Complete Splenic Infarction Research Articles

Indocyanine green fluorescence angiography-guided simultaneous laparoscopic distal gastrectomy and spleen-preserving distal pancreatectomy for conserving the gastrosplenic ligament: A case report.

Introduction and importanceIndocyanine green (ICG) fluorescence angiography is being increasingly performed intraoperatively to detect restricted blood flow intraoperatively for the prevention of postoperative organ ischemia and anastomotic leakage. This is the first case report of simultaneous laparoscopic distal gastrectomy (LDG) and spleen-preserving distal pancreatectomy (LSPDP) involving ICG angiography use to avoid the remnant stomach ischemia.Case presentationA 55-year-old man was diagnosed with early cancer of the stomach body and intraductal papillary mucinous neoplasms of the pancreatic tail. We performed simultaneous LDG with D2 dissection and LSPDP to conserve the gastrosplenic ligament and preserve blood supply to the remnant stomach. Intraoperatively, blood flow to the remnant stomach was visualized using ICG fluorescence angiography, after which Roux-en-Y reconstruction was performed. There was no perioperative remnant stomach ischemia.Clinical discussionDespite the preserved splenic artery and vein, complete splenic infarction occurs after LSPDP possibly due to thrombus formation during surgical procedures. In this patient, we conserved the gastrosplenic ligament for the short gastric artery, which supplied blood to the remnant stomach; however, remnant stomach ischemia may occur. Therefore, we performed ICG fluorescence angiography during this operation to ensure that sufficient blood supply to the remnant stomach was maintained.ConclusionOur experience demonstrates that ICG angiography may be useful for the prevention of remnant stomach ischemia.

S2961 Splenic Infarction Leading to Gastrosplenic Fistula in COVID-19

INTRODUCTION: Gastrosplenic fistulas are rare with no reported cases resulting from acute infarction. Coagulopathy is commonly reported in COVID-19 infection. We present a first instance of gastrosplenic fistula as sequalae of celiac artery plexus thrombosis resulting in splenic infarction in setting of COVID-19 infection. CASE DESCRIPTION/METHODS: A 51 year-old female with chronic gastritis & no personal or family history of thrombosis, treated for COVID-19 pneumonia 1 month prior, presented 2 weeks after discharge with epigastric pain, coffee ground emesis & fever. CT with angiography showed thrombosis of celiac trunk, common hepatic, splenic & left gastric arteries, fistulation of gastric wall & splenic fossa with gastric contents in spleen, splenic abscess & complete splenic infarction. Small bowel follow-through showed contrast in spleen. EGD visualized a large gastric fistula. No specimen was collected as surgical repair was planned. Labs showed positive SAR-CoV2 RNA, negative H. pylori stool antigen, stable hemoglobin 8-9.5g/dL, thrombocytosis of 703K/µL, fibrinogen 397mg/dL, heterozygous Factor V Leiden mutation, & no antithrombin 3 deficiency, protein S deficiency, or JAK2 mutation. She remained on antibiotics, IV heparin & PPI with no further signs of GI bleed. More conservative approach was favored & a percutaneous drain was placed into splenic abscess with cultures growing 2 strains of ESBL E. coli & Candida glabrata. Patient remained stable, tolerated diet & was discharged on long term antibiotics & anticoagulation. DISCUSSION: Gastrosplenic fistulas are rare & caused by gastric or splenic pathologies causing erosion & fistulation due to proximity. Literature review shows no reported cases of splenic infarction as cause of gastrosplenic fistula. We hypothesize COVID-19 related coagulopathy & underlying Factor V Leiden heterozygosity led to arterial thrombosis & complete splenic infarction as mechanism of fistulation. While gastric lymphomas & ulcers are reported causes, EGD 3 months prior showed unremarkable biopsies throughout & EGD during hospitalization showed no gastritis or other lesions. Splenic abscesses are reported in literature as cause of gastrosplenic fistulas. While no imaging timeline is established to rule out abscess as mechanism of fistulation, they are also rare & caused most commonly by hematologic seeding. With negative blood cultures, no other source of infection & triple organism abscess culture, it is more likely fistulation occurred with seeding of spleen through fistula.Figure 1.: Axial view of the upper abdomen. A gastrosplenic fistula is noted. There is a wall defect along the greater curvature of the stomach with gastric contents and air entering a fistulous tract that extends posterolaterally to the spleen.Figure 2.: EGD visualization of non-bleeding gastric fistula in wall of gastric body.Figure 3.: Radiograph of the upper abdomen five minutes after administration of oral contrast. Oral contrast is present within the stomach and the proximal duodenum. There is abnormal contrast in the left upper quadrant of the abdomen overlying the spleen.

