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Management of small bowel volvulus in a patient with simultaneous pancreas-kidney transplantation (SPKT): a case report.

Aydin U, Yazici P, Toz H, Hoscoskun C, Coker A - J Med Case Rep (2007)

Bottom Line: Thus, surgical treatment was successfully employed to solve the problem without any resection procedure.The patient's postoperative follow-up was uneventful and she was discharged from hospital on postoperative day 7.According to our clinical viewpoint, this study emphasizes that if there is even just a suspicion of acute abdominal problem in a patient with SPKT, surgical intervention should be promptly performed to avoid any irreversible result and to achieve a positive outcome.

View Article: PubMed Central - HTML - PubMed

Affiliation: Ege University School of Medicine, Organ Transplantation and Research Center, Izmir, Turkey. drpinaryazici@gmail.com.

ABSTRACT
There are several surgical complications which can occur following simultaneous pancreas-kidney transplantation (SPKT). Although intestinal obstruction is known to be a common complication after any type of abdominal surgery, the occurrence of small bowel volvulus, which is one of the rare causes of intestinal obstruction, following SPKT has not been published before. A 24-year-old woman suffering from type I diabetes mellitus with complications of nephropathy resulting in end stage renal disease (ESRD), neuropathy and retinopathy underwent SPKT. On the postoperative month 5, she was brought to the emergency service due to abdominal distention with mild abdominal pain. After laboratory research and diagnostic radiological tests had been carried out, she underwent exploratory laparotomy to determine the pathology for acute abdominal symptoms. Intra-operative observation revealed the presence of an almost totally ischemic small bowel which had occurred due to clockwise rotation of the mesentery. Initially, simple derotation was performed to avoid intestinal resection because of her risky condition, particularly for short bowel syndrome, and subsequent intestinal response was favorable. Thus, surgical treatment was successfully employed to solve the problem without any resection procedure. The patient's postoperative follow-up was uneventful and she was discharged from hospital on postoperative day 7. According to our clinical viewpoint, this study emphasizes that if there is even just a suspicion of acute abdominal problem in a patient with SPKT, surgical intervention should be promptly performed to avoid any irreversible result and to achieve a positive outcome.

No MeSH data available.


Related in: MedlinePlus

View of the small intestine with a good blood supply, after derotation procedure.
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Figure 2: View of the small intestine with a good blood supply, after derotation procedure.

Mentions: A 24-year-old female with a 14-year history of type I diabetes mellitus that was complicated by nephropathy, neuropathy, and retinopathy underwent SPKT at Ege University School of Medicine's Organ Transplantation Center. In the fifth postoperative month, she was admitted to the hospital with progressive abdominal distension and mild pain. The patient's prior surgical history indicated that her pancreas was located in the retroperitoneal region in the right iliac fossa and her kidney was located to the left. After Y graft interpositioning was performed between the splenic and superior mesenteric artery of the pancreatic graft on the back-table, anastomosis was performed on the right external iliac artery. The portal vein of the graft was end-to-side anastomosed to the recipient external iliac vein. The duodenal part of the graft, which was transected on both sides with circular stapler, was side-to-side anastomosed to the recipient jejunum 30 cm distal to the Treitz ligament (Figure 1a). After completing the transplant of the pancreas, the kidney transplant was performed on the left side. Although both grafts functioned adequately in the early postoperative period, the patient had an acute abdominal episode occurring with mild abdominal pain, distension, nausea and vomiting on the fifth postoperative month. The physical symptoms included tachycardia (120–130 beats/min) and low blood pressure of 90/45 mmHg. Other findings included tenderness, decreased bowel sounds and abdominal distension, which was particularly located in the periumbilical region with palpable, dilated intestines. Laboratory findings indicated leucocytosis (17.9 × 103/mm3), high serum lactate dehydrogenase (852 U/L) and high D-dimer (532 mcg/L) levels. A plain upright radiography of the abdomen was found to be non-specific. Abdominal ultrasonography indicating dilatation and edema of the small intestine, and abdominal tomography were then performed. Both revealed minor intestinal dilatation without determining the primary cause. Seventeen hours after admission to the hospital, we performed exploratory laparotomy. During the operation, we observed that almost the entire small intestine was gangrenous, but only 40 cm at the proximal part had adequate blood supply. The distal segment of the small intestine seemed to be ischemic due to clockwise rotation of the mesentery (Figure 1b–c–d). We therefore performed counter-clockwise rotation of the torsioned intestinal segment in order to restore the original anatomic position. After identifying and solving the primary problem, the temperature of both the abdominal region and the ischemic small intestine were kept at a level of 37°C by wrapping them with warm swabs. The whole serosal surface of the intestine was also packed with warm, wet gauze pads. In addition, papaverine was directly applied to the ischemic intestinal segment. After waiting for almost thirty seconds in this position, reexamination revealed excellent blood supply to the small intestine (Figure 2). Because resectional surgery posed a risk of the development of short bowel syndrome for this case, the operation was completed without any additional intervention. After it was determined that laboratory results continued at normal levels, that there was enough oxygenation in the arterial blood gases and that bowel function was normal, the patient was discharged on the postoperative day 7 without any complications. Her follow-up period was arranged according to a checkup schedule for SPKT procedures. The patient has been well for almost one year and no recurrence has been observed.


