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.