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Complete endoscopic removal of a necrotic spleen (with video)
Complete endoscopic removal of a necrotic spleen (with video) Michael D. Leise, MD, Johan C. Bakken, MD, Martin D. Zielinski, MD, Todd H. Baron, MD, FASGE Rochester, Minnesota, USA
CASE REPORT A 78-year-old woman underwent subtotal gastrectomy, Billroth II reconstruction, and splenic preserving distal pancreatectomy for locally invasive gastric adenocarcinoma (Fig. 1A). Abdominal CT performed 20 days later to evaluate abdominal pain demonstrated a gastrojejunostomy anastomotic leak with adjacent abscess. Splenic necrosis was evident because of a lack of enhancement with emphysematous changes at the hilum contiguous with the abscess (Fig. 1B). Percutaneous catheter placement was impossible without traversing the pleural space, and her hostile abdomen prohibited an anterior surgical approach. Thus, endoscopic therapy was undertaken after informed consent. A therapeutic channel upper endoscope (GIF-1T-Q180; Olympus Medical Systems, Center Valley, Pa) was introduced into the stomach where a large defect was found proximal to the anastomosis. After suctioning purulent material, the endoscope was advanced into the cavity where a large amount of necrotic tissue was débrided with a 2-cm spiral snare (SD-230U-20; Olympus Medical Systems) (Fig. 2A; Video, available online at www.giejournal. org) and was found to be devitalized spleen (Figs. 2B). After additional débridement, a 10F pigtail nasobiliary tube was left in the cavity for irrigation. Later, a CT-guided percutaneous drain was placed in the cavity for irrigation because the débridements had opened a window into the cavity. Four endoscopic débridements resulted in total splenic necrosectomy (Fig. 3A). The percutaneous drain crossed the pleural space, resulting in an abdominopleural fistula and empyema. Therefore, two 10F, 5-cm, double-pigtail stents were placed transgastrically in the residual cavity to allow internal drainage, removal of the percutaneous catheter, and avoidance of an external fistula. Follow-up CT demonstrated complete absence of the spleen (Fig. 3B). No endoscopic complications occurred. The patient was discharged tolerating tube feeds. CT scan 1 month later demonstrated signs of metastatic gastric cancer. The patient died of progressive metastatic disease 3 months later.
DISCUSSION Anastomotic leakage and abscess after gastric cancer resection occur in as many as 12% and 6% of cases, respectively.1 Options include surgical and percutaneous management. Surgery includes open débridement with primary closure, débridement with revision of the anastomosis, or débridement with completion gastrectomy.1 Our 694 GASTROINTESTINAL ENDOSCOPY Volume 75, No. 3 : 2012
Figure 1. A, Preoperative abdominal CT image with intravenous contrast demonstrating a posterior wall gastric mass abutting the pancreas. Note there is normal enhancing spleen. B, Postoperative CT image showing perigastric abscess cavity with necrotic debris.
patient would have also required rib resection. Percutaneous drainage requires appropriate access to avoid the pleural space and the consequent risk of empyema. Transgastric drainage in patients with an anastomotic leak makes intuitive sense because of the naturally available access. This is the first report of total transgastric endoscopic splenic necrosectomy. Two cases of endoscopic splenic resection have been reported, but primarily involved contiguous pancreatic collections that involved the spleen rather than primary splenic necrosis; the degree of splenic removal was not documented in the first case and was www.giejournal.org
Brief Reports
Figure 2. A, Endoscopic view inside necrotic retrogastric collection. B, Postendoscopic débridement CT image shows a decrease in size of the perigastric abscess with evolution of the splenic infarction with loculated gas.
minimal in the second.2,3 In this case, there was confirmation of the endoscope within the spleen and complete splenic removal.
Figure 3. A, Fluoroscopic image obtained during final débridement with the endoscope inside the necrotic cavity. Contrast was injected through the percutaneous tube and shows large filling defect from necrotic debris. B, Follow-up abdominal CT scan with image at the same level as in Figure 1 shows the absence of the spleen. No other splenic tissue was seen on other images.
2. Seewald S, Brand B, Omar S, et al. EUS-guided drainage of subphrenic abscess. Gastrointest Endosc 2004;59:578-80. 3. Lee DH, Cash BD, Womeldorph CM, et al. Endoscopic therapy of a splenic abscess: definitive treatment via EUS-guided transgastric drainage. Gastrointest Endosc 2006;64:631-4.
DISCLOSURE The authors disclosed no financial relationships relevant to this publication. Abbreviations: CT, computed tomography; PA, Pennsylvania.
