Epidermoid splenic cysts in children and adolescents

Epidermoid cysts of the spleen are a rare lesion comprising less than 10% benign non-parasitic splenic cysts. Two boys and three girls, aged 13 to 24 years (mean 18.0 years) were diagnosed over a 4-year period. Presenting symptoms were dull, acute left hypochondrium pain and diffuse abdominal pain. Hemogram and routine analyses, as well as radiography were performed for the diagnosis. Ultrasound and CT confirmed the cystic nature of the lesion. Definitive diagnosis is made by pathological findings. Was performed splenectomy on one patient, and was performed a partial splenectomy on the other patients, in order to eliminate the symptoms produced by the cyst and prevent potential complications (postspleenectomiam sepsis). Patients were examined postoperatively. They were asymptomatic and with a normal spleen remnant detected by ultrasound and CT. Routine hematological data, blood clotting factors, and immunoglobulins were normal.     

Laparoscopic splenectomy for solitary splenic tumors

Background  Solitary splenic masses are a rare entity. There is a paucity of data in the literature on the evaluation and laparoscopic treatment for splenic masses. To further elucidate the evaluation and laparoscopic management of splenic masses we evaluated our own data. Materials and methods  Data was collected retrospectively for all patients who underwent laparoscopic splenectomy (LS) in our institution for the diagnosis of a solid mass. Patients’ charts were reviewed. Complementary data was completed when needed by telephone interviews. Results  28 patients underwent LS for solid splenic masses between 1997 and 2006. Mean age was 54.3 years and 68% were women. Patients’ symptoms included abdominal pain (46.5%), anemia (32%), weight loss (21%), and palpable abdominal mass (21%). Fifty-three percent were asymptomatic at diagnosis. Preoperative patients’ imaging included computed tomography (92.8%), abdominal ultrasound (71.4%), and positron emission tomography (PET, 32%). Seven patients (25%) had a history of lymphoproliferative disease. The mass size as measured by computed tomography (CT) scan ranged from 4 to 11 cm. Three patients (10.7%) had multiple splenic lesions. Mean operative time was 125 min. Mean estimated blood loss was 200 ml. Five patients (17.9%) had massive splenomegaly. Conversion rate was 14.3%. In three patients (10.7%) the spleen was removed with additional organs’ tissue (stomach and pancreas). Two patients (7.1%) were reoperated. There was no postoperative mortality. Mean hospital stay was 4.7 days. Four patients (14.3%) were readmitted due to complications. Pathology revealed eight patients (28%) with benign tumors and the rest (71.4%) with malignant lymphoma. Conclusions  Splenic solid tumor is a rare entity. Most of the cases were eventually diagnosed as malignant tumors. In our series, all malignant tumors were non-Hodgkin lymphoma. The most common benign lesion was inflammatory pseudotumor. This study has demonstrated the feasibility and safety of LS for diagnosis and treatment of both benign and malignant tumors of the spleen.     

Cystic masses of the spleen

Cystic masses of the spleen are unusual, and identification of their origin is critical to proper management. Presenting symptoms frequently are due to compressive effects of the mass or are due to infection. These cystic splenic masses are most commonly secondary cysts that lack a true epithelial lining and are usually related to prior splenic injury. Primary splenic cysts are rare and have an epidermal lining. Computed abdominal tomography outlines the anatomy and character of cystic masses of the spleen. Cystic splenic masses that are large, inflammatory in origin, involve the splenic hilum, or are infected, should be excised by splenectomy. Cysts localized to a single pole can be treated by partial splenectomy. An experience with three illustrative cases is presented.     

Hilar localization of splenic cyst does not always exclude the possibility of resective treatment

Non parasitic cysts of the spleen require surgical treatment because of their progressive growth and in order to prevent the potential severe complications associated with such cysts. Since it is now well known that total splenectomy, especially in young patients, has potential for short- and long-term complications, much emphasis has been placed on splenic salvage, suggesting partial splenectomy as procedure of choice for splenic cysts. However various Authors suggest that many but not all splenic cysts can be treated with partial splenectomy. In particular cystic mass arising from the anterior aspect of the hilum near to vascular peduncle contraindicate partial resection requiring splenectomy. In a case observed TC scan demonstrated a very large epidermoid cyst penetrating hilar parenchyma just above splenic vessels insertion. Preoperative imaging suggested splenectomy as the only possible procedure to remove the cyst. At operation the exposure of the splenic artery extended proximally along the pancreatic tail showed an arterial branch running with satellite vein in the splenopancreatic ligament for inferior segment of the spleen. As we found this branch it was possible to resect cyst preserving a large inferior parenchymal segment normally perfused and functioning at postoperative scintigraphic controls. In conclusion not all hilar cysts must be considered an absolute indication to splenectomy. An accurate and extensive exposure of splenic artery and vein can demonstrate vascular anatomical variations permitting resection also for large cysts located near the splenic hilum.     

