Wandering spleen presenting as duodenal obstruction after repair of congenital diaphragmatic hernia

Delayed finding of congenital duodenal obstruction following congenital diaphragmatic hernia repair

Congenital diaphragmatic hernia (CDH) is encountered in just under 1 in 6000 live births, while congenital duodenal obstruction is seen once every 8000 live births. These congenital anomalies have only been reported together as part of the VACTERL syndrome and therefore in isolation represent an incredibly rare occurrence. This is a case report of a girl born at 34 weeks gestation who had an antenatal diagnosis of left CDH. Five days following operative repair of this, there was extensive pneumoperitoneum and pneumothorax. Upper gastrointestinal contrast study showed a perforation of the duodenum and at laparotomy, a duodenal web was found in the fourth part of the duodenum with perforation immediately proximal. Following duodenoduodenostomy, the postoperative recovery was good. She achieved full enteral feeds and was discharged home. This case highlights the importance of considering rare associations if postoperative recovery is not as expected to prevent delay in undergoing definitive treatment.

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.

Surgical Management of a Volvulus of a Wandering Spleen Associated with a Volvulus of the Small Intestine

Introduction

A wandering spleen is a rare anatomical condition characterized by a free-floating splenic tissue that is not located in its normal position in the left upper quadrant. This condition is usually asymptomatic but can also manifest itself with volvulus of the spleen and consequent infarction and necrosis of the parenchyma, requiring an urgent surgical management. Additionally, a wandering spleen can be associated with other contemporaneous anatomical anomalies. Case Presentation. We report a case of a 21-year-old woman, admitted to our hospital for intense abdominal pain and vomiting. A CT scan revealed a wandering spleen in the mesogastric area with the spleen torted on its axis, associated with a volvulus of the small intestine. Abdominal exploration revealed a macroscopically normal free-floating spleen attached to an abnormally long vascular pedicle. The management of the wandering spleen was conservative, and a splenopexy was performed.

Conclusions

The torsion of the wandering spleen constitutes an infrequent but life-threatening abdominal emergency. The diagnosis of the wandering spleen is frequently challenging since clinical findings are usually not specific. Imaging such as computed tomography scan plays an important role in the differential diagnosis pathway. Treatment should be planned according to the splenic parenchyma conditions. Splenectomy is indicated when massive infarction and thrombosis of splenic vessels have occurred. When splenic parenchyma is not compromised, it is preferred to perform a conservative surgical technique, such as splenopexy, in order to avoid postsplenectomy 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.

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

Wandering spleen with torsion, a rare clinical diagnosis, was found to be the cause of chronic abdominal pain in an 11-year-old female with a history of congenital diaphragmatic hernia repaired at three days of age. Doppler ultrasound revealed patent vessels with splenomegaly, and computed tomography (CT) showed an absence of the spleen in the left subphrenic space with torsion at the splenic hilum. Due to the chronicity of pain and risk of ischemia from torsion, open splenopexy with Vicryl mesh was performed. This case report/review of the literature discusses the rarity of this condition, and the importance of timely diagnosis and intervention.

Right abdominal mass in a 2 year-old child

The authors report a case of a wandering spleen presenting as a right lower quadrant abdominal mass, 2 years post a transabdominal left diaphragmatic hernia repair in a 2-year-old child with a congenital diaphragmatic hernia. The wandering spleen was fixed laparoscopically in an extraperitoneal pouch.

Laparoscopic splenopexy and cystectomy for an enlarged wandering spleen and splenic cyst

Wandering spleen is an uncommon condition, which can present emergently in children. Similarly, nonparasitic splenic cysts are also rarely encountered. In this report, we describe a massive wandering spleen (22 cm in longitudinal dimension) with a pseudocyst (4.6 x 2 cm) in the inferior pole in an asymptomatic 16-year-old adolescent. Only 4 similar cases have been reported in the literature; 2 of them have been in the pediatric age group. These 2 conditions were diagnosed while she was being evaluated for dysmenorrhea, and she was referred for surgical consultation. The cyst was excised laparoscopically, and the spleen was placed into an extraperitoneal pouch. To date, there are no other reports describing laparoscopic cystectomy and splenopexy in a teenager.

Surgical Treatment of Patients with Wandering Spleen: Report of Six Cases with a review of the literature

Wandering spleen, which is defined as a spleen without peritoneal attachments, is a rare disease and a delay in the clinical and/or radiological diagnosis may lead to splenic torsion, infarction, and necrosis. Owing to the physiologic importance of the spleen, especially in children, and the risk of postsplenectomy sepsis, early diagnosis and splenopexy are recommended. In the present article, we describe the results of our management of this rare problem on six patients, and we review all available literature from 1895 to 2005. Briefly, our technique includes flap creation from parietal peritoneum and settlement of spleen in the fossa splenica. Free edges of this flap are stitched to the stomach and the left end of transverse colon and the beginning of the descending colon. The body of the stomach was stitched to the abdominal wall to prevent gastric volvulus, while the fundus region was fixed to the diaphragm to support the spleen. Finally, an omental patch was stitched to the intact abdominal wall above the flap. In conclusion, the procedure of splenopexy without using mesh is considered to be a safe and curative modality for wandering spleen without imposing any undue risk of infection or foreign material reaction.

