Splenic cyst during pregnancy

INTRODUCTION

Splenic cyst during pregnancy is rare and may result in spontaneous rupture during the third trimester, which increases perinatal morality.

PRESENTATION OF CASE

We present a 27-year-old healthy Caucasian female who presented at 18 weeks gestation with left flank pain, early satiety and weight loss. Imaging studies demonstrated a large complex multiloculated splenic cyst. The patient underwent a successful laparoscopic splenectomy and delivered a healthy child at term without complication.

DISCUSSION

Spontaneous rupture of a splenic cyst during the third trimester incurs a perinatal mortality rate as high as 70%. Surgical management includes open or laparoscopic splenectomy or fenestration and preservation of the spleen.

CONCLUSION

Laparoscopic splenectomy during the second trimester appears to be safe and offers definitive management of a large symptomatic splenic cyst during pregnancy.     

Isolated Gastric Varices Resulting from Iatrogenic Splenic Vein Occlusion: Report of a Case

Iatrogenic splenic vein occlusion is known to be a rare cause of left-sided portal hypertension. We herein describe the clinical course of a 43-year-old woman with isolated gastric varices, which proved to be attributable to a segmental splenic vein resection during an operation for a benign pancreatic tumor 11 years previously. Seven years after the initial operation, prominent gastric varices due to left-sided portal hypertension were first noted. During the follow-up period of 4 years, she had no episodes of gastrointestinal hemorrhaging. Although the size of the gastric varices did not change, she decided to have a splenectomy considering the potential risk of variceal hemorrhaging. It may be reasonable to perform a splenectomy concomitantly when the splenic vein is to be resected or ligated during pancreatic surgery to avoid the future development of left-sided portal hypertension. However, the role of prophylactic surgery in asymptomatic patients with iatrogenic splenic vein occlusion remains to be determined. Received: June 3, 2002 / Accepted: November 19, 2002 RID="*" ID="*" Reprint requests to: Y. Ku     

Ruptured spontaneous splenic artery aneurysm: A case report and review of the literature

INTRODUCTION

Splenic artery aneurysm is a rare condition, however, potentially fatal. The importance of splenic artery aneurysm lies in the risk for rupture and life threatening hemorrhage.

PRESENTATION OF CASE

This is a case of a ruptured splenic artery aneurysm in a 58-year-old lady. She presented with hypovolemic shock and intra-peritoneal bleeding. Diagnosis was confirmed by CT angiography and she was managed by operative ligation of the aneurysm with splenectomy and distal pancreatectomy.

DISCUSSION

The literature pointed the presence of some risk factors correlating to the development of splenic artery aneurysm. In this article we discuss a rare case of spontaneous (idiopathic) splenic artery aneurysm and review the literature of this challenging surgical condition.

CONCLUSION

Splenic artery aneurysm needs prompt diagnosis and management to achieve a favorable outcome, high index of suspicion is needed to make the diagnosis in the absence of known risk factors.     

Laparoscopic Resection of an Undifferentiated Pleomorphic Splenic Sarcoma

Background:

Splenic tumors are rare. Malignant fibrous histiocytoma (MFH) of the spleen is one of the least common primary splenic tumors. Review of the literature shows that a laparoscopic resection has never been tried.

Method:

We discuss the case of a 76-year-old man with a 7-cm MFH in the spleen and present a review of splenic sarcomas.

Results:

The patient underwent a successful laparoscopic splenectomy; pathology revealed a rare undifferentiated pleomorphic sarcoma of the spleen. A review of the international literature identified 15 additional cases of primary splenic MFH. Survival was rarely longer than 15 months.

Conclusion:

Malignant fibrous histiocytoma of the spleen is an exceedingly rare tumor with a poor prognosis. In experienced hands, laparoscopic splenectomy is a feasible operative choice for primary splenic sarcoma.     

