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Uchino M, Kitaguchi D, Furuya K, Owada Y, Ogawa K, Ohara Y, Akashi Y, Hashimoto S, Enomoto T, Oda T. Preoperative risk factors for 90-day postoperative mortality outcome in patients with non-occlusive mesenteric ischemia. Langenbecks Arch Surg 2024; 409:201. [PMID: 38954011 DOI: 10.1007/s00423-024-03391-z] [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: 12/27/2023] [Accepted: 06/17/2024] [Indexed: 07/04/2024]
Abstract
PURPOSE The mortality rate for non-occlusive mesenteric ischemia remains high even after patients survive the acute postoperative period with tremendous treatment efforts, including emergency surgery, which is challenging. The aim of this study was to explore the preoperative risk factors for 90-day postoperative mortality in patients with non-occlusive mesenteric ischemia. METHODS This single-center, retrospective cohort study included patients diagnosed with non-occlusive mesenteric ischemia who underwent emergency surgery between August 2014 and January 2023. All patients were divided into survival-to-discharge and mortality outcome groups at the 90-day postoperative follow-up. Preoperative factors, including comorbidities, preoperative status of vital signs and consciousness, blood gas analysis, blood test results, and computed tomography, were compared between the two groups. RESULTS Twenty patients were eligible, and 90-day mortality was observed in 10 patients (50%). The mortality outcome group had significantly lower HCO3- (20.9 vs. 14.6, p = 0.006) and higher lactate (4.4 vs. 9.4, p = 0.023) levels than did the survival outcome group. The median postoperative time to death was 19 [2-69] days, and five patients (50%) died after postoperative day 30, mainly because hemodialysis was discontinued because of hemodynamic instability in patients requiring hemodialysis. CONCLUSION Low preoperative HCO3- and high lactate levels may be preoperative risk factors for 90-day postoperative mortality in patients with non-occlusive mesenteric ischemia. However, patients on hemodialysis die from discontinuing hemodialysis even after surviving the acute postoperative phase. Therefore, indications for emergency surgery in patients with risk factors for postoperative mortality should be carefully determined.
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Affiliation(s)
- Makoto Uchino
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Daichi Kitaguchi
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki, 305-8575, Japan.
| | - Kinji Furuya
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Yohei Owada
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Koichi Ogawa
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Yusuke Ohara
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Yoshimasa Akashi
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Shinji Hashimoto
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Tsuyoshi Enomoto
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Tatsuya Oda
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
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Goto D, Yanishi K, Ozawa T, Yoshimura J, Kawamata H, Fujioka A, Seki T, Zen K, Matoba S. Comparison of Endovascular Therapy and Open Surgical Revascularization in Patients With Acute Superior Mesenteric Artery Occlusion: A Large-Scale Analysis Based on the JROAD-DPC Database. J Am Heart Assoc 2024; 13:e035017. [PMID: 38879458 DOI: 10.1161/jaha.124.035017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 05/23/2024] [Indexed: 06/19/2024]
Abstract
BACKGROUND Acute mesenteric ischemia is rare, and few large-scale trials have evaluated endovascular therapy (EVT) and open surgical revascularization (OS). This study aimed to assess clinical outcomes after EVT or OS for acute superior mesenteric artery occlusion and identify predictors of mortality and bowel resection. METHODS AND RESULTS Data from the Japanese Registry of All Cardiac and Vascular Diseases-Diagnosis Procedure Combination (JROAD-DPC) database from April 2012 to March 2020 were retrospectively analyzed. Overall, 746 patients with acute superior mesenteric artery occlusion who underwent revascularization were classified into 2 groups: EVT (n=475) or OS (n=271). The primary clinical outcome was in-hospital mortality. The secondary outcomes were bowel resection, bleeding complications (transfusion or endoscopic hemostasis), major adverse cardiovascular events, hospitalization duration, and cost. The in-hospital death or bowel resection rate was ≈30%. In-hospital mortality (22.5% versus 21.4%, P=0.72), bowel resection (8.2% versus 8.5%, P=0.90), and major adverse cardiovascular events (11.6% versus 9.2%, P=0.32) were comparable between the EVT and OS groups. Hospitalization duration in the EVT group was 6 days shorter than that in the OS group, and total hospitalization cost was 0.88 million yen lower. Interaction analyses revealed that EVT and OS had no significant difference in terms of in-hospital death in patients with thromboembolic and atherothrombotic characteristics. Advanced age, decreased activities of daily living, chronic kidney disease, and old myocardial infarction were significant predictive factors for in-hospital mortality. Diabetes was a predictor of bowel resection after revascularization. CONCLUSIONS EVT was comparable to OS in terms of clinical outcomes in patients with acute superior mesenteric artery occlusion. Some predictive factors for mortality or bowel resection were obtained. REGISTRATION URL: www.umin.ac.jp/ctr/; Unique Identifier: UMIN000045240.
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Affiliation(s)
- Daiki Goto
- Department of Cardiovascular Medicine, Graduate School of Medical Science Kyoto Prefectural University of Medicine Kyoto Japan
| | - Kenji Yanishi
- Department of Cardiovascular Medicine, Graduate School of Medical Science Kyoto Prefectural University of Medicine Kyoto Japan
| | - Takaaki Ozawa
- Department of Cardiovascular Medicine, Graduate School of Medical Science Kyoto Prefectural University of Medicine Kyoto Japan
| | - Jun Yoshimura
- Department of Cardiovascular Medicine, Graduate School of Medical Science Kyoto Prefectural University of Medicine Kyoto Japan
| | - Hirofumi Kawamata
- Department of Cardiovascular Medicine, Graduate School of Medical Science Kyoto Prefectural University of Medicine Kyoto Japan
| | - Ayumu Fujioka
- Department of Cardiovascular Medicine, Graduate School of Medical Science Kyoto Prefectural University of Medicine Kyoto Japan
| | - Tomotsugu Seki
- Department of Cardiovascular Medicine, Graduate School of Medical Science Kyoto Prefectural University of Medicine Kyoto Japan
| | - Kan Zen
- Department of Cardiovascular Medicine, Graduate School of Medical Science Kyoto Prefectural University of Medicine Kyoto Japan
| | - Satoaki Matoba
- Department of Cardiovascular Medicine, Graduate School of Medical Science Kyoto Prefectural University of Medicine Kyoto Japan
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Minordi LM, Larosa L, Barbaro B, Angelino A, Broglia D, Cipri C, Scaldaferri F, Manfredi R, Natale L. How the Radiologist Must Reason for a Correct Diagnosis in Patients With Small Bowel Mural Thickening Studied by CT or MRI: A Pictorial Review. Curr Probl Diagn Radiol 2023; 52:393-411. [PMID: 37137738 DOI: 10.1067/j.cpradiol.2023.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 02/06/2023] [Accepted: 03/16/2023] [Indexed: 03/30/2023]
Abstract
Conditions that lead to small bowel mural thickening fall into a broad spectrum of diseases, including inflammatory, infectious, vascular or neoplastic. Computed tomography (CT) and Magnetic Resonance Imaging (MRI), especially CT-enterography and MR-enterography, permit evaluation of both entire small bowel and extraluminal structures. In CT/MR-enterography, the main prerequisite for the correct evaluation of small bowel is to obtain optimal intestinal distension. In fact, most errors are related to poor intestinal distension of the bowel which can lead to interpret as pathological a small bowel segment that is not very distended (false positive), or not to recognize presence of pathology in a collapsed segment (false negative). Once the examination has been performed, the images are analyzed in order to identify the presence of small bowel pathology. Pathology of the small bowel can manifest as endoluminal alteration and/or intestinal wall thickening. Once bowel wall thickening has been identified, the radiologist's first objective is trying to define benign or malignant nature of the alteration, using also patient's history and clinical features. Once the suspicion of benign or malignant pathology has been raised, the radiologist must try to formulate a diagnosis of nature. In this pictorial review we describe how the radiologist must reason for a correct diagnosis by answering a pattern of sequential questions in a patient with suspected small bowel disease studied by CT or MRI.
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Affiliation(s)
- Laura Maria Minordi
- Dipartimento di Diagnostica per immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC Radiodiagnostica addominale, Roma, Italy.
| | - Luigi Larosa
- Dipartimento di Diagnostica per immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC Radiodiagnostica addominale, Roma, Italy
| | - Brunella Barbaro
- Dipartimento di Diagnostica per immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC Radiodiagnostica addominale, Roma, Italy; Università Cattolica del Sacro Cuore, Roma, Italy
| | | | | | - Carla Cipri
- Università Cattolica del Sacro Cuore, Roma, Italy
| | - Franco Scaldaferri
- Dipartimento di Scienze Gastroenterologiche, Endocrino-Metaboliche e Nefro-Urologiche, Area Medicina Interna, Gastroenterologia e Oncologia Medica, UOC di Medicina Interna e Gastroenterologia, CEMAD (Centro Malattie Apparato Digerente), Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Riccardo Manfredi
- Dipartimento di Diagnostica per immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC Radiodiagnostica addominale, Roma, Italy; Università Cattolica del Sacro Cuore, Roma, Italy
| | - Luigi Natale
- Dipartimento di Diagnostica per immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC Radiodiagnostica addominale, Roma, Italy; Università Cattolica del Sacro Cuore, Roma, Italy
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Pierro A, Minordi LM, Larosa L, Cipri C, Guerri G, Quinto F, Rotondi F, Marcellino A, Basilico R, Iezzi R, Cilla S. Small Bowel Imaging from Stepchild of Roentgenology to MR Enterography, Part II: The Reliable Disclosure of Crohn's Disease and Non-Inflammatory Small Bowel Disorder Plot through MRI Findings. Life (Basel) 2023; 13:1836. [PMID: 37763240 PMCID: PMC10532809 DOI: 10.3390/life13091836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 08/14/2023] [Accepted: 08/25/2023] [Indexed: 09/29/2023] Open
Abstract
MRE has become a standard imaging test for evaluating patients with small bowel pathology, but a rigorous methodology for describing and interpreting the pathological findings is mandatory. Strictures, abscess, inflammatory activity, sinus tract, wall edema, fistula, mucosal lesions, strictures, and mesentery fat hypertrophy are all indicators of small bowel damage in inflammatory and non-inflammatory small bowel disease, and they are all commonly and accurately explained by MRE. MRE is a non-invasive modality that accurately assesses the intra-luminal, parietal, and extra-luminal small bowel. Differential MRE appearance allows us to distinguish between Crohn's disease and non-inflammatory small bowel disorder. The purpose of this paper is to present the MRE pathological findings of small bowel disorder.
