Treatment Of Nonocclusive Mesenteric Ischemia Research Articles

Successful treatment of nonocclusive mesenteric ischemia in a reconstructed jejunum after esophagectomy and remnant gastric tube resection: a case report

BackgroundNonocclusive mesenteric ischemia (NOMI), an ischemic bowel disease without a disruption of the mesenteric blood flow or strangulation of the mesentery or intestine, may cause a lethal clinical course. We report a very rare case of jejunal necrosis caused by NOMI in the pedicled mesentery of the reconstructed jejunum after remnant gastric tube resection for heterochronous gastric tube cancer after esophagectomy.Case presentationAn 80-year-old man visited our department with chief complaints of fever and appetite loss after 4 months from gastric tube resection and digestive reconstruction with pedicled jejunum. Contrast-enhanced computed tomography (CT) revealed impaired blood flow without torsion of the mesentery, severe wall thickness, and micro-penetration in the reconstructed jejunum and combined pyothorax in the right thoracic cavity. Esophagogastroduodenoscopy demonstrated extensive mucosal necrosis confined to the jejunum, which was elevated in the thoracic cavity. The jejunal necrosis due to NOMI occurring in the reconstructed jejunum was suspected, and lifesaving small bowel resection with right thoracotomy was considered necessary. However, radical operation with right thoracotomy was considered to be excessively invasive and not valid due to the patient’s poor physical status, advanced age, and presence of left adrenal metastasis from the remnant gastric cancer. Therefore, we selected the conservative treatment with fasting, transnasal drainage, and administration of antibiotics due to the patient’s intention. CT-guided right thoracic drainage for the intrathoracic abscess was needed 10 days after starting treatment and the inflammatory response rapidly improved. Follow-up CT and esophagogastroduodenoscopy revealed the improvement in the ischemic changes in jejunal mucosa without perforation. Intake was initiated at 20 days after symptom onset, and the patient was discharged at 40 hospital days without any complications and sequelae.ConclusionsTo the best of our knowledge, this is the first case of NOMI occurring in the reconstructed jejunum after remnant gastric tube resection that was successfully treated with a conservative treatment. For NOMI, it is important to make appropriate diagnosis based on imaging findings and perform proper assessment of the patient’s condition. Conservative treatments may be also useful depending on the patient’s condition.

Nonocclusive mesenteric ischemia associated with postoperative jejunal tube feeding: Indicators for clinical management.

Postoperative nutrition via a jejunal tube after major abdominal surgery is usually well tolerated. However, some patients develop nonocclusive mesenteric ischemia (NOMI). This morbid complication has a grave prognosis with a mortality rate of 41% to 100%. Early symptoms are nonspecific, and no treatment guideline is available. We reviewed cases of NOMI at our institution and cases described in the literature to identify factors that impact the clinical course. Among five patients, three had no necrosis and one had segmental necrosis and perforation. These patients recovered with limited resection and decompression of the bowel and abdominal compartment. In one patient with extended bowel necrosis at the time of re-laparotomy, NOMI progressed and the patient died of multiple organ failure. The extent of small bowel necrosis at the time of re-laparotomy is a relevant prognostic factor. Therefore, early diagnosis and treatment of NOMI can improve the prognosis. Clinical symptoms of abdominal distension, cramps and high reflux plus paraclinical signs of leukocytosis, hypotension and computed tomography findings of a distended small bowel with pneumatosis intestinalis and portal venous gas can help to establish the diagnosis. We herein introduce an algorithm for the diagnosis and management of NOMI associated with jejunal tube feeding.

Treatment of nonocclusive mesenteric ischemia with type B aortic dissection using intra-arterial catheterization after trauma surgery: case report

BackgroundNonocclusive mesenteric ischemia (NOMI) is a mesenteric arterial spasm and intestinal ischemia. This disease is a highly lethal disease because diagnosis and decision of appropriate treatments are often difficult. Operations cannot resolve the spasms and may worsen the situation. However, the safety and effectiveness of catheterization for NOMI with aortic dissection (AD) have not yet been elucidated. Here, we report a successful case of early diagnosis and treatment of NOMI with type B AD involving the superior mesenteric artery (SMA) using the intra-arterial infusion of a vasodilator via the SMA.Case presentationAn 83-year-old man was admitted to our hospital because of abdominal pain after a motor accident. We performed intestinal resection and splenectomy for intestinal perforation and splenic hemorrhage and treated conservatively for acute AD, liver injury, renal hematoma, and pneumothorax. On postoperative day (POD) 2, the patient had localized abdominal pain. Follow-up computed tomography suggested a smaller superior mesenteric vein sign and segmental lack of enhancement in the intestinal wall and ascites without SMA occlusion. Thus, the patient was diagnosed with NOMI. Although the patient had type B AD including the SMA, we performed selective mesenteric arteriography and transcatheter papaverine infusion via the SMA and prostaglandin via the peripheral vein. Seven days post treatment, mesenteric blood flow improved and intestinal wall enhancement was restored.ConclusionThe intra-arterial infusion of a vasodilator is highly efficient and safety treatment option for NOMI with type B AD. Prompt and accurate management can prevent massive small bowel resection, and this procedure is essential in resolving a spasm independent of whether a necrotic bowel has been resected.