Serendipitous adrenal masses: prevalence, significance, and management

Over a 2 year period, 63 of 1,459 patients examined by computerized tomography were found to have adrenal masses. In 19 patients (1.3 percent of patients examined and 30 percent of patients with adrenal masses), they were unexpected and did not give rise to symptoms or signs. Three patients were explored. Two of the patients had adrenocortical adenomas and a third, a ganglioneuroma. Adrenal function tests were performed in 14 patients and showed evidence of Cushing's syndrome in 1 patients and revealed no abnormalities in 13. The lesions in 10 of 11 nonsurgical patients followed by computerized tomography for 11 to 36 months showed no change. One lesion became significantly smaller. In a review of 988 autopsy reports, grossly visible adrenal masses were present in 73 patients (7.3 percent), including 19 adrenocortical adenomas (1.9 percent) and 50 metastases (5 percent). We conclude that serendipitous adrenal masses are usually small, nonfunctioning, and benign, the most common lesion being adrenocortical adenoma. A protocol has been suggested for management to identify the minority of patients with functioning or malignant lesions and to avoid unnecessary surgery in the others who have benign disease.     

Alimentary tract duplications in children.

This report reviews the experience with 78 alimentary tract duplications found in 64 patients over a 40 year period at the Children's Hospital of Pittsburgh. Ten patients had the duplication discovered at autopsy. Multiple duplications were found in 15% of patients. The symptoms and physical findings of a duplication varied with location, size and mucosal pattern. About one-fifth of the duplications contained ectopic mucosa, usually gastric. Two-thirds of the patients were diagnosed prior to one year of age. Vertebral anomalies, as a clue to the presence of the lesion, were present in 15% of the patients. The most common indications for surgery included a mediastinal or abdominal mass, intestinal obstruction, and gastrointestinal bleeding. The results of surgery were favorable, with a mortality of 20%. Surgical complications accounted for six deaths, while four children died of severe associated anomalies. Three others died without surgical treatment, but with symptoms from the duplication.     

Epidermoid cyst of the spleen,a case report

IntroductionSplenic tumors are rare and are either primary or secondary, benign or malignant. Most have none to minimal symptomatology and are found incidentally. Splenic cysts can be infectious, congenital, or traumatic. Epidermoid cysts and parasitic cysts are examples of primary cysts and usually have a classic presentation on imaging. Despite advanced imaging modalities and patient's clinical presentation, it can be difficult to diagnose an epidermoid cyst without histological examination. The purpose of this paper is to discuss typical findings of primary splenic cysts on imaging, but how they may differ in appearance.Presentation of case51 year old female who presented with vague abdominal discomfort and was found to have a large splenic mass with cystic components on imaging which did not demonstrate a typical primary splenic cyst appearance. Patient underwent an uneventful hand-assisted laparoscopic total splenectomy and had an uneventful recovery with histopathology revealing an epidermoid splenic cyst.ConclusionPrimary splenic cysts are difficult to diagnose and differentiate with imaging alone. They have a variable presentation and can present like as a cystic mass. It is important to include them in the differential diagnosis of splenic masses since histopathology is the final determinant of the diagnosis.     

腹腔镜脾部分切除术治疗脾脏良性疾病体会

目的 总结腹腔镜脾部分切除术治疗脾脏良性疾病的经验和体会.方法 回顾性分析2014年1月至2020年12月在金华市中心医院14例行腹腔镜脾部分切除术的患者临床资料.结果 14例中脾脏上叶切除8例,脾脏下叶切除6例,均顺利完成腹腔镜手术,无中转开腹,其中2例在3D腹腔镜下完成.术后病理:脾囊肿6例,血管瘤4例,脉管瘤2例...     

