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Murine typhus is a rickettsial infection that remains endemic in parts of Texas and California. Clinical manifestations of the infection are due to vasculitis. In a patient who acquired the infection in the United States, computed tomography demonstrated intrasplenic pseudoaneurysms, infarcts, and hemorrhage.
We report a case of Behçet's disease with pulmonary and splenic involvement. The radiologic presentation was quite different from the modes defined in the literature. A large, anteriorly located, well circumscribed ovoid mass was the x-ray film image of a large area of infarction with hemorrhage. The involved pulmonary artery showed signs of vasculitis with thrombus formation. To our knowledge, this mode of presentation is different from the cases reported in the literature.
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BACKGROUND: Some reports have suggested that laparoscopic splenectomy (LS) can be successfully performed in adults. However, several aspects of this procedure remain as yet undefined; therefore, several attempts have been made to modify the standard technique to try to optimize the procedure. Herein we analyze our experience with 105 laparoscopic splenectomies. METHODS: From 1993 to 2000, 105 patients underwent LS at our hospital. Twelve of these patients also underwent a concomitant cholecystectomy. There were 66 women and 39 men whose ages ranged between 4 and 78 years (median, 27.7). All patients underwent an elective laparoscopic splenectomy. Seventy five patients had thrombocytopenia (ITP), 14 had hereditary spherocytosis, eight were affected by b-thalassemia, two had splenic cysts, two had lymphoma, (two had myeloid chronic leukemia, one patient presented with a splenic abscess and one had incurred an iatrogenic spleen lesion during adrenalectomy. The first patients in this series were positioned in dorsal decubitus; however, as the team's experience increased, the right lateral decubitus became the position of choice because it provides better exposure of the splenic hilum. This procedure requires the use of only four trocars. RESULTS: Mean operating time was 95 min (range, 35-320). Hospital stay ranged from 2 to 21 days (median, 4.5). There was only one conversion to open surgery. One patient died in the postoperative period due to the evolution of a preexisting malignant disease. We recorded nine complications-four subphrenic abscesses, two cases of pleuritis, two episodes of postoperative bleeding, and one intestinal infarction 16 days after surgery. Only two patients needed redo surgery. CONCLUSIONS: We believe that the laparoscopic approach is a valid alternative to open splenectomy, but mastery of some of the technical details of this procedure could greatly help avoid its complications. On the basis of our experience, it seems that the lateral approach should be considered the position of choice because it provides exposure and easier dissection of the splenic hilar structures. We also found that a 30 degrees scope and an ultrasonic dissector allowed for perfect vision and optimal hemostasis during the procedure. At the end of procedure, the spleen should be fragmented and then extracted using an extraction bag.
Two patients with splenic abscess were successfully treated. In one patient, Streptococcus viridans, possibly arising in a dental abscess, led to inflammatory left upper quadrant signs. An exploratory laparotomy was performed, and the spleen, being found enlarged, was removed. The other patient showed no peritoneal signs. Laparotomy was done for pyrexia of unknown origin, and the removal of a normal-sized spleen was elected on the suspicion of lymphosarcoma. The spleen was abscessed, apparently because of old infarcts. A high index of suspicion is important in diagnosis, and selective angiography, not used in these two patients, is recommended.
The purpose of this study was to analyse the sonographic findings of focal splenic lesions with an attempt to differentiate benign lesions from malignancies. The sonographic findings of 53 cases of verified focal splenic lesions, excluding post-traumatic haematomas and phleboliths, were retrospectively analysed. Of the 53 cases, 30 cases (57%) were benign and 23 cases (43%) were malignant. The malignancies included lymphoma (n=13), metastases (n=10); while the benign lesions included cysts (n=17), infarcts (n=3), and abscesses (n=5), and one case each of haemangioma, hamartoma, spontaneous rupture, tuberculosis, and lymphangioma. Significant differences were noted between the benign and malignant groups with respect to the presence of solitary lesions (p<0.0001), anechoic mass (p<0. 0001), lesions with highly echogenic foci due to gas or calcification (p = 0.0303), hyperechoic/mixed echoic lesions (p<0. 0001), presence of extrasplenic abdominal masses (p<0.0001), and nodules with the target sign (p<0.0001). Solitary lesions, anechoic mass, and lesions with highly echogenic foci due to gas or calcification each had a positive predictive value of 85%, 100%, and 100%, respectively, for the lesions to be benign. The multifocal/diffuse lesions, presence of extrasplenic abdominal masses, hyperechoic/mixed echoic lesions, and nodules with the target sign each had a positive predictive value of 70%, 100%, 70%, and 100%, respectively, for the lesions to be malignant. In summary, focal lesions with anechoic pattern or echogenic foci due to gas or calcification are suggestive signs of benign process. The sonographic observations of multifocal or diffuse solid lesions, especially those associated with target sign or extrasplenic abdominal masses are suggestive of malignancy.
