Laparoscopic management of a large posttraumatic splenic cyst in a child

Nonparasitic Splenic Cysts in Children: Outcomes after Sclerotherapy or Surgical Resection as Initial Management

Management of splenic cysts in children remains undefined. Sclerotherapy is an innovative, less invasive treatment. This study examined the safety and preliminary effectiveness of sclerotherapy for splenic cysts in children compared with those of surgical treatment. A retrospective review of pediatric patients treated for nonparasitic splenic cysts from 2007 to 2021 was performed at a single institution. Posttreatment outcomes for patients who underwent either expectant management, sclerotherapy, or surgery were reviewed. Thirty patients aged between 0 and 18 years met the inclusion criteria. Cysts in 3 of 8 patients who underwent sclerotherapy were either unresolved or recurred. Patients who underwent sclerotherapy and required surgery for residual symptomatic cyst had an initial cyst diameter of >8 cm. Symptoms resolved in 5 of 8 patients who underwent sclerotherapy, with a significantly reduced cyst size compared with that in patients with continued symptoms who underwent sclerotherapy (61.4% vs 7.0%, P = .01). Sclerotherapy is an effective treatment for splenic cysts, particularly those measuring <8 cm. However, surgical excision may be preferable for large cysts.

Management of nonparasitic splenic cysts in children: A French multicenter review of 100 cases

BACKGROUND

The management of nonparasitic splenic cysts (NPSC) remains controversial. Surgical resection is indicated for symptomatic or complicated forms, but no guidelines are available for asymptomatic NPSC. The aims of this study were to evaluate the management of NPSC in French hospitals and to analyze the results of management.

METHODS

We conducted a retrospective multicenter study from January 2004 to December 2014 in 16 university hospitals in France. Patients with a follow-up less than 6months were excluded. Data were extracted from the medical reports.

RESULTS

One hundred patients were included. Median follow-up was 12.8months. No complications were observed for NPSC smaller than 5cm. The size of NPSC increased significantly between the ages of 10 and 12years. Fifteen patients were under observation; 58.3% of cysts decreased in size and 41.7% remained stable. Among the 85 operated patients, no recurrence occurred in the splenectomy group, while 11 recurrences were observed in the cystectomy group (57.9%), 3 of which required redo surgery.

CONCLUSIONS

Observation is a safe treatment option for asymptomatic NPSC smaller than 5cm. Surgery is indicated for symptomatic patients, and can be proposed for asymptomatic NPSC larger than 5cm. Laparoscopic partial splenectomy is the technique of choice. Follow-up must be continued until the end of puberty.

LEVELS OF EVIDENCE RATING

Level III.

Laparoscopic stapled excision of non-parasitic splenic cysts

BACKGROUND

A laparoscopic spleen preserving surgical approach is preferred for the management of symptomatic non-parasitic splenic cysts. The aim of this study was to review our experience with managing this rare presentation.

METHODS

A retrospective review of all cases of splenic cysts was performed over a 10-year period (2001-2011). Demographic data, clinical history, investigations, operative details and the outcome of each case were reviewed with an emphasis on patients who underwent laparoscopic stapled cyst excision.

RESULTS

Eleven cases were identified. Seven patients were managed surgically; six by laparoscopic stapled cyst excision and one by open excision of remnant splenic tissue. Laparoscopic management was successful in all six cases and radiological and clinical follow-up (median: 28 months) revealed no evidence of cyst recurrence in five of six cases. One patient developed an asymptomatic, non-progressing and small recurrent anterior cyst and she continues to be observed.

CONCLUSION

Laparoscopic stapled splenic cyst excision can be performed safely and is particularly effective for large superficial non-parasitic cysts. This technique allows spleen preservation with a low cyst recurrence rate. However, it may not be suitable for deeper intraparenchymal splenic cysts. Further studies are required to refine the management of specific subtypes of non-parasitic splenic cysts.

Re-evaluation of histological findings of nonparasitic splenic cysts

OBJECTIVE

The pathogenesis of nonparasitic splenic cysts (NPSCs) has not been clarified completely. The aim of this multinational and multicentre retrospective study was to further elucidate the origin of NPSCs.

