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Baek MS, Kim JH, Song D, Ahn SJ, Suh KD, Lee KY. Two cases of Superior Mesenteric Artery Occlusion in Acute Cerebral Infarction patients with Atrial Fibrillation. JOURNAL OF NEUROCRITICAL CARE 2016. [DOI: 10.18700/jnc.160078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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102
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Brencher L, Verhaegh R, Kirsch M. Attenuation of intestinal ischemia-reperfusion-injury by β-alanine: a potentially glycine-receptor mediated effect. J Surg Res 2016; 211:233-241. [PMID: 28501123 DOI: 10.1016/j.jss.2016.12.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 12/05/2016] [Accepted: 12/21/2016] [Indexed: 11/15/2022]
Abstract
BACKGROUND Acute mesenteric ischemia is often caused by embolization of the mesenteric arterial circulation. Coherent intestinal injury due to ischemia and following reperfusion get visible on macroscopic and histologic level. In previous studies, application of glycine caused an ameliorated intestinal damage after ischemia-reperfusion in rats. Because we speculated that glycine acted here as a signal molecule, we investigated whether the glycine-receptor agonist β-alanine evokes the same beneficial effect in intestinal ischemia-reperfusion. MATERIALS AND METHODS β-alanine (10, 30, and 100 mg/kg) was administered intravenously. Ischemia/reperfusion of the small intestine was initiated by occluding and reopening the superior mesenteric artery in rats. After 90 min of ischemia and 120 min of reperfusion, the intestine was analyzed with regard to macroscopic and histologic tissue damage, the activity of the saccharase, and accumulation of macrophages. In addition, systemic parameters and metabolic ones (e.g., acid-base balance, electrolytes, and blood glucose) were measured at certain points in time. RESULTS All three dosages of β-alanine did not change systemic parameters but prevent from hyponatremia during the period of reperfusion. Most importantly, application of 100-mg β-alanine clearly diminished intestinal tissue damage, getting visible on macroscopic and histologic level. In addition, I/R-mediated decrease of saccharase activity and accumulation of macrophages in the small intestine were ameliorated. CONCLUSIONS The present study demonstrated that β-alanine was a potent agent to ameliorate I/R-induced injury of the small intestine. Due to its diminishing effect on the accumulation of macrophages, β-alanine is strongly expected to mediate its beneficial effect via glycine receptors.
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Affiliation(s)
- Lisa Brencher
- Institut für Physiologische Chemie, Universitätsklinikum Essen, Universität Duisburg-Essen, Germany
| | - Rabea Verhaegh
- Institut für Physiologische Chemie, Universitätsklinikum Essen, Universität Duisburg-Essen, Germany.
| | - Michael Kirsch
- Institut für Physiologische Chemie, Universitätsklinikum Essen, Universität Duisburg-Essen, Germany
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103
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Parray AM, Mwendwa P, Mehrotra S, Mangla V, Lalwani S, Mehta N, Yadav A, Nundy S. A Review of 2255 Emergency Abdominal Operations Performed over 17 years (1996-2013) in a Gastrointestinal Surgery Unit in India. Indian J Surg 2016; 80:221-226. [PMID: 29973751 DOI: 10.1007/s12262-016-1567-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 12/05/2016] [Indexed: 12/26/2022] Open
Abstract
There is little information regarding the clinical spectrum and outcome of emergency abdominal operations from specialized units in India. We examined these in our gastrointestinal surgery and liver transplantation unit from a prospective database maintained between July 1996 and April 2013. Out of 9966 operations performed, 2255 (26%) were emergency procedures (reoperations during the same admission, e.g., for necrotizing pancreatitis were excluded). The primary outcome was 30-day postoperative mortality. The mean age of the patients was 47 years (range 1-107) and included the following age groups: 0-18 years (n = 105, 4.7%); 19-64 years (n = 1766, 78.3%), and >65 years (n = 384, 17.0%). The majority were males (1609, 71%), and there were 646 females (29%). The most common indications were small bowel emergencies (598, 26.5%), followed by pancreatic (417, 18.5%) and colonic (281, 12.5%) emergencies. Pancreatic operations were the second commonest in the adult and middle aged group. Colorectal operations were the second commonest in the geriatric age group (>65 years). Emergency operations for other conditions were: postoperative complications following elective operations 171 (7.5%), gastroduodenal bleeding or perforation in 144 (6.3%), and liver surgery in 93 patients (4.1%) patients. In the small bowel emergencies, 223 patients (37.2%) had primary diagnosis of adhesive obstruction, gangrene in 135 patients (22.5%), perforation in 121 patients (20%), and fistula in 56 patients (9.3%). Mesenteric venous thrombosis was found to be the primary cause of small bowel emergencies, either as a primary cause in gangrene or as a secondary cause in perforations and adhesions. The postoperative mortality after emergencies was 12.6% compared to 2% in elective procedures. Mortality was significantly higher in males (14%) than females (9.6%), p < 0.005. Category wise mortality was as follows: pancreatic surgery (n = 86, 20.6%), surgery for postoperative complications (n = 33, 19.3%), duodenal surgery (n = 18, 12.5%), small intestinal surgery (n = 68, 11.4%), and colonic surgery (n = 35, 12.45%). Emergency operations comprise a significant proportion of a GI surgical unit's workload. The mortality is greatest after pancreatic operations followed by those done for postoperative complications. Despite advances in surgical and postoperative care, emergency operations for abdominal emergencies are associated with mortality which is six times higher compared to elective procedures.
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Affiliation(s)
- Amir Mushtaq Parray
- 1Department of Surgical Gastroenterology and Liver Transplant, Sir Ganga Ram Hospital, Room No. 1474, Sir Ganga Ram Hospital, New Delhi, India
| | - Peter Mwendwa
- 1Department of Surgical Gastroenterology and Liver Transplant, Sir Ganga Ram Hospital, Room No. 1474, Sir Ganga Ram Hospital, New Delhi, India
| | - Siddharth Mehrotra
- 2Sir Ganga Ram Hospital, Room No. 2222, Sir Ganga Ram Hospital, New Delhi, India
| | - Vivek Mangla
- 2Sir Ganga Ram Hospital, Room No. 2222, Sir Ganga Ram Hospital, New Delhi, India
| | - Shailendra Lalwani
- 2Sir Ganga Ram Hospital, Room No. 2222, Sir Ganga Ram Hospital, New Delhi, India
| | - Naimish Mehta
- 2Sir Ganga Ram Hospital, Room No. 2222, Sir Ganga Ram Hospital, New Delhi, India
| | - Amitabh Yadav
- 2Sir Ganga Ram Hospital, Room No. 2222, Sir Ganga Ram Hospital, New Delhi, India
| | - Samiran Nundy
- 2Sir Ganga Ram Hospital, Room No. 2222, Sir Ganga Ram Hospital, New Delhi, India
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104
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Abe S, Yamakawa T, Kawashima H, Yoshida M, Takanashi S, Kashiyama M, Ishigooka M, Shingu Y, Matsui Y. Surgery for acute exacerbation of chronic mesenteric ischemia: a case report. Surg Case Rep 2016; 2:146. [PMID: 27921277 PMCID: PMC5138179 DOI: 10.1186/s40792-016-0272-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 11/30/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chronic mesenteric ischemia (CMI) is a rare disease; however, symptomatic CMI has a risk of acute exacerbation without timely revascularization. CASE PRESENTATION A 54-year-old man who had had postprandial pain for 6 months was admitted to our hospital because of vomiting and diarrhea. Although the celiac and superior mesenteric arteries were occluded at the proximal portion, contrast enhancement of the bowel wall was good in contrast-enhanced computed tomography (CECT). Endoscopic examination revealed only a healed gastric ulcer and slight mucosal erosions in the colon. He was diagnosed as having acute enteritis or inflammatory digestive disease and observed with conservative therapy, which improved his acute symptoms. On hospitalization day 42, he suddenly complained of lower back pain. CECT showed abdominal free air, which indicated gastrointestinal perforation. Emergency surgery was performed for jejunum resection. Two days later, a second operation was performed for a leak in the anastomotic site of the jejunum. Necrotic change in the small intestinal serosa was also observed and required broad resection of the small intestine. He was diagnosed with acute exacerbation of CMI, and we performed surgical retrograde bypass to the gastroduodenal artery using a saphenous vein graft as the third operation. After the surgery, he was free from digestive symptoms and was discharged. CONCLUSIONS When patients complain of chronic and gradual digestive symptoms, we should always consider symptomatic CMI. Timely mesenteric revascularization is important for symptomatic CMI before severe complications occur.
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Affiliation(s)
- Shinji Abe
- Department of Cardiovascular Surgery, Kin-i-kyou Central Hospital, 5-1-9-1 Higashinaebo, Higashi-ku, Sapporo, 007-8505, Japan.
| | - Tomoji Yamakawa
- Department of Cardiovascular Surgery, Kin-i-kyou Central Hospital, 5-1-9-1 Higashinaebo, Higashi-ku, Sapporo, 007-8505, Japan
| | - Hideaki Kawashima
- Department of Surgery, Kin-i-kyou Central Hospital, 5-1-9-1 Higashinaebo, Higashi-ku, Sapporo, 007-8505, Japan
| | - Makoto Yoshida
- Department of Surgery, Kin-i-kyou Central Hospital, 5-1-9-1 Higashinaebo, Higashi-ku, Sapporo, 007-8505, Japan
| | - Setsuji Takanashi
- Department of Surgery, Kin-i-kyou Central Hospital, 5-1-9-1 Higashinaebo, Higashi-ku, Sapporo, 007-8505, Japan
| | - Motoya Kashiyama
- Department of Surgery, Kin-i-kyou Central Hospital, 5-1-9-1 Higashinaebo, Higashi-ku, Sapporo, 007-8505, Japan
| | - Masahiro Ishigooka
- Department of Surgery, Kin-i-kyou Central Hospital, 5-1-9-1 Higashinaebo, Higashi-ku, Sapporo, 007-8505, Japan
| | - Yasushige Shingu
- Department of Cardiovascular and Thoracic Surgery, Hokkaido University Hospital, Kita-15, Nishi-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Yoshiro Matsui
- Department of Cardiovascular and Thoracic Surgery, Hokkaido University Hospital, Kita-15, Nishi-7, Kita-ku, Sapporo, 060-8638, Japan
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105
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Rosen RJ, Jain A, Drury J. Acute and Chronic Mesenteric Ischemia. Interv Cardiol 2016. [DOI: 10.1002/9781118983652.ch74] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
| | - Amit Jain
- Lenox Hill Heart and Vascular Institute; New York NY USA
| | - Jennifer Drury
- Lenox Hill Heart and Vascular Institute; New York NY USA
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106
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English WP, Pearce JD, Craven TE, Edwards MS, Geary RL, Plonk GW, Hansen KJ. Chronic Visceral Ischemia: Symptom-Free Survival After Open Surgical Repair. Vasc Endovascular Surg 2016; 38:493-503. [PMID: 15592629 DOI: 10.1177/153857440403800602] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A retrospective review of patients treated with a history of chronic visceral ischemia (CVI) was made to determine primary patency of open surgical repair and estimated symptom-free survival. Patients with CVI between 1990 and 2003 were reviewed. Included were those with chronic symptoms alone (C-CVI) and acute-on-chronic symptoms (A-CVI). Data were obtained from a vascular database. Symptom-free survival and graft patency were estimated by using product limit estimates. Fifty-eight patients (13 men, 45 women; mean age: 63 years) were treated surgically for C-CVI (34 patients) and A-CVI (24 patients). All patients had postprandial abdominal pain and weight loss (mean: 17 kg). One fourth reported food fear. Preoperative imaging demonstrated disease of the superior mesenteric artery (SMA) (100%; 64% occluded), celiac axis (89%; 37% occluded), and inferior mesenteric artery (IMA) (54%; 60% occluded). Multiple vessels were involved in 95% of patients (mean: 2.3 vessels/patient). Operative management included antegrade revascularization of 80 vessels. Combined aortic and/or renal procedures were performed in 7 patients. Patient demographics and visceral disease did not differ for C-CVI and A-CVI; however, perioperative mortality differed significantly (10% for C-CVI vs 54% for A-CVI [p<0.001]). Intestinal gangrene at presentation was associated with perioperative (hazard ratio [HR]: 7.6; 95% CI: 2.7–21.6; p=0.0002) and follow-up death (HR: 7.8; CI 2.8–21.9; p< 0.0001). Follow-up (mean: 34 months) was complete for 54/68 vessels (79%). Estimated primary and primary assisted patency at 5 years were 81% and 89% respectively. Estimated symptom-free survival for hospital survivors was 57% at 70 months. Open antegrade methods of visceral artery repair for CVI were durable and associated with 57% symptom-free survival at 70 months. Patient demographics and distribution of visceral artery anatomy were similar; however, perioperative mortality for C-CVI and A-CVI differed dramatically. Improved outcomes for A-CVI require recognition and treatment of CVI before onset of intestinal gangrene.
