Acute abdomen caused by torsion of the pedicle in a wandering spleen

A case of acute abdomen caused by acute torsion of a wandering spleen in a 20-year-old female patient is presented. It underscores the efficiency of the ultrasonic examination in the diagnosis of this type of pathology.

[A case of the successful treatment of pulmonary artery pseudoaneurysm after PA banding]

Pulmonary artery pseudoaneurysm after PA banding is a rare complication and its mortality is very high. The authors successfully operated on this sort of lesion. To our knowledge, this is the first successful case in Japanese literature. The second of twins was found to be suffering asplenia, dextro cardia, TAPVC, atrioventricular septal defect, corrected TGA and PDA. On the 19th day of life, increasingly pulmonary congestion forced us to operate. We performed PDA ligation, correction of TAPVC, together with extrathoracically adjustable PA banding. 5 months following this operation, spike fever and swelling of anterior thorax were noted. PA angiography was performed, and it showed that the pulmonary artery had been cut through by the band and a pseudoaneurysm had developed. The PA banding was removed and an end-to-end anastomosis of the PA was performed using cardiopulmonary bypass and deep hypothermia with surface cooling. The diameter of the PA anastomosis was designed to be one half that of her aorta. Staphylococcus aureus was cultured from the specimen of the PA band. It was thought to have contributed to the development of this aneurysm. The post operative course was uneventful.

Splenic gonadal fusion with persistent müllerian duct syndrome

Splenic gonadal fusion is a rare anomaly that is frequently associated with skeletal abnormalities or occasionally with cryptorchism. But the case of this anomaly accompanied by male pseudohermaphroditism here represents, to our knowledge, the first report of splenic gonadal fusion with persistent müllerian duct syndrome.

[Acute gastric volvulus in a patient with asplenic syndrome]

A 18 month-old boy with asplenic syndrome was admitted to our hospital with a twelve hours history of mucous vomiting, abdominal pain and a round epigastric mass. It was diagnosed as having a gastric volvulus and an emergency laparotomy was performed. The stomach was situated at the right side and a mesenterioaxial volvulus was found, with cyanosis of the antrum. The gastrophrenic and gastrosplenic ligaments were absent. The clinical and radiological characteristics of asplenic syndrome are reviewed. The pediatric surgeons must be aware of the digestive malformations of the asplenic syndrome, because some of that like malfixation of the stomach could be the cause of an acute abdomen.

[The echographic and computed tomographic diagnosis of polysplenia]

Polysplenia syndrome is a malformation with impaired visceral lateralization; it consists in the incomplete development of the spleen which is replaced by two or more splenules (1-3 cm phi). This malformation is often associated with other anomalies and is more frequently seen in situs inversus and situs ambiguus. On the basis of their findings in 3 cases, the authors describe the main US and radiographic patterns of polysplenia syndrome, that is: polysplenia syndrome associated with situs solitus (several splenules where the spleen should be, without other anomalies); polysplenia syndrome associated with situs ambiguus (splenules in the right hypochondrium with such anomalies as "umbrella-like" liver and the absence of the hepatic segment of the inferior vena cava and enlargement of both azygos and hemiazygos veins); polysplenia syndrome associated with situs viscerum inversus (right-sided splenules, with transposition of abdominal and thoracic organs). The splenules exhibit the same echogenicity as the liver; when situs viscerum ambiguus is present. US patterns of splenuli are equivocal and may mimic liver metastases. On the contrary, CT allows better demonstration of both the anomaly and the associated malformations.

[Diagnostic imaging of polysplenia syndrome in the adult]

Polysplenia syndrome is a congenital disorder of situs that is characterized by the presence of multiple spleens and a variable combination of thoracic and visceral anomalies. We present three adult cases of polysplenia syndrome with emphasis on the diagnostic imaging findings. Computed tomography could best determine the exact location and shape of the anomalous organs. The visceral anomalies observed in our patients included multiple spleens, interruption of the inferior vena cava (IVC), azygos or hemiazygos continuation, left-sided IVC, symmetrical liver, anomalous fissure of the liver, anomalous lobe of the liver, median location of the gallbladder, short pancreas, inverted stomach, gallbladder and pancreas, and intestinal malrotation.

