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.     

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.     

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.     

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.     

Idiopathic thyroid abscess

INTRODUCTION

Thyroid abscesses are uncommon because the gland is relatively resistant to developing infection due to its rich blood supply, well-developed capsule and high iodine content. However, clinicians must be aware of this differential to make an early diagnosis.

PRESENTATION OF CASE

We present the case of a patient who required urgent operative resection as definitive treatment for a thyroid abscess secondary to infection with Staphylococcus aureus.

DISCUSSION

Although this is rare, a thyroid abscess left untreated can lead to serious morbidity. Therefore, clinicians must be aware of the presenting features and therapeutic options.

CONCLUSION

Thyroid abscess is an uncommon diagnosis but can lead to significant morbidity. Therefore clinicians must be aware of the diagnosis in order to institute early aggressive management.     

Laparoscopic Drainage of Pyogenic Liver Abscess

Background and Objectives:

Pyogenic liver abscesses are mainly treated by percutaneous aspiration or drainage under antibiotic cover. If interventional radiology fails, surgical drainage becomes necessary. Recently, we performed laparoscopic liver abscess drainage successfully, and we aimed to focus on the topic in light of a systematic review of the literature.

Methods:

A 22-year-old man was admitted with a 4.5-cm multiloculated abscess in the left lobe of the liver. The abscess did not resolve with antibiotic-alone therapy. Percutaneous aspiration was unsuccessful due to viscous and multiloculated contents. Percutaneous catheter placement was not amenable. Laparoscopic abscess drainage was preferred over open abscess drainage. We used 3 trocars, operation time was 40 minutes, and blood loss was minimal. In the mean time, we searched PubMed using the key words [(liver OR hepatic) abscess*] AND [laparoscop* OR (minimal* AND invasiv*)].

Results:

Postoperative recovery of the patient was uneventful, and the patient was asymptomatic after 3 months of follow-up. In the literature search, we found 53 liver abscesses (51 pyogenic and 2 amebic) that were treated by laparoscopy. Mean success rate was 90.5% (range, 85% to 100%) and conversion rate was zero.

Conclusion:

Treatment of liver abscess is mainly percutaneous drainage. Laparoscopic drainage should be selected as an alternative before open drainage when other modalities have failed.     

The incidence of epidural abscess following epidural analgesia in open abdominal aortic aneurysm repair

INTRODUCTION

Complications of epidural catheterisation can cause significant morbidity. Epidural abscess following epidural catheterisation is rare and the reported incidence is variable. The purpose of this study was to review the incidence of epidural abscess in patients undergoing open abdominal aortic aneurysm (AAA) repair.

PATIENTS AND METHODS

A retrospective case note review of all patients having open AAA repair over a 5-year period.

RESULTS

A total of 415 patients underwent open AAA repair between January 2003 and March 2008. Of these, 290 were elective procedures and 125 were for ruptured aneurysms. Six patients underwent postoperative magnetic resonance imaging of the spine for clinical suspicion of an epidural abscess. Two of these (0.48%) had confirmed epidural abscess and two superficial infection at the epidural site.

CONCLUSIONS

The incidence of epidural abscess following epidural analgesia in patients undergoing open AAA repair within our department was 0.48%. Although a rare complication, epidural abscess can cause significant morbidity. Epidural abscesses rarely develop before the third postoperative day.     

The long-term results of percutaneous drainage of diverticular abscess

INTRODUCTION

Diverticulitis is a common condition occasionally complicated by abscess formation. Small abscesses may be managed by antibiotic therapy alone but larger collections require drainage, ideally by the percutaneous route. This minimally invasive approach is appealing but there is little information regarding the long-term follow-up of patients managed in this way. To address this question, we looked at a consecutive series of patients who underwent percutaneous drainage in our institution.

PATIENTS AND METHODS

A retrospective study was performed of patients undergoing percutaneous drainage of a diverticular abscess from 1999–2007.

