Splenic Pseudocyst: Aspiration or Cyst Decapsulation J. Lappin,M. T. Corbally,E. J. Guiney
Departmentof Paediatric Surgery, OurLady's Hospitalfor Sick Children, Cr~din, Dublin 12. Summary A 12 year old boy with a splenic pseudocystis reported. Percutaneousdrainageresulted in complete emptying but rapid reaccumulation. Cyst decapsulationwith splenic preservationwas curative and is recommended for def'mitivetherapy of splenic pseudocysts. Cystic lesions of the spleen in childhood are uncommon and splenectomyhas formerly been regarded as the mainstay of surgical therapy, However,with the awarenessof the risks of post-splenectomysepsis there has been increasinginterest in splenicpreservationtechniques, Wereport a caseof splenic pseudocystin a 12 year old bey treated by initial percutaneous needle aspiration but ultimately requiring partial splenic decapsulation. Although percutaneous drainage provides useful palliation, def'mitivesurgery is required to preventcyst recurrence.
Case Report A 12 year old boy presented with a large, mobile nontender left hypochondrialmass and pain, The mass extended for 4 cm below the costal margin. There was no history of trauma and he was otherwise well. Abdominal ultrasound showed a 15x12 cm cystic lesion arising from the upper splenic pole. A CT scan (Fig, 1) confirmed this and demonstrated a smooth cyst wall and an isotope scan confirmed a large non-functioning,"cold"area. Haematologicalexaminations were normal as was the serology for Echinococcus infection, Pre-operative pneumococcus and H. Influenza vaccinations were given and the cyst drained of 1~850mls of chocolate coloured fluid under ultrasound control. Rapid reaccumulation of fluid occurred and a laparommy was performed five days later. A large, tense cyst in the upperpole of the spleen was resected by partial cyst decapsulation, using a technique similar to that described by Touloukian and Seashore1. Briefly, this involved splenic mobilization, decompression of the cyst and selective ligation of the upper pole vessels with excision of the outer splenic wall and pseudocyst capsule, Haemostasis of the residual surface was achieved using Tisseal fibringlue and a haemostaticabsorbablesuture. There were no complications and review at 3 months with ultrasound, showed him to be free of cyst recurrence. Histological examinationsconfftrmeda splenic pseudoc.yst,
FIG. ] Splanectomy is curative for all types of cysts but is ant currenflyperformedas firstllne therapybecanseofthe significant risk of post-splanectomysepsis and the commitment to long term chemoprophylaxis. Partial splenectomy and cyst dccapsulation are both effectivein removing the cyst and preserving splenic function, but both involve a laparotomy. Recent improvementsin ultra-soundimagingandlocalisation techniclueshave prompted more frequent use of pereutaneous drainage procedures3. Several reports have documented the utility of this approachin thedrainage of splenicabscessesand haematomasbut not in congenitalor traumaticsplenic systsa,s. Failure of cyst drainage has been reported previously both in isolation and using sclerosant therapy5. Pereutaneous drainage and instillation of sclerosant all result in short.term cyst ablation, but surgical therapy was required in ~I cases, The rapidreaecumulationofcyst fluidseen in thispatientconflrms previous reports that percutaneousdrainage of an established splenic psoudocyst is not a valid option in management. Preservationof splenic functionand control of haemostasisis possible using partial splenic decapsulation technique that preservesat lent 25 % of splenic volume4. Tisseal glue would appear to be a useful addition to the technique.
Discussion Splenic cysts are rare and may be either congenital or acquired, due to Echinococcusinfestationor as a late result of splenic trauma, respectively2. The diagnosisof a splenic cyst is made on physical examination and confirmed by current imaging and serological techniques. A history of recent trauma is suggestiveof a traumatic pseudocyst,although it is often lacking as in this patient,
References
1. Touloukian,R. I., Seashore,I. II. Partialsplenicdecapsulafion:A simplgiedoperationfor splenicpseudoeyst.2. Ped.Surg.1987:22(2), 135-137. 2. Blank,E.,Cambc]l,J.R. Epidermoidcystsofthespleen.Pediatr.1973: 51(1),75-84. 3. Kaufman,R. A., Silver,I'. M.,Wesley,J. R. Preoperativediagnosisof spleniccystsin childrenby gray-scaleultrasonography.J. Ped.Surg. 1979:14,450-4543. 4. Khan,A.H.,Bensoussan,A.L.,Ottimet,A.,Blanchard,II.,Gfiguon,A., Ndoye,M. Paniflsplenectomyforbenigneystlclesionsofthespleen. J. Ped.Surg.1986:219(9),749-752. 5. MoinC.,Guttman,F.,Jequir, S.,Sonnino,R.,Youssef,S. Spleniccysts: aspiration,sclerosis,or resection.~. Pod.Surg.1989:24(7l,646-648.