A Case Report of Successful Treatment of Nonocclusive Mesenteric Ischemia after Aortic Dissection Repair

A Case Report of Successful Treatment of Nonocclusive Mesenteric Ischemia after Aortic Dissection Repair

Intraoperative Indocyanine Green Fluorescence Angiography for Diagnosis of Nonocclusive Mesenteric Ischemia: A Case Report

Nonocclusive mesenteric ischemia (NOMI) has a very poor prognosis. It is often difficult to determine the extent to which the necrotic intestine should be resected. We herein report a case in which indocyanine green (ICG) fluorescence angiography was found to be a useful method for diagnosis of NOMI and determination of the extent to which the necrotic intestinal tissue should be resected. A 65-year-old man underwent a second-look operation followed by surgical repair of strangulation of the ileum. A noncontinuous segmental ischemic lesion was detected in the remnant small intestine and cecum. Whether necrotic changes had occurred in the small intestine was difficult to discern. Thus, intraoperative ICG fluorescence angiography was performed with a near-infrared camera system to visualize the blood flow in the intestines and mesentery. ICG fluorescence angiography revealed insufficient blood flow in some parts of the intestine. Based on these findings, ileocecal resection and enterectomy were carried out. Histopathologic examination revealed necrotic changes in all layers of the resected specimens, but no thrombi in the associated blood vessels. The patient received a diagnosis of NOMI based on the findings of intraoperative ICG fluorescence angiography and subsequent histopathologic examination. Intraoperative ICG angiography appears to have the potential to be one of the convenient and useful modalities for the diagnosis and treatment of NOMI.

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

Non-occlusive mesenteric ischemia (NOMI), leading to intestinal gangrene without a demonstrable occlusion in the mesenteric artery, is a rare condition with extremely high mortality. We report a case of NOMI diagnosed preoperatively by computed tomography and treated successfully with surgery, assisted by indocyanine green (ICG) fluorescence in the HyperEye Medical System (HEMS), a new device that can simultaneously detect color and near-infrared rays under room light. This allowed for precise intraoperative evaluation of the mesenteric and bowel circulation. Although the necrotic bowel wall of the distal ileum and the segmental ischemia of the jejunum were visible, the jejunum was finally preserved because perfusion of ICG fluorescence was confirmed. The patient, an 84-year-old man, had an uneventful postoperative course and is alive without critical illness 8 months after surgery. We report this case to demonstrate the potential effectiveness of HEMS during surgery for NOMI.

Fulminant Nonocclusive Mesenteric Ischemia Just after Hip Arthroplasty

Nonocclusive mesenteric ischemia (NOMI) is not a rare clinical entity in intensive medicine, and it can be a consequence of several clinical or surgical situations. This pathology results from reduced intestinal microvascular blood supply associated with an acute inflammatory process, culminating with bowel necrosis. This is a case on a female patient who developed immediate postsurgical NOMI following hip arthroplasty and died. Since diagnosis of this potentially fatal condition remains a dilemma, NOMI should always be considered an eventual postoperative complication in high-risk surgical patients such as elderly individuals with previous history of nicotine abuse, congestive heart failure, and essential hypertension. The present paper highlights the importance of early diagnosis and prompt adequate treatment of NOMI in subjects with diminished cardiac output and severe abdominal pain.

Successful treatment of nonocclusive mesenteric ischemia that developed during the peritransplant period following ABO-incompatible kidney transplantation

Nonocclusive mesenteric ischemia (NOMI) is an infrequent and fatal disorder. We describe a 54-year-old man who developed NOMI during the peritransplant period following ABO-incompatible living-donor kidney transplantation, but who was successfully treated with his renal graft function unimpaired. Abdominal pain appeared on the sixth postoperative day (POD), and emergency surgery was performed on POD 8. Discontinuous segmental necrosis extended throughout the small intestine, and the necrotic segments were entirely removed. He thereafter had ischemia of the ascending colon, which was treated with colectomy, and prostaglandin E1 delivered through the related artery prevented advanced necrosis. Temporary colostomy was closed 20 months after surgery. He maintains excellent graft function at present without secondary disorder. There has been no ABO-incompatible kidney transplant recipient complicated with NOMI. However, patients with end-stage renal disease are at the highest risk for this lethal condition, and physicians and urologists should correctly recognize its diagnostics and therapeutics.

Nonocclusive mesenteric ischemiaの1例

Nonocclusive mesenteric ischemiaの1例

Survival of Three Nonocclusive Mesenteric Ischemia Patients following Early Diagnosis by Multidetector Row Computed Tomography and Prostaglandin E1 Treatment

Nonocclusive mesenteric ischemia (NOMI) is an acute mesenteric circulatory disorder which is characterized by spasm and narrowing of the arterial branches. In contrast to occlusive disease, early diagnosis of NOMI is difficult because of its mild symptoms, thus resulting in a high mortality rate. In this study, we report three cases who survived NOMI because of early diagnosis by multidetector row computed tomography and immediate treatment with prostaglandin E1, which is known to improve blood flow by relaxing vascular smooth muscle. We conclude that early diagnosis and treatment of NOMI with prostaglandin E1 considerably improves the prognosis of this disease.

