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Purpose. To demonstrate capabilities and features in spleen pathology diagnostics based on clinical experience of Botkin City Hospital.Materials and methods. The analysis of 89 patients with spleen abnormalities was performed in the term from 01/2014 till 08/2020. All the patients underwent computed tomography (CT) and/or magnetic resonance imaging (MRI) with contrast enhancing. All cases verified surgically and/or clinically.Results. There were 37 cases of trauma (42%). Accuracy and precision of the method was 100%. In detection of active bleeding the highest diagnostic accuracy (100%) was shown with extravasation symptom – 7 cases. In non-traumatic group (n = 52, 58%) two biggest sub-groups were abscesses (n = 19, 36% in this group) and infarctions (n = 15, 29%). There were 8 cases of cysts (15%), 3 of them – hydatid, 5 cases of spleen hemangiomas. (9.6%), 3 cases of spleen metastases (6%). There was 1 case of angiosarcoma (2%) and 1 case cystic lymphangioma (2%).Conclusion. The most frequent condition in spleen pathology, diagnosed in radiology department is trauma. In non-traumatic cases two biggest groups are abscesses and infarctions. CT features of spleen infarction are pyramidal wedge of hypoperfused splenic tissue with the apex pointing towards the hilum, and the base on the splenic capsule. In all cases in our study cysts were incidental findings. Spleen metastases are rare due to organ hemodynamics. The most rare lesions of the spleen are primal tumors.

Highlights • Mature teratoma, also called a dermoid cyst. • Dermoid cysts have been observed in various anatomical positions. • Mature cystic teratoma with splenic location. • Splenic dermoid tumors., Introduction Teratomas are germ cell neoplasms that can be malignant or benign. Their occurrence is more prevalent in gonads, but there are rare extragonal reports, and splenic teratomas are exceptionally uncommon. Case report A 44-year-old woman with a report of abdominal pain on the left flank for 12 h, was evaluated with TC that visualized spleen showing an oval, intraparenchymal, hypodense image with dense areas, submitted to conventional splenectomy, what identified mature cystic teratoma. Discussion Dermoid cysts have nonspecific symptoms, usually related to extrinsic compression of other structures or rupture of the splenic capsule; the diagnosis is complex, since the alterations in imaging exams are not very specific. Thus, the confirmation is made through anatomopathological analysis. Conclusion Mature splenic cystic teratomas are rare and treatment should be evaluated according to the presence or absence of symptoms and diagnostic certainty.

Splenic injuries during laparoscopic gastrectomy include splenic vascular injury, splenic parenchymal injury and splenic capsule injury. Sometimes, it can lead to lethal hemorrhage. The avoidance of splenic injuries in the laparoscopic radical gastrectomy for gastric cancer is important, especially for the obese patients. Establishing a safe method to avoid splenic injuries in laparoscopic total gastrectomy (LTG) is an urgent issue in the surgical procedure. We developed a novel approach by extended separation of the superficial plane of the posterior gastric fascia to avoid the splenic injury effectively.

Toxoplasma gondii infection induces parasite infiltration and apoptosis in the spleen. However, dose-dependent parasite infiltration, apoptosis, body weight alternations and survival in mice remain largely unknown. In this study, mice were intraperitoneally infected with 10, 30 or 100 tachyzoites of T. gondii, respectively. Parasite infiltration and apoptosis in the spleen were analyzed on days 3, 7, and 9 post-infection by immunohistochemistry and flow cytometry. Significantly higher levels of T. gondii infiltration and apoptosis in the spleen were found in 30 and 100 tachyzoites infected mice compared to 10 tachyzoites infected mice on days 7 and 9 post-infection. Although 30 and 100 tachyzoites infected mice showed significant body weight loss compared to 10 tachyzoites infected mice, all of the 100, 30, and 10 tachyzoites infected mice died by days 12, 15, and 17, each respectively. Interestingly, T. gondii infiltration in 10 tachyzoites infected mice were limited to capsule area of the spleen on day 9 post-infection. Several areas of parasite infiltrations were found in the 30 tachyzoites infected mice, where noticeable levels of splenic capsule de-adhesion occurred. These results indicated that parasite infiltration and apoptosis in the spleen, as well as body weight loss (survival) are closely correlated with infection dosage. The level of T. gondii infiltration and apoptosis in the spleen and splenic de-adhesion were dependent on the parasite dose.

We report findings from an autopsy case who died from massive bleeding because of splenic peliosis. The case subject was an 80-year-old man who had diabetes mellitus and who was receiving hemodialysis and anticoagulant therapy. Postmortem computed tomography demonstrated massive intra-abdominal hemorrhage especially seen around the spleen. At autopsy, we found abundant hemorrhagic ascites, including a large number of clots, in the abdominal cavity. The spleen had several distinct dark red areas ranging in size from 1.5 to 2.5 cm and showed spontaneous rupture along with hematoma formation on the outside of the splenic capsule on the anterior side. From these findings, we concluded that the cause of death in this case was massive hemorrhage owing to spontaneous rupture of splenic peliosis. Although peliosis itself rarely causes death, but when it is destroyed, massive bleeding leads to death. Thus, it is necessary to know the histopathological characteristics of peliosis, in forensics.

Splenic cysts are rare. Most true (congenital) splenic cysts are epithelial in origin and have embryonic inclusion of epithelial cells from adjacent structures. Congenital spleen cysts are also called epidermoid or epithelial cysts. They form when there is an invagination of the mesothelium-lined splenic capsule during development. The lining is pluripotential and may undergo metaplastic changes and fluid accumulation with resultant cyst expansion. We present our own clinical case of the true spleen cysts in twins. Both patients did’t have any complains. In one of the twins, the lesion was up to 85.0 mm in diameter, localized in the spleen gates and squeezed the spleen vascular pedicle, which necessitated the surgical treatment. In the second twin, the cyst also localized in the spleen gates, however, it was of minor dimensions and, there was no growth at dynamic monitoring at the present time.

