Incidental splenic injury during abdominal vascular surgery: a case-controlled analysis

Use of the right retroperitoneum as an alternative approach to the abdominal aorta

OBJECTIVE

The left retroperitoneal approach to the aorta is a well-established technique for aortic exposure. The right retroperitoneal approach to the aorta is performed less commonly, and the outcomes remain unknown. This study aimed to evaluate the outcomes of right retroperitoneal aortic-based procedures and to determine its utility in aortic reconstruction when faced with hostile anatomy or infection in the abdomen or left flank.

METHODS

A retrospective query of a vascular surgery database from a tertiary referral center was performed for all retroperitoneal aortic procedures. Individual patient charts were reviewed, and data were collected. Demographics, indications, intraoperative details, and outcomes were tabulated.

RESULTS

From 1984 through 2020, there have been 7454 open aortic procedures; 6076 were retroperitoneal-based, and 219 of which were performed from the right retroperitoneal approach (Rrp). Aneurysmal disease was the most common indication (48.9%), and graft occlusion was the most common postoperative complication (11.4%). The average aneurysm size was 5.5 cm, and the most common reconstruction was with a bifurcated graft (77.6%). Average intraoperative blood loss was 923.8 mL (range, 50-6800 mL; median, 600 mL). Perioperative complications occurred in 56 patients (25.6%) for a total of 70 complications. Perioperative mortality occurred in two patients (0.91%). The 219 patients treated with Rrp required 66 subsequent procedures in 31 patients. These included 29 extra-anatomic bypasses, 19 thrombectomies/embolectomies, 10 bypass revisions, 5 infected graft excisions, and 3 aneurysm revisions. Eight Rrp eventually underwent a left retroperitoneal approach for aortic reconstruction. Fourteen patients with a left-sided aortic procedure required a Rrp.

CONCLUSIONS

The right retroperitoneal approach to the aorta is a useful technique in the setting of prior surgery, anatomic abnormality, or infection that complicates the use of other more frequently employed approaches. This review demonstrates comparable outcomes and the technical feasibility of this approach. The right retroperitoneal approach to aortic surgery should be considered a viable alternative to left retroperitoneal and transperitoneal access in patients with complex anatomy or prohibitive pathology for more traditional exposure.

Short- and long-term outcomes after concurrent splenectomy during thoracoabdominal aortic aneurysm repair

OBJECTIVE

Splenectomy is often performed during open thoracoabdominal aortic aneurysm (TAAA) repair, because capsular tears are common and can be associated with significant bleeding. It is unknown whether splenectomy affects the short- or long-term outcomes after TAAA repair.

METHODS

All open type I to IV TAAA repairs performed from 1987 to June 2015 were evaluated using a single institutional database. The primary endpoints were in-hospital death, major adverse events (MAE) and long-term survival. The secondary endpoint was hospital length of stay (LOS). All repairs performed for aneurysm rupture were excluded. Univariate analysis was conducted using the Fisher's exact test for categorical variables and the Wilcoxon rank sum test for continuous variables. Logistic and linear multivariable regression were used for the in-hospital endpoints, and survival analyses were performed using Cox proportional hazards modeling and Kaplan-Meier techniques.

RESULTS

A total of 649 patients met the study inclusion criteria. Of the 649 patients, 150 (23%) underwent concurrent splenectomy (CS) and six required emergency splenectomy secondary to bleeding postoperatively, leading to 156 cases of total in-hospital splenectomy. The perioperative mortality rate was 5.2% in the CS group and 5.2% in the non-CS group (P = 1.0). MAE were experienced by 48% of the CS patients compared with 34% of the non-CS patients (P = .003). Multivariable analysis revealed splenectomy was not independently predictive of perioperative death (adjusted odds ratio, 0.95; 95% confidence interval [CI], 0.41-2.23; P = .9). However, splenectomy was independently associated with any MAE (adjusted odds ratio, 1.78; 95% CI, 1.19-2.65; P = .005). Splenectomy was also associated with a longer length of stay (+5.39 days; 95% CI, 1.86-8.92; P = .003). No survival difference was found between the cohorts in the total splenectomy cohort in the unadjusted (log-rank P = 1.0) or adjusted (splenectomy adjusted hazard ratio, 1.02; 95% confidence interval, 0.78-1.35; P = .9).

