Splenic cyst.BJ Birmole, BK Kulkarni, MM Vaidya, SS Borwankar
Dept of Paediatric Surgery, KEM Hospital and Seth GS Medical College, Parel, Bombay, Maharashtra.
Correspondence Address: Source of Support: None, Conflict of Interest: None PMID: 0008295148
Source of Support: None, Conflict of Interest: None
An 11 year old boy presenting with cystic lump in left hypochondrium was diagnosed to have splenic cyst and treated successfully by splenectomy. Large, infected cyst involving hilum was the indication.
Keywords: Case Report, Child, Cysts, diagnosis,surgery,Human, Male, Splenic Diseases, diagnosis,surgery,
The congenital non-parasite cysts comprise about 10% of all splenic. cysts. The traditional treatment of splenic cysts had been splenectomy,. During the last decade, the recognition that splenectomy has potential for short and long term complications, particularly in children, has led to emphasis on conservation of splenic tissue,. Despite the above fact, not all splenic cysts can be treated with partial splenectomy. We report a case in which a large splenic cyst involving the hilum was removed by splenectomy.
An 11-year-old boy presented to our general hospital with a lump in the left hypochondrium of 1 year duration. He had pain and intermittent fever for 15 days. There was a history of a fall 1 year back. The trauma was a trivial one, which did not require admission. He had never been treated for malaria and had no history suggestive of a hematologic disorder.
On examination he was afebrile, anicteric and pink. A well-defined cystic lump was palpable moving well with respiration and the fingers could not be insinuated between the lump and the costal margin. The superior border of the lump was not felt and firm tissue of 2 cm diameter could be palpated on the inferior aspect. There was moderate tenderness. The renal angles were not full. The liver was not palpable and there were no signs of free fluid in abdomen. Clinically a splenic cyst or pseudocyst of pancreas was suspected.
Plain X-ray of abdomen revealed displacement of the stomach bubble to the right and a soft tissue shadow without calcification in the left hypochondrium. Ultrasonography showed a cystic mass of 12 x 11 x 11 cm size in the left hypochondrium with Splenic tissue of around 3 cm thickness on its inferior aspect. There were plenty of internal echoes and the pancreas was not visualised. There was no free fluid in abdomen and kidneys were normal. His blood counts, peripheral blood smear, urine, stool and serum bilirubin were normal.
An exploratory laparotomy was performed by the left supraumbilical transverse incision. There was no fluid in the peritoneal cavity. There was a large cyst arising mainly from upper pole of spleen involving the hilum, displacing the stomach towards the right and the colon inferiorly. There was a nodule of splenic tissue of 3 cm diameter on the inferior aspect of the cyst. Plenty of thick adhesions between cyst and parietal peritoneum were present. To facilitate dissection, 1000 ml of brownish fluid was aspirated from the cyst. The decision to perform total splenectomy was taken as an infected parasitic cyst could not be ruled out. After opening the lesser sac, the splenic vessels were individually ligated and transfixed. Thick adhesions required careful division especially towards the diaphragm.
No drain was kept. Post-operatively the patient was kept on penicillin prophylaxis. Examination of the aspirated fluid showed proteinacious material, no pus cells and proteins of 6.6 gm%. Fluid culture showed growth of pseudomonas. The histopathology report of the spleen was an epidermoid cyst lined by squamous epithelium.
There are approximately 120 cases of benign true congenital cysts reported prior to 1982. The first description of the condition was by Andral in 1829 and of surgical treatment was by Pean, a french surgeon in 1867. Till 1980, the conventional treatment of non-parasitic cysts was splenectomy, The last decade saw an increasing trend towards partial splenectomy although it is unclear exactly how much splenic tissue is required for normal function. The technique has to be individualised to the pathology concerned.
Splenic cysts have been classified by Martin. Type I cysts are primary (true) cysts with a cellular lining, either parasitic or non-parasitic Non-parasitic type I cysts are either congenital or neoplastic. Type II cysts are secondary (false) cysts without cellular lining. Epidermoid cysts lined by squamous epithelium without skin adnexa and grossly a glistening inner surface are congenital cysts thought to be due to an embryonic defect in the aggregation of the mesodermal islands. Patients with congenital splenic cysts are younger than those with false cysts and marked female preponderance is observed. The majority of patients with splenic cysts have minor non-specific symptoms and the diagnosis is easily made by non-invasive imaging. Cysts arising from adjacent organs especially the tail of the pancreas can be an ultrasonic differential diagnosis. Aspiration of the cyst content will not further differentiate true from false cysts or subclassify the congenital Cysts.
Surgery is primarily recommended for the prevention or treatment of complications. Infection haemorrahage and rupture have been reported and may be life threatening. The percutaneous aspiration represents the final logical progression in favour of conservative approach. Since the cysts have an epithelial lining, the reaccumulation of fluid ultimately required partial spienectomy. In spite of partial splenectomy as the preferred approach, Brown et al reported that a total splenectomy was required in one out of seven patients, where the cyst was large, encompassing hilum with only tiny island of splenic tissue. This particular report includes a similar case where partial splenectomy was not feasible.
The world literature reveals that infected lesions are treated by splenectomy or by incision and drainage. The first report of partial splenectomy for infected cyst is by Khan et al from Canada. The multiple adhesions all around and bacterial culture suggested infection of the cyst which necessitated total splenectomy. The haemorrhage in the cyst could be due to trauma, infection or spontaneous.
Hydatid disease is the commonest cause of splenic cyst in this country. The infected hydatid cyst with adhesions all around is difficult to differentiate from infected congenital cyst. The search of the available literature revealed only one previous report of partial splenectomy. This particular hydatid was uninfected and the plane of cleavage was easily found. In our patient external examination of the cyst did not rule out the possibility of an infected hydatid cyst and a safer approach of total splenectomy was followed.
Parlial splenectomy limited by technical difficulty and risk of recurrence was a more difficult proposition than total splenectomy and long-term antibiotic prophylaxis.