Case report
A 61-year-old male consulted for a 4-day history of abdominal pain
associated with weakness, fatigue, right upper quadrant pain, dizziness
and syncope. Initial emergent evaluation at an outside institution,
resulted in the indication of a primary laparoscopic cholecystectomy.
After leaving against medical advice, the patient presented to our
institution 5 days after symptoms began. The initial evaluation revealed
no abdominal pain, but presence of fever, chills, nausea, emesis, and
diarrhea. An ultrasound sonography revealed thickening of the
gallbladder wall with mild pericholecystic fluid without gallstones,
compatible with acute cholecystitis. Computed tomography (CT) showed a
right sided pleural effusion with a 2.3 cm mass at the right lower
pulmonary lobe. On ECHO evaluation, a clot in-transit in the right
atrium (RA) was observed. Upon informed consent, an emergent pulmonary
embolectomy was performed. Surgical approach included median sternotomy,
and cardiopulmonary bypass in the distal ascending aorta, and bi-caval
venous cannulation. A large clot in transit was removed from the RA
through a 3 cm vertical incision. A severe RV failure resulted in
failure to wean-off cardiopulmonary bypass, requiring trans-operative
initiation of VA-ECMO support.
The chest was left open with sterile dressing. On postoperative day 2,
the patient was taken back to the operating room for a chest washout and
attempt decannulation. Patient failed two subsequent attempts to
wean-off support. Further evaluation with CT chest scans revealed high
burden of procedural clots and evidence of RV strain. A bilateral
pulmonary embolectomy was performed through pulmonary arteriotomies at
the level of the hilum loop to provide improved exposure of lobar and
segmented branches. Following intervention, acute kidney injury arose on
postoperative day 4 requiring therapy and parallel increase of
vasopressors with accompanying lactic acidosis. The presence of
coagulopathy, congestive hepatopathy, and decremental renal failure,
resulted in the development of CS.
On postoperative day 11, the patient developed acute MI and underwent
exploratory laparotomy under VA-ECMO support, which resulted in subtotal
colectomy and small bowel resection. Two days later the patient was
taken back to the operative room for an ileostomy and cholecystectomy.
Being under a CS state ensued by primary PE and complicated by acute MI,
all abdominal surgeries were performed under ICG-FA in aims to preserve
as much viable gastrointestinal tract as possible. During the
performance of the subtotal colectomy, small bowel resection, and
ileostomy, multiple infusions of ICG were administered intravenously
(1-3 mL of ICG; 25 mg diluted in 10 mL of saline solution) to assess
bowel perfusion.
Gross viable perfusion was examined at 140 cm from the ligament of
Treitz via ICG-FA and confirmed by adequate hemostasis. The small bowel
was then brought through the abdominal wall for an end-loop fashion
conversion with the afferent limb being superior. The stoma rod was
placed and secured to the skin. The edges of the bowel were re-evaluated
for perfusion and hemostasis showing both fluorescent and subjective
angiographic satisfactory appearance. All procedures were tolerated by
the patient who continued support and was later transferred in critical
condition to the intensive care unit.
On postoperative day 15, multiorgan failure supervened in a vegetative
state, with sustaining therapies to continue life support. Ultimately,
the patient’s surrogate withdrew/withheld care and the patient was
accordingly made DNR and started on a morphine drip and fentanyl for
comfort care. The patient perished on postoperative day 16 after
withdrawal of VA-ECMO and ventilatory support.