Case Report
Open Access
Splenic Artery Embolization for Massive Splenomegaly
Di Martino Marcello*, Mora-Guzman Ismael, Mingo Basail Alberto and Sanchez-Urdazpal Luis
Hospital Universitario de La Princesa, Madrid, Spain
*Corresponding author: Marcello Di Martino, Hospital Universitario de La Princesa, Calle Diego de Leon, 62, 28006, Madrid, Spain; Tel: +34654583554; E-mail:
@
Received: November 30, 2016; Accepted: December 15, 2016; Published: January 27, 2017
Citation: Di Martino M, Mora-Guzmán I, Mingo Basáil A, Sánchez Urdazpal L (2017) Splenic Artery Embolization for Massive Splenomegaly. Gastroenterol Pancreatol Liver Disord 4(1): 1-3. DOI: http://dx.doi. org/10.15226/2374-815X/4/1/00182
Abstract
Massive splenomegaly is related to several challenges for the
surgeon and higher intraoperative complications, due to the limited
working space, the difficulties in spleen manoeuvre and the increase
in bleeding. A splenic artery embolization can be performed before
the surgery, in order to decrease both the size of the spleen and the
risk of bleeding.
Here, we report the case of a 56-year-old man diagnosed with massive splenomegaly, secondary to a marginal splenic lymphoma, which had a maximum diameter of 54 cm. The surgery was recommended because of progressive anemia requiring monthly transfusion of red blood cells, thrombocytopenia, abdominal pain and constitutional symptoms. A splenic artery embolization was undertaken just prior to the splenectomy, in order to achieve a decrease in spleen size and to reduce the risk of intraoperative bleeding. The surgery was performed uneventfully. The diameters of the resected spleen were 48 x 24 x 11 cm and its weight was 6,300 g. The splenic artery embolization is a reliable preoperative procedure before surgery for massive splenomegaly.
Keywords: Splenomegaly; Splenectomy; Massive splenomegaly; Splenic artery embolization
Here, we report the case of a 56-year-old man diagnosed with massive splenomegaly, secondary to a marginal splenic lymphoma, which had a maximum diameter of 54 cm. The surgery was recommended because of progressive anemia requiring monthly transfusion of red blood cells, thrombocytopenia, abdominal pain and constitutional symptoms. A splenic artery embolization was undertaken just prior to the splenectomy, in order to achieve a decrease in spleen size and to reduce the risk of intraoperative bleeding. The surgery was performed uneventfully. The diameters of the resected spleen were 48 x 24 x 11 cm and its weight was 6,300 g. The splenic artery embolization is a reliable preoperative procedure before surgery for massive splenomegaly.
Keywords: Splenomegaly; Splenectomy; Massive splenomegaly; Splenic artery embolization
Abbreviations
MS: massive splenomegaly; SAE: splenic artery embolization;
CT: computed tomography
Introduction
Massive splenomegaly (MS) has been defined as a spleen >17-
20 cm in length or >1000-1,500 g in weight [1, 2]. Splenectomy
for MS presents several challenges for the surgeon; therefore, in
order to reduce intraoperative complications, decreasing both
the size of the spleen and the risk of bleeding, a splenic artery
embolization (SAE) can be performed before the surgery
Here, we report a case of MS with a weight of 6,300 g and a diameter of 48 x 24 x 11 cm submitted to splenectomy combined with SAE.
Here, we report a case of MS with a weight of 6,300 g and a diameter of 48 x 24 x 11 cm submitted to splenectomy combined with SAE.
Case report
A 56-year-old man with marginal splenic lymphoma was
recommended for splenectomy because of progressive anaemia
(4.5 g/dL), requiring monthly transfusion of red blood cells,
leucocytosis (107,000/mm3), thrombocytopenia (63,000 /
mm3), abdominal pain and constitutional symptoms. Clinical
exam showed a massive splenomegaly that overtook the midline
and reached the hypogastric region. Preoperative computed
tomography (CT), performed 6 months before the surgery,
confirmed the enlarged spleen with a diameter of 54 x 28 x 14
cm associated with moderate ascites, bilateral pleural effusion
and enlarged retroperitoneal lymph nodes (Fig. 1). Bone marrow
aspiration demonstrated a low-grade B lymphoproliferative
disorder, CD5 +, CD19+ and CD20+. A complete splenic artery
embolization (SAE) was performed three hours prior to
surgery. The catheter tip, inserted through the femoral artery,
was advanced to the splenic artery distal to the gastroepiploic
artery, and Polyvinil Alcohol Foam of 700 -100 microns, coils
IMWCE-35-15-10 COOK and an Amplazter Vascular Plug 4 were
injected inside the vessel (Fig 2A). A posterior angiogram was
performed to verify the complete occlusion of the splenic artery
(Fig 2B). The patient did not complain of pain, and an evident
decrease in spleen size was observed on physical examination
Figure 1: Computed tomography showing a coronal section of the giant
abdominal mass reaching the pelvis.
