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Stephan F, Facque M, Salem FB, Picq O, Imbert A, Genty T, Zins M. Probabilistic Prediction of Gastrointestinal Ischemia after Cardiothoracic Surgery. Thorac Cardiovasc Surg 2024; 72:510-520. [PMID: 38513707 DOI: 10.1055/a-2292-0247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
BACKGROUND Gastrointestinal ischemia (GIisch) is challenging to diagnose in patients after cardiothoracic surgery. Computed tomography angiography (CTA) carries substantial false-negative and false-positive rates. The aim of the study was to evaluate if a combination of readily available variables improves the diagnosis of GIisch after cardiothoracic surgery. METHODS This retrospective study included patients receiving intensive care after cardiothoracic surgery. GIisch was confirmed by surgical and/or endoscopic findings. A GIisch prediction score was developed using the Spiegelhalter-Knill-Jones system in a training cohort then tested in a validation cohort (patients without obvious signs of GIisch on CTA). RESULTS The training cohort comprised 125 consecutive patients with suspected GIisch in 2008 to 2019, including 85 with confirmed GIisch. CTA, performed in 92 patients, had a high false-negative rate of 17/60 (28%) and a lower false-positive rate of 7/32 (22%). The score included cardiopulmonary bypass, negatively associated with GIisch, and six variables positively associated with GIisch: intraoperative mean arterial pressure < 50 mm Hg, aspartate aminotransferase > 15 N, lactate increase in 24 hour > 20%, and 3 CTA findings, namely, bowel dilation, bowel wall thickening, and mesenteric vasoconstriction. The area under the receiver operating characteristic was 0.82 (95% confidence interval [CI], 0.51-0.93) in the training cohort and 0.82 (95% CI, 0.68-0.96) in the validation cohort (n = 34 patients). Reliability of the predicted probabilities was greatest for probabilities ≤ 30% or ≥ 70%. CONCLUSION In patients receiving intensive care after cardiothoracic surgery, GIisch cannot be ruled out based solely on CTA findings. A scoring system combining CTA findings with other variables may improve the diagnosis of GIisch in this population.
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Affiliation(s)
- Francois Stephan
- Paris Saclay University, School of Medicine, Le Kremlin Bicetre, France
| | - Mathilde Facque
- Intensive Care Unit, Hopital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Fares Ben Salem
- Department of Radiology, Hopital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Olivia Picq
- Intensive Care Unit, Hopital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Audrey Imbert
- Intensive Care Unit, Hopital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Thibaut Genty
- Intensive Care Unit, Hopital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Marc Zins
- Department of Radiology, Hopital Marie-Lannelongue, Le Plessis-Robinson, France
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2
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Garzelli L, Ben Abdallah I, Nuzzo A, Zappa M, Corcos O, Dioguardi Burgio M, Cazals-Hatem D, Rautou PE, Vilgrain V, Calame P, Ronot M. Insights into acute mesenteric ischaemia: an up-to-date, evidence-based review from a mesenteric stroke centre unit. Br J Radiol 2023; 96:20230232. [PMID: 37493183 PMCID: PMC10607400 DOI: 10.1259/bjr.20230232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 05/16/2023] [Accepted: 05/17/2023] [Indexed: 07/27/2023] Open
Abstract
Radiologists play a central role in the diagnostic and prognostic evaluation of patients with acute mesenteric ischaemia (AMI). Unfortunately, more than half of AMI patients undergo imaging with no prior suspicion of AMI, making identifying this disease even more difficult. A confirmed diagnosis of AMI is ideally made with dynamic contrast-enhanced CT but the diagnosis may be made on portal-venous phase images in appropriate clinical settings. AMI is diagnosed on CT based on the identification of vascular impairment and bowel ischaemic injury with no other cause. Moreover, radiologists must evaluate the probability of bowel necrosis, which will influence the treatment options.AMI is usually separated into different entities: arterial, venous, non-occlusive and ischaemic colitis. Arterial AMI can be occlusive or stenotic, the dominant causes being atherothrombosis, embolism and isolated superior mesenteric artery (SMA) dissection. The main finding in the bowel is decreased wall enhancement, and necrosis can be suspected when dilatation >25 mm is identified. Venous AMI is related to superior mesenteric vein (SMV) thrombosis as a result of a thrombophilic state (acquired or inherited), local injury (cancer, inflammation or trauma) or underlying SMV insufficiency. The dominant features in the bowel are hypoattenuating wall thickening with submucosal oedema. Decreased enhancement of the involved bowel suggests necrosis. Non-occlusive mesenteric ischaemia (NOMI) is related to impaired SMA flow following global hypoperfusion associated with low-flow states. There are numerous findings in the bowel characterised by diffuse extension. An absence of bowel enhancement and a thin bowel wall suggest necrosis in NOMI. Finally, ischaemic colitis is a sub-entity of arterial AMI and reflects localised colon ischaemia-reperfusion injury. The main CT finding is a thickened colon wall with fat stranding, which seems to be unrelated to SMA or inferior mesenteric artery lesions. A precise identification and description of vascular lesions, bowel involvement and features associated with transmural necrosis is needed to determine patient treatment and outcome.
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Affiliation(s)
| | - Iannis Ben Abdallah
- Université Paris Cité, France & Service de chirurgie vasculaire, Hôpital Bichat, APHP.Nord, Paris, France
| | - Alexandre Nuzzo
- Intestinal Stroke Center, Service de gastroenterologie, MICI et Insuffisance intestinale, Hôpital Beaujon, APHP.Nord, Clichy, France
| | - Magaly Zappa
- Université des Antilles & Service de radiologie, Centre Hospitalier André Rosemon, Cayenne, France
| | - Olivier Corcos
- Intestinal Stroke Center, Service de gastroenterologie, MICI et Insuffisance intestinale, Hôpital Beaujon, APHP.Nord, Clichy, France
| | - Marco Dioguardi Burgio
- Université Paris Cité, France & Service de radiologie, Hôpital Beaujon, APHP.Nord, Clichy, France
| | - Dominique Cazals-Hatem
- Université Paris Cité, France & Service d’anatomopathologie, Hôpital Beaujon, APHP.Nord, Clichy, France
| | - Pierre-Emmanuel Rautou
- Université Paris Cité, France & Service d’hépatologie, Hôpital Beaujon, APHP.Nord, Clichy, France
| | - Valérie Vilgrain
- Université Paris Cité, France & Service de radiologie, Hôpital Beaujon, APHP.Nord, Clichy, France
| | - Paul Calame
- Université Bourgogne Franche-comté, Service de radiologie, CHU Besançon, France
| | - Maxime Ronot
- Université Paris Cité, France & Service de radiologie, Hôpital Beaujon, APHP.Nord, Clichy, France
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3
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Zhang FL, Hu Z, Wang YF, Zhang WJ, Zhou BW, Sun QS, Lin ZB, Liu KX. Organoids transplantation attenuates intestinal ischemia/reperfusion injury in mice through L-Malic acid-mediated M2 macrophage polarization. Nat Commun 2023; 14:6779. [PMID: 37880227 PMCID: PMC10600233 DOI: 10.1038/s41467-023-42502-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 10/12/2023] [Indexed: 10/27/2023] Open
Abstract
Intestinal organoid transplantation is a promising therapy for the treatment of mucosal injury. However, how the transplanted organoids regulate the immune microenvironment of recipient mice and their role in treating intestinal ischemia-reperfusion (I/R) injury remains unclear. Here, we establish a method for transplanting intestinal organoids into intestinal I/R mice. We find that transplantation improve mouse survival, promote self-renewal of intestinal stem cells and regulate the immune microenvironment after intestinal I/R, depending on the enhanced ability of macrophages polarized to an anti-inflammatory M2 phenotype. Specifically, we report that L-Malic acid (MA) is highly expressed and enriched in the organoids-derived conditioned medium and cecal contents of transplanted mice, demonstrating that organoids secrete MA during engraftment. Both in vivo and in vitro experiments demonstrate that MA induces M2 macrophage polarization and restores interleukin-10 levels in a SOCS2-dependent manner. This study provides a therapeutic strategy for intestinal I/R injury.
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Affiliation(s)
- Fang-Ling Zhang
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Zhen Hu
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Yi-Fan Wang
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Wen-Juan Zhang
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Bo-Wei Zhou
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Qi-Shun Sun
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Ze-Bin Lin
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Ke-Xuan Liu
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China.
