Long-Segment Stricture After Systemic Thrombolysis in a Full-Term Infant with Intestinal Ischemia due to Midgut Volvulus

Background: Midgut volvulus secondary to congenital intestinal malrotation is a neonatal surgical emergency that can quickly progress to intestinal ischemia. Even following timely relief of volvulus and the associated vascular obstruction, persistent thrombosis of mesenteric vessels can lead to extensive intestinal necrosis. Published cases have described the successful use of systemic thrombolysis to treat mesenteric vessel thrombosis following resolution of volvulus; however, the long-term intestinal function after salvage with thrombolysis remains underreported. Case Presentation: We present a case of a two-day old term infant who presented with malrotation and midgut volvulus, with resultant near total intestinal ischemia on initial operation. Systemic tissue-type plasminogen activator (tPA) was administered for 48 hours with dramatic improvement in ischemia and salvage of nearly 150cm of intestinal length. Post-operatively, the patient was unable to tolerate enteral nutrition, and upon re-operation at 7 weeks was found to have multiple long intestinal strictures. Following resection of small bowel strictures, the infant was left with 47cm of small bowel and subsequently underwent a serial transverse enteroplasty procedure (STEP), allowing the infant to tolerate partial enteral feeds. Conclusion: Post-operative use of systemic thrombolysis has shown promise in the reversal of intestinal ischemia following midgut volvulus; however, the outcomes are variable and underreported in the current literature. We describe a case of post-operative thrombolysis resulting in initial intestinal salvage but with development of significant strictures requiring additional intestinal resection. Understanding the potential successes and complications of thrombolysis can improve the care provided to neonates with mesenteric ischemia after midgut volvulus.