Partial Splenic Embolization for Portal Hypertension Before Radical Nephrectomy in Renal Cell Carcinoma Patient: A Case Report

Background: Esophageal varices are one of the most common symptoms of direct outcomes of portal hypertension besides ascites, hepatorenal syndrome, and hypersplenism. Nonselective beta-blockers or band ligation are currently the effective primary preventive options for variceal hemorrhage. The use of partial splenic arterial embolization for the management of variceal hemorrhage in patients with portal hypertension has been described in a small number of reports. Case Report: A girl, 6 y.o., was hospitalized with hematemesis with hypovolemic shock. Laboratory findings show anemia and thrombocytopenia. Radiology and endoscopy show grade III esophageal varices with hepatosplenomegaly. Because of the high risk of morbidity in surgical procedures, partial splenic embolization was performed to treat portal hypertension. Discussion: The combination of varices and a low platelet count puts these patients at high risk for catastrophic hemorrhage. Partial splenic embolization reduces splenic blood volume, resulting in a decrease in venous drainage and a reduction in portal venous flow and pressure. Conclusion: The use of partial splenic arterial embolization to manage variceal hemorrhage in patients with portal hypertension has been described. Embolization can be used alone or in combination with other therapies, like endoscopic ligation or retrograde transvenous variceal obliteration, to treat a variety of conditions. Keywords: Embolization, esophageal varices, splenomegaly, portal hypertension

Solid Renal Masses in Transplanted Allograft Kidneys: A Closer Look at the Epidemiology and Management.

Successful treatment of severe thrombocytopenia in a cirrhotic patient with portal hypertension using partial splenic artery embolization

Comparative Effectiveness for Survival and Renal Function of Partial and Radical Nephrectomy for Localized Renal Tumors: A Systematic Review and Meta-Analysis

Radical Nephrectomy for pT1a Renal Masses May be Associated With Decreased Overall Survival Compared With Partial Nephrectomy

Background and aim of studySpleen is the largest lymphoid organ on the human body, it has a very important immunological functions. Portal hypertension accompanied liver cirrhosis commonly leads to splenomegaly which may be complicated by hypersplenism. Also liver cirrhosis is frequently associated with decreased hematological indices with subsequent anemia, thrombocytopenia and leucopenia. Spontaneous bleeding can delay any surgical or endovascular intervention. Leucopenia with decreased immunity may interfere with treatment of cancer patients using chemotherapy. The objective of this prospective study is to achieve the maximum splenic tissue infarction with the least possible complications by performing partial splenic artery embolization in cases of hypersplenism through comparing two materials; gel foam in one group and microspheres in another group. Patients and methodsThe study was conducted from October 2014 to September 2015. Thirty patients included in this study were presented by hypersplenism. They were 14 males and 16 females with mean age of 51 years. All patients were subjected to full history taking, clinical examination, laboratory investigations, pelvi-abdominal US and interventional procedure (transcatheter partial splenic artery embolization). The patients were divided into two groups, group (1): Fifteen patients were subjected to partial splenic embolization (PSE) using gel foam, group (2): Fifteen patients were subjected to partial splenic embolization (PSE) using microspheres. ResultsMultiple complications appeared after the procedure some of them were of minor importance as post embolization syndrome (fever, pain and nausea) that continued for two days and disappeared in five patients. Haematemesis occurred in one patient of the first group. One case in the first group showed abscess formation after the procedure and this patient underwent the procedure using gel foam particles, four cases showed portal vein thrombosis, two in each group, Pleural effusion appeared in two patients of first group. Regarding the efficacy of the procedure, improvement in laboratory tests were nearly the same in both groups. However, regarding the occurrence of serious complications, the microsphere particles group show fewer complications than gel foam group. ConclusionPSE using gel foam or microsphere showed nearly the same efficacy with no significant difference between the improvement in laboratory tests. However, using microsphere particles was associated with fewer occurrences of serious complications when compared with using gel foam.

