Misdiagnosis of intrapancreatic accessory spleen： A report of two cases / 临床肝胆病杂志

Accessory spleen refers to the spleen tissue that exists outside of the normal spleen， with a similar structure to the main spleen and certain functions. Intrapancreatic accessory spleen （IPAS） completely enveloped by the pancreas has an incidence rate of only 2%， and it is easily misdiagnosed in clinical practice due to its atypical clinical symptoms and similar radiological features to pancreatic neuroendocrine tumor， pancreatic solid pseudopapillary tumor， and other pancreatic space-occupying lesions. This article reports the clinical data of two patients with IPAS who were misdiagnosed as pancreatic neuroendocrine tumor and pancreatic solid pseudopapillary tumor， respectively， analyzes the reasons for misdiagnosis， and summarizes the experience in diagnosis and treatment， in order to improve the ability for the differential diagnosis of IPAS in clinical practice.

Principales modificaciones asociadas a la esplenectomía / Main modifications associated with splenectomy

Introducción. El bazo es un órgano linfoide implicado en el reconocimiento antigénico, la depuración de patógenos y la remoción de eritrocitos envejecidos o con inclusiones citoplasmáticas. La esplenectomía es una técnica utilizada tanto para el diagnóstico (linfomas), el tratamiento (trombocitopenia inmune, anemia hemolítica adquirida) y la curación (microesferocitosis hereditaria) de diversas enfermedades. Métodos. Describir los principales cambios hematológicos y complicaciones asociadas al procedimiento de esplenectomía. Discusión. Los cambios posteriores a la esplenectomía pueden ser inmediatos, como la aparición de cuerpos de Howell-Jolly, la trombocitosis y la presencia de leucocitosis durante las primeras dos semanas. Otras complicaciones tempranas incluyen la presencia de trombosis, en especial en pacientes con factores de riesgo secundarios (edad, sedentarismo, manejo hospitalario, obesidad) o un estado hipercoagulable (diabetes, cáncer, trombofilia primaria), siendo tanto el flujo de la vena porta como el volumen esplénico los principales factores de riesgo para su aparición. Las complicaciones tardías incluyen la alteración en la respuesta inmune, aumentando el riesgo de infecciones por bacterias encapsuladas, en conjunto con una reducción en los niveles de IgM secundario a la ausencia de linfocitos B a nivel de bazo. Debido al riesgo de infecciones, principalmente por Streptococcus pneumoniae, la esplenectomía parcial se ha considerado una opción. Conclusión. Una adecuada valoración de la indicación de esplenectomía y la identificación precoz de complicaciones posoperatorias son fundamentales para reducir la mortalidad asociada a la esplenectomía

Introduction. The spleen is a lymphoid organ involved in antigen recognition, pathogen clearance, and removal of aged erythrocytes or those with cytoplasmic inclusions. Splenectomy is a technique used for diagnosis (lymphomas), treatment (immune thrombocytopenia, acquired hemolytic anemia), and cure (hereditary microspherocytosis) of various diseases. Methods. To describe the main hematological changes and complications associated with the splenectomy procedure. Discussion. Changes after splenectomy can be considered immediate: the appearance of Howell-Jolly bodies, thrombocytosis, and leukocytosis during the first two weeks. Other complications include the presence of thrombosis, especially in patients with risk factors (age, sedentary lifestyle, long hospital stay, obesity) or a hypercoagulable state (diabetes, cancer, primary thrombophilia), with both portal vein flow and splenic volume being the main risk factors for its appearance. Late complications include altered immune response, increased risk of infections by encapsulated bacteria, and a reduction in IgM levels secondary to the absence of B lymphocytes in the spleen; due to the risk of diseases mainly by Streptococcus pneumoniae, partial splenectomy has been considered an option. Conclusion. An adequate assessment of the indication for splenectomy and the early identification of complications are essential to reduce the mortality associated with splenectomy

Miositis por Bartonella henselae: caso clínico en una adolescente / Bartonella henselae myositis: case report in an adolescent

