Patient factors associated with embolization or splenectomy within 30 days of initiating surveillance for splenic trauma.

BACKGROUND: Non-operative management of hemodynamically stable patients with splenic trauma has been recommended for more than 25 years, but in practice embolization and/or splenectomy (intervention) is often needed within the first 30 days. Identifying the risk factors associated with the need for intervention could support more individualized decision-making. METHODS: We used data from the SPLASH randomized clinical trial, a comparison of outcomes of surveillance or embolization. 140 patients were randomized, 133 retained in the study (embolization n = 66; surveillance n = 67) and 103 screened and registered in the non-inclusion register. Multivariate Cox proportional hazards models with time-varying covariates were used to identify risk factors contributing to embolization and/or splenectomy within 30 days after initiating surveillance only for splenic trauma. RESULTS: 123 patients (median age, 30 [23; 48] years; 91 (74%) male) initially received non-operative management. At the day-30 visit, 34 (27.6%) patients had undergone an intervention (31 (25.2%) delayed embolization and 4 (3.3%) splenectomy). Multivariate analysis identified patients with OIS grade 4 or 5 splenic trauma (HR = 4.51 [2.06-9.88]) and (HR = 34.5 [6.84-174]); respectively) and splenic complications: arterial leak (HR = 1.80 [1.45-2.24]), pseudoaneurysm (HR = 1.22 [1.06-1.40]) and pseudocyst (HR = 1.41 [1.21-1.64]) to be independently associated with increased risk of need for an intervention within 30 days of initiating surveillance. CONCLUSIONS: Our study shows that more than 1 in 4 patients who received non-operative management needed embolization or splenectomy by day 30. Arterial leak, pseudoaneurysm, pseudocyst, and OIS grade 4 or 5 were independent risk factors linked to the need for an intervention. TRIAL REGISTRATION: clinicaltrials.gov Identifier NCT02021396.

Splenic rupture secondary to pancreatic malignancy invasion: A rare case.

Malignancy is a rare etiology of splenic rupture, with most documented cases resulting from hematologic cancers. There have been very few reports of splenic rupture resulting from invasion or metastasis of adenocarcinoma and even fewer reports resulting from specifically pancreatic adenocarcinoma. In this case report, we outline the clinical course of a 60-year-old male with splenic rupture and hemoperitoneum following a ground level fall who was transferred to the Shock Trauma Center (STC) from a local emergency department. Outside of the ruptured spleen, no other traumatic injuries were found on examination or imaging. Due to the initial concern for traumatic etiology, exploratory laparotomy was performed with splenectomy and distal pancreatectomy. Postoperative pathology results revealed pancreatic adenocarcinoma with splenic invasion staged pT3N0. This report provides a novel example of splenic rupture in the background of locally advanced pancreatic adenocarcinoma and further solidifies the importance of maintaining a broad differential in cases of seemingly innocuous trauma.

Transumbilical single-site laparoscopic treatment of primary splenic cyst in child: a rare case report and review of literature.

Background: Splenic cysts are relatively rare benign tumors that are asymptomatic in most patients and are usually discovered incidentally by imaging. In our case, we report a splenic cyst in a child who underwent laparoscopic partial splenectomy. Case description: A 13-year-old boy was admitted to the hospital after an incidental finding of a splenic cyst on an abdominal ultrasound conducted 4 days prior. He was asymptomatic before admission. Upon admission, abdominal ultrasound and CT revealed a cystic lesion in the spleen, highly suspicious for a splenic cyst. Then, we used transumbilical single-site laparoscopic exploration and found a cyst measuring approximately 12 cm × 11 cm × 10 cm at the upper pole of the spleen, so we performed a partial splenectomy and diagnosed a primary epithelioid splenic cyst via postoperative pathology. Conclusions: Splenic cysts in children are very rare and can be treated conservatively in asymptomatic patients with a diameter of less than 5 cm, while surgery is required in symptomatic patients or those with a diameter greater than or equal to 5 cm. Transumbilical single-site laparoscopic partial splenectomy is a minimally invasive and effective treatment, especially for children.

Impact of Splenectomy on Long-term Outcomes after Gastrectomy for Gastric Cancer - a Population-based Study.