METHODS

From 1980 to 2006, 50 children and adolescents were surgically treated for NPSC at six paediatric surgical centres in four European countries. The initial histology report of 35 NPSCs, 22 epidermoid cysts, 11 pseudocysts or post-traumatic cysts and two mesothelial cysts was available. Additional re-evaluation, including immunohistochemistry, to detect cytokeratin, carcino-embrionic antigen and mesothelioma antibody in the inner surface of the cysts was carried out. Special attention was given to the possibility of preceding trauma to the splenic area and whether it played a role in the genesis of NPSC.

RESULTS

The pathological re-evaluation showed 30 epidermoid cysts, four mesothelial cysts and one pseudocyst. Immunohistology revealed eight epidermoid and two mesothelial linings of the cysts in those 11 patients in whom pseudocyst was diagnosed originally. No pseudocyst was documented in those patients who had a history of previous blunt abdominal trauma but was not proved by ultrasound and computed tomography scan.

CONCLUSION

In contrast with the prevailing belief, it has been demonstrated that NPSCs are congenital in origin, and there is no clinically proven evidence that trauma does play a role in their genesis.

Nonparasitic splenic cysts in children: Current status

BACKGROUND

at present, the management of nonparasitic splenic (NPS) cysts in children is not well described in literature. The aim of this study was to evaluate the current status of NPS cysts in the world literature and develop some higher level of evidence in the management of this disease entity. In this study, we have also included our experience with NPS cysts.

METHODS

a systematic study of NPS cysts published in the English literature, between the periods of 1989-2008, was performed. The data were analyzed with respect to the type of cysts, mode of presentation, patient's demography, management modalities and complications. Data were quoted as median and range. Categorical data were analyzed using Chi(2) tests. P value ≤ 0.05 was considered as significant. All children, who presented to us with NPS cysts during the last 20 years, were reviewed and followed up till December 2009.

RESULTS

after critical review of 249 abstracts, 25 studies (retrospective 13, cases reports 11 and prospective study 1) were finally included in this project. This included a total of 166 patients. The types of cysts were congenital (82%), traumatic (15%) and hamartomatous (3%). Male to female ratio was one to one. Median age of presentation was 11 years. Abdominal pain was the main complaint in 46% cases. Forty seven percent of the cysts were diagnosed incidentally. History of trauma was present in 11% cases. 1% cases were operated on due to the rupture of the cysts. Open procedures were performed in 60% cases [11% (total splenectomy), 29% (partial splenectomy) and 20% (cystectomy)]. Laparoscopic procedures were performed in the rest 40% cases [2% (total splenectomy), 4% (partial splenectomy) and 34% (cystectomy/partial decapsulation/unroofing)]. Median follow up period was 24 months (range 3-96 months). Recurrences were seen in only 2% of open procedures as Opposed to 41% in laparoscopic procedures (P<0.0001). Looking at the laparoscopic procedures individually, all the recurrences were seen in patients who had had cystectomy/partial decapsulation/unroofing. We treated 7 children (4 males and 3 females), who had a median age of 11 years (range 1-14 years); two of whom presented with large cysts having a diameter of 25 cm and 15 cm, respectively. They underwent open partial splenectomy without recurrence. The other five children had small cysts having a diameter of <5cm and they were asymptomatic. Presently, the children with small cysts are being followed up conservatively, with no concerns so far.

CONCLUSIONS

congenital cysts are the most common NPS cysts in children. About half of the cysts are diagnosed incidentally. For bigger cysts, either open or laparoscopic partial splenectomy is the procedure of choice. Laparoscopic-cystectomy/partial decapsulation/unroofing procedures have unacceptably higher recurrence rates and hence should not be recommended. Smaller cysts (< 5 cm diameter) can be treated conservatively with regular ultrasound follow up, but if they become symptomatic or progress in size, surgical intervention is indicated.

