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Dang JQ, Wang QQ, Yang YL, Shang L, Bian QT, Xiang HJ. Median arcuate ligament syndrome complicated with gallbladder stones: A case report. World J Clin Cases 2023; 11:7881-7887. [DOI: 10.12998/wjcc.v11.i32.7881] [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: 09/04/2023] [Revised: 10/11/2023] [Accepted: 11/09/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND Median arcuate ligament syndrome (MALS) is a rare disease caused by compression of the celiac trunk artery by the median arcuate ligament (MAL). It can cause symptoms of postprandial abdominal pain, weight loss, and nausea and vomiting.
CASE SUMMARY A 55-year-old woman was admitted due to abdominal pain, nausea and vomiting. On admission, the patient presented with epigastric pain that worsened after eating, without signs of peritoneal irritation. Computed tomography angiography of the upper abdomen showed compression of the proximal segment of the abdominal trunk, local luminal stenosis with angular “fishhook” changes, which changed significantly during forceful inspiration and expiration; gallbladder stones; and multiple cysts in the liver. Abdominal duplex ultrasonography showed that peak systolic velocity was 352 cm/s. After diagnosis of MALS was confirmed, an arch ligament release procedure was performed. MALS has no specific symptoms and can be misdiagnosed as other abdominal diseases. Awareness of MALS should be improved to avoid misdiagnosis. The commonly used treatment option is MAL release and resection of the peripheral ganglion of the celiac trunk artery.
CONCLUSION The diagnosis and treatment of MALS must be individualized, and MAL release is effective and provides immediate symptomatic relief.
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Affiliation(s)
- Jun-Qiang Dang
- Department of Hepatobiliary Surgery, Xi’an Daxing Hospital, Xi’an 710016, Shaanxi Province, China
| | - Qing-Qiang Wang
- Department of Hepatobiliary and Pancreatic Surgery, Xijing Hospital, Air Force Medical University, Xi’an 710032, Shaanxi Province, China
| | - Yan-Ling Yang
- Department of Hepatobiliary and Pancreatic Surgery, Xijing Hospital, Air Force Medical University, Xi’an 710032, Shaanxi Province, China
| | - Lin Shang
- Department of Hepatobiliary Surgery, Xi’an Daxing Hospital, Xi’an 710016, Shaanxi Province, China
| | - Qi-Tian Bian
- Department of Hepatobiliary Surgery, Xi’an Daxing Hospital, Xi’an 710016, Shaanxi Province, China
| | - Hong-Jun Xiang
- Department of Hepatobiliary Surgery, Xi’an Daxing Hospital, Xi’an 710016, Shaanxi Province, China
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Høyer C, Zacho HD, Stefanov V, Abrahamsen J. Improvement of the splanchnic blood flow and hepatic vein oxygenation following revascularization in patients with chronic mesenteric ischaemia. Clin Physiol Funct Imaging 2023; 43:33-39. [PMID: 36178112 PMCID: PMC10092538 DOI: 10.1111/cpf.12790] [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: 06/30/2022] [Revised: 09/16/2022] [Accepted: 09/27/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Chronic mesenteric ischaemia (CMI) is an underdiagnosed but severe condition. Access to functional testing is often limited and the diagnosis is usually based primarily on symptoms and imaging. One of the functional tests available is measurement of the splanchnic blood flow (SBF). The purpose of the present investigation was to evaluate if changes in the splanchnic perfusion after revascularization can be detected by measuring the SBF and hepatic vein oxygenation. MATERIALS AND METHODS The SBF was measured in 10 patients before and after revascularization of the mesenteric arteries by either percutaneous transluminal angioplasty (n = 9) or open revascularization (n = 1). The SBF was measured indirectly using Fick's principle and using the tracer Tc-99m Mebrofenin along with assessment of hepatic blood oxygenation, before and after a standard meal, following catheterization of a hepatic vein and the femoral artery. RESULTS Nine of 10 patients (90%) achieved a profound increase in SBF after revascularization (mean increase in postprandial response to meal stimulation from 71 ± 95 to 531 ± 295 ml/min, p = 0.001), and an increase in postprandial hepatic vein oxygen saturation (from 52 ± 14% to 59 ± 13%, p = 0.006). The symptoms of the patients diminished accordingly. One patient had no symptom relief, and no increase in postprandial SBF, but an angiographic result with no significant stenosis postrevascularization. CONCLUSIONS Revascularization increased the SBF and hepatic vein oxygen saturation significantly concurrent with symptom relief and according with the angiographic successful result in the vast majority of patients. A satisfying angiographic result post vascular intervention does not rule out CMI.
