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Splenectomy in children
Splenectomy in Children A Correlative Review of Indications and Complications in Fifty Patients
Burton L. Eisenberg, CAPT, MC, Lackland Air Force Base, Texas Richard J. Andrassy, MAJ, MC, Lackland Air Force Base, Texas Roderick C. Haff, LT COL, MC, Lackland Air Force Base, Texas Irving A. Ratner, MD, FACS, FACP, San Antonio, Texas
The indications for splenectomy in pediatric patients are wide ranging and vary somewhat from those in adult patients [1,2]. Proportionately more pediatric than adult splenectomies are performed for hematologically related disorders [3]. However, traumatic splenic rupture is a frequent cause for splenectomy in both groups [4,5]. Although staging celiotomy with splenectomy for Hodgkins disease has been the accepted practice in adult occurrence, considerable debate has developed about splenectomy in this circumstance in pediatric patients [6,7]. Morbidity and mortality rates after splenectomy in pediatric patients remain high. Most deaths and significant complications are generally correlated to the associated condition of the patient rather than to the splenectomy itself. As is true of all upper abdominal operations, splenectomy involves a pulmonary complication rate of 15 to 30 per cent in most series [8]. Of special note in the pediatric age group is the apparent disruption of immunologic competence which follows splenectomy 191.The risk of delayed systemic infection, particularly of pneumococcal origin, in these patients has been well documented [10,11]. This is especially pertinent in patients less than five years old and can occur more than two years postoperatively. Much of the debate concerning splenectomy in children centers on this problem. Indeed, it has led some authors to recommend a From the Department of Surgery, Wilford Hall USAF Medical Center, Lackland Air Force Base, and the Department of Pediatric Surgery, Santa Rosa Children’s Hosaital. San Antonio. Texas. Reprint requests should be addressed to Burton L. Eisenberg, MD, Department of SurgeryISGHSG, Wilford Hall USAF Medical Center, Lackland Air Force Base, Texas 76236. Presented at the Twenty-Eighth Annual Meeting of the Southwestern Surgical Congress, Houston, Texas, May 3-6. 1976.
nonoperative approach to traumatic splenic rupture, and others to recommend splenic repair rather than removal after trauma in the stable patient under careful observation [12,13]. We have recently reviewed the experience with splenectomy in pediatric patients in both our institutions. We have attempted to relate our indications, complications, and long-term results to the prevailing accepted opinions. Clinical Material The records of fifty patients aged fourteen years or less operated on during the past four years at Santa Rosa Children’s Hospital and Wilford Hall USAF Medical Center were reviewed. Data were obtained concerning age, sex, associated conditions, indications for splenectomy, operative technic, and short- and long-term results. Factors influencing morbidity and mortality were determined. Results
There were twenty-nine males and twenty-one females in this series. The age at operation ranged from two weeks to fourteen years, with a median age of ten years. Twelve of these patients were five years of age or less at the time of spienectomy. Indications for operation included: traumatic splenic rupture (19); incidental to adrenal cystectomy (1); idiopathic thrombocytopenic purpura (9); hereditary spherocytosis (11); hypersplenism due to benign disease (4); hypersplenism associated with malignant Hodgkins
disease (2); and staging laparotomy for disease (4). Most of the traumatic ruptures
were blunt injuries after motor vehicle accidents. All had significant associated injuries. Thirteen patients underwent splenectomy within
The American Journal of Surgery
Splenectomy
24 hours of injury. Six suffered delayed splenic ruptures, three occurring after discharge from the initial hospitalization. Decision for exploration was based on obvious clinical findings in most instances. In five patients, splenectomy followed positive peritoneal lavage in which clinical findings were otherwise equivocal. There were no instances of false-positive or falsenegative lavage. In the hematologically related disorders, all patients operated on for hereditary spherocytosis had excellent results. None had biliary lithiasis at the time of operation. Eight of nine patients who had splenectomies for idiopathic thrombocytopenic purpura (ITP) had good long-term results. One with severe refractory acute ITP at the time of operation is now responding adequately to maintenance on corticosteroids. One patient with primary and three with secondary hypersplenism related to benign conditions were hematologically improved after splenectomy. The same was true of the patient operated on for hypersplenism associated with chronic lymphocytic leukemia. The patient with marked thrombocytopenia associated with acute lymphocytic leukemia failed to respond and died one month post splenectomy of a cerebral hemorrhage. Four patients underwent splenectomy during the course of a staging procedure for Hodgkins disease. One patient had reevaluation of clinical staging as the result of his exploration. There were three deaths in our series. One child with a traumatically ruptured spleen succumbed to a severe associated head injury. A second was the previously mentioned child who suffered an acute