Acute mesenteric ischemia: guidelines of the World Society of Emergency Surgery

Changes in Abdominal Artery Diameter in Patients Treated for Acute Aortic Dissection

BACKGROUND

Mesenteric ischemia significantly increases intraoperative mortality in patients with acute aortic dissection (AAD). The arterial diameter affects both blood flow and arterial resistance. There are no data in the literature on changes in arterial diameter in patients with AAD. It has already been demonstrated that changes in arterial diameter can be observed in patients with non-occlusive intestinal ischemia. The aim of this study was to compare the arterial branches of the abdominal aorta in patients with AAD preoperatively and postoperatively.

METHODS

Preoperative and postoperative contrast-enhanced computed tomography scans of 25 patients who had undergone the frozen elephant trunk procedure for the treatment of AAD were reconstructed and retrospectively analyzed with detailed medical data of the patients.

RESULTS

In patients without AAD at the level of the abdominal aorta, statistically significant differences were observed when comparing the diameter of the superior mesenteric artery (p < 0.001) and the renal arteries (p < 0.001) between preoperative and postoperative scans. Occlusion of the inferior mesenteric artery was more common in patients with AAD involving the abdominal aorta. Statistically significant differences in true and false lumen were observed at each level of the abdominal aorta after a successful frozen elephant trunk procedure.

CONCLUSION

Significant changes in visceral artery diameter were observed at the abdominal aortic level in patients both with and without aortic dissection. Chronic or non-occlusive mesenteric ischemia may be associated with a lack of adjustment in arterial diameter. Patients with AAD of the abdominal aorta are more susceptible to occlusion of the inferior mesenteric artery.

Acute total intestinal volvulus caused by sclerosing mesenteritis: a case report and review of the literature

BACKGROUND

Intestinal volvulus arises from the twisting of an intestinal loop around a fixed axis. This condition is distinguished by both the obstruction and constriction of the intestinal lumen, as well as the entrapment of intestinal blood vessels. Consequently, the intestinal obstruction resulting from volvulus is often of the strangulating variety, which poses a risk for swift intestinal necrosis. Mesenteric tumors are a notable precipitant of volvulus. However, certain nontumor lesions originating from the mesentery can also lead to severe intestinal volvulus.

CASE PRESENTATION

A 68-year-old Chinese female individual was hospitalized because of severe abdominal pain that occurred 6 h after engaging in physical labor. An abdominal computed tomography examination revealed volvulus of the mesenteric root and the presence of a mixed-density mass in the right mesentery, with the possibility of a neoplastic process not ruled out. Emergency surgical exploration confirmed that the small mesenteric tumor served as a pivot, with the mesenteric root twisted 1440°, leading to total necrosis of the small intestine. As a result, total small intestine resection and enterostomy were performed. Postoperative pathological examination of the mesenteric tumor revealed fat necrosis, excessive calcification, peripheral fibrous tissue hyperplasia, and chronic inflammatory cell infiltration, consistent with a diagnosis of sclerosing mesenteritis. The patient's life was saved through timely surgical intervention. However, owing to the development of short bowel syndrome, she will require long-term dependence on parenteral nutrition.

CONCLUSION

Intestinal volvulus due to sclerosing mesenteric inflammation is an exceedingly rare occurrence. Clinicians should maintain a high index of suspicion for this condition when encountering cases of intestinal volvulus attributed to mesenteric tumors. Prompt and decisive surgical intervention is crucial for saving lives and for preserving as much of the intestinal tract as possible.

A comparative study on the transbrachial and transfemoral approaches for the treatment of superior mesenteric artery lesions

BACKGROUND

Superior Mesenteric Artery (SMA) lesions present a significant challenge in endovascular surgery. Both the transbrachial (TBA) and the transfemoral (TFA) approaches have been employed for the treatment of these lesions, but the comparative effectiveness of these methods remains unclear.

MATERIALS AND METHODS

A retrospective analysis was conducted on patients who underwent TBA and TFA at a tertiary center between June 2020 and February 2023. Key parameters including technical success, procedural details, and complication rates were examined.

RESULTS

In a study of 99 patients, 66 underwent Transfemoral Approach (TFA) and 33 underwent Transbrachial Approach (TBA). No significant age or gender differences were noted between groups. TFA procedures were longer (90.0 vs 63.5 min, p = 0.002) and had higher fluoroscopy times (59.0 vs 43.0 min, p = 0.02) and selective SMA times (366.0 vs 245.0 min, p = 0.038) compared to TBA, especially with a smaller aortomesenteric angle (<90°). Technical success rates were high in both groups (TFA 97%, TBA 93.9%, p = 0.60). Complication rates were similar between groups, with no significant predictors for access site complications identified.

CONCLUSION

Both the TBA and the TFA are effective for the treatment of SMA lesions, with TBA potentially offering advantages in terms of efficiency and patient recovery, particularly in cases with certain anatomy. No significant differences in complication rates were found between the two groups. Further research, including prospective randomized trials, is needed to confirm these findings.

Vagus nerve stimulation: A targeted approach for reducing tissue-specific ischemic reperfusion injury

Vagus Nerve Stimulation (VNS), a neuromodulation technique of applying controlled electrical impulses to the vagus nerve, has now emerged as a potential therapeutic approach for ischemia-reperfusion insults. It provides a pivotal link in improving functional outcomes for the central nervous system and multiple target organs affected by ischemia-reperfusion injury (I/RI). Reduced blood flow during ischemia and subsequent resumption of blood supply during reperfusion to the tissue compromises cellular health because of the combination of mitochondrial dysfunction, oxidative stress, cytokine release, inflammation, apoptosis, intracellular calcium overload, and endoplasmic reticulum stress, which ultimately leads to cell death and irreversible tissue damage. Furthermore, inflammation and apoptosis also play critical roles in the acute progression of ischemic injury pathology. Emerging evidence indicates that VNS in I/RI may act in an anti-inflammatory capacity, reducing oxidative stress and apoptosis, while also improving endothelial and mitochondrial function leading to reduced infarct sizes and cytoprotection in skeletal muscle, gastrointestinal tract, liver, kidney, lung, heart, and brain tissue. In this review, we attempt to shed light on the mechanistic links between tissue-specific damage following I/RI and the therapeutic approach of VNS in attenuating damage, considering both direct and remote I/RI scenarios. Thus, we want to advance the understanding of VNS that could further warrant its clinical implementation, especially as a treatment for I/RI.

Dual-energy CT of acute bowel ischemia-influence on diagnostic accuracy and reader confidence

OBJECTIVES

This study evaluates the advantages in diagnostic accuracy, confidence, and reading time of additional dual-energy CT-derived reconstructions for assessing acute bowel ischemia.

METHODS AND MATERIALS

This retrospective study includes 25 patients with surgically proven acute bowel ischemia and 25 gender- and age-matched controls who underwent biphasic abdominal dual-energy CT. Two fellowship-trained abdominal radiologists and two residents evaluated all cases with and without additional dual-energy CT-derived iodine maps and virtual non-contrast images. Diagnostic confidence was rated on a 10-point Likert scale. Reading time was recorded. The inter-reader agreement was assessed using Fleiss' kappa. Sensitivity and specificity were compared using McNemar's test, reader confidence, and reading times with the Wilcoxon signed-rank test.

RESULTS

For conventional images alone, the inter-reader agreement was moderate (κ = 0.58), with a sensitivity of 77% (95% CI: 67.5-84.8%) and specificity of 90% (95% CI: 82.4-95.1%). Adding dual-energy CT images, inter-reader agreement increased to substantial (κ = 0.69), sensitivity increased significantly to 89% (95% CI: 81.2-94.4%, p = 0.02), while specificity increased non-significantly to 93% (95% CI: 86.1-97.1%, p = 0.51). Diagnostic confidence increased significantly from 8 (IQR: 6-8) to 9 (IQR: 8-9) (p < 0.01). Equivalent diagnostic accuracy and confidence increases were observed for fellowship-trained and resident radiologists. A non-significant increase in mean reading time per case from 196 s to 201 s was observed (p = 0.30).

CONCLUSION

Additional dual-energy CT reconstructions increase diagnostic accuracy and confidence without increasing reading time when evaluating suspected acute bowel ischemia. Both experienced and resident readers benefit from dual-energy CT images.

KEY POINTS

Question There are too few clinical studies assessing the diagnostic accuracy of dual-energy CT (DECT) to recommend its use for evaluating suspected acute bowel ischemia. Findings Adding DECT-derived iodine maps and virtual-non-contrast images increase reader sensitivity and confidence while maintaining high specificity when evaluating for acute mesenteric ischemia. Clinical relevance Dual-energy CT should be used to investigate suspected acute bowel ischemia. Both diagnostic accuracy and confidence can be increased independent of reader experience without significantly increasing reading time.

