Splenic Conditions

Question 1

What are the functions of the spleen?

Answer 1

The spleen is primarily a filter, which removes old and damaged red blood cells and platelets.

It also contains immunological cells, including T- and B-cells and reticuloendothelial cells, which remove opsonized bacteria and other particles from the blood.

Question 2

What is the surgical anatomy of the spleen?

Answer 2

The spleen is roughly divided into three sections: the upper pole, the body and the lower pole.

The arterial supply and venous drainage of the upper pole is from the short gastric vessels, the body is supplied by the main hilar vessels, and the lower pole is supplied by gastroepiploic and omental vessels.

The main splenic artery is a branch of the celiac artery, and the main splenic vein joins the superior mesenteric vein to form the portal vein which then drains into the liver.

The spleen is fixed to the diaphragm and to the lateral abdominal wall by peritoneal attachments which prevent torsion or volvulus of the spleen.

Question 3

What are the steps of a splenectomy?

Answer 3

The steps of a splenectomy are

1. Division of the attachments to the diaphragm and retroperitoneum,
2. Division of the lower pole vessels,
3. Division of the hilar vessels,
4. Division of the short gastric vessels,
5. Removal of the spleen, and
6. Identification and excision of accessory spleens.

In most cases, the operation can be done laparoscopically, in which case division of the lateral attachments are often done at the end of the procedure after division of the vessels, and the spleen is placed into a bag inside the abdomen so the neck of the bag can be brought out through a port site and the spleen can be morcellated within the bag and removed in pieces.

Question 4

What is the technique of partial splenectomy?

Answer 4

The goal of a partial splenectomy is to leave a sufficient amount of spleen behind to retain splenic function (although it is not known exactly how much residual spleen is necessary for that purpose).

For spherocytosis, the preferred approach is to divide the lower pole vessels and the main hilar vessels, leaving the upper pole based on the short gastric vessels and stabilized with the phrenosplenic connec- tions.

For a splenic cyst or mass, the surgeon must assess the blood supply to the affected segment and make a decision which part of the spleen to leave behind with an intact blood supply.

Because the spleen is very hard in patients with spherocytosis, the spleen must be divided with a sealing device; in patients with a splenic cyst or mass the residual normal spleen can usually be divided with a stapler.

Question 5

What is the best management for splenic trauma? [1]

Answer 5

Most children with splenic injury can be managed non-operatively with activity restriction and fluid resuscitation.

The indications for transfusion include unstable vital signs after receiving 20 cc/kg of isotonic fluid, a hemoglobin level of less than 7.0 gm/dl, or signs of active bleeding.

The indication for emergency splenectomy is persistent hemodynamic instability despite blood transfusion.

If laparotomy is necessary, the surgeon should attempt to salvage some or all of the spleen if possible.

For those managed non-operatively, discharge can be done when the child is stable and eating, and activity limitation should be maintained for injury grade + two weeks.

Question 6

What are the indications for splenectomy in children with immune throm- bocytopenia purpura (ITP)?

Answer 6

ITP is an immunological condition in which the child makes antibodies to his own platelets, which are then destroyed by the spleen.

Most children have the acute form that resolves on its own.

Many children with the chronic form can be successfully treated medically with steroids or intravenous immunoglobulin (IVIG).

Splenectomy is recommended for those who have persistent recurring thrombocytopenia despite medical therapy, or for those who have complications from the medical therapy itself.

Question 7

What are the perioperative considerations when doing a splenectomy for a child with ITP?

Answer 7

Ideally, the platelet count should be at least 50,000 at the time of splenectomy.

This can usually be accomplished by treating with IVIG within a week of the planned surgery.

For those who cannot achieve an adequate platelet count, platelets should be infused just prior to surgery and continued until after the arterial supply to the spleen has been taken.

Key technical points during the surgery include ensuring that the spleen is completely excised without spilling any splenic tissue, and ensuring that any accessory spleens are identified and excised.

Question 8

What should be done with a child who has persistent or recurrent thrombocytopenia after a splenectomy for ITP?

Answer 8

The two main reasons for thrombocytopenia after a splenectomy are retained accessory splenic tissue, or breakdown of platelets by reticuloendothelial cells in the liver or bone marrow.

A nuclear spleen scan should be done to identify any residual splenic tissue, and if found this tissue should be removed at a second operation.