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4
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Tual A, Garzelli L, Nuzzo A, Corcos O, Castier Y, Ben Abdallah I, Ronot M. Strengthening the Description of Superior Mesenteric Artery Occlusions in Acute Mesenteric Ischaemia: Proposition for an Anatomical Classification. Eur J Vasc Endovasc Surg 2023; 65:802-808. [PMID: 36736617 DOI: 10.1016/j.ejvs.2023.01.041] [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: 09/01/2022] [Revised: 01/14/2023] [Accepted: 01/25/2023] [Indexed: 02/01/2023]
Abstract
OBJECTIVE The aim of this study was to propose computed tomography angiography (CTA) based anatomical segmentation of the superior mesenteric artery (SMA), in order to standardise the reporting of occlusive lesions in acute mesenteric ischaemia (AMI). METHODS A retrospective CTA evaluation of patients with occlusive AMI admitted between 2016 and 2021. After the screening of 468 patients, 95 were included. The SMA was segmented into proximal (S1, ostium to the inferior pancreaticoduodenal artery), middle (S2, from the inferior pancreaticoduodenal to the ileocolic artery), and distal (S3, downstream the ileocolic artery) sections. The jejunal arteries were labelled J1 to J6, and the middle, right, and ileocolic arteries C1, C2, and C3. Two radiologists independently applied the proposed segmentation to a cohort of patients with occlusive AMI to describe occlusive lesions. Intra- and inter-rater agreement was assessed with kappa statistics. RESULTS Occlusions involved one segment in 50 (53%) patients (S1, n = 27 [28%]; S2, n = 12 [13%]; S3, n = 11 [12%]); two segments in 37 (39%) patients (S2/S3, n = 31 [33%]; S1/S2, n = 3 [3%]; S1/S3, n = 3 [3%]); and all three segments in eight patients (S1/S2/S3, 8%). The median number of jejunal arteries was four (interquartile range 3, 4.5). C1 and C2 were present in 93 (98%) and 23 patients (24%), respectively. Almost perfect intra-rater agreement was obtained for S1 (91% agreement, κ = 0.82, 95% confidence interval [CI] 0.72 - 0.92); substantial agreement was obtained for S2 (90% agreement, κ = 0.80, 95% CI 0.68 - 0.92) and S3 (86% agreement, κ = 0.72, 95% CI 0.58 - 0.86). Almost perfect inter-rater agreement (with the second junior reading) was obtained for S1 (97% agreement, κ = 0.95, 95% CI 0.89 - 1.0), S2 (91% agreement, κ = 0.82, 95% CI 0.72 - 0.92), and S3 (agreement 96%, κ = 0.91, 95% CI 0.83 - 0.99). CONCLUSION A standardised CTA based anatomical segmental description of SMA occlusive lesions in AMI is proposed; it provided substantial to almost perfect intra- and inter-rater agreement for most anatomical segments.
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Affiliation(s)
- Arnaud Tual
- Université Paris Cité, France & Service de Radiologie, Hôpital Beaujon, APHP Nord, Clichy, France
| | - Lorenzo Garzelli
- Université Paris Cité, France & Service de Radiologie, Hôpital Beaujon, APHP Nord, Clichy, France
| | - Alexandre Nuzzo
- Intestinal Stroke Centre, Service de Gastroenterologie, MICI et Insuffisance Intestinale, Hôpital Beaujon, APHP Nord, Clichy, France
| | - Olivier Corcos
- Intestinal Stroke Centre, Service de Gastroenterologie, MICI et Insuffisance Intestinale, Hôpital Beaujon, APHP Nord, Clichy, France
| | - Yves Castier
- Université Paris Cité, France & Service de Chirurgie Vasculaire, Hôpital Bichat, APHP Nord, Paris, France
| | - Iannis Ben Abdallah
- Université Paris Cité, France & Service de Chirurgie Vasculaire, Hôpital Bichat, APHP Nord, Paris, France
| | - Maxime Ronot
- Université Paris Cité, France & Service de Radiologie, Hôpital Beaujon, APHP Nord, Clichy, France.
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5
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Zhang FL, Chen XW, Wang YF, Hu Z, Zhang WJ, Zhou BW, Ci PF, Liu KX. Microbiota-derived tryptophan metabolites indole-3-lactic acid is associated with intestinal ischemia/reperfusion injury via positive regulation of YAP and Nrf2. J Transl Med 2023; 21:264. [PMID: 37072757 PMCID: PMC10111656 DOI: 10.1186/s12967-023-04109-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 04/06/2023] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND Lactobacillus has been demonstrated to serve a protective role in intestinal injury. However, the relationship between Lactobacillus murinus (L. murinus)-derived tryptophan metabolites and intestinal ischemia/reperfusion (I/R) injury yet to be investigated. This study aimed to evaluate the role of L. murinus-derived tryptophan metabolites in intestinal I/R injury and the underlying molecular mechanism. METHODS Liquid chromatograph mass spectrometry analysis was used to measure the fecal content of tryptophan metabolites in mice undergoing intestinal I/R injury and in patients undergoing cardiopulmonary bypass (CPB) surgery. Immunofluorescence, quantitative RT-PCR, Western blot, and ELISA were performed to explore the inflammation protective mechanism of tryptophan metabolites in WT and Nrf2-deficient mice undergoing intestinal I/R, hypoxia-reoxygenation (H/R) induced intestinal organoids. RESULTS By comparing the fecal contents of three L. murinus-derived tryptophan metabolites in mice undergoing intestinal I/R injury and in patients undergoing cardiopulmonary bypass (CPB) surgery. We found that the high abundance of indole-3-lactic acid (ILA) in the preoperative feces was associated with better postoperative intestinal function, as evidenced by the correlation of fecal metabolites with postoperative gastrointestinal function, serum I-FABP and D-Lactate levels. Furthermore, ILA administration improved epithelial cell damage, accelerated the proliferation of intestinal stem cells, and alleviated the oxidative stress of epithelial cells. Mechanistically, ILA improved the expression of Yes Associated Protein (YAP) and Nuclear Factor erythroid 2-Related Factor 2 (Nrf2) after intestinal I/R. The YAP inhibitor verteporfin (VP) reversed the anti-inflammatory effect of ILA, both in vivo and in vitro. Additionally, we found that ILA failed to protect epithelial cells from oxidative stress in Nrf2 knockout mice under I/R injury. CONCLUSIONS The content of tryptophan metabolite ILA in the preoperative feces of patients is negatively correlated with intestinal function damage under CPB surgery. Administration of ILA alleviates intestinal I/R injury via the regulation of YAP and Nrf2. This study revealed a novel therapeutic metabolite and promising candidate targets for intestinal I/R injury treatment.
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Affiliation(s)
- Fang-Ling Zhang
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, 1838 Guangzhou Ave N, Guangzhou, 510515, China
| | - Xiao-Wei Chen
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, 1838 Guangzhou Ave N, Guangzhou, 510515, China
- Department of Anaesthesiology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, 518053, Guangdong, China
| | - Yi-Fan Wang
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, 1838 Guangzhou Ave N, Guangzhou, 510515, China
| | - Zhen Hu
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, 1838 Guangzhou Ave N, Guangzhou, 510515, China
| | - Wen-Juan Zhang
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, 1838 Guangzhou Ave N, Guangzhou, 510515, China
| | - Bo-Wei Zhou
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, 1838 Guangzhou Ave N, Guangzhou, 510515, China
| | - Peng-Fei Ci
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, 1838 Guangzhou Ave N, Guangzhou, 510515, China
| | - Ke-Xuan Liu
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, 1838 Guangzhou Ave N, Guangzhou, 510515, China.
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Zeng Y, Yang F, Hu X, Zhu F, Chen W, Lin W. Radiological predictive factors of transmural intestinal necrosis in acute mesenteric ischemia: systematic review and meta-analysis. Eur Radiol 2023; 33:2792-2799. [PMID: 36449058 DOI: 10.1007/s00330-022-09258-5] [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: 07/22/2022] [Revised: 09/25/2022] [Accepted: 10/19/2022] [Indexed: 12/05/2022]
Abstract
OBJECTIVE Transmural intestinal necrosis (TIN) is related to high mortality in patients with acute mesenteric ischemia (AMI). Radiological predictive factors of TIN in AMI remains controversial. This study aimed to identify the CT-based predictive factors of TIN in AMI. METHODS EMBASE and PUBMED were searched for publications predicting TIN using radiological features. Quality Assessment of Diagnostic Accuracy Studies-2 was used to assess the methodological quality of individual studies. Data were presented in terms of diagnostic odds ratio (DOR), sensitivity, specificity, and 95% confidence interval (CI). The random-effects models were used for the meta-analysis. RESULTS Eleven studies including 1037 cases with AMI were considered. The meta-analysis showed that bowel wall thinning (DOR = 13.10; 95% CI: 3.71, 46.25), decreased or absent bowel wall enhancement (DOR = 5.77; 95% CI: 2.95, 11.30), bowel dilation (DOR = 3.23; 95% CI: 2.03, 5.15), pneumatosis intestinalis (DOR = 5.78; 95% CI: 2.24, 14.95), porto-mesenteric venous gas (DOR = 5.36; 95% CI: 2.14, 13.40), and arterial occlusive AMI (DOR = 2.66; 95% CI: 1.53, 4.63) were risk factors for predicting TIN. Bowel wall thinning and porto-mesenteric venous gas displayed high specificity to diagnose TIN (98%, 95%, respectively). The subgroup analysis showed that decreased or absent bowel wall enhancement (DOR = 8.23; 95% CI: 4.67, 14.51) and bowel dilation (DOR = 3.14; 95% CI: 1.55, 6.39) were predictors of TIN in venous occlusive AMI, which were not related to TIN in arterial-origin AMI. CONCLUSIONS For predicting TIN, there are specific radiological features. The radiological predictors of TIN may differ according to the various causes of AMI. Future primary studies should further evaluate the relationships between radiological signs and TIN based on different etiologies. KEY POINTS • Bowel wall thinning, decreased or absent bowel wall enhancement, bowel dilation, pneumatosis intestinalis, porto-mesenteric venous gas, and arterial occlusive AMI were risk factors for predicting TIN. • Decreased or absent bowel wall enhancement and bowel dilation were predictors of TIN in venous occlusive AMI, which were not related to TIN in arterial-origin AMI.