Objective: To describe the findings of an unusual splenic tumor in a kitten. Methods: A grossly multinodular mass arising from the splenic capsule of a 7-month-old male Havana kitten was echographically detected and surgically removed by splenectomy, then analyzed microscopically and ultrastructurally. Results: The mass showed features of an inflammatory myofibroblastic tumor. Treatment and Outcome: Two months after surgical excision, the mass recurred in the same intra-abdominal area but disappeared after 2 months of anti-inflammatory therapy. Follow-up at 18 months after surgery revealed resolution of the disease. Clinical Relevance: Inflammatory myofibroblastic tumor in cats have been rarely reported and are usually in the orbital region. In the present report, an unusual multinodular gross presentation, a recurrence over time, and a favorable clinical course, are described.

A 50-year-old man was diagnosed with multiple myeloma complicating AL amyloidosis. Splenic rupture was complicated during autologous stem cell transplantation (auto-SCT). Granulocyte colony-stimulating factor (G-CSF) was not administered. A pathological examination of the spleen revealed that CD34-positive cells were concentrated in the ruptured part of the splenic capsule. Hematopoietic cells were engrafted in the small gap between the capsule and amyloid protein deposition area of the spleen, which might have caused the splenic rupture in the absence of G-CSF administration. Special attention is thus required for amyloidosis patients undergoing auto-SCT, even when G-CSF is not administered.

Distal pancreatectomy is indicated for lesions in the pancreatic body and tail. Understanding of the anatomical structure of the pancreas and its surroundings is required in various situations in left upper abdominal surgery including the laparoscopic approach. Spleen-preserving distal pancreatectomy is indicated for lesions confined to the pancreas. Two major spleen-preserving procedures reported are the Warshaw procedure that conserves the spleen by blood flow from the short gastric vessels and the Kimura procedure that preserves the spleen with splenic vessels. Considering the laparoscopic approach, the surgeon may preserve splenic vessels from the median toward the splenic hilum without mobilization of the spleen. A standard distal pancreatectomy using the medial approach is presented on video. The intraoperative complications of distal pancreatectomy can be minimized by avoiding splenic capsule injury, by careful differentiation of the splenic artery from the common hepatic artery, and by secure closure of the splenic vein stump. The incidence of postoperative pancreatic fistula following distal pancreatectomy is reported to be 13% in a nationwide pancreatic cancer registry. Based on the results of an international randomized trial of hand-sewn and staple closure of the pancreatic stump, the closure method of the pancreatic stump can be the surgeon's choice.

This report presents the case of a 70-year-old woman with a previous history of a left nephrectomy for renal cell carcinoma (RCC), who developed general malaise and fatigue. Abdominal computed tomography demonstrated an enhancing 6 × 7 cm necrotic lesion in the lower pole of the spleen suggestive of a metastasis. Given the highly suspicious nature of the lesion we proceeded to splenectomy. The tumour did not breach the splenic capsule, and there was no local diaphragmatic involvement. The mass was concluded to be a true metastasis of the original RCC rather than local recurrence of the disease. The causes of isolated solid splenic lesions are wide and varied, however a past or present history of malignancy should lead to a high index of suspicion for a splenic metastasis. We report an extremely unusual case of spread from a RCC.

Background Nonoperative management (NOM) has been established as the standard treatment for isolated blunt organ injury in hemodynamically stable pediatric patients. Although delayed splenic rupture or bleeding is a rare complication in NOM, it is an issue that many pediatric surgeons are greatly concerned about. We herein report a rare pediatric case concerning the mechanisms involved in delayed splenic rupture after NOM. Case presentation A 9-year-old boy with severe abdominal pain was transferred to our hospital. Twenty-one hours before the admission, he had been kicked in the region of his left lateral abdomen. Contrast-enhanced abdominal computed tomography revealed a severe intra-parenchymal hematoma and multiple lacerations of the spleen with a large amount of hemoperitoneum without active bleeding. His condition was diagnosed as a grade III injury on the AAST splenic injury scale. After fluid resuscitation, his vital signs became stable. The patient was treated with NOM in our intensive care unit. However, suddenly after defecation (72 h after the injury), he started complaining of severe abdominal pain and left shoulder pain. His blood pressure dropped to 70/35 mmHg, and he started to lose consciousness. Abdominal ultrasonography (US) revealed increased ascites. Fluid resuscitation and blood transfusion were performed. His symptoms and abdominal US findings suggested that splenic re-bleeding had caused delayed splenic rupture to occur. Emergency splenectomy was performed. The resected spleen was enlarged with a large parenchymal hematoma. The posterior-lateral side of the splenic capsule was ruptured. Conclusions The mechanism of delayed splenic rupture in our case was considered to be the result of a tear in the subcapsular hematoma caused by stretching the splenocolic ligament related to a bowel movement during defecation. Although delayed splenic rupture or bleeding is unpredictable, it is very important to understand the mechanisms and to educate the family of the children with splenic injuries of the warning signs of delayed rupture or bleeding.

In splenic rupture after blunt trauma, iatrogenic spleen injury or non-traumatic cases it is essential that the surgeon makes correct decisions. Conservative treatment must include continual monitoring and repeated, stringent evaluation of the splenic injury (the American Association for the Surgery of Trauma – AAST) in order to avoid any delay in diagnosis of delayed spleen rupture and the high mortality it causes. We present the case of an unexpected complication after radical nephrectomy performed for renal cell carcinoma. A 61-year old man sought medical help for acute abdominal pain. He presented with some cardiovascular risk factors (diabetes mellitus, smoker of 30 cigarettes per day) and moderate alcohol use. In the Emergency Unit, computed tomography scan revealed an incidental tumour of the left kidney. Nephrectomy via the laparoscopic approach was done without any iatrogenic complications, with less than 500 cc of blood loss. Firm adhesions between the spleen and abdominal wall, which caused some minor traction that resulted in a small subcapsular haematoma, were the only surprising intraoperative finding. Within the first 6 h, the patient presented with haemodynamic instability, while the drain evacuated less than 50 cc of discharge. However, CT scan showed that subcapsular haematoma had increased to the size of 10 × 10 cm without free peritoneal fluid present. Unfortunately, 6 h later emergency surgery had to be performed due to rupture of the subcapsular splenic haematoma. Massive haemoperitoneum was evacuated and the splenic capsule was the only remnant of the spleen that could be found on re-intervention. So far, it is the first case describing an increasing subcapsular haematoma of the spleen, most likely caused by the traction of firm adhesions to the organ. We discuss means to avoid such a complication: with liberation of the adhesions, placement of a perisplenic mesh, embolization of the splenic artery or subcapsular nephrectomy. An acute splenic rupture or delayed one demands from the surgeon practical knowledge of how to prevent subcapsular haematoma and how to treat splenic rupture.

