Right colectomy with simultaneous vascular reconstruction for celiac and superior mesenteric arterial occlusion

Identification of the primary feeding vessel and its removal with corresponding lymphatics is crucial for oncologic bowel resection for colon cancer. However, this notion would be challenged if we encountered abnormal mesenteric vascular anatomy. We report a case of colon cancer with abnormal mesenteric circulation, for whom we performed oncologic colectomy with vascular reconstruction.

A 61-year-old man presented with obstructing transverse colon cancer. A contrast-enhanced computed tomography (CT) scan showed complete occlusion at the root of the superior mesenteric artery (SMA) and the celiac artery (CA), with evidently dilated marginal artery (MA). An X-ray angiography revealed retrograde arterial blood flow originating from the inferior mesenteric artery (IMA) via the MA, the SMA, and to the CA. At laparotomy, we found remarkably dilated MA with the mid-transverse colon cancer. There were no other communicating vessels between the IMA and the SMA. Right colectomy with proper lymph node dissection was completed, following vascular anastomosis between the MA to the SMA. His postoperative course was uneventful. A postoperative CT angiography showed revascularization of the areas where the SMA and the CA supplied.

In this patient, if the abberant mesenteric circulation remained unrecognized at the time of surgery, and the MA were divided without vascular reconstruction, severe ischemia and subsequent gangrene of large part of the visceral organs would have occurred.

This case illustrates the fundamental importance of assessment for vascular anatomy in patients undergoing oncologic abdominal surgery which associates with division of major mesenteric arteries.