Perioperative Immunization for Splenectomy and the Surgeon’s Responsibility

Abstract

plenectomy is a common operation, accounting for at least 25 000 procedures per year in the US. Indications include hematological diseases, traumatic injuries, and benign and malignant gastrointestinal, urological, and gynecologic conditions. The most dreadful sequel of splenectomy is overwhelming postsplenectomy infection (OPSI), a syndrome consisting of a nonspecific prodrome rapidly evolving toward pneumonia, meningitis, or fulminating sepsis. Although several strategies have been embraced, namely antibiotic prophylaxis, rescue therapy, and even splenic autotransplant, the cornerstone of OPSI prevention remains prophylactic immunization. Beyond the operating theater, surgeons play a determinant role in the care of patients who have had splenectomy. As the responsible physician in the immediate perioperative period, it is incumbent on them to first educate the patient regarding the nature of asplenic immunodeficiency and then prescribe appropriate immunization. Methods MEDLINE/PubMed, Cochrane Library, and ClinicalTrials.gov databases were searched for randomized clinical trials (RCTs) published from January 1, 1990, to December 31, 2019, addressing immunization in patients who had had splenectomy (eMethods in the Supplement). References of retrieved articles were searched manually, and current clinical guidelines were checked for further relevant literature. Research was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline methodology. 1 The research revealed 5 RCTs and 1 phase III nonrandomized trial (eFigure in the Supplement), Given the dearth of level I evidence focusing on the population of interest, results of systematic reviews, meta-analyses, and observational studies were also considered. Fi-IMPORTANCE Patients who have had splenectomy have a lifelong risk of overwhelming postsplenectomy infection (OPSI), a condition associated with high mortality rates. Surgeons must be aware of the rationale of vaccination in the case of splenectomy, to provide appropriate immunization in the perioperative time.OBSERVATIONS English-language articles published from January 1, 1990, to December 31, 2019, were retrieved from MEDLINE/PubMed, Cochrane Library, and ClinicalTrials.gov databases. Randomized clinical trials as well as systematic reviews and observational studies were considered. Asplenia yields an impairment of both innate and adaptive immunity, thus increasing the risk of severe encapsulated bacterial infections. Current epidemiology of OPSI ranges from 0.1% to 8.5% but is hard to ascertain because of ongoing shifts in patients' baseline conditions and vaccine penetration. Despite the lack of randomized clinical trials, immunization appears to be effective in reducing OPSI incidence. Unfortunately, vaccination coverage is still suboptimal, with a great variability in vaccination rates being reported across institutions and time frames. Notably, current guidelines do not advocate any particular health care qualification responsible for vac...

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