[Role of echography in the differential diagnosis of accessory lobulations and small capsular traumatic fissures of the spleen]

Emergency US in patients with abdominal trauma has become a routine diagnostic exam thanks to both its high reliability and its short acquisition time. US allows the overall evaluation of the patient, relative to both the localization of even very small fluid collections and the evaluation of traumatic changes in parenchymatous abdominal organs, especially the spleen which is often injured. Twelve patients were selected of all the cases submitted to emergency abdominal US between February 1989 and March 1992. All the cases with evident traumatic lesions of the spleen were excluded. In 10 cases US demonstrated interrupted splenic parenchyma, which was highlighted by intraperitoneal fluid collections; the interruption of splenic parenchyma is also evidenced by a thin hyperechoic capsular line with no changes in the echopattern of deep parenchyma. Surgery in 6 patients--4 of them as an emergency for hemoperitoneum and 2 operated subsequently--and US monitoring in the extant cases confirmed the diagnosis of simple accessory splenic lobulations. On the contrary, in 2 patients hospitalized in emergency, US showed no evident traumatic splenic alterations but only interruption of the hyperechoic capsular line with low hypoechogenicity in the splenic parenchyma below and a small fluid collection next to the lower splenic pole. Splenectomy confirmed a limited marginal tear of about 1.5 cm. The misdiagnosis of traumatic tears can be avoided if congenital splenic lobulation--evidenced by hemoperitoneum--is considered. US must also be employed to demonstrate minimal alterations in the hyperechoic capsular line of the spleen, in order to point out possible small tears and, if necessary, to suggest the need for clinical monitoring.

Obstructive jaundice associated with polysplenia syndrome in an older child

Polysplenia syndrome includes malrotation and various forms of heterotaxy. Associated with this and malrotation are extrahepatic biliary anomalies. Actual obstruction, other than in associated biliary atresia, is extremely rare, and rarer still in older children. An 11-year-old girl presented with obstructive jaundice, malrotation, and heterotaxy, which were found in association with common bile duct anomalies and intermittent common bile duct obstruction. This case illustrates that the differential diagnosis of obstructive jaundice, even in older children, should include congenital anomalies, and that biliary anomalies should be considered in cases of malrotation and heterotaxy.

[Anesthetic management of an infant with a single ventricle (asplenia syndrome) for non-cardiac surgery]

Ketamine and fentanyl were used for surgery of esophageal hiatus hernia in a 9 month old boy with single ventricle (asplenia syndrome). The patient was orally premedicated with diazepam 2.5 mg, and intravenously with atropine 0.04 mg. General anesthesia was induced with ketamine-fentanyl-pancuronium-100% oxygen, and maintained with fentanyl-pancuronium-100% oxygen. The total dose of ketamine or fentanyl was 0.8 mg.kg-1 or 15 micrograms.kg-1, respectively. Systolic blood pressure and heart rate of the patient were stable during ketamine-fentanyl anesthesia. Arterial oxygen saturation measured by pulse oximetry was over 90% and arterial oxygen tension was above 60 mmHg during the operation. Ketamine-fentanyl anesthesia might be useful for non-cardiac surgery of a child with cyanotic congenital heart disease.

Accessory spleen in recurrent chronic immune thrombocytopenic purpura

From 1969 to 1985 we discovered accessory spleens in 8 patients with chronic immune thrombocytopenic purpura (ITP) who relapsed or failed after splenectomy. Imaging of accessory spleen used a liver spleen scintigraphy with heat-treated RBC labeled with Tc-99m. Platelet kinetic studies with 51Cr or 111In, including sequestration index, were performed. Five patients had accessory splenectomy. Disappearance of bleeding symptoms was achieved in the 5 splenectomized patients but with only partial response of platelet counts. These results are discussed in the context of diagnosis and therapeutic management of accessory spleens in patients with chronic immune thrombocytopenic purpura who relapsed or failed after splenectomy.

Wandering spleen: anatomic and radiologic considerations

Wandering spleen is a rare clinical entity and remains an elusive clinical diagnosis, particularly in the pediatric patient. Among the imaging modalities (computerized tomography, magnetic resonance imaging, nuclear medicine, ultrasonography, plain films) used in the diagnosis of wandering spleen, ultrasonography is the least invasive and most effective. Elective splenopexy remains the treatment of choice when the diagnosis is made before splenic infarction. We present two cases of wandering spleen manifested as a lower abdominal mass, and we discuss the surgical anatomy of the spleen and splenic ligaments and the hypothetical responsibility of these ligaments for the genesis of this clinical entity.

