Incidental Splenectomy: Early and Late Postoperative Complications Peter Klaue, MD, Wiirzburg, West Germany Peter Eckert, MD, Wiirzburg, West Germany Ernst Kern, MD, FACS, Wtirzburg, West Germany
The increased rate of splenectomy performed by surgeons in all countries during the last 10 years has stimulated interest in the results of the procedure. This has led to a reevaluation of the complications of splenectomy. While some investigators [1,2] have compared the complication rate after upper abdominal surgery and additional splenectomy with the risk of identical surgical procedures without splenectomy, others [3-61 have compared the complication rate after splenectomy for different indications. Both groups found a high rate of morbidity and mortality after incidental splenectomy. However, only a few studies of the long-term sequelae of splenectomy have been presented [7,8]. Therefore, the following investigation was undertaken to examine the complication rate and long-term changes after incidental splenectomy as compared with splenectomy for other indications. Material and Methods The charts of all patients who underwent splenectomy at the University Hospital of Wiirzburg during the years 1964 to 1977 were evaluated retrospectively for indications and complications. The outcome in 155 patients 1.5 to 10 years after splenectomy could be explored. An extensive history was taken in 93 patients concerning 54 symptoms possibly related to loss of the spleen. In 96 patients 18
laboratory variables including the immunoglobulins and humoral antibodies could be examindd. Results
From 1964 to 1977 a total of 542 splenectomies were performed at our institution. Altogether, the From the Chirurgische Universitllsklinik Wlirzburg, Wurzburg. West Germany. Reprint requests should be addressed to Peter Klaue, MD, Chirurgische Universittitsklinik Wurzburg, Josef-Schneider-Strasse 2, 8700 Wtirzburg. West Germany.
296
frequency of splenectomy has increased more than 10 times (Figure 1). In 242 patients removal of the spleen became necessary during surgery for gastrointestinal disease. On 175 occasions surgery was performed for malignant lesions and in 67 for benign lesions. In the first group splenectomy was performed for technical reasons in 167 patients (95.4 per cent) and because of surgical trauma in 8 patients (4.6 per cent). In the group with benign disease surgical trauma to the spleen was significantly more frequent since 24.patients (35.8 per cent) required additional splenectomy due to iatrogenic injury, whereas 43 patients (64.2 per cent) had the spleen removed for technical reasons. Forty-four patients required splenectomy for hematologic disease, 106 for Hodgkin’s disease (staging laparotomy), 132 for blunt abdominal trauma, and 18 for other indications. The primary surgical procedures most frequently complicated by additional incidental splenectomy were vagotomy, gastric resection, and pancreatic resection in patients with benign disease and gastric resection, pancreatectomy, and left hemicolectomy in patients with malignant disease. For example, during 702 vagotomies in the years 1969 to 1977,25 splenectomies were performed (3.6 per cent). During this procedure, which in over 90 per cent was selective proximal vagotomy, 16 patients lost their spleen after surgical trauma and 9 for technical reasons, mainly severe adhesions from previous gastric surgery. The main complications after splenectomy were bronchopneumonia, pleural effusion, subphrenic abscess, and disturbed wound healing. The highest rate of morbidity and mortality was seen in the group with malignant lesions followed by the group with benign gastrointestinal disease and the trauma group, whereas the lowest rate was seen in the 106 patients with splenectomy during a staging procedure for Hodgkin’s lymphoma (Table I). For in-
The American Journal of Surgery
Incidental Splenectomy
420
Figure 1. Annual rates d sph?nectomy for various indications. GI = gastrointestinal.
Q’lYbL
65 66 67 68 69 70 71 72 73 74 75 76 77
stance, 10 of 13 pulmonary embolisms occurred in patients with gastric or pancreatic lesions and none in the group with Hodgkin’s disease. In the course of our investigations concerning the late sequelae of splenectomy, 37 patients with gastrointestinal cancer were rep&ted to be dead by the referring physicians. The next highest rate of late deaths was seen in the group with Hodgkin’s disease (Table II). In both groups death was caused by the primary disease. In 96 patients, among whom were 12 with malignant and 15 with benign gastrointestinal disease, 39 with trauma and 30 with Hodgkin’s disease, 18 laboratory studies, including hemoglobin, red blood cell count, white blood cell count, basal sedimentation rate, diffuse blood smear, platelets, fibrinogen, alkaline phosphatase, serum glutamic oxaloacetic and pyruvate transaminase, iron, copper, urea, serum creatinine, IgA, IgG, IgM, and humoral antibodies, did not show any significant changes in all groups. The normal values of the immunoglobulins IgA, IgG, and IgM as well as a normal humoral antibody response in the Epstein-Barr virus capsid antigen-antibody reaction have to be emphasized.
