Vadim Avulov, DO, Daniel P McQuillen, MD, FIDSA, FACP, Masako Mizusawa, MD, David Brams, MD, FACS. Lahey Clinic.
Introduction:
Splenic abscess after a sleeve gastrectomy is an extremely rare occurrence, with only one case reported internationally and none were yet documented in United States. We are reporting a rare case study of splenic abscess as a progression of splenic infarction after a routine sleeve gastrectomy.
Methods:
Reviewed literature using Pudmed database on the most common complications after a laparoscopic sleeve gastrectomy. Information for preferentially selected ideas and theories supported in multiple studies was reviewed to identify the most appropriate management for this condition.
Results:
19 year-old morbidly obese male had a laparoscopic sleeve gastrectomy. Past surgical history included laparoscopic cholecystectomy. During the operation, the liver, stomach and spleen were of normal anatomy and there were no intra-operative complications. Post-operative course was unremarkable. He tolerated a liquid diet and was discharged home in a stable condition on postoperative day 1.
Two weeks after the operation he presented to outpatient clinic with an isolated temperature of 38.8 C and no other clinical signs and symptoms. Complete blood count and metabolic panel were within normal limits. Computed Tomography (CT) scan of the abdomen revealed a focal medial splenic infarct (Image-1). Two days after, the fevers became persistent and this time the laboratory findings were consistent with hepatic and renal failure: AST 752, ALT 587, alkaline phosphatase 255, total bilirubin 3.2, INR 1.8, amylase 60, lipase 123. Complete blood count remained within normal range. Hepatitis panel, toxicology, blood cultures and serology for other potential viral and parasitic pathogens were negative. Patient was being empirically treated for suspected Acetaminophen toxicity with N-acetylcyteine.
Work-up for choledocholithiasis was negative and upper gastrointestinal swallow study showed no evidence of leak from the gastric sleeve staple line. Because continuous fevers and absence a clear diagnosis at hand, CT scan of abdomen and pelvis was repeated and this time revealed a new multifocal splenic abscess on top of splenic infarction (Image -2). Percutaneous aspiration of the splenic abscess showed gram-negative rods. He was urgently taken to the operating room for a splenectomy. The cultures of the splenic abscess grew Salmonella species. He recovered well after the operation and was discharged home on two-week course of Ciprofloxacin.
Image-1 Image-2
Conclusions:
Splenic abscess in a setting of splenic infarct adds to the list of differential diagnoses as a potential complication of laparoscopic sleeve gastrectomy. Fever of unknown origin in an otherwise negative workup after a sleeve gastrectomy may signify an evolving splenic abscess. CT scan is the best modality to diagnose a splenic abscess and definitive management of multiloculated splenic abscess is splenectomy.
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