La miositis de origen vírico o bacteriano es frecuente en la edad pediátrica. Causa dolor muscular y debilidad, con fiebre y malestar general. Una causa es la infección por Bartonella henselae, bacteria implicada en la enfermedad por arañazo de gato que, a veces, causa afectación multisistémica. Se presenta el caso de una adolescente que acudió al servicio de urgencias por mialgia intensa, malestar, adelgazamiento y esplenomegalia. En el labortorio se observaron parámetros inflamatorios elevados. Refería contacto con un gato. Entre los estudios realizados, la resonancia magnética (RM) de miembros inferiores mostró una imagen compatible con miositis inflamatoria bilateral. En la RM abdominal, se observaron tres lesiones esplénicas no detectadas previamente y el fondo de ojo mostraba una lesión compatible con oclusión arterial retiniana o vasculitis. Se indicó tratamiento antibiótico por vía intravenosa durante 21 días con cefotaxima y cloxacilina, tras los cuales desaparecieron los signos y síntomas, aunque los reactantes inflamatorios persistieron elevados. Con base en el cuadro clínico (miositis + coriorretinitis + absceso esplénico) se pensó en una posible infección por B. henselae y se inició tratamiento oral con azitromicina y rifampicina durante 14 días. Luego del tratamiento, los valores de laboratorio fueron normales, así como la RM de control, y se constató una IgG positiva para la bacteria

Infectious myositis, whether viral or bacterial, is frequent in pediatric age. It causes muscle pain and weakness, associated with fever and general malaise. One cause is Bartonella henselae, responsible for cat scratch disease, which sometimes causes systemic symptoms. We report the case of an adolescent who came to the emergency room with intense myalgia, malaise, weight loss and splenomegaly. Blood tests showed high inflammatory markers. She had been in touch with a cat. Studies were carried out including: lower limbs MRI suggestive of bilateral inflammatory myositis, abdominal MRI with three previously undetected splenic lesions and dilated fundus examination that showed possible retinal arterial occlusion or vasculitis. After 21 days of intravenous antibiotic therapy (cefotaxime + cloxaciline), she became asymptomatic, but inflammatory markers remained high. Suspecting Bartonella henselaeinfection (myositis + chorioretinitis + splenic abscess), oral azithromycin and rifampicin were prescribed for 14 days. Blood tests and control MRI became normal, and IgG was positive.

Quiste epitelial esplénico gigante, características morfológicas y evolución postoperatoria: reporte de un caso / Epithelial splenic cyst. Morphological characteristics and postoperative evolution: case report

RESUMEN: Los quistes primarios del bazo (QPB), son lesiones poco frecuentes en patología quirúrgica; los mayores de 5 cm o sintomáticos deben ser tratados quirúrgicamente para evitar el riesgo de complicaciones. Se debe realizar un examen histopatológico para confirmar el subtipo de quiste esplénico y descartar una eventual transformación maligna del revestimiento epitelial pluripotencial. El objetivo de este manuscrito fue reportar un caso de QPB intervenido quirúrgicamente y revisar la evidencia existente respecto de sus características morfológicas, terapéuticas y pronósticas. Caso clínico: Se trata de una mujer de 18 años (MAC), que consultó por distensión abdominal progresiva, de varios meses de evolución. La tomografía abdominal reveló la existencia de una masa heterogénea de 21 cm de diámetro mayor, en relación con el colon transverso y la curva mayor gástrica. El examen intraoperatorio reveló una masa sólido-quística que surgía del mesocolon transverso. La cirugía consistió en la esplenectomía y exéresis en bloque del tumor. La paciente evolucionó de forma satisfactoria, dándose de alta al quinto día del postoperatorio. El diagnóstico de quiste epitelial esplénicose estableció en base al examen patológico de la pieza quirúrgica. Cursando su 6º mes postoperatorio sin inconvenientes. Se realizó control tomográfico, que permitió verificar un bazo supernumerario funcionante.

SUMMARY: Primary splenic cysts (PSC) are rare lesions in surgical pathology; those symptomatic, or greater than 5 cm, should be treated surgically to avoid the risk of complications. A histopathological examination should be performed to confirm the splenic cyst subtype and rule out a possible malignant transformation of the pluripotential epithelial lining. The aim of this manuscript was to report a case of PSC who had undergone surgery and to review the existing evidence regarding its morphological, therapeutic and prognostic characteristics. An 18- year-old woman (MAC), consulted for progressive abdominal distention of several months of evolution. Abdominal tomography revealed the existence of a large heterogeneous mass, 21 cm in diameter, in relation to the transverse colon and the greater gastric curve. Intraoperative examination revealed a solid cystic mass arising from the transverse mesocolon. Surgery consisted of splenectomy and in-block excision of the tumor. The patient evolved satisfactorily and was discharged on the fifth postoperative day. Diagnosis of epithelial splenic cyst was established based on the pathological examination of the surgical specimen. At six months postoperative the patient had evolved satisfactorily without complications. Following abdominal tomography control a functioning supernumerary spleen was confirmed.

