Wandering spleen: a rare complication of sleeve gastrectomy

Abstract

The spleen is an intraperitoneal organ typically located in the left upper quadrant. Ectopic (‘wandering’) spleen refers to the displacement of the spleen from its normal anatomical location to another region in the abdominal cavity or pelvis. It’s a relatively rare condition with no clear aetiology. We present, here, a case of a wandering spleen following sleeve gastrectomy in a 23-year-old female patient, whose spleen, prior to this event, was demonstrated by imaging in a normal anatomical position. A splenectomy was performed, and after an uneventful postoperative period, the patient was discharged. No similar case description was found in the relevant medical literature. Possible causes and decision-making process are discussed. We conclude that the wandering spleen phenomenon should be considered in the differential diagnosis of patients presenting with abdominal pain and new abdominal mass following sleeve gastrectomy.

Background

Ectopic (‘wandering’) spleen refers to the displacement of the spleen from its normal anatomical location in the left upper quadrant to another region in the abdominal cavity or pelvis. It is a relatively rare condition with no clear aetiology. The most common causes of such a rare entity are embryonic abnormalities and weakness of normal splenic suspensory ligaments, most frequently after pregnancy.¹

Sleeve gastrectomy, removal of a large portion of the stomach along the greater curvature from approximately 3 to 6 cm orally of the pylorus to the angle of His,² may contribute to spleen detachment. Disconnection of the short gastric arteries and the gastrosplenic ligaments is a routine surgical dissection during sleeve gastrectomy.

Due to the worldwide spread of the bariatric procedures, the estimated worldwide number of operations performed in 2016 was 634 897,³ we believe that this report may have an implication on everyday surgical practice.

Case presentation

A 23-year-old female patient was admitted to the surgical department due to an acute right lower quadrant abdominal pain, without any other conditions. Two years prior to her admission, she underwent a laparoscopic sleeve gastrectomy to treat morbid obesity. Her medical history was unremarkable, except for two admissions for the left upper quadrant abdominal pain, 6 and 12 months following her bariatric surgery. On both admissions, she underwent multiple investigations including CT of the abdomen (figure 1) as well as ultrasound Doppler of the spleen. These showed a slightly enlarged, normally located spleen, with no signs of ischaemia. Hence, she was treated conservatively and was discharged home within 2 days of each admission.

Figure 1.

Abdominal CT scan demonstrating the spleen in anatomical position (marked by a yellow arrow).

During the current admission, her physical examination showed a tender, mobile, 15 cm lower abdominal mass. No peritoneal signs were demonstrated.

Investigations

Blood tests including complete blood count (CBC) and full biochemical profile were normal. The CT scan showed the spleen lodged in the pelvis, enlarged veins in the left upper abdomen with enlarged vascular pedicle, and torsion of the body and tail of the pancreas (figure 2). Doppler ultrasound showed no ischaemic compromise of the spleen. The diagnosis of a wandering spleen was confirmed.

Figure 2.

Abdominal CT scan shows wandering spleen located in the pelvis (marked by a yellow arrow), with enlarged surrounding veins and dilated spleen pedicle (marked by a black arrow).

Treatment

The case was discussed in a multidisciplinary forum, and a decision to perform a splenectomy by an open approach was made due to a possible risk of vascular injury during a laparoscopic procedure. A low midline laparotomy was performed and a macroscopically normal-looking spleen, of 15 cm length, was demonstrated in the lower abdomen. The splenic vasculature was stretched and thickened with no signs of ischaemia. A splenectomy was performed without complications.

Outcome and follow-up

The patient had an uneventful postoperative recovery and was discharged home at postoperative day 5. The final pathology report demonstrated severe congested red pulp and preserved white pulp.

Discussion

Wandering spleen is a rare condition with an estimated incidence of less than 0.2%.⁴ However, because this condition is often asymptomatic and undetected, the exact incidence is unknown.¹ While ages of presentation vary, the most common age of presentation is childhood, especially under 1 year of age, followed by the third decade of life, more frequently seen in females of reproductive age.⁵ While the aetiological basis of this phenomenon still remains unclear, the most agreed-upon hypothesis is laxity of the spleen’s primary supporting ligaments. Anatomically, the spleen has six peritoneal attachments (primary suspensory ligaments) that are directly associated with it (gastrosplenic, splenorenal, splenophrenic, splenocolic, pancreaticosplenic and presplenic folds) and two ligaments (pancreaticocolic and phrenicocolic) in indirect association. Failure of fusion of the dorsal mesogastrium to the posterior abdominal wall during embryogenesis leads to failure or defective attachment of these ligaments, leading to spleen wandering.⁶ The presence of abnormally mobile spleen under the age of 1 year may support this hypothesis.⁷ Moreover, early presentation was observed in a patient with congenital absence of the left kidney.⁸ Hormonal changes may also explain the aetiology for wandering spleen, since pregnancy, and furthermore, multiparity, may contribute to the laxity and weakness of the spleen ligaments via direct influence of oestrogen.⁹ Splenomegaly was also observed as a factor which could affect the laxity of the spleen suspensory ligaments.¹

In this case, however, we did not reveal any inherited manifestations, our patient was never pregnant and the degree of the splenomegaly was very mild.

We may only assume that there were two possible mechanisms for the development of wandering spleen following sleeve gastrectomy. First, disconnection of the short gastric arteries and the gastrosplenic ligaments is a routine surgical dissection during sleeve gastrectomy² and it may induce heavier burden, and hence relative weakness of the spleen ligaments, and trigger gradual migration from its original location. Second, a significant weight loss observed after a bariatric procedure, theoretically, may contribute to the weakness of peritoneal attachments. To the best of our knowledge, this is the first description in the literature of a wandering spleen following sleeve gastrectomy.

Patients with wandering spleen are usually asymptomatic. However, the patients may present with abdominal pain due to partial or complete torsion of the splenic vasculature.¹⁰ Reported complications include splenic ischaemia, gastric volvulus and duodenal obstruction, urinary symptoms, haemorrhage from gastric varices and pancreatitis due to torsion of the pancreas.^11–13

Surgery is the treatment of choice, possible options are: open versus laparoscopic splenectomy, splenopexy with mesh or the creation of a peritoneal pocket for the spleen.¹⁴

In our case, we calculated the risk of possible laparoscopic vascular injury and the postgastrectomy peritoneal space, and chose to perform an open splenectomy.

Due to the worldwide spread of the bariatric procedures, we believe that this report may have implications on everyday surgery practice.

Learning points.

• Disconnection of the short gastric arteries and the gastrosplenic ligaments during sleeve gastrectomy may induce weakness of the spleen ligaments and trigger its gradual migration from its original location.

• The significant weight loss observed after a bariatric procedure may contribute to the weakness of peritoneal attachments and to the detachment of the spleen.

• Wandering spleen should be included in the differential diagnosis of the left upper quadrant abdominal pain in patients postbariatric surgery, especially when accompanied by an abdominal mass.