Introduction

The spleen is an encapsulated hematopoietic organ that lies within the posterior aspect of the left upper quadrant in the peritoneal cavity. It has proximity to the 9th, 10th, and 11th ribs; left kidney; stomach; transverse and descending colon; left hemidiaphragm; and the pancreas. Spleen is a part of reticuloendothelial system which clears unopsonized bacteria, serves as a reservoir of mononuclear cells and participates in production of antibodies following exposure to various antigens [1,2]; loss of this immune function of the spleen either due to surgical removal or functional defect put the patient at a risk to develop overwhelming sepsis [3]; but splenectomy is still performed, since it was first time performed in 18494, due to different indications including medical as well as surgical ones [4,5], these indications of splenectomy can be further classified into absolute indications and relative indications [6]; absolute indications include: splenic rupture,tropical splenomegaly,splenic abscess, splenic cysts, neoplasms, angioma and rarely aneurysm of splenic artery [6-8]; for the relative indications of splenectomy hematologic disorders come first [6,9] which include: haemolytic anaemias, haematological malignancy, thrombocytopaenic disorders mainly chronic ITP and some parasitic diseases [9]. Complication of splenectomy include : haemorrhage, thrombocytosis ,deep vein thrombosis and overwhelming postoperative infection [6]; to guarantee specifically against overwhelming postoperative infection all patients should receive pneumococcal vaccination haemophilus influenzae type b conjugate vaccine and meningococcal conjugate vaccine at least 2 weeks before splenectomy [10]; those patients also recommended to receive antimalria in endemic areas [11]. Aim of this study was to determine indications and complications of splenectomy in Kosti teaching hospital,Wite Nile State ,Sudan.

Patients and Methods

The case notes of all patients who underwent splenectomy at the department of surgery, Kosti Teaching Hospital over the 7-year period (2007-2014) were retrieved and reviewed. Kosti is the capital of White Nile State which now is the southern part of Sudan after separation of South Sudan in 2011.The demographic data, the indication for splenectomy, intra operative and post operative complications and mortality were particularly noted. The spleen was approached via an upper midline or a left subcostal incision. None of the patients underwent laparoscopic splenectomy. All patients received broad spectrum antibiotics at induction and postoperatively and also received anti malaria postoperatively because malaria is endemic in study area. No patient was given vaccine prophylaxis against pneumococcal infection because it is not available. All the patients discharged on antibiotic prophylaxis based on penicillin and on tow tablets of fansidar weekly as a prophylaxis against malaria. Patients were followed initially on monthly basis for three months and then every six months. They were checked clinically and complete blood count done for every patient and the preoperative hematological values were compared to the values at the end of the first and third postoperative months.

Results

Fifty one patients underwent splenectomy, 31(60.78%) were males and 20(39.22%) were females. The mean age of the patients was 30.31. Indications of splenectomy in the studied group are shown in (Table 1).Seven (13.73%) patients developed complications which are detailed in (Table 2). Tow (3.92%) patients died, one patient was female with portal hypertension died due to post splenectomy sepsis and the other was intraoperative death, in a female also with portal hypertension, due to intractable intraoperative bleeding.

Discussion

In this study population males are predominant as reported by other studies [2,12].The mean age of the patients in this study is 30.31±SD in consistent with Deodhar report [12]. The main indication for splenectomy in our study was trauma (50.98%) (Table 1) which was also described as first indication for splenectomy in different reports [13,14],only one patient among this group (26 patients) developed post splenectomy sepsis which was the only complication occurred among those patients; post splenectomy sepsis is a common complication following splenectomy [15] specially in patients in whom splenectomy is indicated because of trauma [13,14,16,17] and because of this the general attitude concerning splenectomy for trauma is recently tilted towards preserving the spleen either through spleen-sparing surgical approaches , like partial splenectomy, splenorraphia, use of biological glue or splenic encasement ;  or through  nonoperative management of spleen involved in trauma [18-20] but the decision of  nonoperative management for splenic trauma should be taken carefully and depend not only  on hemodynamic stability of the patients ,in spite of its importance, but also should consider other factors including: absence of peritoneal signs or any associated injuries necessitating laparotomy, presence of multiple injuries, high-grade splenic injury, a large haemoperitoneum, age and high Injury Severity Score (ISS) because those factors are reported as risk factors for failure of nonoperative management [21-23].