BACKGROUND: No national studies comparing long-term survival after total or partial gastrectomy with splenectomy due to injury or due to oncological reasons or spleen preservation exist. The aim of the study was to examine the overall 5-year survival of gastric adenocarcinoma patients undergoing total or partial gastrectomy with splenectomy due to injury or oncological reasons or spleen preservation in a population-based nationwide setting. METHODS: This study included all patients undergoing total or partial gastrectomy with splenectomy or spleen preservation for gastric adenocarcinoma in Finland in 2005-2016, with follow-up until December 31, 2019. A total of 2,196 patients with gastric cancer diagnosis and total or partial gastrectomy were identified in the registries. Of these, 2,118 patients were applicable for this study. Cox proportional hazard models provided hazard ratios (HR) with 95% confidence intervals (CI) of overall 5-year survival. Results were adjusted for age, sex, year of operation, comorbidities, tumor location, pathological stage, and neoadjuvant therapy. RESULTS: The observed overall 5-year survival was 38.7% in patients with no or minor spleen injury, 39.7% in patients with splenectomy due to injury and 30.8% in patients with splenectomy due to oncological reasons (p=0.032). R0 gastrectomy with splenectomy due to oncological reasons was associated with higher 5-year mortality (the adjusted model HR 1.26, 95% CI 1.01-1.56) compared to patients with spleen preservation. CONCLUSION: The overall survival is worst in gastrectomy patients with splenectomy due to oncological reasons highlighting the poor prognosis in patients with advanced gastric cancer. Splenectomy due to injury does not compromise prognosis.

Contemporary National Trend in Surgical Management of Hemodynamically Unstable Pediatric Blunt Splenic Injury.

BACKGROUND: Evaluation of response to blood transfusion after blunt splenic injury (BSI) may prevent the need for splenectomy. The aim of this study was to evaluate factors associated with splenectomy in pediatric patients with isolated BSI who presented with hemodynamic instability with a focus on timing of transfusion. METHODS: The 2021 Trauma Quality Improvement Project database was queried for children ≤18 years with BSI who arrived with a shock index>1.1. Interfacility transfer patients and those with additional intra-abdominal injuries were excluded. Demographic, injury characteristic and timing, transfusion, operative, and outcome data were collected. A sub-analysis of patients without brain injury was also performed. RESULTS: 516 patients met inclusion criteria; 60.1% were male, with mean age 12.3 ± 5.5 years. Initial mean shock index was 1.4 ± 0.4, ISS was 31.7 ± 15.1, and GCS was 10.7 ± 5. Splenectomy occurred in 27% of patients. Among splenectomy patients, 26.2% did not receive blood prior to splenectomy. While treatment at a pediatric trauma center showed an increased OR of splenectomy in univariable analysis, when controlling for lack of transfusion, no differences in splenectomy persisted. Patient Age (aOR-1.26, p < 0.001), BSI grade (aOR-2.30, P < 0.001), male gender, (aOR-2.2, p = 0.003), being non-white (aOR-2.0) ISS (aOR-1.03, p = 0.003), and GCS (aOR-0.95, p = 0.034) were associated with splenectomy. CONCLUSION: More than 26% of patients undergoing splenectomy did not receive blood prior to surgery. Differences in risk of splenectomy by center type seen on univariable analysis were not seen when controlling for transfusion. Evaluating response to blood transfusion may be an opportunity to reduce the frequency of splenectomy. LEVEL OF EVIDENCE: Treatment Study Level III.

Atraumatic splenic rupture: a case report.

Background: Splenic rupture associated with trauma is common within the population, however, spontaneous splenic rupture is noted to be a rarity in clinical practice. Spontaneous splenic rupture is usually associated with hematologic, neoplastic, or infectious disorders, with infectious mononucleosis associated with Epstein-Barr virus being the most common cause worldwide. Spontaneous splenic rupture without underlying cause is thought to be exceedingly rare. In this article we present a case involving a true spontaneous splenic rupture. Case Description: We present the case of a 73-year-old female with past medical history significant for hypothyroidism, hypertension, squamous cell carcinoma of the chest, and history of tobacco use who presented to the emergency department with acute onset of left-sided flank pain radiating to her shoulder beginning three days prior. Computed tomography of the abdomen and pelvis without contrast revealed an acute splenic injury concerning for rupture with contour obscured by blood products with associated mild to moderate hemoperitoneum. The decision was made to proceed with emergent exploratory laparotomy and splenectomy. Patient received her post splenectomy vaccinations. On follow-up appointment, patient was noted to be doing well. Conclusions: This case highlights the importance of early diagnosis and treatment of atraumatic splenic rupture, as delayed diagnosis and treatment is associated with significant morbidity and mortality. Operative intervention including splenectomy remains the mainstay of treatment, in addition to appropriate resuscitation. Some authors have reported cases in which hemodynamically stable patients are able to be treated non-operatively, however, the long-term consequences are unknown. Atraumatic spontaneous splenic rupture is often low on the differential diagnoses due to its rarity. Unfortunately, it carries a high risk of morbidity and mortality, and thus timely diagnosis and intervention is imperative.

