Indication of partial versus complete splenectomy for decreasing need to transfusion

Author: Dr Mahdi Shahriari

Introduction : splenomeglay is a significant clinical finding before starting blood transfusion in thalassemic patients, also is usual in spherocytosis, ovalocytosis , storage diseases like Gaucher s and Neimann Pick . But after second to third transfusion spleen is not palpable in thalassemia major. In some other hemolytic anemias like Pyrovate kinase deficiency splenomegaly may be significant . Because of important role of spleen in immunity total splenectomy may be associated with sever post splenectomy sepsis, so partial splenectomy is a good alternative for it.

Case histories: in last 10 years(1996-2006) partial splenectomy was requested for 84 thalassemia major, 16 thalassemia intermadia, 9 Pyrovate Kinase deficiency, 3 Gaucher s disease. Five percent developed splenomegaly 5-7 years after partial splenecyomy , but no one needed total splenectomy (i.e. second operation). In the same period total splenectomy was requested for 140 cases of thalassemic patient, 3 patients developed increased need to transfusion due to prophylactic penicillin therapy (with Hapten mechanism), 3 cases developed sever Eosinophilia, one case developed increased need to transfusion due to enlargement of accessory spleen.

Discussion: In the cases of hypersplenism after 5 years of age, whose Coomb s test is negative and B.M is not aplastic then there is question about versus partial splenectomy.

B.M is not aplastic then there is a question about total versus parial splenectomy.

Red pulps of the Spleen are site of storage of iron, and white puples are site of production of Opsonins, Properdin factor and antibodies, so total splenectomy may be complic ated by sever life threatening infections. Prophylactic P.O Penicillin therapy is indicated after total splenectomy and may not substituted with monthly Penador injections (because it is sufficient for Streptococcal infection but not for Pneumococal infections).

Sever Eosinophilia, Leufler syndrome and hemolytic anemia (by Hapten mechanism) are some of common complications of prophylactitic penicillin therapy.

There is another question about need for reoperation after partial splenectomy , in my experience if partial splenectomy is done by expert surgeon less than 5% of the patients may have significant splenomegaly, and most of them have no sign of hypersplenism.

THROMBOCYTOSIS which is a known complication of total splenectomy is rare (and always transient) in partial splenectomy.

So if there is not any absolute indication for total splenectomy (like Coomb s positive hemolytic anemia), partial splenectomy is advisable.

In the case of Isoimmunisation who response to medical therapy (steroid, I.V.IGg , …) only total splenectomy is indication for accessory polyvalent vaccine and Sonography before surgery and surgical exploration for accessory spleen is indicated In the cases of hypersplenism before 5 years of age(thalassemia intermedia, congenital spherocytosis, Pyrovate kinase deficiency, some types of Gaucher s and Neiman Pick disease ) partial splenectomy is indicated.

IN OSTEOPETROSIS (Marble bone disease) splenectomy is contraindicated because they have no bone marrow cavity, so spleen is the major organ for hematopoiesis