Massive intestinal mesenteric portal vein ischemia: Percutaneous endovascular thrombolysis as minimally invasive step-up approach

Acute mesenteric ischemia represents a group of diseases, which lead to an abrupt interruption of blood flow to the small intestine resulting in intestinal necrosis. Its first symptoms are vague and in the majority of cases nonspecific, so the diagnostic suspicion is of the utmost importance to establish the correct diagnostic and prompt treatment. It is a complex and difficult event, that needs a multidisciplinary approach involving different specialties such as gastrointestinal and vascular surgeons, interventional radiologists, and expertise from the acute care unit team. The fundamental aspect is the precocity of diagnostic based on abdominal computed angio-tomography and the immediate re-establishment of blood supply to the affected areas. In this report, we introduce a case of a patient with mesenteric venous thrombosis, who has beenundergone a percutaneous endovascular treatment (portal-mesenteric mechanical thrombectomy, besides an intravenous thrombolytic infusion), due to poor clinical response after anticoagulation approach that needed mechanical ventilation.

Open Revascularization for Acute Mesenteric Ischemia is Associated with Increased Morbidity and Mortality when Compared to Endovascular Intervention

OBJECTIVES

Historically, open approaches have been considered the primary treatment for acute mesenteric ischemia (AMI) due to the potential for bowel resection. However, the use of endovascular therapy is increasing. Given the paucity of current data, this study aims to compare outcomes between open and endovascular interventions for AMI.

METHODS

Patients treated for AMI between 2011 and 2022 were identified in the National Surgical Quality Improvement Program (NSQIP) by ICD-9 and ICD-10 codes. Intervention type (open vs. endovascular) was obtained from CPT codes. Demographics, comorbidities, pre-operative laboratory values, and 30-day outcomes were compared between intervention types. Multivariable analysis was utilized to adjust for differences between groups with a patient's need for bowel resection included to account for disease severity.

RESULTS

A total of 1,172 patients underwent revascularization for AMI (1,023 open, 149 endovascular). Among those treated with open revascularization, 577 (56%) underwent thrombectomies/embolectomy, 125 (12%) underwent thromboendarterectomy, and 321 (31%) received bypasses. Of the patients who underwent endovascular revascularizations, 101 (68%) received a stent, 23 (15%) underwent angioplasty without stenting, and 25 (17%) underwent lysis/thrombectomy. Patients who underwent endovascular revascularization had higher rates of smoking (36% open vs. 47% endovascular; P < 0.01), were more likely to have an eGFR less than 30 (6% open vs. 15% endovascular; P < 0.01), and underwent more bowel resections at the time of the initial operation (33% open vs. 48% endovascular; P < 0.01). For outcomes, patients who underwent open repair had longer median hospital stays (10 days vs. 7 days; P < 0.01). All other outcomes including 30-day mortality were similar on univariate analysis. Following adjustment for the need for bowel resection and comorbidities, 30-day-mortality (OR 1.96, 95% CI: 1.28-3.02), failure to wean from ventilator (OR 1.56 95% CI: 1.05-2.34), and length of hospital stay (β 3.7 days, 95% CI: 1.8-5.6) were higher among patients treated with open surgery.

CONCLUSIONS

After accounting for the need for bowel resection and comorbidities, open revascularization for AMI is associated with higher peri-operative morbidity and mortality compared to endovascular intervention. Thus, the need for bowel resection should not preclude endovascular treatment for AMI.

Zinc pretreatment for protection against intestinal ischemia-reperfusion injury

BACKGROUND

Intestinal ischemia-reperfusion (I/R) injury (II/RI) is a critical condition that results in oxidative stress, inflammation, and damage to multiple organs. Zinc, an essential trace element, offers protective benefits in several tissues during I/R injury, but its effects on intestinal II/RI remain unclear.

AIM

To investigate the effects of zinc pretreatment on II/RI and associated multiorgan damage.

METHODS

C57BL/6 mice were pretreated with zinc sulfate (ZnSO4, 10 mg/kg) daily for three days before I/R injury was induced via superior mesenteric artery occlusion (SMAO) and abdominal aortic occlusion (AAO) models. Tissue and serum samples were collected to evaluate intestinal, liver, and kidney damage using Chiu's score, Suzuki score, and histopathological analysis. Caco-2 cells and intestinal organoids were used for in vitro hypoxia-reoxygenation injury models to measure reactive oxygen species (ROS) and superoxide dismutase (SOD) levels.

RESULTS

Zinc pretreatment significantly reduced intestinal damage in the SMAO and AAO models (P < 0.001). The serum levels of liver enzymes (alanine aminotransferase, aspartate aminotransferase) and kidney markers (creatinine and urea) were lower in the zinc-treated mice than in the control mice, indicating reduced hepatic and renal injury. In vitro, zinc decreased ROS levels and increased SOD activity in Caco-2 cells subject to hypoxia-reoxygenation injury. Intestinal organoids pretreated with zinc exhibited enhanced resilience to hypoxic injury compared to controls.

CONCLUSION

Zinc pretreatment mitigates II/RI and reduces associated multiorgan damage. These findings suggest that zinc has potential clinical applications in protecting against I/R injuries.

Computed Tomography Parameters for Prognosis Prediction in Non-Occlusive Mesenteric Ischemia

BACKGROUND Non-occlusive mesenteric ischemia (NOMI) is difficult to diagnose and has a high mortality rate. We aimed to determine the qualitative and quantitative parameters of computed tomography (CT) that can determine patient prognosis and contribute to early diagnosis in order to reduce mortality. MATERIAL AND METHODS The biphasic CT images of 40 patients, mean age 72.7±12 years, 24 men (60%), 14 women 14 (40%), with a diagnosis of NOMI were analyzed retrospectively. Patients were divided into survivor and non-survivor groups. Qualitative CT parameters, consisting of vascular, intestinal, and mesenteric and peritoneal findings, comorbidities, and surgical resection were compared using Fisher's exact test. Quantitative CT parameters of superior mesenteric artery (SMA), celiac trunk, inferior vena cava (IVC), superior mesenteric vein (SMV) diameters, and intestinal wall density difference (delta HU) in arterial and venous phases were compared with patient prognosis by using ANOVA. RESULTS Pneumatosis intestinalis (P=0.012), paper-thin bowel wall (P=0.015), and pale mesentery (P=0.008) were higher in the non-survivor group. In the survivor group, mesentery congestion (P=0.003), bowel wall thickening (P=0.001), bowel wall enhancement (P=0.044), and enhancing mucosa and submucosa of bowel wall (P=0.042) were higher. The celiac trunk, SMA, SMV, IVC, and IMA diameters, artery wall density, and delta HU were statistically significantly lower in the non-survivor group. The IVC diameter was correlated with patient prognosis (P=0.000). CONCLUSIONS A systematic evaluation of CT parameters can make important contributions to the early diagnosis and management of patients with NOMI.

Dual-energy CT late arterial phase iodine maps for the diagnosis of acute non-occlusive mesenteric ischemia

PURPOSE

To evaluate the diagnostic accuracy of dual-energy CT (DECT) iodine maps in comparison to conventional CT series for the assessment of non-occlusive mesenteric ischemia (NOMI).

MATERIAL AND METHODS

We evaluated data from 142 patients (72 men; 50.7%) who underwent DECT between 2018 and 2022, with surgically confirmed diagnosis of NOMI. One board-certified radiologist performed region of interest (ROI) measurements in bowel segments on late arterial (LA) and portal venous (PV) phase DECT iodine maps as well as LA conventional series, in both ischemic and non-ischemic bowel loops, using surgical reports as reference standard, and in a control group of 97 patients. Intra- and inter-reader agreement with a second board-certified radiologist was also evaluated. Receiver operating characteristic (ROC) curve analysis was performed to calculate the optimal threshold for discriminating ischemic from non-ischemic bowel segments. Subjective image rating of LA and PV iodine maps was performed.

RESULTS

DECT-based iodine concentration (IC) measurements showed significant differences in LA phase iodine maps between ischemic (median:0.72; IQR 0.52-0.91 mg/mL) and non-ischemic bowel loops (5.16; IQR 3.45-6.31 mg/ml) (P <.0001). IC quantification on LA phase revealed an AUC of 0.966 for the assessment of acute bowel ischemia, significantly higher compared to both IC quantification based on PV phase (0.951) and attenuation values evaluated on LA conventional CT series (0.828). Excellent intra-observer and strong inter-observer agreements were observed for the quantification of iodine concentration. Conversely, weak inter-observer agreement was noted for conventional HU assessments. The optimal LA phase-based IC threshold for assessing bowel ischemia was 1.34 mg/mL, yielding a sensitivity of 100% and specificity of 96.48%.

CONCLUSION

Iodine maps based on LA phase significantly improve the diagnostic accuracy for the assessment of NOMI compared to conventional CT series and PV phase iodine maps.

Acute mesenteric ischemia secondary to complete AV block and acute systolic heart failure: a case report

BACKGROUND

Acute mesenteric ischemia (AMI) usually presents with abrupt and severe abdominal pain associated with nausea and vomiting. This case is notable due to the occurrence of AMI secondary to acute systolic heart failure caused by new onset complete heart block.

CASE PRESENTATION

A 65-year-old male presented with sudden onset epigastric pain. ECG showed complete AV block and acute ischemia, and a subsequent CTA revealed complete occlusion of the mid superior mesenteric artery. His emergent left heart catheterization showed non-occlusive coronary artery disease. The patient underwent emergent laparotomy and SMA thrombectomy. Postoperative complications included worsening congestive heart failure and persistent bradycardia, requiring a permanent pacemaker. The patient was discharged to a skilled nursing facility in stable condition.