Management of Visceral Artery Aneurysms with Preservation of Organ Perfusion: More Than Twenty Years Experience

Visceral artery aneurysms (VAA) are rare and often incidental findings. Indications for treatment are symptomatic patients, pseudoaneurysms and a true aneurysm of diameter of ≥ 2.5 cm for mesenteric arteries and ≥ 3 cm for renal artery aneurysms. Pregnancy and liver transplantation play an important role in aneurysm rupture. Technical success after open or endovascular procedure and maintenance of organ perfusion are crucial. The aim of this review is to evaluate our data and experience of more than 20 years and to develop a strategy to deal with visceral artery aneurysm in elective and emergency cases. Between 1995 and 2018, 179 patients (84 males, 95 females, median age 62 [18 - 87] years) were diagnosed with VAA at the Regensburg University Hospital. The site of aneurysm was the splenic artery in 113 (63%) patients (pts), hepatic and renal arteries in 22 and 21 pts (12% each), and gastropancreaticoduodenal artery in 14 (8%) and superior/inferior mesenteric artery in 9 (5%) cases. Surveillance without intervention occurred in 110 (62%) pts, and 34 (19%) pts underwent open and 35 (19%) endovascular repair. In all patients, preoperative imaging was performed, preferably by computed tomography angiography (CTA). A total of 69 patients underwent open or endovascular repair. 51 (74%) pts were treated electively, 18 (26%) pts presented urgently with acute bleeding. 16 emergency pts received endovascular treatment, and in 2 pts open surgery was performed. After emergency treatment, two pts exhibited segmental liver malperfusion without consequences. In one case, segmental bowel resection was necessary. 32/51 (63%) patients were treated electively by open surgery, 19/51 (37%) by endovascular procedures. There were no liver or bowel infarctions. Four splenectomies and one unilateral nephrectomy were necessary in patients with splenic or renal artery aneurysms. Moreover, three partial renal infarctions were noticed postoperatively (overall 8/21 [38%]). After endovascular repair of splenic or renal artery aneurysms, two cases of splenic and three cases of renal segmental infarction were observed. Splenectomy had to be performed twice (overall 7/14 [50%]). Organ perfusion was monitored by CTA, and preferentially by contrast enhanced ultrasound. The endovascular approach is the preferred option in an emergency to control bleeding in pseudoaneurysms. Patients for elective splenic or renal artery aneurysm repair have to be evaluated very carefully to achieve technical success with occlusion of the aneurysm and excellent organ perfusion. Imaging techniques such as ultrasound, especially CEUS, are strongly recommended in postoperative follow-up. Partial or complete splenic infarction leads to vaccination.

A retrospective study on the different methods of interventional therapy for splenic artery steal syndrome after liver transplantation

Objective To study the use of contrast-enhanced ultrasound in diagnosing splenic arterial steal syndrome (SASS) after liver transplantation, and to compare the curative effect, safety and follow-up results of the different embolization methods in the treatment of SASS after liver transplantation. Methods From January 2005 to December 2017, 41 patients after liver transplantation in our hospital developed splenic artery steal syndrome and were treated with splenic arterial embolization. All these patients underwent ultrasound, and in 19 patients contrast-enhanced ultrasonography was also done to detect the presence of splenic artery steal. The findings were confirmed by angiography. These patients then underwent splenic arterial embolization. In 32 patients coil embolization was done (group A) and in 9 patients embolization was assisted with Amplatzer occluders (group B). Results In all the 41 patients with SASS, angiography after splenic artery embolization showed the second and third order arterial branches in the liver increased in number and in diameter with good blood flow compared with those before treatment. The postoperative blood flow and pattern on ultrasound returned to normal. In group A, 12 patients (12/32, 37.5%) developed splenic infarction, including 11 patients with partial splenic infarction, and 1 patient developed a splenic abscess after complete splenic infarction. In group B, two patients developed partial splenic infarction (2/9, 22.2%). All the patients with splenic infarct had no clinical symptoms. No treatment was required except for the patient who developed splenic abscess after complete splenic infarction. The patient recovered well after treatment with antibiotics and splenic abscess drainage. There was no other complications. Conclusions Contrast-enhanced ultrasound provided early diagnosis of splenic artery steal after liver transplantation. Interventional splenic artery embolization was safe and effective to treat splenic arterial steal syndrome after liver transplantation. Coil embolization assisted with Amplatzer occluders was better than the traditional coil embolization with more accurate embolization site and fewer complications. Key words: Liver transplantation; Splenic artery steal syndrome; Contrast-enhanced ultrasound; Interventional treatment; Splenic arterial embolization

A case of complete splenic infarction after laparoscopic spleen-preserving distal pancreatectomy

BackgroundLaparoscopic spleen-preserving distal pancreatectomy (LSPDP), a newly developed operative procedure, is indicated for benign and low-grade malignant disease of the pancreas. However, few studies have reported on postoperative splenic infarction after LSPDP.Case presentationWe report a case of complete splenic infarction and obliteration of the splenic artery and vein after LSPDP. The patient was a 69-year-old woman with a 35-mm cystic tumor of the pancreatic body who underwent LSPDP. Although the operation was completed with preservation of the splenic artery and vein, postoperative splenic infarction was revealed with left back pain and fluid collection around the stump of the pancreas on postoperative day 9. Fortunately, clinical symptoms disappeared within days and additional splenectomy was not needed. Splenic infarction was attributed to scattered micro-embolizations within the spleen after drawing strongly on the tape encircling the splenic vessels.ConclusionPreserving splenic vessels in LSPDP is a demanding procedure. To prevent splenic infarction in LSPDP, we should carefully isolate the pancreatic parenchyma from the splenic vessels, and must avoid drawing tightly on the vessel loop encircling splenic vessels.

