Malignant fibrous histiocytoma presenting with complete opacification of the hemithorax: A case report

BACKGROUND

Malignant fibrous histiocytoma, a subtype of primary lung sarcoma is a very rare disease. It usually presents as a lung nodules and the final diagnosis is made by immunohistochemical studies.

METHODS

A 45-year-old patient presented with progressive dyspnea, dry cough and right shoulder pain. Chest X-ray revealed complete opacification of the right hemithorax. Chest computed tomography confirmed the presence of a heterogeneous lesion occupying the whole right hemithorax causing a mass effect on the trachea. Ultrasound guided biopsy was done and final pathology was suggestive of malignant fibrous histiocytoma.

CONCLUSION

Progressive dyspnea in young otherwise healthy patients should be investigated early on. In our case the presence of right shoulder pain indicates advance disease illustrated by the singular imaging findings.     

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.     

Vacuum Stabilization of the Spleen in Laparoscopic Splenectomy

Background and Objectives:

Recovery from laparoscopic splenectomy is greatly enhanced when compared with recovery from the laparotomy approach, yet a minority of spleens are removed laparoscopically. The spleen is smooth, rounded, and vascular, making it difficult to directly grasp, stabilize, or retract laparoscopically. The LiVac Retractor is a laparoscopic liver retractor comprising a soft silicone open ring that apposes 2 substantially planar surfaces when a vacuum is applied. It was evaluated for its efficacy in stabilization of the spleen during 2 laparoscopic splenectomies.

Methods:

The 2 patients gave consent for laparoscopic splenectomy with splenic retraction using the LiVac Retractor. The entire 3-port laparoscopic procedure was video recorded, with the resected spleens weighed as wet specimens. The patients'' postoperative courses are described.

Results:

The spleen was retracted securely for the duration of the hilar dissection in both patients. Exposure of the splenic hilum was excellent. There were no visible signs of injury to either spleen and recovery of both patients was unremarkable.

Conclusions:

The LiVac Retractor provided stable retraction and excellent exposure of the splenic hilum during both laparoscopic splenectomies, without organ injury. Early hilar dissection with vascular control was facilitated, reducing the risk of bleeding from other components of the dissection.     

Torsion of a huge accessory spleen in a 20-year-old patient

INTRODUCTION

Accessory spleen is a rare condition. Torsion of accessory spleen can lead to acute abdomen.

PRESENTATION OF CASE

We describe a young woman with an acute abdomen caused by torsion of accessory spleen. Abdominal computed tomography angiography (CTA) demonstrated an ischemic giant accessory spleen with a twisted vascular pedicle. An emergency laparotomy was performed with resection of the infarcted accessory spleen.

DISCUSSION

Accessory spleen is a rare and asymptomatic condition. Torsion of accessory spleen is also uncommon. Abdominal pain is the main symptom. CTA is effective in reaching a diagnosis. Definitive treatment of an acute abdomen due to accessory splenic torsion is emergency accessory splenectomy.

CONCLUSION

Elective accessory splenectomy should be recommended for known giant accessory spleen to prevent complications in future.     

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.     

Single Incision Laparoscopic Splenectomy in a 5-Year-Old With Hereditary Spherocytosis

Background:

Single incision laparoscopic surgery (SILS) is an emerging technique that has been used as an approach for appendectomy, cholecystectomy, and splenectomy. We describe the technique of single incision laparoscopic splenectomy for hypersplenism in a 5-year-old boy with spherocytosis.

Case Report:

The patient required blood transfusions for anemia secondary to hypersplenism. His spleen measured 9.8 cm in cranio-caudal length on ultrasound. SILS splenectomy was performed through a 2-cm umbilical incision by using 3 ports. The splenic attachments were taken down using an electrosurgical sealing and cutting device, and the hilum was transected with an endosurgical stapler. The spleen was placed in an endosurgical bag, morcellated, and removed from the abdomen via the umbilical incision without complications. Operative time was 84 minutes; blood loss was minimal.

