Successful treatment of severe splenic lymphoma‑associated hemophagocytic syndrome by splenectomy and subsequent chemotherapy: A case report

Hemophagocytic lymphohistiocytosis (HLH) represents a fatal immunopathology derived from excessive inflammatory reactions. In particular, lymphoma-associated hemophagocytic syndrome (LAHS) is associated with a dismal prognosis. The current study presented a challenging case of splenic LAHS. A 71-year-old man presented with fatigue and anorexia. Laboratory test results revealed anemia, thrombocytopenia, lactate dehydrogenase elevation and markedly elevated levels of ferritin (6,210 ng/ml) and soluble interleukin 2 receptor (sIL-2R; 11,328 U/ml). Abdominal computed tomography revealed marked splenomegaly, while fluorodeoxyglucose positron emission tomography revealed increased tracer uptake in the spleen. An elective splenectomy was performed, which led to the diagnosis of B-cell splenic lymphoma with transformation from indolent to aggressive lymphoma. Prior to the splenectomy, thrombocytopenia and hepatic dysfunction with rapidly progressing jaundice appeared, accompanying further elevation of ferritin (25,197 ng/ml) and sIL-2R levels (30,420 U/ml). On postoperative day 5, the patient was transferred to a tertiary care institution and corticosteroid pulse therapy was immediately initiated after establishing the diagnosis of LAHS. Liver dysfunction gradually recovered and subsequent chemotherapy resulted in complete remission with improved performance status. At eight months after the onset, the patient remains alive without any signs of residual lymphoma. Although splenic lymphoma typically manifests with low-grade lymphoma, it can transform into high-grade lymphoma associated with severe complications, such as HLH and multiple organ failure. In this case, splenectomy assisted in not only establishing the diagnosis but also in tumor cytoreduction before commencing chemotherapy. Through interdisciplinary collaboration, the patient was successfully treated by performing a timely splenectomy, followed by steroid pulse therapy and chemotherapy.

Protective effects of COVID-19 vaccination in splenectomized patients with immune thrombocytopenia

Splenectomy is an effective treatment for immune thrombocytopenia (ITP). The effect of COVID-19 vaccination on splenectomized patients with ITP during the COVID-19 pandemic has not been reported. Therefore, this study aimed to investigate the effect of COVID-19 vaccination on clinical outcomes in these patients. This was a longitudinal study of splenectomized patients with ITP. A total of 191 splenectomized patients were included in this study. After a median follow-up of 114 months, 146 (76.4%) patients had a sustained response to splenectomy. During COVID-19 infection, vaccinated patients showed a lower risk of severe infections (odds ratio [OR], 0.13; 95% confidence interval [CI]: 0.05-0.36; p < 0.001), hospitalization (OR, 0.13; 95% CI, 0.04-0.48; p = 0.002), and ITP exacerbation (OR, 0.16; 95% CI, 0.04-0.67; p = 0.012). These findings indicate that COVID-19 vaccination plays a protective role in splenectomized patients with ITP.

British Society for Haematology guidelines to improve the care of asplenic patients: Much work done, some remaining and a call for national registries

Asplenic patients are at high risk of serious infectious or thrombotic complications, especially when they are not adequately informed of the risk and not closely followed. Ladhani et al. on behalf of the British Society for Haematology propose updated guidelines for managing these patients. Healthcare professionals need to improve infection prevention in patients with hypofunctional or absent spleen through better identification and immunisation using established national registries. Commentary on: Ladhani et al. Prevention and treatment of infection in patients with absent or hypofunctional spleen: A British Society for Haematology guideline. Br J Haematol 2024 (Online ahead of print). doi: 10.1111/bjh.19361.

Prevention and treatment of infection in patients with an absent or hypofunctional spleen: A British Society for Haematology guideline

Guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen were published by the British Committee for Standards in Haematology in 1996 and updated in 2002 and 2011. With advances in vaccinations and changes in patterns of infection, the guidelines required updating. Key aspects included in this guideline are the identification of patients at risk of infection, patient education and information and immunisation schedules. This guideline does not address the non-infective complications of splenectomy or functional hyposplenism (FH). This replaces previous guidelines and significantly revises the recommendations related to immunisation. Patients at risk include those who have undergone surgical removal of the spleen, including partial splenectomy and splenic embolisation, and those with medical conditions that predispose to FH. Immunisations should include those against Streptococcus pneumoniae (pneumococcus), Neisseria meningitidis (meningococcus) and influenza. Haemophilus influenzae type b (Hib) is part of the infant immunisation schedule and is no longer required for older hyposplenic patients. Treatment of suspected or proven infections should be based on local protocols and consider relevant anti-microbial resistance patterns. The education of patients and their medical practitioners is essential, particularly in relation to the risk of serious infection and its prevention. Further research is required to establish the effectiveness of vaccinations in hyposplenic patients; infective episodes should be regularly audited. There is no single group ideally placed to conduct audits into complications arising from hyposplenism, highlighting a need for a national registry, as has proved very successful in Australia or alternatively, the establishment of appropriate multidisciplinary networks.

Thrombosis Tendency After Splenectomy in a Danish Family With Hemoglobin Volga, and a Literature Review

Hemoglobin (Hb) Volga is a rare, unstable β-chain hemoglobin variant (β27 Ala→Asp), causing chronic hemolytic anemia. This study presents two members of a Danish family, splenectomized due to Hb Volga at and with multiple thrombotic events. The proband was diagnosed with Hb Volga 9 years old and splenectomy was performed as a part of treatment. Throughout his life, he experienced multiple superficial thrombophlebitis, two episodes of distal deep venous thrombosis (DVT) on lower extremities (age 32 and 33) and a transient ischemic attack (TIA) presented as amaurosis fugax (age 51). Thrombophilia investigation was normal. The proband's son was diagnosed with Hb Volga and underwent splenectomy at the age of 6. Despite anticoagulation therapy, he suffered from multiple venous thromboembolic events in his youth and died of chronic pulmonary embolism (PE)/pulmonary hypertension combined with infection. Given the observed propensity for multiple thromboses in these two patients, a literature review was conducted investigating reported occurrence of thrombotic events in individuals with Hb Volga.

Currently 25 cases of Hb Volga are reported worldwide. The clinical symptoms primarily described are related to hemolytic anemia. Splenectomy is reported in 15 patients. Thromboses have previously been reported in only three patients who were also splenectomized. These cases involved DVT and PE, myocardial infarction, and an unspecified thrombotic event. The proband represents the first reported Hb Volga case with both venous and arterial thrombotic disorders. The exact mechanism underlying thrombotic tendency in patients with Hb Volga remains unknown, but it is probably associated with splenectomy.

A canine case of Ehrlichia canis infection without a history of being in an endemic area in Japan

A mixed-breed, 8-year-old male dog developed neutropenia, thrombocytopenia, and hyperglobulinemia. Bone marrow hyperplasia and splenic plasmacytosis were cytologically observed. The dog had never been outside of Tokyo or Shizuoka Prefecture. Splenectomy was performed to confirm and remove the cause of splenic plasmacytosis. A histopathological diagnosis of splenic plasmacytoma was made; however, serum protein electrophoresis showed polyclonal gammopathy. Further screening was performed, and Ehrlichia canis infection was confirmed. The dog was treated with doxycycline for 5 weeks. After the antibiotic therapy, no relapse of neutropenia, thrombocytopenia, hyperglobulinemia, or positive polymerase chain reaction result of E. canis infection was observed for 3 years. Careful attention should be given to ehrlichiosis when exploring the cause of pancytopenia or hyperglobulinemia, regardless of the travel history.

Temporal trends of splenectomy in pediatric hospitalizations with hereditary spherocytosis from 2000 to 2019: A national survey

BACKGROUND

Total and partial splenectomy are used in pediatric patients with hereditary spherocytosis to resolve anemia and hemolytic complications.

PROCEDURE

Data from the Healthcare Cost and Utilization Project's Kid's Inpatient Database was used to profile and describe temporal trends in pediatric (≤18 years) hospital admissions in the United States from 2000 to 2019 data release years. Survey sampling methods were used to produce national estimates.