intracerebral hemorrhage. The third was an eight year old boy who was staged for Hodgkins disease. He recovered from an episode of pneumococcal meningitis two months after operation. He died of generalized sepsis a year later while receiving chemotherapy for his malignancy. Acute nonfatal complications after splenectomy associated with upper abdominal operations in seven patients include postoperative atelectasis or pneumonitis (4), wound infection (2), and partial small bowel obstruction postoperatively (1). Acute nonfatal complications after splenectomy associated with underlying condition in three patients include left pleural effusion after trauma with splenic and renal rupture (l), upper gastrointestinal stress hemorrhage with multiple injuries (l), and postoperative pneumonia and severe pancytopenia associated with reticuloendotheliosis (1). The postoperative morbidity was 20 per cent. In seven instances the complications
V~132,
Docambw1876
in Children
were directly related to the operation performed. In three patients the associated condition contributed significantly to the eventual complication. Three patients had late septic complications. All had culture-provided pneumcoccal infections. One was the previously noted patient with Hodgkins disease. The other two were both less than five years old when operated on and were not initially placed on prophylactic antibiotics. Both recovered without sequelae after adequate penicillin therapy.
Comments
The indications for splenectomy in our series follow closely the general trend noted in the pediatric and surgical literature. The proportions of our patients operated on for trauma, for benign hematologic disorders, and for underlying malignancies were similar to most larger series. Similarly, the results of splenectomy in our patients correlate well with those in other series. Splenectomy assures the end of hemolysis in hereditary spherocytosis and will have predictably good results in hypersplenism and idiopathic thrombocytopenic purpura [14,15]. Generally, exploratory celiotomy for Hodgkins disease is associated with change in clinical staging in approximately 25 per cent of the cases, a figure reflected in our small experience. We believe that prompt extirpation is the safest approach to the traumatically ruptured spleen. A nonoperative approach to a suspected splenic rupture will predictably increase the already high number of delayed ruptures and will add significant risk to this group of patients. In the clinical setting in which the abdominal examination is equivocal or masked by other injuries, well executed peritoneal lavage can lead to a prompt diagnosis of splenic rupture and allow timely intervention in an otherwise difficult diagnostic circumstance. The complications of splenectomy fall into three general categories: (1) those associated with an upper abdominal operation; (2) those associated with the underlying condition of the patient; and (3) those related to the creation of an immunologic deficiency in the patient. The great bulk of acute postoperative complications in this and other series are those common to any upper abdominal operation such as atelectasis or pneumonitis, postoperative ileus or bowel obstruction, and wound infections [I]. The incidence of these problems in our series agrees with previous reports [16]. Complications attributable to the manifestations of the patient’s systemic disease process are prevalent
721
Eisenberg et al
after pediatric
splenectomy. Hyporesponsiveness to infection can be expected in pancytopenia and hematologic malignancies. An argument certainly can be made for the association of both of the wound infections in our series with the preoperative state for which splenectomy was performed; however, we prefer to attribute this problem to operative technic. The problems of stress associated with multiple severe injuries undoubtedly led to the upper gastrointestinal hemorrhage noted. The two early postoperative deaths in our series were directly associated with the overall condition of the patient at the time of operation. Splenectomy for severe pancytopenia associated with unremittent acute leukemia is a desperate measure associated with a low success rate. The incidence of immunologic deficiency after splenectomy, particularly in patients five years of age and younger, is well documented [ 171 and our experience agrees with this. It is of interest that none of the patients who had pneumococcal infection in this series were maintained on prophylactic antibiotics at the time. It has become our policy to maintain all splenectomy patients less than five years old on oral penicillin until they reach their sixth birthday. We believe that this approach will afford some protection to increasing risk of overwhelming sepsis during that period of time. We do not believe that otherwise valid indications for splenectomy should be compromised in the child less than five years old because of the increased risk of sepsis. However, any decision involving elective splenectomy in this age group should include this added consideration. Summary
We have reported our experience with splenectomy in fifty patients less than fourteen years old. The indications, results, and complications were enumerated. These data were then correlated with the recent literature regarding pediatric splenectomy. Of special note is the problem of immunologic incompetency associated with splenectomy in the patient less than five years old.