REFERENCES 1. Etoh T, Inomata M, Shiraishi N, et al. Revisional surgery after gastrectomy for gastric cancer: review of the literature. Surg Laparosc Endosc Percutan Tech 2010;20:332-7.
www.giejournal.org
Accepted for video presentation at the 2011 Annual American Society for Gastrointestinal Endoscopy Scientific Meeting. Department of Medicine (M.D.L., J.C.B., T.H.B.), Division of Gastroenterology and Hepatology, Department of Surgery (M.D.Z.), Division of Trauma and Critical Care Trauma, Mayo Clinic, Rochester, Minnesota, USA. Reprint requests: Todd H. Baron, MD, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905. Copyright © 2012 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 doi:10.1016/j.gie.2011.04.026
Volume 75, No. 3 : 2012 GASTROINTESTINAL ENDOSCOPY 695
CASE REPORT A 78-year-old woman underwent subtotal gastrectomy, Billroth II reconstruction, and splenic preserving distal pancreatectomy for locally invasive gastric adenocarcinoma (Fig. 1A). Abdominal CT performed 20 days later to evaluate abdominal pain demonstrated a gastrojejunostomy anastomotic leak with adjacent abscess. Splenic necrosis was evident because of a lack of enhancement with emphysematous changes at the hilum contiguous with the abscess (Fig. 1B). Percutaneous catheter placement was impossible without traversing the pleural space, and her hostile abdomen prohibited an anterior surgical approach. Thus, endoscopic therapy was undertaken after informed consent. A therapeutic channel upper endoscope (GIF-1T-Q180; Olympus Medical Systems, Center Valley, Pa) was introduced into the stomach where a large defect was found proximal to the anastomosis. After suctioning purulent material, the endoscope was advanced into the cavity where a large amount of necrotic tissue was débrided with a 2-cm spiral snare (SD-230U-20; Olympus Medical Systems) (Fig. 2A; Video, available online at www.giejournal. org) and was found to be devitalized spleen (Figs. 2B). After additional débridement, a 10F pigtail nasobiliary tube was left in the cavity for irrigation. Later, a CT-guided percutaneous drain was placed in the cavity for irrigation because the débridements had opened a window into the cavity. Four endoscopic débridements resulted in total splenic necrosectomy (Fig. 3A). The percutaneous drain crossed the pleural space, resulting in an abdominopleural fistula and empyema. Therefore, two 10F, 5-cm, double-pigtail stents were placed transgastrically in the residual cavity to allow internal drainage, removal of the percutaneous catheter, and avoidance of an external fistula. Follow-up CT demonstrated complete absence of the spleen (Fig. 3B). No endoscopic complications occurred. The patient was discharged tolerating tube feeds. CT scan 1 month later demonstrated signs of metastatic gastric cancer. The patient died of progressive metastatic disease 3 months later.
DISCUSSION Anastomotic leakage and abscess after gastric cancer resection occur in as many as 12% and 6% of cases, respectively.1 Options include surgical and percutaneous management. Surgery includes open débridement with primary closure, débridement with revision of the anastomosis, or débridement with completion gastrectomy.1 Our 694 GASTROINTESTINAL ENDOSCOPY Volume 75, No. 3 : 2012
Figure 1. A, Preoperative abdominal CT image with intravenous contrast demonstrating a posterior wall gastric mass abutting the pancreas. Note there is normal enhancing spleen. B, Postoperative CT image showing perigastric abscess cavity with necrotic debris.
patient would have also required rib resection. Percutaneous drainage requires appropriate access to avoid the pleural space and the consequent risk of empyema. Transgastric drainage in patients with an anastomotic leak makes intuitive sense because of the naturally available access. This is the first report of total transgastric endoscopic splenic necrosectomy. Two cases of endoscopic splenic resection have been reported, but primarily involved contiguous pancreatic collections that involved the spleen rather than primary splenic necrosis; the degree of splenic removal was not documented in the first case and was www.giejournal.org
Brief Reports
Figure 2. A, Endoscopic view inside necrotic retrogastric collection. B, Postendoscopic débridement CT image shows a decrease in size of the perigastric abscess with evolution of the splenic infarction with loculated gas.
minimal in the second.2,3 In this case, there was confirmation of the endoscope within the spleen and complete splenic removal.
Figure 3. A, Fluoroscopic image obtained during final débridement with the endoscope inside the necrotic cavity. Contrast was injected through the percutaneous tube and shows large filling defect from necrotic debris. B, Follow-up abdominal CT scan with image at the same level as in Figure 1 shows the absence of the spleen. No other splenic tissue was seen on other images.
2. Seewald S, Brand B, Omar S, et al. EUS-guided drainage of subphrenic abscess. Gastrointest Endosc 2004;59:578-80. 3. Lee DH, Cash BD, Womeldorph CM, et al. Endoscopic therapy of a splenic abscess: definitive treatment via EUS-guided transgastric drainage. Gastrointest Endosc 2006;64:631-4.
DISCLOSURE The authors disclosed no financial relationships relevant to this publication. Abbreviations: CT, computed tomography; PA, Pennsylvania.
REFERENCES 1. Etoh T, Inomata M, Shiraishi N, et al. Revisional surgery after gastrectomy for gastric cancer: review of the literature. Surg Laparosc Endosc Percutan Tech 2010;20:332-7.
www.giejournal.org
Accepted for video presentation at the 2011 Annual American Society for Gastrointestinal Endoscopy Scientific Meeting. Department of Medicine (M.D.L., J.C.B., T.H.B.), Division of Gastroenterology and Hepatology, Department of Surgery (M.D.Z.), Division of Trauma and Critical Care Trauma, Mayo Clinic, Rochester, Minnesota, USA. Reprint requests: Todd H. Baron, MD, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905. Copyright © 2012 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 doi:10.1016/j.gie.2011.04.026
Volume 75, No. 3 : 2012 GASTROINTESTINAL ENDOSCOPY 695