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Rehné Jensen L, Snitkjær C, Kokotovic D, Korgaard Jensen T, Burcharth J. Understanding early deaths after major emergency abdominal surgery: An observational study of 754 patients. World J Surg 2024; 48:1797-1807. [PMID: 38886168 DOI: 10.1002/wjs.12254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 06/09/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Major emergency abdominal surgery is associated with severe postoperative complications and high short- and long-term mortality. Despite recent advancements in standardizing multidisciplinary care bundles, a subgroup of patients continues to face a heightened risk of short-term mortality. This study aimed to identify and describe the high-risk surgical patients and risk factors for short-term postoperative mortality. METHODS In this study, we included all patients undergoing major emergency abdominal surgery over 2 years and collected data on demographics, intraoperative variables, and short-term outcomes. The primary outcome measure was short-term mortality and secondary outcome measures were pre, intra, and postoperative risk factors for premature death. Multivariable binary regression analysis was performed to determine possible risk factors for short-term mortality. RESULTS Short-term mortality within 14 days of surgery in this cohort of 754 consecutive patients was 8%. Multivariable analysis identified various independent risk factors for short-term mortality throughout different phases of patient care. These factors included advanced age, preoperative history of myocardial infarction or ischemic heart disease, chronic obstructive pulmonary disease, liver cirrhosis, chronic kidney disease, and vascular bowel ischemia or perforation of the stomach or duodenum during the primary surgery. CONCLUSION Patients at high risk of early mortality following major emergency abdominal surgery exhibited distinct perioperative risk factors. This study underscores the importance of clinicians identifying and managing these factors in high-risk patients to ensure optimal care.
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Affiliation(s)
- Lasse Rehné Jensen
- Department of Gastrointestinal and Hepatic Diseases, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
- Emergency Research Group (EMERGE) Copenhagen, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
| | - Christian Snitkjær
- Department of Gastrointestinal and Hepatic Diseases, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
- Emergency Research Group (EMERGE) Copenhagen, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
| | - Dunja Kokotovic
- Department of Gastrointestinal and Hepatic Diseases, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
- Emergency Research Group (EMERGE) Copenhagen, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
| | - Thomas Korgaard Jensen
- Department of Gastrointestinal and Hepatic Diseases, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
- Emergency Research Group (EMERGE) Copenhagen, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jakob Burcharth
- Department of Gastrointestinal and Hepatic Diseases, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
- Emergency Research Group (EMERGE) Copenhagen, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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2
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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 PMCID: PMC11255773 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 ScienceKyoto Prefectural University of MedicineKyotoJapan
| | - Kenji Yanishi
- Department of Cardiovascular Medicine, Graduate School of Medical ScienceKyoto Prefectural University of MedicineKyotoJapan
| | - Takaaki Ozawa
- Department of Cardiovascular Medicine, Graduate School of Medical ScienceKyoto Prefectural University of MedicineKyotoJapan
| | - Jun Yoshimura
- Department of Cardiovascular Medicine, Graduate School of Medical ScienceKyoto Prefectural University of MedicineKyotoJapan
| | - Hirofumi Kawamata
- Department of Cardiovascular Medicine, Graduate School of Medical ScienceKyoto Prefectural University of MedicineKyotoJapan
| | - Ayumu Fujioka
- Department of Cardiovascular Medicine, Graduate School of Medical ScienceKyoto Prefectural University of MedicineKyotoJapan
| | - Tomotsugu Seki
- Department of Cardiovascular Medicine, Graduate School of Medical ScienceKyoto Prefectural University of MedicineKyotoJapan
| | - Kan Zen
- Department of Cardiovascular Medicine, Graduate School of Medical ScienceKyoto Prefectural University of MedicineKyotoJapan
| | - Satoaki Matoba
- Department of Cardiovascular Medicine, Graduate School of Medical ScienceKyoto Prefectural University of MedicineKyotoJapan
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3
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Qu S, Wen R, Yan M, Qin J, Li J. Early endovascular approaches for treating acute mesenteric arterial occlusive disease in hemodialysis patients. Hemodial Int 2024; 28:241-246. [PMID: 38385856 DOI: 10.1111/hdi.13139] [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: 09/13/2023] [Revised: 02/05/2024] [Accepted: 02/09/2024] [Indexed: 02/23/2024]
Abstract
BACKGROUND Among hemodialysis patients, acute superior mesenteric artery (SMA) thrombosis a condition with a high mortality rate. Very few larger case series have been reported. METHOD We reviewed eight hemodialysis patients with diabetes mellitus and SMA thrombosis managed with endovascular therapy in our institution. Demographic, clinical, and radiological data were described. The patency of the SMA was assessed by computed tomography angiography (CTA) at one month after the endovascular procedure. At the last visit, clinical symptoms and check of mortality were recorded. RESULTS Multidetector CTA scan revealed severe stenosis of SMA in 6 patients and SMA occlusion in the other two patients. The severe stenosis of SMA were verified by angiography. Balloon angioplasty without stenting was performed to obtain satisfactory patency of SMA. Seven of eight patients achieved resolution of abdominal pain after the endovascular procedure. One patient died of suspected intestinal necrosis after 6 days of balloon angioplasty. All seven surviving patients did not experience a recurrence of symptoms with a median follow-up of 2 years. No significant residual stenotic or occlusive lesions were noted in follow-up CTA at one month after the endovascular procedure. CONCLUSION SMA thrombosis should be systematically suspected in hemodialysis patients experiencing abdominal pain. Prompt diagnosis of SMA thrombosis as soon as possible and early endovascular therapy are required to obtain a favorable prognosis in the hemodialysis patient with SMA thrombosis.
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Affiliation(s)
- Siyuan Qu
- Department of Rheumatology and Immunology, University of South China Affiliated Changsha Central Hospital, Hunan Province, China
| | - Rui Wen
- Department of Rheumatology and Immunology, University of South China Affiliated Changsha Central Hospital, Hunan Province, China
| | - Mingming Yan
- Department of Orthopaedic Surgery, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Jiao Qin
- Department of Rheumatology and Immunology, University of South China Affiliated Changsha Central Hospital, Hunan Province, China
| | - Jiali Li
- Department of Rheumatology and Immunology, University of South China Affiliated Changsha Central Hospital, Hunan Province, China
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Mahajan S, Pantbalekundri N, Khurana K, Kadu A. Superior Mesenteric Artery Stenosis Presenting as Chest Pain: Danger in Disguise. Cureus 2023; 15:e50922. [PMID: 38259371 PMCID: PMC10801282 DOI: 10.7759/cureus.50922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 12/21/2023] [Indexed: 01/24/2024] Open
Abstract
Chronic mesenteric ischemia (CMI), often known as abdominal angina, is a syndrome caused by a severe reduction in arterial flow to the digestive loops. It is an uncommon and underdiagnosed entity with potential severe adversities, such as acute mesenteric ischemia (AMI). Patients with coronary artery disease (CAD) are shown to also have mesenteric artery stenosis (MAS). By identifying risk variables, it may be possible to screen for mesenteric artery involvement in patients with CAD who exhibit an elevated risk. Here, we present a unique case of a person with severe retrosternal chest pain with postprandial angina, which turned out to be superior mesenteric artery (SMA) ostial stenosis.
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Affiliation(s)
- Satish Mahajan
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Nikhil Pantbalekundri
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Kashish Khurana
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Ajinkya Kadu
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Savlania A, Vaddavalli VV, Abuji K, Ravi A, Maheshwari N, Kaman L, Behera A, Gorsi U. Outcomes of open revascularization for chronic mesenteric ischemia at a tertiary care center in India. Indian J Gastroenterol 2023; 42:833-838. [PMID: 37768446 DOI: 10.1007/s12664-023-01447-4] [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: 04/25/2023] [Accepted: 08/09/2023] [Indexed: 09/29/2023]
Abstract
OBJECTIVE Chronic mesenteric ischemia (CMI) is a rare, debilitating disease associated with higher morbidity and mortality if not treated on time. In the past two decades, there has been a paradigm shift in its management with endovascular modality due to reduced perioperative morbidity and mortality. In the endovascular era, only a few patients require surgical therapy. We conducted this study to report our experience with open surgical revascularization at our hospital. METHODS We have conducted a retrospective study after obtaining approval from Institutional Ethics Committee. Data regarding patients who underwent open revascularization for CMI with long-segment occlusion from 2016 to 2021 has been retrieved from the institutional database. The demographic data, clinical presentation, type of surgery and graft used, perioperative mortality and morbidity and length of hospital stay were evaluated. Overall survival and disease-free survival were assessed using Kaplan-Meier analysis. RESULTS Twenty-one patients underwent open surgical revascularization; 16 were males and five females. The median age was 43 years. Fourteen (66.7%) were smokers. The mean duration of follow-up was 28.4 ± 13.6 months. Thirty-day postoperative mortality was 0% and morbidity was 28%. The average duration of hospital stay and postoperative weight gain were 6.9 ± 3.7 days and 11 ± 4.9 kgs, respectively. One patient died at two years of follow-up due to myocardial infarction and one had a recurrence. Long-term survival at 60 months of follow-up was 91.6% and the primary-patency rate was 95.2%. CONCLUSION Owing to better long-term and reintervention-free patency, open revascularization should be considered in patients who are fit for surgery, particularly in patients with long-segment mesenteric artery occlusion.
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Affiliation(s)
- Ajay Savlania
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, 160 012, India.
| | - Venkata Vineeth Vaddavalli
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Kishore Abuji
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Ashwitha Ravi
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Naveen Maheshwari
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Lileswar Kaman
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Arunanshu Behera
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Ujjwal Gorsi
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, 160 012, India
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6
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De Pietro R, Martin J, Tradi F, Chopinet S, Barraud M, Gaudry M, Bourenne J, Nafati C, Boussen S, Guidon C, Bartoli M, Mege D. Prognostic factors after acute mesenteric ischemia: which patients require specific management? Int J Colorectal Dis 2023; 38:242. [PMID: 37777708 DOI: 10.1007/s00384-023-04540-4] [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] [Accepted: 09/20/2023] [Indexed: 10/02/2023]
Abstract
PURPOSE Diagnosis and treatment of AMI are a real issue for implicating physicians. In the literature, only one AMI stroke center has reported its results so far, with increasing survival rates. Our aim was to analyze acute mesenteric ischemia (AMI) related mortality and predictive factors, in a single academic center, before creating a dedicated intestinal stroke center. METHODS All the patients with an AMI, between January 2015 and December 2020, were retrospectively included. They were divided into 2 groups according to the early mortality: death during the first 30 days and alive. The 2 groups were compared. RESULTS 173 patients (57% of men), were included, with a mean age of 68 ± 16 years. Overall mortality rate was 61%. Mortality occurred within the first 30 days in 78% of dead cases. Dead patients were significantly older, more frequently admitted from intensive care, with more serious clinical, laboratory and radiological characteristics. We have identified 3 protective factors - history of abdominal surgery (Odd Ratio = 0.1; 95%CI = 0.01-0.8, p = 0.03), medical management with curative anticoagulation (OR = 0.09; 95%CI = 0.02-0.5, p = 0.004) and/or antiplatelets (OR = 0.04; 95%CI = 0.006-0.3, p = 0.001)-, and 2 predictive factors of mortality - age > 70 years (OR = 7; 95%CI = 1.4-37, p = 0.02) and previous history of coronaropathy (OR = 13; 95%CI = 1.7-93, p = 0.01). CONCLUSIONS AMI is a severe disease with high morbidity and mortality rates. Even if its diagnosis is still difficult because of non-specific presentation, its therapeutic management needs to be changed in order to improve survival rates, particularly in patients older than 70 years with history of coronaropathy. Developing a dedicated organization would improve the diagnosis and the management of patients with AMI.
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Affiliation(s)
- Remi De Pietro
- Department of Digestive Surgery, Aix Marseille Univ, APHM, Timone University, 264 rue Saint-Pierre, 13005, Marseille, France
| | - Julie Martin
- Department of Emergency, Aix Marseille Univ, APHM, Timone University, Marseille, France
| | - Farouk Tradi
- Department of Radiology, Aix Marseille Univ, APHM, Timone University, Marseille, France
| | - Sophie Chopinet
- Department of Digestive Surgery, Aix Marseille Univ, APHM, Timone University, 264 rue Saint-Pierre, 13005, Marseille, France
| | - Marine Barraud
- Department of Gastro-enterology, Aix Marseille Univ, APHM, Timone University, Marseille, France
| | - Marine Gaudry
- Department of Vascular Surgery, Aix Marseille Univ, APHM, Timone University, Marseille, France
| | - Jeremy Bourenne
- Department of Emergency Critical Care Medicine, Aix Marseille Univ, APHM, Timone University, Marseille, France
| | - Cyril Nafati
- Department of Intensive Care of Liver Diseases, Aix Marseille Univ, APHM, Timone University, Marseille, France
| | - Salah Boussen
- Department of Intensive Care and Anesthesiology Department2, Aix Marseille Univ, APHM, Timone University, Marseille, France
| | - Catherine Guidon
- Department of Anaesthesiology and Critical Care Medicine, Aix Marseille Univ, APHM, Timone University, Marseille, France
| | - Michel Bartoli
- Department of Vascular Surgery, Aix Marseille Univ, APHM, Timone University, Marseille, France
| | - Diane Mege
- Department of Digestive Surgery, Aix Marseille Univ, APHM, Timone University, 264 rue Saint-Pierre, 13005, Marseille, France.