Os preditores da mortalidade em esplenectomias não traumáticas / The predictors of mortality in non-traumatic splenectomies

ABSTRACT BACKGROUND: There are quite a few studies examining prognostic factors in non-traumatic splenectomies compared to traumatic ones. OBJECTIVE: This study aimed to evaluate the predictors of mortality in patients who underwent splenectomy for non-traumatic spleen diseases. METHODS: Medical records of the patients, who had undergone total splenectomy for non-traumatic spleen diseases at a tertiary center between January 2009 and December 2019, were retrospectively reviewed. Exclusion criteria included patients younger than 18 years of age, partial splenectomies, splenectomies applied to facilitate surgery for malignancy on contiguous organs, and splenectomies performed during liver transplantation. Iatrogenic splenic injuries were regarded as trauma and these cases were also excluded. RESULTS: The current study included 98 patients. Nine (9.2%) patients died. In univariate analysis, age, the presence of hematological neoplasia, hematocrit, hemoglobin, white blood cell counts, neutrophil-to-lymphocyte ratio, indications for splenectomy, application of emergency surgery, surgical technique, and transfusion of blood components were all significantly associated with mortality. In multivariate analysis, the presence of hematological malignancy [P=0.072; OR=7.17; (CI: 0.386-61.56)], the application of emergency surgery [P=0.035; OR=8.33; (CI: 1.165-59.595)] and leukocytosis [P=0.057; OR=1.136; (CI: 0.996-1.296)] were found to be positively associated with mortality. CONCLUSION: Hematologic neoplasia, emergency surgery, and leukocytosis were the independent predictors of mortality in patients, who were operated on for non-traumatic spleen diseases. A thorough preoperative evaluation, early therapeutic intervention, and advanced surgical techniques are important and can serve to minimize complications and mortality in case of inevitable splenectomy. Immunological research can provide new therapeutic opportunities that may impact positively on patients by minimizing morbidity and mortality.

RESUMO CONTEXTO: Há alguns estudos que examinam fatores prognósticos em esplenectomias não traumáticas em comparação com os traumáticos. OBJETIVO: Este estudo teve como objetivo avaliar os preditores de mortalidade em pacientes submetidos à esplenectomia para doenças do baço não traumático. MÉTODOS: Os prontuários dos pacientes, submetidos à esplenectomia total não traumática para doenças do baço em um centro terciário entre janeiro de 2009 e dezembro de 2019, foram revisados retrospectivamente. Os critérios de exclusão incluíram pacientes menores de 18 anos, esplenectomias parciais, esplenectomias aplicadas para facilitar a cirurgia para a malignidade em órgãos contíguos e esplenectomias realizadas durante o transplante hepático. As lesões esplênicas iatrogênicas foram consideradas trauma e esses casos também foram excluídos. RESULTADOS: O presente estudo incluiu 98 pacientes. Nove (9,2%) pacientes morreram. Na análise univariada, idade, presença de neoplasia hematológica, hematócrito, hemoglobina, contagem de glóbulos brancos, razão entre neutrófilos-linfócitos, indicações de esplenectomia, aplicação de cirurgia de emergência, técnica cirúrgica e transfusão de componentes sanguíneos foram significativamente associadas à mortalidade. Na análise multivariada, a presença de malignidade hematológica [P=0,072; OR=7,17; (IC: 0,386-61,56)], aplicação de cirurgia de emergência [P=0,035; OR=8,33; (IC: 1,165-59,595)] e leucocitose [P=0,057; OR=1,136; (IC: 0,996-1,296)] verificou-se que estão positivamente associados à mortalidade. CONCLUSÃO: Neoplasia hematológica, cirurgia de emergência e leucocitose foram os preditores independentes da mortalidade em pacientes, operados por doenças não traumáticas do baço. Uma avaliação pré-operatória minuciosa, intervenção terapêutica precoce e técnicas cirúrgicas avançadas são importantes e podem servir para minimizar complicações e mortalidade em caso de inevitável esplenectomia. Pesquisas imunológicas podem fornecer novas oportunidades terapêuticas que podem impactar positivamente nos pacientes, minimizando a morbidade e a mortalidade.