We report a case of spontaneous splenic rupture (SSR) caused by a Bacillus species (sp.) infection. A 36-year-old man on warfarin therapy since an aortic valve replacement at the age of 13 was admitted to our hospital with a 3-week history of a high fever. He had been asymptomatic until 4 months previously, when he suffered a cerebral embolism despite adequate oral anticoagulation. Abdominal computed tomography revealed splenic infarctions, which resulted in splenic rupture 2 days later. After embolization of the splenic artery, splenectomy was successfully performed. Pathologic examination revealed splenic infarction, resulting from septic emboli, with associated rupture of the splenic capsule, but no abscess was found. Bacillus sp. was isolated from cultures of arterial blood preoperatively, and the excised splenic specimens, postoperatively. In addition to rupture of the suppurating intrasplenic vessels with hematoma formation, the anticoagulant therapy possibly contributed to distension of the intrasplenic hematoma.

Rupture of the spleen occurred in five patients (aged 44-59 years) in the course of chronic or chronic recurrent pancreatitis. In three patients the rupture was a consequence of perisplenic adhesions associated with subclinical chronic pancreatitis, in another there was direct enzymatic erosion of the splenic capsule via the phrenicosplenic ligament, and in the fifth patient haemorrhagic infarction followed splenic venous thrombosis. In four patient there was a history of chronic pancreatitis related to alcohol abuse. On admission all patients complained of breathing-related pains radiating into the shoulder. Three patients also had abnormal radiological signs in the left lower lung field (high diaphragm, effusion, infiltration). The findings can be explained pathogenetically by infiltration of the phrenicosplenic ligament which connects the tail of the pancreas with the splenic hilus and the diaphragm. The final diagnostic confirmation and indication for surgery was in all cases made by computed tomography. This is thus the imaging procedure of choice if splenic involvement is suspected in the course of chronic pancreatitis.

A case of endosalpingiosis appearing as a huge multilocular cyst in the spleen of a 31-year-old woman is reported. The cystic lumens were smooth, and lined by fallopian tubal epithelium containing ciliated and secretory cells. The epithelial lining showed neither atypia nor foci of papillary proliferation, with only 3-5% MIB-1 labeling index. The epithelial lining was histochemically negative for mucin, but positive for MUC1 and progesterone receptor. Despite the appearance of a tumor-like mass, it was diagnosed as florid cystic endosalpingiosis as there was a normal tube-like epithelium. Regarding etiology, it was considered to derive from the secondary mullerian system of the splenic capsule.

Aims and Background Splenic metastases associated with mucinous intraabdominal tumors have been an enigma in the radiologic and oncology literature. These focal parenchymal defects from a non-metastasizing malignancy within an organ that rarely develops metastatic foci, even with high-grade cancer, were studied. Methods Information on 9 patients who underwent splenectomy with intraparenchymal splenic masses associated with appendiceal or colorectal mucinous tumors with peritoneal dissemination was collected. The CT scan, the histopathology and the clinical parameters of these patients were studied. A literature review searching for prior reports of this subject was performed. Results Eight of these patients had mucinous appendiceal tumors and 1 a mucinous sigmoid colon cancer. All patients had mucinous carcinomatosis at some time in their clinical course. These splenic tumor masses had a CT image compatible with metastases and not compatible with mucinous tumor layered out of the splenic capsule. None of the patients had evidence of metastases to other sites such as liver or lymph nodes. All patients had a mucinous histopathology. Splenectomy may be associated with prolonged survival. Conclusions From our review of the clinical information available on these 9 patients, these splenic lesions were thought to be an entrapment of mucinous tumor within splenic surface trabeculae, which expand into the splenic parenchyma resembling metastatic disease. These CT findings may be more accurately referred to as splenic pseudometastases.

Papillary thyroid carcinoma (PTC) commonly metastasizes to cervical lymph nodes. Distant metastases are unusual with the lungs most frequently involved. Well-differentiated thyroid carcinoma very rarely presents with metastases to the spleen. This is the case of a 25-year-old man with a history of PTC (1.4 cm primary; no capsular invasion and negative lymph node metastases). One year after initial surgery, recurrent disease was found in multiple neck nodes by central neck dissection. Whole body scan (WBS) following a therapeutic ablation dose of 150 mCi I(131) revealed mediastinal metastases. Computerized axial tomography (CT) of the chest one year later showed no gross mediastinal or pulmonary disease. However, multiple large splenic lesions were incidentally noted. Evaluation by ultrasound (US) showed lesions to be solid echogenic masses without remarkable Doppler characteristics to suggest vascular tumors. US-guided percutaneous fine-needle aspiration biopsy (FNAB) of one lesion was nondiagnostic. After withdrawal from Levothyroxine, serum TSH was >100 mU/L with a thyroglobulin of 9.4 ng/mL and negative anti-thyroglobulin antibodies. Diagnostic WBS revealed faint splenic uptake but was otherwise unremarkable. Following treatment with 192 mCi I(131), WBS demonstrated increased activity in the mediastinum as well as in the spleen suggesting mediastinal and splenic metastases. Contrast CT of the abdomen showed multiple low-attenuated heterogeneously enhancing splenic masses, normal liver and no intra-abdominal lymphadenopathy. The largest mass (4.5 x 3.5 cm) was exophytic and in close proximity to the splenic capsule. Despite the serum thyroglobulin of only 9.4 ng/mL, the finding of I(131) accumulation within solid splenic masses led to a preoperative diagnosis of thyroid carcinoma metastases. To establish the diagnosis and to remove the risk for splenic rupture, a laparoscopic splenectomy was performed. Histopathologic analysis showed large littoral cell angiomas (LCA). False-positive radioiodine scintigraphy in the setting of PTC involving a vertebral hemangioma has been reported. To our knowledge, this is the first case that describes multiple angiomas mimicking metastatic thyroid carcinoma to the spleen. In one-third of all cases reported, LCA co-exists with various visceral organ cancers or malignant lymphoma. This is the first report of an association between LCA and thyroid carcinoma.

