Abstract
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.
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Toshiyuki Irie, Takeshi Matsutani, Nobutoshi Hagiwara, Tsutomu Nomura, Itsuo Fujita, Yoshikazu Kanazawa, Daisuke Kakinuma and Eiji Uchida declare that they have no conflict interest.
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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)
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Irie, T., Matsutani, T., Hagiwara, N. et al. Successful treatment of non-occlusive mesenteric ischemia with indocyanine green fluorescence and open-abdomen management. Clin J Gastroenterol 10, 514–518 (2017). https://doi.org/10.1007/s12328-017-0779-3
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DOI: https://doi.org/10.1007/s12328-017-0779-3