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

Predictors of iatrogenic splenic injury in radical gastrectomy for gastric cancer

Background

Iatrogenic splenic injury (ISI) is a recognized complication in radical gastrectomy that may result in incidental splenectomy (IS). However, the predictors of such events remain largely unknown.

Methods

Medical records of the patients who underwent radical gastrectomy at our institution between January 2015 and December 2022 were retrospectively reviewed. Potential predictors of ISI and IS were collected and analyzed by multivariate logistic regression. Results were reported as an odds ratio (OR) with 95% confidence intervals (CI).

Results

A total of 2916 patients were included, of whom 211 patients (7.2%) suffered from ISI and 75 patients (2.6%) underwent IS. Multivariate analysis demonstrated that BMI≥25 (OR: 3.198 (2.356-4.326), p<0.001), total gastrectomy (OR: 2.201 (1.601-3.025), p<0.001), and the existence of "criminal fold" (OR: 13.899 (2.824-251.597), p=0.011) were independent predictive risk factors for ISI; whereas laparoscopic surgical approach (OR: 0.048 (0.007-0.172), p<0.001) was a protective factor for ISI. Moreover, the existence of "criminal fold" (OR: 15.745 (3.106-288.470), p=0.008) and BMI≥25 (OR: 2.498 (1.002-6.046), p=0.044) were identified as independent risk factors of ISI under laparoscopic gastrectomy. There was no association between sex, age, previous abdominal surgery, neoadjuvant therapy, outlet obstruction, tumor stage, nodal stage, and total lymph node retrieved and ISI.

Conclusions

BMI≥25 and total gastrectomy can predict high risk of ISI during radical gastrectomy. Laparoscopic surgery is superior to open gastrectomy in lowing the risk of ISI.

Moderate Splenic Injury Caused by Colonoscopy

Little is known about iatrogenic splenic injury (SI) as an adverse event after colonoscopy. SI is sometimes fatal because of hemorrhaging. We herein report a man who developed SI after colonoscopy. He recovered conservatively. His history of left hydronephrosis and insertion with a maximally stiffened scope were suspected as possible risk factors. Endoscopists should consider the possibility of SI when they encounter patients suffering from left-sided abdominal pain after colonoscopy. Careful interview concerning the medical history and gentle maneuvering around the splenic flexure can help avoid SI.

Infarcts and ischemia in the abdomen: an imaging perspective with an emphasis on cross-sectional imaging findings

Infarcts and ischemia of abdominal organs may present with acute abdominal pain, and early diagnosis is crucial to prevent morbidity and mortality. Unfortunately, some of these patients present in poor clinical conditions to the emergency department, and imaging specialists are crucial for optimal outcomes. Although the radiological diagnosis of abdominal infarcts is often straightforward, it is vital to use the appropriate imaging modalities and correct imaging techniques for their detection. Additionally, some non-infarct-related abdominal pathologies may mimic infarcts, cause diagnostic confusion, and result in delayed diagnosis or misdiagnosis. In this article, we aimed to outline the general imaging approach, present cross-sectional imaging findings of infarcts and ischemia in several abdominal organs, including but not limited to, liver, spleen, kidneys, adrenals, omentum, and intestinal segments with relevant vascular anatomy, discuss possible differential diagnoses and emphasize important clinical/radiological clues that may assist radiologists in the diagnostic process.

Impact of site of occlusion in proximal splenic artery embolisation for blunt splenic trauma

Background

Proximal splenic artery embolisation (PSAE) can be performed in stable patients with Association for the Surgery of Trauma (AAST) grade III-V splenic injury. PSAE reduces splenic perfusion but maintains viability of the spleen and pancreas via the collateral circulation. The hypothesized ideal location is between the dorsal pancreatic artery (DPA) and great pancreatic artery (GPA). This study compares the outcomes resulting from PSAE embolisation in different locations along the splenic artery.

Materials and methods

Retrospective review was performed of PSAE for blunt splenic trauma (2015–2020). Embolisation locations were divided into: Type I, proximal to DPA; Type II, DPA-GPA; Type III, distal to GPA. Fifty-eight patients underwent 59 PSAE: Type I (7); Type II (27); Type III (25). Data was collected on technical and clinical success, post-embolisation pancreatitis and splenic perfusion. Statistical significance was assessed using a chi-squared test.