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Affiliation(s)
- Antonio Pierro
- Radiology Unit, San Timoteo Hospital, 86039 Termoli, Italy;
| | - Laura Maria Minordi
- Radiology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Roma, Italy; (L.M.M.); (L.L.); (C.C.); (G.G.); (R.I.)
| | - Luigi Larosa
- Radiology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Roma, Italy; (L.M.M.); (L.L.); (C.C.); (G.G.); (R.I.)
| | - Carla Cipri
- Radiology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Roma, Italy; (L.M.M.); (L.L.); (C.C.); (G.G.); (R.I.)
| | - Giulia Guerri
- Radiology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Roma, Italy; (L.M.M.); (L.L.); (C.C.); (G.G.); (R.I.)
| | - Fabio Quinto
- Angiography Unit, “L. Bonomo” Hospital, 70031 Andria, Italy;
| | - Fabio Rotondi
- Oncological Surgery Unit, Responsible Research Hospital, 86100 Campobasso, Italy;
| | - Annalisa Marcellino
- ASReM, Azienda Sanitaria Regionale del Molise, Via Ugo Petrella 1, 86100 Campobasso, Italy;
| | - Raffaella Basilico
- Department of Neurosciences, Imaging and Clinical Studies, “Gabriele D’Annunzio” University, 66100 Chieti, Italy;
| | - Roberto Iezzi
- Radiology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Roma, Italy; (L.M.M.); (L.L.); (C.C.); (G.G.); (R.I.)
| | - Savino Cilla
- Medical Physics Unit, Responsible Research Hospital, 86100 Campobasso, Italy
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Topolsky A, Pantet O, Liaudet L, Sempoux C, Denys A, Knebel JF, Schmidt S. MDCT-findings in patients with non-occlusive mesenteric ischemia (NOMI): influence of vasoconstrictor agents. Eur Radiol 2023; 33:3627-3637. [PMID: 36692594 PMCID: PMC10121529 DOI: 10.1007/s00330-023-09415-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 11/02/2022] [Accepted: 01/01/2023] [Indexed: 01/25/2023]
Abstract
OBJECTIVES To evaluate the influence of vasoconstrictor agents (VCAs) on signs of vasoconstriction and bowel ischemia on MDCT detected in patients with non-occlusive mesenteric ischemia (NOMI). METHODS This 8-year single-center retrospective study consecutively included all patients with histopathologically proven NOMI who underwent MDCT ≤ 48 h prior to surgical bowel resection. Two blinded radiologists jointly reviewed each examination for signs of bowel ischemia, abdominal organ infarct, mesenteric vessel size and regularity, and ancillary vascular findings. VCA administration (length and dosage), clinical and biochemical data, risk factors, and outcomes were retrieved from patients' medical records. Subgroup comparisons were performed. RESULTS Ninety patients were included (59 males, mean age 65 years); 40 (44.4%) had received VCAs before MDCT. Overall mortality was 32% (n = 29), with no significant difference between the two groups. In patients treated with VCAs, the calibre of the superior mesenteric artery (SMA) was smaller (p = 0.032), and vasoconstriction of its branches tended to be more important (p = 0.096) than in patients not treated with VCAs. The presence and extent of bowel ischemia did not significantly correlate with VCA administration, but abdominal organ infarcts tended to be more frequent (p = 0.005) and involved more organs (p = 0.088). The VCA group had lower mean arterial pressure (p = 0.006) and lower hemoglobin levels (p < 0.001). Several biomarkers of organ failure and inflammation, differed significantly with VCA use, proving worse clinical condition. CONCLUSIONS MDCT demonstrates more severe SMA vasoconstriction and tends to show increased abdominal organ infarcts after VCA administration in NOMI patients compared to NOMI patients not treated with VCAs. KEY POINTS • In critically ill patients with NOMI, MDCT demonstrates VCA support via increased vasoconstriction of the main SMA and its branches. • VCA administration in NOMI patients tends to contribute to the development of organ infarcts, as shown on MDCT. • An important degree of vasoconstriction in NOMI patients may indicate insufficient resuscitation and, thus, help clinicians in further patient management.
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Affiliation(s)
- Antoine Topolsky
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Olivier Pantet
- Service of Adult Intensive Care Medicine and Burns, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Lucas Liaudet
- Service of Adult Intensive Care Medicine and Burns, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Christine Sempoux
- Service of Clinical Pathology, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Alban Denys
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Jean-François Knebel
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Sabine Schmidt
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Rue du Bugnon 46, 1011, Lausanne, Switzerland.
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Superior Mesenteric Artery Occlusion Caused by Infective Endocarditis and Worsened by Mycotic Aneurysm and Intracranial Hemorrhage: A Case Report. Medicina (B Aires) 2022; 58:medicina58111585. [DOI: 10.3390/medicina58111585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 11/02/2022] [Accepted: 11/02/2022] [Indexed: 11/06/2022] Open
Abstract
The superior mesenteric artery (SMA) is more commonly occluded than other abdominal arteries due to anatomical factors. Though rare, SMA occlusion is life-threatening. We present the case of a 50-year-old male patient who presented with fever and abdominal pain and was subsequently diagnosed with SMA embolism, SMA mycotic aneurysm, and infective endocarditis. Many patients visit the emergency room complaining of abdominal pain. Although SMA occlusion diagnosis is rare in these cases, detailed examination and close monitoring of patients are warranted considering the high mortality rate of this disease.
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Mesenteric Ischemia and Its Need for Timely Recognition and Management. Case Rep Surg 2022; 2022:7370634. [PMID: 36213588 PMCID: PMC9534705 DOI: 10.1155/2022/7370634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 08/23/2022] [Accepted: 09/02/2022] [Indexed: 11/17/2022] Open
Abstract
Mesenteric ischemia is a fatal vascular emergency of the small intestine which, if not diagnosed and treated in time, has a very high mortality rate. Presenting with nonspecific symptoms such as abdominal pain, nausea, constipation, tachycardia, and gastrointestinal bleeds, it can masquerade as other causes of acute abdomen, particularly bowel obstruction. Ideal laboratory tests and markers are still lacking due to complexity in bowel's anatomy, physiology, blood supply, and drainage. We report 10 cases of mesenteric ischemia presented in our center with their demography, laboratory findings, approach to diagnosis, and treatment along with their outcomes at discharge. Out of the ten cases, six cases presented with signs and symptoms of acute bowel obstruction without passage of stool and one with passage of black stool. These seven patients underwent laparotomy, while the remaining three cases who either presented with milder symptoms or refused surgical interventions were managed conservatively. All patients were diagnosed with either acute or chronic mesenteric ischemia based on their operative and/or radiographic findings.
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Watada S, Obara H, Okui J, Hosokawa K, Matsubara K, Harada H, Fujimura N, Fujii T, Shimogawara T, Kitagawa Y. Prediction of need for bowel resection in acute superior mesenteric artery occlusion: A retrospective study of 48 Japanese patients. Ann Gastroenterol Surg 2022; 7:175-181. [PMID: 36643371 PMCID: PMC9831903 DOI: 10.1002/ags3.12614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 08/08/2022] [Indexed: 01/18/2023] Open
Abstract
Aim This study aimed to predict cases of acute superior mesenteric artery (SMA) occlusion requiring bowel resection using occlusion site and time from symptom onset to diagnosis at five Japanese institutions. Advances in imaging, endovascular treatment, and perioperative management have improved the clinical outcomes of patients with acute SMA occlusion; however, in clinical practice it remains difficult to effectively determine patients requiring bowel resection. Methods We retrospectively analyzed the data of 48 patients (mean age: 82.5 y; male: 37.5%) diagnosed with acute SMA occlusion between June 2009 and August 2018. Background data of patients who required and did not require bowel resection were compared. A multivariable predictive model was developed using the time from symptom onset to diagnosis and whether SMA occlusion was proximal, including the origin of the middle colic artery. Results Fifteen patients (31.3%) died during the hospital stay. Atrial fibrillation (83.3%) was the most common comorbidity. The median time from symptom onset to diagnosis was 13.0 (interquartile range, 4.75-24.0) h. Laparotomy, bowel resection, and thrombus embolectomy were performed in 41 (85.4%), 26 (54.2%), and 21 (43.8%) patients, respectively. A logistic regression model achieved 78.6% sensitivity in predicting cases not requiring bowel resection. Proximal occlusion was significantly associated with the requirement for bowel resection (P = .039). Conclusion The time from symptom onset to diagnosis and occlusion site contributed to high sensitivity in determining the need for bowel resection in patients with acute SMA occlusion. Further prospective studies are warranted to investigate the clinical impact of this model.
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Affiliation(s)
- Susumu Watada
- Department of SurgeryKawasaki Municipal HospitalKawasakiJapan
| | - Hideaki Obara
- Department of SurgeryKeio University School of MedicineTokyoJapan
| | - Jun Okui
- Department of SurgeryKeio University School of MedicineTokyoJapan,Department of Preventive Medicine and Public HealthKeio University School of MedicineTokyoJapan
| | | | | | - Hirohisa Harada
- Division of Vascular SurgeryTokyo Saiseikai Central HospitalTokyoJapan
| | - Naoki Fujimura
- Division of Vascular SurgeryTokyo Saiseikai Central HospitalTokyoJapan
| | - Taku Fujii
- Department of SurgerySaitama City HospitalSaitamaJapan
| | - Tatsuya Shimogawara
- Department of Vascular SurgerySaisekai Yokohamashi Tobu HospitalKawasakiJapan
| | - Yuko Kitagawa
- Department of SurgeryKeio University School of MedicineTokyoJapan
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Zhang J, Li C, Han X, Chen Z, Adhikari BK, Wang Y, Wang Y, Sun J. The digestive system involvement of antiphospholipid syndrome: pathophysiology, clinical characteristics, and treatment strategies. Ann Med 2021; 53:1328-1339. [PMID: 34409894 PMCID: PMC8381908 DOI: 10.1080/07853890.2021.1962964] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 07/25/2021] [Indexed: 02/03/2023] Open
Abstract
Antiphospholipid syndrome (APS) is an autoimmune disease mainly characterised by vascular thrombosis and pregnancy morbidity. APS has broad spectrum of clinical manifestations. The digestive system involvement of antiphospholipid syndrome is a critical but under-recognised condition. Digestive system involvement may be the result of direct (autoimmune-mediated) or indirect (thrombotic) mechanisms. Liver is the most commonly involved organ, followed by intestines, oesophagus, stomach, pancreas and spleen. This review describes possible digestive system manifestations in APS patients, and illustrates the epidemiology and possible pathophysiology of APS. The role of different treatment strategies in the management of digestive system manifestations of APS were also discussed.Key messagesAntiphospholipid syndrome is a multi-organ, multi-system disease and its clinical manifestation spectrum is gradually expanding. Since the first diagnosis of APS, the clinical manifestations of digestive system have been reported successively. This narrative review describes the major digestive system manifestations of APS and illustrates the epidemiology, pathophysiology and the role of therapeutic strategies of these patients.