Partial splenectomy: the preferred alternative for the treatment of splenic cysts

We report six pediatric patients who had a partial splenectomy for splenic cysts and a seventh patient who had a total splenectomy. There were six epidermoid cysts and one traumatic cyst. All patients had benign postoperative courses. All patients who underwent partial splenectomy had a significant postoperative rise in platelet count that subsequently returned toward baseline. This rise implies a loss of splenic function, although the exact meaning of this is unclear. All patients had late postoperative liver-spleen scans that showed mean spleen size and function to be normal. We have described several methods of partial splenectomy used at Children's Hospital of Philadelphia. Recommendations for patients undergoing partial splenectomy include preoperative pneumococcus and Hemophilus influenzae vaccinations and prophylactic antibiotics postoperatively. The antibiotics are terminated if a liver-spleen scan and platelet count at the end of 3 months' time are normal.     

Hemangioma of the spleen: Presentation, diagnosis, and management

Splenic hemangioma is a rare disorder but remains the most common benign neoplasm of the spleen. It often has a latent clinical picture; however, spontaneous rapture has been reported to occur in as many as 25% of this patient population.1 Treatment most often consists of splenectomy. This report reviews an 8-year experience with splenic hemangioma at Mayo Clinic. Thirty-two patients were identified with SH during the 8-year study period. The average age was 63 years (range 23 to 94 years) with 17 women and 15 men. Six patients presented with symptoms potentially related to the SH. The remainder (80%) were asymptomatic, and the SH was discovered incidentally during evaluation for other disorders. A mass or palpable spleen was appreciated in only four patients (12.5%). SHs ranged in size from 0.3 to 7 cm maximum diameter. A diagnosis of SH was made in 11 patients based on the findings of a splenic mass on computed tomography or ultrasound. Each of these SHs was ≤4 cm. Three of the 11 patients had multiple SHs. All 11 patients were managed successfully with observation. All but one of the patients remains asymptomatic, and no complications have developed during follow-up (range 0.6 to 7 years, mean 2.9 years). The diagnosis of splenic hemangioma was made at the time of surgery in the remaining 21 patients (65%). Splenectomy was performed for suspicion of primary or secondary splenic pathology. There were no instances of spontaneous rupture of the SH. Small splenic lesions, which meet the radiologie criteria for hemangiomas, may be safely observed.     

Partial Splenectomy for Benign Splenic Cysts with the Aid of a Lin Clamp: Technical Note

Background Spleen-preserving procedures deserve every effort by surgeons to reduce the risk of overwhelming postsplenectomy infection. Partial splenectomy at hospitals with restricted sources remains technically demanding. We describe our method of partial splenectomy for benign splenic cysts with the aid of a Lin clamp. Patients and Methods Since April 2003 to August 2004, we have performed partial splenectomy with the aid of a Lin clamp on 5 suitable patients with symptomatic cysts. Detailed patient characteristics, operative variables, and outcomes were collected. Following surgery, they were regularly followed up every 6 months. Results All five partial splenectomies were successfully executed without any complications. The mean operating time was 75 minutes, and a mean operative blood loss of 68 ml could be achieved. With a mean follow-up of 34.4 months, no cyst recurrences were detected to date. Postoperative laboratory data, imaging studies, and clinical situations proved that the preserved splenic parenchyma maintained adequate function. Conclusions Partial splenectomy with the aid of a Lin clamp for benign splenic cysts is a practical method with the advantages of easy application, rapid parenchymal dissection, secure hemostasis, and cost-effectiveness. With encouraging preliminary results, further application of this method to bleeding eccentric parenchymal injuries of the spleen may be warranted.     

The prevalence of malignancy in satellite renal lesions and its surgical implication during nephron sparing surgery

PURPOSE: We examined the prevalence of malignancy in a synchronous ipsilateral renal lesion identified during partial nephrectomy and evaluated its clinical significance. MATERIALS AND METHODS: We retrospectively reviewed the records of 112 patients (114 renal units) who underwent nephron sparing surgery for a clinically localized sporadic renal mass between May 1995 and September 2005. RESULTS: In 37 patients (32%) an additional lesion was diagnosed and excised intraoperatively, while in 67% these lesions were known before the operation and believed to be simple cysts. During surgery the additional mass was suspicious in 8 cases and in the remainder the mass was described as simple cysts that were excised. The mean size of the primary mass was 3.1 cm (SD 1.4). In 29 (78%) cases the primary mass was malignant, in 23 (79%) of these the second mass was benign and in the remainder renal cell carcinoma was diagnosed. In 8 cases (22%) the primary mass was benign and in 2 (25%) the secondary mass was malignant. Overall 22% of all second masses were malignant, and all were low grade and low stage. We found that 7% of second ipsilateral masses could be expected to harbor malignancy. CONCLUSIONS: Based on our data it is questionable whether total nephrectomy is mandatory as an immediate response to an ipsilateral synchronous second renal mass. The present findings may represent an increased appreciation of ipsilateral multicentricity compared to historical data.     