Question 9

What are the indications for splenectomy in children with sickle cell disease (SCD)?

Answer 9

Most children with SCD undergo auto-amputation of the spleen by the age of 10 or so and are therefore not candidates for splenectomy.

However, a small minority will develop a sequestration crisis before that time, which can result in extremely low hemoglobin levels and can be fatal.

Therefore, any child with SCD who has had even one sequestration crisis should have a splenectomy.

Question 10

What are the perioperative considerations when doing a splenectomy for a child with sickle cell disease? [2]

Answer 10

Children with SCD are susceptible to acute chest syndrome after a general anesthetic and surgical procedure, which can be severe and even fatal.

There is general agreement that these children should be well-hydrated and should have an adequate hemoglobin level prior to surgery, but there is continuing controversy about what that level should be, and whether routine preoperative transfusion is beneficial.

Postoperatively it is important to maintain hydration and hemoglobin level, and to adequately prevent postoperative pain.

Question 11

What are the indications for splenectomy in children with spherocytosis?

Answer 11

Children with moderate or severe forms of spherocytosis may be considered for splenectomy because of ongoing transfusion requirements, lethargy, jaundice, or discomfort from a massively enlarged spleen.

Question 12

What are the advantages and disadvantages of partial splenectomy for
children with spherocytosis? [3]

Answer 12

Partial splenectomy, removing approximately 80% of the spleen, has been shown to be very effective in treating the anemia, jaundice and symptoms in children with spherocytosis, while theoretically decreasing the long-term risks of post-splenectomy sepsis and thrombosis.

The operation can be done laparoscopically, but is associated with a higher perioperative transfusion requirement, more pain, and a longer hospital stay than laparoscopic total splenectomy.

There is also a 10–15% risk of regrowth of the splenic remnant with recurrent symptoms and need for a completion splenectomy in the future.

Question 13

What are the perioperative considerations when doing a splenectomy for a child with spherocytosis?

Answer 13

Most children with spherocytosis are otherwise healthy and can tolerate splenectomy well.

Almost half of patients with spherocytosis will develop gallstones; if they are symptomatic the gallbladder should be removed at the time of splenectomy.

There is controversy about whether asymptomatic gallstones should be removed at the time of splenectomy.

Question 14

How should splenic cysts be managed?

Answer 14

Splenic cysts are usually congenital and have an epithelial lining.

These must be differentiated from echinococcal cysts, which should be removed, and liquification of a post-traumatic splenic hematoma, which will usually resolve over time.

Symptomatic epithelial cysts should be removed by partial splenectomy if possible, or total splenectomy if partial splenectomy is not technically feasible.

Asymptomatic epithelial cysts can be managed expectantly with serial imaging, but should be removed if they become symptomatic, or if they enlarge beyond 5 cm in diameter.

Techniques such as unroofing or marsupialization, although less invasive, are associated with a very high incidence of recurrence.

Question 15

How should solid splenic masses be managed?

Answer 15

Solid splenic masses are rare, and usually represent benign lesions such as hemangioma or hamartoma.

These can be managed expectantly if they are asymptomatic, but excision with partial or total splenectomy should be considered if they become symptomatic or enlarge under observation.

Question 16

Are there any other indications for splenectomy?

Answer 16

Occasionally splenectomy will be indicated for hypersplenism due to portal hypertension, splenic vein thrombosis, HIV infection, glycogen storage disease, or idiopathic splenomegaly.

In some cases of lymphoproliferative disease the diagnosis of lymphoma or leukemia will be suspected, and the spleen will be removed for a tissue diagnosis.

Splenic abscess can usually be managed with antibiotics, but occasionally will require splenectomy.

Question 17

What is post-splenectomy sepsis and how can it be prevented? [4]

Answer 17

The spleen is involved in preventing infection with encapsulated organisms like Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis. Splenectomy increases the risk of overwhelming post-splenectomy infection (OPSI), which is fatal in more than 50% of cases.

Because of this, all patients undergoing splenectomy should be immunized prior to the operation against all three organisms, and should take prophylactic antibiotics after splenectomy.

Patients who have a splenectomy for trauma should be immunized after they have recovered from their injuries.

Question 18

What are the risks of thrombosis after splenectomy?

Answer 18

Early after total splenectomy the platelet count in most patients becomes markedly elevated, although this improves over time.

