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Accessory spleen in the greater omentum
The American Journal of Surgery (2011) 202, e28 – e30
Clinical Images
Accessory spleen in the greater omentum Cheng Zhang, M.D.*, Xue-Feng Zhang, M.D. Department of General Surgery, The General Hospital of ShenYang Military Command, Number 83 Wenhua Rd., Shenhe District, ShenTang, Liaoning, 110016 People’s Republic of China KEYWORDS: Accessory spleen; The greater omentum; Intrapancreatic accessory spleen
Abstract. Although accessory spleen is a frequently encountered entity, accessory spleen in the greater omentum is rare. A 22-year-old woman presented with dull pain in the left upper abdomen. Crosssectional imaging studies with 3-dimensional reconstruction suggested the presence of a huge tumor in the greater omentum that was associated with the spleen. At laparotomy, the diagnosis of accessory spleen was made. This accessory spleen was unusual in its size and location. Awareness of this entity and familiarity with typical imaging findings is mandatory for preoperative diagnosis. The importance of recognition and appropriate confirmatory diagnosis of an accessory spleen is discussed. © 2011 Elsevier Inc. All rights reserved.
A 22-year-old woman reported intermittent and dull pain in the left upper abdomen and diarrhea for 3 months. There were no other associated symptoms. Her past and family histories were noncontributory. On admission, physical examination findings were unremarkable. Laboratory data including peripheral blood counts, blood sugar level, and liver function test results were all unremarkable. Tumor markers, including CA19-9, CA125, carcinoembryonic antigen, and ␣-fetoprotein levels, were within the normal range. Abdominal sonography was performed, and a huge irregular solid mass was noted in the left abdominal cavity. The echogenicity of the tumor was homogeneous and lower than that of the hepatic parenchyma. On color Doppler sonography images, an abundant vascular supply with low-resistance blood flow was observed in the tumor. Abdominal contrastenhanced computed tomography (CT) showed a well-marginated, irregular, mass enhanced homogeneously and to a similar degree as splenic parenchyma and superior mesenteric artery (Figs. 1 and 2). A 3-dimensional reconstruction of the CT scan showed that the mass, approximately 12 ⫻ 38 cm in size extending from the splenic hilum to the pelvic * Corresponding author. Tel.: ⫹86-24-28856245; fax: ⫹86-2428856246. E-mail address: [email protected] Manuscript received March 4, 2010; revised manuscript June 29, 2010
0002-9610/$ - see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.amjsurg.2010.06.032
cavity, was supplied by a vascular branch arising from the splenic artery (Fig. 3). Of note, the pancreatic and splenic tissue were normal in appearance on both CT and ultrasound images. No other pathologic process was noted in the abdomen. The size of the tumor, which had never been reported for an accessory spleen, made an exact diagnosis uncertain. At laparotomy, the spleen was normal. A huge wellmarginated irregular mass was observed in the greater omentum on the left side (Fig. 4). The mass was fed by a vascular pedicle from the splenic artery, and extended from the pancreatic tail to pelvis (Fig. 5). The tumor was close to the tail of the pancreas and the pancreatic tail was rigid. The tumor was dark-red, elastic soft, and the gross appearance of mass was quite different from that of sarcoma (Fig. 6). A therapeutic omentectomy and accessory splenectomy were performed. After dissecting the pancreatic tail away from the splenic hilum and the splenic vessels, a distal pancreatectomy was completed. Microscopically, lymphoid follicles and splenic pulp were found in pancreatic tail and pathologic examination of the resected specimen in the greater omentum revealed splenic tissue. Thus, diagnosis of an accessory spleen was certain. The patient had an uneventful recovery with only a transient increase of the platelets and pancreatic fistula.
C. Zhang and X.-F. Zhang
Accessory spleen
Figure 1 Contrast-enhanced CT showed that a well-marginated irregular mass enhanced homogenously as superior mesenteric artery. The superior mesenteric artery (black arrow) and accessory spleen (white arrow) are shown. Li ⫽ liver; St ⫽ stomach; B ⫽ bladder; Ut ⫽ uterus.