Dexon mesh splenorrhaphy for intraoperative splenic injuries

The preferred management option for intraoperative splenic injuries is organ repair and preservation rather than splenectomy given the important immunologic function of the spleen. Wrapping the injured spleen with a Dexon mesh has been shown to be an effective alternative to splenectomy for significant splenic bleeding. However, this technique uses a foreign body that carries a theoretical infectious risk particularly in cases in which the alimentary tract has been opened. This study was undertaken to evaluate whether Dexon mesh splenorrhaphy when used for intraoperative splenic injuries was associated with significant infectious complications. The clinical courses of 23 patients who had Dexon mesh splenorrhaphy performed at a university teaching hospital for intraoperative splenic injury from 1991 to 1999 were reviewed. Eleven patients (48%) had their gastrointestinal tract opened during the surgery. No patients developed an intra-abdominal abscess or required reoperation for bleeding. The most common postoperative complications were left lower lobe atelectasis (18 patients, 78%), postoperative fever (13 patients, 56%), and left pleural effusion (12 patients, 52%). Dexon mesh splenorrhaphy effectively controls splenic bleeding due to intraoperative injury without significant infectious complications.     

Sonography of popliteal masses

Sonography of the popliteal space was performed in 28 patients with a history of a popliteal mass, verified by physical examination in all but 7 patients. The final diagnosis was established by needle biopsy or surgery. Three main types of lesions were found sonographically. A thin-walled echo-free cyst was present in 16 patients. The diagnosis in all of these cases was Baker's cyst. Two patients had a mixed cystic and solid lesion, which was found to be a Baker's cyst, with a loose body in 1 case and a soft-tissue sarcoma with hematoma in the other. Three patients showed solid lesions subsequently diagnosed as an old rupture of the semimembranosus muscle, lipoma, and soft tissue sarcoma. Sonography was normal in the 7 patients without clinical evidence of a popliteal mass.

Sonography of popliteal masses is useful to distinguish benign cysts from other lesions.     

Sonography of popliteal masses

Sonography of the popliteal space was performed in 28 patients with a history of a popliteal mass, verified by physical examination in all but 7 patients. The final diagnosis was established by needle biopsy or surgery. Three main types of lesions were found sonographically. A thin-walled echo-free cyst was present in 16 patients. The diagnosis in all of these cases was Baker's cyst. Two patients had a mixed cystic and solid lesion, which was found to be a Baker's cyst, with a loose body in 1 case and a soft-tissue sarcoma with hematoma in the other. Three patients showed solid lesions subsequently diagnosed as an old rupture of the semimembranosus muscle, lipoma, and soft tissue sarcoma. Sonography was normal in the 7 patients without clinical evidence of a popliteal mass. Sonography of popliteal masses is useful to distinguish benign cysts from other lesions.     

Surgical resection of traumatic spleen cysts by laparoscopy

Surgical resection of traumatic cysts by means of laparoscopy in two female patients is reported. The patients had sustained severe trauma in the left upper quadrant, were symptomatic and developed large splenic cysts found by computerized tomography, with an average diameter of 8.5 cm. Both patients were submitted to puncture and capsule removal by means of videolaparoscopy and diathermy; splenic parenchyma was preserved and the cyst's bed drained. No intra or postoperative complications occurred. After an average 21 months postoperative follow-up, both patients are symptom-free and no late recurrences were found on tomographic studies. The advantages of this technique over others that have been reported are the preservation of splenic parenchyma, its easy performance and efficient relief of symptoms, as well as being minimally invasive, associated with minimal postoperative pain, shorter length of hospital stay, and no early recurrences.     

Functioning and nonfunctioning cysts of the adrenal cortex and medulla.