Wandering spleen--the challenge of ultrasound diagnosis: report of 7 cases

PURPOSE

To summarize our experience with sonographic diagnosis of wandering spleen in children and assess for the typical sonographic findings of wandering spleen, complications, and possible diagnostic pitfalls.

METHODS

We identified all pediatric patients from 1998-2003 with a surgically confirmed diagnosis of wandering spleen. All sonographic examinations were reviewed for splenic position, size, echotexture, and parenchymal blood flow.

RESULTS

Seven children were identified with a mean age of 9.7 years (range 4.2-15.3 years). All presented with abdominal pain. Abdominal sonography, performed in all children demonstrated a low position of the spleen (n = 6), splenomegaly (n = 4), and absence of parenchymal flow in the three patients with splenic torsion and infarction. The diagnosis was made preoperatively via sonography in five children; three required repeated hospital admissions before the correct diagnosis was established. Complications occurred in five patients (gastric obstruction [n = 1], splenic infarction [n = 3], and recurrent pancreatitis [n = 1]).

CONCLUSION

The most specific sonographic finding for wandering spleen is low position of the spleen. However, if the spleen regains its normal or near-normal position, the diagnosis may be missed and the condition may recur, and result in complications.

[Torsion of the spleen in children]

The wandering spleen is caused by congenital absence of fixating ligaments or abnormally long ligaments. It is an uncommon clinical entity, which rarely affects children. The clinical presentation of wandering spleen is variable, but the most dangerous complication is splenic torsion. A 7 year-old boy presented with abdominal pain and vomiting. The abdominal ultrasound scan discovered spleen ischemia. Volvulus of the spleen was evoked. Laparotomy was carried out and the patient underwent splenectomy. In this case the anatomical means of spleen fixity were absent. Because wandering spleen is uncommon in the paediatric population, a heightened awareness of the condition is required for accurate diagnosis and appropriate management. The treatment of choice is splenopexy, while if splenic necrosis is present, splenectomy is required.

Laparoscopic pocket splenopexy for wandering spleen: a case report

Wandering spleen is a very uncommon condition. Because of the risk of pedicle torsion and splenic ischemia, severe consequences may occur if not diagnosed and treated in time. Unfortunately, splenectomy is sometimes necessary (ie, when splenic infarction occurs). Once the diagnosis of wandering spleen is made, splenopexy is the treatment of choice. There are numerous techniques designed for splenopexy, either by open surgery or by minimally invasive approaches. We describe here a laparoscopic procedure that allows an excellent fixation of the spleen using the patient's own tissues. After a 2-year follow-up, the organ remains in place with good perfusion.

The technique of laparoscopic retroperitoneal splenopexy for symptomatic wandering spleen in childhood

BACKGROUND

Wandering spleen is an uncommon diagnosis, difficult to prove by standard investigations. The authors report a new method for laparoscopic splenopexy in children using a balloon-dilated retroperitoneal pouch.

METHODS

From 3 accesses, the spleen is mobilized and displaced into a retroperitoneal pouch dilated to the double splenic volume. The pouch is dilated by a self-made balloon via a further intercostal access and narrowed by sutures incorporating the cranial and caudal edge of the gastrosplenic ligament.

RESULTS

The peritoneal pouch contracts around the retroperitoneal spleen resulting in a firm fixation of the organ. This technique was successful in a 9-year-old girl with a 5-year history of severe recurrent abdominal pain.

CONCLUSIONS

Laparoscopic retroperitoneal pouch splenopexy is a safe and effective procedure for symptomatic wandering spleen precluding the use of foreign materials in this age group.

Clinical presentation of wandering spleen

BACKGROUND

Wandering spleen (WS) is an uncommon condition with a variety of clinical presentations.

METHODS

The medical files of 5 children who underwent operation for WS in the authors' department during the period 1996 through 2000 were retrospectively reviewed.

RESULTS

Splenic salvage procedures (retroperitoneal splenopexy) were performed in 4 patients. One patient underwent splenectomy because of splenic necrosis.

CONCLUSIONS

Early diagnosis and surgical treatment is mandatory to prevent complications. Every effort should be made to preserve the spleen, especially among the pediatric population, and splenopexy is the procedure of choice even in the asymptomatic patient.

Intrauterine torsion of a wandering spleen presenting as an abdominal cystic swelling

Wandering spleen is a rare clinical condition that presents commonly with splenic infarction secondary to torsion. Intrauterine torsion of a wandering spleen, however, is extremely rare. An unusual case of intrauterine torsion of a wandering spleen presenting as an abdominal mass is reported.

Gastric volvulus associated with wandering spleen in a child

Wandering spleen is an uncommon entity in childhood and has been described only rarely in association with gastric volvulus. Wandering spleen and gastric volvulus were diagnosed in a 5-year-old boy who presented with acute abdominal pain and distension. Intraoperatively, normal ligamentous connections between the stomach, spleen, and posterior abdominal wall were absent. Developmental anomalies that result in wandering spleen may lead to hypermobility of the stomach and a predisposition to gastric volvulus. In such patients, prophylactic gastropexy should be considered.