TABLE I
Comparative Rates ( % ) of Principal Complications After Splenectomy
Malignant Benign Complication
Disease (No. = 175)
Disease (No.= 67)
Trauma (No. = 132)
Hodgkin’s Disease (No. = 106)
Pneumonia Pleural effusion Subphrenic abscess Disturbed wound healing Pulmonary embolism
53.7 47.4 16.6 18.3 8.0
31.3 35.8 6.0 7.5 4.3
21.3 28.0 0 5.3 2.7
2.8 0 1.8 2.8 0
Mortality
30.9
25.4
29.2
0.9
Volume138,August1979
,x(q* lo5!
1964 65 ti
~
. . . . . . . . . . . .
07 b!
69 70 71 72 73 74 75 76 77
;q.:~.s.{.:$ .. 1
..~..“.
. . . . . . . . . . . ..!....... Platelets
. . . . . ..I..... I I
. . . . . . ..I.............. I I
it!
c L t
Figure 2. Platelet count in 93 patients 1.5 to 10 years after splenectomy. GI = gastrointestinal.
As one example, the behavior of the platelet count is illustrated in Figure 2, showing practically all values within the normal range in all groups 1.5 to 10 years after splenectomy. The well known temporary increase in platelet count could no longer be found at that time. This may further be documented by the continuous: profile of the thrombocytes in 30 patients with Hodgkin’s disease over 20 months (Figure 3). There is an important increase in the platelets during the first month but normal values from tlie second month on. Ninety-three patients could be interviewed concerning the 54 symptoms that were related to loss of the spleen [7,8]. They were specifically questioned regarding these symptoms and their main complaints were as follows: physical weakness, 41.9 per cent;
TABLE II
Late Postoperative Deaths 1.5 to 10 Years After Splenectomy
Data
Malignant Gastrointestinal Disease
Benign Gastrointestinal Disease
No. of deaths Age (yr) at operation Survival time (yr)
37 60.1 0.9
2 55.5 2.1
Trauma 0 ...
Hodgkin’s Disease 5 30.4 1.3
297
Klaue et al
Figure 3. Monthly p/ate/et count in 30 patients w/th Hodgkin’s disease after splenectomy. preop = preoperative/y.
did not report any changes, the group aged 40 to 50 years showed a maximum of symptoms that they thought were caused by the pperation. The highest rate of complaints was seen in the groups with incidental splenectomy and the lowest in the group with trauma. Only 6.5 per cent complained about an increased susceptibility to infections unknown to them before surgery. Comments
intolerance to alcohol, 40.0 per cent; mental weakness, 20.4 per cent; abdominal pain, 19.4 per cent; weight loss 16.1 per cent; disturbed sleep, 16.1 per cent; nervousness, 12.9 per cent; increased sweating, 12.9 per cent; fever, 9.7 per cent; impaired wound healing, 7.5 per cent; increased rate of infection, 6.5 per cent. Physical and mental weakness, intolerance to alcohol, and abdominal pain were mentioned most frequently. A comparison of the principal late symptoms after splenectomy for different indications showed a distribution somewhat similar to the frequency of the early postoperative complications (Table III). Symptoms generally lasting more than 6 months after surgery remained unchanged thereafter. The complaints were furthermore related to the age of the patient. While those under 20 years of age
TABLE III
Comparative Frequency (%) of Principal Complaints 1.5 to 10 Years After Splenectomy for Varlous Indications
Complaint Physical weakness Mental weakness Nervousness increased infections Intolerance to alcohol
TABLE IV
Malignant Disease (No. =
Benign Disease (No. =
Trauma (No. =
Hodgkin’s Disease (No. =
13)
14)
39)
11)
69.2 46.2 38.5 15.4 50.0
71.4 26.6 28.6 21.4 36.4
35.9 30.8 23.1 25.6 50.0
61.6 18.2 27.3 9.1 25.0
Comparative Review of the Literature Concerning the Rate of Incidental Splenectomy
Author Daoud et al [ 31 Hodam [5] Olsen and Beaudoin [ 701 Slater [ 7I] MC Kinnon et al [ 61 Fabri et al [ 41 Roy and Geller [Z] Cioffirdet al [ 71 Danforth and Thorbjarnasson [ 91 Klaue et al .
