Gastric Fistula Following Splenectomy: Its Cause and Prevention BEN F. HARRISON, M.D., EVALEA GLANGES, M.D., ROBERT S. SPARKMAN, M.D.
Gastro-cutaneous fistula following splenectomy, a rare but serious occurrence, may result in death or prolonged disability. Six previous cases have been reported in detail, while 8 others have been mentioned briefly. The current report reviews the literature and describes 4 additional instances of this complication. Two of the 4 patients died. Several factors, acting singly or in combination, may predispose to the development of post-splenectomy gastrocutaneous fistulas. These include direct surgical trauma to the gastric wall, generalized arteriosclerotic disease, hematoma in the gastrosplenic omentum, and reflection of gastric muscle fibers into the gastrosplenic ligament. The usual site of rupture of the stomach is along the greater curvature in the fundic portion. In circumstances in which splenectomy is associated with known or suspected compromise of the blood supply to this portion of the stomach, a method of enfolding the greater curvature is proposed to prevent the development of a gastro-cutaneous fistula. Awareness of the possibility of this uncommon but serious complication will aid in its early recognition and treatment.
D ELAYED PERFORATION of the stomach following
splenectomy is uncommon. Reports of this complication have appeared sporadically. The perforation is usually situated high on the greater curvature of the stomach where the short gastric vessels in the gastrosplenic omentum have been transsected, and the cause has been assumed to be direct injury to the gastric wall. However, it appears that interference with the vascular supply to the greater curvature may be a factor in fistula formation, even though no gross evidence of damage to the gastric wall at the time of the operation may be evident. This unusual complication may be associated with a substantial morbidity and mortality. Submitted for publication May 20, 1976. All correspondence to: Ben F. Harrison, M.D., 3707 Gaston Avenue, Dallas, Texas 75246.
From the Department of Surgery, Baylor University Medical Center, Dallas, Texas
Awareness of the possibility of its occurrence affords an opportunity for early diagnosis and treatment. The purpose of this communication is to review the literature dealing with the subject, to present four additional cases, and to describe a method for the prevention of this
complication. The danger of injury to the stomach during splenectomy was emphasized by Mayo14 in 1913 and by Balfour1 in 1917. In 1923 Poole,18 in his book "Surgery of the Spleen", stated that the greater curvature should be identified, otherwise the stomach might be accidentally injured or even opened. He reported that Balfour in 1917 had described a case in which the stomach was opened but immediately repaired, thereby preventing any complication. Perforation of the stomach associated with splenectomy with resultant gastric fistula has occasionally been listed among other complications of splenectomy. Peck and Jackson17 in 1964 listed one case in their summary of complications. Other instances were cited by Dabao and Warden,7 Daoud, et al.,8 Williams and Ellison,25 Miller and Dorn,15 Bostram and Page3 and Hodam.12 The first descriptions of gastric fistula as a sequel of splenectomy were published in 1967. Bryk and Petigrow4 described two instances of this complication, and Docci9 reported a single case. Three years later three additional cases were reported by Graves et al.,10 who discussed the pathogenesis of gastric fistula occurring
210
GASTRIC FISTULA FOLLOWING SPLENECTOMY
Vol. 185.9 No. 2
211
without operative procedures on the stomach itself. They The patient was resuscitated and laparotomy was performed. The concluded that splenectomy may result in the loss of col- spleen was removed to facilitate exposure and suture of a tangential of the aorta near the origin of the celiac artery. An opening lateral blood supply to the proximal gastric area where the inwound the diaphragm was repaired. left gastric artery is involved by artieral disease. Left upper quadrant drains were placed in the splenic bed and near Case Reports Case 1: A 43-year-old Caucasian man was hospitalized because of cholelithiasis and splenomegaly. He was thorougly evaluated for the possibility of a lymphoma or Hodgkins disease. The ultimate diagnosis was congestive splenomegaly with lipoidosis. A diagnostic laparotomy was performed and splenectomy and cholecystectomy were accomplished without incident. On the fifth postoperative day bile appeared at the drain site in the left upper quadrant. By the seventh postoperative day it was evident that the patient had a gastric fistula. A sump drain was inserted into the depth of the wound and suction drainage instituted. The sump was removed after 7 days because of bleeding from the fistulous tract and was replaced by a #20 Foley catheter. The