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Affiliation(s)
- William P English
- Division of Surgical Sciences, Section on Vascular Surgery, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA
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107
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Lee SM, An WS. New clinical criteria for septic shock: serum lactate level as new emerging vital sign. J Thorac Dis 2016; 8:1388-90. [PMID: 27501243 DOI: 10.21037/jtd.2016.05.55] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Su Mi Lee
- Department of Internal Medicine, Dong-A University, Busan, Korea
| | - Won Suk An
- Department of Internal Medicine, Dong-A University, Busan, Korea
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108
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Merchan C, Altshuler D, Aberle C, Papadopoulos J, Schwartz D. Tolerability of Enteral Nutrition in Mechanically Ventilated Patients With Septic Shock Who Require Vasopressors. J Intensive Care Med 2016; 32:540-546. [DOI: 10.1177/0885066616656799] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Purpose: Enteral nutrition (EN) is often held in patients receiving vasopressor support for septic shock. The rationale for this practice is to avoid mesenteric ischemia. The objective of this study is to evaluate the tolerability of EN in patients with septic shock who require vasopressor support and determine factors associated with tolerance of EN. Materials and Methods: This was a single-center retrospective review of adult patients admitted to the intensive care unit with a diagnosis of septic shock and an order for EN. The primary outcome was EN tolerance. Secondary outcomes included time to initiation of EN from the start of vasopressor(s), length of stay, and mortality. Results: A total of 120 patients were included. Sixty-two percent of patients tolerated EN. The most common reason for intolerance of EN was gastric residuals > 250 mL (74%). No reports of mesenteric ischemia were observed. A multivariate analysis demonstrated that patients with septic shock initiating EN within 48 hours and receiving norepinephrine-equivalent doses of 0.14 μg/kg/min or less were more likely to tolerate EN. Conclusion: Based on our observation, early EN may be tolerated and safely administered in patients with septic shock who are adequately fluid resuscitated and receive doses of < 0.14 μg/kg/min of norepinephrine equivalents.
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Affiliation(s)
- Cristian Merchan
- Department of Pharmacy, New York University Langone Medical Center, New York, NY, USA
| | - Diana Altshuler
- Department of Pharmacy, New York University Langone Medical Center, New York, NY, USA
| | - Caitlin Aberle
- Department of Pharmacy, New York University Langone Medical Center, New York, NY, USA
| | - John Papadopoulos
- Department of Pharmacy, New York University Langone Medical Center, New York, NY, USA
- Department of Medicine, New York University School of Medicine, New York, NY, USA
| | - David Schwartz
- Department of Medicine, New York University School of Medicine, New York, NY, USA
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109
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Branco BC, Montero-Baker MF, Aziz H, Taylor Z, Mills JL. Endovascular Therapy for Acute Mesenteric Ischemia: an NSQIP Analysis. Am Surg 2016; 81:1170-6. [PMID: 26672589 DOI: 10.1177/000313481508101131] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Acute mesenteric ischemia (AMI) continues to carry high morbidity and mortality. Endovascular strategies have been increasingly used in the management of AMI. The purpose of this study was to evaluate the impact of endovascular therapy on outcomes of patients with AMI. The National Surgical Quality Improvement Program database was queried to identify all patients requiring emergency surgical intervention for AMI. Demographics, clinical data, interventions, and outcomes were extracted. Patients were compared according to treatment (endovascular versus hybrid versus open revascularization). Over the six-year study period, a total of 439 patients were found to have AMI [27 (6.2%) endovascular, 23 (5.2%) hybrid, and 389 (88.6%) open revascularization]. A total of 16 (59.3%) patients in the endovascular group avoided laparotomy. There was a trend toward lower transfusion requirements (intraoperative transfusion: 3.7% for endovascular vs 17.4% for hybrid vs 19.3% for open, adjusted. P = 0.127) and complications in particular pneumonia (22.2% vs 39.1% vs 27.8%, respectively, Adj. P = 0.392) and sepsis (25.9% vs 21.7% vs 35.5%, adjusted P = 0.260). Endovascular therapy was associated with a 2.5-fold decrease in the risk of death [odds ratio, 95% confidence interval: 0.4 (0.2, 0.9), adjusted P = 0.018]. In this analysis of morbidity and mortality, endovascular therapy was associated with decreased need for laparotomy and a trend toward lower transfusion requirements and complications, in particular pneumonia and sepsis. Endovascular first therapy was associated with a 2.5-fold decrease in the risk of death. Further prospective evaluation of these results is warranted.
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Affiliation(s)
- Bernardino C Branco
- Department of General Surgery, Banner University Medical Center, Southern Arizona VA Health Care System, Tucson, Arizona, USA
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110
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Crawford RS, Harris DG, Klyushnenkova EN, Tesoriero RB, Rabin J, Chen H, Diaz JJ. A Statewide Analysis of the Incidence and Outcomes of Acute Mesenteric Ischemia in Maryland from 2009 to 2013. Front Surg 2016; 3:22. [PMID: 27148538 PMCID: PMC4830818 DOI: 10.3389/fsurg.2016.00022] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 04/02/2016] [Indexed: 01/19/2023] Open
Abstract
Introduction Acute mesenteric ischemia is a surgical emergency that entails complex, multi-modal management, but its epidemiology and outcomes remain poorly defined. The aim of this study was to perform a population analysis of the contemporary incidence and outcomes of mesenteric ischemia. Methods This was a retrospective analysis of acute mesenteric ischemia in the state of Maryland during 2009–2013 using a comprehensive statewide hospital admission database. Demographics, illness severity, comorbidities, and outcomes were studied. The primary outcome was inpatient mortality. Survivors and non-survivors were compared using univariate analyses, and multivariable logistic regression analysis was performed to evaluate risk factors for mortality. Results During the 5-year study period, there were 3,157,499 adult hospital admissions in Maryland. A total of 2,255 patients (0.07%) had acute mesenteric ischemia, yielding an annual admission rate of 10/100,000. Increasing age, hypercoagulability, cardiac dysrhythmia, renal insufficiency, increasing illness severity, and tertiary hospital admission were associated with development of mesenteric ischemia. Inpatient mortality was high (24%). After multivariate analysis, independent risk factors for death were age >65 years, critical illness severity, mechanical ventilation, tertiary hospital admission, hypercoagulability, renal insufficiency, and dysrhythmia. Conclusion Acute mesenteric ischemia occurs in approximately 1/1,000 admissions in Maryland. Patients with mesenteric ischemia have significant illness severity, substantial rates of organ dysfunction, and high mortality. Patients with chronic comorbidities and acute organ dysfunction are at increased risk of death, and recognition of these risk factors may enable prevention or earlier control of mesenteric ischemia in high-risk patients.
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Affiliation(s)
- Robert S Crawford
- Division of Vascular Surgery, Center for Aortic Disease, Department of Surgery, University of Maryland School of Medicine , Baltimore, MD , USA
| | - Donald G Harris
- Division of Vascular Surgery, Center for Aortic Disease, Department of Surgery, University of Maryland School of Medicine , Baltimore, MD , USA
| | - Elena N Klyushnenkova
- Department of Epidemiology and Public Health, University of Maryland School of Medicine , Baltimore, MD , USA
| | - Ronald B Tesoriero
- Division of Acute Care Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine , Baltimore, MD , USA
| | - Joseph Rabin
- Division of Acute Care Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine , Baltimore, MD , USA
| | - Hegang Chen
- Department of Epidemiology and Public Health, University of Maryland School of Medicine , Baltimore, MD , USA
| | - Jose J Diaz
- Division of Acute Care Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine , Baltimore, MD , USA
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111
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Nauta FJH, Trimarchi S, Kamman AV, Moll FL, van Herwaarden JA, Patel HJ, Figueroa CA, Eagle KA, Froehlich JB. Update in the management of type B aortic dissection. Vasc Med 2016; 21:251-63. [DOI: 10.1177/1358863x16642318] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Stanford type B aortic dissection (TBAD) is a life-threatening aortic disease. The initial management goal is to prevent aortic rupture, propagation of the dissection, and symptoms by reducing the heart rate and blood pressure. Uncomplicated TBAD patients require prompt medical management to prevent aortic dilatation or rupture during subsequent follow-up. Complicated TBAD patients require immediate invasive management to prevent death or injury caused by rupture or malperfusion. Recent developments in diagnosis and management have reduced mortality related to TBAD considerably. In particular, the introduction of thoracic stent-grafts has shifted the management from surgical to endovascular repair, contributing to a fourfold increase in early survival in complicated TBAD. Furthermore, endovascular repair is now considered in some uncomplicated TBAD patients in addition to optimal medical therapy. For more challenging aortic dissection patients with involvement of the aortic arch, hybrid approaches, combining open and endovascular repair, have had promising results. Regardless of the chosen management strategy, strict antihypertensive control should be administered to all TBAD patients in addition to close imaging surveillance. Future developments in stent-graft design, medical therapy, surgical and hybrid techniques, imaging, and genetic screening may improve the outcomes of TBAD patients even further. We present a comprehensive review of the recommended management strategy based on current evidence in the literature.