CONCLUSIONS

This case highlights the diagnostic challenges of AMI in the setting of acute heart failure and new onset AV block mimicking acute cardiac events and emphasizes the importance of a multidisciplinary approach in managing such complex cases.

Role of spleen density in predicting postoperative complications in patients with acute mesenteric ischemia

BACKGROUND

Acute mesenteric ischemia (AMI) is a life-threatening surgical emergency with a poor prognosis. This study assessed the association of diffuse reduction of spleen density (DROSD) with postoperative complications and identified risk factors for adverse outcomes in AMI patients after surgery.

METHODS

Patients who were diagnosed with AMI and underwent surgical operations between April 2006 and July 2021 were enrolled. Spleen density was assessed using preoperative non-enhanced computed tomography. The lowest quartile of spleen density in all patients was regarded as the cutoff value for DROSD. Univariate and multivariate analyses were performed to determine the risk factors related to postoperative outcomes after surgery.

RESULTS

According to the diagnostic cutoff, patients with a spleen density ≤49.07 HU were defined as DROSD. In a cohort of 97 patients, 34.0% developed complications within 30 days of surgery. The multivariate analysis illustrated that DROSD was an independent risk factor for prognostic outcomes in AMI patients after surgery.

CONCLUSION

Patients with low spleen density were prone to postoperative complications. As an imaging method, preoperative assessment of spleen density is a novel predictor that can be used clinically to identify high-risk AMI patients with poor prognosis.

Endovascular Intervention for Acute Superior Mesenteric Artery Occlusion Following COVID-19 Pneumonia: Two Case Reports

COVID-19 patients may experience acute mesenteric ischaemia. Identifying acute mesenteric ischaemia is challenging, particularly as initial symptoms are often vague and easily overlooked. Early detection and immediate intervention to restore blood flow can prevent these severe consequences. Presented in this report are two cases of superior mesenteric artery (SMA) thrombosis following severe acute respiratory syndrome coronavirus 2 infection. CT scans demonstrated SMA thrombosis in both patients, with no evidence of bowel necrosis. Endovascular intervention with self-expanding stent placement was performed after angiographic confirmation of the diagnosis. At 6-month follow-up, both patients remained asymptomatic on dual antiplatelet therapy. Atypical gastrointestinal manifestations in COVID-19 patients should raise suspicion for uncommon complications, such as SMA thrombosis. For SMA occlusion without associated bowel necrosis, endovascular therapy represents a viable treatment approach.

Portal vein thrombosis: diagnosis, management, and endpoints for future clinical studies

Portal vein thrombosis (PVT) refers to the development of a non-malignant obstruction of the portal vein, its branches, its radicles, or a combination. This Review first provides a comprehensive overview of all aspects of PVT, namely the specifics of the portal venous system, the risk factors for PVT, the pathophysiology of portal hypertension in PVT, the interest in non-invasive tests, as well as therapeutic approaches including the effect of treating risk factors for PVT or cause of cirrhosis, anticoagulation, portal vein recanalisation by interventional radiology, and prevention and management of variceal bleeding in patients with PVT. Specific issues are also addressed including portal cholangiopathy, mesenteric ischaemia and intestinal necrosis, quality of life, fertility, contraception and pregnancy, and PVT in children. This Review will then present endpoints for future clinical studies in PVT, both in patients with and without cirrhosis, agreed by a large panel of experts through a Delphi consensus process. These endpoints include classification of portal vein thrombus extension, classification of PVT evolution, timing of assessment of PVT, and global endpoints for studies on PVT including clinical outcomes. These endpoints will help homogenise studies on PVT and thus facilitate reporting, comparison between studies, and validation of future studies and trials on PVT.

The Open Abdomen After Intra-Abdominal Contamination in Emergency General Surgery

INTRODUCTION

Delayed fascial closure (DFC) is an increasingly utilized technique in emergency general surgery (EGS), despite a lack of data regarding its benefits. We aimed to compare the clinical outcomes of DFC versus immediate fascial closure (IFC) in EGS patients with intra-abdominal contamination.

METHODS

This retrospective study was conducted using the 2013-2020 American College of Surgeons National Surgical Quality Improvement Program database. Adult EGS patients who underwent an exploratory laparotomy with intra-abdominal contamination [wound classification III (contaminated) or IV (dirty)] were included. Patients with agreed upon indications for DFC were excluded. A propensity-matched analysis was performed. The primary outcome was 30-d mortality.

RESULTS

We identified 36,974 eligible patients. 16.8% underwent DFC, of which 51.7% were female, and the median age was 64 y. After matching, there were 6213 pairs. DFC was associated with a higher risk of mortality (15.8% versus 14.2%, P = 0.016), pneumonia (11.7% versus 10.1%, P = 0.007), pulmonary embolism (1.9% versus 1.6%, P = 0.03), and longer hospital stay (11 versus 10 d, P < 0.001). No significant differences in postoperative sepsis and deep surgical site infection rates between the two groups were observed. Subgroup analyses by preoperative diagnosis (diverticulitis, perforation, and undifferentiated sepsis) showed that DFC was associated with longer hospital stay in all subgroups, with a higher mortality rate in patients with diverticulitis (8.1% versus 6.1%, P = 0.027).

CONCLUSIONS

In the presence of intra-abdominal contamination, DFC is associated with longer hospital stay and higher rates of mortality and morbidity. DFC was not associated with decreased risk of infectious complications. Further studies are needed to clearly define the indications of DFC.

Glucose-Stimulated Mucus Secretion by Goblet Cells Mitigates Intestinal Barrier Dysfunction in a Rat Model of Mesenteric Ischemia/Reperfusion Injury

Background

Superior mesenteric ischemia/reperfusion (I/R) causes barrier dysfunction and facilitates bacterial translocation (BT) in the small intestine, which can even lead to systemic sepsis. Our previous research showed that luminal administration of glucose and its anaerobic glycolytic metabolites exerted cytoprotective effects on epithelial cells and ameliorated I/R-induced BT in the liver and spleen. Notably, the reduction of BT occurs over the whole intestinal tract, not only restricted in the ligated glucose-containing loop.

Objectives

In this study, we hypothesized that local jejunal glucose-contacting might confer on the remote intestinal epithelium regeneration potential, fortify their barrier function and goblet cell secretory activity.

Methods

Two 10-cm jejunal segments were isolated in Wistar rats. One segment was ligatured at both ends and infused with Krebs buffer containing 0- or 50-mM glucose (local loop), whereas the adjacent segment was left unaltered and not exposed to glucose (remote loop). The rats then underwent either a sham operation or I/R challenge by occlusion of the superior mesenteric artery for 20 min, followed by reperfusion for 1 h.

Results

Enteral addition of glucose in the local jejunum loop alleviated ischemia-induced barrier defects, histopathological scores, cell death, and mucosal inflammation (myeloperoxidase and inflammatory cytokine production) in the remote jejunum. After ischemia, goblet cells in the remote jejunum showed cavitation of mucin granules and low MUC2 expression. Local addition of glucose enhanced MUC2 synthesis and stimulated a jet-like mucus secretion in the remote jejunum, which was accompanied by the restoration of crypt activity.

Conclusions

Our results showed local enteral glucose effectively mitigates I/R-induced barrier dysfunction, suggesting that local glucose-stimulated mucus secretion by remote goblet cells may serve to mitigate mucosal inflammation and BT. We provide a more precise barrier protection role of enteral glucose upon I/R challenge, presenting new opportunities for future therapeutic potential.

Retrograde open mesenteric stenting and outcomes for acute mesenteric ischemia

OBJECTIVES

Data regarding retrograde open mesenteric stenting (ROMS) for urgent mesenteric ischemia is limited to small single center and case series, with variable utilization across patient populations and ill-defined outcomes. We aimed to evaluate characteristics and outcomes of patients with acute mesenteric ischemia requiring urgent surgical intervention.

METHODS

Retrospective cohort study of patients with mesenteric ischemia requiring urgent surgical intervention from 2018 to 2020 was queried from the National Inpatient Sample (NIS) database. Study groups were defined as those requiring an open bypass (BYPASS), an open superior mesenteric artery embolectomy (OPEN), or ROMS. Descriptive statistics were used to report variables. Comparisons were mad using t test, chi-squares tests, and multivariate regression reported as odds ratio (OR), 95% confidence interval (CI) where appropriate.

