Complications after splenectomy and asplenism

Bleeding

Bleeding may occur from the splenic bed, pedicle or short gastric vessels. Especially important where splenectomy was performed for thrombocytopaenia.

Atelectasis

Left lower lobe atelectasis is common after splenectomy. Active physiotherapy may prevent this complication.

Pancreatic tail injury

The tail of the pancreas is in close relation to the hilum of the spleen and may be injured during the surgical procedure. This may lead to a pancreatic leak and collection.

Fever

Postsplenectomy fever can occur in the absence of any source of infection.

Thrombocytosis

There is an immediate and progressive rise in the platelet count after splenectomy to levels of 600-1000 X 109/l. After a peak at days 7-12, platelet levels usually return to normal, but it may remain elevated for up to 3 months. If the platelet count is persistently elevated above 1000 X 109/l, prophylaxis against deep vein thrombosis should be instituted; for example, oral aspirin at 150 mg/day.

Overwhelming postsplenectomy infection Following splenectomy, patients clear encapsulated bacteria less well from the bloodstream. This is particularly true for S. pneumoniae, but also for Neisseria meningitidis, Escherichia coli and H. influenzae. Overwhelming postsplenectomy infection occurs in 3-5% of patients, particularly in children, and has a mortality rate of 50%. Most serious infections occurs within the first 3 years of splenectomy.

Prophylactic vaccination

Prophylaxis is achieved by vaccination against pneumo-cocci, meningococci and H. influenzae. Vaccines should preferably be given pre-operatively as soon as the decision is made to operate, because antibody titres are 50% greater than when vaccines are given in the post-operative period. The question of prolonged prophylactic antibiotics is still controversial. The standard recommended regimen is a daily

Figure 11.16. (a) Patient with hepato-splenomegaly due to lymphoma with the outlines of the liver and spleen marked on the skin. and (b) a spleen resected for hypersplenism in a patient with lymphoma. (photographs courtesy of Mr T Davidson, UCL Medical School).

Figure 11.16. (a) Patient with hepato-splenomegaly due to lymphoma with the outlines of the liver and spleen marked on the skin. and (b) a spleen resected for hypersplenism in a patient with lymphoma. (photographs courtesy of Mr T Davidson, UCL Medical School).

dose of 250 mg penicillin VK orally for life, and to keep a supply of oral amoxicillin at home to start at the earliest sign of a fever or chest infection.

Recommendations for patients with no spleen or hypo-functioning spleen:

• Pneumococcal vaccine (Pneumovax II) 0.5 ml - 2 weeks before splenectomy or as soon as possible after splenec-tomy is performed in emergency situation.

• Meningococcal polysaccharide vaccine for N. meningitidis type A and C 0.5 ml.

• Consider penicillin as prophylaxis (250 mg twice daily for life).

The three vaccines (subcutaneous or intramuscular) may be given at same time, but different sites should be used.

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