Splenic Cysts: Aspiration, Sclerosis, or Resection By C. Moir, F. Guttman, S. Jequier, R. Sonnino, and S. Youssef Montreal, Quebec 9 Percutaneous aspiration and tetracycline sclerosis is a safe but temporary therapy of large splenic cysts in chil- dren. Between 1985 and 1987, three girls with splenic cysts were seen. Their ages ranged from 5 to 14 years, and the cysts were from B to 16 cm in diameter. Despite their large size, all were asymptomatic and were discovered upon physical examination or ultrasound for unrelated conditions. All cysts were avascular by scan and had irregular cranated or smooth walls by ultrasound. Further investigation excluded infectious or parasitic causes. Each cyst was aspirated for diagnosis, and a pigtail catheter was inserted for drainage and sclerotherapy. All needle aspira- tions resulted in cyst collapse, but in one patient the pigtail catheter insertion was unsuccessful, and in the other two cases, multiple attempts of tetracycline sclerosis failed to obliterate the cysts. There were no other complications. Surgery for the recurrent splenic cysts was performed 3 months to 2 years following the percutaneous procedures. The two patients operated on with 3 months of aspiration underwent successful partial splenectomy and have normal splenic function by ultrasound scan, and absence of RBCs. The third patient had progression of the cystic disease throughout the spleen, and required splenectomy. Pathol- ogy confirmed multiseptate congenital mesothelial cysts in the first two patients and massive lymphangiomatosis in the third. In all three cases, percutaneous therapy was safe but did not result in long-term control. In one patient, the cystic disease progressed following sclerotherapy and may have influenced the need for complete splenectomy, Prior manipulation did not adversely affect the dissection and mobilization of the spleens. Based on this experience, we recommend that partial splenectomy is the procedure of choice for permanent control of congenital splenic cysts until more effective percutaneous methods are available. 91989 by W.B. Saunders Company. INDEX WORDS: Splenic cyst. T HE DRAINAGE and sclerosis of nonparasitic splenic cysts is an attractive alternative for patients who are contemplating major abdominal sur- gery. Benign congenital splenic cysts have minimal symptoms, but because of their large size they are often discovered during childhood. 1 Splenectomy is From the Departments of Surgery and Radiology, McGill Uni- versity, The Montreal Children's Hospital, Montreal, Quebec, Canada. Presented at the 37th Annual Meeting of the Surgical Section of the American Academy of Pediatrics, San Francisco, California, October 15-17, 1988. Address reprint requests to (2. Moir, hiD, Section of Pediatric Surgery, Mayo Clinic, 200 First St SIC, Rochester, MN 55905. 9 1989 by W.B. Saunders Company. 0022-3468/89/2407-0007503.00/0 curative, but the long-term adverse effects2'3 have prompted trials of other more conservative procedures such as percutaneous needle and catheter placement in the spleen. These are safe procedures when performed by experienced physicians. 4'5 The reported safety and relative ease of the percutaneous approach encouraged us to attempt cyst drainage and subsequent sclerosis in three children who presented with uncomplicated but large splenic cysts. It was felt that partial splenectomy would still be feasible if these attempts failed. Herein we report the results of this therapy in three girls, aged 5 to 15 years. CASE REPORTS Patient 1 A 14-year-old girl was seen for a petechial rash and thrombocyto- penia. A physical examination showed an enlarged spleen, which was asymptomatic. A 16-cm upper pole splenic cyst was seen on an ultrasound examination. There was no calcification or other features to suggest parasitic infestation. There was some trabeculation noted. Serology for Echinococcus, mononucleosis, and toxoplasmosis were negative. Pneumococcus and Hemophilus influenza vaccines were given, and the girl underwent cyst aspiration through a 22-gauge needle. Following drainage of 1500 mL of straw-colored fluid, a 12F pigtail catheter was inserted under fluoroscopic control using 30 mL of Renografin m-30 (Squibb Diagnostics, Princeton, N J) to assure correct placement. Three injections of l g of tetracycline were performed over the next three days. The catheter was damped for one hour after injection and then allowed to drain for 23 hours. Each injection produced left upper quadrant pain and high fever that subsided in 24 to 48 hours. The catheter continued to produce 80 to 100 mL of serosanguineous fluid daily. After 2 weeks of drainage, the catheter occluded and the cyst reaccumulated to 17 cm in size. During a laparotomy 21/2 months later, the spleen was easily mobilized, and a partial splenectomy was performed for a 25 x 15 x 10-em epidermoid inclusion cyst (probable mesothelial origin). Follow-up ultrasound and nuclear scanning has shown the spleen to be within normal limits for both size and function. No nucleated RBCs have been found on the peripheral smear. Patient 2 A 131/2-year-old girl was seen for dysfunctional uterine bleeding and lower abdominal pain. These problems resolved with oral contraceptives. During investigation, an ultrasound examination showed an 8-cm splenic cyst. This was in the lower pole of the spleen and showed some trabeculation. A pneumococcal vaccine was given, and the cyst was aspirated with a 22-gauge needle under ultrasound control. Following drainage of 500 to 600 mL of serosanguineous fluid, a small amount of Renografin M-15 was injected. A pigtail catheter could not be placed for technical reasons. There were no complications. The cyst recurred, and the patient underwent a partial splenee- tomy 6 weeks later, Pathology confirmed a 10 x 8 x 4-cm benign mesothelial cyst. There were no adhesions and the surgery was 646 Journal of Pediatric Surgery, Vo124, No 7 (July), 1989: pp 646-648