Splenic Vein Thrombosis Research Articles

Portal Hypertension: 2 years Experience in Department of Pediatric Gastroenterology and Nutrition, at a Tertiary Care Hospital, Bangladesh

Background: Portal hypertension is a clinical syndrome defined by a pathologic increase of portal venous pressure. The objectives of this study were to evaluate etiological and clinical presentation of portal hypertension admitted in a tertiary care centre of Bangladesh.Materials and Methods: This cross sectional study was done at the Department of Paediatric Gastroenterology & Nutrition, BSMMU on 100 consecutive cases admitted during the period from July 2013 through June 2015. Confirmation of the presence of portal hypertension was done by demonstration of oesophageal varices during upper GI endoscopic examination. The diagnosis of chronic liver disease was based on a combination of clinical, biochemical (abnormal liver function tests) and ultrasonographic (coarse echotexture of liver) features. Extrahepatic portal hypertension was diagnosed on the basis of clinical, normal liver function test and ultrasonographic evidence of portal or splenic vein thrombosis, with or without cavernous transformation. Doppler ultrasound showed increase portal venous pressure.Results: Patient's age group was 2 to 15 years. 69 cases were extra hepatic portal hypertension. Haematemesis and/or melaena were found in 42(60.9%) and splenomegaly was found in 68(98.6%) cases. Of extra hepatic 69 cases 10% had history of umbilical sepsis. Of the 31cases of CLD with portal hypertension, haematemesis and/or melaena was found in 20(64.5%) cases, splenomegaly in 30(96.8%), ascites 8(25.8%).Most (50%) of CLD cases were cryptogenic followed by Wilson’s disease 29%. Of the 100 cases, endoscopy revealed grade 3 esophageal varices in 45% cases. All the patients were treated with propranolol. EVL was done in 70% cases.Conclusion: In this study, most of the cases were extra hepatic portal hypertension. Gastrointestinal bleeding & splenomegaly were found in most of the cases. No risk factor was found in most of extra hepatic cases. Portal vein thrombosis & cryptogenic were the most common cause in extra-hepatic and intra-hepatic cases respectively.J Shaheed Suhrawardy Med Coll, June 2016, Vol.8(1); 26-29

Laparoscopic Resection of Pancreatic Tumors in Children: Results of a Multicentric Survey.

This study aimed to report the results of a multicentric survey about laparoscopic treatment of pancreatic tumors in children. The data of patients operated using minimally invasive surgery (MIS) for a pancreatic tumor in 5 International centers of Pediatric Surgery in the last 5 years were retrospectively reviewed. We recorded data relating to the clinical presentation, diagnostic evaluation, surgical technique, and outcome. Fifteen patients (average age 2.2 years) were identified. The most common symptoms at presentation were related to the hypoglycemic hyperinsulinism, followed by abdominal pain and vomiting. Tumor types were insulinoma (n = 4), congenital hyperinsulinism of infancy (CHI) diffuse type (n = 3), CHI focal type (n = 3), solid pseudopapillary tumor (n = 2), and cystic malformation (n = 3). The diagnostic assessment was completed using ultrasound associated with computed tomography (CT) scan in all centers; 18FDOPA positron emission tomography in combination with CT was adopted in 2 centers. The MIS procedures performed were as follows: tumor enucleation (n = 4), distal pancreatectomy (n = 8), subtotal pancreatectomy (n = 2), and pancreatico-jejunostomy (n = 1). Average operative time was 110 minutes. As for postoperative complications, we recorded 1 persistent hypoglycemia, requiring redo-surgery (IIIb Clavien-Dindo) and 1 thrombosis of splenic vein, not requiring any treatment (I Clavien-Dindo). Laparoscopic resection can be considered a safe and effective treatment with minimal morbidity and excellent outcomes for most pediatric pancreatic tumors. Suspension of the stomach with a transparietal stitch and use of new hemostatic devices as Starion TLS3 or Ligasure are key factors for the success of the procedure. A long-term follow-up is mandatory in these patients to evaluate postoperative complications and long-term outcome.

Visceral thromboses (VT) in pancreas adenocarcinoma (PDAC): A systematic review.

