The Value of Sigmoidoscopy to Detect Colonic Ischaemia After Ruptured Abdominal Aortic Aneurysm Repair

Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms

OBJECTIVE

The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy.

METHODS

The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence.

RESULTS

A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed.

CONCLUSION

The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.

Identification of Perioperative Procedural and Hemodynamic Risk Factors for Developing Colonic Ischemia after Ruptured Infrarenal Abdominal Aortic Aneurysm Surgery: A Single-Centre Retrospective Cohort Study

(1) Background: This retrospective study evaluated perioperative and intensive care unit (ICU) variables to predict colonic ischemia (CI) after infrarenal ruptured abdominal aortic aneurysm (RAAA) surgery. (2) Materials and Methods: We retrospectively analyzed the data of the patients treated for infrarenal RAAA from January 2011 to December 2020 in our hospital. (3) Results: A total of 135 (82% male) patients were admitted to ICU after treatment of infrarenal RAAA. The median age of all patients was 75 years (IQR 68-81 years). Of those, 24 (18%) patients developed CI, including 22 (92%) cases within the first three postoperative days. CI was found more often after open repair compared to endovascular treatment (22% vs. 5%, p = 0.021). Laboratory findings in the first seven PODs revealed statistically significant differences between CI and non-CI patients for serum lactate, minimum pH, serum bicarbonate, and platelet count. Norepinephrine (NE) was used in 92 (68%) patients during ICU stay. The highest daily dose of norepinephrine was administered to CI patients at POD1. Multivariable analysis revealed that NE > 64 µg/kg (RD 0.40, 95% CI: 0.25-0.55, p < 0.001), operating time ≥ 200 min (RD 0.18, 95% CI: 0.05-0.31, p = 0.042), and pH < 7.3 (RD 0.21, 95% CI: 0.07-0.35, p = 0.019), significantly predicted the development of CI. A total of 23 (17%) patients died during the hospital stay, including 8 (33%) patients from the CI group and 15 (7%) from the non-CI group (p = 0.032). (4) Conclusions: CI after RAAA is a sever complication occurring most frequently within the first 3 postoperative days. Our study identified many surrogate markers associated with colonic ischemia after aortic RAAA, including norepinephrine dose > 64 µg/kg, operating time ≥ 200 min, and PH < 7.3. Future studies are needed to support these results.

Detection of Ischemic Colitis on Routine Lower Endoscopy and Its Implications After Repair of Ruptured Abdominal Aortic Aneurysm

BACKGROUND

Ischemic colitis (IC) is a known significant complication after repair of a ruptured abdominal aortic aneurysm (rAAA). Lower endoscopy (colonoscopy or flexible sigmoidoscopy) is a helpful adjunct to aid decision making for surgical exploration. We believe routine use of lower endoscopy after rAAA repair provides better patient care through expeditious diagnosis and surgical care.

METHODS

We performed a retrospective chart review of rAAA repairs from 2008 to 2019. All patients undergo screening lower endoscopy after rAAA repair at our institution. The incidence of IC, mortality, and diagnostic characteristics of routine lower endoscopy was analyzed.

RESULTS

Of these, 182 patients underwent rAAA repair, among which 139 (76%) underwent routine lower endoscopy. Ischemic colitis of any grade was diagnosed in 25% of patients. The 30-day mortality was 11% compared to 19% in those without lower endoscopy. The presence of IC portended a 4-fold increase in mortality rate compared to those without (26% vs 6%, P = .005). Surgical exploration rate was 8% after routine lower endoscopy. Grade III ischemia on lower endoscopy had a sensitivity of 50% (95% CI 12-88) and specificity of 99% (95% CI 94-100) for transmural necrosis.

DISCUSSION

We found increased incidence of IC and reliable diagnostic characteristics of routine lower endoscopy in predicting the presence of transmural colonic ischemia. There was decreased mortality with use of routine lower endoscopy but this was not statistically significant.

Influence of perioperative risk factors on the development of transmural colonic ischemia after open repair of ruptured abdominal aortic aneurysm

BACKGROUND

Development of colonic ischemia (CI) after ruptured abdominal aortic aneurysm (RAAA) treatment is a lethal complication with perioperative mortality reported to be high as 50%. Therefore, the main goal of this study was to identify pre-, intra- and postoperative risk factors associated with CI in patients undergoing open repair (OR) due to RAAA, that might help to select patients who are more prone to develop CI.