298
There has been a steady increase in the number of splenectomies performed in surgical centers all over the world. Some possible reasons for this development are: (1) the rising incidence of extended upper abdominal cancer surgery with en bloc resection including the sple’en; (2) more frequently performed operations such as the Nissen procedure for hiatal hernia and selective proximal vagotomy leading in some patients to inadvertent injuries to the spleen; (3) the increase in high velocity accidents leading to splenic rtipture after blunt abdominal trauma; (4) routine staging laparotomy and splenectomy for Hodgkin’s disease or other malignant lymphomas. In most series incidental splenectomy for techtiical reasons or surgical trau?a represents the greatest single indication (Table IV). The high risk of this additional procedure has been pointed out by several investigators [1,2,4,9,10], who all thought that incidental splenectomy added considerably to morbidity in these patients. Although there was not always a clear distinction between unnecessary surgical injury and inevitable removal of the spleen for technical reasons, it did not seem to make any difference. The primary procedures most ffequently complicated by splenectomy were gasttic‘ resection [5,9], vagotomy [1O,ll],‘or resection of the colon [1,2]. Most reports [1,3,5,6,11] mention pulmonary complications such as pleural effusion,’ atelecfasis, and pneumonia as the leading cause of prolonged hospitalization or even death. Only ‘Danforth and
Year
No. of Splenectomies
Incidental Splenectomy
Surgical Trauma
1966 1970 1970 1973 1973 1974 1974 1976 1976 1978
106 310 584 50 406 1944 158 237 981 542
34 121 288 19 163 556 65 it&
24 71 121 17
10 50 167 2
. .
.
‘34
‘ii
. 39 ..
. .
242
32
210
Technical Reasons
The American Journal of Surgery
Incidental Splenectomy
Thorbjarnarson [9] and Olsen and Beaudoin [IO] observed wound infection, particularly subphrenic abscess, as the most frequent complication. In studies comparing complication rates after splenectomy for different indications [1,4-61, the lowest morbidity was uniformly observed after simple splenectomy for either isolated trauma or hematologic disorders. Thus, Fabri et al [4] report a complication rate of 11 per cent after splenectomy for primary hypersplenism and 13.5 per cent for staging laparotomy in Hodgkin’s disease. Hodam [5] found a 2.5 per cent mortality after splenectomy for hematologic disorders. Fabri et al [4] further mention a 5 per cent mortality from isolated splenic rupture in abdominal trauma, increasing threefold in patients with multiple abdominal and retroperitoneal injuries. At the same time in their series there was a 14 per cent mortality and 44 per cent complication rate for incidental splenectomy. The corresponding rates were 15.1 per cent and 38.9 per cent in the series of Danforth and Thorbjarnarson [9] and 8 and 71 per cent in that of Cioffiro et al [I]. Comparing the morbidity and mortality after gastrointestinal surgery alone with that in the group in which additional splenectomy was necessary, Cioffiro et al [I] and Roy and Geller [2] believed that their rates were definitely increased in the second group. For instance, in the series of Cioffiro et al [I] the rate of complications (including prolonged fever and atelectasis) of 50 and 29 per cent in two groups of 38 patients each, in whom vagotomy and colectomy, respectively, were performed increased to 72 per cent in 38 patients in whom splenectomy was added to one of these two procedures [I]. In addition to the early postoperative morbidity and mortality of splenectomy, there are some definite late changes due to loss of the spleen that have rarely been taken into consideration in the surgical literature except for the increased risk of serious infections in children under 5 years of age [12,13]. Recently Robinette and Fraumeni 181,examining the outcome of 740 veterans of the 1939-1945 war subjected to splenectomy for trauma, found a significantly excessive mortality from pneumonia and ischemic heart disease. These data, however, must be confirmed by further studies. Begemann and Rastetter [7] interviewed 310 patients who also had traumatic loss of the spleen and who had symptoms possibly related to the lack of the organ. Seventy-seven of these patients principally complained of general symptoms such as nervousness, fatigue, increased sweating, and circulatory disturbances. Other late changes were increased physical weakness and intolerance to alcohol not observed before splenectomy. They stated
Volume 138, August 1979
