What are the preoperative prerequisites for an adult patient undergoing splenectomy for recurrent anemia?

Preoperative Prerequisites for Splenectomy in Adult Patients with Recurrent Anemia

Before performing a splenectomy in an adult patient with recurrent anemia, vaccination against encapsulated organisms at least 2 weeks prior to surgery is essential to prevent potentially fatal post-splenectomy infections. 1

Vaccination Requirements

• All patients should receive polyvalent pneumococcal vaccine, Haemophilus influenzae type b (Hib) vaccine, and quadrivalent meningococcal polysaccharide vaccine at least 2 weeks before elective splenectomy (preferably) or 2 weeks after emergency splenectomy 1
• If the patient has received rituximab in the previous 6 months, vaccinations may not be effective and should be delayed until B-cell recovery has occurred 1
• These vaccinations are critical as splenectomized patients are at lifelong risk for uncontrolled infections with Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae 1

Preoperative Medical Optimization

• Evaluate and correct preoperative anemia when possible, as preoperative anemia is associated with increased postoperative complications, longer hospital stays, and higher readmission rates 2
• For patients with platelet counts <20,000/μL, preoperative prophylaxis with IVIg or oral glucocorticoid therapy is appropriate to reduce the risk of intraoperative and postoperative bleeding 1
• Platelet transfusions are generally not recommended as preoperative prophylaxis for platelet counts >10,000/μL 1
• Consider delaying splenectomy in patients with ITP of less than 12 months duration due to the potential for spontaneous remission in the first year 1

Preoperative Imaging and Assessment

• Perform imaging studies to detect accessory splenic tissue, which is present in up to 12% of patients and should be removed during surgery 1
• Assess for comorbidities that may increase surgical risk, particularly in patients over 65 years of age who have higher odds of postoperative morbidity 3
• Evaluate Karnofsky performance status, as a score lower than 60 is associated with increased postoperative mortality 3
• Assess hemoglobin levels, as levels ≤9 g/dL are associated with increased postoperative morbidity 3

Antibiotic Prophylaxis Planning

• Prepare a plan for postoperative antibiotic prophylaxis 1
• Ensure patients have a home supply of antibiotics (e.g., penicillin VK, erythromycin, or levofloxacin) for use in case of febrile illness 1
• Educate patients about the risk of post-splenectomy infection, including instructions to seek emergency care if fever higher than 101°F (38°C) occurs 1

Patient Education and Preparation

• Discuss expected outcomes based on the underlying cause of anemia, as success rates vary by indication (63% for anemia, 66.1% for thrombocytopenia) 3
• Inform patients about the need to carry medical alert cards or wear alert bracelets/pendants indicating their asplenic status 1
• Discuss the risk of post-splenectomy complications, including thrombocytosis which occurs in approximately 22% of patients and may increase the risk of perioperative thrombosis 4

Surgical Approach Considerations

• For medically suitable patients, both laparoscopic splenectomy (LS) and open splenectomy (OS) offer similar efficacy 1
• Consider patient factors that might influence the choice between laparoscopic and open approaches, including spleen size, prior abdominal surgery, and patient body habitus 1

By following these preoperative prerequisites, the risk of complications can be minimized and outcomes optimized for adult patients undergoing splenectomy for recurrent anemia.