Struck By Tsunami: Difficult Case of a Severe Refractory ITP

No. 396 Partial splenic artery embolization: a nonsurgical approach to hypersplenism

Splenic artery embolization is an additional way to treat the sequel of portal hypertension like variceal hemorrhage (prevention and treatment), hypersplenism, hepatogenic ascites, and hepatic encephalopathy. Partial splenic embolization (PSE) has been widely used in selected patient for the management of sequels of portal hypertension, where other form of therapy is not useful or feasible because of either comorbid condition or deranged liver functions. Two methods are usually used for partial splenic arterial embolization; selective partial embolization and nonselective partial embolization. Proper selection of patients, intervention technique, aseptic measure, antibiotic coverage, and post-procedure care are key factors of success of PSE.

Renal cell carcinoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up†.

Guideline for Management of the Clinical T1 Renal Mass

A 59-year-old woman presented with frequent episodes of hepatic encephalopathy due to cirrhosis caused by primary biliary cholangitis and a large splenorenal shunt, leading to repeated hospital admissions. We administered maximal medical therapy and enemas to prevent constipation, but her situation did not improve. Subsequently, balloon-occluded retrograde transvenous obliteration (BRTO) was considered;however, because the splenorenal shunt was large and liver function was poor (Child-Pugh C), BRTO might have caused a sudden rise in portal venous pressure and uncontrolled ascites. Therefore, we performed partial splenic artery embolization (PSE), embolizing 43% of the splenic volume, mainly in the lower portion. After PSE, her blood-ammonia level fell and consciousness improved. Since then, she has been hospitalized only once for recurrent encephalopathy. PSE-commonly used for hypersplenism or portal hypertension-decreases splenic venous return and portal pressure, thereby reducing splenorenal-shunt flow and directing ammonia-laden blood to the liver. Thus, PSE is a useful treatment option for hepatic encephalopathy, particularly in patients with large portosystemic shunts.

Oncological Outcomes of Partial Nephrectomy for Multifocal Renal Cell Carcinoma Greater Than 4 cm

Renal cell carcinoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up

BackgroundHypersplenism, one of the major complications of portal hypertension, is traditionally treated by splenectomy. However, partial splenic artery embolization is an evolving minimally invasive intervention to treat these patients effectively.Case presentationA 13-year-old girl was referred for further evaluation of isolated splenomegaly with pancytopenia. She did not have bleeding manifestations or features of anemia. She never had hematemesis or melena. On examination, she was pale. Abdominal examination revealed massive splenomegaly of 10 cm below the costal margin without hepatomegaly. Rest of the examination was unremarkable. Her investigations revealed a white cell count of 1700/mm3 (neutrophils 9.8% and lymphocytes 88.7%), hemoglobin 9.5 g/dL and platelet count 42,000/mm3. Blood picture showed pancytopenia without abnormal cells. Her reticulocyte count was 1.9%. Complete liver profile was normal. Abdominal ultrasonography revealed massive splenomegaly with the oblique length of 17 cm and normal echogenic liver with normal size. Cavernous transformation of portal vein with portal hypertension was evident. Mesenteric angiogram showed portal vein thrombosis and markedly tortuous splenic artery. Anti-nuclear antibodies and double-stranded DNA were negative. Ham test and urine for hemosiderin were negative. Clauss fibrinogen assay was normal. Hemoglobin high performance liquid chromatography for hemoglobin subtypes was normal. Anti-phospholipid antibodies were negative. JAK2 V617F mutation was not identified. Diagnosis of pre hepatic portal hypertension was made. Her upper gastrointestinal endoscopy was normal. Partial splenic artery coil embolization was done by interventional radiology team. Vaccines against capsulated organisms were given. Post-procedure contrast abdominal computed tomography revealed infarction of approximately 70% of the spleen and blood counts were improved. Index case is in the follow up for 3 years. She is on penicillin prophylaxis with regular blood count and annual upper gastrointestinal endoscopy monitoring.ConclusionsMinimally invasive interventions such as partial splenic artery embolization should be considered in managing the patients with hypersplenism secondary to portal hypertension.