Dr. Chun-Chieh Yeh
General Surgery 
China Medical University Hospital

The 28-year-old patient, Dr. Chen, a student who just graduated from the Department of Medicine from medical school, was accidentally found to have a 6-cm cyst in his spleen. While he knew that this kind of cyst was usually benign, he has been suffering from the symptoms of upper abdominal distension and pain. Therefore, he hoped to thoroughly treat and cure the cyst. In March 2021, he sought help at the Department of the General Surgery, China Medical University Hospital and underwent “laparoscopic partial splenectomy surgery.” The surgery was successfully implemented without any blood transfusion therapy, and he was smoothly discharged after 5 days. Two weeks later, he was followed up and checked with a CT scan to show a good circulation of blood supply in the rest of his spleen.

The patient, Dr. Chen, heard that an injection of alcohol may remove the cysts before undergoing the surgery. However, the alcohol injection approach is usually combined with a high recurrence rate. Once the reoccurrence manifested, the complication of abdominal adhesion may result in increased surgery difficulty and complication rates in the future. As a future medical professional, Dr. Chen knew that the spleen possesses important effects on immunological functions, and especially protection effects for bacteria with capsules, i.e., Streptococcus pneumonia, Haemophilius influenza, Neisseria meningitidis, etc., are very important. However, general spleen surgery consists of a full splenectomy operation because the spleen is fragile and tends to bleed. As he will work in the medical field and frequently come into contagious sources in the future, he may encounter “overwhelming post-splenectomy infection (OPSI),” which has a very high mortality rate due to post-surgery immunological deficiency. That’s why he was hesitated to make a determination regarding accept the surgery for such a long time.

The patient, Dr. Chen, was referred to Dr. Chun-Chieh Yeh at the OPD of General Surgery, China Medical University Hospital a few days ago. In addition to the full splenectomy, he was advised of two other surgery types for reserving the functions of the spleen, including “partial splenectomy” and “autotransplantation after full splenectomy.” He accepted the “laparoscopic partial splenectomy surgery” to completely deal with the trouble in his body before serving in a hospital after graduation.

Dr. Chun-Chieh Yeh from the department of General Surgery, China Medical University Hospital explained that the spleen is a solid organ located next to the tail of the pancreas in the abdomen. It is responsible for blood filtration, old blood cell clearance, and contagious bacteria cleaning of the body, especially those bacteria protected by the capsules. The spleen is pretty fragile so massive hemorrhaging of the spleen is common after abdominal trauma, which requires emergent management. Furthermore, some post trauma or congenital splenic cysts will cause compression syndrome of the organs in the abdomen if the diameters of the cysts are bigger than 5 cm and require surgical intervention for removal. In addition, some patients suffering from severe blood related diseases, including Thalassemia, idiopathic thrombocytopenia purpura, and so on, may need to be treated with splenectomy as well.

Dr. Chun-Chieh Yeh mentioned that the immunological cleaning effects of the bacteria with capsules may be reduced, while the risk of thrombosis may increase after the full splenectomy, especially “overwhelming post-splenectomy infection (OPSI),” whose incidence is one per 500 percent year with 5% lifetime risk. In the beginning, patients may only experience some mild symptoms of infections, including fever, headache, tiredness and weakness, muscle soreness, abdominal pain, etc., but within 24-48 hours, it may worsen to fatal shock, with a 40-70% of mortality rate if not properly managed in time.

Dr. Chun-Chieh Yeh indicated that it is suggested to give the pneumococcal conjugate vaccine (PCV-13) as a routine two weeks before the splenectomy surgery to reduce the risk. However, due to the COVID-19 pandemic, many unvaccinated people are obsessed with getting the pneumococcal conjugate vaccines, causing a competitive effect that decreases the vaccination opportunity of patients who actually ought to be vaccinated with PCV-13, influencing patient safety in the future. For such patients, we should be alert to inform the physician of a past history of splenectomy when visiting the physician. The criteria of antibiotics use for the patient should also be relaxed to reduce the risk of “overwhelming post-splenectomy infection (OPSI).”  

In addition to the regular management mentioned above, Dr. Chun-Chieh Yeh indicated that surgeons have proposed tailor-made precision medicine to focus on the loci of the spleen with the features of benign or malignant, locations, sizes, and the physiological conditions of the patients so that the patients may choose to have autotransplantation combined with a partial or full splenectomy. As per the literature review, the original immune functions would remain if the cases may reserve 25% of the original spleen after the splenectomy. On the other hand, if the loci of the spleen are scattered, then the cases may choose to have the immune function fully reserved by having the removed normal spleen transplanted into the greater omentum cavity of the abdomen through autotransplantation after the full splenectomy.  

Along with innovative medical devices and upgrades to surgical technology, both medical behavior and achievement are making progress every day. By way of minimally invasive laparoscopic surgery, we may set the individualized medical strategy to reserve the functions of the spleen after the surgery based on the characteristics and disease level of the patients, thus achieving the goal of precision medicine.