Transjugular intrahepatic portosystemic shunt followed by splenectomy for complicated hepatosplenic schistosomiasis: a case report and review of the literature.

Hepatosplenic schistosomiasis is a complex clinical condition caused by the complications of chronic infection with Schistosoma species that cause intestinal schistosomiasis. Hepatosplenic schistosomiasis derives from the fibrotic reaction stimulated around parasite eggs that are transported by the mesenteric circulation to the liver, causing periportal fibrosis. Portal hypertension and variceal gastrointestinal bleeding are major complications of hepatosplenic schistosomiasis. The clinical management of hepatosplenic schistosomiasis is not standardised and a parameter that could guide clinical decision making has not yet been identified. Transjugular intrahepatic portosystemic shunt (TIPS) appears promising for use in hepatosplenic schistosomiasis but is still reported in very few patients. In this Grand Round, we report one patient with hepatosplenic schistosomiasis treated with TIPS, which resulted in regression of oesophageal varices but had to be followed by splenectomy due to persisting severe splenomegaly and thrombocytopenia. We summarise the main challenges in the clinical management of this patient with hepatosplenic schistosomiasis, highlight results of a scoping review of the literature, and evaluate the use of of TIPS in patients with early hepatosplenic schistosomiasis, to improve the prognosis.

Unraveling cervical cancer screening dilemmas: histopathological insights from VIA and LEEP at bugando medical centre, Mwanza.

BACKGROUND: The single-visit strategy, also known as the "screen-and-treat" approach, is widely used to screen for cervical cancer in low- and middle-income countries. The screen-and-treat approach leads to unnecessary or inadequate treatment. Thus, a study was conducted to determine the histopathological patterns of aceto-white lesions on visual inspection with acetic acid (VIA) in patients who underwent a Loop Electrosurgical Excision Procedure (LEEP) at Bugando Medical Centre between January 2016 and December 2020. METHOD: A 5-year retrospective cross-sectional case record review was conducted on 329 women who had LEEP at Bugando Medical Centre following a positive VIA cervical screening test. A standard data abstraction form was used to collect patient information. Missing client information records and LEEP without histopathological results were exclusion criteria. For statistical analysis, STATA version 15 was used; in descriptive statistics, frequency, mean, and standard deviation were used. The Chi2 and Fisher's exact tests were used to investigate the relationship between patient characteristics and histopathological patterns, and a P-value of 0.05 was considered statistically significant in multinomial models. RESULTS: This study looked at 329 patients who had LEEP following a VIA positive but were not eligible for cryotherapy. Our study participants had a mean age of 40 ± 8.2 SD. There were 203 (61.7%) patients with benign lesions, including 4 with schistosomiasis and 2 with cervical tuberculosis. The precancerous lesions were discovered in 100 cases (30.4%), and 26 (7.9%) already had invasive cervical cancer. Out of 100 patients with precancerous lesions, 58 (17.6%) and 42 (12.8%) have high- and low-grade squamous intraepithelial (HSIL and LSIL) lesions, respectively. The presence of a precancerous lesion was found to be associated with age 31-40 years (P-value 0.042) and HIV positivity (P-value 0.004). CONCLUSION: Most patients in this study had benign cervical lesions, which do not require LEEP treatment. Nonetheless, a considerable percentage of invasive cervical malignancies and rare benign diseases such as schistosomiasis and cervical tuberculosis were identified. A screen-and-treat approach within well-equipped tertiary hospitals like Bugando Medical Centre should explore alternative options instead of relying solely on straight LEEP.

Spinal cord schistosomiasis in a 6-year-old child with complete recovery after spine surgery and medical treatment: case report and discussion.

