Splenic rupture as the presenting manifestation of primary splenic angiosarcoma in a teenage woman: a case report

<p>Abstract</p> <p>Introduction</p> <p>Primary splenic angiosarcoma is a rare neoplasm of vascular origin carrying a very poor prognosis, partly due to its high metastatic potential. This disease presents frequently with splenic rupture and hemorrhage. We report the case of a 17-year-old woman who presented with rupture of a primary splenic angiosarcoma.</p> <p>Case presentation</p> <p>The patient presented with diffuse abdominal pain and distention. Clinical examination revealed severe tenderness in the left upper abdominal quadrant, a palpable abdominal mass, and hemodynamic instability with a systolic arterial blood pressure of 75 mmHg and heart rate of 135 beats per minute. Blood tests revealed anemia (hemoglobin 7.0 g/dl) and thrombocytopenia (platelets 70 × 10⁹/liter). After initial fluid resuscitation and stabilization, abdominal ultrasound and computed tomography were performed, revealing a large quantity of intraperitoneal free fluid, an enlarged spleen, and a heterogeneous low-density signal within the splenic parenchyma, which showed varying degrees of contrast enhancement. At laparotomy a huge (weight 1530 g, diameter 19 cm) actively bleeding spleen was identified and splenectomy was performed. Histopathology showed a primary splenic angiosarcoma. After an uneventful recovery, the patient was discharged on the sixth postoperative day.</p> <p>Conclusion</p> <p>Primary splenic angiosarcoma is rare. Although this malignancy is usually encountered in advanced age, there have been a few reported cases among younger patients. The case reported here presented with splenic rupture, was treated by laparotomy and splenectomy, and the patient is disease free 16 months after surgery.</p

Primary Cavernous Hemangioma of the Thyroid Gland

A 78-year-old euthyroid patient presented for evaluation of a symptomatic, slowly growing neck mass. Ultrasound scan revealed a multinodular goiter and a hypoechoic nodule of the right thyroid lobe. Total thyroidectomy was performed and the lesion was completely excised. Definite diagnosis was obtained after histological examination of the surgical specimen. Cavernous hemangiomas of the thyroid gland are infrequent lesions which may escape diagnosis preoperatively. An effort should be made not to rupture these lesions in order to ensure a bloodless procedure

Sepsis: Prognostic role of apoptosis regulators in gastrointestinal cells

Background: Intestinal epithelial cell apoptosis has been reported in sepsis as a mechanism of organ failure. The aim of this study was to clarify the role of apoptosis-regulating proteins (bcl-2, bax, cytochrome-c, and caspase-8) in septic rats by studying their expression in gastric and intestinal epithelial cells. Methods: Adult Wistar rats were subjected to the cecal ligation and puncture (CLP) model of sepsis and randomly divided into two study groups. Sixty-two animals were sacrificed 6, 12, 24, 36, 48, and 60 h post-procedure, and 50 animals served as the survival study group. Sham-operated animals (n = 40) were used as controls. Gastric and intestinal tissue was excised, and immunohistochemical detection of bcl-2, bax, cytochrome-c, and caspase-8 protein expression was performed. Results: In gastric mucosa, sepsis induced upregulation of bax and downregulation of caspase-8 expression (p = 0.053 and p = 0.05, respectively). Both bax and caspase-8 were upregulated as early as 6 h post CLP and progressively decreased (p = 0.001, p = 0.004 respectively). In contrast, the expression of the anti-apoptotic bcl-2 was upregulated progressively during the sepsis syndrome (p = 0.03). In intestine, sepsis induced a fourfold upregulation of the cytoprotective bcl-2 (p = 0.0001), accompanied by a remarkable increase in bax (p = 0.002) and caspase-8 (p = 0.0001) expression and a decrease in cytochrome-c expression (p = 0.02). The time distribution of the apoptosis regulators followed the same pattern as in gastric tissue, showing an upregulation of the proapoptotic bax and cytochrome c (p = 0.04) during the early phases and a progressively increased expression of bcl-2 during the late phases (p = 0.0001). Bax expression in gastric epithelium of subjects with septic syndrome was detrimental to survival (p = 0.0001), whereas the expression of the cytoprotective bcl-2 in intestinal epithelium appeared to favor a good prognosis (p = 0.0001). Conclusions: Sepsis results in alterations of apoptosis regulators in gastrointestinal cells. Alterations of bax and bcl-2 expression in gastric and intestinal epithelial cells may predict the outcome in septic rats