Heterotropic splenic tissue in the renal fossa is characteristically asymptomatic and is usually an incidental finding that has been reported to mimic renal or adrenal tumors. A 50-year-old man with renal cell carcinoma had undergone radical nephrectomy with splenectomy because of the invasion of the splenic capsule. During a follow-up examination, nodules were detected by computed tomography in the subdiaphragmatic region. Although local recurrence was highly suspected, and these masses were diagnosed as ectopic splenic tissues by a technetium-99m-sulfur colloid scintigraphy and unnecessary surgical exploration was avoided.

Laparoscopic splenectomy (LS) is an alternative to open surgery. However, there is a theoretic risk of splenosis and abdominal cavity dissemination of splenic cells if the splenic capsule is broken, as seen by experimental evidence of tumoral cell mobilization by the pneumoperitoneum. We evaluated the features of splenosis after splenectomy operated via an open approach or under laparoscopic control in an experimental model in the rat. A total of 65 Sprague-Dawley rats were distributed in seven groups that included the open approach, CO2 pneumoperitoneum LS, or wall lift LS with or without a splenic graft. Splenic function was evaluated 90 day later through (1) scintigraphy with Tc-labeled heat-damaged erythrocytes; (2) determination of circulating "pitted" cells; and (3) analysis of the distribution of splenic pulp in the peritoneal cavity. Scintigraphy did not show viable residual tissue in any group after splenectomy; splenic activity in the splenic fossa was observed in 40% of the animals with grafts. Splenectomy increased the "pit" cell count, but it was reduced to normal values with a splenic graft. Necropsy showed normal splenic tissue in the splenic fossa in 100% of animals with a graft. Abdominal implants were observed significantly more frequent after CO2 LS than after the open surgery or a wall lift LS (80% vs. 20% vs. 30%; p0.05). In addition, trocar site implants were observed with CO2 LS (n = 3) or wall lift LS (n = 2), whereas there were no implants in the wound in the open group. We conclude that in an experimental rat model the pneumoperitoneum may facilitate abdominal splenosis after LS if the splenic capsule is ruptured or if splenic tissue spills compared with surgery without gas (open or laparoscopic).

A 14-year-old Thoroughbred gelding with a history of acute onset of hematuria was presented for necropsy. Transitional cell carcinoma of the urinary bladder with intra-abdominal dissemination was diagnosed. Tumor masses were observed on the splenic capsule and surrounding the distal abdominal aorta. Tumor cells showed diffuse cytoplasmic reactivity for cytokeratin but were negative for epithelial membrane antigen, carcinoembryonic antigen, tumor-associated glycoprotein 72, and vimentin.

We report an epithelioid angiosarcoma involving the splenic capsule. This neoplasm developed because of a gauze sponge, retained for 38 years following left-sided nephrectomy. Clinical, radiological, and histological features of this angiosarcoma add to the validity of the concept of inert foreign body tumorigenesis in humans.

Heterotropic splenic tissue in renal fossa is characteristically asymptomatic and is usually an incidental finding that has been reported to mimic renal or adrenal tumors. A 55-year-old man with renal cell carcinoma had undergone radical nephrectomy together with splenectomy because of disrupture of the splenic capsule. During a follow-up examination, three nodules were detected by computed tomography scan in the splenorenal area and they slowly enlarged. Although local recurrence was highly suspected, we decided to rule out splenosis. We successfully diagnosed these masses as ectopic splenic tissues by a technetium sulfur colloid scan and unnecessary surgical exploration was avoided.

Background Laparoscopic cholecystectomy (LC) is generally safe and well-accepted. In rare cases, it is associated with complications (intra- e postoperative bleeding, visceral injury and surgical site infection). Splenic lesion has been reported only after direct trauma. We report an unusual case of splenic rupture presenting after “uncomplicated” LC. Case presentation A 77-year-old woman presented with distended abdomen, tenderness in the left upper quadrant and severe anemia 12 hours after LC. Clinical examination revealed hypovolemic shock. Abdominal computed tomography confirmed the diagnosis of splenic rupture, and the patient required an urgent splenectomy through midline incision. The post-operative course was uneventful and the patient was discharged on 7th postoperative day. Splenic injury rarely complicates LC. We postulate that congenital or post-traumatic adhesions of the parietal peritoneum to the spleen may have been stretched from the splenic capsule during pneumoperitoneum establishment, resulting in subcapsular hematoma and subsequent delayed rupture. Conclusions Splenic rupture is an unusual but life-threatening complication of LC. Direct visualization of the spleen at the end of LC might be a useful procedure to aid early recognition and management in such cases.

Truncal vagotomy is rarely indicated as an adjunct to management of refractory duodenal ulcer disease or during performation of other procedures. This chapter details performance of open truncal vagotomy.