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Affiliation(s)
- Christian Høyer
- Department of Clinical Physiology, Viborg Regional Hospital, Viborg, Denmark
| | - Helle D Zacho
- Department of Nuclear Medicine, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg Oest, Denmark
| | - Viktor Stefanov
- Department of Radiology, Viborg Regional Hospital, Viborg, Denmark
| | - Jan Abrahamsen
- Department of Clinical Physiology, Viborg Regional Hospital, Viborg, Denmark
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Kazama T, Yamano HO, Nakase H. Ischemia-reperfusion injury suggestive of chronic mesenteric ischemia: Real-time capture by colonoscopy. Dig Endosc 2022; 34:e28-e29. [PMID: 34854141 DOI: 10.1111/den.14192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 10/27/2021] [Accepted: 11/12/2021] [Indexed: 02/08/2023]
Affiliation(s)
- Tomoe Kazama
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Hokkaido, Japan
| | - Hiro-O Yamano
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Hokkaido, Japan
| | - Hiroshi Nakase
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Hokkaido, Japan
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Høyer C, Christensen MH, Sandermann J, Leusink R, Abrahamsen J. Chronic mesenteric ischaemia: the importance of the individual mesenteric artery. Clin Physiol Funct Imaging 2021; 42:15-22. [PMID: 34608740 DOI: 10.1111/cpf.12730] [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: 06/07/2021] [Revised: 08/31/2021] [Accepted: 10/01/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Chronic mesenteric ischaemia (CMI) is a vastly underdiagnosed condition that typically leads to postprandial abdominal pain and weight loss. The aim of the study was to explore the involvement of various mesenteric vessels in total splanchnic blood flow (SBF) and hepatic vein oxygenation. METHODS Single-blinded comparative trial of 476 patients clinically suspected of CMI. Routine investigation included measurement of hepatic vein oxygen saturation, indirect measurement of the total splanchnic blood flow (SBF), using Fick's principle and the tracer [99m Tc]Mebrofenin, before and after a meal, and digital subtraction angiography. RESULTS A total of 176 of the 476 patients (36%) had at least one angiographically significant stenosis (lumen reduction ≥70%). In patients with a significant one-vessel disease, the percentage having CMI according to SBF was 10% for a celiac trunk stenosis (n = 60), 50% for a superior mesenteric stenosis (n = 24) and 6% for an inferior mesenteric artery stenosis (n = 34). In patients with a significant two-vessel disease, the percentage with CMI according to SBF response was 92%, 18% and 79%, for no significant stenosis of the celiac trunk (n = 13), superior mesenteric artery (n = 17) and inferior mesenteric artery (n = 19), respectively. CONCLUSION Patients with significant one- or two-vessel stenosis involving the superior mesenteric artery have a higher likelihood of CMI according to flow criteria and a greater postprandial decrease in hepatic vein saturation on average than patients with no involvement of the superior mesenteric artery.
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Affiliation(s)
- Christian Høyer
- Department of Clinical Physiology, Viborg Regional Hospital, Viborg, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | | | - Jes Sandermann
- Department of Vascular Surgery, Viborg Regional Hospital, Viborg, Denmark
| | - Robert Leusink
- Department of Vascular Surgery, Viborg Regional Hospital, Viborg, Denmark
| | - Jan Abrahamsen
- Department of Clinical Physiology, Viborg Regional Hospital, Viborg, Denmark
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van Dijk LJ, van Noord D, Geelkerken RH, Harki J, Berendsen SA, de Vries AC, Moelker A, Vergouwe Y, Verhagen HJ, Kolkman JJ, Bruno MJ. Validation of a score chart to predict the risk of chronic mesenteric ischemia and development of an updated score chart. United European Gastroenterol J 2019; 7:1261-1270. [PMID: 31700639 PMCID: PMC6826523 DOI: 10.1177/2050640619856765] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Accepted: 05/16/2019] [Indexed: 12/23/2022] Open
Abstract
Background and objective The objective of this article is to externally validate and update a recently published score chart for chronic mesenteric ischemia (CMI). Methods A multicenter prospective cohort analysis was conducted of 666 CMI-suspected patients referred to two Dutch specialized CMI centers. Multidisciplinary consultation resulted in expert-based consensus diagnosis after which CMI consensus patients were treated. A definitive diagnosis of CMI was established if successful treatment resulted in durable symptom relief. The absolute CMI risk was calculated and discriminative ability of the original chart was assessed by the c-statistic in the validation cohort. Thereafter the original score chart was updated based on the performance in the combined original and validation cohort with inclusion of celiac artery (CA) stenosis cause. Results In 8% of low-risk patients, 39% of intermediate-risk patients and 94% of high-risk patients of the validation cohort, CMI was diagnosed. Discriminative ability of the original model was acceptable (c-statistic 0.79). The total score of the updated chart ranged from 0 to 28 points (low risk 19% absolute CMI risk, intermediate risk 45%, and high risk 92%). The discriminative ability of the updated chart was slightly better (c-statistic 0.80). Conclusion The CMI prediction model performs and discriminates well in the validation cohort. The updated score chart has excellent discriminative ability and is useful in clinical decision making.