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Affiliation(s)
- Jin Zhang
- Department of Cardiovascular Center, Jilin University First Hospital, Changchun, China
| | - Cheng Li
- Department of Cardiovascular Center, Jilin University First Hospital, Changchun, China
| | - Xiaorong Han
- Department of Cardiovascular Center, Jilin University First Hospital, Changchun, China
| | - Zhongbo Chen
- Department of Cardiovascular Center, Jilin University First Hospital, Changchun, China
| | - Binay Kumar Adhikari
- Department of Medicine, Nepal Armed Police Force Command and Staff hospital, Kathmandu, Nepal
| | - Yinghui Wang
- Department of Cardiovascular Center, Jilin University First Hospital, Changchun, China
| | - Yonggang Wang
- Department of Cardiovascular Center, Jilin University First Hospital, Changchun, China
| | - Jian Sun
- Department of Cardiovascular Center, Jilin University First Hospital, Changchun, China
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Wu M, Rowe JM, Fleming SD. Complement Initiation Varies by Sex in Intestinal Ischemia Reperfusion Injury. Front Immunol 2021; 12:649882. [PMID: 33868287 PMCID: PMC8047102 DOI: 10.3389/fimmu.2021.649882] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 03/08/2021] [Indexed: 01/03/2023] Open
Abstract
Intestinal ischemia reperfusion (IR)-induced tissue injury represents an acute inflammatory response with significant morbidity and mortality. The mechanism of IR-induced injury is not fully elucidated, but recent studies suggest a critical role for complement activation and for differences between sexes. To test the hypothesis that complement initiation differs by sex in intestinal IR, we performed intestinal IR on male and female WT C57B6L/, C1q-/-, MBL-/-, or properdin (P)-/- mice. Intestinal injury, C3b and C5a production and ex vivo secretions were analyzed. Initial studies demonstrated a difference in complement mRNA and protein in male and female WT mice. In response to IR, male C1q-, MBL- and P-deficient mice sustained less injury than male WT mice. In contrast, only female MBL-/- mice sustained significantly less injury than female wildtype mice. Importantly, wildtype, C1q-/- and P-/- female mice sustained significant less injury than the corresponding male mice. In addition, both C1q and MBL expression and deposition increased in WT male mice, while only elevated MBL expression and deposition occurred in WT female mice. These data suggested that males use both C1q and MBL pathways, while females tend to depend on lectin pathway during intestinal IR. Females produced significantly less serum C5a in MBL-/- and P-/- mice. Our findings suggested that complement activation plays a critical role in intestinal IR in a sex-dependent manner.
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Affiliation(s)
- Miaomiao Wu
- Animal Nutritional Genome and Germplasm Innovation Research Center, College of Animal Science and Technology, Hunan Agricultural University, Changsha, China
- Division of Biology, Kansas State University, Manhattan, KS, United States
| | - Jennifer M. Rowe
- Division of Biology, Kansas State University, Manhattan, KS, United States
| | - Sherry D. Fleming
- Division of Biology, Kansas State University, Manhattan, KS, United States
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Kundan M, Chebrolu H, Muniswamppa C, Kumar N, Chintamani, Varma V. Outcomes of Management of Patients with Acute Mesenteric Ischemia: A Prospective Study. Niger J Surg 2021; 27:16-21. [PMID: 34012236 PMCID: PMC8112362 DOI: 10.4103/njs.njs_54_20] [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: 05/15/2020] [Revised: 05/18/2020] [Accepted: 05/26/2020] [Indexed: 11/04/2022] Open
Abstract
Introduction Acute mesenteric ischemia (AMI) is the sudden onset of small intestinal hypoperfusion, which can be due to reduction or cessation of arterial inflow. It can be embolic or thrombotic. AMI is a potentially fatal vascular emergency, with overall mortality of 60%-80%. The present study was designed to study presentation, risk factors, and various outcomes of AMI patients, who were treated in the tertiary hospital. Methodology All patients with features suggestive of AMI were taken in study. All patients underwent explorative laparotomy with exteriorization of bowel after initial resuscitation. Postoperatively, refeeding enteroclysis was done. Observation and Results The total mortality rate was 62.50%. In patients with functional bowel length of 1 foot, 90.90% patients died. In patients with functional bowel length of 5-6 feet, only 12.50% died. It was observed that the mortality rate was more in the age group of 50-59 years with functional bowel length of 1 foot or <1 foot. Refeeding enteroclysis is an effective technique to use distal bowel. Contrast-enhanced computed tomography of the abdomen more suggestive of this pathology. Conclusions A strong clinical suspicion and an aggressive approach should be considered in dealing with this condition because the outcome mainly depends on rapid diagnosis and treatment. With understanding of the pathogenesis of AMI and the better utilization of available radiological investigations, an improved outcome can be achieved. Mortality rates with refeeding enteroclysis are comparable with that of bowel anastomosis. This condition needs future research.
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Affiliation(s)
- Meghraj Kundan
- Department of General Surgery, V.M.M.C and Safdarjung Hospital, New Delhi, India
| | - Hethu Chebrolu
- Department of General Surgery, V.M.M.C and Safdarjung Hospital, New Delhi, India
| | - Chetan Muniswamppa
- Department of General Surgery, V.M.M.C and Safdarjung Hospital, New Delhi, India
| | - Niranjan Kumar
- Department of General Surgery, TMH, Jamshedpur, Jharkhand, India
| | - Chintamani
- Department of General Surgery, V.M.M.C and Safdarjung Hospital, New Delhi, India
| | - Vinayak Varma
- Department of General Surgery, V.M.M.C and Safdarjung Hospital, New Delhi, India
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12
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Dominowski L, Kirsch M. Synergistic Effect of β-alanine and Aprotinin on Mesenteric Ischemia. J Surg Res 2021; 263:78-88. [PMID: 33639373 DOI: 10.1016/j.jss.2021.01.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 01/10/2021] [Accepted: 01/25/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Acute mesenteric ischemia arises through sudden interruption of mesenteric blood flow, mostly due to an occlusion of the superior mesenteric artery and is associated with a high mortality of approximately 50% to 90%. In previous studies, the single application of β-alanine or aprotinin caused an ameliorated intestinal damage but without any systemic effects. METHODS To analyze the combined effect of β-alanine and aprotinin on acute ischemia and reperfusion of the small intestine, a model with anesthetized rats was used. Ischemia and reperfusion were initiated by occluding and reopening the superior mesenteric artery. After 120 min of ischemia and 180 min of reperfusion, the intestine was analyzed for tissue damage, the activity of the saccharase, and accumulation of granulocytes. In addition, systemic and metabolic as well as inflammatory parameters were measured in blood at certain points in time. RESULTS The combination of β-alanine and aprotinin resulted in a clearly stabilized mean arterial blood pressure and blood glucose level during the reperfusion period. Furthermore, the combined administration resulted in significantly reduced tissue damage parameters, cytokine and cell-free hemoglobin concentrations in blood plasma. In addition, the damage to the small intestine was significantly attenuated, so that the animals ultimately survived the entire test period because of the administration of both substances. CONCLUSIONS Overall, the simultaneous application of both substances leads to a synergistic protection without the occurrence of undesirable side effects. The combined usage of β-alanine and aprotinin can be seen as a promising approach to inhibit the onset of acute mesenteric ischemia.
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Affiliation(s)
- Lisa Dominowski
- Institut für Physiologische Chemie, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Germany
| | - Michael Kirsch
- Institut für Physiologische Chemie, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Germany.
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Grotelueschen R, Miller V, Heidelmann LM, Melling N, Ghadban T, Grupp K, Reeh M, Welte MN, Uzunoglu FG, Izbicki JR, Bachmann KA. Acute Mesenteric Infarction: The Chameleon of Acute Abdomen Evaluating the Quality of the Diagnostic Parameters in Acute Mesenteric Ischemia. Dig Surg 2021; 38:149-157. [PMID: 33503619 DOI: 10.1159/000512779] [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] [Received: 03/23/2020] [Accepted: 10/25/2020] [Indexed: 12/10/2022]
Abstract
INTRODUCTION/OBJECTIVE Acute mesenteric ischemia (AMI) is difficult to diagnose. Since the established parameters have low sensitivity and specificity, the aim of this study is to analyze the diagnostic quality of the established parameters of AMI. METHODS All patients that underwent emergency surgery due to suspected diagnosis of mesenteric ischemia at the University Medical Center Hamburg-Eppendorf between 2008 and 2014 were evaluated. Overall, 275 patients were enrolled and pre-, intra- and postoperative data were evaluated. RESULTS In 200 patients, a mesenteric ischemia was confirmed intraoperatively, and 75 patients had no ischemia. Comparing these groups, the rate of patients with pH < 7.2 (25 vs. 12%; p = 0.021) and elevated mean CRP level (175 ± 117 mg/L vs. 139 ± 104 mg/L; p = 0.019) was significantly higher in ischemic patients. There was no significant difference in the level of preoperative lactate. Concerning abdominal CT scan, a sensitivity and specificity of 61 and 68%, respectively, was found. CONCLUSION New diagnostic parameters are needed. So far, explorative laparotomy is the only reliable diagnostic method to detect mesenteric infarction.
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Affiliation(s)
- Rainer Grotelueschen
- Department of General, Visceral and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Verena Miller
- Department of General, Visceral and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Lena M Heidelmann
- Department of General, Visceral and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany,
| | - Nathaniel Melling
- Department of General, Visceral and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Tarik Ghadban
- Department of General, Visceral and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Katharina Grupp
- Department of General, Visceral and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Reeh
- Department of General, Visceral and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Maria-Noemi Welte
- Department of General, Visceral and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Faik Güntac Uzunoglu
- Department of General, Visceral and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Jakob R Izbicki
- Department of General, Visceral and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Kai A Bachmann
- Department of General, Visceral and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
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Acute mesenteric ischemia: A review of the main imaging techniques and signs. RADIOLOGIA 2020. [DOI: 10.1016/j.rxeng.2020.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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15
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Isquemia mesentérica aguda: Revisión de las principales técnicas y signos radiológicos. RADIOLOGIA 2020; 62:336-348. [DOI: 10.1016/j.rx.2020.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 01/15/2020] [Accepted: 02/11/2020] [Indexed: 12/11/2022]
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16
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Suzuki S, Kondo H, Furukawa A, Kawai K, Yukaya T, Shimazui T, Tani M, Yamamoto M. Prognostic Factors of Preoperative Examinations for Non-occlusive Mesenteric Ischemia: A Multicenter Retrospective Project Study Conducted by the Japanese Society for Abdominal Emergency Medicine. World J Surg 2020; 44:3687-3694. [DOI: 10.1007/s00268-020-05678-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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17
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Tucker PK, Macfarlane P. Severe bronchoconstriction as part of a suspected anaphylactic reaction in a dog following administration of gadobutrol. VETERINARY RECORD CASE REPORTS 2020. [DOI: 10.1136/vetreccr-2019-001051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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18
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Erben Y, Spaulding AC, Oderich GS, Da Rocha-Franco JA, Farres H, Cochuyt JJ, Sorrells WS, Oldenburg AW, Frey GT, Toskich BB, Becher R, Hakaim AG. Acute Mesenteric Ischemia Remains a Highly Morbid Diagnosis after Initial Hospitalization Survival. Int J Angiol 2020; 29:189-195. [PMID: 33100803 DOI: 10.1055/s-0039-1700984] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Acute mesenteric ischemia (AMI) remains a vascular emergency. Our aim was to explore readmission for AMI. We identified all patients admitted for AMI from the state of California through the Healthcare and Utilization Project from 2005 to 2011. Our primary end point was the rate and etiology for readmission. Our secondary end points were the length of hospitalization and in-hospital mortality. Cox proportional hazard regression was utilized to assess risk of 30-day readmission. There were 534 (9.9%) readmissions at 30 days. The mean age was 67 ± 17 years and 209 (39.1%) were male. The five most common etiologies for readmission were AMI (7.6%), cardiac events (5.3%), severe sepsis (1.2%), dehydration (1.1%), and acute kidney failure (1.1%). Once readmitted, these patients were most likely to experience cardiac catheterizations (25.4%), red blood cell transfusions (23.6%), intubation and mechanical ventilation (17.6%), biopsy of the large intestine (13.9%), reoperation for small bowel resection (10.9%), administration of total parenteral nutrition (10.5%), and transfusion of other blood products (6.9%). This hospitalization was 8.8 ± 12.7 days long. In-hospital mortality was 36 patients (6.7%). On multivariable Cox-regression analysis, severe (hazard ratio [HR]: 2.1 [1.4-3.2], p = 0.0005) and moderate (HR: 1.5 [1.03-2.13], p = 0.04) Elixhauser Comorbidity Group, complications (HR: 1.5 [1.2-1.9], p = 0.0007), and longer index hospitalization (HR: 1.02 [1.01-1.02], p < 0.0001) were predictors of readmission. Conclusion AMI remains a vascular emergency. Readmissions have a significant rate of morbid invasive procedures and can lead to an in-hospital mortality of 6.7%. The adoption of guidelines similar to the European Society for Trauma and Emergency Surgery should be considered.