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Kapalla M, Choubey R, Weitz J, Reeps C, Wolk S. Results after intraoperative open and endovascular revascularization of acute mesenteric ischemia requiring a laparotomy. Langenbecks Arch Surg 2023; 408:303. [PMID: 37561214 PMCID: PMC10415437 DOI: 10.1007/s00423-023-03035-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 08/01/2023] [Indexed: 08/11/2023]
Abstract
BACKGROUND Acute mesenteric ischemia (AMI) is a dreaded condition with a difficult diagnosis and high mortality. Due to different baseline situations, the frequently performed comparison between endovascular and open surgical treatment is interfered with selection bias. The purpose of this study was to review outcomes in AMI treatment with an open or endovascular approach in association with laparotomy and to evaluate the endovascular-first strategy in similar clinical situations. METHODS The clinical data of 74 patients treated for AMI from 2007 to 2021 were retrospectively reviewed and compared. In-hospital mortality was appointed as the primary study endpoint. Risk factors for mortality were identified by using univariate and multivariate analysis. RESULTS In total, 61 patients (82%) were treated open surgically (OT) and, 13 patients (18%) with an endovascular approach (ET) in combination with laparatomy. The etiology of AMI was 49% arteriosclerotic and 51% thromboembolic occlusions. The total in-hospital mortality manifested at 43% (n =32) (OT 41% vs. ET 53.8%; P=0.54). As independent risk factors for in-hospital mortality, pneumatosis intestinalis (P=0.01), increased lactate concentration (P=0.04), and ischemic intestinal sections (P=0.01) were identified. Additionally, on univariate analysis patient age, congestive heart failure (> NYHA II) and atrial fibrillation were related with higher mortality. CONCLUSIONS Morbidity and mortality of AMI remains at a high level. Conventional open or intraoperative endovascular therapy achieved similar results in patients with indication for laparotomy. Advanced disease stage with ischemic intestinal sections at presentation and cardiovascular comorbidities were associated with adverse outcome.
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Affiliation(s)
- Marvin Kapalla
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Dresden, TU, Germany.
| | - Rahul Choubey
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Dresden, TU, Germany
| | - Jürgen Weitz
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Dresden, TU, Germany
| | - Christian Reeps
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Dresden, TU, Germany
| | - Steffen Wolk
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Dresden, TU, Germany
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Scallan OH, Duncan AA. Current Approaches for Mesenteric Ischemia and Visceral Aneurysms. Surg Clin North Am 2023; 103:703-731. [PMID: 37455033 DOI: 10.1016/j.suc.2023.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
This article provides an overview of acute mesenteric ischemia, chronic mesenteric ischemia, and visceral aneurysms, with a focus on treatment. Acute mesenteric ischemia can be a challenging diagnosis. Early recognition and adequate revascularization are key to patient outcomes. Chronic mesenteric ischemia is a more insidious process, typically caused by atherosclerosis. Various options for revascularization exist, which must be tailored to each patient. Visceral aneurysms are rare and the natural history is not well defined. However, given the risk of rupture and high mortality, treatment may be complex.
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Affiliation(s)
- Oonagh H Scallan
- Division of Vascular and Endovascular Surgery, Western University, 800 Commissioners Road East, PO Box 5010, London, Ontario N6A 5W9, Canada
| | - Audra A Duncan
- Division of Vascular and Endovascular Surgery, Western University, 800 Commissioners Road East, PO Box 5010, London, Ontario N6A 5W9, Canada.
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Nuzzo A, Peoc'h K, Vaittinada Ayar P, Tran-Dinh A, Weiss E, Panis Y, Ronot M, Garzelli L, Eloy P, Ben Abdallah I, Castier Y, Corcos O. Improving clinical suspicion of acute mesenteric ischemia among patients with acute abdomen: a cross-sectional study from an intestinal stroke center. World J Emerg Surg 2023; 18:37. [PMID: 37287011 DOI: 10.1186/s13017-023-00505-8] [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: 05/07/2023] [Accepted: 05/25/2023] [Indexed: 06/09/2023] Open
Abstract
BACKGROUND Early diagnosis of acute mesenteric ischemia (AMI) is essential for a favorable outcome. Selection of patients requiring a dedicated multiphasic computed tomography (CT) scan remains a clinical challenge. METHODS In this cross-sectional diagnostic study conducted from 2016 to 2018, we compared the presentation of AMI patients admitted to an intestinal stroke center to patients with acute abdominal pain of another origin admitted to the emergency room (controls). RESULTS We included 137 patients-52 with AMI and 85 controls. Patients with AMI [median age: 65 years (interquartile range 55-74)] had arterial and venous AMI in 65% and 35% of cases, respectively. Relative to controls, AMI patients were significantly older, more likely to have risk factors or a history of cardiovascular disease, and more likely to present with sudden-onset and morphine-requiring abdominal pain, hematochezia, guarding, organ dysfunction, higher white blood cell and neutrophil counts, and higher plasma C-reactive protein (CRP) and procalcitonin concentrations. On multivariate analysis, two independent factors were associated with the diagnosis of AMI: the sudden-onset (OR = 20, 95%CI 7-60, p < 0.001) and the morphine-requiring nature of the acute abdominal pain (OR = 6, 95%CI 2-16, p = 0.002). Sudden-onset and/or morphine-requiring abdominal pain was present in 88% of AMI patients versus 28% in controls (p < 0.001). The area under the receiver operating characteristic curve for the diagnosis of AMI was 0.84 (95%CI 0.77-0.91), depending on the number of factors. CONCLUSIONS Sudden onset and the need for morphine are suggestive of AMI in patients with acute abdominal pain and should prompt multiphasic CT scan including arterial and venous phase images for confirmation.
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Affiliation(s)
- Alexandre Nuzzo
- Université Paris Cité, INSERM UMR 1148, 75018, Paris, France.
- Department of Gastroenterology, IBD and Intestinal Failure, Intestinal Stroke Center, AP-HP. Nord, Beaujon Hospital, 92110, Clichy, France.
- Structure d'Urgences Vasculaires Intestinales (SURVI), Hôpital Beaujon, 100 bd du général Leclerc, 92110, Clichy, France.
| | - Katell Peoc'h
- Université Paris Cité, INSERM UMR 1149, 75018, Paris, France
- Department of Clinical Biochemistry, AP-HP. Nord, Beaujon Hospital, 92110, Clichy, France
| | | | - Alexy Tran-Dinh
- Université Paris Cité, INSERM UMR 1148, 75018, Paris, France
- Intensive Care Unit, AP-HP. Nord, Bichat Hospital, 75018, Paris, France
| | - Emmanuel Weiss
- Université Paris Cité, INSERM UMR 1149, 75018, Paris, France
- Intensive Care Unit, AP-HP. Nord, Beaujon Hospital, 92110, Clichy, France
| | - Yves Panis
- Department of Colorectal Surgery, AP-HP. Nord, Beaujon Hospital, 92110, Clichy, France
| | - Maxime Ronot
- Department of Clinical Biochemistry, AP-HP. Nord, Beaujon Hospital, 92110, Clichy, France
- Department of Radiology, AP-HP. Nord, Beaujon Hospital, 92110, Clichy, France
| | - Lorenzo Garzelli
- Department of Clinical Biochemistry, AP-HP. Nord, Beaujon Hospital, 92110, Clichy, France
- Department of Radiology, AP-HP. Nord, Beaujon Hospital, 92110, Clichy, France
| | - Philippine Eloy
- Department of Epidemiology, Biostatistics and Clinical Research, APHP. Nord, Bichat Hospital, 75018, Paris, France
- Université Paris Cité, INSERM CIC-EC 1425, 75018, Paris, France
| | - Iannis Ben Abdallah
- Department of Vascular Surgery, AP-HP. Nord, Bichat Hospital, 75018, Paris, France
| | - Yves Castier
- Department of Vascular Surgery, AP-HP. Nord, Bichat Hospital, 75018, Paris, France
| | - Olivier Corcos
- Université Paris Cité, INSERM UMR 1148, 75018, Paris, France
- Department of Gastroenterology, IBD and Intestinal Failure, Intestinal Stroke Center, AP-HP. Nord, Beaujon Hospital, 92110, Clichy, France
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Kobayashi T, Hidaka E, Ando A, Koganezawa I, Nakagawa M, Yokozuka K, Ochiai S, Gunji T, Sano T, Tomita K, Tabuchi S, Chiba N, Kawachi S. Risk factors for postoperative disseminated intravascular coagulation in surgical patients with non-occlusive mesenteric ischemia. Int J Colorectal Dis 2023; 38:146. [PMID: 37247011 DOI: 10.1007/s00384-023-04449-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/25/2023] [Indexed: 05/30/2023]
Abstract
PURPOSE The prognostic impact of disseminated intravascular coagulation (DIC) in surgical patients with non-occlusive mesenteric ischemia (NOMI) is unclear. This study aimed to confirm the association between postoperative DIC and prognosis and to identify preoperative risk factors associated with postoperative DIC. METHODS This retrospective study included 52 patients who underwent emergency surgery for NOMI between January 2012 and March 2022. Kaplan-Meier curve analysis with the log-rank test was used to compare 30-day survival and hospital survival between patients with and without postoperative DIC. In addition, univariable and multivariable logistic regression analyses were performed to identify the preoperative risk factors for postoperative DIC. RESULTS The 30-day and hospital mortality rates were 30.8% and 36.5%, respectively, and the incidence rate of DIC was 51.9%. Compared to patients without DIC, patients with DIC showed significantly lower rates of 30-day survival (41.5% vs 96%, log-rank P < 0.001) and hospital survival (30.2% vs 86.4%, log-rank, P < 0.001). Logistic regression analyses showed that the Japanese Association for Acute Medicine (JAAM) DIC score (OR = 2.697; 95% CI, 1.408-5.169; P = 0.003) and Sequential Organ Failure Assessment (SOFA) score (OR = 1.511; 95% CI, 1.111-2.055; P = 0.009) were independent risk factors for postoperative DIC in surgical patients with NOMI. CONCLUSION The development of postoperative DIC is a significant prognostic factor for 30-day and hospital mortalities in surgical patients with NOMI. In addition, the JAAM DIC score and SOFA score have a high discriminative ability for predicting the development of postoperative DIC.
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Affiliation(s)
- Toshimichi Kobayashi
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo 193-0998, Japan
| | - Eiji Hidaka
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo 193-0998, Japan
| | - Akitoshi Ando
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo 193-0998, Japan
| | - Itsuki Koganezawa
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo 193-0998, Japan
| | - Masashi Nakagawa
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo 193-0998, Japan
| | - Kei Yokozuka
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo 193-0998, Japan
| | - Shigeto Ochiai
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo 193-0998, Japan
| | - Takahiro Gunji
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo 193-0998, Japan
| | - Toru Sano
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo 193-0998, Japan
| | - Koichi Tomita
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo 193-0998, Japan
| | - Satoshi Tabuchi
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo 193-0998, Japan
| | - Naokazu Chiba
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo 193-0998, Japan
| | - Shigeyuki Kawachi
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo 193-0998, Japan.
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Muhtaroğlu A, Çapoğlu R, Uygur FA, Harmantepe AT, Bayhan Z, Gönüllü E. FAR Ratio as Prognostic Biomarker in AMI. SN COMPREHENSIVE CLINICAL MEDICINE 2023; 5:109. [PMID: 36970580 PMCID: PMC10031717 DOI: 10.1007/s42399-023-01451-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/15/2023] [Indexed: 03/28/2023]
Abstract
Acute mesenteric ischemia (AMI) is a vascular emergency resulting from decreased blood flow caused by the occlusion of the mesenteric vessels, hypoperfusion, or vasospasm. This study aimed to investigate the prognostic value of the fibrinogen-to-albumin (FAR) ratio in patients with acute mesenteric ischemia. A total of 91 patients were enrolled in the study. Patients' demographics such as age and gender, pre- and postoperative hemoglobin, CRP, white blood cell (WBC), neutrophils, preoperative lymphocyte, alanine transaminase (ALT), aspartate transaminase (AST), thrombocytes, and postoperative D-dimer values were recorded. In addition, pre- and postoperative fibrinogen and albumin levels were recorded, and FAR was calculated. Patients were divided into two groups, survivors and non-survivors. The mean pre- and postoperative fibrinogen levels were statistically significantly higher in the non-survivor group than in the survivor group (p < 0.001). The mean pre- and postoperative albumin levels were significantly lower in the non-survivors than in the survivors (p = 0.059, p < 0.001; respectively). The mean pre- and postoperative FAR ratios were considerably higher in the non-survivor than in the survivor groups (p < 0.001). The change between pre- and postoperative fibrinogen, albumin, and FAR values was statistically significant between the non-survivors and the survivors (for all, p < 0.05). The preoperative and postoperative fibrinogen levels were significantly lower, and albumin levels were significantly higher in the survivor compared to the non-survivor patients with AMI. Furthermore, the preoperative and postoperative FAR ratio was significantly higher in the non-survivors. The FAR ratio may be a valuable prognostic biomarker for patients with AMI.
