Clinical Management and Outcomes of Splenic Artery Pseudoaneurysm Complicated by Colonic Fistula After Gastrectomy: A Report of Two Cases

Splenic artery pseudoaneurysm (SAP) complicated by colonic fistula is a highly uncommon but life-threatening vascular complication that may occur after upper abdominal surgery, including radical gastrectomy with D2 lymphadenectomy. The diagnosis is often delayed due to the rarity of this condition and its nonspecific presentation, especially when bleeding manifests as hematochezia rather than intraperitoneal hemorrhage. This report presents two cases of SAP with secondary colonic fistula that occurred approximately one month following laparoscopic total gastrectomy for advanced gastric cancer. Both patients presented with recurrent fresh hematochezia, left upper quadrant abdominal pain, and clinical signs of hypovolemic shock. Colonoscopy revealed bulging colonic mucosa with marked hyperemia and erosion, while contrast-enhanced abdominal CT and catheter-based digital subtraction angiography confirmed the presence of pseudoaneurysms communicating with the colon. Both patients underwent successful transcatheter arterial embolization (TAE) using a sandwich technique involving microcoils and gelatin sponge particles, which resulted in immediate hemostasis without major perioperative complications. Postoperative imaging revealed splenic infarction in both cases, but no further intervention was required, and no clinical sequelae were observed. During follow-up periods of 6-12 months, neither patient experienced rebleeding or pseudoaneurysm recurrence. These cases highlight the diagnostic challenges and the importance of early vascular imaging in postoperative gastrointestinal bleeding of obscure origin. Endovascular embolization is a safe, effective, and organ-preserving treatment strategy in such high-risk situations, especially when conventional surgery poses significant risks due to adhesions or patient comorbidities. Multidisciplinary collaboration and heightened clinical suspicion are critical for timely diagnosis and successful management.