Long-term results after surgery for acute mesenteric ischemia

Immediate postoperative parenteral anticoagulant therapy in patients with mesenteric ischemia after intestinal resection: a retrospective cohort study at a single institute

BACKGROUND

Bowel gangrene represents a major fatal event in acute mesenteric ischemia. Intestinal resection is inevitable in patients with peritonitis and bowel gangrene. This retrospective study aimed to elucidate the benefit of postoperative parenteral anticoagulation in patients with intestinal resection.

METHODS

Patients with acute mesenteric ischemia and bowel gangrene were recruited retrospectively between January 2007 and December 2019. All patients underwent bowel resection. They were categorized into two groups: patients without immediate parenteral anticoagulant therapy (Group A) and those with immediate parenteral anticoagulant therapy (Group B). Thirty-day mortality and survival were analyzed.

RESULTS

A total of 85 patients were included, with 29 patients in Group A and 56 patients in Group B. Patients in Group B had lower 30-day mortality (16.1%) and a higher 2-year survival rate (45.4%) than patients in Group A (30-day mortality: 51.7%, p = 0.001; 2-year survival rate: 19.0%, p = 0.001). In the 30-day mortality multivariate analysis, patients in Group B had a better outcome (odds ratio = 0.080, 95% confidence interval between 0.011 and 0.605, p = 0.014). Patients in Group B also had a better outcome in the survival multivariate analysis (hazard ratio: 0.435, 95% confidence interval between 0.213 and 0.887, p = 0.022).

CONCLUSIONS

Immediate postoperative parenteral anticoagulant therapy improves prognosis in patients with acute mesenteric ischemia treated by intestinal resection. Trial registration This research was retrospectively approved by the Institutional Review Board (IRB) I&II of Taichung Veterans General Hospital (TCVGH-IRB No.CE21256B) on July 28th, 2021. The informed consent waiver was also approved by IRB I&II of Taichung Veterans General Hospital. The Declaration of Helsinki and ICH-GCP guidelines were followed during this study.

Potential for intestinal transplantation after acute mesenteric ischemia in patients aged less than 70 years: A population-based study

BACKGROUND AND OBJECTIVE

Acute mesenteric ischemia (AMI) has a high mortality rate due to the development of bowel necrosis. Patients are often ruled outside active care if a large proportion of small bowel is necrotic. With the development of treatment for short bowel syndrome (SBS) and intestinal transplantation methods, long-term survival is possible even after extensive small bowel resections. This study aims to assess the incidence of SBS and potentially suitable candidates for intestinal transplantation among patients treated for AMI.

METHODS

This population-based retrospective study comprised patients aged less than 70 years and diagnosed with AMI between January 2006 and October 2020 in Helsinki and Uusimaa health care district, Finland.

RESULTS

Altogether, AMI was diagnosed in 711 patients, of whom 133 (19%) were aged below 70. An intervention was performed in 110 (83%) patients. Of these 133 patients, 16 (12%) were ruled outside active treatment due to extensive small bowel necrosis at exploratory laparotomy, of whom 6 (5%) were potentially suitable for intestinal transplantation. Two patients were considered as potential candidates for intestinal transplantation at bowel resection but died of AMI. Nine (7%) patients needed parenteral nutrition after resection, and two of them (2%) developed SBS. Only one patient needed long-term parenteral nutrition after hospital discharge. This patient remained dependent on parenteral nutrition but died before evaluation of intestinal transplantation could be carried out while the other patient was able to return to enteral nutrition.

CONCLUSIONS

A small number of patients with AMI below 70 years of age are potentially eligible for intestinal transplantation.

Surgical Emergencies in the ICU

Surgical emergencies are common in the critical care setting and require prompt diagnosis and management. Here, we discuss some of the surgical emergencies involving the gastrointestinal, hepatobiliary, and genitourinary sites. In addition, foreign body aspiration and necrotizing soft-tissue infections have been elaborated. Clinicians should be aware of the risk factors, keys examination findings, diagnostic modalities, and medical as well as surgical treatment options for these potentially fatal illnesses.

Incidence and outcomes of acute mesenteric ischaemia: a systematic review and meta-analysis

OBJECTIVE

To estimate the incidence of acute mesenteric ischaemia (AMI), proportions of its different forms and short-term and long-term mortality.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE (Ovid), Web of Science, Scopus and Cochrane Library were searched until 26 July 2022.

ELIGIBILITY CRITERIA

Studies reporting data on the incidence and outcomes of AMI in adult populations.

DATA EXTRACTION AND SYNTHESIS

Data extraction and quality assessment with modified Newcastle-Ottawa scale were performed using predeveloped standard forms. The outcomes were the incidence of AMI and its different forms in the general population and in patients admitted to hospital, and the mortality of AMI in its different forms.

RESULTS

From 3064 records, 335 full texts were reviewed and 163 included in the quantitative analysis. The mean incidence of AMI was 6.2 (95% CI 1.9 to 12.9) per 100 000 person years. On average 5.0 (95% CI 3.3 to 7.1) of 10 000 hospital admissions were due to AMI. Occlusive arterial AMI was the most common form constituting 68.6% (95% CI 63.7 to 73.2) of all AMI cases, with similar proportions of embolism and thrombosis.Overall short-term mortality (in-hospital or within 30 days) of AMI was 59.6% (95% CI 55.5 to 63.6), being 68.7% (95% CI 60.8 to 74.9) in patients treated before the year 2000 and 55.0% (95% CI 45.5 to 64.1) in patients treated from 2000 onwards (p<0.05). The mid/long-term mortality of AMI was 68.2% (95% CI 60.7 to 74.9). Mortality due to mesenteric venous thrombosis was 24.6% (95% CI 17.0 to 32.9) and of non-occlusive mesenteric ischaemia 58.4% (95% CI 48.6 to 67.7). The short-term mortality of revascularised occlusive arterial AMI was 33.9% (95% CI 30.7 to 37.4).