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Affiliation(s)
- Foeke JH Nauta
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Milan, Italy
- Cardiovascular Center, University of Michigan Health System, Ann Arbor, MI, USA
| | - Santi Trimarchi
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Milan, Italy
| | - Arnoud V Kamman
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Milan, Italy
| | - Frans L Moll
- Vascular Surgery Department, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Joost A van Herwaarden
- Vascular Surgery Department, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - C Alberto Figueroa
- Departments of Biomedical Engineering and Surgery, University of Michigan, USA
| | - Kim A Eagle
- Cardiovascular Center, University of Michigan Health System, Ann Arbor, MI, USA
| | - James B Froehlich
- Cardiovascular Center, University of Michigan Health System, Ann Arbor, MI, USA
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112
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Tilsed JVT, Casamassima A, Kurihara H, Mariani D, Martinez I, Pereira J, Ponchietti L, Shamiyeh A, Al-Ayoubi F, Barco LAB, Ceolin M, D'Almeida AJG, Hilario S, Olavarria AL, Ozmen MM, Pinheiro LF, Poeze M, Triantos G, Fuentes FT, Sierra SU, Soreide K, Yanar H. ESTES guidelines: acute mesenteric ischaemia. Eur J Trauma Emerg Surg 2016; 42:253-70. [PMID: 26820988 PMCID: PMC4830881 DOI: 10.1007/s00068-016-0634-0] [Citation(s) in RCA: 179] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE Acute mesenteric ischaemia (AMI) accounts for about 1:1000 acute hospital admissions. Untreated, AMI will cause mesenteric infarction, intestinal necrosis, an overwhelming inflammatory response and death. Early intervention can halt and reverse this process leading to a full recovery, but the diagnosis of AMI is difficult and failure to recognize AMI before intestinal necrosis has developed is responsible for the high mortality of the disease. Early diagnosis and prompt treatment are the goals of modern therapy, but there are no randomized controlled trials to guide treatment and the published literature contains a high ratio of reviews to original data. Much of that data comes from case reports and often small, retrospective series with no clearly defined treatment criteria. METHODS A study group of the European Society for Trauma and Emergency Surgery (ESTES) was formed in 2013 with the aim of developing guidelines for the management of AMI. A comprehensive literature search was performed using the Medical Subject Heading (MeSH) thesaurus keywords "mesenteric ischaemia", "bowel ischaemia" and "bowel infarction". The bibliographies of relevant articles were screened for additional publications. After an initial systematic review of the literature by the whole group, a steering group formulated questions using a modified Delphi process. The evidence was then reviewed to answer these questions, and recommendations formulated and agreed by the whole group. RESULTS The resultant recommendations are presented in this paper. CONCLUSIONS The aim of these guidelines is to provide recommendations for practice that will lead to improved outcomes for patients.
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Affiliation(s)
- J V T Tilsed
- Surgery Health Care Group, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK.
| | - A Casamassima
- Emergency Department, Istituto Clinico Città Studi, Milan, Italy
| | - H Kurihara
- Emergency Surgery and Trauma Unit, Humanitas Research Hospital, Rozzano, Italy
| | - D Mariani
- Department of General Surgery, Ospedale di Legnano, Milan, Italy
| | - I Martinez
- Servicio de Cirugía General y Digestiva, Hospital Universitario de Torrevieja, Torrevieja, Spain
| | - J Pereira
- Surgery 1-Tondela-Viseu Hospital Centre, Viseu, Portugal
| | - L Ponchietti
- Department of Surgery, Milton Keynes Hospital NHS Foundation Trust, Milton Keynes, UK
| | - A Shamiyeh
- 2nd Surgical Department, Kepler University Clinic Linz, Linz, Austria
| | - F Al-Ayoubi
- Division of Trauma and Acute Care Surgery, Mafraq Hospital, Abu Dhabi, United Arab Emirates
| | - L A B Barco
- Department of Angiology and Vacular Surgery, University Hospital of Torrevieja, Torrevieja, Spain
| | - M Ceolin
- Emergency Surgery and Trauma Unit, Humanitas Research Hospital, Rozzano, Italy
| | - A J G D'Almeida
- Department of General Surgery, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - S Hilario
- 2nd Surgical Department, Santo André Hospital, Leiria, Portugal
| | - A L Olavarria
- Servicio de Cirugía General y Digestiva, Hospital Galdakao Usansolo, Vizcaya, Spain
| | - M M Ozmen
- Department of Surgery, Medical School, Hacettepe University, 06100, Ankara, Turkey
| | - L F Pinheiro
- General Surgery Department, Hospital São Teotónio, Viseu, Portugal
| | - M Poeze
- Department of Surgery/Intensive Care Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - G Triantos
- Department of General Surgery, Rhodes General Hospital, Rhodes, Greece
| | - F T Fuentes
- General Surgery 2 and Emergency Surgery, University General Hospital Gregorio Marañón, Madrid, Spain
| | - S U Sierra
- Department of Surgery, Galdakao-Usansolo Hospital, Galdakao, Vizcaya, Spain
| | - K Soreide
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - H Yanar
- Department of General Surgery, Istanbul Faculty of Medicine, Istanbul University, Çapa, Istanbul, Turkey
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113
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Affiliation(s)
- Karuppiah Arunachalam
- The Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence.
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Zhao Y, Yin H, Yao C, Deng J, Wang M, Li Z, Chang G. Management of Acute Mesenteric Ischemia. Vasc Endovascular Surg 2016; 50:183-92. [PMID: 27036673 DOI: 10.1177/1538574416639151] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Acute mesenteric ischemia (AMI) due to a sudden loss or decrease in blood perfusion to the mesentery represents a highly lethal condition. However, the optimal surgical management remains debatable and merits a more clear recommendation based on a higher level of evidence. Methods: A systematic review of articles published between 2000 and 2013 was performed. Patients were divided into endovascular treatment (ET), open surgery (OS), and hybrid technique (HT) groups. Data of patients’ demographics, procedural information, clinical outcomes including mortality, morbidity, primary patency rate, technique success, primary intestinal resection rate, and second-look laparotomy rate, and follow-up were all retrieved. Comparison between the ET and the OS groups was made using 2-sided Student t test and 2-sided χ2 test or Fisher exact test where appropriate. Results: Twenty-eight articles with a total of 1110 patients were included for the review. The ET group had lower in-hospital mortality and morbidity but similar survival rate during follow-up compared to the OS group. The primary patency rate was higher in the ET group. The overall bowel resection rate was lower in the ET group, and nearly every patient in the cohort who required second-look laparotomy required bowel resection. The HT group seemed to have the lowest mortality and acceptable second-look laparotomy rate and morbidity. Comparison between the HT group and other groups was not possible due to the limited number of cases available for review. Conclusion: Endovascular treatment may serve as a first-line therapy for select patients when there is a low suspicion for intestinal necrosis. Open surgery should be reserved for emergency conditions requiring exploratory laparotomy. Hybrid technique may be an especially effective approach for treating AMI, with low morbidity and mortality, although further studies are required comparing it to OS and ET.
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Affiliation(s)
- Yang Zhao
- Division of Vascular Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Henghui Yin
- Division of Vascular Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Chen Yao
- Division of Vascular Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jiong Deng
- Division of Vascular Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Mian Wang
- Division of Vascular Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zilun Li
- Division of Vascular Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Guangqi Chang
- Division of Vascular Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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Affiliation(s)
- Daniel G Clair
- From the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University (D.G.C.) and the Department of Vascular Surgery, Heart and Vascular Institute, Cleveland Clinic (D.G.C., J.M.B.) - both in Cleveland
| | - Jocelyn M Beach
- From the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University (D.G.C.) and the Department of Vascular Surgery, Heart and Vascular Institute, Cleveland Clinic (D.G.C., J.M.B.) - both in Cleveland
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Abstract
Acute mesenteric ischemia (AMI) is a rare disease that most commonly affects the elderly. The vague symptoms often lead to delayed diagnosis and consequent high mortality. Physical exam and laboratory findings lack the sensitivity and specificity to exclude AMI, but computed tomography angiography can rapidly and accurately confirm the diagnosis. Survival improves with prompt restoration of perfusion and resection of nonviable bowel. Advances in imaging, operative techniques, and critical care have led to a steady decline in overall mortality; however, long-term survival is limited because of the comorbidities in this patient group.
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Affiliation(s)
- Thomas W Carver
- Division of Trauma and Critical Care, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA.
| | - Ravi S Vora
- Division of Digestive Diseases, Emory University, 615 Michael Street, Suite 201, Atlanta, GA 30322, USA
| | - Amit Taneja
- Division of Pulmonary and Critical Care Medicine, The Medical College of Wisconsin, Suite E 5200, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA
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Stephen E, Sarfaraz Z, Abdelhedy I, Al Wahaibi K. Acute mesenteric ischemia: The what, why, and when? INDIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2016. [DOI: 10.4103/0972-0820.180211] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Tseng CY, Chang CM, Yang SC, Chia-Yu Chang J, Chen JD, Huang HH, How CK, Hung-Tsang Yen D, Huang MS. Spontaneous Intramural Intestinal Hemorrhage versus Acute Mesenteric Ischemia by CT Evaluation. Intern Med 2016; 55:2337-41. [PMID: 27580531 DOI: 10.2169/internalmedicine.55.6772] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objective The purpose of our study was to differentiate the imaging findings of patients with spontaneous intramural intestinal hemorrhage (SIIH) from those with acute mesenteric ischemia (AMI) after abdominal computed tomography (CT) survey in the emergency department. Methods We retrospectively included 83 patients diagnosed with SIIH or AMI after abdominal CT. Results The mean ages of 30 SIIH patients and 53 AMI patients were 74.4±14.6 years and 75.8±11.2 years, respectively. Patients with SIIH had significantly thicker maximal intestinal wall thickening (14.8±3.9 vs. 10.9 ±4.1, p<0.001), a lower rate of ileum involvement (26.7% vs. 77.4%, p<0.001) and a higher rate of ascites (96.7% vs. 64.2%, p<0.001) compared with patients with AMI. Neither pneumatosis intestinalis (p<0.001) nor portomesenteric gas (p<0.01) were detected in SIIH patients but were observed in AMI patients. A receiver-operating characteristic (ROC) curve analysis showed that the optimal cut-off value for maximal intestinal wall thickening between groups was 10.4 mm and the area under the ROC curve between groups was 0.752 (p<0.0001). A multiple logistic regression analysis showed that the independent predictors of SIIH were non-involvement of the ileum (odds ratio, OR, 6.998; p=0.001), maximal intestinal wall thickening ≥10.4 mm (OR, 5.748; p=0.040) and ascites (OR, 13.348; p=0.023). The area under the ROC curve for the model was 0.854 (p<0.001). Conclusion The independent predictors of SIIH from AMI after abdominal CT in acute abdominal patients include non-involvement of the ileum, intestinal wall thickening ≥10.4 mm, and ascites.
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Affiliation(s)
- Chia-Ying Tseng
- Department of Emergency Medicine, Taichung Veterans General Hospital, Taiwan
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119
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Japanese Guidelines for Nutrition Support Therapy in the Adult and Pediatric Critically Ill Patients. ACTA ACUST UNITED AC 2016. [DOI: 10.3918/jsicm.23.185] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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120
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Björck M, Orr N, Endean ED. Debate: Whether an endovascular-first strategy is the optimal approach for treating acute mesenteric ischemia. J Vasc Surg 2015; 62:767-72. [PMID: 26304485 DOI: 10.1016/j.jvs.2015.04.431] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Acute mesenteric ischemia continues to be a life-threatening insult in often-elderly patients with many comorbidities. Recognition and correct diagnosis can be an issue leading to delays in therapy that result in loss of bowel or life, or both. The basic surgical principals in treating acute mesenteric ischemia have long been early recognition, resuscitation, urgent revascularization, resection of necrotic bowel, and reassessment with second-look laparotomies. Endovascular techniques now offer a less invasive alternative, but whether an endovascular-first or open surgery-first approach is preferred in most patients is unclear. Our discussants will attempt to clarify these issues.
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Affiliation(s)
- Martin Björck
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden.
| | - Nathan Orr
- Department of Surgery, University of Kentucky, Lexington, Ky
| | - Eric D Endean
- Department of Surgery, University of Kentucky, Lexington, Ky.
