Clinical Journal of Gastroenterology

, Volume 10, Issue 6, pp 514–518 | Cite as

Successful treatment of non-occlusive mesenteric ischemia with indocyanine green fluorescence and open-abdomen management

  • Toshiyuki Irie
  • Takeshi MatsutaniEmail author
  • Nobutoshi Hagiwara
  • Tsutomu Nomura
  • Itsuo Fujita
  • Yoshikazu Kanazawa
  • Daisuke Kakinuma
  • Eiji Uchida
Case Report


Non-occlusive mesenteric ischemia (NOMI), which can lead to multifocal and segmental intestinal necrosis without demonstrable occlusion in the main mesenteric artery, is associated with extremely high mortality. Because these intestinal ischemic changes can progress, it is difficult to make a definitive determination intraoperatively as to whether resection of damaged intestine is required. A 62-year-old man who underwent esophagectomy for advanced cervicothoracic esophageal cancer complained of severe abdominal pain on postoperative day 4. Enhanced computed tomography revealed pneumatosis intestinalis in the wall of the small bowel. Emergency laparotomy revealed ischemia in segments of the small intestine suspicious for NOMI. Intraoperative evaluation of the mesenteric and bowel circulation was performed under indocyanine green (ICG) fluorescence. Although the ischemic bowel segments were visible, open-abdomen management was undertaken so that mesenteric and bowel circulation could be reexamined 24 h later. During the second-look operation, the small intestine was able to be preserved because intestinal perfusion was confirmed on revisualization under ICG fluorescence. The present case demonstrated that open-abdomen management and repeat visualization under ICG fluorescence are effective in preserving damaged intestine during surgery for NOMI.


Non-occlusive mesenteric ischemia Indocyanine green fluorescence Open-abdomen management 


Compliance with ethical standards

Conflict of interest

Toshiyuki Irie, Takeshi Matsutani, Nobutoshi Hagiwara, Tsutomu Nomura, Itsuo Fujita, Yoshikazu Kanazawa, Daisuke Kakinuma and Eiji Uchida declare that they have no conflict interest.

Human rights

All procedures followed have been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.

Informed consent

Informed consent was obtained from all patients for being included in the study.

Supplementary material

Online resource 1: Video taken with a near-infrared camera system (pde-neo Photodynamic Eye; Hamamatsu Photonics K.K., Hamamatsu, Japan). After intravenous injection of 0.2 mg/kg of indocyanine green (ICG), blood flow in the small-bowel wall and mesentery is evaluated with ICG-fluorescence imaging (WMV 2890 kb)


  1. 1.
    Groesdonk HV, Klingele M, Schlempp S, et al. Risk factors for nonocclusive mesenteric ischemia after elective cardiac surgery. J Thorac Cardiovasc Surg. 2013;145:1603–10.CrossRefPubMedGoogle Scholar
  2. 2.
    Mazzei MA, Volterrani L. Nonocclusive mesenteric ischaemia: think about it. Radiol Med. 2015;120:85–95.CrossRefPubMedGoogle Scholar
  3. 3.
    Trompeter M, Brazda T, Remy CT, et al. Non-occlusive mesenteric ischemia: etiology, diagnosis, and interventional therapy. Eur Radiol. 2002;12:1179–87.CrossRefPubMedGoogle Scholar
  4. 4.
    Ward D, Vernava AM, Kaminski DL, et al. Improved outcome by identification of high-risk nonocclusive mesenteric ischemia, aggressive reexploration, and delayed anastomosis. Am J Surg. 1995;170:577–80.CrossRefPubMedGoogle Scholar
  5. 5.
    Ende N. Infarction of the bowel in cardiac failure. N Engl J Med. 1958;258:879–81.CrossRefPubMedGoogle Scholar
  6. 6.
    Dhoble A, Patel K, Khasnis A. Non-occlusive mesenteric ischemia leading to ‘pneumatosis intestinalis’: a series of unfortunate hemodynamic events. Cases J. 2008;1:60. doi: 10.1186/1757-1626-1-60.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Milone M, Di Minno MN, Musella M, et al. Computed tomography findings of pneumatosis and portomesenteric venous gas in acute bowel ischemia. World J Gastroenterol. 2013;19:6579–84.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Sheridan WG, Lowndes RH, Williams GT, et al. Determination of a critical level of tissue oxygenation in acute intestinal ischaemia. Gut. 1992;33:762–6.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Handa T, Katare RG, Nishimori H, et al. New device for intraoperative graft assessment: HyperEye charge-coupled device camera system. Gen Thorac Cardiovasc Surg. 2010;58:68–77.CrossRefPubMedGoogle Scholar
  10. 10.
    Kamp MA, Slotty P, Turowski B, et al. Microscope-integrated quantitative analysis of intraoperative indocyanine green fluorescence angiography for blood flow assessment: first experience in 30 patients. Neurosurgery. 2012;70:65–73.PubMedGoogle Scholar
  11. 11.
    Yamamoto M, Sasaguri S, Sato T. Assessing intraoperative blood flow in cardiovascular surgery. Surg Today. 2011;41:1467–74.CrossRefPubMedGoogle Scholar
  12. 12.
    Matsutani T, Hirakata A, Nomura T, et al. Transabdominal approach for chylorrhea after esophagectomy by using fluorescence navigation with indocyanine green. Case Rep Surg. 2014. doi: 10.1155/2014/464017.PubMedPubMedCentralGoogle Scholar
  13. 13.
    Ishizuka M, Nagata H, Takagi K, et al. Usefulness of intraoperative observation using a fluorescence imaging instrument for patients with nonocclusive mesenteric ischemia. Int Surg. 2015;100:593–9.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Nitori N, Deguchi T, Kubota K, et al. Successful treatment of non-occlusive mesenteric ischemia (NOMI) using the HyperEye Medical System for intraoperative visualization of the mesenteric and bowel circulation: report of a case. Surg Today. 2014;44:359–62.CrossRefPubMedGoogle Scholar
  15. 15.
    American Gastroenterological Association Medical Position Statement: guidelines on intestinal ischemia. Gastroenterology. 2000; 118: 951–3.Google Scholar
  16. 16.
    Anadol AZ, Ersoy E, Taneri F, et al. Laparoscopic “second-look” in the management of mesenteric ischemia. Surg Laparosc Endosc Percutan Tech. 2004;14:191–3.CrossRefPubMedGoogle Scholar
  17. 17.
    Kreis BE, de Mol van Otterloo AJ, Kreis RW. Open abdomen management: a review of its history and a proposed management algorithm. Med Sci Monit. 2013;19:524–33.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Japanese Society of Gastroenterology 2017

Authors and Affiliations

  • Toshiyuki Irie
    • 1
  • Takeshi Matsutani
    • 1
    Email author
  • Nobutoshi Hagiwara
    • 1
  • Tsutomu Nomura
    • 1
  • Itsuo Fujita
    • 1
  • Yoshikazu Kanazawa
    • 1
  • Daisuke Kakinuma
    • 1
  • Eiji Uchida
    • 1
  1. 1.Department of Gastrointestinal Hepato-Biliary-Pancreatic SurgeryNippon Medical SchoolTokyoJapan

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