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Affiliation(s)
- Y Erben
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, Florida
| | - A C Spaulding
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, Florida
| | - G S Oderich
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - J A Da Rocha-Franco
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, Florida
| | - H Farres
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, Florida
| | - J J Cochuyt
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, Florida
| | - W S Sorrells
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, Florida
| | - A W Oldenburg
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, Florida
| | - G T Frey
- Division of Vascular and Interventional Radiology, Mayo Clinic, Jacksonville, Florida
| | - B B Toskich
- Division of Vascular and Interventional Radiology, Mayo Clinic, Jacksonville, Florida
| | - R Becher
- Section of General Surgery, Trauma and Surgical Critical Care, Yale School of Medicine, New Haven, Connecticut
| | - A G Hakaim
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, Florida
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Matthaei H, Klein A, Branchi V, Kalff JC, Koscielny A. Acute mesenteric ischemia (AMI): absence of renal insufficiency and performance of early bowel resection may indicate improved outcomes. Int J Colorectal Dis 2019; 34:1781-1790. [PMID: 31512020 DOI: 10.1007/s00384-019-03388-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/01/2019] [Indexed: 02/06/2023]
Abstract
PURPOSE Acute mesenteric ischemia (AMI) is still associated with very high morbidity and mortality while the rareness and heterogeneity hamper the establishment of evidence-based guidelines. We sought to help standardize contemporary treatment by a cohort study at our tertiary center in the rising endovascular age. METHODS A retrospective cohort study was conducted from 2005 to 2015. Patients with occlusive (OMI), non-occlusive (NOMI), and venous mesenteric ischemia (VMI) were compared with respect to clinical and treatment parameters as well as outcome. RESULTS The study cohort consisted of 48 patients composed of 27 males and 21 females with an average age of 63 years and an average BMI of 25.1 kg/m2. In 48% of patients (N=23), an acute arterial OMI had occurred while NOMI was present in 31% (N=15) and VMI in 21% (N=10). Interventional and intraoperative recanalizations were significantly more often required in OMI patients compared with other entities (p=0.003). Patients with venous mesenteric ischemia had a significant better overall survival than patients with OMI or NOMI in the univariate analysis (p=0.027). Patients with renal failure had a 14.7-fold higher relative risk (Cox p=0.013) and patients without bowel resection during primary surgery had a 17.8-fold higher relative risk (Cox p=0.047) to die of AMI in the postoperative course. CONCLUSIONS AMI remains a rare but oftentimes fatal disease. Our study provides evidence that outcome may depend on the AMI subtype, presence of renal insufficiency, and early bowel resection. Further research should help individualize treatment for optimized outcomes.
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Affiliation(s)
- Hanno Matthaei
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Bonn, Sigmund-Freud-Strasse 25, 53127, Bonn, Germany
| | - Alina Klein
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Bonn, Sigmund-Freud-Strasse 25, 53127, Bonn, Germany
| | - Vittorio Branchi
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Bonn, Sigmund-Freud-Strasse 25, 53127, Bonn, Germany
| | - Jörg C Kalff
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Bonn, Sigmund-Freud-Strasse 25, 53127, Bonn, Germany
| | - Arne Koscielny
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Bonn, Sigmund-Freud-Strasse 25, 53127, Bonn, Germany.
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Hayashi K, Ohshio Y, Hanaoka J. Gangrenous ischaemic colitis following lung wedge resection. BMJ Case Rep 2019; 12:12/5/e227908. [PMID: 31088812 DOI: 10.1136/bcr-2018-227908] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
A 77-year-old man, who was taking prednisolone 7.5 mg, underwent wedge resection for nodules in the right lower lobe of the lung. The nodules were diagnosed as amyloid tumour. On the sixth postoperative day, sudden tachycardia, fever, creatine phosphokinase increase, renal dysfunction and metabolic acidosis were observed. CT showed no signs of infection, exacerbation of interstitial pneumonia, pulmonary embolism or occlusion in the major vessels of the mesentery. Exploratory laparotomy revealed intestinal necrosis in the inferior mesenteric artery area, and left hemicolectomy was performed. Postoperative pathological examination revealed gangrenous ischaemic colitis. Although gangrenous ischaemic colitis is not a complication specific to general thoracic surgery, it can be fatal. Because of the high risk of developing gangrenous ischaemic colitis in elderly patients and the increase in concomitant diseases, thoracic surgeons should always be mindful of the condition.
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Affiliation(s)
| | | | - Jun Hanaoka
- Shiga University of Medical Science, Otsu, Japan
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21
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Bhutra S, Singh A, Devpura TP. Emergency Ileo-cecal Anastomosis with Inclusion of Appendicular Stump in Terminal Ileal Pathology: A Newer Approach. Niger J Surg 2018; 24:116-120. [PMID: 30283223 PMCID: PMC6158983 DOI: 10.4103/njs.njs_35_17] [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] [Indexed: 11/16/2022] Open
Abstract
Background: In emergency settings, several surgical procedures are described while dealing with pathology of terminal ileal lying within 15 cm of the ileocecal valve, but there is still confusion and controversy over the optimal surgical treatment. Methods: A nonrandomized study of 210 patients with near terminal ileal pathology (within 15 cm) was carried out over a period of 10 years. The study included 112 cases in which an ileocecal anastomosis with inclusion of appendicular stump was used in terminal ileal pathologies, and in rest 98 cases, other surgical procedures were used. The outcomes were measured in relation to postoperative complications and mortality. Results: Postoperative complications encountered in emergency ileocecal anastomosis with the inclusion of appendicular stump were wound infection in 31 patients (34.72%), respiratory complications in 10 patients (11.2%), septicemia in 6 patients (6.72.%), and anastomotic leak in one patient (1.12%). Conclusion: The technique of ileocecal single-layer anastomosis with the inclusion of appendicular stump was found to be very effective in dealing this common problem and had less morbidity and mortality.
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Affiliation(s)
- Shyam Bhutra
- Department of General Surgery, J.L.N. Medical College, Ajmer, Rajasthan, India
| | - Amit Singh
- Department of General Surgery, J.L.N. Medical College, Ajmer, Rajasthan, India
| | - T P Devpura
- Department of General Surgery, J.L.N. Medical College, Ajmer, Rajasthan, India
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Bomberg H, Stroeder J, Karrenbauer K, Groesdonk HV, Wagenpfeil S, Klingele M, Bücker A, Schäfers HJ, Minko P. Establishment of Predictive Models for Nonocclusive Mesenteric Ischemia Comparing 8,296 Control with 452 Study Patients. J Cardiothorac Vasc Anesth 2018; 33:1290-1297. [PMID: 30245114 DOI: 10.1053/j.jvca.2018.08.194] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Indexed: 01/14/2023]
Abstract
OBJECTIVE The aim of this study was to develop clinical preoperative, intraoperative, and postoperative scores for early identification of patients who are at risk of nonocclusive mesenteric ischemia (NOMI). DESIGN A retrospective analysis. SETTING Single center. PARTICIPANTS From January 2008 to December 2014, all patients from the Department of Thoracic and Cardiovascular Surgery were included on the basis of the hospital database. INTERVENTIONS All mesenteric angiographically identified NOMI patients were compared with non-NOMI patients. MEASUREMENTS AND MAIN RESULTS The study population of 8,748 patients was randomized into a cohort for developing the scores (non-NOMI 4,214 and NOMI 235) and a cohort for control (non-NOMI 4,082 and NOMI 217). Risk factors were identified using forward and backward Wald test and were included in the predictive scores for the occurrence of NOMI. C statistic showed that the scores had a high discrimination for the prediction of NOMI preoperatively (C statistic 0.79; p < 0.001), intraoperatively (C statistic 0.68; p < 0.001), and postoperatively (C statistic 0.85; p < 0.001). A combination of the preoperative, intraoperative, and postoperative risk scores demonstrated the highest discrimination (C statistic 0.87; p < 0.001). The combined score included the following risk factors: renal insufficiency (preoperative); use of cardiopulmonary bypass and intra-aortic balloon pump support (intraoperative); and reexploration for bleeding, renal replacement therapy, and packed red blood cells ≥ 4 units (postoperative). The results were similar in the control group. CONCLUSIONS These scores could be useful to identify patients at risk for NOMI and promote a rapid diagnosis and therapy.