CONCLUSIONS

In adult patients, AMI is a rarely diagnosed condition with high mortality, although with improvement of treatment results over the last decades. Two thirds of AMI cases are of occlusive arterial origin with potential for better survival if revascularised.

PROSPERO REGISTRATION NUMBER

CRD42021247148.

Outcomes of bowel resection following non-mechanical intestinal obstruction due to mesenteric vein thrombosis in Uganda: A case series

Introduction and importance

Mesenteric venous thrombosis (MVT) is one of the common occlusive causes of compromised bowel perfusion. Contrast-enhanced CT angiography is the diagnostic imaging study of choice for MVT. In-hospital mortality following acute mesenteric infarction is 63 %. Surgical resection may be life saving for patients with peritoneal signs or refractory to conservative management.

Case presentation

We consecutively included records of five patients from Lubaga Hospital with intestinal obstruction who underwent bowel resection following intraoperatively confirmed acute mesenteric ischemia between May 2017 and November 2021. Three of the patients were female. Patients were between 21 and 45 years. One patient had comorbid conditions and an identifiable underlying etiology of polycythemia for MVT. Duration of symptoms ranged from 1 to 11 days. All patients underwent open laparotomy, the length of bowel resection ranged from 77 cm to 600 cm (mean length of 337 cm). Two patients developed short bowel syndrome (SBS) and one patient developed intestinal fistula. There was one in-hospital death due to multi-organ failure.

Clinical discussion

Morbidity and mortality are associated with delay to diagnose the condition. Revascularization is the primary goal, resection of all non-viable regions and preservation of viable bowel. Mortality is commonly related to multi-organ failure. Advanced intensive care and parenteral nutrition have improved survival rates over the years. 2-year and 5-year survival rates have been reported to be 70 % and 50 %.

Conclusion

Good outcomes are still possible for post-operatively optimized patients despite the high mortality and morbidity associated with bowel resection following extensive mesenteric thrombosis.

•

Despite high morbidity and mortality of mesenteric thrombosis, good outcomes are possible in optimized patients.

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Short bowel syndrome and fistulae are a major course of morbidity in massive bowel resected patients.

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Surgery is indicated for patients with peritoneal signs and those refractory to conservative management.

Ischemic bowel disease in 2021

Ischemic bowel disease (ISBODI) includes colon ischemia, acute mesenteric ischemia (AMI) and chronic mesenteric ischemia (CMI). Epidemiologically, colon ischemia is the most common type followed by AMI and CMI. There are various risk factors for the development of ISBODI. Abdominal pain is the common presenting symptom of each type. High clinical suspicion is essential in ordering appropriate tests. Imaging studies and colonoscopy with biopsy are the main diagnostic tests. Treatment varies from conservative measures to surgical resection and revascularization. Involvement of multidisciplinary team is essential in managing ISBODI. Although open surgery with revascularization plays an important role, recently there is an increasing interest in percutaneous endovascular treatment.

Prognostic factors in acute mesenteric ischemia and evaluation with multiple logistic regression analysis effecting morbidity and mortality

&lt;b&gt;Background:&lt;/b&gt; Acute mesenteric ischaemia (AMI) is a catastrophic abdominal emergency characterized by sudden critical interruption to the intestinal blood flow which commonly leads to bowel infarction and death. AMI still has a poor prognosis with an in-hospital mortality rate of 50-69 %. This high mortality rate is related to the delay in diagnosis which is often diffucult and overlooked. Early intervention is crucial and the potential for intestinal viability. &lt;br&gt;&lt;b&gt;Methods:&lt;/b&gt; The charts of 140 patients who were hospitalazed with AMI between May 1997 and August 2013 in Ege University Faculty of Medicine, department of general surgery were retrospectively reviewed. Demographical and clinical features of patients determining the best predictors which effect on morbidity and mortality were evaluated by Multiple Logistic Regression analysis by Enter method after adjustment for all possible confounding factors. &lt;br&gt;&lt;b&gt;Results:&lt;/b&gt; After Multiple LR analysis by Enter method after adjustment for all possible confounding factors affecting morbidity; shock, exploration and stay in hospital were statistically significant. Age, cardiac comorbidities, ASA scores, the time delay between onset of acute abdominal pain to surgery, the presence of acidosis and shock, the involved organs (small bowel and both), type of surgery and medical treatment and small bowel length under 100 cm were statistically significant on mortality. &lt;br&gt;&lt;b&gt;Conclusion:&lt;/b&gt; Risk factors related to mortality and morbidity have been poorly analyzed due to lack of prospective studies and smaller number of patients. Early diagnosis generally depends on clinical awareness and suspicion. Age and time of delay between onset of acute abdominal pain to surgery longer than 24 hours are the most important parameters that predict the mortality for patients presenting with shock and acidosis.

Large Bowel Ischemia/Infarction: How to Recognize It and Make Differential Diagnosis? A Review

Ischemic colitis represents the most frequent form of intestinal ischemia occurring when there is an acute impairment or chronic reduction in the colonic blood supply, resulting in mucosal ulceration, inflammation, hemorrhage and ischemic necrosis of variable severity. The clinical presentation is variable and nonspecific, so it is often misdiagnosed. The most common etiology is hypoperfusion, almost always associated with generalized atherosclerotic disease. The severity ranges from localized and transient ischemia to transmural necrosis of the bowel wall, becoming a surgical emergency, with significant associated morbidity and mortality. The diagnosis is based on clinical, laboratory suspicion and radiological, endoscopic and histopathological findings. Among the radiological tests, enhanced-CT is the diagnostic investigation of choice. It allows us to make the diagnosis in an appropriate clinical setting, and to define the entity of the ischemia. MR may be adopted in the follow-up in patients with iodine allergy or renal dysfunctions, or younger patients who should avoid radiological exposure. In the majority of cases, supportive therapy is the only required treatment. In this article we review the pathophysiology and the imaging findings of ischemic colitis.