Adrenal cysts are rare clinical and pathologic entities. The vast majority are minute in size, unilateral, and found in females at autopsy. They come to the physician's attention when they produce symptoms or are identified on x-ray studies. When symptomatic, they generally produce lumbar discomfort and gastrointestinal symptoms, and occasionally are palpable by abdominal examination. There is no significant agreement as to cause and pathogenesis of the disease. The most common histologic types are lymphangiomatous endothelial cysts, secondary to lymphangiectasis, and the fibrous wall or hemorrhagic pseudocysts. In many patients preoperative diagnosis is now possible with high quality nephrotomography, ultrasonography, and adrenal arteriography. The presence of a suprarenal mass with peripheral or laminar calcification strongly suggests the presence of an adrenal pseudocyst. Selective biochemical studies are mandatory to rule out the presence of an occult cystic pheochromocytoma, and adrenal cortical tumor. Adrenal cysts must be differentiated from all space-occupying lesions of the upper abdomen. Surgical exploration is recommended in almost all patients for accurate diagnosis and to rule out malignant disease or occult pheochromocytoma. The choice of the surgical approach should be planned to provide for safe and adequate exposure, depending on the size and location of the lesion. Careful dissection with preservation of the adjacent kidney, liver, and pancreas should be performed.     

Cystic lesion of the thymus. An occasionally malignant cervical and/or anterior mediastinal mass

Between 1965 and 1982, we treated 46 patients with cystic lesions of the thymus. Thirty patients had anterior mediastinal cysts, nine had cysts which were large enough to be both cervical and mediastinal, and seven had cervical cysts. The majority (40/46) presented with asymptomatic masses. Six patients presented with distinct complaints: dysphagia (four patients), hoarseness owing to vocal cord paralysis (one patient), and cervical pain (one patient). All six had benign thymic cysts. The diagnosis of a cystic mass was established prior to operation by ultrasonography and computed axial tomography in our last three patients. These two techniques delineated the capsule and the central fluid in those three cases. All 46 patients had the mass resected without mortality or significant morbidity, except for resection of the phrenic nerve in one patient with malignant cystic thymoma. Cervical cysts were excised through cervical incisions. Cysts located in the anterior mediastinum and cervical-mediastinal cysts required median sternotomy or right thoracotomy for successful resection. Pathological examination showed that 39 patients had benign thymic cysts, three had benign cystic thymoma, two had malignant thymoma, one had a seminoma arising in the thymus, and one had a lymphoblastoma. We believe that a cystic thymic mass which can be detected by ultrasonography and computed tomography, although usually benign, does not eliminate the possibility of malignancy, and resection, therefore, is indicated.     

脾脏占位性病变29例的临床分析

目的探讨脾脏占位性病变临床诊断和治疗。方法回顾分析1996年1月至2006年12月浙江金华中心医院肝胆外科手术治疗29例脾脏占位的临床资料。结果29例病人中良性19例,恶性10例。19例良性肿瘤中15例行脾切除术1例行脾部分切除术,3例腹腔镜下脾囊肿开窗术。10例恶性肿瘤中8例行脾切除术,1例累及肝左外叶及胃,同时行胃部分切除和肝左外叶切除术。1例脾血管肉瘤因肿瘤巨大并与周围脏器粘连严重,且肝脏有转移结节,无法切除而取活检。结论脾脏占位术前定位诊断较容易,定性较为困难。脾良性肿瘤可根据情况行脾切除或脾部分切除术,恶性肿瘤应采用以手术为主的综合治疗。     

Epidermoid Cyst of the Spleen

Background

The aim of this study is to elucidate the characteristics, clinical presentations, and management of epidermoid cysts located in the spleen and the intrapancreatic accessory spleen.

Methods

Data pooled for analysis were collected from epidermoid cyst cases encountered in the study institution and sporadic case reports obtained from the English literature.

Results

There were 115 cases of epidermoid cyst. Seventy eight (67.8 %) were found in the spleen, whereas 37 (32.2 %) were found in the intrapancreatic accessory spleen. Comparing between the two groups, the splenic group showed female predominance, younger age, and larger cystic size. For symptoms, left upper abdominal mass (57.7 %) and left upper abdominal pain (39.0 %) were more commonly found in the spleen group. Meanwhile, the intrapancreatic accessory spleen group had higher percentage of asymptomatic cysts (59.5 %). As for surgical indication, majority of patients in the spleen group underwent surgery for symptomatic relief (75.4 %), while the intrapancreatic accessory spleen group underwent surgery mainly for suspicious malignancy (90.0 %).

Conclusions

Surgical treatment for epidermoid cysts of the spleen is considered the optimal treatment for either alleviating the symptoms caused by a bulky cyst or for determining the histopathologic nature of a suspicious malignant cystic neoplasm.