RESULTS

From 2000 to 2019, the use of splenectomy declined overall, from 427 to 206 weighted procedures (difference = 222, 95% confidence interval [CI]: 124-320; p < .0001); the risk of undergoing splenectomy during admission also declined from 56.7% to 38.7% (risk difference = 17.9 percentage points [p.p.], 95% CI: 9.7-26.1; p < .0001). Total splenectomy was mostly used. Age at time of splenectomy increased 10.2 years (difference = 1.6 years, 95% CI: 0.6-2.7; p = .0018). The risk of splenectomy increased with age until 10 years, then leveled off until 18 years. The proportion of children aged ≤5 years undergoing splenectomy decreased from 27.7% to 11.2% in 2019 (risk difference: 16.5 p.p., 95% CI: 7.3-25.7; p = .0004). The strongest clinical predictors of splenectomy, adjusting for patient- and hospital-level characteristics, were a co-diagnosis of symptomatic cholelithiasis (adjusted odds ratio [aOR] = 3.18, 95% CI: 1.92-5.28; p < .0001) and splenomegaly or hypersplenism (aOR = 2.52, 95% CI: 1.74-3.65; p < .0001). Risk of splenectomy with splenomegaly or hypersplenism increased over time.

CONCLUSION

Splenectomy was delayed until age greater than 10 years. Older age, co-diagnosis with splenomegaly or hypersplenism, or symptomatic cholelithiasis were strongest clinical predictors of splenectomy. Conservative management of hereditary spherocytosis appears to be more common.

A 16-year-old adolescent with a history of minor abdominal trauma diagnosed with a giant isolated primary splenic hydatid cyst: a case report

Introduction

Hydatosis is a zoonotic parasitic disease caused by echinococcosis larval infection. South America, Africa, the Middle East, South Europe, India, and Australia are endemic to this disease. Splenic involvement is a rare and complicated hydatid disease presentation. A splenic hydatid cyst is an infrequent clinical occurrence, even in regions where the disease is endemic.

Case presentation

A 16-year-old male, having a background of mild abdominal trauma and non-resolving dull abdominal pain attended a paediatric surgical outpatient office and following a thorough examination, was diagnosed with a giant solitary isolated splenic hydatid cyst. Subsequently, the patient received albendazole and underwent total splenectomy, necessitated by the considerable size of the cyst, classified as a giant.

Clinical discussion

Splenic involvement of hydatid disease is a rare presentation (0.5-8%.). With the initial clinical finding often involving the accidental discovery of a palpable mass, the most frequently reported symptoms and signs include the presence of a palpable mass, fever, dull pain, or splenomegaly. Ultrasound and computed tomography are the most helpful tools for evaluating focal splenic diseases. The preferred treatment involves the use of antihelminthic drugs such as albendazole or mebendazole in conjunction with splenectomy. Total splenectomy is the preferred approach and is associated with decreased hospital stay, reduced healthcare costs, and a lower likelihood of recurrence.

Conclusion

in endemic areas, in patients with splenic cysts, hydatidosis should be contemplated.

Littoral cell angioma of the spleen: A study of 10 cases case series and literature review

BACKGROUND

Current study aimed to investigate the clinical characterization, differential diagnosis, and treatment of splenic littoral cell angioma (LCA).

METHODS

A retrospective analysis was performed for 10 LCA cases admitted to Huzhou Central Hospital from 2007 to 2023, for clinical manifestations, hematological tests, imaging features, pathological features, treatment methods, and prognosis along with the relevant literature was also reviewed.

RESULTS

During examinations, no specific clinical manifestations and hematological abnormalities were seen in all 10 cases of LCA. Imaging observations depicted single or even multiple spherical lesions in the spleen. Plains shown by computed tomography (CT) were found somewhat equal or slightly lower in density. On the other hand, magnetic resonance imaging (MRI) plain scans viz. T1 weighted image showed equal low and mixed signals while T2-weighted showed high and low mixed signals. Moreover, punctate low signals could be seen in high signals named "freckle sign" in MRI scans. On contrast-enhanced CT scans, the enhancement of the lesions was not obvious in the arterial phase, and some of the lesions showed edged ring-like enhancements and "filling lake" progressive enhancement during the venous phase and delayed phase. In multiple lesions, the number of enhanced scan lesions showed a variable changing pattern "less-more-less." MRI-enhanced scan showed the characteristics of "fast in and slow out." Microscopic examinations identified tumor tissue actually composed of sinus-like lacunae that anastomosed with each other in the form of a network. Furthermore, cystic expansion and pseudopapillary protrusions were also seen in the dilated sinus cavity which was lined with single-layer endothelial cells having conspicuous cytoplasmic hemosiderin. High immunophenotypic expressions of vascular endothelial cell phenotype (CD31, CD34, FVIII) and tissue cell phenotype (CD68) were also seen. Total and partial splenectomy were performed in 8 and 2 patients, respectively, and follow-up examinations showed survival in all patients with no recurrence.

CONCLUSION

LCA is a rare splenic benign lesion with atypical clinical manifestations. CT and MRI imaging are important tools in preoperative diagnosis based on pathomorphological and immunohistochemical examinations. Splenectomy is a superior therapeutic choice with significant impacts and prognosis.

Proteomics landscape and machine learning prediction of long-term response to splenectomy in primary immune thrombocytopenia

This study aimed to identify key proteomic analytes correlated with response to splenectomy in primary immune thrombocytopenia (ITP). Thirty-four patients were retrospectively collected in the training cohort and 26 were prospectively enrolled as validation cohort. Bone marrow biopsy samples of all participants were collected prior to the splenectomy. A total of 12 modules of proteins were identified by weighted gene co-expression network analysis (WGCNA) method in the developed cohort. The tan module positively correlated with megakaryocyte counts before splenectomy (r = 0.38, p = 0.027), and time to peak platelet level after splenectomy (r = 0.47, p = 0.005). The blue module significantly correlated with response to splenectomy (r = 0.37, p = 0.0031). KEGG pathways analysis found that the PI3K-Akt signalling pathway was predominantly enriched in the tan module, while ribosomal and spliceosome pathways were enriched in the blue module. Machine learning algorithm identified the optimal combination of biomarkers from the blue module in the training cohort, and importantly, cofilin-1 (CFL1) was independently confirmed in the validation cohort. The C-index of CFL1 was >0.7 in both cohorts. Our results highlight the use of bone marrow proteomics analysis for deriving key analytes that predict the response to splenectomy, warranting further exploration of plasma proteomics in this patient population.

The First Iranian Case of Unstable Hemoglobin Santa Ana

In this report, we describe a 6-year-old girl with a medical history of pallor, mild icterus, anemia, blood transfusion and abnormal hemoglobin variant analysis on capillary electrophoresis. She was referred for further analysis. DNA sequencing of the proband revealed a de novo mutation in Codon 88 (CTG > CCG) of the β-globin gene (HBB: c.266T > C) in a heterozygous state compatible with hemoglobin Santa Ana, an unstable hemoglobin. This is the first case of Hb Santa Ana from Iran associated with moderate to severe anemia who underwent splenectomy with clinical improvement.

Splenectomy versus non-splenectomy for gastrointestinal bleeding from left-sided portal hypertension: a systematic review and meta-analysis

Objectives

Left-sided portal hypertension (LSPH) leads to life-threatening gastrointestinal (GI) bleeding. There are no recommendations or consensus about the management of GI bleeding caused by LSPH. This systematic review and meta-analysis were conducted to evaluate the incidence of GI bleeding and the mortality of patients with LSPH receiving different therapeutic strategies.

Design

A systematic review and meta-analysis were performed to determine the efficacy of different therapeutic strategies for GI bleeding caused by LSPH.

Data sources and methods

All relevant studies were searched from PubMed, Embase, Web of Science, Cochrane Library, Scopus, ScienceDirect, MEDLINE, Google Scholar, CNKI, and Wanfang Data without language restriction through 15 November 2023. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated through RevMan5.3 software. (The Cochrane Collaboration, Copenhagen, Denmark).

Results

Seventeen retrospective studies and one prospective study involving 624 patients were included. This systematic review and meta-analysis found that: (1) splenectomy was more effective than non-splenectomy therapeutic strategies in reducing the incidence of GI bleeding caused by LSPH (OR: 0.12; 95% CI: 0.06-0.27); (2) splenectomy was superior to partial splenic artery embolism (PSAE) (OR: 0.06; 95% CI: 0.01-0.62) or endoscopic interventions (OR: 0.04; 95% CI: 0.01-0.19) in the prevention of GI bleeding, respectively; (3) no significant difference in the mortality was observed between splenectomy and non-splenectomy therapeutic strategies (OR: 0.46; 95% CI: 0.20-1.08); and (4) patients receiving preoperative PSAE followed by splenectomy had less intraoperative bleeding and shorter operative time than those receiving splenectomy.

