TWO CASES OF NONOCCLUSIVE MESENTERIC ISCHEMIA AFTER RADICAL CYSTECTOMY

Abstract

Case 1. A 72-year-old man with invasive bladder tumors underwent radical cystectomy and ileal conduit urinary diversion. History was significant for hypertension and ventricular premature contraction. Since intraoperative microscopic examination by frozen section revealed cancer tissue at the proximal stumps of the bilateral lower ureters, further resection and pathological evaluation of the ureters were repeated several times until the proximal ureters became cancer-free. During the transection of Santorini's venous plexus there was massive bleeding, and it was difficult to achieve hemostasis. Notably the ileocolic artery was narrow when we visualized the terminal ileum to isolate the ileal conduit segment. Because of right incomplete ureteral duplication, 3 ureteroileal anastomoses were required. Thus, blood loss and operative time were 4,485 ml. and 610 minutes, respectively. Although we observed transient hypotension and elevation of arterial carbon dioxide tension as well as fractional concentration of end tidal carbon dioxide intraoperatively, carbon dioxide values returned to normal without any treatment in approximately 75 minutes. Severe abdominal pain continued after surgery, and shock developed abruptly on the following day. Because the putrefactive smell of the peritoneal drainage suggested intestinal gangrene, emergency laparotomy was performed. The whole intestine was gangrenous except for the duodenum, 7 cm. of proximal jejunum and rectum. However, the superior and inferior mesenteric pulses were palpable. The gangrenous intestine was completely resected and jejunostomy was performed. On postoperative day 3 the patient died of multiple organ failure. Histopathological examination revealed massive necrosis of the intestine but no evidence of thrombosis, embolism, vasculitis or stenosis in the mesenteric artery or vein. This case was diagnosed as nonocclusive mesenteric ischemia based on the operative and histopathological findings. Case 2. A 67-year-old man with invasive bladder tumors underwent complete cystectomy after 2 courses of neoadjuvant chemotherapy. Each course consisted of 100 mg./m.' methotrexate on days 1 and 7, 600 mg./m.' 5-fluorouracil on days 1 and 7,40 mg./m.' epirubicin on day 2 and 100 mg./m.* cisplatin on day 2. There were no problems during or immediately after the administration of the drugs. Because of a history of appendectomy, gastrectomy, cholecystectomy, right inguinal herniorrhaphy and adhesiotomy for ileus, bilateral cutaneous ureterostomy was elected as urinary diversion to avoid postoperative intraperitoneal complications.