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Affiliation(s)
- Louisa Jd van Dijk
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Radiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Desirée van Noord
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Gastroenterology and Hepatology, Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands
| | - Robert H Geelkerken
- Department of Surgery, Medisch Spectrum Twente and Multimodality Medical Imaging group, TechMed Centre, Faculty Science and Technology, University Twente, Enschede, the Netherlands
| | - Jihan Harki
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Sophie A Berendsen
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Annemarie C de Vries
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Adriaan Moelker
- Department of Radiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Yvonne Vergouwe
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Hence Jm Verhagen
- Department of Vascular Surgery, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Jeroen J Kolkman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede, the Netherlands.,Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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van Dijk LJ, van Noord D, de Vries AC, Kolkman JJ, Geelkerken RH, Verhagen HJ, Moelker A, Bruno MJ. Clinical management of chronic mesenteric ischemia. United European Gastroenterol J 2018; 7:179-188. [PMID: 31080602 PMCID: PMC6498801 DOI: 10.1177/2050640618817698] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 11/15/2018] [Indexed: 12/26/2022] Open
Abstract
This
This Dutch Mesenteric Ischemia Study group consists of: Ron Balm, Academic Medical Center, Amsterdam Gert Jan de Borst, University Medical Center Utrecht, Utrecht Juliette T Blauw, Medisch Spectrum Twente, Enschede Marco J Bruno, Erasmus MC University Medical Center, Rotterdam Olaf J Bakker, St Antonius Hospital, Nieuwegein Louisa JD van Dijk, Erasmus MC University Medical Center, Rotterdam Hessel CJL Buscher, Gelre Hospitals, Apeldoorn Bram Fioole, Maasstad Hospital, Rotterdam Robert H Geelkerken, Medisch Spectrum Twente, Enschede Jaap F Hamming, Leiden University Medical Center, Leiden Jihan Harki, Erasmus MC University Medical Center, Rotterdam Daniel AF van den Heuvel, St Antonius Hospital, Nieuwegein Eline S van Hattum, University Medical Center Utrecht, Utrecht Jan Willem Hinnen, Jeroen Bosch Hospital, ‘s-Hertogenbosch Jeroen J Kolkman, Medisch Spectrum Twente, Enschede Maarten J van der Laan, University Medical Center Groningen, Groningen Kaatje Lenaerts, Maastricht University Medical Center, Maastricht Adriaan Moelker, Erasmus MC University Medical Center, Rotterdam Desirée van Noord, Franciscus Gasthuis & Vlietland, Rotterdam Maikel P Peppelenbosch, Erasmus MC University Medical Center, Rotterdam André S van Petersen, Bernhoven Hospital, Uden Pepijn Rijnja, Medisch Spectrum Twente, Enschede Peter J van der Schaar, St Antonius Hospital, Nieuwegein Luke G Terlouw, Erasmus MC University Medical Center, Rotterdam Hence JM Verhagen, Erasmus MC University Medical Center, Rotterdam Jean Paul PM de Vries, University Medical Center Groningen, Groningen Dammis Vroegindeweij, Maasstad Hospital, Rotterdam review provides an overview on the clinical management of chronic mesenteric ischemia (CMI). CMI is defined as insufficient blood supply to the gastrointestinal tract, most often caused by atherosclerotic stenosis of one or more mesenteric arteries. Patients classically present with postprandial abdominal pain and weight loss. However, patients may present with, atypically, symptoms such as abdominal discomfort, nausea, vomiting, diarrhea or constipation. Early consideration and diagnosis of CMI is important to timely treat, to improve quality of life and to prevent acute-on-chronic mesenteric ischemia. The diagnosis of CMI is based on the triad of clinical symptoms, radiological evaluation of the mesenteric vasculature and if available, functional assessment of mucosal ischemia. Multidisciplinary consensus on the diagnosis of CMI is of paramount importance to adequately select patients for treatment. Patients with a consensus diagnosis of single-vessel or multi-vessel atherosclerotic CMI are preferably treated with endovascular revascularization.