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Affiliation(s)
- Yi Zeng
- Department of Radiology, Sichuan Province Orthopedic Hospital, Chengdu, 610041, Sichuan, China
| | - Fan Yang
- Department of Radiology, Chengdu First People's Hospital, Chengdu, 610041, Sichuan, China
| | - Xiaoyan Hu
- Department of Radiology, Chengdu First People's Hospital, Chengdu, 610041, Sichuan, China
| | - Fei Zhu
- Department of Radiology, West China Hospital, Sichuan University, No.37, Guoxue Road, Chengdu, 610041, Sichuan, China
| | - Weixia Chen
- Department of Radiology, West China Hospital, Sichuan University, No.37, Guoxue Road, Chengdu, 610041, Sichuan, China.
| | - Wei Lin
- Department of Radiology, Chengdu First People's Hospital, Chengdu, 610041, Sichuan, China
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7
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Garzelli L, Felli E, Al-Taher M, Barberio M, Agnus V, Plaforet V, Bonvalet F, Baiocchini A, Nuzzo A, Paulatto L, Vilgrain V, Gallix B, Diana M, Ronot M. MRI for the Detection of Small Bowel Ischemic Injury in Arterial Acute Mesenteric Ischemia: Preclinical Study in a Porcine Model. J Magn Reson Imaging 2023; 57:918-927. [PMID: 35852296 DOI: 10.1002/jmri.28344] [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: 12/08/2021] [Revised: 06/22/2022] [Accepted: 06/22/2022] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND MRI is the reference for the diagnosis of arterial cerebral ischemia, but its role in acute mesenteric ischemia (AMI) is poorly known. PURPOSE To assess MRI detection of early ischemic bowel lesions in a porcine model of arterial AMI. STUDY TYPE Prospective/cohort. ANIMAL MODEL Porcine model of arterial AMI obtained by embolization of the superior mesenteric artery (seven pigs). FIELD STRENGTH/SEQUENCE A 5-T. T1 gradient-echo-weighted-imaging (WI), half-Fourier-acquisition-single-shot-turbo-spin-echo, T2 turbo-spin-echo, true-fast-imaging-with-steady-precession (True-FISP), diffusion-weighted-echo-planar (DWI). ASSESSMENT T1-WI, T2-WI, and DWI were performed before and continuously after embolization for 6 hours. The signal intensity (SI) of the ischemic bowel was assessed visually and quantitatively on all sequences. The apparent diffusion coefficient (ADC) was assessed. STATISTICAL TESTS Paired Student's t-test or Mann-Whitney U-test, significance at P < 0.05. RESULTS One pig died from non-AMI-related causes. The remaining pigs underwent a median 5 h53 (range 1 h24-6 h01) of ischemia. Visually, the ischemic bowel showed signal hyperintensity on DWI-b800 after a median 85 (57-276) minutes compared to the nonischemic bowel. DWI-b800 SI significantly increased after 2 hours (+19%) and the ADC significant decrease within the first hour (-31%). The ischemic bowel was hyperintense on precontrast T1-WI after a median 87 (70-171) minutes with no significant quantitative changes over time (P = 0.46-0.93). The ischemic bowel was hyperintense on T2-WI in three pigs with a significant SI increase on True-FISP after 1 and 2 hours. DATA CONCLUSION Changes in SI and ADC can be seen early after the onset of arterial AMI with DWI. The value of T2-WI appears to be limited. EVIDENCE LEVEL 1 TECHNICAL EFFICACY: Stage 2.
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Affiliation(s)
- Lorenzo Garzelli
- Université Paris Cité, Paris, France & Department of Radiology, Beaujon Hospital, APHP.Nord, Clichy, France.,IHU Strasbourg - Image Guided Surgery, Strasbourg University, Strasbourg, France
| | - Eric Felli
- IHU Strasbourg - Image Guided Surgery, Strasbourg University, Strasbourg, France.,Hepatology, Department of Biomedical Research, Inselspital, University of Bern, Bern, Switzerland
| | - Mahdi Al-Taher
- IHU Strasbourg - Image Guided Surgery, Strasbourg University, Strasbourg, France
| | - Manuel Barberio
- IHU Strasbourg - Image Guided Surgery, Strasbourg University, Strasbourg, France
| | - Vincent Agnus
- IHU Strasbourg - Image Guided Surgery, Strasbourg University, Strasbourg, France
| | - Vincent Plaforet
- Université Paris Cité, Paris, France & Department of Radiology, Beaujon Hospital, APHP.Nord, Clichy, France
| | - Fanny Bonvalet
- Université Paris Cité, Paris, France & Department of Radiology, Beaujon Hospital, APHP.Nord, Clichy, France
| | - Andrea Baiocchini
- Department of Pathology, San Camillo Forlanini Hospital, Rome, Italy
| | - Alexandre Nuzzo
- Université Paris Cité, Paris, France & Structure d'Urgence Vasculaire Intestinales (SURVI), Nutritional support, Gastroenterology, Beaujon Hospital, APHP.Nord, Clichy, France
| | - Luisa Paulatto
- Université Paris Cité, Paris, France & Department of Radiology, Beaujon Hospital, APHP.Nord, Clichy, France
| | - Valérie Vilgrain
- Université Paris Cité, Paris, France & Department of Radiology, Beaujon Hospital, APHP.Nord, Clichy, France
| | - Benoit Gallix
- IHU Strasbourg - Image Guided Surgery, Strasbourg University, Strasbourg, France
| | - Michele Diana
- IHU Strasbourg - Image Guided Surgery, Strasbourg University, Strasbourg, France.,IRCAD, Research Institute against Digestive Cancer, Strasbourg, France.,Department of General, Digestive and Endocrine Surgery, University Hospital of Strasbourg, France.,ICube Lab, Photonics for Health, Strasbourg, France
| | - Maxime Ronot
- Université Paris Cité, Paris, France & Department of Radiology, Beaujon Hospital, APHP.Nord, Clichy, France
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8
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Abstract
Acute mesenteric ischemia (AMI) is an uncommon yet highly lethal cause of acute abdomen in the emergency setting. Computed tomography (CT) imaging, in particular a biphasic protocol consisting of angiographic and venous phase scans, is widely used to corroborate non-specific clinical findings when suspicions of AMI are high. Techniques such as low kilovoltage peak scanning, dual energy acquisition, or a combined arterial/enteric phase can improve iodine conspicuity and evaluation of bowel enhancement. Biphasic CT with CT angiography is mandatory to directly assess for the 3 primary etiologies of AMI-arterial, venous, and non-occlusive mesenteric ischemia (NOMI), and the CT angiographic findings may be the first visible in the disease. In addition, numerous non-vascular CT findings have also been reported. Bowel wall thickening, mesenteric stranding, and ascites are common but non-specific findings that correlate poorly with disease severity. Pneumatosis intestinalis and portomesenteric venous gas, while not pathognomonic for ischemia, are highly specific in cases of high clinical suspicion. Bowel wall hypoenhancement is an early and specific sign but requires a protocol optimizing iodine conspicuity to confidently identify. Finally, intraperitoneal free air and solid organ infarcts are also highly specific ancillary findings in AMI. AMI occurs as a complication in 10% of small bowel obstruction (SBO) patients, and understanding imaging findings of ischemia in the context of SBO is necessary to aid in treatment planning and reduce over- and under-diagnosis of strangulation. Familiarity with the imaging features of ischemia by radiologists is vital to establish an early diagnosis before irreversible necrosis occurs.
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Affiliation(s)
- Hang Yu
- Department of Diagnostic Radiology, 8664University of Manitoba, Winnipeg, MB, Canada
| | - Iain D C Kirkpatrick
- Department of Diagnostic Radiology, 8664University of Manitoba, Winnipeg, MB, Canada
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9
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Topolsky A, Pantet O, Liaudet L, Sempoux C, Denys A, Knebel JF, Schmidt S. MDCT-findings in patients with non-occlusive mesenteric ischemia (NOMI): influence of vasoconstrictor agents. Eur Radiol 2023; 33:3627-3637. [PMID: 36692594 PMCID: PMC10121529 DOI: 10.1007/s00330-023-09415-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 11/02/2022] [Accepted: 01/01/2023] [Indexed: 01/25/2023]
Abstract
OBJECTIVES To evaluate the influence of vasoconstrictor agents (VCAs) on signs of vasoconstriction and bowel ischemia on MDCT detected in patients with non-occlusive mesenteric ischemia (NOMI). METHODS This 8-year single-center retrospective study consecutively included all patients with histopathologically proven NOMI who underwent MDCT ≤ 48 h prior to surgical bowel resection. Two blinded radiologists jointly reviewed each examination for signs of bowel ischemia, abdominal organ infarct, mesenteric vessel size and regularity, and ancillary vascular findings. VCA administration (length and dosage), clinical and biochemical data, risk factors, and outcomes were retrieved from patients' medical records. Subgroup comparisons were performed. RESULTS Ninety patients were included (59 males, mean age 65 years); 40 (44.4%) had received VCAs before MDCT. Overall mortality was 32% (n = 29), with no significant difference between the two groups. In patients treated with VCAs, the calibre of the superior mesenteric artery (SMA) was smaller (p = 0.032), and vasoconstriction of its branches tended to be more important (p = 0.096) than in patients not treated with VCAs. The presence and extent of bowel ischemia did not significantly correlate with VCA administration, but abdominal organ infarcts tended to be more frequent (p = 0.005) and involved more organs (p = 0.088). The VCA group had lower mean arterial pressure (p = 0.006) and lower hemoglobin levels (p < 0.001). Several biomarkers of organ failure and inflammation, differed significantly with VCA use, proving worse clinical condition. CONCLUSIONS MDCT demonstrates more severe SMA vasoconstriction and tends to show increased abdominal organ infarcts after VCA administration in NOMI patients compared to NOMI patients not treated with VCAs. KEY POINTS • In critically ill patients with NOMI, MDCT demonstrates VCA support via increased vasoconstriction of the main SMA and its branches. • VCA administration in NOMI patients tends to contribute to the development of organ infarcts, as shown on MDCT. • An important degree of vasoconstriction in NOMI patients may indicate insufficient resuscitation and, thus, help clinicians in further patient management.
