The Indications for Splenectomy
As an introduction, splenectomy for hemolytic diseases is discussed briefly. The best results of splenectomy are seen in hereditary spherocytosis. The indications for surgery are clear when objective symptoms of the disease are evident. However, even in oligo-symptomatic carriers of this red blood cell abnormality splenectomy must be considered, since hemolytic crises may occur.
Only in the “major” forms of hereditary elliptocytosis splenectomy is indicated. In hereditary non-spherocytic hemolytic anemia, thalassemia major and sickle cell anemia splenectomy is of very limited value. The acquired hemolytic anemias represent a heterogeneous group and a precise diagnosis is essential in every case. When splenectomy is considered it should be preceded by isotope studies. As many as 50% of the patients with chronic, acquired, autoimmune hemolytic anemia can be clinically cured by splenectomy. The others may continue to hemolyze, with prednisone often being ineffective.
In essential thrombocytopenia in which the platelet levels are so low that danger of hemorrhage exists, the indication for splenectomy is clear. In order to exclude from surgery the post-infectious thrombocytopenias of short duration, it is worthwhile to observe the patients for a limited period of time. If the patient, however, still requires relatively high doses of steroids after 2 to 3 months, it is not wise to postpone the operation any longer.
Splenectomy for pancytopenia is indicated only when all other methods of treatment have been exhausted. The result of such an operation is not usually good.
Finally, a number of diseases which are associated with hypersplenism are briefly discussed. Special attention is devoted to two disorders in this group. These are the lympho-proliferative diseases and myelofibrosis.
Hitherto there is no evidence that a patient with a lymphoma of the spleen can be cured by splenectomy. However, in view of the hypersplenism that may occur in the later stages of the disease and because of the lack of response to any other forms of therapy, it is recommended that splenectomy be done early in the course of the disease.
Splenectomy is indicated in myelofibrosis in which thrombocytopenia is severe. In the event of added pronounced hemolysis one must carry out studies with 51Cr-labeled red blood cells in order to determine whether red cell destruction in the spleen is greater than erythropoiesis. Early splenectomy should always be considered.
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