The wandering spleen

Wandering spleen is an unusual entity, occurring in both sexes and at any age, but is more frequent in women of reproductive age and in children. Wandering spleen is probably most often a result of congenital anomalies of development of the dorsal mesogastrium, but acquired factors may have a role in certain instances. Patients present most commonly with an asymptomatic mass, mass and subacute abdominal or gastrointestinal complaints or with acute abdominal findings. Clinical diagnosis can be difficult, but noninvasive imaging procedures, such as sonography, nuclear scintigraphy, computed tomography and magnetic resonance imaging are usually diagnostic. Laboratory tests are usually nonspecific, but may occasionally reveal evidence of hypersplenism or functional splenia. Symptoms may remain limited or absent for long periods of time, but complications related to torsion or compression of abdominal organs by the spleen or the pedicle are quite common. Splenomegaly is usually a result of torsion of the pedicle and splenic sequestration. Significant morbidity and mortality rates seem to be considerably less than described in 1933 and limited primarily to patients presenting initially with acute abdominal findings. Management recommendations have varied, but recognition of a significant risk of postsplenectomy sepsis supports a conservative approach. Patients with limited symptomatology may be medically managed until they exhibit worsening symptoms indicating progressive splenic torsion or gastrointestinal compression. Detorsion and splenopexy may be considered a reasonable surgical option even in patients presenting with acute abdomen, if there is no evidence of infarction, thrombosis or hypersplenism. Splenic preservation is especially recommended in extremely young patients who are at particular risk for postsplenectomy sepsis. However, it should be noted that follow-up evaluation data on splenopexy patients are notably lacking. Splenectomy is ideally reserved for patients presenting with acute abdomen and splenic infarction or thrombosis or with hypersplenism and patients in whom splenopexy is technically unfeasible. Subtotal splenectomy and splenic autotransplantation may be of limited value. Pneumococcal, Hemophilus and meningococcal vaccines are indicated before elective splenectomy and shortly after nonelective splenectomy. Antibiotic prophylaxis is recommended for those at particular risk. Prospective studies are unlikely, but extended follow-up information on patients already reported, particularly those managed expectantly or with conservative surgical measures, is needed.

Factors influencing survival of patients with heterotaxy syndrome undergoing the Fontan procedure

OBJECTIVES

This study was undertaken to determine those factors that may influence survival in patients with heterotaxy syndrome undergoing the Fontan procedure.

BACKGROUND

The Fontan procedure remains the preferred palliative procedure for patients with heterotaxy syndrome. Although the mortality rate has improved for patients without this syndrome undergoing the Fontan procedure, it remains high for patients with heterotaxy syndrome.

METHODS

The medical records of 20 consecutive pediatric patients with asplenia (n = 12) and polysplenia (n = 8) who underwent the Fontan procedure between January 1, 1986 and December 31, 1990 were reviewed. Anatomic and hemodynamic data were collected, as well as data on types of surgical palliative procedures and on outcome of the Fontan procedure.

RESULTS

There were two early and two late deaths for a total mortality rate of 20% in the patients with heterotaxy syndrome, as compared with 8.5% for the patients without this syndrome who underwent the Fontan procedure during the same time period. Factors that significantly increased the risk of the Fontan procedure in these patients were 1) preoperative findings of greater than mild atrioventricular valve regurgitation, b) hypoplastic pulmonary arteries, and c) mean pulmonary artery pressure greater than or equal to 15 mm Hg after 6 months of age. Systemic and pulmonary venous anomalies coupled with single-ventricle anatomy were not significant risk factors for determining a poor outcome of the Fontan procedure.

CONCLUSIONS

This study suggests that the outcome of the Fontan procedure in patients with heterotaxy syndrome may be improved by early protection of the pulmonary vascular bed, despite the existence of other cardiac anomalies.

Discordance between abdominal and atrial arrangement in a case of complex congenital heart disease

The report describes a rare case of a complex congenital heart disease wherein the splenic status and the relationship of the suprarenal abdominal great vessels strongly suggested right isomerism, but atrial morphology demonstrated usual atrial arrangement. It emphasises the increasing recognition that the arrangement of the abdominal organs need not accurately reflect atrial arrangement.

