|Ahead of print
A novel technique of SMA massage with systemic fibrinolytic therapy in ischemic midgut volvulus: As a lifesaving last expedient
Vandana Basappa Giriradder1, Vinay Jadhav1, PL Anilkumar2, M Narendra Babu1
1 Department of Pediatric Surgery, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India
2 Department of Pediatric surgery, Sakra World Hospital, Bengaluru, Karnataka, India
|Date of Submission||19-May-2022|
|Date of Decision||29-Aug-2022|
|Date of Acceptance||07-Oct-2022|
|Date of Web Publication||12-Dec-2022|
Vandana Basappa Giriradder,
No 47, 18th Main, 11th Cross, 4th Sector, HSR Layout, Bengaluru - 560102, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Purpose: Midgut volvulus is a surgical emergency requiring immediate intervention. Intestinal ischemia of the midgut as a consequence of volvulus from malrotation is a fateful event with high mortality and significant morbidity even in survivors. Derotation followed by correction of malrotation is the procedure of choice though has significant morbidity if intestinal reperfusion was not successful. A combined treatment to restore intestinal perfusion based on the digital massage of the superior mesenteric artery after derotation and systemic infusion of fibrinolytic has been previously reported with success but underused. Here, we report three such cases of midgut malrotation with severe intestinal ischemia due to volvulus.
Materials and Methods:A retrospective analysis of three confirmed cases of midgut malrotation with volvulus managed with emergency laparotomy, derotation, and Superior Mesenteric Artery (SMA) massage with systemic fibrinolytic therapy, followed by correction of malrotation was evaluated.
Results: There was dramatic improvement in intestinal perfusion noted in all three patients inspite of delayed presentation. 2 out of 3 patients on follow up are doing well with adequate weight gain while 1 patient succumbed due to sepsis.
Conclusion: Critical intestinal ischemia due to mesenteric thrombosis can persist after derotation of midgut volvulus and can lead to devastating consequences. The use of digital massage of SMA to disrupt the thrombus along with fibrinolytic therapy though reported is underutilized. Hence, awareness of this management and usage needs to be re-emphasized.
Keywords: Fibrinolytic therapy, intestinal ischemia, malrotation, midgut volvulus, SMA massage
|How to cite this URL:|
Giriradder VB, Jadhav V, Anilkumar P L, Babu M N. A novel technique of SMA massage with systemic fibrinolytic therapy in ischemic midgut volvulus: As a lifesaving last expedient. J Indian Assoc Pediatr Surg [Epub ahead of print] [cited 2023 Jun 4]. Available from: https://www.jiaps.com/preprintarticle.asp?id=363425
| Introduction|| |
Intestinal malrotation is one of the common emergencies in the neonatal period. It is found in 1 in 600 live births but symptomatic cases are found in 1 in 6000 live births. The most common presentation is bilious vomiting and gastrointestinal (GI) bleed.
Upper GI contrast study is the gold standard for diagnosing a child with suspected malrotation. Ladd's procedure being the treatment of choice.
While critical ischemic necrosis of the midgut as a consequence of volvulus from malrotation is an ill-fated event with high mortality, there is little published data on the management of arterial occlusion in the newborn period and consensus on appropriate interventions and management protocols which is still evolving.
Here, we report three such cases of midgut malrotation with severe intestinal ischemia due to volvulus, two out of three managed successfully with combined therapy based on the digital massage of the superior mesenteric artery after derotation and systemic infusion of fibrinolytic.
| Material and Methods|| |
Two neonates and a 5-year-old presented to us with abdominal distension and bilious vomiting, imaging modalities done were suggestive of malrotation. After resuscitation, an emergency laparotomy was done in all.
Patient 1: 5y/F
5Y/F presented to us after 3 Days of onset of symptoms i.e abdominal distension and vomiting. On exploration was found to have malrotation with volvulus more than 270° and discoloration of the entire small bowel and ascending colon. Derotation of the gut was done followed by Ladd's procedure after which intestines were covered with warm mop and the patient was given 100% oxygen. The appearance of the intestine did not improve after derotation. Hence, a digital massage of SMA was initiated. After 15 min of continuous efforts, there was a significant improvement in intestinal vascularity [Figure 1]. Viability of intestine assessed, 20 cm of ileal segment resected, both ends closed.
|Figure 1: Pre- and postSMA massage in a 5-year-old female depicting change in bowel perfusion|
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Relook laparotomy was done after 36 h. Another 15 cm length of the intestine with patchy gangrenous segment was resected and end-to-end anastomosis was done. She was started on TPN POD1. Oral feeds started on POD 4 which was not tolerated. Symptoms persisted with bilious vomiting hence decided for re-exploration on POD12. Dense adhesions were released and were found to have two internal strictures which required resection anastomosis. She was started on TPN for a week followed by feeds after 5 days, upgraded slowly as tolerated, and was discharged home on POD27. On follow-up, the child had hypoalbuminemia which was managed successfully.
Now on a 2-year follow-up, she has gained good weight, eating well, and having a normal frequency of stools.
