Safety Of Splenectomy In Hematological Diseases
Authors: Moragues Martinez Maria Cristina , Hurst Kati , Mingot Castellano Maria Eva , Ruiz Jose Coin , Prieto Sanchez Maria Elisa , Mancha Isabel Vidales , Pareja Macarena Ortiz , Espeso de Haro Manuel , Bautista Ojeda Maria Dolores , Heiniger Mazo Ana Isabel 
Published: October 2019

Introduction
Splenectomy is a diagnostic tool and an option of treatment for some diseases. After splenectomy, the risk of infection is not clear in adult populations, therefore designing and implementing the best prevention and management strategys is of upmost importance. Splenectomized patients also have an increased risk of venous thromboembolism. Perioperative anticoagulant prophylaxis with subcutaneous heparin should be administered to all patients and in high risk patients prolonged anticoagulant prophylaxis (at least 4 weeks) should be used. There is not much information about infection and thromboembolic risk after splenectomy in hematological patients.

Aims
To evaluate the efficacy and safety of splenectomy in adult patients with hematological diseases.

Methods
Splenectomies performed in our hospital between March 2003 and February 2013 in adults with hematological disease were reviewed. Diagnosis, age at time of splenectomy, cardiovascular risk factors (CVRF), immunosuppressive therapy, type of surgery, immunization against encapsulated bacteria, antibiotic and thromboembolic prophylaxis, serious infections and thromboembolic events were considered. Severe infection was defined as one that required emergency consultation or admission and antibiotic, antiviral and antifungal treatment.

Results
A total of 65 splenectomies were performed in patients with hematologic disorders. Underlying diseases were primary immune thrombocytopenia (ITP) in 24 patients, splenic marginal zone lymphoma in 13, other lymphoproliferative disorders in 13, microspherocytosis in 10, Evans syndrome (ES) in 2 and immune hemolytic anemia (AIHA) in 2.
The median age at splenectomy was 51 years old (r, 18-78). A laparoscopic procedure was performed in 83% of patients, with a median admission duration of 5 days (r, 3-33) vs 10 days (r, 5-12) for laparotomic procedures.
All patients received prior immunization although in two cases the administration was postoperative. Twenty eight percent of subjects received steroids for ≥ 2 months prior to surgery and 12.5 % rituximab.
Fifty percent of patients suffered a severe infection after a median of 16 months (r, 0-84 months), 75% of which received antibiotic prophylaxis. There was no difference in the incidence of infection between different hematological diagnoses.
The most frequent locations were respiratory and urinary infections, 27.1% and 18.6% respectively. The most commonly isolated germs were Candida, E.Coli, P. Aeruginosa, VEB and P.Mirabillis.
Six patients developed thrombotic events, after a median of 10 days (r, 1-93 days). Of these, 50% had not received thromboembolic prophylaxis. The locations were pulmonary thromboembolism (1), subclavian vein thrombosis (2), portal vein thrombosis (1) and stroke (2). We found no significant differences in the platelet count and cardiovascular risk factors in subjects with and without thromboembolic events.
There were 8 (12.3%) cases of exitus, 3 of which were due to infectious events (2 septic shock, 1 respiratory infection). After a median follow-up of 35 months (r, 1-106 months) 100% of AIHA and ES and 82.6% of PTI are in remission.

Conclusions
In our experience splenectomy is a safe and effective procedure and continues to have an important role in the management of certain hematological disorders. Due to sample size, it is difficult to draw conclusions on the impact of antibiotic prophylaxis maintenance, although, as in our series the risk of infection is present until 84 months after surgery, we believe prophylaxis should be maintained for at least 3 to 5 years. Furthermore, our results support the recommendations provided in the literature on thromboprophylaxis for at least 4 weeks after surgery.

Disclosures:
No relevant conflicts of interest to declare.