Conclusion

This meta-analysis demonstrated that splenectomy is superior to non-splenectomy therapeutic strategies in reducing the incidence of GI bleeding from LSPH, which revealed that splenectomy should be recommended in the management of these patients.

Trial registration

This study has been registered on the PROSPERO database with the registration number CRD42023483764.

A Clinical Review and Experience of Splenic Trauma in North India: A Retrospective Observational Study

INTRODUCTION

The spleen is one of the frequently injured solid organs in abdominal blunt trauma. The standard of care is nonoperative nowadays depending on the hemodynamic stability (World Society of Emergency Surgery (WSES) grade I-III) of the patient due to advancements in treating modalities. Operative interventions are required in hemodynamically unstable patients or failure of nonoperative management. The study was planned to find the clinical spectrum of abdominal blunt trauma, specifically those having splenic trauma, and their subsequent management in an institution.

METHODS

This is a retrospective observational study. All included patients with blunt abdominal injuries were treated in a level 1 trauma center between July 2021 and December 2022. Data regarding demographic profile, blood transfusion, pre- and postoperative findings, and management including the period of hospital stay, morbidity, and mortality were collected and analyzed.

RESULTS

One hundred sixty-four patients were analyzed, of which 142 were males and 22 were females. The commonest mechanism of injury was motor vehicle collision, followed by falls. Grade III splenic injury was the most common injury, while the predominantly associated injury was rib fracture. The patients were managed preferably through nonoperative management, followed by angioembolization and operative management. The commonest postoperative complication was pneumonia.

CONCLUSIONS

Nonoperative management of splenic trauma has evolved as the standard of care replacing operative management in order to sustain its immune function, thereby preventing overwhelming post-splenectomy infection.

Corrigendum: Gut and spleen anomalies associated with DYRK1A syndrome

[This corrects the article DOI: 10.3389/fped.2022.936732.].

Splenectomy as Part of Maximal-Effort Cytoreductive Surgery in Advanced Epithelial Ovarian Cancer

INTRODUCTION

A splenectomy is frequently performed during debulking surgery for advanced ovarian cancer. Its impact on perioperative and survival outcomes remains questionable as current evidence is conflicting. In the present study, we sought to determine the factors that affect survival rates in ovarian cancer patients that undergo a splenectomy as part of maximal-effort cytoreduction.

PATIENTS AND METHODS

A retrospective chart review was conducted that included all epithelial ovarian cancer patients that had surgical cytoreduction for advanced epithelial ovarian cancer. Differences among splenectomized and non splenectomized patients were evaluated as well as the impact of known risk factors on survival outcomes of splenectomized patients.

RESULTS

Overall, 245 patients were identified and 223 were included in the present series, of whom 91 had a splenectomy. Recurrence rates as well as death rates were comparable among splenectomized and non-splenectomized patients; however, both the disease-free survival (log-rank = 0.001), as well as the overall survival of splenectomized patients (log-rank = 0.006), was shorter. Thrombotic events as well as rates of pulmonary embolism were comparable. Sepsis was more common among splenectomized patients. The site of splenic metastases did not influence patients' survival. Among splenectomized patients, those offered primary debulking had longer progression-free survival (log-rank = 0.042), although their overall survival did not differ compared to patients submitted to interval debulking. Complete debulking significantly improved the overall survival compared to optimal debulking (log-rank = 0.047). Splenectomized patients that developed sepsis had worse overall survival (log-rank = 0.005).

DISCUSSION

The findings of our study support the feasibility of splenectomy in advanced epithelial ovarian cancer; however, its impact on patients' survival is considerable. Therefore, every effort should be made to avoid splenic injury which will result in unintended splenectomy for non-oncological reasons.

Splenectomy at Early stage of Autoimmune Arthritis Delayed Inflammatory Response and Reduced Joint Deterioration in Mice

The spleen plays a role in innate- and adaptive immunity, and autoimmune diseases like rheumatoid arthritis (RA). We investigated the effect of splenectomy in early and moderate stages of autoimmune arthritis in a mouse model. To induce recombinant human G1-induced arthritis (GIA), BALB/c mice were immunized intraperitoneally three times in 4 weeks interval with the rhG1 antigen. Mice were splenectomized on day 7 (SPE1) or day 35 (SPE2) after the initiation of immunization, and were tested for clinical severity, joint radiological- and histological changes, serum levels of inflammatory cytokines and autoantibodies, and rhG1-specific immune responses, and compared to those in control mice with spleen left intact. Circulating Tregs and T-helper subset ratios in the spleen and inguinal lymph nodes were also examined using flow cytometry. The onset of severe inflammatory response was significantly delayed in SPE1 and SPE2 groups compared to control mice at early stages of GIA, which was associated with increased circulating Tregs. After the third immunization, as disease progressed, the severity scores were robustly increased in all mice. Nevertheless, in splenectomized mice, we observed reduced joint deterioration and cartilage damage, more Th2 cells in lymph nodes, and reduced levels of pro-inflammatory cytokines and autoantibodies in their sera. Mesenteric lymph node cells of splenectomized mice exhibited weaker response in vitro against the rhG1 antigen compared to control mice spleen. In conclusion, splenectomy in early stages of GIA delayed the inflammatory response, suggesting a protective effect against the development and progression of severe destructive arthritis.

Current Understanding of Immune Thrombocytopenia: A Review of Pathogenesis and Treatment Options

The management of immune thrombocytopenia (ITP) and the prediction of patient response to therapy still represent a significant and constant challenge in hematology. ITP is a heterogeneous disease with an unpredictable evolution. Although the pathogenesis of ITP is currently better known and its etiology has been extensively studied, up to 75% of adult patients with ITP may develop chronicity, which represents a significant burden on patients' quality of life. A major risk of ITP is bleeding, but knowledge on the exact relationship between the degree of thrombocytopenia and bleeding symptoms, especially at a lower platelet count, is lacking. The actual management of ITP is based on immune suppression (corticosteroids and intravenous immunoglobulins), or the use of thrombopoietin receptor agonists (TPO-RAs), rituximab, or spleen tyrosine kinase (Syk) inhibitors. A better understanding of the underlying pathology has facilitated the development of a number of new targeted therapies (Bruton's tyrosine kinase inhibitors, neonatal Fc receptors, strategies targeting B and plasma cells, strategies targeting T cells, complement inhibitors, and newer TPO-RAs for improving megakaryopoiesis), which seem to be highly effective and well tolerated and result in a significant improvement in patients' quality of life. The disadvantage is that there is a lack of knowledge of the predictive factors of response to treatments, which would help in the development of an optimized treatment algorithm for selected patients.

Littoral cell angioma of the spleen: case report and literature review

Littoral cell angioma is an extremely rare splenic vascular tumor originating from the cells lining the splenic red pulp sinuses. Approximately 150 cases of littoral cell angioma have been reported since 1991. Its clinical manifestation is usually asymptomatic and is mostly diagnosed as an incidental finding through abdominal imaging. Herein, we present a case of littoral cell angioma in a 41-year-old woman with no previous comorbidities, which initially presented as a nonspecific splenic lesion diagnosed on imaging in the emergency room. The patient was treated through laparoscopic intervention.

Metastatic splenic angiosarcoma presenting with anemia and bone marrow fibrosis mimicking primary myelofibrosis: A case report and literature review

Angiosarcomas, originating from endothelial cells, are infrequent soft tissue sarcomas characterized by a high propensity for metastasis and an unfavorable prognosis. Splenic angiosarcoma, an exceedingly rare and aggressive neoplasm, exhibits variable clinical manifestations. The present case report describes a patient initially exhibiting anemia and bone marrow fibrosis, mimicking primary myelofibrosis, ultimately diagnosed with splenic angiosarcoma. The findings of the present case report underscore the importance of considering splenectomy for histopathological confirmation. Employing a panel of vascular differentiation markers is invaluable for establishing the diagnosis of angiosarcoma.

Wandering Spleen Torsion: A Diagnostic Challenge

Wandering spleen, or hypermobile spleen, arises from the elongation or maldevelopment of the spleen's suspensory ligaments. This condition is a rare clinical entity, primarily affecting children, with a higher prevalence among adult females in the active reproductive age group. Manifestations may include an asymptomatic abdominal mass or intermittent abdominal discomfort due to the torsion and subsequent spontaneous detorsion of the spleen. This case report details the presentation of a 14-year-old female initially misdiagnosed as having gastroenteritis who later experienced acute abdomen. Subsequent ultrasonography and computed tomography scan revealed splenic torsion, confirmed during exploratory laparotomy, which demonstrated an infarcted spleen. The definitive therapeutic intervention was a total splenectomy. This clinical entity should be taken into account in the differential diagnosis of acute abdominal pain in order to aid in early diagnosis and management. This could allow us to avoid splenectomy whenever possible and instead do splenopexy, especially in pediatric cases, as the spleen plays a crucial role in the reticuloendothelial system.