Case report of rare chronic myelogenous leukemia related multibacterial splenic abscess presenting with scrotal swelling

INTRODUCTION

Splenic abscesses associated with leukemia are rare. Most reported cases of splenic abscesses occur after chemotherapy and are related to the immunosuppressive effects of the chemotherapy. Their etiology is most frequently fungal.

PRESENTATION OF CASE

A 58-year-old male presented with splenomegaly and scrotal swelling secondary to a multibacterial splenic abscess which required a splenectomy. Upon investigation he was found to suffer from chronic myeloid leukemia (CML) and epididymitis.

DISCUSSION

Splenic abscesses are rarely found in leukemic patients. Reported cases are fungal and commonly occur after chemotherapy due to immunosuppression. Scrotal swelling with concurrent splenomegaly can be found in other pathologies including brucellosis, Lyme disease and even non-Hodgkin primary testicular lymphoma. Scrotal swelling in our case was likely secondary to epididymitis and exacerbated by the effects of splenomegaly upon the systemic circulation promoting venous congestion.

CONCLUSION

This case illustrated an unusual presentation of CML because the patient presented with splenomegaly, a multibacterial splenic abscess, and scrotal swelling.     

Left-sided portal hypertension caused by serous cystadenoma of the pancreas: Report of a case

We report a case of serous cystadenoma of pancreas causing left-sided portal hypertension and gastric varices. A 68-year-old man was admitted for treatment of a pancreatic body tumor. Contrast-enhanced computed tomography (CT) showed a honeycombed cystic mass. A celiac angiogram showed a hypervascular tumor supplied mainly by a dilated splenic artery and dorsal pancreatic artery. In the venous phase, the patent splenic vein had a large hepatopetal collateral vein via the coronary gastric vein. Upper gastrointestinal endoscopy showed isolated varices of the gastric fundus. We made a preoperative diagnosis of a serous cystic tumor of the pancreas with left-sided portal hypertension and performed distal pancreatectomy with splenectomy. The resected tumor was 8 cm in diameter and had a typical honeycombed microcystic pattern with central stellate scarring. The spleen was not enlarged. Histopathological examination confirmed a diagnosis of serous cystadenoma without any sign of malignancy. Postoperative endoscopy showed disappearance of the gastric varices.     

A rare case of serous cystadenoma of the pancreas presenting with left-sided portal hypertension

We herein report the case of a 63-year-old woman with a serous cystadenoma of the pancreas presenting with left-sided portal hypertension secondary to isolated splenic vein occlusion. She was admitted to our hospital for sudden hematemesis. Emergency upper gastrointestinal endoscopy revealed hemorrhagic erosive gastritis and isolated varices in the gastric fundus. An abdominal angiographic study disclosed a large hypervascular tumor of the pancreatic tail which caused isolated splenic vein occlusion by tumor compression and formed large hepatopetal collaterals via the gastric varices. The patient underwent tumor resection with splenectomy and, as a result, the gastric varices disappeared and the postoperative course was uneventful. Left-sided portal hypertension secondary to splenic vein occlusion is an uncommon complication mostly associated with pancreatitis and pancreatic carcinoma. Although benign pancreatic neoplasms only rarely cause such a condition, the possibility of gastrointestinal bleeding due to this condition should be carefully taken into consideration when treating pancreatic disease.     

Outcome of laparoscopic splenectomy with preoperative splenic artery embolization for massive splenomegaly

Background  

Laparoscopic splenectomy (LS) has become a safe and feasible procedure for cases involving spleens of normal size. Only a few publications report on the outcome of LS with preoperative splenic artery embolization (SAE) for massive splenomegaly. The authors present their experience in patients with massive splenomegaly who underwent laparoscopic-assisted splenectomy (LAS) or hand-assisted laparoscopic splenectomy (HALS) following SAE.     

Preserved function after angioembolisation of splenic injury in children and adolescents: A case control study

Background

Non-operative management for blunt splenic injuries was introduced to reduce the risk of overwhelming post splenectomy infection in children. To increase splenic preservation rates, splenic artery embolization (SAE) was added to our institutional treatment protocol in 2002. In the presence of clinical signs of ongoing bleeding, SAE was considered also in children. To our knowledge, the long term splenic function after SAE performed in the paediatric population has not been evaluated and constitutes the aim of the present study.