METHODS

This was a single-center prospective cohort study on patients with RAAA undergoing OR between January 1st 2018 and July 1st 2019, at the Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia. During this period 89 patients were treated due to RAAA and all were included in the study. The primary endpoint was grade III CI, or transmural necrosis, diagnosed by laparotomy.

RESULTS

Out of 89 patients operated due to RAAA, CI was diagnosed in 14 (15.73%). During the operation, patients with CI had a longer duration of hypotension (42.86±35.82 vs 24.13±23.48, p=.021) and more common significant hypotension (54.54% vs 14.66%, p=.024). In the postoperative course, patients with CI had more common signs of abdominal compartment syndrome (71.42% vs 25.33%, p=.001) and higher mortality rate (78.57% vs 29.33%, p=.001). The univariate regression model showed that one of the most significant factors that were associated with CI were age higher than 75 years, significant hypotension lasting more than one hour, organ lesion, development of abdominal compartment syndrome and higher potassium values on third and fourth quartile.

CONCLUSIONS

Grade III colon ischemia (transmural) remains the important cause of mortality after ruptured abdominal aortic aneurysm repair. We identified pre- and intraoperative and postoperative risk factors that could improve the selection of patients for primary open abdomen treatment or early exploratory laparotomy in order to prevent or timely diagnose colon ischemia.

Value of Routine Flexible Sigmoidoscopy and Potential Predictive Factors for Colonic Ischemia after Open Ruptured Abdominal Aortic Aneurysm Repair

Background and Objectives: colonic ischemia (CI) after ruptured abdominal aortic aneurysm (rAAA) repair is associated with increased morbidity and mortality. CI may be detected by using flexible sigmoidoscopy, but routine use of flexible sigmoidoscopy after rAAA is not clearly proven. The objective of this study was to evaluate the efficacy of routine flexible sigmoidoscopy in detecting CI after rAAA repair, and to identify potential hemodynamic, biochemical, and clinical variables that can predict the development of CI in the patients who underwent rAAA surgery. Materials and Methods: we retrospectively included all rAAA cases treated in Viborg hospital from 1 April 2014 until 31 August 2017, recorded the findings on flexible sigmoidoscopy, and the incidence of CI. We collected specific hemodynamic, biochemical, and clinical variables, measured pre- and perioperatively, and the first three postoperative days. The association between CI and possible predictors was analyzed in a logistic regression model. Results: a total of 80 patients underwent open rAAA repair during the study period. Flexible sigmoidoscopy was performed in 58 of 80 patients (73.5%) who survived at least 24 h after open rAAA surgery. Perioperative variables lowest arterial pH (p = 0.02) and types of operations—aortobifemoral bypass vs. straight graft (p = 0.04) showed statistically significant differences between CI groups. The analysis of the postoperative variables showed statistically significant difference in highest lactate on postoperative day 1 (p = 0.01), and lowest hemoglobin on postoperative day 2 (p = 0.04) comparing CI groups. Logistic regression model revealed that postoperative hemoglobin and lactate turned out to be independent risk factors for the development of CI (respectively OR = 0.44 (95% CI = 0.29–0.67) and OR = 1.91 (95% CI = 1.2–3.05)). Conclusions: flexible sigmoidoscopy can identify patients being at higher risk of mortality after open rAAA repair. The postoperative lactate and hemoglobin were found to be independent risk factors for the development of CI after open rAAA repair. Further larger studies are warranted to demonstrate these findings.

[Colonic ischemia after open and endovascular aortic surgery : Epidemiology, Risk Factors, Diagnosis And Therapy]

Despite the successful establishment of endovascular techniques, colonic ischemia continues to be a serious complication of aortic surgery.The risk factors for colonic ischemia include aortic aneurysm rupture, prolonged aortic clamping, perioperative hypotension, the need for catecholamine therapy, occlusion of the hypogastric arteries and renal insufficiency.The clinical presentation of postoperative colonic ischemia is often unspecific. Classic symptoms include abdominal pain, diarrhea, peranal bleeding and rise of inflammatory parameters. A specific laboratory parameter for colonic ischemia does not exist. The diagnostic gold standard is endoscopy. Imaging methods such as sonography or computer tomography play only a supportive role. Transmural ischemia resulting in bowel wall necrosis is an indication for emergency surgery, predominantly colonic resection with creation of artificial anus.