A Rare Incidence of Splenic Artery Aneurysm and Hypersplenism

A 31-year-old woman with Child's B liver cirrhosis with portal hypertension and splenomegaly presented with a one-month history of abdominal pain. A physical examination confirmed splenomegaly. A blood investigation revealed a low white blood cell (WBC) and platelet count. Computed tomography (CT) revealed a splenic artery aneurysm at the distal splenic artery measuring 3.4 x 3.4 x 4.3 cm (AP x W x CC) with thrombus and splenic infarction. A successful angiographic embolisation was performed without immediate complications. The abdominal pain symptoms resolved, leading to the patient's discharge from the ward on the third day post-embolisation. Follow-up at the surgical outpatient clinic indicated the patient remained asymptomatic, and repeated blood counts showed improvement in both WBC and platelet counts. Furthermore, follow-up CT scans demonstrated a reduction in spleen size, indicating positive outcomes and a favourable response to the intervention.

Sclerosing Angiomatoid Nodular Transformation of the Spleen in a Patient With Granulomatosis With Polyangiitis

We present an intriguing case involving a rare occurrence of sclerosing angiomatoid nodular transformation (SANT) in a 57-year-old woman with a history of granulomatosis with polyangiitis (GPA). Despite the extensive literature on SANT, its pathogenesis remains elusive. The patient, diagnosed with serum anti-proteinase 3 antineutrophil cytoplasmic antibody (PR3-ANCA)-positive GPA seven years earlier, exhibited a splenic lesion during imaging, leading to laparoscopic splenectomy due to severe abdominal pain. Microscopic analysis unveiled nodular structures with vascular elements surrounded by fibrosclerotic stroma and chronic inflammatory cells. This case raises questions about the interplay between SANT, GPA activity, and vascular damage. Hypotheses regarding SANT's origin, including its potential association with organized hematoma or alterations in splenic blood flow, are discussed. The uniqueness of this case lies in the coexistence of PR3-ANCA-positive GPA and SANT, suggesting a potential link between GPA activity, vascular damage, and SANT development. While causality remains uncertain, this report marks the first documented case of a patient with PR3-ANCA-positive GPA developing SANT. The findings prompt reflection on a potential common pathophysiological mechanism and underscore the importance of considering SANT in cases of splenic lesions associated with conditions causing alterations in splenic blood flow. This contribution serves as a valuable addition to the existing knowledge, urging further research and consideration of SANT in diagnostic scenarios involving splenic abnormalities.

Splenectomy outcomes in immune cytopenias: Treatment outcomes and determinants of response

BACKGROUND

Splenectomy is commonly used to treat refractory immune-mediated cytopenia, but there are no established factors that are associated with response to the procedure.

OBJECTIVES

A cohort study was conducted to evaluate the hematologic and surgical outcomes of splenectomy in adult patients with immune cytopenias and identify preoperative factors associated with response.

METHODS

Data from the Cleveland Clinic Foundation for 1824 patients aged over 18 who underwent splenectomy from 2002 to 2020 were analyzed.

RESULTS

The study found that the most common indications for splenectomy were immune thrombocytopenic purpura (ITP) and autoimmune hemolytic anemia, with a median age of 55 years and median time from diagnosis to splenectomy of 11 months. Hematologic response rates were 74% overall, with relapse in 12% of cases. Postsplenectomy discordant diagnoses were present in 13% of patients, associated with higher relapse rates. Surgery-related complications occurred in 12% of cases, whereas only 3% of patients died from disease complications. On univariate analysis, preoperative factors associated with splenectomy treatment failure were ≥3 lines of pharmacologic treatment, whereas isolated thrombocytopenia, primary ITP, and age ≤40 years had a strong association with response. The multivariable regression confirmed that treatment failure with multiple lines of medical therapy was associated with the failure to respond to splenectomy.

CONCLUSION

Overall, the study demonstrates that splenectomy is an effective treatment option for immune-mediated cytopenias with a low complication rate.

Immune Thrombocytopenia After COVID-19 Vaccine Requiring Splenectomy: A Case Report and Review of the Literature

Post-vaccination immune thrombocytopenia (ITP) is a rare but recognized adverse event believed to result from an autoimmune reaction triggered by the vaccine. This case report presents the fourth documented instance of severe ITP requiring splenectomy following the administration of a COVID-19 vaccine. The patient, a 54-year-old previously healthy female with no familial history of autoimmune or hematological disorders, developed ITP two weeks after the first dose of the COVID-19 vaccine. While most ITP cases associated with COVID-19 vaccines manifested after the second dose, this unique case demonstrated symptoms following the initial vaccination. Initially responsive to first-line management, the patient experienced a relapse upon receiving the second dose from a different vaccine manufacturer. Despite exhaustive medical interventions, the refractory nature of the condition persisted, ultimately mandating splenectomy for the achievement of complete remission. This case underscores the potential for serious, refractory ITP with the second dose of a COVID-19 vaccine, particularly in patients who initially developed ITP after the first dose, even if they had seemingly achieved complete remission. These findings emphasize the importance of vigilant monitoring and individualized treatment strategies in such cases, contributing valuable insights to the growing body of knowledge surrounding vaccine-induced ITP.

Splenic artery embolisation for splenic injury during colonoscopy: A systematic review

BACKGROUND

Splenic injury due to colonoscopy is rare, but has high mortality. While historically treated conservatively for low-grade injuries or with splenectomy for high-grade injuries, splenic artery embolisation is increasingly utilised, reflecting modern treatment guidelines for external blunt trauma. This systematic review evaluates outcomes of published cases of splenic injury due to colonoscopy treated with splenic artery embolisation.

METHODS

A systematic review was performed of published articles concerning splenic injury during colonoscopy treated primarily with splenic artery embolisation, splenectomy, or splenorrhaphy from 1977 to 2022. Datapoints included demographics, past surgical history, indication for colonoscopy, delay to diagnosis, treatment, grade of injury, splenic artery embolisation location, splenic preservation (salvage), and mortality.

RESULTS

The 30 patients treated with splenic artery embolisation were of mean age 65 (SD 9) years and 67% female, with 83% avoiding splenectomy and 6.7% mortality. Splenic artery embolisation was proximal to the splenic hilum in 81%. The 163 patients treated with splenectomy were of mean age 65 (SD 11) years and 66% female, with 5.5% mortality. Three patients treated with splenorrhaphy of median age 60 (range 59-70) years all avoided splenectomy with no mortality. There was no difference in mortality between splenic artery embolisation and splenectomy cohorts (p = 0.81).

CONCLUSIONS

Splenic artery embolisation is an effective treatment option in splenic injury due to colonoscopy. Given the known benefits of splenic salvage compared to splenectomy, including preserved immune function against encapsulated organisms, low cost, and shorter hospital length of stay, embolisation should be incorporated into treatment pathways for splenic injury due to colonoscopy in suitable patients.

Laparoscopic partial splenectomy in distal pancreatectomy may preserve splenic function

INTRODUCTION

Splenectomy is known to carry a risk of infection with encapsulated organisms and associated sepsis. Current Australian guidelines recommend intensive vaccination schedules and long-term antibiotic therapy. We postulate that in some clinical scenarios where distal pancreatectomy (DP) and splenectomy is being performed, a partial splenectomy is feasible. This may preserve splenic function and help retain immunocompetence.

METHODS

Five patients underwent laparoscopic distal pancreatectomy with partial splenectomy (LDPPS). The DP is performed with proximal division and resection of the splenic artery and vein. The inferior portion of the spleen is removed en bloc with the distal pancreas with ligasure and linear cutting staplers. The line of demarcation on the spleen after the division of the splenic artery identifies the portion supplied by the short gastric vessels. Temporary clamping of the short gastrics during splenic parenchymal transection reduces blood loss. All operations were completed laparoscopically and within 4 h.

RESULTS

The pathology of resected lesions includes a serous cystadenoma, a pseudocyst, an IPMN and two small medial pancreatic ductal adenocarcinomas. The benign lesions involved splenic vessels at the hilum, making Kimura or Warshaw procedures untenable. No patient required blood transfusion. One patient suffered a postoperative collection consistent with postoperative pancreatic fistula requiring a drain for 10 days. Follow-up ranged from 6 to 24 months. Following surgery, all patients had a perfused splenic remnant on imaging and benign blood films, which suggests retained splenic function.