Correslxmdencrto: M. T. CorbaUy,C~sultantPaediatficSurgeon, BristolRoyalHospitalforSickChildren, St.Michael'sHill,Bils~l,BS28BI,U.K. 48
Departmentof Paediatric Surgery, OurLady's Hospitalfor Sick Children, Cr~din, Dublin 12. Summary A 12 year old boy with a splenic pseudocystis reported. Percutaneousdrainageresulted in complete emptying but rapid reaccumulation. Cyst decapsulationwith splenic preservationwas curative and is recommended for def'mitivetherapy of splenic pseudocysts. Cystic lesions of the spleen in childhood are uncommon and splenectomyhas formerly been regarded as the mainstay of surgical therapy, However,with the awarenessof the risks of post-splenectomysepsis there has been increasinginterest in splenicpreservationtechniques, Wereport a caseof splenic pseudocystin a 12 year old bey treated by initial percutaneous needle aspiration but ultimately requiring partial splenic decapsulation. Although percutaneous drainage provides useful palliation, def'mitivesurgery is required to preventcyst recurrence.
Case Report A 12 year old boy presented with a large, mobile nontender left hypochondrialmass and pain, The mass extended for 4 cm below the costal margin. There was no history of trauma and he was otherwise well. Abdominal ultrasound showed a 15x12 cm cystic lesion arising from the upper splenic pole. A CT scan (Fig, 1) confirmed this and demonstrated a smooth cyst wall and an isotope scan confirmed a large non-functioning,"cold"area. Haematologicalexaminations were normal as was the serology for Echinococcus infection, Pre-operative pneumococcus and H. Influenza vaccinations were given and the cyst drained of 1~850mls of chocolate coloured fluid under ultrasound control. Rapid reaccumulation of fluid occurred and a laparommy was performed five days later. A large, tense cyst in the upperpole of the spleen was resected by partial cyst decapsulation, using a technique similar to that described by Touloukian and Seashore1. Briefly, this involved splenic mobilization, decompression of the cyst and selective ligation of the upper pole vessels with excision of the outer splenic wall and pseudocyst capsule, Haemostasis of the residual surface was achieved using Tisseal fibringlue and a haemostaticabsorbablesuture. There were no complications and review at 3 months with ultrasound, showed him to be free of cyst recurrence. Histological examinationsconfftrmeda splenic pseudoc.yst,
FIG. ] Splanectomy is curative for all types of cysts but is ant currenflyperformedas firstllne therapybecanseofthe significant risk of post-splanectomysepsis and the commitment to long term chemoprophylaxis. Partial splenectomy and cyst dccapsulation are both effectivein removing the cyst and preserving splenic function, but both involve a laparotomy. Recent improvementsin ultra-soundimagingandlocalisation techniclueshave prompted more frequent use of pereutaneous drainage procedures3. Several reports have documented the utility of this approachin thedrainage of splenicabscessesand haematomasbut not in congenitalor traumaticsplenic systsa,s. Failure of cyst drainage has been reported previously both in isolation and using sclerosant therapy5. Pereutaneous drainage and instillation of sclerosant all result in short.term cyst ablation, but surgical therapy was required in ~I cases, The rapidreaecumulationofcyst fluidseen in thispatientconflrms previous reports that percutaneousdrainage of an established splenic psoudocyst is not a valid option in management. Preservationof splenic functionand control of haemostasisis possible using partial splenic decapsulation technique that preservesat lent 25 % of splenic volume4. Tisseal glue would appear to be a useful addition to the technique.
Discussion Splenic cysts are rare and may be either congenital or acquired, due to Echinococcusinfestationor as a late result of splenic trauma, respectively2. The diagnosisof a splenic cyst is made on physical examination and confirmed by current imaging and serological techniques. A history of recent trauma is suggestiveof a traumatic pseudocyst,although it is often lacking as in this patient,
References
1. Touloukian,R. I., Seashore,I. II. Partialsplenicdecapsulafion:A simplgiedoperationfor splenicpseudoeyst.2. Ped.Surg.1987:22(2), 135-137. 2. Blank,E.,Cambc]l,J.R. Epidermoidcystsofthespleen.Pediatr.1973: 51(1),75-84. 3. Kaufman,R. A., Silver,I'. M.,Wesley,J. R. Preoperativediagnosisof spleniccystsin childrenby gray-scaleultrasonography.J. Ped.Surg. 1979:14,450-4543. 4. Khan,A.H.,Bensoussan,A.L.,Ottimet,A.,Blanchard,II.,Gfiguon,A., Ndoye,M. Paniflsplenectomyforbenigneystlclesionsofthespleen. J. Ped.Surg.1986:219(9),749-752. 5. MoinC.,Guttman,F.,Jequir, S.,Sonnino,R.,Youssef,S. Spleniccysts: aspiration,sclerosis,or resection.~. Pod.Surg.1989:24(7l,646-648.
Correslxmdencrto: M. T. CorbaUy,C~sultantPaediatficSurgeon, BristolRoyalHospitalforSickChildren, St.Michael'sHill,Bils~l,BS28BI,U.K. 48