RESULTS

A total of 26 abscesses were identified in 16 patients. In 69% of cases, the abscess was located in the pelvis. The mean size of the abscesses was 8.5 ± 0.9 cm. Drainage was performed under CT (83%) or ultrasound guidance. The mean duration of drainage was 8 days. Fistula formation following drainage occurred in 38% of cases. Eight patients (mean age, 71 years) underwent subsequent surgical resection 9 days to 22 months (mean, 7 months) following initial presentation. Eight patients with significant co-morbid conditions were managed by percutaneous drainage only. The 1-year mortality was 20% and resulted from unrelated causes. The long-term stoma rate was 13%.

CONCLUSIONS

Percutaneous drainage can safely be performed in patients with a diverticular abscess. It can be used as a bridge before definitive surgery but also as a treatment option in its own right in high-risk surgical patients. We believe percutaneous drainage reduces the need for major surgery and reduces the risk of a permanent stoma.     

Microsurgical Varicocele Repair on Men with Grade III Lesions and Chronic Dull Scrotal Pain: A Pilot Study

Introduction

The aim of the present study was to evaluate the effectiveness of microsurgical varicocele repair in patients with grade III lesions and chronic dull scrotal pain.

Materials and Methods

The study was based on 8 patients with grade III left-sided varicocele and chronic dull scrotal pain for whom a microsurgical subinguinal varicocele repair was performed. The 1-year follow-up included pain assessment and scrotal examination.

Results

Of the 8 patients, 7 (88%) reported complete resolution of pain with no palpable varicocele on scrotal examination. No cases of testicular atrophy or hydrocele formation were reported.

Conclusion

These results indicated that microsurgical varicocele repair may benefit patients with grade III lesions and chronic dull scrotal pain.Key Words: Microsurgery, Chronic scrotal pain, Varicocele, Varicocele repair     

Management of splenic injuries in a Canadian trauma centre

Objectives

To document the current practice pattern for the treatment of splenic injuries in one Canadian trauma centre and to identify factors that determined which method was employed.

Design

A cohort study.

Setting

A Canadian lead trauma centre.

Patients

A cohort of 100 patients with splenic injury treated at one trauma hospital over 5 years was identified from a prospective trauma database.

Main Outcome Measures

The success rate and failure rate for splenic salvage by splenectomy, splenorrhaphy or observation. Volume of blood transfused, injury severity score (ISS) and method of diagnosis.

Results

The median ISS for the cohort was 34 (36 for splenectomy, 38 for splenorrhaphy and 35 for observation). A blunt mechanism of injury was present in 96%. The diagnosis was made by computed tomography (CT) in 55%. Splenic salvage was accomplished in 51 patients; of these, 44 (86%) were in the observation group, and the success rate was 90% (within the range reported in the literature). Only seven patients underwent splenorrhaphy. CT was performed more frequently in the observation group than in the splenectomy group (82% v. 25%, p < 0.0001). The splenectomy group had more blood tranfused than the successful observation group (mean units 15 v. 3, p = 0.0001) and had a higher median ISS (36 v. 29, p = 0.02). Multivariate analysis revealed that the method of diagnosis (CT v. diagnostic peritoneal lavage) was the strongest factor associated with how the splenic injury was treated.

Conclusions

The finding in this report of an increase in observational treatment of splenic injuries represents a shift in practice from a previous Canadian report and is in keeping with recent published trends from the United States. Future studies are needed to assess whether any strong regional practice pattern variations in the management of blunt splenic injuries exists in other trauma centres across Canada.     

Transition of Spleen Volume Long After Pediatric Living Donor Liver Transplantation for Biliary Atresia

Purpose

After undergoing the Kasai procedure for biliary atresia (BA), most patients develop severe splenomegaly that tends to be improved by liver transplantation. However, fluctuations in splenic volume long after transplantation remain to be elucidated.

NOTES for the management of an intra-abdominal abscess: transcolonic peritonoscopy and abscess drainage in a canine model

Background

We studied natural orifice transcolonic drainage of intra-abdominal abscesses in a canine survival model to evaluate the difficulty of peritonoscopy and abscess drainage and the reliability of endoluminal colotomy closure.

