Partial splenectomy for treatment of splenic hemangioma

Introduction
Since 1984, we have performed subtotal splenectomy combined with splenorenal shunt or portal-variceal disconnection, with the aim of preserving splenic function of 128 patients who have undergone treatment for schistosomatic portal hypertension (1,2). Other 59 patients with severe splenic trauma (3,4), ten with myeloid hepatosplenomegaly due to myelofibrosis (5), eight with Gaucher’s disease (6), four with somatic and sexual development retardation associated with splenomegaly (7), two with splenic cysts, two with painful splenic ischemia (8), one with Hodgkin’s disease, one with chronic lymphocytic leukemia (9) and one with cysta-denoma of the pancreas (10,11,12).
Even being rare, hemangioma is the most common neoplasm of the spleen with a rate that range between 0.03 % and 14 % (13,14,15). In the majority of cases, this vascular tumor is symptomless, and its diagnosis is achieved per chance through imaging examination of the abdomen for other reasons (15,16). They grow generally to less than four centimeters, although the hemangioma may be larger and in this case or when discomfort occurs a treatment is indicated (13,14).
The greatest risk of a larger hemangioma is its possible rupture with severe hemorrhage (14,17). Despite the successful treatment with embolisation of the specific splenic arterial branch to the hemangioma or with radiotherapy (17,18,19), and with antiangiogenic therapy 20), the best results are achieved with splenectomy, either by laparotomy or laparoscopy (13,14,16, 21,22,23,24).
Although total splenectomy may solve the problem of the hemangioma, a very severe illness, namely asplenia, is provoked by this procedure. Presently, there is no doubt about the importance of the spleen, mainly in the defense against infections (25,26,27).
In order to avoid the complications of the asplenism and the precocious death due to isolated or associated sepsis, conservative procedures on the spleen, such as partial splenectomy, subtotal splenectomy and splenic autotransplants after total splenectomy have been proposed with very positive results. It must be considered that no overwhelming or severe infection, neither precocious death have been registered after conservative splenic surgical procedures (1-12, 28,29,30).
The purpose of this study is to present partial splenectomy as a good option for the treatment of splenic hemangioma.

Case report
A thirteen-year-old boy complaining of intense and persistent testicular pain, was diagnosed of left varicocele, identified at the physical examination. The pathogenesis of this abnormality was investigated and a big hemangioma of the lower pole of the spleen was identified by mean of an abdominal CT scan. (Fig. 2a) This tumor compressed the renal pedicle at the level of the testicular vein entrance. Due to the diagnosis of a symptomatic splenic hemangioma the surgical procedure was indicated.
The abdomen was entered through a left subcostal incision of ten centimeters. Initially the splenic artery was tied in the retrogastric space in order to decrease the blood flow to spleen. The frenocolic, splenorenal and splenofrenic ligaments were divided and the lower splenic pole was devascularized. The lower part of the spleen, containing the hemangioma was sectioned, leaving two free wedges. The parenchymatous vessels were sutured with 3-0 chromic catgut thread. The splenic capsule wedges of the remnant spleen were sutured with 3-0 chromic catgut. The spleen was replaced in its bed. (Fig. 1)
The surgical procedure was carried out almost without bleeding events and no technical problem. The patient was given diet on the day following the surgical procedure and was discharged from the hospital on the second postoperative day. The over twenty five-month-follow-up period was uneventful and the patient returned to his normal activities in the second postoperative week. The testicular pain did not occur anymore and the varicocele disappeared completely. The hematological and immunological blood tests did not show any abnormality. The imaging examination, using CT-scan and scitigraphy with 99mTc sulphur colloid demonstrated the remnant spleen with normal aspect since the third postoperative month and throughout all the post-operative period. (Fig. 2b)

