surgical disease of spleen part 2

Splenic Cysts

• Parasitic Cysts

• Non-parasitic Cysts : True/ Pseudocyst

Non- parasitic cyst• True cyst:

- Either congenital or acquired- Rare, usually harmless and asymptomatic. - If symptomatic, enlarging , gets infected, or bleeds

over time available options include:

1. Percutaneous procedures (eg, biopsy, aspiration, drainage), 2. Direct surgical interventions such as encapsulation/cyst wall unroofing, 3. Partial or total splenectomy - provides diagnostic certainty, which is rarely clinically justified.

• Pseudocyst: the spleen is a common site for pseudocyst formation following an attack of pancreatitis.

Tumors of the Spleen

Primary is rare, include: - Lymphoma, sarcoma, hemangioma,

hamartoma. - Treatment is Splenectomy.

Secondary metastasis from solid tumors is uncommon.

Splenic hemanigoma

Splenic Abscess • Incidence : is uncommon, (0.05-0.7 %)

• Etiology: seeding from some other site of infection, e.g.:

• Infected embolus, • endocarditis• typhoid/ paratyphoid fever,• Osteomyelitis • Otitis media• Puerperal sepsis• Pancreatic necrosis• Intra-abdominal infection

• Presentation: – Fever– Abdominal pain – Pleuritic chest pain – Left shoulder pain

Physical examination : abdominal tenderness(>50%) splenomegaly(<50%)

Splenic Abscess - Work-up • CBC : leukocytosis.

• Imaging :– CXR :• Elevated left hemi-diaphragm (30%)• Pleural effusion (20%)

– Ultrasound– CT

Splenic abscess - Treatment

Medical: → Antibiotics Surgical: Splenectomy Percutaneous drainage of the splenic abscess

under radiological guidance (CT/US) – occasionally successful.

Contraindications for drainage :

–Multiloculated or debris filled abscess– multiple small abscess–Diffuse ascites–No safe route for drainage

Medical diseases of Surgical importance

Splenomegaly vs. Hypersplenism

SplenomegalyAn enlargement of the spleen.

HypersplenismAn indefinite clinical syndrome characterized by

splenomegaly and pancytopenia, in the absence of bone marrow or auto- immune disease.

Pancytopenia thrombocytopenia, leucopenia & anemia.

HypersplenismPrimary: rare, idiopathic - dx of exclusion

Secondary: to a pathologic condition: a. disorders of splenic blood flowb. Hemolytic diseasesc. Immunologic disordersd. Infiltrative diseases e. Infectious diseasesf . Neoplastic diseases

Presentation

1. Anemia, leukopenia, or thrombocytopenia. 2. Splenomegaly, incidentally during PE or imaging

studies.

3. Pain secondary to enlargement

Evaluation1. Peripheral blood smears.↓RBCs, ↓WBCs, ↓plts, reticulocytosis, abnormal

morphology.

2. Bone marrow aspirate.

3. Imaging: US or CT scan.

4. Immunologic tests.

Treatment

• Depends on the underlying cause.

• The management of most cases of hypersplenism is medical.

• Splenectomy usually has only a secondary role, when symptoms are significant or medical therapy fails to control the disease.

• Careful clinical judgments is required to balance the long term and short term risks of splenectomy against continued conservative management.

a. Disorders of splenic blood flow

1. Portal Hypertension

2. Splenic Vein Thrombosis

3. Splenic Artery Aneurysm

b. Hemolytic diseases

1. Hereditary Spherocytosis (absolute indication)

2. Congenital HA: Enzyme deficiencies (G6PD, Pyruvate kinase D), Hereditary elliptocytosis, Thalassemia major.

3. Sickle cell Anemia

4. Porphyria

c. Immunologic disorders

1. Idiopathic thrombocytopenic purpura (ITP)2. Felty’s Syndrome3. Idiopathic autoimmune HA4. Thromobtic thrombocytopenic purpura (TTP)5. SLE

Immune thrombocytopenic purpura (ITP)

- Ab directed against platelets are produced by the spleen, resulting in their destruction.

- The most frequent hematological indication for splenectomy”.

In primary ITP, we start with steroid tx for 6-9months.

- Splenectomy is indicated: i - 2 relapses on steroid therapyii - platelet count remains low.

Felty’s Syndrome

• Triad = RA + leukopenia + splenomegaly

• Splenectomy = transient improvement in the blood picture + RA responds better to steroids.

d. Infiltrative diseases

1. Gaucher’s disease2. Myeloid metaplasia3. Sarcoidosis

e. Infectious Diseases

1. Bacterial infectionsStaph.aureus, Streptococcus

2. Viral infectionsInfectious mononucleosis, HIV, hepatitis

3. Parasitic infectionsmalaria, leishmaniasis, echinococcus

4. Fungal infectionsHistoplasmosis

f . Neoplastic diseases

1. Primary tumors2. Secondary 3. Hodgkin’s disease4. Non-hodgkin’s lymphoma5. Leukemias

g. Miscellaneous

1. Rupture2. Ectopic “wandering” spleen3. Accessory spleens

Splenectomy

Splenectomy• Indications: Trauma: - massive splenic trauma whether accidental or operative.

- spontaneous rupture

Oncological:→ Primary splenic tumors Removal en bloc with the stomach as a part of radical gasterectomy, or with the

pancreas as part of distal or total pancreatectomy. Diagnostic Therapeutic.