Results

Technical success was achieved in 100% of cases. Clinical success was 100% for Type I/II embolisation and 88% for Type III: one patient underwent reintervention and two had splenectomies for ongoing instability. Clinical success was significantly higher in Type II embolisation compared to Type III (p = 0.02). No episodes of pancreatitis occurred post-embolisation. Where post-procedural imaging was obtained, splenic perfusion remained 100% in Type I and II embolisation and 94% in Type III. Splenic perfusion was significantly higher in the theorized ideal Type II group compared to Type I and III combined (p = 0.01).

Conclusion

The results support the proposed optimal embolisation location as being between the DPA and GPA.

Pancreatic Fistula and Biochemical Leak after Splenectomy: Incidence and Risk Factors-A Retrospective Single-Center Analysis

Purpose

Postoperative pancreatic fistula (POPF) is a complication discussed in the context of pancreatic surgery, but may also result from splenectomy; a relationship that has not been investigated extensively yet.

Methods

This retrospective single-center study aimed to analyze incidence of and risk factors for POPF after splenectomy. Patient characteristics included demographic data, surgical procedure, and intra- and postoperative complications. POPF was defined according to the International Study Group on Pancreatic Surgery as POPF of grade B and C or biochemical leak (BL).

Results

Over ten years, 247 patients were identified, of whom 163 underwent primary (spleen-associated pathologies) and 84 secondary (extrasplenic oncological or technical reasons) splenectomy. Thirty-six patients (14.6%) developed POPF of grade B/C or BL, of which 13 occurred after primary (7.9%) and 23 after secondary splenectomy (27.3%). Of these, 25 (69.4%) were BL, 7 (19.4%) POPF of grade B and 4 (11.1%) POPF of grade C. BL were treated conservatively while three patients with POPF of grade B required interventional procedures and 4 with POPF of grade C required surgery. POPF and BL was noted significantly more often after secondary splenectomy and longer procedures. Multivariate analysis confirmed secondary splenectomy and use of energy-based devices as independent risk factors for development of POPF/BL after splenectomy.

Conclusion

With an incidence of 4.5%, POPF is a relevant complication after splenectomy. The main risk factor identified was secondary splenectomy. Although POPF and BL can usually be treated conservatively, it should be emphasized when obtaining patients’ informed consent and treated at centers with experience in pancreatic surgery.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00423-022-02531-7.

Risk Factors for Infections, Antibiotic Therapy, and Its Impact on Cancer Therapy Outcomes for Patients with Solid Tumors

Infections represent a significant cause of morbidity and mortality in cancer patients. Multiple factors related to the patient, tumor, and cancer therapy can affect the risk of infection in patients with solid tumors. A thorough understanding of such factors can aid in the identification of patients with substantial risk of infection, allowing medical practitioners to tailor therapy and apply prophylactic measures to avoid serious complications. The use of novel treatment modalities, including targeted therapy and immunotherapy, brings diagnostic and therapeutic challenges into the management of infections in cancer patients. A growing body of evidence suggests that antibiotic therapy can modulate both toxicity and antitumor response induced by chemotherapy, radiotherapy, and especially immunotherapy. This article provides a comprehensive review of potential risk factors for infections and therapeutic approaches for the most prevalent infections in patients with solid tumors, and discusses the potential effect of antibiotic therapy on toxicity and efficacy of cancer therapy.

Successful non-invasive management of iatrogenic splenic injury associated with a peritoneal dialysis catheter in a dog

An 11-month-old, intact female Labrador retriever was presented with oligoanuric acute kidney injury and overhydration after grape ingestion. Percutaneous placement of a 12G × 30 cm Mila chest tube was done as an emergency temporary peritoneal dialysis catheter. Although no serious immediate complications were noted, an iatrogenic splenic injury had occurred. The catheter was used for peritoneal dialysis and urine output and hydration status improved over time. When the dialysis catheter was removed 3 d later, a synthetic hemostatic matrix, Surgiflo, was deposited through the catheter. No complications were noted. The dog recovered uneventfully and was doing well with normal kidney function. Key clinical message: To the authors' knowledge, this report represents the first description of non-invasive management of iatrogenic splenic injury secondary to percutaneous peritoneal dialysis catheter placement in a dog.

Evaluation of Operative Notes for Splenic Flexure Mobilization: Are the Key Aspects Being Reported?