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Affiliation(s)
- Hagen Bomberg
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany; Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, Saarland University Medical Center, Homburg/Saar, Germany.
| | - Jonas Stroeder
- Department of Diagnostic and Interventional Radiology, Saarland University Medical Center, Homburg/Saar, Germany
| | - Kathrin Karrenbauer
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
| | - Heinrich V Groesdonk
- Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, Saarland University Medical Center, Homburg/Saar, Germany
| | - Stefan Wagenpfeil
- Institute for Medical Biometry, Epidemiology and Medical Informatics, Saarland University Medical Center, Homburg/Saar, Germany
| | - Matthias Klingele
- Department of Medicine, Division of Nephrology and Hypertension, Saarland University Medical Center, Homburg/Saar, Germany; Department of Nephrology, Hochtaunus-Kliniken, Bad Homburg, Germany
| | - Arno Bücker
- Department of Diagnostic and Interventional Radiology, Saarland University Medical Center, Homburg/Saar, Germany
| | - Hans-Joachim Schäfers
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
| | - Peter Minko
- Department of Diagnostic and Interventional Radiology, Saarland University Medical Center, Homburg/Saar, Germany
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Cen C, McGinn J, Aziz M, Yang WL, Cagliani J, Nicastro JM, Coppa GF, Wang P. Deficiency in cold-inducible RNA-binding protein attenuates acute respiratory distress syndrome induced by intestinal ischemia-reperfusion. Surgery 2017; 162:917-927. [PMID: 28709648 DOI: 10.1016/j.surg.2017.06.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 05/17/2017] [Accepted: 06/01/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Intestinal ischemia-reperfusion can occur in shock and mesenteric occlusive diseases, causing significant morbidity and mortality. Aside from local injury, intestinal ischemia-reperfusion can result in remote organ damage, particularly in the lungs. Cold-inducible RNA-binding protein (CIRP) was identified as a novel inflammatory mediator. We hypothesized that a deficiency in CIRP would protect the lungs during intestinal ischemia-reperfusion injury. METHODS Intestinal ischemia was induced in adult male C57BL/6 wild-type and CIRP knock-out (CIRP-/-) mice via clamping of the superior mesenteric artery for 60 minutes. Reperfusion was allowed for 4 hours or 20 hours, and blood, gut, and lung tissues were harvested for various analyses. RESULTS After intestinal ischemia-reperfusion, the elevated levels of serum lactate dehydrogenase and inflammatory cytokine interleukin-6 were reduced by 68% and 98%, respectively, at 20 hours after ischemia-reperfusion in CIRP-/- mice compared with the wild-type mice. In the gut, mRNA levels of inflammatory cytokine interleukin-6 were reduced by 67% at 4 hours after ischemia-reperfusion in CIRP-/- mice. In the lungs, inflammatory cytokine interleukin-6 protein and myeloperoxidase activity were reduced by 78% and 26% at 20 hours and 4 hours after ischemia-reperfusion, respectively, in CIRP-/- mice. Finally, the elevated lung caspase-3 was significantly decreased by 55%, terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling-positive cells decreased by 91%, and lung injury score decreased by 37% in CIRP-/- mice at 20 hours after ischemia-reperfusion. CONCLUSION Increased levels of proinflammatory cytokines, myeloperoxidase, and apoptosis are the hallmarks of acute respiratory distress syndrome. We noticed after intestinal ischemia-reperfusion the proinflammatory milieu in lungs was elevated significantly, while the CIRP-/- mice had significantly decreased levels of proinflammatory cytokine, myeloperoxidase, and apoptotic cells leading to decreased lung injury. These findings strongly established a causal link between CIRP and acute respiratory distress syndrome during intestinal ischemia-reperfusion injuries. Targeting CIRP may therefore be beneficial for treatment of intestinal ischemia-reperfusion-associated acute respiratory distress syndrome acute respiratory distress syndrome.
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Affiliation(s)
- Cindy Cen
- Department of Surgery, Hofstra Northwell School of Medicine, Manhasset, NY
| | - Joseph McGinn
- Department of Surgery, Hofstra Northwell School of Medicine, Manhasset, NY
| | - Monowar Aziz
- Center for Immunology and Inflammation, The Feinstein Institute for Medical Research, Manhasset, NY
| | - Weng-Lang Yang
- Department of Surgery, Hofstra Northwell School of Medicine, Manhasset, NY; Center for Immunology and Inflammation, The Feinstein Institute for Medical Research, Manhasset, NY
| | - Joaquin Cagliani
- Center for Immunology and Inflammation, The Feinstein Institute for Medical Research, Manhasset, NY
| | - Jeffrey M Nicastro
- Department of Surgery, Hofstra Northwell School of Medicine, Manhasset, NY
| | - Gene F Coppa
- Department of Surgery, Hofstra Northwell School of Medicine, Manhasset, NY
| | - Ping Wang
- Department of Surgery, Hofstra Northwell School of Medicine, Manhasset, NY; Center for Immunology and Inflammation, The Feinstein Institute for Medical Research, Manhasset, NY.
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A Novel Scoring System for Diagnosing Acute Mesenteric Ischemia in the Emergency Ward. World J Surg 2017; 41:1966-1974. [DOI: 10.1007/s00268-017-3984-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Ambe PC, Kang K, Papadakis M, Zirngibl H. Can the Preoperative Serum Lactate Level Predict the Extent of Bowel Ischemia in Patients Presenting to the Emergency Department with Acute Mesenteric Ischemia? BIOMED RESEARCH INTERNATIONAL 2017; 2017:8038796. [PMID: 28261615 PMCID: PMC5316433 DOI: 10.1155/2017/8038796] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/28/2016] [Revised: 11/29/2016] [Accepted: 12/06/2016] [Indexed: 12/22/2022]
Abstract
Purpose. Early recognition of acute mesenteric ischemia (AMI) can be challenging. Extensive bowel necrosis secondary to AMI is associated with high rates of mortality. The aim of this study was to investigate the association between preoperative serum lactate level and the extent of bowel ischemia in patients with AMI. Methods. Data of patients with abdominal pain and elevated serum lactate undergoing emergency laparotomy for suspected AMI within 24 hours of presentation was retrospectively abstracted. The length of the ischemic bowel segment was compared with the preoperative serum lactate level. Results. 36 female and 39 male patients, with median age 73.1 ± 12.3 years, were included for analysis. The median preoperative lactate was 2.96 ± 2.59 mmol/l in patients with ≤50 cm, 6.86 ± 4.08 mmol/l in patients with 51-100 cm, 4.73 ± 2.76 mmol/l in patients with >100 cm ischemic bowel, and 14.07 ± 4.91 mmol/l in the group with multivisceral ischemia. Conclusion. Although elevated serum lactate might permit an early suspicion and thus influence the clinical decision-making with regard to prioritization of surgery in patients with suspected AMI, a linear relationship between serum lactate and the extent of bowel ischemia could not be established in this study.
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Affiliation(s)
- Peter C. Ambe
- Department of Surgery II, HELIOS Universitätsklinikum Wuppertal, Witten-Herdecke University, Heusnerstr. 40, 42283 Wuppertal, Germany
- *Peter C. Ambe:
| | - Kai Kang
- Department of Surgery II, HELIOS Universitätsklinikum Wuppertal, Witten-Herdecke University, Heusnerstr. 40, 42283 Wuppertal, Germany
| | - Marios Papadakis
- Department of Surgery II, HELIOS Universitätsklinikum Wuppertal, Witten-Herdecke University, Heusnerstr. 40, 42283 Wuppertal, Germany
| | - Hubert Zirngibl
- Department of Surgery II, HELIOS Universitätsklinikum Wuppertal, Witten-Herdecke University, Heusnerstr. 40, 42283 Wuppertal, Germany
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Ha YR, Park SY. Young Man With Epigastric Pain. Ann Emerg Med 2016; 68:e83-e84. [PMID: 27772689 DOI: 10.1016/j.annemergmed.2016.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Young-Rock Ha
- Department of Emergency Medicine, Bundang Jesaeng General Hospital, Gyeonggi-do, Korea
| | - Sin-Youl Park
- Department of Emergency Medicine, College of Medicine, Yeungnam University, Daegu, Korea
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Coskun AK, Halici Z, Oral A, Bayir Y, Deniz F, Caycı T, Mentes O, Oz BS, Harlak A, Yigit T, Kozak O, Peker Y. The value of combined elevation of D-dimer and neopterin as a predictive parameter for early stage acute mesenteric ischemia: An experimental study. Vascular 2016; 25:163-169. [PMID: 27278523 DOI: 10.1177/1708538116652267] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background The diagnosis of acute mesenteric ischemia is variable. Early diagnosis is important for reducing the mortality and morbidity rates. Aim This experimental study aims to investigate the diagnostic utility of D-dimer and neopterin as a marker for the early stage of acute mesenteric ischemia caused by occlusion of superior mesenteric artery. Methods The levels of D-dimer and neopterin were measured using an animal acute mesenteric ischemia model in 21 male rabbits. Superior mesenteric artery occlusion (Group 1, n = 14) and control (Group 2, n = 7) groups were identified. Blood samples at different times are collected from each rabbits. Blood samples from superior mesenteric artery occlusion group were taken 30 min after anesthesia but before laparotomy, 1, 2, and 3 h after superior mesenteric artery ligation. Blood samples from control group were taken 1 h before, 1 and 3 h after anesthesia and laparotomy. The D-dimer and neopterin levels of each blood sample were measured. Results The probability of acute mesenteric ischemia was found to be 36 times higher when the D-dimer level was over 0.125 ng/L, whereas the probability was 19.2 times higher when the neopterin level was over 1.25 nmol/L. Conclusions In this experimental study, the combined elevation of two significant markers, D-dimer and neopterin, may be helpful for the early diagnosis of acute mesenteric ischemia.
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Affiliation(s)
| | - Zekai Halici
- Department of Pharmacology, Gulhane Medical School, Turkey
- Department of Pharmacology, Ataturk University, Turkey
| | - Akgun Oral
- Department of Pediatric Surgery, Gulhane Medical School, Turkey
- Department of Pediatric Surgery, Ataturk University, Turkey
| | - Yasin Bayir
- Faculty of Pharmacy, Ataturk University, Turkey
| | - Ferhat Deniz
- Department of Endocrinology, Gulhane Medical School, Turkey
| | - Tuncer Caycı
- Department of Biochemistry, Gulhane Medical School, Turkey
| | - Oner Mentes
- Department of General Surgery, Gulhane Medical School, Turkey
| | - Bilgehan Savas Oz
- Department of Cardiovascular Surgery, Gulhane Medical School, Turkey
| | - Ali Harlak
- Department of General Surgery, Gulhane Medical School, Turkey
| | - Taner Yigit
- Department of General Surgery, Gulhane Medical School, Turkey
| | - Orhan Kozak
- Department of General Surgery, Gulhane Medical School, Turkey
| | - Yusuf Peker
- Department of General Surgery, Gulhane Medical School, Turkey
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Higashizono K, Yano H, Miyake O, Yamasawa K, Hashimoto M. Postoperative pneumatosis intestinalis (PI) and portal venous gas (PVG) may indicate bowel necrosis: a 52-case study. BMC Surg 2016; 16:42. [PMID: 27391125 PMCID: PMC4938969 DOI: 10.1186/s12893-016-0158-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 06/13/2016] [Indexed: 12/11/2022] Open
Abstract
Background The significance of pneumatosis intestinalis (PI) and portal venous gas (PVG) is controversial. This retrospective study evaluated the risk factors for bowel necrosis in patients with PI and/or PVG. Methods Between 2002 and 2015, 52 patients were diagnosed with PI and/or PVG and were included in this study. The patients were classified according to the presence or absence of bowel necrosis in surgical findings or at autopsy. Patient characteristics and clinical findings related to bowel necrosis were investigated. Results Bowel necrosis was diagnosed in 17 (32.7 %) patients. Amongst these 17, 10 patients received salvage surgical intervention, and seven of those diagnosed with bowel necrosis survived after the operation. The remaining 35 patients received conservative treatment with or without exploratory laparotomy. Between patients with and without bowel necrosis, laboratory data revealed significant differences in the levels of C-reactive protein (P = 0.0038), creatinine (P = 0.0054), and lactate (P = 0.045); clinical findings showed differences in abdominal pain (P = 0.019) and peritoneal irritation signs (P = 0.016); computed tomography detected ascites (P = 0.011) and changes of bowel wall enhancement (P = 0.03) that were significantly higher in patients with bowel necrosis. The rate of PI and/or PVG detected in patients postoperatively was significantly higher in patients with bowel necrosis (P < 0.0001). Multivariate analysis showed that bowel necrosis was significantly more likely when PI or PVG was detected in postoperative patients than in patients who had not had surgery (P = 0.003). Conclusions PI and/or PVG, alone, are not automatically indicative of bowel necrosis. However, when these conditions occur postoperatively, they indicate bowel necrosis requiring reoperation.