The presenting symptoms of dull pain and diarrhea were absent 6 months after surgery.
e29
Figure 3 Three-dimensional reconstruction CT scan shows trophic vessel linking mass to the splenic artery. Splenic artery (black arrow) and left gastroepiploic artery (white arrow) are shown.
mimic lymphadenopathy and tumors in other abdominal organs, such as the pancreas, the adrenal gland, and the kidney.2 In these cases, the recognition and appropriate
Comments Accessory spleen is an ectopic mass of healthy splenic tissue separate from the main body of the spleen. Accessory spleen occurs in 10% to 30% of the population.1 They are always situated on the left side: hilum of the spleen, splenic artery, pancreas, splenocolic ligament, greater omentum, mesenterium, adnexal region, and scrotum. The detection and characterization of an accessory spleen can be important for several reasons. First, an accessory spleen may
Figure 2 Contrast-enhanced CT showed that accessory spleen enhanced homogenously as splenic parenchyma. The splenic parenchyma (black arrow) and accessory spleen (white arrow) are shown. Li ⫽ liver; k ⫽ kidney.
Figure 4 An accessory spleen emerging from the greater omentum was observed during laparotomy. Transverse colon (white arrow) and greater omentum (black arrow) are shown.
e30
The American Journal of Surgery, Vol 202, No 3, September 2011
confirmatory diagnostic imaging of accessory spleen is important to avoid an unnecessary surgery. Second, accessory spleens occasionally may become symptomatic because of torsion, spontaneous rupture, hemorrhage, and cyst formation.3 In our case, because the pain and diarrhea were relieved after surgery, the presenting symptoms may be caused by mechanical irritation of the mass. Third, in hematologic disorders accessory spleen can take over the function of the original spleen after splenectomy. Accordingly, a surgeon’s awareness of their presence may be important when the intention is to remove all functional splenic tissue.4 CT/magnetic resonance imaging and scintigraphy with technitium-99m are helpful in marking the diagnosis of accessory spleen. This accessory spleen was unusual in its size and location. This was a large accessory spleen. Although intrapancreatic accessory spleen is a rarely encountered entity, their CT features are characteristic. Typically, they are well-marginated, homogeneously enhanc-
Figure 6
Transection of the resected accessory spleen.
ing, round masses in the tail of pancreas.5 In our case, no mass was found in the pancreas on either CT or ultrasound imaging, and this was confirmed by the findings at surgery. Microscopically, pancreatic acini and splenic pulp coexisted in pancreatic tail. However, awareness of accessory spleen and familiarity with typical imaging findings are necessary for surgeons to make a precise preoperative diagnosis.
References
Figure 5 A vascular pedicle between the mass and the splenic artery was found during surgery. Splenic artery (black arrow) and left gastroepiploic artery (white arrow) are shown. Sp ⫽ spleen; Panc ⫽ pancreas; TC ⫽ transverse colon.
1. Gardakis S, Pitiakoudis M, Sigalas I, et al. Infarction of an accessory spleen presenting as acute abdomen in a neonate. Eur J Pediatr Surg 2005;15:203–5. 2. Servais EL, Sarkaria IS, Solomon GJ, et al. Giant epidermoid cyst within an intrapancreatic accessory spleen mimicking a cystic neoplasm of the pancreas: case report and review of the literature. Pancreas 2008;36:98 –100. 3. Wacha M, Danis J, Wayand W. Laparoscopic resection of an accessory spleen in a patient with chronic lower abdominal pain. Surg Endosc 2002;16:1242–3. 4. Budzynski A, Bobrzynski A, Sacha T, et al. Laparoscopic removal of retroperitoneal accessory spleen in patient with relapsing idiopathic thrombocytopenic purpura 30 years after classical splenectomy. Surg Endosc 2002;16:1636. 5. Uchiyama S, Chijiiwa K, Hiyoshi M, et al. Intrapancreatic accessory spleen mimicking endocrine tumor of the pancreas: case report and review of the literature. J Gastrointest Surg 2008;12:1471–3.