Spinal cord schistosomiasis is a rare and severe form of schistosomiasis. The prognosis is largely conditioned by early diagnosis and treatment. The authors present a case of spinal cord schistosomiasis complicated by spinal cord compression syndrome. This is the case of a 6-year-old patient who presented with febrile gastroenteritis followed by complete paralysis of both lower limbs of sudden onset following a brief stay in a village setting with notion of multiple baths at a stream. Spinal cord MRI revealed an enlarged spinal cord spanning D10 to D12 with heterogeneous contrast enhancement and a syrinx cavity above the lesion. Biological workup revealed an inflammatory syndrome. Treatment consisted of decompressive laminectomy with biopsy of the lesion and a syringo-subarachnoid shunt. Pathological analysis revealed fragments of central nervous system tissues with an infiltrate composed of lymphocytes, plasmocytes, and macrophages producing granulomatous foci lined with areas of necrosis in addition to a large contingent of polynuclear eosinophils, agglutinating around or covering in some places elongated ovoid structures, with relatively thick eosinophilic shells and presenting a terminal spur. Adjuvant treatment consisted of praziquantel and corticotherapy for 1 month. The evolution showed marked improvement in the neurological deficits. She now walks unassisted and has good sphincter control. Spinal cord schistosomiasis is rare in our context; its diagnosis is difficult. The treatment is both medical and surgical.

Efficacy and safety of transjugular intrahepatic portosystemic shunt for the treatment of schistosomiasis-induced portal hypertension: a retrospective case series.

BACKGROUND AND AIM: The aim of this study was to evaluate the efficacy and safety of transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of portal hypertension caused by schistosomiasis. METHODS: This study included 43 patients with schistosomiasis-induced portal hypertension treated with TIPS in our institution from December 2015 to May 2021. The demographic, imaging, clinical and follow-up data of patients were recorded retrospectively to evaluate the efficacy and safety of the procedure. RESULTS: All patients were successfully implanted with stents to establish shunt, and 90.7% of the patients were in good postoperative condition with no complications. After TIPS, the Yerdel grade of portal vein thrombosis decreased, and the portal pressure gradient decreased from 27.0 ± 4.9 mmHg to 11.3 ± 3.8 mmHg (P < 0.001). Bleeding was effectively controlled, with a postoperative rebleeding rate of 9.3%, which was an 87.9% reduction from the preoperative rate. The cumulative incidence of postoperative refractory ascites, shunt dysfunction, overt hepatic encephalopathy (OHE) and death were all similar to those of TIPS for nonschistosomiasis portal hypertension. There were no differences in liver and kidney function and blood coagulation indexes before and 3 months after TIPS. Albumin was identified as an independent risk factor for mortality after TIPS for schistosomal liver fibrosis. CONCLUSION: TIPS can be used as a well-tolerated and effective treatment for schistosomiasis-induced portal hypertension, effectively reduce portal pressure gradient and improve portal vein thrombosis.

Incidental Finding of Schistosomiasis Mimicking as Endometriosis.

Schistosomiasis is a common endemic cause of abdominal pain outside the United States that can present with symptoms overlapping with endometriosis, a common cause of chronic pelvic pain in reproductive women. In this case, operative laparoscopy aided and resulted in the diagnosis of schistosomiasis.

Positive consequences of splenectomy for patients with schistosomiasis-induced variceal bleeding.

BACKGROUND: Patients with hepatic schistosomiasis are at high risk of gastroesophageal variceal bleeding, which is highly torrential and life threatening. This study aimed to assess the effects of splenectomy on patients with schistosomiasis-induced variceal bleeding, especially those influences related to overall survival (OS) rate. METHODS: From January 2005 to December 2018, 112 patients with schistosomiasis-induced varices were enrolled. In that period, all the patients with hepatic schistosomiasis who received endoscopic treatment for primary and secondary prophylaxis of gastroesophageal variceal bleeding were found eligible. The patients were divided into splenectomized group (n = 44, 39.3%) and control group (n = 68, 60.7%). RESULTS: Multivariate regression analysis of OS showed that splenectomy, hepatic carcinoma, and times of endoscopic treatment were independent prognostic factors for OS. Kaplan-Meier analysis revealed that the 5-year OS rate was 82.7% in splenectomized group versus 53.2% in control group (P = 0.037). The rate of no recurrence of variceal bleeding during 5-year (56.8% vs. 47.7%, P = 0.449) indicated that there was no significant difference between the two groups. Patients who received splenectomy had increased risk of portal vein thrombosis (52.3% vs. 29.4%, P = 0.012) and decreased proportion of severe ascites (20.5% vs 50.0%, P = 0.002). CONCLUSION: Splenectomy prior to endoscopic treatment provides a superior long-term survival for patients with schistosomiasis-induced variceal bleeding.