CONCLUSION

Preserving some spleen when performing distal pancreatectomy may provide long-term benefits for patients.

Novel Preoperative Type IV Collagen to Predict the Risk of Hepatocellular Carcinoma in Patients with Hepatitis B Virus-Related Cirrhotic Portal Hypertension After Laparoscopic Splenectomy and Azygoportal Disconnection

Purpose

Although laparoscopic splenectomy and azygoportal disconnection (LSD) can significantly decrease portal vein pressure and even the incidence of hepatocellular carcinoma (HCC) in patients with cirrhotic portal hypertension (CPH), postoperative HCC inevitably occurs in certain patients. The purpose of this study was to seek a novel preoperative non-invasive predictive indicator to predict the occurrence of postoperative HCC.

Patients and Methods

From April 2012 to April 2022, we collected clinical data of 178 hepatitis B virus (HBV)-related CPH patients. Based on inverse treatment probability weighting, candidate variables for predicting postoperative HCC were determined by means analysis. Then, a novel preoperative non-invasive prediction indicator (ie, type IV collagen-alpha fetoprotein-fibrosis-4 score [IVAF-FIB-4]) was established based on candidate variables, and its predictive ability was explored.

Results

Postoperative HCC occurred in 9 (5.1%) patients. Correlation analyses showed that the IVAF-FIB-4 had a significant positive correlation with HCC (r = 0.835, P < 0.001). IVAF-FIB-4 showed a high accuracy (the area under the receiver operating characteristic curve: 0.939, 95% confidence interval [CI]: 0.818-1.000; sensitivity: 88.9%; specificity: 93.5%). At the end of follow-up, the incidence density of HCC in patients with IVAF-FIB-4 (1) was significant higher than that in patients with IVAF-FIB-4 (0) (138.1/1000 vs 1.1/1000 person-years; rate ratio: 130.475, 95% CI: 16.318-1043.227). In logistic regression, IVAF-FIB-4 was an independent risk factor for HCC (odds ratio: 668.000, 95% CI: 53.895-8279.541; P < 0.001).

Conclusion

IVAF-FIB-4 is a novel preoperative noninvasive predictive indicator for predicting postoperative HCC in HBV-related CPH patients after LSD, with satisfactory predictive ability.

A computational model-based study on the feasibility of predicting post-splenectomy thrombosis using hemodynamic metrics

For portal hypertensive patients with splenomegaly and hypersplenism, splenectomy is an effective surgery to relieve the complications. However, patients who have undergone splenectomy often suffer from portal venous system thrombosis, a sequela that requires prophylaxis and timely treatment to avoid deterioration and death. The aim of this study is to investigate the feasibility of predicting post-splenectomy thrombosis using hemodynamic metrics based on computational models. First, 15 portal hypertensive patients who had undergone splenectomy were enrolled, and their preoperative clinical data and postoperative follow-up results were collected. Next, computational models of the portal venous system were constructed based on the preoperative computed tomography angiography images and ultrasound-measured flow velocities. On this basis, splenectomy was mimicked and the postoperative area of low wall shear stress (ALWSS) was simulated for each patient-specific model. Finally, model-simulated ALWSS was statistically compared with the patient follow-up results to investigate the feasibility of predicting post-splenectomy thrombosis using hemodynamic metrics. Results showed that ALWSS could predict the occurrence of post-splenectomy thrombosis with the area under the receiver operating characteristic curve (AUC) equal to 0.75. Moreover, statistical analysis implied that the diameter of the splenic vein is positively correlated with ALWSS (r = 0.883, p < 0.0001), and the anatomical structures of the portal venous system also influence the ALWSS. These findings demonstrated that the computational model-based hemodynamic metric ALWSS, which is associated with the anatomorphological features of the portal venous system, is capable of predicting the occurrence of post-splenectomy thrombosis, promoting better prophylaxis and postoperative management for portal hypertensive patients receiving splenectomy.

Robotic-Assisted and Laparoscopic Splenectomy in Children: A Single Center Comparative Study

Background: To explore the safety, efficacy, advantages, and disadvantages of robotic-assisted splenectomy (RS) in children by analyzing and comparing the clinical data of RS and laparoscopic splenectomy (LS). Methods: The clinical data of 35 children who underwent laparoscopic or RS or partial splenectomy from February 2010 to October 2022 were included. A retrospective analysis based on general information, clinical data, and prognosis were performed. Results: Among 35 cases, 14 cases, and 21 cases underwent RS and LS, respectively. The average operation time was 167 (120-224) minutes in the RS group and 176 (166-188) minutes in the LS group. The intraoperative blood loss was significantly larger in LS group than RS group (P = .0009). The length of hospital stay was significantly longer in LS group than RS group (P = .0015), and the hospitalization cost was significantly higher in RS group than LS group (P < .0001). There were no cases of conversion to laparotomy in the RS group, but two cases in the LS group. In terms of postoperative complications, there were one and three cases in the RS and LS groups, respectively. Conclusion: The Robotic Surgical System was safe and feasible in pediatric splenectomy or partial splenectomy which was an alternative to laparoscopic surgery.

Improving the chances of response to splenectomy in immune thrombocytopenia

Immune thrombocytopenia (ITP) is an autoimmune bleeding disorder characterized by isolated thrombocytopenia. Its pathogenesis is complex relying in large part on destruction of platelets recognized by autoantibodies within the spleen. However, other mechanisms, such as platelet desialylation, may play a role in platelet reduction by accelerating their clearance in the liver. In their study, Mendoza and colleagues reported on platelet scintigraphy performed in 51 ITP patients, showing a response in 87.5% when the sequestration occurred in the spleen versus 45% in case of non-splenic destruction. Platelet desialylation was also measured after splenectomy and found to be higher in non-responder patients. These latter results, while requiring confirmation prior to splenectomy, support platelet desialylation may also be a potential biomarker of non-response to splenectomy. Commentary on: Mendoza et al. Study of platelet kinetics in immune thrombocytopenia to predict splenectomy response. Br J Haematol 2024;204:315-323.

Sinistral Portal Hypertension Due to a Pancreatic Pseudocyst: A Rare Cause of Upper Gastrointestinal Bleeding

Sinistral portal hypertension (SPH), also known as segmental portal hypertension, is a complication of pancreatic disorders and an extremely rare cause of upper gastrointestinal (GI) bleeding. SPH is observed in patients without cirrhosis and arises from splenic vein thrombosis. Unmitigated backflow of blood may cause gastric venous congestion and ultimately GI hemorrhage. Herein, we report a rare case of massive hematemesis due to SPH in a male patient with a history of chronic pancreatitis and pancreatic pseudocyst. Our patient was successfully treated with endoscopic necrosectomy followed by open splenectomy, distal pancreatectomy, and partial gastric resection.

Study of platelet kinetics in immune thrombocytopenia to predict splenectomy response

Despite the efficacy of splenectomy for chronic immune thrombocytopenia (ITP), its considerable failure rate and its possible related complications prove the need for further research into potential predictors of response. The platelet sequestration site determined by 111 In-labelled autologous platelet scintigraphy has been proposed to predict splenectomy outcome, but without standardisation in clinical practice. Here, we conducted a single-centre study by analysing a cohort of splenectomised patients with ITP in whom 111 In-scintigraphy was performed at La Paz University Hospital in Madrid to evaluate the predictive value of the platelet kinetic studies. We also studied other factors that could impact the splenectomy outcome, such as patient and platelet characteristics. A total of 51 patients were splenectomised, and 82.3% responded. The splenic sequestration pattern predicted a higher rate of complete response up to 12 months after splenectomy (p = 0.005), with 90% sensitivity and 77% specificity. Neither age, comorbidities, therapy lines nor previous response to them showed any association with response. Results from the platelet characteristics analysis revealed a significant loss of sialic acid in platelets from the non-responding patients compared with those who maintained a response (p = 0.0017). Our findings highlight the value of splenic sequestration as an independent predictor of splenectomy response.

