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

BACKGROUND: Pediatric splenic torsion is a rare entity, and the most common cause is wandering spleen. This study aimed to summarize our clinical experience in the diagnosis and surgical treatment pediatric patients with splenic torsion, and to use preoperative thrombocytosis as a preoperative predictive factor for splenic infarction. METHODS: From January 1st, 2016 to December 31st, 2021, 6 children diagnosed as splenic torsion were included. All patients were surgically treated and followed up. The clinical data was collected including clinical presentations, laboratory tests, imaging results, surgical procedures, and prognosis. Clinical experience of diagnosis and surgical treatment were summarized. RESULTS: There were 4 females and 2 males, with median age at surgery 102.6 (range 9.4-170.7) months. Abdominal pain and abdominal mass were the most common presentations. The diagnosis of splenic torsion depended on imaging studies, and adjacent organ involvement (gastric and pancreas torsion) was observed on contrast CT in one patient. Five patients were diagnosed as torsion of wandering spleen, and one was torsion of wandering accessory spleen. Emergent laparoscopic or open splenectomy was performed in all patients. Pathology revealed total splenic infarction in 4 patients, partial infarction in 1 patient, and viable spleen with congestion and hemorrhage in 1 patient. Preoperative platelet counts were elevated in all 4 patients with splenic infarction, but normal in the rest 2 with viable spleen. Postoperative transient portal vein branch thromboembolism occurred in one patient. CONCLUSIONS: Imaging modalities are crucial for the diagnosis of pediatric splenic torsion and adjacent organ involvement. Preoperative thrombocytosis may predict splenic infarction. Spleen preserving surgery should be seriously considered over splenectomy in patients with a viable spleen.

Patients with gastric volvulus recurrence have high incidence of wandering spleen requiring laparoscopic gastropexy and splenopexy.

PURPOSE: Though gastric volvulus in neonates and infants resolves by conservative therapy and aging, some cases require surgical intervention. This study aimed to review the cases of gastric volvulus requiring surgical intervention and evaluate their characteristics. METHODS: We retrospectively reviewed gastric volvulus cases requiring surgical intervention. Surgical indication was persistent acute gastric volvulus and repeated hospitalization for gastric volvulus. We evaluated the characteristics of those cases requiring surgical intervention and the surgical results of laparoscopic gastropexy. RESULTS: The median age of patients included was 4 years (range: 1-6 years). All eight cases of gastric volvulus requiring sugery had congenital spleen diseases. Six of the eight cases suffered from a wandering spleen, while two cases presented with situs inversus with asplenia. Both splenopexy (preperitoneal distension balloon [PDB] or blunt separaion methods) and gastropexy were performed in cases with wandering spleen. No postoperative complications were reported in any of the eight cases, except the recurrence of gastric volvulus due to suture shedding in one case. CONCLUSION: Laparoscopic gastropexy for gastric volvulus and splenopexy for cases concomitant with wandering spleen were found to be effective surgical approaches. Both PDB and blunt separation methods for making extraperitoneal pockets for the spleen were employed successfully.

Gastric volvulus and wandering spleen; a life-threatening surgical emergency.

Wandering spleen and gastric volvulus are two of the rarely encountered conditions occurring together with or without other congenital and acquired defects. These potentially fatal conditions originate from a shared cause, i.e. the defect of intraperitoneal ligaments resulting in a failure to withhold these organs at their anatomical position and alignment. This can come to attention in both childhood and/or adulthood, and the diagnosis calls for a high degree of suspicion and a failure to diagnose can culminate in death of both the organs, i.e. the spleen and stomach. We are presenting the case of a 20-year-old girl who underwent an emergency laparotomy for gastric volvulus and wandering spleen.

The likely association between wandering spleen and absent left kidney.

