Acute superior mesenteric artery occlusion associated with COVID-19 pneumonia: a case report

Background The novel 2019 coronavirus disease (COVID-19), which is caused by infection with the severe acute respiratory syndrome coronavirus 2, has spread rapidly around the world and has caused many deaths. COVID-19 involves a systemic hypercoagulable state and arterial/venous thrombosis which induces unfavorable prognosis. Herein, we present a first case in East Asia where an acute superior mesenteric artery (SMA) occlusion associated with COVID-19 pneumonia was successfully treated by surgical intervention. Case presentation A 70-year-old man presented to his local physician with a 3-day history of cough and diarrhea. A real-time reverse transcriptase-polymerase chain reaction test showed positive for COVID-19, and he was admitted to the source hospital with the diagnosis of moderate COVID-19 pneumonia. Eight days later, acute onset of severe abdominal pain appeared with worsening respiratory condition. Contrast CT showed that bilateral lower lobe/middle lobe and lingula ground glass opacification with distribution suggestive of COVID-19 pneumonia and right renal infarction. In addition, it demonstrated SMA occlusion with intestinal ischemia suggesting extensive necrosis from the jejunum to the transverse colon. The patient underwent an emergency exploratory laparotomy with implementing institutional COVID-19 precaution guideline. Upon exploration, the intestine from jejunum at 100 cm from Treitz ligament to middle of transverse colon appeared necrotic. Necrotic bowel resection was performed with constructing jejunostomy and transverse colon mucous fistula. We performed second surgery to close the jejunostomy and transverse colon mucous fistula with end-to-end anastomosis on postoperative day 22. The postoperative course was uneventful and he moved to another hospital for rehabilitation to improve activities of daily living (ADLs) on postoperative day 45. As of 6 months after the surgery, his ADLs have completely improved and he has returned to social life without any intravenous nutritional supports. Conclusions Intensive treatment including surgical procedures allowed the patient with SMA occlusion in COVID-19 pneumonia to return to social life with completely independent ADLs. Although treatment for COVID-19 involves many challenges, including securing medical resources and controlling the spread of infection, when severe abdominal pain occurs in patients with COVID-19, physicians should consider SMA occlusion and treat promptly for life-saving from this deadly combination.

Mesenteric occlusive disease of the inferior mesenteric artery is associated with anastomotic leak after left-sided colon and rectal cancer surgery: a retrospective cohort study

Purpose Anastomotic leak (AL) is a serious complication following colorectal surgery. Atherosclerosis causes inadequate anastomotic perfusion and is suggested to be a risk factor for AL. The aim of this study was to investigate the association of mesenteric occlusive disease on preoperative computed tomography (CT) scan with AL after left-sided colon or rectal cancer surgery. Methods This was a retrospective, multicenter cohort study including 1273 patients that underwent left-sided or rectal cancer resection between 2009 and 2018 from three hospitals in the Netherlands. AL patients were 1:1 matched with non-leak patients and preoperative contrast-enhanced CT-scans were retrospectively analyzed for mesenteric atherosclerotic lesions. The main outcome measure was the presence of mesenteric occlusive disease on the preoperative CT-scan. Results Anastomotic leak developed in 6% of 1273 patients (N = 76). Low anterior resection and stage I–III disease were statistically significant associated with AL (p = 0.01, p = 0.04). No other statistically significant differences in patient characteristics between AL and non-leak patients were found. A clinically significant stenosis (≥ 70–100%) of the inferior mesenteric artery was statistically significant more frequent present in AL patients, compared to non-leak patients (p < 0.01). No statistically significant differences in the presence of mesenteric occlusive disease of the celiac artery and superior mesenteric artery between AL patients and non-leak patients were found. Conclusion Mesenteric occlusive disease of the IMA on preoperative CT-scan is associated with AL after left-sided colon or rectal resection for cancer. Preoperative identification of high-risk patients with a preoperative CT-scan of the mesenteric vasculature might be useful to reduce the risk of AL.

Surgical Excision of a Contained Rupture of an Inferior Mesenteric Aneurysm

Inferior mesenteric artery (IMA) aneurysms represent the minority of visceral aneurysm presentations. A 57-year-old female was admitted with a symptomatic IMA aneurysm secondary to atherosclerotic disease. She was treated with open excision which revealed a contained ruptured of a true aneurysm. This case highlights the challenges of an accurate preoperative diagnosis of IMA aneurysm and the correct position of the recent guidelines on visceral aneurysms issued by the Society of Vascular Surgery (SVS).