268 Background: Within the spectrum of gastrointestinal malignancies, primary liver (HCC) and pancreatic ductal adenocarcinoma (PDAC) are frequently associated with visceral thromboses (VT). Thrombus formation in the portal (PVT), mesenteric (MVT), or splenic vein (SVT) system leads to portal hypertension and intestinal ischemia. VT in PDAC may convey a risk of increased distal thrombosis and poses therapeutic uncertainty regarding the role of anticoagulation. An increasing number of reports describe VT associated with PDAC. It is possible that early diagnosis of these events may help reduce morbidity speculatively improve oncologic outcomes. Methods: Perform a systematic review to study occurrences of visceral thromboses (portal, mesenteric and splenic vein thromboses) associated with PDAC and provide a clinical review on this area. Main databased were searched; PubMed, EMBASE, Web of Science, Scopus, and the Cochrane library. Two blinded independent observers extracted and assessed the studies for diagnosis of PVT, MVT, and SVT in PDAC. Studies were restricted to English literature published after 2007 to 2016. Results: Eleven articles were identified. Five case reports and 7 retrospective studies were found with a total of N=127 patients meeting the inclusion criteria. The mean age at diagnosis was 64 years. PVT was found in 35% (N= 46), SVT in 52% (N= 65), MVT in 13 %( N= 15). Mean follow up time was 26 months. Only 3 of the selected articles studied the impact of anticoagulation in visceral thrombosis. All patients with non-visceral thrombosis (e.g. DVT, PE) were therapeutically treated, in contrast, to only rare occurrences with VT received treatment. Conclusions: Visceral thrombosis in PDAC can be a frequent finding at diagnosis or during disease progression. This literature analysis has shown VT to be a poor prognostic indicator for short term survival. Evidence to guide treatment choices are inadequate and current management is based on inferred experience from other non-oncologic populations. Anticoagulation appeared to be a safe modality in visceral thrombosis with most of the large studies recommending a careful assessment for patients with high risk of bleeding.

Distal pancreatectomy for benign and low grade malignant tumors: Short-term postoperative outcomes of spleen preservation-A systematic review and update meta-analysis.

The value of spleen preservation with distal pancreatectomy (DP) for benign and low grade malignant tumors remains unclear. The aim of this study was to evaluate the short-term postoperative clinical outcomes in patients undergoing DP with splenectomy (DPS) or spleen preservation (SPDP). Online database search was performed (2000 to present); key bibliographies were reviewed. Studies comparing patients undergoing DP with either DPS or SPDP, and assessing postoperative complications were included. Meta-analysis of included data showed SPDP patients had significantly less operative blood loss, shorter duration of hospitalization, lower incidence of fluid collection and abscess, lower incidence of postoperative splenic and portal vein thrombosis, and lower incidence of new onset postoperative diabetes. For the whole group, there was no difference in incidence of postoperative pancreatic fistula (POPF) (RR = 0.95; 95%CI 0.65-1.40, P = 0.80), however, subgroup analysis of studies using ISGPF criteria showed that DPS patients had increased rates of Grade B/C POPF (RR = 1.35; 95%CI 1.08-1.70, P = 0.01). SPDP for benign and low grade malignant tumors is associated with shorter hospital stay and decreased morbidity compared to DPS. J. Surg. Oncol. 2017;115:137-143. © 2017 Wiley Periodicals, Inc.

Partial Splenectomy is Superior to Total Splenectomy for Selected Patients with Hemangiomas or Cysts.

The superiority of partial splenectomy (PS) as a treatment for benign tumors has not well been confirmed. This study aimed to identify the short- and long-term outcomes of PS, to compare laparoscopic and laparotomic PS, and to demonstrate whether the effects of PS are superior to that of total splenectomy (TS). Patients with either a hemangioma or cyst who underwent PS or TS from 2009 to 2015 at Qilu Hospital of Shandong University were included. Clinical parameters were collected and analyzed. A total of 17 patients underwent PS were collected, including 2 men and 15 women with a mean age of 43.9±11.3years old. Patients who underwent laparoscopic PS (9 cases) had a longer operative time and shorter postoperative hospital stay than those who underwent laparotomy (8 cases). Compared with TS (22 cases), PS significantly decreased the incidence of thrombocytosis, shortened time until drainage removal, and shortened postoperative hospital stay. After an average follow-up of 34.8months, patients who underwent TS showed a higher incidence of thrombocytosis and splenic vein thrombosis compared with patients underwent PS. PS is technically feasible and provides favorable short- and long-term outcomes for selected patients with either a hemangioma or cyst compared with TS. Laparoscopic PS shows lower morbidity and equal therapeutic efficacy compared with laparotomic PS and can be widely performed.

Pancreatic Neuroendocrine Tumors Complicated by Sinistral Portal Hypertension: Insights into Pathogenesis.

