The Great Pretender: Pediatric Wandering Spleen: Two Case Reports and Review of the Literature

"Wandering Spleen" With Lymphomatous Involvement

ABSTRACT

Wandering spleen is a rare condition caused by either lack or the laxity of ligaments, which results malposition in the lower abdomen or pelvis. FDG PET/CT is the cornerstone of the staging procedures in the management of lymphomas leading to upstaging and picking up occult lesions in the spleen and extranodal sites. Herein, we reported initial staging 18 F-FDG PET/CT findings of a woman with Hodgkin lymphoma whose spleen was absent in normal position and multiple intense heterogenous hypermetabolism in a pelvic mass raised a suspicion of wandering splenic involvement. The confirmation was made with selective spleen SPECT/CT images thereafter.

Wandering spleen: An unsuspected presentation at a general hospital in Uganda

INTRODUCTION AND IMPORTANCE

Wandering spleen is an uncommon condition marked by splenic hypermobility due to laxity or underdevelopment of the supporting splenic ligaments. Patients may be asymptomatic, have a palpable mass in the abdomen, or exhibit acute, long-lasting, or sporadic symptoms as a result of the spleen's pedicle torsion. The management should be determined by the spleen's vitality.

CASE PRESENTATION

We report a case of a 29-year-old male who presented with a 5-year history of progressive abdominal swelling, surgically managed as an intrabdominal tumor at a general hospital in Uganda, with a postoperative confirmation of a wandering spleen.

CLINICAL DISCUSSION

Wandering spleen is a rare condition both in high- and low-income countries. Clinical presentations vary from an asymptomatic abdominal mass to acute abdominal pain due to vascular pedicle torsion leading to splenic infarction. When possible, splenopexy is the procedure of choice, especially in children and in tropical countries, to avoid post-splenectomy sepsis. Splenectomy is the definitive treatment for spleen fracture, spleen infarction, or symptoms that recur after splenopexy.

CONCLUSION

Wandering spleen is a rare differential diagnosis of intrabdominal tumor that must be considered in patients with a palpable abdominal mass with or without acute or chronic abdominal pain. Though a CT scan is the best method to confirm the diagnosis, the radiologist's and surgeon's experience and keenness seem very vital in making the correct diagnosis. Intraoperative complete abdominal exploration by the surgeon is essential to confirm the radiological findings, to enhance the diagnosis, and to make the best treatment decision.

Diagnosis and treatment of splenic torsion in children: preoperative thrombocytosis predicts splenic infarction

Background

Pediatric splenic torsion is a rare entity, and the most common cause is wandering spleen. This study aimed to summarize our clinical experience in the diagnosis and surgical treatment pediatric patients with splenic torsion, and to use preoperative thrombocytosis as a preoperative predictive factor for splenic infarction.

Methods

From January 1st, 2016 to December 31st, 2021, 6 children diagnosed as splenic torsion were included. All patients were surgically treated and followed up. The clinical data was collected including clinical presentations, laboratory tests, imaging results, surgical procedures, and prognosis. Clinical experience of diagnosis and surgical treatment were summarized.

Results

There were 4 females and 2 males, with median age at surgery 102.6 (range 9.4–170.7) months. Abdominal pain and abdominal mass were the most common presentations. The diagnosis of splenic torsion depended on imaging studies, and adjacent organ involvement (gastric and pancreas torsion) was observed on contrast CT in one patient. Five patients were diagnosed as torsion of wandering spleen, and one was torsion of wandering accessory spleen. Emergent laparoscopic or open splenectomy was performed in all patients. Pathology revealed total splenic infarction in 4 patients, partial infarction in 1 patient, and viable spleen with congestion and hemorrhage in 1 patient. Preoperative platelet counts were elevated in all 4 patients with splenic infarction, but normal in the rest 2 with viable spleen. Postoperative transient portal vein branch thromboembolism occurred in one patient.

Conclusions

Imaging modalities are crucial for the diagnosis of pediatric splenic torsion and adjacent organ involvement. Preoperative thrombocytosis may predict splenic infarction. Spleen preserving surgery should be seriously considered over splenectomy in patients with a viable spleen.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03484-y.

Surgical Approach of Wandering Spleen in Infants and Children: A Systematic Review

Introduction: Splenopexy has been proposed as the treatment of choice in case of wandering spleen (WS). We report our experience and review the current literature focusing on surgical management and outcomes of children affected by WS. Materials and Methods: Data regarding demographics, clinical manifestations, diagnosis, and treatment of children treated for WS at our Institution were analyzed. Systematic review was registered on Prospero (CRD42018089971). Scientific databases were searched using defined keywords. Articles were selected using predefined exclusion and inclusion criteria. Analysis was conducted adding our center's cases. Results: One hundred sixty-six articles were included in the review, 197 cases were analyzed, 3 of which unpublished. Female/male ratio was 1.5:1 and median age at diagnosis was 8 years. Most frequent clinical manifestation was isolated abdominal pain (42.6%). Torsion of splenic pedicle was diagnosed in 56.3%. Among surgical procedures, 39% underwent splenopexy and 54.8% underwent splenectomy. In case of splenopexy, the most commonly used techniques were using of a mesh (45.5%) or creation of a retroperitoneal pouch (30.9%). In 48.2% of splenopexies, minimally invasive surgery (MIS) was used. Splenopexy was effective in 94.8% (88% considering only cases with a spleen torsion). Conclusion: WS is a rare condition potentially leading to torsion of the spleen. This entity has to be kept in mind as a differential diagnosis in case of abdominal pain. Splenopexy should be the treatment of choice; its success rate in terms of preserved spleens can be affected by the presence of a torted organ. Retroperitoneal pouch or mesh fixation are the most preferred techniques. Authors recommend MIS approach.