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Dear Readers,

Welcome to the October issue of the The Surgeons’ Lounge. In this issue, our guest expert John McNelis, MD, FACS, FCCM, chairman, Department of Surgery, North Bronx Healthcare Network, Jacobi Medical Center and North Central Bronx Hospital, New York City, discusses the case of a patient with a grade IV splenic laceration. Plus, check out the reply to the September challenge—how did you do?

I look forward to your questions, comments and feedback.

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Sincerely,

Samuel Szomstein, MD, FACS
Editor, The Surgeons’ Lounge
Szomsts@ccf.org

Dr. Szomstein is associate director, Bariatric Institute, Section of Minimally Invasive Surgery, Department of General and Vascular Surgery, Cleveland Clinic Florida, Weston.



Surgeon’s Challenge

From September 2013 Issue

Submitted by: S. Al-Bahri, MD, M. Casasanta, MD, and E. McCarron, MD
from the Department of Surgery, MedStar Union Memorial Hospital, Baltimore, Md.

An 80-year-old woman with a history significant for hypertension, pneumonia and coronary artery disease, as well as a remote history of hysterectomy for symptomatic fibroids, was admitted for hydration and a workup for pneumonia. During her hospital stay, she developed diarrhea and abdominal pain for which a computed tomography (CT) scan of the abdomen and pelvis was obtained. A pelvic mass of unclear origin was seen; tumor markers CEA and CA 125 were well within normal limits. Attempts were made to perform an image-guided biopsy, but were unsuccessful due to the mobile nature of this mass. A recent colonoscopy failed to show any significant pathologic process originating in the colon.

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Figure 1. Parasitic leiomyoma, which derives its blood supply from local structures such as the colon.

The patient recovered from the acute infectious process and was scheduled for exploratory laparotomy. Upon entering the peritoneal cavity, all surfaces were free of any pathology. The mass, originating off of the transverse colon, was readily identified. It had several serpentine arteries feeding into it from the mesentery of the bowel (Figure 1).

Challenge question: What is the diagnosis? a. carcinoid tumor; b. colonic adenocarcinoma; c. parasitic leiomyoma; d. Meckel’s diverticulum; or e. omental cyst.


Answer to Challenge

Parasitic leiomyoma. A rare cause of laparotomy for a presumed malignancy, a parasitic leiomyoma can mimic the presence of a malignant mass on CT imaging, and cause symptoms depending on its location and size. It is defined as an extra-uterine seeding from a uterine leiomyoma.1It is most commonly seen in patients who have undergone a hysterectomy for uterine fibroids. Of particular interest is that these masses are “parasitic,” which means they derive their blood supply from local structures, such as the colon in this case.

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Figure 2. A simple excision of the parasitic leiomyoma.

Parasitic leiomyomas are so uncommon that discussion about this topic is limited to case reports. It is hypothesized that seeding from morcellation of the uterus or even an open hysterectomy can result in the pathogenesis of this tumor. It can present as a painful symptomatic mass or an incidental finding on imaging performed for other reasons. A thorough examination of the abdominal cavity is required to search for other such masses and it can be removed by a simple excision (Figure 2).

It is therefore reasonable to consider this diagnosis on the differential in a patient with an extraluminal mass and a history of hysterectomy.2


Question for Dr. McNelis

Edward Chao, PGY-5, Montefiore Medical Center, New York, NY

I would appreciate your advice regarding a 26-year-old woman with no significant comorbidities who presented to our emergency room after falling in the bathtub one morning. She fell to her left side, landing awkwardly on her flank region against the tub. She did not lose consciousness or suffer any head trauma. Her vital signs were: blood pressure 110/77; heart rate 83, respiratory rate 16, and SaO2 on room air of 98%. The patient was otherwise alert and oriented complaining only of left flank pain. She appeared pale but was not diaphoretic. A focused abdominal sonogram was performed, which was positive in the left upper quadrant (LUQ). Chest and pelvic x-rays were unremarkable. A CT scan with IV contrast was obtained, which revealed hemoperitoneum secondary to a grade IV splenic laceration with active extravasation of IV contrast (Figures 1 and 2). Associated left rib fractures (eighth to 11th) were the only other pertinent findings.