Robotic Cystoprostatectomy With Intracorporeal Ileal Conduit Diversion in a Patient With Chronic Schistosomiasis.

We present an interesting case of a patient who initially presented with urinary retention and was subsequently found to have bilateral grade 5 vesicoureteral reflux, a thick and noncompliant bladder, and biopsy proven ova of Schistosoma haematobium. This patient was subsequently managed surgically with a robotic radical cystoprostatectomy with intracorporeal ileal conduit diversion. Final pathology revealed chronic schistosomiasis with numerous ova present throughout the bladder. To our knowledge, no similar cases have been previously documented in the literature.

Surgery for Pulmonary Parenchymatous Schistosomiasis (Bilharziomas): A 20-Year Single-Centre Experience.

BACKGROUND: Pulmonary schistosomiasis may complicate urinary or intestinal infestations. Pulmonary pathology is either in the acute or chronic form. The chronic form of the disease may result in granuloma formation. This study presents 20 years of experience in surgical management of pulmonary bilharziomas. METHODS: A retrospective review was undertaken of 17 consecutive patients who had surgery for lung bilharziomas from 1996-2016. Demographics, clinical presentation, underlying lung disease, investigations performed, operative procedure, and outcome were retrieved and reviewed. RESULTS: All patients were males, with ages ranging from 22-52 years (median 33 years). Haemoptysis was the main presentation (53%). Coexisting lung tuberculosis was present in five (29.4%) patients. Indications for surgery were solitary shadows in 12 (70.6%) patients and persistent tuberculous cavities in five (29.4%) patients. Segmentectomy was performed in one (5.9%) patient, lingulectomy in one (5.9%) patient, lobectomy in 14 (82.3%) patients, and bi-lobectomy in one (5.9%) patient. The histologic nature of the infestation was: bilharzial ova with extensive granulomatous reaction and suppuration in eight cases (47%); both tuberculosis and bilharzial ova within a granulomatous tissue reaction in five cases (29.4%); and bilharzial ova within malignant tissue in four cases (23.6%). There was no operative mortality. One (1) patient (5.9%) developed postoperative bronchopleural fistula after left upper lobectomy; surgical repair of the fistula and omental flap buttress was needed after failure of conservative management. CONCLUSION: Pulmonary schistosomiasis is not an uncommon infestation and occurs more frequently in patients with underlying tuberculosis. It may predispose to granulomatous parenchymatous lung masses or even malignancy, which necessitate surgical intervention with a good outcome. However, predisposition of pulmonary schistosomiasis for the development of bronchogenic carcinoma warrants further studies.

Schistosomal Peritonitis Presenting as Acute Abdomen: A Case Report.

BACKGROUND: Schistosomiasis is a trematode infestation causing a chronic granulomatous disease in various organs. Both S. mansoni & S. haematobium are endemic in Ethiopia. Most infected individuals are asymptomatic. Ectopic schistosomiasis can affect the lungs, genitalia, CNS, skin, peritoneum, Lymph nodes & other organs. Schistosomiasis as a cause of acute abdomen is seldom reported. CASE DETAIL: A 51 years-old male Ethiopian farmer presented with a two weeks history of abdominal pain with recent onset bilious vomiting and abdominal distention. Emergency laparotomy done & the finding was multiple tiny whitish nodule over the peritoneum & small bowel with multiple mesenteric lymphadenopathy. The diagnosis was confirmed with histopathology study. CONCLUSIONS: Schistosomal peritonitis is a very uncommon form of schistosomiasis. Physicians should be aware of such atypical presentation in patients from endemic areas of schistosomiasis. And biopsy should be considered in unsettled forms of peritonitis during laparotomy. The pathogenesis is not well known which warrants further study.

Gallbladder schistosomiasis: rare but possible, a case report and review of the literature.