There may be a role for anti-platelet therapy if it exceeds 1,000,000.

There is also a recognized risk of portal vein thrombosis early after splenectomy, a risk which appears to be higher in adults than in children.

Recent long-term follow-up studies have also suggested that there may be an increased risk of thrombotic complications, including thromboembolic pulmonary hypertension, in adults who have had a previous splenectomy.

Question 19

Regarding splenectomy, all of the following are false except:

A. Electrocoagulation should not be used to achieve haemostasis.

B. Subcostal incision is preferred over midline incision for splenectomy after trauma.

C. Squeeze spleen gently to return as much blood as possible before clamping vessels.

D. Splenic vein should be clamped before artery.

E. Posterior peritoneum and fascia is closed by non-absorbable suture.

Answer 19

C

Squeeze spleen gently to return as much blood as possible before clamping vessels.

Hemostasis during splenectomy after trauma is achieved using electrocoagulation, argon beam coagulation, plagete in suture and absorbable mash.

Midline incision is preferred in splenectomy after trauma, while subcostal incision is good for elective splenectomy.

It is preferable to clamp splenic artery first.

Absorbable suture is used for closure of posterior peritoneum and fascia.

Syed/MCQ

Question 20

For overwhelming post-splenectomy infection, which of the following is false?

A. Mortality rate is 25 percent.

B. It is caused by pneumococcus (most common), Haemophilus influenzae, and meningococcus.

C. Risk is high in children less than 5 years of age.

D. It is more common in first two years after splenectomy.

E. It is more common in children undergoes elective splenectomy for haematological disease.

Answer 20

A

The incidence of infection after splenectomy in children under 16 years old is 4.4 percent, with a mortality rate of 2.2 percent.

Syed/MCQ

Question 21

Of the spleen’s many peritoneal attachments, the only vascularised ligaments are:

A the lienorenal ligament containing the splenic vessels and the lienophrenic ligament containing the short gastric vessels

B the lienocolic ligament containing the splenic vessels and the lieno-renal ligament containing the short gastric vessels

C the lienogastric ligament containing the splenic vessels and the lienorenal ligament containing the short gastric vessels

D the lienorenal ligament containing the splenic vessels and the lienogastric ligament containing the short gastric vessels

E the lienogastric ligament containing the splenic and short gastric vessels.

Answer 21

D

The spleen has up to six peritoneal attachments including the lienorenal ligament, which courses along the anterior surface of the left kidney and contains the splenic artery and the splenic vein, and the lienogastric ligament, which envelops the short gastric vessels.

The avascular attachments of the spleen include the lienocolic, lienophrenic, lienopancreatic ligaments and the sometimes-present presplenic fold.

SPSE 1

Question 22

Which of the following is not true regarding the development and basic physiology of the spleen?

A The splenic primordium originates in the dorsal mesogastrium at around 5 weeks’ gestation.

B The spleen is the primary organ of haematopoiesis until approximately 1 year of age.

C The spleen consists of red pulp and white pulp. The red pulp is primarily responsible for haemofiltration and removal of damaged/ senescent red blood cells and opsonised bacterial particles, while the white pulp contains lymphoid follicles and is a site of antigen presentation and initiation of the humoral immune response.

D The ‘closed’ circulatory theory describes a small portion of splenic blood flow that progresses directly from the arterial to the venous circulation through the splenic capillary bed.

E The ‘open’ circulatory theory describes the majority of the splenic blood that flows from the splenic arterioles into a sinusoidal network lined by the reticuloendothelial cells prior to entering the venous circulation.

Answer 22

B

The spleen is the primary organ of haematopoiesis until approximately 5 months’ gestation, at which point the bone marrow assumes the production of both red and white blood cells.

With gastric rotation, the dorsal mesogastrium folds to situate the spleen in the left upper quadrant anterior to the left kidney.

The dorsal aspect of the dorsal mesogastrium forms the lienorenal ligament while the more ventral portion forms the lienogastric ligament and extends caudad to form the greater omentum.

The two major functions of the spleen are haematological (‘pitting’ and ‘culling’ of red blood cells) and immunologic (production of opsonins and complement, filtration of antigens, antibody production, and stimulation of the lymphoid proliferation).

These functions primarily take place in the red and white pulp, respectively.