CONCLUSIONS

CS during open TAAA repair did not lead to increased perioperative mortality but did lead to significantly increased perioperative morbidity and longer hospital lengths of stay. We found no difference in long-term survival outcomes when CS was performed. Splenectomy during TAAA repair did not affect long-term survival.

Splenic rupture as a rare and unpredicted complication in a patient with systemic lupus erythematosus after colonoscopy

Colonoscopy is a common procedure that gastroenterologists perform on a daily basis. It is considered a low-risk outpatient procedure and patients can be discharged on the same day after the procedure. Colonoscopy has become more feasible with the increasing application of standard screening for colon cancer and diagnostic procedures for large intestinal disease. There are reported possible risk factors of splenic rupture during the procedure. However, splenic injury after colonoscopy is considered a rare complication and less than 100 cases have been reported in international literature. Interestingly, this is the first case report demonstrating systemic lupus erythematosus (SLE) as a possible risk factor leading to splenic rupture post-colonoscopy. Failure to recognise this possibility even in its rarity can lead to life-threatening complications. We present a case of an acute splenic rupture with massive intraperitoneal bleeding after colonoscopy in a patient with SLE.

Laparoscopy reduces iatrogenic splenic injuries during colorectal surgery

BACKGROUND

Splenic injury can occur during colorectal surgery especially in cases, where the splenic flexure is mobilized. The aim of this study was to analyze whether the operative approach (laparoscopic vs. open) was associated with an increased risk for splenic injury during colorectal surgery and to compare the outcomes of different management options.

METHODS

All accidental injuries that occurred during colorectal resections performed in our department between January 2010 and June 2013 were identified from an administrative database. All patients with iatrogenic splenic injuries were classified into two groups according to the operative approach. Only procedures that required splenic flexure mobilization were included. Splenic injury management options and outcomes were compared.

RESULTS

There were 2336 colorectal resections (1520 open, 816 laparoscopic) performed during the study period. There were 25 (1.1%) iatrogenic splenic injuries. 23 out of 25 splenic injuries occurred during open colorectal surgery. Overall, 16 (64%) patients were managed with topical hemostatic methods, 5 (20%) with splenectomy, and 4 (16%) with splenorrhaphy. It was possible to salvage the spleen in both laparoscopic patients. The laparoscopic approach was associated with a lower splenic injury rate (0.25% vs. 1.5%, p = 0.005) and a lower need for splenectomy/splenorrhaphy (p = 0.03).

CONCLUSIONS

Our data suggest that laparoscopic colorectal surgery may be associated with a lower risk of iatrogenic splenic injury, and that most splenic injuries can be managed with spleen-preserving approaches.

Splenectomy during cytoreductive surgery in epithelial ovarian cancer

Background

The aim of the study was to analyze the underlying causes and application of splenectomy in patients with epithelial ovarian cancer (EOC) and assess its effect on the surgical satisfaction and prognosis of these patients.

Materials and methods

Clinical data of patients with ovarian epithelial cancer treated with cytoreductive surgery were collected from 2000 to 2015 at Peking Union Medical College Hospital.

Results

A total of 2,882 patients underwent ovarian cancer cytoreductive surgery at Peking Union Medical College Hospital between 2000 and 2015, of whom 38 (1.3%) also underwent spleen resections. Of these 38 patients, one underwent splenectomy due to intraoperative trauma, whereas the remaining 37 patients underwent splenectomy due to splenic metastasis. Among these 37 patients, 27 underwent resection due to direct tumor spread in the spleen and 10 underwent resection due to hematogenous metastasis. For subsequent first-line chemotherapy, 22 patients were platinum sensitive and 15 were platinum resistant. Overall median survival and the postsplenectomy median survival time were 106 and 75 months, respectively. The overall median survival in secondary cytoreduction was 101 months compared with 20.3–56 months in literature reviews. Univariate analysis revealed that platinum resistance to first-line chemotherapy, suboptimal surgery, and hematogenous metastasis influenced survival. Chemosensitivity and residual disease were identified as independent risk factors by multivariate analysis. We also report a literature review concerning the efficacy and safety of splenectomy during cytoreductive surgery in EOC.

Conclusion

Approximately 1.3% of patients with EOC underwent spleen resection during initial cytoreductive surgery and more often during recytoreductive surgery. Tumor involvement was the most common indication for splenectomy, and rare patients underwent splenectomy due to intraoperative trauma. Most patients achieved optimal surgery, and thus their overall survival and postsplenectomy survival rates were longer. The prognosis of patients was closely related to chemosensitivity and presence of residual tumors. Splenectomy should be attempted in all patients with splenic involvement in whom optimal cytoreductive surgery was achievable, no matter in primary or secondary cytoreduction.

