63 - Freie Mitteilung
16. Mai 2019, 13:45 - 15:15, Sopra Grande, 4. OG
Retrograde open intraoperative stenting in acute mesenteric ischemia with long segment bowel necrosis
K. Dallago, P. Villiger, P. Knüsel, M. Furrer, Presenter: K. Dallago (Chur)
Acute mesenteric ischemia results in progressive transmural bowel necrosis and needs urgent evaluation of bowel viability and early revascularisation. Different treatment options for revascularisation of the superior mesenteric artery (SMA) are available. The classic open surgical revascularisation approach has been more and more replaced by endovascular techniques. In some cases, percutaneous antegrade recanalization of the SMA might be difficult. Intraoperative retrograde open mesenteric stenting offers the advantage of open surgical and endovascular approaches in a one step hybrid technique.
An 84 years old male presented as an emergent case with abdominal pain and diarrhea. We found a tender abdomen with signs of peritonitis. In the CT scan long segment pneumatosis of the small bowel has been seen in the presence of massive aortoiliac sclerosis with high grade ostial stenosis of the SMA with loss of contrast distally. We performed urgent explorative laparotomy and extensive small bowel resection with blind closure as a damage control procedure. 180cm pale but vital small bowel could be left in situ. The immediate postoperative attempt of percutaneous antegrade mesenteric stenting failed.
A second look laparotomy with open retrograde stenting was planned for the following day. The SMA was exposed 5cm distally to the ostial occlusion. A 0.035-inch guidewire (Terumo) was inserted over a 0.9 x 40mm cannula crossing the lesion with successful placement in the aorta. After predilatation retrograde stenting could be performed using a 6mm dynamic Biotronic stent. The remaining small bowel showed an immediate increase in motility and change in colour. End-to-end jejuno-ileal anastomosis was performed. The postoperative course was uneventful and the patient recovered well but is still suffering from a mild short bowel syndrome.
Acute mesenteric ischemia is still a devasting event. If percutaneous mesenteric artery stenting is not feasible, open intraoperative retrograde stenting is a reliable alternative possibility of revascularisation and might even be performed as a primary approach during explorative laparotomy.