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Affiliation(s)
- Ali Muhtaroğlu
- Department of General Surgery, Giresun University Faculty of Medicine, Giresun University Training and Research Hospital, Aksu District, Mehmet İzmen Street, Number: 145, 28100 Giresun, PC Turkey
| | - Recayi Çapoğlu
- General Surgery Clinic, Sakarya Training and Research Hospital, Adapazari, Turkey
| | - Furkan Ali Uygur
- Department of General Surgery, Giresun University Faculty of Medicine, Giresun University Training and Research Hospital, Aksu District, Mehmet İzmen Street, Number: 145, 28100 Giresun, PC Turkey
| | | | - Zülfü Bayhan
- Department of General Surgery, Sakarya University Faculty of Medicine, Adapazari, Turkey
| | - Emre Gönüllü
- Department of Gastroenterological Surgery, Sakarya University Faculty of Medicine, Adapazari, Turkey
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12
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Akute mesenteriale Durchblutungsstörung – arterielle Embolie. COLOPROCTOLOGY 2023. [DOI: 10.1007/s00053-023-00690-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
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13
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Wolk S, Kapalla M, Weitz J, Reeps C. Akute mesenteriale Ischämie – diagnostischer und therapeutischer Algorithmus. COLOPROCTOLOGY 2023. [DOI: 10.1007/s00053-023-00693-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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14
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Molyneux K, Beck-Esmay J, Koyfman A, Long B. High risk and low prevalence diseases: Mesenteric ischemia. Am J Emerg Med 2023; 65:154-161. [PMID: 36638612 DOI: 10.1016/j.ajem.2023.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 12/19/2022] [Accepted: 01/02/2023] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION Mesenteric ischemia is a rare, frequently misdiagnosed, serious condition that carries with it a high rate of morbidity and mortality. OBJECTIVE This review highlights the pearls and pitfalls of mesenteric ischemia, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION Mesenteric ischemia is an abdominal vascular emergency that includes superior mesenteric arterial embolism, arterial thrombosis, venous mesenteric ischemia, and non-occlusive mesenteric ischemia. It is associated with a variety of risk factors including older age, cardiovascular disease, hypercoagulable state, and end-stage renal disease. The presentation depends on the underlying pathophysiology. While arterial embolic disease may present with sudden, severe pain, the early stages of the disease and other forms can present with vague symptoms, including generalized abdominal pain, weight loss, vomiting, and diarrhea. Laboratory testing can suggest the disease with leukocytosis and elevated lactate, but normal values should not be used to exclude the diagnosis. The imaging modality of choice is triple phase computed tomography with non-contrast, arterial, and delayed phases. The initial ED management includes fluid resuscitation, symptomatic therapy, broad-spectrum antibiotics, and anticoagulation. Emergent consultation with a multidisciplinary team including diagnostic and interventional radiologists and cardiovascular and general surgeons is necessary for definitive treatment. CONCLUSIONS An understanding of mesenteric ischemia can assist emergency clinicians in diagnosing and managing this disease.
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Affiliation(s)
- Kevin Molyneux
- Department of Emergency Medicine, Columbia University Irving Medical Center, 622 W 168th St, New York, NY 10032, USA
| | - Jennifer Beck-Esmay
- Department of Emergency Medicine, Mount Sinai Morningside - Mount Sinai West, 1111 Amsterdam Ave, New York, NY 10025, USA.
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
| | - Brit Long
- SAUSHEC, Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
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15
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Cirillo-Penn NC, DeMartino RR, Rasmussen TE, Shuja F, Colglazier JJ, Kalra M, Oderich GS, Mendes BC. Midterm Clinical Outcomes of Retrograde Open Mesenteric Stenting for Mesenteric Ischemia. Ann Vasc Surg 2023; 89:20-27. [PMID: 36404451 DOI: 10.1016/j.avsg.2022.09.062] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 08/03/2022] [Accepted: 09/26/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Retrograde open mesenteric stenting (ROMS) has become a mainstay in treatment of mesenteric ischemia; however, follow-up in contemporary studies is limited. METHODS A single-center retrospective review of patients undergoing ROMS from 2007 to 2020 was conducted. Demographics, presentation, and procedural details were reviewed. End points were morbidity and mortality, technical success, primary patency, reinterventions, and freedom from clinical recurrence. RESULTS ROMS was performed in 34 patients, 19 female (56%). Mean age was 71 ± 10 years. Eighteen patients (53%) presented with acute mesenteric ischemia (AMI), 11 (32%) with acute-on-chronic, and 5 (15%) with chronic mesenteric ischemia. Etiology was chronic atherosclerosis with/without in-situ thrombosis in 28 patients (82%), superior mesenteric artery dissection in 3, and 1 each with embolic, vasculitic, and nonocclusive ischemia. Four patients (12%) had prior mesenteric procedures (3 Celiac/1 superior mesenteric artery stent) and 1 had unsuccessful transbrachial stenting attempt. Technical success, defined as successful stenting through a retrograde approach was attained in 31 patients (91%), with the 3 remaining patients treated with transbrachial stenting in 2 and iliomesenteric bypass in 1. Covered stents were used in 21 patients (64%) with or without stent extension with bare-metal stents. Eight patients (23%) required thromboembolectomy and 9 (26%) underwent patch angioplasty. Thirty-day mortality rate was 35%, all in patients with AMI (10) or acute-on-chronic (2). Eighteen patients (53%) underwent bowel resection, all presenting acutely. Early reinterventions within the first 30 days were required in 5 patients (15%), including 2 redo ROMS with thrombectomy and endarterectomy, 2 percutaneous stent extensions, and 1 aortic septum fenestration with coiling of a jejunal branch pseudoaneurysm. With a median follow-up of 3.7 (interquartile range: 0.8-5.0) years, in patients surviving discharge, 5 required reintervention yielding freedom from reintervention rates of 87% at 1 year and 71% at 3 years. All postdischarge reinterventions were endovascular with no conversion to bypass. The overall 1-year and 3-year primary patency rates were 70% and 61% (primary-assisted patency at 1 and 3 years was 87% and secondary patency at 1 and 3 years was 97%). The freedom from symptom recurrence was 95% at 1 and 3 years. CONCLUSIONS ROMS carries high rates of technical success in patients with mesenteric ischemia, despite a high chronic atherosclerotic burden. Although mid-term patency rates are acceptable, AMI is still associated with high early morbidity and mortality, with high rates of associated bowel resection. ROMS is a valuable tool in the armamentarium of vascular surgeons.
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Affiliation(s)
| | | | - Todd E Rasmussen
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Fahad Shuja
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Jill J Colglazier
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Manju Kalra
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Gustavo S Oderich
- Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Center at Houston, Houston, TX
| | - Bernardo C Mendes
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN.
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16
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Feng R, Chang G, Hu Z, Yao C, Ma R, Li D, Wang S, Wang S. The Influencing Factors and Prognostic Evaluation in the Treatment Decisions for Acute and Subacute Nondissection-Related Superior Mesenteric Artery Thromboembolism. Ann Vasc Surg 2023:S0890-5096(23)00023-7. [PMID: 36681269 DOI: 10.1016/j.avsg.2023.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 01/04/2023] [Accepted: 01/07/2023] [Indexed: 01/19/2023]
Abstract
BACKGROUND The unclarified treatment strategy for acute and subacute ndSMA-TE limits the therapeutic efficacy and worsens the prognosis. This study aimed to determine the predictive factors impacting the treatment strategy for acute and subacute ndSMA-TE. METHOD A database of 116 patients with nonchronic ndSMA-TE admitted between January 2001 and December 2021 was retrospectively analyzed. Univariate/multivariate logistic regression and the predictive models constructed by stepwise backward regression were used to explore the influencing factors of the treatment decisions and the risk factors for failed conservative treatment. The EuroQol-5 Dimension questionnaire was used to evaluate the long-term quality of life. RESULTS Only the white blood cell (WBC) levels were significantly different between the conservative group and the surgical group (P = 0.013 < 0 .05, odds ratio (OR) = 1.153, 95% confidence interval (CI) [1.038, 1.306]). The WBC levels (P < 0.001, OR = 1.169, 95% CI [1.080, 1.286]) and heart diseases (except atrial fibrillation) (P = 0.011 < 0 .05, OR = 5.116, 95% CI [1.541, 20.452]) were included in the predictive model of the treatment decision. The hemoglobin levels (P = 0.005 < 0 .05, OR = 1.095, 95% CI [1.040, 1.187]) and no flatus or stool (P = 0.007 < 0 .05, OR = 0.031, 95% CI [0.002, 0.296]) were significant risk factors for the conservative treatment outcome. The EuroQol-5 Dimension evaluation demonstrated a fairly high long-term quality of life in both treatment strategies. CONCLUSIONS Elevated WBC levels, decreased hemoglobin levels, and no flatus or stool can be used as predictive indicators for the surgical treatment of nonchronic ndSMA-TE to avoid a misdiagnosis and an inappropriate treatment.
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Affiliation(s)
- Ruijia Feng
- Department of Vascular Surgery, National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Guangqi Chang
- Department of Vascular Surgery, National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zuojun Hu
- Department of Vascular Surgery, National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Chen Yao
- Department of Vascular Surgery, National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ruixia Ma
- Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Di Li
- Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Shenming Wang
- Department of Vascular Surgery, National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.
| | - Siwen Wang
- Department of Vascular Surgery, National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.
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17
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Intra-Arterial Urokinase for Acute Superior Mesenteric Artery Occlusion: A Retrospective 12-Year Report of 13 Cases. Biomedicines 2023; 11:biomedicines11020267. [PMID: 36830803 PMCID: PMC9952883 DOI: 10.3390/biomedicines11020267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 01/04/2023] [Accepted: 01/14/2023] [Indexed: 01/20/2023] Open
Abstract
This retrospective study aimed to evaluate the outcomes of 13 patients with acute superior mesenteric artery (SMA) occlusion who underwent intra-arterial urokinase thrombolysis between 2008 and 2020. On angiography, seven presented with complete SMA occlusion versus six with incomplete occlusion. The median time from abdominal pain to attempting urokinase thrombolysis was 15.0 h (interquartile range, 6.0 h). After urokinase therapy, bowel perfusion was restored with bowel preservation in six patients; however, treatment failed in the other seven patients. The degree of SMA occlusion (complete vs. incomplete, p = 0.002), degree of recanalisation (p = 0.012), and length of stay (p = 0.032) differed significantly between groups. Of the seven patients with complete SMA occlusion, six underwent bowel resection, of whom three died, and the remaining patient died of shock due to delayed surgery. Among the six patients with incomplete SMA occlusion, no bowel resection was performed. In our experience, intra-arterial urokinase thrombolysis may serve as an adjunctive treatment modality, being a potential replacement for open thrombectomy that is able to preserve the bowel and obviate surgery in cases of incomplete SMA occlusion; however, its use is unsuitable in cases of complete SMA occlusion, for which surgery is warranted.
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18
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Yamamoto R, Suzuki S, Homma K, Yamaguchi S, Sujino T, Sasaki J. Hydrogen gas and preservation of intestinal stem cells in mesenteric ischemia and reperfusion. World J Gastrointest Surg 2022; 14:1329-1339. [PMID: 36632117 PMCID: PMC9827576 DOI: 10.4240/wjgs.v14.i12.1329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 09/11/2022] [Accepted: 11/07/2022] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Patients with mesenteric ischemia frequently suffer from bowel necrosis even after revascularization. Hydrogen gas has showed promising effects for ischemia-reperfusion injury by reducing reactive oxygen species in various animal and clinical studies. We examined intestinal tissue injury by ischemia and reperfusion under continuous initiation of 3% hydrogen gas.
AIM To clarify the treatment effects and target cells of hydrogen gas for mesenteric ischemia.
METHODS Three rat groups underwent 60-min mesenteric artery occlusion (ischemia), 60-min reperfusion following 60-min occlusion (reperfusion), or ischemia-reperfusion with the same duration under continuous 3% hydrogen gas inhalation (hydrogen). The distal ileum was harvested. Immunofluorescence staining with caspase-3 and leucine-rich repeat-containing G-protein-coupled 5 (LGR5), a specific marker of intestinal stem cell, was conducted to evaluate the injury location and cell types protected by hydrogen. mRNA expressions of LGR5, olfactomedin 4 (OLFM4), hairy and enhancer of split 1, Jagged 2, and Neurogenic locus notch homolog protein 1 were measured by quantitative polymerase chain reaction. Tissue oxidative stress was analyzed with immunostaining for 8-hydroxy-2'-deoxyguanosine (8-OHdG). Systemic oxidative stress was evaluated by plasma 8-OHdG.