Wandering spleen is a cause of acute surgical abdomen with serious consequences. It arises from an absence or weakness of the supporting suspensory splenic ligaments. There is often a delayed diagnosis due to its non-specific clinical presentation. This leads to stalled acquisition of confirmatory diagnostic imaging with resultant increased morbidity and mortality. Congenital or acquired absence of the left kidney results in loss of the splenorenal ligament, a key ligament to maintain normal splenic position in the abdomen. Two patients, one with OHVIRA (obstructed hemivagina ipsilateral renal anomaly) syndrome and another who underwent a left nephrectomy during infancy, developed a wandering spleen with acute splenic torsion in the setting of an absent left kidney. This case series aims to increase awareness to the likely predisposition for individuals with an absent left kidney to develop a wandering spleen.

Torsion of Wandering Spleen: A Case Report.

BACKGROUND: Wandering spleen is defined as the localization of the spleen in the lower parts of the abdomen or the pelvic region, rather than the left upper quadrant. The torsion of wandering spleen is a rare clinical condition. CASE REPORT: We evaluate a case diagnosed with torsion of wandering spleen and underwent splenectomy in our hospital and discuss it in light of the literature. A 26-year-old man presented to the emergency department with abdominal pain and abdominal distention. The patient was diagnosed with the torsion of wandering spleen based on computed tomography scan results. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The torsion of wandering spleen is rare in patients presenting with acute abdominal pain, but it is an important condition that should be considered in the differential diagnosis. The diagnosis of wandering spleen should be made before the development of potentially life-threatening complications. Emergency surgery should be undertaken in patients with splenic infarction.

Extraperitoneal pocket splenopexy is a suitable solution for wandering spleen in children and adolescents - case report.

INTRODUCTION: Wandering spleen is a rare cause of recurrent abdominal pain in children that is difficult to diagnose. Splenopexy should be preferred to splenectomy. CASE REPORT: The patient, a 4 years old girl on growth hormone therapy, was referred to the Department of Paediatric Surgery for an assessment of episodes of abdominal colic and frequent vomiting. Sonography did not indicate any pathology, gastrointestinal contrast study showed an altered shape of the gastric outlet, and upper endoscopy diagnosed a prepyloric membrane. Open surgery was indicated based on these examinations, revealing a large wandering spleen and dilated stomach and small bowel loops oppressed by the long splenic suspensory ligaments. Pyloroplasty was performed with the antral membrane excision and shortening of the long gastrosplenic ligament and placement of the spleen into the left hypochondrium. No complications occurred in the postoperative period. Four months later the patient was hospitalised again for abdominal colic pain. Surgical revision of the abdomen revealed the wandering spleen in the mesogastrium. Even though the spleen was the cause of the second surgery, we decided to preserve the spleen. Partial splenectomy was done, fixing the large spleen into an extraperitoneal pocket in the left hypochondrium. The postoperative course was uneventful. Blood flow to the spleen is regularly monitored by Doppler ultrasound. Vaccination was indicated at the office of haematology according to the scheme for splenectomy patients; however, prophylactic antibiotic therapy was not needed given the good function of the preserved part of the spleen. CONCLUSION: Extraperitoneal fixation of the spleen seems to be a good choice for patients with a wandering spleen, particularly for children and adolescents.

Emergencies in the Treatment of Wandering Spleen.

BACKGROUND: Wandering spleen is a rare entity that may pose a surgical emergency following torsion of the splenic vessels, mainly because of a delayed diagnosis. Complications after surgery for wandering spleen may necessitate emergency treatment. OBJECTIVES: To describe the clinical course and treatment for children who underwent emergency surgeries for wandering spleen at a tertiary pediatric medical center over a 21 year period and to indicate the pitfalls in diagnosis and treatment as reflected by our experience and in the literature. METHODS: The database of a tertiary pediatric medical center was searched retrospectively for all children who underwent emergency treatment for wandering spleen between 1996 and 2017. Data were collected from the medical files. The relevant literature was reviewed. RESULTS: Of ten patients who underwent surgery for wandering spleen during the study period, five underwent seven emergency surgeries. One patient underwent surgery immediately at initial presentation. In the other four, surgical treatment was delayed either due to misdiagnosis or for repeated imaging studies to confirm the diagnosis. Emergency laparotomy revealed an ischemic spleen in all patients; splenectomy was performed in two and the spleen was preserved in three. Four of the seven emergency operations were performed as the primary surgery and three were performed to treat complications. CONCLUSIONS: Wandering spleen should ideally be treated on an elective or semi-elective basis. Surgical delays could be partially minimized by a high index of suspicion at diagnosis and by eliminating unnecessary and time-consuming repeated imaging studies.

