What are the indications for splenectomy?

Indications for Splenectomy

Splenectomy should be performed for hemodynamically unstable trauma patients who fail non-operative management, for chronic immune thrombocytopenic purpura refractory to medical therapy (particularly after 1 year), and for symptomatic hypersplenism unresponsive to less invasive interventions, while recognizing that the lifelong risk of overwhelming post-splenectomy infection (OPSI) with 30-70% mortality makes splenic preservation the priority whenever feasible. 1, 2

Traumatic Indications

Absolute Indications in Trauma

• Hemodynamic instability unresponsive to resuscitation remains the primary indication for immediate splenectomy in trauma patients 1
• Splenectomy is mandatory when non-operative management (NOM) with angiographic embolization fails and the patient shows persistent hemodynamic instability, significant hematocrit drop, or requires continuous transfusions 1
• In centers lacking intensive monitoring capabilities or where angiographic embolization is unavailable, operative management including splenectomy should be performed even for moderate-to-severe lesions in stable patients 1

Special Trauma Scenarios

• Concomitant severe traumatic brain injury (STBI) or blunt spinal trauma (BST) with AAST-OIS grade IV-V splenic injuries may benefit from immediate splenectomy in centers without readily available angiographic embolization, as one study showed general survival benefit 1
• However, in centers with angiographic embolization capabilities, immediate splenectomy for severe brain injury does not demonstrate improved survival regardless of injury grade 1
• Laparoscopic splenectomy in acute trauma with active bleeding cannot be recommended due to safety concerns 1

Important Trauma Caveats

The overall hospital mortality of splenectomy for trauma is approximately 2%, but postoperative bleeding occurs in 1.6-3% of cases with mortality approaching 20% when bleeding complications develop 1. This underscores why splenic preservation through non-operative management or splenorrhaphy is now preferred when feasible, with splenectomy rates declining from 35% to 24% over recent decades 1.

Hematologic Indications

Immune Thrombocytopenic Purpura (ITP)

• For chronic ITP lasting ≥3 months that is corticosteroid-dependent or non-responsive, splenectomy should be delayed for at least 1 year after diagnosis due to potential for spontaneous remission 3
• Thrombopoietin receptor agonists should be considered before rituximab, and rituximab before splenectomy, in the treatment hierarchy 3
• In children with ITP, splenectomy achieves complete remission in 72% of cases, but the long-term risk of fatal bacterial infection (particularly in children <5 years) may be 1 death per 300-1,000 patient-years 1
• Splenectomy in children is typically reserved for those with thrombocytopenia persisting >1 year with clinically important bleeding unresponsive to medical therapy 1

Other Hematologic Disorders

• Splenectomy for thalassemia and portal hypertension carries increased risk of serious post-splenectomy infections compared to removal for hereditary spherocytosis, ITP, or trauma 4
• The risk of overwhelming infection in asplenic individuals ranges from 5-10% with lifelong persistence 5

Hypersplenism

When to Consider Splenectomy for Hypersplenism

• Partial splenic embolization is the preferred first-line interventional approach for persistent symptomatic hypersplenism, as it effectively reduces splenic volume and portal pressure while preserving some immune function 3
• Splenectomy should be reserved for hypersplenism refractory to medical management (including thrombopoietin receptor agonists) and partial splenic embolization 3
• In portal hypertension with hypersplenism, transjugular intrahepatic portosystemic shunt (TIPS) or surgical shunt procedures may be considered before splenectomy, though surgical shunts have not shown survival advantage 3

Hypersplenism Treatment Algorithm

1. Identify and treat underlying cause (portal hypertension, cirrhosis, hematological disorders) 3
2. For thrombocytopenia requiring procedures, use thrombopoietin receptor agonists 10-14 days before planned intervention 3
3. For resistant hypersplenism, proceed with partial splenic embolization as first option 3
4. Consider TIPS or surgical shunt for refractory cases 3
5. Reserve splenectomy as last resort when all other options have failed 3

Critical Post-Splenectomy Considerations

The OPSI Risk

• OPSI is a fulminant, life-threatening infection with 30-70% mortality that can progress from mild flu-like symptoms to septic shock within hours 2
• Streptococcus pneumoniae accounts for approximately 50% of OPSI cases 2
• Risk is highest in the first year post-splenectomy but remains elevated for >10 years and is almost certainly lifelong 2
• Children under 5 years, especially infants, face dramatically higher risk with infection rates exceeding 10% compared to <1% in adults 2

Mandatory Preventive Measures

• All asplenic patients must receive vaccination against pneumococcal, meningococcal, and Haemophilus influenzae type B before or immediately after splenectomy 2
• Lifelong prophylactic antibiotics should be offered to all patients, with highest priority in the first 2 years post-splenectomy 2
• Patients must have emergency standby antibiotics at home to use immediately at first sign of fever, malaise, or chills 2
• Every patient requires education about their lifelong infection risk and need for immediate medical attention with any fever >101°F (38°C) 2

Common Pitfalls to Avoid

• Failing to vaccinate before elective splenectomy 2
• Assuming infection risk diminishes significantly over time 2
• Not providing emergency standby antibiotics for home use 2
• Inadequate patient education about medical alert identification and immediate fever response 2
• Forgetting that functional hyposplenism (from sickle cell disease, celiac disease, etc.) carries the same OPSI risk as surgical splenectomy 2