surge - spleen 2008
TRANSCRIPT
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SPLEENSPLEEN
EMMANUEL G. DIAZ, MD, MHA, FPCS, FPSGSEMMANUEL G. DIAZ, MD, MHA, FPCS, FPSGS
Department of SurgeryDepartment of Surgery
De La Salle University Medical CenterDe La Salle University Medical Center
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SURGICAL ANATOMYSURGICAL ANATOMY
Located at the left upper quadrantLocated at the left upper quadrant Arise from the mesodermArise from the mesoderm Evident during the 5Evident during the 5thth week of pregnancy week of pregnancy Has a notch at the anterior borderHas a notch at the anterior border
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SURGICAL ANATOMYSURGICAL ANATOMY
7 – 11 cms in length7 – 11 cms in length 150 gm average weight150 gm average weight Wedge-shaped with colic, gastric, renalWedge-shaped with colic, gastric, renal
& pancreatic impressions & pancreatic impressions diaphragm separates it from left lower lung diaphragm separates it from left lower lung
& left 9& left 9thth – 11 – 11thth ribs ribs
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SURGICAL ANATOMYSURGICAL ANATOMY
4 Suspensory ligaments of Spleen4 Suspensory ligaments of Spleen
1. Splenocolic1. Splenocolic
2. Gastrosplenic **2. Gastrosplenic **
3. Phrenosplenic3. Phrenosplenic
4. Splenorenal4. Splenorenal
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SURGICAL ANATOMYSURGICAL ANATOMY
Vascular supplyVascular supply
Splenic arterySplenic artery
Short gastric vesselsShort gastric vessels
Splenic veinSplenic vein
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HISTOLOGYHISTOLOGY
3 Elements of Splenic Parenchyma3 Elements of Splenic Parenchyma 1. Outer red pulp – cords & sinuses1. Outer red pulp – cords & sinuses
2. Middle marginal zone – plasma cell2. Middle marginal zone – plasma cell
3. Inner white pulp – lymphoid tissues3. Inner white pulp – lymphoid tissues
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PHYSIOLOGYPHYSIOLOGY
Basic functions of the SpleenBasic functions of the Spleen
1. Filtration1. Filtration
2. Immunologic2. Immunologic
3. Storage3. Storage
4. Cytopoiesis4. Cytopoiesis
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Diagnostic Procedures forDiagnostic Procedures forSplenic ImagingSplenic Imaging
1. Ultrasound ( US )1. Ultrasound ( US )
2. Computed Tomography ( CT )2. Computed Tomography ( CT )
3. Magnetic Resonance Imaging ( MRI )3. Magnetic Resonance Imaging ( MRI )
4. Radioscintigraphy4. Radioscintigraphy
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Diagnostic tests for Splenic Diagnostic tests for Splenic DisordersDisorders
AngiographyAngiography Plain & contrast radiographyPlain & contrast radiography Diagnostic Peritoneal Lavage ( DPL )Diagnostic Peritoneal Lavage ( DPL ) Bone marrow cytologyBone marrow cytology Coomb’s testCoomb’s test LaparoscopyLaparoscopy
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INDICATIONS FOR INDICATIONS FOR SPLENECTOMYSPLENECTOMY
1. Red cell disorders1. Red cell disorders
2. White cell disorders2. White cell disorders
3. Platelet disorders3. Platelet disorders
4. Bone marrow disorders4. Bone marrow disorders
5. Various diseases – 5. Various diseases – abscess, cysts, tumors, abscess, cysts, tumors,
trauma, portal hypertension, vascular trauma, portal hypertension, vascular
diseasesdiseases
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SPLENIC ABSCESSSPLENIC ABSCESS
Becoming rare occurrenceBecoming rare occurrence Routes of InfectionRoutes of Infection
1. hematogenous ( 75% )1. hematogenous ( 75% )
2. direct contiguous2. direct contiguous
3. trauma3. trauma
4. immunosuppression4. immunosuppression
5. hemoglobinopathy5. hemoglobinopathy
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SPLENIC ABSCESSSPLENIC ABSCESS
