PMC2846357_01
An intraoperative image after dissection of regional lymph nodes. The stump of the SRA is visible (arrow).
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The IMA was tagged and preserved, separating the nervous and lymphatic tissues from the root to a site just peripheral of the confluence of the left colic artery (LCA), then the superior.rectal artery (SRA) was ligated (Figure 1).
(a) A decompression tube was placed for postoperative ileus on day 3 post surgery. (b) Upper endoscopy shows an ulcerative lesion with pulsatile bleeding in the third portion of the duodenum. A marking clip was placed near the ulcer. (c) A computed tomography reveals that the marking clip and the stump of the SRA were very close (arrow).
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Under upper endoscopy, a decompression tube was placed at the upper jejunum 30 cm distal to the ligament of Treitz (Figure 2(a)). Upper endoscopy demonstrated a large amount of fresh blood in the stomach and a longuitudinal ulcerative lesion having a visible pulsative vessel in the base of the third portion of the duodenum (Figure 2(b)). Surprisingly, on arterial-phase CT revealed that the marking clip placed at the third portion of the duodenum was very close to the stump of the SRA (Figure 2(c), arrow).
(a) An emergency angiography shows active bleeding from the stump of the SRA directly communicating with the third portion of the duodenum. (b) A complete embolization with microcoils was performed.
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Emergency angiography revealed active projectile bleeding from the stump of the SRA (Figure 3(a)). The stump of the SRA was in direct communication with the third portion of the duodenum (Figure 3(a), arrow). The stump of the SRA was obliterated using microcoils (TORNADO) between the root of the IMA and the tip of the ligation distal to the LCA (Figure 3(b)).
(a) Upper endoscopy on day 14 post coil embolization reveals neither ulceration nor stenosis of the third portion of the duodenum. (b and c) Computed tomography on day 14 post coil embolization. Intraabdominal abscess formation is not observed around the microcoils (b). The end colostomy was edematous and significantly affected by the obliteration of the left colic artery (c).
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On the 14th day after coil embolization, upper endoscopy revealed only the flexion of the third portion of the duodenum (Figure 4(a)). CT showed no sign of intraabdominal hemorrhage (Figure 4(b)).
A schematic presentation of the mechanism of bleeding in the present case.
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SRA was located approximately 4 cm distal to the base of the IMA (Figure 5(a)). Second, through the excision of the mesocolon, the peritoneum was resected from the infraduodenal portion to the bifurcation of the iliac artery, exposing the anterior aspect of the aorta, resulting in thebroad range of peritoneal defect. Accordingly, the third portion of the duodenum was displaced downward (Figure 5(b)). Therefore, elevation of the end colostomy toward the abdominal wall yielded spasiticity of the mesenteric root of the left colon, including the stump of the SRA, leading to rotation of the stump of the SRA toward the cephalad portion very close to the anterior aspect of the duodenum (Figure 5(c)). We infer that a strong force to the third portion of the duodenum during the insertion of the decompression tube violated the duodenal wall, and the stump of the SRA (Figure 5(d)).