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Affiliation(s)
- Louisa Jd van Dijk
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Radiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Desirée van Noord
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Gastroenterology and Hepatology, Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands
| | - Annemarie C de Vries
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Jeroen J Kolkman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede, the Netherlands.,Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, the Netherlands
| | - Robert H Geelkerken
- Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, the Netherlands.,Technical Medical Center, Faculty Science and Technology, University Twente, Enschede, the Netherlands
| | - Hence Jm Verhagen
- Department of Vascular Surgery, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Adriaan Moelker
- Department of Radiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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Harki J, Suker M, Tovar-Doncel MS, van Dijk LJ, van Noord D, van Eijck CH, Bruno MJ, Kuipers EJ, Ince C. Patients with chronic mesenteric ischemia have an altered sublingual microcirculation. Clin Exp Gastroenterol 2018; 11:405-414. [PMID: 30425547 PMCID: PMC6200368 DOI: 10.2147/ceg.s159160] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Background Little is known about the microcirculatory alterations in patients with chronic mesenteric ischemia (CMI). We hypothesized that patients with CMI have an impaired microcirculatory function and show an oral microcirculatory response after caloric challenge compared to healthy controls. Methods All patients and controls received the standard workup for CMI. Sublingual micro-circulation was evaluated before (T0) and 20 minutes after (T1) feeding. The total vessel density (TVD; mm/mm2), perfused vessel density (PVD; mm/mm2), proportion of perfused vessels (PPV; %) and microvascular flow index (MFI; AU) were assessed. Results We included 12 patients (63.2 years [IQR 48.8–70.4 years], 67% males) and 12 controls (32.7 years [IQR 27.7–38.1 years], 42% males). At baseline, patients with CMI had a decreased PPV of the sublingual small vessels (median 84.8% vs 95.7%, P=0.006), PPV of all vessels (PPV median 85.4% vs 95.3%, P=0.007) and microvascular flow index of all vessels (MFIa; median 3.00 vs 2.80, P=0.039) compared to healthy controls. After caloric challenge, PVD increased significantly in both small vessels (perfused vessel density of the small vessels [PVDs]) and all vessels (perfused vessel density of all vessels [PVDa]; PVDs [T0]) median 16.3 [IQR 13.3–22.1] vs [T1] median 19.9 [IQR 14.2–26.2], P=0.008; PVDa [T0] median 19.1 [IQR 16.2–23.6] vs [T1] median 22.2 [IQR 16.5–28.9], P=0.02; proportion of perfused vessels of the small vessels (PPVs; [T0] median 84.8% [IQR 75.3–90.4] vs [T1] median 91.0% [IQR 80.1–93.8], P=0.010). In contrast, no significant changes in microcirculatory parameters were observed after caloric challenge in healthy controls. Conclusion Patients with CMI have an impaired sublingual microcirculation at baseline and show a significant response in the sublingual microcirculation after caloric challenge, whereas healthy controls have a normal microcirculation at baseline and show no reactive response upon a caloric challenge as seen in CMI patients. Sublingual microcirculation visualization may offer a rapid noninvasive method to identify patients at risk for having CMI.