RESULTS Ischemia damaged the epithelial layer at the tip of the villi, whereas reperfusion induced extensive apoptosis of the cells at the crypt base, which were identified as intestinal stem cells with double immunofluorescence stain. Hydrogen mitigated such apoptosis at the crypt base, and the LGR5 expression of the tissues was higher in the hydrogen group than in the reperfusion group. OLFM4 was also relatively higher in the hydrogen group, whereas other measured RNAs were comparable between the groups. 8-OHdG concentration was high in the reperfusion group, which was reduced by hydrogen, particularly at the crypt base. Serum 8-OHdG concentrations were relatively higher in both reperfusion and hydrogen groups without significance.
CONCLUSION This study demonstrated that hydrogen gas inhalation preserves intestinal stem cells and mitigates oxidative stress caused by mesenteric ischemia and reperfusion.
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Affiliation(s)
- Ryo Yamamoto
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo 1608582, Japan
| | - Sayuri Suzuki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo 1608582, Japan
| | - Koichiro Homma
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo 1608582, Japan
| | - Shintaro Yamaguchi
- Division of Endocrinology, Metabolism and Nephrology, Department of Internal Medicine, Keio University School of Medicine, Tokyo 1608582, Japan
| | - Tomohisa Sujino
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo 1608582, Japan
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo 1608582, Japan
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Wu W, He J, Zhang S, Zeng C, Wang Q. Basic demographic characteristics and prevalence of comorbidities in acute mesenteric ischemia: a systematic review and proportional meta-analysis. Scand J Gastroenterol 2022; 58:605-618. [PMID: 36458699 DOI: 10.1080/00365521.2022.2152289] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
PURPOSE The aim of this systematic review and meta-analysis was to examine and assess the basic demographic characteristics and prevalence of comorbidities in acute mesenteric ischemia (AMI) and its various subtypes. PATIENTS AND METHODS A literature search was conducted by using the databases PubMed, EMBASE, and Google Scholar (to June 1, 2022). Random-effects or fixed-effects models were selected to pool means and proportions and their corresponding 95% confidence intervals (CI), based on heterogeneity between studies. The results of meta-analyses for basic demographic characteristics and prevalence (proportions) of each specific comorbidities of acute mesenteric ischemia (AMI) and its various subtypes were described. RESULTS Ninety-nine studies were included in the meta-analysis, including 17,103 patients with AMI. Furthermore, 7941 patients with subclass diagnoses of AMI were identified, including 3,239 patients with arterial occlusive mesenteric ischemia (AOMI), 2,977 patients with nonocclusive mesenteric ischemia (NOMI), and 1,725 patients with mesenteric venous thrombosis (MVT). As a surgical emergency, AMI is associated with older patients and a high likelihood of multisystem comorbidities. Comorbidities of AMI involved multiple systemic diseases, including cardiovascular disease, endocrine and metabolic diseases, kidney diseases, digestive diseases, respiratory diseases, cerebrovascular diseases, vascular diseases, and cancer. CONCLUSION The basic demographic characteristics and the prevalence of comorbidities of different subtypes of AMI are different. The management of comorbidities should be an essential part of improving the prognosis of AMI patients and may contribute to precise prevention of AMI.
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Affiliation(s)
- Wenhan Wu
- Department of General Surgery (Gastrointestinal Surgery), The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Jia He
- Faculty Affairs and Human Resources Management Department, Southwest Medical University, Luzhou, China
| | - Shijian Zhang
- School of Clinical Medicine, Southwest Medical University, Luzhou, China
| | - Changtong Zeng
- School of Clinical Medicine, Southwest Medical University, Luzhou, China
| | - Qifa Wang
- School of Clinical Medicine, Southwest Medical University, Luzhou, China
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20
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Conde Monroy DM, Girón Arango F, Rodríguez Moreno L, Rey Chaves CE, Donoso-Samper A, Nassar R, Isaza-Restrepo A. Succoring the challenging acute mesenteric ischemia: Feasibility of lactate dehydrogenase for evaluation of intestinal necrosis extension and mortality. Ann Med Surg (Lond) 2022; 84:104922. [DOI: 10.1016/j.amsu.2022.104922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 10/23/2022] [Accepted: 11/12/2022] [Indexed: 11/19/2022] Open
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Tamme K, Reintam Blaser A, Laisaar KT, Mändul M, Kals J, Forbes A, Kiss O, Acosta S, Bjørck M, Starkopf J. Incidence and outcomes of acute mesenteric ischaemia: a systematic review and meta-analysis. BMJ Open 2022; 12:e062846. [PMID: 36283747 PMCID: PMC9608543 DOI: 10.1136/bmjopen-2022-062846] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To estimate the incidence of acute mesenteric ischaemia (AMI), proportions of its different forms and short-term and long-term mortality. DESIGN Systematic review and meta-analysis. DATA SOURCES MEDLINE (Ovid), Web of Science, Scopus and Cochrane Library were searched until 26 July 2022. ELIGIBILITY CRITERIA Studies reporting data on the incidence and outcomes of AMI in adult populations. DATA EXTRACTION AND SYNTHESIS Data extraction and quality assessment with modified Newcastle-Ottawa scale were performed using predeveloped standard forms. The outcomes were the incidence of AMI and its different forms in the general population and in patients admitted to hospital, and the mortality of AMI in its different forms. RESULTS From 3064 records, 335 full texts were reviewed and 163 included in the quantitative analysis. The mean incidence of AMI was 6.2 (95% CI 1.9 to 12.9) per 100 000 person years. On average 5.0 (95% CI 3.3 to 7.1) of 10 000 hospital admissions were due to AMI. Occlusive arterial AMI was the most common form constituting 68.6% (95% CI 63.7 to 73.2) of all AMI cases, with similar proportions of embolism and thrombosis.Overall short-term mortality (in-hospital or within 30 days) of AMI was 59.6% (95% CI 55.5 to 63.6), being 68.7% (95% CI 60.8 to 74.9) in patients treated before the year 2000 and 55.0% (95% CI 45.5 to 64.1) in patients treated from 2000 onwards (p<0.05). The mid/long-term mortality of AMI was 68.2% (95% CI 60.7 to 74.9). Mortality due to mesenteric venous thrombosis was 24.6% (95% CI 17.0 to 32.9) and of non-occlusive mesenteric ischaemia 58.4% (95% CI 48.6 to 67.7). The short-term mortality of revascularised occlusive arterial AMI was 33.9% (95% CI 30.7 to 37.4). CONCLUSIONS In adult patients, AMI is a rarely diagnosed condition with high mortality, although with improvement of treatment results over the last decades. Two thirds of AMI cases are of occlusive arterial origin with potential for better survival if revascularised. PROSPERO REGISTRATION NUMBER CRD42021247148.
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Affiliation(s)
- Kadri Tamme
- Department of Anaesthesiology and Intensive Care, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Anaesthesiology and Intensive Care Clinic, Tartu University Hospital, Tartu, Estonia
| | - Annika Reintam Blaser
- Department of Anaesthesiology and Intensive Care, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Department of Intensive Care Medicine, Luzerner Kantonsspital, Luzern, Luzern, Switzerland
| | - Kaja-Triin Laisaar
- Department of Epidemiology and Biostatistics, Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia
| | - Merli Mändul
- Department of Anaesthesiology and Intensive Care, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Department of Statistics, Institute of Mathematics and Statistics, University of Tartu, Tartu, Estonia
| | - Jaak Kals
- Department of Surgery, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Surgery Clinic, Tartu University Hospital, Tartu, Estonia
| | - Alastair Forbes
- Department of Internal Medicine, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Internal Medicine Clinic, Tartu University Hospital, Tartu, Estonia
| | - Olga Kiss
- Anaesthesiology and Intensive Care Clinic, Tartu University Hospital, Tartu, Estonia
| | - Stefan Acosta
- Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Martin Bjørck
- Department of Surgery, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Joel Starkopf
- Department of Anaesthesiology and Intensive Care, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Anaesthesiology and Intensive Care Clinic, Tartu University Hospital, Tartu, Estonia
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22
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Bala M, Catena F, Kashuk J, De Simone B, Gomes CA, Weber D, Sartelli M, Coccolini F, Kluger Y, Abu-Zidan FM, Picetti E, Ansaloni L, Augustin G, Biffl WL, Ceresoli M, Chiara O, Chiarugi M, Coimbra R, Cui Y, Damaskos D, Di Saverio S, Galante JM, Khokha V, Kirkpatrick AW, Inaba K, Leppäniemi A, Litvin A, Peitzman AB, Shelat VG, Sugrue M, Tolonen M, Rizoli S, Sall I, Beka SG, Di Carlo I, Ten Broek R, Mircea C, Tebala G, Pisano M, van Goor H, Maier RV, Jeekel H, Civil I, Hecker A, Tan E, Soreide K, Lee MJ, Wani I, Bonavina L, Malangoni MA, Koike K, Velmahos GC, Fraga GP, Fette A, de'Angelis N, Balogh ZJ, Scalea TM, Sganga G, Kelly MD, Khan J, Stahel PF, Moore EE. Acute mesenteric ischemia: updated guidelines of the World Society of Emergency Surgery. World J Emerg Surg 2022; 17:54. [PMID: 36261857 PMCID: PMC9580452 DOI: 10.1186/s13017-022-00443-x] [Citation(s) in RCA: 78] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 06/17/2022] [Indexed: 02/08/2023] Open
Abstract
Acute mesenteric ischemia (AMI) is a group of diseases characterized by an interruption of the blood supply to varying portions of the intestine, leading to ischemia and secondary inflammatory changes. If untreated, this process may progress to life-threatening intestinal necrosis. The incidence is low, estimated at 0.09-0.2% of all acute surgical admissions, but increases with age. Although the entity is an uncommon cause of abdominal pain, diligence is required because if untreated, mortality remains in the range of 50%. Early diagnosis and timely surgical intervention are the cornerstones of modern treatment to reduce the high mortality associated with this entity. The advent of endovascular approaches in parallel with modern imaging techniques is evolving and provides new treatment options. Lastly, a focused multidisciplinary approach based on early diagnosis and individualized treatment is essential. Thus, we believe that updated guidelines from World Society of Emergency Surgery are warranted, in order to provide the most recent and practical recommendations for diagnosis and treatment of AMI.
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Affiliation(s)
- Miklosh Bala
- Director of Acute Care Surgery and Trauma Unit, Department of General Surgery, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem Kiriat Hadassah, POB 12000, 91120, Jerusalem, Israel.