A small percentage of the splenic blood flow bypasses the reticuloendothelial system through the ‘closed’ circulation while the majority flows through the reticuloendothelial meshwork and venous sinusoids of the ‘open’ circulation.

SPSE 1

Question 23

During a routine prenatal ultrasound the diagnosis of transposition of the great vessels is made. The ultrasonographer has difficulty visualising the spleen. All of the following are associated with congenital asplenia except:

A right-sided stomach B biliary atresia C isomerism of the right atrial appendage D Howell–Jolly bodies on postnatal peripheral blood smear e increased rate of postnatal infection with encapsulated bacteria. During a routine prenatal ultrasound the diagnosis of transposition of the great vessels is made. The ultrasonographer has difficulty visualising the spleen. All of the following are associated with congenital asplenia except:

A right-sided stomach

B biliary atresia

C isomerism of the right atrial appendage

D Howell–Jolly bodies on postnatal peripheral blood smear

E increased rate of postnatal infection with encapsulated bacteria.

Answer 23

B

The condition described is congenital asplenism, which is frequently associated with severe cyanotic heart disease, isomerism of the right atrial appendage, a right-sided stomach, central displacement of the liver and peripheral blood smear findings consistent with splenic insufficiency.

Ivemark’s syndrome or asplenia syndrome is the presence of visceral heterotaxy with bilateral rightsidedness. This syndrome is also associated with malrotation and increased frequency of midgut volvulus.

Congenital polysplenism is associated with biliary atresia, situs inversus, absent inferior vena cava, preduodenal portal vein and aberrant hepatic artery.

SPSE 1

Question 24

A 14-year-old female is struck by a car while riding her bicycle and sustains a grade 4 splenic laceration requiring an emergency splenectomy. Fifteen years later the patient presents again with an adhesive smallbowel obstruction requiring repeat laparotomy. The lysis of adhesions is carried out without difficulty; however, at the time of the operation she is found to have multiple 5 mm to 4 cm purple, fleshy nodules implanted on the surface of the liver, stomach and omentum. Which of the following statements is true about this patient’s condition?

A The most common location for this tissue to be found is within the splenic hilum.

B The tissue is a congenital anomaly that occurs in 20%–30% of the general population.

C The nodules likely represent a malignant process and should be completely resected.

D This process occurs secondary to seeding of the peritoneum with splenic particles following splenic rupture and frequently provides adequate immunologic function to obviate the need for postsplenectomy vaccination.

E This tissue is likely to look similar to normal splenic tissue, histologically, with the exception of having a fibrotic capsule, multiple small vascular tributaries, and an incomplete or disorganised trabecular network.

Answer 24

E

The condition described in this question is splenosis. It results from seeding of the peritoneum following splenic trauma and is most frequently found on the surface of the liver, stomach and omentum.

It is a completely benign process and does not need to be resected unless it is causing a problem secondary to a mass effect.

Histologically, the splenosis nodules appear similar to native spleen; however, they lack the dominant trabecular arterial inflow and structured splenic capsule.

Splenosis often performs pitting and culling (i.e. removes deformed or senescent red blood cells), but for incompletely understood reasons, it does not provide the immunologic function of the native spleen.

As a result, such individuals should be treated as asplenic. options A and B refer to accessory spleens.

SPSE 1

Question 25

A 12-year-old male with hereditary elliptocytosis is taken for a laparoscopic splenectomy. Intraoperatively, a 2 cm purple, fleshy nodule is visualised within the connective tissue of the splenic hilum. The spleen itself, while enlarged, appears otherwise normal. Which of the following is true regarding this finding?

A This nodule represents histologically normal, ectopic splenic tissue. B The most common location to find this process is within the greater omentum.

C This tissue is non-functional and may be left in place at the time of elective splenectomy for the described condition.

D When present, this anomaly typically occurs in multiple locations.

E This condition is so rare that there is no need to actively assess for its presence during the initial operation.

Answer 25

A

Accessory spleens are common, occurring in 20%–30% of the general population. They are most commonly located in the splenic hilum (~40%), lienorenal ligament (~20%), lienogastric (~15%), greater omentum, lienophrenic ligament, and very rarely in the scrotum.

Accessory spleens are most frequently single (85%), occasionally double (10%), and rarely three or more (<5%).

The tissue is histologically similar to normal spleen and provides typical immunologic and haematological functions of splenic tissue.