catheter was irrigated intermittently with a solution of neomyocin and polycillin. Sinograms at this time revealed a communication between the fistulous cavity and the fundus of the stomach. By the eighth week after splenectomy the tract had healed spontaneously. Case 2: A 23-year-old Caucasian man was admitted because of injuries sustained in an automobile accident. There were multiple skeletal fractures, a ruptured urinary bladder, ruptured spleen, and right hemopneumothorax. On admission a tracheostomy was done and chest tubes were inserted into the right pleural space. At operation the open comminuted fractures were debrided and the ruptured bladder was repaired. The ruptured spleen was removed. On the fifth postoperative day three Steinmann pins were placed in the right tibia, closed manipulation performed and traction applied. On the tenth postoperative day intestinal fluid escaped from the drain aperture in the left upper quadrant. A sinogram demonstrated a gastro-cutaneous fistula. On the fifteenth postoperative day massive upper gastrointestinal bleeding occurred, necessitating emergency surgery. At operation a perforation was found high on the greater curvature of the stomach in the fundus. The perforation was closed and a gastrostomy done. The patient subsequently suffered many other complications necessitating 10 additional operations, including a partial and later a total gastric resection. He finally died on the 74th day after his initial surgical procedure. Case 3: A 67-year-old Caucasian man with a history of episodes of severe anemia for the previous 9 years was admitted because of marked weakness. Examination revealed thrombocytopenia, leukopenia, markedly decreased red cell survival time, and splenomegaly. At operation the huge spleen was found to be completely covered with adhesions and densely attached to the omentum and colon. There were many areas of organized hematoma in the surrounding tissues suggesting antecedent rupture of the spleen. Splenectomy was done with difficulty and multiple drains were placed through a left subcostal incision. Marked oozing of blood from the drain site persisted for several days. On the seventh postoperative day there appeared a large amount of clear fluid and a few hours later black liquid. Sump drainage was established and a gastrografin swallow demonstrated a gastro-cutaneous fistula. At reoperation an opening high on the greater curvature of the fundus was easily demonstrated and closed. Within the next 6 hours, however, continuous bleeding occurred from the wound and a short time later generalized subcutaneous hemorrhage also developed. In spite of multiple transfusions, the patient developed cardiac decompensation and expired 20 hours after
a liver wound. A tube gastrostomy and a left closed thoracotomy were performed. On the fifth postoperative day a small amount of bile-colored fluid appeared at the drain site. Gastrografin studies revealed a fistula high on the greater curvature of the stomach. On the eleventh day the fistula on the posterolateral aspect of the greater curvature about 4 cm from the esophagogastric junction was closed and another gastrostomy was performed. Subseuqent convalescence was
uncomplicated.
Discussion
There have been several reports of gastro-cutaneous fistula secondary to splenectomy in the recent literature. Six cases have been described in detail4 9'10 all of whom survived, and 8 others3'7'12'17'25 have been reported without discussion. This occurrence fortunately has been rare, but may be associated with prolonged disability. In a discussion of gastric and small bowel fistulas Halversen et al.11 reported a mortality rate of 46% from 24 upper tract fistulas and 35% from 17 post-gastrectomy fistulas. He also summarized 51 other post-gastrectomy fistulas from the literature with mortality rates of 52% to 73%. Classically this complication has been thought to be secondary to direct trauma to the gastric wall by surgical instrumentation.4 An area of necrosis presumably appears high on the posterior gastric wall and is followed by ulceration and perforation. At the apex of the triangular shaped gastrosplenic omentum, the superior pole of the spleen is in its closest proximity to the stomach. In the course of ligation of the short gastric arteries in the apex of this triangle, direct injury to the stomach wall may occur. In describing the technique of splenectomy, various authors'2'14'18'23 have cautioned against inadvertent instrumentation of this area of the stomach. In spite of this precaution and careful surgical technique, gastric fistulas still do occur following splenectomy. It has postulated recently by Rutter19 and later by Spencer22 that ischemic necrosis of the stomach wall from devascularization of the proximal stomach may occur. Their observations were made in association with gastric resection. In certain situations they caution that, contrary to popular belief, the stomach does not have an inexhaustible blood supply. The apical portion of the stomach is supplied by the ascending gastroesophageal branches of the left gastric artery and by 5 to 7 vasa brevia (short gastric arteries) which arise from the distal splenic artery. In addition a small component is delivered to this area by a branch of the left phrenic operation. Case 4: A 24-year-old Negro woman suffered a gunshot wound of the artery which in 2 to 3% of cases arises from the left left lower chest. Radiologic studies showed that the bullet was lying gastric artery. Ordinarily these arteries anastomose freely adjacent to the lower anterior portion of the first lumbar vertebra. to form a rich intramural blood supply. Ligation of the