Staphylococcus lugdunensis Endocarditis Causing Secondary Splenic Abscess: A Potentially Lethal Complication

Infective endocarditis is a potentially life-threatening condition caused by a bacterial infection of the heart valves. The incidence of splenic abscess associated with infective endocarditis varies between 1-10% of cases, and its presence may indicate a severe form of the disease. We present a 24-year-old man diagnosed with infective endocarditis who was found to have a splenic abscess upon further evaluation. The patient was initially managed conservatively with targeted antibiotics, but after unsuccessful percutaneous drainage, a splenectomy was performed. The patient underwent mitral valve replacement surgery and made a good recovery. The patient's case highlights the importance of considering a secondary abscess in the management of infective endocarditis. This complication can easily be missed and cause significant morbidity. This case underscores the importance of early diagnosis and effective collaboration between various healthcare professionals to achieve the best possible outcome for patients with infective endocarditis and its associated complications.

Recent trends in organ-preserving pancreatectomy: Its problems and clinical advantages compared with other standard pancreatectomies

In this review article, we focus on recent papers on organ-preserving pancreatectomy procedures published since 2010. When comparing central pancreatectomy (CP) and distal pancreatectomy (DP), most studies have concluded that the CP group exhibited significantly lower incidence of new-onset diabetes or diabetes exacerbation than the DP group postoperatively. However, because of increased incidence of morbidities such as pancreatic fistula, the surgeon faces a considerable trade-off between increased short-term morbidity and long-term preservation of endocrine function. When the outcomes of two types of spleen-preserving DP (Kimura and Warshaw procedures) are compared, most studies mentioned the low incidence of postoperative gastric varices and splenic infarction with the Kimura procedure. Although there are several reports regarding the effect of spleen preservation on prevention of postoperative infections, no report on the contribution of spleen preservation to the prevention of overwhelming post-splenectomy infection is seen. The advantages of duodenum-preserving pancreatic head resection (DPPHR) concerning endocrine and exocrine functions continue to be subjects of discussion, mainly due to the limited number of institutions that have adopted this approach; however, DPPHR should be presented as an option for patients due to its low incidence of postoperative cholangitis. Organ-preserving pancreatectomy requires meticulous surgical techniques, and postoperative complications may increase with this surgery compared with standard pancreatectomy, which may be influenced by the surgeon's skill and the surgical facility where the procedure is performed. Nonetheless, this technique has significant long-term advantages in terms of endocrine and exocrine functions and its wider adoption in the future is expected.

Clinical Characteristics and Treatment Outcome of Hereditary Spherocytosis: A Single Center's Experience

Objectives

The objective of the study is to present the demographic characteristics, clinical and laboratory features and outcome of our patients with hereditary spherocytosis (HS).

Methods

Demographic, clinical, and laboratory data; complications; and splenectomy results were analyzed retrospectively. The severity of the disease was scaled according to Eber's criteria.

Results

Sixty-nine patients (42 boys, 27 girls, median age: 3 years) were eligible. Sixty-eight percent of the patients had a history of neonatal jaundice. The complaints at admission were jaundice (71%), fatigue (27.5%), fainting (4.3%), and pallor (4.3%). The median follow-up duration was 8.5 years. According to Eber's criteria, three (4.3%), 57 (82.6%), and nine (13.1%) patients had mild, moderate, and severe diseases, respectively. Thirty-six patients (52.1%) had a splenectomy. Following splenectomy, we observed a significant rise in hemoglobin levels and a decline in indirect bilirubin levels. Post-operative thrombocytosis was common, with a tendency to fall and stabilize after 1 month. There were no thromboembolic complications.

Conclusion

In spite of the high rate of consanguinity, familial history of HS, and neonatal jaundice in our study group, the majority of the HS patients were identified relatively late, about 3 years. This finding shows that HS might be insufficiently acknowledged by primary care. Splenectomy, in selected cases, may reduce the need for transfusions. Post-splenectomy transient thrombocytosis is common and has a benign course.

A Large Splenic Epidermoid Cyst Initially Misdiagnosed as a Hydatid Cyst

BACKGROUND Splenic cysts are classified as either parasitic or non-parasitic cysts, with both types sharing similarities in their clinical presentation and imaging findings. Most splenic cysts are of parasitic origin, while non-parasitic splenic cysts are less common. Splenic epidermoid cysts (SECs) are a rare subtype of non-parasitic cysts and compromise only around 10% of them. CASE REPORT In this paper we present a case of 22-year-old man with no significant past clinical history, who presented with non-specific, vague symptoms, including persistent left upper-quadrant pain and discomfort for the last 2 years. A physical examination and extensive laboratory tests were inconclusive. Subsequently, the patient underwent multiple imaging studies including ultrasonography and computed tomography (CT) scan of the abdomen. His ultrasonographic findings were consistent with the diagnosis of hydatid cyst, which was further emphasized by its frequent occurrence in clinical practice, as our country is considered an endemic region. In light of this, he underwent laparoscopic splenectomy following percutaneous cyst drainage. The consequent histopathological examination revealed the diagnosis of splenic epidermoid cysts. CONCLUSIONS When encountering splenic cysts in regions where parasitic infections are endemic, special attention is needed, as physical examination, laboratory tests, and imaging studies alone are insufficient to differentiate among the types of cysts. Histopathological examination remains the diagnostic tool of choice, particularly when imaging findings are inconclusive. Splenectomy, with either a laparoscopic or open approach, is the treatment of choice for splenic cysts to prevent recurrence as well as other potential catastrophic complications.

The American Association for the Surgery of Trauma Organ Injury Scale for Spleen Does Not Equally Predict Interventions in Penetrating and Blunt Trauma

BACKGROUND

The American Association for the Surgery of Trauma (AAST) Organ Injury Scale (OIS) for the spleen (and other organs) was created in 1989. It has been validated to predict mortality, need for operation, length of stay (LOS), and intensive care unit (ICU) LOS.

PURPOSE

We aimed to determine if the Spleen OIS is applied equally to blunt and penetrating trauma.

RESEARCH DESIGN/STUDY SAMPLE

We analyzed the Trauma Quality Improvement Program (TQIP) database from 2017-2019, including patients with spleen injuries.

DATA COLLECTION

Outcomes included the rates of mortality, operation, spleen-specific operation, splenectomy, and splenic embolization.

RESULTS

60900 patients had a spleen injury with an OIS grade. Mortality rates increased in Grades IV and V for both blunt and penetrating trauma. In blunt trauma, the odds for any operation, spleen-specific operation, and splenectomy increased, for each increase in grade. Penetrating trauma showed similar trends in grades up to grade IV, but were statistically similar between grade IV and V. Splenectomy was higher in penetrating trauma for all grades. Splenic embolization peaked at 25% of grade IV trauma before decreasing in grade V. Rates in penetrating trauma were significantly lower in all grades, peaking at 2.5% of Grade III injuries.

CONCLUSIONS

The mechanism of trauma is a significant factor for all outcomes, independent of AAST-OIS. Hemostasis is predominantly surgical in penetrating trauma, achieved with angioembolization more frequently in blunt trauma. Penetrating trauma management is influenced by the potential for injury to peri-splenic organs.

Changes in Hepatic Function After Splenectomy for Hepatolenticular Degeneration, Cirrhosis, and Hypersplenism

BACKGROUND

Patients with hepatic reticulum degeneration (HLD) may eventually develop complications of cirrhosis with splenomegaly and hypersplenism, requiring splenectomy to alleviate hypersplenism and complete lifelong copper therapy. The purpose of this study is to investigate the effect of splenectomy on liver function in patients with hypersplenism.

METHODS

A retrospective systematic analysis was conducted on the liver function indicators of 220 HLD patients who underwent splenectomy from January 2015 to January 2018 before surgery and on days 1, 3, 5, 7, and 14 after surgery. Among them, 30 patients were followed up for 6 months.

RESULTS

The Child score increased on the 1st day after surgery and gradually decreased after the 1st day. The level of alanine aminotransferase (ALT), aspartate aminotransferase (AST), and total bilirubin (TB) increased 5 days after surgery (P < .01) and decreased on the 14th day after surgery (P < .01); the level of albumin (ALB) decreased on the 1st, 3rd, and 5th day after surgery (P < .01) and increased on the 14th day (P < .01). The follow-up results of the patient for 6 months showed that the levels of ALT and AST decreased, while the levels of ALB increased 6 months after surgery.

CONCLUSION

Splenectomy is proved to be beneficial for the improvement of liver function in HLD patients combined with hypersplenism, which realize a lifelong anti-copper treatment.

Wandering spleen; a rare clinical presentation of chronic pain with acute torsion

Wandering spleen results from abnormal ligamentous laxity and is often symptomatic, presented with abdominal pain and other non-specific symptoms. These symptoms, make the diagnosis very difficult and most of the times even impossible. As such, keeping in mind this pathology, can make further complications less frequent.