Purpose: To investigate the association between pancreatic neuroendocrine tumors (panNETs) and sinistral portal hypertension (SPH) and provide insights into the pathogenesis.Methods: A retrospective review of panNETs was conducted from our institution for 12 years. Medical imaging findings were analyzed to determine any association with splenic vein thrombosis (SVT) at diagnosis. The cases were further selected based on the criteria for SPH, namely, (1) presence of SVT, (2) gastric varices, (3) patent portal vein, and (4) normal liver function tests.Results: There were 61 patients with panNETs and 8 (8/61) had SVT and gastric varices at diagnosis. Four (4/8) met the strict criteria for SPH while the other four had more conventional portal hypertension. The four with SPH had large tumors located in the tail with splenic vein invasion and three of four presented with bleeding gastric varices. All four patients underwent surgical resection. Mean follow-up was 8.5 years and the hematemesis never recurred. The other four patients (four of eight) with gastric varices had unresectable disease and all died after a mean survival of 29 months.Conclusion: PanNETs appear to be more commonly associated with SVT and SPH compared with other tumors. This could be related to their relatively indolent nature and their intrinsic vascularity. From a surgical viewpoint, the decision to operate depends on many factors including but not limited to the size/stage, grade, and functionality of the tumor and comorbidities. These considerations notwithstanding, the association between panNETs and SPH suggests that there is benefit in timely resection of panNETs located in the tail.

Splenic abscess secondary to sleeve gastrectomy leak

Sleeve gastrectomy is currently a stand-alone bariatric procedure with a low complication profi le. A rare complication of leak following sleeve gastrectomy was reported in this study. A 34-year-old male patient with a body mass index of 69.9 was admitted to hospital four months after sleeve gastrectomy with epigastric pain and fever and was found to have a leak at the gastroesophageal junction demonstrated on CT scan. In addition, he had splenic vein thrombosis with partial splenic infarction infected with the formation of abscess. An endoscopic stent was used in order to cover the leak and percutaneous drainage of the splenic abscess was performed. Partial infarction of the spleen is not a rare occurrence after LSG. However, abscess development is extremely rare. Familiarity with these rare complications will allow for a prompt diagnosis and treatment.

Diagnosis and treatment of recurrent upper gastrointestinal bleed with endoscopic ultrasound (gastric varix with splenic artery aneurysm)

Background:Endoscopic ultrasound (EUS)-guided vascular therapy is evolving. Herein, we report a case of recurrent gastrointestinal bleed which was incriminated to gastric varix, but EUS picked up 3 cm splenic artery pseudoaneurysm which was treated by EUS-guided coil and glue.Case Report:A 33-year-old male, chronic alcoholic, presented with hematemesis in August 2015, for which three units of blood were transfused and upper gastrointestinal (UGI) showed esophageal varices with gastric varix, for which endoscopic sclerotherapy and glue injection were done, respectively. The patient remained asymptomatic for the next 18 months, when in January 2017, he presented with melena over 1 month requiring 10 units of blood transfusion. Patient underwent repeat UGI with endoscopic sclerotherapy and glue injection for esophageal and gastric varix. Ultrasound showed splenic vein thrombosis with collaterals around the splenic hilum. After 1 month in February 2017, he again had hematemesis and melena, for which after resuscitation, he was referred to SGPGI. The patient was diagnosed as having splenic vein thrombosis with gastric varix. Since patient had undergone multiple session of glue injection, he was planned for EUS-guided therapy of gastric varix. However, on EUS, a large 3 cm splenic artery pseudoaneurysm was picked up which was missed by prior imaging. Pseudoaneurysm was confirmed on computed tomography (CT) angiogram. The patient underwent endoscopic glue therapy for residual gastric varix and EUS guided-coil and glue in splenic artery. Obliteration after EUS therapy was confirmed by repeat EUS and CT angiogram after 2 weeks which showed no splenic artery aneurysm and patient had no symptoms.

Reversible Extrapyramidal Syndrome in a Patient with Splenic Vein Thrombosis without Overt Hepatic Dysfunction

Acquired hepatocerebral degeneration (AHD) is an extrapyramidal syndrome that develops secondary to hepatic dysfunction. It may accompany advanced liver disease and is related to the presence of portosystemic shunts. We describe a 44-year-old woman who presented with bleeding from gastric fundus varices secondary to splenic vein thrombosis and concomitant development of rapidly progressive extrapyramidal symptoms. No overt liver dysfunction was identified. Brain imaging demonstrated damage to the basal ganglia. The splenic artery was embolized with disappearance of the varices. Medical treatment consisted of amantadine and low-dose clonazepam for 6 months. The patient's neurologic symptoms gradually improved with few sequelae, although imaging demonstrated residual basal ganglia damage. This case highlights the need to identify reversible causes of AHD and treat them rapidly in order to halt progressive damage. The general prognosis of patients with AHD remains poor, and flow interruption in portosystemic shunts must always be taken into account. Rapid diagnosis and treatment could ameliorate the poor prognosis.

The fatty spleen: Severe hypertriglyceridemia leading to splenomegaly in a child

Abstract This report describes a 3-year-old male with splenomegaly that presented as an infant with pancreatitis, a pancreatic pseudocyst, and a liver nodule. The patient underwent prophylactic splenectomy at age 3 years due to rapid enlargement and increasing risk for traumatic hemorrhage. Pathology revealed lipid-laden histiocytes rather than stigmata of the expected diagnosis of sinistral hypertension from splenic vein thrombosis.

