Success of microvascular surgery; repair mesenteric injury and prevent short bowel syndrome: a case report
© Aydin et al; licensee BioMed Central Ltd. 2007
Received: 13 November 2006
Accepted: 14 August 2007
Published: 14 August 2007
Superior mesenteric injury is a rare entity but when it occurs, short bowel syndrome is one of the uninvited results of the emergency surgical procedures.
We present a 19-year-old boy with blunt abdominal trauma which caused serious mesenteric injury. Because ultrasound revealed free intraabdominal fluid, he underwent emergency laparotomy. Adequate vascularization of approximately 20 cm of proximal jejunal segment and approximately 20 cm of terminal ileum was observed. Nevertheless, the mesentery of the rest of the small intestine segments was ruptured completely. We performed an end-to-end anastomosis between a distal branch of the superior mesenteric artery in the mesentery of the ileal segment and a branch of the superior mesenteric artery using separate sutures of 7.0 monofilament polypropylene. The patient's gastrointestinal passage returned to normal on the postoperative day 2. He recovered without any complication and was discharged from hospital on the postoperative day seven.
In this case report, we emphasize the importance of preservation of injured mesenteric artery due to abdominal trauma which could have resulted in short bowel syndrome.
Although isolated small bowel or superior mesenteric artery (SMA) injury due to blunt abdominal trauma is quite rare, abdominal trauma is the reason of short bowel syndrome (SBS) in approximately 10% of the patients. Treatment and management of the SBS are difficult. SBS as a result of major intestinal resection due to isolated SMA injury was reported in the literature before. To our knowledge, this is the first case in the literature that the small intestine segment was preserved by arterial anastomosis to prevent SBS in a young patient with blunt abdominal injury. In this case report, we emphasized the importance of preservation of injured mesenteric artery due to abdominal trauma which could have resulted in SBS.
Trauma to the small bowel accounts for less than 1% of all traumas [1–3]. Blunt trauma accounts for 33% of small bowel injuries and penetrating trauma accounts for 67%. Of those sustaining injury to small bowel, 93% require intestinal resection (4). Intestinal resection after traumatic injury may be due to the trauma to the mesenteric vessels and/or the bowel wall itself. Injury to the superior mesenteric artery (SMA) is an uncommon and devastating entity with mortality rates reported as high as 64% . Exsanguinating hemorrhage is the main reason of early deaths. Late deaths usually are occurred secondary to sepsis, multiple organ failure, and the sequelae of ischemic bowel in those who survive their initial surgical procedure and SBS.
The common reasons of SBS in adults are; tumors such as desmoid tumor, ischemia due to thromboembolic events, intussusception or volvulus, Crohn's disease, malabsorption and motility disorders and traumatic injury of the bowel and its blood vessels. In the past, repetitive resections of small intestine in Crohn's disease were the main cause of SBS. As a result of the improvements of conservative and surgical therapy of Crohn's disease, SBS in adult patients now occurs more frequently due to vascular disorders (such as embolism/thrombosis of the superior mesenteric artery/thrombosis of the mesenteric veins) or intestinal strangulation (such as volvulus or incarceration). Rarely, in patients with trauma, extensive bowel resection is indicated. The small bowel has a large functional reserve capacity. Thus, resection of up to 50% of the small bowel is usually tolerated without any symptoms, and in most patients, resection of up to 50–70% leads to transient malabsorption, only. However, a residual length of the small bowel of less than 200 cm may result in SBS in the early postoperative period, and if less than 70–100 cm of small bowel are left almost all patients develop SBS. Moreover, almost all patients with less than 60 cm of small bowel need long-term parenteral nutrition . The resection of the colon is crucial as the overall extension of bowel resection in deciding the severity of the symptoms of the SBS. Moreover, losses of the duodenum or the terminal ileum, particularly the ileocecal valve, impair absorption much more than loss of other parts of the small bowel. The duodenum and the ileocecal region have specific absorptive functions and play a crucial role in the regulation of postprandial gastrointestinal motility and secretion. These functions may not or only partly be replaced by other parts of the small bowel.
The usual mechanism of the mesenteric injury is direct crushing of the small bowel against the vertebral column . Tearing and shearing forces, especially seat belts in car accidents, applied to the abdomen, particularly at points of mesenteric attachment, can also be the mechanism. According to the surgical literature, proximal jejunum and distal ileum are more prone to injury from blunt trauma because of the short mesentery in these areas .
Treatment modalities in short bowel syndrome can be classified as; dietary therapy, medical treatment, total parenteral nutrition, small bowel transplantation. The 5-year survival rate of isolated small bowel transplantation is 45%, and that of combined small bowel and liver transplantation is 37% . Although enteral independency can be achieved in time, in about half of the cases, parenteral nutrition (PN) is indicated for irreversible and chronic intestinal failure [10, 11]. By the usage of parenteral nutrition, long-term survival in patients with SBS can be achieved, but has associated morbidity and high expense. Prevention of this condition remains an important and challenging goal.
Conservative surgical approach to the mesenteric vascular structures and small intestine by using microvascular surgical techniques can help preventing the development of SBS in patients with mesenteric trauma. We preferred the anatomical anastomosis between the branches of the superior mesenteric arcade which were appropriate after preparing the damaged ends. Several choices of grafts, synthetic or autologous, are also possible to maintain the arterial patency. But due to limited time on this emergency operation, we firstly tried reconstruction of the mesenteric artery branches using advantages of easy mobilization of the mesentery. It did work fine and the patency of anastomosis as its original form was proved by angiography control. Thus, we didn't need to use any interpositional graft, which is generally unnecessary for intraabdominal anastomosis unlike extremity injuries. Revitalized small intestine segments by using microsurgery can be crucial in prevention of SBS in the postoperative period in patients with blunt trauma. Saving small intestine segment of 40 cm in our case prevented the SBS and served a better quality of life for the patient.
In conclusion, in appropriate cases, alternative conservative procedures including microvascular surgery should be considered when extensive small bowel resections are required because of mesenteric injury for preventing SBS.
Written consent was obtained from the patient for publication of the patient's details.
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