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Affiliation(s)
- Antoine Topolsky
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Olivier Pantet
- Service of Adult Intensive Care Medicine and Burns, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Lucas Liaudet
- Service of Adult Intensive Care Medicine and Burns, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Christine Sempoux
- Service of Clinical Pathology, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Alban Denys
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Jean-François Knebel
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Sabine Schmidt
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Rue du Bugnon 46, 1011, Lausanne, Switzerland.
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Srisajjakul S, Prapaisilp P, Bangchokdee S. Comprehensive review of acute small bowel ischemia: CT imaging findings, pearls, and pitfalls. Emerg Radiol 2022; 29:531-544. [PMID: 35122558 DOI: 10.1007/s10140-022-02028-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 01/31/2022] [Indexed: 01/12/2023]
Abstract
Acute small bowel ischemia is a life-threatening condition with a high mortality rate due to its lack of specific symptoms and laboratory profile, which render difficulty in establishing early diagnosis. The etiology of acute small bowel ischemia includes occlusive forms (arterial embolism, arterial thrombosis, and venous thrombosis) and nonocclusive mesenteric ischemia, of which arterial causes are far more common than venous causes. CT, the mainstay of accurate diagnoses, allows the identification of the features of vascular abnormalities and intestinal ischemic injuries, and helps clinicians to restore intestinal blood flow. Without treatment, the prognosis for acute small bowel ischemia is poor. A high index of suspicion and familiarity with the CT spectral findings of bowel ischemia are required to ensure rapid recognition of this condition.
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Affiliation(s)
- Sitthipong Srisajjakul
- Department of Radiology, Faculty of Medicine, Division of Diagnostic Radiology, Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand.
| | - Patcharin Prapaisilp
- Department of Radiology, Faculty of Medicine, Division of Diagnostic Radiology, Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Sirikan Bangchokdee
- Department of Internal Medicine, Pratumthani Hospital, 7 Ladlumkaew Muang District, Pratumthani, 12000, Thailand
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11
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Bourcier S, Klug J, Nguyen LS. Non-occlusive mesenteric ischemia: Diagnostic challenges and perspectives in the era of artificial intelligence. World J Gastroenterol 2021; 27:4088-4103. [PMID: 34326613 PMCID: PMC8311528 DOI: 10.3748/wjg.v27.i26.4088] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 03/25/2021] [Accepted: 06/18/2021] [Indexed: 02/06/2023] Open
Abstract
Acute mesenteric ischemia (AMI) is a severe condition associated with poor prognosis, ultimately leading to death due to multiorgan failure. Several mechanisms may lead to AMI, and non-occlusive mesenteric ischemia (NOMI) represents a particular form of AMI. NOMI is prevalent in intensive care units in critically ill patients. In NOMI management, promptness and accuracy of diagnosis are paramount to achieve decisive treatment, but the last decades have been marked by failure to improve NOMI prognosis, due to lack of tools to detect this condition. While real-life diagnostic management relies on a combination of physical examination, several biomarkers, imaging, and endoscopy to detect the possibility of several grades of NOMI, research studies only focus on a few elements at a time. In the era of artificial intelligence (AI), which can aggregate thousands of variables in complex longitudinal models, the prospect of achieving accurate diagnosis through machine-learning-based algorithms may be sought. In the following work, we bring you a state-of-the-art literature review regarding NOMI, its presentation, its mechanics, and the pitfalls of routine work-up diagnostic exams including biomarkers, imaging, and endoscopy, we raise the perspectives of new biomarker exams, and finally we discuss what AI may add to the field, after summarizing what this technique encompasses.
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Affiliation(s)
- Simon Bourcier
- Department of Intensive Care Medicine, University Hospital of Geneva, Geneva 1201, Switzerland
| | - Julian Klug
- Department of Internal Medicine, Groupement Hospitalier de l’Ouest Lémanique, Nyon 1260, Switzerland
| | - Lee S Nguyen
- Department of Intensive Care Medicine, CMC Ambroise Paré, Neuilly-sur-Seine 92200, France
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12
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Davarpanah AH, Ghamari Khameneh A, Khosravi B, Mir A, Saffar H, Radmard AR. Many faces of acute bowel ischemia: overview of radiologic staging. Insights Imaging 2021; 12:56. [PMID: 33914188 PMCID: PMC8085211 DOI: 10.1186/s13244-021-00985-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 03/16/2021] [Indexed: 12/12/2022] Open
Abstract
Acute bowel ischemia (ABI) can be life threatening with high mortality rate. In spite of the advances made in diagnosis and treatment of ABI, no significant change has occurred in the mortality over the past decade. ABI is potentially reversible with prompt diagnosis. The radiologist plays a central role in the initial diagnosis and preventing progression to irreversible intestinal ischemic injury or bowel necrosis. The most single imaging findings described in the literature are either non-specific or only present in the late stages of ABI, urging the use of a constellation of features to reach a more confident diagnosis. While ABI has been traditionally categorized based on the etiology with a wide spectrum of imaging findings overlapped with each other, the final decision for patient’s management is usually made on the stage of the ABI with respect to the underlying pathophysiology. In this review, we first discuss the pathologic stages of ischemia and then summarize the various imaging signs and causes of ABI. We also emphasize on the correlation of imaging findings and pathological staging of the disease. Finally, a management approach is proposed using combined clinical and radiological findings to determine whether the patient may benefit from surgery or not.
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Affiliation(s)
- Amir H Davarpanah
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, USA
| | - Afshar Ghamari Khameneh
- Department of Radiology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Bardia Khosravi
- Department of Radiology, Shariati Hospital, Tehran University of Medical Sciences, 14117, North Kargar St., Tehran, Iran
| | - Ali Mir
- Department of Surgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Hiva Saffar
- Department of Pathology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Reza Radmard
- Department of Radiology, Shariati Hospital, Tehran University of Medical Sciences, 14117, North Kargar St., Tehran, Iran.
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13
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Verdot P, Calame P, Winiszewski H, Grillet F, Malakhia A, Lakkis Z, Ronot M, Pili-Floury S, Piton G, Delabrousse E. Diagnostic performance of CT for the detection of transmural bowel necrosis in non-occlusive mesenteric ischemia. Eur Radiol 2021; 31:6835-6845. [PMID: 33585993 DOI: 10.1007/s00330-021-07728-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 12/29/2020] [Accepted: 01/28/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To evaluate the diagnostic performance of CT for transmural necrosis (TN) in non-occlusive mesenteric ischemia (NOMI) according to the bowel segment involved. METHODS From January 2009 to December 2019, all patients admitted to the intensive care unit (ICU) and requiring laparotomy for NOMI were retrospectively studied. CT had to have been performed within 24 h prior to laparotomy and were reviewed by two abdominal radiologists, with a consensus reading in case of disagreement. A set of CT features of mesenteric ischemia were assessed, separating the stomach, jejunum, ileum, and right (RC) and left colon (LC). Univariate and multivariate analyses were performed to identify features associated with TN. Its influence on overall survival (OS) was assessed. RESULTS Among 145 patients, 95 (66%) had ≥ 1 bowel segment with TN, including 7 (5%), 31 (21%), 43 (29%), 45 (31%), and 52 (35%) in the stomach, jejunum, ileum, RC, and LC, respectively. Overall inter-reader agreement of CT features was significantly lower in the colon than in the small bowel (0.59 [0.52-0.65] vs 0.74 [0.70-0.77] respectively). The absence of bowel wall enhancement was the only CT feature associated with TN by multivariate analysis, whatever the bowel segment involved. Proximal TN was associated with poorer OS (p < 0.001). CONCLUSIONS The absence of bowel wall enhancement remains the most consistent CT feature of transmural necrosis, whatever the bowel segment involved in NOMI. Inter-reader agreement of CT features is lower in the colon than in the small bowel. Proximal TN seems to be associated with poorer OS. KEY POINTS • The absence of bowel wall enhancement is the most consistent CT feature associated with transmural necrosis in NOMI, whatever is the bowel segment involved. • Inter-reader agreement is lower in the colon than in the small bowel in NOMI. • In NOMI, the more proximal the bowel necrosis, the worse the prognosis.