Infective Endocarditis After a Splenectomy: A Complex Association.

Infective endocarditis is a potentially life-threatening condition that can have grave cardiac and neurologic complications. Recognizing risk factors, such as the presence of Gram-positive bacteremia and cardiac devices, has improved early recognition and management. The spleen plays an important role in the immune response, helping protect the body from infection from various bacteria. However, there is a paucity of literature regarding post-splenectomy patients with cardiac devices and the risk of endocarditis in this population. We present a case of infective endocarditis as a late sequela post-splenectomy in a 60-year-old patient with a history of a dual-chamber pacemaker. The patient was initially found to have bacteremia after splenectomy with repeat transesophageal echocardiogram confirming a tricuspid vegetation. The patient ultimately required pacemaker extraction and a prolonged course of intravenous cefazolin. The clinical course was complicated by a septic pulmonary embolus.

Fecal microbiota transplantation in a patient with chronic diarrhea and primary and secondary immunodeficiency (common variable immunodeficiency and splenectomy).

The gut microbiota serves a crucial role in the development of host immunity. Immunocompromised patients are particularly vulnerable to dysbiosis not only by virtue of a defect in the immune system but also due to increased susceptibility to infection and multiple courses of antibiotic therapy. Fecal microbiota transplantation is by far the most effective option for restoring gastrointestinal homeostasis. However, it is contraindicated in patients with significant primary and secondary immunodeficiencies. This article presents the case of a 59-year-old patient with common variable immunodeficiency, after splenectomy at age 39 for primary immune thrombocytopenia, who manifested diarrhea of up to 10 stools per day accompanied by secondary malnutrition and cachexia. The patient was admitted to the hospital on multiple occasions due to this condition, with stool PCR tests confirming a HHV-5 (Cytomegalovirus, CMV) infection. Following the administration of valganciclovir, the patient's complaints diminished, although, upon cessation of the drug, the symptoms recurred. In addition, the patient had an intestinal infection with C. difficile etiology. Given that the patient's therapeutic options had been exhausted, after obtaining informed consent from the patient and approval from the bioethics committee to conduct a medical experiment, treatment of diarrhea was undertaken by fecal microbiota transplantation with the certified preparation Mbiotix HBI from the Human Biome Institute. The patient underwent two transplants, with a one-week interval between them. The initial procedure was performed using the endoscopic method, while the subsequent was conducted using the capsule method. Following the administration of the applied treatment, the patient's symptoms were successfully alleviated, and no adverse effects were observed. A microbiological analysis of the intestinal microbiota was conducted prior to and following transplantation via next-generation sequencing (NGS). No recurrence of symptoms was observed during the two-year follow-up period. To the best of our knowledge, this is the first fecal microbiota transplantation in an adult patient with primary and secondary immunodeficiency.

Course of immune thrombocytopenia according to the site of platelet destruction identified by indium-111 platelet scintigraphy.