After Malaria, schistosomiasis remains the most important tropical disease in large parts of the world. It affects mainly the colon and the urinary tract. The hepatic involvement is significantly frequent, particularly by the mansoni species. Still one of the extremely rare locations is the gallbladder. Our case is about a 51 year old woman from Tunisia, which is no longer considered an endemic country, with no particular medical history, underwent surgery for symptomatic cholelithiasis. She had a laparoscopic cholecystectomy. Post operative period was uneventful. Histology of the gallbladder showed fibrosis in the mucosa and schistosomal ova in the wall. As a conclusion we can see that due to the lack of specific clinical and radiological signs, the diagnosis of gallbladder schistosomiasis is established only after the histological examination.

PORTAL PRESSURE DECREASE AFTER ESOPHAGOGASTRIC DEVASCULARIZATION AND SPLENECTOMY IN SCHISTOSOMIASIS: LONG-TERM VARICES BEHAVIOR, REBLEEDING RATE, AND ROLE OF ENDOSCOPIC TREATMENT.

BACKGROUND: Schistosomiasis is an endemic health problem affecting about four million people. The hepatosplenic form of the disease is characterized by periportal hepatic fibrosis, pre-sinusoidal portal hypertension and splenomegaly. Liver function is preserved, being varices bleeding the main complication of the disease. The surgical treatment used in the majority of centers for the prevention of rebleeding is esophagogastric devascularization and splenectomy. Most authors reported better results with the association of surgical and postoperative endoscopic treatment. OBJECTIVE: The aim of this study was to compare the intra operative portal pressure decrease and esophageal varices behavior and rebleeding rates in patients submitted to surgical and postoperative endoscopic treatment after long-term follow-up. METHODS: A retrospective study of 36 patients with schistosomiasis with, at least, one previous bleeding from esophageal varices rupture submitted to esophagogastric devascularization and splenectomy, added to endoscopic varices postoperative treatment was performed. Patients were stratified according to the intra operative portal pressure decrease in two groups: reduction below and above 30%. Long-term varices presence, size and bleeding recurrence were evaluated. RESULTS: Regarding varices behavior, no significant influence was observed in both groups of portal pressure fall. Regarding bleeding recurrence, despite three times more frequent in the group with lower portal pressure fall, no significant difference was observed. All patients were submitted to postoperative endoscopic treatment. CONCLUSION: Esophageal varices banding, rather than portal pressure decrease, seems to be the main responsible factor for good results after combination of two therapies (surgery and endoscopy) for patients with portal hypertension due to schistosomiasis; further studies are necessary to confirm this hypothesis.

Diminuição da pressão portal após desconexão ázigo-portal e esplenectomia na esquistossomose: comportamento a longo prazo das varizes, taxa de ressangramento e papel do tratamento endoscópico / Portal pressure decrease after esophagogastric devascularization and splenectomy in schistosomiasis: long-term varices behavior, rebleeding rate, and role of endoscopic treatment

ABSTRACT BACKGROUND: Schistosomiasis is an endemic health problem affecting about four million people. The hepatosplenic form of the disease is characterized by periportal hepatic fibrosis, pre-sinusoidal portal hypertension and splenomegaly. Liver function is preserved, being varices bleeding the main complication of the disease. The surgical treatment used in the majority of centers for the prevention of rebleeding is esophagogastric devascularization and splenectomy. Most authors reported better results with the association of surgical and postoperative endoscopic treatment. OBJECTIVE: The aim of this study was to compare the intra operative portal pressure decrease and esophageal varices behavior and rebleeding rates in patients submitted to surgical and postoperative endoscopic treatment after long-term follow-up. METHODS: A retrospective study of 36 patients with schistosomiasis with, at least, one previous bleeding from esophageal varices rupture submitted to esophagogastric devascularization and splenectomy, added to endoscopic varices postoperative treatment was performed. Patients were stratified according to the intra operative portal pressure decrease in two groups: reduction below and above 30%. Long-term varices presence, size and bleeding recurrence were evaluated. RESULTS: Regarding varices behavior, no significant influence was observed in both groups of portal pressure fall. Regarding bleeding recurrence, despite three times more frequent in the group with lower portal pressure fall, no significant difference was observed. All patients were submitted to postoperative endoscopic treatment. CONCLUSION: Esophageal varices banding, rather than portal pressure decrease, seems to be the main responsible factor for good results after combination of two therapies (surgery and endoscopy) for patients with portal hypertension due to schistosomiasis; further studies are necessary to confirm this hypothesis.

