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Stonko DP, Edwards J, Abdou H, Treffalls R, Walker P, Morrison JJ. Raising Systemic Blood Pressure to Delay Irreversible Intestinal Ischemia in a Swine Model of Proximal Superior Mesenteric ArteryOcclusion. J Surg Res 2024; 295:70-80. [PMID: 37992455 DOI: 10.1016/j.jss.2023.09.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 09/13/2023] [Accepted: 09/26/2023] [Indexed: 11/24/2023]
Abstract
INTRODUCTION Acute proximal superior mesenteric artery (SMA) occlusion is highly lethal, and adjuncts are needed to mitigate ischemic injury until definitive therapy. We hypothesized that raising mean arterial pressure (MAP) >90 mmHg with norepinephrine may delay irreversible bowel ischemia by increasing gastroduodenal artery (GDA) flow despite possible pressor-induced vasospasm. METHODS 12 anesthetized swine underwent laparotomy, GDA flow probe placement, and proximal SMA exposure and clamping. Animals were randomized between conventional therapy (CT) versus targeted MAP >90 mmHg (MAP push; MP) where norepinephrine was titrated after 45 min of SMA occlusion. Animals were followed until bowel death or 4 h. Kaplan-Meier bowel survival, mean normalized GDA flow, and histology were compared. RESULTS 12 swine (mean 57.8 ± 7.6 kgs) were included, six per group. Baseline weight, HR, MAP and GDA flows were not different. Within 5 min following SMA clamping, all 12 animals had an increase in MAP without other intervention from 81.7 to 105.5 mmHg (29.1%, P < 0.01) with a concomitant 74.9% increase in GDA flow as compared to baseline (P < 0.01). Beyond 45 min postclamp, MAP was greater in the MP group as intended, as were GDA flows. Median time to irreversibly ischemic bowel was 31% longer for MAP push animals (CT: 178 versus MP: 233 min, P = 0.006), Hazard Ratio of CT 8.85 (95% CI: 1.86-42.06); 3/6 MP animals versus 0/6 CT animals with bowel survived to predetermined end point. CONCLUSIONS In this swine model of acute complete proximal SMA occlusion, increasing MAP >90 mmHg with norepinephrine was associated with an increase in macrovascular blood flow through the GDA and bowel survival. Norepinephrine was not associated with worse bowel survival and a MAP push may increase the time window where ischemic bowel can be salvaged.
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Affiliation(s)
- David P Stonko
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland; R. Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland
| | - Joseph Edwards
- R. Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland
| | - Hossam Abdou
- R. Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland
| | - Rebecca Treffalls
- University of the Incarnate Word School of Medicine (R.N.T.), San Antonio, Texas
| | - Patrick Walker
- R. Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland
| | - Jonathan J Morrison
- Division of Vascular and Endovascular Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota.
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2
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Xu JJ, Ulriksen PS, Jawad S, Rohde YZ, Sejer M, Achiam MP, Resch TA, Lönn L, Hansen KL. Iodine density mapping for the diagnosis of acute bowel ischemia using fast kV-switching dual-energy CT. Abdom Radiol (NY) 2024; 49:312-319. [PMID: 37978076 PMCID: PMC10789852 DOI: 10.1007/s00261-023-04097-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 10/11/2023] [Accepted: 10/18/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE To evaluate the diagnostic capabilities of a supplementary color ramped iodine density map compared to virtual monoenergetic images (VMIs) at 74 keV in the diagnosis of acute bowel ischemia (ABI). METHODS Data for this study were prospectively gathered and retrospectively evaluated. Patients referred to the Department of Diagnostic Radiology between October 2020 and August 2022 on the suspicion of ABI and underwent surgery < 12 h following fast kV-switching venous phase abdominal dual-energy CT (DECT) were consecutively included. Images were evaluated by two board-certified radiologists and two radiology residents. First round included only 74 keV VMIs resembling conventional 120 kVp images, and the second round included a supplementary iodine density map. Readers were asked to register presence of ABI as well as their confidence in their diagnosis based on a 5-point Likert scale. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for each observer with the surgical findings as the gold-standard. McNemar's and Wilcoxon signed-rank test were used to compare registrations and diagnostic confidence across assessment rounds. RESULTS A total of 29 patients resulting in 31 DECT scans were included. Fourteen cases of ischemic/necrotic bowel were reported following surgery. Sensitivity and NPV were decreased with the use of supplementary iodine map images compared to 120 kVp-like images without supplementary iodine map images for three of four observers (round 1 range: 71.4-92.9% and 78.0-94.8%; round 2 range: 57.1-78.6% and 70.1-83.3%, respectively), while specificity and PPV were increased for three of four observers (round 1 range: 64.7-94.1% and 67.4-93.1%; round 2 range: 88.2-94.1% and 73.8-91.1%, respectively). However, no significant difference in ABI diagnosis or diagnostic confidence was found (p-value range: 0.07-1.00 and 0.23-0.58, respectively). CONCLUSION No significant difference for the diagnosis of ABI was found using supplementary iodine mapping. Our study may suggest a trend of increased specificity and decreased sensitivity, hence, the use of supplementary iodine mapping should be carefully considered.
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Affiliation(s)
- Jack Junchi Xu
- Department of Diagnostic Radiology, Copenhagen University Hospital, Rigshospitalet, 2100, Copenhagen, Denmark.
- Department of Clinical Medicine, University of Copenhagen, 2100, Copenhagen, Denmark.
| | - Peter Sommer Ulriksen
- Department of Diagnostic Radiology, Copenhagen University Hospital, Rigshospitalet, 2100, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, 2100, Copenhagen, Denmark
| | - Samir Jawad
- Department of Diagnostic Radiology, Copenhagen University Hospital, Rigshospitalet, 2100, Copenhagen, Denmark
| | - Yecatarina Zincuk Rohde
- Department of Diagnostic Radiology, Copenhagen University Hospital, Rigshospitalet, 2100, Copenhagen, Denmark
| | - Morten Sejer
- Department of Diagnostic Radiology, Copenhagen University Hospital, Rigshospitalet, 2100, Copenhagen, Denmark
| | - Michael Patrick Achiam
- Department of Clinical Medicine, University of Copenhagen, 2100, Copenhagen, Denmark
- Department of Surgery and Transplantation, Copenhagen University Hospital, Rigshospitalet, 2100, Copenhagen, Denmark
| | - Timothy Andrew Resch
- Department of Clinical Medicine, University of Copenhagen, 2100, Copenhagen, Denmark
- Department of Vascular Surgery, Copenhagen University Hospital, Rigshospitalet, 2100, Copenhagen, Denmark
| | - Lars Lönn
- Department of Diagnostic Radiology, Copenhagen University Hospital, Rigshospitalet, 2100, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, 2100, Copenhagen, Denmark
| | - Kristoffer Lindskov Hansen
- Department of Diagnostic Radiology, Copenhagen University Hospital, Rigshospitalet, 2100, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, 2100, Copenhagen, Denmark
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Arfan S, Anbazhagan L, Tiesenga F. First Line of Defense: The Vital Role of Family Medicine Physicians in Preventing Acute Mesenteric Ischemia in High-Risk Patients. Cureus 2023; 15:e40359. [PMID: 37456441 PMCID: PMC10339772 DOI: 10.7759/cureus.40359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2023] [Indexed: 07/18/2023] Open
Abstract
Acute mesenteric ischemia (AMI) is a life-threatening condition with a high mortality rate despite surgical interventions. Morbidity and mortality are especially high in those with risk factors, which include diabetes mellitus (DM), hypertension (HTN), coronary artery disease, recent myocardial infarction, and rheumatic autoimmune diseases, among others. We present the case of a 70-year-old Caucasian woman diagnosed with AMI. The patient presented acutely to the emergency department after nine episodes of vomiting and was admitted to the surgical floor the same day for an emergent exploratory laparotomy. She presented acutely with an atypical presentation and without any progressive symptoms, despite various comorbidities. This patient was classified as "very high risk", but she had not been on any medications or monitored for any of her comorbidities. We highlight the essential and multifaceted role of family medicine physicians, also known as primary care physicians (PCPs), in the prevention of bowel ischemia and recommend the use of routine outpatient monitoring with clinical examination, blood testing, and imaging. These, along with a high index of suspicion, have clinical utility in preventing hospitalization, surgical intervention (bowel resection), and other serious sequelae of AMI. Timely detection, management, and specialist referrals from a family medicine physician can lower the overall burden on healthcare resources and personnel.
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Affiliation(s)
- Sara Arfan
- General Surgery, Windsor University School of Medicine, Chicago, USA
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Magnus L, Lejay A, Philouze G, Chakfé N, Collange O, Thaveau F, Georg Y. Mortality and Delays of Management of Acute Mesenteric Ischemia: The Need of a Dedicated Program. Ann Vasc Surg 2023; 91:28-35. [PMID: 36549474 DOI: 10.1016/j.avsg.2022.12.070] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 11/26/2022] [Accepted: 12/06/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND To study the mortality and delays of management of patients with acute mesenteric ischemia (AMI) admitted to the emergency department of a tertiary hospital and identify risk factors for 1-month mortality. METHODS A single-center and retrospective study including all consecutive patients treated for AMI from January 2008 to December 2018 was conducted. Short- and medium-term survival was studied with a Kaplan-Meier analysis. Delays before diagnosis and surgical intervention were collected. To determine factors associated with mortality at 1 month postoperatively, univariate and multivariate analyzes were performed. RESULTS The survival rate of the 67 included patients was 55.22% at 1 month and 37.31% at 1 year. In-hospital mortality was 50.74%. The average delay between admission and diagnosis was 4.83 ± 5.03 hr (95% confidence interval [CI], 3.60-6.05), and the delay between admission and surgical treatment was 10.64 ± 8.80 hr (95% CI, 8.49-12.79). The independent variables associated with an increased mortality at 1 month postoperatively in the univariate analysis were age >65 years old (odds ratio [OR] = 3.52; P = 0.046), lactate >3.31 mmol/l at admission (H0) (OR = 7.38; P < 0.001), lactate >3.32 mmol/l on day 1 (H24) (OR = 5.60; P = 0.002), creatinine >95.9 μmol/l at H0 (OR = 4.66; P = 0.004), aspartate aminotransferase (AST) >59 U/l at H0 (OR = 3.55; P = 0.017), and having hypertension as comorbidity (OR = 9.32; P = 0.040). Early curative anticoagulation (z = -2.4; P = 0.016) was an independent protective factor for mortality, and lactate >3.31 mmol/l at H0 (z = 2.62; P = 0.009) was an independent predictor factor of mortality at 1 month postoperatively in the multivariate analysis. CONCLUSION AMI remains a serious and lethal condition with delays of surgical management remaining too long due to a lack of a dedicated therapeutic protocol allowing an early diagnosis.