In primary immune thrombocytopenia (ITP), predictors of disease evolution and treatment response are needed. Data based on the site of platelet destruction are scarce. We performed a retrospective single-centre study of adult patients with primary ITP undergoing at least one Indium-111 platelet scintigraphy (IPS) between 2009 and 2018. Thirty-three patients had isolated hepatic platelet destruction (H-group), and 97 isolated splenic destruction (S-group). Median age at diagnosis (p < 0.001), proportion of associated cardiovascular (p < 0.001), organ-specific autoimmune diseases (p = 0.02), dependence on steroids (p = 0.003) and failure to rituximab (p = 0.01) were higher and relapse more frequent (p = 0.03) in H-group compared to non-splenectomized patients in S-group. Splenectomy was only performed in patients from S-group (as patients with hepatic sequestration are not splenectomized in our centre): 79% were in relapse-free remission at the end of a median 3.4-year post-IPS follow-up, 16% relapsed. In multivariate analyses, only a history of organ-specific autoimmune or inflammatory disease was significantly associated with hepatic sequestration (OR = 4.3, 95% CI = 1.2-15, p = 0.02). Patients with isolated hepatic sequestration were older, had more cardiovascular events and organ-specific autoimmune diseases, greater dependence on steroids, more relapses and a decreased response rate to rituximab suggesting an increased refractoriness to immunomodulatory therapies. Patients with isolated splenic sequestration responded well to splenectomy.

Splenic Torsion From a Wandering Spleen.

Wandering spleen is a unique condition defined as a hypermobile spleen with a sole attachment to its vascular pedicle. The most common complication is torsion of the spleen, resulting in a surgical emergency. Early diagnosis and prevention of splenic infarction are the mainstays of treatment to help preserve immunologic function. We report a case of torsion of the wandering spleen in a 23-year-old active-duty male with a prior childhood history of duodenal atresia. His abdominal examination demonstrated a palpable midline mass, which was confirmed by CT abdomen and pelvis to be a wandering spleen with twisting of the vascular pedicle. The patient was taken for an exploratory laparotomy, where an infarcted spleen was identified with associated twisting of the splenic hilum, and a splenectomy was performed. Post-operatively, the patient is healthy and symptom-free at the three-month follow-up and has returned to active duty.

An Unusual Case of a Central Pontine Myelinolysis Associated with Primary Splenic Diffuse Large B-cell Lymphoma.

A 54-year-old woman with persistent fatigue and a high fever presented with central pontine myelinolysis (CPM) on brain imaging, despite the absence of neurological symptoms. The patient had a slightly low serum sodium concentration. Further investigation led to a diagnosis of primary splenic diffuse large B-cell lymphoma (PS-DLBCL). Brainstem auditory-evoked potentials (BAEP) indicated minor abnormalities. CPM was successfully resolved after splenectomy and immunochemotherapy. This is the first reported case of CPM in a patient with PS-DLBCL confirmed by a pathological diagnosis following splenectomy and BAEP-detected abnormalities that improved with immunochemotherapy.

Splenectomy Before Kidney Transplantation for Hypersplenism: A Case Report.

Hypersplenism, although a rare hematological complication seen in chronic kidney disease patients, poses a significant challenge for successful kidney transplantation due to potential complications such as cytopenias and inadequate immunosuppressive therapy. We present a 40-year old end-stage kidney disease patient on dialysis with hypersplenism who underwent a laparoscopic splenectomy prior to high immunological risk renal transplantation. Post-splenectomy, there was a remarkable improvement in cytopenias, and effective immunosuppressive therapy could be administered prior to renal transplantation. Splenectomy remains a valuable strategy for managing hypersplenism, ensuring correction of cytopenias, for optimal immunosuppression prior to kidney transplantation. Pre-transplant vaccination further mitigates the risk infections with capsulated organisms. Our case underscores the importance of a multidisciplinary approach in decision-making and highlights splenectomy as a safe and effective intervention to address cytopenias due to hypersplenism prior to renal transplantation.

Experience with Pediatric Chronic Immune Thrombocytopenia over 30 Years in the Era before Eltrombopag.

BACKGROUND: There is limited information on the natural course of chronic ITP in children. We aimed to evaluate the clinical and demographic characteristics of children with chronic ITP in the era before the availability of eltrombopag. METHODS: A total of 86 children with chronic ITP between 1978-2014 were included. Demographic findings, laboratory results, clinical signs, bleeding scores, response time and time of complete remission were recorded. RESULTS: The male/female ratio was 1.09, and median follow-up time was 3 years (range: 1.5-17 years). The median age at diagnosis of chronic ITP was 7 years (range: 2-17), and the median initial platelet count was 10 × 109/L (range: 1-66 × 109/L). Petechiae/ecchymoses were the most common clinical sign (86%) and followed by mucosal bleeding (39.5%). Severe bleeding was seen in 5% of the patients. None of them had intracranial hemorrhage. Twenty patients underwent splenectomy, and the rate of complete remission was 70%. Spontaneous complete remission was seen in 29% of the patients, and the median time to spontaneous complete remission was 3 years. CONCLUSIONS: Our study showed that almost one-third of patients with chronic ITP experienced spontaneous complete remission in an average of 3 years, and splenectomy provided satisfactory results in severe cases. This study demonstrates the natural history of chronic ITP in childhood before the era of eltrombopag.