Aim : The authors studied changes in splenic volume after partial splenic embolization (PSE) in children who had thrombocytopenia caused by splenomegaly. Materials and Methods : Five children with hypersplenism (ages of 1, 6, 7, 10, and 14 years) underwent PSE. The follow-up period ranged from 1 month to 8 years 9 months. Whole and infarcted splenic volumes were measured from computed tomography images obtained before and after PSE. Results : Within 2 weeks after PSE, the whole splenic volume increased to 110% to 140% of the pre-PSE volume. The infacted area disappeared 3 to 4 months after PSE, and the whole splenic volume decreased markedly. The decreased volume tended to be stable during the follow-up period. The splenic enlargement before PSE ranged from 7.2 to 14.2 times the standard splenic volume for a corresponding body weight. The splenic volume did not become normal after PSE; it remained between 2 and 7 times larger than standard. Platelet counts stayed above 10 × 10 4 /mm 3 when the splenic volume reduced to 2 times the standard volume. Conclusion : The first 4 weeks after PSE is the most dangerous period for the development of splenic rupture because of marked expansion of the splenic capsule. The infarcted parenchyma is absorbed 3 to 4 months after PSE, and the whole splenic volume is reduced. Thereafter, the splenic volume is stable for several years. Reembolization is not likely to be necessary in the majority of patients who have had splenic embolization with an infarction rate of ≥80%.

Dr. Fiorentino: A 44-year-old black woman from Cuba was admitted to the Emergency Department (ED) because of stabbing abdominal pain in the left upper quadrant, which had begun suddenly after she finished working. During the week prior to admission, she had no fever, no symptoms or signs of gastroenteritis, no dysuria, and no change in bowel habit. The patient said that she had the same symptoms 2 years prior to this episode after an airplane flight. On that occasion, she was admitted to a hospital, but she did not remember the diagnosis and no records were available. The patient also had no recollection of previous diagnosis of hemoglobinopathies, was not aware of previous health problems or diseases and had no recollection of childhood hospitalization. On admission to the ED, she presented symptomatic with mild tenderness in the left upper quadrant of the abdomen. The vital signs were: pulse 93 beats/min, respiratory rate (RR) 16 breaths/min, blood pressure (BP) 130/85 mmHg, body temperature 36.7 C. The finger stick glucose was 91 mg%. The 12-lead ECG showed a sinus rhythm with a normal QRS shape. Physical examination revealed a soft abdomen that was mildly tender in the left upper quadrant. There were no pulsating masses, no splenomegaly, no asymmetrical peripheral pulses nor detectable bruits. The liver was slightly enlarged on palpation. The remainder of the examination was unremarkable. The results of routine laboratory findings, including b-HCG, ALT, AST, pancreatic amylase, bilirubin, creatinine, coagulation parameters were within normal range, except for a mild anemia (Hb = 11.2 g/dl; Htc = 33.4%; VCM = 80.5 fl), mild LDH (903 U/L) and PCR increase (3.29 mg/dl) [1, 2]. The ultrasound (US) abdominal examination [3] revealed an abnormal and inhomogeneous splenic echostructure because of multiple lesions, with the characteristics of ischemic infarctions and scarring (Fig. 1, see white arrows); there were no other pathological findings in the liver, kidneys, pancreas, abdominal aorta and pelvic organs. Acute splenic infarctions appear as more or less echogenic lesions, without Doppler signal (Fig. 2; see white arrows), with variable dimensions, that extend to the surface. Their characteristic pyramidal shape allows us to distinguish splenic infarction from abscesses or tumoral infiltration. The chronic relapsing infarction is typical of sickle cell anemia. In this case, the spleen has multiple echogenic or hypoechoic focal lesions that led to a progressive splenic capsule retraction because of fibrous scars. During recovery there is an increase in echogenicity and the retraction of the infarcted area. The complications (20% of all cases) are [4]: gradual colliquation (degeneration of splenic tissue to a liquid state after a necrotic process), sub-capsular bleedings, pseudoaneurysms or arterio-venous fistulae and hemoperitoneum. The possible evolutions are

The aim of this study was to investigate whether complications occur after haemostatic agents are injected into blunt splenic injuries. After undergoing ultrasound (US), contrast-enhanced US (CEUS) and contrast-enhanced computed tomography (CECT) examinations, dogs with grade III–IV injury received the minimally invasive therapy. After treatment, CEUS was performed to observe changes in the regions treated. In the immediate group, dogs underwent laparotomy 30 min after treatment to observe the haemostatic effect. In the survival group, animals underwent CEUS and CECT examinations to observe the short-term healing outcome and complications at 3, 7, 14, and 21 days after the injection. After undergoing CEUS and CECT examinations, 12 dogs with grade III-IV injury received the minimally invasive therapy. Before injection, CEUS examinations showed anechoic and/or hypoechoic perfusion defects and active bleeding at the injury sites, and CECT showed traumatic lesions as low-density regions without enhancement. After treatment, CEUS demonstrated the disappearance of active bleeding, and hyperechoic spots emerged at the injury sites. Uneven density regions were displayed on CECT. Treated areas were covered by blood clots and glue membrane in the immediate-group animals. Three weeks later, CEUS showed a decrease of hyperechoic spots in the survival group, and the splenic parenchyma enhanced uniformly on CECT. Laparotomy showed that the greater omentum had moved upwards and partly covered the wound in four animals, and the injury sites had completely healed. Histopathological examination showed that fibrous connective tissue covered the splenic capsule and that the haemostatic glue had degraded. No complication occurred, such as delayed splenic haemorrhage, splenic abscesses, splenic pseudoaneurysms, intestinal obstruction or intestinal adhesions. CEUS-guided haemostatic injection is not only effective in stopping active bleeding immediately, but it is also safe in that no complications occurred during the 3 weeks of follow-up. This study indicates that CEUS-guided percutaneous injection may provide a safe, feasible and effective therapy for blunt splenic trauma.

We describe herein a clinical case in which a subcapsular splenic hematoma complicated chronic relapsing pancreatitis. A pathogenetic mechanism is postulated that explains the subacute insorgence of the liquid collection with the diffusion of proteolytic enzymes between the splenic capsule and parenchyma. Radical therapy, consisting of exeresis of the cystic formation, splenectomy and caudal pancreatectomy, is recommended for this extremely rare complication.