Conclusion:

SILS splenectomy is feasible in pediatric patients. More experience is needed to assess advantages and disadvantages compared with the standard laparoscopic approach.     

Splenic torsion requiring splenectomy six years following laparoscopic Nissen fundoplication

Background:

Laparoscopic Nissen fundoplication has become a mainstay in the surgical treatment of gastroesophageal reflux disease, as it has proved to be a durable, well-tolerated procedure. Despite the safety and efficacy associated with this procedure, surgeons performing this advanced laparoscopic surgery should be well versed in the potential intraoperative and postoperative complications.

Methods:

A case is presented of a rare complication of splenic torsion following laparoscopic Nissen fundoplication. Diagnostic evaluations and intraoperative findings are discussed.

Results:

We present an otherwise healthy 41-year-old woman who underwent a laparoscopic Nissen fundoplication 6 years earlier at another medical center and presented with worsening chronic left upper quadrant abdominal pain. She was diagnosed with torsion of the splenic vascular pedicle, resulting in heterogenicity of perfusion with associated hematoma requiring open splenectomy.

Conclusion:

Surgeons should be aware of splenic torsion as a potential, albeit rare, complication related to laparoscopic Nissen fundoplication.     

Primary Malignant Fibrous Histiocytoma of the Spleen-an Extremely Rare Entity

Malignant fibrous histiocytoma (MFH) is a frequently occurring soft tissue tumour with aggressive biological behaviour. Primary MFH of the spleen, however, is an exceedingly rare occurrence. Herein, we report a case of such a neoplasm in a 66-year-old female. The tumour was well localised within the spleen and the patient remains alive and well 34 months after splenectomy without any adjuvant therapy. A brief discussion and review of the few cases of primary splenic MFH previously reported in the English language literature is included.     

Primary malignant fibrous histiocytoma of the spleen--an extremely rare entity

Malignant fibrous histiocytoma (MFH) is a frequently occurring soft tissue tumour with aggressive biological behaviour. Primary MFH of the spleen, however, is an exceedingly rare occurrence. Herein, we report a case of such a neoplasm in a 66-year-old female. The tumour was well localised within the spleen and the patient remains alive and well 34 months after splenectomy without any adjuvant therapy. A brief discussion and review of the few cases of primary splenic MFH previously reported in the English language literature is included.     

REDUCE PORT LAPAROSCOPIC SPLENECTOMY FOR GIANT EPITELIAL CYST

Background:

Delaitre and Maignien performed the first successful laparoscopic splenectomy in 1991. After that, laparoscopic splenectomy has become one of the most frequently performed laparoscopic solid organ procedures.

Aim:

To demonstrate the surgical techique of laparoscopic splenetomy with reduced portals.

Methods:

A reduce port laparoscopic splenectomy was performed by using a 10 mm and two 5 mm trocars. To entered the abdomen a trans-umbilical open technique was done and a 10 mm trocar was placed. A subcostal 5 mm trocar was placed under direct vision at the level of the anterior axillary line and another 5 mm port was inserted at the mid-epigastric region. Once it was completely dissected and freed from all of its attachments the hilum, splenic artery and vein, was clipped with hem-o-lock and divided with scissors. Then an endobag was used to retrieve the spleen after being morcellated trough the umbilical incision.

Results:

This technique was used in a 15 years old female with epigastric and left upper quadrant pain. An abdominal ultrasound demonstrated a giant cyst located in the spleen. Laboratory tests findings were normal. The CT scan was also done, and showed a giant cyst, which squeeze the stomach. The patient tolerated well the procedure, with an unremarkable postoperative. She was discharge home 72 h after the surgery.

Conclusion:

The use of reduce port minimizes abdominal trauma and has the hypothetical advantages of shorter postoperative stay, greater pain control, and better cosmesis. Laparoscopic splenectomy for giant cysts by using reduce port trocars is safe and feasible and less invasive.     