The authors report a very unusual case of non-invasive diagnosis of acute ischemic bowel disease detected as hepatic portal venous gas during intra-aortic balloon percutaneous counterpulsation. A 64-year-old man with acute ST-elevation myocardial infarction complicated by cardiogenic shock was treated with percutaneous angioplasty and intra-aortic balloon percutaneous counterpulsation. The post-procedural period was complicated by severe abdominal pain. Abdominal computed tomography revealed hepatic portal venous gas. Multiple kidney and splenic ischemic areas were also identified. Colonoscopy showed signs referring to acute ischemic colitis. Computed tomography detection of hepatic portal venous gas has permitted the non-invasive diagnosis of bowel necrosis.
In search of new sources for cardiac revascularization of the myocardium in ischemic heart disease the authors elaborated experimentally on dogs an operation of construction of retrograde arterial splenocoronary anastomosis. The results of the operation were estimated by means of EEG findings, vital and postmortem coronarography and histological studies of the myocardium and zone of the anastomosis. An analysis of the experimental data obtained has revealed a patency of the vascular anastomosis in most animals; electrocardiographic signs of acute myocardial infarction, developed in high ligation of the anterior intraventricular branch of the left coronary artery, would undergo a prompt reverse dynamics after constructing a splenocoronary anastomosis. Further studies of the mentioned method of revascularization of the myocardium seems to be rather perspective.
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A sample of 409 individuals with sickle cell anemia in the city of Rio de Janeiro was studied. Information about the age of onset, first manifestations, most common clinical features, physical and sexual development, types of crises, laboratory determinations, and age at death was provided. The most salient findings were the low frequencies of bone lesions (12-18%), gnathopathy (4%), persistence of splenomegaly in adults (4%), and abnormal cardiograms (16%). Bone infarctions and osteomyelitis were correlated significantly, the frequency of the latter increasing with age. A significant sex difference was observed in the types of crises. Chest pains were more frequent in males, while bone or joint pains, as well as splenic sequestration, were more common in females.
This report presents a case of a 40 year old Caucasian female with a 15 cm inflammatory pseudotumor (IPT) of the spleen with associated areas of splenic hemangioma of the cavernous type. Abdominal CT showed a largely fatty splenic mass with enhancing septations, and scattered calcifications, and a small density in the liver. Grossly, the splenic lesion showed a lobulated cut surface with areas of myxoid change, necrosis, hemorrhage and cystic softening. The diagnosis of IPT was suggested at intraoperative consultation using cytologic smears and was, subsequently confirmed on permanent sections. Histologically, the lesion consisted of a densely collagenized spindle cell stroma with patchy aggregates of lymphocytes and plasma cells, and scattered foci showing hemosiderin-laden macrophages extracellular calcium deposits and osseous metaplasia. The stromal spindle cells were immuoreactive for smooth muscle actin and vimentin confirming their myofibroblastic phenotype. There were extensive areas of infarction within the mass. The patient, however, remained asymptomatic preoperatively. Histologic analysis in this case raises the possibility that low grade, perhaps repetitive, trauma to the hemangioma may have resulted in intralesional hemorrhages which, through a process of organization, may have evolved into this sizable inflammatory pseudotumor. In addition, this report reviews the current literature on the clinical significance and presentation, morphologic and immunohistochemical findings, prognosis, differential diagnosis, pathogenesis and therapy of the splenic IPT.
