Splenic torsion after congenital diaphragmatic hernia repair: case report and review of the literature

Volvulus of the stomach and wandering spleen after repair of congenital diaphragmatic hernia: unexpected manifestations in a neonate

Background

Congenital diaphragmatic hernia (CDH) is sometimes associated with complications involving herniation of intrathoracic organs, which further increase mortality rate. We encountered a case of postoperative gastric and splenic volvulus shortly after left CDH repair in a female neonate who was treated with gastropexy.

Case presentation

At 39 weeks gestation, a female patient with left Bochdalek CDH was delivered (birth weight: 3748 g, Apgar score: 3/4). The patient was provided ventilator support with nitric oxide. After pulmonary hypertension improved, CDH repair was performed via the abdominal approach on day 7. The stomach, small intestine, large intestine, and spleen were herniated through a diaphragmatic defect of 4 × 2 cm. Although the diaphragm was directly closed, it was tight and the reconstructed diaphragm “dome” was shallow, restricting space for the spleen and stomach. Nonetheless, the spleen was positioned in the left upper abdomen and the stomach was positioned medially. The postoperative course was complicated by organo-axial gastric volvulus, and laparotomy was performed on day 14. In addition to the gastric volvulus, we confirmed a wandering splenic volvulus. The spleen was easily detorted and returned to the left upper abdomen. However, the patient experienced relapse of gastric volvulus without splenic volvulus. Gastropexy was performed electively on day 47. Postoperatively, the patient could be fed orally, and the patient’s development was satisfactory 6 years after surgery.

Conclusions

The cause of these rare complications appeared to be tight direct diaphragmatic closure, which reduced space for the spleen and stomach beneath the left diaphragm.

Challenge of diagnosing splenic torsion in a paediatric patient with gastroschisis

Gastroschisis is an uncommon congenital defect of the abdominal wall resulting in intestinal prolapse, most commonly associated with short gut syndrome or bowel obstruction. Wandering spleen, movement of the spleen due to the underdevelopment of splenic ligaments, has a prevalence of 0.25% and is asymptomatic in 15% of paediatric cases. An 11-year-old patient, admitted with a history of gastroschisis repaired at birth, presents with 18 months of intermittent, worsening abdominal pain. Imaging demonstrated splenomegaly and tortuosity of the splenic vein with abnormal positioning of the superior mesenteric artery and vein. The patient was found to have a wandering spleen with subacute splenic infarct secondary to splenic torsion, necessitating emergent surgical intervention. This patient experienced an extremely rare complication of gastroschisis that has not previously been reported. This complication is caused by a lack of appropriate abdominal fixation points for the spleen.

Treatment of a congenital diaphragmatic hernia with associated wandering spleen: Case report of a 17-year-old girl

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Wandering spleen with an associated congenital diaphragmatic hernia is an extremely rare diagnosis.

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Clinical diagnosis is unlikely, making computed tomography the diagnostic test of choice.

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Prompt surgical management is required given the risk of significant morbidity associated with both conditions.

Introduction

A congenital diaphragmatic hernia (CDH) is rarely diagnosed in adults and can allow passage of abdominal viscera into the chest cavity. A particularly rare association is a wandering spleen due to absence of its diaphragmatic and retroperitoneal attachment which predisposes to elongation of the vascular pedicle with risk of torsion, infarction and rupture.

Presentation of case

A 17-year-old girl presented with a two-day history of increasing abdominal pain. Examination identified an abdominal mass. Computer tomography (CT) chest, abdomen and pelvis revealed a significantly enlarged wandering spleen with signs of torsion and an associated large left CDH with viscera in the chest cavity. The patient proceeded to an open splenectomy and repair of CDH. Post-operatively the patient developed ileus and required a temporary chest tube for pneumothorax, but otherwise progressed well.

Discussion

Untreated CDH with a symptomatic wandering spleen is an extremely rare diagnosis with only one similar previous case report. Clinical detection is unlikely, making CT scanning the diagnostic test of choice. Surgery is recommended given the high morbidity and mortality of associated complications of both conditions. Splenic preserving options are favoured, however the majority of identified cases require splenectomy because of associated torsion or splenomegaly. Reduction of the CDH should be performed with primary closure of the defect and mesh reinforcement where possible.

Conclusion

CDH with associated wandering spleen in adults presents an extremely rare but clinically important diagnosis. Prompt surgical management as reported in this case should be performed to minimise immediate and future complications.

Wandering Spleen and Organoaxial Gastric Volvulus after Morgagni Hernia Repair: A Case Report and Review of the Literature

Wandering spleen and gastric volvulus are two rare entities that have been described in association with congenital diaphragmatic hernia. The diagnosis is difficult and any delay can result in ischemia and necrosis of both organs. We present a case of a 13-year-old girl, previously operated on for anterior diaphragmatic hernia and intrathoracic gastric volvulus, that presented to our service for a subdiaphragmatic gastric volvulus recurrence associated with a wandering spleen. In this report we reviewed the literature, analyzing the clinical presentation, diagnostic assessment, and treatment options of both conditions, in particular in the case associated with diaphragmatic hernia.

The Great Pretender: Pediatric Wandering Spleen: Two Case Reports and Review of the Literature

Wandering spleen is a rare condition, typically not only due to embryological defects of the splenic ligaments, but also secondary to trauma and splenomegaly. The most common presentation is acute abdomen with a mobile abdominal mass or recurrent abdominal pain. However, the spleen may be temporary in its normal position, and patients could be asymptomatic. A familiarity, if present, strengthens the diagnostic suspect.Abdominal ultrasonography and computed tomography are the examination of choice, and the management is surgical.

Laparoscopic transperitoneal left adrenalectomy and wandering spleen risk

Background and Objectives:

Laparoscopic transperitoneal left adrenalectomy (LTLA) has become the standard treatment for adrenal masses <6 cm. LTLA involves the dissection of splenic suspensory ligaments, which replicates their congenital absence or weakening, present in cases of wandering spleen (WS). WS is a rare condition in which the spleen migrates from the left upper quadrant to a more caudal location in the abdomen. A unique case of WS after LTLA was described by Corcione et al. In this prospective study, we investigated the possibility of WS as a consequence of LTLA.

Methods:

Twenty-four patients, 8 men and 16 women, who underwent LTLA with the dissection of splenoparietal and splenorenal ligaments were selected.

Results:

Clinical and ultrasonographic follow-up showed no evidence of postoperative WS.

Conclusions:

In the literature, WS is not commonly reported as a postoperative complication of LTLA. In effect, especially in the case of small adrenal masses, the spleen's repositioning in its seat is autonomous. However, the alarming possibility of WS should not be ignored, especially in the case of extensive dissection of the left colic flexure. It would be useful for other authors to signal this complication, so that different approaches and consequent results may be compared.