212
HARRISON, GLANGES AND SPARKMAN
Ann. Surg. * February 1977
which may predispose to a gastric fistula following splenectomy, including the following: 1) Abrasions or denudement of the serosal covering of the greater curvature of the stomach resulting from a technically difficult splenectomy. 2) Interruption of a reflection of gastric muscle fibers into the gastrosplenic ligament at the attachment to the stomach wall. This condition has been demonstrated by Whitesell.24 3) Decreased vascularity, especially in elderly patients with arteriosclerotic disease of the gastric vasculature. 4) Organizing hematoma with inflammatory reaction in the gastrosplenic omentum adjacent to the gastric wall secondary to rupture of the spleen. 5) Severe trauma with multiple injuries, or any condition predisposing to stress ulceration. Prevention In selected cases of splenectomy where risk of gastric fistula is considered to be relatively great, we recommend that a portion of the upper greater curvature be enfolded. The area of susceptibility to perforation lies on the greater curvature, high on the posterior gastric wall, and anatomically is a narrow zone coinciding with the position of the gastrosplenic ligament. Several broad Lembert sutures are used to invert the entire danger zone. FIG. 1. Plication of "dangerzone. of gastric fundus. The gastric shape lends itself nicely to this procedure so that there is no compromise of the lumen of the short gastric arteries could cause a senious diminution stomach (Fig. 1). in blood supply to the apical segment in the following References two instances: 1) if the left gastric artery should be the site of advanced arteriosclerosis; or 2) if the intramural 1. Balfour, D. C.: Surgery of the Spleen. Collected Papers of Mayo Clinic, 9:375, 1917. anastomosis is adversely affected by previous surgery, W. F. and Erslev, A. J.: Splenectomy. Curr. Prob. Surg., by inflammatory reaction or scarring in the past or at the 2. Ballinger, Feb., 1965; pp. 35. time of surgery, or by any degenerative disease in the 3. Bostrom, P. D. and Page, H. G.: Splenectomy, An ElevenYear Review. Arch. Surg., 98:167, 1969. arterioles.10 D. and Petigrow, N.: Postsplenectomy Gastric PerforaKilgore et al.13 have shown experimentally that this 4. Bryk, tion. Surgery, 61:239, 1967. compromised blood supply can be insufficient to produce 5. Cerise, D. J., Pierce, W. A. and Diamond, D. L.: Abdominal Drains: Their Role as a Source of Infection Following overt gangrene but sufficient to prevent healing of minor Splenectomy. Ann. Surg., 171:764, 1970. and otherwise insignificant injuries or serosal tears. 6. Cohn, L. H.: Local Infections After Splenectomy-Relationship Drainage after splenectomy has not been cited of Drainage. Arch. Surg., 90:230, 1965. specifically as a cause of gastro-cutaneous fistula, al- 7. Dabao, R. V. and Warden, M. J.: Splenectomy, Its Indications and Complications. Am. Surg., 31:700, 1965. though it is believed by some to result in an increased 8. Daoud, F. S., Fisher, D. C. and Hofner, C. D.: Complicaincidence of infection in the subphrenic area.5,6,16,21 tions Following Splenectomy With Special Emphasis on Drainage. Arch. Surg., 92:32, 1966. Whatever one' s views may be regarding the desirability of C.: External (Thoracic) Postero-lateral Gastric Fistula routine drainage after splenectomy, there are certain 9. Docci, Secondary to Splenectomy for Trauma. Fracastoro, 60:157, situations in which this precaution is of paramount im1967. portance. Notable among these is the instance in which 10. Graves, H. A., Nelson, A. and Byrd, B. F.: Gastrocutaneous Fistula-As a Postoperative Complication. Ann. Surg., 171: there is some reason to suspect that a gastric fistula 656, 1970. may develop. Drainage of the splenic area permits 11. Halversen, R. C., Hogle, H. H. and Richards, R. C.: Gastric and Small Bowel Fistulas. Am. J. Surg. 118:968, 1969. early recognition of a fistula and thereby affords the best 12. Hodam, R. P.: The Risk of Splenectomy. Am. J. Surg., 119: opportunity for treatment. 709, 1970. The authors believe that there are several conditions 13. Kilgore, T. L., Turner, D. M. and Hardy, J. D.: Clinical
Vol. 185 . No. 2
14. 15. 16.