The second major indication for splenectomy in our study is hypersplenism as a consequence of portal hypertension (37.26% ) secondary to schistosomiasis, a disease which is endemic in Sudan particularly in White Nile State [24,25] where we conducted our study. Among the nineteen patients with hypersplenism and portal hypertension five patients (26.3%) developed complications which include: intraoperative  bleeding, post splenectomy sepsis, adhesive intestinal obstruction and incisional hernia (Table 2). Two patients died in this group, which represents  a total mortality rate of (3.92%) for the (51) studied patients; one patient died due to intractable intraoperative bleeding and the other patient’s cause of death was post splenectomy sepsis . One more spleen was removed because of hypersplenism in a patient with thalassemia ,this patient developed post operative bleeding (Table 2).

The other hematologic disorder which indicated splenectomy in our series is immune thrombocytopenic purpura (ITP) which is a common indication for splenectomy [5,6,26] and splenectomy remains one of the second line options for treatment of this condition [27-29] for patients who relapsed after the first line treatment or refractory to it. First line treatment of ITP include corticosteroids,  Anti-D and IVIG while the second line treatment include thrombopoietin receptor agonists (TRAs) such as eltrombopag, avatrombopag and romiplostim as well as chimeric monoclonal antibody rituximab and more recently the spleen tyrosine kinase (Syk) inhibitor fostamatinib, [30-33] ,with the introduction of these new second line treatments and in the face of complications that might accompanying splenectomy which may range from poor response to surgical mortality [34,35] splenectomy for ITP is slowed down but not vanished of course [33,36,37]. Spontaneous rupture of the spleen was indication of splenectomy in tow of our patients (Table 1) ; the etiology behind splenic rupture in those patients was falciparum malaria; another parasitic disease which is endemic in Sudan especially White Nile state [38-40] ,area of our study;the most prevalent species in this area is plasmodium falciparum [40] which causes severe disease and complications among them is rupture of the spleen which is not confined to falciparum malaria and may complicate malaria caused by other species as well [41-43] with a estimated incidence of 2% in some reports [44]. About 252 cases of ruptured spleen reported in Sudan were associated with malaria [45]. Splenectomy and nonoperative management for ruptured spleen due to malaria are both in practice and again the hemodynamic stability of the patient is the major factor among others that will determine the decision of which mode of treatment will be taken [42-47] and even when splenectomy is chosen surgical complications are rarely reported [42,44,47]. Our two patients were hemodynamic instable so splenectomy was the treatment of choice and the procedure went without complications in both of them (Table 2).

   One patient in our series was subjected to splenectomy because of rupture of splenic artery aneurism (Table 1). Splenic artery aneurysm (SAA) is a rare but potentially life threatening condition, almost all visceral artery aneurysms occur in splenic artery and splenic artery aneurysm comes third only to aorta and the iliac artery aneurysms in the abdomen; splenic artery aneurysm is common in women and prone to rupture when diameter exceeds 2 cm [48-52].Rupture of splenic artery aneurysm is commonly occur during pregnancy and puerperium [53-57] with the third trimester being the commonest time for rupture of SAA [58] especially the last two weeks of pregnancy. Factors thought to be contributors in development of SAA and its rupture during pregnancy include increase splanchnic and splenic arterial blood flow due to pregnant uterus by compression of the aorta and iliac vessels, and alterations of the arterial wall structures, induced by hormonal modifications [59]. Our patient was scheduled for caesarean section at 37 week gestational age, the c/section was planned because of pure obstetric indication and the pregnancy course was normal without any event; the procedure went normally and a viable baby was delivered but after closing the uterus intraperitoneal bleeding was observed which first was thought to come from the uterus but tracing demonstrated a ruptured splenic artery aneurysm and splenectomy was performed, patient received transfusion intra operative and recovered smoothly. The final spleen in our series was removed because of torsion of wandering spleen (Table 1); we reported this case which was10 year old girl who was presented to the emergency department with severe central abdominal pain and a firm, rounded, tender and freely mobile central abdominal mass. Ultrasonography revealed absence of the spleen in its usual site, and a hypo-echoic mobile mass in the mid abdomen. The patient underwent laparotomy in which we found mobile, infracted spleen which lacked ligamentous attachment with torsion in long splenic pedicle. The splenectomy was done after detorsion of the pedicle, she was discharged in good condition [60].

