A New Approach to the Treatment of Large Splenic Cysts: Transgastric Puncture and De-epithelialization under Endosonographic Guidance

Introduction. Splenic cysts are rare benign neoplasms, occurring with an incidence of approximately 0.75 per 100,000 population per year. These neoplasms are significantly less common than cystic lesions of other organs, such as the liver, pancreas, and kidneys, and account for less than 1% of all cystic lesions of internal organs. In most cases, splenic cysts are asymptomatic and are discovered incidentally during instrumental examinations. For a long time, surgical treatment of patients with splenic cysts involved open or laparoscopic spleen resection, as well as splenectomy. However, in recent years, minimally invasive treatment approaches have become increasingly used in clinical practice, particularly ultrasound-guided cyst drainage followed by sclerotherapy and de-epithelialization of the cyst walls. Clinical observation. A 20-year-old female patient underwent surgical treatment in the Surgical Endoscopic Department of the A.V. Vishnevsky National Medical Research Center of Surgery for a nonparasitic cyst located in the hilum of the spleen, measuring over 6 cm. Results. In our clinical observation of a patient with a large splenic cyst, we successfully performed a minimally invasive procedure involving endoluminal transgastric puncture and endosonographically guided splenic cyst de-epithelialization. Conclusion. Endoscopic endoluminal transgastric puncture followed by endosonographically guided splenic cyst de-epithelialization represents an optimal minimally invasive technique and a preferred alternative to traditional surgical interventions.

BACKGROUND Splenic cysts are classified as either parasitic or non-parasitic cysts, with both types sharing similarities in their clinical presentation and imaging findings. Most splenic cysts are of parasitic origin, while non-parasitic splenic cysts are less common. Splenic epidermoid cysts (SECs) are a rare subtype of non-parasitic cysts and compromise only around 10% of them. CASE REPORT In this paper we present a case of 22-year-old man with no significant past clinical history, who presented with non-specific, vague symptoms, including persistent left upper-quadrant pain and discomfort for the last 2 years. A physical examination and extensive laboratory tests were inconclusive. Subsequently, the patient underwent multiple imaging studies including ultrasonography and computed tomography (CT) scan of the abdomen. His ultrasonographic findings were consistent with the diagnosis of hydatid cyst, which was further emphasized by its frequent occurrence in clinical practice, as our country is considered an endemic region. In light of this, he underwent laparoscopic splenectomy following percutaneous cyst drainage. The consequent histopathological examination revealed the diagnosis of splenic epidermoid cysts. CONCLUSIONS When encountering splenic cysts in regions where parasitic infections are endemic, special attention is needed, as physical examination, laboratory tests, and imaging studies alone are insufficient to differentiate among the types of cysts. Histopathological examination remains the diagnostic tool of choice, particularly when imaging findings are inconclusive. Splenectomy, with either a laparoscopic or open approach, is the treatment of choice for splenic cysts to prevent recurrence as well as other potential catastrophic complications.

BackgroundSpontaneously ruptured large splenic cyst is a rare in children, and traditionally total or partial splenectomy has been performed for treating an emergent case. We herein present a first case with spontaneously ruptured pediatric splenic cyst treated with emergent laparoscopic dome resection with omental suturing to the parenchymal edge of the spleen.Case presentationA 12-year-old girl with a spontaneously ruptured large non-parasitic splenic cyst (SC) was successfully treated by emergent laparoscopic dome resection with omental suturing to the edge of the splenic parenchyma. The patient presented with acute abdominal pain and was diagnosed with a ruptured non-parasitic SC and peritonitis by contrast-enhanced computed tomography (CT). Emergent laparoscopic dome resection of the SC and omental suturing to the splenic parenchymal edge were then performed. The protruding part of the cyst wall was completely resected using an ultrasonically activated device (USAD), and the greater omentum was then sutured to the anterior edge of the splenic parenchyma under a laparoscopic view. No complications were observed during the operation. A histological examination revealed a congenital splenic cyst lined by epithelial cells. The postoperative course was uneventful, and an ultrasound scan showed no evidence of cyst recurrence at 3 years after the operation.ConclusionsThis minimally invasive laparoscopic procedure was feasible and effective for treating a ruptured large splenic cyst in an emergent pediatric patient.