Spleen Stiffness in Myeloproliferative Disease Related Splanchnic Vein Thrombosis

Introduction: Myeloproliferative neoplasms (MPN) account for the majority of non-cirrhotic and non-malignant Splanchnic vein thrombosis (SVT). SVT comprises extrahepatic portal vein obstruction (EHPVO), Budd-Chiari syndrome (BCS), mesenteric vein thrombosis (MVT) and splenic vein thrombosis (SpVT). 30% of EHPVO and 45% BCS are attributable to MPN. Portal hypertension (PH) is a major complication of SVT and hepatic and splenic elastography is increasingly used as a non-invasive tool for the characterization of hepatic fibrosis and PH. We had already established in 17 patients with chronic liver disease (CLD) that SS was the only predictor of clinically significant PH (CSPH) with an AUROC of 0.908, SE=0.45, p<0.0001, 95% CI 0.821-0.996, Cut-off 44.3 kPa, sensitivity 88%, specificity 85%. We wished to explore the role of tissue stiffness in characterizing splenomegaly in MPN patients with SVT.Methods: As part of an observational study of patients with MPN-SVT (Mascot study) from September 2015 we assessed 18 patients with MPN-SVT for spleen stiffness (SS) and spleen size (SSz) using point shear wave elastography (ElastoPQ Phillips Healthcare system). 14 patients had measurements at two time points 3-8 months apart (median 4.5m). Their clinical and radiologic details are presented in Table 1. SVT was diagnosed 1-16 years prior to the investigations (median 5 years). Patients were treated with LMWH and warfarin. Most patients also received Aspirin at the outset and 2/14 patients had thrombolysis in the acute phase. Review of SVT with imaging by CT/MR was undertaken at 6-12 monthly intervals. MPN was diagnosed on the basis of blood and bone marrow morphology and molecular analysis. 1 patient had CALR mutation, the others JAK2V617F mutation. Treatment included venesection, Hydroxycarbamide, Pegylated Interferon and Ruxolitinib.Results: 8/14 were male, median age 45 years. All patients had splenomegaly at baseline. All patients showed stable or improved appearances of the site of thrombus with patent TIPS on follow-up imaging.9/14 were on MPN directed medication; median time between commencing medication and 1st SS measurement was 3 months (range -3m to 7 yrs) including 1 patient who commenced Ruxolitinib 3 months after 1st assessment but 7 months before the 2nd assessment (patient 12).In 6/14 patients SS worsened (pts 1-6, Table 1), SSz was stable or worse. 4/6 had TIPS and 4/6 had cytoreductive treatment including 2 receiving Ruxolitinib.In 6 patients SS reduced along with a reduction in SSz (pts 9-14). 2 had TIPS and 5/6 had cytoreductive treatment including 4 receiving Ruxolitinib.Patients with increasing SS over time also had microcytic erythrocytosis that persisted over the period of measurement. Patients with improving SS had improvement in the MCV leading to normal values of RBC and MCV (Fig 1).Conclusions:In this small pilot study on a cohort of well characterised MPN-SVT patients we have assessed SS and considered clinical variables affecting this. This study shows that1. Spleen elastography provides a novel method of characterising the spleen. In patients with CLD it correlates well with clinically significant PH.2. All patients with MPN-SVT have residual splenomegaly3. Patients had no recurrence of the SVT after adequate anticoagulation was instituted.4. More patients with reduction in SS received JAK2 inhibitor drugs.5. Reduction in SS is not a consistent feature of PH reduction via TIPS.6. Persistent microcytic erythrocytosis is seen in the patients with worsening spleen stiffness and improvement in patients with improving stiffness.7. The dynamics of splenomegaly in these patients remains unclear.Discussion: TIPS reduces portal pressure and in PH related to CLD and thereby reduces SSz. In our patients this has not been a consistent result. Previous studies have shown a reduction in SSz with Ruxolitinib. In our patients the reduction is size and stiffness is noted in patients on Ruxolitinib/Pegylated Interferon but it is not consistent. This lack of response in some patients occurs despite normalisation /improvement of counts. The persistence of splenomegaly with abnormal stiffness in the face of TIPS and cytoreduction is puzzling and worthy of longitudinal studies using elastography which may offer valuable insights into the role and behaviour of the spleen in these disorders. [Display omitted] [Display omitted] DisclosuresSekhar:Novartis: Research Funding.

Thromboembolism in Dogs with Protein-Losing Enteropathy with Non-Neoplastic Chronic Small Intestinal Disease.