In conclusion we reported 51 patients whom underwent splenectomy, in all of them the procedure was performed through laparotomy. Indications for splenectomy include :trauma, hypersplenism as a complication of schistosomiasis,hematologic disorders,complication of malaria, rupture of splenic artery aneurism and torsion of wandering spleen. Complication occurred in 7(13.73%) of patients most of them are among the group of hypersplenism as a complication of schistosomiasis. Mortality rate is 3.92%.

Tables

References

1. Splenic Rupture (2020). (accessed on 24 March 2020).
2. Meshikhes AN, Mubark MA, Abu-Alrahi AI, Al-Saif OH. (2004)The pattern of indications and complications of splenectomy in Eastern Saudi Arabia.Saudi Med J, 25: 1892-1895.
3. King H, Schummacher HB. (1952) Splenic studies: 1. Susceptibility to infection after splenectomy performed in infancy. Ann Surg,136:
4. Clarke PJ, Morris PJ. (1994) Surgery of the spleen. In: Oxford textbook of Surgery, vol. 2.Morris and Matt Oxford University Press; 1994.
5. Govindaraj S and Roshini AP. (2019) Indications for splenectomy in a tertiary care hospital in South India. International Journal of Surgery Science 3: 04-06.
6. Weledji EP. (2014) Benefits and risks of splenectomy. Int J of Surg,12: 113-119.
7. Cochrane JPS. (1980 ) The spleen-ruptured spleen. Br J Hosp Med,25: 398e404.
8. Lewis SM, Swirsk D. (1996) The spleen and its disorders. In: Weatherall D, Ledingham JG, Warrel DA, editors. Oxford textbook of Medicine.
9. Coon WW. (1985 ) Splenectomy for splenomegaly and secondary World J Surg,0: 437e43.
10. Davies JM, Lewis MP, Wimperis J, Rafi I, Ladhani S, Bolton‐Maggs (2011) Review of guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen: prepared on behalf of the British Committee for Standards in Haematology by a working party of the Haemato‐Oncology task force. Br J Haematol, 155: 308-317.
11. Ashley D and Watson R (2003). Pretravel Health Advice for Asplenic J Travel Med ; 10: 117-121.
12. Deodhar M , Kakkar N (2004). An audit of splenectomies in ateaching hospital in North India.Are postsplenectomy guidelines being complied with? J Clin Pathol , 57: 407-410.
13. Dendle C, Sundararajan V, Spelman T, Jolley D, Woolley I, (2012) Splenectomy sequelae: an analysis of infectious outcomes among adults in Victoria. Med J Aust, 196: 582-586.
14. Barmparas G, Alexander W. Lee DL, Nguyen B, EngJ,Matthew B et al. (2015 ) Postoperative infection risk after splenectomy: A prospective cohort study. International Journal of Surgery, 17: 10e14.
15. Shatney CH. (1987) Complications of splenectomy.Acta Anaesthesiol 38: 333-339.
16. Wiseman J1, Brown CV, Weng J, Salim A, Rhee P, Demetriades (2006) Splenectomy for trauma increases the rate of early postoperative infections. Am Surg,72: 947-950.
17. Demetriades D1, Scalea TM, Degiannis E, Barmparas G,
18. Konstantinidis A, Massahis J, Inaba K (2012). Blunt splenic trauma: splenectomy increases early infectious complications: a prospective multicenter study. J Trauma Acute Care Surg;72: 229-234.
19. Fransvea P, Costa G, Massa G, FrezzaB, MercantiniP,BaIducciG (2019). Non-operative management of blunt splenic injury: is it really so extensively feasible? a critical appraisal of a single-center experience. Pan African Medical Journal; 32: 52.
20. SpijkermanR , TeubenMP, Hoosain F, TaylorLP, Craig T et al. (2017) Non-operative management for penetrating splenic trauma: how far can we go to save splenic function? .World Journal of Emergency Surgery,12: 33.
21. Beuran M, Gheju I, Venter MD, Marian RC, Smarandache R. (2012) Non-operative management of splenic trauma. Journal of Medicine and Life, 5: 48-58.
22. Yorkgitis BK. (2017) Primary Care of the Blunt Splenic Injured Adult. Am J Med, 130: 365.e1-365.e5.