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Affiliation(s)
- Pierre Verdot
- Department of Radiology, University of Bourgogne Franche-Comté, CHRU Besançon, 25030, Besançon, France
| | - Paul Calame
- Department of Radiology, University of Bourgogne Franche-Comté, CHRU Besançon, 25030, Besançon, France. .,EA 4662 Nanomedicine Lab, Imagery and Therapeutics, University of Franche-Comté, Besançon, France.
| | - Hadrien Winiszewski
- Medical Intensive Care Unit, University of Bourgogne Franche-Comté, CHRU Besançon, 25030, Besançon, France
| | - Franck Grillet
- Department of Radiology, University of Bourgogne Franche-Comté, CHRU Besançon, 25030, Besançon, France
| | - Alexandre Malakhia
- Department of Radiology, University of Bourgogne Franche-Comté, CHRU Besançon, 25030, Besançon, France
| | - Zaher Lakkis
- Digestive Surgery Unit, University of Bourgogne Franche-Comté, CHRU Besançon, 25030, Besançon, France
| | - Maxime Ronot
- Department of Radiology, Hôpital Beaujon, APHP.Nord,Université de Paris, 92110, Clichy, France
| | - Sebastien Pili-Floury
- Surgical Intensive Care Unit, University of Bourgogne Franche-Comté, CHRU Besançon, 25030, Besançon, France
| | - Gael Piton
- Medical Intensive Care Unit, University of Bourgogne Franche-Comté, CHRU Besançon, 25030, Besançon, France
| | - Eric Delabrousse
- Department of Radiology, University of Bourgogne Franche-Comté, CHRU Besançon, 25030, Besançon, France.,EA 4662 Nanomedicine Lab, Imagery and Therapeutics, University of Franche-Comté, Besançon, France
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14
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Tang W, Jin B, Kuang LQ, Zhang J, Li CX, Wang Y. Risk factors of geriatrics index of comorbidity and MDCT findings for predicting mortality in patients with acute mesenteric ischemia due to superior mesenteric artery thromboembolism. Br J Radiol 2020; 93:20190605. [PMID: 32886528 DOI: 10.1259/bjr.20190605] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES To identify risk factors of geriatrics index of comorbidity (GIC) and multidetector CT (MDCT) findings for predicting mortality in patients with acute mesenteric ischemia (AMI) due to superior mesenteric artery (SMA) thromboembolism. METHODS 33 patients with AMI due to SMA thromboembolism underwent abdominal MDCT and angiography. Patients' comorbidities and MDCT findings of ischemic bowel/mesenteric injuries, regions of SMA involved by thromboembolism, and degrees of SMA stenosis were retrospectively reviewed. The comorbidities were classified into 1-4 levels according to GIC. The association of MDCT signs and GIC classification with mortality were analyzed. Diagnostic performances of risk factors associated with mortality were evaluated by receiver operating characteristic (ROC) curve analyses. RESULTS Eighteen patients (54.5%) died during hospitalization or follow-up, including one patient with class 1, two patients with class 2, eight patients with class 3, and seven patients with class 4 according to GIC. Three risk factors significantly associated with mortality were identified, including pneumatosis and/or portomesenteric venous gas (PPMVG) (p = 0.017), four regions of SMA involved by thromboembolism (region I + II + III + IV) (p = 0.036), and class 3 + 4 of comorbidities (p = 0.001). The sensitivity and specificity of PPMVG, region I + II + III + IV, class 3 + 4 of comorbidities, and the three risk factors combined for diagnosing mortality were 33.3 and 100%, 27.8 and 100%, 83.3 and 73.3%, and 88.9 and 73.3%, respectively. The areas under the ROC curve (AUC) of the three risk factors combined (0.88) and class 3 + 4 of comorbidities (0.78) were larger than that of PPMVG (0.67) and region I + II + III + IV (0.64). The mortality rate rose from 15.4% in patients without risk factor to 66.7%, 100%, and 100% in patients with one, two, and three factors, respectively. CONCLUSION Three risk factors for mortality were identified in patients with AMI due to SMA thromboembolism, including PPMVG and four regions of SMA involved by thromboembolism on MDCT images, and class 3 + 4 of comorbidities. Close monitoring of these risk factors could possibly lower the mortality. ADVANCES IN KNOWLEDGE Risk factors based on GIC and MDCT findings may be used to predict mortality in patients with AMI. Close monitoring of these risk factors could possibly lower the mortality.
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Affiliation(s)
- Wei Tang
- Department of Radiology, Daping Hospital, Army Medical University, Chongqing 400042, China.,Sichuan Key Laboratory of Medical Imaging, Department of Radiology, Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, China
| | - Bo Jin
- Department of Radiology, Daping Hospital, Army Medical University, Chongqing 400042, China
| | - Lian-Qin Kuang
- Department of Radiology, Daping Hospital, Army Medical University, Chongqing 400042, China
| | - Jing Zhang
- Department of Radiology, Daping Hospital, Army Medical University, Chongqing 400042, China
| | - Chun-Xue Li
- Department of Gastrointestinal Surgery, Daping Hospital, Army Medical University, Chongqing 400042, China
| | - Yi Wang
- Department of Radiology, Daping Hospital, Army Medical University, Chongqing 400042, China
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15
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Mothes H, Mueller-Mau V, Lehmkuhl L, Lehmann T, Settmacher U, Teichgräber U, Ludewig S. The role of computed tomography in the diagnostic pathway of acute mesenteric ischemia: a nested case-control study. Acta Radiol 2020; 61:1444-1451. [PMID: 32077303 DOI: 10.1177/0284185120905086] [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: 01/25/2023]
Abstract
BACKGROUND Computed tomography (CT) can be used as the primary screening modality for the evaluation of patients suspected of having acute mesenteric ischemia known to show high sensitivity and specificity rates. PURPOSE To prove the value of CT in patients with pathological abdominal findings following cardiac surgery. MATERIAL AND METHODS In a retrospective case-control study, 12 different CT scan parameters of patients with or without mesenteric ischemia following cardiac surgery were compared using univariate and logistic regression analyses. RESULTS Of 14,176 patients, 133 (0.9%) received an abdominal CT scan during postoperative care due to pathological abdominal findings. Sixty-eight patients were diagnosed with acute mesenteric ischemia. In-hospital mortality was 73.5% for this group. CT parameters with the highest specificity for indicating colonic ischemia were intestinal (99%) or porto-venous (96%) pneumatosis, abnormal contrast medium enhancement (89%), and occlusion of the proximal inferior mesenteric artery (81%). All of those parameters showed low sensitivity levels in the range of 15%-23%. A statistically significant association between acute mesenteric ischemia and CT appearance was obtained for contrast medium enhancement (odds ratio [OR] 12.2, 95% confidence interval [CI] 1.5-99.2) and intestinal pneumatosis (OR 21.0, 95% CI 2.7-165.2) only. CONCLUSION The typical CT criteria indicating mesenteric ischemia lose their accuracy in patients under critical clinical conditions. As CT remains the first-line diagnostic imaging modality for abnormal abdominal findings following cardiac surgery, negative signs should not prevent early laparotomy if clinical suspicion remains high.
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Affiliation(s)
- Henning Mothes
- Department of General, Visceral and Vascular Surgery, Sophien- und Hufeland-Klinikum, Weimar, Germany
| | - Vetlana Mueller-Mau
- Department of General, Visceral and Vascular Surgery, Robert-Koch-Krankenhaus, Apolda, Germany
| | - Lukas Lehmkuhl
- Rhön-Klinikum Campus Bad-Neustadt, Department of Diagnostic Radiology, Bad Neustadt, Germany
| | - Thomas Lehmann
- Institute of Medical Statistics, Informatics and Documentation, University Hospital, Jena, Germany
| | - Utz Settmacher
- Department of General, Visceral and Vascular Surgery, University Hospital, Friedrich-Schiller-University Jena, Jena, Germany
| | - Ulf Teichgräber
- Department of Diagnostic and Interventional Radiology, University Hospital, Friedrich-Schiller-University Jena, Jena, Germany
| | - Stefan Ludewig
- Department of General, Visceral and Vascular Surgery, University Hospital, Friedrich-Schiller-University Jena, Jena, Germany
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Abstract
OBJECTIVE. The purpose of this article is to provide an overview of the diagnostic and prognostic roles of CT in the management of acute mesenteric ischemia. CONCLUSION. Acute mesenteric ischemia is defined as inadequate blood supply to the gastrointestinal tract resulting in ischemic and inflammatory injury. The prognosis is poor without treatment. Contrast-enhanced CT has become the cornerstone of diagnosis to identify features of vascular disorders and of intestinal ischemic injury and to visualize bowel necrosis.