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Figures 1 and 2. CT scan with IV contrast revealed hemoperitoneum secondary to a grade IV splenic laceration with active extravasation of IV contrast.

Question: How would you manage this patient?


Dr. McNelis’ Reply

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Good question, Edward. In the past, the answer would have been simple: To the operating room (OR) for splenectomy or possibly a splenorrhaphy. Given the CT appearance here, I would suspect that this could be a possible grade V injury1 (Figure 3). Your CT certainly demonstrates extravasation of contrast consistent with an active bleed. Indeed, if you were in a solo setting without advanced capabilities to actively observe this patient, and if the patient had associated injuries or manifested any form of hemodynamic instability, the OR would be the next appropriate step.

In most modern trauma centers, however, there is another approach to managing hemodynamically stable patients with splenic injuries. Angiographic embolization is rapidly gaining favor in managing these patients. In the May 2012 issue of the Journal of Trauma, Bhullar et al published an excellent review on angiographic embolization of splenic injuries.2 In their experience at a level 1 trauma center, the addition of angiographic embolization in selected cases significantly decreased the failure rates of nonoperative management in grades IV and V splenic injuries. In grade IV splenic lacerations, a nonoperative failure rate of 23% was reported, whereas in grade V, a nonoperative failure rate of 63% was reported, as would be expected. When angiographic embolization was added, the failure rates dropped to 3% and 9% for grades IV and V, respectively. Indeed, I would recommend angiographic embolization in that subset of patients who have an associated pelvic fracture requiring embolization as well.

Figure 3. Organ injury scale
Grade Injury Type Injury Description
I Hematoma Subcapsular <10% surface area
Laceration Capsular tear <1 cm parenchymal depth
II Hematoma Supcapsular 10-50% surface area: intraparenchymal <5 cm
Laceration Capsular tear 1-3 cm parenchymal depth not involving trabecular vessel
III Hematoma Subcapsular >50% surface area or expanding; ruptured subcapsular or parenchymal hematoma; intraparenchymal haematoma >5 cm or expanding
Laceration >3 cm parenchymal depth or involving trabecular vessels
IV Laceration Laceration involving segmental or hilar vessels producing major devascularization (>25% of spleen)
V Laceration Completely shattered spleen
Vascular Hilar vascular injury with devascularized spleen
Advance one grade for multiple injuries up to grade III.
From: Moore et al. Organ Injury Scaling: spleen and liver J Trauma 1995;38:323.

Splenic embolization, however, does have its limitations. Success is dependent on many factors such as the operator’s skill, and the availability of equipment and interventional

radiology. Embolization coils, microspheres, absorbable gelatin sponges, endogenous clots, or a vascular plug device have all been employed to embolize the splenic artery.1 One word of caution: Splenic artery embolization may not stop bleeding from the short gastrics due to collateral flow from the left gastric and left gastroepiploic arteries. In this case, the angiographer should be facile with celiac artery arteriography to stem the bleeding.3 Other possible complications include failure of therapy, and transfusion-related risks (reaction, infections, transfusion-related acute lung injury, etc.), as well as shock and coagulopathy. Preservation of the spleen, on the other hand, eliminates the risk for overwhelming postsplenectomy infection, a viable consideration in this woman.

Follow-up is an issue that frequently arises post-discharge. The general recommendation is to avoid any high-risk contact activity for up to three months.4 This would include contact sports or any activity that would risk injury to the LUQ. There also is controversy regarding the question of obtaining a follow-up CT. Repeat CT indications are variable, but a selective approach has been advocated for individuals returning to high-risk activities.5

Given this patient’s clinical presentation and your institution’s interventional radiology capabilities, I would recommend nonoperative management with selective embolization. Our institutional success rate is very high in embolization of these injuries.

References

  1. J Trauma. 1995;38:323-324.
  2. J Trauma Acute Care Surg. 2012;72:1127-1134.
  3. J Trauma. 2008;65:1346.
  4. J Trauma. 2005;59:836.
  5. Clin J Sport Med. 2002;12:400.