As such, all accessory spleens should be removed at the time of splenectomy for any reason other than trauma.

SPSE 1

Question 26

A 10-year-old male is referred by his primary care doctor with complaints of intermittent abdominal pain, a palpable mass in his left lower quadrant, and a computed tomography scan that shows a very lowlying spleen. He is currently asymptomatic. What is the appropriate next step in the management of this patient?

A Assure the patient and his parents that all is well and no further action is required.

B Advise the patient and his parents to return to the emergency room if the symptoms return.

C Administer splenectomy vaccines and schedule the patient for elective splenopexy.

D Proceed directly to the operating room for urgent splenectomy.

E Obtain further imaging and laboratory studies.

Answer 26

C

This is a case of a wandering spleen with intermittent torsion.

Wandering spleen is a rare condition in which the spleen is attached only to the hilar vessels and a small lienogastric ligament.

The avascular peritoneal attachments are absent allowing the spleen to sit low in the abdomen and rotate around the narrow splenic pedicle.

Wandering spleen occasionally presents as acute torsion and requires emergency operative intervention with splenectomy if infarction is present.

In case of chronic, intermittent torsion, elective splenopexy may be performed, but vaccinations should be administered in case the patient has actually become functionally asplenic due to repeated partial infarction

SPSE 1

Question 27

A 5-week-old ex-36-week gestational age male is found to have only one testicle in his scrotum and a palpable mass in the left inguinal region. He is taken for a laparoscopic left herniorrhaphy and possible orchidopexy. Intraoperatively, the patient is found to have an indirect left inguinal hernia and an undescended left testis sitting in the left inguinal canal with an associated nodule of purple, fleshy tissue that appears to be attached to the native spleen by a fibrous band of connective tissue. Which of the following statements is false regarding this patient’s condition?

A These findings likely represent in utero testicular torsion.

B This is one of two typical presentations for this rare congenital anomaly.

C This condition is thought to result from the close proximity of the left mesonephros and spleen during early organogenesis.

D The appropriate next step in management is transection of the fibrous band, resection of the ectopic tissue, herniorrhaphy and orchidopexy if possible.

E The ectopic tissue in this condition is histologically normal spleen.

Answer 27

A

The congenital anomaly described in this question is splenogonadal fusion.

It occurs in two forms, one being the ‘continuous’ form with an associated band of fibrous connective tissue, the other being the ‘discontinuous’ form without any connection to the native spleen.

The continuous form is often associated with other congenital anomalies, while the discontinuous form is usually isolated and sometimes considered simply an ectopic or accessory spleen. The testis is often normal.

management consists of resection of the ectopic tissue, salvage or removal of the left testis, and repair of any concomitant hernia defect.

SPSE 1

Question 28

In which of the following patients is splenectomy indicated?

A A 6-year-old female with a recent history of cough and rhinorrhoea who presents with petechiae. She has a palpable spleen and a platelet count of 30 × 109 /L.

B A 6-year-old male with splenomegaly, jaundice, anaemia requiring increasingly frequent transfusions and spherocytes on peripheral blood smear.

C A 2-year-old male with β-thalassaemia, stable transfusion requirements, and no splenomegaly.

D A 10-year-old black female with sickle-cell disease and multiple repeated attacks of extremity pain requiring admission to the hospital for pain control and hydration.

E A 17-year-old male recently diagnosed with Hodgkin’s lymphoma.

Answer 28

B

There are very few absolute indications for splenectomy in children.

Symptomatic hereditary spherocytosis in a child over the age of 5 is an indication for splenectomy given that there is no medical management for this disease and the patient is old enough to receive pre-splenectomy vaccinations with relative success.

The patient in option A is presenting with findings characteristic of idiopathic thrombocytopenic purpura. Spontaneous resolution or resolution with medical management (steroids or intravenous immunoglobulin) occurs in greater than 90% of affected children and should be attempted prior to splenectomy.

Indications for splenectomy in β-thalassaemia include increasing transfusion requirements or symptomatic splenomegaly and one should attempt to avoid splenectomy until the patient reaches the age of 5 years to increase the efficacy of preoperative vaccination.

Splenectomy is indicated in the setting of sickle-cell anaemia when acute splenic sequestration is encountered.

Typically, sickle-cell anaemia leads to repeated episodes of microinfarction and eventual autosplenectomy.