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17
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Li Y, Liu M, Gao S, Cai L, Zhang Q, Yan S, Liu G, Ji B. Cold-inducible RNA-binding protein maintains intestinal barrier during deep hypothermic circulatory arrest. Interact Cardiovasc Thorac Surg 2020; 29:583-591. [PMID: 31271215 DOI: 10.1093/icvts/ivz147] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 05/14/2019] [Accepted: 05/23/2019] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES The intestinal injury during deep hypothermic circulatory arrest (DHCA) is harmful to clinical outcomes. Cold-inducible RNA-binding protein (CIRBP) plays a protective role in hypothermia. The aim of this study was to explore the effects of CIRBP on intestinal barrier during DHCA. METHODS Sprague-Dawley (wild type, n = 13) and knockout of Cirbp (Cirbp-/-, n = 8) rats were used in the model of DHCA. The histomorphology of the epithelial barrier was evaluated by haematoxylin-eosin, Chiu's scores, Gram's stain and Ki67. The function of the intestinal barrier was evaluated by serum intestinal fatty acid-binding protein, diamine oxidase and d-lactate. The structure of the epithelial barrier, phosphocreatine-creatine kinase system and adenosine triphosphate were assessed in the intestine. RESULTS The expression of CIRBP significantly increased in the intestine during DHCA. Cirbp-/- rats showed obvious destruction of intestinal barrier after DHCA. Chiu's scores, intestinal fatty acid-binding protein, diamine oxidase and d-lactate significantly increased in the Cirbp-/- group. Ki67 showed that cell proliferation decreased in the Cirbp-/- rats. In the Cirbp-/- group, zonula occludens-1, E-cadherin and occludin levels were significantly decreased, and these proteins either disappeared or redistributed in the monolayer. Besides, Cirbp-/- resulted in decreased levels of creatine kinase B, glycine amidinotransferase, adenosine triphosphate and creatine contents in the intestine, affecting energy metabolism and balance, which is associated with the maintenance of epithelial barrier during acute injury. CONCLUSIONS CIRBP is related to the maintenance of the intestinal epithelial barrier during DHCA, which is expected to be a new target for the prevention of intestinal injury.
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Affiliation(s)
- Yongnan Li
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.,Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
| | - Mingyue Liu
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Sizhe Gao
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Liming Cai
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.,Department of Cardiac Surgery, Capital Institute of Pediatrics, Beijing, China
| | - Qiaoni Zhang
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Shujie Yan
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Gang Liu
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Bingyang Ji
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
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18
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Canfora A, Ferronetti A, Marte G, Maio VD, Mauriello C, Maida P, Bottino V, Aprea G, Amato B. Predictive Factors of Intestinal Necrosis in Acute Mesenteric Ischemia. Open Med (Wars) 2019; 14:883-889. [PMID: 31934635 PMCID: PMC6947755 DOI: 10.1515/med-2019-0104] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 09/30/2019] [Indexed: 12/17/2022] Open
Abstract
Objectives Acute mesenteric ischemia (AMI) is a gastrointestinal and vascular emergency in which the detection of patients requiring intestinal resection is mandatory. Methods Registered data of 55 consecutive patients admitted to our center between January 2010 and December 2016 that underwent an explorative laparotomy for a suspected diagnosis of irreversible transmural intestinal necrosis (ITIN) were analyzed. Demographic, clinical, laboratory and CT findings were statistically analyzed in order to search predictive factors of ITIN and their correlation to its clinical spectre. Results Tobacco use was the most statistically significant (p<0.01) cardiovascular disease risk factor involved in ITIN. Among lab tests, Serum lactate levels ˃ 2mmol/L resulted in a statistically significant association with ITIN (p=0.0001). Organ failure (defined as Marshall score> 2) and the three main CT findings (decreased bowel wall enhancement, bowel loop dilation and demonstrated vessel occlusion) were strongly associated with ITIN (p values: 0.001, 0.007, 0.0013, 0.0005). Only serum lactate levels>2 mmol/L resulted as statistically significant as predictive factors of ITIN in multivariate analysis using logistic regression (OR 49.66 and p-value 0.0021). Conclusion Our univariate and multivariate analysis identified multiple factors (Serum lactate levels ˃ 2mmol/L, Organ failure, CT signs) that could suggest patients that require a surgical approach for ITIN.
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Affiliation(s)
- Alfonso Canfora
- Department of General Surgery, Evangelic Hospital Betania, Via Argine, 604 - 80147, Naples-Italy
| | - Antonio Ferronetti
- Department of General Surgery, Evangelic Hospital Betania, Via Argine, 604 - 80147, Naples-Italy
| | - Gianpaolo Marte
- Department of General Surgery, Evangelic Hospital Betania, Via Argine, 604 - 80147, Naples-Italy
| | - Vittorio Di Maio
- Department of General Surgery, Evangelic Hospital Betania, Via Argine, 604 - 80147, Naples-Italy
| | - Claudio Mauriello
- Department of General Surgery, Evangelic Hospital Betania, Via Argine, 604 - 80147, Naples-Italy
| | - Pietro Maida
- Department of General Surgery, Evangelic Hospital Betania, Via Argine, 604 - 80147, Naples-Italy
| | - Vincenzo Bottino
- Department of General Surgery, Evangelic Hospital Betania, Via Argine, 604 - 80147, Naples-Italy
| | - Giovanni Aprea
- Department of General Surgery, University of Naples Federico II, Naples, Italy
| | - Bruno Amato
- Department of General Surgery, University of Naples Federico II, Naples, Italy
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19
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Predictive Risk Factors of Intestinal Necrosis in Patients with Mesenteric Venous Thrombosis: Retrospective Study from a Single Center. Can J Gastroenterol Hepatol 2019; 2019:8906803. [PMID: 31205904 PMCID: PMC6530214 DOI: 10.1155/2019/8906803] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 03/07/2019] [Accepted: 03/21/2019] [Indexed: 02/05/2023] Open
Abstract
PURPOSES Mesenteric venous thrombosis (MVT) is a serious condition. The current study aimed to identify risk factors of intestinal necrosis (IN) in patients with MVT to predict the onset of patients. METHODS Data pertaining to patients diagnosed with MVT between 2014 and May 2018 were reviewed. Patients' characteristics and risk factors of IN were assessed. RESULTS Seventy-eight patients were included in our study, of whom all cases were diagnosed as superior mesenteric venous thrombosis. There were fifty-eight cases (74%) with intestinal necrosis and twenty cases (26%) without intestinal necrosis. Multivariate analysis of factors associated with IN was organ failure (odds ratio (OR): 4.1; 95% confidence interval (95%CI): 1.26-8.59; P=0.028), elevated serum lactate (OR:3.6; 95% CI: 1.51-5.47; P=0.024), bowel loop dilation on computerized tomography (CT) scan (OR: 2.8; 95% CI: 1.32-7.23; P=0.031), and the time between onset of symptoms and operation (OR: 4.8; 95% CI: 1.36-9.89; P=0.012). Area under the receiver operating characteristics curve for the diagnosis of IN with MVT was 0.901 (95%CI: 0.809-0.993; P=0.000) depending on the different number of predictive factors. CONCLUSION Predictive risk factors for IN with MVT were organ failure, elevated serum lactate level, bowel loop dilation on CT, and the time between onset of symptoms and operation. However, this result is from a retrospective study and further long-term, large-sample prospective studies are required to confirm this finding.
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Presepsin and Inflammatory Markers Correlate With Occurrence and Severity of Nonocclusive Mesenteric Ischemia After Cardiovascular Surgery. Crit Care Med 2018; 46:e575-e583. [DOI: 10.1097/ccm.0000000000003091] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Copin P, Ronot M, Nuzzo A, Maggiori L, Bouhnik Y, Corcos O, Vilgrain V. Inter-reader agreement of CT features of acute mesenteric ischemia. Eur J Radiol 2018; 105:87-95. [PMID: 30017304 DOI: 10.1016/j.ejrad.2018.05.027] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Revised: 05/15/2018] [Accepted: 05/29/2018] [Indexed: 02/06/2023]
Abstract
PURPOSE To evaluate the inter-reader agreement of the CT features of acute mesenteric ischemia (AMI). METHODS Between 2006 and 2014, 109 patients (57 men, 52%, mean age 50 years old [17-83]) admitted to our institution with a diagnosis of AMI were included. CT scans (42% were initially performed in our institution) were reviewed by two abdominal radiologists. Inter-observer agreement of the imaging features of vascular insufficiency and bowel ischemia was assessed by the percentage of agreement and the kappa value. RESULTS The final population included, Inter-observer agreement varied according to the different features (κ = 0.25-0.98). Inter-observer agreement for decreased/absent bowel wall enhancement was moderate (κ = 0.52), but was almost perfect (κ = 0.82) in the 47 patients (43%) with both unenhanced and arterial-phase images without positive oral contrast agent and excellent CT images quality. CONCLUSION Inter-reader agreement was moderate to substantial for most CT features of AMI. Multiphasic CT scan protocol, including unenhanced, arterial phase and venous phase images, without positive oral contrast agent, and excellent CT images quality improve inter-observer agreement of imaging features of AMI, especially for decreased/absent bowel wall enhancement, and should be performed in patients with suspected AMI.