Methods

A total of 11 SAE patients less than 17 years of age at the time of injury were included with 11 healthy volunteers serving as matched controls. Clinical examination, medical history, general blood counts, immunoglobulin quantifications and flowcytometric analysis of lymphocyte phenotypes were performed. Peripheral blood smears were examined for Howell–Jolly bodies (H–J bodies) and abdominal ultrasound was performed in order to assess the size and perfusion of the spleen.

Results

On average 4.6 years after SAE (range 1–8 years), no significant differences could be detected between the SAE patients and their controls. Total and Pneumococcus serospecific immunoglobulins and H–J bodies did not differ between the study groups, nor did general blood counts and lymphocyte numbers, including memory B cell proportions. The ultrasound examinations revealed normal sized and well perfused spleens in the SAE patients when compared to their controls.

Conclusion

This case control study indicates preserved splenic function after SAE for splenic injury in children. Mandatory immunization to prevent severe infections does not seem warranted.     

Spontaneous Splenic Rupture Four Days after an Open Appendicectomy

Introduction

Spontaneous splenic rupture is a rare but dangerous event that requires prompt diagnosis and frequently an emergency splenectomy. Previous case reports have described the occurrence in patients with medical conditions, anticoagulant treatments, endoscopic procedures, laparoscopic surgery or no particular predisposing factor. Our report is the first to describe the occurrence of spontaneous spleen rupture following a laparotomy conducted in the lower abdomen.

Case History

A 62-year-old woman presented with a 10-day history of right iliac fossa pain radiating to the right leg and associated vomiting. Following a routine blood check and computed tomography (CT), she underwent an open appendicectomy through a lower midline laparotomy for an appendicular abscess. Four days later, she experienced haemorrhagic shock and a second CT scan diagnosed a spontaneous splenic rupture that required a prompt splenectomy.

Conclusions

Our case is the first that describes the spontaneous rupture of the spleen following an open procedure conducted in the lower quadrants. This entity must still be considered as a rare but potential cause for postoperative bleeding when no other obvious sources are identified.     

The impact of splenic artery embolization on the management of splenic trauma: an 8-year review

Background

Splenic artery embolization (SAE) is an adjunct to nonoperative management (NOM) of splenic injuries. We reviewed our experience with SAE to identify its impact on splenic operations.

Methods

Patients admitted with splenic injuries over an 8-year period were identified and the initial method of management noted (simple observation, SAE, or splenic surgery). The first 4 years (period 1) during which SAE was introduced was compared with the latter 4 years (period 2) when it was used frequently.

Results

There were 304 patients in period 1 and 416 in period 2. NOM was initial management in 59.9% in period 1% and 60.1% in period 2 (P = 1.0) and failure rates were 5.3% versus 2.9%, respectively (P = .12). More SAE procedures were performed in period 2—13.7% versus 4.9% (P ≤.001)—and there was a reduction in the proportion of splenic operations—35.2% versus 26.2% (P <.01).

Conclusions

SAE is associated with a reduction in splenic operations, although it did not alter the failure rate of NOM.     

Laparoscopic Splenectomy Using LigaSure

Background:

Laparoscopic splenectomy (LS) has become the standard approach for most splenectomy cases. Bleeding is the main complication and cause for conversion. We present our experience with the LigaSure and discuss its advantage as a vessel sealing system in achieving safe vascular control.

Method:

Over a 3-year period, we performed 12 consecutive LS using LigaSure at a single center. A literature review of all the patients who had undergone laparoscopic splenectomy with of the LigaSure to achieve vascular control at the hilum was carried out, assessing its advantages and outcome.