Left-sided portal hypertension: Successful management by laparoscopic splenectomy following splenic artery embolization

INTRODUCTION

Left-sided portal hypertension is a rare clinical condition most often associated with a pancreatic disease. In case of hemorrhage from gastric fundus varices, splenectomy is indicated. Commonly, the operation is carried out by laparotomy, as portal hypertension is considered a relative contraindication to laparoscopic splenectomy (LS). Although some studies have reported the feasibility of the laparoscopic approach in the setting of cirrhosis-related portal hypertension, experience concerning LS in left-sided portal hypertension is lacking.

PRESENTATION OF CASE

A 39-year-old man was admitted to the Emergency Department for haemorrhagic shock due to acute hemorrhage from gastric fundus varices. Diagnostic work up revealed a chronic pancreatitis-related splenic vein thrombosis causing left-sided portal hypertension with gastric fundus varices and splenic cavernoma. Following splenic artery embolization (SAE), the case was successfully managed by LS.

DISCUSSION

The advantages of laparoscopic over open splenectomy include lower complication rate, quicker recovery and shorter hospital stay. Splenic artery embolization prior to LS has been used to reduce intraoperative blood losses and conversion rate, especially in complex cases of splenomegaly or cirrhosis-related portal hypertension. We report a case of complicated left-sided portal hypertension managed by LS following SAE. In spite of the presence of large varices at the splenic hilum, the operation was performed by laparoscopy without any major intraoperative complication, thanks to the reduced venous pressure achieved by SAE.

CONCLUSION

Splenic artery embolization may be a valuable adjunct in case of left-sided portal hypertension requiring splenectomy, allowing a safe dissection of the splenic vessels even by laparoscopy.     

Postsplenectomy recurrence of idiopathic thrombocitopenic purpura: role of laparoscopic splenectomy in the treatment of accessory spleen

Aim

Idiopatic thrombocytopenic purpura (ITP) is the most common indication for splenectomy. The failure rate of surgery is about 8% and the failure rate after splenectomy is approximately 28% for all patients. When the presence of an accessory spleen is diagnosed, splenectomy is recommended. Laparoscopic approach is considered the first choice.

Patients and methods

At our Department, between July and November 2011 two patients underwent laparoscopic accessory splenectomy for recurrence of ITP. Both patients had a previously laparoscopic splenectomy. Preoperative Magnetic Resonance (MR) was performed in both the cases revealing the presence of an accessory spleen.

Results

The operative time was 105 and 100 minutes respectively. No perioperative complications occured. Hospital stay was four days in both cases. The first patient had a disease free period of two months; the second one of one month. Both patients restarted immunosuppressive therapy.

Conclusions

The relapse of thrombocytopenia post-splenectomy can be associated with the presence of an accessory spleen. The laparoscopic accessory splenectomy should be considered the first choice approach. Surgical accessory splenectomy allows a transitory remission of the disease.     

Oversized pseudocysts of the spleen: Report of two cases: Optimal management of oversized pseudocysts of the spleen

INTRODUCTION

Pseudocysts of the spleen are usually asymptomatic and associated with a history of trauma, infection or infarction. In this report, we present two uncommon cases of solitary, oversized pseudocysts of the spleen.

PRESENTATION OF CASE

Two patients (cases A and B), with symptoms of abdominal pain, were investigated. The laboratory and ultrasound examination confirmed the diagnosis of a large, non-parasitic splenic cyst in both cases. Computed tomography described an oversized pseudocyst occupying almost the entire splenic parenchyma in both cases and in patient A, the cyst was located in the splenic hilum. The medical history revealed a previous abdominal injury only in case A. The two patients underwent an open total splenectomy. The pathology examination verified the diagnosis of a non-parasitic splenic pseudocyst.

DISCUSSION

Both patients presented with symptoms, in contrast to the majority of patients with splenic cysts. The medical history of patients with splenic pseudocysts does not always reveal the cause of the pseudocyst formation. Any type of spleen-sparing procedure is not easy to perform in cases of surgical and anatomical difficulty, because of recurrence and the risk of intractable bleeding from the spleen.