RESUMO CONTEXTO: A esquistossomose é um problema de saúde pública endêmico, afetando cerca de quatro milhões de pessoas. A forma hepato-esplênica da doença é caracterizada por fibrose peri-portal, hipertensão pré-sinusoidal e esplenomegalia. A função hepática está preservada, sendo o sangramento por varizes a principal complicação da afecção. O tratamento cirúrgico usado pela maioria dos serviços para prevenção do ressangramento é a desconexão ázigo-portal e esplenectomia. Muitos autores reportaram melhores resultados com a associação do tratamento cirúrgico e o tratamento endoscópico pós-operatório. OBJETIVO: O objetivo deste estudo foi comparar a queda da pressão portal intraoperatória com o comportamento das varizes esofagianas e as taxas de ressangramento em pacientes submetidos a tratamento cirúrgico e endoscópico pós-operatório após seguimento de longo prazo. MÉTODOS: Foi realizado um estudo retrospectivo de 36 pacientes esquistossomóticos com pelo menos um episódio de sangramento prévio por ruptura de varizes esofagianas, submetidos a desconexão ázigo-portal e esplenectomia, associada a tratamento endoscópico pós-operatório das varizes. Os pacientes foram divididos de acordo com a queda da pressão portal intraoperatória em dois grupos: redução menor e maior que 30%. Foram avaliadas a presença de tamanho das varizes a longo prazo e a recorrência do sangramento. RESULTADOS: Levando-se em conta o comportamento das varizes, não foi observada influência significativa em ambos os grupos de queda de pressão portal. Com relação ao ressangramento das varizes, embora três vezes mais frequente no grupo com menor queda de pressão portal, não foi observada diferença estatística. Todos pacientes foram submetidos a tratamento endoscópico pós-operatório. CONCLUSÃO: A ligadura elástica das varizes esofagianas, mais do que a queda da pressão portal, parece ser o principal fator responsável pelos bons resultados após a combinação das duas terapias (cirúrgica e endoscópica) para pacientes com hipertensão portal devido à esquistossomose. Estudos futuros serão necessário para confirmar esta hipótese.

Laparoscopic Treatment of Presinusoidal Schistosomal Portal Hypertension Associated With Postoperative Endoscopic Treatment: Results of a New Approach.

AIM: To propose a laparoscopic treatment for schistosomal portal hypertension. METHODS: Ten patients with schistosomiasis and portal hypertension, with previous gastrointestinal hemorrhage from esophageal varices rupture, were evaluated. Patients were subjected to a laparoscopic procedure, with ligature of splenic artery and left gastric vein. Upper gastrointestinal endoscopy was performed on the 30th postoperative day, when esophageal varices diameter was measured and band ligature performed. During follow-up, other endoscopic procedures were performed according to endoscopy findings. RESULTS: There was no operative mortality. One patient had a postoperative splenic infarction that was conservatively treated. Mean hospitalization time was 5 days. During endoscopy 30 days after surgery, a decrease in variceal diameters was observed in 6 patients. During follow-up (mean 84 mo), after endoscopic therapy 8 patients had eradicated varices, but 4 presented with recurrence. Considering the late postoperative evaluation, all patients had a decrease in variceal diameters. A mean of 3.8 endoscopic banding sessions were performed per patient. Two patients presented bleeding recurrence; one had a minor bleeding episode and the other had 2 episodes of bleeding varices requiring blood transfusion. In both patients, bleeding was controlled with endoscopic therapy. No late mortality was observed. CONCLUSIONS: Laparoscopic ligature of the splenic artery and the left gastric vein is a promising and less-invasive method for the treatment of schistosomal portal hypertension.

[Application effect of pericardial devascularization plus gastric fundus transaction in advanced schistosomiasis].