17.
18. 19.
GASTRIC FISTULA FOLLOWING SPLENECTOMY
and Experimental Ischemia of Gastric Remnant. Surg. Gynecol. Obstet., 118:1312, 1964. Mayo, W. J.: Surgery of the Spleen. Surg. Gynecol. Obstet., 16:233, 1913. Miller, W. I. and Dorn, B. C.: Postoperative Gastrointestinal Fistulas. Am. J. Surg., 116:382, 1968. Olsen, W. R. and Beaudoin, D. E.: Wound Drainage After Splenectomy. Indications and Complications. Am. J. Surg., 117:615, 1969. Peck, D. A. and Jackson, F. C.: Splenectomy After Surgical Trauma. Arch. Surg., 89:54, 1964. Poole, E. H. and Stellman, R. G.: Surgery of the Spleen. New York, D. Appleton and Co., 1923; p. 318. Rutter, A. G.: Ischemic Necrosis of the Stomach Following Subtotal Gastrectomy. Lancet, 2:1021, 1953.
213
20. Schwegman, C. W. and Miller, L. D.: Splenectomy: Reduction of Mortality and Morbidity. Surg. Clin. North Am., 42:1509, 1962. 21. Slate, R. W., Getzen, L. C. and Lanning, R. C.: 100 Cases of Traumatic Rupture of the Spleen. Arch. Surg., 99:498, 1969. 22. Spencer, F. C.: Ischemic Necrosis of the Remaining Stomach Following Subtotal Gastrectomy. Arch. Surg., 73:844, 1956. 23. Vaughn, A. M. and Coleman, J. M.: Spenectomy. Surg. Clin. North Am., 35:93, 1958. 24. Whitesell, F. B.: A Clinical and Surgical Anatomic Study of the Spleen. Surg. Gynecol. Obstet., 110:750, 1960. 25. Williams, R. D. and Ellison, E. H.: Complications Following Splnectomy. In Complications in Surgery and Their Management. Artz, C. P. and Hardy, J. D., Philadelphia, W. B. Saunders Co., 1967; p. 544.
Gastro-cutaneous fistula following splenectomy, a rare but serious occurrence, may result in death or prolonged disability. Six previous cases have been reported in detail, while 8 others have been mentioned briefly. The current report reviews the literature and describes 4 additional instances of this complication. Two of the 4 patients died. Several factors, acting singly or in combination, may predispose to the development of post-splenectomy gastrocutaneous fistulas. These include direct surgical trauma to the gastric wall, generalized arteriosclerotic disease, hematoma in the gastrosplenic omentum, and reflection of gastric muscle fibers into the gastrosplenic ligament. The usual site of rupture of the stomach is along the greater curvature in the fundic portion. In circumstances in which splenectomy is associated with known or suspected compromise of the blood supply to this portion of the stomach, a method of enfolding the greater curvature is proposed to prevent the development of a gastro-cutaneous fistula. Awareness of the possibility of this uncommon but serious complication will aid in its early recognition and treatment.
D ELAYED PERFORATION of the stomach following
splenectomy is uncommon. Reports of this complication have appeared sporadically. The perforation is usually situated high on the greater curvature of the stomach where the short gastric vessels in the gastrosplenic omentum have been transsected, and the cause has been assumed to be direct injury to the gastric wall. However, it appears that interference with the vascular supply to the greater curvature may be a factor in fistula formation, even though no gross evidence of damage to the gastric wall at the time of the operation may be evident. This unusual complication may be associated with a substantial morbidity and mortality. Submitted for publication May 20, 1976. All correspondence to: Ben F. Harrison, M.D., 3707 Gaston Avenue, Dallas, Texas 75246.