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Lai JP, Lee CC, Crocker M, Najmuddin M, Lange E, Merino M, Stratakis CA. Isolated Large Cell Calcifying Sertoli Cell Tumor in a Young Boy, not Associated with Peutz-Jeghers Syndrome or Carney Complex. ACTA ACUST UNITED AC 2015; 3:2. [PMID: 26587565 DOI: 10.21767/2386-5180.10002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Large cell calcifying sertoli cell tumor (LCCSCT) is an exceedingly rare lesion of the testicle. It is most often seen in patients with Carney complex (CNC) or Peutz-Jeghers syndrome (PJS). We now report the first pediatric patient with what appears to be bilateral LCCSCT and no other conditions or a genetic syndrome, such as PJS or CNC, have been associated with it. METHODS A 10-year-old boy was found to have a right testicular mass during a routine pediatric examination; he underwent right orchiectomy. He was then evaluated clinically for PJS or CNC and underwent genetic testing. His tumor was studied by immunohistochemistry for the expression of calretinin, NY-ESO-1, inhibin, CD99, S100, PLAP, AE1/AE3, Bcl-2, p53, and Mib1. RESULTS Patient did not have clinical features or genetic abnormalities of CNC and PJS. Microscopic features showed large, round or cubical intratubular and aggregated tumor cells with prominent nuclear atypia, large and prominent nucleoli and extensive calcification. In the Immunohistochemical studies, calretinin and inhibin alpha were up regulated in LCCSCT as compared to the adjacent benign Sertoli cells. Meanwhile, NY-ESO-1 and CD99 were down-regulated in LCCSCT. Focally and weakly positive S100 was found in the tumor tissue, but no S100 expression was present in the adjacent Sertoli cells. There was no expression of PLAP, P53, Bcl-2, Mib1 and AE1/AE3 in LCCSCT and adjacent Sertoli cells. Micro-calcifications were found in the other gonad by ultrasonography, suggesting LCCSCT. CONCLUSION LCCSCT is a rare testicular neoplasm, and may present in isolated rather than in more typical association with syndromes such as CNC and PJS.
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Affiliation(s)
- Jin-Ping Lai
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA ; Department of Pathology, Saint Louis University School of Medicine, St Louis, MO 63104, USA
| | - Chyi-Chia Lee
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Melissa Crocker
- Section on Endocrinology and Genetics, Program on Developmental Endocrinology Genetics (PDEGEN), Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), USA ; Inter-Institute Pediatric Endocrinology Training Program, National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Mufaddal Najmuddin
- Department of Pathology, Saint Louis University School of Medicine, St Louis, MO 63104, USA
| | - Eileen Lange
- Section on Endocrinology and Genetics, Program on Developmental Endocrinology Genetics (PDEGEN), Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), USA ; Inter-Institute Pediatric Endocrinology Training Program, National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Maria Merino
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Constantine A Stratakis
- Section on Endocrinology and Genetics, Program on Developmental Endocrinology Genetics (PDEGEN), Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), USA ; Inter-Institute Pediatric Endocrinology Training Program, National Institutes of Health (NIH), Bethesda, MD 20892, USA
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Orr NT, Endean ED. Part Two: Against the Motion. An Endovascular First Strategy is not the Optimal Approach for Treating Acute Mesenteric Ischemia. Eur J Vasc Endovasc Surg 2015; 50:276-9. [PMID: 26315053 DOI: 10.1016/j.ejvs.2015.04.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- N T Orr
- Department of Surgery, University of Kentucky, Lexington, KY 40536, USA
| | - E D Endean
- Department of Surgery, University of Kentucky, Lexington, KY 40536, USA.
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123
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Liu K, Meng J, Yang S, Liu B, Ding W, Wu X, Li J. Transcatheter thrombolysis combined with damage control surgery for treatment of acute mesenteric venous thrombosis associated with bowel necrosis: a retrospective study. World J Emerg Surg 2015; 10:50. [PMID: 26516342 PMCID: PMC4625718 DOI: 10.1186/s13017-015-0045-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 10/21/2015] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE This study aims to evaluate the clinical outcomes of transcatheter thrombolysis in acute superior mesenteric venous thrombosis (ASMVT) associated with bowel necrosis. METHODS A retrospective study of six patients with ASMVT treated with catheter-directed thrombectomy/thrombolysis and damage control surgery at Jinling Hospital (Nanjing, China) between 2010 and 2013 was conducted. Demographics, past medical history, risk factors, therapeutic methods and effects, mortality, and follow-up of the study population were assessed. RESULTS Five of six patients underwent arteriovenous combined thrombolysis, while one patient underwent arterial thrombolysis. All patients required damage control surgery, and four of these patients underwent temporary abdominal closure. All patients survived and were free of recurrence. CONCLUSIONS Transcatheter thrombectomy/thrombolysis and damage control surgery could help avoid extensive bowel resection, prevent short bowel syndrome and reduce mortality for critically ill patients with acute mesenteric venous thrombosis associated with bowel necrosis.
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Affiliation(s)
- Kai Liu
- Medical School of Nanjing University, Nanjing, 210002 Jiangsu Province P. R. China
| | - Jiaxiang Meng
- Medical School of Nanjing University, Nanjing, 210002 Jiangsu Province P. R. China
| | - Shuofei Yang
- Medical School of Nanjing University, Nanjing, 210002 Jiangsu Province P. R. China
| | - Baochen Liu
- Medical School of Nanjing University, Nanjing, 210002 Jiangsu Province P. R. China
| | - Weiwei Ding
- Research Institute of General Surgery, Jinling Hospital, 305 East Zhongshan Road, 210002 Nanjing, Jiangsu China
| | - Xingjiang Wu
- Research Institute of General Surgery, Jinling Hospital, 305 East Zhongshan Road, 210002 Nanjing, Jiangsu China
| | - Jieshou Li
- Research Institute of General Surgery, Jinling Hospital, 305 East Zhongshan Road, 210002 Nanjing, Jiangsu China
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124
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Qian Y, Chen XN, Shi H, Xie J, Chen N. Refractory Abdominal Pain in a Hemodialysis Patient. Case Rep Nephrol Dial 2015; 5:145-51. [PMID: 26266246 PMCID: PMC4519607 DOI: 10.1159/000431084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Nonocclusive mesenteric ischemia (NOMI) is a rare disorder. Failure of an early diagnosis may cause progressive intestinal ischemia, leading to abdominal pain, sepsis, and death. Patients with end-stage renal disease are among the highest risk populations for developing this lethal complication. The key to a correct diagnosis at an early stage is a high index of suspicion in predisposed patients. In our case, we present a 62-year-old female undergoing maintenance hemodialysis for 8 years; she complained of abdominal pain after hemodialysis in the last 3 months; NOMI was suspected after a CT angiography. She partially recovered after multiple clinical interventions such as decreased ultrafiltration, an increased dose of low molecular-weight heparin and the use of vasoactive drugs. In conclusion, NOMI can be reversible if it is diagnosed as early as possible and after the necessary diagnostic measurements are initiated.
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Affiliation(s)
- Ying Qian
- Department of Nephrology, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xiao-Nong Chen
- Department of Nephrology, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Hao Shi
- Department of Nephrology, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jingyuan Xie
- Department of Nephrology, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Nan Chen
- Department of Nephrology, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
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Revascularization of acute mesenteric ischemia after creation of a dedicated multidisciplinary center. J Vasc Surg 2015; 62:1251-6. [PMID: 26243208 DOI: 10.1016/j.jvs.2015.06.204] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 06/04/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Arterial acute mesenteric ischemia (AAMI) is a vascular and gastroenterologic emergency, most often surgical, still associated with a poor prognosis and frequent short bowel syndrome in survivors. We report the results of revascularization in AAMI patients after the creation of an intestinal stroke center. METHODS Since July 2009, we developed a multimodal and multidisciplinary management for AMI, focusing on intestinal viability and involving gastroenterologists, vascular and abdominal surgeons, radiologists, and intensive care specialists. This management was the first step to the creation of an intestinal stroke center, based on the stroke unit model. All patients received: (1) a specific medical protocol; (2) endovascular and/or open surgical revascularization whenever possible; and/or (3) resection of non-viable small bowel. We aimed to study survival, morbidity, type of revascularization, and bowel resection in patients who benefited from arterial revascularization in our intestinal stroke center. RESULTS Eighty-three patients with AMI were prospectively enrolled in the intestinal stroke center. Among them, 29 patients with AAMI underwent revascularization. The mean age was 50.2 ± 12 years, with 41% of male gender. The mean follow-up was 22.7 ± 19 months. Overall 2-year survival was 89.2%, and 30-day operative mortality was 6.9%. Surgical revascularization included bypass grafting (65%), endarterectomy with patch angioplasty (21%) ± retrograde open mesenteric stenting of the superior mesenteric artery (7%), and endovascular revascularization as first stage procedure (38%). The 2-year primary patency rate of open revascularization was 88%. The rate and the median length of bowel resected were 24% and 43 cm (range, 36-49 cm), respectively. CONCLUSIONS In our experience, revascularization of AAMI patients as part of a multidisciplinary and multimodal management leads to encouraging results. Vascular surgeons have a central role in a dedicated intestinal stroke center.
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Choi KS, Kim JD, Kim HC, Min SI, Min SK, Jae HJ, Chung JW. Percutaneous Aspiration Embolectomy Using Guiding Catheter for the Superior Mesenteric Artery Embolism. Korean J Radiol 2015; 16:736-43. [PMID: 26175572 PMCID: PMC4499537 DOI: 10.3348/kjr.2015.16.4.736] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2015] [Accepted: 03/04/2015] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE To evaluate the technical feasibility and clinical outcome of percutaneous aspiration embolectomy for embolic occlusion of the superior mesenteric artery (SMA). MATERIALS AND METHODS Between January 2010 and December 2013, 9 patients with embolic occlusion of the SMA were treated by percutaneous aspiration embolectomy in 2 academic teaching hospitals. The aspiration embolectomy procedure was performed with the 6-Fr and 7-Fr guiding catheter. Thrombolysis was performed with urokinase using a multiple-sidehole infusion catheter. The clinical outcome was investigated retrospectively. RESULTS Superior mesenteric artery occlusion was initially diagnosed by computed tomography (CT) in all patients, and all patients had no obvious evidence of bowel infarction on CT scan. Percutaneous aspiration embolectomy was primarily performed in 6 patients, and thrombolysis was initially performed in 3 patients. In 3 patients who received primary thrombolysis, percutaneous aspiration was undertaken because the emboli were resistant to urokinase. Complete angiographic success was achieved in 6 patients and partial angiographic success was accomplished in 3 patients. One patient underwent bowel resection. One patient died of whole bowel necrosis and sepsis, and 8 patients survived without complications. CONCLUSION Percutaneous aspiration embolectomy is a useful tool in recanalization of embolic occlusion of the SMA in select patients.