Wandering spleen: a unique cause of acute abdomen.

We present the case of a 16-year-old boy presented with 2-week episode of wor-sening lower abdominal pain. Clinically, there was a tender palpable mass on the suprapubic region. Ultrasonography showed an absent spleen at its usual area, instead suprapubic mass suggestive of ectopic spleen was identified. An emer-gency laparotomy revealed a congested spleen in the pelvic cavity. Splenectomy was undertaken as it was non-viable. The patient was discharged uneventfully with triple vaccinations. We describe this unique entity with its literature review. (Folia Morphol 2018; 77, 2: 400-402).

Laparoscopic splenopexy for wandering spleen, a video demonstration of technique by encircling the spleen with polyglactin 910 woven mesh.

BACKGROUND: Wandering spleen is a rare clinical entity caused by absence of the spleen's peritoneal attachments, allowing the spleen to move freely within the peritoneal cavity [1]. This disease is most commonly seen in children and young women [1, 2]. Affected individuals are predisposed to complications including splenic torsion, splenic infarction, and pancreatic necrosis [3, 4]. Patients may present with constipation, an abdominal mass, swelling, or acute abdominal pain if splenic torsion has occurred [4]. Wandering spleen is difficult to diagnose without imaging, as symptoms are non-specific or may be absent. Imaging studies to confirm the diagnosis may include computed tomography (CT) scan or duplex ultrasonography [5]. Definitive management of a wandering spleen is primarily surgical [2]. Splenectomy is the preferred treatment in patients who present with an acute splenic infarction [2, 6]. Splenopexy, however, is first line treatment for patients with a non-infarcted wandering spleen [2, 7, 8]. CASE PRESENTATION: In this video, we present a case of an 11 year old male with a symptomatic wandering spleen who was treated at our institution with laparoscopic splenopexy. The patient had a history of arthrogryposis multiplex congenita and presented with recurrent, episodic abdominal pain, nausea, and vomiting. The diagnosis was confirmed by CT scan which demonstrated the spleen in the right lower quadrant. We performed laparoscopic splenopexy by encircling the spleen with polyglactin 910 woven mesh and attaching the mesh to the left lateral abdominal wall with absorbable tacks. DISCUSSION: Our surgical technique for splenopexy was successful and the patient returned home on postoperative day four. No significant complications occurred. This video demonstrates this technique and highlights the key steps. Splenopexy by encircling the spleen with polyglactin 910 mesh is feasible, preserves splenic function, and can be performed with standard laparoscopic equipment. Tacks or transfascial sutures are a potential option for securing mesh.

[Wandering spleen: an unusual cause of acute abdomen]. / Bazo errante: una causa infrecuente de abdomen agudo.

Wandering spleen syndrome is a rare condition in which absence or laxity of splenic fixing elements predisposes to an unusual location in the abdomen and an increasing risk of twisting and infarction. Its etiology may be congenital or acquired and clinical presentation is variable. Diagnosis is based on clinical suspicion, laboratory and imaging. Surgery is the only definitive treatment for this pathology. We report the case of a 23 year old woman with a history of recurrent episodes of abdominal pain in the left upper quadrant since childhood. On physical examination she was afebrile, hemodynamically stable, with marked abdominal tenderness in the left upper quadrant. Ultrasonography showed homogeneous splenomegaly. Abdominal CT-scan presented an enlarged, eutopic spleen, with swirling and congestion of hilum vessels. Splenic ischemia due to organ torsion was suspected. Exploratory laparoscopy was performed showing an 18 cm in diameter spleen free in left upper quadrant, with varicose veins in the periphery and without fixing ligaments. Laparoscopic splenectomy was completed. The pathology report showed ischemic necrosis of the organ. The patient progressed favorably and was discharged on the third postoperative day.