Methods

We placed a 7 cm nonsterile saline-filled latex balloon intra-abdominally to mimic or induce an abscess or inflammatory mass. Seven days later, we advanced a single-channel endoscope transanally into the sigmoid colon of the animal, made a colotomy and then advanced the endoscope intraperitoneally. We evacuated the identified abscess and placed a drain transabdominally. We closed the colotomy endoluminally with a tissue approximation system using 2 polypropylene sutures attached to metal T-bars. Two weeks later, we evaluated the colotomy closure at laparotomy.

Results

We studied 12 dogs: 8 had subphrenic balloon implants and 4 had inter-bowel loop implants. Eleven survived and underwent transcolonic peritonoscopy; we identified the “abscess” in 9. The colotomy was successfully closed in 10 of 11 dogs. Although abscesses were easily identified, the overall difficulty of the peritonoscopy was moderate to severe. One dog required colotomy closure via laparotomy, while 9 had successful endoluminal closure. After colotomy closure, 8 animals survived for 2 weeks (study end point) without surgical complications, sepsis or localized abdominal infections. On postmortem examination, all closures were intact without any adjacent organ damage or procedure-related complications.

Conclusion

Natural orifice transluminal endoscopic surgery provides a novel alternative to treating intra-abdominal pathology. It is technically feasible to perform endoscopic transcolonic peritonoscopy and drainage of an intra-abdominal abscess with reliable closure of the colotomy in a canine experimental model.     

Role of Conventional and Diffusion-Weighted Magnetic Resonance Imaging of Spinal Treatment Protocol for Hydatid Disease

Objective:

To demonstrate the role of magnetic resonance imaging (MRI) in determining the treatment protocol for hydatid disease of the spine.

Design:

Case report; literature review.

Findings:

Diffusion-weighted MRI can help differentiate complicated infected hydatidosis from abscesses, epidermoid cysts from arachnoid cysts, and benign from malignant vertebral compression fractures. It is also helpful in differentiating between abscesses and necrotic tumors.

Conclusion:

Diffusion-weighted MRI can help differentiate between infections requiring immediate surgery and those that can be treated medically with antihelmintic treatment.     

Management of splenic abscess in children by percutaneous drainage

Background/Purpose

Isolated splenic abscesses are rare in pediatric patients. The recommended treatment in the literature has been in favor of splenectomy, although conservative treatment with splenic preservation is being increasingly reported. We report successful management of 4 pediatric patients with splenic abscess by needle aspirations and antibiotics.

Materials and Methods

Four children (aged 7-11 years; male-female, 3:1) were admitted in our institution with history of high-grade fever with chills, anorexia, left hypochondrial pain, and splenomegaly. One child was a known case of thalassemia, and one had a history of typhoid fever. The others did not have any predisposing condition. Ultrasonography (USG) and computed tomographic scan of the abdomen showed a solitary abscess in the spleen in 2 patients and multiple abscesses in the other 2. Ultrasonography-guided needle aspiration in 3 cases revealed purulent fluid, which, on culture, grew Escherichia coli in 1 case, Salmonella paratyphi A in 1 case, but sterile in 1 case. Blood culture was sterile in all the cases, but Widal's test was positive in 2 patients. Treatment protocol included USG-guided needle aspiration of pus along with intravenous ceftriaxone, metronidazole, and amikacin for 3 to 12 weeks.

Results

All 4 patients showed a good response to conservative treatment. Serial USG showed gradual resolution of abscess, and none was subjected to splenectomy.

Conclusion

Isolated splenic abscess in children can be successfully treated with needle aspirations and intravenous antibiotics, thereby avoiding splenectomy.     

Primary scrotal tuberculosis: A rare but intriguing entity

Introduction

Tuberculosis (TB) of the genitourinary tract is usually secondary to a primary site in another part of the body. Primary scrotal TB is an extremely rare condition and it may mimic viral orchitis, epididymitis, hydrocele, spermatocele, testicular torsion, scrotal trauma, or a tumour.

