Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 8  |  Issue : 6  |  Page : 172-174

Acute-on-Chronic mesenteric ischemia successfully managed by superior and inferior mesenteric artery reimplantation and cholecystectomy for gangrenous gallbladder


Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission20-May-2021
Date of Decision02-Jun-2021
Date of Acceptance22-Jun-2021
Date of Web Publication20-Jan-2022

Correspondence Address:
Ajay Savlania
Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_55_21

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  Abstract 


Acute-on-chronic mesenteric ischemia (CMI) leading to gallbladder gangrene is a rare event, and successful use of mesenteric arterial reimplantation with regard to contaminated field is not reported. In contaminated field from gangrenous gallbladder due to acute-on-CMI, reimplantation of the superior and inferior mesenteric artery (SMA and IMA, respectively) for revascularization is a feasible option, and was used to revascularize in this patient. SMA and IMA require one anastomosis at the aorta, and it was successfully used in contaminated field to revascularize the threatened bowel. In acute-on-CMI, with contaminated field, reimplantation of SMA makes one of an option in surgical armamentarium of using autologous tissue and it reduces number of anastomosis in infected field. Acalculous gangrenous cholecystitis is a rare pathology associated with acute-on-CMI.

Keywords: Acalculous cholecystitis, mesenteric ischemia, superior mesenteric artery reimplantation


How to cite this article:
Savlania A, Sriharsha B, Kaman L. Acute-on-Chronic mesenteric ischemia successfully managed by superior and inferior mesenteric artery reimplantation and cholecystectomy for gangrenous gallbladder. Indian J Vasc Endovasc Surg 2021;8, Suppl S2:172-4

How to cite this URL:
Savlania A, Sriharsha B, Kaman L. Acute-on-Chronic mesenteric ischemia successfully managed by superior and inferior mesenteric artery reimplantation and cholecystectomy for gangrenous gallbladder. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2022 Jul 4];8, Suppl S2:172-4. Available from: https://www.indjvascsurg.org/text.asp?2021/8/6/172/336025



A 42-year-old man, a chronic smoker for 15 pack-years, presented to our emergency services with diffuse abdominal pain from the past 1 day. He had a history of pain abdomen, which was intermittent and postprandial in nature for the past 2 years, associated with significant loss of weight and recent-onset fear for food. On examination, the patient was emaciated and poorly nourished with a body mass index (BMI) of 10.81 kg/m2. On abdominal examination, there was diffuse tenderness, but no distension was noticed. On hematological investigation, his hemoglobin was 9.9 g% with an increased leukocyte count of 17,400/mm3. Renal function test and liver function test were within normal range, except hypoalbuminemia with a serum albumin level of 3 g%. Ultrasonography abdomen showed distended gallbladder with edematous wall with a thickness of 7 mm. Computed tomography (CT) angiography showed an ostio-proximal occlusion of the celiac trunk and superior mesenteric artery (SMA) with distal reformation of SMA and ostial 90% stenosis of the inferior mesenteric artery (IMA) [Figure 1]a. CT also showed dilatation of distal jejunal loops along with mesenteric stranding. In view of acute-on-chronic mesenteric ischemia, we planned for exploratory laparotomy. Intraoperatively, the gallbladder was found gangrenous with tissues surrounding the gallbladder were bile tinged and the whole of small bowel was underperfused with bluish discoloration, however it was healthy [Figure 1]b. SMA pulsation was absent and IMA pulsation was feeble with post stenotic dilatation and palpable thrill. We performed a standard cholecystectomy [Figure 1]c with mesenteric revascularization through SMA and IMA reimplantation on the aorta [Figure 2]a. Celiac revascularization was not considered as there was good pulsation felt after SMA reimplantation in the hepatic artery and the color of the liver also improved post revascularization of SMA and IMA. The bowel color improved to normal post revascularization [Figure 2]b. The patient had an uneventful postoperative course with good oral intake helping him gain 8 kg of weight in the 1st month. His postoperative CT angiogram confirmed the patency of reimplanted vessels [Figure 3]. At 2 years of follow-up, the patient is having normal routine life with a weight gain of 21 kg and BMI is 19.9 kg/m2.
Figure 1: (a) Computed tomography angiogram volume-rendered image showing occlusion of celiac and superior mesenteric artery with distal reformation (yellow arrows). The inferior mesenteric artery had more than 90% stenosis (red arrow) with a prominent arc of Riolan connecting the superior mesenteric artery and inferior mesenteric artery (green arrowhead). (b) Intraoperative picture showing dusky cyanosed small bowel. (c) Cholecystectomy specimen with gangrenous wall with diffuse ooze of bile