Post-traumatic splenic cysts treated with laparoscopy: two case reports

Introduction

Today, laparoscopy tends to become a useful alternative to open procedure for the surgical treatment of spleen disorders, offering at the same time a conservative approach for the management of selected spleen lesions such as posttraumatic cysts.

Case presentation

This article describes two cases of posttraumatic splenic cysts, one of which was treated with laparoscopic total splenectomy and the second with laparoscopic cystectomy. The procedure was carried out successfully with no complications in both cases, and the patients were discharged a few days after the operation.

Conclusion

Laparoscopy with preservation of functional splenic parenchyma, when feasible, should be the procedure of choice in cases of posttraumatic splenic cysts, as it provides safe and definite treatment with all of the other advantages of minimally invasive surgery.

Recurrence after laparoscopic excision of nonparasitic splenic cysts

BACKGROUND

Minimally invasive treatments for nonparasitic splenic cysts are well described. Recent evidence suggests that laparoscopic splenic cystectomy is associated with high recurrence rates in children. Because these cysts are uncommon, no large series is available. We reviewed our clinical data focusing on cyst recurrences and their management.

METHODS

All children who underwent laparoscopic excision of a nonparasitic splenic cyst from January 2002 to December 2006 were identified. Medical and surgical records were reviewed for perioperative details, hospital course, and outcome.

RESULTS

Eight children (median age, 13 years; range, 7-16 years) who underwent laparoscopic splenic cystectomy were identified. The most common presenting complaint was left upper quadrant pain or mass (n = 6; 75%). Median cyst size was 13 cm (range, 4-20 cm). There were no conversions to an open technique, completion splenectomies, or perioperative complications. Cysts were identified pathologically as epidermoid (n = 6) or posttraumatic (n = 2). Median hospital stay was 1.5 days. One child required partial splenectomy because of cyst anatomy and remains recurrence-free at 12 months. Cyst recurrence occurred in 7 patients (88%) at a median of 9.4 months (range, 3-18 months) after initial surgery. Median recurrent cyst size was 5.6 cm (range, 3-11 cm). Of 7 recurrences, 4 (57%) were symptomatic. Percutaneous ultrasound-guided cyst drainage and sclerosis were performed in 2 children with symptomatic recurrences, one of whom required 4 separate interventions. There were no complications during management of cyst recurrences. Five children with recurrence (71%) have been followed conservatively and are free of morbidity at a median of 23 months (range, 8-55 months).

CONCLUSIONS

Laparoscopic excision of nonparasitic splenic cysts in children is associated with a high recurrence rate and may be insufficient treatment. Partial splenectomy may decrease recurrence rates. Conservative management of splenic cyst recurrence after laparoscopic excision is associated with good short-term outcomes. If necessary, image-guided management of symptomatic recurrences can be performed safely.

Laparoscopic unroofing of splenic cysts results in a high rate of recurrences

PURPOSE

Laparoscopic unroofing is described as an appropriate treatment modality of nonparasitic splenic cysts. However, we repeatedly encountered recurrences with this technique. Because splenic cysts are rare, we analyzed the combined experience of 3 German pediatric surgical departments.

MATERIALS AND METHODS

Between 1995 and 2005, primary and secondary nonparasitic splenic cysts were unroofed laparoscopically in 14 children (aged 5-12 years; median, 8.5 years). In 3 patients, the inner surface was coagulated with the argon beamer. In most children, the cavity was surfaced with omentum. In addition, in 4 patients the omentum was sutured to the splenic parenchyma.

RESULTS

No intraoperative complications occurred, and no inadvertent splenectomy or blood transfusions were necessary. However, in 9 children (64%) the cysts recurred at intervals ranging from 6 to 12 months (median, 12 months). Also, argon laser treatment of the surface resulted in recurrence.

CONCLUSION

Laparoscopic unroofing of true splenic cysts alone proved inadequate in this series. Either removal of the inner layer or partial splenectomy appears to be necessary to prevent recurrences.