Large splenic epithelial cyst: A rare presentation

The nonparasitic primary splenic cysts are very rare clinical entity. In the past, splenectomy was the treatment of choice but with the recognition of the spleen's important immunological function, spleen-preserving surgery is the preferred treatment modality. We hereby present a case of a large splenic mesothelial cyst and its treatment with preservation of the remaining splenic parenchyma. Our case shows that spleen-preserving surgery in treatment of the large splenic cysts is possible and safe procedure with maintenance of the splenic function.

Key Clinical MessageThe splenic epidermoid cysts are rare benign tumors, and a definitive treatment remains unclear. Although some spleen‐preserving approaches have been reportedly used, splenic cyst recurrence usually occurs in true cyst cases, wherein the cyst is incompletely removed. In our case, partial splenectomy was performed and the giant cyst was completely removed.

Partial decapsulation of splenic epithelial cysts: Studies on etiology and outcome

BackgroundNon-parasitic splenic cysts are associated with elevated serum carbohydrate antigen (CA) 19–9 levels. We report a case in which a 23-year-old female exhibited a large ruptured splenic cyst and an elevated serum CA19–9 level.Case presentationThe patient, who experienced postprandial abdominal pain and vomiting, was transferred to our hospital and was found to have a large splenic cyst during an abdominal computed tomography (CT) scan. On physical examination, her vital signs were stable, and she demonstrated rebound tenderness in the epigastric region. An abdominal CT scan revealed abdominal fluid and a low-density region (12 × 12 × 8 cm) with enhanced margins in the spleen. The patient’s serum levels of CA19–9 and CA125 were elevated to 17,580 U/mL and 909 U/mL, respectively. A cytological examination of the ascitic fluid resulted in it being categorized as class II. Finally, we made a diagnosis of a ruptured splenic epidermoid cyst and performed laparoscopic splenic fenestration. The patient’s postoperative course was uneventful, and she was discharged on postoperative day 5. The cystic lesion was histopathologically diagnosed as a true cyst, and the epithelial cells were positive for CA19–9. Follow-up laboratory tests performed at 4 postoperative months showed normal CA19–9 (24.6 U/L) and CA125 (26.8 U/L) levels. No recurrence of the splenic cyst was detected during the 6 months after surgery.ConclusionLaparoscopic fenestration of a ruptured splenic cyst was performed to preserve the spleen, after the results of abdominal fluid cytology and MRI were negative for malignancy.

Primary splenic epithelial cyst is an unusual event in everyday surgical practice with about 800 cases reported until date in the English literature. Splenic cysts may be parasitic or non-parasitic in origin. Nonparasitic cysts are either primary or secondary. Primary cysts are also called true, congenital, epidermoid or epithelial cysts. Primary splenic cysts account for 10% of all benign non-parasitic splenic cysts and are the most frequent type of splenic cysts in children. Usually, splenic cysts are asymptomatic and can be found incidentally during imaging techniques or on laparotomy. The symptoms are related to the size of cysts. When they assume large sizes, they may present with fullness in the left abdomen, local or referred pain, symptoms due to compression of adjacent structures (like nausea, vomiting, flatulence, diarrhoea) or rarely thrombocytopenia, and occasionally complications such as infection, rupture and/or haemorrhage. The preoperative diagnosis of primary splenic cysts can be ascertained by ultrasonography (USG), computed tomography or magnetic resonance imaging, although the wide use of USG today has led to an increase in the incidence of splenic cysts by 1%. However, careful histopathological evaluation along with immunostaining for presence of epithelial lining is mandatory to arrive at the diagnosis. The treatment has changed drastically from total splenectomy in the past to splenic preservation methods recently.

