Experience of splenic mass saving procedures in children

Splenic Mass Saving Procedures (SMSP) are used to prevent long-term risks of splenectomy. In order to assess the current state of SMSP in the surgery of the spleen, their efficacy and long term results, we reviewed the records of 289 children operated for the splenic lesion over a 15-year period. Splenectomy was performed in all cases of hematological disorders, with hemolytic disorders making up to 85% of the material. SMSP were effectively used in patients with epidermoid cysts (n=13), pseudocysts (n=2), parasitic cysts (n=2), hemangioma (n=1), and splenic injuries (n=14). The following SMSP were performed: partial splenectomy or cystectomy of epidermoid cysts; aspiration of parasitic cysts; unroofing and washing out the cavity with 20% saline; outer wall decapsulation with oversewing of the splenic wall of post-traumatic pseudocysts; suturing combined with ligation of the splenic artery in injuries involving major hilar vessels; suturing combined with excision of the emaciated lower pole. The postoperative course was free of complications in this series. Radioscintigraphic imaging and platelet counts showed preservation in splenic function in the follow-up period. It is concluded that: 1) SMSP represent 11% of splenic surgery in this series, 2) Non-splenectomy operations can be safely and effectively performed in order to avoid long risks of splenectomy, and 3) There is a variety of non-splenectomy operations that can be done in relation with the underlying pathology of the spleen.
Material and Methods Two hundred eighty nine children were operated for the splenic lesions during the between 1984 and 1998. Hemolytic disorders comprise 85% of this material, followed in order of frequency by splenic injuries, congenital cysts, thrombocytopenic purpura, myeloblastic syndromes, hydatid cysts, post-traumatic pseudocysts and Casabach-Merritt syndrome. Splenectomy was performed in all cases of hematological disorders. SMSP were performed on 32 patients (11%) with congenital cysts (13 cases), parasitic cysts (2 cases), pseudocysts (2 cases), hemangioma (1 case), hilar injuries (11 cases), and emaciation of the lower pole (3 cases) (Table 1.).
The age of patients submitted to SMSP ranged from 2 to 14 years. The male/female ratio was 1,2:1. There was a predominance in number of females over males in the benign <@147>tumors<@148> group and of males over females in the trauma group.
Results
Seventeen patients were admitted with cysts, as follows: 13 epidermoid, 2 parasitic and 2 post-traumatic. One patient was admitted with haemangioma. The size of the cyst ranged from 4 cm to 15 cm. Left upper quadrant abdominal discomfort was the main symptom in patients with large cysts. The enlarged spleen was palpable in 14/17 patients. Imaging techniques were employed for diagnosis. These included ultrasonography and CT scan. Ultrasonography accurately provided the diagnosis of splenic cysts as confirmed by operative findings. Hemisplenectomy was performed in 10 children with epidermoid cysts and in one child with hemangioma. Three children with epidermoid cysts underwent cystectomy. In two children solitary hydatid cysts were emptied of their contents by aspiration, and the resulting cavity was washed with 20% saline solution to kill the contained scolices. Two children with pseudocysts underwent partial decapsulation and oversewing of the outer wall. All epidermoid cysts had trabeculated internal surface and multiple septa. The cyst fluid was light yellow. Microscopic studies demonstrated epithelial lining. Hydatid cysts had epithelial lining without trabeculation. They contained crystal clear fluid as well as mother and daughter cysts. Pseudocysts had no epithelial lining. They contained fluid consistent with hematoma. Fourteen patients were admitted following blunt abdominal trauma. The diagnosis of splenic injury was established by ultrasonography and computed tomography. Non-operative treatment initially followed the diagnosis, but had to be discontinued due to the deterioration of vital signs and laparotomy was undertaken. Eleven patients had hilar injuries involving major segmental vessels. They were treated by suturing, combined with ligation of the splenic artery. Three patients with emaciation of the lower pole underwent hemisplenectomy. Postoperative recovery was free of complications in all the patients submitted to SMSP. Splenic function was routinely screened at 3-6 months after the operation. Platelet counts were normal. Radionuclide scans demonstrated normal uptake in this series, including the patients with ligated splenic artery.
Discussion
SMSP are enabled by the arterial network of the spleen and its anatomical arrangement. As it has been described by many authors, the hilar branches of the splenic artery are further divided into 5 or more branches, supplying the splenic parenchyma in a segmental fashion. The segmental vascularization of the spleen allows splenorrhaphy of transverse tears on the one hand, and partial splenectomy on the other hand (1, 7, 8, 10).
Partial splenectomy was performed on patients with epidermoid cysts, solitary hemangioma and injuries with emaciation of the lower pole. The main steps of the operation were: ligation of the segmental artery, mobilization of the spleen, sharp incision of the capsle, transsection on the demarcation line using the finger, hemostasis of the intraparenchymal vessels and suturing of the raw surface by either mattress or continuing sutures. No stapler was used in our patients (10). Not all epidermoid were dealt with by partial splenectomy. Instead, cystectomy was performed in 3 cases, by resection of the major portion of the cyst leaving behind a small part of the cyst wall (8). The collateral circulation of the spleen is derived mainly from the superior polar artery (which occurs within less than 2 cm before the bifurcation of the splenic artery in children), the short gastric arteries, and the left gastroepiploic artery whose branches traverse the gastroepiploic ligament. Additionally, minor vessels traverse the ligaments and peritoneal attachments of the spleen. If the spleen has not been mobilized and the splenic ligaments are intact, ligation of the splenic artery is permissible. In children, it was found that the spleen is visualized in radioscintigraphies after the ligation of the splenic artery in the hilum or the ligation of one of its branches (3, 4, 6). It was also demonstrated, by means of arteriographies, that the collateral arterial network develops rapidly after the ligation of the splenic artery (5). Finally, in experimental animals, revascularization was demonstrated by the development of small vessels bridging the two parts of the ligated artery (2). The ligation of the splenic artery as an adjunct to splenorrhaphy in rare injuries involving hilar vessels, has the immunologic advantage of preserving larger splenic mass than partial splenectomy. the latter is reserved for treatment of injuries with emaciation of splenic tissue.
Unroofing of pseudocysts and oversewing of the capsule was recommended by T o u l u k i a n (9) and gave excellent results in this series. Contrary to the recommendation that hydatid cysts should be treated by splenectomy (or at least partial splenectomy), we treated 2 patients by mere aspiration of the contents and washing out the cavity with 20% saline solution. This is the usual mode of treatment of solitary hydatid cysts in other organs, such as the lungs and occasionally the liver. Long term follow-up of 2 and 5 years respectively, confirmed the efectiveness of this minor procedure on solitary hydatid cysts of the spleen.
It is concluded from this material that the spectrum of indications of SMSP is large. SMSP are widely accepted in the surgery of the spleen and with increasing experience (11) some of them are now performed by means of laparoscopy.