Portal venous thrombosis developing after torsion of a wandering spleen.

Torsion of a wandering spleen is a rare disease. The symptoms and signs of this condition are only present when the splenic pedicle torts. The etiological factors are the congenital absence of the ligaments that hold the spleen in its normal anatomic position, or the relaxation of these ligaments resulting from conditions like trauma and abdominal surgery. We aimed to present a rare case with torsion of wandering spleen that consequently developed thrombosis of portal vein and its branches, taking into consideration the relevant literature.

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

Wandering spleen is a rare condition, typically not only due to embryological defects of the splenic ligaments, but also secondary to trauma and splenomegaly. The most common presentation is acute abdomen with a mobile abdominal mass or recurrent abdominal pain. However, the spleen may be temporary in its normal position, and patients could be asymptomatic. A familiarity, if present, strengthens the diagnostic suspect.Abdominal ultrasonography and computed tomography are the examination of choice, and the management is surgical.

Torsion of wandering spleen, an unusual cause of acute abdomen; a report of two cases.

BACKGROUND: Wandering spleen is an uncommon entity that is rarely considered in the evaluation of patients with acute abdominal conditions. OBJECTIVE: To report two cases of wandering spleen presenting with acute abdominal pain. METHODS: The clinical records of the patients including preoperative evaluation, intra-operative findings and postoperative care were reviewed RESULT: A 6 year old boy presented with right lumbar pain which worsened over a 36 hour period with findings of a tender right lumbar mass. Abdominal ultrasound showed a mass with echogenicity consistent with that of the spleen with no blood flow and an empty splenic bed. The pre-operative diagnosis was torsion of a wandering spleen. The second case was that of a 42 year old woman who presented with severe colicky lower abdominal pain which worsened over three days with a background history of progressively increasing lower abdominal mass which was tender and about 26 week gestational size at presentation. The initial diagnosis was torsion of an ovarian cyst. Abdomino-pelvic Ultrasound scan showed a heterogeneously hypo-echoic mass overlying the uterus and the left ovary with no blood flow. The presence of wandering spleen with torsion of the vascular pedicle was confirmed at laparotomy in both instances. Splenectomy was performed in both cases with good recovery. CONCLUSION: Torsion of a wandering spleen poses a diagnostic challenge. A high level of suspicion is required to make a diagnosis and institute appropriate treatment.

Wandering spleen torsion causing acute abdominal pain in a child: case report and review of literature.

Wandering spleen is a rare occurrence where the spleen normal fixation to the abdominal wall is lost and thus allowed to change in position. We report a case of a child who presented with acute abdominal pain secondary to a wandering spleen complicated by torsion of its vascular pedicle. The diagnosis was promptly made using computed tomography and managed with splenectomy.

Wandering spleen presenting in the form of right sided pelvic mass and pain in a patient with AD-PCKD: a case report and review of the literature.