furthermore that these symptoms disappeared after months to years in younger patients, whereas the elderly did not tolerate the loss of the spleen as well. Concerning late changes of laboratory variables they mentioned the increase in the white blood cell count, especially the lymphocytes and platelets, as well as a transient decrease in IgM in some patients. There were no comparative studies in these long-term sequelae after splenectomy for other indications. Our results confirm the significance of incidental splenectomy during gastrointestinal surgery. As in the majority of reported series vagotomy and gastric resection were the principal primary procedures to be complicated by loss of the spleen. As reported by others, incidental splenectomy had the highest morbidity and mortality compared with other indications such as abdominal trauma or Hodgkin‘s disease. In contrast to other studies, we separated patients with incidental splenectomy for gastrointestinal malignant disease from those with benign disease and as expected found a significantly higher rate of complications in patients with malignant disease. From our experience and that of other investigators we confirm the editorial comment of Zollinger in the report of Cioffiro et al [I] which emphasizes that a patient can well lose the spleen without undue concern but that the addition of splenectomy to other procedures is associated with an increase in complications. To this we may add that this increase is closely related to the primary disease of the patient and to the extent of the surgical procedure. The same is true for the frequency of the principal late complaints after splenectomy. Although confirming the observations of Begemann and Rastetter [ 71 after loss of the spleen from abdominal trauma, we found even more frequent complaints about the corresponding symptoms after incidental splenectomy. Of the patients with malignant disease 21 per cent had already died of the primary disease. However, there was no significant difference in the frequency of late symptoms among survivors with gastrointestinal cancer and those with benign disease. The high rate of patients reporting physical weakness after staging procedures for Hodgkin’s lymphoma is certainly due to the subsequent specific treatment with either radiotherapy or cytostatic drugs. The relatively high rate of complaints in patients with trauma may be explained by the fact that many of these patients receive financial compensation from insurance companies. However, the complaints of patients with Hodgkin’s disease and especially those with trauma are still so frequent as to indicate some specific effect due to loss of the
299
Klaue et al
spleen. Thus, the high rate of late symptoms after incidental splenectomy can only partially be explained by the effect of the primary disease and the extent of the surgical procedure, especially if the similar behavior of patients with malignant disease and those with benign disease is considered. The complete lack of late changes in the different laboratory variables confirms the statement of Begemann and Rastetter [7] that findings were inconsistent in this respect. The normal values of the immunoglobulins and the normal function of the humoral antibody response may explain why only 6.5 per cent of our patients reported an increased susceptibility to infections after splenectomy. In conclusion we must confirm the increased rate of splenectomy incidental to gastrointestinal surgery with considerable early morbidity and mortality. Laboratory evaluations did not reveal any hard data indicating specific long-term sequelae due to loss of the spleen. However, there were many general symptoms that cannot exclusively be attributed to the.primary disease or ‘the extent of the surgical procedure. Summary
Of 542 splenectomies performed from 1964 to 1977, 242 were incidental to gastrointestinal surgery. The highest rate of complications was observed in these patients as opposed to those who underwent splenectomy for trauma or Hodgkin’s disease. Eighteen laboratory studies did not show significant changes
300
1.5 to 10 years postoperatively in 96 patients. Ninety-three patients questioned because of late symptoms had the highest rate of complaints after incidental splenectomy. Acknowledgment: We appreciate the kind assistance of Drs. Gunzer and Niirnberger in performing the laboratory examinations. Referencw 1. Cioffiro W, Schlin CJ, Gliedman ML: Splenic injury during abdominal surgery. Arch Surg 111: 167, 1976. 2. Roy M, Geller JS: Increased morbidity of iatrogenic splenectomy. Surg Gynecol Obstet 139: 392, 1974. 3. Daoud FS, Fischer DC, Hafner CD: Complications following splenectomy. Arch Surg 92: 32, 1966. 4. Fabri PJ, Metz EN, Nick WV, Zollinger RM: A quarter century with splenectomy. Arch Surg 108: 569, 1974. 5. Hodam RP: The risk of splenectomy. Am J Surg 119: 709, 1970. 6. MC Kinnon WMP, Sanders HS, Zamora LF, Marion L: Splenectomy: indications, results and complications in 406 patients. Am Surg 39: 72, 1973. 7. Begemann H, Rastetter J: Folgen und gutachtliche Bewertung dei Milzentfernung. Chirurg 42: 494, 1971. 8. Robinette DC, Fraumeni JF: Splenectomy and subsequent mortality in veterans of the 1939-45 war. Lancet 127, 1977. 9. Danforth DN, Thorbjarnarson B: Incidental splenectomy. Ann Surg 183,124, 1976. 10. Olsen WE, Beaudoin DE: Surgical injury to the spleen. Surg Gynecol Obstet 131: 57, 1970. 11. Slater H: Complications of splenectomy. Am Surg 39: 121, 1973. 12. Ein SH, Shandling B, Simpson IS, Stephens CA, Bandi SK, Biggar WD; Freedman MH: The morbidity and mortality of splenectomy.in childhood. Ann Surg 185: 307, 1977. 13. Eisenberg BL, Andrassy RJ. Haff RC, Ratner JA: Splenectomy in children. Am J Surg 132:. 720, 1976.