Laparoscopic Distal Pancreatectomy Using the Modified Prolonged Prefiring Compression Technique Reduces Pancreatic Fistula.

Pancreatic fistula (PF) is a common postoperative complication following distal pancreatectomy. The prolonged prefiring compression (PFC) technique to reduce PF has been described by Nakamura and colleagues in Japan. The present study assessed if this technique can be applied to the United Kingdom patient population in a tertiary referral center and replicate the low incidence of PF after the laparoscopic approach to distal pancreatectomy (Lap-DP). This is a retrospective study of all patients who underwent Lap-DP using the modified PFC technique by the senior author between June 2011 and July 2014. The modified PFC technique involved compression of the pancreatic parenchyma with an endo-stapler for a 3-minute period prior to firing and further 1-minute compression after firing prior to removal of the stapler, which is a small variant to the original technique of maintaining a 2-minute compression post firing. Twenty patients (15 females; median age, 66 [range, 25-77] years) underwent Lap-DP using the PFC technique during the study period. Six patients had splenic-preserving Lap-DP. Median operating time was 240 minutes (range, 150-420 minutes) with a median length of hospital stay of 6 days (range, 3-22 days). Six patients (30%) developed Type A (biochemically noted as high drain fluid amylase) PF, and none of the patients had Type B/C PF. In the splenic preservation group, 1 patient had complete splenic infarction requiring laparoscopic splenectomy on Day 3, and 1 patient had partial infarction requiring prolonged hospital stay for pain relief. One patient required prolonged respiratory support due to severe preexisting lung disease. Overall mortality was zero. Our data confirm that the PFC technique is safe, feasible, and effective in reducing clinically significant PF post-Lap-DP in the United Kingdom patient population.

Capnocytophaga canimorsus infection presenting with complete splenic infarction and thrombotic thrombocytopenic purpura: a case report

BackgroundAnimal bites are typically harmless, but in rare cases infections introduced by such bites can be fatal. Capnocytophaga canimorsus, found in the normal oral flora of dogs, has the potential to cause conditions ranging from minor cellulitis to fatal sepsis. The tendency of C. canimorsus infections to present with varied symptoms, the organism’s fastidious nature, and difficulty of culturing make this a challenging diagnosis. Rarely, bacterial cytotoxins such as those produced by C. canimorsus may act as causative agents of TTP, further complicating the diagnosis. Early recognition is crucial for survival, and the variability of presentation must be appreciated. We present the first known case of C. canimorsus infection resulting in TTP that initially presented as splenic infarction.Case presentation72-year-old Caucasian male presented with a four-day history of abdominal pain, nausea, vomiting, diarrhea, and intermittent confusion. On presentation, vital signs were stable and the patient was afebrile. Physical examination was unremarkable apart from petechiae on the inner left thigh, and extreme diffuse abdominal pain to palpation and percussion along with positive rebound tenderness. Initial investigations revealed leukocytosis with left shift and thrombocytopenia, but normal liver enzymes, cardiac enzymes, lipase, INR and PTT. Abdominal CT demonstrated a non-enhancing spleen and hemoperitoneum, suggesting complete splenic infarction. Although the patient remained afebrile, he continued deteriorating over the next two days with worsening thrombocytopenia. After becoming febrile, he developed microangiopathic hemolytic anemia and hemodynamic instability, and soon after was intubated due to hypoxic respiratory failure and decreased consciousness. Plasma exchange was initiated but subsequently stopped when positive blood cultures grew a gram-negative organism. The patient progressively improved following therapy with piperacillin-tazobactam, which was switched to imipenem, then meropenem when Capnocytophaga was identified.ConclusionsThere is a common misconception amongst practitioners that the presence of systemic infection excludes the possibility of TTP and vice versa. This case emphasizes that TTP may occur secondary to a systemic infection, thereby allowing the two processes to coexist. It is important to maintain a wide differential when considering the diagnosis of either TTP or C. canimorsus infection since delays in treatment may have fatal consequences.

Fatal, complete splenic infarction and hepatic infection due to disseminated Trichosporon beigelii infection

We report on a 56-year-old woman with acute lymphocytic leukemia who presented with right upper quadrant pain, fever, nausea, and vomiting. Laboratory studies confirmed fungemia with Trichosporum beigelii, and contrast-enhanced computed tomography of the abdomen demonstrated numerous low-attenuation liver lesions and a hypodense spleen with capsular enhancement suggestive of complete splenic infarction. Subsequent splenectomy confirmed that the spleen was completely infarcted and infiltrated with Trichosporum. The patient had a difficult postoperative course and died despite aggressive antifungal therapy.