A Novel Technique of SMA Massage with Systemic Fibrinolytic Therapy in Ischemic Midgut Volvulus

Abstract

Purpose: Midgut volvulus is a surgical emergency requiring immediate intervention. Intestinal ischemia of the midgut as a consequence of volvulus from malrotation is a fateful event with high mortality and significant morbidity even in survivors. Derotation followed by correction of malrotation is the procedure of choice though has significant morbidity if intestinal reperfusion was not successful. A combined treatment to restore intestinal perfusion based on the digital massage of the superior mesenteric artery after derotation and systemic infusion of fibrinolytic has been previously reported with success but underused. Here, we report three such cases of midgut malrotation with severe intestinal ischemia due to volvulus. Materials and Methods: A retrospective analysis of three confirmed cases of midgut malrotation with volvulus managed with emergency laparotomy, derotation, and Superior Mesenteric Artery (SMA) massage with systemic fibrinolytic therapy, followed by correction of malrotation was evaluated. Results: There was dramatic improvement in intestinal perfusion noted in all three patients inspite of delayed presentation. 2 out of 3 patients on follow up are doing well with adequate weight gain while 1 patient succumbed due to sepsis. Conclusion: Critical intestinal ischemia due to mesenteric thrombosis can persist after derotation of midgut volvulus and can lead to devastating consequences. The use of digital massage of SMA to disrupt the thrombus along with fibrinolytic therapy though reported is underutilized. Hence, awareness of this management and usage needs to be re-emphasized.