The American Journal of Surgery
The increased rate of splenectomy performed by surgeons in all countries during the last 10 years has stimulated interest in the results of the procedure. This has led to a reevaluation of the complications of splenectomy. While some investigators [1,2] have compared the complication rate after upper abdominal surgery and additional splenectomy with the risk of identical surgical procedures without splenectomy, others [3-61 have compared the complication rate after splenectomy for different indications. Both groups found a high rate of morbidity and mortality after incidental splenectomy. However, only a few studies of the long-term sequelae of splenectomy have been presented [7,8]. Therefore, the following investigation was undertaken to examine the complication rate and long-term changes after incidental splenectomy as compared with splenectomy for other indications. Material and Methods The charts of all patients who underwent splenectomy at the University Hospital of Wiirzburg during the years 1964 to 1977 were evaluated retrospectively for indications and complications. The outcome in 155 patients 1.5 to 10 years after splenectomy could be explored. An extensive history was taken in 93 patients concerning 54 symptoms possibly related to loss of the spleen. In 96 patients 18
laboratory variables including the immunoglobulins and humoral antibodies could be examindd. Results
From 1964 to 1977 a total of 542 splenectomies were performed at our institution. Altogether, the From the Chirurgische Universitllsklinik Wlirzburg, Wurzburg. West Germany. Reprint requests should be addressed to Peter Klaue, MD, Chirurgische Universittitsklinik Wurzburg, Josef-Schneider-Strasse 2, 8700 Wtirzburg. West Germany.
296
frequency of splenectomy has increased more than 10 times (Figure 1). In 242 patients removal of the spleen became necessary during surgery for gastrointestinal disease. On 175 occasions surgery was performed for malignant lesions and in 67 for benign lesions. In the first group splenectomy was performed for technical reasons in 167 patients (95.4 per cent) and because of surgical trauma in 8 patients (4.6 per cent). In the group with benign disease surgical trauma to the spleen was significantly more frequent since 24.patients (35.8 per cent) required additional splenectomy due to iatrogenic injury, whereas 43 patients (64.2 per cent) had the spleen removed for technical reasons. Forty-four patients required splenectomy for hematologic disease, 106 for Hodgkin’s disease (staging laparotomy), 132 for blunt abdominal trauma, and 18 for other indications. The primary surgical procedures most frequently complicated by additional incidental splenectomy were vagotomy, gastric resection, and pancreatic resection in patients with benign disease and gastric resection, pancreatectomy, and left hemicolectomy in patients with malignant disease. For example, during 702 vagotomies in the years 1969 to 1977,25 splenectomies were performed (3.6 per cent). During this procedure, which in over 90 per cent was selective proximal vagotomy, 16 patients lost their spleen after surgical trauma and 9 for technical reasons, mainly severe adhesions from previous gastric surgery. The main complications after splenectomy were bronchopneumonia, pleural effusion, subphrenic abscess, and disturbed wound healing. The highest rate of morbidity and mortality was seen in the group with malignant lesions followed by the group with benign gastrointestinal disease and the trauma group, whereas the lowest rate was seen in the 106 patients with splenectomy during a staging procedure for Hodgkin’s lymphoma (Table I). For in-
The American Journal of Surgery
Incidental Splenectomy
420
Figure 1. Annual rates d sph?nectomy for various indications. GI = gastrointestinal.
Q’lYbL
65 66 67 68 69 70 71 72 73 74 75 76 77
stance, 10 of 13 pulmonary embolisms occurred in patients with gastric or pancreatic lesions and none in the group with Hodgkin’s disease. In the course of our investigations concerning the late sequelae of splenectomy, 37 patients with gastrointestinal cancer were rep&ted to be dead by the referring physicians. The next highest rate of late deaths was seen in the group with Hodgkin’s disease (Table II). In both groups death was caused by the primary disease. In 96 patients, among whom were 12 with malignant and 15 with benign gastrointestinal disease, 39 with trauma and 30 with Hodgkin’s disease, 18 laboratory studies, including hemoglobin, red blood cell count, white blood cell count, basal sedimentation rate, diffuse blood smear, platelets, fibrinogen, alkaline phosphatase, serum glutamic oxaloacetic and pyruvate transaminase, iron, copper, urea, serum creatinine, IgA, IgG, IgM, and humoral antibodies, did not show any significant changes in all groups. The normal values of the immunoglobulins IgA, IgG, and IgM as well as a normal humoral antibody response in the Epstein-Barr virus capsid antigen-antibody reaction have to be emphasized.
