SPLENECTOMY

SUMMARY Rupture of the spleen is an important cause of disability and death after Motor Vehicle Accidents. Brisk hemorrhage may kill within minutes; slower bleeding commonly requires emergency surgery. The blood management functions of the spleen are largely taken over by other tissues, but complete splenectomy leaves the client permanently vulnerable to life-threatening infection. Immunisation, education and antibiotics incompletely prevent excess disability and mortality.

PATTERNS OF INJURY

Rupture of the spleen is an important cause of disability and death after Motor Vehicle Accidents.

Even moderate blunt trauma to the left lower chest or upper abdomen may cause the healthy spleen to rupture.

In about one in twenty victims, the rupture may be delayed up to a couple of weeks after trauma ¹.

A spleen that is diseased by, for instance, malaria or even mononucleosis is more fragile and may rupture after relatively minor trauma, or even spontaneously.

If the spleen escapes injury from direct blunt trauma, it may yet be injured inadvertently during surgery for exploration or repair of other traumatised abdominal organs.

NEED FOR SPLENECTOMY

Brisk hemorrhage may kill within minutes; slower bleeding commonly requires emergency surgery.

The two principal litigation concerns of ruptured spleen are hemorrhage and postsplenectomy infection.

Bleeding from a ruptured spleen may at the one extreme be rapidly lethal and at the other extreme be insufficient to require surgery. The spleen, even when healthy, is relatively fragile and richly supplied with blood.

When an operation is required, the traditional approach has been complete removal of the injured spleen (total splenectomy).

However, repair (splenorrhaphy) is sometimes feasible ², and there has been a recent trend to retain or relocate some spleen tissue if possible ³. The long-term benefits of these salvaging procedures remains unproven.

LONG-TERM RISK OF INFECTION

The blood management functions of the spleen are largely taken over by other tissues, but complete splenectomy leaves the client permanently vulnerable to life-threatening infection.

As the spleen is concerned with production and destruction of blood cells, including lymphocytes that fight infection, greater susceptibility to sepsis is a particular concern.

Not only is the post-splenectomy patient more vulnerable to certain types of infection, but some forms of sepsis may be very rapidly fatal - the so-called Overwhelming Post-Splenectomy Infection (OPSI) syndrome.

Post-splenectomy patients should be offered specific routine immunisations, particularly to the bacterial germ known as the pneumococcus (streptococcus pneumoniae) that is a cause of pneumonia and other respiratory infections even in those who have not had a splenectomy.

After the spleen has been surgically removed, patients should be advised explicitly of the warning symptoms that require more urgent medical attention as a result of that previous surgery ⁴.

The administration of prophylactic antibiotics is controversial. Although the main danger of more liberal use of antibacterial agents in such susceptible clients is the development of antibiotic-resistance in the community, there is no proven benefit to those who have required splenectomy.

At least in children, implementation of immunisation and education guidelines ⁵ for prevention of postsplenectomy sepsis has resulted in material improvements ⁶ in rates of infection and death ⁷.

DAMAGES

Immunisation, education and antibiotics incompletely prevent excess disability and mortality.

The quantum of damages attributable to risk of OPSI remains contentious, in part because of the general problem that research on longevity takes decades whereas medical advances occur faster.

About one in twenty clients who have had the spleen removed will develop OPSI at some time during their lives.

Following splenectomy for traumatic injury, sepsis is 58 times more lethal than in the uninjured population.

Under age 15 years, the younger the child the more susceptible is s/he to potentially life-threatening pneumococcal infection ⁸. Infants have a 16% probability of developing postsplenectomy sepsis.

Although more than half the hospitalisations for serious infection occur within the first two years following splenectomy ^{9, 10}, a third of postsplenectomy pneumocococcal infections, and 2 in 5 cases of OPSI, occur beyond 5 years after surgery ¹¹.

Within a decade, the cumulative risk of infection serious enough to require hospitalisation is 33%. The paper ¹² from which this figure derives is arguably the most authoritative currently on incidence of OPSI after traumatic splenectomy, and should be addressed by all medical expert opinions on quantum of damages.

Copyright © 2008 Electronic Handbook of Legal Medicine