Scot Med J 1990; 35: 86
0036-9330/90/0369/0861$2.00 in USA C>
1990 Scottish Medical Journal
GASTRIC NECROSIS AND PERFORATION FOLLOWING SPLENECTOMY FOR MASSIVE SPLENOMEGALY S. Stallard and S. G. McPherson Department of Surgery, Western Infirmary, Glasgow
Abstract: Ischaemia of the greater curve ofthe stomach is a possible complication ofsplenectomy. We describe a case in which ischaemia resulted in necrosis and perforation of the stomach in a patient after splenectomy for massive splenomegaly. There are no previously reported cases in the literature.
Key words: Splenectomy, gastric ischaemia, gastric perforation. Introduction IVIDING the short gastric and splenic arteries during splenectomy can in theory reduce the blood supply to the area of the gastric greater curve, supplied by these vessels. Although this is described as a possible complication of splenectomy, 1 there are no cases reported in the literature in which the blood supply to the stomach has been compromised to the extent that ischaemia has resulted in necrosis ofthe greater curve, of the stomach. We report a case of gastric necrosis and perforation, in a patient five days after splenectomy for massive splenomegaly.
D
Case Report A 54-year-old woman with polycythaernia rubra vera was referred with massive splenomegaly producing abdominal distension and left upper quadrant pain. The disease was slowly progressive with increasing spienomegally and myelofibrosis despite previous treatment over five years. Splenectomy was indicated in an attempt to alleviate symptoms. Prior to surgery her haemoglobin was 16.8 gms, her white cell count was 4.8 x 1()3/L and her platelets were 600 x 1()3/L. The spleen was removed without difficulty. The splenic artery was ligated early, the spleen was then mobilised and the short gastric vessels and colic attachments were divided prior to delivery of the spleen. Following the operation there was persistent bleeding into abdominal drains requiring a six-unit packed cell transfusion. Despite this the patient had an episode of sudden cardiovascular instability with hypotension (systolic blood pressure of 70mm Hg) for ten minutes. This responded to fluid replacement therapy and she was returned to theatre six hours post-operatively. At laparotomy, clot was evacuated from the abdominal cavity and there was mild oozing noted from the splenic bed. Haemostasis was secured and the patient was transferred to the intensive care where she was commenced on intermittent positive pressure ventilation. During the next two days, there was continued bleeding into abdominal drains, an episode of haematemisis and an episode of melanoma. Upper G 1 tract endoscopy on the second post-operative day showed adherent clot, high on the greater curve of the stomach. On the fifth post-operative day, the patient was given Aludrox via a nasogastric tube and this appeared in the abdominal drainage bag. At a third laparotomy, a 2cm diameter perforated necrotic area was found in the fundus of the stomach on the greater curve, the edge of which was bleeding. Necrotic tissue was excised and the perforation oversewn. Following this the patient had recurrent left subphrenic abscess collections, but eventually made a good recovery.
routine splenectomy. Post-operative bleeding from the splenic bed is particularly a problem.v" In massive splenomegaly the splenic and short gastric vessels are larger in diameter than usual, and therefore, theoretically provide a greater proportion than usual of the blood supply to the stomach. The greater curve of the stomach is supplied by the right gastroepiploic (a branch of the gastroduodenal) artery and the left gastroepiploic (a branch of the splenic) artery. The fundus of the stomach along the greater curve is supplied by 'the short gastric arteries (branches of the splenic and left gastroepiploic vessels). Dividing the splenic and short gastric arteries during splenectomy is therefore likely to reduce the blood supply to the greater curve at the fundus of the stomach, at least temporarily. The fact that ischaemia leading to necrosis of the stomach has never previously been reported, means that normally the rich anastomosing network of vessels to the greater curve is sufficient to take over the blood supply to the gastric mucosa after division of the splenic and short gastric arteries. This case suggests, however, that the blood supply to the greater curve may be significantly reduced after splenectomy. In our patient, the additional factor of a period of hypotension following reactionary haemorrhage was presumably enough to produce irreversible ischaemia. Perforation of a hollow viscus can be difficult to diagnose in the early post-operative period, especially in patients in intensive care, who are relaxed and ventilated. The lack of adequate progress in this patient and eventually the appearance of Aludrox in the abdominal drain, led to the diagnosis. Necrosis and perforation was more likely in this case, where the spleen was massive (1.5kg) and where the patient had post-operative hypotension; however, it should be borne in mind as a possible complication of splenectomy, especially in cases of massive splenomegaly. ACKNOWLEDGEMENTS. Fiona Conway for typing the manuscript.
Discussion Removal of the massive spleen is known to be associated with increased mortality, and morbidity, compared with Correspondence to and reprints from: Ms S. Stallard, Department of Surgery, Western Infirmary, Dumbarton Road, Glasgow G116NT.
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REFERENCES I Surgery of the spleen. Surgical Clinics of North America, 1975. 2 Wobbes T, Rigtje F, Evert-Jan C. Removal of the massive spleen: A surgical risk? Am J Surg 1984; 147: 800-802. 3 Goldstone J. Splenectomy for massive splenomegaly. Am J Surg 1978; 135: 385-8.