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Affiliation(s)
- Kyu Sung Choi
- Department of Radiology, Seoul National University College of Medicine, Institute of Radiation Medicine, Seoul National University Medical Research Center, and Clinical Research Institute, Seoul National University Hospital, Seoul 110-744, Korea
| | - Ji Dae Kim
- Department of Radiology, Eulji University Hospital, Daejeon 302-799, Korea
| | - Hyo-Cheol Kim
- Department of Radiology, Seoul National University College of Medicine, Institute of Radiation Medicine, Seoul National University Medical Research Center, and Clinical Research Institute, Seoul National University Hospital, Seoul 110-744, Korea
| | - Sang-Il Min
- Department of Surgery, Seoul National University Hospital, Seoul 110-744, Korea
| | - Seung-Kee Min
- Department of Surgery, Seoul National University Hospital, Seoul 110-744, Korea
| | - Hwan Jun Jae
- Department of Radiology, Seoul National University College of Medicine, Institute of Radiation Medicine, Seoul National University Medical Research Center, and Clinical Research Institute, Seoul National University Hospital, Seoul 110-744, Korea
| | - Jin Wook Chung
- Department of Radiology, Seoul National University College of Medicine, Institute of Radiation Medicine, Seoul National University Medical Research Center, and Clinical Research Institute, Seoul National University Hospital, Seoul 110-744, Korea
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Adaba F, Askari A, Dastur J, Patel A, Gabe SM, Vaizey CJ, Faiz O, Nightingale JMD, Warusavitarne J. Mortality after acute primary mesenteric infarction: a systematic review and meta-analysis of observational studies. Colorectal Dis 2015; 17:566-77. [PMID: 25739990 DOI: 10.1111/codi.12938] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Accepted: 01/19/2015] [Indexed: 12/12/2022]
Abstract
AIM The primary aim of this study was to determine whether the in-hospital mortality for acute mesenteric infarction has reduced in the last decade. The secondary aim was to determine if there was a statistical difference in mortality between patients having acute primary mesenteric infarction due to different causes. METHOD A literature search was performed of PubMed, Ovid (Embase) and Google Scholar databases. Studies on acute mesenteric infarction of primary vascular pathology were included for pooled analyses while studies that had reported comparative mortality between arterial, venous and non-occlusive mesenteric infarction (NOMI) were included in meta-analyses. Their quality was assessed using the National Institute for Health and Care Excellence assessment scale. Odds ratios (ORs) of mortality were calculated using a Mantel-Haenszel random effect model. RESULTS The total number of patients was 4527 and the male/female ratio was 1912/2247. The pooled in-hospital mortality was 63%. There was no significant reduction of in-hospital mortality rate in the last decade (P = 0.78). There was a significant difference in in-hospital mortality between acute arterial mesenteric infarction (73.9%) compared with acute venous mesenteric infarction (41.7%) [OR 3.47, confidence interval (CI) 2.43-4.96, P < 0.001] and NOMI (68.5%) compared with acute venous mesenteric infarction (44.2%) (OR 3.2, CI 1.83-5.6, P < 0.001). There was no difference in mortality between acute arterial mesenteric infarction and NOMI (OR 1.08, CI 0.57-2.03, P = 0.82). CONCLUSION In-hospital mortality rate has not changed in the last decade. Patients with arterial mesenteric infarction or with NOMI are over three times more likely to die during the first hospital admission compared with those with venous mesenteric infarction.
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Affiliation(s)
- F Adaba
- Intestinal Failure Unit, St Mark's Hospital, Harrow, UK
| | - A Askari
- Surgical Epidemiology Trials and Outcome Centre, St Mark's Hospital, Harrow, UK
| | - J Dastur
- Intestinal Failure Unit, St Mark's Hospital, Harrow, UK
| | - A Patel
- Intestinal Failure Unit, St Mark's Hospital, Harrow, UK
| | - S M Gabe
- Intestinal Failure Unit, St Mark's Hospital, Harrow, UK
| | - C J Vaizey
- Intestinal Failure Unit, St Mark's Hospital, Harrow, UK
| | - O Faiz
- Surgical Epidemiology Trials and Outcome Centre, St Mark's Hospital, Harrow, UK
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Ariyaratnam P, Vijayan A, Cale AR, Cowen ME, Haqzad Y, Balasubramanian S, Loubani M. Long-term prognosis and a prediction model for acute bowel ischaemia following cardiac surgery. Interact Cardiovasc Thorac Surg 2015; 21:336-41. [PMID: 26070320 DOI: 10.1093/icvts/ivv148] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Accepted: 05/13/2015] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Bowel ischaemia following cardiac surgery is associated with a high postoperative mortality. No scoring system exists as yet to predict this complication following surgery. In addition, the long-term survival is not known. We sought to evaluate in-hospital outcomes and long-term outcomes in bowel ischaemia following cardiac surgery. We also sought to devise a simple risk prediction model for this catastrophic entity. METHODS This was a retrospective study of data entered prospectively into our cardiac surgical database between July 1999 and May 2014. We compared the short- and long-term outcomes of patients who developed bowel ischaemia following cardiac surgery with those who did not develop bowel ischaemia using propensity-matched analysis. We developed a prediction model for bowel ischaemia from logistic regression. RESULTS In total, 13 853 patients underwent cardiac surgery. Of these, 85 had confirmed bowel ischaemia following surgery. The in-hospital mortality rate for those with bowel ischaemia was 60%, while in those without bowel ischaemia, the mortality rate was 3% (P < 0.0001). In those bowel ischaemia patients who had a laparotomy for corrective surgery, the in-hospital mortality was significantly less compared with those who did not have a laparotomy (39.2 vs 91.2%, P < 0.0001). The long-term survival for bowel ischaemia at 2, 6 and 10 years was 35% (±5), 31% (±5) and 26% (+/6), respectively. Multivariable analysis revealed that advanced age at surgery, peripheral vascular disease, intra-aortic balloon pump usage, NYHA IV and postoperative atrial fibrillation were the significant (P < 0.005) determinants of developing postoperative bowel ischaemia. We developed a model to predict bowel ischaemia and validated it within our population (c-index = 0.781). CONCLUSIONS We have shown that whilst bowel ischaemia carries a higher short-term mortality, the long-term mortality is not significantly greater for those few who survive to discharge. We have developed a simple prediction model to identify those at high risk of developing bowel ischaemia following cardiac surgery in order to optimize perioperative strategies in future.
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Affiliation(s)
| | - Ajith Vijayan
- Department of Cardiothoracic Surgery, Castle Hill Hospital, Cottingham, UK
| | - Alexander R Cale
- Department of Cardiothoracic Surgery, Castle Hill Hospital, Cottingham, UK
| | - Michael E Cowen
- Department of Cardiothoracic Surgery, Castle Hill Hospital, Cottingham, UK
| | - Yama Haqzad
- Department of Cardiothoracic Surgery, Castle Hill Hospital, Cottingham, UK
| | | | - Mahmoud Loubani
- Department of Cardiothoracic Surgery, Castle Hill Hospital, Cottingham, UK
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Jonker FH, Patel HJ, Upchurch GR, Williams DM, Montgomery DG, Gleason TG, Braverman AC, Sechtem U, Fattori R, Di Eusanio M, Evangelista A, Nienaber CA, Isselbacher EM, Eagle KA, Trimarchi S. Acute type B aortic dissection complicated by visceral ischemia. J Thorac Cardiovasc Surg 2015; 149:1081-6.e1. [DOI: 10.1016/j.jtcvs.2014.11.012] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Revised: 10/22/2014] [Accepted: 11/04/2014] [Indexed: 01/07/2023]
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130
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Cosse C, Sabbagh C, Browet F, Mauvais F, Rebibo L, Zogheib E, Chatelain D, Kamel S, Regimbeau JM. Serum value of procalcitonin as a marker of intestinal damages: type, extension, and prognosis. Surg Endosc 2015; 29:3132-9. [PMID: 25701059 DOI: 10.1007/s00464-014-4038-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Accepted: 12/09/2014] [Indexed: 12/31/2022]
Abstract
BACKGROUND Ischemic and necrotic damages are complications of digestive diseases and require emergency management. Nevertheless, the decision to surgically manage could be delayed because of no sufficiently preoperative accurate marker of ischemia diagnosis, extension, and prognosis. METHODS The aim of this study was to assess the predictive value of serum procalcitonin (PCT) levels for diagnosing intestinal necrotic damages, their extension, and their prognosis in patients with ischemic disease including ischemic colitis and mesenteric infarction by a gray zone approach. Between January 2007 to June 2014, 128 patients with ischemic colitis and mesenteric infarction (codes K55.0 and K51.9) were operated, for whom data on PCT were available. We perform a retrospective, multicenter review of their medical records. Patients were divided into subgroups: ischemia (ID group) versus necrosis (ND group); the extension [focal (FD) vs. extended (ED)] and the vital status [deceased (D) vs. alive (A)]. RESULTS PCT levels were higher in the ND (n = 94; p = 0.009); ED (n = 100; p = 0.02); and D (n = 70; p = 0.0003) groups. With a gray zone approach, the predictive thresholds were (i) for necrosis 2.473 ng/mL, (ii) for extension 3.884 ng/mL, and (iii) for mortality 7.87 ng/mL. CONCLUSION In our population, PCT could be used as a marker of necrosis; especially in case of extended damages and reflects the patient's prognosis.
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Affiliation(s)
- C Cosse
- Department of Digestive and Oncological Surgery, Amiens North Hospital, University of Picardie, Place Victor Pauchet, 80054, Amiens Cedex 01, France.,INSERM U1088, Jules Verne University of Picardie, Amiens, France
| | - C Sabbagh
- Department of Digestive and Oncological Surgery, Amiens North Hospital, University of Picardie, Place Victor Pauchet, 80054, Amiens Cedex 01, France
| | - F Browet
- Department of Digestive Surgery, Beauvais Hospital, Beauvais, France
| | - F Mauvais
- Department of Digestive Surgery, Beauvais Hospital, Beauvais, France
| | - L Rebibo
- Department of Digestive and Oncological Surgery, Amiens North Hospital, University of Picardie, Place Victor Pauchet, 80054, Amiens Cedex 01, France
| | - E Zogheib
- Department of Anesthesiology, Amiens South Hospital, University of Picardie, 80054, Amiens Cedex 01, France
| | - D Chatelain
- Department of Pathology, Amiens North Hospital, University of Picardie, 80054, Amiens Cedex 01, France
| | - S Kamel
- INSERM U1088, Jules Verne University of Picardie, Amiens, France.,Department of Biochemistry, Amiens South Hospital, University of Picardie, 80054, Amiens Cedex 01, France
| | - J M Regimbeau
- Department of Digestive and Oncological Surgery, Amiens North Hospital, University of Picardie, Place Victor Pauchet, 80054, Amiens Cedex 01, France. .,EA4294, Jules Verne University of Picardie, Amiens, France. .,Department of Digestive and Oncological Surgery, CHU Nord Amiens and University of Picardie, Place Victor Pauchet, 80054, Amiens Cedex 01, France. .,Clinical Research Center, Amiens University Hospital, Amiens, France.
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131
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Powell A, Armstrong P. Plasma biomarkers for early diagnosis of acute intestinal ischemia. Semin Vasc Surg 2015; 27:170-5. [PMID: 26073827 DOI: 10.1053/j.semvascsurg.2015.01.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Determining the severity of acute mesenteric ischemia or reperfusion injury can be problematic, as early visceral hypoperfusion is difficult to detect by traditional laboratory testing. Likewise gauging the success of resuscitation and therapeutic intervention is also challenging to determine by laboratory analysis alone. Investigators continue to actively search for plasma biomarkers that will aide clinicians in identifying the early microvascular changes associated with visceral splanchnic malperfusion in an effort to allow for earlier diagnosis and expedient intervention in order to minimize overall intestinal ischemia and reperfusion injury for the potential of improving clinical outcomes.