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Affiliation(s)
- Pauline Copin
- Department of Radiology, APHP, University Hospitals Paris Nord Val de Seine, Beaujon, Clichy, Hauts-de-Seine, France
| | - Maxime Ronot
- Department of Radiology, APHP, University Hospitals Paris Nord Val de Seine, Beaujon, Clichy, Hauts-de-Seine, France; University Paris Diderot, Sorbonne Paris Cité, Paris, France; INSERM U1149, centre de recherche biomédicale Bichat-Beaujon, CRB3, Paris, France.
| | - Alexandre Nuzzo
- Department of Gastroenterology, IBD and Intestinal Failure, APHP, University Hospitals Paris Nord Val de Seine, Beaujon, Clichy, Hauts-de-Seine, France; SURVI - Structure d'URgences Vasculaires Intestinales (Intestinal Stroke), France
| | - Léon Maggiori
- University Paris Diderot, Sorbonne Paris Cité, Paris, France; Department of Surgery, APHP, University Hospitals Paris Nord Val de Seine, Beaujon, Clichy, Hauts-de-Seine, France
| | - Yoram Bouhnik
- Department of Gastroenterology, IBD and Intestinal Failure, APHP, University Hospitals Paris Nord Val de Seine, Beaujon, Clichy, Hauts-de-Seine, France; SURVI - Structure d'URgences Vasculaires Intestinales (Intestinal Stroke), France
| | - Olivier Corcos
- Department of Gastroenterology, IBD and Intestinal Failure, APHP, University Hospitals Paris Nord Val de Seine, Beaujon, Clichy, Hauts-de-Seine, France; SURVI - Structure d'URgences Vasculaires Intestinales (Intestinal Stroke), France
| | - Valérie Vilgrain
- Department of Radiology, APHP, University Hospitals Paris Nord Val de Seine, Beaujon, Clichy, Hauts-de-Seine, France; University Paris Diderot, Sorbonne Paris Cité, Paris, France; INSERM U1149, centre de recherche biomédicale Bichat-Beaujon, CRB3, Paris, France
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Copin P, Zins M, Nuzzo A, Purcell Y, Beranger-Gibert S, Maggiori L, Corcos O, Vilgrain V, Ronot M. Acute mesenteric ischemia: A critical role for the radiologist. Diagn Interv Imaging 2018; 99:123-134. [DOI: 10.1016/j.diii.2018.01.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Revised: 01/16/2018] [Accepted: 01/18/2018] [Indexed: 12/13/2022]
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Stroeder J, Klingele M, Bomberg H, Wagenpfeil S, Buecker A, Schaefers HJ, Katoh M, Minko P. Occurrence and severity of non-occlusive mesenteric ischemia (NOMI) after cardiovascular surgery correlate with preoperatively assessed FGF-23 levels. PLoS One 2017; 12:e0182670. [PMID: 28792535 PMCID: PMC5549750 DOI: 10.1371/journal.pone.0182670] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 07/17/2017] [Indexed: 12/30/2022] Open
Abstract
Purpose To evaluate the value of preoperatively assessed fibroblast growth factor 23 (FGF-23) levels and to correlate FGF-23 with angiographic findings in non-occlusive mesenteric (NOMI) ischemia using a standardized scoring system. Materials and methods Between 2/2011 and 3/2012 a total of 865 patients (median age: 67 years) underwent cardiovascular surgery during this ethics committee approved, prospective study. 65 of these patients had clinical suspicion of NOMI and consequently underwent catheter angiography of the superior mesenteric artery. Images were assessed using a standardized reporting system (Homburg-NOMI-Score). These data were correlated to following preoperative parameters of kidney function: cystatin C, creatinine, FGF-23 and estimated glomerular filtration rate (eGFR), and outcome data (death, acute renal failure) using linear and logistic regressions, as well as nonparametric tests. Results Significant correlations were found between FGF-23 and the angiographic appearance of NOMI (p = 0.03). Linear regression analysis showed no significant correlation to the severity of NOMI with creatinine (p = 0.273), cystatin C (p = 0.484), cystatin C eGFR (p = 0.914) and creatinine eGFR (p = 0.380). Logistic regression revealed a significant correlation between death and the Homburg-NOMI-Score (p<0.001), but not between development of NOMI and acute renal failure (p = 0.122). The ROC Analysis yielded an area under the curve of 0.695 (95% CI: 0.627–0.763) with a sensitivity of 0.672 and specificity of 0.658. Conclusions FGF-23 significantly correlates with the severity of NOMI, which is in contrast to other renal function parameters. The applied scoring system allows to predict mortality in NOMI patients.
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Affiliation(s)
- Jonas Stroeder
- Department of Diagnostic and Interventional Radiology, Saarland University Medical Center, Homburg, Germany
| | - Matthias Klingele
- Department of Internal Medicine IV - Nephrology and Hypertension, Saarland University Medical Center, Homburg, Germany
| | - Hagen Bomberg
- Department of Anaesthesiology, Critical Care and Pain Medicine, Saarland University Medical Center, Homburg, Germany
| | - Stefan Wagenpfeil
- Institute for Medical Biometry, Epidemiology and Medical Informatics, Saarland University, Saarland University Medical Center, Homburg, Germany
| | - Arno Buecker
- Department of Diagnostic and Interventional Radiology, Saarland University Medical Center, Homburg, Germany
| | - Hans-Joachim Schaefers
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg, Germany
| | - Marcus Katoh
- Helios Klinikum Krefeld, Clinic for Diagnostic and Interventional Radiology, Krefeld, Germany
| | - Peter Minko
- Department of Diagnostic and Interventional Radiology, Saarland University Medical Center, Homburg, Germany
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Nuzzo A, Maggiori L, Ronot M, Becq A, Plessier A, Gault N, Joly F, Castier Y, Vilgrain V, Paugam C, Panis Y, Bouhnik Y, Cazals-Hatem D, Corcos O. Predictive Factors of Intestinal Necrosis in Acute Mesenteric Ischemia: Prospective Study from an Intestinal Stroke Center. Am J Gastroenterol 2017; 112:597-605. [PMID: 28266590 DOI: 10.1038/ajg.2017.38] [Citation(s) in RCA: 125] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 01/02/2017] [Indexed: 02/08/2023]
Abstract
OBJECTIVES To identify predictive factors for irreversible transmural intestinal necrosis (ITIN) in acute mesenteric ischemia (AMI) and establish a risk score for ITIN. METHODS This single-center prospective cohort study was performed between 2009 and 2015 in patients with AMI. The primary outcome was the occurrence of ITIN, confirmed by specimen analysis in patients who underwent surgery. Patients who recovered from AMI with no need for intestinal resection were considered not to have ITIN. Clinical, biological and radiological data were compared in a Cox regression model. RESULTS A total of 67 patients were included. The origin of AMI was arterial, venous, or non-occlusive in 61%, 37%, 2% of cases, respectively. Intestinal resection and ITIN concerned 42% and 34% of patients, respectively. Factors associated with ITIN in multivariate analysis were: organ failure (hazard ratio (HR): 3.1 (95% confidence interval (CI): 1.1-8.5); P=0.03), serum lactate levels >2 mmol/l (HR: 4.1 (95% CI: 1.4-11.5); P=0.01), and bowel loop dilation on computerized tomography scan (HR: 2.6 (95% CI: 1.2-5.7); P=0.02). ITIN rate increased from 3% to 38%, 89%, and 100% in patients with 0, 1, 2, and 3 factors, respectively. Area under the receiver operating characteristics curve for the diagnosis of ITIN was 0.936 (95% CI: 0.866-0.997) depending on the number of predictive factors. CONCLUSIONS We identified three predictive factors for irreversible intestinal ischemic injury requiring resection in the setting of AMI. Close monitoring of these factors could help avoid unnecessary laparotomy, prevent resection, as well as complications due to unresected necrosis, and possibly lower the overall mortality.
