Disorders of the Spleen

The main indications for splenectomy are trauma (patients > 55 do not fare well with expectant management of blunt injuries to the spleen), idiopathic thrombocytopenic purpura, massive splenomegaly, disease of adjacent organs (eg, the stomach, pancreas, or colon), and abscesses. Rarely in the elderly, splenectomy is performed for hypersplenism and splenic artery aneurysms, as a staging procedure for Hodgkin's disease, or as a requirement of splenorenal shunt for portal hypertension.

Iatrogenic damage to the spleen commonly results from vagotomy and operations involving the stomach, tail of the pancreas, or colon. Such trauma as well as blunt and penetrating trauma often require splenectomy.

The surgeon decides whether the injury is severe enough to warrant splenectomy or whether simple suturing or hemostasis is possible. Compared with children, elderly patients have a much lower incidence of overwhelming postsplenectomy sepsis. However, elderly patients do not tolerate continued bleeding as well as younger patients do. Therefore, in an elderly patient, unless hemostasis is certain, splenectomy should be performed. If possible, pneumococcal vaccine should be given to unvaccinated persons before splenectomy.

Surgical treatment of gastric cancer often includes splenectomy because of the frequency of splenic lymph node metastases. Other reasons for splenectomy include cancer of the splenic flexure of the colon, which also may invade the spleen; large cysts of the distal pancreas; and splenic artery aneurysms.

Abscesses may form in the spleen secondary to sepsis. For diagnosis, CT is helpful. Many abscesses can be drained by using percutaneous catheters guided by CT scan. When percutaneous drainage fails, surgical debridement and wide drainage are usually effective.