Management of small bowel volvulus in a patient with simultaneous pancreas-kidney transplantation (SPKT): a case report.

Aydin U, Yazici P, Toz H, Hoscoskun C, Coker A - J Med Case Rep (2007)

View of the small intestine with a good blood supply, after derotation procedure.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2117004&req=5

Figure 2: View of the small intestine with a good blood supply, after derotation procedure.
Mentions: A 24-year-old female with a 14-year history of type I diabetes mellitus that was complicated by nephropathy, neuropathy, and retinopathy underwent SPKT at Ege University School of Medicine's Organ Transplantation Center. In the fifth postoperative month, she was admitted to the hospital with progressive abdominal distension and mild pain. The patient's prior surgical history indicated that her pancreas was located in the retroperitoneal region in the right iliac fossa and her kidney was located to the left. After Y graft interpositioning was performed between the splenic and superior mesenteric artery of the pancreatic graft on the back-table, anastomosis was performed on the right external iliac artery. The portal vein of the graft was end-to-side anastomosed to the recipient external iliac vein. The duodenal part of the graft, which was transected on both sides with circular stapler, was side-to-side anastomosed to the recipient jejunum 30 cm distal to the Treitz ligament (Figure 1a). After completing the transplant of the pancreas, the kidney transplant was performed on the left side. Although both grafts functioned adequately in the early postoperative period, the patient had an acute abdominal episode occurring with mild abdominal pain, distension, nausea and vomiting on the fifth postoperative month. The physical symptoms included tachycardia (120–130 beats/min) and low blood pressure of 90/45 mmHg. Other findings included tenderness, decreased bowel sounds and abdominal distension, which was particularly located in the periumbilical region with palpable, dilated intestines. Laboratory findings indicated leucocytosis (17.9 × 103/mm3), high serum lactate dehydrogenase (852 U/L) and high D-dimer (532 mcg/L) levels. A plain upright radiography of the abdomen was found to be non-specific. Abdominal ultrasonography indicating dilatation and edema of the small intestine, and abdominal tomography were then performed. Both revealed minor intestinal dilatation without determining the primary cause. Seventeen hours after admission to the hospital, we performed exploratory laparotomy. During the operation, we observed that almost the entire small intestine was gangrenous, but only 40 cm at the proximal part had adequate blood supply. The distal segment of the small intestine seemed to be ischemic due to clockwise rotation of the mesentery (Figure 1b–c–d). We therefore performed counter-clockwise rotation of the torsioned intestinal segment in order to restore the original anatomic position. After identifying and solving the primary problem, the temperature of both the abdominal region and the ischemic small intestine were kept at a level of 37°C by wrapping them with warm swabs. The whole serosal surface of the intestine was also packed with warm, wet gauze pads. In addition, papaverine was directly applied to the ischemic intestinal segment. After waiting for almost thirty seconds in this position, reexamination revealed excellent blood supply to the small intestine (Figure 2). Because resectional surgery posed a risk of the development of short bowel syndrome for this case, the operation was completed without any additional intervention. After it was determined that laboratory results continued at normal levels, that there was enough oxygenation in the arterial blood gases and that bowel function was normal, the patient was discharged on the postoperative day 7 without any complications. Her follow-up period was arranged according to a checkup schedule for SPKT procedures. The patient has been well for almost one year and no recurrence has been observed.

Bottom Line: Thus, surgical treatment was successfully employed to solve the problem without any resection procedure.The patient's postoperative follow-up was uneventful and she was discharged from hospital on postoperative day 7.According to our clinical viewpoint, this study emphasizes that if there is even just a suspicion of acute abdominal problem in a patient with SPKT, surgical intervention should be promptly performed to avoid any irreversible result and to achieve a positive outcome.

View Article: PubMed Central - HTML - PubMed

Affiliation: Ege University School of Medicine, Organ Transplantation and Research Center, Izmir, Turkey. drpinaryazici@gmail.com.

ABSTRACT
There are several surgical complications which can occur following simultaneous pancreas-kidney transplantation (SPKT). Although intestinal obstruction is known to be a common complication after any type of abdominal surgery, the occurrence of small bowel volvulus, which is one of the rare causes of intestinal obstruction, following SPKT has not been published before. A 24-year-old woman suffering from type I diabetes mellitus with complications of nephropathy resulting in end stage renal disease (ESRD), neuropathy and retinopathy underwent SPKT. On the postoperative month 5, she was brought to the emergency service due to abdominal distention with mild abdominal pain. After laboratory research and diagnostic radiological tests had been carried out, she underwent exploratory laparotomy to determine the pathology for acute abdominal symptoms. Intra-operative observation revealed the presence of an almost totally ischemic small bowel which had occurred due to clockwise rotation of the mesentery. Initially, simple derotation was performed to avoid intestinal resection because of her risky condition, particularly for short bowel syndrome, and subsequent intestinal response was favorable. Thus, surgical treatment was successfully employed to solve the problem without any resection procedure. The patient's postoperative follow-up was uneventful and she was discharged from hospital on postoperative day 7. According to our clinical viewpoint, this study emphasizes that if there is even just a suspicion of acute abdominal problem in a patient with SPKT, surgical intervention should be promptly performed to avoid any irreversible result and to achieve a positive outcome.

No MeSH data available.


Related in: MedlinePlus