Case presentation

A 45-year-old man presented with a 3-month history of diffuse scrotal enlargement followed a month later by swelling in the left groin. Scrotal ultrasonography revealed a 4 cm x 4 cm hypoechoic, heterogeneous, inflammatory mass with multiple fistulae at the bottom of the scrotum without any extension to the deeper structures, and bilateral multiple inguinal adenopathy.

Discussion

Genitourinary TB may present with adrenal insufficiency, renal disease, obstructive uropathy and chronic cystitis with sterile pyuria. Although scrotal USG is very helpful, it is not a definitive diagnostic tool. Histopathology is mandatory either in the form of FNAB or formal biopsy. Most cases respond well to antitubercular drugs only.

Conclusion

An optimum diagnostic and therapeutic protocol is urgently needed for cases of primary scrotal TB to prevent misuse of costly investigations and treatments and to avoid unnecessary surgical interventions when the patient can be cured by antitubercular treatment only.     

A complex fistula-in-ano presenting as a soft tissue tumor

INTRODUCTION

Anorectal abscess and fistula are quite commonly encountered diseases. Both of these are the acute and chronic manifestations of the same entity. While abscess are thought to begin as an infection in the anal glands, their spreading into adjacent spaces results in a fistula formation. At many times this spread occurs in a complex pattern which is difficult to map and treat.

PRESENTATION OF CASE

This paper describes a complex perianal fistula that presented as a painless benign lump in the upper outer quadrant of the right buttock. The lump initially thought to be a soft tissue swelling was later diagnosed to be a chronic abscess cavity extending medially toward the anal canal in the form of a complex fistulous tract.

DISCUSSION

Complex perianal fistulas are difficult to treat and are prone to recurrences. Correct diagnosis and characterization of the fistula is essential to optimize the treatment. Clinical examination alone may not give a correct picture of the actual disease, thereby requiring radiological investigations like MRI.

CONCLUSION

Although rare, sometimes common clinical conditions like fistula-in-ano may also present in complex manner. It is important to establish the diagnosis firmly and map the fistula properly before going in for surgery. Complexity of fistulas and improper mapping often leads to recurrences and other complications like incontinence.     

Unusual presentation of follicular carcinoma thyroid with special emphasis on their management

INTRODUCTION

Follicular carcinoma of thyroid usually behaves in an indolent manner with low metastatic potential. Distant metastases as initial presentation is rare in follicular carcinoma; especially in young patients.

PRESENTATION OF CASE

We report the clinical, pathological features and the management of three different cases of follicular carcinoma of the thyroid with unusual presentations at the time of diagnosis. First case presented as thyroid abscess, second case with a large skull swelling in a pre-exiting goiter and the third case with a swelling in the sternum.

DISCUSSION

Follicular carcinoma of thyroid is the second category of well-differentiated thyroid cancer that constitutes about 10% of all thyroid malignancies. Blood borne metastasis is common with spread to lung, bone and other solid organs. In less than 10% cases of follicular carcinoma, there is evidence of lymphatic involvement. The patients’ presentations above are highly unusual.

CONCLUSION

Recognizing these cases has a significant impact on clinical decision-making and prognosis of the patients. Treatment in these patients should be individualized and an alternative therapeutic approach should be considered.     

An irreducible left scrotal hernia containing a sigmoid colon tumor (adenocarcinoma) – Case report

INTRODUCTION

In relation to all inguinal hernias, large irreducible scrotal hernias are quite rare, while such hernias containing colon tumors in the sac have so far been described in fewer than 30 cases.

PRESENTATION OF CASE

A 61-year-old patient was admitted for a planned surgery because of a large irreducible left-sided scrotal hernia. Intraoperatively, a large tumor of the sigmoid colon was found in the hernial sac. In a histopathological examination it was diagnosed as adenocarcinoma. A palliative operation was performed and he was referred to further systemic and palliative treatment (because of numerous coexisting liver metastases).

DISCUSSION

Until now, only about 30 cases of colon tumor in inguinal hernia sac have been reported.

CONCLUSION

It should be remembered that even the most obvious preoperative diagnosis may be verified intraoperatively.