Scientific letter
Ectopic Spleen. Urgent or Elective Surgery?
Bazo ectópico. ¿Cirugía urgente o programada?
Juan Pérez-Legaz
, Pedro Moya Forcén, Inma Oller, Antonio Arroyo, Rafael Calpena
Corresponding author
Cirugía General y Aparato Digestivo, Hospital General Universitario, Elche, Alicante, Spain
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Urgent or Elective Surgery?" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "344" "paginaFinal" => "345" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Juan Pérez-Legaz, Pedro Moya Forcén, Inma Oller, Antonio Arroyo, Rafael Calpena" "autores" => array:5 [ 0 => array:4 [ "nombre" => "Juan" "apellidos" => "Pérez-Legaz" "email" => array:1 [ 0 => "juanperezlegaz@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Pedro" "apellidos" => "Moya Forcén" ] 2 => array:2 [ "nombre" => "Inma" "apellidos" => "Oller" ] 3 => array:2 [ "nombre" => "Antonio" "apellidos" => "Arroyo" ] 4 => array:2 [ "nombre" => "Rafael" "apellidos" => "Calpena" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Cirugía General y Aparato Digestivo, Hospital General Universitario, Elche, Alicante, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Bazo ectópico. ¿Cirugía urgente o programada?" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 737 "Ancho" => 981 "Tamanyo" => 96291 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">On top of the bladder a homogenous mass is identified with a vascular pedicle, compatible with a wandering spleen.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Wandering spleen (WS) is an uncommon entity originated by a congenital or acquired laxity of the peritoneal ligaments, which causes an ectopic location of the spleen in the abdominal cavity.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The first description of this clinical entity was reported by Van Horne in 1667 as an incidental finding in an autopsy. The real incidence of this problem is not known, but its rareness has been documented in a series of 1413 splenectomies where the incidence was 0.16%. It usually presents in middle aged adults and is more common in women in a proportion of 20:1.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Symptoms are usually vague and non-specific, although in cases of torsion of the vascular pedicle it can present as an acute abdomen. This presentation is uncommon.</p><p id="par0020" class="elsevierStylePara elsevierViewall">We present two cases of wandering spleen, one an incidental finding and the other that presented as an acute abdomen.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case 1</span><p id="par0025" class="elsevierStylePara elsevierViewall">A 30 year-old woman with no prior medical history was diagnosed of a pelvic mass in a routine gynecological exam. A CT scan of the abdomen identified a homogenous mass on top of the bladder with hilar vessels compatible with a wandering spleen; the vascular pedicle descended from the left upper quadrant (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Elective surgery was scheduled. A laparoscopic splenectomy was performed using a Hasson trocar for creation of the pneumoperitoneum and two 10<span class="elsevierStyleHsp" style=""></span>mm trocars. The vascular pedicle was dissected with a white GIA and the spleen was removed through the umbilical trocar.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The patient had an uneventful recovery and was discharged three days after surgery. Three weeks after surgery an antipneumococcal vaccination was administered.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Case 2</span><p id="par0040" class="elsevierStylePara elsevierViewall">A 25 year old woman with no prior medical history presented to the emergency department for abdominal pain located in the left upper quadrant and vomiting. On arrival she presented a temperature of 38<span class="elsevierStyleHsp" style=""></span>°C and on physical examination had diffuse abdominal pain with signs of peritoneal irritation.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Blood tests revealed leukocytosis of 20.06×10<span class="elsevierStyleSup">3</span><span class="elsevierStyleHsp" style=""></span>μl<span class="elsevierStyleSup">−1</span>, with neutrophils of 857% and fibrinogen of 10<span class="elsevierStyleHsp" style=""></span>g/l; all other parameters were normal.</p><p id="par0050" class="elsevierStylePara elsevierViewall">An abdominal CT scan revealed splenomegaly with no contrast uptake and a “whirl sign” at the vascular pedicle, indicative of torsion.