Scintigraphic diagnosis and computed tomographic localization of an accessory spleen following relapse of chronic immune thrombocytopaenia

Chronic immune thrombocytopaenia is an immunologically mediated disorder resulting in disordered platelet kinetics and potentially life-threatening thrombocytopaenia. Failure of medical therapy is an indication for splenectomy, and responses are seen in 80% of patients following this procedure. An important cause of relapse following splenectomy is the presence of an accessory spleen. We describe a patient with Hodgkin's Disease who developed chronic immune thrombocytopaenia despite previous splenectomy. A remission was induced with immunosuppressive therapy, but he later relapsed. An accessory spleen was detected using 99mTc denatured red blood cells and localized using computed tomography (CT). Resection of the accessory spleen resulted in clinical remission. Accessory spleens are often small in size. Combined modality imaging is recommended in the evaluation of patients with a possible accessory spleen.

Polysplenia syndrome with various visceral anomalies in an adult: embryological and clinical considerations

A 26-year-old female with polysplenia syndrome is reported. She had numerous visceral anomalies including polysplenia, a short pancreas, a preduodenal portal vein, malrotation of the bowel, azygos continuation of the inferior vena cava, bilateral hyparterial bronchi and symmetrical liver lobation. Embryological and clinical considerations of polysplenia syndrome are described.

Abnormal laterality and congenital cardiac anomalies. Relations of visceral and cardiac morphologies in the iv/iv mouse

BACKGROUND

In the management of hearts with deranged laterality, it is essential that the left and right atrial chambers are correctly identified. There are two major approaches, which are based on venous connections or on the morphology of the atrial appendages, and there is no consensus as to which is the most useful. We used the iv/iv mouse mutant, which is known to be pertinent to this problem, to evaluate the relations of cardiac defects with atrial, venous, and other visceral morphologies.

METHODS AND RESULTS

The morphology of the heart and other organs was examined in 275 iv/iv mice using criteria based on abnormal laterality in humans. The arrangement of the atrial appendages was determined by morphological examination of the junction between the appendage and the venous component of the atrium. On this basis, 45.1% of cases were shown to have usual atrial arrangement, 50.2% had mirror imagery, 1.5% had right isomerism, and 3.3% had left isomerism. Every case of atrial isomerism had a cardiac lesion; the morphological types were similar to those seen in human cases. Of cases with either usual or mirror-image arrangement of the appendages, 33.2% had abnormal spleens, but only 3.1% had cardiac defects. Similarly, venous abnormalities were much more common (30.1%) than cardiac defects.

CONCLUSIONS

Study results endorse the importance of the morphology of atrial appendages in predicting cardiac abnormalities and point to the marked inconsistency of the arrangement of other organs, including the spleen and the connections of the systemic veins.

The splenic snood: an improved approach for the management of the wandering spleen

A wandering spleen is in constant danger of torsion and infarction. Splenectomy, the traditional treatment, leaves children in danger of postsplenectomy sepsis. Three children with wandering spleens were treated by a new splenopexy technique, the splenic snood. After detorsion, the spleens were wrapped in polyglycolic mesh and anchored by the mesh subdiaphragmatically in the left upper quadrant. All have retained their spleens which have remained where anchored up to a 4-year follow-up. The simplicity and technical ease of the splenic snood operation recommend it as an improved method to avoid splenectomy and safely normalize intraabdominal anatomy in the management of the wandering spleen.

Pulmonary circulation in pulmonary atresia associated with the asplenia cardiac syndrome

OBJECTIVE

The goal of this study was to determine the patterns of the pulmonary circulation in patients with pulmonary atresia and asplenia.

BACKGROUND

The asplenic cardiac syndromes characteristically have complex cardiac anomalies including pulmonary stenosis or atresia. Definition of the pulmonary artery circulation and pulmonary venous connections is needed for consideration of surgical procedures.

METHODS

In 35 patients, the sources of pulmonary blood flow, anatomic features of pulmonary arteries and pulmonary venous connections were determined from angiograms or autopsy specimens.

RESULTS

The main pulmonary artery was absent or hypoplastic in 91% of patients; most had a ductus arteriosus. The right and left pulmonary arteries were confluent in 90% and usually of normal size (right 71%, left 63%). Total anomalous pulmonary venous connections were present in 38%.

CONCLUSIONS

The anatomic features of the pulmonary arteries in pulmonary atresia associated with the asplenic cardiac syndrome are usually favorable for palliative surgical procedures. Total anomalous pulmonary venous connection may exist as a complicating factor.