RESULTS

898 patients with mesenteric ischemia requiring urgent surgical intervention were included: Bypass: 284, OPEN: 363, ROMS: 251. There was no difference in gender or race between groups. Patients requiring ROMS were more likely to be older 70.2 + 11.3versus Bypass 66.81 + 11.6 and OPEN 67.17 + 14.5, p = 0.0035. ROMS patients had the highest Charlson Comorbidity Index (CCI) 2.9 versus 2.5 Bypass and 2.6 OPEN, p = 0.0292 with the most frequent comorbidities: Diabetes 37% (p = 0.01), renal disease 24.3% (p = 0.5), and previous preoperative myocardial infarction 9.2%, p = 0.05; however, the lowest mortality rate was seen within this Group 15.9% versus bypass 19.7%, OPEN 34.5%, p < 0.0001. Patients requiring bypass were more likely to have chronic pulmonary disease 34.5% versus OPEN 24.2% and ROMS 31.5%, p = 0.013, peripheral vascular disease (PVD) 38% versus OPEN 16%, and ROMS 29.9%, p < 0.0001. On multivariate regression, ROMS was associated with 50% decreased incidence of mortality (OR 0.45, 95% CI 0.27-0.75). Open SMA embolectomy was associated with nearly 2x mortality rate compared to bypass procedures OR 2.0, 95% CI 1.3-3.0, p < 0.001. Previous MI was also associated with nearly 2x incidence of mortality (OR 1.9, 95% CI 1.01-3.6), while pre-existing PVD conferred a protective effect (OR 0.56, 95% CI 0.36-0.89). Higher CCI and age were associated with slightly increased risk for mortality OR 1.2 and 1.03, p < 0.05 for both.

CONCLUSIONS

In patients with acute mesenteric ischemia, ROMS demonstrated a significant mortality benefit compared to traditional open procedures. Advanced age, history of MI, and open SMA embolectomy were associated with increased mortality. Little data exists regarding ROMS in a real-world population evaluating ROMS, which is a newer technique. These data suggest that ROMS may be a superior alternative to restore mesenteric flow in the acute setting and further prospective studies evaluating ROMS to other procedural types in urgent and elective settings are needed.

Totally thoracoscopic atrial fibrillation surgery following massive small bowel resection due to superior mesenteric artery embolization: report of two cases

BACKGROUND

Thromboembolic occlusion of the superior mesenteric artery (SMA) is a grave complication in individuals diagnosed with atrial fibrillation (AF). This condition often necessitates extensive bowel resection, culminating in short bowel syndrome, which presents challenges for anticoagulant administration and/or antiarrhythmic therapy.

CASE PRESENTATION

Presented here are findings of two patients, aged 78 and 72 years, respectively, who underwent comprehensive thoracoscopic AF surgery subsequent to extensive small bowel resection following SMA embolization. In each, onset of AF precipitated an embolic event, while the concurrent presence of short bowel syndrome complicated anticoagulation management. Total thoracoscopic AF surgery, comprised stapler-closure of the left atrial appendage (LAA) and bilateral epicardial clamp-isolation of the pulmonary veins, an operative modality aimed at addressing AF rhythm control and mitigating embolic events such as cerebral infarction, led to favorable outcomes in both cases. Additionally, computed tomography (CT) conducted one month post-surgery revealed the absence of residual tissue in the LAA, with the left atrium demonstrating a well-rounded, spherical shape. At the time of writing, the patients have remained asymptomatic following surgery regarding thromboembolic and arrhythmic manifestations for 29 and 10 months, respectively, notwithstanding the absence of anticoagulant or antiarrhythmic pharmacotherapy. Additionally, electrocardiographic surveillance has revealed persistent sinus rhythm.

CONCLUSIONS

The present findings underscore the feasibility and efficacy of a total thoracoscopic AF surgery procedure for patients presented with short bowel syndrome complicating SMA embolization, thus warranting consideration for its broader clinical application.

Nonocclusive mesenteric ischemia (NOMI) on Roux limb after biliary reconstruction successfully treated by interventional radiology (IVR)

Nonocclusive mesenteric ischemia (NOMI) is a life-threatening disorder. Early diagnosis is challenging because NOMI lacks specific symptoms. A 52-year-old man who received extended cholecystectomy with Roux-en-Y hepaticojejunostomy for gallbladder cancer (GBC) presented to our hospital with nausea and vomiting. Neither tender nor peritoneal irritation sign was present on abdominal examination. Blood test exhibited marked leukocytosis (WBC:19,800/mm3). A contrast-enhanced abdominal computed tomography (CT) scan revealed remarkable wall thickening and lower contrast enhancement effect localized to Roux limb. On hospital day 2, abdominal arterial angiography revealed angio-spasm at marginal artery and arterial recta between 2nd jejunal artery and 3rd jejunal artery, leading us to the diagnosis of NOMI. We then administered continuous catheter-directed infusion of papaverine hydrochloride until hospital day 7. Furthermore, the patient was anticoagulated with intravenous unfractionated heparin and antithrombin agents for increasing D-dimer level and decreasing antithrombin III level. On hospital day 8, diluted oral nutrition diet was initiated and gradually advanced as tolerated. On hospital day 21, the patient was confirmed of improved laboratory test data and discharged with eating a regular diet. We experienced a rare case of NOMI on Roux limb after 2 years of extended cholecystectomy with hepaticojejunostomy for GBC, promptly diagnosed and successfully treated by interventional radiology (IVR).

Irreversible Transmural Intestinal Necrosis in Acute Mesenteric Ischemia: Retrospective Cohort Study from a High-Volume Hospital

Background: Owing to the low incidence rate and nonspecific symptoms of acute mesenteric ischemia (AMI), the identification and prediction of irreversible transmural intestinal necrosis (ITIN) and extensive bowel resection (≥100 cm) (EBR) are difficult and critical. This study aimed to investigate the risk factors for ITIN and EBR in patients with AMI. Methods: The clinical data of 254 AMI patients were retrospectively analyzed. Furthermore, the incidence of ITIN and EBR were set as dependent variables, and relevant risk factors were screened using univariate and multivariate logistic regression analyses. The comparisons of surgical characteristics and postoperative recovery outcomes between the EBR and control group were also conducted. Results: The presence of hemorrhagic (odds ratio [OR] = 28.356, P < .001) or other types ascites (OR = 13.051, P = .003), peritonitis (OR = 8.463, P = .005), intestinal diameter >2.35 cm (OR = 5.493, P = .020), and serum creatinine (CREA) >95 μmol/L (OR = 4.866, P = .048) were identified as independent risk factors for ITIN in patients with AMI. In addition, serum C-reactive protein (CRP) >15 mg/L (OR = 38.023, P = .006), and CREA >100 μmol/L (OR = 6.248, P = .035) were proved to be independently associated with EBR for ITIN cases. Compared to the control group, EBR significantly increased the likelihood of requiring enterostomy (P = .001), blood transfusion (P = .002), and transfer to intensive care unit (P = .016), while also prolonging the recovery time for intestinal function (P = .014). Conclusions: The presence of ascites, peritonitis, intestinal diameter >2.35 cm, and serum CREA >95 μmol/L were independently correlated with ITIN for AMI cases, while serum CRP >15 mg/L and CREA >100 μmol/L independently increased the risk of EBR.

Predictors of Survival Without Intestinal Resection after First-Line Endovascular Revascularization in Patients with Acute Arterial Mesenteric Ischemia

Background Acute arterial mesenteric ischemia requires emergency treatment and is associated with high mortality rate and poor quality of life. Identifying factors associated with survival without intestinal resection (hereafter, intestinal resection-free [IRF] survival) could help in treatment decision-making after first-line endovascular revascularization. Purpose To identify factors associated with 30-day IRF survival in patients with acute arterial mesenteric ischemia whose first-line treatment was endovascular revascularization. Materials and Methods Patients with acute arterial mesenteric ischemia whose first-line treatment was endovascular revascularization because of a low probability of bowel necrosis were included in this single-center retrospective cohort (May 2014 to August 2022). Patient demographics, laboratory values, clinical characteristics at admission, CT scans, angiograms, and endovascular revascularization-related variables were included. The primary end point was 30-day IRF survival, and secondary end points were 3-month, 1-year, and 3-year overall survival. Factors independently associated with 30-day IRF survival were identified with binary logistic regression. Results A total of 117 patients (median age, 70 years [IQR, 60-77]; 53 female, 64 male) were included. Within 30 days after revascularization, 73 of 117 patients (62%) survived without resection, 28 of 117 (24%) survived after resection, 14 of 117 (12%) died without resection, and two of 117 (2%) underwent resection but died. The 30-day IRF survival was 63% (74 of 117). The 3-month, 1-year, and 3-year mortality rate was 18% (21 of 117), 21% (25 of 117), and 27% (32 of 117), respectively. Independent predictors of 30-day IRF survival were persistent bowel enhancement at initial CT (odds ratio [OR], 0.3; 95% CI: 0.2, 0.8; P = .013) and C-reactive protein (CRP) level less than 100 mg/L (OR, 0.3; 95% CI: 0.1, 0.8; P = .002). The 30-day IRF survival was 86%, 61%, 47%, and 23% in patients with both favorable features, persistent bowel enhancement but CRP level greater than 100 mg/L, no bowel enhancement but CRP level less than 100 mg/L, and both unfavorable features, respectively. Conclusion Independent predictors associated with 30-day IRF survival in patients with acute arterial mesenteric ischemia whose first-line treatment was endovascular revascularization were persistent bowel wall enhancement at initial CT and CRP level less than 100 mg/L. © RSNA, 2024 Supplemental material is available for this article.