Laparoscopic splenopexy and cystectomy for an enlarged wandering spleen and splenic cyst

Wandering spleen is an uncommon condition, which can present emergently in children. Similarly, nonparasitic splenic cysts are also rarely encountered. In this report, we describe a massive wandering spleen (22 cm in longitudinal dimension) with a pseudocyst (4.6 x 2 cm) in the inferior pole in an asymptomatic 16-year-old adolescent. Only 4 similar cases have been reported in the literature; 2 of them have been in the pediatric age group. These 2 conditions were diagnosed while she was being evaluated for dysmenorrhea, and she was referred for surgical consultation. The cyst was excised laparoscopically, and the spleen was placed into an extraperitoneal pouch. To date, there are no other reports describing laparoscopic cystectomy and splenopexy in a teenager.

Italian multicentric survey on laparoscopic spleen surgery in the pediatric population

BACKGROUND

Some technical aspects of laparoscopic spleen surgery still are debated, although efforts have been made to standardize them. The position of the patient, the approach to the spleen, vessel identification and division, and spleen extraction can vary from center to center.

METHODS

This retrospective muticentric study led by the Società Italiana di Videochirurgia Infantile (SIVI) examined indications, surgical details, and complications of laparoscopic spleen surgery in the pediatric population during a 5-year period.

RESULTS

The study period from January 1999 to December 2003 (5 years) involved nine centers and included 85 patients with a mean age of 10 years (range, 2-17 years). Hypersplenism or severe hemolysis in cases of hematologic disorders represented the most important indications. More than 90% of the patients underwent total laparoscopic splenectomy. Specific technical details from each center were collected. Intraoperative complications occurred in 19% of the patients (hemorrhage in 8% and technical problems in 14%), and 6% of the patients required conversion to the open approach. No deaths occurred, and no reoperations were required. Postoperative complications were experienced by 2% of the patients.

CONCLUSION

Laparoscopic spleen surgery is safe, reliable, and effective in the pediatric population. On the basis of the results, some technical details for laparoscopic spleen surgery can be suggested. The patient is preferably kept supine or lateral, approaching the spleen anteriorly. Moreover, the ilar vessels should be identified selectively and individually, with initial artery division performed to achieve spleen shrinking. Any hemostatic device proved to be effective in experienced hands. Once freed, the spleen is preferably extracted via a suprapubic cosmetic transverse incision (faster, easier, and safer), although a bag can be used. Finally, the size of the spleen does not represent a contraindication for a trained and experienced surgeon. Nevertheless, this parameter must be considered when laparoscopic spleen surgery is planned.

Nonelevation of Serum CA 19-9 Level in a True NonParasitic Splenic Cyst

The diagnosis and management of true nonparasitic splenic cysts has markedly changed in recent years. The use of serum CA 19-9 has been increasingly advocated for diagnosis, while the advent of minimally invasive surgery has radically altered surgical management. We present the first case of a true nonparasitic splenic cyst in which serum CA 19-9 was not elevated. Treatment was by laparoscopic cyst decapsulation utilising the endoscopic Ligasure.

Management of splenic pseudocysts following trauma: a retrospective case series

BACKGROUND

Post-traumatic splenic pseudocysts are uncommon. The optimal treatment is not well defined.

METHODS

A retrospective chart review was conducted at the three adult hospitals in the Calgary Health Region.

RESULTS

Six cases of splenic pseudocysts were found over a 6-year period. One splenic pseudocyst spontaneously resolved. A second splenic cyst was removed by open splenectomy. The remaining 4 patients were all first treated with percutaneous drainage. However, 3 of the 4 cysts recurred. Two of these 3 recurrent cysts were treated with laparoscopic fenestration, and all subsequently recurred; 1 of these patients later developed a splenic abscess. The third patient had a repeat percutaneous drain with subsequent recurrence. The last patient died of sepsis secondary to an iatrogenic punctured colon.

CONCLUSIONS

Percutaneous drainage and laparoscopic fenestration have an unacceptably high rate of failure. Partial or complete splenectomy should be considered for young and otherwise healthy patients who have large symptomatic splenic pseudocysts.

