Colosplenic fistula diagnosis and management: a case series and review of literature

BACKGROUND

A colosplenic fistula (CsF) is an extremely rare complication. Its diagnosis and management remain poorly understood, owing to its infrequent incidence. Our objective was to systematically review the etiology, clinical features, diagnosis, management, and prognosis to help clinicians gain a better understanding of this unusual complication and provide aid if it is to be encountered.

METHODS

A systematic review of studies reporting CsF diagnosis in Ovid MEDLINE, Ovid EMBASE, Scopus, Web of Science, and Wiley Cochrane Library from 1946 to June 2022. Additionally, a retrospective review of four cases at our institution were included. Cases were evaluated for patient characteristics (age, sex, and comorbidities), CsF characteristics including causes, symptoms at presentation, diagnosis approach, management approach, pathology findings, intraoperative complications, postoperative complications, 30-day mortality, and prognosis were collected.

RESULTS

Thirty patients with CsFs were analyzed, including four cases at our institution and 26 single-case reports. Most of the patients were male (70%), with a median age of 56 years. The most common etiologies were colonic lymphoma (30%) and colorectal carcinoma (17%). Computed tomography (CT) was commonly used for diagnosis (90%). Approximately 87% of patients underwent a surgical intervention, most commonly segmental resection (81%) of the affected colon and splenectomy (77%). Nineteen patients were initially managed surgically, and 12 patients were initially managed nonoperatively. However, 11 of the nonoperative patients ultimately required surgery due to unresolved symptoms. The rate of postoperative complications was (17%). Symptoms resolved with surgical intervention in 25 (83%) patients. Only one patient (3%) had had postoperative mortality.

CONCLUSIONS

Our review of 30 cases worldwide is the largest in literature. CsFs are predominantly complications of neoplastic processes. CsF may be successfully and safely treated with splenectomy and resection of the affected colon, with a low rate of postoperative complications.

Occurrence of spontaneous fistulas detected by contrast filling during computed tomography-guided percutaneous drainage placement of splenic and perisplenic fluid collections

BACKGROUND

Fistulas are serious complications of splenic and perisplenic fluid accumulations, which are often difficult to detect by routine imaging methods.

PURPOSE

To evaluate the occurrence of spontaneous fistulas detectable during computed tomography-guided percutaneous drainage placement (CTGDP) with contrast filling of splenic or perisplenic fluid collections and to assess characteristics in comparison with perihepatic or peripancreatic fluid accumulations, also being treated with CTGDP.

MATERIAL AND METHODS

In 127 CTGDP-procedures, pre-interventional CTs conducted with intravenous contrast agent were compared to post-interventional CTs including contrast filling of the drain to identify spontaneous fistulas. Patient and case characteristics were evaluated, and therapeutic consequences of fistula identification were analyzed.

RESULTS

A total of 43 perisplenic, 40 peripancreatic, and 44 perihepatic drains were evaluated; 13 (30.2%) perisplenic, 7 (17.5%) peripancreatic, and 10 (22.7%) perihepatic fistulas were observed. Concerning the frequency of fistulas, no significant difference was found between the patient groups (P = 0.39). All fistulas were solely proven in CT scans including contrast filling of the drain. Seven fistulas (23.3%) required additional interventions. Perihepatic drains were significantly more often associated with recent surgery (P < 0.001). The mean size of peripancreatic drains was significantly greater (11.8 ± 3.9 F; P < 0.001) than in perihepatic or perisplenic fluid collections.

CONCLUSION

Spontaneous fistulas detected during CTGDP of splenic or perisplenic fluid collections are common. Post-interventional contrast filling of the drain drastically improves the detection rate of perisplenic, peripancreatic and perihepatic fistulas simultaneously initiating appropriate follow-up interventions.

Colosplenic fistula presentation in the context of undiagnosed colon cancer: Case report and review of literature

Introduction and importance

Enteric fistulas commonly arise from inflammatory, infectious, or neoplastic processes. Colosplenic fistulas are rare with only several reported worldwide.

Case presentation

Herein, we present a case of colosplenic fistula in a 39-year-old gentleman with past history of rectal cancer previously in remission. He was admitted with severe abdominal pain and hemodynamic instability due to septic shock. The erect chest x-ray revealed pneumoperitoneum under the diaphragm.

Clinical discussion

Laparotomy was performed and ileum perforation was managed by resection and anastomosis. The post-op recovery was complicated by a febrile episode. To locate the source of infection a contrasted abdominal computed tomography was ordered, confirming the presence of a splenic abscess, suggestive of colosplenic fistula. We proceeded with laparotomy for drainage of the abscess, with splenectomy and splenic flexure resections. He was discharged 40 days post-op at a pre-morbid state.

Conclusion

Due to the high prevalence of colon cancer worldwide, novel complications such as the one reported here, are important to be reflected on. We hope this case can exemplify the significance of higher index of suspicion in at risk patient groups by the surgical teams and appropriate training on acute management of this rare complication.

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Critically unwell surgical patients require immediate septic work-up and management.

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Colosplenic fistula are formed due to an inflammatory or neoplastic response.

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Colosplenic fistula can be treated with en-block surgical resection of colon and spleen.

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We recommend early initiation of genetic testing in patients with early presentation of rectal adenocarcinoma.

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In young patients, we should consider total colo-proctectomy to minimize the burden on the patients and healthcare system.