Joya:
Here is the most current information regarding splenectomy:
Splenectomy. Eighty percent of patients respond to splenectomy, and response is sustained in 66% with no additional therapy for at least 5 years103–105 (supplemental Document 8, Recommendation Box 6). Many patients without a complete response can still expect a partial or transient response.15,106 Approximately 14% of patients do not respond and approximately 20% of responders relapse weeks, months, or years later103 (evidence level IIb).
Complications of splenectomy. Complications of splenectomy include bleeding, infection, thrombosis, prolonged hospitalization, readmission to the hospital, and requirement for additional intervention.104 Reported complication rates vary considerably30,103,104,107,108 and may be greater in patients aged 65 years or older.29 In a recent systematic analysis, splenectomy complication rates were 12.9% with laparotomy and 9.6% with laparoscopy; mortality was 1.0% with laparotomy and 0.2% with laparoscopy.104
Because ITP22 and splenectomy109 are both associated with thromboembolic risks, ITP patients should receive appropriate postoperative thromboprophylaxis.
Predicting response to splenectomy. There is no widely accepted test predicting response to splenectomy. Response to oral corticosteroids or high-dose IVIg has a low predictive value110,111 (evidence level IIb). Indium-labeled autologous platelet scanning may be the most sensitive predictor of response to splenectomy, but here too studies vary.112,113 When scanning reveals splenic platelet destruction, approximately 90% of patients respond to splenectomy.112 This test is currently limited to several research centers, but if available may be useful before splenectomy (evidence level III, grade B recommendation).
Accessory splenic tissue (evidence level III/IV). Imaging techniques show accessory splenic tissue in up to 12% of splenectomized patients and almost all is removed during surgery.114 In patients who relapse following an initial response to splenectomy, assessment for accessory spleen should be considered. However, in patients who never responded to initial splenectomy, response is extremely rare.42,115
Prevention of infection after splenectomy. Splenectomized patients are at lifelong risk for uncontrolled infection with a poor outcome from Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae.116,117
Patients are usually given prophylactic polyvalent pneumococcal, meningococcal C conjugate, and H influenzae b (Hib) vaccines at least 4 weeks before (preferably) or 2 weeks after splenectomy and revaccinated according to the country-specific recommendations (evidence level IV).118,119 In patients who have received rituximab in the previous 6 months, vaccinations may not be effective. Vaccination for these patients should be readdressed once B-cell recovery has occurred.
In some studies, asplenic patients were given long-term antibiotic prophylaxis (phenoxymethylpenicillin 250-500 mg twice a day or equivalent, or erythromycin 500 mg twice a day).120 However, the benefit of lifelong antibiotic prophylaxis is unproven121,122 and the risk of late infection is quite low, and therefore no consensus has been reached.123
A practical policy is for splenectomized patients to have a home supply of antibiotics (eg, penicillin VK, erythromycin, or levofloxacillin) for use in case of a febrile illness. Patients should be educated about the risk of postsplenectomy infection, including the need to go to the emergency department if fever higher than 101°F (38°C) occurs. In addition, cards should be carried to alert physicians that the patient is asplenic; some patients may wish to wear alert bracelets or pendants.
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