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Affiliation(s)
- Louis Magnus
- Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France; Department of Vascular and Endovascular Surgery, Gabriel Montpied Hospital, Clermont-Ferrand, France.
| | - Anne Lejay
- Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France
| | - Guillaume Philouze
- Department of Visceral and Digestive Surgery, University Hospital of Strasbourg, Strasbourg, France
| | - Nabil Chakfé
- Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France
| | - Olivier Collange
- Intensive Care Unit and Department of Anesthesiology, University Hospital of Strasbourg, Strasbourg, France
| | - Fabien Thaveau
- Department of Vascular and Endovascular Surgery, Gabriel Montpied Hospital, Clermont-Ferrand, France
| | - Yannick Georg
- Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France
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Muhtaroğlu A, Çapoğlu R, Uygur FA, Harmantepe AT, Bayhan Z, Gönüllü E. FAR Ratio as Prognostic Biomarker in AMI. SN COMPREHENSIVE CLINICAL MEDICINE 2023; 5:109. [PMID: 36970580 PMCID: PMC10031717 DOI: 10.1007/s42399-023-01451-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/15/2023] [Indexed: 03/28/2023]
Abstract
Acute mesenteric ischemia (AMI) is a vascular emergency resulting from decreased blood flow caused by the occlusion of the mesenteric vessels, hypoperfusion, or vasospasm. This study aimed to investigate the prognostic value of the fibrinogen-to-albumin (FAR) ratio in patients with acute mesenteric ischemia. A total of 91 patients were enrolled in the study. Patients' demographics such as age and gender, pre- and postoperative hemoglobin, CRP, white blood cell (WBC), neutrophils, preoperative lymphocyte, alanine transaminase (ALT), aspartate transaminase (AST), thrombocytes, and postoperative D-dimer values were recorded. In addition, pre- and postoperative fibrinogen and albumin levels were recorded, and FAR was calculated. Patients were divided into two groups, survivors and non-survivors. The mean pre- and postoperative fibrinogen levels were statistically significantly higher in the non-survivor group than in the survivor group (p < 0.001). The mean pre- and postoperative albumin levels were significantly lower in the non-survivors than in the survivors (p = 0.059, p < 0.001; respectively). The mean pre- and postoperative FAR ratios were considerably higher in the non-survivor than in the survivor groups (p < 0.001). The change between pre- and postoperative fibrinogen, albumin, and FAR values was statistically significant between the non-survivors and the survivors (for all, p < 0.05). The preoperative and postoperative fibrinogen levels were significantly lower, and albumin levels were significantly higher in the survivor compared to the non-survivor patients with AMI. Furthermore, the preoperative and postoperative FAR ratio was significantly higher in the non-survivors. The FAR ratio may be a valuable prognostic biomarker for patients with AMI.
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Affiliation(s)
- Ali Muhtaroğlu
- Department of General Surgery, Giresun University Faculty of Medicine, Giresun University Training and Research Hospital, Aksu District, Mehmet İzmen Street, Number: 145, 28100 Giresun, PC Turkey
| | - Recayi Çapoğlu
- General Surgery Clinic, Sakarya Training and Research Hospital, Adapazari, Turkey
| | - Furkan Ali Uygur
- Department of General Surgery, Giresun University Faculty of Medicine, Giresun University Training and Research Hospital, Aksu District, Mehmet İzmen Street, Number: 145, 28100 Giresun, PC Turkey
| | | | - Zülfü Bayhan
- Department of General Surgery, Sakarya University Faculty of Medicine, Adapazari, Turkey
| | - Emre Gönüllü
- Department of Gastroenterological Surgery, Sakarya University Faculty of Medicine, Adapazari, Turkey
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Molyneux K, Beck-Esmay J, Koyfman A, Long B. High risk and low prevalence diseases: Mesenteric ischemia. Am J Emerg Med 2023; 65:154-161. [PMID: 36638612 DOI: 10.1016/j.ajem.2023.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 12/19/2022] [Accepted: 01/02/2023] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION Mesenteric ischemia is a rare, frequently misdiagnosed, serious condition that carries with it a high rate of morbidity and mortality. OBJECTIVE This review highlights the pearls and pitfalls of mesenteric ischemia, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION Mesenteric ischemia is an abdominal vascular emergency that includes superior mesenteric arterial embolism, arterial thrombosis, venous mesenteric ischemia, and non-occlusive mesenteric ischemia. It is associated with a variety of risk factors including older age, cardiovascular disease, hypercoagulable state, and end-stage renal disease. The presentation depends on the underlying pathophysiology. While arterial embolic disease may present with sudden, severe pain, the early stages of the disease and other forms can present with vague symptoms, including generalized abdominal pain, weight loss, vomiting, and diarrhea. Laboratory testing can suggest the disease with leukocytosis and elevated lactate, but normal values should not be used to exclude the diagnosis. The imaging modality of choice is triple phase computed tomography with non-contrast, arterial, and delayed phases. The initial ED management includes fluid resuscitation, symptomatic therapy, broad-spectrum antibiotics, and anticoagulation. Emergent consultation with a multidisciplinary team including diagnostic and interventional radiologists and cardiovascular and general surgeons is necessary for definitive treatment. CONCLUSIONS An understanding of mesenteric ischemia can assist emergency clinicians in diagnosing and managing this disease.
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Affiliation(s)
- Kevin Molyneux
- Department of Emergency Medicine, Columbia University Irving Medical Center, 622 W 168th St, New York, NY 10032, USA
| | - Jennifer Beck-Esmay
- Department of Emergency Medicine, Mount Sinai Morningside - Mount Sinai West, 1111 Amsterdam Ave, New York, NY 10025, USA.
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
| | - Brit Long
- SAUSHEC, Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
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Tomandlova M, Novotny T, Staffa R, Smutna J, Krivka T, Kruzliak P, Slaby O, Kubicek L, Vlachovsky R, Radova L, Tomandl J. Kinetics of d-lactate and ischemia-modified albumin after abdominal aortic surgery and their ability to predict intestinal ischemia. Clin Biochem 2023; 112:43-47. [PMID: 36502884 DOI: 10.1016/j.clinbiochem.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 12/02/2022] [Accepted: 12/05/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Acute intestinal ischemia is a severe complication of abdominal aortic surgery that is difficult to diagnose early and therefore to treat adequately and timely. In this study the perioperative kinetics of d-lactate and ischemia-modified albumin (IMA) are described and the predictive value of these markers for the early diagnosis of acute intestinal ischemia is assessed. DESIGN & METHODS This non-randomised, single-centre cohort study enrolled 50 patients with abdominal aortic aneurysm (AAA) and 30 patients with aortoiliac occlusive disease (AOID). Serum d-lactate and IMA were assessed pre-, intra-, and postoperatively at eight defined time points. RESULTS The highest serum d-lactate was at 6 h after complete declamping of the vascular graft. The highest predictive power of d-lactate was at 3 h after complete declamping (AUC 0.857). IMA was found to be higher in the AAA group in ischemic patients 10 min after complete declamping than in the AOID group. The highest predictive values of IMA were at 1 h after aortic cross-clamping (AUC 0.758) and 3 and 6 h after complete declamping (0.745 and 0.721, respectively). Moreover, the multivariate model with both markers at 3 h after complete declamping improved the detection of intestinal ischemia (AUC 0.894). CONCLUSIONS Serum levels of IMA and d-lactate seem to be influential predictive markers for postoperative intestinal ischemia, especially after 3 h from complete declamping of vascular reconstruction.
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Affiliation(s)
- Marie Tomandlova
- Department of Biochemistry, Faculty of Medicine, Masaryk University, Kamenice 5, Brno 625 00, Czech Republic.
| | - Tomas Novotny
- 2(nd) Department of Surgery, Center for Vascular Disease, St. Anne's University Hospital Brno, Pekarska 53, Brno 656 91, Czech Republic; 2(nd) Department of Surgery, Center for Vascular Disease, Faculty of Medicine, Masaryk University, Pekarska 53, Brno 656 91, Czech Republic.
| | - Robert Staffa
- 2(nd) Department of Surgery, Center for Vascular Disease, St. Anne's University Hospital Brno, Pekarska 53, Brno 656 91, Czech Republic; 2(nd) Department of Surgery, Center for Vascular Disease, Faculty of Medicine, Masaryk University, Pekarska 53, Brno 656 91, Czech Republic.
| | - Jindra Smutna
- Department of Biochemistry, Faculty of Medicine, Masaryk University, Kamenice 5, Brno 625 00, Czech Republic.
| | - Tomas Krivka
- Department of Medical Imaging, St. Anne's University Hospital Brno, Pekarska 53, Brno 656 91, Czech Republic; Department of Medical Imaging, Faculty of Medicine, Masaryk University, Pekarska 53, Brno 656 91, Czech Republic.
| | - Peter Kruzliak
- 2(nd) Department of Surgery, Center for Vascular Disease, St. Anne's University Hospital Brno, Pekarska 53, Brno 656 91, Czech Republic; 2(nd) Department of Surgery, Center for Vascular Disease, Faculty of Medicine, Masaryk University, Pekarska 53, Brno 656 91, Czech Republic
| | - Ondrej Slaby
- Central European Institute of Technology, Masaryk University, Kamenice 5, Brno 625 00, Czech Republic; Department of Biology, Faculty of Medicine, Masaryk University, Kamenice 5, Brno 625 00, Czech Republic.
| | - Lubos Kubicek
- 2(nd) Department of Surgery, Center for Vascular Disease, St. Anne's University Hospital Brno, Pekarska 53, Brno 656 91, Czech Republic; 2(nd) Department of Surgery, Center for Vascular Disease, Faculty of Medicine, Masaryk University, Pekarska 53, Brno 656 91, Czech Republic.
| | - Robert Vlachovsky
- 2(nd) Department of Surgery, Center for Vascular Disease, St. Anne's University Hospital Brno, Pekarska 53, Brno 656 91, Czech Republic; 2(nd) Department of Surgery, Center for Vascular Disease, Faculty of Medicine, Masaryk University, Pekarska 53, Brno 656 91, Czech Republic.
| | - Lenka Radova
- Central European Institute of Technology, Masaryk University, Kamenice 5, Brno 625 00, Czech Republic.
| | - Josef Tomandl
- Department of Biochemistry, Faculty of Medicine, Masaryk University, Kamenice 5, Brno 625 00, Czech Republic.
