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Journal of Indian Association of Pediatric Surgeons
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LETTER TO THE EDITOR
Year : 2014  |  Volume : 19  |  Issue : 4  |  Page : 247
 

Intraoperative acute mesenteric ischemia: A hard nut to crack


Department of Pediatric Surgery, The Children's Hospital and The Institute of Child Health Lahore, Pakistan

Date of Web Publication30-Sep-2014

Correspondence Address:
Bilal Mirza
Senior Registrar Department of Pediatric Surgery, The Children's Hospital and The Institute of Child Health Lahore, Lahore
Pakistan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9261.142026

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How to cite this article:
Mirza B, Ahmad S, Iqbal S, Talat N, Saleem M. Intraoperative acute mesenteric ischemia: A hard nut to crack . J Indian Assoc Pediatr Surg 2014;19:247

How to cite this URL:
Mirza B, Ahmad S, Iqbal S, Talat N, Saleem M. Intraoperative acute mesenteric ischemia: A hard nut to crack . J Indian Assoc Pediatr Surg [serial online] 2014 [cited 2019 Dec 7];19:247. Available from: http://www.jiaps.com/text.asp?2014/19/4/247/142026


Sir,

Mesenteric ischemia (MI) is a vascular emergency with a myriad of presentations, from postprandial subtle pain abdomen to acute abdomen. [1],[2] English literature is silent on intraoperative MI.

A 5-year-old girl, diagnosed case of situs inversus abdominus and polysplenia syndrome was admitted for correction of malrotation. Blood tests (CBC, PT/APTT, serum electrolytes, renal function tests etc.) were normal. At operation, Ladd's procedure performed in reverse fashion. The intestines turned dusky before placing bowel back to the abdomen. Bowel was fomented and replaced in abdomen, but in vain. The ischemia (DJ to transverse colon) continued to worsen therefore it was decided to explore superior mesenteric artery (SMA). Intravenous heparin and prophylactic antibiotics were started. Anesthetist confirmed a brief episode of hypotension (BP 80/50 mmHg) which had been corrected with fluids. At root of mesentery, first few centimeters of SMA had pulsations followed by no pulsations. A small longitudinal incision was given at beginning of pulse-less portion of SMA with bulldog vascular clamp applied at pulsating part. There was no thrombus or abnormal constriction at the site of incision. Flow was present on unclamping the proximal vessel. Fogarty catheter was traversed distally to remove any thrombus or embolus but none were found. SMA was flushed with warm normal saline to clear any micro thrombi followed by closure of arteriotomy. Surprisingly, on unclamping flow established distally and intestines turned pink over few minutes. The gut was replaced in the abdominal cavity and abdomen closed with a plan to re-surgery after 24hrs. Patient was shifted to surgical ICU. PT and APTT were performed and INR was maintained at 2.5 times the normal. Doppler ultrasound before re-operation showed normal mesenteric flow. Patient was hemodynamically stable thus surgery not done. Contrary to our expectations of prolonged ileus, patient started passing stool on 3 rd postoperative day. We deliberately delayed oral for a week. Anticoagulation therapy tapered and patient was discharged.

Occlusive MI is caused by thromboembolism of SMA, portal venous thrombosis, atherosclerosis, and vascular stenosis. Non-occlusive MI is caused by vascular spasm, hypovolemia, arrhythmias, and external compression by tumors. [1] In our case, MI was acute and non-occlusive as no thromboembolism or occlusive factors were identified. Bowel evisceration, intraoperative hypotension, and situs inversus abdominis are risk factor for mesenteric artery spasm in our case. The treatment of non-occlusive MI is antispasmodics like papaverive and prostaglandins. [1] In retrospect, a trial of papaverive may have achieved the established resolution of vascular spasm prior to the performance of arteriotomy. Initially we thought some problem with orientation of vessels at the root of mesentery; arteriotomy was planned later to rule out any thromboembolism. Those few hours were quite hard on the part of patient as well as operation team. A delay of more than 24hr is associated with 100% mortality. Our patient was fortunate, if it would have occurred postoperatively, the outcome could be different as postoperative pain is largely managed with analgesics rather than re-operation.

 
   References Top

1.Klar E, Rahmanian PB, Bücker A, Hauenstein K, Jauch A, Luther B. Acute mesenteric ischemia: A vascular emergency. Dtsch Arztebl Int 2012;109:249-56.  Back to cited text no. 1
    
2.Unalp HR, Atahan K, Kamer E, Yasa H, Tarcan E, Onal MA. Prognostic factors for hospital mortality in patients with acute mesenteric ischemia who undergo intestinal resection due to necrosis. Ulus Travma Acil Cerrahi Derg 2010;16:63-70.  Back to cited text no. 2
    




 

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