23. Smith SR, Morris L, Spreadborough S, Al-Obaydi W, D’Auria M, White H, Brooks AJ. (2018) Management of blunt splenic injury in a UK major trauma centre and predicting the failure of non-operative management: a retrospective, cross-sectional study. Eur J Trauma Emerg Surg; 44: 397-406.
24. Tugnoli, G., Bianchi, E., Biscardi, A. et al. (2015) Nonoperative management of blunt splenic injury in adults: there is (still) a long way to go. The results of the Bologna-Maggiore Hospital trauma center experience and development of a clinical algorithm. Surg Today 45: 1210–1217.
25. Ismail HA, Hong TS, Babiker AT, HassanRM, SulaimanMA et al. (2014) Prevalence, risk factors, and clinical manifestations of schistosomiasis among school children in the White Nile River basin, Sudan. Parasites & Vectors 2014, 7: 478.
26. Lee1YH, LeeSJ, Jeoung GH, In-Sun Kwon IS, Mohamed AS, Tae HongTS. (2019) Epidemiological Survey on Schistosomiasis and Intestinal Helminthiasis among Village Residents of the Rural River Basin Area in White Nile State, Sudan. Korean J Parasitol, 57: 135144.
27. Srinivasan S, Sabapathy K, Bharadwaj TPR, Sethuraman S (2003):Role of Splenectomy in Chronic Idiopathic Thrombocytopenic Purpura. J Assoc Physicians India, 51: 159-166.
28. Vianelli N, Palandri F, Polverelli N, Stasi R, Joelsson J, Johansson E et al (2013): Splenectomy as a curative treatment for immune thrombocytopenia: a retrospective analysis of 233 patients with a minimum follow up of 10 years.Haematologica, 98:875-880.
29. Thai LH, Mahévas M, Roudot-Thoraval F, Limal N, Languille L et al (2016): Long-term complications of splenectomy in adult immune thrombocytopenia.Medicine (Baltimore), 95: e5098
30. JiJi RM, Firozvi T, Spurling CL. (1973) chronic idiopathic thrombocytopenic purpura. Treatment with steroids and splenectomy. Arch Intern Med. 1973, 132: 380-383.
31. Stasi R, Pagano A, Stipa E, Amadori S(2001): Rituximab chimeric antiCD20 monoclonal antibody treatment for adults with chronic idiopathic thrombocytopenic purpura.Blood, 98: 952-957.
32. Bussel JB, Kuter DJ, George JN, McMillan R, Aledort LM(2006): AMG 531, a thrombopoiesis-stimulating protein, for chronic ITP.N Engl J Med, 355:1672-1681.
33. Jenkins JM, Williams D, Deng Y, Uhl J, Kitchen V, Collins D. (2007) Phase 1 clinical study of eltrombopag, an oral, nonpeptide thrombopoietin receptor agonistBlood, 109: 4739-4741.
34. Provan D, Arnold MD, BusselJB,Chong BH, CooperN. (2019) Updated international consensus report on the investigation and management of primary immune thrombocytopenia.Blood Advances , 3: 3780-3817.
35. Kojouri K, Vesely SK, Terrell DR, George JN. (2004) Splenectomy for adult patients with idiopathic thrombocytopenic purpura: a systematic review to assess long-term platelet count responses, prediction of response, and surgical complications. Blood, 104: 2623–2634.
36. Vianelli N, Palandri F, Polverelli N, et al. (2013) Splenectomy as a curative treatment for immune thrombocytopenia: a retrospective analysis of 233 patients with a minimum follow up of 10 years. Haematologica,98: 875‐880.
37. Chaturvedi S, Arnold DM, McCrae KR. (2018)Splenectomy for immune thrombocytopenia: down but not out. Blood,131: 1172‐1182.
38. Boyle S, White RH, Brunson A, Wun T. (2013) Splenectomy and the incidence of venous thromboembolism and sepsis in patients with immune thrombocytopenia. Blood,121: 4782‐4790.
39. Abdalla SI, Malik EM, Ali KM. (2007) The burden of malaria in Sudan:incidence, mortality and disability--adjusted life--years. Malar J, 6: 97
40. Amanda G Elgoraish, Salah Eldin G Elzaki, Rania TagElsir Ahmed, Arwa Ibrahim Ahmed, Huda A Fadlalmula et al. ( 2019) Epidemiology and distribution of Plasmodium vivax malaria in Sudan, Transactions of The Royal Society of Tropical Medicine and Hygiene,113: 517-524.
