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1. Impact of Splenectomy on Subsequent Infections

   • Tetsuji Fujita, Associate Professor

   Jikei University School of Medicine

   TO THE EDITOR: Linking the national hospital discharge records to the civil registration system in 3812 splenectomized patients, 38120 general population members, 16962 appendectomized patients and 8310 matched patients with hematologic disorder, Dr Thomsen and colleagues (1) clarified the clinical impact of splenectomy on subsequent infections. Compared with the general population, the odds ratio of infection was 18.1 in the first 90 days after splenectomy, and the hazard ratio was 4.6 from 91 to 365 days, and 2.5 more than 365 days after splenectomy. Surprisingly, in a subcohort for which detailed data on bacterial infections were available, the 90-day odds ratio for bacteremia was 138.2 compared to the general population cohort. These results may compel the patients to receive pneumococcal vaccines or antibiotic prophylaxis to reduce infection rates. However, I suppose that a markedly increased infection rate in the first study period does not necessarily reflect the role of the spleen in the elimination of bacteria. The removal of a huge spleen is a challenging operation, and is not rarely associated with infectious complications such as wound infection, catheter sepsis, subphrenic abscess, and pneumonia. In a study of 135 patients undergoing splenectomy for hematologic malignancies, overall morbidity and mortality rates were 52 % and 9 % (2). Even for patients with immune thrombocytopenic purpura, splenectomy was associated with a morbidity of 40 % if they had received medical therapy for a long time (3). In the current study, among the infections within 90 days after splenectomy, a substantial portion is thought to be attributable to operative insult, but not to immune deficit resulting from splenectomy

   Besides increased susceptibility to infection, another concern about splenectomy is whether it can affect long-term survival rates, particularly for patients with abdominal cancer or hematologic malignancy. In a recent cohort study using the Scottish hospital records and death registration system in 1648 splenectomized patients with a mean follow-up of 4.45 years, 739 patients (45 %) died during the study period (4). Unfortunately, in that study, how many deaths were related to severe infections or how many patients died of the progression of the disease is not known. In the study by Thomsen et al, it appears that about 18 % of patients died within 1 year after splenectomy, and about 27 % of splenectomized patients died during a median follow-up of 2,2 years, whereas about 15 % of the matched patients with hematologic disorder died within 1year and about 28 % of these died during a median follow-up of 2.1 years, as shown in Table 3 of the article. Defining whether splenectomy contributed to the death of patients with abdominal or hematologic malignancies would be clinically important.

   References

   1. Thomsen RW, Schoonen WM, Farkas DK, Riis A, Jacobsen J, Fryzek JP, et al. Risk for hospital contact with infection in patients with splenectomy. Ann Intern Med. 2009; 151: 546-55.

   2. Horowitz J, Smith JL, Weber TK, Rodriguez-Bigas MA, Petrelli NJ. Postoperative complications after splenectomy for hematologic malignancies. Ann Surg 1996; 223: 290-6.

   3. Gibson M, Sehon JK, White S, Zibari GB, Johnson LW. Splenectomy for idiopathic thrombocytopenic purpura: a five-year retrospective review. Am Surg 2000; 66: 952-5.

   4. Kyaw MH, Holmes EM, Toolis F, Wayne B, Chalmers J, Jones IG, et al. Evaluation of severe infection and survival after splenectomy. Am J Med 2006; 119: 276.e1-e7.

   Conflict of Interest:

   None declared

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   Published November 10, 2009