Historically, Hodgkin’s lymphoma was staged by laparotomy with concomitant splenectomy. This is rarely indicated today with the available imaging options (CT, mRI, PET) and systemic therapies (combined chemo/radiation therapy).

SPSE 1

Question 29

Which of the following statements is true regarding blunt splenic trauma in children?

A Splenectomy is indicated in a haemodynamically stable patient with free fluid in the pelvis and an isolated grade 3 splenic laceration on computed tomography scan.

B Non-operative management of splenic trauma has led to increased hospital lengths-of-stay.

C Non-operative management of splenic trauma has resulted in increased rates of transfusion.

D Non-operative management of isolated splenic injuries is associated with decreased mortality compared with patients with isolated splenic injuries undergoing splenectomy.

E There is a relatively high rate of overwhelming post-splenectomy infection in children who undergo splenectomy for trauma relative to those undergoing splenectomy for one of the haemoglobinopathies.

Answer 29

D

Non-operative management of isolated splenic injuries is associated with a lower mortality rate than splenectomy (0.7% vs. 8%, respectively).

There is no grade of injury or imaging finding that is a definite indication for splenectomy.

A patient that is haemodynamically unstable after receiving adequate crystalloid resuscitation and two units of packed red blood cells or requires continued transfusions to maintain a haematocrit >25 should be considered for splenectomy.

Both rates of transfusions and length of stay have decreased as non-operative management of paediatric splenic trauma has become ubiquitous.

Children undergoing splenectomy for trauma have a lower rate of overwhelming postsplenectomy infection when compared with children who undergo splenectomy for haemoglobinopathies.

For reasons that are not entirely understood, patients undergoing splenectomy for β-thalassaemia have the highest rate of postsplenectomy infection.

SPSE 1

Question 30

An 8-year-old female with hereditary spherocytosis has required more frequent transfusions over the past year, has experienced increasing splenomegaly, and has been found to have gallstones on right upper quadrant ultrasound. What is the most appropriate next step in the management of this patient?

A preoperative vaccines followed by open splenectomy

B open splenectomy without preoperative vaccines

C preoperative vaccines followed by open partial splenectomy

D open partial splenectomy without preoperative vaccines

E preoperative vaccines followed by laparoscopic partial or total splenectomy with combined cholecystectomy

Answer 30

E

Partial splenectomy has been proven to provide good long-term haematological outcomes with prolonged elevation in haemoglobin levels and decreased reticulocyte counts in patients with hereditary spherocytosis.

In the appropriate hands, laparoscopic partial splenectomy can be performed safely with retained immunologic function when 10%–30% of the original splenic mass is preserved.

It is important to always vaccinate patients undergoing both total and partial splenectomy, as there is always the chance that the patient will be left functionally asplenic.

Finally, when gallstones are found preoperatively, it is necessary to perform a cholecystectomy given the high rate of future biliary colic in these patients. of note, performing a total splenectomy with cholecystectomy would be an acceptable management strategy in this patient.

SPSE 1

Question 31

All of the following are true of laparoscopic splenectomy except:

A there is a higher rate of complications associated with laparoscopic splenectomy in patients with sickle-cell disease relative to other haemoglobinopathies

B compared with the open procedure, there is a higher rate of postoperative pancreatitis associated with laparoscopic splenectomy

C laparoscopic splenectomy leads to extensive left upper quadrant adhesions and makes it impossible to undergo future laparoscopic procedures

D laparoscopic splenectomy is associated with a negligible rate of surgical site infection

E laparoscopy is safe and efficacious and is now considered the procedure of choice for most splenic operations in children.

Answer 31

C

Current literature reports multiple cases of reoperation performed laparoscopically for completion splenectomy following partial splenectomy as well as repeat laparoscopy for missed accessory spleens.

A recent report cites an overall complication rate of 22% in patients with sickle-cell disease compared with 11% for all patients undergoing laparoscopic splenectomy.

The same report noted a zero incidence of both pancreatitis and surgical site infection for laparoscopic splenectomy.

SPSE 1

Question 32

Whether performing an open or laparoscopic splenectomy the basic steps of the operation remain the same. Which of the following statements is incorrect regarding the technical aspects of paediatric splenectomy?

A Right-side down or partial right-side down facilitates suspension of the spleen from its superolateral attachments.

