Friday, June 22, 2007

One Spleen...


The above is snapped off a page of the book that might have saved my life. Well, no. But it kept my mind off self-pity when I was in the waning months of my tour of duty in Vietnam. Rather than attending only to that part of the world which was within three feet of me, I could ponder the power of the human mind; could hope the stories therein weren't just chemical aberrations. (Likely, of course, they were.)

The book is "Be Here Now," by Ram Dass, formerly Richard Alpert PhD, associate of Tim Leary at Harvard; tripper on and contemplater of LSD. A friend sent it (the book, not the pharmaceutical) to me while I was serving my time. (Cool fact: all you had to do with mail to and from Vietnam soldiers was write "free" on the corner, and it got where it was aimed. I hope that's still true for the troops and their families.) The volume is divided into three parts, one of which is actually readable. In the snippet to which I refer, Ram Dass describes his first meeting, in India, with the man who would become his guru. Along with "how was the cookie?" (guess you'd have to read it), "Spleen. She died of spleen" still brings a smile when I think of it....

* * * * * *

Soon after I arrived in my current location, I was sent a patient in need of splenectomy. Neither for the first time nor the last, the operation proceeded in such a way that I plopped the organ in a pan about five or seven minutes after laying knife to skin. "Wow," said the scrub nurse. "Wow," said the anesthesiologist, turning dials and scrambling for drugs. Thanks again, Vic, I said to myself, giving homage to my most influential teacher of technique. "The spleen is a mid line organ, Dockie," he used to say, as he harassed me into quickly loosening it from its attachments to the diaphragm and pulling it toward me.

The spleen, you may properly infer, has a special place in my heart. Under it, actually. And a little to the left. Despite Vic's surgically relevant aphorism.


It's nice to have a spleen, but you can live without it. Put simply (and I'm a simple guy) that red-mahogany and spongy organ does two unrelated things: it acts as a giant lymph node, and it filters out aging blood cells. Absent the spleen, those functions can get carried on elsewhere, and so it is that people who lose their spleen, either from injury or because of various blood disorders, generally have no occasion to miss it. But the world is imperfect, so the previous statement is not always true. There is, in fact, an incidence of overwhelming and highly fatal infection in a small percentage of people who have been splenectomized; the good news is that the infections tend to be by organisms for which vaccinations are available. Those vaccines ought to be given in advance of a planned splenectomy, and soon after an unplanned one. And since infectious consequences seem more frequent in children, it's recommended by some (not universally, for various reasons) that kids who lose their spleens be given daily antibiotics for prophylaxis. Who, and how long: not agreed upon

The greatest risk is within the first two years after splenectomy. Some people give antibiotics for that interval; others till age 21; some advocate it for life. Much of the data are muddled by the fact that people lose their spleens for differing reasons: when it's removed for hematological reasons, the long-term risks are probably higher, since those people have remaining underlying pathology. Splenectomy for trauma has a higher risk of infection at the time of surgery (in part, I think, because of concomitant injuries to other organs) but lower long-term, compared to hematologic patients. Still, there's no doubt there are some risks. The only case of overwhelming post-splenectomy sepsis I ever saw was in a person who'd had it for hairy-cell leukemia. Never in a person with trauma.

The other potentially adverse consequence of splenectomy can be turned into a good thing: it's common after the operation to note a rise in platelets, those little packets of clotting paraphernalia that float in the bloodstream. Too many, and there's a risk of thrombosis (clots when you don't want them); too few, and there's risk of spontaneous or prolonged bleeding. In the condition known as ITP, for "idiopathic thrombocytopenic purpura," in which the platelet (thrombocyte) count can get dangerously low, splenectomy may be curative. That was always my favorite situation in which to see a patient needing the surgery, because, under the right circumstances, there was a pretty good chance it would work out well.

Among people with ITP who require treatment, the mainstay drug is prednisone (as you can read in the above ITP link, there are others, too). It's those people in whom it works well that I liked to see; and if that sounds like the words of a knife-happy surgeon, hear me out. Steroids like prednisone can be very effective, but, depending on dose, they can have significant side-effects. Some lucky people with ITP get their drugs, respond well, and it's over. Others, though, either require prolonged treatment with high doses, or they get a good response but recur whenever the drugs are stopped. At some point surgery becomes a consideration; and the good news is that response to drugs is quite a good predictor of response to surgery, which is why I liked to see those people. The news isn't as good -- the outcome much less certain -- when splenectomy is pursued as a last resort after all other treatments have failed.

In many cases when the platelet count is low in ITP, bleeding during or after surgery is not a great worry: the platelets that are present are young and sexy, and clotting is less affected than in other situations with comparably low platelet counts. Surgery proceeds apace, and it's rewarding to see the counts begin to rise immediately after surgery. In those more questionable situations -- very low counts with no response to medical treatment -- surgery is carried out with more drama: platelets at the ready in the OR, the splenic artery clamped as early as possible in the proceedings, after which the platelet infusion begins (the clamping keeps the new platelets from being gobbled by the spleen.) No five-minute job; great care is taken to avoid and to control the tiniest bleeders. I should also mention that it's not rare to have "accessory" spleens, little grape-oid items tucked in various abdominal locations, the failing to locate and extirpate which can lead to recurrence of the disease. Mostly, they're close to the spleen, so the search tends not to require dogs and flushers.