A marked change toward a more conservative approach in the treatment of abdominal trauma has been noted, especially during the last decade. This change in regimen was first seen in the handling of splenic trauma, initiated by pediatric surgeons. Later, the concept of conservative management was also introduced among adults and it is now widely accepted. Here, an almost mandatory splenectomy has been replaced by attempts at various forms of splenic salvage. The development followed an initial report by King and Shumacker in 1952 [1] on an increased susceptibility to overwhelming sepsis in splenectomized children, findings which later also were demonstrated among adults [2, 3]. It has also been shown that the bleeding from intraparenchymal lesions with an intact splenic capsule or minor capsular tears frequently ceases spontaneously, hereby making nonoperative management possible in selective cases [4, 5].

Objective— To report a laparoscopic technique for insertion of polypropylene mesh in the nephrosplenic space in horses and evaluate outcome. Study Design— Descriptive experimental study. Animals— Five healthy mature horses. Methods— One laparoscope and 2 instrument portals were made on the left side of the horse. The nephrosplenic space was measured and appropriately sized polypropylene mesh was inserted and attached to the dorsolateral splenic capsule and perirenal fascia using helical titanium coils. All horses had repeat laparoscopy 4 weeks later and were necropsied at intervals 4–14 weeks after mesh placement. Results— Mean time for laparoscopic mesh placement was 104 minutes. None of the horses had signs of colic and at 4 weeks all mesh implants were covered by fibrous tissue. One horse had a descending colon mesenteric adhesion to the mesh. At necropsy, the fibrous tissue covering the mesh had adhered to itself and pulled the splenic capsule and perirenal fascia into close apposition. Each mesh implant was firmly adhered to the spleen, nephrosplenic ligament, and perirenal fascia. Conclusions— Laparoscopic mesh placement was easily performed, well tolerated, and provided excellent fibrous obliteration of the nephrosplenic space. The single important complication observed was a mesenteric adhesion of the descending colon to the mesh in 1 horse. Clinical Relevance— Laparoscopic placement of polypropylene mesh leads to obliteration of the nephrosplenic space within 4 weeks and should prevent entrapment of viscera in the nephrosplenic space.

This paper describes the ultrasonographic appearance, location and size of the spleen in 50 healthy commercial milk cows destined for slaughter. The intercostal spaces of the left thoracic wall were scanned with a 3.5 MHz linear transducer. In each intercostal space, the appearance of the splenic parenchyma, the dorsal and ventral margins and the distance between them, and the diameter of the splenic vessels were recorded. The spleen was seen in intercostal spaces 7-12. It was 2.0-5.0 cm thick, and tapered ventrally. The splenic capsule appeared as an echogenic line. The splenic parenchyma consisted of numerous small regularly spaced echoes, and vessels within the parenchyma appeared as anechoic round to oval or elongated images. The long axis was oblique, running caudodorsal to cranioventral. The distance from the dorsal margin of the spleen to the midline of the back was greatest in the 7th intercostal space (60.9+/-6.81) and smallest in the 12th intercostal space (12.7+/-2.85 cm). The extent of the spleen was greatest in the 8th intercostal space (24.9+/-10.77 cm) and smallest in the 12th intercostal space (9.5+/-5.38 cm). The mean diameter of the splenic vessels ranged from 0.66+/-0.28 to 0.90+/-0.65 cm, depending on the intercostal space scanned. Ultrasonography of the spleen in healthy cows provides information that can be used as a reference when examining cattle with suspected splenic disease.

An 18-year-old woman with abdominal pain was diagnosed as having splenic cysts by computed tomography scan. She had high serum levels of CA19-9 (2886.8 U/mL; normal value

We present a case of an atraumatic, occult rupture of the spleen. It is only in a distinct minority of cases, that the splenic capsule remains intact, thereby preventing intraperitoneal bleeding. Nevertheless, this condition can be accompanied by a severe loss of blood. A nonoperative management can be considered. Reviewing the literature on splenic rupture, the lack of uniformity in nomenclature is striking. The etiological and morphological classifications are reviewed.

Summary A 72 year old female was admitted for an operation of gastric cancer. At the operation, a 3 x 3 cm-sized, whitish and multilocular nodule was incidently found at the left side o f the spleen. This nodule was adjoining the splenic capsule and was characterized with sparsely found multilocular lymphatic cysts with varying sizes. The walls of these cysts were composed o f partly thin fibrous tissue, or partly thin to thick splenic trabeculae. Abnormally elongated, nodular or fragmentary trabeculae were also present in the nodule. White and red splenic pulp was found widely dispersed among the cysts. The surrounding splenic tissue was not compressed. We considered the essence o f this tumor to be an abnormal mixture o f normal s plenic elements such as lymphatics, splenic trabeculae, and red and white pulp, and regarded this tumor as a focal malformation (lym phangiomatous hamartoma) rather than a true neoplasm such as a lymphangioma.

This study was designed to compare Nd:YAG laser to fibrin glue, electrocautery, and avitene in the management of superficial splenic injury. Six dogs were submitted to laparotomy. A #11 blade scalpel was used to sharply excise the splenic capsule inflicting four 1″ × 1″ superficial injuries on each spleen. The lesions were treated. All animals had a second laparotomy (“first relaparotomy”); 2 dogs each were reexplored on postop days 3, 7, and 14. Morphologic and histologic observations were made. A third and final relaparotomy was performed on all dogs at 21 days with repeated morphologic and histologic assessments. Hemostatic times, grades of adhesions, and microscopic changes were not significantly different among the various treatments (P > 0.25). Capsular plaque formations were significantly different at the first relaparotomy (P < 0.01) and at final relaparotomy (P < 0.05). Both adhesions and capsular plaque formation were least at fibrin glue-treated sites, whereas Nd:YAG (1.06 μm) was most effective for average hemostatic time (mean = 109.67 s). Electrocautery produced the greatest necrosis at treatment sites. We conclude that all modalities are effective in controlling hemorrhage. © 1994 Wiley-Liss, Inc.