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Affiliation(s)
- Kazuya Higashizono
- Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-0054, Japan. .,, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Hideaki Yano
- Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-0054, Japan
| | - Ouki Miyake
- Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-0054, Japan
| | - Kunihiro Yamasawa
- Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-0054, Japan
| | - Masanori Hashimoto
- Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-0054, Japan
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29
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The association of elevated mean platelet volume with the outcome of acute mesenteric ischemia. Blood Coagul Fibrinolysis 2015; 26:727-30. [DOI: 10.1097/mbc.0000000000000208] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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30
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Kisaoglu A, Bayramoglu A, Ozogul B, Atac K, Emet M, Atamanalp SS. Sensitivity and specificity of red cell distribution width in diagnosing acute mesenteric ischemia in patients with abdominal pain. World J Surg 2015; 38:2770-6. [PMID: 25096361 DOI: 10.1007/s00268-014-2706-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND We investigated the utility of the red cell distribution width (RDW) in diagnosing acute mesenteric ischemia (AMI) in patients with abdominal pain. METHODS The patients were divided into two groups in this retrospective case-control study: patients with AMI and patients with abdominal pain who did not require urgent surgery. Venous blood was collected from the patients upon admission to the emergency department, and abdominal computed tomography angiography was performed. The RDW and hematological and biochemical parameters of the groups were compared. The primary outcome was AMI among the patients with abdominal pain. The secondary outcome was mortality, complaint period, and size of ischemia/necrosis among the AMI patients. RESULTS The RDW, white blood cell lactate dehydrogenase, and blood urea nitrogen of the patients with AMI were significantly different from those of the control group. When the average RDW (15.04 %) of the patients with AMI was used as a cut-off value, the sensitivity, specificity, positive likelihood ratio (+LR), and negative likelihood (-LR) were 40.8 %, 81.2 %, 2.17, and 0.73, respectively. When patients with AMI and anemia were included in the group, the sensitivity and specificity values did not change. There was no relation between the RDW and mortality, size of the ischemia/necrosis, and complaint period. Furthermore, there was no significant difference in the average RDW between the patients with ischemia/necrosis in the small intestine only and those with ischemia/necrosis in the colon. CONCLUSION The RDW on admission is of marginal help to diagnose AMI among patients with abdominal pain.
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Affiliation(s)
- Abdullah Kisaoglu
- Department of General Surgery, School of Medicine, Ataturk University, 25070, Erzurum, Turkey,
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Raupach J, Lojik M, Chovanec V, Renc O, Strýček M, Dvořák P, Hoffmann P, Guňka I, Ferko A, Ryška P, Omran N, Krajina A, Čabelková P, Čermáková E, Malý R. Endovascular Management of Acute Embolic Occlusion of the Superior Mesenteric Artery: A 12-Year Single-Centre Experience. Cardiovasc Intervent Radiol 2015. [PMID: 26202388 DOI: 10.1007/s00270-015-1156-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE Retrospective evaluation of 12-year experience with endovascular management of acute mesenteric ischemia (AMI) due to embolic occlusion of the superior mesenteric artery (SMA). MATERIALS AND METHODS From 2003 to 2014, we analysed the in-hospital mortality of 37 patients with acute mesenteric embolism who underwent primary endovascular therapy with subsequent on-demand laparotomy. Transcatheter embolus aspiration was used in all 37 patients (19 women, 18 men, median age 76 years) with embolic occlusion of the SMA. Adjunctive local thrombolysis (n = 2) and stenting (n = 2) were also utilised. RESULTS We achieved complete recanalization of the SMA stem in 91.9 %. One patient was successfully treated by surgical embolectomy due to a failed endovascular approach. Subsequent exploratory laparotomy was performed in 73.0 % (n = 27), and necrotic bowel resection in 40.5 %. The total in-hospital mortality was 27.0 %. CONCLUSION Primary endovascular therapy for acute embolic SMA occlusion with on-demand laparotomy is a recommended algorithm used in our centre to treat SMA occlusion. This combined approach for the treatment of AMI is associated with in-hospital mortality rate of 27.0 %.
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Affiliation(s)
- J Raupach
- Department of Radiology, Faculty of Medicine at Charles University and University Hospital, Sokolska Street, Hradec Kralove, Czech Republic.
| | - M Lojik
- Department of Radiology, Faculty of Medicine at Charles University and University Hospital, Sokolska Street, Hradec Kralove, Czech Republic.
| | - V Chovanec
- Department of Radiology, Faculty of Medicine at Charles University and University Hospital, Sokolska Street, Hradec Kralove, Czech Republic.
| | - O Renc
- Department of Radiology, Faculty of Medicine at Charles University and University Hospital, Sokolska Street, Hradec Kralove, Czech Republic.
| | - M Strýček
- Faculty of Medicine at Charles University, Hradec Kralove, Czech Republic.
| | - P Dvořák
- Department of Radiology, Faculty of Medicine at Charles University and University Hospital, Sokolska Street, Hradec Kralove, Czech Republic.
| | - P Hoffmann
- Department of Radiology, Faculty of Medicine at Charles University and University Hospital, Sokolska Street, Hradec Kralove, Czech Republic.
| | - I Guňka
- Department of Surgery, Faculty of Medicine at Charles University and University Hospital, Hradec Kralove, Czech Republic.
| | - A Ferko
- Department of Surgery, Faculty of Medicine at Charles University and University Hospital, Hradec Kralove, Czech Republic.
| | - P Ryška
- Department of Radiology, Faculty of Medicine at Charles University and University Hospital, Sokolska Street, Hradec Kralove, Czech Republic.
| | - N Omran
- Department of Cardiac Surgery, Faculty of Medicine at Charles University and University Hospital, Hradec Kralove, Czech Republic.
| | - A Krajina
- Department of Radiology, Faculty of Medicine at Charles University and University Hospital, Sokolska Street, Hradec Kralove, Czech Republic.
| | - P Čabelková
- Department of Radiology, Faculty of Medicine at Charles University and University Hospital, Sokolska Street, Hradec Kralove, Czech Republic.
| | - E Čermáková
- Computer Technology Center, Faculty of Medicine at Charles University, Hradec Kralove, Czech Republic.
| | - R Malý
- Department of Medicine, Faculty of Medicine at Charles University and University Hospital, Hradec Kralove, Czech Republic.
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Acute Mesenteric Ischemia Caused by Rare Cardiac Tumor Embolus. ACG Case Rep J 2015; 2:27-9. [PMID: 26157897 PMCID: PMC4435340 DOI: 10.14309/crj.2014.74] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Accepted: 09/25/2014] [Indexed: 12/21/2022] Open
Abstract
Acute mesenteric ischemia (AMI) is a rare vascular emergency associated with a high mortality rate. The most common cause of AMI is cardiac emboli from thrombi associated with atrial fibrillation or following myocardial infarction. We present a case of AMI caused by a unique source of emboli, confirmed as an embolization of a cardiac sarcoma to the small bowel by matching biopsies obtained from the superior mesenteric artery (SMA) and the embolic source.
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The value of serial serum lactate measurements in predicting the extent of ischemic bowel and outcome of patients suffering acute mesenteric ischemia. J Gastrointest Surg 2015; 19:751-5. [PMID: 25633108 DOI: 10.1007/s11605-015-2752-0] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 01/14/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Acute mesenteric ischemia (AMI) is an emergency with a mortality rate up to 50%. Detecting AMI continues to be a major challenge. This study assed the correlation of repeated preoperative serum lactate with bowel necrosis and to identify risk factors for a lethal outcome in patients with AMI. METHODS A retrospective study of 91 patients with clinically and pathologically confirmed AMI from January 2006 to December 2012 was performed. RESULTS In-hospital mortality rate was 42.9%. Two hundred nine preoperative lactate measurements were analyzed (2.3 ± 1.1 values per patient). Less than or equal to six hours prior to surgery, the mean serum lactate level was significantly higher (4.97 ± 4.21 vs. 3.24 ± 3.05 mmol/L, p = 0.006) and the mean pH significantly lower (7.28 ± 0.12 vs. 7.37 ± 0.08, p = 0.001) compared to >6 h before surgery. Thirty-four patients had at least two lactate measurements within 24 h prior to surgery. In this subgroup, 17 patients (50%) exhibited an increase, 17 patients (50%) a decrease in lactate levels. Forward logistic regression analysis showed that length of necrotic bowel and the highest lactate value 24 h prior to surgery were independent risk factors for mortality (r2 = 0.329). CONCLUSION The value of serial lactate and pH measurements to predict the length of necrotic bowel is very limited. Length of necrotic bowel and lactate values are independent risk factors for mortality.