A novel spleen-preserving laparoscopic technique using radiofrequency ablation in a porcine model

BACKGROUND

Partial splenectomy is considered to be the optimal management for a variety of diseases. At the same time, laparoscopic procedures are increasingly used because they present certain advantages against their open counterparts. In this study, the safety and efficacy of radiofrequency ablation (RFA) were evaluated in laparoscopic partial splenectomy performed in a pig model.

METHODS

Eight domestic pigs were used. Four abdominal trocars were inserted under general anesthesia and the spleen was stabilized with laparoscopic clamps. A RFA needle electrode was inserted transcutaneously, and coagulative necrosis of a zone of the splenic parenchyma between the body and the lower pole was performed. Bloodless sharp division and removal of the lower pole followed. After 0, 7, 30, or 120 days, the animals were killed and examined.

RESULTS

Blood loss and operation time were minimal. Mortality and morbidity were zero. No abnormal findings were encountered during the postmortem abdominal exploration.

CONCLUSION

This study demonstrates the feasibility, safety, and efficacy of laparoscopic RFA-assisted partial splenectomy. The RFA-assisted laparoscopic partial splenectomy adds a novel technique to the surgeon's armamentarium for the preservation of a part of the spleen.

Splenic cysts

The treatment of splenic cysts is a difficult challenge to surgeons and physicians. This paper reviews the literature on splenic cysts, with special attention to the pathogenesis, diagnosis, and various options of surgical treatment. Splenic cysts are classified as primary or secondary cysts, according to the presence of an epithelial lining. The primary cysts are further subdivided as parasitic or non-parasitic. Secondary cysts are in most cases posttraumatic. Symptoms are usually correlated to the size of the cyst. Prior to surgery, imaging with ultrasound and computer tomography or magnetic resonance should be performed. A cyst puncture should be conducted for diagnostic purposes (amylase and bacteria) as well as to reduce the size of the cyst. Furthermore, the titer of Echinococcus and other biomarkers can be measured. Surgeons should make every possible effort to preserve splenic tissue and spleen-saving techniques with laparoscopic techniques are recommended.

Pediatric laparoscopic surgery--Indian scenario

Laparpscopic Surgery/Minimally Invasive Surgery (MIS) in children have witnessed tremendous progress in the last decade. Presently, there are extensive applications of this novel technique and several advanced level intricate surgeries have been done safely in small children. This is a brief overview of the common indications and utility of MIS in pediatric practice in the Indian Scenario. We discuss some common clinical settings like recurrent abdominal pain, Impalpable testis, intersex disorders Empyema, Thoracis etc., where MIS has had a significant benefit. We also present our experience of MIS in children without using any sophisticated equipment like the harmonic scalpel, endo-staplers etc. MIS has come to stay and it will definitely have lasting impact on surgical problems in children.

Partial laparoscopic decapsulation of congenital splenic cysts. A medium-term evaluation proves the efficiency in children

BACKGROUND

In children, laparoscopic decapsulation of large congenital splenic cysts has occasionally been advocated, but substantial series focusing on its long-term success are still lacking. We report the follow-up experiences from two pediatric surgical centers.

METHODS

The decision to proceed to surgery was based on patient symptoms and cyst size (>4 cm and/or progression), after strictly exclusion of a parasitic cause (by serology and CT scan). With the use of three ports (5-10-mm) and a Harmonic Scalpel, the epithelial portion of the cyst was radically excised. The remaining hilar epithelium was coagulated carefully. After discharge, the children were examined regularly by ultrasound to detect recurrences.

RESULTS

From 1998 until 2002, eight children (mean age, 11.1 years; range, 3.1-16.4) were treated for cysts ranging from 4 to 15 cm in diameter. All procedures were completed without significant intraoperative complications (no major bleeding, no conversions). The mean operating time was 75 min (range, 56-184). Postoperatively, one child developed a cystic remnant (2 cm), which remained unchanged during 30 months of observation. After a mean follow-up of 2.2 years (range, 13-38 months), none of the patients showed any evidence of recurrent growth, and all of them had healthy splenic remnants.

CONCLUSION

Partial laparoscopic decapsulation is an advantageous approach to large splenic cysts in children, because it is effective, preserves splenic tissue, and provides good medium-term results.