722
References 1. Eraklis AJ, Filler RM: Splenectomy in childhood: a review of 1413 cases. J P&ah Surg 7: 362, 1972. 2. Sandusky WR, Leavell BS, Benjamin BI: Splenectomy: indications and results in hematologic disorders. Ann Surg 159: 695,1964. Kiesewetter WB: Pediatric splenectomy. Surg C/in Notih Am 55: 449, 1975. Richardson JD, Belin RP, Griffen WD: Blunt abdominal trauma in children. Ann Surg 176: 213, 1972. Fabri PJ, Metz EN, Nich WV, Zollinger RM: A quarter century with splenectomy. Arch Surg 106: 569, 1974. Filler RM, Joffe N, Cas$ady JR, Traggis DG, Vawter GF: Experience with clinical and operative staging of Hod&ins disease in children. J Pediatr Surg 10: 321, 1975. 7. Hays DM, Hittle RE, lsaacs H, Karon MR: Laparotomy for the Surg 7: staging of Hodgkins disease in children. J P&a& 517.1972. 6. Daoud FS, Fischer DC, Hafner CD: Complications following splenectomy with special emphasis on drainage. Arch Surg 92: 32, 1966. 9. Erickson WD, Burgert EO, Lynn HB: The hazard of infection following splenectomy in children. Am J Dis Child 116: 1, 1966. 10. Hailer JA: Role of spleen in experimental neonatal infections and transplantation. J Pediatr Surg 5: 172, 1970. 11. Eraklis AJ, Kevy SV, Diamond LK, Gross RE: Hazard of overwhelming infection after splenectomy in childhood. N Eng/ J Med 276: 1225, 1967. 12. Douglas GJ, Simpson JS: The conservative management of splenic trauma. J PediaB Surg 6: 565, 1971. 13. Mishalany H: Repair of the ruptured spleen. J Pedjafr Surg 9: 175, 1974. 14. Yam L, Crosby W: Early splenectomy in lymphoproliferative disorders. Arch Intern Med 133~270, 1974. 15. Thompson RL, Moore RA, Hess CE, Wheby MS, Leavell BS: Idiopathic thrombocytopenic purpura. Arch Intern A&d 130: 730, 1972. 16. Slater H: Complications of splenectomy. Am Surg 39: 221, 1973. 17. Claret I, Morales L, Montoner A: Immunological studies in the post splenectomy syndrome. J Pediatr Surg 10: 59, 1975.
Discussion Luke W. Able (Houston, TX): During the past twenty years 176 splenectomies have been done at Texas Children’s Hospital. Ten survivors have now died of sepsis. At present splenectomy is deferred as long as possible. It is necessary in patients wit-hcongenital spherocytic anemia and idiopathic thrombocytopenia but can be avoided in many other conditions. It is recommended for trauma when it is the only way to stop bleeding. Partial splenectomy and splenorrhaphies have been successful.
