Acute Crit Care.  2020 Aug;35(3):213-217. 10.4266/acc.2018.00423.

Early laparoscopic exploration for acute mesenteric ischemia after cardiac surgery

• Kim SH
• Hwang HY
• Kim MJ
• Park KJ
• Kim KB

• KMID: 2506102
• DOI: http://doi.org/10.4266/acc.2018.00423

Abstract

Acute mesenteric ischemia (AMI) after cardiac surgery is a rare but fatal complication. Early diagnosis and intervention can be lifesaving. We report two cases of patients who underwent early diagnostic laparoscopy for suspicious AMI after cardiac surgery and demonstrated favorable outcomes. An 83-year-old male with severe left ventricular dysfunction underwent off-pump coronary artery bypass grafting. Severe ileus with gaseous distension of the small bowel was developed on the 3rd postoperative day and computed tomographic angiography (CTA) showed pneumatosis intestinalis of small bowel suggestive of AMI. An immediate bedside laparoscopy was performed and it showed preserved perfusion of small bowel. He recovered without complication under supportive medical management. Another 69-year-old male who underwent aortic valve replacement complained of whole abdominal tenderness with severe distension on the 3rd postoperative day. The CTA found segmental non-enhancing bowel wall with air bubbles suggestive of AMI with possible microperforation. A diagnostic laparoscopy demonstrated small-bowel infarction with pus-like fluid collection in the peritoneal cavity. The operation was converted to laparotomy and complete resection of ischemic segments of small bowel was done. He recovered well without any other complications and discharged home on the 35th postoperative day.

Keyword

cardiac surgical procedure; laparoscopy; mesenteric ischemia

Figure

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  Figure 1. (A) Plain abdominal X-ray showed ileus with gaseous distension of small bowel. (B) Computed tomographic angiography showed multifocal, bubble-like pneumatosis intestinalis of small bowel (arrows).

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  Figure 2. Laparoscopic findings. (A) Relatively pinkish color of distended small bowel without perfusion deficit except a few focal ischemic foci (arrow). (B) Focal ischemic spot (arrow) without evidence of transmural infarction.

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  Figure 3. (A) Plain abdominal X-ray showed ileus with gaseous distension of small and large bowel loops. (B) Computed tomographic angiography (CTA) showed multifocal pneumatosis intestinalis of small bowel (arrows). (C) Follow-up CTA showed decreased perfusion of small bowel with segmental nonenhancing bowel wall (arrowhead) suggestive of bowel infarction. Air bubbles with uncertain continuity of bowel segment signify possible combined microperforation (arrow).

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  Figure 4. (A) Laparoscopic findings of small bowel ischemia (arrow) and pus-like fluid collection in peritoneal cavity (arrowhead). (B) Ischemic segments of small bowel (arrow) were resected via laparotomy.

Reference

1. Mangi AA, Christison-Lagay ER, Torchiana DF, Warshaw AL, Berger DL. Gastrointestinal complications in patients undergoing heart operation: an analysis of 8709 consecutive cardiac surgical patients. Ann Surg. 2005; 241:895–901.

2. Venkateswaran RV, Charman SC, Goddard M, Large SR. Lethal mesenteric ischaemia after cardiopulmonary bypass: a common complication? Eur J Cardiothorac Surg. 2002; 22:534–8.

3. Wyers MC. Acute mesenteric ischemia: diagnostic approach and surgical treatment. Semin Vasc Surg. 2010; 23:9–20.

4. Hackert T, Kienle P, Weitz J, Werner J, Szabo G, Hagl S, et al. Accuracy of diagnostic laparoscopy for early diagnosis of abdominal complications after cardiac surgery. Surg Endosc. 2003; 17:1671–4.

5. Lorusso R, Mariscalco G, Vizzardi E, Bonadei I, Renzulli A, Gelsomino S. Acute bowel ischemia after heart operations. Ann Thorac Surg. 2014; 97:2219–27.

6. Tilsed JV, Casamassima A, Kurihara H, Mariani D, Martinez I, Pereira J, et al. ESTES guidelines: acute mesenteric ischaemia. Eur J Trauma Emerg Surg. 2016; 42:253–70.

7. Demir IE, Ceyhan GO, Friess H. Beyond lactate: is there a role for serum lactate measurement in diagnosing acute mesenteric ischemia? Dig Surg. 2012; 29:226–35.

8. Yikilmaz A, Karahan OI, Senol S, Tuna IS, Akyildiz HY. Value of multislice computed tomography in the diagnosis of acute mesenteric ischemia. Eur J Radiol. 2011; 80:297–302.

9. Filsoufi F, Rahmanian PB, Castillo JG, Scurlock C, Legnani PE, Adams DH. Predictors and outcome of gastrointestinal complications in patients undergoing cardiac surgery. Ann Surg. 2007; 246:323–9.