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Affiliation(s)
- Alexis Powell
- Division of Vascular and Endovascular Surgery, University of South Florida College of Medicine, 2 Tampa General Circle, Suite 7001, Tampa, FL
| | - Paul Armstrong
- Division of Vascular and Endovascular Surgery, University of South Florida College of Medicine, 2 Tampa General Circle, Suite 7001, Tampa, FL.
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Isquemia mesentérica «crónica agudizada» – a multidisciplinaridade subjacente ao sucesso terapêutico. ANGIOLOGIA E CIRURGIA VASCULAR 2014. [DOI: 10.1016/j.ancv.2014.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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133
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Yang S, Wu X, Yu W, Li J. Early enteral nutrition in critically ill patients with hemodynamic instability: an evidence-based review and practical advice. Nutr Clin Pract 2014; 29:90-6. [PMID: 24449685 DOI: 10.1177/0884533613516167] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Early enteral nutrition (EEN) in critically ill patients is associated with significant benefit as well as elevated risk of complications. Concomitant use of EEN with vasopressors has been associated with nonocclusive bowel necrosis in critically ill patients with hemodynamic instability. The decision when to initiate enteral nutrition in hemodynamically unstable patients that require vasoactive substances remains a clinical dilemma. This review summarizes the effect of EEN and vasoactive agents on gastrointestinal blood flow and perfusion in critically ill patients, based on current evidence. Animal and clinical data involving simultaneous administration of EEN and vasoactive agents for hemodynamic instability are reviewed, and the factors related to the safety and effectiveness of EEN support in this patient population are analyzed. Moreover, practical recommendations are provided. Additional randomized clinical trials are warranted to provide cutting-edge evidence-based guidance about this issue for practitioners of critical care.
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Affiliation(s)
- Shuofei Yang
- Wenkui Yu, Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing 210002, Jiangsu Province, People's Republic of China, Nanjing, 210002, China.
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Akyıldız HY, Sözüer E, Uzer H, Baykan M, Oz B. The length of necrosis and renal insufficiency predict the outcome of acute mesenteric ischemia. Asian J Surg 2014; 38:28-32. [PMID: 25183292 DOI: 10.1016/j.asjsur.2014.06.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Revised: 04/29/2014] [Accepted: 06/10/2014] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Acute mesenteric ischemia (AMI) is a potentially life-threatening condition because of its diagnostic difficulty, operative challenges, and comorbidities a patient may have. The aim of this study was to identify factors associated with adverse outcomes in patients with AMI. METHODS The hospital records and clinical data of all patients with AMI were reviewed for a recent 4-year period. Clinical outcomes and factors influencing mortality were analyzed. RESULTS Included in the study were 104 patients (46 females and 58 males) with an overall mean age of 66 ± 13.4 years. The cause of AMI was arterial pathology in 74 (71%) patients, venous thrombosis in 15 (14%) patients, and nonocclusive ischemia in 12 (12%) patients. Abdominal pain was the most common presenting symptom (97% of patients). The 30-day mortality rate was 66%. Univariate analysis showed that mortality was associated with renal insufficiency (p = 0.004), an age greater than 70 years (p = 0.02), the presence of comorbidities (p = 0.001), a leukocyte count greater than 18,000/mL (p = 0.04), and small bowel necrosis of more than 100 cm (p < 0.0001). Logistic regression analysis showed that independent predictors of mortality were small bowel necrosis of more than 100 cm (p = 0.002) and a serum creatinine level greater than 2 mg/dL (p = 0.04). CONCLUSION The length of the necrosis and renal insufficiency are the primary factors that result in a poor outcome in AMI patients. Prompt diagnostic evaluation and early therapeutic interventions may help to prevent the development of these fatal predictors.
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Affiliation(s)
- Hızır Yakup Akyıldız
- Department of General Surgery, Erciyes University School of Medicine, Melikgazi, Kayseri 38039, Turkey.
| | - Erdogan Sözüer
- Department of General Surgery, Erciyes University School of Medicine, Melikgazi, Kayseri 38039, Turkey
| | - Hasan Uzer
- Department of General Surgery, Erciyes University School of Medicine, Melikgazi, Kayseri 38039, Turkey
| | - Mehmet Baykan
- Department of General Surgery, Erciyes University School of Medicine, Melikgazi, Kayseri 38039, Turkey
| | - Bahadır Oz
- Department of General Surgery, Erciyes University School of Medicine, Melikgazi, Kayseri 38039, Turkey
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135
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Impaired intestinal mucosal barrier upon ischemia-reperfusion: "patching holes in the shield with a simple surgical method". BIOMED RESEARCH INTERNATIONAL 2014; 2014:210901. [PMID: 24955347 PMCID: PMC4053295 DOI: 10.1155/2014/210901] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Revised: 04/08/2014] [Accepted: 04/17/2014] [Indexed: 12/14/2022]
Abstract
Mesenteric ischemia-reperfusion (IR) is associated with impairment of the gut barrier function and the initiation of a proinflammatory cascade with life-threatening results. Therefore methods directed to ameliorate IR injury are of great importance. We aimed at describing the effects of postconditioning (PC) on the alterations of the intestinal mucosal function and the inflammatory response upon mesenteric IR. Methods. Male Wistar rats were gavaged with green fluorescent protein-expressing E. coli suspensions. Animals were randomized into three groups (n = 15), sham-operated, IR-, and PC-groups, and underwent 60 minutes of superior mesenteric artery occlusion, followed by 6 hours of reperfusion. Postconditioning was performed at the onset of reperfusion. Blood and tissue samples were taken at the end of reperfusion, for histological, bacteriological, and plasma examinations. Results. The PC-group presented a more favorable claudin-2, claudin-3, claudin-4, and zonula occludens-1 membrane expression profile, and significantly lower rates of bacterial translocation to distant organs and plasma D-lactate levels compared to the IR-group. Histopathological lesions, plasma I-FABP, IL-6, and TNF-α levels were significantly lower in the PC-group compared to the IR-group. Conclusion. The use of postconditioning improved the integrity of the intestinal mucosal barrier upon mesenteric IR, and thus reduced the incidence of bacterial translocation and development of a systemic inflammatory response.
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136
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Blauw JTM, Meerwaldt R, Brusse-Keizer M, Kolkman JJ, Gerrits D, Geelkerken RH. Retrograde open mesenteric stenting for acute mesenteric ischemia. J Vasc Surg 2014; 60:726-34. [PMID: 24820898 DOI: 10.1016/j.jvs.2014.04.001] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Accepted: 04/03/2014] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Acute mesenteric ischemia (AMI) encompasses the sequels of end-stage untreated chronic mesenteric ischemia and acute mesenteric artery thrombosis. Percutaneous mesenteric artery stenting (PMAS) is the preferred treatment of patients with AMI but is not always feasible. Retrograde open mesenteric stenting (ROMS) is a hybrid technique that combines the advantages of open surgical and endovascular approaches. The literature on the results of this new technique is scarce. The aim of this study was to evaluate the results of ROMS in a consecutive series of patients with AMI. METHODS All patients with emergent mesenteric revascularization for AMI between January 2007 and September 2011 were entered in our prospective registry. Technical success, mortality, patency, clinical success, and complication rate at 30 days and 6 and 12 months were assessed. RESULTS Sixty-eight patients presented with AMI and 54 underwent PMAS, of which four were unsuccessful and followed by ROMS. Eleven patients were directly treated with ROMS, making a total of 15 patients (10 women and five men; median age, 66 years [interquartile range, 54-73 years]). In all patients, only the superior mesenteric artery was revascularized. In nine of the 15 patients, all three mesenteric arteries were severely stenotic or occluded. Technical success was achieved in 14 patients. At ROMS in two patients, the small bowel was severely ischemic. One of these patients needed a partial bowel resection because of irreversible transmural ischemia. At 30 days, the mortality rate was 20% and the primary patency was 92%. Ten patients underwent unplanned relaparotomy, of whom one needed resection of a large part of the small bowel. At 12 months, the mortality rate was still 20%. The primary patency was 83%. Primary assisted patency was 91%, and secondary patency was 100%. Clinical success at 30 days, 6 months, and 12 months, respectively, was 73%, 67%, and 67%. CONCLUSIONS AMI is still a devastating event. If PMAS is not feasible, ROMS is a reliable alternative and is associated with a relatively low mortality and morbidity rate.
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Affiliation(s)
- Juliette T M Blauw
- Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, The Netherlands; Department of Surgery, Isala Clinics, Zwolle, The Netherlands.
| | - Robert Meerwaldt
- Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | | | - Jeroen J Kolkman
- Department of Gastroenterology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Dick Gerrits
- Department of Interventional Radiology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Robert H Geelkerken
- Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
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137
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Karakaş BR, Sırcan-Küçüksayan A, Elpek OE, Canpolat M. Investigating viability of intestine using spectroscopy: a pilot study. J Surg Res 2014; 191:91-8. [PMID: 24746953 DOI: 10.1016/j.jss.2014.03.052] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Revised: 02/21/2014] [Accepted: 03/18/2014] [Indexed: 12/19/2022]
Abstract
BACKGROUND The differentiation of "viable" from "nonviable" bowel remains a challenge in the treatment of acute mesenteric ischemia. In this study, diffuse reflectance spectroscopy (DRS) was used to investigate the viability of bowel tissue after ischemia and reperfusion in an animal model in vivo and in real time. METHODS A total of 25 females Sprague-Dawley rats were divided into five groups based on different bowel ischemia times. In each study group for four of them, the superior mesenteric artery was occluded using a vascular clamp for a different period (i.e., 30, 45, 60, and 90 min; n = 5 for each group). Intestinal reperfusion was accomplished by releasing the clamps after the given occlusion period for each group. Spectra were acquired by gently touching the optical fiber probe to the bowel tissue before the induce ischemia, at the end of the induced ischemia, and after the reperfusion. The data acquired before the ischemia were used as a control group. Without occluding the superior mesenteric artery, the spectra were acquired on the bowel with the same time intervals of the experiments were used as a sham group (n = 5). Subsequently, the same bowel segments were sent for histopathologic examination. RESULTS Based on the correlation between the spectra acquired from the bowel segments and the results from the histopathologic investigation, DRS is able to differentiate the histopathologic grading that appears when the Chiu/Park score ≥5 (i.e., high-level ischemic injury) than Chiu/Park score <5. Eight out of nine low-level ischemic injury tissue samples were correctly defined using the spectroscopic classification system. All eleven high-level ischemic injury tissues that were histopathologically assigned grade 5 and above were correctly defined using the spectroscopic classification system in the ischemia-reperfusion groups. CONCLUSIONS DRS could potentially be used intraoperatively for the assessment of bowel viability in real time. These preliminary findings suggest that DRS has the potential to reduce unnecessary resection of viable tissue or insufficient resection of nonviable tissues may reduce the mortality and morbidity rates of intestinal ischemia-reperfusion as acute mesenteric ischemia.
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Affiliation(s)
- Barış R Karakaş
- Department of General Surgery, Antalya Training and Research Hospital, Antalya, Turkey
| | - Aslınur Sırcan-Küçüksayan
- Department of Biophysics, Faculty of Medicine, Biomedical Optics Research Unit, Akdeniz University, Antalya, Turkey
| | - Ozlem E Elpek
- Department of Pathology, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - Murat Canpolat
- Department of Biophysics, Faculty of Medicine, Biomedical Optics Research Unit, Akdeniz University, Antalya, Turkey.