Survival in Nonocclusive Mesenteric Ischemia

The aim of the study was to establish a procedure for early diagnosis and treatment of nonocclusive mesenteric ischemia (NOMI). NOMI has a high mortality rate, and early diagnosis and treatment are important for improving survival in patients with this condition. The subjects were 22 patients treated at our hospital over 13 years. Diagnostic criteria for NOMI were established based on the first 13 cases. In the 9 more recent cases, we performed abdominal contrast multidetector row computed tomography (MDCT) upon suspicion of NOMI based on these criteria. Imaging allowed definite diagnosis of NOMI, and continuous intravenous high-dose PGE1 administration was initiated immediately after diagnosis (dose, 0.01-0.03 microg/kg per min; mean administration period, 4.8 days). Nine of the first 13 patients died of multiple organ failure associated with multiple intestinal necrosis. These cases suggested that NOMI may develop when 3 of the following 4 criteria are met after cardiovascular surgery or maintenance dialysis in elderly patients: symptoms of the ileus develop slowly from abdominal symptoms, such as an unpleasant abdominal feeling or pain; a requirement for catecholamine treatment; an episode of hypotension; and slow elevation of the serum transaminase level. In the 9 recent cases, definite diagnosis was made from spasm of the principal arteries in arterial volume rendering and curved planar reformation MDCT images. Early treatment with PGE1 prevented acute-stage NOMI in 8 of the 9 cases. Early diagnosis of NOMI is possible using the above criteria and MDCT, and initiation of PGE1 treatment may increase survival in patients with NOMI.

Diagnosis and treatment of nonocclusive mesenteric ischemia after open heart surgery

Background. Acute nonocclusive mesenteric ischemia (NOMI) is a rare but often fatal event after cardiac surgery. Methods. Twenty patients with ongoing ileus after cardiac surgery despite maximal laxative treatment underwent selective mesenteric angiography. In cases of pathological radiographic findings, papaverine was continuously administered via an intraarterial perfusion catheter. Results. Severe NOMI was confirmed in seven patients (mean lactate: 6.9 ± 8.3 mg/dL), mild to moderate findings in another seven (mean lactate: 1.4 ± 1.1 mg/dL). One patient had thromboembolic occlusion of the superior mesenteric artery; five patients demonstrated normal imaging findings. In nine of fourteen patients (64%) treated with papaverine, symptoms improved within hours (defecation occurred after 4–29 hours, mean 13 ± 8.1 hours). No side effects or complications occurred in connection with the papaverine treatment. The clinical condition of five patients deteriorated. Four patients underwent laparotomy with creation of an ileostomy or colostomy, two of whom presented with severe intestinal ischemia and later died. One patient died prior to laparotomy. Conclusions. Selective mesenteric angiography with continuous papaverine administration is a simple, fast, and effective diagnostic and therapeutic tool to reduce the need for laparotomy for symptoms of ileus after open-heart surgery.

Current theories of pathogenesis and treatment of nonocclusive mesenteric ischemia

Nonocclusive mesenteric ischemia (NOMI) is a poorly understood condition marked by progressive intestinal ischemia leading to infarction, sepsis, and death in a high proportion of patients. The mortality rate for this intestinal disorder remains high, even when the diagnosis is made early in the disease course. This paper presents a comprehensive review of NOMI with a detailed discussion of its history, pathophysiology, diagnosis, and treatment.

Vasodilation, fibrinolysis, and thrombolysis with intraarterial infusion of urokinase in the canine superior mesenteric artery

Urokinase, the plasminogen activator from human urine, produces a dose-dependent increase in blood flow in the canine superior mesenteric artery when injected intraarterially at doses from 10−1 to 103 units kg−1. This vasodilation persists despite blockade of β-adrenergic and histamine H1 and H2 receptors as well as inhibition of plasminogen activation, suggesting that these mechanisms are not involved. Infusion of urokinase at 102 CTA (Committee on Thrombolytic Agents) units kg−1 min−1 does not produce a sustained vasodilation, but is effective in achieving complete lysis of thrombi within 100 min in the superior mesenteric arterial circulation. Increasing the dose slightly to 125 CTA units kg−1 min−1 results in unwanted clotting abnormalities without attaining a vasodilator level. Decreasing the dose to 75 CTA units kg−1 min−1 still results in complete thrombolysis. In contrast to the results in the femoral circulation, the dose required for fibrinolysis-thrombolysis does not overlap with that for vasodilation in the superior mesenteric artery. Nevertheless, these experiments provide some basis for the use of intraarterial urokinase infusion in the treatment of nonocclusive mesenteric ischemia and, perhaps, thrombotic occlusion of the superior mesenteric artery.