Clinical Images
Accessory spleen in the greater omentum Cheng Zhang, M.D.*, Xue-Feng Zhang, M.D. Department of General Surgery, The General Hospital of ShenYang Military Command, Number 83 Wenhua Rd., Shenhe District, ShenTang, Liaoning, 110016 People’s Republic of China KEYWORDS: Accessory spleen; The greater omentum; Intrapancreatic accessory spleen
Abstract. Although accessory spleen is a frequently encountered entity, accessory spleen in the greater omentum is rare. A 22-year-old woman presented with dull pain in the left upper abdomen. Crosssectional imaging studies with 3-dimensional reconstruction suggested the presence of a huge tumor in the greater omentum that was associated with the spleen. At laparotomy, the diagnosis of accessory spleen was made. This accessory spleen was unusual in its size and location. Awareness of this entity and familiarity with typical imaging findings is mandatory for preoperative diagnosis. The importance of recognition and appropriate confirmatory diagnosis of an accessory spleen is discussed. © 2011 Elsevier Inc. All rights reserved.
A 22-year-old woman reported intermittent and dull pain in the left upper abdomen and diarrhea for 3 months. There were no other associated symptoms. Her past and family histories were noncontributory. On admission, physical examination findings were unremarkable. Laboratory data including peripheral blood counts, blood sugar level, and liver function test results were all unremarkable. Tumor markers, including CA19-9, CA125, carcinoembryonic antigen, and ␣-fetoprotein levels, were within the normal range. Abdominal sonography was performed, and a huge irregular solid mass was noted in the left abdominal cavity. The echogenicity of the tumor was homogeneous and lower than that of the hepatic parenchyma. On color Doppler sonography images, an abundant vascular supply with low-resistance blood flow was observed in the tumor. Abdominal contrastenhanced computed tomography (CT) showed a well-marginated, irregular, mass enhanced homogeneously and to a similar degree as splenic parenchyma and superior mesenteric artery (Figs. 1 and 2). A 3-dimensional reconstruction of the CT scan showed that the mass, approximately 12 ⫻ 38 cm in size extending from the splenic hilum to the pelvic * Corresponding author. Tel.: ⫹86-24-28856245; fax: ⫹86-2428856246. E-mail address: [email protected] Manuscript received March 4, 2010; revised manuscript June 29, 2010
0002-9610/$ - see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.amjsurg.2010.06.032
cavity, was supplied by a vascular branch arising from the splenic artery (Fig. 3). Of note, the pancreatic and splenic tissue were normal in appearance on both CT and ultrasound images. No other pathologic process was noted in the abdomen. The size of the tumor, which had never been reported for an accessory spleen, made an exact diagnosis uncertain. At laparotomy, the spleen was normal. A huge wellmarginated irregular mass was observed in the greater omentum on the left side (Fig. 4). The mass was fed by a vascular pedicle from the splenic artery, and extended from the pancreatic tail to pelvis (Fig. 5). The tumor was close to the tail of the pancreas and the pancreatic tail was rigid. The tumor was dark-red, elastic soft, and the gross appearance of mass was quite different from that of sarcoma (Fig. 6). A therapeutic omentectomy and accessory splenectomy were performed. After dissecting the pancreatic tail away from the splenic hilum and the splenic vessels, a distal pancreatectomy was completed. Microscopically, lymphoid follicles and splenic pulp were found in pancreatic tail and pathologic examination of the resected specimen in the greater omentum revealed splenic tissue. Thus, diagnosis of an accessory spleen was certain. The patient had an uneventful recovery with only a transient increase of the platelets and pancreatic fistula.
C. Zhang and X.-F. Zhang
Accessory spleen
Figure 1 Contrast-enhanced CT showed that a well-marginated irregular mass enhanced homogenously as superior mesenteric artery. The superior mesenteric artery (black arrow) and accessory spleen (white arrow) are shown. Li ⫽ liver; St ⫽ stomach; B ⫽ bladder; Ut ⫽ uterus.