Risk factors of portal vein system thrombosis after splenectomy: a meta-analysis

BACKGROUND

The primary aim of the present study was to explore risk factors for portal vein system thrombosis following splenectomy.

METHODS

A systematic search of PubMed, Embase and Cochrane libraries was conducted to identify original studies that fulfilled the inclusion criteria. Raw data on potential risk factors for portal vein system thrombosis after splenectomy were extracted for meta-analysis. Subsequently, a sensitivity analysis was conducted to verify the stability of the results.

RESULTS

Eighteen studies with 626 thrombosis events from 1807 splenectomy met the inclusion criteria. Larger spleen volume (SMD 0.44, P = 0.000), broader splenic vein diameter (WMD 2.30, P = 0.000), broader portal vein diameter (WMD 2.08, P = 0.000), a lower velocity of portal blood flow (WMD -0.91, P = 0.001), decreased platelet count (WMD -5.14, P = 0.007), decreased white blood cell (WMD -0.40, P = 0.027), decreased haemoglobin (WMD -9.14, P = 0.002), ascites (OR 1.81, P = 0.003) and bleeding history before surgery (OR 1.88, P = 0.002) were identified to be factors that exacerbated the risk of portal vein system thrombosis after splenectomy. Sex, age, preoperative prothrombin time, postoperative platelet count, postoperative D-dimer, operation time and intraoperative blood loss, did not increase the risk of thrombosis.

CONCLUSION

Larger spleen volume, broader splenic vein diameter, broader portal vein diameter, a lower velocity of portal blood flow, ascites, bleeding history before surgery, decreased platelet count, white blood cell and haemoglobin may increase the risk of portal vein system thrombosis.

Perioperative ventricular arrhythmias are increased with hemoperitoneum and are associated with increased mortality in dogs undergoing splenectomy for splenic masses

OBJECTIVE

To identify risk factors for intra- and postoperative ventricular arrhythmias (VAs) and in-hospital mortality in dogs undergoing splenectomy for splenic masses.

ANIMALS

308 dogs.

METHODS

Records from 2010 through 2018 were reviewed for dogs undergoing splenectomy for a splenic mass. Clinical and laboratory findings on admission, diagnostic imaging, anesthesia, surgery and pathology reports, treatment records, and in-hospital mortality were evaluated with logistic regression.

RESULTS

VAs occurred in 138 (44.8%) dogs (126/308 [40.9%] postoperative, 51/308 [16.6%] intraoperative, 26/308 [8.4%] preoperative), with 50/308 (16.2%) dogs having more than one type of VA. Increasing heart rate and body weight, decreasing PCV and platelet count, hemoperitoneum, receipt of a transfusion, and diagnosis of hemangiosarcoma were associated with the presence of intra- and postoperative VAs on univariable analysis (all P < .001). On multivariable analysis, hemoperitoneum (P < .001 , < .001), increasing body weight (P = .026, < .001), and increasing heart rate (P = .028, < .001) were significant for intra- and postoperative VAs, respectively. Twenty dogs died (20/308 [6.5%]; 14/138 [10.1%] with VAs, 6/170 [3.5%] without VAs). Intra- and postoperative VAs were associated with in-hospital mortality (P = .009, .025, respectively).

CLINICAL RELEVANCE

Perioperative VAs were common and odds of VAs were increased with hemoperitoneum, increasing heart rate, and increasing body weight. Presence of VAs increased the odds of in-hospital mortality. Despite this, the overall in-hospital mortality rate was low (6.5%), indicating a good prognosis for survival of surgery in dogs with splenic masses, regardless of the presence of VAs or hemoperitoneum.

Spontaneous Rupture of Splenic Artery Aneurysm

Splenic artery aneurysms are rare and usually asymptomatic, with a high risk of mortality once they get ruptured. A case report of a spontaneous rupture of a splenic artery aneurysm in a 65-year-old female is reported. The patient presented in the emergency department with abdominal pain, nausea, and vomiting, followed by syncope. A contrast-enhanced CT scan was performed and showed a splenic artery aneurysm measuring 40 × 35 mm surrounded by a hematoma. The patient was submitted to emergency laparotomy with ligation of the splenic artery, aneurysm resection, and splenectomy. There were no surgical complications, and the patient was discharged home on the fifth postoperative day. A rupture of a splenic aneurysm is a rare condition with a high mortality rate and should be considered a differential diagnosis in a patient with abdominal pain and hemodynamic instability.

Delayed Hemolytic Transfusion Reaction With Hyperhemolysis Syndrome Due to Anti-M Alloantibody in Myelofibrosis: A Case Report

Hyperhemolysis syndrome (HHS) and delayed hemolytic transfusion reaction (DHTR) commonly occur in patients with sickle cell disease (SCD) and thalassemia, due to the need for recurrent red blood cell (RBC) transfusion, but rarely in patients with myelofibrosis. HHS is a life-threatening condition that occurs with or without DHTR, in which both transfused and autologous RBCs are destroyed. It needs a high clinical suspicion for diagnosis, especially when there is a drop in hemoglobin level to the level of pretransfusion of RBCs, accompanied by hyperbilirubinemia and reticulocytopenia. The management of HHS includes avoiding RBC transfusion, supportive care, and immunomodulatory therapy. We present a case of HHS with DHTR in a patient with primary myelofibrosis who was treated successfully with steroids and splenectomy.

A rare intrahepatic splenosis mimicking hepatocellular carcinoma: A case report

Intrahepatic splenosis (IHS) is a rare disease that is considered to result from heterotopic autotransplantation or implantation of splenic tissue after splenic trauma or surgery. A 46-year-old man with a treatment history of a left lateral liver segmentectomy and splenectomy for a road traffic injury 30 years earlier presented to Sakai City Medical Center (Sakai, Japan) with acute abdominal pain in November 2019. Physical examination showed no significant signs, and serum data were normal. Computed tomography revealed a hypodense mass measuring 2.5x1.7 cm in segment 7 of the liver. Gadoxetic acid-enhanced magnetic resonance imaging showed early enhancement in the arterial phase and washout in the delayed phase. Therefore, laparoscopic surgery was performed with a preoperative diagnosis of hepatocellular carcinoma. Pathological examination of the tumor showed IHS. The postoperative course was uneventful, and the patient developed no new abnormal region in the liver during 2 years of follow-up. The present study presented a case of IHS assumed to be hepatocellular carcinoma. IHS should be considered as a differential diagnosis of a liver mass detected years after splenic trauma or surgery, even in cases with imaging patterns suggesting malignancy.

Predictors of Long-Term Rebleeding Risk in Cirrhotic Patients Undergoing Esophagogastric Devascularization and Splenectomy: Impact of Portal Vein Thrombosis and Hemoglobin Levels

BACKGROUND Esophagogastric devascularization and splenectomy (EGDS) is widely used to treat patients with portal hypertension in China. This study aimed to determine risk factors that increase risk of rebleeding after EGDS and evaluate the effect of portal vein thrombosis (PVT) on rebleeding rates after EGDS. MATERIAL AND METHODS Clinical data of patients with cirrhosis (n=138) who underwent EGDS between December 2010 and January 2016 were retrospectively analyzed. Patients were assigned to rebleeding or non-rebleeding groups and followed up. Univariate and multivariate Cox regression analyses identified the independent predictors of 3-year and 5-year rebleeding. RESULTS A total of 138 consecutive patients who underwent EGDS and met the inclusion criteria were enrolled. Total bilirubin (HR: 2.392, 95% CI 1.032-5.545, P=0.042) and PVT (HR: 3.345, 95% CI 1.477-7.573, P=0.004) predicted 3-year rebleeding during univariate analysis. Multivariate analysis revealed that PVT (HR: 3.967, 95% CI 1.742-9.035, P=0.001) was an independent predictor. Hemoglobin >87.5 g/L (HR: 3.104, 95% CI 1.283-7.510, P=0.012) and PVT (HR: 2.349, 95% CI 1.231-4.483, P=0.010) were predictors of 5-year rebleeding during multivariate analysis. Albumin >37.5 g/L was an independent predictor of rebleeding in patients with PVT at 3 and 5 years (HR: 3.964, 95% CI 1.301-9.883, P=0.008; HR: 3.193, 95% CI 1.275-7.997, P=0.013, respectively). CONCLUSIONS PVT is associated with increased 3-year and 5-year rebleeding rates after EGDS but not at 10 years. Also, hemoglobin >87.5 g/L predicted rebleeding at 5 years. Albumin has huge prospects as a predictor of rebleeding at 3 and 5 years in patients with PVT.

