Surg Edinb. 2002 Dec;47(6):731-41

8. Van Stiegmann G, Moore EE Jr, Moore GE. Failure of spleen repair. J Trauma. 1979 Sep;19(9):698-700.

9. Knudson MM, Maull KI. Nonoperative management of solid organ injuries. Past, present, and future. Surg Clin North Am. 1999 Dec;79(6):1357-71.

10. Bufalari A, Giustozzi G, Moggi L. Postoperative intraabdominal abscesses: percutaneous versus surgical treatment. Acta Chir Belg. 1996 Sep-Oct;96(5):197-200.