Dogs with protein-losing enteropathy (PLE) are suggested to be at increased risk of developing thromboembolic events. However, with some exceptions, there are very few reports of thromboembolism in such dogs. This multicentre retrospective observational study describes a case series of thromboembolism (TE) in eight dogs with PLE secondary to non-neoplastic, chronic small intestinal disease. Seven dogs had poorly controlled PLE when the thromboembolic event occurred. Pulmonary thromboembolism (PTE) occurred in six dogs, while one dog developed splenic vein thrombosis and another had concurrent splenic vein and aortic TE. Six dogs died, all with PTE. Antithrombin activity was decreased in one of two dogs in which it was measured. Serum cobalamin and folate concentrations were measured in three dogs and cobalamin was subnormal in all three. Serum magnesium, measured in two dogs, was low in both. Dogs with uncontrolled chronic small intestinal disease and PLE are at risk for developing serious life-threatening TE, mostly PTE.

Assessment the Effect of Prophylaxis Therapy on Splenic and Portal Vein Thrombosis after Open Splenectomy: A Controlled Randomized Clinical Trial

&lt;p&gt;Splenic and portal vein thrombosis (SPVT) is considered as a serious complication of splenectomy with potential life-threatening. Chemoprophylaxis may help to curb the incidence of SPVT after splenectomy. This clinical trial study was conducted to determine the incidence rate of SPVT after splenectomy and investigate the effect of chemoprophylaxis to reduce its incidence. Sixty six patients undergoing open splenectomy were included in this single-blind clinical randomized controlled trial (RCT). Patients were randomly assigned in two groups of intervention and control using block randomization to either d receive 40 mg of enoxaparin subcutaneously once a day for 5 days and then 100mg aspirin for one month or no postoperative drug. After one month, all patients over a week underwent Doppler ultrasonography of the splenic, portal and superior mesenteric veins for thrombosis. The mean age of patients was similar between intervention and control groups (28.3±14.5 and 25.6±14.9, respectively) (P value=0.9).Furthermore, two groups were matched regarding distribution of gender. None of patients in intervention group developed portal vein thrombosis, while of 23 patients in control group, 2 (8.69%) subjects were diagnosed with portal vein thrombosis. The two groups had no statistically significant difference in the rate of portal vein thrombosis (P=0.18). Based on the results of our study, prophylaxis therapy had no effects in preventing portal vein thrombosis developed in patients undergoing open splenectomy for any reason.&lt;/p&gt;

Streptococcal Hepatic Abscess: A Rare Complication of Severe Necrotizing Pancreatitis

A 60-year-old female was admitted with severe pancreatitis of unknown etiology, with symptoms of epigastric abdominal pain, and nausea with vomiting. Contrast enhanced computed tomography (CT) scan showed large areas of non-enhancement of the pancreatic body, and extensive peripancreatic free fluid and stranding in the regions of the pancreatic head and tail consistent with acute necrotizing pancreatitis. She was also noted to have non-occluding thrombi of the superior mesenteric vein that extended into the portal vein and was started on long-term anticoagulation treatment with oral warfarin. Her clinical course was complicated by the development of a large pancreatic pseudocyst (11 x 13 x 23 cm on CT) that was managed successfully by endoscopic cystogastrostomy [Figure 1]. Unfortunately, after initial good recovery, she was hospitalized 3 months later with ascites and failure to thrive. A repeat contrast enhanced CT scan showed a large multi-loculated 7.4 x 7.8 x 9.2 cm mass in the liver involving caudate lobe, and right lobe of liver concerning for hepatocellular carcinoma [Figure 2]. On endoscopic ultrasound a large hypoechoic, heterogeneous mass was noted in the liver. Fine needle aspiration using a 25G needle was performed and on site evaluation by cytopathology showed extensive necrosis and acute inflammation concerning for hepatic abscess. Additional FNA was performed for culture and sensitivity that revealed gram-positive bacteria in clusters (Group F streptococcus). Patient was treated with longterm intravenous vancomycin. She had near complete resolution of liver abscess at 6-week follow-up. Pancreatic pseudocyst and splenic vein thrombosis are the known complications of severe pancreatitis. However, the development of a liver abscess possibly following pylephlebitis in the background setting of acute necrotizing pancreatitis is a rare entity with only a few cases reported in the literature. Our patient developed severe hepatic abscess and ascites mimicking hepatocellular cancer. Likely etiology of this abscess was superior mesenteric vein and portal vein thrombosis. This case highlights the rare complication of severe necrotizing pancreatitis and role of EUS guided tissue acquisition in diagnosis and management of hepatic abscess.Figure 1Figure 2