BACKGROUND: Wandering spleen is a rare clinical entity in which the spleen is hypermobile and migrate from its normal left hypochondriac position to any other abdominal or pelvic position as a result of absent or abnormal laxity of the suspensory ligaments (Puranik in Gastroenterol Rep 5:241, 2015, Evangelos in Am J Case Rep. 21, 2020) which in turn is due to either congenital laxity or precipitated by trauma, pregnancy, or connective tissue disorder (Puranik in Gastroenterol Rep 5:241, 2015, Jawad in Cureus 15, 2023). It may be asymptomatic and accidentally discovered for imaging done for other reasons or cause symptoms as a result of torsion of its pedicle and infarction or compression on adjacent viscera on its new position. It needs to be surgically treated upon discovery either by splenopexy or splectomy based on whether the spleen is mobile or not. CASE PRESENTATION: We present a case of 39 years old female Ethiopian patient who presented to us complaining constant lower abdominal pain especially on the right side associated with swelling of one year which got worse over the preceding few months of her presentation to our facility. She is primiparous with delivery by C/section and a known case of HIV infection on HAART. Physical examination revealed a right lower quadrant well defined, fairly mobile and slightly tender swelling. Hematologic investigations are unremarkable. Imaging with abdominopelvic U/S and CT-scan showed a predominantly cystic, hypo attenuating right sided pelvic mass with narrow elongated attachment to pancreatic tail and absent spleen in its normal position. CT also showed multiple different sized purely cystic lesions all over both kidneys and the pancreas compatible with AD polycystic kidney and pancreatic disease. With a diagnosis of wandering possibly infarcted spleen, she underwent laparotomy, the finding being a fully infarcted spleen located on the right half of the upper pelvis with twisted pedicle and dense adhesions to the adjacent distal ileum and colon. Release of adhesions and splenectomy was done. Her post-operative course was uneventful. CONCLUSION: Wandering spleen is a rare clinical condition that needs to be included in the list of differential diagnosis in patients presenting with lower abdominal and pelvic masses. As we have learnt from our case, a high index of suspicion is required to detect it early and intervene by doing splenopexy and thereby avoiding splenectomy and its related complications.

Wandering spleen: a medical enigma, its natural history and rationalization.

INTRODUCTION: Wandering spleen is a rare condition in which the spleen is not located in the left upper quadrant but is found lower in the abdomen or in the pelvic region because of the laxity of the peritoneal attachments. Many patients with wandering spleen are asymptomatic, hence the condition can be discovered only by abdominal examination or at a hospital emergency department if a patient is admitted to hospital because of severe abdominal pain, vomiting or obstipation. METHODS: This article aims to provide a historical overview of wandering spleen diagnostics and surgical treatment supplemented with an analyses of articles on wandering spleen included in the PubMed database. RESULTS: One of the first clinical descriptions of a wandering spleen was written by Józef Dietl in 1854. The next years of vital importance are 1877 when A. Martin conducted the first splenectomy and in 1895 when Ludwik Rydygier carried out the first splenopexy to immobilize a wandering spleen. Since that time various techniques of splenectomy and splenopexy have been developed. CONCLUSIONS: Introducing medical technologies was a watershed in the development and treatment of wandering spleen, which is confirmed by the PubMed database. Despite the increased number of publications medical literature shows that a wandering spleen still remains a misdiagnosed condition, especially among children.

Torsion in wandering spleen: CT demonstration of whirl sign.

Wandering spleen is a rare occurrence. Torsion of the splenic pedicle is the major life-threatening complication of this entity. Preoperative diagnosis is based on radiological investigation. We report two consecutive cases, one adult and one child, in whom torsion in a wandering spleen was diagnosed based on a typical whirled appearance of the splenic vessels on computed tomography. We present a review of computed tomographic appearance of splenic torsion, and emphasize the "whirled appearance" as a specific sign for splenic torsion in wandering spleen.

Torsion of a wandering spleen treated with partial splenectomy and splenopexy.

BACKGROUND: Wandering spleen is a rare and unusual entity, characterized by excessive mobility and displacement of the organ from its normal position. This happens due to congenital or acquired anomalies leading to the lack of the spleen's suspensory ligaments. Clinical presentation is variable; acute abdominal pain may occur when persistent torsion of the splenic pedicle results in splenic infarction. Ultrasonography, computed tomography, and magnetic resonance imaging are modalities that may be used in diagnosis. The treatment of choice is surgery, with splenectomy or splenopexy, the latter being preferred. CASE REPORT: The patient was a 38-year-old woman with a 10-day history of left-sided abdominal pain. Imaging demonstrated a wandering spleen with partial infarction of the inferior pole. An open partial splenectomy with splenopexy of the remaining spleen was performed with the use of an absorbable mesh sutured to the abdominal wall and stomach. Her recovery was uneventful and on follow-up she had no signs of recurrence or complications. CONCLUSION: Wandering spleen should be considered in cases of acute abdominal pain, and surgery is the treatment of choice, with the goal of preservation of the organ whenever possible.