From the Department of Surgery, Baylor University Medical Center, Dallas, Texas
Awareness of the possibility of its occurrence affords an opportunity for early diagnosis and treatment. The purpose of this communication is to review the literature dealing with the subject, to present four additional cases, and to describe a method for the prevention of this
complication. The danger of injury to the stomach during splenectomy was emphasized by Mayo14 in 1913 and by Balfour1 in 1917. In 1923 Poole,18 in his book "Surgery of the Spleen", stated that the greater curvature should be identified, otherwise the stomach might be accidentally injured or even opened. He reported that Balfour in 1917 had described a case in which the stomach was opened but immediately repaired, thereby preventing any complication. Perforation of the stomach associated with splenectomy with resultant gastric fistula has occasionally been listed among other complications of splenectomy. Peck and Jackson17 in 1964 listed one case in their summary of complications. Other instances were cited by Dabao and Warden,7 Daoud, et al.,8 Williams and Ellison,25 Miller and Dorn,15 Bostram and Page3 and Hodam.12 The first descriptions of gastric fistula as a sequel of splenectomy were published in 1967. Bryk and Petigrow4 described two instances of this complication, and Docci9 reported a single case. Three years later three additional cases were reported by Graves et al.,10 who discussed the pathogenesis of gastric fistula occurring
210
GASTRIC FISTULA FOLLOWING SPLENECTOMY
Vol. 185.9 No. 2
211
without operative procedures on the stomach itself. They The patient was resuscitated and laparotomy was performed. The concluded that splenectomy may result in the loss of col- spleen was removed to facilitate exposure and suture of a tangential of the aorta near the origin of the celiac artery. An opening lateral blood supply to the proximal gastric area where the inwound the diaphragm was repaired. left gastric artery is involved by artieral disease. Left upper quadrant drains were placed in the splenic bed and near Case Reports Case 1: A 43-year-old Caucasian man was hospitalized because of cholelithiasis and splenomegaly. He was thorougly evaluated for the possibility of a lymphoma or Hodgkins disease. The ultimate diagnosis was congestive splenomegaly with lipoidosis. A diagnostic laparotomy was performed and splenectomy and cholecystectomy were accomplished without incident. On the fifth postoperative day bile appeared at the drain site in the left upper quadrant. By the seventh postoperative day it was evident that the patient had a gastric fistula. A sump drain was inserted into the depth of the wound and suction drainage instituted. The sump was removed after 7 days because of bleeding from the fistulous tract and was replaced by a #20 Foley catheter. The catheter was irrigated intermittently with a solution of neomyocin and polycillin. Sinograms at this time revealed a communication between the fistulous cavity and the fundus of the stomach. By the eighth week after splenectomy the tract had healed spontaneously. Case 2: A 23-year-old Caucasian man was admitted because of injuries sustained in an automobile accident. There were multiple skeletal fractures, a ruptured urinary bladder, ruptured spleen, and right hemopneumothorax. On admission a tracheostomy was done and chest tubes were inserted into the right pleural space. At operation the open comminuted fractures were debrided and the ruptured bladder was repaired. The ruptured spleen was removed. On the fifth postoperative day three Steinmann pins were placed in the right tibia, closed manipulation performed and traction applied. On the tenth postoperative day intestinal fluid escaped from the drain aperture in the left upper quadrant. A sinogram demonstrated a gastro-cutaneous fistula. On the fifteenth postoperative day massive upper gastrointestinal bleeding occurred, necessitating emergency surgery. At operation a perforation was found high on the greater curvature of the stomach in the fundus. The perforation was closed and a gastrostomy done. The patient subsequently suffered many other complications necessitating 10 additional operations, including a partial and later a total gastric resection. He finally died on the 74th day after his initial surgical procedure. Case 3: A 67-year-old Caucasian man with a history of episodes of severe anemia for the previous 9 years was admitted because of marked weakness. Examination revealed thrombocytopenia, leukopenia, markedly decreased red cell survival time, and splenomegaly. At operation the huge spleen was found to be completely covered with adhesions and densely attached to the omentum and colon. There were many areas of organized hematoma in the surrounding tissues suggesting antecedent rupture of the spleen. Splenectomy was done with difficulty and multiple drains were placed through a left subcostal incision. Marked oozing of blood from the drain site persisted for several days. On the seventh postoperative day there appeared a large amount of clear fluid and a few hours later black liquid. Sump drainage was established and a gastrografin swallow demonstrated a gastro-cutaneous fistula. At reoperation an opening high on the greater curvature of the fundus was easily demonstrated and closed. Within the next 6 hours, however, continuous bleeding occurred from the wound and a short time later generalized subcutaneous hemorrhage also developed. In spite of multiple transfusions, the patient developed cardiac decompensation and expired 20 hours after
a liver wound. A tube gastrostomy and a left closed thoracotomy were performed. On the fifth postoperative day a small amount of bile-colored fluid appeared at the drain site. Gastrografin studies revealed a fistula high on the greater curvature of the stomach. On the eleventh day the fistula on the posterolateral aspect of the greater curvature about 4 cm from the esophagogastric junction was closed and another gastrostomy was performed. Subseuqent convalescence was
uncomplicated.