Prostaglandin E-major urinary metabolites as a new biomarker for acute mesenteric ischemia

BACKGROUND

Acute mesenteric ischemia (AMI) is an emergent vascular disease caused by cessation of the blood supply to the small intestine. Despite advances in the diagnosis, intervention, and surgical procedures, AMI remains a life-threatening condition. Prostaglandin E2 major urinary metabolite (PGE-MUM), the urinary metabolite of prostaglandin E2, is known to be stable in urine and has been suggested to be a valuable biomarker for intestinal mucosal inflammation, such as ulcerative colitis. We therefore investigated whether or not PGE-MUM levels reflect the degree of ischemia in an intestinal ischemia-reperfusion model.

METHODS

Male rats were used to establish a superior mesenteric artery occlusion (SMAO) group, in which the superior mesenteric artery was clamped, and a sham group. The clamping times in the SMAO group were either 30 minutes or 60 minutes, and reperfusion times were either 3 hours or 6 hours, after which PGE-MUM values were measured.

RESULTS

The histological injury score of the SMAO (30-minute ischemia and 6-hour reperfusion group, 1.8 ± 0.4; 60-minute ischemia and 6-hour reperfusion group, 4.7 ± 0.5) and were significantly greater than that of the sham group (0.4 ± 0.7, p < 0.05). The PGE-MUM levels in the SMAO group (30-minutes ischemia and 6-hour reperfusion group, 483 ± 256; 60-minutes ischemia and 6-hour reperfusion group, 889 ± 402 ng/mL) were significantly higher than in the sham group (30-minute and 6-hour observation group, 51 ± 20; 60-minute and 6-hour observation group, 73 ± 32 ng/mL; p < 0.05). Furthermore, the PGE-MUM value was corrected by the concentration of urinary creatinine (Cr). The PGE-MUM/urinary Cr levels in the SMAO group were also significantly higher than in the sham group ( p < 0.05).

CONCLUSION

We found that intestinal ischemia-reperfusion increased urinary PGE-MUM levels depending on the ischemic time. This suggests the potential utility of PGE-MUM as a noninvasive marker of intestinal ischemia.

Is there a faster and easier method for assessing the severity of acute mesenteric ischemia?

Acute mesenteric ischemia (AMI) is a potentially fatal abdominal emergency. The estimation of the severity of AMI is of great importance since changes in disease severity may have different impacts on the treatment options. This study aims to define laboratory and radiological parameters that can successfully predict the severity of AMI. Data from 100 patients who were treated conservatively and underwent an operation with a diagnosis of AMI between the years 2010 and 2019 were reviewed. The patients were divided into 3 groups as those treated with a conservative approach (group 1), those with partial intestinal ischemia (group 2), and those with complete intestinal ischemia (group 3) according to the pathology results. Laboratory findings of the patients were recorded and matched with radiological findings. The white blood cell (WBC) count, neutrophil (NEUT) count, neutrophil/lymphocyte ratio, and C-reactive protein/albumin ratios were the considered distinctive parameters for distinguishing the third group from the first group. However, the same result cannot be applied to the first and the second groups since only the WBC and NEUT counts showed distinctive performance. The measurement of neutrophil/lymphocyte ratio, WBC, NEUT, and albumin levels can be used to predict the severity of AMI. We believe that evaluating these laboratory parameters will greatly prevent possible morbidity and mortality in the patient. Also, we were able to observe that the parameters used in predicting AMI severity can be verified with rapid and low-cost radiological imaging techniques.

A comprehensive scoring system for the better prediction of bowel resection in pediatric intussusception

BACKGROUND

Intussusception presents a significant emergency that often necessitates bowel resection, leading to severe complications and management challenges. This study aims to investigate and establish a scoring system to enhance the prediction of bowel resection necessity in pediatric intussusception patients.

METHODS

This retrospective study analyzed 660 hospitalized patients with intussusception who underwent surgical management at a pediatric hospital in Southwest China from April 2008 to December 2020. The necessity of bowel resection was assessed and categorized in this cohort. Variables associated with bowel resection were examined using univariate and multivariate logistic regression analyses. Based on these analyses, a scoring system was developed, grounded on the summation of the coefficients (β).

RESULTS

Among the 660 patients meeting the inclusion criteria, 218 required bowel resection during surgery. Bowel resection occurrence was linked to an extended duration of symptoms (Odds Ratio [OR] = 2.14; 95% Confidence Interval [CI], 1.03-5.23; P = 0.0015), the presence of gross bloody stool (OR = 8.98; 95% CI, 1.76-48.75, P < 0.001), elevated C-reactive protein levels (OR = 4.79; 95% CI, 1.12-28.31, P = 0.0072), lactate clearance rate (LCR) (OR = 17.25; 95% CI, 2.36-80.35; P < 0.001), and the intussusception location (OR = 12.65; 95% CI, 1.46-62.67, P < 0.001), as determined by multivariate logistic regression analysis. A scoring system (totaling 14.02 points) was developed from the cumulative β coefficients, with a threshold of 5.22 effectively differentiating infants requiring surgical intervention from others with necrotizing enterocolitis (NEC), exhibiting a sensitivity of 78.3% and a specificity of 71.9%.

CONCLUSIONS

This study successfully identified multiple risk factors for bowel resection and effectively used a scoring system to identify patients for optimal clinical management.

[Indications and surgical strategy for bowel resection in mesenteric ischemia : Resection margins considering current guidelines and literature as well as the influence of new technical possibilities]

Acute mesenteric ischemia (AMI) is still a time-critical and life-threatening clinical picture. If exploration of the abdominal cavity is necessary during treatment, an intraoperative assessment of which segments of the intestines have a sufficient potential for recovery must be made. These decisions are mostly based on purely clinical parameters, which are subject to high level of uncertainty. This review article provides an overview of how this decision-making process and the determination of resection margins can be improved using technical aids, such as laser Doppler flowmetry (LDF), indocyanine green (ICG) fluorescence angiography or hyperspectral imaging (HSI). Furthermore, this article compiles guideline recommendations on the role of laparoscopy and the value of a planned second-look laparotomy. In addition, an overview of strategies for preventing short bowel syndrome is given and other aspects, such as the timing and technical aspects of placement of a preternatural anus and an anastomosis are highlighted.

An engineered poly(A) tail attenuates gut ischemia/reperfusion-induced acute lung injury

BACKGROUND

Gut ischemia/reperfusion causes the release of damage-associated molecular patterns, leading to acute lung injury and high mortality. Cold-inducible ribonucleic acid-binding protein is a ribonucleic acid chaperon that binds the polyadenylation tail of messenger ribonucleic acid intracellularly. Upon cell stress, cold-inducible ribonucleic acid-binding protein is released, and extracellular cold-inducible ribonucleic acid-binding protein acts as a damage-associated molecular pattern, worsening inflammation. To inhibit extracellular cold-inducible ribonucleic acid-binding protein, we have recently developed an engineered polyadenylation tail named A12. Here, we sought to investigate the therapeutic potential of A12 in gut ischemia/reperfusion-induced acute lung injury.

METHODS

Male C57BL6/J mice underwent superior mesenteric artery occlusion and were treated with intraperitoneal A12 (0.5 nmol/g body weight) or vehicle at the time of reperfusion. Blood and lungs were collected 4 hours after gut ischemia/reperfusion. Systemic levels of extracellular cold-inducible ribonucleic acid-binding protein, interleukin-6, aspartate transaminase, alanine transaminase, and lactate dehydrogenase were determined. The pulmonary gene expression of cytokines (interleukin-6, interleukin-1β) and chemokines (macrophage-inflammatory protein-2, keratinocyte-derived chemokine) was also assessed. In addition, lung myeloperoxidase, injury score, and cell death were determined. Mice were monitored for 48 hours after gut ischemia/reperfusion for survival assessment.

RESULTS

Gut ischemia/reperfusion significantly increased the serum extracellular cold-inducible ribonucleic acid-binding protein levels. A12 treatment markedly reduced the elevated serum interleukin-6, alanine transaminase, aspartate transaminase, and lactate dehydrogenase by 53%, 23%, 23%, and 24%, respectively, in gut ischemia/reperfusion mice. A12 also significantly decreased cytokine and chemokine messenger ribonucleic acids and myeloperoxidase activity in the lungs of gut ischemia/reperfusion mice. Histological analysis revealed that A12 attenuated tissue injury and cell death in the lungs of gut ischemia/reperfusion mice. Finally, administration of A12 markedly improved the survival of gut ischemia/reperfusion mice.

CONCLUSION

A12, a novel extracellular cold-inducible ribonucleic acid-binding protein inhibitor, diminishes inflammation and mitigates acute lung injury when employed as a treatment during gut ischemia/reperfusion. Hence, the targeted approach toward extracellular cold-inducible ribonucleic acid-binding protein emerges as a promising therapeutic strategy for alleviating gut ischemia/reperfusion-induced acute lung injury.