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Estler A, Estler E, Feng YS, Seith F, Wießmeier M, Archid R, Nikolaou K, Grözinger G, Artzner C. Treatment of Acute Mesenteric Ischemia: Individual Challenges for Interventional Radiologists and Abdominal Surgeons. J Pers Med 2022; 13:jpm13010055. [PMID: 36675716 PMCID: PMC9864352 DOI: 10.3390/jpm13010055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 12/23/2022] [Accepted: 12/24/2022] [Indexed: 12/29/2022] Open
Abstract
Background: Acute mesenteric ischemia (AMI) is a life-threatening condition resulting from occlusion of the mesenteric arterial vessels. AMI requires immediate treatment with revascularization of the occluded vessels. Purpose: to evaluate the technical success, clinical outcomes and survival of patients receiving endovascular treatment for AMI followed by surgery. Material and Methods: A search of our institution’s database for AMI revealed 149 potential patients between 08/2016 and 08/2021, of which 91 were excluded due to incomplete clinical data, insufficient imaging or missing follow-up laparoscopy. The final cohort included 58 consecutive patients [(median age 73.5 years [range: 43−96 years], 55% female), median BMI 26.2 kg/m2 (range:16.0−39.2 kg/m2)]. Periinterventional imaging regarding the cause of AMI (acute-embolic or acute-on-chronic) was evaluated by two radiologists in consensus. The extent of AMI and the degree of technical success was graded according to a modified TICI (Thrombolysis in Cerebral Infarction scale) score (TICI-AMI) classification (0: no perfusion; 1: minimal; 2a < 50% filling; 2b > 50%; 2c: near complete or slow; 3: complete). Lab data and clinical data were collected, including the results of follow-up laparoscopy. Non-parametric statistics were used. Results: All interventions were considered technically successful. The most common causes of AMI were emboli (51.7%) and acute-on-chronic thrombotic occlusions (37.9%). Initial imaging showed a TICI-AMI score of 0, 1 or 2a in 87.9% (n = 51) of patients. Post-therapeutic TICI-AMI scores improved significantly with 87.9% of patients grade 2b and better. Median lactate levels reduced from 2.7 (IQR 2.0−3.7) mg/dL (1−18) to 1.45 (IQR 0.99−1.90). Intestinal ischemia was documented in 79.1% of cases with resection of the infarcted intestinal loops. In total, 22/58 (37.9%) patients died during the first 30 days after intervention and surgery. According to CIRSE criteria, we did not observe any SAE scores of grade 2 or higher. Conclusions: AMI is a serious disease with high lethality within the first 30 days despite optimal treatment. However, interventional revascularization before surgery with resection of the infarcted bowel can save two out of three of critically ill patients.
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Affiliation(s)
- Arne Estler
- Diagnostic and Interventional Radiology, University Hospital Tuebingen, 72076 Tübingen, Germany
- Correspondence: ; Tel.: +49-707-1298-5453
| | - Eva Estler
- Faculty of Medicine, University of Tuebingen, 72074 Tübingen, Germany
| | - You-Shan Feng
- Institute for Clinical Epidemiology and Applied Biometrics, Medical University of Tübingen, 72076 Tübingen, Germany
| | - Ferdinand Seith
- Diagnostic and Interventional Radiology, University Hospital Tuebingen, 72076 Tübingen, Germany
| | | | - Rami Archid
- Department of General & Transplant Surgery, University Hospital Tuebingen, 72076 Tübingen, Germany
| | - Konstantin Nikolaou
- Diagnostic and Interventional Radiology, University Hospital Tuebingen, 72076 Tübingen, Germany
| | - Gerd Grözinger
- Diagnostic and Interventional Radiology, University Hospital Tuebingen, 72076 Tübingen, Germany
| | - Christoph Artzner
- Diagnostic and Interventional Radiology, University Hospital Tuebingen, 72076 Tübingen, Germany
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Bala M, Catena F, Kashuk J, De Simone B, Gomes CA, Weber D, Sartelli M, Coccolini F, Kluger Y, Abu-Zidan FM, Picetti E, Ansaloni L, Augustin G, Biffl WL, Ceresoli M, Chiara O, Chiarugi M, Coimbra R, Cui Y, Damaskos D, Di Saverio S, Galante JM, Khokha V, Kirkpatrick AW, Inaba K, Leppäniemi A, Litvin A, Peitzman AB, Shelat VG, Sugrue M, Tolonen M, Rizoli S, Sall I, Beka SG, Di Carlo I, Ten Broek R, Mircea C, Tebala G, Pisano M, van Goor H, Maier RV, Jeekel H, Civil I, Hecker A, Tan E, Soreide K, Lee MJ, Wani I, Bonavina L, Malangoni MA, Koike K, Velmahos GC, Fraga GP, Fette A, de'Angelis N, Balogh ZJ, Scalea TM, Sganga G, Kelly MD, Khan J, Stahel PF, Moore EE. Acute mesenteric ischemia: updated guidelines of the World Society of Emergency Surgery. World J Emerg Surg 2022; 17:54. [PMID: 36261857 PMCID: PMC9580452 DOI: 10.1186/s13017-022-00443-x] [Citation(s) in RCA: 71] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 06/17/2022] [Indexed: 02/08/2023] Open
Abstract
Acute mesenteric ischemia (AMI) is a group of diseases characterized by an interruption of the blood supply to varying portions of the intestine, leading to ischemia and secondary inflammatory changes. If untreated, this process may progress to life-threatening intestinal necrosis. The incidence is low, estimated at 0.09-0.2% of all acute surgical admissions, but increases with age. Although the entity is an uncommon cause of abdominal pain, diligence is required because if untreated, mortality remains in the range of 50%. Early diagnosis and timely surgical intervention are the cornerstones of modern treatment to reduce the high mortality associated with this entity. The advent of endovascular approaches in parallel with modern imaging techniques is evolving and provides new treatment options. Lastly, a focused multidisciplinary approach based on early diagnosis and individualized treatment is essential. Thus, we believe that updated guidelines from World Society of Emergency Surgery are warranted, in order to provide the most recent and practical recommendations for diagnosis and treatment of AMI.
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Affiliation(s)
- Miklosh Bala
- Director of Acute Care Surgery and Trauma Unit, Department of General Surgery, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem Kiriat Hadassah, POB 12000, 91120, Jerusalem, Israel.
| | - Fausto Catena
- General and Emergency Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Jeffry Kashuk
- Tel Aviv Sackler School of Medicine, Tel Aviv, Israel
| | - Belinda De Simone
- Department of General, Digestive and Metabolic Minimally Invasive Surgery, Centre Hospitalier Intercommunal De Poissy/St Germain en Laye, Poissy, France
| | - Carlos Augusto Gomes
- Department of Surgery, Faculdade de Ciências Médicas e da Saúde de Juiz de Fora, Hospital Universitário Terezinha de Jesus, Juiz de Fora, Brazil
| | - Dieter Weber
- Department of General Surgery, Royal Perth Hospital, The University of Western Australia, Perth, Australia
| | | | - Federico Coccolini
- Department of General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Yoram Kluger
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Parma, Parma, Italy
| | - Luca Ansaloni
- Department of Surgery, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Goran Augustin
- Department of Surgery, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Walter L Biffl
- Division of Trauma/Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, CA, USA
| | - Marco Ceresoli
- Emergency and General Surgery Department, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Osvaldo Chiara
- Emergency Department, Niguarda Ca'Granda Hospital, Milan, Italy
| | - Massimo Chiarugi
- Department of General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Raul Coimbra
- CECORC Research Center, Riverside University Health System, Loma Linda University, Loma Linda, USA
| | - Yunfeng Cui
- Department of Surgery, Nankai Clinical School of Medicine, Tianjin Nankai Hospital, Tianjin Medical University, Tianjin, China
| | | | - Salomone Di Saverio
- General Surgery Department Hospital of San Benedetto del Tronto, Marche region, Italy
| | - Joseph M Galante
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of California Davis, Sacramento, CA, USA
| | - Vladimir Khokha
- Department of Emergency Surgery, City Hospital, Mozyr, Belarus
| | - Andrew W Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, AB, Canada
| | - Kenji Inaba
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Ari Leppäniemi
- Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Andrey Litvin
- Department of Surgical Disciplines, Regional Clinical Hospital, Immanuel Kant Baltic Federal University, Kaliningrad, Russia
| | - Andrew B Peitzman
- Department of Surgery, University of Pittsburgh School of Medicine, UPMC-Presbyterian, Pittsburgh, USA
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Novena, Singapore
| | - Michael Sugrue
- Donegal Clinical Research Academy Emergency Surgery Outcome Project, Letterkenny University Hospital, Donegal, Ireland
| | - Matti Tolonen
- Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Sandro Rizoli
- Surgery Department, Section of Trauma Surgery, Hamad General Hospital (HGH), Doha, Qatar
| | - Ibrahima Sall
- General Surgery Department, Military Teaching Hospital, Dakar, Senegal
| | | | - Isidoro Di Carlo
- Department of Surgical Sciences and Advanced Technologies, General Surgery Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Richard Ten Broek
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Chirika Mircea
- Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Giovanni Tebala
- Department of Digestive and Emergency Surgery, S.Maria Hospital Trust, Terni, Italy
| | - Michele Pisano
- General and Emergency Surgery, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Harry van Goor
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ronald V Maier
- Harborview Medical Center, University of Washington School of Medicine, Seattle, WA, USA
| | - Hans Jeekel
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Ian Civil
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Andreas Hecker
- Emergency Medicine Department of General and Thoracic Surgery, University Hospital of Giessen, Giessen, Germany
| | - Edward Tan
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Kjetil Soreide
- HPB Unit, Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Matthew J Lee
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | | | - Luigi Bonavina
- Department of Surgery, IRCCS Policlinico San Donato, University of Milano, Milano, Italy
| | - Mark A Malangoni
- Case Western Reserve University School of Medicine, Cleveland, USA
| | | | - George C Velmahos
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, PA, USA
| | - Gustavo P Fraga
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas (Unicamp), Campinas, Brazil
| | - Andreas Fette
- Pediatric Surgery, Children's Care Center, SRH Klinikum Suhl, Suhl, Thueringen, Germany
| | - Nicola de'Angelis
- Unit of Digestive and HPB Surgery, Faculty of Medicine, University of Paris, Paris, France
| | - Zsolt J Balogh
- John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia
| | - Thomas M Scalea
- Cowley Shock Trauma Center at the University of Maryland, Baltimore, MD, USA
| | - Gabriele Sganga
- Emergency Surgery and Trauma, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Michael D Kelly
- Department of General Surgery, Albury Hospital, Albury, Australia
| | - Jim Khan
- University of Portsmouth, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Philip F Stahel
- College of Osteopathic Medicine, Rocky Vista University, Parker, CO, USA
| | - Ernest E Moore
- Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO, USA
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Sumbal R, Ali Baig MM, Sumbal A. Predictors of Mortality in Acute Mesenteric Ischemia: A Systematic Review and Meta-Analysis. J Surg Res 2022; 275:72-86. [DOI: 10.1016/j.jss.2022.01.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 12/24/2021] [Accepted: 01/27/2022] [Indexed: 12/12/2022]
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11
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ÖZKAN MB, TOPCU R, ŞAHİN F, YILDIRIM MB. Diagnostic and prognostic value of the ratio of mean platelet volume to platelet count in acute mesenteric ischemia. JOURNAL OF HEALTH SCIENCES AND MEDICINE 2022. [DOI: 10.32322/jhsm.1076082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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12
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The role of adropin, HIF-1α and apelin biomarkers in the diagnosis of acute mesentaric ischemia. Am J Emerg Med 2021; 51:223-227. [PMID: 34775196 DOI: 10.1016/j.ajem.2021.10.058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 10/25/2021] [Accepted: 10/28/2021] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE The absence of a specific biomarker for acute mesenteric ischemia diagnosis results in a delay in diagnosis and treatment, as well as a high mortality rate. The current research examined whether the proteins adropin, HIF-1α, and apelin may be used to help in the early detection of acute mesenteric ischemia. MATERIALS AND METHODS A total of 20 patients with acute mesenteric ischemia, 20 patients with abdominal pain, and 20 healthy controls were included in the study. The levels of adropin, HIF-1, and apelin in the serum were determined using the ELISA method. RESULTS Adropin concentrations were significantly higher in the acute mesenteric ischemia group than in the abdominal pain and healthy control groups (p < 0.05). HIF-1α levels were considerably greater in patients with acute mesenteric ischemia compared to both the abdominal pain group and the healthy control group (p < 0.05). There was no difference in apelin levels between the acute mesenteric ischemia and abdominal pain groups (p > 0.05). HIF-1α was found to be moderate (AUC: 0.705) and adropin was found to be a weak biomarker (AUC: 0.692) in the ROC analysis for acute mesenteric ischemia. CONCLUSION In this study of 20 patients with acute mesenteric ischemia, we found adropin and HIF-1α levels to be increased compared to patients with abdominal pain who did not have acute mesenteric ischemia.