TABLE I
Comparative Rates ( % ) of Principal Complications After Splenectomy
Malignant Benign Complication
Disease (No. = 175)
Disease (No.= 67)
Trauma (No. = 132)
Hodgkin’s Disease (No. = 106)
Pneumonia Pleural effusion Subphrenic abscess Disturbed wound healing Pulmonary embolism
53.7 47.4 16.6 18.3 8.0
31.3 35.8 6.0 7.5 4.3
21.3 28.0 0 5.3 2.7
2.8 0 1.8 2.8 0
Mortality
30.9
25.4
29.2
0.9
Volume138,August1979
,x(q* lo5!
1964 65 ti
~
. . . . . . . . . . . .
07 b!
69 70 71 72 73 74 75 76 77
;q.:~.s.{.:$ .. 1
..~..“.
. . . . . . . . . . . ..!....... Platelets
. . . . . ..I..... I I
. . . . . . ..I.............. I I
it!
c L t
Figure 2. Platelet count in 93 patients 1.5 to 10 years after splenectomy. GI = gastrointestinal.
As one example, the behavior of the platelet count is illustrated in Figure 2, showing practically all values within the normal range in all groups 1.5 to 10 years after splenectomy. The well known temporary increase in platelet count could no longer be found at that time. This may further be documented by the continuous: profile of the thrombocytes in 30 patients with Hodgkin’s disease over 20 months (Figure 3). There is an important increase in the platelets during the first month but normal values from tlie second month on. Ninety-three patients could be interviewed concerning the 54 symptoms that were related to loss of the spleen [7,8]. They were specifically questioned regarding these symptoms and their main complaints were as follows: physical weakness, 41.9 per cent;
TABLE II
Late Postoperative Deaths 1.5 to 10 Years After Splenectomy
Data
Malignant Gastrointestinal Disease
Benign Gastrointestinal Disease
No. of deaths Age (yr) at operation Survival time (yr)
37 60.1 0.9
2 55.5 2.1
Trauma 0 ...
Hodgkin’s Disease 5 30.4 1.3
297
Klaue et al
Figure 3. Monthly p/ate/et count in 30 patients w/th Hodgkin’s disease after splenectomy. preop = preoperative/y.
did not report any changes, the group aged 40 to 50 years showed a maximum of symptoms that they thought were caused by the pperation. The highest rate of complaints was seen in the groups with incidental splenectomy and the lowest in the group with trauma. Only 6.5 per cent complained about an increased susceptibility to infections unknown to them before surgery. Comments
intolerance to alcohol, 40.0 per cent; mental weakness, 20.4 per cent; abdominal pain, 19.4 per cent; weight loss 16.1 per cent; disturbed sleep, 16.1 per cent; nervousness, 12.9 per cent; increased sweating, 12.9 per cent; fever, 9.7 per cent; impaired wound healing, 7.5 per cent; increased rate of infection, 6.5 per cent. Physical and mental weakness, intolerance to alcohol, and abdominal pain were mentioned most frequently. A comparison of the principal late symptoms after splenectomy for different indications showed a distribution somewhat similar to the frequency of the early postoperative complications (Table III). Symptoms generally lasting more than 6 months after surgery remained unchanged thereafter. The complaints were furthermore related to the age of the patient. While those under 20 years of age
TABLE III
Comparative Frequency (%) of Principal Complaints 1.5 to 10 Years After Splenectomy for Varlous Indications
Complaint Physical weakness Mental weakness Nervousness increased infections Intolerance to alcohol
TABLE IV
Malignant Disease (No. =
Benign Disease (No. =
Trauma (No. =
Hodgkin’s Disease (No. =
13)
14)
39)
11)
69.2 46.2 38.5 15.4 50.0
71.4 26.6 28.6 21.4 36.4
35.9 30.8 23.1 25.6 50.0
61.6 18.2 27.3 9.1 25.0
Comparative Review of the Literature Concerning the Rate of Incidental Splenectomy
Author Daoud et al [ 31 Hodam [5] Olsen and Beaudoin [ 701 Slater [ 7I] MC Kinnon et al [ 61 Fabri et al [ 41 Roy and Geller [Z] Cioffirdet al [ 71 Danforth and Thorbjarnasson [ 91 Klaue et al .