Emergency laparoscopic splenectomy for a grade-V splenic injury following blunt abdominal trauma: A case report.

INTRODUCTION AND IMPORTANCE: The utilization of laparoscopy in severe splenic injuries following blunt abdominal trauma is limited because of difficulties encountered due to ongoing bleeding, chances of missed injury, and lack of experience. CASE PRESENTATION: We report a young male with polytrauma (head injury, haemothorax, femur fracture, Grade V splenic injury) who underwent a successful laparoscopic splenectomy on day 3 following the failure of conservative management of grade V blunt splenic injury involving the hilum. CLINICAL DISCUSSION: The utility of laparoscopy in the management of blunt trauma is controversial besides several series have shown acceptable outcomes for both solid organ and visceral injuries in experienced hands. Furthermore, there are several reports describing the utility of the laparoscopic approach for isolated splenic injuries in stable patients. CONCLUSION: The utility of the laparoscopic approach for this patient was successful without major challenges during the procedure. The key initial step was achieving complete hemostasis as early as possible.

Nomogram based on lymphocyte-associated inflammatory indexes predicts portal vein thrombosis after splenectomy with esophagogastric devascularization.

OBJECTIVE: The relationship between lymphocyte-associated inflammatory indices and portal vein thrombosis (PVT) following splenectomy combined with esophagogastric devascularization (SED) is currently unclear. This study aims to investigate the association between these inflammatory indices and PVT, and to develop a nomogram based on these indices to predict the risk of PVT after SED, providing an early warning tool for clinical practice. METHODS: We conducted a retrospective analysis of clinical data from 131 cirrhotic patients who underwent SED at Lanzhou University's Second Hospital between January 2014 and January 2024. Independent risk factors for PVT were identified through univariate and multivariate logistic regression analyses, and the best variables were selected using the Akaike Information Criterion (AIC) to construct the nomogram. The model's predictive performance was assessed through receiver operating characteristic (ROC), calibration, decision, and clinical impact curves, with bootstrap resampling used for internal validation. RESULTS: The final model incorporated five variables: splenic vein diameter (SVD), D-Dimer, platelet-to-lymphocyte ratio (PLR), monocyte-to-lymphocyte ratio (MLR), and red cell distribution width-to-lymphocyte ratio (RLR), achieving an area under the curve (AUC) of 0.807, demonstrating high predictive accuracy. Calibration and decision curves demonstrated good calibration and significant clinical benefits. The model exhibited good stability through internal validation. CONCLUSION: The nomogram model based on lymphocyte-associated inflammatory indices effectively predicts the risk of portal vein thrombosis after SED, demonstrating high accuracy and clinical utility. Further validation in larger, multicenter studies is needed.

Angioembolization in patients with blunt splenic trauma in Germany -guidelines vs. Reality a retrospective registry-based cohort study of the TraumaRegister DGU®.

PURPOSE: Nonoperative management (NOM) for blunt splenic injuries (BSIs) is supported by both international and national guidelines in Germany, with high success rates even for severe organ injuries. Angioembolization (ANGIO) has been recommended for stabilizable patients with BSI requiring intervention since the 2016 German National Trauma Guideline. The objectives were to study treatment modalities in the adult BSI population according to different severity parameters including NOM, ANGIO and splenectomy in Germany. METHODS: Between 2015 and 2020, a retrospective registry-based cohort study was performed on patients with BSIs with an Abbreviated Injury Score ≥ 2 in Germany using registry data from the TraumaRegister DGU® (TR DGU). This registry includes patients which were treated in a resuscitation room and spend more than 24-h in an intensive care unit or died in the resuscitation room. RESULTS: A total of 2,782 patients with BSIs were included in the analysis. ANGIO was used in 28 patients (1.0%). NOM was performed in 57.5% of all patients, predominantly those with less severe organ injuries measured by the American Association for the Surgery of Trauma Organ Injury Scale (AAST) ≤ 2. The splenectomy rate for patients with an AAST ≥ 3 was 58.5%, and the overall mortality associated with BSI was 15%. CONCLUSIONS: In this cohort splenic injuries AAST ≥ 3 were predominantly managed surgically and ANGIO was rarely used to augment NOM. Therefore, clinical reality deviates from guideline recommendations regarding the use of ANGIO and NOM. Local interdisciplinary treatment protocols might close that gap in the future.