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Affiliation(s)
- Jihan Harki
- Department of Gastroenterology and Hepatology,
| | - Mustafa Suker
- Department of Surgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | | | | | | | - Casper Hj van Eijck
- Department of Surgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | | | - Ernst J Kuipers
- Department of Gastroenterology and Hepatology, .,Department of Internal Medicine
| | - Can Ince
- Department of Intensive Care, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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Invited commentary. J Vasc Surg 2018; 68:785-786. [DOI: 10.1016/j.jvs.2018.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Accepted: 01/09/2018] [Indexed: 11/17/2022]
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van Dijk LJ, Moons LM, van Noord D, Moelker A, Verhagen HJ, Bruno MJ, Rouwet EV. Persistent symptom relief after revascularization in patients with single-artery chronic mesenteric ischemia. J Vasc Surg 2018. [DOI: 10.1016/j.jvs.2017.12.038] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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10
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Nuzzo A, Huguet A, Corcos O. [Modern treatment of mesenteric ischemia]. Presse Med 2018; 47:519-530. [PMID: 29776790 DOI: 10.1016/j.lpm.2018.03.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 03/27/2018] [Indexed: 01/16/2023] Open
Abstract
Acute mesenteric ischemia is a highly morbid affliction which requires urgent care. Acute mesenteric ischemia consists in an ischemia injury of the small bowel, secondary to vascular insufficiency, either occlusive (thrombosis, embolism, arterial, venous) or non-occlusive (low flow or vasospasm). Given that the superior mesenteric artery supplies the small bowel as well as the right part of the colon, any ischemic process involving the right colon should be considered an acute mesenteric ischemia until proven otherwise. Acute mesenteric ischemia should always be suspected in the setting of a sudden, unusual and intense abdominal pain requiring opioids. Chronic mesenteric ischemia can also be revealed by postprandial abdominal pain associated with significant weight loss. The clinical presentation of mesenteric ischemia is nonspecific. Thus, a suspected diagnosis must be confirmed by imaging usually consisting in an abdominal computed tomography scan. Imaging will also provide guidance with regards to treatment decision. Organ failure, serum lactate elevation as well as bowel loop dilationper imaging are predictive of irreversible intestinal necrosis. In the presence of any of these predictive factors, surgical management should be considered. The modern treatment of mesenteric ischemia in Intestinal Stroke Centers has allowed rates of resection-free survival in nearly two-thirds of patients. The management of mesenteric ischemia relies in a combination of: (1) a medical protocol including oral/enteral antibiotics; (2) the revascularization of viable bowel and (3) the surgical resection of necrosic, non viable intestinal tissue. The inception and development of Intestinal Stroke Centers has been the cornerstone of significantly improved management and survival rates as well as crucial asset in research, specifically in the field of biomarkers associated with early diagnosis.
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Affiliation(s)
- Alexandre Nuzzo
- AP-HP, hôpital Beaujon, structure d'urgence vasculaire intestinale (SURVI), service de gastroentérologie, MICI et assistance nutritive, 100, boulevard du Général-Leclerc, 92100 Clichy, France; Université Sorbonne-Paris Cité, 2, rue Albert-Einstein, 75013 Paris, France; Hôpital Bichat, Laboratory for Vascular Translationnal Science, Inserm U1148, 75018 Paris, France.
| | - Audrey Huguet
- AP-HP, hôpital Beaujon, structure d'urgence vasculaire intestinale (SURVI), service de gastroentérologie, MICI et assistance nutritive, 100, boulevard du Général-Leclerc, 92100 Clichy, France
| | - Olivier Corcos
- AP-HP, hôpital Beaujon, structure d'urgence vasculaire intestinale (SURVI), service de gastroentérologie, MICI et assistance nutritive, 100, boulevard du Général-Leclerc, 92100 Clichy, France; Université Sorbonne-Paris Cité, 2, rue Albert-Einstein, 75013 Paris, France; Hôpital Bichat, Laboratory for Vascular Translationnal Science, Inserm U1148, 75018 Paris, France
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Kolkman JJ, Geelkerken RH. Diagnosis and treatment of chronic mesenteric ischemia: An update. Best Pract Res Clin Gastroenterol 2017; 31:49-57. [PMID: 28395788 DOI: 10.1016/j.bpg.2017.01.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Revised: 01/17/2017] [Accepted: 01/30/2017] [Indexed: 02/06/2023]
Abstract
Although the prevalence of mesenteric artery stenoses (MAS) is high, symptomatic chronic mesenteric ischemia (CMI) is rare. The collateral network in the mesenteric circulation, a remnant of the extensive embryonal vascular network, serves to prevent most cases of ischemia. This explains the high incidence of MAS and relative rarity of cases of CMI. The number of affected vessels is the major determinant in CMI development. Most subjects with single vessel mesenteric stenosis do not develop ischemic complaints. Our experience is that most subjects with CA and SMA stenoses with abdominal complaints have CMI. A special mention should be made on patients with median arcuate ligament compression (MALS). There is ongoing debate whether the intermittent compression, caused by respiration movement, can cause ischemic complaints. The arguments pro and con treatment of MALS will be discussed. The clinical presentation of CMI consists of postprandial pain, weight loss, and an adapted eating pattern caused by fear of eating. In end-stage disease more continuous pain, diarrhea or a dyspepsia-like presentation can be observed. Workup of patients suspected for CMI consists of three elements: the anamnesis, the vascular anatomy and proof of ischemia. The main modalities to establish mesenteric vessel patency are duplex ultrasound, CT angiography or MR angiography. Assessing actual ischemia is still challenging, with only tonometry and visual light spectroscopy as tested candidates. Treatment consists of limiting metabolic demand, treatment of the atherosclerotic process and endovascular or operative revascularisation. Metabolic demand can be reduced by using smaller and more frequent meals, proton pump inhibition. Treatment of the atherosclerotic process consists of cessation of smoking, treatment of dyslipidemia, hypertension, hyperglycaemia, and medication with trombocyte aggregation inhibitors.