Discussion
There have been several reports of gastro-cutaneous fistula secondary to splenectomy in the recent literature. Six cases have been described in detail4 9'10 all of whom survived, and 8 others3'7'12'17'25 have been reported without discussion. This occurrence fortunately has been rare, but may be associated with prolonged disability. In a discussion of gastric and small bowel fistulas Halversen et al.11 reported a mortality rate of 46% from 24 upper tract fistulas and 35% from 17 post-gastrectomy fistulas. He also summarized 51 other post-gastrectomy fistulas from the literature with mortality rates of 52% to 73%. Classically this complication has been thought to be secondary to direct trauma to the gastric wall by surgical instrumentation.4 An area of necrosis presumably appears high on the posterior gastric wall and is followed by ulceration and perforation. At the apex of the triangular shaped gastrosplenic omentum, the superior pole of the spleen is in its closest proximity to the stomach. In the course of ligation of the short gastric arteries in the apex of this triangle, direct injury to the stomach wall may occur. In describing the technique of splenectomy, various authors'2'14'18'23 have cautioned against inadvertent instrumentation of this area of the stomach. In spite of this precaution and careful surgical technique, gastric fistulas still do occur following splenectomy. It has postulated recently by Rutter19 and later by Spencer22 that ischemic necrosis of the stomach wall from devascularization of the proximal stomach may occur. Their observations were made in association with gastric resection. In certain situations they caution that, contrary to popular belief, the stomach does not have an inexhaustible blood supply. The apical portion of the stomach is supplied by the ascending gastroesophageal branches of the left gastric artery and by 5 to 7 vasa brevia (short gastric arteries) which arise from the distal splenic artery. In addition a small component is delivered to this area by a branch of the left phrenic operation. Case 4: A 24-year-old Negro woman suffered a gunshot wound of the artery which in 2 to 3% of cases arises from the left left lower chest. Radiologic studies showed that the bullet was lying gastric artery. Ordinarily these arteries anastomose freely adjacent to the lower anterior portion of the first lumbar vertebra. to form a rich intramural blood supply. Ligation of the
212
HARRISON, GLANGES AND SPARKMAN
Ann. Surg. * February 1977
which may predispose to a gastric fistula following splenectomy, including the following: 1) Abrasions or denudement of the serosal covering of the greater curvature of the stomach resulting from a technically difficult splenectomy. 2) Interruption of a reflection of gastric muscle fibers into the gastrosplenic ligament at the attachment to the stomach wall. This condition has been demonstrated by Whitesell.24 3) Decreased vascularity, especially in elderly patients with arteriosclerotic disease of the gastric vasculature. 4) Organizing hematoma with inflammatory reaction in the gastrosplenic omentum adjacent to the gastric wall secondary to rupture of the spleen. 5) Severe trauma with multiple injuries, or any condition predisposing to stress ulceration. Prevention In selected cases of splenectomy where risk of gastric fistula is considered to be relatively great, we recommend that a portion of the upper greater curvature be enfolded. The area of susceptibility to perforation lies on the greater curvature, high on the posterior gastric wall, and anatomically is a narrow zone coinciding with the position of the gastrosplenic ligament. Several broad Lembert sutures are used to invert the entire danger zone. FIG. 1. Plication of "dangerzone. of gastric fundus. The gastric shape lends itself nicely to this procedure so that there is no compromise of the lumen of the short gastric arteries could cause a senious diminution stomach (Fig. 1). in blood supply to the apical segment in the following References two instances: 1) if the left gastric artery should