Minilaparoscopy-guided spleen biopsy in systemic disease with splenomegaly of unknown origin

Laparoscopic Splenic Biopsy in Dogs and Cats: 15 Cases (2006–2008)

This retrospective study describes a technique and evaluates outcome associated with laparoscopic splenic biopsy in dogs and cats. Medical records of dogs (n = 10) and cats (n = 5) that had a laparoscopic splenic biopsy performed as part of their diagnostic evaluation for systemic disease were evaluated. Splenic biopsies were performed with the patient in dorsal recumbency using a two-portal approach. In some cases, concurrent organ biopsy was also performed. A pair of 5 mm cup biopsy forceps was used for biopsy collection, and an absorbable gelatin hemostatic sponge was placed at the biopsy site to aid in hemostasis. All patients recovered without major complications. Conversion to an open surgical approach was not required. Median survival time was 180 days, and nine patients were alive at the time of manuscript preparation. Four patients were diagnosed with neoplasia; however, only one had neoplasia involving the spleen. Median survival time for the nonneoplasia group (n = 11) was 300 days. Eight of those patients were alive at time of manuscript preparation. Minimal morbidity was observed in this cohort of clinical patients. Histopathology may be preferred over cytology in some clinical situations, and laparoscopic splenic biopsy provides a minimally invasive diagnostic option.

Mini-laparoscopy in the endoscopy unit

PURPOSE OF REVIEW

The evaluation of liver histology is an important component of the diagnosis and staging of liver diseases. The most common technique employed to sample liver tissue for decades has been percutaneous liver biopsy. Although this is a relatively well tolerated technique in the early stages of liver disease, it carries a high risk of complications, particularly hemorrhage, in patients with advanced cirrhosis. Mini-laparoscopy allows macroscopic assessment and biopsy under direct vision and therefore is a well tolerated and effective technique.

RECENT FINDINGS

The major advantages of this technique are direct visualization of the liver surface, thereby allowing inspection for morphologic changes of cirrhosis as well as targeted biopsies, the ability to immediately treat potential complications (bleeding and bile leakage), furthermore the peritoneal cavity can be visualized to stage gastrointestinal (GI) malignancies. Additionally, 'blind' percutaneous liver biopsy fails to establish a diagnosis in about 25% of cases, largely because of sampling error.

SUMMARY

This technique presents the opportunity to visualize the surface of the liver and the peritoneal cavity, making it a valuable tool for liver biopsy. This review summarizes the technique of mini-laparoscopy and addresses its potential uses and limitations as a diagnostic modality.

Mini-laparoscopy in the endoscopy unit: Safety and outcomes in over one thousand patients

AIM: To investigate the safety of consecutive mini-laparoscopy guided liver biopsies for the diagnosis and staging of liver diseases.

METHODS: In this study we retrospectively analyzed the safety of mini-laparoscopic liver biopsy performed in an endoscopy unit in 1071 patients. We measured the incidence of bleeding and evaluated the management and outcome of bleeding interventions.

RESULTS: The most common etiologies of liver injury were viral hepatitis and autoimmune liver disease. 250 patients had macroscopically and histologically proven cirrhosis. 13 patients had no pathological findings. 33% of all patients had bleeding that required argon plasma coagulation of the puncture site during laparoscopy. Significant bleeding occurred more often in patients with liver cirrhosis compared to non-cirrhotic liver diseases but was effectively treated with laparoscopic coagulation.

CONCLUSION: In conclusion, mini-laparoscopy liver biopsy can be performed safely and effectively in high risk patients with advanced liver disease; mini-laparoscopy with liver biopsy can be done safely in an endoscopy unit.

Tuberculosis of the spleen as a cause of Fever of unknown origin and splenomegaly

BACKGROUND/AIMS

Splenic involvement of tuberculosis, which is rare, warrants better definition in the current era of resurgence of tuberculosis.

METHODS

Out of 339 splenectomies performed between January 1989 and December 2008 for indications other than trauma, histopathologic analysis of the spleen revealed tuberculosis in 8 patients.

RESULTS

All eight patients were referred for splenectomy due to fever of unknown origin (FUO). No patient was infected with HIV, and all had at least moderate splenomegaly and hepatomegaly. Three patients had hypersplenism with bleeding manifestations. Radiologic evaluations demonstrated that splenic lesions were present in five patients. Five patients had evidence of tuberculosis manifested as enlarged splenic hilar lymph nodes, cystic lymph nodes, or liver. Two patients exhibited tubercle bacilli in their sputum during the postoperative period.

CONCLUSIONS

In areas where tuberculosis is prevalent, tuberculosis should be considered in the differential diagnosis of patients presenting with FUO and splenomegaly. Extrasplenic involvement is usually seen in splenic tuberculosis, although it may not be apparent at presentation. Splenic tuberculosis can present in isolation without extrasplenic involvement, and even in immunocompetent individuals.

Safety and diagnostic accuracy of percutaneous ultrasound-guided biopsy of the spleen: a multicenter study

PURPOSE

To analyze the safety and accuracy of ultrasound-guided (USG) percutaneous needle biopsy of the spleen.

METHODS

Sixty-two USG needle biopsies performed in 52 patients were retrospectively analyzed: there were 53 biopsies of local lesions and 9 biopsies of diffuse lesions. Fine-needle aspiration (FNA) was performed in 37 cases and core-needle biopsy (CNB) in 25 cases. The complications and diagnostic accuracy of the 2 types of biopsy were compared.

RESULTS

Two patients (3.8%) had postprocedural hemorrhage after CNB; one was minor, and the other severe, requiring splenectomy. No bleeding occurred with FNA. The diagnostic accuracy was similar with FNA (86.5%) and CNB (92%), whereas in patients with lymphoma, accuracy of FNA (80%) tended to be lower than that of CNB (100%), although the difference was not statistically significant.

CONCLUSION

USG needle biopsy is safe and effective for diagnosing both focal and diffuse splenic lesions. The risk of bleeding may be lower with FNA than with CNB.

Splenic peliosis - a potentially fatal condition which can mimick malignancy

Isolated splenic peliosis is an extremely rare occurrence, and this disease often manifests itself with spontaneous haemoperitoneum.

We report a case where an otherwise healthy patient was found to have splenomegaly on clinical examination. On computerised tomography, a diagnosis of splenic malignancy was made, and the patient underwent a splenectomy. Histological examination gave the diagnosis of splenic peliosis, which had not been considered prior to the operation. In retrospect, splenectomy was the most prudent course of action, as the risk of spontaneous haemorrhage and fatality was eliminated. This case emphasises the need to retain an index of suspicion for this condition, even in otherwise healthy patients, and is a reminder of the usefulness of total splenectomy in the current era of minimally invasive diagnostic techniques.