The American Journal of Surgery
Burton L. Eisenberg, CAPT, MC, Lackland Air Force Base, Texas Richard J. Andrassy, MAJ, MC, Lackland Air Force Base, Texas Roderick C. Haff, LT COL, MC, Lackland Air Force Base, Texas Irving A. Ratner, MD, FACS, FACP, San Antonio, Texas
The indications for splenectomy in pediatric patients are wide ranging and vary somewhat from those in adult patients [1,2]. Proportionately more pediatric than adult splenectomies are performed for hematologically related disorders [3]. However, traumatic splenic rupture is a frequent cause for splenectomy in both groups [4,5]. Although staging celiotomy with splenectomy for Hodgkins disease has been the accepted practice in adult occurrence, considerable debate has developed about splenectomy in this circumstance in pediatric patients [6,7]. Morbidity and mortality rates after splenectomy in pediatric patients remain high. Most deaths and significant complications are generally correlated to the associated condition of the patient rather than to the splenectomy itself. As is true of all upper abdominal operations, splenectomy involves a pulmonary complication rate of 15 to 30 per cent in most series [8]. Of special note in the pediatric age group is the apparent disruption of immunologic competence which follows splenectomy 191.The risk of delayed systemic infection, particularly of pneumococcal origin, in these patients has been well documented [10,11]. This is especially pertinent in patients less than five years old and can occur more than two years postoperatively. Much of the debate concerning splenectomy in children centers on this problem. Indeed, it has led some authors to recommend a From the Department of Surgery, Wilford Hall USAF Medical Center, Lackland Air Force Base, and the Department of Pediatric Surgery, Santa Rosa Children’s Hosaital. San Antonio. Texas. Reprint requests should be addressed to Burton L. Eisenberg, MD, Department of SurgeryISGHSG, Wilford Hall USAF Medical Center, Lackland Air Force Base, Texas 76236. Presented at the Twenty-Eighth Annual Meeting of the Southwestern Surgical Congress, Houston, Texas, May 3-6. 1976.
nonoperative approach to traumatic splenic rupture, and others to recommend splenic repair rather than removal after trauma in the stable patient under careful observation [12,13]. We have recently reviewed the experience with splenectomy in pediatric patients in both our institutions. We have attempted to relate our indications, complications, and long-term results to the prevailing accepted opinions. Clinical Material The records of fifty patients aged fourteen years or less operated on during the past four years at Santa Rosa Children’s Hospital and Wilford Hall USAF Medical Center were reviewed. Data were obtained concerning age, sex, associated conditions, indications for splenectomy, operative technic, and short- and long-term results. Factors influencing morbidity and mortality were determined. Results
There were twenty-nine males and twenty-one females in this series. The age at operation ranged from two weeks to fourteen years, with a median age of ten years. Twelve of these patients were five years of age or less at the time of spienectomy. Indications for operation included: traumatic splenic rupture (19); incidental to adrenal cystectomy (1); idiopathic thrombocytopenic purpura (9); hereditary spherocytosis (11); hypersplenism due to benign disease (4); hypersplenism associated with malignant Hodgkins
disease (2); and staging laparotomy for disease (4). Most of the traumatic ruptures
were blunt injuries after motor vehicle accidents. All had significant associated injuries. Thirteen patients underwent splenectomy within
The American Journal of Surgery
Splenectomy
24 hours of injury. Six suffered delayed splenic ruptures, three occurring after discharge from the initial hospitalization. Decision for exploration was based on obvious clinical findings in most instances. In five patients, splenectomy followed positive peritoneal lavage in which clinical findings were otherwise equivocal. There were no instances of false-positive or falsenegative lavage. In the hematologically related disorders, all patients operated on for hereditary spherocytosis had excellent results. None had biliary lithiasis at the time of operation. Eight of nine patients who had splenectomies for idiopathic thrombocytopenic purpura (ITP) had good long-term results. One with severe refractory acute ITP at the time of operation is now responding adequately to maintenance on corticosteroids. One patient with primary and three with secondary hypersplenism related to benign conditions were hematologically improved after splenectomy. The same was true of the patient operated on for hypersplenism associated with chronic lymphocytic leukemia. The patient with marked thrombocytopenia associated with acute lymphocytic leukemia failed to respond and died one month post splenectomy of a cerebral hemorrhage. Four patients underwent splenectomy during the course of a staging procedure for Hodgkins disease. One patient had reevaluation of clinical staging as the result of his exploration. There were three deaths in our series. One child with a traumatically ruptured spleen succumbed to a severe associated head injury. A second was the previously mentioned child who suffered an acute intracerebral hemorrhage. The third was an eight year old boy who was