splenectomy - suny downstate medical · pdf fileindications for splenectomy excluding...
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SplenectomySplenectomySplenectomySplenectomy
Jason Levine MDJason Levine MD
Long Island College HospitalLong Island College Hospitalg g pg g p
January 7, 2010 January 7, 2010
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CASE PRESENTATIONCASE PRESENTATIONCASE PRESENTATIONCASE PRESENTATION
58 YO AAM
No PMH
2005: Aphasia, Fevers, Generalized Purpurap p
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CASE PRESENTATIONCASE PRESENTATIONCASE PRESENTATIONCASE PRESENTATION
HospitalizedHospitalized HospitalizedHospitalized
H d CT N iH d CT N i Head CT NegativeHead CT Negative
Routine Labs: platelet count <20,000 Routine Labs: platelet count <20,000 Peripheral smear Peripheral smear pp
SchistocytesSchistocytes
Coombs NegativeCoombs Negative
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HOSPITAL COURSEHOSPITAL COURSEHOSPITAL COURSEHOSPITAL COURSE
Diagnosis: TTPDiagnosis: TTP Diagnosis: TTPDiagnosis: TTP
Pl h iPl h i PlasmapheresisPlasmapheresis
RituximabRituximab
Surgery ConsultSurgery Consult
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HOSPITAL COURSEHOSPITAL COURSEHOSPITAL COURSEHOSPITAL COURSE
Immunized Immunized H. flu Pneumovax Meningococcus
Laparoscopic Splenectomy Discharged POD#4 Discharged POD#4
Pathology: 133 gms 10 x 8 x 5 cm Congested sinusoids
Platelet count: 274,000
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INDICATIONS FOR INDICATIONS FOR SPLENECTOMYSPLENECTOMY
EXCLUDING TRAUMATRAUMA
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HISTORYHISTORYHISTORYHISTORY
1549 11549 1stst reported splenectomyreported splenectomy1549 11549 1 reported splenectomyreported splenectomy Zaccarella Zaccarella ItalyItalyyy
1865 11865 1stst sucessful splenectomysucessful splenectomy PaenPaenPaenPaen FranceFrance Splenic cystSplenic cystp yp y
1991 1991 11stst laparoscopic splenectomylaparoscopic splenectomy11 laparoscopic splenectomylaparoscopic splenectomy
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HISTOLOGYHISTOLOGYHISTOLOGYHISTOLOGY
Spleen: white pulp, p p pmarginal zone and red pulp
White pulp: surrounding the arteries
Marginal zone: lymphatics and macrophages
Red pulp: mature macrophages erythrocytesmacrophages, erythrocytes
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PHYSIOLOGYPHYSIOLOGYPHYSIOLOGYPHYSIOLOGY
H l i d I l i F i Hematologic and Immunologic Functions
Destroys Senescent or Deformed Red Blood Cells
Stores Platelets Stores Platelets
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PHYSIOLOGYPHYSIOLOGYPHYSIOLOGYPHYSIOLOGY
Produces Red Blood CellsProduces Red Blood Cells
Filters AntigensFilters Antigens
Opsonization of Encapsulated BacteriaOpsonization of Encapsulated Bacteria
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ANATOMYANATOMYANATOMYANATOMY
LUQLUQ
9th-11th ribs 9 -11 ribs
Size: 13 x 7 x 4cm Size: 13 x 7 x 4cm
W i ht: 150 m Weight: 150 gms
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HEMATOLOGIC DISORDERSHEMATOLOGIC DISORDERSHEMATOLOGIC DISORDERSHEMATOLOGIC DISORDERS
ITPITP Failure Medical Tx, Failure Medical Tx, 7575--85% Response85% Response,,Recurrent DxRecurrent Dx
% p% p
TTPTTP Excessive Plasma Excessive Plasma ExchangeExchange
40 % Response Rate40 % Response RateExchangeExchange
Hereditary Hereditary SpherocytosisSpherocytosis
Hemolytic Anemia, Hemolytic Anemia, transfusions, Leg transfusions, Leg UlcersUlcers
Improves / Eliminates AnemiaImproves / Eliminates Anemia
UlcersUlcers
Felty’s SyndromeFelty’s Syndrome NeutropeniaNeutropenia 80% Response80% Response