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139
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Nagaraja R, Rao P, Kumaran V, Yadav A, Kapoor S, Varma V, Mehta N, Nundy S. Acute Mesenteric Ischaemia-An Indian Perspective. Indian J Surg 2014; 77:843-9. [PMID: 27011468 DOI: 10.1007/s12262-014-1034-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Accepted: 01/08/2014] [Indexed: 12/13/2022] Open
Abstract
In Western countries, acute mesenteric ischaemia is commonly due to arterial occlusion and occurs in patients who are usually in their seventh decade. A venous cause for intestinal gangrene has been reported in only about 10 %. We examined whether this was so in India and compared the clinical features of patients with mesenteric arterial and venous ischaemia and relate these to their ultimate prognosis. We studied retrospectively, the records of all patients admitted or referred to the department with a diagnosis of acute mesenteric ischaemia between January 1997 and October 2012, noting their demographic details and mode of presentation, the results of preoperative imaging and blood investigations, the extent of bowel ischaemia, and the length of bowel that was resected at operation and their outcome. There were 117 patients, 85 males and 32 females whose median age was 53 years. Mesenteric venous thrombosis was seen in 56 patients (48 %) and mesenteric arterial occlusion in 61 (52 %). Forty six patients died (39 %); 15 with venous occlusion (27 %) and 31 with arterial occlusion (51 %). Compared to patients with arterial occlusion, the patients with venous obstruction were younger, had a longer duration of symptoms, were less frequently hypotensive at presentation, had higher platelet counts, had a shorter length of bowel resected, had fewer colonic resections and had a lower mortality. Other predictors of mortality on multivariate analysis were a longer duration of symptoms, lower serum albumin and higher creatinine levels at presentation and a shorter length of residual bowel. In India, acute mesenteric ischaemia in tertiary care centres is due to venous thrombosis in almost half of the patients who are at least a decade younger than those in the West. Significant predictors of mortality include low serum albumin and raised creatinine levels, a shorter residual bowel length and an arterial cause for mesenteric ischaemia.
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Affiliation(s)
- Raghavendra Nagaraja
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, India ; Department of Surgical Gastroenterology and Liver Transplantation, Manipal Hospital, Old Airport Road, Kodihalli, Bengaluru India
| | - Prashantha Rao
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, India
| | - Vinay Kumaran
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, India
| | - Amitabh Yadav
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, India
| | - Sorabh Kapoor
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, India
| | - Vibha Varma
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, India
| | - Naimish Mehta
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, India
| | - Samiran Nundy
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, India
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Al-Jundi W, Haqzad Y, Madbak K, Chan P. Ileocolic to right iliac arterial transposition for the treatment of chronic mesenteric ischemia. Int J Angiol 2014; 22:259-62. [PMID: 24436624 DOI: 10.1055/s-0033-1347910] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
The treatment of chronic mesenteric ischemia remains challenging and controversy exists over the best interventional option. Endovascular treatment has emerged as first-line management due to its associated lower morbidity and mortality than surgical reconstruction. However, open mesenteric reconstructions continue to play an important role in patients with lesions that are unsuitable for an endovascular option. Mesenteric operations utilize the aorta or iliac artery as the inflow source for a vein or prosthetic bypass to the celiac artery or superior mesenteric artery. We describe an exceptional case of chronic mesenteric ischemia due to atherosclerosis that was treated successfully with a novel ileocolic to right iliac arterial transposition.
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Affiliation(s)
- Wissam Al-Jundi
- Sheffield Vascular Institute, Department of Vascular Surgery, Northern General Hospital, Sheffield, South Yorkshire, United Kingdom
| | - Yama Haqzad
- Sheffield Vascular Institute, Department of Vascular Surgery, Northern General Hospital, Sheffield, South Yorkshire, United Kingdom
| | - Khalil Madbak
- Sheffield Vascular Institute, Department of Vascular Surgery, Northern General Hospital, Sheffield, South Yorkshire, United Kingdom
| | - Phillip Chan
- Sheffield Vascular Institute, Department of Vascular Surgery, Northern General Hospital, Sheffield, South Yorkshire, United Kingdom
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Conaway D. Hypothermia and the acute abdomen. BMJ Case Rep 2014; 2014:bcr-2013-202774. [PMID: 24429054 DOI: 10.1136/bcr-2013-202774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 64-year old man presented to A&E with a 24 h history of persistent hypothermia and increasing confusion. His medical history included congestive heart failure, hypertension and intermittent claudication secondary to distal abdominal aortic occlusion. Examination revealed profound hypothermia-31°C, bilateral reduced power in the lower limbs and no palpable peripheral pulses. Initial blood tests revealed a metabolic acidosis with hyperlactactaemia, neutrophilia and deranged electrolytes. CT scan of the abdomen revealed extensive thromboemobolic disease of the abdominal arterial tree and diagnosed acute mesenteric ischaemia. The patient was taken to theatre where an emergency laparotomy demonstrated a perforated duodenum, which was subsequently patched, followed immediately by an axillofemoral bypass with subsequent femoral-femoral crossover. Sadly, the patient passed away shortly after completion of surgery.
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Affiliation(s)
- Daniel Conaway
- Department of Neurosurgery, John Radcliffe Hospital, Oxford, UK
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142
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Demir M, Amanvermez R, Kamalı Polat A, Karabıçak İ, Çınar H, Kesicioğlu T, Polat C. The effect of silymarin on mesenteric ischemia-reperfusion injury. Med Princ Pract 2014; 23:140-4. [PMID: 24356575 PMCID: PMC5586953 DOI: 10.1159/000356860] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Accepted: 10/21/2013] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To examine the effect of silymarin (SM), a mixture of flavonoids and polyphenols extracted from Silybum marianum, on mesenteric ischemia-reperfusion (I-R) injury in a rat model. MATERIALS AND METHODS Fifty rats were randomly divided into 5 groups (n = 10). Group 1 was sham operated, while groups 2-5 were subjected to mesenteric I-R lasting 1 h. Group 2 received isotonic sodium chloride, group 3 received SM (100 mg/kg/day) for 7 days before I-R, group 4 received SM for 7 days after I-R, and group 5 received SM for 7 days both before and after I-R. The rats were sacrificed by exsanguination in groups 1-3 at the 24th hour and groups 4 and 5 were sacrificed on the 7th day of reperfusion. Blood and intestinal specimens were taken for biochemical and pathological evaluations. RESULTS Serum superoxide dismutase (SOD) and heat shock protein 70 levels were significantly higher in group 2 (5.24 ± 1.76 U/l and 261.4 ± 16.8 ng/ml) compared to the sham group (2.08 ± 1.76 U/l and 189.9 ± 28.7 ng/ml) (p < 0.001 and p < 0.0001, respectively). However, SOD activity and the extent and severity of the histopathological lesions were significantly less in groups 3 [3.11 ± 1.18 U/l, 1.0 (range 0.0-2.0)], 4 [2.15 ± 0.87 U/l, 1.0 (range 1.0-3.0)], and 5 [1.80 ± 0.61 U/l, 0.5 (range 0.0-2.0)], treated with SM, than in group 2 [5.24 ± 1.76 U/l, 2.0 (range 2.0-3.0)] (p = 0.002, p < 0.001, and p = 0.0001; p < 0.001, p = 0.007, and p = 0.0001, respectively). Also, TNF-α levels were lower in the SM-supplemented groups compared to group 2. Serum thiobarbituric acid-reactive substance concentrations were low in the pre-/posttreatment groups treated with SM compared to group 2. No statistical difference was observed for protein carbonyls between the groups. CONCLUSION Our findings suggest that SM therapy may attenuate the oxidative and intestinal damage induced by I-R injuries.
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Affiliation(s)
- M. Demir
- Department of General Surgery, Ondokuz Mayıs University, Samsun, Turkey
| | - R. Amanvermez
- Department of Medical Biochemistry, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Turkey
- *Dr. Ramazan Amanvermez, Department of Medical Biochemistry, Faculty of Medicine, Ondokuz Mayıs University, TR-55139 Samsun (Turkey), E-Mail
| | - A. Kamalı Polat
- Department of General Surgery, Ondokuz Mayıs University, Samsun, Turkey
| | - İ. Karabıçak
- Department of General Surgery, Ondokuz Mayıs University, Samsun, Turkey
| | - H. Çınar
- Department of General Surgery, Ondokuz Mayıs University, Samsun, Turkey
| | - T. Kesicioğlu
- Department of General Surgery, Ondokuz Mayıs University, Samsun, Turkey
| | - C. Polat
- Department of General Surgery, Ondokuz Mayıs University, Samsun, Turkey
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143
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Yang J, Su Y, Zhou Y, Besner GE. Heparin-binding EGF-like growth factor (HB-EGF) therapy for intestinal injury: Application and future prospects. ACTA ACUST UNITED AC 2013; 21:95-104. [PMID: 24345808 DOI: 10.1016/j.pathophys.2013.11.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Throughout the past 20 years, we have been investigating the potential therapeutic roles of heparin-binding EGF-like growth factor (HB-EGF), a member of the epidermal growth factor family, in various models of intestinal injury including necrotizing enterocolitis (NEC), intestinal ischemia/reperfusion (I/R) injury, and hemorrhagic shock and resuscitation (HS/R). Our studies have demonstrated that HB-EGF acts as an effective mitogen, a restitution-inducing reagent, a cellular trophic factor, an anti-apoptotic protein and a vasodilator, via its effects on various cell types in the intestine. In the current paper, we have reviewed the application and therapeutic effects of HB-EGF in three classic animal models of intestinal injury, with particular emphasis on its protection of the intestines from NEC. Additionally, we have summarized the protective functions of HB-EGF on various target cells in the intestine. Lastly, we have provided a brief discussion focusing on the future development of HB-EGF clinical applications for the treatment of various forms of intestinal injury including NEC.
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Affiliation(s)
- Jixin Yang
- The Research Institute at Nationwide Children's Hospital, Center for Perinatal Research, Department of Pediatric Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH 43205, USA.
| | - Yanwei Su
- The Research Institute at Nationwide Children's Hospital, Center for Perinatal Research, Department of Pediatric Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH 43205, USA.
| | - Yu Zhou
- The Research Institute at Nationwide Children's Hospital, Center for Perinatal Research, Department of Pediatric Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH 43205, USA.
| | - Gail E Besner
- The Research Institute at Nationwide Children's Hospital, Center for Perinatal Research, Department of Pediatric Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH 43205, USA.
