Mesenteric traction syndrome during sub-total colectomy
Bhiken Naik MBBCh, Laurie Davies MD
Dept of Anesthesiology, University of Florida
CASE REPORT
A 71-year-old woman, ASA physical status III, with a body mass
index of 31.6 was scheduled for subtotal colectomy secondary to
persistent rectal bleeding. Her medical history was unremarkable
except for long-standing hypertension without clinical evidence
of target organ damage. Perioperative laboratory results were
normal. On the morning of surgery she was premedicated with
midazolam, 2 mg. Anesthesia was induced with thiopental, 5
mg/kg, and fentanyl, 100 ?g; succinylcholine, 100 mg was used
for muscle relaxation. After anesthetic induction, the patient
was hemodynamically stable with minimal fluctuation in heart
rate or blood pressure until a Bookwalter abdominal retractor
was secured in position. The patient then developed marked
tachycardia with a 50% reduction in systolic blood pressure, and
marked flushing of the head and neck area. Retraction was
stopped and ephedrine, 20 mg, and phenylephrine, 80 ?g were
given in two divided doses without significant improvement in
the patient’s condition. Therefore, 10 ?g of epinephrine in two
divided doses was given. She responded to the epinephrine bolus
doses with both blood pressure and heart rate returning to the
pre-traction levels. There was also dramatic resolution of the
head and neck flushing. The surgery proceeded uneventfully and
the patient was extubated.
DISCUSSION
An association between traction on the abdominal mesentery and a
decrease in systolic blood pressure has been documented in
patients undergoing abdominal aortic aneurysm repair (1-3). In
addition to the hemodynamic changes, a significant number of
patients developed marked flushing of the head and neck area
(1). The mechanism of the head and neck flushing is not well
understood. However, histamine, nucleotides (cyclic AMP + ATP),
bradykinins, and prostaglandins have been implicated (1). One
study demonstrated that elevated plasma levels of
6-keto-prostaglandin F1 (the stable metabolite of prostacyclin)
was significantly associated with decreases in systemic vascular
resistance and mean arterial pressure (2). In addition, elevated
levels of 6-keto-prostaglandin F1 were associated with marked
head and neck flushing. Interestingly, histamine levels remained
unchanged with mesenteric traction. Other researchers have
demonstrated that ibuprofen pretreatment prevented the
mesenteric traction syndrome in patients undergoing abdominal
aortic aneurysm repair (3). The strong temporal relationship of
the decrease in blood pressure, tachycardia, and head and neck
flushing with mesenteric traction in our patient suggest the
occurrence of the mesenteric traction syndrome previously
described in abdominal aortic aneurysm repair.
References
1. Anesthesiology 1985; 63: 96-99
2. Ann Surgery 1989; 209: 363-367
3. Anesthesiology 1990; 72: 443-44