CONCLUSION

Partial splenectomy is the recommended method for parenchymal preservation, but total splenectomy is preferred when the splenic cyst is oversized or cannot be excised with safety.     

A case of primary malignant fibrous histiocytoma of the duodenum

Background

Primary malignant fibrous histiocytoma (MFH) of the duodenum is rare and a distinct clinical entity.

Case report

A 55-year-old man presented with a history of upper gastrointestinal bleeding, vomiting and decreased body weight over the past 2 months. Abdominal exam showed an epigastric mass of 10 cm. An upper gastrointestinal endoscopy documented a tumor in the third part of duodenum. The histopathological examination of biopsy has concluded a MFH. Abdominal CT revealed a large and heterogeneous mass of 10 cm in the third part of the duodenum. The intervention was conducted by way of a bi-subcostal laparotomy. Exploration of the tumor revealed involvement of the third part of duodenum. This lesion adhered and invaded the inferior vena cava. A palliative procedure using a gastro-entero-anastomosis was carried out with uneventful postoperative course. Neither adjuvant chemotherapy nor radiotherapy were conducted. The patient died four months following his operation.

Conclusion

The biological behavior of malignat fibrous histiocytomas is extremely aggressive and mainly conditioned by size and histological grading. The treatment of choice, whenever possible, is based on early and complete surgical excision of the tumor.     

Splenic Injury During Percutaneous Nephrolithotomy

Background:

Injury to the spleen is a recognized complication during percutaneous renal access due to the close anatomical relationship of the spleen and the left kidney. However, transsplenic renal access is a rare complication of percutaneous nephrolithotomy and can also result in considerable morbidity, often requiring emergent splenectomy.

Methods:

We present our experience with splenic injury during percutaneous nephrolithotomy managed conservatively with the use of a collagen-thrombin hemostatic sealant (D-Stat; Vascular Solutions, Inc., Minneapolis, MN) after delayed removal of the nephrostomy tubes.

Results:

The patient had an uneventful recovery and was discharged home on postoperative day 6.

Conclusion:

In select hemodynamically stable patients, nonoperative management with the adjunctive use of hemostatic sealants may be considered.     

Single Access Laparoscopic Splenectomy

Background:

Laparoscopic splenectomy has been performed in a standard fashion with 4 to 5 trocars since the early 1990s. Single access laparoscopy has recently gained interest, but single access laparoscopic splenectomy has not been reported to date. It has the possible benefits of less pain, faster recovery, better cosmesis, with theoretically similar costs to that of traditional trocars.

Methods:

A case is presented and the surgical technique of single access laparoscopic splenectomy is detailed.

Results:

The patient is an otherwise healthy 24-year-old male with medically refractory idiopathic thrombocytopenic purpura and a platelet count of 15 000. A splenectomy was performed using a single incision laparoscopic technique. The patient was placed in a right lateral decubitus position, and a 2.5-cm left upper quadrant incision was made. A multi-instrument flexible single incision port was used that held 3 trocars. A standard splenectomy was performed through this port. A linear stapler was used to transect the splenic hilum. The procedure time was just over 2 hours. The patient did well, was happy with his incision, and was discharged with a platelet count of 108 000.

Conclusions:

Single access laparoscopic splenectomy is feasible in select patients and may provide a less painful, better cosmetic result.     

Massive Splenomegaly in Children: Laparoscopic Versus Open Splenectomy

Background and Objectives:

Laparoscopic splenectomy for massive splenomegaly is still a controversial procedure as compared with open splenectomy. We aimed to compare the feasibility of laparoscopic splenectomy versus open splenectomy for massive splenomegaly from different surgical aspects in children.

Methods:

The data of children aged <12 years with massive splenomegaly who underwent splenectomy for hematologic disorders were retrospectively reviewed in 2 pediatric surgery centers from June 2004 until July 2012.