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Beaulieu RJ, Arnaoutakis KD, Abularrage CJ, Efron DT, Schneider E, Black JH. Comparison of open and endovascular treatment of acute mesenteric ischemia. J Vasc Surg 2013; 59:159-64. [PMID: 24199769 DOI: 10.1016/j.jvs.2013.06.084] [Citation(s) in RCA: 115] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Revised: 06/19/2013] [Accepted: 06/20/2013] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Acute mesenteric ischemia (AMI) is a commonly fatal result of inadequate bowel perfusion that requires immediate evaluation by both vascular and general surgeons. Treatment often involves vascular repair as well as bowel resection and the possible need for parenteral nutrition. Little data exist regarding the rates of bowel resection following endovascular vs open repair of AMI. METHODS Using the National Inpatient Sample database, admissions from 2005 through 2009 were identified according to International Classification of Diseases, Ninth Revision codes correlating to both AMI (557.0) and subsequent vascular intervention (39.26, 38.16, 38.06, 39.9, 99.10). Patients with a diagnosis of AMI but no intervention or nonemergent admission status were excluded. Patient level data regarding age, gender, and comorbidities were also examined. Outcome measures included mortality, length of stay, the need for bowel resection (45.6, 45.71-9, 45.8), or infusion of total parenteral nutrition (TPN; 99.10) during the same hospitalization. Statistical analysis was conducted by χ(2) tests and Wilcoxon rank-sum comparisons. RESULTS Of 23,744 patients presenting with AMI, 4665 underwent interventional treatment from 2005 through 2009. Of these patients, 57.1% were female, and the mean age was 70.5 years. A total of 679 patients underwent vascular intervention; 514 (75.7%) underwent open surgery and 165 (24.3%) underwent endovascular treatment overall during the study period. The proportion of patients undergoing endovascular repair increased from 11.9% of patients in 2005 to 30.0% in 2009. Severity of comorbidities, as measured by the Charlson index, did not differ significantly between the treatment groups. Mortality was significantly more commonly associated with open revascularization compared with endovascular intervention (39.3% vs 24.9%; P = .01). Length of stay was also significantly longer in the patient group undergoing open revascularization (12.9 vs 17.1 days; P = .006). During the study time period, 14.4% of patients undergoing endovascular procedures required bowel resection compared with 33.4% for open revascularization (P < .001). Endovascular repair was also less commonly associated with requirement for TPN support (13.7% vs 24.4%; P = .025). CONCLUSIONS Endovascular intervention for AMI had increased significantly in the modern era. Among AMI patients undergoing revascularization, endovascular treatment was associated with decreased mortality and shorter length of stay. Furthermore, endovascular intervention was associated with lower rates of bowel resection and need for TPN. Further research is warranted to determine if increased use of endovascular repair could improve overall and gastrointestinal outcomes among patients requiring vascular repair for AMI.
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Affiliation(s)
- Robert J Beaulieu
- Department of Surgery, Johns Hopkins Medical Institutes, Baltimore, Md
| | | | | | - David T Efron
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Md
| | - Eric Schneider
- Center for Surgical Trials and Outcomes Research, Johns Hopkins Hospital, Baltimore, Md
| | - James H Black
- Division of Vascular Surgery, Johns Hopkins Hospital, Baltimore, Md.
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145
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Cudnik MT, Darbha S, Jones J, Macedo J, Stockton SW, Hiestand BC. The diagnosis of acute mesenteric ischemia: A systematic review and meta-analysis. Acad Emerg Med 2013; 20:1087-100. [PMID: 24238311 DOI: 10.1111/acem.12254] [Citation(s) in RCA: 118] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2012] [Revised: 02/13/2013] [Accepted: 07/20/2013] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Acute mesenteric ischemia is an infrequent cause of abdominal pain in emergency department (ED) patients; however, mortality for this condition is high. Rapid diagnosis and surgery are key to survival, but presenting signs are often vague or variable, and there is no pathognomonic laboratory screening test. A systematic review and meta-analysis of the available literature was performed to determine diagnostic test characteristics of patient symptoms, objective signs, laboratory studies, and diagnostic modalities to help rule in or out the diagnosis of acute mesenteric ischemia in the ED. METHODS In concordance with published guidelines for systematic reviews, the medical literature was searched for relevant articles. The Quality Assessment Tool for Diagnostic Accuracy Studies-2 (QUADAS-2) for systematic reviews was used to evaluate the overall quality of the trials included. Summary estimates of diagnostic accuracy were computed by using a random-effects model to combine studies. Those studies without data to fully complete a two-by-two table were not included in the meta-analysis portion of the project. RESULTS The literature search identified 1,149 potentially relevant studies, of which 23 were included in the final analysis. The quality of the diagnostic studies was highly variable. A total of 1,970 patients were included in the combined population of all included studies. The prevalence of acute mesenteric ischemia ranged from 8% to 60%. There was a pooled sensitivity for l-lactate of 86% (95% confidence interval [CI] = 73% to 94%) and a pooled specificity of 44% (95% CI = 32% to 55%). There was a pooled sensitivity for D-dimer of 96% (95% CI = 89% to 99%) and a pooled specificity of 40% (95% CI = 33% to 47%). For computed tomography (CT), we found a pooled sensitivity of 94% (95% CI = 90% to 97%) and specificity of 95% (95% CI = 93% to 97%). The positive likelihood ratio (+LR) for a positive CT was 17.5 (95% CI = 5.99 to 51.29), and the negative likelihood ratio (-LR) was 0.09 (95% CI = 0.05 to 0.17). The pooled operative mortality rate for mesenteric ischemia was 47% (95% CI = 40% to 54%). Given these findings, the test threshold of 2.1% (below this pretest probability, do not test further) and a treatment threshold of 74% (above this pretest probability, proceed to surgical management) were calculated. CONCLUSIONS The quality of the overall literature base for mesenteric ischemia is varied. Signs, symptoms, and laboratory testing are insufficiently diagnostic for the condition. Only CT angiography had adequate accuracy to establish the diagnosis of acute mesenteric ischemia in lieu of laparotomy.
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Affiliation(s)
- Michael T. Cudnik
- The Departments of Emergency Medicine; The Ohio State University; Columbus OH
| | - Subrahmanyam Darbha
- The Departments of Emergency Medicine; The Ohio State University; Columbus OH
| | - Janice Jones
- The Departments of Emergency Medicine; The Ohio State University; Columbus OH
| | - Julian Macedo
- The Departments of Emergency Medicine; The Ohio State University; Columbus OH
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Acute mesenteric ischemia after cardiac surgery: an analysis of 52 patients. ScientificWorldJournal 2013; 2013:631534. [PMID: 24288499 PMCID: PMC3826337 DOI: 10.1155/2013/631534] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Accepted: 09/08/2013] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVE Acute mesenteric ischemia (AMI) is a rare but serious complication after cardiac surgery. The aim of this retrospective study was to evaluate the incidence, outcome, and perioperative risk factors of AMI in the patients undergoing elective cardiac surgery. METHODS From January 2005 to May 2013, all patients who underwent cardiac surgery were screened for participation, and patients with registered gastrointestinal complications were retrospectively reviewed. Univariate analyses were performed. RESULTS The study included 6013 patients, of which 52 (0.86%) patients suffered from AMI, 35 (67%) of whom died. The control group (150 patients) was randomly chosen from among cases undergoing cardiopulmonary bypass (CPB). Preoperative parameters including age (P = 0.03), renal insufficiency (P = 0.004), peripheral vascular disease (P = 0.04), preoperative inotropic support (P < 0.001), poor left ventricular ejection fraction (P = 0.002), cardiogenic shock (P = 0.003), and preoperative intra-aortic balloon pump (IABP) support (P = 0.05) revealed significantly higher levels in the AMI group. Among intra- and postoperative parameters, CPB time (P < 0.001), dialysis (P = 0.04), inotropic support (P = 0.007), prolonged ventilator time (P < 0.001), and IABP support (P = 0.007) appeared significantly higher in the AMI group than the control group. CONCLUSIONS Prompt diagnosis and early treatment should be initiated as early as possible in any patient suspected of AMI, leading to dramatic reduction in the mortality rate.
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Corcos O, Nuzzo A. Gastro-intestinal vascular emergencies. Best Pract Res Clin Gastroenterol 2013; 27:709-25. [PMID: 24160929 DOI: 10.1016/j.bpg.2013.08.006] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Revised: 08/13/2013] [Accepted: 08/21/2013] [Indexed: 01/31/2023]
Abstract
Gastro-Intestinal Vascular Emergencies include all digestive ischaemic injuries related to acute or chronic vascular and/or haemodynamic diseases. Gastro-intestinal ischaemic injuries can be occlusive or non-occlusive, arterial or venous, localized or generalized, superficial or transmural and share the risks of infarction, organ failure and death. The diagnosis must be suspected, at the initial presentation of any sudden, continuous and unusual abdominal pain, contrasting with normal physical examination. Risk factors are often unknown at presentation and no biomarker is currently available. The diagnosis is confirmed by abdominal computed tomography angiography identifying intestinal ischaemic injury, either with vascular occlusion or in a context of low flow. Recent knowledge in the pathophysiology of acute mesenteric ischaemia, clinical experience and existing recommendations have generated a multimodal and multidisciplinary management strategy. Based on the gastro-intestinal viability around a simple algorithm, and coordinated by gastroenterologists, the dual aim is to avoid large intestinal resections and death.
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Affiliation(s)
- Olivier Corcos
- Department of Gastroenterology, IBD, Nutritional Support and Intestinal Transplantation, Beaujon Hospital Clichy, Paris VII University, 100 Boulevard du General Leclerc, 92110 Clichy, France.
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Tseng CY, Chiu YH, Chuang JL, Chen JD, Huang HH, How CK, Yen DHT, Huang MS. How to differentiate spontaneous intramural intestinal hemorrhage from acute mesenteric ischemia. Am J Emerg Med 2013; 31:1586-90. [PMID: 24051008 DOI: 10.1016/j.ajem.2013.08.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Revised: 08/08/2013] [Accepted: 08/09/2013] [Indexed: 01/20/2023] Open
Abstract
OBJECTS The purpose of our study was to assess the diagnostic values of laboratory tests to differentiate spontaneous intramural intestinal hemorrhage (SIIH) from acute mesenteric ischemia (AMI) after abdominal computed tomography (CT) survey in the emergency department (ED). METHOD We retrospectively included 76 patients diagnosed SIIH or AMI after abdominal CT. RESULTS The mean ages of 28 SIIH patients and 48 AMI patients were 75.9 ± 13.7 years and 75.8 ± 11.6 years, respectively. Patients with SIIH had significantly higher rate of Coumadin use (P < .001) and localized tenderness (P < .05). In laboratory findings, SIIH patients had prolonged prothrombin time (PT) (83.6 ± 30.0 vs. 13.4 ± 3.2, P < .001), lower blood urea nitrogen (P < .05), lower creatinine (P < .05), and lower creatine kinase (P < .05). Prolonged PT showed good discriminative value to differentiate acute abdomen patients with SIIH from AMI after abdominal CT, with an area under the receiver operating characteristic curve of 0.980 (95% confidence interval, 0.918-0.998; P < .0001). Prolonged PT cut-off value of ≧22.5 seconds had a sensitivity of 92.9% and a specificity of 100%. Logistic regression analysis identified prolonged PT as an independent predictor of SIIH (odds ratio, OR, 22.2; P = .007). CONCLUSION Abdominal pain patients with either SIIH or AMI are rare in the ED, but abdominal CT sometimes cannot help to differentiate them due to similar CT findings. Prolonged PT might help emergency physicians and surgeons differentiate SIIH from AMI in such cases.
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Affiliation(s)
- Chia-Ying Tseng
- Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung 407, Taiwan; Emergency Medicine, College of Medicine, National Yang-Ming University, Taipei 112, Taiwan
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Meyer ZC, Schreinemakers JM, Mulder PG, de Waal RA, Ermens AA, van der Laan L. Determining the clinical value of lactate in surgical patients on the intensive care unit. J Surg Res 2013; 183:814-20. [DOI: 10.1016/j.jss.2013.02.048] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Revised: 02/20/2013] [Accepted: 02/22/2013] [Indexed: 12/22/2022]
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150
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An unusual case of mesenteric ischemia in a patient with cardiac myxoma. Rev Port Cardiol 2013; 32:609-12. [DOI: 10.1016/j.repc.2012.11.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Revised: 06/02/2012] [Accepted: 11/06/2012] [Indexed: 11/17/2022] Open
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