</p><p id="par0055" class="elsevierStylePara elsevierViewall">A left subcostal laparotomy was performed that revealed an enlarged spleen with no ligament fixation that was free in the peritoneal cavity, and torsion of the vascular pedicle. After de-torsion the spleen remained ischemic and a splenectomy was performed. The patient had an uneventful postoperative recovery and was discharged 8 days later. Three weeks after surgery an antipneumococcal vaccination was administered.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Discussion</span><p id="par0060" class="elsevierStylePara elsevierViewall">A wandering spleen is caused by the absence or abnormal development of the normal ligaments that hold the spleen into position: the gastrosplenic ligament, the splenorenal ligament and the phrenocolic ligament. This laxitude allows the spleen to be mobile and can fall freely into the peritoneal cavity, and be predisposed to complications.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The clinical presentation is variable; it can be an incidental finding in an asymptomatic patient or can cause different symptoms in cases of torsion, depending on the degree of vessel rotation.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Imaging methods are very useful for the diagnosis of this entity. Ultrasound can show its abnormal location, and can frequently show an enlarged spleen with homogenous echostructure or heterogeneous structure (infarction or congestion) depending on the degree of torsion. In cases of torsion or infarction, a CT scan can show a “whorled appearance” of the vascular pedicle and an absence of intravenous contrast uptake.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Treatment of the wandering spleen has changed over time. Initially an expectant management was defended, but this was associated with a high rate of morbidity, and therefore splenectomy was advised in all cases. In recent years the importance of the spleen for immunity has been better studied and conservative management is again recommended when possible.</p><p id="par0080" class="elsevierStylePara elsevierViewall">At present, the treatment of choice is de-torsion and splenopexy when there are no signs of irreversible ischemia; in these cases a splenectomy should be performed. A splenopexy can be performed using different techniques: fixing the splenic capsule to the left upper quadrant or the anterior abdominal wall; with or without the use of polyglycolic acid mesh. In recent years laparoscopic de-torsion and splenopexy using mesh has been described with apparent similar results to open surgery.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Case 1" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Case 2" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Pérez-Legaz J, Moya Forcén P, Oller I, Arroyo A, Calpena R. Bazo ectópico. ¿Cirugía urgente o programada? Cir Esp. 2013;91:344–345.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 737 "Ancho" => 981 "Tamanyo" => 96291 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">On top of the bladder a homogenous mass is identified with a vascular pedicle, compatible with a wandering spleen.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Wandering spleen presenting as an asymptomatic mass" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M.E. Zimmermann" 1 => "R.C. Cohen" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Aust N Z J Surg" "fecha" => "2000" "volumen" => "70" "paginaInicial" => "904" "paginaFinal" => "906" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11167584" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Wandering spleen with torsion of vascular pedicle: early diagnosis with multiplanar reformation technique of multislicespiral CT" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "K. Taori" 1 => "N. Ghonge" 2 => "A. Prakash" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Emerg Radiol" "fecha" => "2004" "volumen" => "29" "paginaInicial" => "479" "paginaFinal" => "481" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Wandering spleen: an unusual association with gastric volvulus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "H.T.M. Liu" 1 => "K.K. Lau" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Am J Roentgenol" "fecha" => "2007" "volumen" => "188" "paginaInicial" => "328" "paginaFinal" => "330" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Splenic torsion" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S. Chawla" 1 => "D.K. Boal" 2 => "P.W. Dillon" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Radio-graphics" "fecha" => "2003" "volumen" => "23" "paginaInicial" => "305" "paginaFinal" => "308" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A wandering spleen presenting as an acute abdomen. Case report" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M. Kapan" 1 => "M. Gumus" 2 => "A. Onder" 3 => "H. Gümüş" 4 => "M. Aldemir" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jemermed.2010.06.029" "Revista" => array:3 [ "tituloSerie" => "J Emerg Med" "fecha" => "2010" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21215553" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Laparoscopic splenopexy for wandering spleen: a case report and review of the literatura" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M.I. Montenovo" 1 => "S. Ahad" 2 => "B.K. Oelschlager" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Surg Laparosc Endosc Percutan Tech" "fecha" => "2010" "volumen" => "20" "paginaInicial" => "el82" "paginaFinal" => "el84" ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Splenic torsion: a case report" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M. Hussain" 1 => "R. Desphande" 2 => "S.T. 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| 2024 July | 54 | 4 | 58 |
| 2024 June | 40 | 2 | 42 |
| 2024 May | 36 | 3 | 39 |
| 2024 April | 32 | 3 | 35 |
| 2024 March | 41 | 8 | 49 |
| 2024 February | 55 | 3 | 58 |
| 2024 January | 79 | 4 | 83 |
| 2023 December | 57 | 4 | 61 |
| 2023 November | 73 | 7 | 80 |
| 2023 October | 44 | 3 | 47 |
| 2023 September | 43 | 13 | 56 |
| 2023 August | 45 | 4 | 49 |
| 2023 July | 91 | 2 | 93 |
| 2023 June | 51 | 7 | 58 |
| 2023 May | 101 | 3 | 104 |
| 2023 April | 52 | 2 | 54 |
| 2023 March | 88 | 4 | 92 |
| 2023 February | 76 | 1 | 77 |
| 2023 January | 64 | 15 | 79 |
| 2022 December | 45 | 9 | 54 |
| 2022 November | 60 | 7 | 67 |
| 2022 October | 60 | 44 | 104 |
| 2022 September | 57 | 25 | 82 |
| 2022 August | 80 | 19 | 99 |
| 2022 July | 48 | 11 | 59 |
| 2022 June | 44 | 7 | 51 |
| 2022 May | 36 | 7 | 43 |
| 2022 April | 43 | 4 | 47 |
| 2022 March | 76 | 6 | 82 |
| 2022 February | 64 | 6 | 70 |
| 2022 January | 55 | 13 | 68 |
| 2021 December | 69 | 7 | 76 |
| 2021 November | 59 | 10 | 69 |
| 2021 October | 54 | 12 | 66 |
| 2021 September | 50 | 6 | 56 |
| 2021 August | 37 | 7 | 44 |
| 2021 July | 29 | 6 | 35 |
| 2021 June | 24 | 10 | 34 |
| 2021 May | 19 | 10 | 29 |
| 2021 April | 28 | 15 | 43 |
| 2021 March | 16 | 12 | 28 |
| 2021 February | 12 | 8 | 20 |
| 2021 January | 11 | 10 | 21 |
| 2020 December | 17 | 13 | 30 |
| 2020 November | 17 | 5 | 22 |
| 2020 October | 12 | 6 | 18 |
| 2020 September | 19 | 39 | 58 |
| 2020 August | 20 | 34 | 54 |
| 2020 July | 18 | 16 | 34 |
| 2020 June | 11 | 10 | 21 |
| 2020 May | 16 | 11 | 27 |
| 2020 April | 12 | 5 | 17 |
| 2020 March | 5 | 1 | 6 |
| 2020 February | 14 | 7 | 21 |
| 2020 January | 12 | 5 | 17 |
| 2019 December | 12 | 8 | 20 |
| 2019 November | 22 | 13 | 35 |
| 2019 October | 17 | 3 | 20 |
| 2019 September | 20 | 6 | 26 |
| 2019 August | 16 | 4 | 20 |
| 2019 July | 14 | 11 | 25 |
| 2019 June | 29 | 21 | 50 |
| 2019 May | 85 | 47 | 132 |
| 2019 April | 34 | 10 | 44 |
| 2019 March | 10 | 7 | 17 |
| 2019 February | 8 | 7 | 15 |
| 2019 January | 8 | 2 | 10 |
| 2018 December | 11 | 8 | 19 |
| 2018 November | 18 | 3 | 21 |
| 2018 October | 11 | 2 | 13 |
| 2018 September | 3 | 4 | 7 |
| 2018 August | 3 | 0 | 3 |
| 2018 July | 7 | 2 | 9 |
| 2018 June | 6 | 4 | 10 |
| 2018 May | 4 | 2 | 6 |
| 2018 April | 7 | 3 | 10 |
| 2018 March | 7 | 0 | 7 |
| 2018 February | 5 | 0 | 5 |
| 2018 January | 5 | 0 | 5 |
| 2017 December | 20 | 2 | 22 |
| 2017 November | 12 | 1 | 13 |
| 2017 October | 15 | 1 | 16 |
| 2017 September | 8 | 4 | 12 |
| 2017 August | 19 | 2 | 21 |
| 2017 July | 20 | 1 | 21 |
| 2017 June | 27 | 8 | 35 |
| 2017 May | 22 | 2 | 24 |
| 2017 April | 19 | 1 | 20 |
| 2017 March | 23 | 42 | 65 |
| 2017 February | 19 | 2 | 21 |
| 2017 January | 31 | 2 | 33 |
| 2016 December | 18 | 6 | 24 |
| 2016 November | 14 | 3 | 17 |
| 2016 October | 26 | 3 | 29 |
| 2016 September | 32 | 6 | 38 |
| 2016 August | 23 | 1 | 24 |
| 2016 July | 8 | 2 | 10 |
| 2016 June | 15 | 3 | 18 |
| 2016 May | 27 | 9 | 36 |
| 2016 April | 22 | 8 | 30 |
| 2016 March | 17 | 13 | 30 |
| 2016 February | 10 | 4 | 14 |
| 2016 January | 12 | 8 | 20 |
| 2015 December | 10 | 3 | 13 |
| 2015 November | 10 | 1 | 11 |
| 2015 October | 15 | 5 | 20 |
| 2015 September | 12 | 5 | 17 |
| 2015 August | 9 | 5 | 14 |
| 2015 July | 10 | 5 | 15 |
| 2015 June | 2 | 2 | 4 |
| 2015 May | 10 | 1 | 11 |
| 2015 April | 16 | 9 | 25 |
| 2015 March | 13 | 6 | 19 |
| 2015 February | 8 | 6 | 14 |
| 2015 January | 30 | 3 | 33 |
| 2014 December | 30 | 12 | 42 |
| 2014 November | 28 | 3 | 31 |
| 2014 October | 27 | 5 | 32 |
| 2014 September | 17 | 4 | 21 |
| 2014 August | 12 | 1 | 13 |
| 2014 July | 22 | 3 | 25 |
| 2014 June | 11 | 5 | 16 |
| 2014 May | 10 | 1 | 11 |
| 2014 April | 7 | 2 | 9 |
| 2014 March | 6 | 2 | 8 |
| 2014 February | 10 | 2 | 12 |
| 2014 January | 12 | 4 | 16 |
| 2013 December | 7 | 1 | 8 |
| 2013 November | 3 | 3 | 6 |
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