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13
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Davarpanah AH, Ghamari Khameneh A, Khosravi B, Mir A, Saffar H, Radmard AR. Many faces of acute bowel ischemia: overview of radiologic staging. Insights Imaging 2021; 12:56. [PMID: 33914188 PMCID: PMC8085211 DOI: 10.1186/s13244-021-00985-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 03/16/2021] [Indexed: 12/12/2022] Open
Abstract
Acute bowel ischemia (ABI) can be life threatening with high mortality rate. In spite of the advances made in diagnosis and treatment of ABI, no significant change has occurred in the mortality over the past decade. ABI is potentially reversible with prompt diagnosis. The radiologist plays a central role in the initial diagnosis and preventing progression to irreversible intestinal ischemic injury or bowel necrosis. The most single imaging findings described in the literature are either non-specific or only present in the late stages of ABI, urging the use of a constellation of features to reach a more confident diagnosis. While ABI has been traditionally categorized based on the etiology with a wide spectrum of imaging findings overlapped with each other, the final decision for patient’s management is usually made on the stage of the ABI with respect to the underlying pathophysiology. In this review, we first discuss the pathologic stages of ischemia and then summarize the various imaging signs and causes of ABI. We also emphasize on the correlation of imaging findings and pathological staging of the disease. Finally, a management approach is proposed using combined clinical and radiological findings to determine whether the patient may benefit from surgery or not.
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Affiliation(s)
- Amir H Davarpanah
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, USA
| | - Afshar Ghamari Khameneh
- Department of Radiology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Bardia Khosravi
- Department of Radiology, Shariati Hospital, Tehran University of Medical Sciences, 14117, North Kargar St., Tehran, Iran
| | - Ali Mir
- Department of Surgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Hiva Saffar
- Department of Pathology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Reza Radmard
- Department of Radiology, Shariati Hospital, Tehran University of Medical Sciences, 14117, North Kargar St., Tehran, Iran.
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14
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Kiseleva E, Ryabkov M, Baleev M, Bederina E, Shilyagin P, Moiseev A, Beschastnov V, Romanov I, Gelikonov G, Gladkova N. Prospects of Intraoperative Multimodal OCT Application in Patients with Acute Mesenteric Ischemia. Diagnostics (Basel) 2021; 11:705. [PMID: 33920827 PMCID: PMC8071199 DOI: 10.3390/diagnostics11040705] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/11/2021] [Accepted: 04/13/2021] [Indexed: 01/02/2023] Open
Abstract
INTRODUCTION Despite the introduction of increasingly multifaceted diagnostic techniques and the general advances in emergency abdominal and vascular surgery, the outcome of treatment of patients with acute impaired intestinal circulation remains unsatisfactory. The non-invasive and high-resolution technique of optical coherence tomography (OCT) can be used intraoperatively to assess intestine viability and associated conditions that frequently emerge under conditions of impaired blood circulation. This study aims to demonstrate the effectiveness of multimodal (MM) OCT for intraoperative diagnostics of both the microstructure (cross-polarization OCT mode) and microcirculation (OCT angiography mode) of the small intestine wall in patients with acute mesenteric ischemia (AMI). METHODS AND PARTICIPANTS A total of 18 patients were enrolled in the study. Nine of them suffered from AMI in segments II-III of the superior mesenteric artery (AMI group), whereby the ischemic segments of the intestine were examined. Nine others were operated on for adenocarcinoma of the colon (control group), thus allowing areas of their normal small intestine to be examined for comparison. Data on the microstructure and microcirculation in the walls of the small intestine were obtained intraoperatively from the side of the serous membrane using the MM OCT system (IAP RAS, Russia) before bowel resection. The MM OCT data were compared with the results of histological examination. RESULTS The study finds that MM OCT visualized the damage to serosa, muscularis externa, and blood vessels localized in these layers in 100% of AMI cases. It also visualized the submucosa in 33.3% of AMI cases. The MM OCT images of non-ischemic (control group), viable ischemic, and necrotic small intestines (AMI group) differed significantly across stratification of the distinguishable layers, the severity of intermuscular fluid accumulations, and the type and density of the vasculature. CONCLUSION The MM OCT diagnostic procedure optimally meets the requirements of emergency surgery. Data on the microstructure and microcirculation of the intestinal wall can be obtained simultaneously in real time without requiring contrast agent injections. The depth of visualization of the intestinal wall from the side of the serous membrane is sufficient to assess the volume of the affected tissues. However, the methodology for obtaining MM OCT data needs to be improved to minimize the motion artefacts generated in actual clinical conditions.
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Affiliation(s)
- Elena Kiseleva
- Institute of Experimental Oncology and Biomedical Technologies, Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Sq., 603950 Nizhny Novgorod, Russia;
| | - Maxim Ryabkov
- Thermal Injury Group, University Clinic, Privolzhsky Research Medical University, 18/1 Verkhnevolzhskaya Naberezhnaja, 603155 Nizhny Novgorod, Russia;
| | - Mikhail Baleev
- City Clinical Hospital No.30, 85A Berezovskaya St., 605157 Nizhny Novgorod, Russia; (M.B.); (V.B.); (I.R.)
| | - Evgeniya Bederina
- The Department of Pathology, University Clinic, Privolzhsky Research Medical University, 18/1 Verkhnevolzhskaya Naberezhnaja, 603155 Nizhny Novgorod, Russia;
| | - Pavel Shilyagin
- Institute of Applied Physics of the RAS, 46 Ulyanova St., 603950 Nizhny Novgorod, Russia; (P.S.); (A.M.); (G.G.)
| | - Alexander Moiseev
- Institute of Applied Physics of the RAS, 46 Ulyanova St., 603950 Nizhny Novgorod, Russia; (P.S.); (A.M.); (G.G.)
| | - Vladimir Beschastnov
- City Clinical Hospital No.30, 85A Berezovskaya St., 605157 Nizhny Novgorod, Russia; (M.B.); (V.B.); (I.R.)
| | - Ivan Romanov
- City Clinical Hospital No.30, 85A Berezovskaya St., 605157 Nizhny Novgorod, Russia; (M.B.); (V.B.); (I.R.)
| | - Grigory Gelikonov
- Institute of Applied Physics of the RAS, 46 Ulyanova St., 603950 Nizhny Novgorod, Russia; (P.S.); (A.M.); (G.G.)
| | - Natalia Gladkova
- Institute of Experimental Oncology and Biomedical Technologies, Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Sq., 603950 Nizhny Novgorod, Russia;
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15
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Ben-Shahar Y, Abassi Z, Pollak Y, Koppelmann T, Gorelik G, Sukhotnik I. Cell death induction (extrinsic versus intrinsic apoptotic pathway) by intestinal ischemia-reperfusion injury in rats is time-depended. Pediatr Surg Int 2021; 37:369-376. [PMID: 33566162 DOI: 10.1007/s00383-020-04817-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/30/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE We investigate the mechanism of intestinal cell apoptosis and its relation to the time of reperfusion in a rat model of intestinal ischemia-reperfusion (IR). METHODS Rats were divided into 4 groups: Sham-24 and Sham-48 rats underwent laparotomy without an intentional ischemic intervention and were sacrificed 24 or 48 h hours later; IR-24 and IR-48 rats underwent occlusion of SMA and portal vein for 20 min followed by 24 or 48 h of reperfusion, respectively. Park's injury score, cell proliferation and apoptosis were determined at sacrifice. Proliferation and apoptosis-related gene and protein expression were determined using Real-Time PCR, Western Blot and Immunohistochemistry. RESULTS IR-24 rats demonstrated a strong increase in cell apoptosis along with an elevated Bax and decreased Bcl-2 expression and a decrease in cell proliferation (vs Sham-24). IR-48 group showed an increase in cell proliferation and a decrease in cell apoptosis compared to IR-24 animals. IR-48 rats demonstrated an increase in apoptotic rate that was accompanied by greater TNF-α mRNA, Fas mRNA and FasL mRNA compared to Sham-48 animals. CONCLUSION While cell apoptosis in IR-24 rats is regulated mainly by intrinsic apoptotic pathway, 48 h followed ischemia extrinsic apoptotic pathway is responsible for pro-apoptotic effects of IR injury.
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Affiliation(s)
- Yoav Ben-Shahar
- Department of Pediatric Surgery, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, 6 Weizmann st, 6423906, Tel Aviv, Israel. .,Department of Physiology, The Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.
| | - Zaid Abassi
- Department of Physiology, The Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Yulia Pollak
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tal Koppelmann
- Department of Pediatric Surgery, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, 6 Weizmann st, 6423906, Tel Aviv, Israel
| | - Gregory Gorelik
- Department of Pathology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Igor Sukhotnik
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Pediatric Surgery, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, 6 Weizmann st, 6423906, Tel Aviv, Israel
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Miller AS, Boyce K, Box B, Clarke MD, Duff SE, Foley NM, Guy RJ, Massey LH, Ramsay G, Slade DAJ, Stephenson JA, Tozer PJ, Wright D. The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery. Colorectal Dis 2021; 23:476-547. [PMID: 33470518 PMCID: PMC9291558 DOI: 10.1111/codi.15503] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 12/08/2020] [Accepted: 12/12/2020] [Indexed: 12/15/2022]
Abstract
AIM There is a requirement for an expansive and up to date review of the management of emergency colorectal conditions seen in adults. The primary objective is to provide detailed evidence-based guidelines for the target audience of general and colorectal surgeons who are responsible for an adult population and who practise in Great Britain and Ireland. METHODS Surgeons who are elected members of the Association of Coloproctology of Great Britain and Ireland Emergency Surgery Subcommittee were invited to contribute various sections to the guidelines. They were directed to produce a pathology-based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. Each author was asked to provide a set of recommendations which were evidence-based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after two votes were included in the guidelines. RESULTS All aspects of care (excluding abdominal trauma) for emergency colorectal conditions have been included along with 122 recommendations for management. CONCLUSION These guidelines provide an up to date and evidence-based summary of the current surgical knowledge in the management of emergency colorectal conditions and should serve as practical text for clinicians managing colorectal conditions in the emergency setting.