298
There has been a steady increase in the number of splenectomies performed in surgical centers all over the world. Some possible reasons for this development are: (1) the rising incidence of extended upper abdominal cancer surgery with en bloc resection including the sple’en; (2) more frequently performed operations such as the Nissen procedure for hiatal hernia and selective proximal vagotomy leading in some patients to inadvertent injuries to the spleen; (3) the increase in high velocity accidents leading to splenic rtipture after blunt abdominal trauma; (4) routine staging laparotomy and splenectomy for Hodgkin’s disease or other malignant lymphomas. In most series incidental splenectomy for techtiical reasons or surgical trau?a represents the greatest single indication (Table IV). The high risk of this additional procedure has been pointed out by several investigators [1,2,4,9,10], who all thought that incidental splenectomy added considerably to morbidity in these patients. Although there was not always a clear distinction between unnecessary surgical injury and inevitable removal of the spleen for technical reasons, it did not seem to make any difference. The primary procedures most ffequently complicated by splenectomy were gasttic‘ resection [5,9], vagotomy [1O,ll],‘or resection of the colon [1,2]. Most reports [1,3,5,6,11] mention pulmonary complications such as pleural effusion,’ atelecfasis, and pneumonia as the leading cause of prolonged hospitalization or even death. Only ‘Danforth and
Year
No. of Splenectomies
Incidental Splenectomy
Surgical Trauma
1966 1970 1970 1973 1973 1974 1974 1976 1976 1978
106 310 584 50 406 1944 158 237 981 542
34 121 288 19 163 556 65 it&
24 71 121 17
10 50 167 2
. .
.
‘34
‘ii
. 39 ..
. .
242
32
210
Technical Reasons
The American Journal of Surgery
Incidental Splenectomy
Thorbjarnarson [9] and Olsen and Beaudoin [IO] observed wound infection, particularly subphrenic abscess, as the most frequent complication. In studies comparing complication rates after splenectomy for different indications [1,4-61, the lowest morbidity was uniformly observed after simple splenectomy for either isolated trauma or hematologic disorders. Thus, Fabri et al [4] report a complication rate of 11 per cent after splenectomy for primary hypersplenism and 13.5 per cent for staging laparotomy in Hodgkin’s disease. Hodam [5] found a 2.5 per cent mortality after splenectomy for hematologic disorders. Fabri et al [4] further mention a 5 per cent mortality from isolated splenic rupture in abdominal trauma, increasing threefold in patients with multiple abdominal and retroperitoneal injuries. At the same time in their series there was a 14 per cent mortality and 44 per cent complication rate for incidental splenectomy. The corresponding rates were 15.1 per cent and 38.9 per cent in the series of Danforth and Thorbjarnarson [9] and 8 and 71 per cent in that of Cioffiro et al [I]. Comparing the morbidity and mortality after gastrointestinal surgery alone with that in the group in which additional splenectomy was necessary, Cioffiro et al [I] and Roy and Geller [2] believed that their rates were definitely increased in the second group. For instance, in the series of Cioffiro et al [I] the rate of complications (including prolonged fever and atelectasis) of 50 and 29 per cent in two groups of 38 patients each, in whom vagotomy and colectomy, respectively, were performed increased to 72 per cent in 38 patients in whom splenectomy was added to one of these two procedures [I]. In addition to the early postoperative morbidity and mortality of splenectomy, there are some definite late changes due to loss of the spleen that have rarely been taken into consideration in the surgical literature except for the increased risk of serious infections in children under 5 years of age [12,13]. Recently Robinette and Fraumeni 181,examining the outcome of 740 veterans of the 1939-1945 war subjected to splenectomy for trauma, found a significantly excessive mortality from pneumonia and ischemic heart disease. These data, however, must be confirmed by further studies. Begemann and Rastetter [7] interviewed 310 patients who also had traumatic loss of the spleen and who had symptoms possibly related to the lack of the organ. Seventy-seven of these patients principally complained of general symptoms such as nervousness, fatigue, increased sweating, and circulatory disturbances. Other late changes were increased physical weakness and intolerance to alcohol not observed before splenectomy. They stated
Volume 138, August 1979