staged for Hodgkins disease. He recovered from an episode of pneumococcal meningitis two months after operation. He died of generalized sepsis a year later while receiving chemotherapy for his malignancy. Acute nonfatal complications after splenectomy associated with upper abdominal operations in seven patients include postoperative atelectasis or pneumonitis (4), wound infection (2), and partial small bowel obstruction postoperatively (1). Acute nonfatal complications after splenectomy associated with underlying condition in three patients include left pleural effusion after trauma with splenic and renal rupture (l), upper gastrointestinal stress hemorrhage with multiple injuries (l), and postoperative pneumonia and severe pancytopenia associated with reticuloendotheliosis (1). The postoperative morbidity was 20 per cent. In seven instances the complications
V~132,
Docambw1876
in Children
were directly related to the operation performed. In three patients the associated condition contributed significantly to the eventual complication. Three patients had late septic complications. All had culture-provided pneumcoccal infections. One was the previously noted patient with Hodgkins disease. The other two were both less than five years old when operated on and were not initially placed on prophylactic antibiotics. Both recovered without sequelae after adequate penicillin therapy.
Comments
The indications for splenectomy in our series follow closely the general trend noted in the pediatric and surgical literature. The proportions of our patients operated on for trauma, for benign hematologic disorders, and for underlying malignancies were similar to most larger series. Similarly, the results of splenectomy in our patients correlate well with those in other series. Splenectomy assures the end of hemolysis in hereditary spherocytosis and will have predictably good results in hypersplenism and idiopathic thrombocytopenic purpura [14,15]. Generally, exploratory celiotomy for Hodgkins disease is associated with change in clinical staging in approximately 25 per cent of the cases, a figure reflected in our small experience. We believe that prompt extirpation is the safest approach to the traumatically ruptured spleen. A nonoperative approach to a suspected splenic rupture will predictably increase the already high number of delayed ruptures and will add significant risk to this group of patients. In the clinical setting in which the abdominal examination is equivocal or masked by other injuries, well executed peritoneal lavage can lead to a prompt diagnosis of splenic rupture and allow timely intervention in an otherwise difficult diagnostic circumstance. The complications of splenectomy fall into three general categories: (1) those associated with an upper abdominal operation; (2) those associated with the underlying condition of the patient; and (3) those related to the creation of an immunologic deficiency in the patient. The great bulk of acute postoperative complications in this and other series are those common to any upper abdominal operation such as atelectasis or pneumonitis, postoperative ileus or bowel obstruction, and wound infections [I]. The incidence of these problems in our series agrees with previous reports [16]. Complications attributable to the manifestations of the patient’s systemic disease process are prevalent
721
Eisenberg et al
after pediatric
splenectomy. Hyporesponsiveness to infection can be expected in pancytopenia and hematologic malignancies. An argument certainly can be made for the association of both of the wound infections in our series with the preoperative state for which splenectomy was performed; however, we prefer to attribute this problem to operative technic. The problems of stress associated with multiple severe injuries undoubtedly led to the upper gastrointestinal hemorrhage noted. The two early postoperative deaths in our series were directly associated with the overall condition of the patient at the time of operation. Splenectomy for severe pancytopenia associated with unremittent acute leukemia is a desperate measure associated with a low success rate. The incidence of immunologic deficiency after splenectomy, particularly in patients five years of age and younger, is well documented [ 171 and our experience agrees with this. It is of interest that none of the patients who had pneumococcal infection in this series were maintained on prophylactic antibiotics at the time. It has become our policy to maintain all splenectomy patients less than five years old on oral penicillin until they reach their sixth birthday. We believe that this approach will afford some protection to increasing risk of overwhelming sepsis during that period of time. We do not believe that otherwise valid indications for splenectomy should be compromised in the child less than five years old because of the increased risk of sepsis. However, any decision involving elective splenectomy in this age group should include this added consideration. Summary
We have reported our experience with splenectomy in fifty patients less than fourteen years old. The indications, results, and complications were enumerated. These data were then correlated with the recent literature regarding pediatric splenectomy. Of special note is the problem of immunologic incompetency associated with splenectomy in the patient less than five years old.
