Post-operative gastric wall necrosis and splenic infarction

Case contributed by Faeze Salahshour

Presentation

The patient is a known case of a large pancreatic solid pseudopapillary tumor with hepatic metastases, which became a candidate for tumor resection and liver transplantation based on MDT decisions. On the 8th day after the surgery, she referred for a CT scan because of abdominal tenderness, ill appearance, leukocytosis of about 71,000 µ/L, and a fever episode. The surgical drain discharge contains pancreatic juice.

Patient Data

Age: 35 years
Gender: Female

Evidence of liver transplantation with hepaticojejunostomy is seen. Some hypo-enhancing peripheral foci are seen in segment VII and left lateral lobe of the liver, likely due to ischemic changes. The celiac trunk 2 cm after the origin was ligated during surgery, and its branches are not visible. The transplanted liver vasculature is patent. Moderate ascites and omental haziness are seen. The spleen does not show any enhancement.  An important finding is the absence of gastric wall enhancement with a length of about 10 cm in proximal of the greater curvature concerning for gastric wall necrosis. There is no extraluminal or free intraperitoneal air to imply gastric wall perforation.

The red arrows depict the absence of gastric mural enhancement in a proximal segment of the greater curvature, and the white arrow shows a normal enhancing gastric wall. The blue arrow points to the infarcted spleen and the greens to the ischemic foci of the transplanted liver.

The patient underwent surgery. The infarcted segment has not been disrupted but was bulged outward as a large bleb relative to normal parts of the gastric wall. Because of the poor blood supply of the stomach and high risk of anastomosis failure, the necrotic segment of the gastric wall was plicated into the gastric lumen. Follow up CT (box below) was done to assure the stomach condition.

The post-op CT scan shows evidence of gastric plication surgery. The other findings are the same as the previous CT scan.

The black arrows point the necrotic gastric wall that plicates toward the gastric lumen (plication surgery).

 About 1 month after the plication surgery, another surgery for resection of the infarcted spleen, the stomach, duodenum, and residual pancreatic head performed because of persistent fever. Unfortunately, the patient died a few days after the last surgery.

The last surgery photos show infarcted spleen, hypovascular stomach, duodenum, and residual pancreas head.

Case Discussion

During surgical resection of the pancreas' huge solid pseudopapillary tumor, there may have been ligation of the celiac trunk branches, short gastric and splenic vessels, and the spleen and gastric blood supply were just from the collaterals. The splenic infarct and segmental gastric wall necrosis developed because of compromised blood supply.

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