furthermore that these symptoms disappeared after months to years in younger patients, whereas the elderly did not tolerate the loss of the spleen as well. Concerning late changes of laboratory variables they mentioned the increase in the white blood cell count, especially the lymphocytes and platelets, as well as a transient decrease in IgM in some patients. There were no comparative studies in these long-term sequelae after splenectomy for other indications. Our results confirm the significance of incidental splenectomy during gastrointestinal surgery. As in the majority of reported series vagotomy and gastric resection were the principal primary procedures to be complicated by loss of the spleen. As reported by others, incidental splenectomy had the highest morbidity and mortality compared with other indications such as abdominal trauma or Hodgkin‘s disease. In contrast to other studies, we separated patients with incidental splenectomy for gastrointestinal malignant disease from those with benign disease and as expected found a significantly higher rate of complications in patients with malignant disease. From our experience and that of other investigators we confirm the editorial comment of Zollinger in the report of Cioffiro et al [I] which emphasizes that a patient can well lose the spleen without undue concern but that the addition of splenectomy to other procedures is associated with an increase in complications. To this we may add that this increase is closely related to the primary disease of the patient and to the extent of the surgical procedure. The same is true for the frequency of the principal late complaints after splenectomy. Although confirming the observations of Begemann and Rastetter [ 71 after loss of the spleen from abdominal trauma, we found even more frequent complaints about the corresponding symptoms after incidental splenectomy. Of the patients with malignant disease 21 per cent had already died of the primary disease. However, there was no significant difference in the frequency of late symptoms among survivors with gastrointestinal cancer and those with benign disease. The high rate of patients reporting physical weakness after staging procedures for Hodgkin’s lymphoma is certainly due to the subsequent specific treatment with either radiotherapy or cytostatic drugs. The relatively high rate of complaints in patients with trauma may be explained by the fact that many of these patients receive financial compensation from insurance companies. However, the complaints of patients with Hodgkin’s disease and especially those with trauma are still so frequent as to indicate some specific effect due to loss of the
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spleen. Thus, the high rate of late symptoms after incidental splenectomy can only partially be explained by the effect of the primary disease and the extent of the surgical procedure, especially if the similar behavior of patients with malignant disease and those with benign disease is considered. The complete lack of late changes in the different laboratory variables confirms the statement of Begemann and Rastetter [7] that findings were inconsistent in this respect. The normal values of the immunoglobulins and the normal function of the humoral antibody response may explain why only 6.5 per cent of our patients reported an increased susceptibility to infections after splenectomy. In conclusion we must confirm the increased rate of splenectomy incidental to gastrointestinal surgery with considerable early morbidity and mortality. Laboratory evaluations did not reveal any hard data indicating specific long-term sequelae due to loss of the spleen. However, there were many general symptoms that cannot exclusively be attributed to the.primary disease or ‘the extent of the surgical procedure. Summary
Of 542 splenectomies performed from 1964 to 1977, 242 were incidental to gastrointestinal surgery. The highest rate of complications was observed in these patients as opposed to those who underwent splenectomy for trauma or Hodgkin’s disease. Eighteen laboratory studies did not show significant changes
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1.5 to 10 years postoperatively in 96 patients. Ninety-three patients questioned because of late symptoms had the highest rate of complaints after incidental splenectomy. Acknowledgment: We appreciate the kind assistance of Drs. Gunzer and Niirnberger in performing the laboratory examinations. Referencw 1. Cioffiro W, Schlin CJ, Gliedman ML: Splenic injury during abdominal surgery. Arch Surg 111: 167, 1976. 2. Roy M, Geller JS: Increased morbidity of iatrogenic splenectomy. Surg Gynecol Obstet 139: 392, 1974. 3. Daoud FS, Fischer DC, Hafner CD: Complications following splenectomy. Arch Surg 92: 32, 1966. 4. Fabri PJ, Metz EN, Nick WV, Zollinger RM: A quarter century with splenectomy. Arch Surg 108: 569, 1974. 5. Hodam RP: The risk of splenectomy. Am J Surg 119: 709, 1970. 6. MC Kinnon WMP, Sanders HS, Zamora LF, Marion L: Splenectomy: indications, results and complications in 406 patients. Am Surg 39: 72, 1973. 7. Begemann H, Rastetter J: Folgen und gutachtliche Bewertung dei Milzentfernung. Chirurg 42: 494, 1971. 8. Robinette DC, Fraumeni JF: Splenectomy and subsequent mortality in veterans of the 1939-45 war. Lancet 127, 1977. 9. Danforth DN, Thorbjarnarson B: Incidental splenectomy. Ann Surg 183,124, 1976. 10. Olsen WE, Beaudoin DE: Surgical injury to the spleen. Surg Gynecol Obstet 131: 57, 1970. 11. Slater H: Complications of splenectomy. Am Surg 39: 121, 1973. 12. Ein SH, Shandling B, Simpson IS, Stephens CA, Bandi SK, Biggar WD; Freedman MH: The morbidity and mortality of splenectomy.in childhood. Ann Surg 185: 307, 1977. 13. Eisenberg BL, Andrassy RJ. Haff RC, Ratner JA: Splenectomy in children. Am J Surg 132:. 720, 1976.
The American Journal of Surgery