A fetus excised from the small intestinal mesentery of a neonate (fetus in fetu): a case report

Background Fetus in fetu is a rare congenital anomaly. Its incidence is 1/500,000 births. So, pediatric surgeons may encounter this pathology only once or twice during their professional careers. Case presentation We present a rare case of a fetus extracted from the small intestinal mesentery of a healthy neonate who was explored after delivery. The extracted fetal mass included a fully differentiated skull and limbs with a celomic cavity. The fetal mass was supplied by a main feeding vessel branching from the superior mesenteric artery. Conclusion Fetus in fetu, despite being a rare variant, must be kept in mind when dealing with a neonatal abdominal mass showing bony parts on radiography.

Laparoscopic Hand-Sewn Duodenojejunostomy for Superior Mesenteric Artery Syndrome Using 3D-4K Image - A Case Study

Background: Superior mesenteric artery (SMA) syndrome, also known as wilkie’s syndrome, is a rare condition characterized by vascular compression of third part of the duodenum that leads to duodenal obstruction. Traditionally, open or laparoscopic stapled duodenojejunostomy is recommended when conservative management failed. We report a 3D-4K image hand-sewn duodenojejunostomy (DJ) for the treatment of SMA syndrome. Materials and Methods: A 13 years old patient presented with anorexia, post prandial vomiting, dull abdominal pain & weight loss for 6 years. Upper GI endoscopy revealed duodenal stenosis and Barium follow through demonstrated obstruction to the third part of the duodenum. Ultrasound examination revealed gastric & duodenal dilatation. With these clinical and radiological findings, the diagnosis of SMA syndrome was suspected. He was identified as a candidate for a duodenojejunostomy. 3D-4K image system was used for superior image quality and binocular depth perception and a laparoscopic hand-sewn duodenojejunostomy performed on september 20, 2020 Results: Diagnostic laparoscopy detected SMA syndrome. Laparoscopic hand-sewn duodenojejunostomy took 120 minutes time. There were no intraoperative complications. The blood loss was minimum. The postoperative course was uneventful with resolution of duodenal obstruction. The patient discharged on 6th postoperative day. He gained 10 kg weight 6weeks after surgery. Conclusion: 3D-4K image laparoscopic hand-sewn duodenojejunostomy as a surgical option for the treatment of SMA syndrome is safe, cost effective, feasible, and valid alternative to open and laparoscopic stapled technique with added benefits of a minimally invasive approach. Additionally hand-sewn anastomosis ensures good tissue approximation. Of course it is time consuming and needs expertise in intracorporeal suturing. 3D-4K image technology makes this difficult procedure easier. J Bangladesh Coll Phys Surg 2022; 40: 68-71

Protective effect of melatonin as an antioxidant in the intestine of rats with superior mesenteric arterial occlusion

The superior mesenteric artery is a branch of the aortic artery that supplies blood to the small and some parts of the large intestine. Any obstruction in blood flow and reperfusion causes tissue damage in the intestine. This study aimed to determine the rate of fat peroxidation and tissue protein as an indicator of tissue degradation after ischemia and reperfusion following induction of superior mesenteric artery occlusion in the intestine and to evaluate the protective effect of melatonin as a free radical scavenger and antioxidants in rats. In this study, 36 male Wistar-Albino rats weighing between 80-120 g were equally divided into six groups and received different melatonin doses (10, 20, and 30 mg/kg) intramuscularly. In this regard, Group 1 was the control group, Group 2 was the Sham group (underwent surgery to dissect the upper mesenteric artery and injected the same volume of solvent), Group 3 was Ischemia-reperfusion (IR), Group 4 was IR with melatonin at a dose of 10 mg/kg, Group 5 was IR with melatonin at a dose of 20 mg/kg, and Group 6 was IR with melatonin at a dose of 30 mg/kg. The results showed that the level of tissue malondialdehyde (MDA) was significantly lower in groups 4, 5, and 6 than in group 3 (P <0.05). Tissue protein levels were significantly higher in group 4 than in group 3 (P <0.001). Tissue protein levels in groups 5 and 6 did not significantly differ from group 3 (P = 0.191). Overall, this study showed that melatonin at a dose of 10 mg/kg has an antioxidant effect preventing induced damage due to superior mesenteric artery occlusion.