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Affiliation(s)
- Andrew S. Miller
- Leicester Royal InfirmaryUniversity Hospitals of Leicester NHS TrustLeicesterUK
| | | | - Benjamin Box
- Northumbria Healthcare Foundation NHS TrustNorth ShieldsUK
| | | | - Sarah E. Duff
- Manchester University NHS Foundation TrustManchesterUK
| | | | | | | | | | | | | | - Phil J. Tozer
- St Mark’s Hospital and Imperial College LondonHarrowUK
| | - Danette Wright
- Western Sydney Local Health DistrictSydneyNew South WalesAustralia
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17
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Khetarpal A, Khetarpal A. Bowel ischemia and gangrene-primary true enterolith. Int J Surg Case Rep 2021; 80:105562. [PMID: 33592410 PMCID: PMC7893413 DOI: 10.1016/j.ijscr.2021.01.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 01/14/2021] [Accepted: 01/14/2021] [Indexed: 02/07/2023] Open
Abstract
Enterolithiasis, or presence of stone concretions in the gastrointestinal tract, is an important but relatively uncommon clinical condition that has recently gained significant attention with advances in the gastrointestinal field. Here, we present a case of an old male having features of bowel Ischemia and gangrene formation. Patient underwent exploratory laparotomy and there was a presence of inflamed Gut with a perforation just one and half feet away from IC junction and an obstruction was also identified by following the dilated bowel loops distally, palpation revealed a hard stone and enterotomy incision at the site delivered a stone. Following it, resection of thickened mesentery was done and loop ileostomy was made. The most important prognostic factor in such cases relies on time interval between onset of symptoms and definitive treatment. By improving the awareness and early recognition of mesenteric ischemia will lead to improved survival in the condition.
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Non-occlusive Mesenteric Ischemia as a Fatal Complication in Acute Pancreatitis: A Case Series. Dig Dis Sci 2020; 65:1212-1222. [PMID: 31529415 DOI: 10.1007/s10620-019-05835-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 09/07/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Vascular complications of severe acute pancreatitis are well known and largely described unlike non-occlusive mesenteric ischemia, which is a rare and potentially fatal complication. Non-occlusive mesenteric ischemia is an acute mesenteric ischemia without thrombotic occlusion of blood vessels, poorly described as a complication of acute pancreatitis. METHODS We retrospectively reviewed a prospectively maintained registry of all pancreatic diseases referred to our center from 2013 to 2018, in order to determine the causes of early death. We identified three patients who died within 48 h after hospital admission from severe acute pancreatitis complicated by irreversible non-occlusive mesenteric ischemia. Their clinical presentation, management, and outcomes were herein reported. RESULTS Three consecutive patients with severe acute pancreatitis developed non-occlusive mesenteric ischemia within the first 5 days after onset of symptoms and died 48 h after non-occlusive mesenteric ischemia diagnosis despite optimal intensive care management and surgery, giving a prevalence of 3/609 (0.5%). Symptoms were unspecific with consequently potential delayed diagnosis and management. High doses of norepinephrine required for hemodynamic support (n = 3) potentially leading to splanchnic vessels vasoconstriction, transient hypotension (n = 3), and previous severe ischemic cardiomyopathy (n = 1) could be involved as precipitating factors of non-occlusive mesenteric ischemia. CONCLUSION Non-occlusive mesenteric ischemia can be a fatal complication of acute pancreatitis but is also challenging to diagnose. Priority is to reestablish a splanchno-mesenteric perfusion flow. Surgery should be offered in case of treatment failure or deterioration but is still under debate in early stage, to interrupt the vicious circle of intestinal hypoperfusion and ischemia.
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19
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Gao Z, Yin L, Pan Y, Chen B. Treatment of Superior Mesenteric Vein Thrombus by Catheter-Directed Thrombolysis. Ann Vasc Surg 2019; 65:286.e9-286.e13. [PMID: 31743781 DOI: 10.1016/j.avsg.2019.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Revised: 10/31/2019] [Accepted: 11/09/2019] [Indexed: 02/07/2023]
Abstract
Contrast-enhanced computed tomography (CT) greatly improves the diagnosis of superior mesenteric vein (SMV) thrombosis, which presents as the unspecific symptom of abdominal pain. Prothrombotic states or thrombophilia and local intra-abdominal infections are major causes of SMV thrombosis. A 37-year-old Chinese woman was diagnosed with SMV and portal vein thrombosis. The patient was initially given 40 mg of heparin sodium every 12 hr and 80,0000 U/day of urokinase using superior mesenteric artery angiography. The abdominal pain was not relieved after treatment. The patient then underwent open surgery, where an ileal branch of the SMV was punctured, a 4F sheath was introduced into the vein toward the portal vein, and a 20-cm Unifuse catheter was placed inside the thrombus for further thrombolysis. Both heparin sodium and urokinase were infused through catheter-directed thrombolysis. The patient's symptoms then gradually resolved.
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Affiliation(s)
- Zhiwei Gao
- Department of Vascular Surgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, PR China
| | - Libo Yin
- Department of Vascular Surgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, PR China
| | - Yifeng Pan
- Department of Vascular Surgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, PR China
| | - Bing Chen
- Department of Vascular Surgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, PR China.
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Montagnana M, Danese E, Lippi G. Biochemical markers of acute intestinal ischemia: possibilities and limitations. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:341. [PMID: 30306080 DOI: 10.21037/atm.2018.07.22] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Acute intestinal ischemia is a relative rare abdominal emergency, associated with considerably high morbidity and mortality rates. Although the conventional diagnostic approach to acute intestinal ischemia entails a preliminary evaluation of signs and symptoms, followed by radiological and laboratory investigations, a definitive diagnosis is can usually be made after laparotomy, which still remains the gold standard diagnostic (and therapeutic) procedure. Several potential laboratory biomarkers have been investigated over the past decades, but none of these seems to reach a suitable diagnostic accuracy for an early and reliable diagnosis of intestinal ischemia. The aim of this narrative review is to provide an overview on traditional laboratory tests for diagnosing acute intestinal ischemia (i.e., complete blood count, D-dimer, blood gas analysis, total lactic acid, C-reactive protein and procalcitonin), and summarize current evidence regarding some emerging and potentially useful biomarkers such as D-lactate, intestinal fatty acid-binding protein (I-FABP), ischemia modified albumin (IMA), α-glutathione S-transferase (α-GST), interleukin-6 (IL-6), citrulline and smooth muscle protein of 22 kDa (SM22). Among the various tests, D-lactate, IMA and I-FABP are perhaps the most promising, since they are characterized by optimal sensitivity and relatively good specificity, early kinetics, and can be measured with assays suited for a rapid diagnosis.
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Affiliation(s)
- Martina Montagnana
- Clinical Biochemistry Section, University Hospital of Verona, Verona, Italy
| | - Elisa Danese
- Clinical Biochemistry Section, University Hospital of Verona, Verona, Italy
| | - Giuseppe Lippi
- Clinical Biochemistry Section, University Hospital of Verona, Verona, Italy
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21
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Bala M, Kashuk J, Moore EE, Kluger Y, Biffl W, Gomes CA, Ben-Ishay O, Rubinstein C, Balogh ZJ, Civil I, Coccolini F, Leppaniemi A, Peitzman A, Ansaloni L, Sugrue M, Sartelli M, Di Saverio S, Fraga GP, Catena F. Acute mesenteric ischemia: guidelines of the World Society of Emergency Surgery. World J Emerg Surg 2017; 12:38. [PMID: 28794797 PMCID: PMC5545843 DOI: 10.1186/s13017-017-0150-5] [Citation(s) in RCA: 274] [Impact Index Per Article: 39.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 08/01/2017] [Indexed: 02/07/2023] Open
Abstract
Acute mesenteric ischemia (AMI) is typically defined as a group of diseases characterized by an interruption of the blood supply to varying portions of the small intestine, leading to ischemia and secondary inflammatory changes. If untreated, this process will eventuate in life threatening intestinal necrosis. The incidence is low, estimated at 0.09–0.2% of all acute surgical admissions. Therefore, although the entity is an uncommon cause of abdominal pain, diligence is always required because if untreated, mortality has consistently been reported in the range of 50%. Early diagnosis and timely surgical intervention are the cornerstones of modern treatment and are essential to reduce the high mortality associated with this entity. The advent of endovascular approaches in parallel with modern imaging techniques may provide new options. Thus, we believe that a current position paper from World Society of Emergency Surgery (WSES) is warranted, in order to put forth the most recent and practical recommendations for diagnosis and treatment of AMI. This review will address the concepts of AMI with the aim of focusing on specific areas where early diagnosis and management hold the strongest potential for improving outcomes in this disease process. Some of the key points include the prompt use of CT angiography to establish the diagnosis, evaluation of the potential for revascularization to re-establish blood flow to ischemic bowel, resection of necrotic intestine, and use of damage control techniques when appropriate to allow for re-assessment of bowel viability prior to definitive anastomosis and abdominal closure.
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Affiliation(s)
- Miklosh Bala
- Acute Care Surgery and Trauma Unit, General Surgery Department, Hadassah - Hebrew University Medical Center, Kiriat Hadassah, POB 12000, 91120 Jerusalem, Israel
| | - Jeffry Kashuk
- Assia Medical Group, Tel Aviv University Sackler School of Medicine, Tel Aviv, Israel
| | - Ernest E Moore
- Department of Surgery, Denver Health Medical Center, University of Colorado, Denver, USA
| | - Yoram Kluger
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Walter Biffl
- Department of Surgery, Queens Medical Center, Honolulu, Hi USA
| | - Carlos Augusto Gomes
- Faculdade de Ciências Médicas e da Saúde de Juiz de Fora (SUPREMA), Federal University of Juiz de Fora (UFJF), Juiz de Fora, MG Brazil
| | - Offir Ben-Ishay
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Chen Rubinstein
- Department of Vascular Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Zsolt J Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW Australia
| | - Ian Civil
- Department of Surgery, Auckland City Hospital, Auckland, New Zealand
| | | | - Ari Leppaniemi
- Abdominal Center, University Hospital Meilahti, Helsinki, Finland
| | - Andrew Peitzman
- Department of Surgery, UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA USA
| | - Luca Ansaloni
- General Surgery I, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Michael Sugrue
- Donegal Clinical Research Academy, Letterkenny University Hospital, Letterkenny, Ireland
| | | | | | - Gustavo P Fraga
- Division of Trauma Surgery, Hospital de Clinica, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Fausto Catena
- Emergency Department, Maggiore University Hospital, Parma, Italy
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Zhu RC, Marey G, Kurbatov V, Kashan D, Sulkowski J, Sugiyama G, Tolete Velcek F. Topical intraperitoneal papaverine to minimize non-viable bowel resection from non-occlusive bowel ischemia in neonatal segmental volvulus: A case report. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2016. [DOI: 10.1016/j.epsc.2016.07.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Daly MC, Atkinson SJ, Varisco BM, Klingbeil L, Hake P, Lahni P, Piraino G, Wu D, Hogan SP, Zingarelli B, Wong HR. Role of matrix metalloproteinase-8 as a mediator of injury in intestinal ischemia and reperfusion. FASEB J 2016; 30:3453-3460. [PMID: 27435263 DOI: 10.1096/fj.201600242r] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 06/21/2016] [Indexed: 12/13/2022]
Abstract
Acute mesenteric ischemia is associated with high morbidity and mortality. In recent studies, we found that the intestine is an important source of matrix metalloproteinase (MMP)8 during intestinal injury. We hypothesized that genetic ablation or pharmacological inhibition of MMP8 would reduce intestinal injury in mice subjected to intestinal ischemia-reperfusion (I/R) injury. Male mice aged 8-12 wk were subjected to intestinal I/R injury by transient occlusion of the superior mesenteric artery for 30 min. MMP8 was inhibited by genetic and pharmacological approaches. In vivo study endpoints included several functional, histological, and biochemical assays. Intestinal sections were assessed for barrier function and expression of tight junction proteins. I/R injury led to increased intestinal and systemic expression of MMP8. This increase was associated with increased intestinal neutrophil infiltration, epithelial injury, and permeability. I/R injury was associated with increased systemic inflammation and weight loss. These parameters were ameliorated by inhibiting MMP8. I/R injury caused a loss of the tight junction protein claudin-3, which was ameliorated by genetic ablation of MMP8. MMP8 plays an important role in intestinal I/R injury through mechanisms involving increased inflammation and loss of claudin-3. Inhibition of MMP8 is a potential therapeutic strategy in this setting.-Daly, M. C., Atkinson, S. J., Varisco, B. M., Klingbeil L., Hake, P., Lahni, P., Piraino, G., Wu, D., Hogan, S. P., Zingarelli, B., Wong, H. R. Role of matrix metalloproteinase-8 as a mediator of injury in intestinal ischemia and reperfusion.