Forty-five percent of the 121 million persons who live in Brazil have morphological indications of Black admixture, and 5-6% of them are carriers of the hemoglobin S gene. But even in persons identified as white, the hemoglobin AS genotype is present in about 1%. The total number of people with sickle cell disease is estimated as 45,000. The present analysis is based in 409 patients studied in Rio de Janeiro. The observed frequency of deformities of the vertebrae (18%), bone infarcts (12%), and gnathopathy (4%) was lower than those found in any other series. The proportion of adults with splenomegaly was also lower than that of other studies. Chest pains were more frequent in males, while bone or joint pains and splenic sequestration crises seemed to be more common in females. Effects of the disease in the viability and fertility of these patients were quantified. Fetal loss in 67 pregnancies was 48%. Hemoglobin F levels showed a clear age effect, and higher levels were associated with a more benign course of the disease. Information about the services for prevention and treatment of sickle cell disease that exist in Brazil and one place in Venezuela, is provided. Treatment is only symptomatic in 12 centers, while in São Paulo piracetam is being successfully used in the treatment of crises. A brief overview about the current Brazilian studies on this disease is also presented.
The Angelchik prosthesis was used in 26 cases of gastroesophageal reflux disease resistant to medical therapy. The operations were crowned with success in 24 cases out of 26 (92.3%), with complete disappearance of reflux. The procedure failed in two cases: the prosthesis was removed in one case due to postoperative acute haemorrhagic gastritis with a subsequent positive outcome; in this patient the Angelchik ring had been removed as a precaution. Failure in the second case, a patient with oesophageal stenosis and a short oesophagus, was due to mediastinal migration of the prosthesis. In this latter case, a successful duodenal bypass was created with antrectomy and a long Roux-en-Y anastomosis. The only intraoperative complication in the patient sample was a splenectomy for rupture of the splenic capsule. Postoperative complications not directly related to the prosthesis were perforation of a duodenal ulcer not diagnosed preoperatively and treated with raphia without impairing the functional efficacy of the ring, one case of pulmonary embolism and one case of cardiac infarction, all resolved with medical therapy. In all, the prostheses were removed in 3 cases out of 26 (11.5%). In addition to the two cases already described, the prosthesis was removed in one patient one year after the operation at the patient's specific request for "psychological" reasons. Migration of the prosthesis occurred in four cases of severe oesophageal stenosis with a short oesophagus, in three of which the prosthesis functioned perfectly even in the intrathoracic site. At follow-up examinations there was radiological disappearance of the hiatal hernia in 20 cases out of 25. In one case there was no hernia even before the operation, and in four cases there was a short oesophagus with severe oesophagitis. Owing to the very easy performance of the operation together with its unquestionable antireflux efficacy, in our opinion three reliable indications emerge, namely: (i) in elderly patients at high surgical risk; (ii) in obese, brachytypical patients; and (iii) in the presence of severe oesophagitis, even with a short oesophagus.
Leukemic reticuloendotheliosis, or "hairy cell leukemia," is a neoplasm of the reticuloendothelial system. It is characterized by the presence of many "hairy cells" in blood, marrow, lymph nodes, and spleen; by anemia, leukopenia, thrombocytopenia, and often, by massive splenomegaly. Three such patients with spontaneous rupture and one patient with multiple infarctions of the spleen all had spleens which were large, congested, and diffusely infiltrated by "hairy cells." The lacerations in all three ruptured spleens were located in areas of extensive infarction. Indications for splenectomy in this disease include hypersplenism, severe cytopenia, hemodilution, splenomegaly with severe pressure symptoms, massive splenomegaly, rupture, or infarction.
