Grand Rounds

Splenectomy without Prior Vaccination

Consultant in Pediatric Infectious Diseases and Pediatric Hepatology, Nanavati Hospital and Incharge Pediatric HIV, TB and Liver Clinics, B J Wadia Hospital for Children, Mumbai, India

Address for Correspondence: Dr Ira Shah, 1, B Saguna, 271, B St Francis Road, Vile Parle {W}, Mumbai 400056.

Clinical Problem :
A 9 years old boy presented with pain in left part of abdomen since days. There was no fever or trauma. On examination, vital parameters were normal. There was firm splenomegaly. Other systems were normal. Investigations showed hemoglobin of 10.8 gm, dl, white cell count of 9,400, cumm {with platelets of 2,49,000, cumm. Ultrasound abdomen showed 12.6 x 10.4 x 9.4 large hypoechoic area with internal echoes in the spleen. CT abdomen showed 12.8 x 9 cm hypodense homogenous lesion with lobulated margins suggestive of large splenic abscess. At the time of surgery, it was diagnosed to be a cyst and histopathology proved it to be an epidermoid cyst of spleen. The child is asymptomatic on follow up.

When to do splenectomy in splenic cysts_? How to vaccinate in emergency splenectomy_?

Discussion :
Splenic cystic lesions are rare. They may be congenital, neoplastic, vascular, inflammatory and post-traumatic in origin. The traditional treatment of splenic cysts had been splenectomy but it has its morbidity of leading to immunodeficiency. {1} Asymptomatic splenic cysts Less than 5cm in diameter are managed conservatively with total cystectomy, marsupialization, or cyst decapsulation {unroofing}, accessed either by open laparotomy or laparoscopy. Partial splenectomy preserves more than 25 percent of splenic parenchyma and can also be done laproscopically. {3} In special situation such as presence of multiple cysts, very large-sized cyst, in cases of cysts in the hilum of the spleen, a cyst completely covered by the splenic parenchyma, uncontrolled bleeding during surgery or cysts that are inaccessible for fenestration or marsupialization, one may consider doing a total splenectomy. {4} In our patient, since the cyst was very large, a total splenectomy was done.
Patients who undergo splenectomy are at increased risk of infections due to pneumococcus, H. influenzae type B {Hib}, and meningococcus. Thus, conjugated pneumococcal vaccine, conjugated Hib vaccine and conjugated Meningococcal Vaccine is recommended in these patients. The vaccines should ideally be given 4-6 weeks prior to a planned splenectomy. In case of emergency splenectomy, the vaccines can be given 14 or more days after emergency removal of the spleen. The polysaccharide pneumococcal vaccine {PPSV23} is given 8 weeks after the conjugated pneumococcal vaccine to cover the other serotypes. {5}

References :
  1. Rana APS, Kaur M, Singh P, Malhotra S, Kuka AS. Splenic Epidermoid Cyst - A Rare Entity. J Clin Diagn Res. 2014; 8: 175–176.
  2. Hansen MB, Moller AC. Splenic cysts. Surg Laparosc Endosc Percutan Tech. 2004; 14:316-22.
  3. Karfis EA, Roustanis E, Tsimoyiannis EC. Surgical Management of Nonparasitic Splenic Cysts. JSLS?. 2009;13:207-212.
  4. Macheras A, Misiakos EP, Liakakos T, Mpistarakis D, Fotiadis C, Karatzas G. Non-parasitic splenic cysts: A report of three cases. World J Gastroenterol. 2005;11:6884-6887.
  5. Miniero R, Barretta M, Dolceamore TR, De Luca G, Altomare F, Chiarello P. Update on prevention of infections in patients without spleen or with diminished splenic function. Minerva Pediatr. 2013;65:427-45.

Correct Answers :  yes 100%
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