| | - Fausto Catena
- General and Emergency Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Jeffry Kashuk
- Tel Aviv Sackler School of Medicine, Tel Aviv, Israel
| | - Belinda De Simone
- Department of General, Digestive and Metabolic Minimally Invasive Surgery, Centre Hospitalier Intercommunal De Poissy/St Germain en Laye, Poissy, France
| | - Carlos Augusto Gomes
- Department of Surgery, Faculdade de Ciências Médicas e da Saúde de Juiz de Fora, Hospital Universitário Terezinha de Jesus, Juiz de Fora, Brazil
| | - Dieter Weber
- Department of General Surgery, Royal Perth Hospital, The University of Western Australia, Perth, Australia
| | | | - Federico Coccolini
- Department of General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Yoram Kluger
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Parma, Parma, Italy
| | - Luca Ansaloni
- Department of Surgery, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Goran Augustin
- Department of Surgery, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Walter L Biffl
- Division of Trauma/Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, CA, USA
| | - Marco Ceresoli
- Emergency and General Surgery Department, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Osvaldo Chiara
- Emergency Department, Niguarda Ca'Granda Hospital, Milan, Italy
| | - Massimo Chiarugi
- Department of General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Raul Coimbra
- CECORC Research Center, Riverside University Health System, Loma Linda University, Loma Linda, USA
| | - Yunfeng Cui
- Department of Surgery, Nankai Clinical School of Medicine, Tianjin Nankai Hospital, Tianjin Medical University, Tianjin, China
| | | | - Salomone Di Saverio
- General Surgery Department Hospital of San Benedetto del Tronto, Marche region, Italy
| | - Joseph M Galante
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of California Davis, Sacramento, CA, USA
| | - Vladimir Khokha
- Department of Emergency Surgery, City Hospital, Mozyr, Belarus
| | - Andrew W Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, AB, Canada
| | - Kenji Inaba
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Ari Leppäniemi
- Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Andrey Litvin
- Department of Surgical Disciplines, Regional Clinical Hospital, Immanuel Kant Baltic Federal University, Kaliningrad, Russia
| | - Andrew B Peitzman
- Department of Surgery, University of Pittsburgh School of Medicine, UPMC-Presbyterian, Pittsburgh, USA
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Novena, Singapore
| | - Michael Sugrue
- Donegal Clinical Research Academy Emergency Surgery Outcome Project, Letterkenny University Hospital, Donegal, Ireland
| | - Matti Tolonen
- Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Sandro Rizoli
- Surgery Department, Section of Trauma Surgery, Hamad General Hospital (HGH), Doha, Qatar
| | - Ibrahima Sall
- General Surgery Department, Military Teaching Hospital, Dakar, Senegal
| | | | - Isidoro Di Carlo
- Department of Surgical Sciences and Advanced Technologies, General Surgery Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Richard Ten Broek
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Chirika Mircea
- Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Giovanni Tebala
- Department of Digestive and Emergency Surgery, S.Maria Hospital Trust, Terni, Italy
| | - Michele Pisano
- General and Emergency Surgery, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Harry van Goor
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ronald V Maier
- Harborview Medical Center, University of Washington School of Medicine, Seattle, WA, USA
| | - Hans Jeekel
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Ian Civil
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Andreas Hecker
- Emergency Medicine Department of General and Thoracic Surgery, University Hospital of Giessen, Giessen, Germany
| | - Edward Tan
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Kjetil Soreide
- HPB Unit, Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Matthew J Lee
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | | | - Luigi Bonavina
- Department of Surgery, IRCCS Policlinico San Donato, University of Milano, Milano, Italy
| | - Mark A Malangoni
- Case Western Reserve University School of Medicine, Cleveland, USA
| | | | - George C Velmahos
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, PA, USA
| | - Gustavo P Fraga
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas (Unicamp), Campinas, Brazil
| | - Andreas Fette
- Pediatric Surgery, Children's Care Center, SRH Klinikum Suhl, Suhl, Thueringen, Germany
| | - Nicola de'Angelis
- Unit of Digestive and HPB Surgery, Faculty of Medicine, University of Paris, Paris, France
| | - Zsolt J Balogh
- John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia
| | - Thomas M Scalea
- Cowley Shock Trauma Center at the University of Maryland, Baltimore, MD, USA
| | - Gabriele Sganga
- Emergency Surgery and Trauma, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Michael D Kelly
- Department of General Surgery, Albury Hospital, Albury, Australia
| | - Jim Khan
- University of Portsmouth, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Philip F Stahel
- College of Osteopathic Medicine, Rocky Vista University, Parker, CO, USA
| | - Ernest E Moore
- Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO, USA
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Sumbal R, Ali Baig MM, Sumbal A. Predictors of Mortality in Acute Mesenteric Ischemia: A Systematic Review and Meta-Analysis. J Surg Res 2022; 275:72-86. [DOI: 10.1016/j.jss.2022.01.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 12/24/2021] [Accepted: 01/27/2022] [Indexed: 12/12/2022]
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Conway AM, Carroccio A, Rosen RJ. Acute and Chronic Mesenteric Ischemia. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch78] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Sheng M, Gong W, Zhao K, Li W, Qian A, Chang L, Wu Y, Chen Q, Chen Z, Yang X, Zhong F, Xing C. Nonocclusive mesenteric ischemia caused by type B aortic dissection: a case report. BMC Surg 2022; 22:214. [PMID: 35658940 PMCID: PMC9166441 DOI: 10.1186/s12893-022-01656-2] [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: 01/17/2022] [Accepted: 05/18/2022] [Indexed: 11/22/2022] Open
Abstract
Background Nonocclusive mesenteric ischemia (NOMI) is defined as acute intestinal ischemia because of decreased blood flow in mesenteric vessels. Only a few cases of NOMI that occur secondary to aortic dissection (AD) have been reported, resulting in the lack of sufficient knowledge of diagnosis and treatment. Case presentation We aimed to report a case of NOMI caused by type B Aortic Dissection. A 26-year-old male patient was transferred to our hospital with the diagnose of NOMI and aortic dissection in April 2018. The abdominal computed tomography (CT) assists the diagnosis of paralytic intestinal obstruction, intestinal wall pneumatosis, and perforation. Emergency laparotomy revealed that the bowel wall supplied by the superior mesenteric artery (SMA) was pale with the palpable but weak pulsation of the parietal artery. The small intestine was extremely dilated with a paper-thin, fragile wall that was ruptured easily and could not be sutured. In this case, extensive resection and segmental drainage were done. Postoperatively, the digestive tract was reconstructed. However, the patient suffered from iron deficiency anemia and short bowel syndrome eight months later, and unfortunately died from long-term complications. Conclusion Aortic dissection leads to continuous decrease in blood pressure and blood flow to the SMA, considering as a predisposing factor for NOMI. During the treatment, extensive resection and segmental drainage are the optimal surgical strategy, which can make benefit in emergencies especially.
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Graber SD, Sinz S, Turina M, Alkadhi H. Pneumatosis intestinalis in abdominal CT: predictors of short-term mortality in patients with clinical suspicion of mesenteric ischemia. Abdom Radiol (NY) 2022; 47:1625-1635. [PMID: 35050403 PMCID: PMC9038897 DOI: 10.1007/s00261-022-03410-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 01/03/2022] [Accepted: 01/05/2022] [Indexed: 11/26/2022]
Abstract
Purpose Pneumatosis intestinalis (PI) in the bowel wall demonstrated in computed tomography (CT) of the abdomen is unspecific and its prognostic relevance remains poorly understood. The purpose of this study was to identify predictors of short-term mortality in patients with suspected mesenteric ischemia who were referred to abdominal CT and showed PI. Methods In this retrospective, IRB-approved, single-centre study, CT scans and electronic medical records of 540 patients who were referred to abdominal CT with clinical suspicion of mesenteric ischemia were analysed. 109/540 (20%) patients (median age 66 years, 39 females) showed PI. CT findings were correlated with surgical and pathology reports (if available), with clinical and laboratory findings, and with patient history. Short-term outcome was defined as survival within 30 days after CT. Results PI was found in the stomach (n = 6), small bowel (n = 65), and colon (n = 85). Further gas was found in mesenteric (n = 54), portal (n = 19) and intrahepatic veins (n = 36). Multivariate analysis revealed that PI in the colon [odds ratio (OR) 2.86], elevated blood AST levels (OR 3.00), and presence of perfusion inhomogeneities in other abdominal organs (OR 3.38) were independent predictors of short-term mortality. Surgery had a positive effect on mortality (88% lower likelihood of mortality), similar to the presence of abdominal pain (65% lower likelihood). Conclusions Our study suggests that in patients referred for abdominal CT with clinical suspicion of mesenteric ischemia, location of PI in the colon, elevation of blood AST, and presence of perfusion inhomogeneities in parenchymatous organs are predictors of short-term mortality. Graphical abstract ![]()
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Affiliation(s)
- Simon D Graber
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Raemistr. 100, 8091, Zürich, Switzerland
| | - Stefanie Sinz
- Department of Visceral Surgery, University Hospital Zurich, University of Zurich, Zürich, Switzerland
| | - Matthias Turina
- Department of Visceral Surgery, University Hospital Zurich, University of Zurich, Zürich, Switzerland
| | - Hatem Alkadhi
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Raemistr. 100, 8091, Zürich, Switzerland.
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Computed-tomography angiography in arterial acute intestinal ischemia: prognostic interest of vascular semiology. Abdom Radiol (NY) 2022; 47:1614-1624. [PMID: 34687324 DOI: 10.1007/s00261-021-03312-4] [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: 03/27/2021] [Revised: 10/04/2021] [Accepted: 10/04/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE To investigate vascular features on abdominal Computed-Tomography Angiography (CTA) correlated with 48-h mortality in patients who underwent arterial acute intestinal ischemia (AAII) surgery. The secondary objective was to create a prognostic score on the 48-h mortality after surgery, based on the most relevant signs. METHOD We included 104 patients who underwent surgery for acute mesenteric ischemia. 2 radiologists retrospectively blind reviewed the preoperative CTA scans. They used a standardized analysis grid for the arterial and venous vascular signs described in angiography. When signs were present, the affected abdominal quadrant was specified in coronal reconstruction. Each sign was analyzed for 48-h mortality on CTA. A score based on signs correlated with early mortality was developed and evaluated by ROC curve analysis. RESULTS 22 patients died within 48 h. The number of superior mesenteric artery (SMA) branches was significantly reduced in deceased patients (p = 0.006). Other prognostic factors associated with 48-h mortality were decreased venous return in area number 1 corresponding to right colic flexure, proximal half of the transverse colon, proximal ileum (p = 0.04) and decreased venous return in more than 2 zones (p = 0.01). The weighted AAII48 score included 1 protective clinical item and 5 radiological items. The area under the ROC curve was 0.784 with, for a 6-point threshold value, a sensitivity of 68% and a specificity of 77%. The intraclass correlation coefficient for interobserver reproducibility of the score was 0.81 [95% CI 0.73; 0.87]. CONCLUSION Three vascular signs on CTA were found to be prognostic factors for early mortality: SMA branches number ≤ 5 (p = 0.006), decreased venous return in area 1 (p = 0.04), and > 2 areas of decreased venous return (p = 0.01). They were incorporated into the AAII48 score. This score could help to identify patients at risk and to adapt subsequent management.
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28
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Role of Platelet to Lymphocyte Ratio and Red Cell Distribution Width in Predicting Postoperative Complications in Patients with Acute Mesenteric Ischemia. Ann Vasc Surg 2022; 84:298-304. [PMID: 35247535 DOI: 10.1016/j.avsg.2022.01.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 12/20/2021] [Accepted: 01/26/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND The predictive values of the platelet to lymphocyte ratio (PLR) and red cell distribution width (RDW) have been demonstrated in different types of abdominal surgery. The aim of this study was to investigate the interest of the preoperative PLR and RDW as predictors of 30-day postoperative complications in patients with acute mesenteric ischemia (AMI). METHODS Clinical data of 105 AMI patients were retrospectively reviewed. Postoperative complications were evaluated by the Clavien-Dindo classification. The cutoff values for neutrophil to lymphocyte ratio (NLR), PLR, and RDW were determined by receiver operating characteristic curves. Univariate and multivariate analyses evaluating the risk factors for postoperative complications were performed. RESULTS In the univariate analyses, advanced age, female, anemia, high white blood cell (WBC), high PLR, high NLR, high RDW, Charlson comorbidity index (CCI) score ≥2, and bowel resection were associated with the postoperative complications. A multivariable analysis revealed that advanced age, high PLR, high RDW, and bowel resection were independent predictors of postoperative complications. CONCLUSIONS The PLR and RDW might play important roles in evaluation of the risk of postoperative complications in AMI patients. The preoperative PLR and RDW are simple and useful predictors of postoperative complications in AMI patients.
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Surgical and endovascular revascularization of chronic mesenteric ischemia. Langenbecks Arch Surg 2022; 407:2085-2094. [PMID: 35182180 PMCID: PMC9399053 DOI: 10.1007/s00423-022-02462-3] [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: 02/07/2021] [Accepted: 02/08/2022] [Indexed: 11/05/2022]
Abstract
Purpose Chronic mesenteric ischemia (CMI) is a rare but life-threatening disease. This study reviewed outcomes in patients treated surgically for CMI by open treatment (OT) and endovascular treatment (ET), analyzing risk factors for endovascular failure. Methods Clinical data for 36 patients treated for CMI from 2007 to 2017 were retrospectively analyzed. The study’s primary endpoint was symptom-free survival. The secondary endpoint was the primary technical success for endovascular and open surgical treatments. Risk factors for endovascular failure were identified by using univariate analysis. Results Patients were analyzed as treated: 21 patients (58.3%) in the ET and 15 (41.6%) in the OT group. Overall, 20 patients (56%) presented with abdominal angina, 9 (25%) with rest pain, and 7 (19%) without symptoms. An ET was initially attempted in 31 patients (86.1%). The conversion rate from ET to OT was 32.3%, which resulted in a primary technical success of 67.6% in ET and 100% in OT. Six patients from the ET group (19.3%) required surgical revision due to restenosis. One-year (OT 91.6% vs. ET 96.8%; n.s.) and three-year primary patency (OT 91.6% vs. ET 80.6%; n.s.) as well as 3-year symptom-free survival did not differ between the groups (OT 62.5% vs. ET 69.4%; n.s). Overall, in-hospital mortality was 2.8% (n = 1), which was not statistically different between the groups (OT 6% vs. ET 0%; n.s.). High-grade stenosis of the superior mesenteric artery tended to be associated with higher technical failure (P = 0.06). Conclusions ET showed a comparable perioperative outcome with higher technical failure. OT was distinguished by excellent early and late technical success.
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Acute-On-Chronic Mesenteric Ischemia: The Use of Fluorescence Guidance to Diagnose a Nonsurvivable Injury. Case Rep Surg 2022; 2022:5459774. [PMID: 35178268 PMCID: PMC8844395 DOI: 10.1155/2022/5459774] [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: 10/09/2021] [Accepted: 01/25/2022] [Indexed: 11/17/2022] Open
Abstract
Mesenteric ischemia (MI) is a condition characterized by compromised intestinal perfusion, leading to varied patterns of bowel hypoxia that requires prompt diagnosis and surgical intervention. Here, we report a case in which indocyanine green (ICG) was utilized to evaluate intestinal blood flow in a patient with acute-on-chronic MI. A 65-year-old underweight female presented with abdominal pain out of proportion to exam and was found to have diffuse aortic atherosclerotic disease with chronic occlusion of both superior and inferior mesenteric arteries with distal reconstitution. After multidisciplinary evaluation, elective treatment with vascular surgery was planned; however, on day three of her hospitalization, the patient’s abdominal pain acutely worsened. She was taken to the OR for exploratory laparotomy. Under white light, the small bowel from the ligament of Treitz (LOT) to the terminal ileum and the large bowel from the cecum to the splenic flexure appeared ischemic with patchy areas of necrosis. Fluorescence angiography was then performed; injection of indocyanine green (ICG) dye and imaging with the SPY-PHI near-infrared camera system demonstrated appropriate blood flow into the bowel mesentery, with complete absence of flow into the bowel mucosal surface from the LOT to the splenic flexure, confirming irreversible bowel necrosis. Introduction of ICG intraoperatively decreased the uncertainty associated with white light assessment of bowel viability, leading to a definitive intraoperative diagnosis and clear plan of care. The use of fluorescence guidance to diagnose fulminant small and large bowel necrosis prevented the surgical team from having to perform multiple takebacks to the operating room in the setting of a nonsurvivable injury. Had the surgical team relied on the white light appearance of the bowel, they would not have been able to diagnose the true extent of bowel demise. The patient was placed on comfort care for this devastating nonsurvivable injury.
