Staged Surgical Management of a Colosplenic Fistula Caused by Locally Advanced Splenic‐Flexure Adenocarcinoma

ABSTRACT

Colosplenic fistula is a rare complication most commonly associated with colonic lymphoma, adenocarcinoma, and Crohn's disease. In unstable and septic patients, a staged strategy consisting of initial laparoscopic source control and diversion followed by definitive multivisceral resection can balance urgent management of sepsis with adherence to oncological therapy.

1. Case Description

A 72‐year‐old woman with no significant past medical history presented with 1 week of fevers, chills, diaphoresis, and left upper quadrant abdominal pain. She denied nausea, vomiting, hematochezia, intolerance to oral intake, and changes in bowel habits. She had no prior surgical history and had never undergone colonoscopy. Her only medications were supplemental vitamins. Family history was notable for breast, esophageal, and prostate cancer in first‐degree relatives, and she reported a 0.5 pack‐per‐day smoking history.

On examination, her abdomen was soft and non‐distended, with mild left upper quadrant tenderness without peritoneal signs. Initial laboratory studies were notable for leukocytosis (white blood cell count 23.0 × 10⁹/L) and elevated lactate (3.7 mmol/L). Contrast‐enhanced computed tomography (CT) of the abdomen and pelvis demonstrated an 8.3 × 3.2 × 6.8 cm air‐fluid collection within the spleen communicating with an inflamed segment of colon at the splenic flexure (Figure 1), consistent with colonic perforation and splenic abscess, highly suspicious for colosplenic fistula (CsF). Additionally, enlarged pericolonic lymph nodes and a 2.8 cm left mid‐abdominal lesion raised concern for phlegmon versus malignancy. CT chest revealed a mildly enlarged left supraclavicular lymph node (1.2 × 1.4 cm) and two 2 mm pulmonary nodules.

FIGURE 1.

Contrast‐enhanced computed tomography of the abdomen and pelvis demonstrating an irregular 8.3 × 3.2 × 6.8 cm air‐fluid collection within the spleen communicating with a severely inflamed adjacent segment of colon at the splenic flexure, consistent with colosplenic fistula (yellow arrows). (A) Axial view. (B) Coronal view.

Although initially hemodynamically stable, she developed progressive tachycardia and worsening leukocytosis on hospital day 2. She was urgently taken to the operating room for diagnostic laparoscopy with possible conversion to laparotomy. Intraoperatively, the splenic flexure was firm with dense omental adhesions and proximal transverse colonic dilation. A splenic abscess with necrotic tissue at the inferior pole of the spleen was identified. Given the absence of tissue diagnosis and complete staging, formal oncologic resection was deferred. Instead, laparoscopic drainage of the splenic abscess with debridement was performed, along with creation of a transverse loop colostomy. Ascitic fluid and splenic abscess cultures were obtained, and biopsy of the colonic mass was performed. The operation was completed laparoscopically with an operative time of 92 min and minimal estimated blood loss (10 mL). Her postoperative course was uneventful, and she was discharged on postoperative day 9. Pathology confirmed moderately differentiated invasive adenocarcinoma.

Repeat CT 1 month later demonstrated progression of the mass with invasion into the spleen, pancreatic tail, left kidney, and lateral abdominal wall. The case was discussed at a multidisciplinary tumor board. The patient subsequently underwent definitive oncologic resection, including left colectomy with en bloc resection of the left upper quadrant abdominal wall and diaphragm, distal pancreatectomy, splenectomy, left nephrectomy and adrenalectomy, omentectomy, and appendectomy. Additionally, she underwent cytoreductive surgery with abdominal wall tumor resection and revision colostomy with re‐siting. She tolerated the operation well and was discharged home on postoperative day 7. Adjuvant chemotherapy with folinic acid, fluorouracil, and oxaliplatin (FOLFOX) was initiated 8 weeks postoperatively and completed as planned. She subsequently developed recurrence and underwent palliative chemotherapy and radiation therapy. She remained alive 27 months after the index operation, with surveillance colonoscopy at 26 months demonstrating no intraluminal recurrence.

2. Clinical Question

In septic patients with CsF secondary to locally advanced colon adenocarcinoma, should definitive en bloc multivisceral resection be performed emergently, or can a staged damage‐control strategy optimize physiologic stability without compromising oncological management?

3. Discussion

CsF represents an abnormal communication between the colon and the spleen and is an exceedingly rare entity. Delayed recognition may result in ongoing intra‐abdominal sepsis, splenic abscess, bacteremia, and increased morbidity and mortality. The differential diagnosis includes splenic abscess and perforated colon cancer with localized contamination, as these conditions may present with similar left upper quadrant pain, fever, and perisplenic fluid or gas on imaging.

First reported in 1985 as a complication of Crohn's disease [1], only 30–40 CsF cases have been reported so far. Hernandez Dominguez et al. from Cleveland Clinic provide the most comprehensive review to date, summarizing 4 institutional cases and 26 cases from the literature [2]. Patients range in age from 2 to 84 years (median 56), with 70% being male. The most common underlying cause is colonic lymphoma (30%), followed by colorectal carcinoma (17%) and Crohn's disease (13%). Other reported causes include infections, trauma, and pancreatic cancer. Diagnosis is made by CT in 90% of cases. Surgical intervention is required in 87% of patients, with segmental colectomy and splenectomy being the most frequent procedures. Even among the 12 patients initially managed nonoperatively, 11 ultimately require surgery. Outcomes are favorable, with a 3% postoperative mortality rate and a 17% complication rate.

CsF secondary to colon adenocarcinoma is rare and occurs less frequently than cases related to inflammatory etiologies. It represents T4 disease with direct invasion into adjacent structures for which en bloc multivisceral resection is the oncologic standard to achieve margin‐negative resection. Although no comparative data exist between single‐stage and staged approaches, most reported malignant CsF cases undergo en bloc resection via laparotomy. However, emergency colorectal cancer resection is independently associated with worse perioperative and long‐term outcomes [3]. In our patient, active sepsis further complicated operative planning by creating hostile inflammatory conditions. Although urgent intervention was required, proceeding directly to definitive oncological resection in a hemodynamically unstable patient was considered high risk. We therefore adopted a staged strategy. The initial laparoscopic debridement and diversion functioned as damage control surgery, prioritizing rapid source control, decompression, and tissue diagnosis. This approach intentionally separated sepsis management from formal oncologic resection, allowing physiologic optimization, complete staging, and multidisciplinary tumor board discussion prior to definitive resection. The second‐stage operation then addressed all sites of local invasion in a controlled setting. Although delaying resection in T4 disease carries a theoretical risk of cancer progression, this staged strategy appropriately prioritized physiologic stabilization while maintaining adherence to oncologic principles.

This case highlights the importance of staged management of CsF in the setting of sepsis complicating locally advanced colorectal cancer. Initial source control with drainage and diversion, followed by definitive oncologic resection after stabilization, represents a safe and sound strategy in carefully selected patients with metastatic malignancy. It also highlights that structured collaboration between acute care surgery and surgical oncology teams can lead to favorable outcomes.

Author Contributions

Alyssa J. Fesmire: conceptualization, methodology, resources, supervision, writing – review and editing. Megan E. McNally: resources, supervision, writing – review and editing. Kanhua Yin: conceptualization, data curation, formal analysis, writing – original draft.

Funding

The authors have nothing to report.

Consent

Institutional review board approval was not required for this case report. Written informed consent was obtained from the patient for publication of this case report and accompanying images.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

Data available on request due to privacy/ethical restrictions.