Villus Growth, Increased Intestinal Epithelial Sodium Selectivity, and Hyperaldosteronism Are Mechanisms of Adaptation in a Murine Model of Short Bowel Syndrome

BACKGROUND

Short bowel syndrome results from extensive small bowel resection and induces adaptation of the remaining intestine. Ileocecal resection (ICR) is the most frequent situation in humans. Villus hypertrophy is one hallmark of mucosal adaptation, but the functional mechanisms of mucosal adaptation are incompletely understood.

AIMS

The aim of the study was to characterize a clinically relevant model of short bowel syndrome but not intestinal failure in mice and to identify outcome predictors and mechanisms of adaptation.

METHODS

Male C57BL6/J mice underwent 40% ICR and were followed for 7 or 14 days. Small bowel transection served as control. All mice underwent autopsy. Survival, body weight, wellness score, stool water content, plasma aldosterone concentrations, and paracellular permeability were recorded.

RESULTS

Unlike controls, resected mice developed significant diarrhea with increased stool water. This was accompanied by sustained weight loss throughout follow-up. Villus length increased but did not correlate positively with adaptation. Plasma aldosterone concentrations correlated inversely with body weight at day 14. After ICR, intestinal epithelial (i.e., tight junctional) sodium permeability was increased.

CONCLUSIONS

40% ICR results in moderate to severe short bowel syndrome. Successful adaptation to the short bowel situation involves villus elongation but does not correlate with the degree of villus elongation alone. In addition, increased intestinal epithelial sodium permeability facilitates sodium-coupled solute transport. Hyperaldosteronism correlates with the severity of weight loss, indicates volume depletion, and counterregulates water loss.

Arterial thrombosis in unusual sites: A practical review

While cardiovascular disease is common, occasionally hematologists and other practitioners will encounter patients with arterial thrombosis/infarction in unusual sites, without clear cause or obvious diagnostic and treatment paradigms. Contrary to the more commonly encountered cerebrovascular accident and cardiovascular disorders, the various infarctions outlined in this review have unique presentations, pathophysiology, workup, and treatments that all hematologists should be aware of. This review outlines the current literature on arterial thrombosis, with consideration given to anatomic sources and hypercoagulable associations, while focusing on the epidemiology, pathophysiology, provoking factors, and current recommended treatments for intracardiac thrombus, primary aortic mural thrombus, visceral infarctions, and cryptogenic limb ischemia to provide a useful and practical review for the practitioner.

Decision Tool for Predicting Outcomes in Geriatric Acute Mesenteric Ischemia

Acute mesenteric ischemia is a morbid disease process that is most common in elderly patients who often have multiple medical comorbidities. Intervention can progress to costly and futile care. The goal of this study was to develop a tool for practitioners to assess the risk of mortality. Patients treated at our institution over the past decade diagnosed with acute mesenteric ischemia were identified. Patients aged less than 65 years were excluded. Data were collected by retrospective chart review. Univariate analysis was used to identify significant risk factors for death. Decision tree analysis yielded a prognostic tool to assess death risk. Univariate analysis demonstrated that lactate (P ≤ 0.001) and pressor requirement (P ≤ 0.001) were predictive of death. Decision tree analysis showed that 79 per cent of patients with day of surgery (DOS) lactate ≥5.4 died postoperatively. Seventy per cent of patients with DOS lactate <5.4 progressed to death if they required pressors and had a creatinine >1.18. Only 6.1 per cent patients with a DOS lactate <5.4, creatinine <1.54, and no pressor requirement progressed to death. Several variables can be used to set expectations for families and help guide decision-making. Our tool was predictive of outcomes in 82 per cent of our study population.

Role of iRhom2 in intestinal ischemia-reperfusion-mediated acute lung injury

Intestinal ischemia-reperfusion (I/R) may cause acute systemic and lung inflammation. However, the detailed mechanism of this inflammatory cascade has not been fully elucidated. Inactive rhomboid protein 2 (iRhom2) is essential for the maturation of TNF-α converting enzyme (TACE), which is required for TNF-α secretion. We evaluated the role of iRhom2 in a mouse model of intestinal I/R using iRhom2 knockout (KO) and wild-type (WT) mice. Lung injury following intestinal I/R was significantly attenuated in iRhom2 KO mice compared with WT mice. After intestinal I/R, lungs from iRhom2 KO mice showed significantly lower myeloperoxidase (MPO) activity and markedly reduced cell apoptosis associated with a decreased level of active caspase 3 and decreased TUNEL staining compared with lungs from WT mice. TNF-α levels were elevated in the serum and lungs of WT mice with intestinal I/R and significantly reduced in iRhom2 KO mice with intestinal I/R. iRhom2 may play a critical role in the pathogenesis of acute lung injury (ALI) after intestinal I/R and thus may be a novel therapeutic target for ALI after intestinal I/R injury.

Metabolomic profiling to characterize acute intestinal ischemia/reperfusion injury

Sepsis and septic shock are the leading causes of death in critically ill patients. Acute intestinal ischemia/reperfusion (AII/R) is an adaptive response to shock. The high mortality rate from AII/R is due to the severity of the disease and, more importantly, the failure of timely diagnosis. The objective of this investigation is to use nuclear magnetic resonance (NMR) analysis to characterize urine metabolomic profile of AII/R injury in a mouse model. Animals were exposed to sham, early (30 min) or late (60 min) acute intestinal ischemia by complete occlusion of the superior mesenteric artery, followed by 2 hrs of reperfusion. Urine was collected and analyzed by NMR spectroscopy. Urinary metabolite concentrations demonstrated that different profiles could be delineated based on the duration of the intestinal ischemia. Metabolites such as allantoin, creatinine, proline, and methylamine could be predictive of AII/R injury. Lactate, currently used for clinical diagnosis, was found not to significantly contribute to the classification model for either early or late ischemia. This study demonstrates that patterns of changes in urinary metabolites are effective at distinguishing AII/R progression in an animal model. This is a proof-of-concept study to further support examination of metabolites in the clinical diagnosis of intestinal ischemia reperfusion injury in patients. The discovery of a fingerprint metabolite profile of AII/R will be a major advancement in the diagnosis, treatment, and prevention of systemic injury in critically ill patients.