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Affiliation(s)
- Alexandre Nuzzo
- Structure d'URgences Vasculaires Intestinales (SURVI), Gastroenterology, IBD, Nutritional Support, Beaujon Hospital, Clichy, APHP, France.,Univ Paris Diderot, Sorbonne Paris Cite, Paris, France
| | - Leon Maggiori
- Univ Paris Diderot, Sorbonne Paris Cite, Paris, France.,Department of Colorectal Surgery, Beaujon Hospital, Clichy, APHP, France
| | - Maxime Ronot
- Univ Paris Diderot, Sorbonne Paris Cite, Paris, France.,Department of Radiology, Beaujon Hospital, Clichy, APHP, France
| | - Aymeric Becq
- Structure d'URgences Vasculaires Intestinales (SURVI), Gastroenterology, IBD, Nutritional Support, Beaujon Hospital, Clichy, APHP, France
| | - Aurelie Plessier
- Department of Hepatology, Beaujon Hospital, Clichy, APHP, France
| | - Nathalie Gault
- Univ Paris Diderot, Sorbonne Paris Cite, Paris, France.,Department of Epidemiology, Biostatistics and Clinical Research, APHP, Beaujon Hospital, Clichy, APHP, France.,INSERM CIC-EC 1425 Bichat Hospital, Paris, France
| | - Francisca Joly
- Structure d'URgences Vasculaires Intestinales (SURVI), Gastroenterology, IBD, Nutritional Support, Beaujon Hospital, Clichy, APHP, France.,Univ Paris Diderot, Sorbonne Paris Cite, Paris, France
| | - Yves Castier
- Univ Paris Diderot, Sorbonne Paris Cite, Paris, France.,Department of Vascular Surgery, Bichat Hospital, Paris, APHP, France
| | - Valerie Vilgrain
- Univ Paris Diderot, Sorbonne Paris Cite, Paris, France.,Department of Radiology, Beaujon Hospital, Clichy, APHP, France
| | - Catherine Paugam
- Univ Paris Diderot, Sorbonne Paris Cite, Paris, France.,Department of Intensive Care Unit and Anesthesiology, Beaujon Hospital, Clichy, APHP, France
| | - Yves Panis
- Univ Paris Diderot, Sorbonne Paris Cite, Paris, France.,Department of Colorectal Surgery, Beaujon Hospital, Clichy, APHP, France
| | - Yoram Bouhnik
- Structure d'URgences Vasculaires Intestinales (SURVI), Gastroenterology, IBD, Nutritional Support, Beaujon Hospital, Clichy, APHP, France.,Univ Paris Diderot, Sorbonne Paris Cite, Paris, France
| | | | - Olivier Corcos
- Structure d'URgences Vasculaires Intestinales (SURVI), Gastroenterology, IBD, Nutritional Support, Beaujon Hospital, Clichy, APHP, France.,Univ Paris Diderot, Sorbonne Paris Cite, Paris, France
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Interpretative Guidelines and Possible Indications for Indocyanine Green Fluorescence Imaging in Robot-Assisted Sphincter-Saving Operations. Dis Colon Rectum 2017; 60:376-384. [PMID: 28267004 DOI: 10.1097/dcr.0000000000000782] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Since the introduction of indocyanine green angiography more than 25 years ago, few studies have presented interpretative guidelines for indocyanine green fluorescent imaging. OBJECTIVE We aimed to provide interpretative guidelines for indocyanine green fluorescent imaging through quantitative analysis and to suggest possible indications for indocyanine green fluorescent imaging during robot-assisted sphincter-saving operations. DESIGN This is a retrospective observational study. SETTINGS This study was conducted at a single center. PATIENTS A cohort of 657 patients with rectal cancer who consecutively underwent curative robot-assisted sphincter-saving operations was enrolled between 2010 and 2016, including 310 patients with indocyanine green imaging (indocyanine green fluorescent imaging+ group) and 347 patients without indocyanine green imaging (indocyanine green fluorescent imaging- group). MAIN OUTCOME MEASURES We tried to quantitatively define the indocyanine green fluorescent imaging findings based on perfusion (mesocolic and colic) time and perfusion intensity (5 grades) to provide probable indications. RESULTS The anastomotic leakage rate was significantly lower in the indocyanine green fluorescent imaging+ group than in the indocyanine green fluorescent imaging- group (0.6% vs 5.2%) (OR, 0.123; 95% CI, 0.028-0.544; p = 0.006). Anastomotic stricture was closely correlated with anastomotic leakage (p = 0.002) and a short descending mesocolon (p = 0.003). Delayed perfusion (>60 s) and low perfusion intensity (1-2) were more frequently detected in patients with anastomotic stricture and marginal artery defects than in those without these factors (p ≤ 0.001). In addition, perfusion times greater than the mean were more frequently observed in patients aged >58 years, whereas low perfusion intensity was seen more in patients with short descending mesocolon and high ASA classes (≥3). LIMITATIONS The 300 patients in the indocyanine green fluorescent imaging- group underwent operations 3 years before indocyanine green fluorescent imaging. CONCLUSIONS Quantitative analysis of indocyanine green fluorescent imaging may help prevent anastomotic complications during robot-assisted sphincter-saving operations, and may be of particular value in high-class ASA patients, older patients, and patients with a short descending mesocolon.
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Wurm R, Cho A, Arfsten H, van Tulder R, Wallmüller C, Steininger P, Sterz F, Tendl K, Balassy C, Distelmaier K, Hülsmann M, Heinz G, Adlbrecht C. Non-occlusive mesenteric ischaemia in out of hospital cardiac arrest survivors. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2017; 7:450-458. [PMID: 28045326 DOI: 10.1177/2048872616687096] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND AIM OF THE STUDY Non-occlusive mesenteric ischaemia (NOMI) is characterised by hypoperfusion of the intestines without evidence of mechanical obstruction, potentially leading to extensive ischaemia and necrosis. Low cardiac output appears to be a major risk factor. Cardiopulmonary resuscitation aims at restoring blood flow after cardiac arrest. However, post restoration of spontaneous circulation, myocardial stunning limits immediate recovery of sufficient cardiac function. Since after successful cardiopulmonary resuscitation patients are often ventilated and sedated, NOMI might be underdiagnosed and potentially life-saving treatment delayed. MATERIAL AND METHODS A prospectively maintained multi-purpose cohort of out of hospital cardiac arrest survivors, who had successful restoration of spontaneous circulation, was used for this retrospective database analysis. Patients' charts were screened for clinical, radiological or pathological evidence of NOMI and clinical data were collected. RESULTS Between 2000 and 2014, 1780 patients who were successfully resuscitated after out of hospital cardiac arrest were screened for NOMI. Twelve patients (0.68 %) suffered from NOMI and six of those died (50 %). Patients suffering from NOMI tended to have a longer duration until restoration of spontaneous circulation (27 vs. 20 min, p=0.128) and had significantly higher lactate (14 mmol/l vs. 8 mmol/l, p=0.002) and base deficit levels at admission (-17 vs. -10, p=0.012). Median leukocyte counts in NOMI patients peaked at the day of diagnosis. CONCLUSION NOMI is a rare but life-threatening and potentially curable complication following successful cardiopulmonary resuscitation. Lactate and base deficit at admission could help to identify patients at risk for developing NOMI who might benefit from increased clinical attention.
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Affiliation(s)
- Raphael Wurm
- 1 Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Austria
| | - Anna Cho
- 1 Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Austria
| | - Henrike Arfsten
- 1 Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Austria
| | - Raphael van Tulder
- 2 Department of Emergency Medicine, Medical University of Vienna, Austria
| | | | - Philipp Steininger
- 2 Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Fritz Sterz
- 2 Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Kristina Tendl
- 3 Clinical Institute of Pathology, Medical University of Vienna, Austria
| | - Csilla Balassy
- 4 Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Austria
| | - Klaus Distelmaier
- 1 Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Austria
| | - Martin Hülsmann
- 1 Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Austria
| | - Gottfried Heinz
- 1 Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Austria
| | - Christopher Adlbrecht
- 1 Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Austria.,5 4th Medical Department, Hietzing Hospital, Vienna, Austria
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Dhatt HS, Behr SC, Miracle A, Wang ZJ, Yeh BM. Radiological Evaluation of Bowel Ischemia. Radiol Clin North Am 2016; 53:1241-54. [PMID: 26526436 DOI: 10.1016/j.rcl.2015.06.009] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Intestinal ischemia, which refers to insufficient blood flow to the bowel, is a potentially catastrophic entity that may require emergent intervention or surgery in the acute setting. Although the clinical signs and symptoms of intestinal ischemia are nonspecific, computed tomography (CT) findings can be highly suggestive in the correct clinical setting. In our article, we review the CT diagnosis of arterial, venous, and nonocclusive intestinal ischemia. We discuss the vascular anatomy, pathophysiology of intestinal ischemia, CT techniques for optimal imaging, key and ancillary radiological findings, and differential diagnosis.
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Affiliation(s)
- Harpreet S Dhatt
- Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143-0628, USA
| | - Spencer C Behr
- Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143-0628, USA
| | - Aaron Miracle
- Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143-0628, USA
| | - Zhen Jane Wang
- Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143-0628, USA
| | - Benjamin M Yeh
- Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143-0628, USA.
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Neesse A, Nimphius W, Schoppet M, Gress TM. Abdominal pain following percutaneous mitral valve repair (MitraClip). Pneumatosis intestinalis (PI) of the ascending colon. Gut 2015; 64:458, 494. [PMID: 25360035 DOI: 10.1136/gutjnl-2014-308495] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Albrecht Neesse
- Department of Gastroenterology II, University Medicine Goettingen, Goettingen, Germany
| | - Wilhelm Nimphius
- Department of Pathology, University Hospital Giessen und Marburg GmbH, Standort Marburg, Marburg, Germany
| | - Michael Schoppet
- Department of Cardiology, University Hospital Giessen und Marburg GmbH, Standort Marburg, Marburg, Germany
| | - Thomas M Gress
- Department of Gastroenterology, Endocrinology, Infectiology and Metabolism, University Hospital Giessen und Marburg GmbH, Standort Marburg, Marburg, Germany
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29
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Abu-Hmeidan JH, Bismar HA, Hamid AM. Small bowel feces sign in association with occlusive mesenteric ischemia. Acta Radiol Short Rep 2014; 3:2047981614540142. [PMID: 25298875 PMCID: PMC4184457 DOI: 10.1177/2047981614540142] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Accepted: 05/28/2014] [Indexed: 12/11/2022] Open
Abstract
Small bowel feces sign (SBFS) is a computed tomography (CT) finding that appears as fecal like material in dilated small bowel loops. This sign is usually seen in association with gradually progressive small bowel obstruction. We present a case of occlusive mesenteric ischemia in which the SBFS appeared on CT scan early on in the course of the disease. We put forward a suggested alternative mechanism to the appearance of this sign in association with mesenteric ischemia. The SBFS might have the potential to serve as an early sign of mesenteric ischemia on CT scan.
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Affiliation(s)
- Jareer H Abu-Hmeidan
- Department of General Surgery, Prince Mohammed bin Abdulaziz Hospital, Riyadh, Saudi Arabia
| | - Hayan A Bismar
- Department of General Surgery, Prince Mohammed bin Abdulaziz Hospital, Riyadh, Saudi Arabia
| | - Abdullgabbar M Hamid
- Department of Radiology, Prince Mohammed bin Abdulaziz Hospital, Riyadh, Saudi Arabia
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