Advances in Stem Cell Transplantation for Myelofibrosis.

PURPOSE OF REVIEW: Allogeneic hematopoietic cell transplantation is the only potentially curative treatment for myelofibrosis. This review discusses issues not well-covered by existing guidelines: timing of transplant, pre-transplant spleen management and alternative donors; providing our approach to these situations. RECENT FINDINGS: Research continues to allow better identification, by better risk stratification and advances in understanding likelihood of durable JAKi response, which patients are likely to derive benefit from upfront transplant versus those for whom delayed transplant may be more appropriate. Several options of JAKi therapy provide a non-surgical option for pre-HCT splenomegaly management, allowing some patients to avoid risks associated with splenectomy. Recent years have also seen a sharp spike in haploidentical donor transplants, along with narrowing of the gap in outcomes between donor types. Continuous enrollment in prospective studies or well-designed registries is required to generate the high-quality data needed to develop better decision tools for these scenarios.

Splenectomy unveils thrombocytosis in underlying myeloproliferative neoplasms with extrahepatic portal vein obstruction.

Extrahepatic portal vein obstruction (EHPVO) is a rare disease with myeloproliferative neoplasm (MPN) as the most common cause. We report that hypersplenic hematologic changes in EHPVO might be eliminated by MPN. Through experience with splenectomy for variceal control with EHPVO, we suspected that spleen might mask MPN-induced thrombocytosis, and that MPN might have a significant influence on excessive thrombocytosis after splenectomy. To clarify the influence of MPN and spleen on platelet trends, we conducted a retrospective hospital database analysis, evaluating 8 EHPVO patients with splenectomy (2 males, 6 females; from 17 years to 64 years, mean 38.3 years). Three (37.5%) of 8 were diagnosed as MPN by JAK2V617F mutation. The perioperative serum platelet counts in EHPVO without MPN were 10.5, 35.4, and 36.6 (x104/µL) preoperatively, after 1 week and 3 weeks, respectively. The platelet counts in EHPVO with MPN were 34.2, 86.4, and 137.0 (x104/µL), respectively. Splenectomy and MPN showed positive interaction on platelet increasing with statistical significance. We also examined the spleen volume index (SpVI: splenic volume (cm3) / body surface area (m2) and postoperative platelet elevations ratio (PER: 3-week postoperative platelet counts / preoperative platelet counts). However, both SpVI and PER showed no significant difference with or without MPN. Histological examination revealed splenic congestion in all 8 EHPVO cases, and splenic extramedullary hematopoiesis in 2 of 3 MPN. In EHPVO with MPN, hypersplenism causes feigned normalization of platelet count by masking MPN-induced thrombocytosis; however, splenectomy unveils postoperative thrombocytosis. Spleen in EHPVO with MPN also participates in extramedullary hematopoiesis.

Isolated Splenic Metastasis From Large-Cell Neuroendocrine Carcinoma of Lung: A Case Report.

Splenic malignancies are mostly primary and lymphocytic. Metastases to the spleen are rare and imply tumor dissemination. Limited cases were reporting isolated splenic metastasis from non-small cell cancer of the lung (NSCLC). We report the case of a 68-year-old male with mixed large-cell neuroendocrine carcinoma (LCNEC) and adenocarcinoma of the lung who presented with asymptomatic, synchronous, and isolated splenic metastasis. The patient refused adjuvant or neoadjuvant therapies. Surgical removal of both primary and metastatic lesions was achieved separately. In the scenario of isolated splenic metastasis, local consolidative therapy such as splenectomy appears to benefit survival by alleviating tumor burden. The patient is currently disease-free after one year of postoperative follow-up.