OBJECTIVE: To discuss the effect of pericardial devascularization plus gastric fundus transaction in advance schistosomiasis patients with portal hypertension. METHODS: Thirty-six advanced schistosomiasis patients with portal hypertension treated with devascularization plus gastric fundus transaction (a portal hypertension group), as well as 10 patients treated with modified Sugiura operation (a modified Sugiura operation group) in the Third People's Hospital of Yangxin County since 2006 were chosen as the observation objects, and the clinical effects of the two groups were observed and compared. RESULTS: The operation time, indwelling time of stomach tube, time to taking food after operation, drainage tube removal time of the portal hypertension group were all shorten than those of the modified Sugiura operation group (all P＜0.05). The hospitalization expenses of the two groups were (25 466.00 ± 2 888.48) Yuan and (34 517.10 ± 4 948.39) Yuan respectively, and the difference was also statistically significant (P＜0.05). The incidence rates of portal thrombosis of the portal hypertension group and modified Sugiura operation group were 33.33% (12/36) and 40.00% (4/10), respectively, and the incidence rates of rehaemorrhagia of the two groups 12 months after the operation were 16.67% (6/36) and 10.00% (1/10), respectively, but the differences had no statistically significance (both P ＞ 0.05). In addition, 1 case with delayed gastric emptying and 1 case with stomal leak of esophagus happened in the modified Sugiura operation group, while no corresponding complications happened in the portal hypertension group. CONCLUSIONS: Pericardial devascularization plus gastric fundus is a relatively easy procedure which has a good short-term clinical effect, and therefore it is suitable for application in primary hospitals. However, its long-term effect still needs further observation.

Late results of esophagogastric devascularization and splenectomy associated with endoscopic treatment in patients with schistosomiasis.

BACKGROUND: Schistosomiasis is endemic problem in Brazil affecting about three to four million people, and digestive hemorrhage caused by esophageal varices rupture is the main complication of the disease. Surgical treatment has become a therapeutic option, especially for secondary prophylaxis after at least one episode of bleeding. The surgical technique used by the vast majority of surgeons for the prevention of rebleeding is esophagogastric devascularization and splenectomy. Although with good postoperative results, rebleeding rate is significant, showing the need to follow-up endoscopy in all patients. AIM: To evaluate long-term results of patients submitted to esophagogastric devascularization and splenectomy and postoperative endoscopic treatment regarding esophageal varices caliber and rebleeding rates. METHODS: A retrospective study of 12 patients underwent esophagogastric devascularization and splenectomy followed for more than five years. RESULTS: All patients showed varices size reduction, and no patient had postoperative bleeding recurrence. CONCLUSION: Esophagogastric devascularization and splenectomy decreased significantly the esophageal variceal size when associated with endoscopic follow-up, being effective for bleeding recurrence prophylaxis.

LAPAROSCOPIC MANAGEMENT OF DISTAL URETERIC STONE IN BILHARZIAL URETER: RESULTS OF A SINGLE CENTER PROSPECTIVE STUDY.

No doubt, Bilharzial ureters are complicated by distal stricture due to precipitation of Bilharzial ova in distal ureter. These cases are associated with poorly functioning and grossly hydronephroic kidneys that hinder endoscopic manipulation of the coexistent distal, high burden, long standing impacted stones. Thus, laparoscopic uretrolithotomy was performed in 51 bilharzial patients with distal ureteric stones 4 trocars were used. The ureter was opened directly over the stone and the stone was extracted. A double-J stent was inserted into the ureter which was closed by 4-0 polyglactin running suture. The results showed that among 51 cases 33 males and 18 females; the mean age was 40.13 years. the mean stone size was 2.73 cm. Conversion to open surgery was in only one case; the mean operative time 92.05 (range 75-120 minutes); postoperative pain score ranged from 20 to 60, the mean number of PO analgesic request was 1.72 (range 1-3); it was once in 21, twice in 23 and thrice in 7 cases. Hospital stay ranged from 2 to 5 with a mean of 2.74 days; total duration of follow up ranged from 7 to 12 with a mean of 9.68. Stone recurrence reported in 4 cases; ureteric stricture reported in 2 cases. Stone free rate was reported to be 100%.