Hemosuccus Pancreaticus: An Unusual Cause of Gastrointestinal Bleeding

Introduction: Hemosuccus pancreaticus is a very rare cause of gastrointestinal (GI) bleeding, usually reported in patients with chronic pancreatitis, pancreatic tumors and pseudocysts. We describe a case of hemosuccus pancreaticus from a gastroduodenal artery aneurysm's bleeding. Case description: 50 year old male with no past medical history presented to the hospital, after a syncopal episode causing a motor vehicle accident. He complained of progressive fatigue and melena for one week. On exam, his vitals were stable. Physical exam showed pale conjuctiva. Laboratories showed hemoglobin of 3 mg/dl. Liver profile, coagulation panel and basic metabolic panel were normal. CT abdomen showed multiple hemorrhagic cysts in pancreas and splenic vein thrombosis. Patient received appropriate blood transfusions. Upper endoscopy revealed non bleeding gastric varices and gastritis. Hospital stay was complicated with hemoglobin drop, requiring daily transfusions. Single ballon push enteroscopy was done, and after three attempts, bleeding in to the ampulla of Vater was identified. The patient underwent angiogram. Bleeding from gastroduodenal artery aneurysm was found, which was coiled to stasis. Discussion: Hemosuccus pancreaticus is defined as hemorrhage into pancreatic duct. It is an extremely rare cause of GI bleeding. It is almost always seen in association with chronic pancreatitis, pseudocysts and tumors. Most common cause of bleeding is from splenic artery aneurysm, however bleeding from pseudocysts, celiac artery, gastroduodenal artery and pancreaticoduodenal artery aneurysms into the pancreatic duct have also been reported. It is associated with high mortality rates if untreated. Diagnosis is made by visualization of bleeding from pancreatic duct during endoscopy. Angiography can identify the source of bleeding if performed during active hemorrhage. If angiography is negative or treatment is not feasible, surgery should be considered emergently. Our patient had a history of alcohol abuse without any previous episode of pancreatitis. During his hospitalization he had intermittent bleeding that made his diagnosis difficult. Hemosuccus pancreaticus should be suspected as a cause of GI bleeding in patients with history of chronic pancreatitis or imaging evidence of pancreatic cysts or tumors. Upper GI endoscopy or angiography during active hemorrhage aids in diagnosis. Endovascular coiling is the treatment of choice in patients with known source of bleeding.

Laparoscopic partial splenectomy: a study on 13 cases

Objective To evaluate the feasibility and clinical value of laparoscopic partial splenectomy to treat benign splenic diseases. Methods The clinical data of 13 patients who underwent laparoscopic partial splenectomy carried out by a single operating surgeon from June 2010 to January 2016 in our hospital were analyzed retrospectively. The enrolled patients included 6 with a splenic epidermoid cyst, 4 with a splenic pseudocyst and 3 with splenic hemangioma. The lesion diameters ranged from 5.1 to 12.4 cm, with an average of (7.2±2.3) cm. Results The operations were all successful. There was no conversion to laparotomy and there was no perioperative death. The operations included 4 upper pole splenic resection, 5 lower pole resection, 2 middle and upper pole resection and 2 middle and lower pole resection. The operative time ranged from 95 to 155 min, with an average of (119±17) min. The volume of intra-operative blood loss ranged from 100 to 350 ml, with an average of (187±78) ml. There was no postoperative bleeding, pancreatic fistula, digestive fistula, intra-abdominal infection, splenic vein thrombosis and other complications after the operation. The average postoperative hospitalization stay was (5±1) d. Conclusions In carefully selected patients, laparoscopic partial splenectomy carried out by experienced surgeons to treat benign splenic diseases is safe and feasible. Key words: Benign spleen diseases; Partial splenectomy; Laparoscopy

Dépistage systématique d’une thrombose veineuse splénique ou portale après splénectomie

BackgroundPortal and/or splenic vein thrombosis (PSVT) is common after splenectomy. It can be a life-threatening complication, with a risk of bowel ischemia and portal hypertension. An early diagnosis allows an effective medical treatment and prevents life-threatening complications. There is no consensus regarding the benefit of systematic screening of patients after splenectomy for PSVT. We started in January 2012 a routine screening of PSVT after elective splenectomy. The aim of this study was to assess this policy. MethodsSince January 2012, all patients undergoing an elective splenectomy had an abdominal CT-scan on postoperative-day 7. Demographic data, pathology, type of surgery, platelet counts before and after surgery, outcome, results of medical imaging, and management of PSVT and its results were recorded. ResultsOver 3 years, 52 patients underwent an elective splenectomy. All of them had a CT-scan at postoperative-day 7. A PSVT was found in 11 patients (21.2 %). They were all asymptomatic. Lymphoma and splenomegaly were the main factors associated with PSVT in the univariate analysis. All patients with PSVT were treated with anticoagulation and no complication of PSVT occurred. The follow-up CT confirmed the efficacy of anticoagulation therapy in all patients. ConclusionsRoutine screening of PSVT after elective splenectomy is warranted because it allows to start anticoagulant therapy and avoid further life-threatening complications. The incidence of PSVT is particularly high among patients operated on for lymphoma or with splenomegaly.