Hepatorenal and splenorenal bypasses are gaining an increased popularity as an alternative to renal artery endarterectomy and aortorenal bypass in selected patients. However, there are few reports of the long-term results of this procedure. The purpose of this study was to assess the performance of the hepatic and splenic arterial sources in patients with atherosclerotic renal artery disease. We reviewed our 7-year experience between 1988-1995. A total of 146 operative renal artery reconstructions were performed, including 45 hepatorenal and/or splenorenal bypass in 38 patients, (19 male, 19 female, mean age 62 +/- 12 years) for treatment of renovascular hypertension, renal preservation or both. The mean preoperative creatinine was 2.95 mg/dl (2.11-3.47, 95% confidence limits). The average number of antihypertensive medications was 2.63. There was one postoperative death from myocardial infarction and two cases of early graft thrombosis, one of which was treated by thrombectomy reestablishing patency. In two patients with persistent hypertension selective angiography demonstrated high-grade anastomotic stenoses which were successfully dilated by balloon angioplasty. The postoperative mean creatinine decreased to 2.54 mg/dl (1.82-3.27, 95% confidence limits), (p = 0.17) and the average number of antihypertensive medications decreased to 1.9 (p = 0.001). During the median follow-up of 33 months, 10 patients died, mainly from cardiac causes. Our experience indicates that the splenic and hepatic arteries provide useful alternatives to renal revascularization in selected circumstances with an acceptable rate of perioperative mortality and morbidity. The expected long-term survival in this group of patients is low.
BACKGROUND: Hand-assisted laparoscopic surgery (HALS) has been proposed as a useful alternative to conventional laparoscopic and open surgery. As compared with conventional laparoscopic surgery, it offers the advantages of tactile feedback, better exposure, and a shorter learning curve. There is increasing evidence that HALS retains the advantages of minimal-access surgery. The aim of this study was to analyze the feasibility as well as the short- and medium-term outcomes of HALS sigmoid resection for diverticular disease. METHODS: The study included 100 consecutive patients between July 1999 and August 2004. Data were prospectively recorded. Follow-up evaluation was performed by standardized telephone interview after a mean postoperative period of 19 months (range, 2-55 months). RESULTS: Two major intraoperative complications occurred: splenic laceration requiring splenectomy and ureteral injury requiring suture. There were only three conversions: one case of pararectal incision and two cases of extended lower Pfannestiel incision. There was no single case of conversion to midline laparotomy. One patient died postoperatively of myocardial infarction. The postoperative complications included intraabdominal hematoma (2%), anastomotic leakage (3%), wound infection (11%) and bladder dysfunction (1%). The reoperation rate was 5%. The median hospital stay was 8 days. In terms of satisfaction with the results, 97% of patients would choose HALS again. CONCLUSIONS: When used for diverticular disease, HALS sigmoid resection has a low intra- and postoperative complication rate. The satisfaction rate among patients is high. Even in technically difficult cases, conversion to midline laparotomy can be avoided.
Vascular emergencies are an uncommon but significant cause of abdominal pain, back pain, hemorrhagic shock, and death in adults. This article reviews abdominal vascular anatomy, risk factors, signs and symptoms, abdominal vascular thrombosis, mesenteric ischemia and infarction, and abdominal vascular emboli and aneurysms.
BACKGROUND: A hydatid cyst is still a serious health problem in endemic areas. Invasion of the spleen is rare in hydatid disease. In the medical literature, reports about isolated splenic hydatidoses are quite rare. Also there is not a consensus about the way of treatment. METHODS: Between 1978 and 2000, in our clinic approximately 900 patients were operated on for an abdominal hydatidosis; 850 of these patients were treated for a hepatic hydatidosis and 14 patients for an isolated splenic hydatidosis. Six (42.8%) of the latter patients were male and 8 (57.1%) were female. The mean age of the patients was 47.14 +/- 4.9 (range 17-72) years. Ten patients (71.4%) presented with a painful mass in the left upper quadrant of the abdomen, and the other 4 patients (28.5%) were asymptomatic and were diagnosed incidentally. RESULTS: All of the patients underwent elective splenectomy. There was no mortality, but complications occurred in 4 (28.5%) patients. The period of hospitalization ranged from 7 to 17 days with a mean of 9.8 days. 1 patient died from an acute myocardial infarction during the 2nd postoperative year, and 1 patient died as a consequence of a traffic accident during the 5th postoperative year. Nine patients, after follow-up periods of between 2 and 14 years, are living free from disease. No recurrence occurred in any of them. In the remaining 3 patients, long-term follow-up could not be maintained. CONCLUSIONS: A hydatid cyst must be included in the differential diagnosis of cystic lesions of the spleen. A splenic hydatid cyst should be treated surgically due to the high risk of a rupture, and the ideal procedure in adulthood is standard splenectomy.