Retrospective Evaluation of Splenic Artery Embolization Outcomes in the Management of Blunt Splenic Trauma: A Single Centre Experience at a Large Level 1 Trauma Centre

PURPOSE

Retrospective review of splenic artery embolization (SAE) outcomes performed for blunt abdominal trauma.

MATERIALS AND METHODS

11-year retrospective review at a large level-1 Canadian trauma centre. All patients who underwent SAE after blunt trauma were included. Technical success was defined as angiographic occlusion of the target vessel and clinical success was defined as successful non-operative management and splenic salvage on follow-up.

RESULTS

138 patients were included of which 68.1% were male. The median age was 47 years (interquartile range (IQR) = 32.5 years). The most common mechanisms of injury were motor vehicle accidents (37.0%), mechanical falls (25.4%), and pedestrians hit by motor vehicles (10.9%). 70.3% of patients had American Association for the Surgery of Trauma (AAST) grade 4 injuries. Patients were treated with proximal SAE (n = 97), distal SAE (n = 23) or combined SAE (n = 18), and 68% were embolized with an Amplatzer plug. No significant differences were observed across all measures of hospitalization (Length of hospital stay: x2(2) = .358, P = .836; intensive care unit (ICU) stay: x2(2) = .390, P = .823; ICU stay post-procedure: x2(2) = 1.048, P = .592). Technical success and splenic salvage were achieved in 100% and 97.8% of patients, respectively. 7 patients (5%) had post-embolization complications and 7 patients (5%) died during hospital admission, but death was secondary to other injuries sustained in the trauma rather than complications related to splenic injury or its management.

CONCLUSION

We report that SAE as an adjunct to non-operative management of blunt splenic trauma can be performed safely and effectively with a high rate of clinical success.

Prevalence of malignancy and factors affecting outcome of cats undergoing splenectomy

OBJECTIVE

To determine the prevalence of splenic malignancy in cats undergoing splenectomy and to investigate possible factors associated with post-operative outcome.

ANIMALS

62 client-owned cats that underwent splenectomy.

METHODS

Medical records of 4 UK-based referral hospitals were searched and data reviewed retrospectively over 17 years. Factors associated with outcomes post-splenectomy were analyzed.

RESULTS

50 out of 62 cats (81%) were diagnosed with splenic neoplasia. Mast cell tumor ([MCT], 42%), hemangiosarcoma ([HSA], 40%), lymphoma and histiocytic sarcoma (6% each) were the most common tumor types. Fifteen cats (24%) presented with spontaneous hemoabdomen and were all diagnosed with splenic neoplasia. The diagnostic accuracy of cytology to detect splenic malignant lesions was 73% (100% for MCTs and 54% for mesenchymal tumors). Median survival time for cats with nonneoplastic splenic lesions was 715 days (IQR, 18 to 1,368) and 136 days for cats with splenic neoplasia (IQR, 35 to 348); median survival time was longer for cats with splenic MCT when compared to cats with HSA (348 vs 94 days; P < .001). Presence of metastatic disease and anemia (PCV < 24%) at diagnosis were associated with a poorer survival when considering all cats. Presence of anemia, a splenic mass on imaging or spontaneous hemoabdomen were associated with a diagnosis of HSA (P < .001).

CLINICAL RELEVANCE

Benign splenic lesions were uncommon in this cohort of cats. Spontaneous hemoabdomen should prompt the clinician to suspect neoplasia in cats with splenic disease. Anemia and evidence of metastasis at diagnosis were poor prognostic factors regardless of the final diagnosis.

Porto-spleno-mesenteric venous thrombosis after elective splenectomy: a retrospective cohort study

Background

Elective splenectomy is the main treatment for a wide range of haematological diseases. Porto-spleno-mesenteric venous thrombosis represents one of the most severe complications of this procedure. The aim of this study was to evaluate risk factors associated with development of porto-spleno-mesenteric venous thrombosis after elective splenectomy.

Methods

All cases of elective splenectomy carried out from April 1st 2017 to January 31st 2023 were included in this single centre retrospective cohort study. Patients' demographics and perioperative data were analysed and correlated with the incidence of postoperative thrombosis. All patients underwent postoperative doppler ultrasound screening for thrombosis. Analysis was performed using SPSS 28, with p-value < 0.05 considered significant.

Results

Twenty-two patients (10 women, 12 men) underwent splenectomy during the study period. Indications were: immune thrombocytopenia (n: 6), myeloproliferative disorder (n: 6), hereditary spherocytosis (n: 4), thalassemia (n: 1), lymphoma (n: 1), leukaemia (n: 1), other malignancies (n: 3). Six patients developed porto-spleno-mesenteric venous thrombosis and only 2 of them were symptomatic. Patients were treated with anticoagulation therapy with complete resolution. Analysis identified three main factors associated with thrombosis: spleen diameter (p = 0.03), myeloproliferative disorder (p = 0.02), intraoperative platelet transfusion (p = 0.002) and intraoperative red blood cells transfusion (p = 0.009).

Conclusion

Standardized postoperative screening allows prompt diagnosis and treatment of porto-spleno-mesenteric venous thrombosis even in asymptomatic cases. Patient with splenomegaly and affected by myeloproliferative disorder have a greater risk to develop this complication.

Splenectomy and tumor size are risk factors for serious perioperative morbidity of laparoscopic distal pancreatectomies

<b><br>Introduction:</b> The determinants influencing the risk for complications of laparoscopic distal pancreatectomies (LDP) are not yet fully defined, thus we aimed to determine risk factors for serious perioperative morbidity after LDP with spleen preservation, LDP and radical antegrade modular pancreatosplenectomy for adenocarcinoma of the body and tail of the pancreas (RAMPS).</br> <b><br>Material and methods:</b> Retrospective cohort study of consecutive patients that underwent LDP between January 2019 and December 2022. The study group included cases of serious perioperative morbidity (III-V grades in Clavien-Dindo classification) during a 30-day period after operation. The control group consisted of patients without serious perioperative morbidity. As many as 142 patients were included in the study.</br> <b><br>Results:</b> Serious perioperative morbidity was found in 33 (23.24%) operated patients, while mortality in 3 cases (2.11%). Serious perioperative morbidity after LDP with spleen preservation was found in 9/68 (13.2%) patients (27.3% of the perioperative morbidity group). Thirteen out of 51 patients, i.e. 25.5%, after LDP with splenectomy were included in the perioperative morbidity group (39.4%). Serious perioperative morbidity after RAMPS was found in 11/23 (47.8%) patients (33.3% of the perioperative morbidity group). In multivariate logistic regression, the need for splenectomy during pancreatectomy (OR 3.66, 95%CI 1.20-11.18) and tumor above 28 millimeters in size (OR 3.01, 95%CI 1.19-9.59) were independent risk factors for serious perioperative morbidity.</br> <b><br>Conclusions:</b> The need for splenectomy during laparoscopic distal pancreatectomy and tumor size above 28 millimeters were independent risk factors for serious perioperative morbidity after laparoscopic distal pancreatectomies.</br>.

Splenectomy is significantly associated with thrombosis but not with pulmonary hypertension in patients with transfusion-dependent thalassemia: a meta-analysis of observational studies

Introduction

Thromboembolism (TE) and pulmonary hypertension (PH) constitute frequently occurring complications in patients with transfusion-dependent thalassemia and have been associated with splenectomy in different studies. Nevertheless, the size of the possible association varies greatly in literature. Herein, we sought to provide pooled effect estimates regarding the impact of splenectomy on TE and PH in transfusion dependent thalassemia (TDT) by retrieving relevant, available studies.

Methods

We systematically searched articles published in PubMed, Cochrane library, Scopus and gray literature from inception until the 30th of May, 2023. Pooled estimates in terms of odds ratios (OR) and 95% confidence intervals (CI) were calculated according to outcome measures. Risk of bias and quality of studies were evaluated.

Results

Regarding TE, 4 studies were selected for meta-analysis and the pooled data demonstrated that splenectomy was significantly associated with this outcome in TDT patients [OR = 4.08, 95% CI (1.03, 16.11), p = 0.04]. On the other hand, we pooled data from seven investigating PH, and, interestingly, the quantitative analysis revealed no association between splenectomy and PH [OR = 1.76, 95% CI (0.91, 3.41), p = 0.1].

Conclusion

Splenectomy is associated with higher risks of TE, but not with PH in patients with TDT.