The surgical approach to near-total small bowel infarction in a patient with massive portomesenteric thrombosis. Case report.

AIM: To describe an acute portomesenteric venous thrombosis, with massive small bowel infarction, which is managed with small bowel resection, primary anastomosis, and open abdomen management (OAM). CASE REPORT: A 76-year-old male patient was admitted to the surgical ward, complaining spread abdominal pain. Contrast Enhanced Computed Tomography (CECT) diagnosed massive bowel ischemia, caused by portomesenteric thrombosis. He had negative coagulation tests for thrombophilia, while he presented concomitant risk factors (cancer, previous venous thrombosis, obesity). Surgery was performed, including open abdomen management, and the patient was discharged one month after surgery. No recurrences of portal thrombosis were found in one-year follow-up. DISCUSSION: Mesenteric venous thrombosis (MVT) diagnosis could be difficult to establish and it often presented itself late with peritonitis. Currently, CECT scanning is considered the gold standard for MVT, because it identifies not only filling defects in the portomesenteric system, but also possible complications, such as bowel ischemia. Standard initial treatment of MVT included heparin anticoagulation alone or in combination with surgery. When peritoneal signs initially are present, immediate surgery is indicated. During laparotomy, assessment of bowel viability and of the border between ischemia and vivid bowel could be more difficult to define. A planned "second-look" operation remains the gold standard for final bowel viability assessment. CONCLUSIONS: OAM strategy could possibly play an important role, also in case of resection for bowel ischemia, in improving survival in critically patients with increased risks of complications of re- anaesthesia and re-laparotomy. KEY WORDS: Acute Mesenteric Ischemia, Open Abdomen, Portal vein, Venous Thrombosis.