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Table of Contents
CASE REPORT
Year : 2018  |  Volume : 15  |  Issue : 2  |  Page : 99-101

Superior mesenteric artery thrombosis: A rare complication after pancreaticoduodenectomy


Department of Surgical Gastroenterology, Indraprastha Apollo Hospital, New Delhi, India

Date of Web Publication5-Jul-2018

Correspondence Address:
G K Adithya
Department of Surgical Gastroenterology, Indraprastha Apollo Hospital, New Delhi - 110 076
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_11_18

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  Abstract 

Pancreaticoduodenectomy (PD) is the treatment of choice for malignant and some benign diseases of the pancreas and periampullary region. Common complications after PD include delayed gastric emptying, pancreatic fistula, anastomotic leak, and intra-abdominal collection. Postoperative medical complications include arrhythmia, renal failure, pulmonary complications, urinary tract infection, and deep vein thrombosis. Superior mesenteric artery (SMA) thrombosis is rarely been reported after PD. SMA thrombosis is difficult to diagnose in postoperative period due to nonspecific symptoms and associated with high mortality rate up to 80%–90%. The patient was a 68-year-old female with lower end cholangiocarcinoma without any other comorbidity. She underwent PD without any intraoperative complications. Postoperatively, she developed SMA thrombosis. Unfortunately, the patient could not be salvaged, and she succumbs to death.

Keywords: Cholangiocarcinoma, pancreaticoduodenectomy, superior mesenteric artery thrombosis


How to cite this article:
Jindal S, Adithya G K, Madaan V, Tandon V, Govil D. Superior mesenteric artery thrombosis: A rare complication after pancreaticoduodenectomy. Apollo Med 2018;15:99-101

How to cite this URL:
Jindal S, Adithya G K, Madaan V, Tandon V, Govil D. Superior mesenteric artery thrombosis: A rare complication after pancreaticoduodenectomy. Apollo Med [serial online] 2018 [cited 2022 May 22];15:99-101. Available from: https://www.apollomedicine.org/text.asp?2018/15/2/99/235990


  Introduction Top


Pancreaticoduodenectomy (PD) is the treatment of choice for malignant lesions of the pancreas and periampullary region. PD consists of multivisceral dissection and associated with high morbidity. Common complications associated with this morbid procedure include delayed gastric emptying, pancreatic fistula, anastomotic leak and intra-abdominal collection. Other medical complications include arrhythmia, renal failure, pulmonary complications, urinary tract infection, and deep vein thrombosis. Here, we present a case of superior mesenteric artery (SMA) thrombosis after PD done for lower end cholangiocarcinoma, which has ever been reported in literature.


  Case Report Top


A 68-year-old female presented with obstructive jaundice, anorexia, and weight loss for 2 months. She was diagnosed with lower-end cholangiocarcinoma. She had no other comorbidity with Eastern Cooperative Oncology Group 1. Her serum bilirubin was 30 mg/dl, and CA19.9 level was 418.5. Preoperative imaging was consistent with cholangiocarcinoma without any evidence of vascular pathology [Figure 1]. Preoperative biliary drainage was done, and the patient was optimized for surgery. She underwent classic PD with feeding jejunostomy. Intraoperatively, the lesion was well localized to periampullary region, and there was no evidence of any vascular involvement. The patient tolerated the procedure well without any intraoperative complication.
Figure 1: Preoperative contrast-enhanced computed tomography abdomen (arrow) indicate normal flow into superior mesenteric artery

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Thromboprophylaxis was given in perioperative period with low molecular weight heparins and pneumatic pump. She was started on enteral feeding by feeding jejunostomy on the 4th postoperative day (POD), which she tolerated well. Her initial postoperative course was smooth, but she developed drowsiness on POD-8. Besides that, she was hemodynamically stable, and her biochemical parameters were normal. In view of persistent drowsiness, neurological evaluation was done including computed tomography (CT) scan of the head, which revealed no abnormality. On the next day, she became progressively unresponsive and developed abdominal distension. She had gastrointestinal bleed, which precipitates as melana and hemorrhagic aspirate from nasogastric tube. CT abdomen was done which revealed SMA thrombosis [Figure 2] without any evidence of bowel gangrene. In view of the poor general condition, she was managed conservatively with anticoagulative therapy. However, the patient progressively deteriorated and succumbs to death within 24 h. We retrospectively evaluated for any predisposing factor for vascular thrombosis but were unable to find any obvious cause for SMA thrombosis in this patient.
Figure 2: Postoperative CT contrast-enhanced computed tomography abdomen showing superior mesenteric artery thrombosis (arrow) indicates superior mesenteric artery

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  Discussion Top


PD is recommended treatment for malignant diseases of periampullary region. In the past decades, postoperative mortality rates up to 40% have been reported for this morbid procedure, but after improvement of technical and perioperative care, this has been reduced to <5% in high-volume centers.[1] Despite these advances, morbidity still remains high, with reported complication rate of 30%–60%. The majority of perioperative complications after PD are not life-threatening although they result in prolonged hospital stay and readmissions.[2] The most common complication reported is delayed gastric emptying, seen in 30%–35% of cases. Other associated surgical complications are anastomotic failure, among which pancreaticoenteric anastomotic leak is most common followed by gastrojejunostomy and choledoco/hepaticojejunostomy. Other nonsurgical complications in these patients consisted of cardiac complications such as cardiac arrhythmias, pneumonia, hemorrhage, and renal failure. Other reported complications after PD are pulmonary embolism, myocardial infarction, and splanchnic vein thrombosis.[3]

Portal vein and superior mesenteric vein thrombosis has been reported after PD in literature. As increased experience with vascular resection and reconstruction during PD for borderline resectable tumors, there is an increasing trend toward these complications. SMA thrombosis as a complication of PD is rarely been reported in literature. Although there is theoretical risk of SMA thrombosis after SMA reconstruction, there is paucity of data on this complication. Arterial thrombosis can be precipitated due to postoperative hypovolemia in patients with preexisting atherosclerosis. The patient underwent classical PD without any vascular intervention or intraoperative complication. Preoperatively, the patient was otherwise fit without any comorbidity and initial postoperative period was smooth. There was no evidence of any vascular disease including atherosclerosis in this patient.

