Introduction

Splenectomies have been performed as early as 2.000 years ago, as per references in ancient Greek and Roman literature. The first total splenectomy for disease is attributed to Adriano Zaccarello in 1549, although it has been suggested that excised viscus was an ovarian cyst. Clark (1676) performed splenectomy in dogs with survival. Nicholas Mathias is credited with first total splenectomy for trauma in 1678₁. Mayo in 1928 did a retrospective study of 500 splenectomies with special reference to mortality and end results. Mainly splenectomies were done for anemia and leukemia; 80 percent patients had very good results and lived comfortably₂.

The land mark report of king and shumacker (1952) poslutated that spleen may play a role in resisting infection particularly in infancy₃ which was supported by other authors in coming years₄.

However, with the advent of safe anaestheia, modern surgical techniques, broad spectrum antibiotics and specific vaccines, the morbidity and mortality following splenectomy is definitely on a decline, hence more and more studies were conducted in last 35 years in an attempt to determine the true morbidity, mortality and long term infection following splenectomy.₅,₆,₇

Material & Methods

Our Study included 18 patients with various hematological disorders subjected to be splenectomy from 1982 to 2002 at Sher-i-Kashmir institute of Medical Sciences Srinagar (J&K) India in the department of Surgery.

Medical records of all retrospective cases were reviewed. Preoperative management included a detailed clinical examination, hematological and coagulation studies. Patients with very low hemoglobin were build up with pre-operative transfusions of whole blood. Preoperative antibiotics like ampicillin and gentamycin or a third generation cephalosporin were used for prophylaxis. Cortiosteroids were given in the pre-operative period in all patients. All patients were put on I/V fluids post operatively for 24-48 hours. Hydrocortisone was used and tapered for 48-72 hours in the post-operative period. Antibiotics were routinely given in the post operative period.

A preset routine was followed by taking blood samples on day “0” , day “3” and day “7” for assessment of hematological parameters which included hemoglobin (Hb%), total leukocyte count (TLC) and platelet count (PC) and again on follow up in 1^st month, 3^rd month and 6^th month. The mean of all these readings were used for comparison with pre-operative parameters to assess the response as described under:₇,₈,₉,₁₀

Response in an anemic patient

Figure 1

Since none of the patients in this group presented with thromobocytopenia or leucopenia, hence those criteria are excluded here₈,₉,₁₀.

The follow up was complete in 94% cases. The duration of follow-up ranged from 1 week to 8 years with a mean of 8 months. The diagnosis of all these patients was confirmed after surgery by histopathological examination of spleen.

Results

The age distribution ranged from 12-72 years. Mean age was 43 years. Male to female ratio was 1:3.5. the preoperative hematological parameters of our study group are described in Table 1. Mean Hb was 7.2g%. The response to splenectomy is described in Table 2. the mean splenic weight was 830 gms (range 225-2000 grams). The accessory spleen was found in 2 patients (10%). The morbidity was quite significant; 3 patients (16%) developed complications; 2 developed intra abdominal abcess and other patient developed wound dehiscence. One patient (5.5%) died on 7^th post operative day secondary to sepsis who was the youngest patient in the study group.

Figure 2

Table 1: Preoperative hematological parameters (n=18)

All patients presented with anemia and none of the patients with thrombocytopenia or leucopenia.

Figure 3

Table 2: Response to Splenectomy

Discussion

The blanket term embraces all hemolytic disorders that are not due to inborn defects in the red blood corpuscles. It is possible to define 2 broad groups, an autoimmune and a secondary. In autoimmune an antibody has developed which coats the erythrocyte and shortens its survival by rendering it more liable to phagocytosis in the spleen and elsewhere. It may arise apparently spontaneously (idiopathic acquired hemolytic anemia) or during the course of certain infections and of disease involving antibody producing cells. Almost always the presence of antibody can be demonstrated by a positive direct antiglobulin reaction, the comb's test. In the secondary group an antibody cannot be demonstrated and the coomb's test is usually negative. It includes certain abnormalities (acquired) or the erythrocyte, for example pernicious anemia, malaria, chronic infection, extensive burns and has been reported after implantation of plastic heart valves. It may also occur in association with malignant tumors in young people.₁₁ In our study group of 18 patients mean age was 43 years (range 12-72 years) consistent with Musser et al₇ but less then other study₁₂ out of 18 patients, 4 patients were males (22%) and 4 patients (78%) were females consistent with other studies₁₃ but on the contrary some authors report a higher incidence of males₇. the main pre-operative hematological finding was anemia in all the patients. The mean Hb was 7.2g% (range 5.2 -9.0g%). None of the patients presented with thrombocytopenia or leucopenia. All the patients were on steroids pre-operatively. All the patients received whole blood in the pre-operative period. Splenectomy drastically decreased the need of post operative transfusions.

All patients were subjected to elective splenectomy. 3 patients (16%) developed complications in the postoperative period. 2 patients developed intraabdominal abscess and other patient developed wound dehiscence. 1 patient (5.5%) was lost on 7^th postoperative day secondary to sepsis. 2 patients (10%) were found to have accessory spleen quite less as observed in other study₆. The mean splenic weight was 830 gms (range 225-2000 grams) quite near to Musser et al. (1984) study₇. Our results of morbidity and mortality (16% & 5.5%) are somewhere between as observed by others₁₂,₁₃.

The response to splenectomy in terms of hematological parameters was excellent. Out of 18 patients, 13 patients (76%) showed complete response, 2 patients showed partial response (12%) while as 2 patients did not improve (12%). Overall 88% patients were benefited by the procedure. Thus, we conclude that splenectomy is an excellent form of treatment to improve hematological parameters in patients with acquired hemolytic anemia refractory to other types of therapy provided the patient is diagnosed, discussed and prepared for the surgery by an expert team of a hematologist and a surgeon.

Correspondence to

Dr. Fazl Q. Parray 44-Rawalpora, Govt. Housing Colony. (Sanat-nagar), Srinagar -190005 J&K India Tel No: 0194-2433433,2431155 E-mail: fazlparray@rediffmail.com