Splenic cysts remain an unusual pathology in surgical practice. Traditionally, splenic cysts are classified into two main categories. (1) True cysts which are also referred to as primary cysts, these contains epithelial lining and (2) pseudo cysts which are basically devoid of the epithelial lining and mostly are of post-traumatic origin. Majority of splenic cysts are asymptomatic, often they are inadvertently revealed during physical abdominal examination or following use of various abdominal imaging techniques. However, splenic cysts may produce pressure symptoms to the adjacent organs and manifest as an unusual pain and heaviness in the left hypochondriac region. We herein, present a 35-year-old lady with a giant non-traumatic splenic pseudo cyst. Her main presenting symptom being long standing history of intervallic left upper quadrant abdominal pain. Splenic cystic lesions remain a rare pathology in our sub region. Therefore, this report serves as a reminder to clinicians in our setting to consider splenic cyst as a differential diagnosis when evaluating patients with left upper quadrant abdominal pains. Several surgical therapies have been recommended for management of splenic cysts. However, today where feasible, minimally invasive and spleen-salvaging alternatives are highly regarded as standard approaches. Key words: Spleen, splenic cyst, splenic pseudocyst, non-parasitic splenic cysts, non-traumatic splenic pseudo cyst, left upper quadrant abdominal pain.

Introduction: Splenic pseudo cysts are extremely uncommon. Most of these cysts are asymptomatic and may result from previous blunt abdominal trauma. We report an interesting uncommon case of a large splenic pseudo cyst without a history of previous abdominal trauma. Case Presentation: 44 years old female with normal BMI, married, non-smoker, non-alcoholic, and housewife. She had no past medical or surgical history and was not on any oral medications. She presented with upper abdominal pain and discomfort for 6 months. Irregular pain with mild intensity associated with shortness of breath, her physical examination was unremarkable. The abdominal ultrasound and contras-enchased CT showed a large splenic cyst occupying the lower pole of the spleen, Echinococcus multilocularis antibody test was negative (Titer<1:16), Thus the Echinococcosis was excluded from the differential diagnosis. The differential diagnosis, in this case, was a non-parasitic splenic cyst. The patient underwent elective diagnostic laparoscopic with laparoscopic splenectomy. Discussion: The patient had an uneventful postoperative recovery course. He was discharged from the hospital on the third postoperative day (within the expected time frame), and instructed to avoid heavy lifting for a few months and to complete the post-splenectomy vaccination protocol. Conclusion: Pseudocyst of the spleen is quite uncommon in routine clinical practice and should be differentiated from more common lesions such as hydatid cysts, abscess of the spleen, etc. The Pseudocyst of the spleen is usually asymptomatic and is detected incidentally during the abdominal scan for other reasons. Splenectomy is the gold standard treatment for splenic pseudocysts. Partial splenectomy is the recommended procedure if at least 25% of splenic parenchyma is achievable.

Patient: Male, 16-year-oldFinal Diagnosis: Splenic epidermoid cystSymptoms: Abdominal asymmetry • abdominal distention • decreased oral intakeMedication: —Clinical Procedure: Open splenectomySpecialty: SurgeryObjective:Rare coexistence of disease or pathologyBackground:Splenic epidermoid cysts rarely occur and the majority of cases are discovered incidentally. However, large cysts can present with symptoms due to mass effect. Splenectomy is the treatment indicated for most splenic cysts and definitive diagnosis can only be made after histopathological examination.Case Report:A 16-year-old boy was referred to the general surgery clinic from a local hospital with a history of abdominal asymmetry, distention, decreased oral intake, and early satiety. Abdominal computed tomography (CT) was performed and revealed a large splenic mass measuring 18.4×14×17.4 cm with multiple mural calcifications at the rim. The mass was displacing the stomach, jejunal loops, pancreas, left kidney, and transverse colon. Preoperative biopsy was not possible because a parasitic cyst was suspected; therefore, splenectomy was performed through midline laparotomy. The patient recovered well, with no complications except for transient reactive thrombocytosis. Histopathology was reported as benign epithelial cysts, with the most likely diagnosis being a splenic epidermoid cyst. Subsequently, the patient was followed up at the surgery clinic. During the last outpatient visit, the patient exhibited good recovery with no problems.Conclusions:Large splenic epidermoid cysts are rare, particularly in the pediatric population. Nonspecific clinical and radiological findings are hurdles to an accurate diagnosis. Preoperative diagnosis is crucial to determine the type of intervention. However, a final diagnosis can only be made after histopathological examination.

Ex vivo resection of giant epidermoid cyst and vascularized partial splenic autotransplantation: 3.5-year follow-up

A case report of a large Splenic epidermoid cyst treated with partial splenectomy

Unusual Cause of Abdominal Pain