Prospective study of the incidence and risk factors of postsplenectomy thrombosis of the portal, mesenteric, and splenic veins

Hypothesis: Splenectomy is recognized as a cause of portal, mesenteric, and splenic vein thrombosis. The exact incidence of the complication and its predisposing factors are not known. Design: Prospective observational cohort study. The median follow-up time of the patients was 22.6 months. Setting: University surgical clinic in a teaching hospital Patients: A total of 147 consecutive patients who underwent splenectomy in a 4-year period were enrolled in the study. Interventions: Preoperative and postoperative evaluation included ultrasonography with color Doppler flow imaging of the portal system, results of blood coagulation tests, fibrinogen levels, D-dimer levels, and complete blood counts. Operative sheets were recorded and reviewed. When portal system thrombosis (PST) was diagnosed, a complete control for acquired and congenital thrombophilia disorders was obtained. Main Outcome Measures: Primary end points of the study were the assessment of the incidence of postsplenectomy PST and the identification of risk factors for its occurrence. Results: Portal system thrombosis occurred in 7 (4.79%) of 146 patients who underwent splenectomy. The age, sex, type or length of the operation, and use of preoperative and postoperative thromboprophylaxis with low molecular weight heparin did not prove to be significant factors in the occurrence of PST. Platelet count of more than 650 X 10(3)/mu L and greater spleen weight (&gt; 650 g) was associated with the development of PST (P=.01, P=.03). Normal D-dimer levels on diagnosis of the complication showed a negative predictive value of 98%. Two of the affected patients were diagnosed with thrombophilia disorders. In a median follow-up period of 22.6 months, no other case of PST was recorded. Conclusions: Postsplenectomy PST occurs in approximately 5% of patients. Possible risk factors are thrombocytosis, splenomegaly, and congenital thrombophilia disorders

Thyroid surgery: comparison between the electrothermal bipolar vessel sealing system, harmonic scalpel, and classic suture ligation

Background: This study was conducted to compare the outcome of total thyroidectomy using the electrothermal bipolar vessel sealing system, the harmonic scalpel, and the classic suture ligation technique. Methods: This was a retrospective study of prospectively collected data from 382 consecutive total thyroidectomies from September 2004 to August 2006. Patients were divided into 3 groups: group SL patients (n = 90) underwent total thyroidectomy with the classic suture ligation technique, group L (n = 148) with the electrothermal bipolar vessel sealer, and group U (n = 144) with the harmonic scalpel. The main outcomes measured were surgical and hospitalization time, intraoperative and postoperative bleeding, postoperative hypocalcemia, and superior and inferior laryngeal nerves injuries. Results: The 3 groups were similar in terms of demographics, thyroid gland weight and pathology, perioperative complications, and hospital stay. Compared with the classic technique, surgical time was reduced significantly by about 20% when the bipolar vessel sealer or harmonic scalpel was used (93.3 +/- 12.5 vs 74.3 +/- 14.2 and 73.8 +/- 13.8 min, P = .001, and P = .001, respectively). Conclusions: Both the bipolar vessel sealer and harmonic scalpel are safe, useful, and time-saving alternatives to the traditional suture ligation technique for thyroid surgery. Because no differences were observed regarding these 2 devices, the choice should be made based on the surgeon’s preferences and experience. (c) 2008 Excerpta Medica Inc. All rights reserved