Results:

Twelve LS were performed. Eleven of these patients had ITP, and one patient had sickle cell disease. The mean blood loss was 70mL (range, 50 to 460), and operating time was 126 minutes (range, 110 to 240). Two postoperative complications occurred: portal vein thrombosis in one case and subphrenic collection in the other. The literature review revealed 8 studies with 231 cases in which the LigaSure was used to perform laparoscopic splenectomy. A significant reduction in operating time (average 102 minutes) and intraabdominal blood loss (66mL) was observed with the LigaSure compared with endostaplers.

Conclusion:

The use of LigaSure and the semilateral position results in a gain of time and safety in addition to low intraoperative bleeding, need for transfusion, minimal complications and a low conversion rate.     

Significance of splenic vein thrombosis in chronic pancreatitis

BACKGROUND: Splenic vein thrombosis leading to sinistral portal hypertension and variceal bleeding is a complication of chronic pancreatitis. The management of these patients without variceal bleeding remains controversial. METHODS: A total of 157 patients with chronic pancreatitis were managed consecutively in our center between January 1996 and December 2005. Thirty-four patients with chronic pancreatitis were diagnosed to have splenic vein thrombosis. RESULTS: The incidence of splenic vein thrombosis in patients with chronic pancreatitis was 22%. Fifteen percent of patients with chronic pancreatitis and splenic vein thrombosis presented with gastroesophageal variceal bleeding. Nine patients underwent splenectomy along with pancreatic procedures and 21 patients underwent pancreatic procedures only. Adding splenectomy to the pancreatic procedure did not lead to increased morbidity or mortality. CONCLUSION: Splenectomy should be added to the pancreatic procedure in patients who have evidence of portal hypertension on preoperative evaluation, especially if gastric varices are found.     

全脾栓塞对完全腹腔镜巨脾切除术的价值探讨

目的 探讨全脾栓塞对腹腔镜巨脾切除术(laparoscopic megasplenectomy,LMS)的价值.方法 12例门脉高压巨脾脾亢病人采用全脾栓塞,再于4 h内行完全腹腔镜下巨脾切除术,分析病人的临床资料.结果 12例均顺利完成全脾栓塞及腹腔镜巨脾切除,无中转开腹,手术时间平均120.2 min,术中出血量平均107.5 ml,无术后并发症.结论 对门脉高压巨脾者采用介入全脾栓塞后完全腹腔镜巨脾切除的方式,是一种可供选择的安全、有效的微创方法 .     

Previous portal hypertension surgery negatively affects results of mesenteric to left portal vein bypass

Purpose

The mesenteric to left portal vein bypass (MLPVB) has been successfully used to treat extrahepatic portal vein obstruction (EHPVO) in children. We examined the effect of failed prior surgical or radiological procedures intended to treat complications of portal hypertension on the success rate of subsequent MLPVB surgery.

Methods

Sixty-two patients younger than 18 years with EHPVO underwent MLPVB between 1997 and 2006. Children were divided into 3 groups: those with no prior surgery related to portal hypertension, those with prior portosystemic shunts, and those with either splenectomy or mesenteric vascular embolization procedures. The effect of prior procedures on the patency rate of the MLPVB was then examined.

Results

Of 62 children, 11 (17.7%) had significant procedures to treat symptoms of portal hypertension: 6 had at least 1 portosystemic shunt attempt, 3 had isolated splenectomy, and 2 had embolization of the splenic artery or coronary and peripancreatic varices. Patients with previous portal hypertension surgery were significantly older and larger than those with no surgery. Patients with no prior interventions had a significantly higher MLPVB patency rate (88.2%, 45/51) than those with no prior interventions (63.6%, 7/11). Prior splenectomy alone was not found to adversely affect MLPVB. Patients with prior embolization procedures or unsuccessful shunts had significantly poorer successful outcomes (0% and 66.7%) than those with no prior interventions (88.2%; P < .005).