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Fatal hyperkalemia after vasodilator therapy for nonocclusive mesenteric ischemia. Am J Emerg Med 2014; 32:949.e3-4. [PMID: 24602899 DOI: 10.1016/j.ajem.2014.01.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 01/25/2014] [Indexed: 11/22/2022] Open
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Plasma intestinal fatty acid-binding protein levels correlate with morphologic epithelial intestinal damage in a human translational ischemia-reperfusion model. J Clin Gastroenterol 2014; 48:253-60. [PMID: 24100750 DOI: 10.1097/mcg.0b013e3182a87e3e] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Intestinal fatty acid-binding protein (I-FABP) is a useful marker in the detection of intestinal ischemia. However, more insight into the test characteristics of I-FABP release is needed. This study aimed to investigate the relationship between plasma I-FABP levels and the severity of ischemic mucosal injury, and define the clinical usefulness of systemic I-FABP following ischemia. METHODS In a human experimental model, 6 cm of the jejunum, to be removed for surgical reasons, was selectively exposed to either 15, 30, or 60 minutes of ischemia (I) followed by 30 and 120 minutes of reperfusion (R). Blood and tissue was sampled at all time points. Arteriovenous (V-A) concentration differences of I-FABP were measured. Tissue sections were stained with hematoxylin/eosin, and villus height was measured to score epithelial damage. RESULTS Histologic analysis showed only minor reversible intestinal damage following 15 I and 30 I; however, severe irreversible epithelial damage was observed in the jejunum exposed to 60 I. I-FABP V-A differences paralleled the degree of tissue damage over time [7.79 (± 1.8) ng/mL, 128.6 (± 44.2) ng/mL, 463.3 (± 139.8) ng/mL for 15 I, 30 I and 60 I, respectively]. A good correlation was found between histologic epithelial damage and V-A I-FABP (r=-0.82, P<0.001). Interestingly, systemic I-FABP levels were significantly increased after 60 I of this short small intestinal segment. CONCLUSIONS This study demonstrates the relationship between the duration of ischemia and the extent of tissue damage, which is reflected by I-FABP V-A plasma levels. In addition, systemic I-FABP levels appear valuable in detecting irreversible intestinal ischemia-reperfusion damage.
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Conaway D. Hypothermia and the acute abdomen. BMJ Case Rep 2014; 2014:bcr-2013-202774. [PMID: 24429054 DOI: 10.1136/bcr-2013-202774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 64-year old man presented to A&E with a 24 h history of persistent hypothermia and increasing confusion. His medical history included congestive heart failure, hypertension and intermittent claudication secondary to distal abdominal aortic occlusion. Examination revealed profound hypothermia-31°C, bilateral reduced power in the lower limbs and no palpable peripheral pulses. Initial blood tests revealed a metabolic acidosis with hyperlactactaemia, neutrophilia and deranged electrolytes. CT scan of the abdomen revealed extensive thromboemobolic disease of the abdominal arterial tree and diagnosed acute mesenteric ischaemia. The patient was taken to theatre where an emergency laparotomy demonstrated a perforated duodenum, which was subsequently patched, followed immediately by an axillofemoral bypass with subsequent femoral-femoral crossover. Sadly, the patient passed away shortly after completion of surgery.
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Affiliation(s)
- Daniel Conaway
- Department of Neurosurgery, John Radcliffe Hospital, Oxford, UK
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Matsumoto S, Sekine K, Funaoka H, Yamazaki M, Shimizu M, Hayashida K, Kitano M. Diagnostic performance of plasma biomarkers in patients with acute intestinal ischaemia. Br J Surg 2014; 101:232-8. [PMID: 24402763 DOI: 10.1002/bjs.9331] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2013] [Indexed: 12/22/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the use of intestinal fatty acid binding protein (I-FABP) and traditional biomarkers in the early diagnosis of acute intestinal ischaemia of different causes. METHODS I-FABP, white blood cell (WBC) count, C-reactive protein, base deficit, lactate, lactate dehydrogenase, aspartate aminotransferase, creatine kinase and D-dimer were measured prospectively in consecutive patients suspected of having acute intestinal ischaemia. Biomarker levels were compared in patients with vascular and non-vascular ischaemia. RESULTS Two hundred and eight patients with a clinical suspicion of acute intestinal ischaemia were enrolled. Vascular intestinal ischaemia was diagnosed in 24 patients (11·5 per cent), non-vascular ischaemia in 62 (29·8 per cent) and non-ischaemic disease in 122 (58·7 per cent). The levels of most biomarkers (except WBC count and creatine kinase) were significantly higher in the vascular ischaemia group than in the other groups (P < 0·010). However, none of the biomarker levels differed between patients with non-vascular intestinal ischaemia and those with non-ischaemic disease. Receiver operating characteristic (ROC) curve analysis suggested that I-FABP was best at diagnosing vascular intestinal ischaemia (area under the curve 0·88). CONCLUSION Serum biomarkers may be useful in the diagnosis of vascular, but not non-vascular, intestinal ischaemia. Among them, I-FABP shows promise for detecting vascular ischaemia.
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Affiliation(s)
- S Matsumoto
- Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan
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Salman AE, Çeliksoy M, Yetişir F, Atasoy Ş, Katırcıoğlu F. The importance of clinical suspicion in the diagnosis of a successfully managed case with De Bakey Type 1 acute aortic dissection: A case report. ULUSAL CERRAHI DERGISI 2014; 30:51-3. [PMID: 25931881 DOI: 10.5152/ucd.2013.44] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Accepted: 01/14/2013] [Indexed: 11/22/2022]
Abstract
Type 1 aortic dissection is a catastrophic clinical entity originating from the ascending aorta. Clinical suspicion in patients with epigastric pain, chest pain and gastrointestinal symptoms might be life saving. Aortic dissection and acute mesenteric ischemia might be confusing in diagnosis of patients with epigastric pain, chest pain, gastrointestinal symptoms and high white blood cell count and D-dimer. In this case report of a patient who was admitted to the emergency room with a presentation resembling acute mesenteric ischemia, this diagnosis was excluded within the first 24 hours as a result of clinical suspicion. In this case report, the successful management in diagnosis and treatment of a 30-year-old male patient with type 1 aortic dissection is discussed in light of the literature.
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Affiliation(s)
- A Ebru Salman
- Clinic of Anesthesiology, Ministry of Health Ankara Etlik Teaching Hospital, Ankara, Turkey
| | - Muzaffer Çeliksoy
- Clinic of Cardiothoracic Surgery, Ministry of Health Ankara Etlik Teaching Hospital, Ankara, Turkey
| | - Fahri Yetişir
- Clinic of General Surgery, Ministry of Health Ankara Etlik Teaching Hospital, Ankara, Turkey
| | - Şevket Atasoy
- Clinic of Cardiothoracic Surgery, Ministry of Health Ankara Etlik Teaching Hospital, Ankara, Turkey
| | - Fehmi Katırcıoğlu
- Clinic of Cardiothoracic Surgery, Ministry of Health Ankara Etlik Teaching Hospital, Ankara, Turkey
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Erdogan E, Turfan M, Akkaya M, Bacaksız A, Tasal A, Ergelen M, Göktekin Ö. Successful recanalization of acute superior mesenteric artery ischemia with balloon angioplasty and aspiration embolectomy. Eur Geriatr Med 2013. [DOI: 10.1016/j.eurger.2013.05.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Reginelli A, Genovese E, Cappabianca S, Iacobellis F, Berritto D, Fonio P, Coppolino F, Grassi R. Intestinal Ischemia: US-CT findings correlations. Crit Ultrasound J 2013; 5 Suppl 1:S7. [PMID: 23902826 PMCID: PMC3711730 DOI: 10.1186/2036-7902-5-s1-s7] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background Intestinal ischemia is an abdominal emergency that accounts for approximately 2% of gastrointestinal illnesses. It represents a complex of diseases caused by impaired blood perfusion to the small and/or large bowel including acute arterial mesenteric ischemia (AAMI), acute venous mesenteric ischemia (AVMI), non occlusive mesenteric ischemia (NOMI), ischemia/reperfusion injury (I/R), ischemic colitis (IC). In this study different study methods (US, CT) will be correlated in the detection of mesenteric ischemia imaging findings due to various etiologies. Methods Basing on experience of our institutions, over 200 cases of mesenteric ischemia/infarction investigated with both US and CT were evaluated considering, in particular, the following findings: presence/absence of arterial/venous obstruction, bowel wall thickness and enhancement, presence/absence of spastic reflex ileus, hypotonic reflex ileus or paralitic ileus, mural and/or portal/mesenteric pneumatosis, abdominal free fluid, parenchymal ischemia/infarction (liver, kidney, spleen). Results To make an early diagnosis useful to ensure a correct therapeutic approach, it is very important to differentiate between occlusive (arterial,venous) and nonocclusive causes (NOMI). The typical findings of each forms of mesenteric ischemia are explained in the text. Conclusion At present, the reference diagnostic modality for intestinal ischaemia is contrast-enhanced CT. However, there are some disadvantages associated with these techniques, such as radiation exposure, potential nephrotoxicity and the risk of an allergic reaction to the contrast agents. Thus, not all patients with suspected bowel ischaemia can be subjected to these examinations. Despite its limitations, US could constitutes a good imaging method as first examination in acute settings of suspected mesenteric ischemia.
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Affiliation(s)
- A Reginelli
- Second University of Naples, Department of Clinical and Experimental Internistic F, Magrassi - A, Lanzara, Naples, Italy.
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Waqas M, Waheed S, Haider Z, Shariff AH. Acute mesenteric ischaemia with infective endocarditis: is there a role for anticoagulation? BMJ Case Rep 2013; 2013:bcr-2013-009741. [PMID: 23774707 DOI: 10.1136/bcr-2013-009741] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A case of a 30-year-old woman with an end-stage renal disease and recently diagnosed with infective endocarditis, who presented with acute abdominal pain. An initial assessment of acute appendicitis was made. A CT scan of the abdomen showed a partially occluded superior mesenteric artery with radiographic evidence of ischaemia in an ileal loop. Intraoperatively, a 5-6 cm segment of the distal ileum was found to be non-viable. The segment was resected with the creation of a double-barrel ileostomy. This case report draws attention to the question of a need for anticoagulation for a septic embolus in the superior mesenteric artery. We could not find evidence on the use of postoperative anticoagulation in this scenario. In this case, the patient was started on oral anticoagulation.
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Affiliation(s)
- Muhammad Waqas
- Department of Surgery, The Aga Khan University, Karachi, Pakistan
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Groesdonk HV, Klingele M, Schlempp S, Bomberg H, Schmied W, Minko P, Schäfers HJ. Risk factors for nonocclusive mesenteric ischemia after elective cardiac surgery. J Thorac Cardiovasc Surg 2013; 145:1603-10. [DOI: 10.1016/j.jtcvs.2012.11.022] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Revised: 10/06/2012] [Accepted: 11/06/2012] [Indexed: 02/07/2023]
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Haruna L, Aber A, Rashid F, Barreca M. Acute mesenteric ischemia and duodenal ulcer perforation: a unique double pathology. BMC Surg 2012; 12:21. [PMID: 23110681 PMCID: PMC3506509 DOI: 10.1186/1471-2482-12-21] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2012] [Accepted: 10/11/2012] [Indexed: 12/01/2022] Open
Abstract
Background Acute mesenteric ischaemia and duodenal perforation are surgical emergencies with serious consequences. Patients presenting with acute mesenteric ischaemia alone face a high mortality rate as high as 60% whereas those presenting with peptic ulcer perforation the mortality rates range from 6-14%. There are very few reported cases of patients presenting with this dual pathology. Case presentation We report a unique case of a 53 year old Italian lady who presented with acute mesenteric ischaemia and duodenal perforation. This is the first report of massive bowel ischaemia and duodenal perforation with no apparent underlying common pathophysiology leading to this presentation. Conclusion Early management in the intensive care unit and appropriate surgical intervention maximised the patient’s chances of survival despite the poor prognosis associated with her dual pathology. The rare pathology of the patient described can be explained by two possible hypotheses: peptic ulcer disease causing duodenal ulceration, which precipitated ischaemic infarction of the small bowel. The second hypothesis is the patient developed a stress related ulcer following ischaemic bowel infarction secondary to arterial thrombosis.