Iatrogenic splenic injury: review of the literature and medico-legal issues

INTRODUCTION

Iatrogenic splenic injury is a recognized complication in abdominal surgery. The aim of this paper is to understand the medico-legal issues of iatrogenic splenic injuries. We performed a literature review on PubMed and Scopus using iatrogenic splenic or spleen injury and iatrogenic splenic rupture as keywords. Iatrogenic splenic injury cases were identified. Most cases were related to colonoscopy, but we also identified cases related to upper gastrointestinal procedures, colonic surgery, ERCP, left nephrectomy and/or adrenalectomy, percutaneous nephrolithotomy, vascular operations involving the abdominal aorta, gynecological operation, left lung biopsy, chest drain, very rarely spinal surgery and even cardiopulmonary resuscitation. There are several surgical procedures that can lead to a splenic injury. However, from a medico-legal point of view, it is important to assess whether the cause can be attributed to a technical error of the operator rather than being an unpredictable and unpreventable complication. It is important for the medico-legal expert to have great knowledge on iatrogenic splenic injuries because it is important to evaluate every step of the first procedure performed, how a splenic injury is produced, and whether the correct treatment for the splenic injury was administered in a judgment.

High-fat diet- and angiotensin II-induced aneurysm concurrently elicits splenic hypertrophy

BACKGROUND

Angiotensin II (Ang II) and high-fat diet are implicated in causing pathological changes in the vascular endothelium, brain, kidney and liver. The association of aneurysm leading to histopathological changes in the splenic compartment remains elusive. Further, the salubrious credentials of antioxidants, especially α-tocopherol and β-carotene in the resolution of splenic pathology have not been investigated.

METHODS

Four-month-old Apoe(-/-) mice were used in the induction of aneurysm by infusing Ang II, and subsequently were orally administered with α-tocopherol and β-carotene-enriched diet for 60 days.

RESULTS

We observed splenomegaly in Ang II-infused aneurysm and high-fat diet-supplemented mice as compared to normal mice. These observations were further confirmed through histopathological investigations, demonstrating splenic follicular hypertrophy. We observed a remarkable decrease in the size of spleen in α-tocopherol and β-carotene-treated Apoe(-/-) mice as compared with Ang II-treated animals. Furthermore, no marked changes in the histopathological splenic sections were seen in the β-carotene-treated group. However, hyperplasia and proliferation of immature lymphocytes in the follicles were observed in the α-tocopherol-treated animals. We found that CD4+ T-cell levels were increased in the high-fat diet group relative to the control group and were decreased in the β-carotene-treated animals.

CONCLUSIONS

Our study provides evidence that Ang II infusion and high-fat supplementation induces abdominal aortic aneurysm that has pathological implications to the spleen. The use of β-carotene but not α-tocopherol as an antioxidant markedly ameliorates the pathological changes in spleen.

Lengthening of the colon for low rectal anastomosis in a cadaveric study: how much can we gain?

BACKGROUND

Lengthening of the colon for tension-free low rectal anastomosis comprises ligation of the inferior mesenteric vessels and splenic flexure mobilization. The aim of our study was to evaluate the length gained after each level of mesenteric vessel ligation with or without splenic flexure mobilization.

METHODS

The length of the colon after each mobilization technique, that is, low ligation of the inferior mesenteric artery (IMA), high ligation of IMA, high ligation of the inferior mesenteric vein (IMV), and mobilization of splenic flexure, was measured in 13 cadaveric specimens. After each step, the colon and vessels were placed back in their original position.

RESULTS

The distance from the colosigmoid junction (CSJ) to the pubic symphysis (PS) was measured after each mobilization technique. The average elongation of the colon from original CSJ-PS distance to the CSJ-PS distance after low ligation of IMA, high ligation of IMA, high ligation of IMA plus splenic flexure mobilization, and high ligation of IMV was 2.08 ± 4.39 cm, 5.02 ± 5.51 cm, 8.20 ± 5.95 cm, and 17.98 ± 6.80 cm, respectively. The length of colon gained after IMV ligation was greater than the length obtained after low ligation of IMA, high ligation of IMA, and high ligation of IMA plus splenic flexure mobilization (p < 0.0001).