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Affiliation(s)
- Jeroen J Kolkman
- Medisch Spectrum Twente, Department of Gastroenterology, Enschede, The Netherlands; University Medical Center Groningen, Department of Gastroenterology, Groningen, The Netherlands.
| | - Robert H Geelkerken
- Medisch Spectrum Twente, Department of Vascular Surgery, Enschede, The Netherlands; University of Twente, Faculty of Science and Technology, Enschede, The Netherlands.
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Abstract
PURPOSE OF REVIEW Diagnosis of acute mesenteric ischemia in the early stages is now possible with modern computed tomography (CT), using intravenous contrast enhancement and imaging in the arterial and/or portal venous phase. The availability of CT around the clock means that more patients with acute mesenteric ischemia may be treated with urgent intestinal revascularization. RECENT FINDINGS The establishment of a hybrid operation room is most important to be able to perform explorative laparotomy for evaluation of the extent of mesenteric ischemia and successful intestinal revascularization. Endovascular recanalization and stenting has become an important alternative, especially in patients with both acute and chronic thrombotic superior mesenteric artery (SMA) occlusion. Aspiration embolectomy, thrombolysis and open surgical embolectomy, followed by on-table angiography, are the treatment options for embolic SMA occlusion. Endovascular therapy may be an option in the few patients with mesenteric venous thrombosis who do not respond to anticoagulation therapy. The concept of damage-control surgery is recommended after intestinal revascularization. SUMMARY Intestinal revascularization in patients with arterial occlusive mesenteric ischemia reduces bowel morbidity and mortality. Observational studies report that both endovascular and open vascular therapy options are effective, but endovascular technique may be preferred in these often elderly and fragile patients.
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Ozawa H, Imanishi Y, Ito F, Watanabe Y, Kato T, Nameki H, Isobe K, Ogawa K. PiCO2 monitoring of transferred jejunum perfusion using an air tonometry technique after hypopharyngeal cancer surgery. Medicine (Baltimore) 2015; 94:e632. [PMID: 25789955 PMCID: PMC4602482 DOI: 10.1097/md.0000000000000632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
This study aimed to investigate the usefulness of intraluminal PCO2 (PiCO2) monitoring by air tonometry for the assessment of the vascular condition of the transferred jejunum after surgery for hypopharyngeal cancer.PiCO2 in the transplanted jejunum of 24 patients was monitored using air tonometry after radical surgery for hypopharyngeal cancer from 2003 to 2010.All but 1 patient, who removed the catheter before monitoring began, were monitored safely. PiCO2 in the transferred jejunum correlated with arterial PCO2 (PaCO2) that was measured concurrently, and dissociation of PiCO2 from PaCO2 was observed in cases with vascular complication. In those cases without postoperative vascular complication, the PiCO2 value gradually increased for 3 hours but then decreased by 12 hours after surgery. Three patients experienced major vascular complication. All 3 patients had continuous elevation of PiCO2 >100 mm Hg, although vascular flow in 1 patient recovered by removal of a venous thrombosis and reanastomosis of the vein 7.5 hours after surgery. Four other patients who experienced elevation of PiCO2 had their skin suture released for decompression of their neck wound, resulting in a decrease in PiCO2 after treatment.The current results demonstrated that continuous monitoring of PiCO2 by air tonometry accurately reflects the vascular condition of the transferred jejunum, and this method is one of the best options for postoperative monitoring of jejunum blood perfusion.
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Affiliation(s)
- Hiroyuki Ozawa
- From the Department of Otolaryngology-Head and Neck Surgery (HO, FI, YW, KO), Keio University School of Medicine; Department of Otolaryngology, Head and Neck Surgery (YI), Kyorin University School of Medicine, Tokyo; Department of Otolaryngology, Head and Neck Surgery (TK, HN); Department of Surgery (KI), Shizuoka Red Cross Hospital, Shizuoka, Japan
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