What is the surgical management of a splenic abscess?

From the Guidelines

Surgical management of splenic abscess typically involves splenectomy, which remains the gold standard treatment, especially for multiple or large abscesses, as supported by the most recent evidence from 2020 1, 2. The procedure can be performed via open laparotomy or laparoscopically depending on patient factors and surgeon expertise. Preoperative preparation includes broad-spectrum antibiotics (such as a third-generation cephalosporin plus metronidazole, or piperacillin-tazobactam) which should be started immediately upon diagnosis and continued postoperatively for 7-14 days based on culture results, as suggested by previous guidelines 3. Patients should receive pneumococcal, meningococcal, and Haemophilus influenzae type B vaccines ideally 2 weeks before elective splenectomy or as soon as possible after emergency procedures to prevent overwhelming post-splenectomy infection. Less invasive alternatives include percutaneous drainage for unilocular, accessible abscesses in stable patients, or splenic conservation procedures like partial splenectomy or drainage with omental packing, which may be considered based on the patient's condition and the characteristics of the abscess 1, 2. These conservation approaches are particularly important in children and young adults to preserve splenic immune function. Postoperative care includes monitoring for bleeding, subphrenic abscess formation, and pancreatic injury. The surgical approach is justified by the high mortality rate of untreated splenic abscesses and the need to eliminate the source of infection completely, especially in cases with multiple loculations or when medical therapy has failed, as highlighted in earlier studies 4, 3.

Some key points to consider in the management of splenic abscess include:

• The use of imaging studies such as abdominal CT and MRI for diagnosis, which have high sensitivities and specificities for detecting splenic abscess 3.
• The importance of differentiating between splenic abscess and bland infarction, as the treatment approaches may differ, with splenic abscess requiring more aggressive management 3.
• The potential role of percutaneous drainage or aspiration as an alternative to splenectomy in certain cases, such as in patients who are poor surgical candidates 1, 2.
• The need for prompt treatment to prevent complications such as splenic rupture and to reduce mortality, as emphasized in the guidelines 4, 3.

Overall, the management of splenic abscess requires a multidisciplinary approach, taking into account the patient's overall condition, the characteristics of the abscess, and the potential risks and benefits of different treatment options, with the goal of reducing morbidity, mortality, and improving quality of life.

From the Research

Surgical Management of Splenic Abscess

The surgical management of a splenic abscess involves several approaches, including:

• Percutaneous drainage: This method is recommended for splenic abscesses larger than 4 cm in diameter 5, and is indicated for uniloculated or biloculated abscesses, and for high-risk surgical patients 6.
• Splenectomy: This approach is typically reserved for cases where medical treatment has failed 5, or for patients with poor general conditions where laparotomy and splenectomy may be necessary 7.
• Antibiotics: These are the first line of therapy in treatment, with eventual surgical intervention 8.
• Simplified percutaneous drainage: This procedure is feasible in rural settings where resources are limited, and can be followed by open surgery abscess drainage if necessary 7.
• Abscess drainage: This approach can be used to manage large splenic abscesses if the lesion is unifocal, with the goal of preserving the spleen 7.

Considerations for Surgical Management

When considering surgical management of a splenic abscess, the following factors should be taken into account:

• Size and location of the abscess: Percutaneous drainage is recommended for abscesses larger than 4 cm in diameter 5.
• Patient's general condition: Patients with poor general conditions may require a simplified approach, such as simplified percutaneous drainage 7.
• Presence of complications: Complications such as pleural effusion or empyema thoracis may require additional management, such as tube thoracostomy and broad-spectrum antibiotics 9, 7.
• Goal of preserving the spleen: Spleen preservation surgery along with antibiotics is preferable to retain immunologic functions 7.