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Affiliation(s)
- Meghan C Daly
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Sarah J Atkinson
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Brian M Varisco
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Lindsey Klingbeil
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Paul Hake
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Patrick Lahni
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Giovanna Piraino
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - David Wu
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Simon P Hogan
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Basilia Zingarelli
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Hector R Wong
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA;
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Nielsen C, Kirkegård J, Erlandsen EJ, Lindholt JS, Mortensen FV. D-lactate is a valid biomarker of intestinal ischemia induced by abdominal compartment syndrome. J Surg Res 2015; 194:400-404. [DOI: 10.1016/j.jss.2014.10.057] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Revised: 09/29/2014] [Accepted: 10/31/2014] [Indexed: 11/28/2022]
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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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Guillaumon AT, Couto MA. Hystopathological study of the intestinal epithelium submitted to different times of programmed ischemia and twenty four hours reperfusion. Acta Cir Bras 2013; 28:288-98. [DOI: 10.1590/s0102-86502013000400009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Accepted: 03/19/2013] [Indexed: 11/21/2022] Open
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Guillaumon AT, Couto MA. Hystopathological study of the intestinal epithelium submitted to different times of programmed ischemia and twenty four hours reperfusion. Acta Cir Bras 2013. [DOI: 10.1590/s0102-86502013000400009 10.1590/s0102-86502013000400009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023] Open
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28
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Lee SS, Park SH. Computed Tomography Evaluation of Gastrointestinal Bleeding and Acute Mesenteric Ischemia. Radiol Clin North Am 2013. [DOI: 10.1016/j.rcl.2012.09.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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29
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Nielsen C, Mortensen FV, Erlandsen EJ, Lindholt JS. l- and d-lactate as biomarkers of arterial-induced intestinal ischemia: An experimental study in pigs. Int J Surg 2012; 10:296-300. [DOI: 10.1016/j.ijsu.2012.05.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2011] [Revised: 05/02/2012] [Accepted: 05/08/2012] [Indexed: 12/22/2022]
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Nielsen C, Pedersen LT, Lindholt JS, Mortensen FV, Erlandsen EJ. An automated plasma D-lactate assay with a new sample preparation method to prevent interference from L-lactate and L-lactate dehydrogenase. Scandinavian Journal of Clinical and Laboratory Investigation 2011; 71:507-14. [PMID: 21861600 DOI: 10.3109/00365513.2011.590900] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To establish an automated plasma D-lactate assay without interference from L-lactate and L-lactate dehydrogenase (L-LDH). METHODS AND MATERIALS The D-lactate assay was programmed as a 2-point endpoint assay on the Roche Modular P using the D-lactic acid kit from Biocontrol Systems, USA. In the chemical reaction, D-lactate was oxidized to pyruvate by NAD(+) in the presence of D-lactate dehydrogenase. The resultant pyruvate was converted to alanine in the presence of alanine aminotransferase. The amount of NADH formed in the coupled reaction, measured by the change in the absorbance at 340 nm, was proportional to the concentration of D-lactate in the sample. Human serum albumin (HSA) solutions and plasma from pigs with experimentally-induced gut ischemia were used in this study. Blood samples were collected into Venosafe® tubes. RESULTS The D-lactate assay was linear up to 1.000 mmol/L in HSA solutions and plasma. The detection limit was 0.003 mmol/L. Within-run CVs ≤ 2.0% and total CVs ≤ 3.2% were obtained in the control material. Recovery was 87.1 ± 5.2 % (Mean ± SD). The L-LDH activity was completely inactivated in plasma samples by the addition of 20 µL of a 5 mol/L NaOH solution to 500 µL of plasma (pH 11.5). No interference could be detected from concentrations of bilirubin < 450 µmol/L, haemoglobin < 0.2 mmol/L or Intralipid® < 2.5 g/L. CONCLUSIONS The performance of the established D-lactate assay meets the requirements to be implemented into hospital laboratories. The sample preparation method is simple, cheap and requires minimal labour.
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Affiliation(s)
- Casper Nielsen
- Department of Vascular Surgery, Viborg Regional Hospital, Viborg, Denmark.
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Nielsen C, Lindholt JS, Erlandsen EJ, Mortensen FV. d-lactate as a marker of venous-induced intestinal ischemia: an experimental study in pigs. Int J Surg 2011; 9:428-32. [PMID: 21530695 DOI: 10.1016/j.ijsu.2011.04.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2011] [Revised: 04/09/2011] [Accepted: 04/11/2011] [Indexed: 12/22/2022]
Abstract
BACKGROUND Intestinal ischemia is difficult to diagnose. The search for biomarkers has led to an increased interest in d-lactate. d-lactate measured in higher concentrations arises from bacterial fermentation in the gastrointestinal tract. Permeable intestinal wall is an early consequence of intestinal ischemia, which allows d-lactate to enter the portal circulation. METHODS The superior mesenteric vein was clamped in eight pigs for two hours to induce ischemia of the intestine. Eight sham-operated pigs served as controls. Systemic and portal plasma d- and l-lactate, l-LDH and leukocytes were measured. RESULTS Plasma d-lactate increased significantly and nearly simultaneously in the systemic and portal circulation. After 75 min, samples from the jugular vein showed concentrations of .019 ± .008 mmol/L in the sham group and .042 ± .022 mmol/L in the intervention group (P = .023). A similar significant effect was seen in the portal circulation after 90 min. l-lactate increased five minutes after clamping in the portal circulation, with values of 3.396 ± 1.119 mmol/L in the intervention group compared to 1.696 ± .483 mmol/L in the control group (P = .006). l-LDH increased significantly in the intervention group, while leukocytes were unaffected. l-LDH and l-lactate in plasma led to an overestimation of d-lactate if not handled. CONCLUSION Both systemic d- and l-lactate were markers of venous-induced intestinal ischemia. We speculate that d-lactate may be a valuable aid to the clinician in search of the anaerobic focus, because it may be more specific for mesenteric ischemia than l-lactate, in the sense that it is of bacterial origin.
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Affiliation(s)
- Casper Nielsen
- Vascular Research Unit, Viborg Regional Hospital, Heibergs Allé 4, DK-8800 Viborg, Denmark.
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Vitin AA, Metzner JI. Anesthetic management of acute mesenteric ischemia in elderly patients. Anesthesiol Clin 2009; 27:551-67, table of contents. [PMID: 19825492 DOI: 10.1016/j.anclin.2009.07.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Ischemic insult to the splanchnic vasculature can jeopardize bowel viability and lead to devastating consequences, including bowel necrosis and gangrene. Although acute mesenteric ischemia (AMI) may occur at any age, the elderly are most commonly affected due to their higher incidence of underlying systemic pathology, most notably atherosclerotic cardiovascular disease. Treatment options include pharmacology-based actions, endovascular, and surgical interventions. AMI remains a life-threatening condition with a mortality rate of 60% to 80%, especially if intestinal infarction has occurred and surgical intervention becomes emergent. Early recognition and an aggressive therapeutic approach are essential if the usually poor outcome is to be improved. Anesthetic management is complex and must account for comorbid disease as well as the patient's presumptive acute deterioration. Blood pressure support typically involves careful, but often massive, fluid resuscitation and may also additionally require pharmacologic support.
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Affiliation(s)
- Alexander A Vitin
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA 98195-6540, USA.
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Abstract
Abdominal angina is an underrecognized cause of postprandial abdominal pain and weight loss. Diagnosis is often delayed and requires both a careful exclusion of more common causes and a high degree of clinical suspicion, based on the patient's age, the coexistence of multiple risk factors for atherosclerosis, and the presence of vasculopathy in other districts. Appropriate investigations include duplex ultrasound, traditional angiography, magnetic resonance angiography, computed tomography angiography, and tonometry. The purpose of this review is to discuss the pathophysiology and clinical presentation of chronic mesenteric ischemia and to suggest a diagnostic flowchart for this complex condition.
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Affiliation(s)
- Marco Biolato
- Department of Internal Medicine, Catholic University of Rome, Rome, Italy
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Altinyollar H, Boyabatli M, Berberoğlu U. D-dimer as a marker for early diagnosis of acute mesenteric ischemia. Thromb Res 2009; 117:463-7. [PMID: 15922412 DOI: 10.1016/j.thromres.2005.04.025] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2004] [Revised: 02/24/2005] [Accepted: 04/05/2005] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Acute obstruction of mesenteric artery generally has an unfavorable prognosis because of late diagnosis. In this study we evaluated the diagnostic value of plasma D-dimer level as an early indicator in acute mesenteric ischemia in rats caused by ligation of superior mesenteric artery. MATERIALS AND METHODS Twenty-eight mature male Wistar rats were used in the study. These were divided into four groups, each consisting of seven rats. In group I, after performing a simple laparotomy, blood was sampled at minute 30. In group II, first the superior mesenteric artery was ligated, and blood samples were taken at the 30th minute. Group III consisted of rats undergoing a simple laparotomy and blood samples were taken 7 h later. From the subjects in group IV blood samples were obtained 7 h after the ligation of their superior mesenteric artery. RESULTS Plasma D-dimer levels of the ligated groups were significantly higher both at the 30th minute and the 7th hour compared to the levels of those having undergone simple laparotomies (p<0.002). Likewise, this level was higher in the 7th hour blood samples of the ligated group than in the 30th minute (p<0.008). CONCLUSIONS In rats undergoing acute mesenteric ischemia by ligation of superior mesenteric artery, plasma D-dimer levels increase with the duration of the intestinal ischemia period. This finding suggests that the measurement of the plasma D-dimer levels might be a useful tool for the early diagnosis of acute mesenteric obstruction.
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Affiliation(s)
- Hüseyin Altinyollar
- Ankara Oncology Education and Research Hospital, Department of General Surgery, Batikent-Ankara, Turkey.