Discussion
Despite the fact that there still exists professionals who, due to technical limitations or lack of knowledge, carry out routinely total splenectomy, several surgeons are already prone to choosing conservative splenic surgical procedures when there is no established indication for the total removal of the splenic tissue, like in cancer or hypersplenism and thrombocytopenia refractory to medicamentous treatment (1-12,28,29,30).
This is the second report in the literature 24 of partial splenectomy for treating splenic hemangioma. After complete mobilization the spleen to the surgical field and the ligature of the vessels to the hemangioma a perfect domination of the spleen is achieved. The partial splenectomy with the removal of the tumor becomes easier to be performed. The literature points to several methods for hemostasia of parenchyma (28,29,30), although the direct vessels suture followed by closure of splenic capsule using absorbable thin thread is sufficient.
In our experience with over 210 subtotal splenectomies to treat several different diseases, such as portal hypertension, trauma, Gaucher’s disease, myeloid metaplasia due to myelo-fibrosis, lymphoma, leukemia, pancreatic and splenic cysts, retardation of somatic development due to splenomegaly in teenagers, splenic ischemia and now splenic hemangioma, there was no complication provoked by the splenic remnant (1-12). In the instances we could not perform subtotal or partial splenectomy, we opted for the transplant of twenty fragments of the splenic tissue (1 to 4 cm2 each fragment) on the greater omentum in order to preserve enough splenic tissue with drainage throughout the portal vein into the liver, which ensures its perfect function, a fact which has been corroborated by several studies (31,32,33,34,35,36,37).

Conclusion
The good result obtained in the present case and technical facility in performing partial splenectomy for treating splenic hemangioma have been shown to be a good therapeutical approach, which removed entirely the disease, keeping the rest of the organ and the patient remains free of the risk of sepsis or other adverse effects that occur in asplenic state. Thus this paper gives support to the recommendation for the partial splenectomy in presence of splenic hemangioma.