Trombosis espleno-portal no cirrótica, no tumoral y policitemia vera: una asociación poco frecuente / Non-cirrhotic Splenic-portal Thrombosis, non-tumoral Polycitemia Vera: an Infrequent Association

La policitemia vera se incluye dentro del grupo de las neoplasias mieloproliferativas crónicas. Tiene una incidencia inferior a 2,5 de cada 100 000 personas. Las formas trombóticas de presentación representan solo entre el 10-15 % de casos. La trombosis del eje espleno-portal no asociada a cirrosis o neoplasias tiene una prevalencia inferior a 5 por cada 10000 habitantes, entre el 17-53 % se asocian a algún tipo de síndrome mieloproliferativo primario. Se presenta el caso de una paciente de 70 años de edad que acudió debido a dolor abdominal de 15 días de evolución. El ultrasonido abdominal mostró en el hígado un marcado aumento de la ecogenicidad hacia las paredes de las estructuras vasculares, compatible con extensas áreas de trombosis del eje espleno-portal, corroborado luego por tomografía por contraste. La biopsia de médula ósea concluyó una hiperplasia de las tres series, la determinación de la mutación JAK2V617F resultó positiva. La baja incidencia de la policitemia vera y la forma inusual de mostrarse como una trombosis del sistema espleno-portal motivó a la presentación de este caso.

Polycitemia vera is included in the group chronic mieloproliferative neoplasias. It has an incidence below 2.5 every 100 000 people. The thrombotic forms represent only between 10.15 % of the cases. Splenic-portal thrombosis not associated to cirrhosis or neoplasias have an incidence below 5 every 10000 inhabitants, between 17-53 % are associated to any type of primary mieloproliferative syndrome. A case of a 70 year old patient who came to the doctor complainig of an abdominal pain of 15 day duration. Abdominal ultrasound showed a markedly ecogenic liver towards vascular structures, compatible with extensive thrombotic areas of the splenic-portal axis, corroborated later by contrast tomography. Bone morrow biopsy concluded a three series hyperplasia, the determination of JAK2V617F mutation was positive. The low incidence of polycitemia vera and its unusual way of presenting as thromobosis of splenic-portal system motivated the presentation of this case.

Role of CT in Differentiating Malignant Focal Splenic Lesions

OBJECTIVE: The purpose of this study was to asses the CT findings and clinical features differentiating malignant from benign focal splenic lesions. MATERIALS AND METHODS: Among 673 patients with splenectomy, we included 114 patients with pathologically confirmed focal splenic lesions (malignant = 66, benign = 48). Two radiologists retrospectively assessed CT findings including: size, number, solid component, margin, wall, calcification, contrast-enhancement, lymph node (LN) enlargement and possible malignancy. We assessed clinical features including age, sex, underlying malignancy, fever, and leukocytosis. Multivariate logistic regression analysis was performed to identify significant predictors of malignant lesion. We used receiver operating curve analysis for determination of diagnostic performance. RESULTS: Common findings of malignant lesions include enhanced, mainly solid, ill-defined margin, absence of splenomegaly, absence of the wall, absence of calcification, LN enlargement, and presence of underlying malignancy (p < 0.05). Among them, mainly solid features (odds ratio [OR], 39.098, p = 0.007), LN enlargement (OR, 6.326, p = 0.005), and presence of underlying malignancy (OR, 8.615, p = 0.001) were significant predictors of malignancy. The mean size of benign splenic lesions (5.8 ± 3.3 cm) was larger than that of malignant splenic lesions (4.0 ± 3.4 cm). Diagnostic performance of CT findings by two reviewers using receiver operating characteristic curve analysis for differentiation of malignant lesions was 0.856 and 0.893, respectively. CONCLUSION: Solid nature of the splenic mass on CT images, LN enlargement, and presence of underlying malignancy are significant predictors of malignant splenic lesion.

Laparoscopic partial splenectomy for benign splenic neoplasms / 中华普通外科杂志

Objective To evaluate laparoscopic partial splenectomy (LPS) for benign splenic neoplasms.Methods From Sep 2016 to Aug 2017,7 patents with splenic benign lesions underwent laparoscopic partial splenectomy,results were compared with 15 cases receiving total splenectomy.Results All the patients underwent laparoscopic total or partial splenectomy successfully without conversion.There was no statistic difference in operative time,intra-operative blood loss and transfusion between the two groups.However,the morbidity of LPS group was significant lower (x2 =17.679,P =0.000),and no thrombocytosis occurred in LPS patients.Additionally,the patients received LPS recovered quicker and the postoperative hospital stay was shorter (5.7 ± 2.3) d vs.(15.3 ± 3.4) d (t =6.741,P =0.000 1) with a lower medical expenditure (19 288 ± 2 760) Yuan vs.(27 737 ± 4 626) Yuan (t =4.442,P =0.000 3).No thrombocytosis and recurrence were observed during follow up.Conclusions LPS is safe and effective to cure spleen benign lesions with quicker recovery and lower expenditure.