Background: Given the importance of operative documentation, we reviewed operative notes for surgeries that required splenic flexure mobilization (SFM) to determine their accuracy. Materials and Methods: We performed a retrospective review of 51 operative notes for complete SFMs performed at a single institution from January 2015 to June 2020. Results: None of the operative notes reported a rationale for performing SFM, use of preoperative imaging to guide technical approach, reasoning for the operative method and mobilization approach used, or specific steps taken to ensure that SFM was done safely. Most reports did not include technical details, with one-third of the notes merely reporting that "the splenic flexure was mobilized." Conclusions: Increased awareness about the lack of operative documentation of the critical aspects of the SFM could stimulate initiatives to standardize the SFM method and improve the quality of operative notes for SFM.

A Case of Iatrogenic Splenic Injury Following Routine Colonoscopy With Possible Influence of Unique Anatomy Due to Severe Scoliosis

Iatrogenic splenic injury is a rare complication of all abdominal surgeries. Despite the procedure's overall safety, colonoscopy is now the procedure most frequently associated with iatrogenic splenic injury. A 58-year-old male with a past medical history of hypertension, lung cancer in remission, colon polyps, and severe scoliosis presented for grade three splenic laceration two days following a routine colonoscopy. He had no recent history of injury or other inciting events that could have led to traumatic injury. Non-operative management included splenic artery embolization and transfusion of one unit of packed red blood cells, after which he improved in the hospital and was discharged home in stable condition. This case postulates the possible influence of his severe scoliosis, and thus altered abdominal viscera anatomy, on his iatrogenic splenic injury, as well as the potential importance of investigating scoliosis as a risk factor for difficult colonoscopy or even iatrogenic splenic injury during colonoscopy.

Splenic rupture as an endoscopic complication: as rare as it appears?

The case was an 86-year-old male with multiple cardiovascular comorbidites, including anticoagulated atrial fibrillation, who underwent a colonoscopy due to acute lower gastrointestinal bleeding and anemia. Colonoscopy only showed some small angiodysplasias in the cecum. A few hours later, the patient presented with abdominal pain and hemodynamic instability. An abdominal computed tomography was performed, which showed a splenic laceration and hemoperitoneum. An expectant attitude was decided, with a good evolution from the abdominal point of view. There was no sign of active splenic bleeding in a control computed tomography. However, he developed decompensated heart failure and finally died.

Splenic Laceration: A Rare Complication of Abdominal Paracentesis

Abdominal paracentesis is a commonly performed diagnostic and therapeutic procedure with a low complication rate. Previously described complications include injury to the abdominal wall, small bowel perforation, and abdominal hemorrhage. Splenic injury has also been described as a complication from bedside procedures including colonoscopy, upper gastrointestinal endoscopy, thoracentesis, and pleural biopsy. This case highlights a previously unreported complication from an abdominal paracentesis, splenic laceration.

Intermittent Splenic Artery Occlusion Plus Gauze Compression Is a Simple and Effective Treatment for Iatrogenic Splenic Injury

Background

The aim of this study was to evaluate the feasibility and safety of intermittent splenic artery occlusion plus gauze compression in treating iatrogenic splenic injury.

Material/Methods

We retrospectively analyzed 12 iatrogenic splenic injury cases (grade I to III) treated with intermittent splenic artery occlusion plus gauze compression. The hemostatic effect was then observed after unblocking and decompression. The total operation time, gauze compression time, total blood loss, blood loss from the injured spleen, and platelet counts of each patient before and 1 week after surgery were noted.

Results

The average operation time was 209.58±57.11 min, and the average gauze compression time after spleen artery occlusion was 23.75±4.33 min. The average total blood loss and blood loss due to iatrogenic spleen injury were 468.33±138.22 ml and 264.17±165.72 ml, respectively. Two cases (both grade I) had successful hemostasis after 15 min of splenic artery occlusion and wound compression. Another 9 cases (all grade II) and 1 case (grade III) attained hemostasis after 25 min and 30 min, respectively, of splenic artery occlusion and wound compression. The platelet counts of all patients were within the normal range before and 1 week after surgery. No postoperative complications occurred.

Conclusions

Intermittent splenic artery occlusion plus gauze compression is a simple and effective treatment for iatrogenic splenic injury.