(Fig. 3). The patient was placed in the left semilateral position
and an open splenectomy through a left Makuuchi incision was
performed without intraoperative complications. Intraoperative
blood loss was 300 cc, the operative time was 180 minutes.
The resected spleen weighed 6,300 g and had a diameter of
48 x 24 x 11 cm. The pathologic report described a low-grade
B lymphoproliferative disorder, CD5+, CD20+ and Bcl-2+,
compatible with marginal splenic lymphoma stage IVB Ann
Arbor. The post-operative course was characterized by a postoperative
ileus. The total length of hospital stay was 16 days
Discussion
Laparoscopic splenectomy, since its first report in 1991
[3], has become the gold standard for normal-sized spleen,
Figure 2: Angiogram realized before selective splenic artery embolization
(2A) and later (2b), showing the coils and the Amplazter Vascular
Plug in the splenic artery (black arrow)
Figure 3: Spleen size before (A) and after embolization (B).
although massive splenomegaly removal is associated with
higher intraoperative complications compared to normalsize
splenectomy. The main challenges for the surgeon are
represented by the limited working space, the difficulties in
spleen manoeuvre and the increase in bleeding risk, because of
its peculiar vascularity. Targarona et al. [4], in their series of 186
patients submitted to splenectomy, reported that all spleen over
3.2 kg required conversion, although later reports have shown
low conversion rate even in spleen > 3 kg [5]. For this reason, an
open approach can be reasonably preferred in selected patients
like ours, which represents one of the biggest spleen resected
after SAE.
The SAE prior to surgery, firstly described by Maddison in 1973 [6], represents a reliable procedure as it can decrease spleen size, intraoperative bleeding and operative time. As shown by Iwase et al. [7], a decrease of 60% in spleen volume can be observed after SAE. In our case, a significant reduction in the size of the spleen was observed after the embolization, and this achievement considerably simplified the surgery. Naoum et al. [8] reported a significant reduction in intraoperative blood from 240 mL to 25 mL (p < 0.003) when SAE was performed. Even though it is generally recommended realizing a SAE for spleen > 20 cm, a consensus about the indication of the procedure and the timing does not exist.
Complications related to SAE have been described. Postinfarction syndrome, as well as pancreatitis or pancreatic necrosis, and acute gastritis ulcers may occur [9]. Post infarction syndrome is characterized by fever and left flank pain. It has been recommended to perform the SAE the day before or on the same day as the surgery, but probably the best strategy to decrease the likelihood of uncontrolled pain is to carry out the procedure on the day of the splenectomy or combine both procedures in an intraoperative approach.
The SAE prior to surgery, firstly described by Maddison in 1973 [6], represents a reliable procedure as it can decrease spleen size, intraoperative bleeding and operative time. As shown by Iwase et al. [7], a decrease of 60% in spleen volume can be observed after SAE. In our case, a significant reduction in the size of the spleen was observed after the embolization, and this achievement considerably simplified the surgery. Naoum et al. [8] reported a significant reduction in intraoperative blood from 240 mL to 25 mL (p < 0.003) when SAE was performed. Even though it is generally recommended realizing a SAE for spleen > 20 cm, a consensus about the indication of the procedure and the timing does not exist.
Complications related to SAE have been described. Postinfarction syndrome, as well as pancreatitis or pancreatic necrosis, and acute gastritis ulcers may occur [9]. Post infarction syndrome is characterized by fever and left flank pain. It has been recommended to perform the SAE the day before or on the same day as the surgery, but probably the best strategy to decrease the likelihood of uncontrolled pain is to carry out the procedure on the day of the splenectomy or combine both procedures in an intraoperative approach.
Conclusion
SAE represents a safe and feasible technique in cases of
massive splenomegaly, in order to reduce the spleen size and
the risk of bleeding. The laparoscopic approach should be
recommended, however, in selected cases, an open approach
represents a valid alternative to the extent of reducing the
chances of intraoperative complications.
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- Targarona EM, Espert JJ, Cerdan G, Balague C, Piulachs J, Sugranes G, et al. Effect of spleen size on splenectomy outcome. A comparison of open and laparoscopic surgery. Surg Endosc. 1999;13(6):559-562.
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