722
References 1. Eraklis AJ, Filler RM: Splenectomy in childhood: a review of 1413 cases. J P&ah Surg 7: 362, 1972. 2. Sandusky WR, Leavell BS, Benjamin BI: Splenectomy: indications and results in hematologic disorders. Ann Surg 159: 695,1964. Kiesewetter WB: Pediatric splenectomy. Surg C/in Notih Am 55: 449, 1975. Richardson JD, Belin RP, Griffen WD: Blunt abdominal trauma in children. Ann Surg 176: 213, 1972. Fabri PJ, Metz EN, Nich WV, Zollinger RM: A quarter century with splenectomy. Arch Surg 106: 569, 1974. Filler RM, Joffe N, Cas$ady JR, Traggis DG, Vawter GF: Experience with clinical and operative staging of Hod&ins disease in children. J Pediatr Surg 10: 321, 1975. 7. Hays DM, Hittle RE, lsaacs H, Karon MR: Laparotomy for the Surg 7: staging of Hodgkins disease in children. J P&a& 517.1972. 6. Daoud FS, Fischer DC, Hafner CD: Complications following splenectomy with special emphasis on drainage. Arch Surg 92: 32, 1966. 9. Erickson WD, Burgert EO, Lynn HB: The hazard of infection following splenectomy in children. Am J Dis Child 116: 1, 1966. 10. Hailer JA: Role of spleen in experimental neonatal infections and transplantation. J Pediatr Surg 5: 172, 1970. 11. Eraklis AJ, Kevy SV, Diamond LK, Gross RE: Hazard of overwhelming infection after splenectomy in childhood. N Eng/ J Med 276: 1225, 1967. 12. Douglas GJ, Simpson JS: The conservative management of splenic trauma. J PediaB Surg 6: 565, 1971. 13. Mishalany H: Repair of the ruptured spleen. J Pedjafr Surg 9: 175, 1974. 14. Yam L, Crosby W: Early splenectomy in lymphoproliferative disorders. Arch Intern Med 133~270, 1974. 15. Thompson RL, Moore RA, Hess CE, Wheby MS, Leavell BS: Idiopathic thrombocytopenic purpura. Arch Intern A&d 130: 730, 1972. 16. Slater H: Complications of splenectomy. Am Surg 39: 221, 1973. 17. Claret I, Morales L, Montoner A: Immunological studies in the post splenectomy syndrome. J Pediatr Surg 10: 59, 1975.
Discussion Luke W. Able (Houston, TX): During the past twenty years 176 splenectomies have been done at Texas Children’s Hospital. Ten survivors have now died of sepsis. At present splenectomy is deferred as long as possible. It is necessary in patients wit-hcongenital spherocytic anemia and idiopathic thrombocytopenia but can be avoided in many other conditions. It is recommended for trauma when it is the only way to stop bleeding. Partial splenectomy and splenorrhaphies have been successful.
The American Journal of Surgery