Mesenchymal stromal cell therapy for the treatment of intestinal ischemia: Defining the optimal cell isolate for maximum therapeutic benefit

Intestinal ischemia is a devastating intraabdominal emergency that often necessitates surgical intervention. Mortality rates can be high, and patients who survive often have significant long-term morbidity. The implementation of traditional medical therapies to prevent or treat intestinal ischemia have been sparse over the last decade, and therefore, the use of novel therapies are becoming more prevalent. Cellular therapy using mesenchymal stromal cells is one such treatment modality that is attracting noteworthy attention in the scientific community. Several groups have seen benefit with cellular therapy, but the optimal cell line has not been identified. The purpose of this review is to: 1) Review the mechanism of intestinal ischemia and reperfusion injury, 2) Identify the mechanisms of how cellular therapy may be therapeutic for this disease, and 3) Compare various MSC tissue sources to maximize potential therapeutic efficacy in the treatment of intestinal I/R diseases.

A Statewide Analysis of the Incidence and Outcomes of Acute Mesenteric Ischemia in Maryland from 2009 to 2013

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.

ESTES guidelines: acute mesenteric ischaemia

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.

Mortality after acute primary mesenteric infarction: a systematic review and meta-analysis of observational studies

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.

Long-term prognosis and a prediction model for acute bowel ischaemia following cardiac surgery

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.

I-FABP as biomarker for the early diagnosis of acute mesenteric ischemia and resultant lung injury

Acute mesenteric ischemia (AMI) is a life-threatening condition that can result in multiple organ injury and death. A timely diagnosis and treatment would have a significant impact on the morbidity and mortality in high-risk patient population. The purpose of this study was to investigate if intestinal fatty acid binding protein (I-FABP) and α-defensins can be used as biomarkers for early AMI and resultant lung injury. C57BL/6 mice were subjected to intestinal ischemia by occlusion of the superior mesenteric artery. A time course of intestinal ischemia from 0.5 to 3 h was performed and followed by reperfusion for 2 h. Additional mice were treated with N-acetyl-cysteine (NAC) at 300 mg/kg given intraperitoneally prior to reperfusion. AMI resulted in severe intestinal injury characterized by neutrophil infiltrate, myeloperoxidase (MPO) levels, cytokine/chemokine levels, and tissue histopathology. Pathologic signs of ischemia were evident at 1 h, and by 3 h of ischemia, the full thickness of the intestine mucosa had areas of coagulative necrosis. It was noted that the levels of α-defensins in intestinal tissue peaked at 1 h and I-FABP in plasma peaked at 3 h after AMI. Intestinal ischemia also resulted in lung injury in a time-dependent manner. Pretreatment with NAC decreased the levels of intestinal α-defensins and plasma I-FABP, as well as lung MPO and cytokines. In summary, the concentrations of intestinal α-defensins and plasma I-FABP predicted intestinal ischemia prior to pathological evidence of ischemia and I-FABP directly correlated with resultant lung injury. The antioxidant NAC reduced intestinal and lung injury induced by AMI, suggesting a role for oxidants in the mechanism for distant organ injury. I-FABP and α-defensins are promising biomarkers, and may guide the treatment with antioxidant in early intestinal and distal organ injury.

Mesenteric ischemia

This article reviews the presentation, diagnosis, evaluation, and treatment of the various forms of mesenteric ischemia, including acute and chronic ischemia. In addition, nonocclusive mesenteric ischemia and median arcuate ligament compressive syndrome are covered. The goals are to provide a structured and evidence-based framework for the evaluation and management of patients with these intestinal ischemia syndromes. Special attention is given to avoiding typical pitfalls in the diagnostic and treatment pathways. Operative techniques are also briefly discussed, including an evidence-based review of newer endovascular techniques.

Treatment outcome in patients with acute superior mesenteric artery embolism

PURPOSE

The goals of this study were to investigate the treatment outcomes of acute mesenteric ischemia caused by superior mesenteric artery (SMA) embolism and identify the posttreatment prognostic factors.

METHODS

The clinical data of 32 episodes of acute SMA embolism in 30 patients, including 2 recurrent cases, between April 2003 and March 2011 were retrospectively reviewed.

RESULTS

Median patient age was 74 years (range, 39-89 years), and 50% were male. Conservative treatment, including bowel rest, nasogastric drainage, intravenous fluid therapy, parenteral nutritional support, and anticoagulation therapy, was undertaken in 5 patients with no clinical evidence of bowel gangrene, including 1 with recurrent ischemia. No deaths occurred among patients treated conservatively. A total of 27 patients were treated with open surgical repair (25 embolectomies and 2 bowel resections alone). Among 25 patients treated with embolectomy, 14 required bowel resection. Most bowel resections (94%, 15/16) were limited, with the remaining length of small bowel greater than 150 cm, which could not cause short bowel syndrome. In-hospital mortality of surgery was 30%. No variables were associated with mortality after surgical intervention, including, age, gender, presence of bowel gangrene, and symptom duration. The overall 1-, 3-, and 5-year survival rates after initial successful treatment were 96%, 73%, and 44%, respectively, regardless of treatment type.

CONCLUSIONS

Prompt diagnosis and treatment before extensive irreversible gangrene is the mainstay in the treatment of SMA embolism. Limited bowel gangrene was not associated with mortality.

Tissue engineering of the intestine in a murine model

Tissue-engineered small intestine (TESI) has successfully been used to rescue Lewis rats after massive small bowel resection, resulting in return to preoperative weights within 40 days.(1) In humans, massive small bowel resection can result in short bowel syndrome, a functional malabsorptive state that confers significant morbidity, mortality, and healthcare costs including parenteral nutrition dependence, liver failure and cirrhosis, and the need for multivisceral organ transplantation.(2) In this paper, we describe and document our protocol for creating tissue-engineered intestine in a mouse model with a multicellular organoid units-on-scaffold approach. Organoid units are multicellular aggregates derived from the intestine that contain both mucosal and mesenchymal elements,(3) the relationship between which preserves the intestinal stem cell niche.(4) In ongoing and future research, the transition of our technique into the mouse will allow for investigation of the processes involved during TESI formation by utilizing the transgenic tools available in this species.(5)The availability of immunocompromised mouse strains will also permit us to apply the technique to human intestinal tissue and optimize the formation of human TESI as a mouse xenograft before its transition into humans. Our method employs good manufacturing practice (GMP) reagents and materials that have already been approved for use in human patients, and therefore offers a significant advantage over approaches that rely upon decellularized animal tissues. The ultimate goal of this method is its translation to humans as a regenerative medicine therapeutic strategy for short bowel syndrome.

