Medication Summary
The goals of pharmacotherapy in cases of splenomegaly are to reduce mortality and prevent complications. In the absence of a functional spleen, patients have a defect in bacterial clearance due to impaired opsonization. In particular, these patients are at risk for overwhelming postsplenectomy infection (OPSI) due to infection with encapsulated organisms such as Haemophilus influenzae, Neisseria meningitidis, and Streptococcus pneumoniae. [36] Appropriate vaccination is indicated. [37]
Patients with clinical evidence of OPSI require empirical antibiotics. Please see separate guidelines for treatment of infections in the splenectomized patient. [38, 39]
Vaccines, Inactivated, Bacterial
Class Summary
Patients should ideally undergo the following prophylactic vaccinations against encapsulated organisms prior to splenectomy.
Vaccines should be administered at least 14 days prior to scheduled splenectomy. If indicated, multiple vaccines can be given during the same visit at different anatomic sites usually. If it is not possible to vaccinate patients preoperatively, immunizations can be given after the 14th postoperative day. Vaccinations should be delayed for at least 3 months in patients undergoing immunosuppressive chemotherapy or radiotherapy.
Pneumococcal vaccine (Pneumovax 23)
This vaccine contains capsular polysaccharides of 23 pneumococcal types that together account for 98% of pneumococcal disease isolates.
Meningitis group A C Y and W-135 vaccine (Menomune-A/C/Y/W-135)
This vaccine contains capsular polysaccharide antigens (groups A, C, Y, and W-135) of Neisseria meningitidis. It may be used to prevent and control outbreaks of serogroup C meningococcal disease, according to guidelines from the US Centers for Disease Control and Prevention (CDC).
The quadrivalent meningococcal polysaccharide vaccine (Menomune, MPSV4) has been approved by the US Food and Drug Administration for individuals over 56 years of age; however, this vaccine was discontinued in 2017. A quadrivalent meningococcal conjugate vaccine (Menactra or Menveo) is preferred by the United States Advisory Committee on Immunization Practices (ACIP) for individuals in this age group who are expected to require revaccination .
Meningococcal serogroup B vaccine is also recommended.
Haemophilus influenza type b conjugate vaccine (ActHIB, Hiberix, PedvaxHIB)
This vaccine is also used for the routine immunization of children against invasive diseases caused by Haemophilus influenzae type B.
Antibiotics, Other
Class Summary
The diagnostic workup should never delay the use of empiric therapy. Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Ceftriaxone (Rocephin)
Ceftriaxone (adult dose of 2 g IV q12-24h; pediatric dose of 50 mg/kg IV q12h) is a third-generation cephalosporin with broad-spectrum gram-negative activity; it has lower efficacy against gram-positive organisms and higher efficacy against resistant organisms. Ceftriaxone arrests bacterial growth by binding to 1 or more penicillin-binding proteins.
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This patient has a splenic abscess due to pneumococcal bacteremia. Note that the massively enlarged spleen is readily visible, with minimal retraction in the left upper quadrant.
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Resected specimen from the patient in the previous image. Note the discrete abscesses adjacent to normal parenchyma.
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The margins of this massive spleen were palpated easily preoperatively. Medially, the 3.18 kg (7 lb) spleen crosses the midline. Inferiorly, it extends into the pelvis.
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Massive splenomegaly does not preclude splenectomy through a minimally invasive approach. This photograph depicts a fragmented 3.2 kg (7.05 lb) spleen after removal via a hand-assisted laparoscopic technique.
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A portion of a massive spleen is extracted via hand-assisted laparoscopy.
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Intraoperative photograph of a laparoscopic splenectomy being taken down using the hanging-pedicle technique. The tip of the spleen is visualized in the background, whereas the stapler is detailed in the foreground across a segment of the pedicle.
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A massive spleen that was removed from an elderly woman with lymphoma.