Laparoscopic Splenectomy for a Huge Splenic Cyst Without Preoperative Drainage

Laparoscopic splenectomy currently is a safe procedure and offers better cosmetic results, less pain, and a shorter hospital stay than the traditional open procedure. However, there have been only a few reports of laparoscopic removal of giant splenic cysts. An 18-year-old woman was admitted with abdominal fullness. CT scans and MRI images of the upper abdomen revealed a cystic mass having a diameter of 19 cm. Preoperative diagnosis was a large splenic cyst, and laparoscopic splenectomy with intraoperative cyst drainage (amount of drained fluid: 3,000 mL) was performed. Histologically, almost the entire cyst wall was lined with fibrous tissue, but a small portion was covered with stratified squamous epithelium. The final diagnosis was epidermoid cyst. The postoperative course was uneventful. Laparoscopic splenectomy should be tried first even in patients with a huge cyst, and intraoperative drainage under laparoscopic guidance facilitates laparoscopic splenectomy.

Current concepts in minimal access surgery for children

Since the introduction of minimal access surgery to general surgeons in the 1980s, pediatric surgeons have been employing this innovative technology to perform surgery on children. Video technology and miniaturized instruments have brought the laboratory to the operating room; in many cases several small incisions are the only access necessary to perform complicated procedures that would otherwise require a large wound. Additional benefits of minimal access surgery may include reduced postoperative analgesic requirements, shortened length of stay, and faster resumption of normal activities. Increased operative costs offset some of these gains. The pediatric surgical community has embraced minimal access techniques for some operations; others remain controversial.

Experience with laparoscopic management of solitary symptomatic splenic cysts

Aggressive laparoscopic procedures can be used to manage pathologic lesions of solid organs. We attempted laparoscopic management of solitary symptomatic splenic cysts in four patients--two men and two women--ranging in age from 19 to 63 years (mean, 35 years). The cysts involved the whole spleen in one case, the upper pole in one, and the lower pole in two. We performed laparoscopic splenectomy in one case and laparoscopic unroofing of the cyst wall in three. In two procedures we successfully used needlescopic instruments. The duration of surgery and the volume of intraoperative bleeding were 300 minutes and 200 mL, respectively, for the splenectomy, and an average of 170 minutes (range, 120-240) and minimum volume, respectively, for the unroofing. There were no intra- or postoperative complications related to the laparoscopic procedures. The postoperative hospital stay was 9 days for the patient who underwent splenectomy and an average of 5.6 days (range, 5-7) for the patients who underwent unroofing. Laparoscopic management of splenic cysts is technically feasible and safe and has the advantages of reduced postoperative pain, shortened convalescence, and improved cosmesis.

Nonparasitic splenic cysts: pathogenesis, classification, and treatment

BACKGROUND

Nonparasitic splenic cysts (NPSCs) are uncommon lesions of the spleen, many being reported in anecdotal fashion. Early classifications of this disorder have been based on the presence or absence of an epithelial lining, indicating either a congenital or traumatic etiology. This criterion has led to confusion and mistaken reporting because the lining alone is not a reliable criterion.

STUDY DESIGN

Over a 28-year period, the author has observed and studied 23 patients with NPSC. Special attention has been given to the role of trauma in the history, the nature (or absence) of a cyst lining, the gross pathology, and the preferred method of treatment.

RESULTS

NPSC present as lesions with a very characteristic gross appearance and lining. The trabeculated interior can be lined with epidermoid, transitional, or mesothelial epithelium. Desquamation of the lining can lead to a spurious diagnosis, but careful search usually discloses the lining remnant. Although most NPSC in this series were treated by open partial splenectomy, the more recent approach by laparoscopic techniques offers great promise.

CONCLUSIONS

A new classification of NPSC is offered, based on characteristic gross findings. NPSC are of congenital origin, with a lining derived from mesothelium. Trauma does not play a primary role in pathogenesis. Cysts that are symptomatic or over 5 cm in diameter should be removed by partial splenectomy or near-total cystectomy "decapsulation," either by the open or laparoscopic approach.