[Acute mesenteric ischemia: analysis of cases over a ten-years period (2001-2010)]

Acute mesenteric ischemia is a rare disorder; it occurs on average of 0.4% of acute surgery cases. Its diagnosis is often difficult because of the poor symptoms, and mortality of the patients is still as high as 70-90%.

AIMS

The aims of the study were to assess the importance of time factor that may influence the outcome and to find out whether it is possible to decrease the high mortality rate in this disease.

METHOD

Among patients admitted to Saint Pantaleon Hospital in Hungary between January 2001 and December 2010, patients whose surgery or autopsy findings confirmed intestinal necrosis were analyzed. A total of 114 patients with acute mesenteric ischemia were included in the study.

RESULTS

55% of the patients had typical symptoms. 43.8% of the patients underwent surgery and among these patients the mortality rate was 70% despite surgical intervention. The survival rate was 72.3% when surgery was performed within less than 12 hours after the onset of symptoms, but only 20% of patients survived when surgery was delayed between 24 and 48 hours after the onset of symptoms.

CONCLUSION

With early diagnosis and intervention, patients with acute mesenteric ischemia may have a better a chance to survive.

Intestinal ischemia

Ischemic changes of the abdominal organs are crucial since they develop slowly and are therefore often diagnosed at a late stage. Due to this general aspect, mortality from this disease could not be significantly reduced over the last decade. One of the main causes of these high mortality rates is the insufficient integration of the overall clinical picture into the diagnostic work-up. Acute mesenteric ischemia should be differentiated from chronic visceral ischemia. Acute intestinal ischemia is a vascular emergency with a mortality rate of 60-80%. The incidence of chronic visceral vascular disorders accounts for approximately 1-2% of all abdominal conditions and has to be differentiated from the acute form, since intestinal ischemia has a progressive nature and usually is related to general atherosclerotic disease. Therefore, this condition is associated with an increase of arteriosclerotic-related multimorbidity in an increasingly elderly population. Due to excellent collateralization, extensive chronic occlusion processes affecting the visceral arteries can be asymptomatically treated on a long-term basis.

Acute thrombosis of the superior mesenteric artery in a 39-year-old woman with protein-S deficiency: a case report

Introduction

Acute thromboembolic occlusion of the superior mesenteric artery is a condition with an unfavorable prognosis. Treatment of this condition is focused on early diagnosis, surgical or intravascular restoration of blood flow to the ischemic intestine, surgical resection of the necrotic bowel and supportive intensive care. In this report, we describe a case of a 39-year-old woman who developed a small bowel infarct because of an acute thrombotic occlusion of the superior mesenteric artery, also involving the splenic artery.

Case presentation

A 39-year-old Caucasian woman presented with acute abdominal pain and signs of intestinal occlusion. The patient was given an abdominal computed tomography scan and ultrasonography in association with Doppler ultrasonography, highlighting a thrombosis of the celiac trunk, of the superior mesenteric artery, and of the splenic artery. She immediately underwent an explorative laparotomy, and revascularization was performed by thromboendarterectomy with a Fogarty catheter. In the following postoperative days, she was given a scheduled second and third look, evidencing necrotic jejunal and ileal handles. During all the surgical procedures, we performed intraoperative Doppler ultrasound of the superior mesenteric artery and celiac trunk to control the arterial flow without evidence of a new thrombosis.

Conclusion

Acute mesenteric ischemia is a rare abdominal emergency that is characterized by a high mortality rate. Generally, acute mesenteric ischemia is due to an impaired blood supply to the intestine caused by thromboembolic phenomena. These phenomena may be associated with a variety of congenital prothrombotic disorders. A prompt diagnosis is a prerequisite for successful treatment. The treatment of choice remains laparotomy and thromboendarterectomy, although some prefer an endovascular approach. A second-look laparotomy could be required to evaluate viable intestinal handles. Some authors support a laparoscopic second-look. The possibility of evaluating the arteriotomy, during a repeated laparotomy with a Doppler ultrasound, is crucial to show a new thrombosis. Although the prognosis of acute mesenteric ischemia due to an acute arterial mesenteric thrombosis remains poor, a prompt diagnosis, aggressive surgical treatment and supportive intensive care unit could improve the outcome for patients with this condition.

Intestinal ischemia: current treatment concepts

PURPOSE

Mesenteric ischemia is a condition well-known among physicians treating patients with abdominal symptoms. Even so, mortality rates have not decreased significantly over the last decades. The purpose of this article is to review current treatment concepts of acute and chronic mesenteric ischemia.

RESULTS

Early diagnosis is one of the most important features that determine a patient's prognosis. Conventional angiography and multidetector computed tomography are therefore appropriate to quickly diagnose mesenteric ischemia, the latter being commonly more available. Once a patient presents with signs of peritonitis, instant laparotomy is indicated, and infarcted bowel segments need to be resected, followed by a second-look operation if necessary. If bowel necrosis is clinically not suspected, different approaches should be applied according to source and nature of mesenteric ischemia. Besides established surgical treatment concepts, more and more interventional procedures are developed and evaluated. However, superiority of these new techniques could only be shown for selected patient groups so far. In chronic mesenteric ischemia, interventional approaches seem to be an attractive alternative in patients who are in a condition too bad to undergo surgery. Patients with colonic ischemia are treated best in a conservative manner and by resolving the underlying cause, if identified.