A delayed presentation of splenic laceration and hemoperitoneum following an elective colonoscopy: A rare complication with uncertain risk factors

Splenic laceration is a rare yet often underreported complication of colonoscopy that is infrequently discussed with the patient during the consent process. Most cases present within 48 h after the inciting colonoscopy; a delayed presentation is rare. We present a case of splenic laceration with hemoperitoneum that manifested 5 days after the initial colonoscopy. The patient was treated conservatively. Traditionally perceived risk factors such as intra-abdominal adhesions, splenomegaly, anticoagulation use, biopsy, polypectomy, a technically challenging procedure, and anesthesia assistance have not been clearly shown to increase the incidence of splenic injury following a colonoscopy. Since the risk factors of splenic injury remain unclear, the clinical presentation is nonspecific, and the consequences can be serious, the endoscopist should make an effort to inform the patient of this rare complication before the procedure.

Delayed presentation of iatrogenic splenic injury 21 days after laparoscopic donor left nephrectomy

We report the case of a 46-year-old woman who had presented with left-sided abdominal pain 21 days after undergoing a left-sided laparoscopic nephrectomy for donation. Initial haemoglobin and haematocrit levels were within normal range, and vital signs on admission were unremarkable. Significant intra-abdominal pathology was not suspected; however, inpatient CT scan of the abdomen showed a posterolateral subcapsular splenic haematoma with free abdominal fluid. Initial trial of conservative management was not successful as the patient became hypotensive on the third day of admission with a sudden decrease in haemoglobin and haematocrit. The patient was immediately taken to theatre for laparotomy and splenectomy. Recovery was uneventful and was discharged home on the fifth postoperative day. In this article, we aim to discuss several important clinical lessons involving iatrogenic injury of the spleen, its management, and diagnosis of acute and severe haemorrhage.

Iatrogenic spleen injury risk during robotic left colonic and rectal resections by routine left flexure mobilization technique: a retrospective study

BACKGROUND

The routine mobilization of the left colonic flexure as a standard procedure during left colonic/rectal resection is a controversial topic in open and minimally invasive surgery. According to some authors, this maneuver may increase the risk of iatrogenic spleen damage; for others this does not change the odds. Ligaments over-traction is the most frequent injury mechanism. Some documented risk factors are reported: laparotomic approach, male gender, vascular disease, cancer, diverticulitis, surgery performed in emergency-setting. The type of procedure influences the associated risk: transverse colectomy is the riskiest, followed by left colonic resection and pancolectomy.

METHODS

Retrospective original paper. Sample size - a total of 125 patients have been considered. 75 robotic left colonic resections (60%), 40 robotic rectal resections (32%) and 10 robotic pancolectomy (8%). Primary outcomes - 1) percentage of iatrogenic splenic injuries; 2) conversion rate. Secondary outcomes - 1) intra-/postoperative complications; 2) anastomotic leakage rate; 3) mortality. In order to avoid potential confounding factors and technical/expertise heterogeneity, all the procedures included have been performed using the same standardized operative technique and by the same experienced surgeon (P.C.G.).

RESULTS

We retrospectively analyzed 125 procedures. Primary outcomes - 1) iatrogenic splenic injuries: 0%; 2) conversion rate: 1.6%. Secondary outcomes - 1) intraoperative complications: 0%; 2) anastomotic leakage rate: 1 case of leakage out of 125 cases (1.3% of the left colectomy sub-sample); in this case the leakage was probably due to an infectious process rather than a vascular deficit; 3) mortality: 0%; 4) miscellanea postoperatory complications (small bowel obstructions, wound infection, pelvic collections, pneumonia and acute kidney injury) are detailed in the manuscript.

CONCLUSIONS

In our experience, and according to some of the literature data as well, during robotic left colonic/rectal resections the routine mobilization of the left flexure as a standard procedure is not a risk factor in terms of iatrogenic spleen injury rate. Conversely, this technique may be beneficial as it does not excessively extend the operative time, increases the surgical skills acquirement, and reduces the tension-related anastomotic ischemia. It also allows a better oncological dissection. Standard laparoscopic approach reduces the rate of spleen by almost 3.5 times in comparison to open surgery. The improved technical accuracy provided by the robotic platform may decrease the rate of splenic injury. More studies are needed on the topic to confirm our findings.