Fibrosarcoma of the spleen are generally single lesions and vary in size from a few millimeters up to several centimeters in diameter. Most lesions cause the splenic capsule to bulge, but smaller lesions may occasionally be embedded in the splenic parenchyma and cause little or no external distortion. Rarely, these neoplasms appear to be associated only with the deep surface of the capsule with little evidence of extension into the parenchyma. Such lesions have been designated capsular sarcomas.

pedicle. The condition is associated with other congenital abnormalities including the prune-belly syndrome, in which dilatation of the genitourinary tract interferes with gut rotation and fusion of the dorsal mesogastrium7. Some have suggested that it is the abnormal laxity of the splenic ligaments that is the primary aetiology8. An excess incidence in child-bearing years and in the multiparous has raised the possibility of ligamentous lengthening as a cause. Increased splenic mass has also been proposed as a possible aetiology but data regarding malarial and lymphomatous splenomegaly are conflicting; in most patients with a wandering spleen there is nothing wrong with the spleen itself9. Many patients with a wandering spleen are symptomfree, the condition being discovered incidentally on abdominal examination. Intermittent abdominal pains are a common mode of presentationl. Severe and persistent abdominal pain suggests splenic torsion which may vary from 90 to 160 degrees. Delay in diagnosis risks not only splenic infarction but also pancreatic necrosis10. How should a symptomatic wandering spleen be managed? At one time the favoured treatment was splenectomy, but this operation is now avoided when possible because of the spleen's important role in the reticuloendothelial system; therefore there is renewed interest in splenopexy. Torsion of the spleen and consequent infarction still necessitates splenectomy. All patients undergoing elective splenopexy should undergo pneumococcal vaccination in case the need for splenectomy should arise during splenopexy. Of the splenopexy techniques describedll, suturing of the spleen is said not to be complicated by haemorrhage though some feel this applies only to paediatric splenopexy where a thicker splenic capsule is more forgiving12. Our approach, whereby a Prolene pouch is fashioned and secured in the left upper quadrant, is novel. The spleen can then be easily placed within and the pouch closed thus securing the spleen in its correct anatomical position.

Spontaneous rupture of the spleen is an uncommon dramatic abdominal emergency that requires immediate diagnosis and prompt surgical treatment to ensure the patients survival. Infections have been cited in most cases involving splenic rupture but are rare in hematological malignancies despite frequent involvement of the spleen. We present a case of a splenic rupture caused by infiltration of B-cell lymphoma. A 43 year old gentleman presented with a 1 day h/o left upper quadrant pain; nausea and vomiting for 2 days with associated dizziness and anorexia. The CT showed abnormal spleen 20 × 11 cm with free fluid in the abdomen and enlarged retroperitoneal LNs. The patient underwent a splenectomy after initial resuscitation and the operative finding was that of a massively enlarged spleen with areas of tumor extruding through the splenic capsule. Although the spleen is often involved in hematological malignancies, splenic rupture is an infrequent occurrence. In a recent literature review 136 cases were of splenic rupture secondary to hematological malignancy were identified. Acute leukemia and non Hodgkin lymphoma were the frequent causes followed by chronic myelogeneous leukemia. Male sex, adulthood, severe splenomegaly and cytoreductive chemotherapy were factors more often associated with splenic rupture. Emergency splenectomy remains the cornerstone treatment for splenic rupture. We present a case report of a "spontaneous splenic rupture" and discuss the presentation, etiology and treatment options along with discussion of relevant literature

Nonparasitic cysts of the spleen are classified as primary or epithelial cysts if their inner surface has a cellular lining. Depending upon the pattern of the inner surface cell layer, the primary splenic cysts are divided into mesothelial or epidermoid subtypes. In order to study their pathogenesis, five epithelial splenic cysts (two with mesothelial lining, and three with foci of stratified squamous epithelium) were investigated by scanning and transmission electron microscopy and by immunohistochemistry. In places, the squamous epithelium was continuous with a flattened mesothelial layer. Furthermore, within the stratified epithelium, a continuous spectrum of cytodifferentiation from mesothelial to squamous cells was found. Thus, the epidermoid splenic cyst seems to be a variant of the mesothelial cyst with focal squamous metaplasia. Rupture of the splenic capsule with hemosiderin deposits and infoliation of the mesothelium was seen in one case, implying a traumatic genesis. In addition, stoma-like channels providing connections between the lumen of the cyst and the sinus of the adjacent splenic tissue were detected by scanning electron microscopy. As with other cystic lesions, the influx of blood cells and proteinaceous fluid from these stomata may contribute to the growth of the cysts, which are usually of considerable size when surgically removed.

Pathologic rupture of the spleen is a rare phenomenon in acute lymphocytic leukemia, and its mechanism is unknown. This complication has been seen almost exclusively in men, and at ages much older than those of the majority of patients who have this leukemia; these unusual features are also unexplained. A case of acute lymphoctyic leukemia with pathologic rupture of the spleen in which the pathologic findings suggest that the splenic rupture was due to infiltration and destruction of the splenic capsule by leukemic cells is reported.

Two patients with rheumatoid arthritis without splenomegaly or Felty's syndrome developed spontaneous rupture of the spleen. The histological appearance was consistent with involvement of the splenic capsule by the rheumatoid process, and this may have predisposed to splenic rupture.

The use of a nasogastric tube to empty the stomach contents prevents compression of the splenic parenchyma and allows clear visualization of the anterior medial border of the spleen and perisplenic area. Unsuspected superficial lacerations or a contained hematoma by the splenic capsule may become apparent only following this procedure. A representative case is reported. Routine application of this simple procedure aids avoiding occasional pitfalls and helps in early diagnosis of splenic injury at the time of a CT study.