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Pankratov AA, Snitsar AV, Vasilchenko MI, Zelenin DA, Matkov IV, Varfalomeev SI, Izrailov RE, Perekhodov SN. [CT angiography and endovascular treatment in acute mesenteric ischemia]. Khirurgiia (Mosk) 2022:50-55. [PMID: 35289549 DOI: 10.17116/hirurgia202203150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To optimize the treatment strategy for acute mesenteric ischemia (AMI). MATERIAL AND METHODS The study included 43 patients aged 76.4±10.3 years. CT angiography and endovascular repair of mesenteric vessels underlie the new treatment approach. RESULTS CT angiography according to the established criteria was performed in 31 patients with suspected AMI throughout 1 year. Sensitivity was 90.0%, specificity - 100%, accuracy - 95%. Endovascular interventions were applied in 13 patients (successful in 8 cases and unsuccessful in 5 patients). Mortality rate was 37.5%. Fifteen patients with clinical signs of peritonitis or after previous unsuccessful interventional revascularization underwent open surgery. Mortality rate was 86.7%. CONCLUSION CT angiography is valuable to diagnose AMI at the stage of reversible changes in bowel wall in some cases. Endovascular revascularization as the first-line treatment has certain prospects.
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Affiliation(s)
- A A Pankratov
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
- Demikhov Moscow City Clinical Hospital, Moscow, Russia
| | - A V Snitsar
- Demikhov Moscow City Clinical Hospital, Moscow, Russia
| | | | - D A Zelenin
- Demikhov Moscow City Clinical Hospital, Moscow, Russia
| | - I V Matkov
- Demikhov Moscow City Clinical Hospital, Moscow, Russia
| | | | - R E Izrailov
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
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Liu WJ, Zhong J, Luo JC, Zheng JL, Ma JF, Ju MJ, Su Y, Liu K, Tu GW, Luo Z. Early Enteral Nutrition Tolerance in Patients With Cardiogenic Shock Requiring Mechanical Circulatory Support. Front Med (Lausanne) 2021; 8:765424. [PMID: 34938748 PMCID: PMC8685379 DOI: 10.3389/fmed.2021.765424] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 10/04/2021] [Indexed: 02/05/2023] Open
Abstract
Background: Enteral nutrition (EN) is recommended within the first 24-48 h for patients with hemodynamic stability, following admission to an intensive care unit (ICU). However, for patients with approximate stable hemodynamics requiring mechanical circulatory support and vasoactive drugs, the application of early EN remains controversial. We sought to evaluate the tolerance of early EN in patients with cardiogenic shock who required vasoactive drugs and mechanical circulatory support after cardiac surgery. Methods: This single-center, prospective observational study included patients with cardiogenic shock, requiring vasoactive drugs and mechanical circulatory support after cardiac surgery, undergoing EN. The primary endpoint was EN tolerance and secondary endpoints were mortality, length of mechanical ventilation, and length of ICU stay. Results: From February 2019 to December 2020, 59 patients were enrolled, of which 25 (42.37%) developed intolerance within 3 days of starting EN. Patients in the EN intolerant group had a longer median length of mechanical ventilation (380 vs. 128 h, p = 0.006), a longer median ICU stay (20 vs. 11.5 days, p = 0.03), and a higher proportion of bloodstream infections (44 vs. 14.71%, p = 0.018). The median EN calorie levels for all patients in the first 3 days of EN were 4.00, 4.13, and 4.28 kcal/kg/day, respectively. Median protein intake levels of EN in the first 3 days were 0.18, 0.17, and 0.17 g/kg/day, respectively. No significant difference was observed in the median dose of vasoactive drugs between the groups (0.035 vs. 0.05 μg/kg/min, p = 0.306). Conclusions: Patients with cardiogenic shock after cardiac surgery had a high proportion of early EN intolerance, and patients with EN intolerance had a worse prognosis, but no significant correlation was identified between EN tolerance and the dose of vasoactive drugs.
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Affiliation(s)
- Wen-jun Liu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jun Zhong
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jing-chao Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ji-li Zheng
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jie-fei Ma
- Department of Critical Care Medicine, Xiamen Branch, Zhongshan Hospital, Fudan University, Xiamen, China
| | - Min-jie Ju
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ying Su
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Kai Liu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Guo-wei Tu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhe Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
- Department of Critical Care Medicine, Xiamen Branch, Zhongshan Hospital, Fudan University, Xiamen, China
- Shanghai Key Lab of Pulmonary Inflammation and Injury, Fudan University, Shanghai, China
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Naazar AA, Omair A, Chu SH, Keane KG, Weber DG. A Shifting Trend Towards Endovascular Intervention in the Treatment of Acute Mesenteric Ischemia. Cureus 2021; 13:e18544. [PMID: 34754689 PMCID: PMC8570678 DOI: 10.7759/cureus.18544] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/06/2021] [Indexed: 01/16/2023] Open
Abstract
Background Acute mesenteric ischemia (AMI) is a vascular emergency with a quite low incidence, but it is associated with disproportionately more severe morbidity and mortality. The aim of this study was to assess the current trend in the treatment of AMI and to see if endovascular intervention is an effective treatment modality in the selected group of patients. Methods A retrospective review of patients admitted with AMI between 2007 and 2018 was performed. Outcome measures were length of stay (LOS) at hospital and intensive care unit (ICU), and post-treatment mortality. Results A total of 98 patients with AMI were admitted during the study period. Patients undergoing endovascular treatment compared with surgery were younger (62.9 ± 13.7 years vs. 69.5 ± 12.8 years; p = 0.01). Shorter LOS in hospital and ICU was observed for those treated with endovascular approach (6.8 ± 3.4 and 3.25 ± 0.5 days) compared to the surgical group (25 ± 8.6 and 12.8 ± 26.8 days; p < 0.001). Out of 39 patients requiring ICU admission, 48.7% were surgically treated and 10.2% underwent endovascular intervention (p < 0.001). Mortality associated with surgery was 30.6% compared to only 6.6% with endovascular intervention (p < 0.001). Between 2007 and 2012, only one patient underwent endovascular intervention and 20 underwent surgery compared to 14 patients treated with endovascular approach and 16 with surgery between 2013 and 2018. Conclusion In this non-randomized, retrospective case series, patients with endovascular treatment fared clinically better and the intervention was found to be safe and feasible in the selected group of patients. We suggest a preference for this modality where possible. At our hospital, a trend favoring this approach is apparent during the last six years.
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Affiliation(s)
- Ali A Naazar
- General Surgery, Royal Perth Hospital, Perth, AUS
| | - Ahmad Omair
- Pathology, College of Science & Health Professions, King Saud bin Abdulaziz University for Health Sciences & King Abdullah International Medical Research Center, Riyadh, SAU
| | - Samuel H Chu
- General Surgery, Royal Perth Hospital, Perth, AUS
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The role of adropin, HIF-1α and apelin biomarkers in the diagnosis of acute mesentaric ischemia. Am J Emerg Med 2021; 51:223-227. [PMID: 34775196 DOI: 10.1016/j.ajem.2021.10.058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 10/25/2021] [Accepted: 10/28/2021] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE The absence of a specific biomarker for acute mesenteric ischemia diagnosis results in a delay in diagnosis and treatment, as well as a high mortality rate. The current research examined whether the proteins adropin, HIF-1α, and apelin may be used to help in the early detection of acute mesenteric ischemia. MATERIALS AND METHODS A total of 20 patients with acute mesenteric ischemia, 20 patients with abdominal pain, and 20 healthy controls were included in the study. The levels of adropin, HIF-1, and apelin in the serum were determined using the ELISA method. RESULTS Adropin concentrations were significantly higher in the acute mesenteric ischemia group than in the abdominal pain and healthy control groups (p < 0.05). HIF-1α levels were considerably greater in patients with acute mesenteric ischemia compared to both the abdominal pain group and the healthy control group (p < 0.05). There was no difference in apelin levels between the acute mesenteric ischemia and abdominal pain groups (p > 0.05). HIF-1α was found to be moderate (AUC: 0.705) and adropin was found to be a weak biomarker (AUC: 0.692) in the ROC analysis for acute mesenteric ischemia. CONCLUSION In this study of 20 patients with acute mesenteric ischemia, we found adropin and HIF-1α levels to be increased compared to patients with abdominal pain who did not have acute mesenteric ischemia.
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Stewart AS, Schaaf CR, Luff JA, Freund JM, Becker TC, Tufts SR, Robertson JB, Gonzalez LM. HOPX + injury-resistant intestinal stem cells drive epithelial recovery after severe intestinal ischemia. Am J Physiol Gastrointest Liver Physiol 2021; 321:G588-G602. [PMID: 34549599 PMCID: PMC8616590 DOI: 10.1152/ajpgi.00165.2021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Intestinal ischemia is a life-threatening emergency with mortality rates of 50%-80% due to epithelial cell death and resultant barrier loss. Loss of the epithelial barrier occurs in conditions including intestinal volvulus and neonatal necrotizing enterocolitis. Survival depends on effective epithelial repair; crypt-based intestinal epithelial stem cells (ISCs) are the source of epithelial renewal in homeostasis and after injury. Two ISC populations have been described: 1) active ISC [aISC; highly proliferative; leucine-rich-repeat-containing G protein-coupled receptor 5 (LGR5+)-positive or sex-determining region Y-box 9 -antigen Ki67-positive (SOX9+Ki67+)] and 2) reserve ISC [rISC; less proliferative; homeodomain-only protein X positive (HOPX+)]. The contributions of these ISCs have been evaluated both in vivo and in vitro using a porcine model of mesenteric vascular occlusion to understand mechanisms that modulate ISC recovery responses following ischemic injury. In our previously published work, we observed that rISC conversion to an activated state was associated with decreased HOPX expression during in vitro recovery. In the present study, we wanted to evaluate the direct role of HOPX on cellular proliferation during recovery after injury. Our data demonstrated that during early in vivo recovery, injury-resistant HOPX+ cells maintain quiescence. Subsequent early regeneration within the intestinal crypt occurs around 2 days after injury, a period in which HOPX expression decreased. When HOPX was silenced in vitro, cellular proliferation of injured cells was promoted during recovery. This suggests that HOPX may serve a functional role in ISC-mediated regeneration after injury and could be a target to control ISC proliferation.NEW & NOTEWORTHY This paper supports that rISCs are resistant to ischemic injury and likely an important source of cellular renewal following near-complete epithelial loss. Furthermore, we have evidence that HOPX controls ISC activity state and may be a critical signaling pathway during ISC-mediated repair. Finally, we use multiple novel methods to evaluate ISCs in a translationally relevant large animal model of severe intestinal injury and provide evidence for the potential role of rISCs as therapeutic targets.