Clinical ManifestationsClinical Manifestations
- LUQ pain- LUQ pain
- fever- fever
- leukocytosis- leukocytosis
- painful splenomegaly- painful splenomegaly
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SPLENIC ABSCESSSPLENIC ABSCESS
Diagnosis - US , CT ScanDiagnosis - US , CT Scan
Treatment - broad spectrum antibioticsTreatment - broad spectrum antibiotics
- percutaneous drainage- percutaneous drainage
- splenectomy- splenectomy
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SPLENIC CYSTSPLENIC CYST
ClassificationClassification
1. Primary ( True )1. Primary ( True )
a. Parasitica. Parasitic
b. Non-parasiticb. Non-parasitic
2. Secondary ( False )2. Secondary ( False )
a. Traumatica. Traumatic
b. Inflammatoryb. Inflammatory
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SPLENIC CYSTSPLENIC CYST
Clinical Manifestations due to :Clinical Manifestations due to :
1. mass effect1. mass effect
2. pressure & adhesion2. pressure & adhesion
3. complications3. complications
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SPLENIC CYSTSPLENIC CYST
DiagnosisDiagnosis
- History & physical examination- History & physical examination
- US- US
- CT Scan- CT Scan
- MRI- MRI
Treatment - Treatment - SplenectomySplenectomy
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SPLENIC TUMORSSPLENIC TUMORS
Poor medium for malignant cell growthPoor medium for malignant cell growth Metastatic lesions from lung, breastMetastatic lesions from lung, breast Non-Hodgkin’s lymphomaNon-Hodgkin’s lymphoma AngiosarcomaAngiosarcoma HemangiomasHemangiomas
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SPLENIC TUMORSSPLENIC TUMORS
Clinical ManifestationsClinical Manifestations
- anorexia- anorexia
- weight loss- weight loss
- body weakness- body weakness
- splenomegaly- splenomegaly
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SPLENIC TUMORSPLENIC TUMOR Diagnosis Diagnosis - US- US - CT Scan - CT Scan - Peripheral smear- Peripheral smear - Percutaneous biopsy- Percutaneous biopsy - Laparoscopy- Laparoscopy
Treatment - SplenectomyTreatment - Splenectomy
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SPLENIC ARTERY SPLENIC ARTERY ANEURYSMANEURYSM
most common visceral artery aneurysmmost common visceral artery aneurysm 4x more common in elderly females4x more common in elderly females 2 cm size is indication for surgery2 cm size is indication for surgery presence of circular calcification at LUQpresence of circular calcification at LUQ
on x-ray is diagnosticon x-ray is diagnostic
Treatment - excision or ligationTreatment - excision or ligation
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SPLENIC INJURYSPLENIC INJURY
increasing incidenceincreasing incidence young male > femalesyoung male > females blunt abdominal trauma ** - most commonblunt abdominal trauma ** - most common Iatrogenic injuries result from undue Iatrogenic injuries result from undue
traction during surgerytraction during surgery
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SPLENIC INJURY SPLENIC INJURY
Clinical ManifestationsClinical Manifestations
- signs & symptoms of hypovolemia- signs & symptoms of hypovolemia
- Kehr’s sign , Ballance sign- Kehr’s sign , Ballance sign
- peritoneal irritation- peritoneal irritation
- left lower rib fracture- left lower rib fracture
- hematuria- hematuria
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SPLENIC INJURY SPLENIC INJURY
DiagnosisDiagnosis
- History & PE- History & PE
- anemia & decreasing hematocrit - anemia & decreasing hematocrit
- leukocytosis- leukocytosis
- US , CT Scan , DPL- US , CT Scan , DPL
- laparoscopy- laparoscopy
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SPLENIC INJURYSPLENIC INJURY Treatment depends on extent of injuryTreatment depends on extent of injury Splenic Injury ScaleSplenic Injury Scale ( ( AAST 1994AAST 1994 ) ) Grade I – subcapsular hematoma < 10%Grade I – subcapsular hematoma < 10%