A Retrospective Study of Invasive Bacterial Infections in Children with Asplenia

PURPOSE: Because children with asplenia have an increased risk of fulminant infection associated with a high fatality, chemoprophylaxis, and vaccinations against encapsulated bacteria are recommended. However, there have been few reports of the burden of severe bacterial infection and the current status of chemoprophylaxis and immunization among children with asplenia in Korea. METHODS: We conducted a retrospective study including children with asplenia who were treated at our institute between January 1997 and December 2016. RESULTS: From a total of 213 children with asplenia, 114 (53.5%) had congenital asplenia and 58 (27.2%) had functional asplenia. The remaining 41 (19.3%) had acquired asplenia with the median age at splenectomy being 12.2 years (range, 5.0 to 16.9 years); the most common cause of splenectomy was hereditary spherocytosis (39.0%). The chemoprophylaxis rate was 16.4%. The immunization rates were 44.1% for pneumococcus, 53.0% for Haemophilus influenzae type B, and 10.7% for meningococcus. The incidence of invasive bacterial infection among children with asplenia was 0.28/100 person-year; a total of six episodes (2.8%) were observed in five patients with congenital asplenia and one patient with functional asplenia. The median age for these infections was 15 months (range, 4 to 68 months). Five of the six episodes were bacteremia, and the other was meningitis. The most common pathogen was Streptococcus pneumoniae (n=3), followed by H.influenzae (n=1). Three of the six patients (50.0%) died, all of whom had pneumococcal bacteremia. None of the six had chemoprophylaxis or proper vaccinations. CONCLUSIONS: Although there is an increased risk of a severe infection proper vaccinations and chemoprophylaxis are still lacking. Physicians should be encouraged to implement appropriate chemoprophylaxis and immunizations for patients with asplenia.

A Retrospective Study of Invasive Bacterial Infections in Children with Asplenia

PURPOSE: Because children with asplenia have an increased risk of fulminant infection associated with a high fatality, chemoprophylaxis, and vaccinations against encapsulated bacteria are recommended. However, there have been few reports of the burden of severe bacterial infection and the current status of chemoprophylaxis and immunization among children with asplenia in Korea. METHODS: We conducted a retrospective study including children with asplenia who were treated at our institute between January 1997 and December 2016. RESULTS: From a total of 213 children with asplenia, 114 (53.5%) had congenital asplenia and 58 (27.2%) had functional asplenia. The remaining 41 (19.3%) had acquired asplenia with the median age at splenectomy being 12.2 years (range, 5.0 to 16.9 years); the most common cause of splenectomy was hereditary spherocytosis (39.0%). The chemoprophylaxis rate was 16.4%. The immunization rates were 44.1% for pneumococcus, 53.0% for Haemophilus influenzae type B, and 10.7% for meningococcus. The incidence of invasive bacterial infection among children with asplenia was 0.28/100 person-year; a total of six episodes (2.8%) were observed in five patients with congenital asplenia and one patient with functional asplenia. The median age for these infections was 15 months (range, 4 to 68 months). Five of the six episodes were bacteremia, and the other was meningitis. The most common pathogen was Streptococcus pneumoniae (n=3), followed by H.influenzae (n=1). Three of the six patients (50.0%) died, all of whom had pneumococcal bacteremia. None of the six had chemoprophylaxis or proper vaccinations. CONCLUSIONS: Although there is an increased risk of a severe infection proper vaccinations and chemoprophylaxis are still lacking. Physicians should be encouraged to implement appropriate chemoprophylaxis and immunizations for patients with asplenia.

Absceso esplénico: ¿drenaje percutáneo o esplenectomía? / Splenic abscess: percutaneous drainage or splenectomy?

El absceso esplénico es una entidad poco común, su incidencia es de 0,2 a 0,7 %. El trabajo diagnóstico temprano y el tratamiento oportuno han permitido un mayor número de resultados exitosos. El tratamiento convencional ha sido la esplenectomía; sin embargo, por la importancia inmunológica del bazo y la morbimortalidad del tratamiento quirúrgico, hay una tendencia al tratamiento médico y de menor invasión. En este artículo se presenta una revisión narrativa del problema con base en la literatura médica con mayor 'evidencia', se discuten las diferentes alternativas de tratamiento y se concluye que el tratamiento debe individualizarse a cada paciente. El drenaje percutáneo es la primera línea de tratamiento; si este fracasa, debe considerarse la esplenectomía. Aunque con tiempos quirúrgicos más prolongados, la esplenectomía laparoscópica se asocia con una reducción significativa de la morbilidad posquirúrgica.