References
1. Petroianu, A. - Treatment of portal hypertension by subtotal splenectomy and central splenorenal shunt. Postgrad. Med. J., 1988, 64:38.
2. Petroianu, A. - Subtotal splenectomy and portal-variceal disconnection in the treatment of portal hypertension. Can. J. Surg., 1993, 36:251.
3. Resende, V., Petroianu, A. - Subtotal splenectomy in severe trauma of the spleen. J. Trauma, 1998, 44:933.
4. Resende, V., Petroianu, A. - Functions of the splenic remnant after subtotal splenectomy for treatment of severe splenic injuries. Am. J. Surg., 2003, 185:311.
5. Petroianu, A. - Subtotal splenectomy for treatment of patients with myelofibrosis and myeloid metaplasia. Int. Surg., 1996, 81:177.
6. Petroianu, A. - Subtotal splenectomy in Gaucher’s disease. Eur. J. Surg., 1996, 162:511.
7. Petroianu, A. - Subtotal splenectomy for treatment of retarded growth and sexual development associated with splenomegaly. Minerva Chir., 2002, 57:428.
8. Petroianu, A., Andrade, M.A.C., Neto, R.B. -Laparoscopic subtotal splenectomy for treatment of severe splenic pain. Surg. Laparosc. Endosc. Percutan Tech., 2007, in press.
9. Petroianu, A., Murad, A.M. - New research on treatment of chronic lymphocytic leukemia. Res. Adv. Hematology, 2007, 2:21.
10. Petroianu, A. - Treatment of cystadenoma of the pancreatic tail by distal pancreatectomy and subtotal splenectomy. Dig Surg 1995; 12: 259-261.
11. Petroianu, A., Silva, R.G., Simal, C.J.R., Carvalho, D.G., Silva, R.A.P. - Late postoperative follow-up of patients submitted to subtotal splenectomy. Am. Surg., 1997, 63:735.
12. Petroianu, A., Resende, V., Silva, R.G. - Late follow-up of patients submitted to subtotal splenectomy. Int. J. Surg., 2006, 4:172.
13. Willcox, T.M., Speer, R.W., Schlinkert, R.T., Sarr, M.G. - Hemangioma of the spleen. J. Gastrointest. Surg., 2000, 4:611.
14. Husni, E.A. - The clinical course of splenic hemangioma with emphasis on spontaneous rupture. Arch. Surg., 1961, 83: 681.
15. Phillpott, J., Ali, S.A., Briscoe, E.G., Cesani, F. - Three-phase Tc-99m labeled RBC scintigraphy of a splenic hemangioma. Clin. Nucl. Med., 1997, 22:158.
16. Kato, M., Lubitz, C., Finley, D., Chadburn, A., Fahey, T.J. - Splenic cord capillary hemangioma and anemia. Am. J. Hematol., 2006, 81:538.
17. Norris, P.M., Hughes, S.C., Strachan, C.J. - Spontaneous rupture of a benign cavernous haemangioma of the spleen following thrombolysis. Eur. J. Vasc. Endovasc. Surg., 2003, 25:476.
18. Brandt, C.T., Rothbarth, L.J., Kumpe, D., Frederick, K., Lilly, J.R. - Splenic embolization in children. J. Ped. Surg., 1989, 24:642.
19. Vasilescu, C., Tomulescu, V., Ciurea, S., Popescu, I. - Laparoscopic splenectomy--lessons learned from a series of 40 cases. Chirurgia (Bucur.), 2001, 96:231.
20. Saleem, I., Newman, E.A., Strouse, P.J. Geiger, J.D. - Antiangiogenic therapy for a large splenic hemangioma. Pediatr. Surg. Int., 2005, 21:1007.
21. Vasilescu, C., Stanciulea, O., Popa, M., Colita, A., Arion, C. - Subtotal laparoscopic splenectomy and esophagogastric devascularization for the thrombocytopenia because of portal cavernoma. J. Pediatr. Surg., 2008, 43:1373.
22. Vasilescu, C. - Laparoscopic splenectomy. Chirurgia (Bucur.), 2005, 100:595.
23. Yano, H., Imasato, M., Monden, T., Okamoto, S. - Hand-assisted laparoscopic splenectomy for splenic vascular tumors. Surg. Laparosc. Endosc. Percutan Tech., 2003, 13:286.
24. Dema, A., TÃban, S., Cornianu, M., LazÃr, E., Herman, D., Cepoiu, R., MiculiT, F., BârsÃşteanu, F., Oneş, D. - An unusual splenic tumor. Littoral cell angioma. Chirurgia (Bucur.), 2007, 102:739.
25. Cooper, M.J., Williamson, R.C.N. - Splenectomy. Br. J. Surg., 1984, 71:173.
26. Tiron, A., Vasilescu, C. - Role of the spleen in immunity. Immunologic consequences of splenectomy. Chirurgia (Bucur.), 103:255.
27. Pimpl, W., Dapunt, O., Kaindl, H. - Incidence of septic and thromboembolic-related deaths after splenectomy in adults. Br. J. Surg., 1989, 76:517.
28. Charzalette, J.P., Feigelson, J., Louis, D. - Partial splenectomy. Arch. Dis. Child., 2003, 88:649.
29. Upadhyaya, P. - Conservative management of splenic trauma. Pediatr. Surg. Int., 2003, 19:617.
30. Itamoto, T., Fukuda, S., Tashiro, H., Ohda, H., Asahara, T. - Radiofrequency-assisted partial splenectomy with a new simple device. Am. J. Surg., 2006, 192:252.
31. Petroianu, A., Petroianu, L.P.G. - Splenic autotransplantation combined with splenectomy and portal-variceal disconnection in the treatment of portal hypertension. Can. J. Surg., 2005, 48:382.
32. Resende, V., Petroianu, A., Junior, W.C.T. - Autotrans-plantation for treatment of severe splenic lesions. Emerg. Radiol., 2002, 9:208.
33. Petroianu, A., Andrade, M.A.C., Neto, R.B. -Laparoscopic splenic autotransplantation. Surg. Laparosc. Endosc. Percutan Tech., 2006, 16:259.
34. Simal, C.J.R., Barbosa, A.J.A. - Assessment of phagocytic function in remnants of subtotal splenectomy and in autologous spleen implantation. Med. Sci. Res., 1993, 21:715.
35. Marques, R.G., Petroianu, A., Coelho, J.M., Portela, M.C. - Regeneration of splenic autotransplants. Ann. Hematol., 2002, 81:622.
36. Petroianu, A., Berindoague, R.N. - Laparoscopic subtotal splenectomy. Minerva Chir., 2004, 59:501.
37. Vasilescu, C., StÃnciulea, O., ColiTÃ, A., Stoia, R., Moicean, A., Arion, C. - Laparoscopic subtotal splenectomy in the treatment of hereditary spherocytosis. Chirurgia (Bucur.), 2003, 98:571.

• Timeviewed: 4870 times