PMC3038967_01
Preoperative abdominal CT scan demonstrating large mesenteric soft tissue mass (white arrows) encasing the mesenteric vasculature with evident bowel wall and mesenteric edema, along with trace ascites fluid.
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F1
He underwent an unrevealing esophagogastroduodenoscopy (EGD) and colonoscopy, but an abdominal CT scan showed a 4.6 x 2.5 cm mesenteric soft tissue mass encasing the superior mesenteric vein and extending along the mesenteric root to the base of the pancreas (Figure 1).
Pre-operative mesenteric angiogram. Whereas the celiac and inferior mesenteric arteries were patent, cannulation of the superior mesenteric artery shown here reveals severe stenosis or occlusion of multiple SMA branches (black arrows) from extrinsic compression by the carcinoid tumor. Flow to the ileocolic artery is occluded proximally and reconstituted distally from jejunoileal collaterals
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F2
SMA branches such as the ileocolic artery, which was reconstituted distally by jejunoileal collaterals (Figure 2). Staging chest/abdomen/pelvis CT scans showed no evidence of metastatic disease.
A. Initial postoperative anatomy. Both ileocecal and ileojejunal segments of bowel were removed to permit access and resection of the mesenteric carcinoid tumor. The ileojejunal autograft was revascularized by anastomosing the jejunal artery and vein to the residual stumps of the SMA and SMV. The ileocecal segment was revascularized by anastomosing the ileocolic vessels to the abdominal aorta and IVC. The GI tract was reconstructed with a pancreaticojejunostomy, hepaticojejunostomy, gastrojejunostomy and ileoileostomy. B. Final postoperative anatomy. Due to SMA thrombosis, the jejunoileal bowel autograft was lost. The ileocolic segment was explanted and revascularized using the SMA and SMV stumps. GI tract continuity was restored with a pancreaticoileostomy, hepaticoileostomy, gastroileostomy and cecocolostomy
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F3
The descending colon was left stapled off, and a Bardex cecostomy tube was brought out through the skin to temporarily drain the cecum (Figure 3A). Reconstruction was completed by anastomosing the cecum to the descending colon (Figure 3B).