Sickle Cell DxSickle Cell Dx Crisis, InfarctionCrisis, Infarction VariableVariable
ThalassemiaThalassemia Transfusions, Transfusions, InfarctionInfarction
Less Transfusions, PainLess Transfusions, Pain
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IDIOPATHIC IDIOPATHIC THROMBOCYTOPENIC PURPURATHROMBOCYTOPENIC PURPURATHROMBOCYTOPENIC PURPURATHROMBOCYTOPENIC PURPURA
SplenectomyEl ti I di ti Elective Indication Thrombocytopenia
Ecchymoses
P Purpura
Abnormal Bleeding
Antiplatelet IgG AutoABs
Childr n lf limitin Children, self limiting symptomatic
thrombocytopenia present f > 1for > 1 year
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IDIOPATHIC IDIOPATHIC THROMBOCYTOPENIC PURPURATHROMBOCYTOPENIC PURPURATHROMBOCYTOPENIC PURPURATHROMBOCYTOPENIC PURPURA
Adults: 1-2% risk intracranial
hemorrhageO l t id Oral steroids
IV Immunoglobin
Splenectomy Splenectomy Failure medical therapy
no improvement 8 weeksl l l recurrence low platelets
intracranial hemorrhage
75-85% cure rate
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IDIOPATHIC IDIOPATHIC T O OC TO C AT O OC TO C ATHROMBOCYTOPENIC PURPURATHROMBOCYTOPENIC PURPURA
No Platelets: Splenic Artery Ligation 1st. No Platelets: Splenic Artery Ligation 1 30% patients accessory spleen
MUST search Intra - op MUST search Intra - op gastrosplenic
gastrocolic
lienorenal ligaments
Recurrent symptoms Recurrent symptoms indium scan
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THROMBOTIC THROMBOTIC THROMBOCYTOPENIC PURPURATHROMBOCYTOPENIC PURPURATHROMBOCYTOPENIC PURPURATHROMBOCYTOPENIC PURPURA
Abnormal Plt Clumping p g Arterioles & Capillaries
Hemolysis
Classic Pentad Purpura
Fe er Fever
Microangiopathic hemolytic anemia
N l i d fi i Neurologic deficits
Renal dysfunction
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THROMBOTIC THROMBOTIC THROMBOCYTOPENIC PURPURATHROMBOCYTOPENIC PURPURATHROMBOCYTOPENIC PURPURATHROMBOCYTOPENIC PURPURA
Plasma Exchange
Indication for splenectomy F il f di l hFailure of medical therapy
Approximately 40% cure rate
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Laproscopic Splenectomy in Patients with Laproscopic Splenectomy in Patients with R f R l i TTPR f R l i TTPRefractory or Relapsing TTPRefractory or Relapsing TTP
8 laproscopic splenectomies for refractory TTP Patients followed 32 months post operatively
7 patients remaining relapse free
S h J MD l A h S 2001 V l 136 1236 1238Schwartz, J MD; et.al. Arch Surgery 2001 Vol 136 p1236-1238
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FELTY SYNDROMEFELTY SYNDROMEFELTY SYNDROMEFELTY SYNDROME
Triad Triad Rheumatoid arthritis
Neutropenia Neutropenia
Splenomegaly
1% of RA patients
Antineutrophil IgG
Recurrent infections & chronic leg ulcersg
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HEREDITARY SPHEROCYTOSISHEREDITARY SPHEROCYTOSISHEREDITARY SPHEROCYTOSISHEREDITARY SPHEROCYTOSIS
AD Erythrocyte membrane
protein dysfunction Anemia Anemia Jaundice
Splenomegaly
Splenectomy Age >5yo
Spherocytes persistSpherocytes persist Anemia & Jaundice
improve
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THALASSEMIATHALASSEMIATHALASSEMIATHALASSEMIA
AD: premature destruction of RBCsp Pallor Ulcers Gallstones Head Enlargement Splenomegaly
Peripheral smear : target cells Peripheral smear : target cells Splenectomy
> 1 blood transfusion per month i severe pain
severe thrombocytopenia (<20,000)
Children (esp. <4yo) Highest risk for OPSI
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SICKLE CELL DISEASESICKLE CELL DISEASESICKLE CELL DISEASESICKLE CELL DISEASE
Single amino acid gsubstitution B chain of hemoglobin
R d Mi l Repeated Microvascular
Infarcts
Splenomegaly Splenomegaly Autosplenectomy
