Prognostic factors for the successful conservative management of nonocclusive mesenteric ischemia

Preoperative prognostic predictors and treatment strategies for surgical procedure focused on the sequential organ failure assessment score in nonocclusive mesenteric ischemia: a multicenter retrospective cohort study

BACKGROUND

Several large-scale studies have assessed endovascular and surgical treatment methods for nonocclusive mesenteric ischemia (NOMI); however, the prognostic factors for NOMI remain unclear. Therefore, this study aimed to evaluate risk factors for in-hospital mortality among patients with NOMI who underwent laparotomy and to examine therapeutic strategies that may improve the prognosis.

MATERIALS AND METHODS

In this multicenter retrospective study, the authors reviewed the electronic medical records retrieved from the inpatient database of patients with NOMI at eight district general hospitals between January 2011 and January 2021. A total of 88 patients who underwent laparotomies were divided into survivor and nonsurvivor groups, and statistical analysis was performed to determine clinical and physiological factors.

RESULTS

Exploratory laparotomy based on second-look surgery was the first treatment choice. The overall mortality rate was 48.8%, with a male-to-female ratio of 1.1:1. The median Sequential Organ Failure Assessment (SOFA) score was 8 [interquartile range: 3.75-14.2], and the median SOFA scores were 5 [3-7] in the survivor group and 13 [9-17.5] in the nonsurvivor group. Univariate analysis revealed a significant difference in BMI ( P <0.001), hypoglycemia ( P =0.0012), previous cardiovascular surgery ( P =0.0019), catecholamine use ( P <0.001), SOFA score ( P <0.001), platelet count ( P =0.0023), and lactate level ( P <0.001). Logistic regression analysis using the factors with significant differences revealed that SOFA score ≥10 (odds ratio 23.3; 95% CI: 1.94-280.00; P =0.013) was an independent prognostic factor. In addition, catecholamine use was suggested as a factor with a SOFA score greater than or equal to 10.

CONCLUSION

This study confirmed that a SOFA score of greater than or equal to 10 may be associated with increased mortality. While closely monitoring low blood pressure and renal dysfunction, survival rates may be improved if surgical intervention is performed before the SOFA score reaches greater than or equal to 10.

Non-Occlusive Mesenteric Ischemia in Cardiac Arrest Patients

Non-occlusive mesenteric ischemia (NOMI) is a severe complication in patients after cardiac arrest (CA). The diagnosis is complicated, the treatment options are limited. Given the susceptibility of enterocytes to ischemia, the incidence and severity of NOMI in the post-resuscitation period may reflect the intensity and duration of both ischemia and subsequent reperfusion injury. NOMI is considered to be associated with adverse neurological outcomes in CA patients. Therefore, NOMI should not only be regarded as a post-resuscitation complication but also as one of the prognostic markers in CA patients.This paper summarizes current knowledge on NOMI's pathophysiology, diagnosis, treatment, and prognostic significance in CA patients.

Spontaneous pneumoperitoneum and diabetic ketoacidosis in fulminant type 1 diabetes: a case report

A 41-year-old woman was referred to our emergency department with a 3-day history of upper abdominal pain. We diagnosed her with diabetic ketoacidosis (DKA) after laboratory tests indicated a blood glucose level of 569 mg/dL, positive urine ketone bodies and metabolic acidosis. Plain computed tomography (CT) scan revealed free gas surrounding the porta hepatis and gastric pylorus, which disappeared on the subsequent contrast-enhanced CT scan. Upper gastrointestinal endoscopy demonstrated no perforations; therefore, we assumed that the free gas was caused by spontaneous pneumoperitoneum. The patient had fulminant type 1 diabetes mellitus, as evidenced by her glycated hemoglobin A1c level of 6.9%, reduced insulin secretion and negative islet-specific autoantibodies. Pneumoperitoneum did not recur with conservative treatment, and DKA improved with intravenous fluids and insulin administration. Conservative management of DKA with spontaneous pneumoperitoneum may be considered if the patient's general condition is stable and there are no signs of peritoneal irritation.

Identifying survival protective factors for chronic dialysis patients with surgically confirmed acute mesenteric ischemia

BACKGROUND

Mesenteric ischemia is significantly more common in end-stage kidney disease patients undergoing chronic dialysis than in the general population and is associated with high morbidity and mortality. However, reports on prognostic factors in this population are limited.

AIM

To elucidate the in-hospital outcomes of acute mesenteric ischemia in chronic dialysis patients and to analyze protective factors for survival.

METHODS

The case data of 426 chronic dialysis patients who were hospitalized in a tertiary medical center for acute mesenteric ischemia over a 14-year period were retrospectively reviewed. Of these cases, 103 were surgically confirmed, and the patients were enrolled in this study. A Cox regression analysis was used to evaluate the protective factors for survival.

RESULTS

The in-hospital mortality rate among the 103 enrolled patients was 46.6%. Univariate analysis was performed to compare factors in survivors and nonsurvivors, with better in-hospital outcomes associated with a surgery delay (defined as the time from onset of signs and symptoms to operation) < 4.5 d, no shock, a higher potassium level on day 1 of hospitalization, no resection of the colon, and a total bowel resection length < 110 cm. After 1 wk of hospitalization, patients with lower white blood cell count and neutrophil counts, higher lymphocyte counts, and lower C-reactive protein levels had better in-hospital outcomes. Following multivariate adjustment, a higher potassium level on day 1 of hospitalization (HR 1.71, 95%CI 1.19 to 2.46; P = 0.004), a lower neutrophil count (HR 0.91, 95%CI 0.84 to 0.99; P = 0.037) at 1 wk after admission, resection not involving the colon (HR 2.70, 95%CI 1.05 to 7.14; P = 0.039), and a total bowel resection length < 110 cm (HR 4.55, 95%CI 1.43 to 14.29; P = 0.010) were significantly associated with survival.

CONCLUSION

A surgery delay < 4.5 d, no shock, no resection of the colon, and a total bowel resection length < 110 cm predicted better outcomes in chronic dialysis patients with acute mesenteric ischemia.