Splenectomy

It has been a very difficult decision to make, because in many textbooks we read that splenectomy can be associated with an increase in morbidity and mortality, especially in Tropical Countries: actually, after splenectomy patients can be more prone to getting malaria, meningitis, pneumonia.

But our patient was very difficult to manage conservatively. 

His hemoglobin was ranging between 1.5 and 3 g/dl. 

Even after transfusion we could hardly get at 4 grams, but even that modest improvement was not to last and the HB was back to 2 grams or less after very few days.

The problem of our patient was only with the red blood cells; in fact either the white blood cells or the platelets were normal.

The peripheral blood film (PBF) was negative for blasts or immature cells, leading us to rule out a myeloproliferative disorder. Negative was also the bone marrow aspirate (BMA): that has helped us to rule out leukaemia or leishmaniasis (the sample was negative also for amastigotes).

Because of the tests quoted above, together with the absence of other signs of malignancy at chest X-Ray and abdominal ultrasound, we have come to the diagnosis of a tropical splenomegaly (hyper-reactive malarial splenomegaly) with important hypersplenism.

The challenges we faced in the decision about splenectomy were the following:

The chronic scarcity of blood available for transfusion.

The necessity of doing an operation on a patient already extremely anemic.

Nevertheless, because it was not possible to keep transfusing every now and then, just waiting for the HB to go down again to 2 grams in about a week, comforted by the advice of Dr Nyaga and by the expertise of Dr Pietro, we have decided to operate.

One pint of blood was given to the patient before the operation; the second one was transfused in theater, and the third one on the first day post-op.

The spleen was enormous, reaching up to the left inguinal fossa, but Dr Pietro and Dr Giorgia were very quick and precise and the splenectomy was done in quite a short time and with no intra-operative bleeding at all.

Apart from the three pints quoted before, we did not transfuse him again (mainly because of scarcity of blood), but the Hb has been steadily increasing and today (6th day post-op) it is 6 grams/dl.

We have not observed any piastrinosis in our patient, who therefore has not been put on prophylactic ASA, but we will follow him up after discharge, and we will start if need be.

We have also advised him on antipneumococcus, anti-meningococcus and anti-H. influenzae vaccines, as per international protocol. We will discuss with him the need of anti-malarial prophylaxis for some time with proguanil or mefloquine.

Tomorrow we will remove alternate stitches from the operation site, and we hope to discharge the patient on Thursday. He is now feeding well and he is mobile.

I think we took the right decision, although it was quite difficult for me to agree on an operation for a person showing 2.8 grams of hemoglobin. 

What convinced me was the patient himself who told me one day: “will you wait for me to be dead, before you decide to operate on me?”

And now I am very happy that I have listened to him. I really think it was the right choice.

Bro Dr Beppe Gaido