0036-9330/90/0369/0861$2.00 in USA C>
1990 Scottish Medical Journal
GASTRIC NECROSIS AND PERFORATION FOLLOWING SPLENECTOMY FOR MASSIVE SPLENOMEGALY S. Stallard and S. G. McPherson Department of Surgery, Western Infirmary, Glasgow
Abstract: Ischaemia of the greater curve ofthe stomach is a possible complication ofsplenectomy. We describe a case in which ischaemia resulted in necrosis and perforation of the stomach in a patient after splenectomy for massive splenomegaly. There are no previously reported cases in the literature.
Key words: Splenectomy, gastric ischaemia, gastric perforation. Introduction IVIDING the short gastric and splenic arteries during splenectomy can in theory reduce the blood supply to the area of the gastric greater curve, supplied by these vessels. Although this is described as a possible complication of splenectomy, 1 there are no cases reported in the literature in which the blood supply to the stomach has been compromised to the extent that ischaemia has resulted in necrosis ofthe greater curve, of the stomach. We report a case of gastric necrosis and perforation, in a patient five days after splenectomy for massive splenomegaly.
D
Case Report A 54-year-old woman with polycythaernia rubra vera was referred with massive splenomegaly producing abdominal distension and left upper quadrant pain. The disease was slowly progressive with increasing spienomegally and myelofibrosis despite previous treatment over five years. Splenectomy was indicated in an attempt to alleviate symptoms. Prior to surgery her haemoglobin was 16.8 gms, her white cell count was 4.8 x 1()3/L and her platelets were 600 x 1()3/L. The spleen was removed without difficulty. The splenic artery was ligated early, the spleen was then mobilised and the short gastric vessels and colic attachments were divided prior to delivery of the spleen. Following the operation there was persistent bleeding into abdominal drains requiring a six-unit packed cell transfusion. Despite this the patient had an episode of sudden cardiovascular instability with hypotension (systolic blood pressure of 70mm Hg) for ten minutes. This responded to fluid replacement therapy and she was returned to theatre six hours post-operatively. At laparotomy, clot was evacuated from the abdominal cavity and there was mild oozing noted from the splenic bed. Haemostasis was secured and the patient was transferred to the intensive care where she was commenced on intermittent positive pressure ventilation. During the next two days, there was continued bleeding into abdominal drains, an episode of haematemisis and an episode of melanoma. Upper G 1 tract endoscopy on the second post-operative day showed adherent clot, high on the greater curve of the stomach. On the fifth post-operative day, the patient was given Aludrox via a nasogastric tube and this appeared in the abdominal drainage bag. At a third laparotomy, a 2cm diameter perforated necrotic area was found in the fundus of the stomach on the greater curve, the edge of which was bleeding. Necrotic tissue was excised and the perforation oversewn. Following this the patient had recurrent left subphrenic abscess collections, but eventually made a good recovery.
routine splenectomy. Post-operative bleeding from the splenic bed is particularly a problem.v" In massive splenomegaly the splenic and short gastric vessels are larger in diameter than usual, and therefore, theoretically provide a greater proportion than usual of the blood supply to the stomach. The greater curve of the stomach is supplied by the right gastroepiploic (a branch of the gastroduodenal) artery and the left gastroepiploic (a branch of the splenic) artery. The fundus of the stomach along the greater curve is supplied by 'the short gastric arteries (branches of the splenic and left gastroepiploic vessels). Dividing the splenic and short gastric arteries during splenectomy is therefore likely to reduce the blood supply to the greater curve at the fundus of the stomach, at least temporarily. The fact that ischaemia leading to necrosis of the stomach has never previously been reported, means that normally the rich anastomosing network of vessels to the greater curve is sufficient to take over the blood supply to the gastric mucosa after division of the splenic and short gastric arteries. This case suggests, however, that the blood supply to the greater curve may be significantly reduced after splenectomy. In our patient, the additional factor of a period of hypotension following reactionary haemorrhage was presumably enough to produce irreversible ischaemia. Perforation of a hollow viscus can be difficult to diagnose in the early post-operative period, especially in patients in intensive care, who are relaxed and ventilated. The lack of adequate progress in this patient and eventually the appearance of Aludrox in the abdominal drain, led to the diagnosis. Necrosis and perforation was more likely in this case, where the spleen was massive (1.5kg) and where the patient had post-operative hypotension; however, it should be borne in mind as a possible complication of splenectomy, especially in cases of massive splenomegaly. ACKNOWLEDGEMENTS. Fiona Conway for typing the manuscript.
Discussion Removal of the massive spleen is known to be associated with increased mortality, and morbidity, compared with Correspondence to and reprints from: Ms S. Stallard, Department of Surgery, Western Infirmary, Dumbarton Road, Glasgow G116NT.
86
REFERENCES I Surgery of the spleen. Surgical Clinics of North America, 1975. 2 Wobbes T, Rigtje F, Evert-Jan C. Removal of the massive spleen: A surgical risk? Am J Surg 1984; 147: 800-802. 3 Goldstone J. Splenectomy for massive splenomegaly. Am J Surg 1978; 135: 385-8.