Splenic abscess is not a common entity, with an incidence of 0.2 to 0.7%. Early diagnosis and prompt treatment of this condition is associated with better outcomes. The conventional treatment for splenic abscess has been splenectomy; however, given its immunological importance and the morbidity associated with the procedure there is a tendency for less invasive treatment modalities. This article is a literature review that discusses the evidence behind the different treatment modalities available. Patient treatment should be individualized, but percutaneous drainage procedures can be regarded as the first option in most cases, Splenectomy should be the second line treatment. Laparoscopic splenectomy, although with longer intraoperative times, is associated with a significant reduction in postoperative complications.

Applied Research of CT Perfusion Imaging on the Diagnosis of Splenic Diseases / 昆明医科大学学报

Objective To discuss the applied research of CT perfusion imaging on the diagnosis of splenic diseases. Methods 20 patients with splenic diseases which accepted treatment in our hospital from January 2012 to December 2014 were assigned into group A,including 7 cases of splenic lymphoma patients(group A1),8 cases of leukemia patients with spleen infiltration(group A2)and 5 cases of splenic metastasis(group A3). At the same time,20 healthy persons were selected as the control(group B). Results The result of CT scan was normal in group B,but that showed a variety of lesions in the spleen in group A. The spleen perfusion volume in the group A was significantly higher than that in the control group(P<0.05). The detection rate of CT perfusion imaging was significantly higher than that of CT scan(P<0.05). TIP and MTT in group A were significantly higher than those in group B,while BF,PEI and BV were significantly lower(P<0.05). Conclusion CT perfusion imaging has advantage of simple,short imaging time,less trauma,and a high diagnostic value for the spleen disease,which is an ideal detection means and can be used in clinic.

Effects of inferior splenic lobe pole fixation and gastrosplenic peritoneal membrane section on the vitality of the remanent of subtotal splenectomy in rats

PURPOSE: To investigate the vitality of the spleen lower pole after subtotal splenectomy with suture to the stomach and after posterior peritoneal gastro-splenic membrane section, using macro and microscopic evaluations. METHODS: Sixty Wistar rats were used in this study and were randomly distributed in the three groups: Group 1: (n=20), subtotal splenectomy with lower pole preservation, Group 2: (n=20) subtotal splenectomy with lower pole preservation and suture to the stomach, Group 3: subtotal splenectomy with lower pole preservation and posterior peritoneal gastrosplenic ligament section. The animals were sacrificed 45 days after the surgery and the spleen lower poles were removed for macroscopic and microscopic examination. RESULTS: All animals in this series survived. No macroscopic differences were encountered between the groups. Microscopic evaluation observed statistic difference concerning fibrosis between group 1 and 3 (p≤0.05), but the analysis for necrosis and inflammation presented no differences. CONCLUSION: Vitality of the spleen lower pole after subtotal splenectomy is minimally modified when it is fixed to the stomach or when the posterior peritoneal gastrosplenic ligament is resected. .

Difficult splenectomy in 126 cases / 中华普通外科杂志

Objective To evaluate the operative safety of difficult splenectomy.Methods The clinical data of 126 splenectomy cases from January 2005 to December 2011 were analyzed retrospectively.Results All patients were cured and discharged.There was no mortality and pancreatic leakage,no gastric and colonic injury.The postoperative complications occurred in 14 patients including intra-abdominal hemorrhage in 5 cases,pulmonary complications in 7 cases (left pleural effusion and left subphrenic abscess),splenic venous thrombophlebitis in 11 cases and massive ascites in 10 patients.After splenectomy splenic and portal vein thrombi rate in HBV-related cirrhosis was 7％ (6/84) and that was 50％ (6/12) in schistosoma-related cirrhosis (t =13.4,P ＜ 0.01).Conclusions Careful evaluation before operation,skillful technique during operation are determinants for the safety of complex splenectomy.