CONCLUSION

Patients with acute mesenteric ischemia are still at highest risk for a fatal course of disease. New diagnostic and therapeutic developments have not been tested in larger studies yet, neither has any of these methods led to an increased survival in studies published so far. Taken together, mesenteric ischemia requires high awareness, earliest possible diagnosis, and treatment by an experienced interdisciplinary team of gastroenterologists, radiologists, and surgeons.

Acute mesenteric ischaemia on unenhanced computer-tomography

We present a 39-year old man with mesenteric ischaemia. The initial unenhanced images of the, non-oral contrast CT abdomen clearly demonstrated increased density in a significant length of the small bowel and in the veins of the adjacent mesentery. Mesenteric ischaemia is a difficult diagnosis both clinically and radiologically and we demonstrate the potential benefits of an unenhanced abdominal scan (often left out if a contrast enhanced scan is to be performed) and the omission of oral bowel contrast in emergency scans.

[Acute intestinal ischemia]

Etiologically, therapeutically and prognostically, acute mesenteric ischemia is distinguished from chronic splanchnic ischemia. Acute mesenteric ischemia always is a case of emergency and associated with a 60-80% lethality. Difficult diagnosis, combined rapid progression of ischemic tissue loss and bacterial translocation are the main reasons for this depressing situation. Furthermore, obvious deficits in management and professional treatment are concomitant reasons. Only by intervening these factors prognosis of this deleting disease can be optimized.The main vessel, causing symptoms in 85%, is the superior mesenteric artery. Severe courses are characterized by abdominal rest pain and tissue lesions. In all symptomatic cases we see an indication for invasive treatment. CT-angiography with 3D-reconstruction is the diagnostic tool of choice. Today, conventional angiography only plays a role in combination with endovascular treatment (catheter-derived infusion therapy, lysis, PTA, stent). Duplex sonography should be performed, since this technique reveals relevant insight in hemodynamic severity of the lesion. However, diagnostic accuracy often is restricted due to air-filled bowels.

Poisoning-related bowel infarction: characteristics and outcomes

BACKGROUND

Bowel infarction (BI) is a rare complication of poisoning. We aimed to describe the characteristics of BI in poisoned patients compared to nonpoisoned patients.

METHODS

A retrospective review over a 4-year period of patients hospitalized in an intensive care unit who were diagnosed with BI; Mann-Whitney and Fischer's exact tests were used for comparisons.

RESULTS

Seventeen patients with BI [11 F/6 M, 66-year olds (55-72), median (25-75% percentiles)], including five out of around 1,800 poisoned patients, were identified (toxicants: nicardipine + venlafaxine, amlodipine, propranolol + hydroxyzine, dextropropoxyphene + clomipramine, and turpentine). Clinical presentation and severity were comparable between both groups. However, poisoned patients were significantly younger (p = 0.03) with less cardiovascular disease (p = 0.04) and fewer risk factors (p = 0.008). Delayed BI occurred 48 h (36-60) after the start of vasopressor administration [15.5 mg/h (4.5-30.0) norepinephrine and 6.0 mg/h (4.9-6.3) epinephrine]. Typical poisoning-related injury was jejunal ischemia without ileal localization. The predominant mechanism was nonocclusive mesenteric ischemia. Mortality was lower in poisoned patients (20 vs. 90%, p = 0.009).

CONCLUSION

Physicians should be aware that, despite patient age and the lack of cardiovascular risk factors, BI may rarely complicate severe poisonings requiring elevated doses of vasopressors and may present in a delayed fashion.

Mesenteric ischemia: still a deadly puzzle for the medical community

The main goal of this article is to update etiology, epidemiology, diagnosis, treatment and outcome of the various causes of mesenteric ischemia in order to elucidate its labyrinthine clinical riddle, by reviewing the current English medical literature. Mesenteric ischemia is a quite uncommon disorder, observed in the emergency department. It is a life-threatening vascular emergency that requires early diagnosis and intervention to restore mesenteric blood flow and to prevent bowel necrosis and patient death. Consequently, it is a vital diagnosis to make because of its high mortality rate and its thorny complications. The underlying causes vary, and the prognosis depends on the specific findings during clinical examination. Vague and nonspecific clinical findings and limitations of diagnostic studies make the diagnosis a significant challenge. The prognosis of acute mesenteric ischemia of any type is grave. The complications following this medical jigsaw puzzle are also severe. Patients in whom the diagnosis is missed until infarction occurs have a mortality rate of 90%. Even with good treatment, up to 50-80% of patients die. Survivors of extensive bowel resection face lifelong disability. Despite the progress in understanding the pathogenesis of mesenteric ischemia and the development of treatment modalities, the entity remains a diagnostic challenge for clinicians. Delay in diagnosis contributes to a high mortality rate. Early diagnosis and adequate treatment can improve the clinical outcome. Even if diagnostic modalities have improved since the first successful attempts to confront effectively this clinical entity, mesenteric ischemia still remains a lethal diagnostic enigma for the medical community.

Clinical symptoms of intestinal vascular disorders

Despite advances made in the diagnostic and therapeutic field, acute intestinal ischemia remains a highly lethal condition. This is related to the variability of symptoms and the absence of typical laboratory alterations in early stage.

Acute mesenteric ischemia after cardio-pulmonary bypass surgery

Acute mesenteric ischemia (AMI) is a highly-lethal surgical emergency. Several pathophysiologic events (arterial obstruction, venous thrombosis and diffuse vasospasm) lead to a sudden decrease in mesenteric blood flow. Ischemia/reperfusion syndrome of the intestine is responsible for systemic abnormalities, leading to multi-organ failure and death. Early diagnosis is difficult because the clinical presentation is subtle, and the biological and radiological diagnostic tools lack sensitivity and specificity. Therapeutic options vary from conservative resuscitation, medical treatment, endovascular techniques and surgical resection and revascularization. A high index of suspicion is required for diagnosis, and prompt treatment is the only hope of reducing the mortality rate. Studies are in progress to provide more accurate diagnostic tools for early diagnosis. AMI can complicate the post-operative course of patients following cardio-pulmonary bypass (CPB). Several factors contribute to the systemic hypo-perfusion state, which is the most frequent pathophysiologic event. In this particular setting, the clinical presentation of AMI can be misleading, while the laboratory and radiological diagnostic tests often produce inconclusive results. The management strategies are controversial, but early treatment is critical for saving lives. Based on the experience of our team, we consider prompt exploratory laparotomy, irrespective of the results of the diagnostic tests, is the only way to provide objective assessment and adequate treatment, leading to dramatic reduction in the mortality rate.