A visceral organ function-focused therapeutic strategy using a 6-hour time window for patients with acute type a aortic dissection complicated by mesenteric malperfusion

BACKGROUND

Acute type A aortic dissection (ATAAD) complicated by mesenteric malperfusion is a critical and complicated condition. The optimal treatment strategy remains controversial, debate exists as to whether aortic dissection or mesenteric malperfusion should be addressed first, and the exact time window for mesenteric ischemia intervention is still unclear. To solve this problem, we developed a new concept based on the pathophysiological mechanism of mesenteric ischemia, using a 6-hour time window to divide newly admitted patients by the time from onset to admission, applying different treatment protocols to improve the clinical outcomes of patients with ATAAD complicated by mesenteric malperfusion.

METHODS

This was a retrospective study that covered a five-year period. From July 2018 to December 2020(phase I), all patients underwent emergency open surgery. From January 2021 to June 2023(phase II), patients with an onset within 6 h all underwent open surgical repair, followed by immediately postoperative examination if the malperfusion is suspected, while the restoration of mesenteric perfusion and visceral organ function was performed first, followed by open repair, in patients with an onset beyond 6 h.

RESULTS

There were no significant differences in baseline and surgical data. In phase I, eleven patients with mesenteric malperfusion underwent open surgery, while in phase II, our novel strategy was applied, with sixteen patients with an onset greater than 6 h and eleven patients with an onset less than 6 h. During the waiting period, none died of aortic rupture, but four patients died of organ failure, twelve patients had organ function improvement and underwent surgery successfully survived. The overall mortality rate decreased with the use of this novel strategy (54.55% vs. 18.52%, p = 0.047). Furthermore, the surgical mortality rate between the two periods showed even stronger statistical significance (54.55% vs. 4.35%, p = 0.022). Moreover, the proportions of patients with sepsis and multiorgan failure also showed differences.

CONCLUSIONS

Our novel strategy for patients with ATAAD complicated by mesenteric malperfusion not only improves the surgical success rate but also reduces the overall mortality rate.

Early endovascular approaches for treating acute mesenteric arterial occlusive disease in hemodialysis patients

BACKGROUND

Among hemodialysis patients, acute superior mesenteric artery (SMA) thrombosis a condition with a high mortality rate. Very few larger case series have been reported.

METHOD

We reviewed eight hemodialysis patients with diabetes mellitus and SMA thrombosis managed with endovascular therapy in our institution. Demographic, clinical, and radiological data were described. The patency of the SMA was assessed by computed tomography angiography (CTA) at one month after the endovascular procedure. At the last visit, clinical symptoms and check of mortality were recorded.

RESULTS

Multidetector CTA scan revealed severe stenosis of SMA in 6 patients and SMA occlusion in the other two patients. The severe stenosis of SMA were verified by angiography. Balloon angioplasty without stenting was performed to obtain satisfactory patency of SMA. Seven of eight patients achieved resolution of abdominal pain after the endovascular procedure. One patient died of suspected intestinal necrosis after 6 days of balloon angioplasty. All seven surviving patients did not experience a recurrence of symptoms with a median follow-up of 2 years. No significant residual stenotic or occlusive lesions were noted in follow-up CTA at one month after the endovascular procedure.

CONCLUSION

SMA thrombosis should be systematically suspected in hemodialysis patients experiencing abdominal pain. Prompt diagnosis of SMA thrombosis as soon as possible and early endovascular therapy are required to obtain a favorable prognosis in the hemodialysis patient with SMA thrombosis.

The Evaluation and Management of Intestinal Ischemia

AbstractIntestinal ischemia can result from various pathologic conditions. The presentations of ischemia can range from acute to subacute and mild to severe. Diagnosis of this condition may pose challenges, particularly in the early, potentially salvageable, stages of disease. This review offers an evidence-based approach to understanding the diagnosis and management of inadequate intestinal perfusion.

Therapeutic effect and study of human umbilical cord blood mononuclear cells in patients with ischaemic bowel disease

Ischaemic bowel disease (ICBD) is a group of intestinal ischaemia syndromes caused by various aetiologies of reduced intestinal blood flow or vascular occlusion. ICBD can present as abdominal pain, bloody stool, and diarrhoea. This disease often occurs in middle-aged and elderly individuals with cardiovascular and cerebrovascular diseases. The incidence of ischaemic bowel disease has been increasing for decades, and it is difficult to diagnose, resulting in rapid disease progression and a high mortality rate. Therefore, fully understanding this disease, improving the diagnosis rate of this disease, and finding appropriate treatment methods are urgently needed to improve the condition and prognosis of patients. Umbilical cord blood stem cells are accessible, have weak immunogenicity, and have various biological functions, such as angiogenesis, inflammation and immune regulation. Many studies have confirmed that cord blood stem cells can relieve ischaemia, and these cells have attracted tremendous amounts of attention in regenerative medicine in recent years. In this paper, we discuss the clinical characteristics of ICBD, analyse the characteristics of human umbilical cord blood mononuclear cells (HUCB-MNCs), and use its to treat ischaemic bowel disease. Additionally, we compare the clinical manifestations and related indicators before and after treatment to evaluate the efficacy and safety of these methods.

Raising Systemic Blood Pressure to Delay Irreversible Intestinal Ischemia in a Swine Model of Proximal Superior Mesenteric ArteryOcclusion

INTRODUCTION

Acute proximal superior mesenteric artery (SMA) occlusion is highly lethal, and adjuncts are needed to mitigate ischemic injury until definitive therapy. We hypothesized that raising mean arterial pressure (MAP) >90 mmHg with norepinephrine may delay irreversible bowel ischemia by increasing gastroduodenal artery (GDA) flow despite possible pressor-induced vasospasm.

METHODS

12 anesthetized swine underwent laparotomy, GDA flow probe placement, and proximal SMA exposure and clamping. Animals were randomized between conventional therapy (CT) versus targeted MAP >90 mmHg (MAP push; MP) where norepinephrine was titrated after 45 min of SMA occlusion. Animals were followed until bowel death or 4 h. Kaplan-Meier bowel survival, mean normalized GDA flow, and histology were compared.

RESULTS

12 swine (mean 57.8 ± 7.6 kgs) were included, six per group. Baseline weight, HR, MAP and GDA flows were not different. Within 5 min following SMA clamping, all 12 animals had an increase in MAP without other intervention from 81.7 to 105.5 mmHg (29.1%, P < 0.01) with a concomitant 74.9% increase in GDA flow as compared to baseline (P < 0.01). Beyond 45 min postclamp, MAP was greater in the MP group as intended, as were GDA flows. Median time to irreversibly ischemic bowel was 31% longer for MAP push animals (CT: 178 versus MP: 233 min, P = 0.006), Hazard Ratio of CT 8.85 (95% CI: 1.86-42.06); 3/6 MP animals versus 0/6 CT animals with bowel survived to predetermined end point.

CONCLUSIONS

In this swine model of acute complete proximal SMA occlusion, increasing MAP >90 mmHg with norepinephrine was associated with an increase in macrovascular blood flow through the GDA and bowel survival. Norepinephrine was not associated with worse bowel survival and a MAP push may increase the time window where ischemic bowel can be salvaged.

Correlation between white blood cell count and intestinal resection in patients with acute mesenteric vein thrombosis

OBJECTIVE

Acute mesenteric vein thrombosis (AMVT) is an acute abdominal disease with onset, rapid progression, and extensive intestinal necrosis that requires immediate surgical resection. The purpose of this study was to determine the risk factors for nosocomial intestinal resection in patients with AMVT.

METHODS

We retrospectively analysed 64 patients with AMVT diagnosed by CTA at the Affiliated Hospital of Kunming University of Science and Technology from January 2013 to December 2021. We compared patients who underwent intestinal resection (42 patients) with those who did not undergo intestinal resection (22 patients). The area under the ROC curve was evaluated, and a forest map was drawn.

RESULTS

Among the 64 patients, 6 (9.38%) had a fever, 60 (93.75%) had abdominal pain, 9 (14.06%) had a history of diabetes, 8 (12.5%) had a history of deep vein thrombosis (DVT), and 25 (39.06%) had ascites suggested by B ultrasound or CT after admission. The mean age of all patients was 49.86 ± 16.25 years. The mean age of the patients in the enterectomy group was 47.71 ± 16.20 years. The mean age of the patients in the conservative treatment group (without enterectomy) was 53.95 ± 15.90 years. In the univariate analysis, there were statistically significant differences in leukocyte count (P = 0.003), neutrophil count (P = 0.001), AST (P = 0.048), total bilirubin (P = 0.047), fibrinogen (P = 0.022) and DD2 (P = 0.024) between the two groups. The multivariate logistic regression analysis showed that admission white blood cell count (OR = 1.153, 95% CI: 1.039-1.280, P = 0.007) was an independent risk factor for intestinal resection in patients with AMVT. The ROC curve showed that the white blood cell count (AUC = 0.759 95% CI: 0.620-0.897; P = 0.001; optimal threshold: 7.815; sensitivity: 0.881; specificity: 0.636) had good predictive value for emergency enterectomy for AMVT.

CONCLUSIONS

Among patients with AMVT, patients with a higher white blood cell count at admission were more likely to have intestinal necrosis and require emergency enterectomy. This study is helpful for clinicians to accurately determine whether emergency intestinal resection is needed in patients with AMVT after admission, prevent further intestinal necrosis, and improve the prognosis of patients.