Splenic cysts .

Hematological : hereditary spherocytosis, hypersplenism.

Portal hypertension: in association with shunt or variceal surgery.

Pre-operative Preparation

1. Blood components:• If bleeding tendency – FFP, cryoprecipitate, platelets.• Coagulation profile – normal. • Thrombocytopenia - platelets are needed during and post-

operatively.

2. Pre-immunization:Pneumococcal, HIB and meningococcal vaccines.

Should be given at least 14 days before a scheduled splenectomy and in the post-operative period after emergency removal of the spleen.

3. Antibiotic prophylaxis.

Techniques

1. Open splenectomy. Midline or transverse sub-costal incision.

2. Laparoscopic splenectomy.Access is obtained through an incision 1cm from the costal margin at the left mid-clavicular line.

Note: Accessory splenic tissue occurs in 10-30% of individuals, mostly in the hilar region. This accessory tissue should be carefully searched for and excised.

Post-operative Course and Complications

• Hemorrhage usually occurs intra operatively resulting from a slipped ligature.

• Injury to surrounding structures: 1. The gastric wall – necrosis/ perforation.2. Tail of the pancreas .

• Fistula may result from damage to greater curvature of the stomach during ligation of the short gastric vessels.

• Damage to the tail of pancreas may result in: pancreatitis, localized abscess, pancreatic fistula.

• Pulmonary: left lower lung atelectasis* , pneumonia , pleural effusion.

• Thrombocytosis, if plt count exceeds 1 x 10^6/ml –

prophylactic aspirin. Also abnormal cell morphology.

• Sub-phrenic abscess. • Splenosis - consists of transplanted splenic tissue, which,

if spontaneous, can be located anywhere within the abdomen or pelvis. The nodules associated with splenosis contain functioning splenic tissue and are usually multiple.

Post-operative Course and Complications

Overwhelming post-splenectomy sepsis (OPSS)

• A rapidly fatal illness caused by encapsulated bacteria including: - Streptococcus pneumoniae (50%). - Neissieria Meningitidis- H.influenzae type B

• Incidence is low < 0.5%• Mortality rate is high (75%)• Begins with non-specific, mild, influenza –like symptoms.• Progresses to high fever, bacteremia, thrombosis, DIC, shock, and

death. • Risk is greatest if splenectomy is performed the first 2-4 years of

life. • 80% of episodes occur within 2 years of splenectomy.

Post-operative considerations Immunizations: Pneumococcal vaccine, recommended in patients who are > 2 years of age,

every 5 years. Meningococcal, every 5 years. H.influenzae type B vaccine is recommended irrespective of age, every 10 years. Influenza vaccine – annually.

Antibiotics: Children whose spleens have been removed should receive penicillin until the

age of 18. In adults, antibiotics are to be given for 2-3 years. Patients should be instructed to seek medical care immediately if fever or

prodromal symptoms occurred.

Post-splenectomy identification — The patient should have identification item (eg, bracelet, necklace, wallet card).

• Note.- here some questions from schwartz just to test your knowledge :P - as far as I’m concern, past year final question for spleen concerns about indication splenectomy, anatomy of spleen, investigation for trauma…hek!

QUIZ

• Patient undergoing elective splenectomy should receive vaccination against Streptococcus pneumonia, H. influenza type b and meningococcus

A. 2-4 weeks before surgeryB. 1 hour prior to surgeryC. 1 week after surgeryD. 1 month after surgery

• The most common complication after open splenectomy is ?

A. atelectasisB. hemorrhageC. subphrenic abscessD. wound infection

• The treatment of choice in an otherwise healthy 22 year old patient with a large septate splenic abscess is

A. antibiotic therapy only B. antibiotic + percutaneous drainage

C. antibiotic + partial splenectomyD. antibiotic + splenectomy

• Splenectomy is indicated in a child with sickle cell following

A. 1 episode of sequestrationB. 2 episodes of sequestrationC. 3 episodes of sequestrationD. none

• In a normal patient, what is the percentage of platelets sequestrated in spleen ?

A. 2%B. 16%C. 33%D. 50%

• A 48 year old patient presents with isolated bleeding gastric varices, splenic vein thrombosis, and normal liver function. Which of the following is likely treatment of choice ?

A. beta blocker and bandingB. splenorenal bypassC. splenic vein ligationD. splenectomy

• An 18 year old otherwise healthy woman is incidentally found to have 2 cm splenic aneurysm of the mid portion of splenic artery. Which of the following is the treatment of choice ?

A. observationB. embolization C. ligation or resection of aneurysmD. splenectomy

Splenic Artery Aneurysms• Splenic artery aneurysms (SAAs) are the most common of the visceral artery aneurysms.

After the aorta and iliac they are the third most common intra abdominal aneurysms.

• predominantly a disease of the female sex. There is a close association with parity. More than 90% females with SAAs have been pregnant at least once.

• Asymptomatic.

• Indications for treatment are symptoms, documented enlargement, pregnancy or anticipated pregnancy, and diameter of greater than 2.5 cm. SAAs discovered during pregnancy should be repaired, because pregnancy greatly increases the risk of rupture.

• All potential surgical candidates should receive preoperative immunizations, similar to splenectomy patients. However, aneurysm repair with splenic preservation is the ideal treatment.

• The main complication of SAAs is rupture.

Thank you for listening !