[General surgery under discussion. From the viewpoint of vascular surgery]

Vascular diseases are common and their frequency is rising. Statistics show that 15% of the German population over 65 display some kind of peripheral arterial pathology. Even aneurysmatic degeneration and cardiac and visceral perfusion disorders are being observed more frequently, while peak age is dropping. Therapeutic surgical options are accordingly being continually advanced and refined. Additionally the range of interventional therapies and new conservative options has substantially increased vascular surgeons' armamentarium. Updates in surgical training have responded to this increase in such disorders, and the diversification of therapeutic modalities has resulted in the elevation of vascular surgery from specialized techniques to a fully accredited specialty equal in standing to the other seven surgical disciplines. Controversy exists however about the new accredition, beginning with the question of advancement from basic surgical training while excluding important elements of general surgery. Since those training for this specialty will branch off immediately after 2 years of basic surgical training, their final accreditation in the new classification would exclude essential skills that remain part of the training as general surgeons.

Unchanged high mortality rates from acute occlusive intestinal ischemia: six year review

OBJECTIVE

Acute intestinal ischemia (AII) is an uncommon surgical emergency that has been increasing in incidence and remains a highly lethal condition with a difficult diagnosis. We undertook this study to evaluate our experience in treating this condition with a view to expand the cumulative information in the literature.

MATERIALS AND METHODS

Between January 2000 and December 2006, 60 patients with AII caused by thrombotic vascular event underwent surgery at our surgical center. The patients' medical records including data covering demographic features, comorbid medical conditions, medical risk factors, clinical symptoms, history and physical examination findings, and biochemical and radiologic examinations were reviewed. Operative records, the American Society of Anesthesiology physical status classification (ASA-PS), postoperative complications, duration of hospital stay, and final outcome were also considered.

RESULTS

Of the 60 patients with primary thrombotic vascular event, 20 patients had embolism and 19 patients arterial thrombosis. In 21 patients, mesenteric venous thrombosis was the etiology of AII. The median age was 73 years (range, 43-96). Higher ASA classification, age >70 years, late presentation, and high serum lactate levels were predictors of adverse outcome. The overall death rate was 60% (36/60), which was within the range of that observed in the published series.

CONCLUSION

AII remains a highly lethal condition. Mortality rates remain as high as they did decades ago due in part to advanced presentation and advanced age with multiple associated conditions and risk factors, all of which are independent predictors of adverse outcome.

Acute Bowel Ischemia Following Spinal Surgery

Acute mesenteric ischemia is a morbid condition that may be difficult to diagnose due to nonspecific nature of its symptoms. To our knowledge, such a complication has not previously been reported after spinal surgery via the posterior approach. We describe the case of a 43-year-old woman who developed acute mesenteric ischemia several days after a surgical procedure for a lumbar spondylolisthesis via the posterior route. This chronic course is suggestive for venous intestinal ischemia. Prone position and hypotension during the procedure may have favored blood stasis and mesenteric vein occlusion in this patient with an inherited hypercoagulable state.

Percutaneous endovascular treatment of acute sequential systemic emboli

A 65-year-old woman was evaluated for acute right lower-extremity ischemia secondary to embolization from atrial fibrillation and subtherapeutic anticoagulation. Her symptoms quickly evolved in a dynamic fashion to involve multiple vascular beds, including a transient ischemic attack, abdominal pain secondary to mesenteric ischemia, and contralateral lower-extremity ischemia. Synchronous emboli were treated by using mechanical and pharmacologic thrombolysis via an endovascular approach under local anesthesia. This intervention allows prompt evaluation of multiple vascular beds with good short-term outcomes and minimal morbidity.

Imaging of acute mesenteric ischemia using multidetector CT and CT angiography in a porcine model

Acute mesenteric ischemia, a frequently lethal disease, requires prompt diagnosis and intervention for favorable clinical outcomes. This goal remains elusive due, in part, to lack of a noninvasive and accurate imaging study. Traditional angiography is the diagnostic gold standard but is invasive and costly. Computed tomography (CT) is readily available and noninvasive but has shown variable success in diagnosing this disease. The faster scanning time of multidetector row CT (M.D.CT) greatly facilitates the use of CT angiography (CTA) in the clinical setting. We sought to determine whether M.D.CT-CTA could accurately demonstrate vascular anatomy and capture the earliest stages of mesenteric ischemia in a porcine model. Pigs underwent embolization of branches of the superior mesenteric artery, then imaging by M.D.CT-CTA with three-dimensional reconstruction protocols. After scanning, diseased bowel segments were surgically resected and pathologically examined. Multidetector row CT and CT angiography reliably defined normal and occluded mesenteric vessels in the pig. It detected early changes of ischemia including poor arterial enhancement and venous dilatation, which were seen in all ischemic animals. The radiographic findings--compared with pathologic diagnoses-- predicted ischemia, with a positive predictive value of 92%. These results indicate that M.D.CT-CTA holds great promise for the early detection necessary for successful treatment of acute mesenteric ischemia.

Clinical factors and outcomes in patients with acute mesenteric ischemia in the emergency department

BACKGROUND

The purpose of this study was to determine the initial clinical characteristics of acute mesenteric ischemia and identify variables associated with adverse outcomes in the emergency department (ED).