Utility of indocyanine green fluorescent dye in emergency general surgery: a review of the contemporary literature

For decades, indocyanine green (ICG) has been available for medical and surgical use. The indications for ICG use in surgery have expanded where guided surgery directed by fluorescence and near-infrared fluorescent imaging offers numerous advantages. Recently, surgeons have reported using ICG operative navigation in the emergency setting, with fluorescent cholangiography being the most common procedure. The utility of ICG also involves real-time perfusion assessment, such as ischemic organs and limbs. The rising use of ICG in surgery can be explained by the ICG's rapid technological evolution, accuracy, ease of use, and great potential to guide precision surgical diagnosis and management. The review aims to summarize the current literature on the uses of ICG in emergency general surgery. It provides a comprehensive and practical summary of the use of ICG, including indication, route of administration, and dosages. To simplify the application of ICG, we subdivided its use into anatomical mapping and perfusion assessment. Anatomical mapping includes the biliary tree, ureters, and bowel. Perfusion assessment includes bowel, pancreas, skin and soft tissue, and gonads. This review provides a reference to emergency general surgeons to aid in implementing ICG in the emergency setting for more enhanced and safer patient care.

Automatic detection of ischemic necrotic sites in small intestinal tissue using hyperspectral imaging and transfer learning

Acquiring large amounts of hyperspectral data of small intestinal tissue with real labels in the clinic is difficult, and the data shows inter-patient variability. Building an automatic identification model using a small dataset presents a crucial challenge in obtaining a strong generalization of the model. This study aimed to explore the performance of hyperspectral imaging and transfer learning techniques in the automatic identification of normal and ischemic necrotic sites in small intestinal tissue. Hyperspectral data of small intestinal tissues were collected from eight white rabbit samples. The transfer component analysis (TCA) method was performed to transfer learning on hyperspectral data between different samples and the variability of data distribution between samples was reduced. The results showed that the TCA transfer learning method improved the accuracy of the classification model with less training data. This study provided a reliable method for single-sample modelling to detect necrotic sites in small intestinal tissue .

Factors that may affect the outcome of acute occlusive mesenteric ischemia. A single-center study

BACKGROUND

Acute mesenteric ischemia is a rare but lethal disease. Acute occlusive mesenteric ischemia consists of mesenteric artery embolism, mesenteric artery thrombosis, and mesenteric vein thrombosis. This study aimed to investigate the factors that may affect the outcome of acute occlusive mesenteric ischemia.

METHODS

Data from acute occlusive mesenteric ischemia patients admitted between May 2016 and May 2022 were reviewed retrospectively. Patients were divided into 2 groups according to whether complications(Clavien‒Dindo ≥ 2) occurred within 6 months of the first admission. Demographics, symptoms, signs, laboratory results, computed tomography angiography features, management and outcomes were analyzed.

RESULTS

59 patients were enrolled in this study. Complications(Clavien‒Dindo ≥ 2) occurred within 6 months of the first admission in 17 patients. Transmural intestinal necrosis, peritonitis, white blood cell count, percentage of neutrophils, percentage of lymphocytes, neutrophil-to-lymphocyte ratio, lactate dehydrogenase, creatine kinase isoenzyme, cardiac troponin I, laparoscopic exploration rate, open embolectomy rate, enterostomy rate, length of necrotic small bowel, length of healthy small bowel, surgical time and intraoperative blood loss differed significantly between groups. Creatine kinase isoenzyme (OR = 1.415, 95% CI: 1.060-1.888) and surgical time (OR = 1.014, 95% CI: 1.001-1.026) were independent risk factors associated with complications(Clavien‒Dindo ≥ 2).

CONCLUSIONS

Our analysis suggests that acute occlusive mesenteric ischemia patients with a creatine kinase isoenzyme level greater than 2.22 ng/mL or a surgical time longer than 156 min are more likely to experience complications'(Clavien‒Dindo ≥ 2) occurrence within 6 months of the first admission.

Association between Postoperative Adjuvant Vasodilator Therapy and In-Hospital Mortality for Non-Occlusive Mesenteric Ischemia: A Nationwide Observational Study

BACKGROUND

Although several clinical guidelines recommend vasodilator therapy for non-occlusive mesenteric ischemia (NOMI) and immediate surgery when bowel necrosis is suspected, these recommendations are based on limited evidence.

METHODS

In this retrospective nationwide observational study, we used information from the Japanese Diagnosis Procedure Combination inpatient database from July 2010 to March 2018 to identify patients with NOMI who underwent abdominal surgeries on the day of admission. We compared patients who received postoperative vasodilator therapy (vasodilator group) with those who did not (control group). Vasodilator therapy was defined as venous and/or arterial administration of papaverine and/or prostaglandin E1 within 2 days of admission. The primary outcome was in-hospital mortality. Secondary outcomes included the prevalence of additional abdominal surgery performed ≥3 days after admission and short bowel syndrome.

RESULTS

We identified 928 eligible patients (149 in the vasodilator group and 779 in the control group). One-to-four propensity score matching yielded 149 and 596 patients for the vasodilator and control groups, respectively. There was no significant difference in in-hospital mortality between the groups (control vs. vasodilator, 27.5% vs. 30.9%; risk difference, 3.4%; 95% confidence interval, -4.9 to 11.6; p=0.42) and no significant difference in the prevalences of abdominal surgery, bowel resection ≥3 days after admission, and short bowel syndrome.

CONCLUSIONS

Postoperative vasodilator use was not significantly associated with a reduction in in-hospital mortality or additional abdominal surgery performed ≥3 days after admission in surgically treated NOMI patients.

Medical, Surgical and Experimental Approaches to Acute Mesenteric Ischemia and Reperfusion

Background

Acute mesenteric ishemia(AMI) is a rare but very serious disease with high rate of mortality and morbidity. About 1-2% of all gastrointestinal disease is AMI. Mortality is about 60-80% and depends of time between starting of symptoms and establishing of diagnosis, type AMI, comorbidities. AMI is often in older population with coronary syndrom and atrial fibrilation. AMI may be occlusive(embolisatio arteriae mesentericae superior(AMS), or thrombosis of AMS, mesenterial vein thrombosis) and nonoclusive form(NOMI). NOMI is rising in critical ill patients in shock or sepsis. Pathophysiology of AMI is very complex and significant role in this proces has ischemia and also reperfusion. Reperfusion injury including oxidative stres, inflamation, infection. The best diagnostic approach is CT angiography but after high clinical suspicion on AMI. Patients have sudden, catastrophic abdominal pain, vomitus, bloody diarrhoea. Therapy is multidisciplinary-basic treatment(resuscitation with cristaloids, antibiotic, anticoagulans...), surgical treatment-resection necrotic segments of intestinum without anastomosis or endovascular treatment. In early phases conservative treatment is possible( vasodilatation, thrombolysis). In some countries there are Intestinal Stroke Centers (ISC) in which patients with AMI have better prognosis. Because of progressive nature of AMI( rapide worsening) rare are clinical study,but there are many experimental study on animal models. Most of experimental study investigate protective effects of some supstances on damage on intestinum and remote organs during ishemia and reperfusion.

Objective

To present literature data of clinical and experimental study, describe experiments on animal models and mention supstances whit promising results in protective strategies during AMI.

Methods

We analysed Pubmed by using mesh terms such as acute mesenteric ischemia, intestinal injury, reperfusion, experimental study, clinical and therapeutic approach. Results: Sudden abdominal pain resists on opioids analgetics, high rate of CRP, hyperlactatemia, increase of D dimer is enough for suspicion of AMI. Often is delayed in establishing of diagnosis of AMI. CT angiography has sensitivity of 94%. Pneumatosis is sign of necrosis of intestinal wall. Classical surgical approach is dominant, more than 70%,. Endovascular treatment became often last few years. Experimental studies investigate occlusion of AMS with atraumatic clamp, with schemia and reperfusion in different intervals Most animals models are on wistar male rats.

Conclusion

AMI has still high rate of mortality. Better diagnostic and therapeutic principles (shorter interval between appearance of symptoms and starting of therapy, multidisciplinary approach, higher percent of endovascular procedures), could decrease mortality. Experimental studies on animal models may be succesfull in development of new clinical, conservative approaches in the early phases of AMI in the future.

Iodine density mapping for the diagnosis of acute bowel ischemia using fast kV-switching dual-energy CT

PURPOSE

To evaluate the diagnostic capabilities of a supplementary color ramped iodine density map compared to virtual monoenergetic images (VMIs) at 74 keV in the diagnosis of acute bowel ischemia (ABI).

METHODS

Data for this study were prospectively gathered and retrospectively evaluated. Patients referred to the Department of Diagnostic Radiology between October 2020 and August 2022 on the suspicion of ABI and underwent surgery < 12 h following fast kV-switching venous phase abdominal dual-energy CT (DECT) were consecutively included. Images were evaluated by two board-certified radiologists and two radiology residents. First round included only 74 keV VMIs resembling conventional 120 kVp images, and the second round included a supplementary iodine density map. Readers were asked to register presence of ABI as well as their confidence in their diagnosis based on a 5-point Likert scale. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for each observer with the surgical findings as the gold-standard. McNemar's and Wilcoxon signed-rank test were used to compare registrations and diagnostic confidence across assessment rounds.

