Laparoscopic splenectomy for a wandering spleen complicating gastric varices: report of a case

Wandering spleen is a rare clinical entity, and its complication with gastric varices
is even rarer 1],4]. The gastric varices most likely arose from splenic vein occlusion secondary to chronic
torsion of the vascular pedicle, leading to retrograde congestion of the short gastric
and left gastroepiploic veins. As the patient was not suffering from hematemesis or
melena in our case, presence of the gastric varices was detected by the CT image.
The contrast-enhanced CT was quite useful, not only for a definitive diagnosis and
assessment of splenic viability but also accompanying collateral venous expansion.
Especially by means of 3D-CT image, the disruption of the splenic vein at the origin
of the vascular pedicle could be recognized.

The definitive treatment for wandering spleen is surgery, since non-operative treatment
is associated with a complication rate as high as 65% 5]. Splenectomy has long been the conventional treatment for wandering spleen. Currently,
splenopexy becomes a favorable alternative especially in pediatric patients, without
involving splenic infarction or venous thrombosis, to avoid the risk of overwhelming
post-splenectomy sepsis 3]. In cases complicated by gastric varices, meanwhile, elimination of the gastric varices
is another purpose of the treatment in addition to symptom relief and relapse prevention.
Regression of the varicose vein would be expected once the splenic vein was recanalized
6], but it is unpredictable pre- or intraoperatively. A recent multicenter study reported
a complication of splenic ischemia after splenopexy with a mesh in 60% of cases 2]. It was speculated that the elongated vascular pedicle might kink after splenopexy
to impair the blood flow.

There were few reports discussed about appropriate surgical management with chronic
torsion of the vascular pedicle complicating gastric varices. We reviewed cases of
gastric varices secondary to wandering spleen including our case in the literatures
(Table 1). Of 14 cases in total, 10 patients (71%) were adult, being consistent with prolonged
suffering from chronic torsion of the vascular pedicle. Gastrointestinal bleeding
presenting hematemesis and/or melena were presented in nine patients. The region of
the varices was not extended to the esophagus but confined to the stomach in all cases.
No cases were complicated with total splenic ischemia. Thrombosis in the splenic vein
was reported intraoperatively or histologically in three cases. Splenectomy was selected
in the 13 cases (93%), and the outcomes were satisfactory as the varicose veins were
not detected with endoscopy or CT in all case follow-ups. Splenectomy was selected
for two young patients complicating with not only gastric but also portal and mesenteric
varices 6]. However, only a single case reported by Wani S et al. underwent detorsion and splenopexy
in which elimination of the gastric varices was confirmed with the follow-up endoscopy
4]. Thus, splenectomy was employed in almost all cases. Therefore, it remains unclear
whether the collateral varicose veins will be reduced or not by splenopexy.

Table 1. Literature review of case reports on wandering spleens complicating gastric varices