A case of occlusion of the superior mesenteric artery after total gastrectomy

Abstract

A 58-year-old man with atrial fibrillation and liver cirrhosis was admitted due to abdominal pain. The patient had a total gastrectomy for gastric cancer 1 year prior. Under the diagnosis of a strangulated ileus, an urgent laparotomy was performed 29 hours after the onset of abdominal pain. The operative diagnosis was necrosis of a large portion of the small intestine due to occlusion of the superior mesenteric artery. Though the jejunum which had been reconstructed at the Y arm of the total gastrectomy and the right part of the colon had undergone ischemic change making their resection was judged hazardous. Therefore only a 550-cm length of the necrotic small intestine was excised and the patient had a jejunostomy, an ileal mucous fistula created, and a tube duodenostomy. The preserved small intestine was 50 cm long. Five months after surgery, ischemic stenosis in the lower part of the Y arm had progressed, so that a severe dilatation of the Y arm was present above the stenotic site resulting in repeat episodes of aspiration pneumonia. Therefore, a percutaneous jejunostomy was created endoscopically at the site of the dilated Y arm ; subsequently the patients aspiration pneumonia was well controlled. However, he developed short bowel syndrome and required home intermittent total parenteral nutrition. The patient died 13 months after surgery due to liver failure.