METHODS

The charts of 124 consecutive patients with surgically and pathologically identified acute mesenteric ischemia from September 1990 to September 2000 were reviewed retrospectively to obtain data about demographics, initial clinical presentations, predisposing diseases, previous medications, laboratory tests, and common findings on computed tomography scans with contrast. Only patients admitted through the ED and treated on medical or surgical wards were enrolled.

RESULTS

Mean patient age was 71.1 years (range, 25-100 years). The overall mortality rate was 50%. There were no significant differences in gender, underlying disease, previous medication, initial signs and symptoms, and causes of mesenteric infarction, between survivors and non-survivors. Univariate analysis demonstrated that older age, bandemia, hepatic and renal impairment, hyperamylasemia, metabolic acidosis, hypoxia, intramural pneumatosis, and septic syndrome, were more frequent in patients who died than in those who survived (p < 0.05). Logistic regression identified the following variables as independent predictors of death: old age (odds ratio, OR, 1.077; 95% confidence interval, Cl, 1.013, 1.146; p = 0.02); bandemia (OR, 3.894; 95% Cl, 1.160, 13.074; p = 0.03); elevated serum aspartate aminotransferase (AST; OR, 4.532; 95% Cl, 1.274, 16.122; p = 0.02); increased blood urea nitrogen (BUN; OR, 7.219; 95% Cl, 1.166, 44.696; p = 0.03); and metabolic acidosis (OR, 6.604; 95% Cl, 1.804, 24.171; p < 0.01).

CONCLUSION

A high index of suspicion and aggressive diagnostic imaging can facilitate early diagnosis and improve outcomes for patients with acute mesenteric ischemia. Risk stratification showed that elderly patients with metabolic acidosis, bandemia, or elevated AST and BUN had a poor prognosis. Greater therapeutic intervention is advocated to reduce mortality in high-risk patients with acute mesenteric ischemia.

Isolated Left Ventricular Noncompaction of the Myocardium as a Cause of Embolic Superior Mesenteric Artery Occlusion

Isolated noncompaction of the left ventricular (LV) myocardium is a rare congenital disorder resulting from an arrest of the compaction process of the myocardial trabeculae during normal embryogenesis. It is characterized by the presence of prominent LV myocardial trabeculations and deep intertrabecular recesses that are in continuity with the LV cavity. The most common clinical presentation includes progressive LV dysfunction, life-threatening tachyarrhythmias, and the risk for severe cardioembolic events. We describe a case where isolated noncompaction of the LV myocardium was diagnosed after an embolic occlusion of the superior mesenteric artery in a 40-year-old Caucasian woman.

Infarcted intestine: a diagnostic void

The diagnostic approaches to infarction of the small intestine are reviewed in the present paper. The inadequacy of current methods, especially biochemical methods, are highlighted. Additionally, the benefits of a sensitive and specific test of intestinal infarction are discussed.

Acute superior mesenteric artery embolism: rapid reperfusion with hydrodynamic thrombectomy and pharmacological thrombolysis

PURPOSE

To report a case of acute superior mesenteric artery (SMA) embolism successfully treated with hydrodynamic thrombectomy and pharmacological thrombolysis.

CASE REPORT

A 67-year-old man was admitted to the hospital with acute severe abdominal pain. Selective angiography via a femoral puncture revealed a complete embolic occlusion distal to the first jejunal branch of the SMA. Hydrodynamic thrombectomy resolved the severe abdominal pain of the patient in approximately 10 minutes after the start of thrombectomy. Local continuous thrombolysis with urokinase resulted in near complete restoration of the mesenteric flow after 24 hours. The patient made an uneventful recovery and continues to do well on warfarin therapy 8 months after treatment; he has shown no evidence of malabsorption.

CONCLUSIONS

Although insertion of the device into the SMA via a femoral puncture is a difficult approach, we propose that hydrodynamic thrombectomy followed by local thrombolysis is a useful treatment for acute superior mesenteric artery embolism.

Determinants of in-hospital mortality and length of stay for acute intestinal gangrene

BACKGROUND

Intestinal gangrene carries high operative mortality and morbidity rates. This study was undertaken to identify predictors of in-hospital death and length of stay.

METHODS

Retrospective review of hospital data over a 6-year period identified 107 patients diagnosed with acute bowel gangrene.

RESULTS

Among the baseline factors that had a significant univariable association with mortality (51%) were age (P = 0.04), symptom duration (P = 0.01), preoperative and postoperative pH and lactic acid (P < or = 0.02), history of hypertension (P = 0.001), and renal failure (P = 0.008). Symptom duration and history of hypertension were independent risk factors for mortality. Longer length of stay was univariably associated with symptom duration (P = 0.006), systemic acidosis (P < or =0.005), vascular etiology (P = 0.04), amount of resected bowel (P = 0.001), and need for second-look procedures (P <0.001).

CONCLUSIONS

The presence of multiple risk factors predictive of a high mortality rate may aid more realistic decision making for physicians, patients, and family members.

Systematic review: the epidemiology of ischaemic colitis

BACKGROUND

Ischaemic colitis has been associated with co-morbid conditions, medications, vascular surgery and advanced age in case reports and case series. Few data exist on the baseline incidence in the general population or on the increased risk imposed by these risk factors.

AIM

To systematically review the literature regarding the incidence, prevalence and risk factors for ischaemic colitis.

METHODS

Searches of bibliographic databases were performed independently by two investigators. Studies were included if they used population-based samples, disease-specific population samples or case-control population-based samples of adults with ischaemic colitis, and reported the incidence, prevalence or risk factors for ischaemic colitis. Eligible articles were reviewed and data were abstracted in a duplicate, independent manner.

RESULTS

Four studies were identified that reported the general population incidence and four that reported the disease-specific population incidence. The incidence of ischaemic colitis in general populations ranged from 4.5 to 44 cases per 100 000 person-years. The risk was increased two- to four-fold by either prevalent irritable bowel syndrome or chronic obstructive pulmonary disease. The risk was also increased in females and in subjects of 65 years and older.

CONCLUSIONS

Ischaemic colitis is uncommon in the general population. The effect sizes of the most commonly reported risk factors have not been adequately quantified in population-based studies.