Conclusions

The results demonstrate that prior portosystemic shunts or mesenteric embolizations have a deleterious effect on outcome after MLPVB and should be avoided whenever possible. This study suggests that patients with symptomatic EHPVO should undergo MLPVB as a primary intervention rather than as a rescue procedure to optimize MLPVB patency.     

Morbidity of hand-assisted laparoscopic splenectomy compared to conventional laparoscopic splenectomy: a 6-year review

Background

Laparoscopic splenectomy (LS) has several advantages over the open procedure but can be technically demanding when performed in patients with massive splenomegaly. We hypothesized that patients who undergo hand-assisted LS (HALS) may experience the benefits of LS while having their enlarged spleens removed safely.

Methods

We reviewed the charts of patients who underwent HALS or LS between January 2003 and June 2008. Evaluated parameters included intraoperative and early postoperative morbidity and mortality, conversion to open surgery, need for blood transfusion, length of postoperative hospital stay, patient demographics, diagnosis leading to splenectomy, splenic weight and number of postoperative days to resuming normal diet. Differences were analyzed while controlling for splenic weight and malignant diagnosis using multiple linear and logistic regression analysis.

Results

In all, 103 patients underwent splenectomy (23 HALS, 80 LS). Patients who had HALS were older and had larger spleens, and a greater proportion had malignant diagnoses. We observed no significant differences in morbidity, conversion to open surgery or need for blood transfusion. The mean length of postoperative stay, duration of surgery and days to resuming full diet were longer in the HALS group. No patients died. No group differences were significant after controlling for splenic weight and malignant diagnosis.

Conclusion

The morbidity associated with HALS is comparable to that with LS. The longer duration of surgery and hospital stay for HALS patients was likely related to greater splenic weight, older age and greater proportion of malignant diagnoses. Hand-assisted LS is a viable alternative to open surgery in patients with massive spleens.     

Randomized controlled trial to investigate the impact of anticoagulation on the incidence of splenic or portal vein thrombosis after laparoscopic splenectomy

Background

Splenic and portal vein thrombosis (SPVT) is a potentially life-threatening complication of splenectomy. There is a paucity of studies examining the role of prophylactic pre- and postoperative anticoagulation in the prevention of this complication. We designed a prospective randomized controlled trial (RCT) to more rigorously address the impact of prophylactic anticoagulation on the incidence of asymptomatic or symptomatic SPVT, detected on Doppler ultrasound, after laparoscopic splenectomy.

Methods

This 2-centre, phase II, prospective, open-label, parallel-assignment RCT compared no postoperative anticoagulation to a regimen of 40 mg of enoxaparin subcutaneously once daily for 21 days. All patients underwent Doppler ultrasonography of the splenoportal system preoperatively and again 14–28 days after surgery to screen for nonocclusive or occlusive thrombosis.

Results

From November 2006 to November 2008, 35 patients were enrolled in the RCT. Four patients withdrew, 1 required conversion to an open procedure and 1 died at 3 months (the cause of death was not related to the study). Of the 29 patients remaining, 15 were randomly assigned to the anticoagulation group and 14 to the nonanticoagulation group. One (3.4%) patient in the treatment group experienced portal thrombosis. Rates of postoperative bleeding were similar in both groups.

Conclusion

This RCT of anticoagulation found a low overall risk of SPVT after laparoscopic splenectomy; however, this is an underpowered study, and further multi-centred clinical trials are needed.     

脾切除术后脾动静脉瘘的诊断与治疗

脾动静脉瘘临床罕见,容易误诊.脾动静脉瘘临床上可表现为门静脉高压症、食管胃底静脉曲张、消化道出血、腹泻、腹痛、腹腔积液、呼吸障碍、心脏衰竭等.2014年4-5月苏州大学附属第一医院收治1例脾切除术后脾动静脉瘘患者,经多学科讨论由介入放射科协助,运用脾动脉栓塞术＋腹腔动脉造影术成功治疗该例脾动静脉瘘患者,术后2个月复查腹部增强CT示腹腔积液消失,门静脉高压症症状消失,肝肾功能恢复正常.