Abscesso esplênico: relato de caso / Splenic abscess: case report

JUSTIFICATIVA E OBJETIVOS: O abscesso esplênico é uma doença rara, porém com um número crescente de casos publicados nos últimos anos. Geralmente, resulta de disseminação hematogênica, especialmente relacionada à endocardite, mas também pode ocorrer por contiguidade e relacionada a outros focos infecciosos.A grande maioria dos casos ocorre em pacientes imunossuprimidos. A doença é responsável por graves complicações e apresenta alto índice de mortalidade na ausência de terapêutica adequada. Oobjetivo deste estudo foi lembrar aos clínicos dessa possibilidade diagnóstica, que exige alto grau de suspeição, devido ao quadro clínico inespecífico. RELATO DO CASO: Paciente do sexo feminino, 44 anos, com quadro clínico de dor abdominal difusa, mais acentuada em flanco esquerdo com evolução de um mês e febre de 40º C com início há 5 dias. Previamente hígida, exceto por história de hipertensão arterial sistêmica, insuficiência cardíaca e prótese metálica em valva mitral. Ao exame encontrava-se em regular estado geral, desorientada,hipotensa, com depleção extracelular de 30%, afebril e eupneica. O abdômen era plano, flácido, doloroso à palpação em flanco esquerdo e hipogástrio e sem sinais de irritação peritoneal. Realizada tomografia computadorizada, que evidenciou imagem hipodensa no interior do baço. Diagnosticado abscesso esplênico,sendo tratada com esplenectomia e antibioticoterapia. CONCLUSÃO: Esse relato demonstrou que o abscesso esplênico pode ocorrer em pacientes imunocompetentes e sem outra fonte de infecção.

BACKGROUND AND OBJECTIVES: Splenic abscess is a rare disease, however the number of cases published in literature has increase in recent years. Generally, it appears after hematogenous dissemination, especially related with endocarditis, but can also occurby contiguity and related with other infections sites. The majorityof the cases happen in immunocompromised hosts. The disease is responsible for serious complications and has high mortality rate without appropriate treatment. The objective of this report was to remind doctors of this diagnostic, which needs a high degree of suspicion due its nonspecific clinical manifestation. CASE REPORT: Female patient, 44-years-old, with clinical symptoms of diffuse abdominal pain, more important in left flank,with one month of evolution, and 40º C fever that started withinfive days. Previously healthy, except for history of hypertension,cardiac failure and metallic prosthesis in the mitral valve. On examinationshe was in regular condition, disoriented, hypotensive, with extracellular depletion of 30%, afebrile and eupneic. The abdomen was flat, flaccid, painful to palpation in the left flank and hypogastric and without signs of peritoneal irritation. A CT scan was performed which showed a hypodense image on spleen. Diagnosed splenic abscess, the patient was treated with splenectomy and antimicrobial therapy. CONCLUSION: This report showed that splenic abscess may occurin immunocompetents patients without other source of infection.

Evaluation of contrast-enhanced ultrasonography in diagnosis of focal splenic solid lesions / 中华超声影像学杂志

Objective To investigate the value of contrast-enhanced ultrasonography(CEUS) for differential diagnosis of focal splenic solid lesions.Methods Thirty-two patients with 32 focal splenic lesions were examined with CEUS.The enhancement phases and perfusion were observed.Each group has 16 patients.Results The contrast media extincted more quickly in malignant lesions than in benign ones.The peak time and initial decreasing time of the malignant lesions were (19.7±4.5)s and (29.7±10.9)s.The opposite time of the benign lesions were (24.2±4.4)s and (50.9±22.8)s.The initial decreasing time of the malignant lesions was earlier than that of the benign ones.The enhancement pattern was similar between the two groups.More lesions can be detected after CEUS.The number of the lesions was 111 before CEUS and 142 after CEUS.Conclusions CEUS is useful in the differential diagnosis of splenic lesions.