41. Suliman MM, Hamad BM, Albasheer MM, et al. ( 2016 ) Molecular Evidence of High Proportion of Plasmodium vivax Malaria Infection in White Nile Area in Sudan. J Parasitol Res,2016: 2892371.
42. Zidouh S, Jidane S, Belkouch A, Bekkali H, Belyamani L. ( 2017 ) Spontaneous splenic rupture from Plasmodium ovalae malaria. Am J Emerg Med ,35: 347-349.
43. Lemmerer R, Unger M, Voßen M, Forstner C, Jalili A et al. (2016) Case report: spontaneous rupture of spleen in patient with Plasmodium ovale malaria. Wien Klin Wochenschr,128: 74-77.
44. Bansal VK, Krishna A, Misra MC, Khan RN, Noba AL, Kishore N. (2010) Spontaneous splenic rupture in complicated malaria: nonoperative management. Trop Gastroenterol, 31: 233-235.
45. Waweru P, Macleod J, Gikonyo A. (2014) Complicated malaria and a covert ruptured spleen: a case report.J Surg Case Rep, 13: 2014
46. Osman MF, Elkhidir IM, Rogers SO Jr, Williams M. (2012) Nonoperative management of malarial splenic rupture: the Khartoum experience and an international review. Int J Surg,10: 410-414.
47. Saad E, Elsamani E, Abdelrahman W. (2019) Spontaneous Splenic Rupture Complicating Severe P. falciparum Infection: A Case Report and Literature Review. Case Rep Infect Dis ,2019: 2781647.
48. Imbert P, Rapp C, Buffet PA. (2009 ) Pathological rupture of the spleen in malaria: analysis of 55 cases (1958-2008).Travel Med Infect Dis, 7: 147-159.
49. Mariúba JVO( 2019 ):Splenic aneurysms: natural history and treatment techniques. J Vasc Bras,19:e20190058.
50. Hogendoorn W, Lavida A, Hunink MG, et al. (2014 ) Open repair, endovascular repair, and conservative management of true splenic artery aneurysms. J Vasc Surg,60: 1667-76.e1.
51. Zhang Y, Liu Z, Shen G, Zhang J, Assa CR, Hong D. (2017) Treatment of distal splenic artery aneurysm by laparoscopic aneurysmectomy with end-to-end anastomosis: A case report. Medicine (Baltimore) 96: e6260.
52. Illuminati G, Pizzardi G, Pasqua R. (2018) Open surgery for aneurysms of the splenic artery at the hilum of the spleen: Report of three cases. Int J Surg Case Rep, 48: 47-49.
53. Telfah MM. (2014) Splenic artery aneurysm: pre-rupture diagnosis is lifesaving. BMJ Case Rep,2014: bcr2014205115.
54. Dhinakar M, Al Mashini S, Golash V. (2011) Rupture of Splenic Artery Aneurysm during Pregnancy: A Report of two Cases. Oman Med J,26:e025.
55. Ballout RA, Ghanem R, Nassar A, Hallal AH, Ghulmiyyah LM (2019): Splenic Artery Aneurysm (SAA) Rupture in Pregnancy: A Case Report of a Rare but Life-Threatening Obstetrical Complication. J Womens Health Dev,2: 19–27.
56. Richardson AJ1, Bahlool S, Knight J. (2006) Ruptured splenic artery aneurysm in pregnancy presenting in a manner similar to pulmonary embolus. Anaesthesia,61: 187- 189.
57. Algwiser Aa. (1991): Rupture Of Splenic Artery Aneurysm During Pregnancy:Three Case Reports With A Review Of The Literature. Annals Of Saudi Medicine, 11: 221-225.
58. Nanez L, Knowles M, Modrall JG, Valentine RJ. (2014) Ruptured splenic artery aneurysms are exceedingly rare in pregnant women. J Vasc Surg, 60: 1520-1523.
59. Daniel P, Ward William H, Harwood Jared L, et al. (2012) An Institutional Review of Splenic Artery Aneurysm in Childbearing-Aged Females and Splenic Artery Aneurysm Rupture During Pregnancy. Is Screening Justified? MILITARY MEDICINE 177: 96-98.
60. Veluppillai C, Perreve S, de Kerviler B, Ducarme G (2015). [Splenic arterial aneurysm and pregnancy: A review]. Presse Med, 44: 991-994.
61. Mohammed EH Azooz, Mohammed AM Turkawi, Habab M Abdelhameed, Sakina SA Baloul (2013). Torsion of a wandering spleen: Case report. Sudan Med J, 49: m89-92.