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Gunduz A, Turkmen S, Turedi S, Mentese A, Yulug E, Ulusoy H, Karahan SC, Topbas M. Time-dependent variations in ischemia-modified albumin levels in mesenteric ischemia. Acad Emerg Med 2009; 16:539-43. [PMID: 19388911 DOI: 10.1111/j.1553-2712.2009.00414.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The objective was to determine the value of ischemia-modified albumin (IMA) in the diagnosis of mesenteric embolism. The authors investigated whether or not plasma IMA levels rose in the acute period in a rat model of mesenteric ischemia and the related time-dependent changes. METHODS In this randomized, controlled, nonblinded trial, 36 mature female Wistar rats were divided into six groups: three control (Groups I, III, and V) and three ischemia (Groups II, IV, and VI). In the control groups, blood was sampled at 30 minutes (Group I), 2 hours (Group III), and 6 hours (Group V) following a simple laparotomy. In the ischemia groups, following laparotomy, the superior mesenteric artery (SMA) was clamped using a bulldog clamp, and blood samples were taken at 30 minutes (Group II), 2 hours (Group IV), and 6 hours (Group VI). RESULTS Plasma IMA levels in the ischemia groups were significantly higher compared to those of the control groups (p < 0.004). In addition, levels were higher in the 6-hour blood samples of the ischemia group than in the 2-hour and 30-minute samples (p < 0.001). Serum IMA was also higher in the 2-hour blood samples of the ischemia group than in the 30-minute samples (p < 0.001). CONCLUSIONS These preliminary findings suggest that serum IMA levels may represent a significant parameter in the early diagnosis of acute mesenteric ischemia and that further studies are necessary.
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Affiliation(s)
- Abdulkadir Gunduz
- Department of Emergency Medicine, Karadeniz Technical University Faculty of Medicine, Trabzon, Turkey
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The effect of 100% oxygen on intestinal preservation and recovery following ischemia-reperfusion injury in rats*. Crit Care Med 2009; 37:1054-61. [DOI: 10.1097/ccm.0b013e31819d0f5c] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Usefulness of Computed Tomography in Differentiating Transmural Infarction from Nontransmural Ischemia of the Small Intestine in Patients With Acute Mesenteric Venous Thrombosis. J Comput Assist Tomogr 2008; 32:730-7. [DOI: 10.1097/rct.0b013e318159f135] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Gunduz A, Turedi S, Mentese A, Karahan SC, Hos G, Tatli O, Turan I, Ucar U, Russell RM, Topbas M. Ischemia-modified albumin in the diagnosis of acute mesenteric ischemia: a preliminary study. Am J Emerg Med 2008; 26:202-5. [PMID: 18272103 DOI: 10.1016/j.ajem.2007.04.030] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2007] [Revised: 04/09/2007] [Accepted: 04/11/2007] [Indexed: 01/30/2023] Open
Abstract
Ischemia-modified albumin (IMA) is a sensitive marker of myocardial ischemia, skeletal muscle ischemia, pulmonary embolism, and stroke. However, there are no studies showing whether IMA increases in mesenteric ischemia. The aim of this study was to determine whether IMA was elevated in acute mesenteric ischemia. This case-controlled study was performed in an emergency department of a university hospital. The measurement of IMA levels in patient plasma yielded means of 0.264 +/- 0.057 absorbance units (ABSU) in the thromboembolic occlusion of the superior mesenteric artery (SMA) group and 0.163 +/- 0.025 ABSU in the control group. When plasma IMA levels in the thromboembolic occlusion SMA group were compared with those in the control group, statistically significant increases in IMA were observed in the occlusion group (P = .003). Findings indicating that IMA may have a place in the diagnosis of acute mesenteric embolism were obtained in this preliminary study. Further prospective studies are needed to see if IMA is clinically useful in the early detection of thromboembolic occlusion of the SMA.
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Affiliation(s)
- Abdulkadir Gunduz
- Department of Emergency Medicine, Karadeniz Technical University Faculty of Medicine, 61080 Trabzon, Turkey
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Sukhotnik I, Coran AG, Greenblatt R, Brod V, Mogilner J, Shiloni E, Shaoul R, Bitterman H. Effect of 100% oxygen on E-selectin expression, recruitment of neutrophils and enterocyte apoptosis following intestinal ischemia-reperfusion in a rat. Pediatr Surg Int 2008; 24:29-35. [PMID: 17962962 DOI: 10.1007/s00383-007-2039-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Recent evidence suggests that neutrophil recruitment may initiate cell apoptosis in ischemic tissues. We have recently shown that enterocyte apoptosis is increased following intestinal ischemia-reperfusion (IR) injury. The purpose of the present study was to examine the effect of hyperoxia on E-selectin expression, neutrophil recruitment and enterocyte apoptosis following intestinal IR in a rat. Male Sprague-Dawley rats were divided into three experimental groups: (1) sham rats underwent laparotomy without vascular occlusion and were ventilated with air (Sham) (2) IR rats underwent occlusion of both the superior mesenteric artery and portal vein for 30 min and were ventilated with air (IR), and (3) IR-O2 rats underwent IR and were ventilated with 100% started 10 min before reperfusion and continued for 6 h (IR-O2). Intestinal structural changes were determined 24 h following IR. Immunohistochemistry for E-selectin (using E-selectin cleaved concentrated polyclonal antibody) was performed to identify E-selectin immunoreactivity localized to the endothelium of venules. The recruitment of neutrophils was calculated per 100 venules. Immunohistochemistry for Caspase-3 was performed for identification of apoptotic cells. Non-parametric one-way ANOVA test was used for statistical analysis with p less than 0.05 considered statistically significant. A significant increase in E-selectin expression in the jejunum (6.1 +/- 2.2 vs. 2.5 +/- 1.0 E-selectin positive vessels/100 vessels, p < 0.05) and ileum (12.1 +/- 2.7 vs. 3.3 +/- 1.2 E-selectin positive vessels/100 vessels, p < 0.05) and a concomitant increase in neutrophil recruitment in the ileum (5.5 +/- 1.6 vs. 1.3 +/- 0.6 adhered PMN's per 100 venules) were observed in IR rats compared to sham animals and were accompanied by increased cell apoptosis (p < 0.05). Treatment with 100% oxygen resulted in a significant attenuation in E-selectin expression in the ileum (2.7 +/- 1.1 vs. 12.1 +/- 2.7 E-selectin positive vessels/100 vessels, p < 0.05), and neutrophil recruitment in the jejunum (2.5 +/- 1.4 vs. 7.7 +/- 1.9 adhered PMN's per 100 venules, p < 0.05) and ileum (1.5 +/- 0.7 vs. 5.5 +/- 1.6 adhered PMN's per 100 venules, p < 0.05) compared to IR animals, and was accompanied by decreased cell apoptosis (p < 0.05). Hyperoxia inhibits enterocyte apoptosis following intestinal ischemia-reperfusion. Down-regulation of E-selectin expression with subsequent decrease in neutrophil recruitment may be responsible for this effect.
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Affiliation(s)
- Igor Sukhotnik
- Department of Pediatric Surgery, Bnai Zion Medical Center, The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, 47 Golomb St, POB 4940, Haifa, Israel.
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O'Mahony GD, Gallucci MR, Córdova-Fraga T, Berch B, Richards WO, Bradshaw LA. Biomagnetic investigation of injury currents in rabbit intestinal smooth muscle during mesenteric ischemia and reperfusion. Dig Dis Sci 2007; 52:292-301. [PMID: 17160467 DOI: 10.1007/s10620-006-9559-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2006] [Accepted: 08/03/2006] [Indexed: 12/29/2022]
Abstract
A noninvasive, sensitive, and specific method of detecting mesenteric ischemia would be of great use in reducing the morbidity and mortality with which it is associated. Acute lesions in polarized electrically coupled tissues lead to injury currents driven by the transmembrane resting potential gradient. These injury currents are an effective indicator of pathophysiology. The presence of near-DC injury currents in rabbit intestinal smooth muscle has already been demonstrated using a Superconducting quantum interference device (SQUID), and the aim of this study was to evaluate the effect of arterial reperfusion upon these currents. We exteriorized the small bowel of 14 New Zealand white rabbits and placed a remotely operated vascular occluder around the distal most artery supplying a 3-in segment of the jejunum. Experiments were conducted in three groups, i.e., control (n=3), ischemia (n=6), and reperfusion following ischemia (n=5). The subject's position was modulated in and out of the biological field detection range of a SQUID magnetometer using a lift constructed of nonmagnetic material. The changes in magnetic field amplitude were 9.3 and 31.01% for the control and ischemia groups, respectively. The reperfusion group first exhibited a decrease of 17.35% from the pre-ischemic to the ischemic period, followed by an increase of 13.88% of the ischemic value after reestablishing perfusion. In conclusion, injury currents in GI smooth muscle that appear during ischemia are reduced to near-pre-ischemic levels during reperfusion.
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Affiliation(s)
- Gavin D O'Mahony
- Department of Surgery, Vanderbilt University School of Medicine, D 5219 MCN, Nashville, Tennessee 37232, USA
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Karamlou T, Landry GJ, Taylor LM, Moneta GL. Epidemiology and Pathophysiology. Vasc Med 2006. [DOI: 10.1016/b978-0-7216-0284-4.50031-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
BACKGROUND Cecal volvulus is an uncommon clinical event. The literature contains many recommended treatments with varied results. STUDY DESIGN A series of 10 consecutive patients treated by the author was reviewed. Each patient had complete clinical follow-up. The cecal volvulus was resected without detorsion and reperfusion of the volvulus. The intestine was resected using a surgical stapling device, transection of the mesentery at the axial twist, and a stapled anastomosis of the terminal ileum to the remnant of the right colon. Permanent sutures between the colonic tenia and the peritoneum of the right paracolic gutter fixed the remainder of the right colon to prevent recurrence of the volvulus. RESULTS The author in clinical practice surgically treated a series of 10 consecutive patients with complete follow-up between 1981 to 2004. All patients survived the surgical procedure and were discharged from the hospital. The diagnosis was determined preoperatively in 5 of the 10 patients. Five patients had gangrene of the colon, and two of these patients had perforation. All patients required postoperative intensive care from 2 to 9 days. Five of the 10 patients required ventilator support for 1 to 3 days. Postoperative complications included intraperitoneal bleeding, pneumonia, and surgical incision infection with a subcutaneous abscess. There has been no recurrence of the volvulus in any of these patients. CONCLUSIONS Ten consecutive cases of cecal volvulus were surgically treated by a uniform resection procedure. The cecal volvulus was not reperfused by detorsion. Reperfusion of ischemic or gangrenous bowel can possibly produce reperfusion injury, metabolic acidosis, intestinal bacterial, and toxin translocation with possible irreversible septic shock. Recurrence of the cecal volvulus was prevented by colopexy of the right colon remnant. Avoidance of reperfusion of the cecal volvulus with resection, primary anastomosis, and colopexy resulted in successful results in a small series in clinical practice.