Splenic Abscess in Gachon Medical School, Gil Medical Center

PURPOSE: A splenic abscess is a rare disease, but appears to be increasing in frequency. The key to successful treatment is early diagnosis, effective antibiotics treatment and surgical management when needed. This study was intended to clarify the clinico-pathological and radiological findings of splenic abscesses from their therapeutic aspects. METHODS: Between Jan. 1993 and Dec. 2003, the outcomes of 8 splenic abscess patients were retrospectively analyzed. RESULTS: The male to female ratio was 6: 2, with a mean age of 57 years, ranging from 34 to 70 years. Predisposing conditions were identified in 7, including diabetes mellitus, steroid medication, chronic alcoholism, infective endocarditis and lymphoma. As chief complaints, fever/chills was present in 2, left upper quadrant pain/tenderness in 4, diffuse abdominal pain in 1 and dyspnea in 1, with leukocytosis found in 6 (75%). Ultrasonography or computed tomography detected left pleural effusion, splenomegaly and splenic abscess in 7 (88%). The solitary to multiple ratio was 2: 6. An emergency laparotomy for peritonitis detected a solitary abscess rupture in 1. The original site of infection was detected in 5, including endocarditis, dental abscess, urinary tract infection and pancreatitis in 2. Blood cultures were positive in 3 (43%), with Escherichia coli in 1 and Streptococcus viridans in 2. 3 (75%) of 4 specimens had positive culture results, including Pseudomonas, Streptoccus viridans and Enterococcus. 1 (25%) had pathogens identical to bacteria isolated form the blood culture. 1 was identified as mixed infection, with actinomycosis. A splenectomy was performed in 5, including 2 with a distal pancreatectomy, intraoperative fine needle aspiration in a lymphoma and endoscope-guided aspiration in a gastrosplenic fistula. One lymphoma patient, with multiple abscesses, died of aspiration pneumonia during chemotherapy. CONCLUSION: A splenic abscess is rare, and failure of early diagnose and institution of treatment is fatal. Although patients have various underlying diseases, a splenic abscess can develop arising from a dental abscess in a healthy man. Percutaneous drainage may not be suitable for multiple or hilar locations; therefore, a splenectomy, with appropriate antibiotics, is the definitive treatment. A less-invasive treatment modality can be considered, taking into account the patient's clinical situation from an immunological aspect for preservation of the spleen.

Ojo de buey en tomografía hepática / The 'bull's eye' pattern in hepatic tomography

Las infecciones micóticas invasoras se presentan con mayor frecuencia en pacientes con neutropenia posterior al uso de quimioterapia para el tratamiento del cáncer. Se presenta una paciente de 4 años con diagnóstico de leucemia linfoide aguda, quien, luego de la quimioterapia, desarrolló neutropenia febril y diarrea. Recibió tratamiento antibiótico y antimicótico de amplio espectro. Se aisló Candida albicans y se observaron trofozoítos de Entamoeba histolytica en la materia fecal . La paciente desarrolló candidiosis crónica diseminada que fue tratada con anfotericina B y, posteriormente, con fluconazol. Se ilustra la imagen tomográfica conocida como 'ojo de buey' y su correspondiente estudio histopatológico. Candida spp. es la levadura más común en pacientes inmunosuprimidos con tumores hematológicos que reciben quimioterapia. La candidiosis diseminada que se presenta en estos pacientes persiste y se hace evidente clínicamente una vez se resuelve la neutropenia; se denomina candidiosis crónica diseminada. En la paciente se presentaron varios factores de riesgo, como el tratamiento previo con antibióticos de amplio espectro, la colonización del tracto gastrointestinal por Candida y la neutropenia prolongada. El diagnóstico por imagen se hace principalmente por ecografía, tomografía axial computarizada y resonancia magnética. Se han descrito cuatro patrones tanto ecográficos como tomográficos, de los cuales se destacan el tipo 1 ('ruedas entre ruedas') y el tipo 2 ('ojo de buey'), que son característicos de la candidiosis crónica diseminada. El tercer patrón (imágenes hipoecoicas), aunque no es específico de la candidiosis crónica diseminada, es el más comúnmente hallado en ambas técnicas. En la paciente se observaron los patrones 2 y 3, y el diagnóstico se confirmó con el estudio histopatológico.

Invasive fungal infections are more commonly found in patients who develop neutropenia after chemotherapy. A 4-year-old girl with diagnosis of acute lymphoid leukemia developed febrile neutropenia after chemotherapy. Broad spectrum antibiotics and antimycotic therapy were initiated. Candida albicans was isolated and Entamoeba histolytica was observed in stool examination. Chronic disseminated candidiasis had developed and was treated with amphotericin B, initially, and fluconazol. Computed tomography images were obtained that demonstrated a classic 'bull´s eye' pattern; a concurrent histological study confirmed the diagnosis. Candida spp. is the major cause of opportunistic mycosis in immunosuppresed patients receiving chemotherapy for haematologic malignancies. An initial infection results in disseminated candidiasis, which persists and becomes chronic. In the 4-year-old patient, the identified risk factors consisted of a previous therapy with broad spectrum antibiotics, the gastrointestinal tract colonization with Candida albicans and prolonged neutropenia. Imaging diagnoses are made by ultrasonography, computed tomography and magnetic resonance. With ultrasound and tomography, 4 distinct patterns have been described. Pattern 1 ('wheels within wheels') and 2 ('bull´s eye') are important, since they are characteristic of chronic disseminated candidiasis. The third pattern (hypoechoic image) is the most common finding with both techniques. In the current patient, patterns 2 and 3 were seen and the diagnosis was confirmed by histological study.