One Spleen...

The above is snapped off a page of the book that might have saved my life. Well, no. But it kept my mind off self-pity when I was in the waning months of my tour of duty in Vietnam. Rather than attending only to that part of the world which was within three feet of me, I could ponder the power of the human mind; could hope the stories therein weren't just chemical aberrations. (Likely, of course, they were.)

The book is "Be Here Now," by Ram Dass, formerly Richard Alpert PhD, associate of Tim Leary at Harvard; tripper on and contemplater of LSD. A friend sent it (the book, not the pharmaceutical) to me while I was serving my time. (Cool fact: all you had to do with mail to and from Vietnam soldiers was write "free" on the corner, and it got where it was aimed. I hope that's still true for the troops and their families.) The volume is divided into three parts, one of which is actually readable. In the snippet to which I refer, Ram Dass describes his first meeting, in India, with the man who would become his guru. Along with "how was the cookie?" (guess you'd have to read it), "Spleen. She died of spleen" still brings a smile when I think of it....

* * * * * *

Soon after I arrived in my current location, I was sent a patient in need of splenectomy. Neither for the first time nor the last, the operation proceeded in such a way that I plopped the organ in a pan about five or seven minutes after laying knife to skin. "Wow," said the scrub nurse. "Wow," said the anesthesiologist, turning dials and scrambling for drugs. Thanks again, Vic, I said to myself, giving homage to my most influential teacher of technique. "The spleen is a mid line organ, Dockie," he used to say, as he harassed me into quickly loosening it from its attachments to the diaphragm and pulling it toward me.

The spleen, you may properly infer, has a special place in my heart. Under it, actually. And a little to the left. Despite Vic's surgically relevant aphorism.


It's nice to have a spleen, but you can live without it. Put simply (and I'm a simple guy) that red-mahogany and spongy organ does two unrelated things: it acts as a giant lymph node, and it filters out aging blood cells. Absent the spleen, those functions can get carried on elsewhere, and so it is that people who lose their spleen, either from injury or because of various blood disorders, generally have no occasion to miss it. But the world is imperfect, so the previous statement is not always true.

There is, in fact, an incidence of overwhelming and highly fatal infection in a small percentage of people who have been splenectomized; the good news is that the infections tend to be by organisms for which vaccinations are available. Those vaccines ought to be given in advance of a planned splenectomy, and soon after an unplanned one. And since infectious consequences seem more frequent in children, it's recommended by some (not universally, for various reasons) that kids who lose their spleens be given daily antibiotics for prophylaxis. Who, and how long: not agreed upon.

The greatest risk is within the first two years after splenectomy. Some people give antibiotics for that interval; others till age 21; some advocate it for life. Much of the data are muddled by the fact that people lose their spleens for differing reasons: when it's removed for hematological reasons, the long-term risks are probably higher, since those people have remaining underlying pathology. Splenectomy for trauma has a higher risk of infection at the time of surgery (in part, I think, because of concomitant injuries to other organs) but lower long-term, compared to hematologic patients. Still, there's no doubt there are some risks. The only case of overwhelming post-splenectomy sepsis I ever saw was in a person who'd had it for hairy-cell leukemia. Never in a person with trauma.

The other potentially adverse consequence of splenectomy can be turned into a good thing: it's common after the operation to note a rise in platelets, those little packets of clotting paraphernalia that float in the bloodstream. Too many, and there's a risk of thrombosis (clots when you don't want them); too few, and there's risk of spontaneous or prolonged bleeding. In the condition known as ITP, for "idiopathic thrombocytopenic purpura," in which the platelet (thrombocyte) count can get dangerously low, splenectomy may be curative. That was always my favorite situation in which to see a patient needing the surgery, because, under the right circumstances, there was a pretty good chance it would work out well.

Among people with ITP who require treatment, the mainstay drug is prednisone (as you can read in the above ITP link, there are others, too). It's those people in whom it works well that I liked to see; and if that sounds like the words of a knife-happy surgeon, hear me out. Steroids like prednisone can be very effective, but, depending on dose, they can have significant side-effects. Some lucky people with ITP get their drugs, respond well, and it's over. Others, though, either require prolonged treatment with high doses, or they get a good response but recur whenever the drugs are stopped.

At some point surgery becomes a consideration; and the good news is that response to drugs is quite a good predictor of response to surgery, which is why I liked to see those people. The news isn't as good -- the outcome much less certain -- when splenectomy is pursued as a last resort after all other treatments have failed.

In many cases when the platelet count is low in ITP, bleeding during or after surgery is not a great worry: the platelets that are present are young and sexy, and clotting is less affected than in other situations with comparably low platelet counts. Surgery proceeds apace, and it's rewarding to see the counts begin to rise immediately after surgery. In those more questionable situations -- very low counts with no response to medical treatment -- surgery is carried out with more drama: platelets at the ready in the OR, the splenic artery clamped as early as possible in the proceedings, after which the platelet infusion begins (the clamping keeps the new platelets from being gobbled by the spleen.) No five-minute job; great care is taken to avoid and to control the tiniest bleeders. I should also mention that it's not rare to have "accessory" spleens, little grape-oid items tucked in various abdominal locations, failing to locate and extirpate which can lead to recurrence of the disease. Mostly, they're close to the spleen, so the search tends not to require dogs and flushers.

Residing high in the left upper abdomen, attached to the colon and the stomach as well as to the pancreas, kissing the left kidney, not far from the adrenal and stuck to the diaphragm, the spleen is anatomically more daunting on paper than in the flesh. Unless the organ is really huge, operating is usually straightforward; and yes, it's even quite amenable to the laparoscopic approach (takes a lot longer than five minutes to get it in the bucket, though). I think it has the makings of at least one more post. And we haven't yet talked much about ruptured spleens...