Patient 2: D5/F
On laparotomy, malrotation with volvulus and extensive small bowel ischemia extending from duodenojejunal flexure to 70cm of the bowel was observed with perforation in the proximal jejunum. Only the distal ileum of 7cm and large bowel were found to be healthy. After the derotation and Ladd's procedure, there was no improvement in the ischemic gut hence, SMA massage was initiated and continued for 20 min along with 100% oxygen. Noticeable improvement in the color of the small bowel was present [Figure 2].
|Figure 2: Pre- and postSMA massage in a 5-day-old depicting change in bowel perfusion|
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The perforated segment of the small bowel was resected, and duodenojejunal flexure with distal jejunal anastomosis was done. Injection of urokinase 4400u/kg stat dose was given.
Postoperatively, the child was started on injection urokinase 4400u/kg maintenance dose for 3 days. Graded feeds started on POD3 and attained full feeds on POD14. The baby was discharged on POD17 with adequate weight gain and on exclusive breastfeeding. Now on 10 months of follow-up, the child is having good weight gain and feeding well.
Patient 3: D3/F
On laparotomy, critical ischemia of the midgut with volvulus was seen involving the whole length of the bowel with pregangrenous changes and thinned-out bowel in certain areas. SMA massage was initiated and continued for 20 min, there was a noticeable improvement in the bowel vascularity in most areas. Second look laparotomy was planned but the baby succumbed to death the next day due to preoperative sepsis.
| Results|| |
With this novel technique of SMA massage and fibrinolytic therapy for midgut volvulus we have noticed a striking improvement in bowel perfusion in all of our patients that alleviated the chances of extensive bowel resection leading to short bowel syndrome. Presently on follow up 2 out of 3 patients are doing well with adequate weight gain.
| Discussion|| |
The majority of malrotation with midgut volvulus can be corrected without morbidity if identified early while around 15% of these patients develop complete obstruction of the mesenteric vessels resulting in thrombosis and bowel infarction which may need additional procedures. Critical intestinal ischemia is found to persist even after derotation of the gut leading to ruinous effects because of the thrombosis, related to the severity of the twist. If the blood supply is not restored, necrosis and loss of the intestine occur. To cap resection at the time of the first surgery, the intestine of doubtful viability is often left in situ and a second look laparotomy is then performed after 48 h,as a standard protocol to mitigate extensive resection and its consequence. When challenged with complete necrosis of the small bowel, some surgeons advocate withdrawal of care.
In such situations where the bowel is not necrotic but critically ischemic, to treat such deleterious effects, Edward Kiley and colleagues first reported, successful combined treatment (massage and systemic tPA) specifically directed at the intravascular thrombosis, which is a consequence of the volvulus in the year 2012 with success in two patients. Literature has very limited reports in the described technique and appears to be underutilized for a possible lack of awareness.
The use of digital massage was based on their experience with limb and digital ischemia where dramatic reperfusion has sometimes occurred with this maneuver which was extrapolated to mesenteric ischemia. The disruption of arterial thrombus by massage will result in fragments of blood clot passing downstream into the mesenteric vessels more distally [Figure 3]. The addition of systemic fibrinolysis dissolves these fragments of clots.
|Figure 3: (a) Drawing depicting derotation of bowel (b) Drawing depicting site of SMA Massage|
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UK and t-PA would appear to be the preferred agents for neonates. Half-life of urokinase is 16 mins and that of tPA is 5 mins. Urokinase exerts its effects by binding to clot-bound fibrin., This complex produces plasmin at the site of clot, which is then dissolved. Urokinase (Uni-kinase, Unichem laboratories Ltd) was used in our patient as it was easily available and cost-effective in comparison to tPA. There are no standardized thrombolytic maintenance dosing protocols, hence the duration is based on the response to treatment, but typical regimens are shown in [Table 1].
Systemic fibrinolysis is of concern because of the associated small risk of intraventricular hemorrhage in infants. In the unfortunate event that bleeding occurs, the fibrinolytic infusion should be stopped and cryoprecipitate is given.
In all three patients, we were able to appreciate the dramatic improvement in intestine color and mitigate extensive intestinal resection though one patient succumbed, due to sepsis.
Long-term follow-up is required in such children as they may present with malabsorption syndromes, mucosal ulceration, and short-segment strictures due to ischemia. These problems can occur because of the thrombus been broken down and pushed from the main artery to the periphery during the SMA massage.
| Conclusion|| |
Critical intestinal ischemia due to malrotation with midgut volvulus is a dire surgical emergency with high mortality if not intervened immediately. Early diagnosis and intervention are the keys to successful outcomes. Digital SMA massage and systemic fibrinolytic therapy is effective and has been noted to have a good outcome.
In cases with extensive small bowel ischemia with no improvement even after derotation, digital SMA massage with systemic fibrinolytic therapy should be attempted in all, before proceeding to extensive small bowel resections or abandoning further care.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Sketches by Dr. S Ramesh (HOD, Pediatric surgery)
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]