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Perioperative Immunization for Splenectomy and the Surgeon’s ResponsibilityA Review

Educational Objective
To identify the role for surgeons in the perioperative immunization in patients undergoing splenectomy.
1 Credit CME
Abstract

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 vaccine prescription or administration. Given the dearth of high-level basic science or clinical evidence, the optimal vaccination timing and the need for booster doses are not yet well established. Although almost all guidelines indicate to not administer vaccines within 14 days before and after surgery, most data suggest that immunization might be effective even in the immediate perioperative time, thus placing the surgeon in a primary position for vaccine delivery. Furthermore, revaccination schedules are the target of ongoing debates, since a vaccine-driven hyporesponsiveness has been postulated.

Conclusions and Relevance  In patients who have undergone splenectomy, OPSI might be effectively prevented by proper immunization. Surgeons have the primary responsibility for achieving adequate, initial immunization in the setting of both planned and urgent splenectomy.

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Article Information

Accepted for Publication: March 31, 2020.

Corresponding Author: Charles M. Vollmer Jr, MD, Perelman School of Medicine, Department of Surgery, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 (charles.vollmer@uphs.upenn.edu).

Published Online: September 16, 2020. doi:10.1001/jamasurg.2020.1463

Author Contributions: Dr Casciani and Vollmer had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: Casciani, Trudeau.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: Casciani, Trudeau.

Statistical analysis: Casciani.

Administrative, technical, or material support: All authors.

Supervision: Casciani, Vollmer.

Conflict of Interest Disclosures: None reported.

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