The presenting symptoms of dull pain and diarrhea were absent 6 months after surgery.
e29
Figure 3 Three-dimensional reconstruction CT scan shows trophic vessel linking mass to the splenic artery. Splenic artery (black arrow) and left gastroepiploic artery (white arrow) are shown.
mimic lymphadenopathy and tumors in other abdominal organs, such as the pancreas, the adrenal gland, and the kidney.2 In these cases, the recognition and appropriate
Comments Accessory spleen is an ectopic mass of healthy splenic tissue separate from the main body of the spleen. Accessory spleen occurs in 10% to 30% of the population.1 They are always situated on the left side: hilum of the spleen, splenic artery, pancreas, splenocolic ligament, greater omentum, mesenterium, adnexal region, and scrotum. The detection and characterization of an accessory spleen can be important for several reasons. First, an accessory spleen may
Figure 2 Contrast-enhanced CT showed that accessory spleen enhanced homogenously as splenic parenchyma. The splenic parenchyma (black arrow) and accessory spleen (white arrow) are shown. Li ⫽ liver; k ⫽ kidney.
Figure 4 An accessory spleen emerging from the greater omentum was observed during laparotomy. Transverse colon (white arrow) and greater omentum (black arrow) are shown.
e30
The American Journal of Surgery, Vol 202, No 3, September 2011
confirmatory diagnostic imaging of accessory spleen is important to avoid an unnecessary surgery. Second, accessory spleens occasionally may become symptomatic because of torsion, spontaneous rupture, hemorrhage, and cyst formation.3 In our case, because the pain and diarrhea were relieved after surgery, the presenting symptoms may be caused by mechanical irritation of the mass. Third, in hematologic disorders accessory spleen can take over the function of the original spleen after splenectomy. Accordingly, a surgeon’s awareness of their presence may be important when the intention is to remove all functional splenic tissue.4 CT/magnetic resonance imaging and scintigraphy with technitium-99m are helpful in marking the diagnosis of accessory spleen. This accessory spleen was unusual in its size and location. This was a large accessory spleen. Although intrapancreatic accessory spleen is a rarely encountered entity, their CT features are characteristic. Typically, they are well-marginated, homogeneously enhanc-
Figure 6
Transection of the resected accessory spleen.
ing, round masses in the tail of pancreas.5 In our case, no mass was found in the pancreas on either CT or ultrasound imaging, and this was confirmed by the findings at surgery. Microscopically, pancreatic acini and splenic pulp coexisted in pancreatic tail. However, awareness of accessory spleen and familiarity with typical imaging findings are necessary for surgeons to make a precise preoperative diagnosis.
References
Figure 5 A vascular pedicle between the mass and the splenic artery was found during surgery. Splenic artery (black arrow) and left gastroepiploic artery (white arrow) are shown. Sp ⫽ spleen; Panc ⫽ pancreas; TC ⫽ transverse colon.
1. Gardakis S, Pitiakoudis M, Sigalas I, et al. Infarction of an accessory spleen presenting as acute abdomen in a neonate. Eur J Pediatr Surg 2005;15:203–5. 2. Servais EL, Sarkaria IS, Solomon GJ, et al. Giant epidermoid cyst within an intrapancreatic accessory spleen mimicking a cystic neoplasm of the pancreas: case report and review of the literature. Pancreas 2008;36:98 –100. 3. Wacha M, Danis J, Wayand W. Laparoscopic resection of an accessory spleen in a patient with chronic lower abdominal pain. Surg Endosc 2002;16:1242–3. 4. Budzynski A, Bobrzynski A, Sacha T, et al. Laparoscopic removal of retroperitoneal accessory spleen in patient with relapsing idiopathic thrombocytopenic purpura 30 years after classical splenectomy. Surg Endosc 2002;16:1636. 5. Uchiyama S, Chijiiwa K, Hiyoshi M, et al. Intrapancreatic accessory spleen mimicking endocrine tumor of the pancreas: case report and review of the literature. J Gastrointest Surg 2008;12:1471–3.