Residing high in the left upper abdomen, attached to the colon and the stomach as well as to the pancreas, kissing the left kidney, not far from the adrenal and stuck to the diaphragm, the spleen is anatomically more daunting on paper than in the flesh. Unless the organ is really huge, operating is usually straightforward; and yes, it's even quite amenable to the laparoscopic approach (takes a lot longer than five minutes to get it in the bucket, though). I think it has the makings of at least one more post. And we haven't yet talked much about ruptured spleens...

25 comments:

Lisa said...

I want to hear about the burst ones, too. Have you ever found any 'incidentalomas' on the nearby adrenal while you were in the neighborhood?

I'll tell you about my pit surgery scabs if you need a trade. ;) lol

Max X said...

Another fine post. Thank you, Dr. Schwab.

You make it sound so easy, I think I will try doing one later this weekend.

Xavier Emmanuelle said...

Wow --- what an amazing post Dr. Schwab. I learned more reading this one post than I've learned in weeks. Awesome!

enrico said...

As cool as this post was, I'm especially excited waiting to hear about the ruptured spleens. Did you ever do any splenectomies for heredetary spherocytosis? Off the top of my head, that's another slam-dunk indication for one, with reasonably good surgical outcome.

I absolutely LOVE the abd. graphic at the bottom. Excellent visual 3D presentation. If only the real thing was so nicely demarcated! :) The iliac bifurcations seem way too high, though; can they be found this way as part of normal anatomic variation? Thanks!

rlbates said...

Very nice. Thanks for sharing. Soldiers can write free on their letters home, but it doesn't always work that way to send it to them (http://usgovinfo.about.com/library/weekly/aatroopmail.htm)

Sid Schwab said...

enrico: you're right. I overlooked mention of hereditary spherocytosis, which is a clear indication for splenectomy, and for which I've done it a few times. Also very nice response. And you get to do a gallbladder too, usually.

Looking at the 3D image, it's not entirely accurate, but what looks like a bifurcation may not be, since the little "IVC" arrow is pointing to one "limb," suggesting the other is, maybe, some sort of mesenteric vein; by inference the division of the aorta at that same level might be trying to show a visceral branch. Or maybe it's a really short person. Besides, as we know, most cartoon figures only have three fingers. Inside, who knows?

Gallgizzard said...

I would like to hear what you say regarding the DX of ruptured spleen using ultrasound. I teach trauma ultrasound to physicians, and promote US as the first in line for hemoperitoneum. Also, the FDA is getting ready to OK ultrasound contrast for use in the abdomen and elsewhere. RE: the 3-D pic? that appears to be the superior mesenteric vein.
Peace, GG

Lynn Price said...

Sid, is the normal recuperation time still 4-6 weeks for a normal splenectomy? I have a character just itching for one, but I need to get her on a plane within three weeks. Is this possible?

Lynn Price said...

I need to get her on a plane three weeks after the surgery. Sorry...didn't make that clear.

Sid Schwab said...

lynn: it varies, and would depend in part on why and by what method the splenectomy was done. If for trauma, it was likely open, as opposed to laparoscopic. If the latter, the recovery would be less. And "recovery" is a sort of vague concept. Good as new, no fatigue, as if it never happened? For most any open abdominal operation it can be two or three months: healing work is going on for that long. To be able to do most anything, maybe feel a little tired, sore if over-doing it? Depending on the age and health of the person, three weeks would be possible. But most people would still feel less energy at that time, and if your character is running up and down mountains, or jumping around in buildings like the latest James Bond, after three weeks, she'd be beat. But flying on a plane ought to work out. I can accompany her if you like...

makeminetrauma said...

I am so happy to see the anatomy graphic. I scrubbed (and assisted for lack of another willing soul or second scrub)one right nephrectomy, and assisted a couple of weeks later on a lap, hand assisted, right nephrectomy. I research (or try to, time permitting) my cases the night before and found it extremely frusting not to be able to find a plate in my anatomy books relaying the intimacy shared between the spleen and the doudenum. Thank you!

P.S. Removal of a ruptured spleen is one of my favorite procedures! Even though as an assist I don't get to see much, my main job is exposure, exposure, exposure...Can't wait to read your take on it.

TBTAM said...

Great post, Dr Sid.

Sometimes I think I need a splenectomy - I have vented mine one too many times....

Anonymous said...

I had a splenectomy in 2003 because lymphoma was feared. It turned out that I had sarcoidosis. The surgeon missed an accessory spleen hiding behind the kidney. Can this little splenule take over any splenic function? I have stayed very well re infections etc since my splenectomy and only have the pneumonia shot every 5 years.

Sid Schwab said...

It is certainly possible; so it's good it was missed. How much function it will have is hard to say, but it's likely there'd at least be some.

