Postsplenectomy Complications

Splenectomy removes an important component of:

• Clearance of encapsulated bacteria
• IgM memory B cell function
• Removal of abnormal erythrocytes
• Platelet sequestration

Complications can be divided into:

Early surgical complications

• Haemorrhage
• Pancreatic injury
• Subphrenic collection
• Atelectasis
• Wound infection
• Portal or splenic vein thrombosis

Haematological complications

• Reactive thrombocytosis
• Increased thromboembolic risk

Long term infectious complications

• Overwhelming postsplenectomy infection

The risk of serious infection is lifelong, although it is particularly important during the first years after splenectomy and in immunocompromised patients.

Postoperative haemorrhage

Features include:

• Tachycardia
• Falling haemoglobin
• Hypotension
• Increasing abdominal drain output
• Abdominal distension

Major bleeding may arise from:

• Splenic pedicle
• Short gastric vessels
• Capsular injury elsewhere
• Raw retroperitoneal surfaces

Persistent haemodynamic instability after splenectomy requires urgent reexploration or targeted angiographic treatment according to the bleeding source.

Pancreatic injury

The pancreatic tail lies close to the splenic hilum.

Postoperative pancreatic fistula can present with:

• Persistent upper abdominal drain output
• Elevated drain amylase
• Fever
• Peripancreatic collection

Manage according to fistula severity with:

• Adequate drainage
• Nutritional support
• Treatment of infected collections
• Endoscopic pancreatic intervention in selected persistent leaks

Subphrenic abscess

Suspect with:

• Persistent fever
• Left upper abdominal pain
• Leukocytosis
• Left pleural effusion
• Delayed recovery

Contrast CT identifies the collection.

Drain percutaneously when accessible, with antibiotics directed at the clinical source.

Reactive thrombocytosis

Platelet counts often rise substantially after splenectomy.

The peak commonly occurs during the first several postoperative weeks.

Reactive thrombocytosis alone does not automatically require cytoreductive therapy.

Assess thrombosis risk according to:

• Underlying haematological disorder
• Platelet magnitude
• Portal hypertension
• Previous thrombosis
• Other prothrombotic factors

Portal and splenic venous thrombosis

This is particularly important after splenectomy for:

• Massive splenomegaly
• Myeloproliferative disease
• Haemolytic disease
• Cirrhosis and portal hypertension

Symptoms can include:

• Abdominal pain
• Fever
• Nausea
• Ascites
• Gastrointestinal bleeding
• Bowel ischaemia if mesenteric veins become involved

Use Doppler ultrasound or contrast CT.

Therapeutic anticoagulation is generally indicated when clinically significant portal, splenic or mesenteric venous thrombosis is confirmed, provided bleeding risk is acceptable.

Overwhelming postsplenectomy infection

OPSI is fulminant sepsis occurring in an asplenic or severely hyposplenic patient.

Important pathogens include:

• Streptococcus pneumoniae
• Neisseria meningitidis
• Haemophilus influenzae type b

Other important infections include:

• Capnocytophaga canimorsus after dog bites
• Severe malaria
• Babesiosis in relevant endemic exposure

A seemingly minor febrile illness can progress to:

• Septic shock
• Disseminated intravascular coagulation
• Purpura fulminans
• Multiorgan failure

within hours.

Suspected OPSI

Do not delay antibiotics for extensive investigation.

Obtain rapidly where possible:

• Blood cultures
• Full blood count
• Lactate
• Renal function
• Liver function
• Coagulation profile
• Blood glucose
• Malaria testing where exposure or endemic setting makes it relevant

Begin treatment immediately after cultures if they can be obtained without meaningful delay.

Vaccination before elective splenectomy

Give required asplenia vaccines preferably at least 14 days before planned splenectomy.

Vaccination after emergency splenectomy

For best immune response, vaccinate approximately 14 days after emergency splenectomy.

If the patient is likely to be lost to follow up, vaccination before discharge once clinically stable is preferable to missing vaccination entirely.

Pneumococcal vaccination

For a previously unvaccinated adult with asplenia, current options include:

PCV20 once

or

PCV21 once

with no additional PPSV23 required.

An alternative is:

PCV15 once

followed by:

PPSV23, normally at least 1 year later, with a minimum interval of 8 weeks acceptable in immunocompromising conditions such as asplenia.

Previous vaccination history must be checked before prescribing a new schedule.

Haemophilus influenzae type b

For an adult who has never received Hib vaccine:

Hib vaccine, one dose.

Meningococcal ACWY

Give:

Two dose primary series, doses at least 8 weeks apart

then:

Booster after 5 years and every 5 years thereafter while asplenia persists.

Meningococcal B

For an adult with anatomical or functional asplenia:

Three dose primary series at 0, 1 to 2 months and 6 months

using the same vaccine product throughout.

Then:

• Booster 1 year after completion
• Booster every 2 to 3 years while risk persists.

Influenza

Give annual seasonal influenza vaccination.

Influenza itself is not an encapsulated bacterial infection, but prevention reduces secondary bacterial infection risk.

After splenic artery embolisation

Routine postsplenectomy vaccination is not generally required after successful splenic artery embolisation, because clinically important splenic immune function is usually retained.

Consider vaccination individually when embolisation has effectively produced near total splenic infarction or functional asplenia.

Antibiotic prophylaxis

Routine lifelong prophylaxis for every healthy asplenic adult remains controversial.

A practical adult prophylactic regimen when prophylaxis is indicated is:

Penicillin V 250 mg orally twice daily

or

Amoxicillin 500 mg orally twice daily.

Prolonged or lifelong prophylaxis should be strongly considered in:

• Previous OPSI
• Significant immunocompromise
• Haematological malignancy
• Poor vaccine response
• Other particularly high risk patients

Many protocols use prophylaxis for at least the first 1 to 3 years after splenectomy in otherwise healthy individuals, with duration individualised.

Fever in an asplenic patient

Treat fever seriously.

If immediate medical assessment is not available, patients can carry emergency oral antibiotics.

A practical adult standby regimen is:

Amoxicillin clavulanate 875/125 mg orally immediately

then urgent hospital assessment rather than waiting at home to see whether fever settles.

At hospital, suspected severe bacterial infection requires immediate IV treatment.

A practical initial regimen is:

Ceftriaxone 2 g IV every 24 hours

with:

Vancomycin IV added when severe sepsis, meningitis or resistant pneumococcal infection is a meaningful concern.

Adjust immediately to:

• Local susceptibility data
• Culture results
• Clinical source

Do not wait for confirmatory cultures before treating a shocked asplenic patient.

Animal bites

Dog and other mammalian bites can cause rapidly progressive Capnocytophaga infection.

Use prompt wound care and appropriate antimicrobial treatment.

A practical adult regimen for a significant dog bite is:

Amoxicillin clavulanate 875/125 mg orally twice daily

with IV therapy for severe systemic infection.

Patient safety measures

Every splenectomised patient should know that absence of the spleen is permanent and clinically relevant.

They should:

• Carry an asplenia medical alert card or equivalent
• Inform clinicians of splenectomy
• Maintain vaccine boosters
• Seek urgent assessment for fever
• Obtain travel advice before malaria endemic travel
• Seek early care after significant animal bites

Prevention and immediate treatment of infection are as important as the original splenectomy itself.