postsplenectomy infection decreased over time with an overall hazard ratio of 4.6-fold between 90 days

and 365 days after splenectomy and 2.5-fold for more than 365 days after splenectomy.182 There is

definite evidence of that use of vaccination decreases this risk of infection. Another large national study

from Scotland showed that the overall rate of first severe infection was 7.0 per 100 person-years after

splenectomy. In that subgroup of patients who had a severe infection, the rate of subsequent infections

was significantly increased and the second severe infection rate was 44.9 per 100 person-years and a

third episode of severe infection was 109.3 per 100 person-years.183 This would indicate that the

patients who had significant postsplenectomy sepsis should be observed very closely and counseled on

seeking medical attention for any sign of any infectious process. There are also accumulating data with

the increased trend particularly in blunt splenic trauma and other hematologic diseases for spleenpreserving procedures such as splenorrhaphy or partial splenectomy, that there are still increased risks

of infection in these patients that are comparable with those of patients who have a complete

splenectomy.184

A recent survey of practicing surgeons indicated patterns of utilization of immunization for

splenectomy patients. Of the practices, essentially universally 99.2% of active surgeons said they do

immunize patients they treat with splenectomy.185 Virtually every one administers vaccine to

pneumococcus. Most (72.4%) practicing surgeons routinely use a Haemophilus influenzae type vaccine,

62.8% give meningococcal vaccination, and 56.7% utilize all three vaccines. A small portion of

practicing surgeons immunize their patients who have splenorrhaphy (15.7%) and a very small

proportion immunize patients who have splenic injury but who are managed nonoperatively. Current

guidelines would be that all patients with elective splenectomies should have prophylactic immunization

prior to surgery whereas patients who have unexpected splenectomy should have immunization on or

after 14 days after the procedure. All patients should get pneumococcal vaccines and patients at high

risk should have vaccination for H. influenzae and meningococcus.185,186 Revaccinations may be

considered at appropriate time intervals, taking into account the age and immune status of the patient,

although these are not typically needed for H. influenzae.

For decades, it has been known that patients after splenectomy are susceptible to infections as

described earlier. It has only recently been realized that there are a variety of vascular complications

that occur to a greater degree in patients with splenectomy than in cohort of abdominal surgery patients

without splenectomy.187 These include arterial thrombosis, venous thrombosis, and pulmonary artery

hypertension. Data from patients with hereditary spherocytosis who have undergone splenectomy

report between a 5.6- and 7.2-fold increase in ischemic heart disease compared with patients who do not

have splenectomy. The most marked finding for arterial events occurs in thalassemia in which patients

who undergo splenectomy have a 20-fold increase in arterial atherosclerosis of arterial structures. Acute

portal venous thrombosis is reported after splenectomy in one series up to 4.8% for a variety of

patients.188 It is clearly seen more commonly after splenectomy in patients with cirrhosis and

hypersplenism where the rate of portal vein thrombosis (PVT) may be 30% to 40%.189 A recent study

suggests that splenic volume may predict the likelihood of patients with cirrhosis developing PVT, with

spleen volumes >450 mL associated with significantly increased risk for PVT.190 Prophylactic

anticoagulation may be considered in these high-risk patients.191 Moreover, while some earlier study

data suggested a higher incidence of PVT in patients undergoing laparoscopic surgery when

postoperative imaging is routinely performed,192 there does not appear to be a clear association

between the surgical approach (laparoscopy vs. open) of splenectomy and the incidence of clinically

apparent PVT, despite concerns of pneumoperitoneum and perhaps more commonly longer splenic vein

stump length in laparoscopic cases leading to a more thrombotic state in the portal venous system. In

one recent study of 162 splenectomised patients, the incidence of PVT was 1 of 60 (1.7%) in open

splenectomy patients and 3 of 102 (2.9%) in laparoscopic splenectomy patients.193 The incidence of

venous thrombosis may go beyond the mesenteric/portal venous system and include deep venous

thrombosis in the pelvis and lower extremities as well as subsequent pulmonary embolus to a much

greater extent. This also has led to increased evidence of pulmonary arterial hypertension in patients

after splenectomy for hematologic diseases. A large retrospective analysis of 375,748 patients

undergoing abdominal surgery found patients undergoing splenectomy to be at highest risk for venous

thromboembolic events.194

The pathogenesis of these vascular events after splenectomy is likely multifactorial.187 They may

involve some elements of hypocoagulative state due to altered platelet function and number. There may

be some disturbances in vascular epithelium related to the other blood elements that are altered after

splenectomy. The spleen moreover may also play an important role in clearing certain cellular

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microparticles that may have a prothrombotic effect, such as phosphatidyl-serine.195 There is also

evidence that there may be some changes in lipid profiles after splenectomy that would promote

atherosclerosis and thrombosis.187 Although these vascular events clearly are increased in frequency,

they nonetheless occur in a minority of patients but would argue toward using splenectomy

conservatively particularly in certain high-risk individuals such as patients with thalassemia.

Finally, splenectomy may increase the risk of development of certain malignancies. In one recent

study of 8149 cancer- free American veterans who had undergone splenectomy with long-term followup, there was an increase noted in various both solid and hematologic malignancies, many of these

occurring years following surgery.25 Other studies have shown less consistent associations of

splenectomy with subsequent malignancy; one Danish and one Swedish study found an increased

incidence of malignancy among patients undergoing splenectomy only for nontrauma-related

etiologies.142,196 Further study is needed to define the precise association between splenectomy and

subsequent malignancy.

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