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Figure 2: (a) Intraoperative picture showing reimplantation of the superior mesenteric artery and inferior mesenteric artery. The superior mesenteric artery was implanted to the infrarenal aorta (red arrow) and the inferior mesenteric artery was implanted inferior to its normal origin (yellow arrow). (b) Bowel color improved to normal after revascularization

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Figure 3: Computed tomography angiogram abdomen showing the patent origin of the superior mesenteric artery and inferior mesenteric artery

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  Discussion Top


Mesenteric ischemia is known to occur when the perfusion of abdominal visceral organs fails to meet the normal metabolic requirements. The presentation may be acute when it occurs in hours to days or chronic when the duration is for weeks to months. Acute mesenteric ischemia most often results when there is embolization to the mesenteric vessels or acute thrombosis related to a preexisting plaque while chronic mesenteric ischemia (CMI) occurs when there is progressive occlusion of visceral arteries in a background of atherosclerotic disease. Patients with CMI usually have a positive history of smoking and hyperlipidemia.[1]

CMI is a more insidious process where postprandial abdominal pain and progressive weight loss are the most common symptoms. Pain often occurs 15–45 min after taking a meal, and the severity varies according to the type and size of meal. It is often described that the patient typically develops “food fear” which eventually leads to decreased food intake and weight loss. The present case had a classic triad of CMI, postprandial pain, weight loss, and sitophobia. A heavy smoking history is often found along with cerebrovascular, coronary, and peripheral arterial thrombotic manifestations in majority of the patients.[1] CT is an accurate, noninvasive imaging modality for the diagnosis of mesenteric ischemia. Modern multidetector CT enables imaging with an excellent spatial and temporal resolution with a sensitivity of 93% and specificity of 96% aiding in the diagnosis.[2]

Acute acalculous cholecystitis (AAC) is a rare complication of CMI, which, when associated with abdominal pain located to right upper quadrant, elevated total counts, should raise its suspicion. It is usually seen in critically ill patients such as trauma, sepsis, refractory shock, and burns. It is associated with high complication and mortality rates.[3] It is considered to be a multifactorial process in which bile stasis and ischemia play a major role.[4] Over the past several years, very few numbers of cases with AAC in an underlying CMI have been reported. In a study conducted by Savoca et al., 72% of patients who developed AAC had clinically significant atherosclerotic vascular disease which only reinforced aortic atherosclerosis as a risk factor for AAC.[5]

In the present case, the patient had features of CMI which progressed to acute-on-CMI 24 h before his presentation to the emergency department. Intraoperatively in view of contaminated field due to gangrenous gallbladder, reimplantation of SMA was favored for revascularization than bypass as it reduced our number of anastomosis.[6]

The cause for AAC in our case must be due to the underlying atherosclerotic disease and long-standing CMI. In any patient with symptomatic CMI, if complicated with AAC, a cholecystectomy is indicated along with revascularization.[7]


  Conclusion Top


In acute-on-CMI, with contaminated field, reimplantation of SMA makes one of an option in surgical armamentarium of using autologous tissue and it reduces number of anastomosis in infected field. Acalculous gangrenous cholecystitis is a rare pathology associated with acute-on-CMI.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.



 
  References Top

1.
Brandt LJ, Boley SJ. Intestinal ischemia, Sleisinger and Fordtran's Gastrointestinal and Liver Disease. 7th ed. Philadelphia: Saunders; 2002. p. 2321-40.  Back to cited text no. 1
    
2.
Menke J. Diagnostic accuracy of multidetector CT in acute mesenteric ischemia: Systematic review and meta-analysis. Radiology 2010;256:93-101.  Back to cited text no. 2
    
3.
Melo R, M Pedro L, Silvestre L, P Freire J, Pereira C, Fernandes E Fernandes R, et al. Acute acalculous cholecystitis as a rare manifestation of chronic mesenteric ischemia. A case report. Int J Surg Case Rep 2016;25:207-11.  Back to cited text no. 3
    
4.
Huffman JL, Schenker S. Acute acalculous cholecystitis: A review. Clin Gastroenterol Hepatol 2010;8:15-22.  Back to cited text no. 4
    
5.
Savoca PE, Longo WE, Zucker KA, McMillen MM, Modlin IM. The increasing prevalence of acalculous cholecystitis in outpatients. Results of a 7-year study. Ann Surg 1990;211:433-7.  Back to cited text no. 5
    
6.
Aksoy M, Dilege S, Kayabali M. Superior mesenteric artery re-implantation in chronic mesenteric ischemia. EJVES Extra 2005;9:54-7.  Back to cited text no. 6
    
7.
Higuchi R, Takada T, Strasberg SM, Pitt HA, Gouma DJ, Garden OJ, et al. Tokyo Guideline Revision Committee. TG13 miscellaneous etiology of cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci 2013;20:97-105.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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