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Affiliation(s)
- Lois Haruna
- Department of General Surgery, Luton and Dunstable Hospital, Lewsey Road, Luton, Bedfordshire LU4 ODZ, UK
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Pope MR, Bukovnik U, Tomich JM, Fleming SD. Small β2-glycoprotein I peptides protect from intestinal ischemia reperfusion injury. THE JOURNAL OF IMMUNOLOGY 2012; 189:5047-56. [PMID: 23034168 DOI: 10.4049/jimmunol.1200290] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Intestinal ischemic events, which are followed by reperfusion, induce significant tissue damage and frequently result in multiple organ failure, with >70% mortality. Upon reperfusion, excessive inflammation leads to exacerbated tissue damage. Previous studies indicated that binding of the serum protein, β2-glycoprotein I, to the endothelium initiates a cascade of inflammatory molecules that is required for damage. We hypothesized that peptides derived from the binding domain (domain V) of β2-glycoprotein I would attenuate ischemia/reperfusion-induced damage and inflammation in a therapeutic manner. Using a mouse model of intestinal ischemia/reperfusion, we administered peptides either prior to ischemia or at clinically relevant time points during reperfusion and evaluated intestinal tissue damage and inflammation after 2 h of reperfusion. We demonstrate that multiple peptides attenuate injury and inflammation in a dose-dependent manner and, perhaps more significantly, are efficacious when administered up to 30 min after the onset of reperfusion. In addition, an all D-amino acid retro-inverso peptide was biologically active. Thus, the β2-glycoprotein I-derived peptides attenuate injury and inflammation when administered in a therapeutic manner in intestinal ischemia/reperfusion injury.
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Affiliation(s)
- Michael R Pope
- Division of Biology, Kansas State University, Manhattan, KS 66506, USA
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Park JH, Jeong SH, Kwag SJ, Park TJ, Jeong CY, Ju YT, Jung EJ, Hong SC, Choi SK, Ha WS, Lee YJ. Identification of Prognostic Factors for In-Hospital Mortality in Acute Mesenteric Ischemia. Vasc Specialist Int 2012. [DOI: 10.5758/kjves.2012.28.3.133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Affiliation(s)
- Ji Ho Park
- Department of Surgery, Gyeongsang National University, Post-graduate School of Medicine, Jinju, Korea
| | - Sang Ho Jeong
- Department of Surgery, Gyeongsang National University, Post-graduate School of Medicine, Jinju, Korea
| | - Seung Jin Kwag
- Department of Surgery, Gyeongsang National University, Post-graduate School of Medicine, Jinju, Korea
| | - Tae Jin Park
- Department of Surgery, Gyeongsang National University, Post-graduate School of Medicine, Jinju, Korea
| | - Chi Young Jeong
- Department of Surgery, Gyeongsang National University, Post-graduate School of Medicine, Jinju, Korea
| | - Young Tae Ju
- Department of Surgery, Gyeongsang National University, Post-graduate School of Medicine, Jinju, Korea
| | - Eun Jung Jung
- Department of Surgery, Gyeongsang National University, Post-graduate School of Medicine, Jinju, Korea
| | - Soon Chan Hong
- Department of Surgery, Gyeongsang National University, Post-graduate School of Medicine, Jinju, Korea
| | - Sang Kyung Choi
- Department of Surgery, Gyeongsang National University, Post-graduate School of Medicine, Jinju, Korea
| | - Woo Song Ha
- Department of Surgery, Gyeongsang National University, Post-graduate School of Medicine, Jinju, Korea
| | - Young Joon Lee
- Department of Surgery, Gyeongsang National University, Post-graduate School of Medicine, Jinju, Korea
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Yamada T, Yoshii T, Yoshimura H, Suzuki K, Okawa A. Upper limb amputation due to a brachial arterial embolism associated with a superior mesenteric arterial embolism: a case report. BMC Res Notes 2012; 5:372. [PMID: 22828325 PMCID: PMC3410779 DOI: 10.1186/1756-0500-5-372] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2012] [Accepted: 07/24/2012] [Indexed: 12/02/2022] Open
Abstract
Background Acute mesenteric ischemia due to an embolism of the superior mesenteric artery is associated with a high mortality rate. Over 20 percent of acute mesenteric embolism cases consist of multiple emboli, and the long-term prognosis depends on the incidence of subsequent embolic events at other sites. The incidence of emboli in the upper extremity associated with a superior mesenteric arterial embolism has rarely been described. The signs and symptoms of ischemic change in the upper limb can be masked by other circumstances, such as postoperative conditions or complications. In these cases, a late presentation or delayed diagnosis and treatment can result in limb loss. Case presentation We present a rare case of a 67-year-old Japanese woman with atrial fibrillation who developed an embolic occlusion of the brachial artery associated with a superior mesenteric arterial embolism. She developed gangrene in her right hand, which had progressed to the point that amputation was necessary by the time the gastrointestinal surgeon had consulted the Department of Orthopedic Surgery. The brachial arterial embolism diagnosis was delayed by the severe abdominal symptoms and shock conditions that followed the emergency enterectomy, resulting in amputation of the upper limb despite anticoagulation therapy. In this case, multiple infarctions of the spleen were also observed, indicating a shower embolism. Conclusions When treating a superior mesenteric arterial embolism in a patient with atrial fibrillation, the possibility of recurrent or multiple arterial thromboembolic events should be considered, even after the procedure is completed.
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Affiliation(s)
- Tsuyoshi Yamada
- Section of Orthopedic and Spinal Surgery, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
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Abstract
Acute mesenteric ischemia (AMI) is a rare cause of acute abdomen. Coupled with a high patient age, non-specific clinical symptoms and a significant co-morbidity the disease is still associated with a significant mortality of 60-85%. With a combination of preexisting cardiac arrhythmia and sudden abdominal pain AMI should always first be ruled out. Contrast-enhanced computed tomography (CT) scanning has replaced angiography as the first diagnostic step, largely because both intravascular and intra-abdominal pathologies can be diagnosed. In the case of an acute abdomen or lack of immediate access to diagnostic tools, rapid surgical exploration should be preferred. Surgical therapy includes embolectomy and resection of ischemic bowel segments. There should be a wide indication for second-look surgery. The most important prognostic factor and the only factor that can be influenced by the surgeon is the time interval between onset of symptoms and surgery. Therefore angiography or laparotomy should be performed as early as possible in cases of suspected AMI.
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Abstract
OPINION STATEMENT Acute mesenteric ischemia is caused by a critical reduction in intestinal blood flow that frequently results in bowel necrosis and is associated with a high mortality. Clinicians must maintain a high index of suspicion because a prompt diagnosis and early aggressive treatment before the onset of bowel infarction results in reduced mortality. Medical management includes aggressive rehydration and the use of antibiotics, anticoagulation, vasodilators, and inhibitors of reperfusion injury. If acute mesenteric ischemia is suspected, early angiography is imperative, as it permits accurate diagnosis and possible therapeutic intervention. Therapeutic options during angiography depend on the cause of ischemia and include administering intra-arterial vasodilators and/or thrombolytic agents and angioplasty with or without stent placement. If interventional techniques are not possible or if the patient presents with suspicion of bowel infarction, surgery is warranted. Surgical techniques include superior mesenteric artery embolectomy or visceral artery bypass, which should be used before bowel resection to ensure only resection of nonviable bowel.
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Yang HJ, Cho YK, Son TJ, Jung YY, Choi SA, Lee SH. Rapidly aggravated dissecting flap by angiography during percutaneous stent placement for acute isolated superior mesenteric artery dissection. Yonsei Med J 2011; 52:859-62. [PMID: 21786454 PMCID: PMC3159931 DOI: 10.3349/ymj.2011.52.5.859] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Acutely aggravated dissecting flap and consequent occlusion of the superior mesenteric artery (SMA) by simple contrast passage during initial angiography for percutaneous stent placement is a uncommon event, which usually is not reported. After analysis of many factors that underlie development of such complications, we present herein one case of successful treatment of isolated SMA dissection and its complications with favorable outcomes during 25 months follow-up after percutaneous stent placement.
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Affiliation(s)
- Hye Jin Yang
- Department of Radiology, Eulji General Hospital, Eulji University, Seoul, Korea
| | - Young Kwon Cho
- Department of Radiology, Eulji General Hospital, Eulji University, Seoul, Korea
| | - Tae Jun Son
- Department of General Surgery, Eulji General Hospital, Eulji University, Seoul, Korea
| | - Yoon Young Jung
- Department of Radiology, Eulji General Hospital, Eulji University, Seoul, Korea
| | - Seung A Choi
- Department of Radiology, Eulji General Hospital, Eulji University, Seoul, Korea
| | - Suk Hoon Lee
- Department of Radiology, Eulji General Hospital, Eulji University, Seoul, Korea
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Abstract
OBJECTIVE This study aims at improving diagnosis of intestinal ischemia, by measuring plasma and urinary fatty acid binding protein (FABP) levels. METHODS Fifty consecutive patients suspected of intestinal ischemia were included and blood and urine were sampled at time of suspicion. Plasma and urinary concentrations of intestinal FABP (I-FABP), liver FABP (L-FABP) and ileal bile acid binding protein (I-BABP) were measured using enzyme-linked immunosorbent assays. RESULTS Twenty-two patients suspected of intestinal ischemia were diagnosed with intestinal ischemia, 24 patients were diagnosed with other diseases, and 4 patients were excluded from further analysis fulfilling exclusion criteria. Median plasma concentrations of I-FABP and L-FABP and urinary concentrations of all 3 markers were significantly higher in patients with proven intestinal ischemia than in patients suspected of intestinal ischemia with other final diagnoses (plasma I-FABP; 653 pg/mL vs. 109 pg/mL, P = 0.02, plasma L-FABP; 117 ng/mL vs. 25 ng/mL, P = 0.006, urine I-FABP; 3377 pg/mL vs. 115 pg/mL, P = 0.001, urine L-FABP; 1,199 ng/mL vs. 37 ng/mL, P =0.004, urine I-BABP; 48.6 ng/mL vs. 0.6 ng/mL, P = 0.002). Positive and negative likelihood ratios significantly increased positive posttest probability and decreased negative posttest probability on intestinal ischemia. In patients with intestinal ischemia a trend to higher plasma I-BABP levels was observed when the ileum was involved (18.4 ng/mL vs. 2.9 ng/mL, P = 0.05). CONCLUSION Plasma and especially urinary I-FABP and L-FABP levels and urinary I-BABP levels can improve early diagnosis of intestinal ischemia. Furthermore, plasma I-BABP levels can help in localizing ileal ischemia.
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