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Kozuch PL, Brandt LJ. Review article: diagnosis and management of mesenteric ischaemia with an emphasis on pharmacotherapy. Aliment Pharmacol Ther 2005; 21:201-15. [PMID: 15691294 DOI: 10.1111/j.1365-2036.2005.02269.x] [Citation(s) in RCA: 121] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Mesenteric ischaemia results from decreased blood flow to the bowel, causing cellular injury from lack of oxygen and nutrients. Acute mesenteric ischaemia (AMI) is an uncommon disorder with high morbidity and mortality, but outcomes are improved with prompt recognition and aggressive treatment. Five subgroups of AMI have been identified, with superior mesenteric artery embolism (SMAE) the most common. Older age and cardiovascular disease are common risk factors for AMI, excepting acute mesenteric venous thrombosis (AMVT), which affects younger patients with hypercoaguable states. AMI is characterized by sudden onset of abdominal pain; a benign abdominal exam may be observed prior to bowel infarction. Conventional angiography and more recently, computed tomography angiography, are the cornerstones of diagnosis. Correction of predisposing conditions, volume resuscitation and antibiotic treatment are standard treatments for AMI, and surgery is mandated in the setting of peritoneal signs. Intra-arterial vasodilators are used routinely in the treatment of non-occlusive mesenteric ischaemia (NOMI) and also are advocated in the treatment of occlusive AMI to decrease associated vasospasm. Thrombolytics have been used on a limited basis to treat occlusive AMI. A variety of agents have been studied in animal models to treat reperfusion injury, which sometimes can be more harmful than ischaemic injury. Chronic mesenteric ischaemia (CMI) usually is caused by severe obstructive atherosclerotic disease of two or more splanchnic vessels, presents with post-prandial pain and weight loss, and is treated by either surgical revascularization or percutaneous angioplasty and stenting.
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Affiliation(s)
- P L Kozuch
- Division of Gastroenterology, Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY 10467, USA
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Angelelli G, Scardapane A, Memeo M, Stabile Ianora AA, Rotondo A. Acute bowel ischemia: CT findings. Eur J Radiol 2004; 50:37-47. [PMID: 15093234 DOI: 10.1016/j.ejrad.2003.11.013] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2003] [Revised: 11/19/2003] [Accepted: 11/27/2003] [Indexed: 02/06/2023]
Abstract
Acute bowel ischemia represents one of the most dramatic abdominal emergencies and, despite the fact it is more and more frequently observed in clinical practice, its mortality rate remains very high. In recent years Computed Tomography (CT) has proved to be a valid diagnostic tool in the evaluation of patients with acute abdominal syndrome and in the visualization of early signs of bowel ischemia. This paper reviews the aetiological and pathophysiological aspects as well as a broad spectrum of CT findings of this clinical condition.
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Affiliation(s)
- Giuseppe Angelelli
- Department of Radiology--University Hospital "Policlinico" of Bari--Piazza G. Cesare, 11-70124 Bari, Italy.
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Daniliuc S, Bitterman H, Rahat MA, Kinarty A, Rosenzweig D, Lahat N, Nitza L. Hypoxia inactivates inducible nitric oxide synthase in mouse macrophages by disrupting its interaction with alpha-actinin 4. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2003; 171:3225-32. [PMID: 12960352 DOI: 10.4049/jimmunol.171.6.3225] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Nitric oxide, produced in macrophages by the high output isoform inducible NO synthase (iNOS), is associated with cytotoxic effects and modulation of Th1 inflammatory/immune responses. Ischemia and reperfusion lead to generation of high NO levels that contribute to irreversible tissue damage. Ischemia and reperfusion, as well as their in vitro simulation by hypoxia and reoxygenation, induce the expression of iNOS in macrophages. However, the molecular regulation of iNOS expression and activity in hypoxia and reoxygenation has hardly been studied. We show in this study that IFN-gamma induced iNOS protein expression (by 50-fold from control, p < 0.01) and nitrite accumulation (71.6 +/- 14 micro M, p < 0.01 relative to control), and that hypoxia inhibited NO production (7.6 +/- 1.7 micro M, p < 0.01) without altering iNOS protein expression. Only prolonged reoxygenation restored NO production, thus ruling out the possibility that lack of oxygen, as a substrate, was the cause of hypoxia-induced iNOS inactivation. Hypoxia did not change the ratio between iNOS monomers and dimers, which are essential for iNOS activity, but the dimers were unable to produce NO, despite the exogenous addition of all cofactors and oxygen. Using immunoprecipitation, mass spectroscopy, and confocal microscopy, we demonstrated in normoxia, but not in hypoxia, an interaction between iNOS and alpha-actinin 4, an adapter protein that anchors enzymes to the actin cytoskeleton. Furthermore, hypoxia caused displacement of iNOS from the submembranal zones. We suggest that the intracellular localization and interactions of iNOS with the cytoskeleton are crucial for its activity, and that hypoxia inactivates iNOS by disrupting these interactions.
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Affiliation(s)
- Sharon Daniliuc
- Immunology Research Unit and Ischemia-Shock Research Laboratory, Carmel Medical Center, Rappaport Family Institute for Research in the Medical Sciences, and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
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Waisman D, Brod V, Wolff R, Sabo E, Chernin M, Weintraub Z, Rotschild A, Bitterman H. Effects of hyperoxia on local and remote microcirculatory inflammatory response after splanchnic ischemia and reperfusion. Am J Physiol Heart Circ Physiol 2003; 285:H643-52. [PMID: 12714329 DOI: 10.1152/ajpheart.00900.2002] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Splanchnic ischemia-reperfusion (I/R) causes tissue hypoxia that triggers local and systemic microcirculatory inflammatory responses. We evaluated the effects of hyperoxia in I/R induced by 40-min superior mesenteric artery (SMA) occlusion and 120-min reperfusion in four groups of rats: 1) control (anesthesia only), 2) sham operated (all surgical procedures without vascular occlusion; air ventilation), 3) SMA I/R and air, 4) SMA I/R and 100% oxygen ventilation started 10 min before reperfusion. Leukocyte rolling and adhesion in mesenteric microvessels, pulmonary microvascular blood flow velocity (BFV), and macromolecular (FITC-albumin) flux into lungs were monitored by intravital videomicroscopy. We also determined pulmonary leukocyte infiltration. SMA I/R caused marked decreases in mean arterial blood pressure (MABP) and blood flow to the splanchnic and hindquarters vascular beds and pulmonary BFV and shear rates, followed by extensive increase in leukocyte rolling and adhesion and plugging of >50% of the mesenteric microvasculature. SMA I/R also caused marked increase in pulmonary sequestration of leukocytes and macromolecular leak with concomitant decrease in circulating leukocytes. Inhalation of 100% oxygen maintained MABP at significantly higher values (P < 0.001) but did not change regional blood flows. Oxygen therapy attenuated the increase in mesenteric leukocyte rolling and adherence (P < 0.0001) and maintained microvascular patency at values not significantly different from sham-operated animals. Hyperoxia also attenuated the decrease in pulmonary capillary BFV and shear rates, reduced leukocyte infiltration in the lungs (P < 0.001), and prevented the increase in pulmonary macromolecular leak (P < 0.001), maintaining it at values not different from sham-operated animals. The data suggest that beneficial effects of normobaric hyperoxia in splanchnic I/R are mediated by attenuation of both local and remote inflammatory microvascular responses.
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Affiliation(s)
- Dan Waisman
- Department of Medicine, Carmel Medical Center, Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, 7 Michal St., Haifa 34362, Israel
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Lahat N, Rahat MA, Ballan M, Weiss-Cerem L, Engelmayer M, Bitterman H. Hypoxia reduces CD80 expression on monocytes but enhances their LPS-stimulated TNF-alpha secretion. J Leukoc Biol 2003; 74:197-205. [PMID: 12885936 DOI: 10.1189/jlb.0303105] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Monocytes/macrophages in ischemic tissues are involved in inflammation and suppression of adaptive immunity via secretion of proinflammatory cytokines and reduced ability to trigger T cells, respectively. We subjected human mononuclear cells and mouse macrophages to hypoxia and reoxygenation, the main constituents of ischemia and reperfusion, and added lipopolysaccharide (LPS) to simulate bacterial translocation, which frequently accompanies ischemia. We monitored the secretion of tumor necrosis factor alpha (TNF-alpha) and the surface expression of human leukocyte antigen-DR and the costimulatory molecules CD80 and CD86 on monocytes/macrophages. Hypoxia selectively reduced the surface expression of CD80 (P<0.01), and synergistically with LPS, it enhanced TNF-alpha secretion (P<0.003). Reoxygenation reversed both phenomena. In the mouse macrophage cell line RAW 264.7, hypoxia reduced the surface expression of CD80 and increased its concentrations in the supernatants (P<0.01). Down-regulation of the mRNA coding for the membrane-anchored CD80 was observed, suggesting that hypoxia triggers alternative splicing to generate soluble CD80. Cumulatively, these results suggest that hypoxia simultaneously affects monocytes/macrophages to enhance inflammation and reduce their ability to initiate adaptive-immunity responses associated with ischemic injury.
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Affiliation(s)
- Nitza Lahat
- Immunology Research Unit, Carmel Medical Center, Rappaport Family Institute for Research in the Medical Sciences, and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel.
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Ramaswamy CM, Eades SC, Venugopal CS, Hosgood GL, Garza F, Barker SA, Moore RM. Plasma concentrations of endothelin-like immunoreactivity in healthy horses and horses with naturally acquired gastrointestinal tract disorders. Am J Vet Res 2002; 63:454-8. [PMID: 11911584 DOI: 10.2460/ajvr.2002.63.454] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To compare plasma endothelin (ET)- like immunoreactivity between healthy horses and those with naturally acquired gastrointestinal tract disorders. ANIMALS 29 healthy horses and 142 horses with gastrointestinal tract disorders. PROCEDURE Blood samples were collected from healthy horses and from horses with gastrointestinal tract disorders prior to treatment. Magnitude and duration of abnormal clinical signs were recorded, and clinical variables were assessed via thorough physical examinations. Plasma concentrations of ET-like immunoreactivity were measured by use of a radioimmunoassay for human endothelin-1, and CBC and plasma biochemical analyses were performed. RESULTS Plasma ET-like immunoreactivity concentration was significantly increased in horses with gastrointestinal tract disorders, compared with healthy horses. Median plasma concentration of ET-like immunoreactivity was 1.80 pg/ml (range, 1.09 to 3.2 pg/ml) in healthy horses. Plasma ET-like immunoreactivity was greatest in horses with strangulating large-intestinal obstruction (median, 10.02 pg/ml; range, 3.8 to 22.62 pg/ml), peritonitis (9.19 pg/ml; 789 to 25.83 pg/ml), and enterocolitis (8.89 pg/mI; 6.30 to 18.36 pg/ml). Concentration of ET-like immunoreactivity was significantly associated with survival, PCV, and duration of signs of pain. However, correlations for associations with PCV and duration of pain were low. CONCLUSIONS AND CLINICAL RELEVANCE Horses with gastrointestinal tract disorders have increased plasma concentrations of ET-like immunoreactivity, compared with healthy horses. The greatest values were detected in horses with large-intestinal strangulating obstructions, peritonitis, and enterocolitis. This suggests a potential involvement of ET in the pathogenesis of certain gastrointestinal tract disorders in horses.
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Affiliation(s)
- Chidambaram M Ramaswamy
- Department of Comparative Biomedical Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge 70803-8410, USA
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Affiliation(s)
- Chung Kuao Chou
- Department of Radiology, Chi Mei Foundation Hospital, 901 Chung Hwa Rd., Tainan 71010, Taiwan, Republic of China
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