Intestinal ischemia following laparoscopic surgery: a case series

Superior Mesenteric Arterial Occlusion Following Laparoscopic Partial Fundoplication

A 62-year-old male with history and endoscopic findings consistent with gastroesophageal reflux underwent elective laparoscopic fundoplication. He developed severe abdominal pain four days postoperatively, and computed tomography (CT) angiogram of the abdomen demonstrated occlusion of the superior mesenteric artery due to dissection. The patient was administered intravenous heparin following vascular surgical advice, resulting in resolution of the pain within an hour and no subsequent complications. Laparoscopy-associated mesenteric vascular events are rare but associated with very high morbidity and mortality. Mesenteric arterial occlusion is most frequently reported following laparoscopic cholecystectomy but may occur following many common laparoscopic procedures. Presentation generally occurs hours to days following the procedure, with severe abdominal pain out of proportion with physical signs. If left unrecognized, patients progress to bowel and visceral ischemia, necrosis, and multiorgan failure. Mechanisms postulated to cause these mesenteric vascular events involve changes in splanchnic blood flow, reduced cardiac output and systemic venous return, and hypercapnia related to carbon dioxide insufflation. Diagnosis may be made promptly with CT angiography, and potentially treated with intravenous heparin alone, avoiding a laparotomy or bowel resection. This is the first reported case of successful anticoagulation causing resolution of the occlusion sufficient to avoid reoperation or bowel resection. Once identified, this condition should be treated in liaison with vascular surgery colleagues, which may require anticoagulation, endovascular, or open intervention.

First Report of Two Cases of Acute Gastric Ischemia after Robot-Assisted Radical Cystectomy

Gastrointestinal ischemia is rare after small pelvis surgery. Minimal invasive robotic surgery requires adaptation of the surgical approach for cystectomy and derivation construction such as the use of pneumoperitoneum and Trendelenburg positioning of the patient. Two cases with gastric ischemic complications after robot-assisted radical cystectomy are described. The first case was a 68-year-old female who had prolonged gastroparalysis and blood in a replaced gastric tube at day 10 after robotic cystectomy and Bricker urinary derivation. Gastroscopy revealed ischemia of gastric and proximal duodenal mucosa while computed tomography showed multiple calcifications and thrombi in the coeliac trunk branches and splenic infarcts. The stenosis of the origin of the mesenteric superior artery was stented via an endovascular procedure, and the patient recovered with normal gastroscopy 1 month postoperatively. The second case was a 73-year-old male who developed abdominal pain and fever 5 days after robotic cystectomy and Bricker. On abdominal computed tomography imaging, subcutaneous emphysema, intra-abdominal air, and calcification at the origin of the coeliac trunk were found. At laparotomy 5 days after the cystectomy, a 3 cm hole in the fundus of the stomach was found which was removed with the major stomach curvature. Gastroscopy 5 days after hemigastrectomy revealed no remnant ischemia. The prolonged pneumoperitoneum during robotic cystectomy, the deep Trendelenburg position, and the preoperatively impaired vascular system can be the reasons of our first two cases of gastric ischemia. This rare complication should be kept in mind in patients with symptoms of gastric ischemia since it can result in gastric perforation.

Mesenteric ischemia: what the radiologist needs to know

Acute mesenteric ischemia (AMI) is a life-threatening condition that often presents with abdominal pain. Early diagnosis with contrast-enhanced computed tomography and revascularization can reduce the overall mortality in AMI. This article reviews practical etiological classification, pathophysiology of imaging manifestations and common pitfalls in intestinal ischemia.

Can We Predict the Perioperative Pulmonary Complications Before Laparoscopic Sleeve Gastrectomy: Original Research

BACKGROUND

The increasing prevalence of obesity in worldwide is one of the most serious chronic public health problems and is considered to be a global epidemic. Bariatric surgical procedures have also been applied more often with increased prevalence of obesity. As a result, the incidence of surgical complications has increased. Preoperative evaluation is quite important for these patients.

AIMS

The aim of our study is to determine the predictors of perioperative pulmonary complications of laparoscopic sleeve gastrectomy.

STUDY DESIGN

The study is a cross-sectional study.

METHODS

One hundred eighty-three consecutive patients who received laparoscopic bariatric surgery were followed up during 3 months. Patients were divided into two groups A and B. Group A being the patients who had perioperative pulmonary complications (n = 28) and group B being patients who had not (n = 155). Pulmonary function test (PFT), body mass index (BMI), preoperative oxygen saturation, age, gender, comorbid diseases, and smoking history were compared between these groups.

RESULTS

Mean age, size, weight, BMI, PFT parameters of groups A and B were close to each other. The strongest predictors of perioperative pulmonary complications were duration of smoking in current smokers and low baseline oxygen saturation.

CONCLUSIONS

Preoperative oxygen saturation and smoking history may help to predict perioperative complications of laparoscopic sleeve gastrectomy.

Biliary imaging: multimodality approach to imaging of biliary injuries and their complications

Although traumatic and iatrogenic bile leaks are rare, they have become more prevalent in recent years due to an increased propensity toward nonsurgical management of patients with liver trauma and an overall increase in the number of hepatobiliary surgeries being performed. Because clinical signs and symptoms of bile leaks are nonspecific and delay in the recognition of bile leaks is associated with high morbidity and mortality rates, imaging is crucial for establishing an early diagnosis and guiding the treatment algorithm. At computed tomography or ultrasonography, free or contained peri- or intrahepatic low-attenuation (low-density) fluid in the setting of recent trauma or hepatobiliary surgery should raise suspicion for a bile leak. Hepatobiliary scintigraphy and magnetic resonance (MR) cholangiopancreatography with hepatobiliary contrast agents can help detect active or contained bile leaks. MR cholangiopancreatography with hepatobiliary contrast agents has the added advantage of being able to help localize the bile leak, which in turn can help determine if endoscopic management is sufficient or if surgical management is warranted. Endoscopic retrograde cholangiopancreatography may provide diagnostic confirmation and concurrent therapy when nonsurgical management is pursued. A multimodality imaging approach is helpful in diagnosing traumatic or iatrogenic biliary injuries, accurately localizing a bile leak, and determining appropriate treatment.