SMA thrombosis is characterized by a high mortality rate. Although relatively less commonly seen in clinical practice, SMA thrombosis is the most common cause of acute mesenteric ischemia. Thrombosis in SMA most commonly occurs at the level of ostia and results in ischemia of the entire midgut, which consequently leads to infarction if left untreated. Prognosis of acute thrombotic ischemia is worse even after restoration of mesenteric blood supply.[4]

Patients with SMA thrombosis share the common features associated with atherosclerotic disease such as hypertension, hyperlipidemia, diabetes, and smoking. These patients often have a history of other vascular event such as myocardial infarction, stroke or peripheral vascular disease.[5] Acute SMA thrombosis commonly occurs in a patient of chronic mesenteric ischemia and frequently precipitated by intravascular volume depletion from dehydration. This dehydration can occur after severe diarrhea or vomiting associated with gastrointestinal diseases, postoperative fluid losses, and sepsis or due to third space fluid loss, such as acute pancreatitis. Clinical symptoms of SMA thrombosis are nonspecific, which can lead to delay in diagnosis. Patients often present with severe abdominal pain that is out of proportional to clinical finding.[6]

A high index of suspicion is required to the diagnosis of SMA thrombosis. Angiography is considered as the “gold standard” for diagnosing mesenteric vascular occlusion. However, nowadays, multidetector CT (MDCT) angiography has become investigation of choice with high specificity. In a recent meta-analysis, MDCT angiography had a sensitivity and specificity of 93.3% and 95.9%, respectively.[7] An aggressive approach to resuscitation and hemodynamic monitoring is strongly encouraged in these patients. Intra-arterial administration of thrombolytic agents has effectively restored mesenteric blood flow in selected patients when administered within hours of symptom onset. The goals of surgical therapy are to restore mesenteric blood flow, assess intestinal viability, and resect nonviable or necrotic intestine. Endarterectomy or antegrade bypass using a prosthetic conduit are the revascularization procedures of choice in the absence of enteric contamination. Endovascular treatments, such as thrombolysis, are generally avoided owing to the urgent need to restore intestinal perfusion and prevent intestinal infarction.[8]

SMA thrombosis is associated with high mortality, and earlier studies reported mortality rate up to 80%–90%. Conservative treatment results in a mortality of 100% with rare exceptions. In patients treated with bowel resection, short-term survival can be achieved in 49% of the cases. Despite advances in surgical and diagnostic management, literature reported a short-term mortality rate of 30%–60% in patients undergoing revascularization of the SMA.[9]


  Conclusion Top


PD is a morbid procedure and associated with some known complications. However, SMA thrombosis is a rare complication after PD. These patients often have unusual presentation, so high suspicion is required, and early diagnostic intervention including radiological imaging are recommended for any deviation from normal postoperative course. SMA thrombosis is associated with high mortality, and these patients are difficult to salvage.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
van Heek NT, Kuhlmann KF, Scholten RJ, de Castro SM, Busch OR, van Gulik TM, et al. Hospital volume and mortality after pancreatic resection: A systematic review and an evaluation of intervention in the Netherlands. Ann Surg 2005;242:781-8.  Back to cited text no. 1
    
2.
Lin JW, Cameron JL, Yeo CJ, Riall TS, Lillemoe KD. Risk factors and outcomes in postpancreaticoduodenectomy pancreaticocutaneous fistula. J Gastrointest Surg 2004;8:951-9.  Back to cited text no. 2
    
3.
Saraee A, Vahedian-Ardakani J, Saraee E, Pakzad R, Wadji MB. Whipple procedure: A review of a 7-year clinical experience in a referral center for hepatobiliary and pancreas diseases. World J Surg Oncol 2015;13:98.  Back to cited text no. 3
    
4.
Schoots IG, Koffeman GI, Legemate DA, Levi M, van Gulik TM. Systematic review of survival after acute mesenteric ischaemia according to disease aetiology. Br J Surg 2004;91:17-27.  Back to cited text no. 4
    
5.
Jrvinen O, Laurikka J, Salenius JP, Tarkka M. Acute intestinal ischaemia. A review of 214 cases. Ann Chir Gynaecol 1994;83:22-5.  Back to cited text no. 5
    
6.
Shanley CJ, Weinberger JB. Acute abdominal vascular emergencies. Med Clin North Am 2008;92:627-47, ix.  Back to cited text no. 6
    
7.
Menke J. Diagnostic accuracy of multidetector CT in acute mesenteric ischemia: Systematic review and meta-analysis. Radiology 2010;256:93-101.  Back to cited text no. 7
    
8.
Schoots IG, Levi MM, Reekers JA, Lameris JS, van Gulik TM. Thrombolytic therapy for acute superior mesenteric artery occlusion. J Vasc Interv Radiol 2005;16:317-29.  Back to cited text no. 8
    
9.
Björck M, Acosta S, Lindberg F, Troëng T, Bergqvist D. Revascularization of the superior mesenteric artery after acute thromboembolic occlusion. Br J Surg 2002;89:923-7.  Back to cited text no. 9
    


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