Anonymous said...

Thanks, Dr S. Good to hear that I may in fact have a bit of splenic function. I do have what I imagine are adhesions/ scar tissue in the area my deceased spleen once inhabited, but I can live with that. Pity the drs at the Cleveland would not listen to me when I asked if I could have sarcoidosis. They were hell - bent on a dx of lymphoma and insisted the spleen had to be removed.They refused to check out the lungs, which would have given them a definitive answer. Turned out it did not, any more than the sarc in my lungs, liver or kidneys were a cause for removal. So, I became a study case and can only hope others don't become asplenic for the same reason.

Anonymous said...

So let me just ask, as somebody who had my spleen removed about 20 years ago (had been robbed, and the doctors said my body pumped so much adrenaline into my system that somehow the blood vessle(s) pulled out of the spleen, ending it's useful function), and has never paid any mind to missing it since that time, what kinds of things (and vaccines) should I be making sure I have had, to keep myself a little safer?

Sid Schwab said...

Well, that's a strange story; I can't imagine the physiology behind it. There are things that can cause spontaneous rupture, but I've never heard that one!!

The most important vaccine would be pneumovax, for the pneumonia bug. H. flu is another, especially for kids.

Never be Sick again said...

Hello doctor..

I will be having a splenectomy in July and I'm very nervous and scared about it. I never have surgery in my life. I am 44 years old female and always keeping up my healthy life style but for some unknown reason. The CT scan shown that I have lesion growing inside my spleen from a spot to 3.1cm in 2 years. I have been having 7 CT, 1 PET/CT and 1 MRI in the past 2 years. After reveiwing the recent CT, my surgeon determined that he will have to make about 3-6" incision in additional of 3 holes for laporascopic procedure so that he can take the whole spleen out through that incision. He gave me 2 options, 1 is to make an incision above the belly or he can make it on the bikini area to hide the scar. My question is, from your surgeon point of view. would it be more difficult to remote the spleen from bikini area than from the above belly button? I just don't want to add a complication by having him removed the spleen from the bikini area. The second question is, what will be the closing method use to close the incision? would it be glue or staple? From your experience, have you ever encountered the similar situation that I have with my spleen? I don't drink or smoke. I just don't know how on earth I have this lesion growing inside my spleen. The only thing that I see bad for me is that I have been on birth control pill for 11 years but I stopped taking it last year. So it sounds like I will have a partial open splenectomy. Any advices would be greatly appreciated. Thank you

Sid Schwab said...

It shouldn't make a difference which incision you choose: the spleen is gotten loose with the smaller incisions. Once it's free, the incision to remove it could be made anywhere.

Since there are several ways to close the skin, and choosing is generally a matter of personal preference, I can't guess how your surgeon will do it. But it's certainly something you should feel free to ask; same with the question you asked about incision placement.

Similarly, you should ask what possibilities are on the list after the studies you've had: a slow-growing lesion such as you describe could be any number of things, from infection to tumor. Anything I'd say, without the ability to see the results of the PET and MRI and CT scans would simply be a guess.

All of your questions are reasonable ones, and you certainly have a right to have them answered before you have your operation: you shouldn't feel reluctant to ask your surgeon.

Amy said...

Hello. That 3rd picture with the deudenum that says "technicalanimations.com" across it is very good and helped me study for anatomy. Did you create it yourself? Or where did you get it from? Do you have anymore pictures like it?

Sid Schwab said...

Like all the other images I've used, I just did an image search and downloaded it. Gray zone, I suppose.

lorkav said...

Was bopping around online looking at spleen/pancreas things because I was scrubbed on a distal pancreas/splenectomy a couple days ago. Couldn't see squat from my vantage point with surgeon and two residents , but got to peek here and there and feel-up the tumor. I loved your photo. I'm on the cusp of first assistant-ness ( even though the cusp is hard to get to - getting internship time with all the fellows and residents and PA students etc etc, is complicated .. ) , the attachments and anatomical locations are great to learn and memorize. P.S. I LOVE how you write. Very down to earth and funny. I've been in the O.R. 11 yrs. Wanna read all you have. THANKS !! Enjoyed this immensely. :))

Sid Schwab said...

Thank you very much! I love hearing that. And good luck in your career.

P.S. When I was an intern, holding hooks on a big case, one of the vascular surgeons asked me, Can you see all right, Sid? I said yes, sir. He said, Then you're not pulling hard enough.

Anonymous said...

I'm an old retired scrub nurse. I used to work with a surgeon who would scream for a mixter at various times that I was too busy sweating it out to see what was going on. He would get mad if I slapped a standard mixter into his hand and hollar out for a longer one. We finally had a friendly discussion after the procedure and agreed on a standard mixter length (long)and all was well. I really love your blog and whenever I hear splenectomy, I hear mixter screams in the background.

Sid Schwab said...

Good story. Thanks!

I just called them "right angle," and usually specified long or short. And, in honor of one of my favorite teachers, I referred to the really big honking ones as "giant noogerer."