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Affiliation(s)
- Amy Stieler Stewart
- 1College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina
| | - Cecilia Renee Schaaf
- 1College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina
| | - Jennifer A. Luff
- 1College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina
| | - John M. Freund
- 1College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina
| | - Thomas C. Becker
- 2Duke Molecular Physiology Institute and Sarah W. Stedman Nutrition and Metabolism Center, Duke University Medical Center, Durham, North Carolina
| | - Sara R. Tufts
- 1College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina
| | - James B. Robertson
- 1College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina
| | - Liara M. Gonzalez
- 1College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina
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Tran LM, Andraska E, Haga L, Sridharan N, Chaer RA, Eslami MH. Hospital-based Delays to Revascularization Increase Risk of Post-operative Mortality and Short Bowel Syndrome in Acute Mesenteric Ischemia. J Vasc Surg 2021; 75:1323-1333.e3. [PMID: 34634418 DOI: 10.1016/j.jvs.2021.09.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 09/13/2021] [Indexed: 01/16/2023]
Abstract
OBJECTIVE Acute mesenteric ischemia (AMI) is a surgical emergency for which delays in treatment have been closely associated with high morbidity and mortality. Although the duration of ischemia as a determinant of outcomes for AMI is well known, the objective of this study was to identify hospital-based determinants of delayed revascularization and their effects on post-operative morbidity and mortality in AMI. METHODS All patients who underwent any surgery for acute mesenteric ischemia (AMI) from a multi-center hospital system between 2010 and 2020 were divided into two groups based on timeliness of mesenteric revascularization after presentation. Early revascularization (ER) was defined as having both vascular consultation ≤ 12 hours of presentation and vascular surgery performed at the patient's initial operation. Delayed revascularization (DR) was defined as having either delays to vascular consultation or vascular surgery. A retrospective review of demographic and post-operative data was performed. Effect of DR on major post-operative outcomes including 30-day and 2-year mortality, total length of bowel resection, and development of short bowel syndrome were analyzed. Effects of delayed vascular consultation alone, delayed vascular surgery alone, no revascularization during admission, and admitting service on outcomes were also examined on sub-group analyses. RESULTS A total of 212 patients were analyzed. 99 patients received ER while the remaining 113 patients experienced a delay to revascularization after hospital presentation. Among the DR group, 55 (25.9%) patients had delayed vascular consultation while vascular surgery was deferred until after the initial operation in 37 (17.4%) patients. 51 (24.0%) patients were never revascularized during admission. DR was a significant predictor of 30-day (odds ratio (OR) 2.09, 95% confidence interval (CI) [1.4-4.9], P=0.03) and 2-year mortality (hazard ratio (HR) 1.55, CI [1.0-2.3], P= 0.04). DR was also independently associated with increased bowel resection length (OR 7.47, P <0.01) and post-operative short bowel syndrome (OR 2.4, P=0.03) on multivariate analyses. When examined separately on sub-group analysis, both delayed vascular consultation (OR 3.38, P=0.03) and vascular surgery (OR 4.31, P <0.01) independently increased risk of 30-day mortality. Hospital discharge after AMI without mesenteric revascularization was associated with increased risk of short bowel syndrome (OR 2.94, P <0.01) and late mortality (HR 1.60, P=0.04). CONCLUSIONS Delayed vascular consultation and vascular surgery are both significant hospital-based determinants of post-operative mortality and short bowel syndrome in AMI. Timing-based management protocols which emphasize routine evaluation by a vascular surgeon and early, definitive mesenteric revascularization should be established and widely adopted for all patients with clinically suspected AMI at presentation.
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Affiliation(s)
- Lillian M Tran
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Elizabeth Andraska
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Lindsey Haga
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Natalie Sridharan
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Rabih A Chaer
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Mohammad H Eslami
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pa.
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Abstract
Ischemic bowel disease (ISBODI) includes colon ischemia, acute mesenteric ischemia (AMI) and chronic mesenteric ischemia (CMI). Epidemiologically, colon ischemia is the most common type followed by AMI and CMI. There are various risk factors for the development of ISBODI. Abdominal pain is the common presenting symptom of each type. High clinical suspicion is essential in ordering appropriate tests. Imaging studies and colonoscopy with biopsy are the main diagnostic tests. Treatment varies from conservative measures to surgical resection and revascularization. Involvement of multidisciplinary team is essential in managing ISBODI. Although open surgery with revascularization plays an important role, recently there is an increasing interest in percutaneous endovascular treatment.
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Affiliation(s)
- Monjur Ahmed
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, PA 19107, United States
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Chaouch N, Zagzoog MM. Antegrade revascularization of the three mesenteric vessels to treat chronic mesenteric ischemia. J Surg Case Rep 2021; 2021:rjab328. [PMID: 34377433 PMCID: PMC8341690 DOI: 10.1093/jscr/rjab328] [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: 05/22/2021] [Revised: 07/07/2021] [Accepted: 07/07/2021] [Indexed: 11/18/2022] Open
Abstract
Chronic mesenteric ischemia is a serious vascular disease that progresses with acute mesenteric ischemia, along with high mortality. Elective intervention has been shown to prevent this progression and improve symptoms. Controversy remains about whether antegrade or retrograde mesenteric bypass has better outcomes and whether restoration of flow to a single vessel versus multiple mesenteric vessels should be performed. This study reports on our experience using an antegrade prosthetic bypass graft to treat chronic occlusions of the celiac trunk, superior mesenteric artery, and inferior mesenteric artery at their origins, all of which result in visceral ischemia.
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Affiliation(s)
- Nazih Chaouch
- Service of Vascular and Endovascular Surgery, Rene Dubos Hospital Center, Pontoise, France
| | - Mohammad M Zagzoog
- Service of Vascular and Endovascular Surgery, University of Sorbonne, Paris, France
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Hou L, Wang T, Wang J, Zhao J, Yuan D. Outcomes of different acute mesenteric ischemia therapies in the last 20 years: A meta-analysis and systematic review. Vascular 2021; 30:669-680. [PMID: 34154466 DOI: 10.1177/17085381211024503] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Acute mesenteric ischemia is a disease with high morbidity and mortality, and it is traditionally treated with open surgery. Endovascular therapy and hybrid techniques are alternative treatments that are also currently available. We performed a meta-analysis to evaluate the outcomes of the different treatment approaches in the last 20 years. METHODS Studies on acute mesenteric ischemia that were indexed in PubMed, Embase, and MEDLINE databases (from January 1, 2000, to April 1, 2021) were reviewed. All related retrospective observational studies and case series were included. A random-effects model was used to calculate pooled estimates, and the results were reported as proportions and 95% confidence intervals (CIs). RESULTS In our study, a total of 2369 patients (in 39 studies) underwent endovascular, open surgery, or retrograde open mesenteric stenting. The pooled mortality estimates for open surgery, endovascular therapy, and retrograde open mesenteric stenting were 40% (95% CI, 0.33-0.47; I2 = 84%), 26% (95% CI, 0.19-0.33; I2 = 33%), and 32% (95% CI, 0.21-0.44; I2 = 26%), respectively. CONCLUSIONS The mortality associated with open surgical treatment, endovascular therapy, and retrograde open mesenteric stenting tend to be similar in the last 20 years.
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Affiliation(s)
- Li Hou
- West China School of Medicine, West China Hospital, 12530Sichuan University, Chengdu, China.,Department of Vascular Surgery, West China Hospital, 12530Sichuan University, Chengdu, China
| | - Tiehao Wang
- Department of Vascular Surgery, West China Hospital, 12530Sichuan University, Chengdu, China
| | - Jiarong Wang
- Department of Vascular Surgery, West China Hospital, 12530Sichuan University, Chengdu, China
| | - Jichun Zhao
- Department of Vascular Surgery, West China Hospital, 12530Sichuan University, Chengdu, China
| | - Ding Yuan
- Department of Vascular Surgery, West China Hospital, 12530Sichuan University, Chengdu, China
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Early Surgical Intervention Improves Survival in Acute Intestinal Ischemia in the Intensive Care Unit. BIOMED RESEARCH INTERNATIONAL 2021; 2021:6672591. [PMID: 34055998 PMCID: PMC8147527 DOI: 10.1155/2021/6672591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 05/10/2021] [Indexed: 11/18/2022]
Abstract
The study is aimed at assessing whether the early surgical intervention improves survival in acute mesenteric ischemia with septic shock. A retrospective study design was applied to review the charts of patients admitted to the intensive care unit. The data were collected through a review of the full patient chart including physician and nursing notes, pathology reports, intraoperative findings, CT findings, and endoscopy. The diagnosis of AMI for each patient was determined through clinical presentation/endoscopic visualization/laboratory results/radiographic imaging, surgical exam (tissue or visual) and/or autopsy. Death and survival were evaluated between short and long-time-interval for septic shock groups using the chi-square test followed by calculating the P value. Total survival among the surgery group was 60 patients (95.24%) compared to 3 (4.76%) survival among patients who did not have surgery. The time from the onset of a shock to the time of surgical incision was calculated. The mean time to surgery was 17.7 hours. Total 65 patients (29.52%) had surgery between 4 and 12 hours from the onset of hypotension. Survivals among this group of patients were 41.7% (n = 25). The survival difference was statistically significant than died patients with respect to the time of surgical intervention (P = <0.001). Early removal of ischemic bowel in patients with AII-related surgery has improved survival.
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Katano K, Yoshimitsu Y, Haba Y, Maeda T. Mild nonocclusive mesenteric ischemia associated with syncope. Clin J Gastroenterol 2021; 14:776-781. [PMID: 33682023 DOI: 10.1007/s12328-021-01379-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 02/26/2021] [Indexed: 11/30/2022]
Abstract
Nonocclusive mesenteric ischemia (NOMI) is a life-threatening disease caused by a reduction in mesenteric blood supply without vascular occlusion. Early diagnosis of NOMI is often difficult because there are no specific findings suggesting NOMI. Here, we report a rare case of a very elderly patient with mild NOMI caused by dehydration due to short-term reduced oral intake and associated with syncope. A 90-year-old man was admitted to our hospital with syncope and melena. The syncope was thought to be caused by orthostatic hypotension due to dehydration owing to reduced oral intake for approximately 24 h. Abdominal computed tomography (CT) revealed marked bowel wall thickening with mesenteric stranding in the ileum and ascending colon, dilated small intestine with thinned bowel wall, collapsed superior mesenteric vein, hemorrhagic ascites, and absence of obvious vascular occlusion in the mesenteric vessels. Abdominal symptoms, laboratory abnormalities, and CT findings improved gradually with the correction of dehydration. Therefore, we diagnosed our patient with mild NOMI. NOMI can be associated with syncope and can occur even with dehydration due to short-term reduced oral intake. When examining elderly patients with hypovolemic signs, such as syncope, who exhibit abdominal symptoms, clinicians must keep in mind the possibility of NOMI.
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Affiliation(s)
- Kaoru Katano
- Department of Surgery, Houju Memorial Hospital, 11-71 Midorigaoka, Nomi, Ishikawa, 923-1226, Japan.
| | - Yutaka Yoshimitsu
- Department of Surgery, Houju Memorial Hospital, 11-71 Midorigaoka, Nomi, Ishikawa, 923-1226, Japan
| | - Yusuke Haba
- Department of Surgery, Houju Memorial Hospital, 11-71 Midorigaoka, Nomi, Ishikawa, 923-1226, Japan
| | - Tsutomu Maeda
- Department of Surgery, Houju Memorial Hospital, 11-71 Midorigaoka, Nomi, Ishikawa, 923-1226, Japan
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The interplay between gastrointestinal and cardiovascular diseases: a narrative review focusing on the clinical perspective. Eur J Gastroenterol Hepatol 2021; 32:132-139. [PMID: 32516176 DOI: 10.1097/meg.0000000000001779] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Both cardiovascular and gastrointestinal disorders represent considerable health burden on community clinics and hospitals with overwhelming economic cost. An overlap in the occurrence of these disorders is encountered in daily practice. Both affect each other in bidirectional manner through several mechanisms including altered hemodynamics, systemic inflammation, bacterial overgrowth and interactions and adverse effects of medications. In addition, to the known overlap in the symptoms occurrence of upper gastrointestinal tract diseases and cardiovascular diseases (CVDs). Awareness of this interplay and its clinical manifestations optimizes patient management, and could prevent catastrophic consequences and even save lives. In this review, we highlighted the clinical aspects of this bidirectional association between gastrointestinal and CVDs aiming to shed light on this topic and improve patients' care.
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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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Pankratov AA, Perehodov SN, Zelenin DA, Izrailov RE, Matkov IV. [Is acute mesenteric ischemia incurable situation? The current state of the problem]. Khirurgiia (Mosk) 2020:105-110. [PMID: 33301263 DOI: 10.17116/hirurgia2020121105] [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: 01/19/2023]
Abstract
Mortality rates in acute mesenteric ischemia remain at an extremely high level for many decades. Early diagnosis and selection of the optimal method of revascularization are among the ways to optimize tactics. The diagnostic study of choice is CT angiography. Its active and systemic use can help to detect ischemia at the reversible stage. The article examines in detail the indications for the application of this diagnostic study. The question of preference for the revascularization method remains debatable. The arguments of proponents of open and endovascular interventions on mesenteric vessels are presented. Other, still unresolved tactical issues are also considered, such as indications for re-operations and application of the principles of damage control tactics.
