Monday, January 29, 2018

Cosmetic Surgery After Splenectomy

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The spleen  is located in the left upper abdomen under the rib cage.

The spleen's key function is the removal of old red blood cells (RBCs), defective circulating blood cells, and circulating bacteria. In addition, the spleen helps maintain normal red blood cell appearance by processing immature red blood cells, removing their nuclei, and changing the shape of the cellular membrane. Other functions of the spleen include the removal of nuclear remnants of red blood cells, denatured hemoglobin, and iron granules and the manufacture of opsonins (properdin and tuftsin). It is recognized as the host for immune cells essential for antibody production and filters out blood impurities, particularly encapsulated bacteria. It also functions as a secondary source of red blood cells if the bone marrow fails to produce sufficient red blood cells. The spleen can become enlarged  in a variety of conditions such as malaria, mononucleosis and most commonly in cancers of the lymphatics, such as lymphomas or leukemia. A very large spleen is prone to rupture resulting in severe blood loss.

A splenectomy is a surgical procedure that partially or completely removes the spleen. The indications for spleen removal include:

  1. Traumatic rupture
  2. Hodgkin disease - In patients who are refractory to medical therapy, splenectomy is indicated to decrease pain, fullness, and an overactive spleen
  3. Felty syndrome (rheumatoid arthritis, enlarged spleen, and white blood cell deficiency) -  
  4. Splenic abscess, cyst, sarcoidosis
  5. Blood abnormality that causes the spleen to remove too many blood components from circulation such as in cases of genetic misshapen red blood cells

Also the spleen can die in sickle cell if the number of sickled cells filtered is so high that the spleen becomes clogged impeding blood flow through it. Patients without a functioning spleen are predisposed to overwhelming fulminant infections caused by encapsulated bacteria (Streptococcus pneumoniae, Haemophilus influenzae, Neisseria meningitidis [a cause of meningitis], and Capnocytophaga canimorsus[from contact with dogs]) that do not respond to the usual antibiotic treatments, 40% to 54% of these patients will die. They are also susceptible to Babeosis from tick bites. Therefore prevention of infection by vaccination is a key feature of the management of these patients and vaccination protocols are commonly followed before and/or after surgical removal of the spleen.

The usual/recommended vaccines are:
  • Haemophilus influenzae b conjugate
  • Diphtheria toxoid, tetanus toxoid, acellular pertussis; tetanus toxoid, reduced diphtheria toxoid; tetanus toxoid, reduced diphtheria toxoid, and reduced acellular pertussis
  • Influenza-inactivated (inactivated influenza vaccine)
  • Measles, mumps, and rubella-live 
  • Measles, mumps, and rubella-varicella-live 
  • Meningococcal conjugate (Menactra or Menveo for patients 56 years old and older and given every 5 years)
  • Meningococcal serogroup B
  • Pneumococcal conjugate (PCV13)
  • Pneumococcal polysaccharide (PPSV23)
  • Polio-inactivated (inactivated poliovirus vaccine) e
  • Rotavirus-live 
  • Varicella-live 
  • Zoster-live
Live attenuated influenza vaccine should not be given to patients who do not have a functioning spleen.

If your spleen has been removed or is non-functional you should not undergo any elective surgery unless all of your immunization vaccines are up to date. Strep pneumoniae, Neisseria meningitidis, and Haemophilus influenzae vaccines are usually given 2 weeks before elective surgery and you should be up to date with your yearly influeza vaccine (flu shot). ​

​​Since blood flow in the portal system is altered by splenectomy there is also risk of clot in the portal vein to the liver during the low blood flow states associated with anesthesia, surgery and recovery from surgery. Therefore a blood thinner should be considered around the time of surgery. ​ ​

For procedures involving the paranasal sinuses or respiratory tract such as rhinoplasty amoxicillin 2gm orally 30 to 60 minutes prior to the procedure or the equivalent intravenously is given because  encapsulated bacteria responsible for postsplenectomy sepsis live on the mucosal surfaces of the respiratory tract. For patients who are penicillin allergic an extended-spectrum fluoroquinolone (levofloxacin, moxifloxacin, or gemifloxacin) can be substituted. After the initial course of antibiotics these patients have to have extra pills on hand in their home, at work, and ideally on their person for immediate initiation at the onset of fever or chills.

The next important factor is why you had the splenectomy. If it was performed because of trauma that is all you should require. If it was removed because of lupus, sickle cell, ITP or other blood disorder vaccination alone will not be enough. Further precautions required before elective surgery would depend on what the exact reason for splenectomy was. ​​ ​This is clearly something you should not do without careful planning, appropriate specialist input and making sure every t is crossed and every i is dotted.

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