Results:

The study included 32 patients, 12 who underwent laparoscopic splenectomy versus 20 who underwent open splenectomy. The mean ages were 8.5 years and 8 years in the laparoscopic splenectomy group and open splenectomy group, respectively. The mean operative time was 180 minutes for laparoscopic splenectomy and 120 minutes for open splenectomy. The conversion rate was 8%. The mean amount of intraoperative blood loss was 60 mL in the laparoscopic splenectomy group versus 110 mL in the open splenectomy group. Postoperative atelectasis developed in 2 cases in the open splenectomy group (10%) and 1 case in the laparoscopic splenectomy group (8%). Oral feeding postoperatively resumed at a mean of 7.5 hours in the laparoscopic splenectomy group versus 30 hours in the open splenectomy group. The mean hospital stay was 36 hours in the laparoscopic splenectomy group versus 96 hours in the open splenectomy group. Postoperative pain was less in the laparoscopic splenectomy group.

Conclusion:

Laparoscopic splenectomy for massive splenomegaly in children is safe and feasible. Although the operative time was significantly greater in the laparoscopic splenectomy group, laparoscopic splenectomy was associated with statistically significantly less pain, less blood loss, better recovery, and shorter hospital stay. Laparoscopic splenectomy for pediatric hematologic disorders should be the gold-standard approach regardless of the size of the spleen.     

Identification of Accessory Spleens During Laparoscopic Splenectomy Is Superior to Preoperative Computed Tomography for Detection of Accessory Spleens

Background:

Missed accessory spleen (AcS) can cause recurrence of hematologic disease after splenectomy. The objective of the study was to determine whether detection of AcS is more accurate with preoperative computed tomography (CT) scan or with exploration during laparoscopic splenectomy.

Methods:

A retrospective chart review was performed for 75 adult patients who underwent laparoscopic splenectomy for various hematologic disorders from 1999 to 2009. Preoperative CT scans were performed in all patients. Patients were followed for recurrence of disease, and a scintigraphy scan was performed in those with suspected missed AcS.

Results:

The most common diagnosis was idiopathic thrombocytopenic purpura in 29 patients (39%), followed by non-Hodgkin''s lymphoma in 22 patients (29%). Sixteen AcSs were found during surgery in 15 patients (20%), and preoperative CT scan identified 2 of these. Twelve AcSs were located at the splenic hilum (75%). Nine patients experienced recurrence of their disease, and none had a missed AcS on subsequent scintigraphy. Sensitivity of exploratory laparoscopy for detection of AcS was 100%, and for preoperative CT scan was 12.5% (P = .005).

Conclusion:

Exploratory laparoscopy during splenectomy is more accurate than preoperative imaging with CT scan for detection of AcS. Preoperative CT scan misses AcS frequently and should not be obtained for the purpose of its identification.     

Accessory wandering spleen: Report of a case of laparoscopic approach in an asymptomatic patient

INTRODUCTION

Accessory wandering spleen is a rare but dangerous condition. Abnormalities of the ligamentous apparatus of an accessory spleen may evolve into torsion of its vascular axis, which can lead to a splenic infarct making surgery necessary. Patients are often asymptomatic and the diagnosis can be accidental. An early diagnosis and a correct treatment are fundamental.

PRESENTATION OF CASE

In this case report a young woman underwent laparoscopic surgery after an incidental finding at a Pelvic Ultrasound of an accessory wandering spleen.

DISCUSSION

In literature are reported cases of asymptomatic patients with an accessory wandering spleen treated with a conservative approach. However, a torsion or infarct of the accessory wandering spleen leads to emergency surgery. The presence of an independent vascular axis of the accessory spleen reduces the risk of postoperative complications (e.g. thrombocytosis) and the administration of low molecular weight heparin should prevent the risk of portal thrombosis.

CONCLUSION

We suggest performing surgery with a laparoscopic approach in patients with accessory wandering spleen, though asymptomatic, because of the risk of serious complications in case of accessory spleen torsion.