be the site of advanced arteriosclerosis; or 2) if the intramural 1. Balfour, D. C.: Surgery of the Spleen. Collected Papers of Mayo Clinic, 9:375, 1917. anastomosis is adversely affected by previous surgery, W. F. and Erslev, A. J.: Splenectomy. Curr. Prob. Surg., by inflammatory reaction or scarring in the past or at the 2. Ballinger, Feb., 1965; pp. 35. time of surgery, or by any degenerative disease in the 3. Bostrom, P. D. and Page, H. G.: Splenectomy, An ElevenYear Review. Arch. Surg., 98:167, 1969. arterioles.10 D. and Petigrow, N.: Postsplenectomy Gastric PerforaKilgore et al.13 have shown experimentally that this 4. Bryk, tion. Surgery, 61:239, 1967. compromised blood supply can be insufficient to produce 5. Cerise, D. J., Pierce, W. A. and Diamond, D. L.: Abdominal Drains: Their Role as a Source of Infection Following overt gangrene but sufficient to prevent healing of minor Splenectomy. Ann. Surg., 171:764, 1970. and otherwise insignificant injuries or serosal tears. 6. Cohn, L. H.: Local Infections After Splenectomy-Relationship Drainage after splenectomy has not been cited of Drainage. Arch. Surg., 90:230, 1965. specifically as a cause of gastro-cutaneous fistula, al- 7. Dabao, R. V. and Warden, M. J.: Splenectomy, Its Indications and Complications. Am. Surg., 31:700, 1965. though it is believed by some to result in an increased 8. Daoud, F. S., Fisher, D. C. and Hofner, C. D.: Complicaincidence of infection in the subphrenic area.5,6,16,21 tions Following Splenectomy With Special Emphasis on Drainage. Arch. Surg., 92:32, 1966. Whatever one' s views may be regarding the desirability of C.: External (Thoracic) Postero-lateral Gastric Fistula routine drainage after splenectomy, there are certain 9. Docci, Secondary to Splenectomy for Trauma. Fracastoro, 60:157, situations in which this precaution is of paramount im1967. portance. Notable among these is the instance in which 10. Graves, H. A., Nelson, A. and Byrd, B. F.: Gastrocutaneous Fistula-As a Postoperative Complication. Ann. Surg., 171: there is some reason to suspect that a gastric fistula 656, 1970. may develop. Drainage of the splenic area permits 11. Halversen, R. C., Hogle, H. H. and Richards, R. C.: Gastric and Small Bowel Fistulas. Am. J. Surg. 118:968, 1969. early recognition of a fistula and thereby affords the best 12. Hodam, R. P.: The Risk of Splenectomy. Am. J. Surg., 119: opportunity for treatment. 709, 1970. The authors believe that there are several conditions 13. Kilgore, T. L., Turner, D. M. and Hardy, J. D.: Clinical
Vol. 185 . No. 2
14. 15. 16.
17.
18. 19.
GASTRIC FISTULA FOLLOWING SPLENECTOMY
and Experimental Ischemia of Gastric Remnant. Surg. Gynecol. Obstet., 118:1312, 1964. Mayo, W. J.: Surgery of the Spleen. Surg. Gynecol. Obstet., 16:233, 1913. Miller, W. I. and Dorn, B. C.: Postoperative Gastrointestinal Fistulas. Am. J. Surg., 116:382, 1968. Olsen, W. R. and Beaudoin, D. E.: Wound Drainage After Splenectomy. Indications and Complications. Am. J. Surg., 117:615, 1969. Peck, D. A. and Jackson, F. C.: Splenectomy After Surgical Trauma. Arch. Surg., 89:54, 1964. Poole, E. H. and Stellman, R. G.: Surgery of the Spleen. New York, D. Appleton and Co., 1923; p. 318. Rutter, A. G.: Ischemic Necrosis of the Stomach Following Subtotal Gastrectomy. Lancet, 2:1021, 1953.
213
20. Schwegman, C. W. and Miller, L. D.: Splenectomy: Reduction of Mortality and Morbidity. Surg. Clin. North Am., 42:1509, 1962. 21. Slate, R. W., Getzen, L. C. and Lanning, R. C.: 100 Cases of Traumatic Rupture of the Spleen. Arch. Surg., 99:498, 1969. 22. Spencer, F. C.: Ischemic Necrosis of the Remaining Stomach Following Subtotal Gastrectomy. Arch. Surg., 73:844, 1956. 23. Vaughn, A. M. and Coleman, J. M.: Spenectomy. Surg. Clin. North Am., 35:93, 1958. 24. Whitesell, F. B.: A Clinical and Surgical Anatomic Study of the Spleen. Surg. Gynecol. Obstet., 110:750, 1960. 25. Williams, R. D. and Ellison, E. H.: Complications Following Splnectomy. In Complications in Surgery and Their Management. Artz, C. P. and Hardy, J. D., Philadelphia, W. B. Saunders Co., 1967; p. 544.