Outcomes of transjugular intrahepatic portosystemic shunt creation for flow-enabled dissolution of spleno-mesenterico-portal venous thrombosis.

To evaluate the outcomes of transjugular intrahepatic portosystemic shunt (TIPS) for flow-enabled clearance of portal (PVT), splenic (SVT) and/or superior mesenteric (MVT) vein thrombosis. In this single-center study, 12 patients underwent TIPS using Viatorr covered stent-grafts (W.L.Gore & Associates, Flagstaff, AZ, USA) from 2008-2014 for PVT as a primary (n=8) or secondary (n=4) indication. TIPS were not accompanied by pharmacomechanical clot disruption; rather, shunts served to increase portal blood flow to allow flow-mediated physiologic clot dissolution. Pre- and post-TIPS cross-sectional imaging were used to assess clot location, size, and clearance, defined by resolution (vessel patency with no clot), reduction (decrease in clot size), stability (no change in clot size), or extension (increase in clot size). The cohort included 5 men and 7 women (median age 63 years, range 45-73 years, median MELD score 15) with 30 non-occlusive and asymptomatic thrombi spanning main or intrahepatic PVT (n=15/30, 50%), SVT (n=6/30, 20%), and MVT (n=9/30, 30%). TIPS were generally created with 10mm covered stent-grafts; mean final portosystemic pressure gradient was 8mmHg. At mean 190 days post-TIPS, 58% (n=7/12) had clot resolution, 33% (n=4/12) had clot reduction, and 8% (n=1/12) had stable clot; there were no cases of clot extension. Resolution rate was 67% for PVT (10/15), SVT (4/6), and MVT (6/9). Two of 12 (17%) patients underwent successful liver transplant post-TIPS. TIPS prompts dissolution of or decrease in PVT, SVT, and MVT in cirrhotic patients. This may be a useful approach notwithstanding omission of pharmacomechanical methods.

Clinical efficacy of complex splenectomy in 235 patients

Objective To explore the clinical efficacy and safety of complex splenectomy. Methods The retrospective cohort study was adopted. The clinical data of 235 patients including 135 from Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, 67 from Shanghai Jiaotong University Affiliated First People's Hospital, 26 from Shanghai Jiaotong University Affiliated Sixth People's Hospital, 7 from 85 Hospital of PLA who underwent complex splenectomy from January 2005 to December 2015 were collected. All the patients received total splenectomy after splenic artery ligation. The observation indexes included: (1) surgical situations, (2) major complications including intraperitoneal hemorrhage, pulmonary complication, left subphrenic abscess and peritoneal effusion, (3) follow-up situations: portal vein (PV) complications (splenic venous thrombo-phlebitis, thrombosis of splenic vein and main portal vein thrombosis), survival of patients. The follow-up using outpatient examination and telephone interview was performed up to March 2016, and patients received regularly ultrasound reexamination, computed tomography (CT) rescan, routine blood retest and coagulation function. Measurement data with normal distribution were presented as ±s, and count data were analyzed using the chi-square test. Results (1) Surgical situations: of 235 patients, 200 patients underwent secondary spleen pedicle severance and 35 patients underwent non-secondary spleen pedicle severance. Volume of intraoperative blood loss and duration of splenic resection were (268±103)mL and (82±29)minutes. (2) Major complications: of 31 patients with postoperative complications, intraperitoneal hemorrhage was detected in 12 patients, pulmonary complication in 17 patients, left subphrenic abscess in 3 patients and massive peritoneal effusion in 21 patients. Some patients were combined with multiple symptoms. The patients with above complications were cured after reoperations and non-operative treatments. (3) Follow-up situations: PV complications: splenic venous thrombo-phlebitis was detected in 16 patients, thrombosis of splenic vein in 17 patients, thrombosis of splenic vein combined with main portal vein thrombosis in 7 patients, and they were improved after the treatments of anti-inflammation, anti-coagulation and thrombolysis. The thrombi rate after splenectomy was 32.4%(12/37) in patients with schistosoma-related cirrhosis and 8.1%(12/149) in patients with HBV-related cirrhosis, with a statistically significant difference (χ2=10.9, P<0.05). Survival of patients: of 235 patients, 228 were followed up for (7.9±4.2)years, with good survival. Conclusion Complex splenectomy is safe and effective, and the key procedure determining the safety of complex splenectomy includes careful preoperative evaluation, delicate surgical technique, proper splenic pedicle severance and peritoneal wounds. Key words: Portal hypertension; Complex splenectomy; Splenomegaly

