Superior Mesenteric Arterial Occlusion Following Laparoscopic Partial Fundoplication

A 62-year-old male with history and endoscopic findings consistent with gastroesophageal reflux underwent elective laparoscopic fundoplication. He developed severe abdominal pain four days postoperatively, and computed tomography (CT) angiogram of the abdomen demonstrated occlusion of the superior mesenteric artery due to dissection. The patient was administered intravenous heparin following vascular surgical advice, resulting in resolution of the pain within an hour and no subsequent complications. Laparoscopy-associated mesenteric vascular events are rare but associated with very high morbidity and mortality. Mesenteric arterial occlusion is most frequently reported following laparoscopic cholecystectomy but may occur following many common laparoscopic procedures. Presentation generally occurs hours to days following the procedure, with severe abdominal pain out of proportion with physical signs. If left unrecognized, patients progress to bowel and visceral ischemia, necrosis, and multiorgan failure. Mechanisms postulated to cause these mesenteric vascular events involve changes in splanchnic blood flow, reduced cardiac output and systemic venous return, and hypercapnia related to carbon dioxide insufflation. Diagnosis may be made promptly with CT angiography, and potentially treated with intravenous heparin alone, avoiding a laparotomy or bowel resection. This is the first reported case of successful anticoagulation causing resolution of the occlusion sufficient to avoid reoperation or bowel resection. Once identified, this condition should be treated in liaison with vascular surgery colleagues, which may require anticoagulation, endovascular, or open intervention.