What are the guidelines for managing patients undergoing splenectomy (removal of the spleen)?

Splenectomy Management Guidelines

All patients undergoing splenectomy require comprehensive vaccination at least 2 weeks before elective surgery, lifelong antibiotic prophylaxis (especially in the first 2 years), and patient education about the lifelong risk of overwhelming post-splenectomy infection (OPSI), which can occur decades after surgery and carries 30-70% mortality. 1, 2

Pre-Operative Vaccination Protocol

Timing and Core Vaccines

• Administer all vaccines at least 2 weeks before elective splenectomy to ensure optimal antibody response 1, 2, 3
• For emergency splenectomy, vaccinate at least 2 weeks post-operatively once the patient stabilizes 2
• Required vaccines include:
  • Pneumococcal vaccines: PCV13 (or PCV15/PCV20) first, followed by PPSV23 at least 8 weeks later 4, 2
  • Meningococcal vaccines: Both MenACWY and meningococcal serogroup B 4, 2
  • Haemophilus influenzae type b (Hib) vaccine for unvaccinated adults 4, 2

Additional Vaccination Considerations

• Annual influenza vaccination is mandatory for all asplenic patients over 6 months of age, as it reduces mortality by 54% and prevents secondary bacterial infections 5
• Use only inactivated influenza vaccine, never live attenuated (nasal spray) 5
• The 23-valent pneumococcal vaccine is >90% effective in healthy adults under age 55 1

Pre-Operative Testing and Evaluation

Required Screening

• Test for HCV and HIV in all ITP patients, as these can cause secondary ITP and influence management 1, 4
• Screen for H. pylori and provide eradication therapy if positive before proceeding with splenectomy 4
• Perform further investigations only if abnormalities exist beyond thrombocytopenia or iron deficiency findings 1, 4
• Bone marrow examination is not necessary in patients with typical ITP presentation 1, 4

Pre-Operative Platelet Management

• Use IVIg at 1 g/kg as a one-time dose (repeatable if necessary) to raise platelet counts before surgery 1, 4
• Anti-D immunoglobulin can be considered as an alternative if corticosteroids are contraindicated 1, 4

Surgical Approach

Both laparoscopic and open splenectomy offer similar efficacy for medically suitable patients 1, 4

• Laparoscopic approach is now the gold standard due to lower postoperative pain, less blood loss, and shorter hospital stay 3

Post-Operative Infection Prevention

Antibiotic Prophylaxis Strategy

• Offer lifelong prophylactic antibiotics to all patients, with highest priority in the first 2 years post-splenectomy 1, 2
• Phenoxymethylpenicillin (penicillin VK) is the standard prophylactic agent 1, 2
• For penicillin-allergic patients, prescribe erythromycin 1
• Provide emergency standby antibiotics (amoxicillin) for home use at first sign of fever, malaise, or chills 1, 2

Critical Caveat on Antibiotic Coverage

• Phenoxymethylpenicillin does not cover H. influenzae, and amoxicillin does not reliably cover it either 1
• This limitation underscores the critical importance of vaccination, as antibiotics alone cannot prevent all OPSI 1

Revaccination Schedule

Long-Term Vaccination Maintenance

• PPSV23 revaccination every 5-10 years is essential for maintained protection 1, 2
• MenACWY revaccination every 5 years 2, 5
• Children under 2 years require reimmunization after 2 years due to inherently reduced antibody response 1
• Antibody levels decline more rapidly in asplenic patients than expected, potentially requiring earlier revaccination 1, 5

Patient Education and Safety Measures

Critical Information for Patients

• Educate about lifelong infection risk: OPSI can occur more than 20 years after splenectomy 1, 2
• Instruct to seek immediate medical attention for fever >101°F (38°C) 4, 2
• Provide written information and ensure primary care providers are formally notified of asplenic status 2
• Issue Medic-Alert disc and post-splenectomy card indicating asplenic status 1, 4

Special Infection Risks

• After dog or animal bites: Require 5-day course of co-amoxiclav (or erythromycin if allergic) due to susceptibility to Capnocytophaga canimorsus 1, 2
• Tick bites: Warn about babesiosis risk; treat with quinine with or without clindamycin 1
• Travel considerations: Seek immediate medical help for febrile illness; consider malaria prophylaxis in endemic areas 1

Age-Specific Risk Stratification

Pediatric Considerations

• Children under 5 years have infection rates >10%, compared to <1% in adults 1
• Infants are at highest risk 1
• Avoid splenectomy in children under 3-4 years if possible, as most serious infections occur in this age group 6
• If unavoidable, rely initially on prophylactic antibiotics and immunize after the second birthday 1

Elderly Patients

• Patients over 65 years have significantly higher infection risk (HR=6.2) 7
• The incidence of infection differs according to underlying reason for splenectomy 7

Timeline of Infection Risk

Temporal Pattern of OPSI

• Most infections occur within the first 2 years after splenectomy 1, 8
• However, 57% of severe infections occur after 2 years and 14.3% after 10 years 7
• Cases of fulminant infection reported more than 20 years post-splenectomy 1
• The risk is clinically significant and almost certainly lifelong 1

Common Causative Organisms

Streptococcus pneumoniae accounts for approximately 50% of OPSI cases 2

• Other encapsulated bacteria include Neissococcus meningitidis and Haemophilus influenzae type b 1, 8
• Less common but significant: E. coli, malaria, babesiosis 1

Thromboembolic Complications

• Splenectomized patients are at increased risk of venous thromboembolism, particularly within the splenoportal system 8, 9
• Portal vein thrombosis occurs more commonly in patients with myeloproliferative disease and cirrhosis 8
• No routine thromboembolic prophylaxis recommended beyond perioperative low molecular weight heparin 8
• Some clinicians prescribe short-course antiplatelet medication if significant post-splenectomy thrombocytosis develops 8

Functional Hyposplenism

Patients with functional hyposplenism require identical preventive measures as those with surgical splenectomy 1, 5

• Detected on blood film by Howell-Jolly bodies and Heinz bodies 1
• Occurs in sickle cell disease (HbSS, HbSC), thalassemia major, coeliac disease, inflammatory bowel disease, and lymphoproliferative disorders 1
• Immunize as soon as diagnosis is made 1