Splenectomy Acute Sequestration Crisis
Hypersplenism
Splenic abscesses Splenic abscesses
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SPLENIC CYSTSSPLENIC CYSTSSPLENIC CYSTSSPLENIC CYSTS
True (parasitic or (pnonparasitic) Parasitic cysts
E hi Echinococcus
Nonparasitic cysts Congenital Neoplastic
Epidermoid cysts
PseudocystsPseudocysts Trauma
Remove if Symptomatic
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TUMORSTUMORSTUMORSTUMORS
Non Hodgkin’s lymphoma Non Hodgkin s lymphoma Most common malignancy
Splenectomy Splenectomy
Hodgkin’s Hodgkin s Splenectomy for staging
Leukemias: Symptomatic
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SPLENIC ABSCESSSPLENIC ABSCESSSPLENIC ABSCESSSPLENIC ABSCESS
Hematogenous Seeding Organisms
Staph
Strep
Salmonella
Splenectomy
IV ABx
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VASCULAR DISEASESVASCULAR DISEASESVASCULAR DISEASESVASCULAR DISEASES
Splenic vein thrombosisSplenic vein thrombosis Pancreatitis
Pancreatic Carcinoma
Trauma
Gastric Varices
Splenic artery aneurysm Young Women
Pain
Nausea / Vomiting
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SPLENECTOMYSPLENECTOMYSPLENECTOMYSPLENECTOMY
Laproscopicp p standard
Open splenectomy
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LAPAROSCOPIC APPROACHLAPAROSCOPIC APPROACHLAPAROSCOPIC APPROACHLAPAROSCOPIC APPROACH
Mobilization splenic flexure
Free lateral attachments
Ligate short gastric vessels
Divide Splenic Hilum
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OPEN SPLENECTOMYOPEN SPLENECTOMYOPEN SPLENECTOMYOPEN SPLENECTOMY
Mobilization of ligaments Mobilization of ligaments
Sh i l Short gastric vessels
Hilar Dissection Ligation of splenic arteryg p y
Ligation of splenic vein
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COMPLICATIONSCOMPLICATIONSCOMPLICATIONSCOMPLICATIONS
Hemorrhage Atelectasisg
Pneumonia
P titi
Pleural Effusion
S b h i Ab Pancreatitis
Pancreatic fistula
Subphrenic Abscess
Portal Vein Thrombosis
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Overwhelming Post Splenectomy InfectionOverwhelming Post Splenectomy InfectionOverwhelming Post Splenectomy InfectionOverwhelming Post Splenectomy Infection
Lifetime risk of 1-5% Emergency SurgeryLifetime risk of 1 5% URI:
Rapid decompensation Sh k
g y g y Vaccinate before
discharge
Shock
Highest risk: Children
Medical Bracelet
Underlying hematologic conditions
Vaccinated 10-14 days prior
Booster every 5 yrs
Strep. pneumo H. influenza Meningococcus
Yearly vaccination influenza
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Perioperative outcomes of Laparoscopic vs. Open splenectomyPerioperative outcomes of Laparoscopic vs. Open splenectomyA tA t l i ith h i li til i ith h i li tiA metaA meta--analysis with an emphasis on complicationsanalysis with an emphasis on complications
51 series (2940 pts) of Splenectomy from 199151 series (2940 pts) of Splenectomy from 1991--20022002( p ) p y( p ) p y Laparoscopic Splenectomy (2119 pts)Laparoscopic Splenectomy (2119 pts)
Longer to perform Longer to perform Hi h i k f bl diHi h i k f bl di Higher risk of bleeding Higher risk of bleeding Superior to open Superior to open
Decreased length of stayDecreased length of stayL l li iL l li i Less pulmonary complicationsLess pulmonary complications
Less wound complicationsLess wound complications
Emily R. Winslow MD and L. Michael Brunt MD Surgery 2003 Vol134 Issue 4Surgery 2003 Vol134 Issue 4Department of Surgery and the Institute for Minimally Invasive Surgery, WashingtonUniversity School of Medicine, St. Louis, Mo, USA
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THE ENDTHE END
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