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Affiliation(s)
- A A Pankratov
- Moscow State University of Medicine and Dentistry named after A.I. Evdokimov, Moscow, Russia.,City Clinical Hospital named after V.P. Demihov of the Moscow City Health Department, Moscow, Russia
| | - S N Perehodov
- City Clinical Hospital named after V.P. Demihov of the Moscow City Health Department, Moscow, Russia
| | - D A Zelenin
- City Clinical Hospital named after V.P. Demihov of the Moscow City Health Department, Moscow, Russia
| | - R E Izrailov
- Moscow State University of Medicine and Dentistry named after A.I. Evdokimov, Moscow, Russia
| | - I V Matkov
- City Clinical Hospital named after V.P. Demihov of the Moscow City Health Department, Moscow, Russia
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Wu W, Yang L, Zhou Z. Clinical Features and Factors Affecting Postoperative Mortality for Obstructive Acute Mesenteric Ischemia in China: A Hospital- Based Survey. Vasc Health Risk Manag 2020; 16:479-487. [PMID: 33268989 PMCID: PMC7701155 DOI: 10.2147/vhrm.s261167] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 11/09/2020] [Indexed: 02/05/2023] Open
Abstract
Purpose The study aimed to report the clinical manifestation and identify the risk factors for postoperative mortality in patients who were diagnosed with obstructive acute mesenteric ischemia (AMI) based on a survey of a hospital in western China. Patients and Methods We reviewed clinical data of 108 patients with obstructive AMI at West China Hospital, Sichuan University, from 2011 to 2017. Clinical characteristic was described and compared. Factors affecting postoperative survival were analyzed. Results A total of 108 obstructive AMI cases were included in this study, with an overall average age of 57.1 years, including 58 arterial occlusive mesenteric ischemia (AOMI) and 50 mesenteric venous thrombosis (MVT). AOMI patients were older and had a significantly higher frequency of these comorbidities, including heart disease, hypertension, and diabetes. In comparison, MVT had a significantly higher proportion of male patients and a higher frequency of liver disease. A total of 77 patients underwent laparotomy, and the 30-day postoperative mortality rate was 29.9%. Multivariate logistic regression analysis showed that the time interval from admission to surgery (adjust OR 1.19; 95% CI [1.07–1.34], P = 0.005), platelet count (adjust OR = 0.98; 95% CI [0.97–0.99], P = 0.008) and AOMI (adjust OR = 5.55; 95% CI [1.36–22.55], P = 0.017) were independent predictors of 30-day mortality after exploratory laparotomy for obstructive AMI. Further analysis of the 45 AOMI showed that the time interval from admission to surgery (adjustOR 1.22; 95% CI [1.01–1.47], P = 0.036) and platelet count (adjustOR = 0.98; 95% CI [0.97–0.99], P = 0.020) were independent risk factors for 30-day postoperative mortality of AOMI. Conclusion Early identification of AOMI, improving the efficiency of enhanced CT examination, strengthening doctor–patient communication, active laparotomy, and optimize platelet management may also help reduce the overall short-term mortality of obstructive AMI. Building the multidisciplinary team model of diagnostic imaging, vascular intervention, and surgical treatment to manage obstructive AMI may be urgently needed in western China.
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Affiliation(s)
- Wenhan Wu
- Institute of Digestive Surgery of Sichuan University and Department of Gastrointestinal Surgery, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, Sichuan, 610041, People's Republic of China
| | - Lie Yang
- Institute of Digestive Surgery of Sichuan University and Department of Gastrointestinal Surgery, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, Sichuan, 610041, People's Republic of China
| | - Zongguang Zhou
- Institute of Digestive Surgery of Sichuan University and Department of Gastrointestinal Surgery, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, Sichuan, 610041, People's Republic of China
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Preoperative Risk Factors for Short-Term Postoperative Mortality of Acute Mesenteric Ischemia after Laparotomy: A Systematic Review and Meta-Analysis. Emerg Med Int 2020; 2020:1382475. [PMID: 33083058 PMCID: PMC7556094 DOI: 10.1155/2020/1382475] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 08/28/2020] [Accepted: 09/01/2020] [Indexed: 02/05/2023] Open
Abstract
Objective Our objective was to comprehensively present the evidence of preoperative risk factors for short-term postoperative mortality of acute mesenteric ischemia after laparotomy. Methods PubMed, Embase, and Google Scholar were searched from January 2000 to January 2020. Studies evaluating the postoperative risk factors for short-term postoperative mortality of acute mesenteric ischemia after laparotomy were included. The outcome extracted were patients' demographics, medical history, and preoperative laboratory tests. Results Twenty studies (5011 patients) met the inclusion criteria. Studies were of high quality, with a median Newcastle-Ottawa Scale Score of 7. Summary short-term postoperative mortality was 44.38% (range, 18.80%–67.80%). Across included studies, 49 potential risk factors were examined, at least two studies. Meta-analysis of predictors based on more than three studies identified the following preoperative risk factors for higher short-term postoperative mortality risk: old age (odds ratio [OR], 1.90, 95% confidence interval [CI], 1.57–2.30), arterial occlusive mesenteric ischemia versus mesenteric venous thrombosis (OR, 2.45, 95% CI 1.12–5.33), heart failure (OR 1.33, 95% CI 1.03–1.72), renal disorders (OR 1.61, 95% CI 1.24–2.07), and peripheral vascular disease (OR 1.38, 95% CI 1.00–1.91). Nonsurvivors were older (standardized mean difference [SMD], 0.32, 95% CI 0.24–0.40), had higher creatinine levels (SMD 0.50, 95% CI 0.25–0.75), and had lower platelet counts (SMD −0.32, 95% CI −0.50 to −0.14). Conclusion The short-term postoperative mortality of acute mesenteric ischemia who underwent laparotomy is still high. A better understanding of these risk factors may help in the early identification of high-risk patients, optimization of surgical procedure, and improvement of perioperative management.
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Mao Z, Liu G, Yu Q, Qi S, Lou Y, Liu C, Li Q, Xue C, Kang H, Hong Q, Zhou F. Association between serum lactate levels and enteral feeding intolerance in septic patients treated with vasopressors: a retrospective cohort study. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1240. [PMID: 33178772 PMCID: PMC7607076 DOI: 10.21037/atm-20-6317] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background To assess the association between serum lactate levels and intolerance to enteral nutrition (EN) in septic patients treated with vasopressors. Methods This retrospective study was conducted between January 1, 2015 and May 1, 2018 in an intensive care unit (ICU). Patients with sepsis who were given EN and treated with vasopressors were included. EmpowerStats software and R (version 3.3.2) was used to examine the association between serum lactate levels and intolerance to EN. Results Among the 132 septic patients (age, 60.6±18.1 years) enrolled, 35 (26.5%) patients suffered intolerance to EN. Multiple logistic regression analysis demonstrated that an elevated lactate level was an independent risk factor for EN intolerance [odds ratio (OR): 2.7; 95% confidence interval (CI): 1.6–4.4; P<0.001]. The area under the receiver operating characteristic (ROC) curve for serum lactate levels was 0.764 (95% CI: 0.664–0.864). Stratified analysis suggested that age was the most prominent interactive factor for serum lactate levels in EN intolerance. Serum lactate levels were closely correlated to EN intolerance in elderly patients (age ≥65 years) (OR: 9.5; 95% CI: 2.1–42.4; P=0.0261 for interaction), while no such association was identified in younger patients (age <65 years; OR: 1.7; 95% CI: 1.0–2.9; P=0.052). Conclusions Serum lactate levels were associated with an increased risk of EN intolerance in patients with sepsis, especially in elderly individuals. An elevated serum lactate level may be an early predictor of EN intolerance in elderly septic patients treated with vasopressors. However, further studies are called for to verify these findings.
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Affiliation(s)
- Zhi Mao
- Department of Critical Care Medicine, the First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Guoxiong Liu
- Emergency Department, the First Affiliated Hospital of Guizhou University of TCM, Guiyang, China
| | - Qing Yu
- Chifeng Municipal Hospital, Chifeng, China
| | - Shuang Qi
- Department of Critical Care Medicine, the First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Yunchi Lou
- Department of Surgery, People's Liberation Army 968 Hospital, Jinzhou, China
| | - Chao Liu
- Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Diseases, Beijing, China
| | - Qinglin Li
- Department of Critical Care Medicine, the First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Chao Xue
- Department of Critical Care Medicine, the First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Hongjun Kang
- Department of Critical Care Medicine, the First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Quan Hong
- Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Diseases, Beijing, China
| | - Feihu Zhou
- Department of Critical Care Medicine, the First Medical Centre, Chinese PLA General Hospital, Beijing, China.,Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Diseases, Beijing, China.,National Clinical Research Center for Geriatric Diseases, Chinese People's Liberation Army General Hospital, Beijing, China
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Vascular Calcifications are Associated with Increased Mortality in Patients with Acute Mesenteric Ischemia. Ann Vasc Surg 2020; 72:88-97. [PMID: 32866577 DOI: 10.1016/j.avsg.2020.08.086] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 08/07/2020] [Accepted: 08/10/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Vascular calcifications have been identified as predictors of mortality in several cardiovascular diseases but have not been investigated in context of acute mesenteric ischemia. The aim of this study was to investigate the impact of vascular calcifications in patients with acute mesenteric ischemia. METHODS Patients admitted for an acute mesenteric ischemia were retrospectively included. The presence of calcifications in the visceral aorta, the celiac trunk, the superior mesenteric artery, and the renal arteries was assessed on computed tomography scan images at the arterial phase. The calcification volumes were measured using the software Aquarius iNtuition Edition®. RESULTS The all-cause mortality was 55 out of 86 patients (63.9%) for a median follow-up of 3.5 days (1-243). The survival rate of patients with calcification in the superior mesenteric artery was significantly lower than that of those without calcification (22% vs. 55.6%, P = 0.019). Patients who died had significantly a higher frequency of calcifications in the superior mesenteric artery, the visceral aorta, the celiac trunk, and the renal arteries. CONCLUSIONS The presence of vascular calcifications in the superior mesenteric artery is associated with increased mortality in patients diagnosed with acute mesenteric ischemia. Further studies are required to identify the mechanisms underlying this association.
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Predictors of bowel necrosis in patients with acute mesenteric ischemia: systematic review and meta-analysis. Updates Surg 2020; 73:47-57. [PMID: 32728981 DOI: 10.1007/s13304-020-00857-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 07/23/2020] [Indexed: 12/14/2022]
Abstract
Acute mesenteric ischemia (AMI) is a serious medical condition that can progress to transmural bowel necrosis. Prediction of the onset of bowel necrosis in AMI is crucial to justify surgical intervention before more severe consequences supervene. This systematic review aimed to identify the significant predictors of bowel necrosis in AMI in the current literature. In adherence to the PRISMA guidelines, electronic databases were searched for studies that reported significant independent predictors of bowel necrosis in AMI. The quality of the studies was assessed with MINORS score. The main outcomes of the review were the incidence and predictors of bowel necrosis in patients with AMI and the mortality rate. This systematic review comprised nine articles that included 963 patients of a median age of 57 years. Irreversible bowel necrosis was found in 402 (41.7%) patients. The significant predictors of bowel necrosis were subdivided into eight clinical, seven biochemical, and six radiologic parameters. Eight parameters were reported by two or more studies, whereas 13 were reported by a single study. Based on the weight and odds ratio of the predictive parameters, a prognostic scoring system, Emile-Khan Score, was proposed. Several clinical, biochemical, and radiologic predictors of bowel necrosis were reported in the literature. Pooling of odds ratios was feasible for eight factors that were reported by more than one study. Further studies are needed to ascertain the utility of the other predictive factors.Level of evidence: Level II (systematic review and meta-analysis).
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Murphy B, Dejong CHC, Winter DC. Open and Endovascular Management of Acute Mesenteric Ischaemia: A Systematic Review. World J Surg 2020; 43:3224-3231. [PMID: 31482344 DOI: 10.1007/s00268-019-05149-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Acute mesenteric ischaemia (AMI) is a life-threatening surgical emergency resulting from thromboembolic occlusion of the mesenteric vasculature. Traditional management of AMI has been open revascularisation with or without bowel resection-a procedure which carries considerable morbidity and mortality in an already unwell, compromised patient. Endovascular and more minimally invasive management approaches to AMI have been reported. Proponents of endovascular management suggest this approach may be associated with reduced morbidity and mortality compared with open surgery. OBJECTIVES To assess the impact of endovascular approach for AMI on mortality and need for subsequent laparotomy and/or bowel resection. DATA SOURCES The search bodies PubMed and Medline were interrogated. ELIGIBILITY CRITERIA, PARTICIPANTS AND INTERVENTIONS All studies in English with greater than 10 patients examining outcomes for patients undergoing endovascular intervention for acute mesenteric ischaemia were included. All patients over 18 years presenting with a diagnosis of acute mesenteric ischaemia secondary to an arterial thromboembolic source were included. Studies examining endovascular intervention alone or endovascular and open intervention were selected. RESULTS The 30-day mortality for endovascular approach from all 13 studies was 16-42%. Of the 7 comparative studies including results of open revascularisation, the 30-day mortality for patient treated with an endovascular approach was 15-39% versus 33-50% for open revascularisation. Laparotomy rates post-initial endovascular intervention ranged from 13 to 73%. Bowel resection post-endovascular therapy ranged from 14 to 40% among studies. Concerning 7 comparative studies for open versus endovascular revascularisation, the rate of bowel resection in the endovascular group ranged 14-28% and 33-63% in the open cohort. Endovascular intervention also demonstrated lower median length (s) of bowel resected. LIMITATIONS Heterogeneity of studies and patient populations studied including selection bias. CONCLUSIONS AND IMPLICATIONS OF FINDINGS Endovascular management may be associated with reduced mortality and need for/length of bowel resection compared with the traditional open approach, but there remains a paucity of robust data to support this. The available literature illustrates that a subgroup of patients without haemodynamic compromise and more insidious onset may garner benefit from endovascular intervention.
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Affiliation(s)
- B Murphy
- Departments of General Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland.
| | - C H C Dejong
- Departments of Surgery, Maastricht University, Maastricht, The Netherlands
| | - D C Winter
- Departments of General Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
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