CONCLUSIONS

This study shows the objective length gained following each standard surgical technique in colonic mobilization for low rectal anastomosis. The maximum length gained is after high ligation of IMV.

Intraoperative injuries during liver resection: analysis of 1,005 procedures

PURPOSE

Risk of liver resection has been well investigated in many studies. However, the problem of intraoperative injuries is rarely mentioned. The aim of this study was to assess the incidence, the type, and management of intraoperative injuries during liver resection.

METHODS

A total of 1,005 liver resections between 2004 and 2009 were included in this retrospective investigation. We analyzed the incidence of intraoperative injuries, risk factors, and an impact on patients' clinical outcome.

RESULTS

The overall incidence of intraoperative injuries was 4.4% (44 of 1,005). Injuries of the diaphragm (1.6%, 16 of 1,005) and hepatocaval junction (1%, 10 of 1,005) were the most frequent. In multivariate analysis, tumor recurrence (p = 0.0199) and tumor size (p = 0.0317) were the only independent risk factors for diaphragm injuries, whereas the extent of resection (p = 0.0007) was the only independent risk factor for caval or hepatic vein injuries. Injuries of the inferior vena cava or hepatic veins significantly increased perioperative mortality (p = 0.0005).

CONCLUSIONS

Minor injuries causing no significant complications were the most frequent. However, prevention and proper management of the rare injuries of hepatocaval junction are essential to avoid increased mortality in major liver resections.

Clinicopathologic characteristics, surgical treatment and outcomes for splenic flexure colon cancer

PURPOSE

This current study examined the clinicopathologic characteristics of patients with splenic flexure (SF) colon cancer and the association with the surgical outcomes to find the optimal procedure to treat this malady.

MATERIALS AND METHODS

A total of 167 operated patients with SF colon cancer were consecutively recruited between 1993 and 2003. The clinicopathological, operative and survival data was reviewed and analyzed.

RESULTS

For the SF colon cancer patients, the proportion of males was higher than that for the right-sided colon patients or the sigmoid-descending junction & sigmoid (SD & S) colon patients (p≤=0.05, respectively) and the age at the time of diagnosis was younger (p≤=0.05). Obstruction was more frequent in the patients with SF colon cancer than that for the patients with colon cancer at other sites (p≤=0.001). The incidence of mucinous adenocarcinoma for the SF patients was similar to that for the patients with right-sided colon cancer, but it was higher than that for the patients with SD & S colon cancer (11.4% vs. 6.5%, p=0.248 or 2.5%, respectively, p=0.001). Disease-free and overall survival did not differ between the patients who underwent a left hemicolectomy and extended surgery such as combined splenectomy or subtotal colectomy. Multivariate analysis showed that old age (≥=60 years) and a N1-2 and M1 status were the independent risk factors for overall survival.

CONCLUSION

The SF colon cancers exhibited exclusively different characteristics as compared to colon cancers at other site colon cancers. It appears that left hemicolectomy was generally sufficient for a satisfactory oncological outcome, obviating concurrent splenectomy.

Iatrogenic splenic injury in postoperative patients: a series of case reports

The purpose of this study was to report case studies of iatrogenic splenic injuries on computed tomography (CT) in symptomatic postsurgical patients. The medical records and CT studies of all patients with injury to the spleen after abdominal surgery were reviewed. CT was performed in the postoperative period, urgently in all patients. Unsuspected splenic injuries were found on CT performed in the early postoperative period in seven symptomatic patients (five women and two men, age range 21-81 years) after various abdominal surgical procedures. Injuries as detected on CT included splenic infarct in five, subcapsular hematoma in two, and laceration of the spleen in one. These findings were the only abnormal abdominal findings in four of the patients and were probably the source of the postoperative abdominal pain and fever. Splenic injury is a rare complication of abdominal surgery. It is often the radiologist who diagnoses the injury, and awareness of this possible complication can obviate further investigations.

Iatrogenic Injury to the Spleen—CT Appearance

Splenic injury is a well-known but rare complication of various abdominal surgical and invasive procedures, and even of cardiac surgery. The true incidence of iatrogenic splenic trauma is, however, difficult to assess and is probably underestimated. Overt injuries diagnosed during surgery are usually immediately treated by splenectomy without imaging. This review focuses on missed splenic injuries that are diagnosed on imaging following surgery or an invasive procedure.