B By first dividing the lienocolic and gastrocolic ligaments one frees the splenic flexure of the colon and gains access to the lesser sac.

C Leaving the lienophrenic ligament intact allows for continued suspension of the spleen while carrying out the dissection and ligation of the short gastric and hilar vessels.

D Division of the lienogastric ligament with ligation of the short gastric vessels exposes the lienorenal ligament.

E The final stage of the operation includes division of the lienophrenic ligament followed by ligation of the splenic vessels near the hilum of the spleen.

Answer 32

E

The final stage of the operation involves ligation of the splenic vessels followed by division of the remaining avascular superolateral attachments. one of the keys to the operation is to leave these attachments intact until the ligation of all the splenic vessels is complete to avoid having the spleen fall into the field of dissection.

SPSE 1

Question 33

Which of the following statements is true regarding overwhelming post-splenectomy infection (OPSI)?

A In vaccinated patients, most cases of OPSI occur within 1 month of splenectomy.

B Patients at the highest risk for OPSI are 6–10 years old at the time of splenectomy.

C The most common pathogen in all age groups is Haemophilus influenzae.

D The incidence of OPSI drops dramatically if splenectomy is performed after the age of 5 years.

E Early recognition and initiation of broad- spectrum antibiotic therapy does not improve outcomes.

Answer 33

D

Existing data show a dramatic increase in the incidence of oPSI when splenectomy is performed in patients <5 years old compared with patients >5 years old (as high as 5% in some studies compared with <1%).

mortality in documented cases of oPSI approach 50% in paediatric populations. In non-vaccinated patients oPSI frequently occurs within the first few weeks following splenectomy.

In vaccinated individuals, however, oPSI most frequently occurs 2–3 years postoperatively.

The most common pathogen is Streptococcus pneumoniae in all age groups (50%–90% of all cases of oPSI). H. influenzae and Neisseria meningitidis are the two other encapsulated organisms most commonly associated with oPSI.

Patient and parent education to seek medical attention at the first signs of infection, followed by prompt initiation of broad-spectrum antibiotics, is the most effective management strategy.

The most common signs of oPSI include fever, chills, general malaise and rigors leading to rapid deterioration with or without the overt signs of meningitis and or pneumonia.

SPSE 1

Question 34

Which of the following is false regarding immunisation in splenectomised patients?

A Current guidelines recommend giving the following vaccines up to 1 month prior to elective splenectomy: 23-valent pneumococcal vaccine, H. influenzae type b conjugate vaccine, and the meningococcal polysaccharide vaccine.

B The majority of OPSI cases today occur in patients who were not vaccinated postoperatively.

C Recent data shows that in splenectomies performed for trauma, postoperative vaccines are given to patients 95% of the time before they leave the hospital.

D Most immunocompetent splenectomy patients will show a greater than twofold rise in antibody titres within 2 weeks of vaccination.

E There are no strong data to support or refute the need for revaccination.

Answer 34

C

Studies suggest that patients undergoing urgent/emergency splenectomy receive their recommended postoperative vaccinations approximately 10%–75% of the time and that the majority of contemporary cases of oPSI occur in individuals who have not been properly vaccinated.

There are no strong data to support revaccination; however, given the relatively high risk of developing oPSI in young children many healthcare providers recommend revaccination after 5 years in children 10 years or younger.

SPSE 1

Question 35

Which of the following statements is true regarding the use of antibiotic prophylaxis in children following splenectomy?

A There is no strong evidence to support or refute the use of prophylactic antibiotics in splenectomised patients.

B There is strong evidence to support the use of lifelong daily antibiotic prophylaxis in all children following splenectomy.

C There is strong evidence to support the use of ‘as needed’ penicillin, to be taken by the patient at the first sign of infection.

D There is strong evidence to support the use of daily antibiotic prophylaxis for 2 years following splenectomy in all children and for 5 years in children with sickle-cell disease.

E There are strong data to support the use of daily antibiotic prophylaxis for 6 months followed by ‘as needed’ penicillin thereafter in all children undergoing splenectomy.

Answer 35

A

There are no definitive evidence to support or oppose the use of prophylactic antibiotics in splenectomised children.

Given that all children are at relatively high risk for developing oPSI, most haematologists and surgeons recommend at least a 6-month to 2-year course of daily penicillin prophylaxis.

SPSE 1