Small Bowel Volvulus Diagnosed and Treated Using Intraoperative Angiography in a Hybrid Operating Room: A Case Report.

INTRODUCTION

Small bowel volvulus is a surgical emergency that may cause mesenteric ischemia; however, diagnosis may be difficult when bowel perfusion appears preserved.

CASE PRESENTATION: An 84-year-old man presented with recurrent postprandial abdominal pain and melena 6 months after a total pharyngolaryngectomy with a jejunal free flap reconstruction. Extensive endoscopic evaluations, including capsule endoscopy, revealed no bleeding source. Contrast-enhanced CT revealed the whirl sign at the root of the small-bowel mesentery with the narrowing of the superior mesenteric artery (SMA), while bowel wall enhancement was preserved. Because the symptoms recurred after resuming oral intake, a hybrid surgery combined with angiography was planned for both diagnostic and therapeutic purposes. The SMA angiography demonstrated significant stenosis without apparent bowel hypoperfusion. After the intra-arterial administration of alprostadil, distal mesenteric perfusion deteriorated on the angiography, and laparoscopic exploration revealed ischemic changes consistent with small bowel volvulus. Because laparoscopic reduction was difficult, an open reduction was performed. Repeat angiography confirmed the resolution of the SMA narrowing and the restoration of distal flow. The patient's symptoms resolved completely.

CONCLUSIONS

The hybrid surgery enabled a functional assessment of mesenteric hemodynamics and immediate surgical treatment during a single procedure. It may be useful in selected patients with small bowel volvulus who have preserved bowel perfusion at rest but recurrent symptoms suggestive of intermittent mesenteric ischemia, and in whom the indication for surgical detorsion remains uncertain.