Splenic pseudocysts have traditionally required splenectomy because of the risks imposed by partial splenectomy or excision of the cyst lining. During the past 2 years, a 6-year-old boy and a 9-year-old girl presenting with vague upper abdominal discomfort, palpable splenomegaly, and a large unilocular sonolucent cyst within the spleen, were treated by partial splenic decapsulation with preservation of the hilar blood supply. This procedure involves (1) mobilizing the spleen by dividing the renal, colic, and diaphragmatic attachments; (2) decompressing the liquefied cyst contents through a thoracostomy trochar; (3) excising the outer splenic capsule and gaining hemostasis of the splenic wall with a running interlocked silk suture; and (4) providing external tube drainage of the left upper quadrant. During the follow-up period of 26 and 12 months, splenic size has returned to normal. Serial nuclear scan and ultrasound show a small residual crescent-shaped deformity of the functioning splenic remnant. We conclude that partial splenic decapsulation for splenic pseudocyst is simpler and safer than other preservation procedures attempted, and carries no increased risk of recurrence from leaving a portion of the pseudocyst wall.

In six carcinogenicity bioassays, male and female F344 rats were fed diets containing aniline hydrochloride (CAS: 142-04-1; hydrochloride benzenamide), p-chloroaniline (CAS: 106-47-8), azobenzene (CAS: 103-33-3), o-toluidine hydrochloride (CAS: 636-21-5), dapsone (CAS: 80-08-0; 4,4'-sulfonyldianiline), or D & C red No. 9 [CAS: D85500000; 5-chloro-2-[2-hydroxy-1-naphthalenyl)azo)-4-methylbenzenesulfon ic acid, barium salt]. The rats, from 6 weeks to 2 years old, were given the compounds at two dose levels, the estimated maximum tolerated dose and one-half that dose. In all six bioassays, dose-dependent incidences of splenic sarcomas and fibrosis were seen, with the highest incidences in male rats. Fibrosis occurred in the splenic parenchyma and/or the capsule. Fatty infiltration also was seen in the spleen. Sarcomas appeared to arise in the splenic red pulp or splenic capsule, usually in association with areas of parenchymal and capsular fibrosis and pigmentation. Larger tumors metastasized to the peritoneal cavity and abdominal organs. In some rats there was marked osseous metaplasia when the primary tumor metastasized to peritoneal surfaces. Other, less common, splenic neoplasms included hemangiosarcoma and hemangiopericytoma. Some rats had such extensive peritoneal involvement that the site of origin of their sarcoma was difficult to determine.

Mixed mesenchymal neoplasms of the uterus of 8 mice had either leiomyosarcoma or fibrosarcoma components. 6 had osteoid and 2 had both vacuolated and undifferentiated neoplastic cells. The putative chondrosarcoma component varied from a poorly-differentiated appearance (sheet-like masses of cells) to a myxoid appearance with giant cells and cells with cytoplasmic vacuoles. 1 tumour contained well-differentiated bone that was located within the primary and just beneath the splenic capsule. In another tumour composed of osteosarcoma, chondrosarcoma and fibrosarcoma, the latter component had invaded the wall of the rectum.

A 43-year-old man with acute undifferentiated leukemia developed high fever and stomatitis followed by severe abdominal pain after completion of a first course of chemotherapy. A 99mTc-sulfur colloid (SC) scan showed multiple, irregular defects in an enlarged spleen. A 67Ga-citrate scan showed uniform tracer distribution except for a large defect in the upper portion of the spleen. The size of the spleen in the 67Ga-scan was much larger than in the SC scan. At surgery an abscess cavity was found between the spleen and the greater gastric curvature with multiple smaller abscesses on the splenic capsule and throughout the splenic parenchyma. A hematoma was present in the upper pole of the spleen. The disparate splenic size and seemingly discordant distribution patterns of tracer in the 99mTc- and 67Ga-scans were fully explained by histopathological study of the surgically resected spleen.

Fifty male F344 rats were given diets containing 500 mg/kg P-chloroaniline. Controls received diets without the chemical. Eighteen of the dosed rats developed proliferative lesions of the spleen. Lesions included parenchymal fibrosis and fatty infiltration, well and poorly differentiated fibrosarcomas, osteosarcomas and hemangiosarcomas. All dosed rats had focal and diffuse fibrosis and papillary hyperplasia of the splenic capsule.

Four hundred and twenty beagles 1 to 4 years of age were examined for spontaneous pathological changes. In the liver were seen fine granular gallstones (87.5%), granulomas (59.9%), intranuclear hyaline inclusions (52.6%), lipofuscin deposition (50%) and eosinophilic inclusions (3.7%) in the cytoplasm of hepatocytes and parenchymal necrosis at the base of the ligaments (7.3%). Intranuclear hyaline inclusions and lipofuscin deposition were more frequently seen in dogs after being subjected to tests for more than 13 weeks. Besides, hyperplasia of follicular epithelial cells of the thyroid gland (46.3%), Gandy-Gamna like bodies of the splenic capsule (43.1%), small cysts in the anterior lobe of the hypophysis (35.1%) and prostatitis (13,7%) were observed. Lesions due to migration of Toxocara canis larvae were detected in the liver, kidney, lung and other organs from 33.1% of cases examined.

Subcapsular hematoma of the spleen is a rare complication of pancreatitis. In one patient successful percutaneous drainage of a large hematoma was performed during the subacute phase, preventing rupture of the splenic capsule and obviating splenectomy.

OF THE many noted physiological effects of adrenocorticotropin (ACTH) and cortisone, perhaps their ability to produce variable degrees of remission in thrombocytopenic states may prove to be one of the most practicable. While splenectomy has been widely used in the treatment of idiopathic thrombocytopenic purpura for over 35 years, the results have not been entirely satisfactory. Welch and Dameshek 1 reported that in a series of 92 patients splenectomized for idiopathic thrombocytopenic purpura, 61% showed complete and sustained therapeutic response and an additional 19% showed a partial response with a great reduction in the bleeding tendency. Most of the mortality associated with splenectomy for this condition has occurred in those instances when it became necessary to operate during an acute fulminating crisis. It is in these hazardous cases that sufficient search may not be made for accessory spleens and also where the splenic capsule may be torn and thus small