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Guenter Weiss, Hans Lippert and Frank Meyer

Successful Management of Non-Occlusive Mesenteric Ischemia (Nomi) - Case Report

Patients with non-occlusive mesenteric ischemia (NOMI) are still confronted with high mortality. The diagnostic is challenging and difficult because of the unspecific symptomatology. The aim of this systematic scientific report on an extraordinary and uncommon single clinical case and its successful course was to demonstrate the great potential of a partially novel non-surgical approach including its periinterventional management.

A 73-year old female is precisely described, who developed an acute abdomen during the postoperative course after cardiosurgical intervention. Only explorative laparotomy clarified the correct diagnosis - NOMI. Despite general intensive care, patient developed multi-organ failure after this second intervention. Using consequently an image-guided minimally invasive radiological approach comprising the introduction of a catheter into the superior mesenteric artery (Seldinger's technique) and the continuous application of vasodilating medication such as alprostadil (prostaglandin) through this catheter enabled us to improve mesenteric perfusion effectively and to overcome multiorgan failure.

In conclusion, specific risk factors may help to focus on the suspicion of NOMI. Diagnostic of choice is the arterial mesentericography, which allows specifically to exclude vascular occlusion including the consequence of a prompt surgical approach. Simultaneously, using the setting of the mesenteric angiography catheter can be placed for initiation of regional vasodilating treatment in case of NOMI. Only this approach may avoid fatal outcome.

Open access

Guenter Weiss and Frank Meyer

Abstract

An exemplary rare case of neurogenic pulmonary edema induced by intracranial hemorrhage was reported including diagnostic and therapeutic implications as well as management recommendations. A 35-year old man who was treated first by a neurosurgical approach because of a subarachnoid hemorrhage (bore hole trepanation) and subsequently on a surgical intensive care unit because of severe postoperative hemodynamic, cardiocirculatory, and pulmonary disruptions. To monitor cardiopulmonary condition and treatment effects, a Swan-Ganz catheter was placed in the pulmonary artery, since after trepanation, a critical cardiopulmonary status developed during postoperative mechanical ventilation and catecholamine administration. This condition was indicated by neurogenic pulmonary edema detected by control chest X-ray film and high oxygen load in the inspiratory air required for sufficient arterial oxygenation. After use of high positive end-exspiratory pressure (PEEP) (initially directed against neurogenic lesion), adaptation of initial dobutamine doses, initiation of norepinephrine administration, and substitution of fluids, the patient's blood pressure finally rose sufficiently to sustain regular cerebral blood perfusion and achieve better arterial oxygenation. Thus, the patient‘s cardiopulmonary condition stabilized and temporary cardiac insufficiency could be overcome. Subsequently, it became possible to decrease PEEP according to requirements to prevent or limit cerebral edema and to diminish catecholamine doses.

Open access

Guenter Weiss, Cora Wex, Hans Lippert, Jens Schreiber and Frank Meyer

Abstract

Fistula development after esophageal resection is considered as one of the most serious postoperative complications.

The authors reported a case on clinical experiences in the postoperative diagnostic and successful therapeutic management of a tracheomediastinal fistula after esophageal resection, using endoscopic application of fibrin glue.

The early approach of an anastomotic insufficiency after esophageal resection because of a squamous cell carcinoma (pT3pN0M0G2) below the tracheal bifurcation including transposition of a re-modelled gastric tube and end-to-side anastomosis 24 hours postoperatively in a 55-year old patient combined i) surgical re-intervention from the periesophageal site (reanastomosis, gastroplication, lavage, local and mediastinal drainage) and, later on, ii) extensive rinsing with consecutive endoscopic fibrin glue application into the tracheal mouth of the subsequently developed tracheomediastinal fistula as a consequence of the inflammatory changes within the surrounding tissue.

In conclusion, this approach was successful and beneficial for the patient's further postoperative course, which was associated with other complications such as pneumonia and acute myocardial infarction. The fistula closed sufficiently and permanently with no further surgical intervention at the tracheal as well as mediastinal site and allowed patient's later discharge with no further complaints or problems.