laceration < 1 cmlaceration < 1 cm
Grade II – subcapsular hematoma 10 – 50%Grade II – subcapsular hematoma 10 – 50%
laceration 3 cmlaceration 3 cm
Grade III – subcapsular hematoma > 50%Grade III – subcapsular hematoma > 50%
laceration > 3cmlaceration > 3cm
Grade IV – deep hilar lacerationGrade IV – deep hilar laceration
Grade V – shattered spleenGrade V – shattered spleen
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SPLENIC INJURYSPLENIC INJURY
Treatment Options : Treatment Options :
1. Non-operative management1. Non-operative management
2. Operative management2. Operative management
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SPLENIC INJURYSPLENIC INJURY
Criteria for Non-operative managementCriteria for Non-operative management
1. Hemodynamic stability1. Hemodynamic stability
2. Negative abdominal examination2. Negative abdominal examination
3. CT Scan injury grade I, II or III3. CT Scan injury grade I, II or III
4. Younger age group4. Younger age group
5. No liver pathology5. No liver pathology
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SPLENIC INJURYSPLENIC INJURY
Clinical signs of failure of non-operative Clinical signs of failure of non-operative
management :management :
1. persistent tachycardia1. persistent tachycardia
2. hypotension2. hypotension
3. worsening abdominal findings3. worsening abdominal findings
4. falling hematocrit4. falling hematocrit
5. persistent ileus5. persistent ileus
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SPLENIC INJURYSPLENIC INJURY
Delayed splenic ruptureDelayed splenic rupture
- latent period of Baudet- latent period of Baudet
- occurs 2 – 7 days post trauma- occurs 2 – 7 days post trauma
- minor capsular or parenchymal - minor capsular or parenchymal
hemorrhage or lacerationhemorrhage or laceration
- diagnosis & treatment as above- diagnosis & treatment as above
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SPLENIC INJURYSPLENIC INJURY
Operative managementOperative management
- salvage vs splenectomy- salvage vs splenectomy
- midline laparotomy incision- midline laparotomy incision
- packing with hemostatic pads- packing with hemostatic pads
- fibrin glue , cautery , coagulator- fibrin glue , cautery , coagulator
- Splenorrhaphy , partial splenectomy- Splenorrhaphy , partial splenectomy
- Splenectomy ( open or laparoscopic )- Splenectomy ( open or laparoscopic )
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SPLENIC INJURYSPLENIC INJURY
Complications of SplenectomyComplications of Splenectomy
1. Pulmonary1. Pulmonary
2. Hemorrhagic2. Hemorrhagic
3. Infectious3. Infectious
4. Pancreatic 4. Pancreatic
5. Thromboembolic5. Thromboembolic
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SPLENIC INJURYSPLENIC INJURY
Overwhelmimg Postsplenectomy SepsisOverwhelmimg Postsplenectomy Sepsis
( ( OPSSOPSS / / OPSIOPSI ) )
- highest incidence in children- highest incidence in children
- causative agents: - causative agents: S. pneumoniaS. pneumonia
H. influenzaH. influenza
E. coliE. coli
N. meningitidisN. meningitidis
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OPSS / OPSIOPSS / OPSI
Clinical ManifestationsClinical Manifestations
- fever- fever
- muscle & headaches- muscle & headaches
- vomiting & diarrhea- vomiting & diarrhea
- abdominal pain- abdominal pain
- septic shock- septic shock
- DIC- DIC
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OPSS / OPSIOPSS / OPSI
Uncommon but fatalUncommon but fatal No current diagnostic testNo current diagnostic test Risk remains until 2 years postoperativeRisk remains until 2 years postoperative Polyvalent vaccine Polyvalent vaccine Penicillin administrationPenicillin administration
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THANK YOUTHANK YOU