Coronary renal shunt via splenic vein for portal hypertension after splenectomy

Objective To investigate the clinical efficacy of coronary renal shunt via splenic vein for portal hypertension (PHT) after splenectomy. Methods The retrospective descriptive study was adopted. The clinical data of 5 patients with PHT who were admitted to the People's Hospital of Ningxia Autonomous Region from August 2012 to April 2015 were collected. Operative procedures: two procedures of coronary renal shunt via splenic vein (SV) were carried out after primary splenectomy. Procedure 1: the SV was freed from the residual end to the right for 5-6 cm in length and end-to-side spleno-renal shunt was carried out. The anterior wall of superior mesenteric vein (SMV) was exposed beneath the pancreatic neck and dissected behind the neck upward until the upper edge of the SV and its confluence with the left gastric vein (LGV) were exposed. The SV was ligated with clip between portal vein (PV) and LGV to let blood flow from LGV drain through the whole course of SV to left renal vein (LRV). Procedure 2: the peritoneum at the inferior border of the pancreas was incised, and the junctions of the SV and SMV and junctions of the SV and LGV were exposed. The inferior mesenteric vein (IMV) was divided between ligations. Dissection of the SV was carried out to the left for 3-4 cm in length and was divided. Its distal end was tied and proximal stump anastomosed to LRV by the end-to-side anastomosis. The SV was ligated with clip between PV and LGV. The right gastric and gastroepiploic vessels were ligated at the junction of the antrum and the body, and from this point, the hepatogastric ligment and the omentum were divided upward and downward respectively to completely separate the venous flow between the hepatointestinal area and the stomach in the two procedures. Patients took oral enteric-coated aspirin and warfarin after operation. (1) Intraoperative observation indicators included surgical procedures, operation time, volume of blood loos and free portal pressure (FPP). (2)Postoperative observation indicators included recovery of patients, time to anal exsufflation, time for diet intake, time of abdominal drainage, duration of hospital stay and occurrence of complications. (3)The follow-up using telephone interview and outpatient examination was performed to detect the changes of platelet (PLT), portal vein thrombosis (PVT), patency of spleno-renal vein anastomosis, oral anticoagulants and gastroesophageal varices up to October 2015. Measurement data with skewed distribution were analyzed by M (range). Results (1)Intraoperative observation indicators: 5 patients underwent successful coronary renal shunt via splenic vein. Two patients received procedure 1 and 3 patients received procedure 2. Operation time and volume of blood loss were 226 minutes (range, 195-298 minutes) and 425ml (range, 235-820 mL). FPP was 3.46 kPa (range, 2.69-4.61 kPa) before spleen resection, 2.69 kPa (range, 2.11-3.07 kPa) after spleen resection, 2.98 kPa (range, 2.30-3.36 kPa) after spleno-renal anastomosis, respectively. (2)Postoperative observation indicators: 5 patients had good recovery, and time to anal exsufflation, time for fluid diet intake, time of abdominal drainage removal and duration of hospital stay were respectively 3 days (range, 2-4 days), 3 days (range, 2-4 days), 5 days (range, 4-9 days) and 14 days (range, 10-17 days). Of 5 patients, 1 was complicated with pleural effusion and atelectasis and 1 with serum tumescence of incision. (3) Follow-up situations: 5 patients were followed up for a median time of 18 months (range, 6-36 months). The level of postoperative PLT was continuously growing, and the dose of oral warfarin was increased according to the level of growing PLT. The follow-up results of procedure 1 in 2 patients: 1 patient was followed up for 36 months and complicated with splenic vein thrombosis at postoperative month 6, and underwent transcatheter hepatic arterial chemoembolization (TACE) due to primary liver cancer at postoperative month 12, and then no special treatment was conducted due to splenic vein occlusion and sever esophageal varices without red-color sign or bleeding at postoperative month 36. The other patient was followed up for 24 months, and didn't undergo special treatment due to mild hepatic encephalopathy with a level of blood ammonia of 76 μmol/L at postoperative month 3, and then was found to have mild esophageal varices at postoperative month 18 by computed tomography (CT) and gastroscopy. Three patients using procedure 2 were followed up at month 6, 12, 18, with increased body mass index (BMI) and without occurrence of peritoneal effusion and hepatic encephalopathy, and they were complicated with mild gastroesophageal varices by reexamination of CT angiography and gastroscopy at postoperative month 6. Conclusion Coronary renal shunt via splenic vein for PHT after splenectomy could relieve hypersplenism and reduce selectively vein decompression of gastroesophageal varices. Key words: Portal hypertension; Coronary renal shunt; Trans-splenic vein; Splenectomy; Selective shunt