RESULTS

A total of 29 patients resulting in 31 DECT scans were included. Fourteen cases of ischemic/necrotic bowel were reported following surgery. Sensitivity and NPV were decreased with the use of supplementary iodine map images compared to 120 kVp-like images without supplementary iodine map images for three of four observers (round 1 range: 71.4-92.9% and 78.0-94.8%; round 2 range: 57.1-78.6% and 70.1-83.3%, respectively), while specificity and PPV were increased for three of four observers (round 1 range: 64.7-94.1% and 67.4-93.1%; round 2 range: 88.2-94.1% and 73.8-91.1%, respectively). However, no significant difference in ABI diagnosis or diagnostic confidence was found (p-value range: 0.07-1.00 and 0.23-0.58, respectively).

CONCLUSION

No significant difference for the diagnosis of ABI was found using supplementary iodine mapping. Our study may suggest a trend of increased specificity and decreased sensitivity, hence, the use of supplementary iodine mapping should be carefully considered.

Establishment of a swine experimental model of non-occlusive mesenteric ischemia: Combining induced hemorrhagic shock and vasopressor administration

Aim

Non-occlusive mesenteric ischemia (NOMI) is associated with high mortality rates, but definitive treatments have not yet been established. Although experimental animal models are worthwhile, reproducible models that reflect the pathophysiology of NOMI have not been developed.

Methods

We combined risk factors for NOMI, comprising hemorrhagic shock, systemic vasopressor infusion, and local vasopressor infusion from the superior mesenteric artery (SMA) in swine under maintained anesthesia. Experiment 1 involved full-intensity (40%) phlebotomy and systemic vasopressor (norepinephrine and epinephrine). Experiment 2 involved full-intensity (40%) phlebotomy, systemic norepinephrine, and local vasopressor infusion into the SMA. Experiment 3 involved moderate (27%) phlebotomy, systemic norepinephrine infusion, and local epinephrine infusion. We evaluated serum lactate levels, intestinal serosa color, computed tomography (CT) angiography, and pathological findings.

Results

After inducing hemorrhage, systemic vasopressor alone and in combination with local vasopressin or norepinephrine infusion did not induce ischemic color changes in the intestine. The combination of systemic norepinephrine and local epinephrine (0.5 μg/kg/min) after moderate (27% blood loss) hemorrhage induced gross color change, pathological destruction, and elevation of serum lactate. Patent flow in the SMA was confirmed on CT angiography.

Conclusion

We established a swine NOMI model with systemic norepinephrine infusion and local epinephrine with moderate hemorrhagic shock.

A Miraculous Save: Gangrenous Bowel and Meckle's Diverticulum With Acute Superior Mesenteric Artery Thrombosis

The superior mesenteric artery (SMA) is vital for parts of the small intestine and ascending colon. Thrombosis of this major artery is a severe and potentially fatal condition involving the occlusion of the arterial vascular supply, causing ischemia predisposing to gangrene. Meckel's diverticulum is a congenital outpouching in the lower part of the small intestine. The condition of gangrenous meckels diverticulum is, therefore, even more limited. This study presents a unique case of a 45-year-old male with coexisting features of SMA thrombus with acute small bowel intestinal obstruction. During the study, the patient was found to have sickle cell anemia with an AS pattern, which may have predisposed the formation of a thrombus. The patient underwent sequential management of active thrombus by thrombolysis first, followed by resection anastomosis for gangrenous bowel. With precise monitoring and therapeutic care, the patient made a remarkable recovery. The condition possesses a high mortality rate. Prompt recognition and timely intervention in this case are of utmost significance.

Acute Mesenteric Ischemia: The Diagnostic Value of QT Parameters and their Relationship with CT Findings

BACKGROUND

One of the greatest challenges in the diagnosis of acute mesenteric ischemia (AMI) is the lack of specific laboratory tests that support multidetector computed tomography (CT). Our aim is to investigate the diagnostic value of electrocardiographic QT parameters in AMI and their relationship with CT findings.

MATERIALS AND METHODS

Patients who were admitted to the emergency department with abdominal pain were recruited retrospectively from the hospital information system. Grouping was carried out on the basis of AMI (n=78) and non-AMI (n=78). In both groups, the corrected QT (QTc) and QT dispersion (QTD) were measured on electrocardiographs, and the qualitative and quantitative CT findings were evaluated on CT examinations.

RESULTS

The QTc and QTD values were higher in the AMI group. The median QTc values were 456.16 (IQR: 422.88-483.16) for the AMI group and 388.83 (IQR: 359.74-415.83) for the control group (p<0.001), and the median QTD values were 58 (IQR: 50.3-68.25) for the AMI group and 46 (IQR: 42-50) for the control group (p<0.001). In the CT analysis, the QTc values were significantly higher among AMI patients, with images of paper-thin bowel walls and the absence of bowel wall enhancement (p=0.042 and p=0.042, respectively). Meanwhile, the QTD values were significantly higher among patients with venous pneumatosis findings on CT (p=0.005). In the regression analysis, a significant relationship was found between the QT parameters and AMI (p<0.001). For QTc, an AUC of 0.903 (95% CI: 0.857-0.950, p<0.001), a sensitivity of 80.8%, and a specificity of 82.3% were found. For QTD, an AUC of 0.821 (95% CI: 0.753-0.889, p<0.001), a sensitivity of 73.1%, and a specificity of 82.3% were found.

CONCLUSION

We found the QTc and QTD values to be significantly higher among AMI patients. Furthermore, we found a significant relationship between the CT findings and QTc and QTD and a significant relationship between survival and QTc in the AMI group.

The Impact of Biomarkers on the Early Detection of Acute Mesenteric Ischemia

BACKGROUND

acute mesenteric ischemia (AMI) is a life-threatening condition that is caused by inadequate blood flow through the mesenteric vessel and is related to high mortality rates due to systemic complications. This study aims to systematically review the available literature concerning the major findings of possible biomarkers for early detection of acute mesenteric ischemia in the human population.

METHODS

studies that measured the performance of biomarkers during acute mesenteric ischemia were identified with the search of PubMed, Embase, Medline, and Cochrane library.

RESULTS

from a total of 654 articles, 46 articles examining 14 different biomarkers were filtered, falling within our inclusion criteria. Intestinal fatty acid-binding protein (I-FABP) was the most commonly researched biomarker regarding AMI, with sensitivity ranging from 61.5% to 100% and specificity ranging from 40% to 100%. The second most commonly researched biomarker was D-dimer, with a sensitivity of 60-100% and a specificity of 18-85.71%. L-lactate had a sensitivity of 36.6-90.91% and a specificity of 64.29-96%. Several parameters within the blood count were examined as potential markers for AMI, including NLR, PLR, MPV, RDW, DNI, and IG. Citrulline, interleukin 6 (IL-6), and procalcitonin (PCT) were the least-researched biomarkers.

CONCLUSION

different biomarkers showed different accuracies in detecting AMI. I-FABP and D-dimer have been the most researched and shown to be valuable in the diagnosis of AMI, whereas L-lactate could be used as an additional tool. Ischemia-modified albumin (IMA), alpha glutathione S-transferase (αGST), interleukin 6 (IL-6), and citrulline showed potential use in their respective studies. However, further research needs to be done on larger sample sizes and with controls to reduce bias. Several studies showed that neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), mean platelet volume (MPV), red-cell distribution width (RDW), delta neutrophil index (DNI), and immature granulocytes (IGs) might be useful, as well at the same time be widely distributed and affordable in combination with other markers presenting higher specificity and sensitivity.

Cesena guidelines: WSES consensus statement on laparoscopic-first approach to general surgery emergencies and abdominal trauma

BACKGROUND

Laparoscopy is widely adopted across nearly all surgical subspecialties in the elective setting. Initially finding indication in minor abdominal emergencies, it has gradually become the standard approach in the majority of elective general surgery procedures. Despite many technological advances and increasing acceptance, the laparoscopic approach remains underutilized in emergency general surgery and in abdominal trauma. Emergency laparotomy continues to carry a high morbidity and mortality. In recent years, there has been a growing interest from emergency and trauma surgeons in adopting minimally invasive surgery approaches in the acute surgical setting. The present position paper, supported by the World Society of Emergency Surgery (WSES), aims to provide a review of the literature to reach a consensus on the indications and benefits of a laparoscopic-first approach in patients requiring emergency abdominal surgery for general surgery emergencies or abdominal trauma.

METHODS

This position paper was developed according to the WSES methodology. A steering committee performed the literature review and drafted the position paper. An international panel of 54 experts then critically revised the manuscript and discussed it in detail, to develop a consensus on a position statement.

RESULTS

A total of 323 studies (systematic review and meta-analysis, randomized clinical trial, retrospective comparative cohort studies, case series) have been selected from an initial pool of 7409 studies. Evidence demonstrates several benefits of the laparoscopic approach in stable patients undergoing emergency abdominal surgery for general surgical emergencies or abdominal trauma. The selection of a stable patient seems to be of paramount importance for a safe adoption of a laparoscopic approach. In hemodynamically stable patients, the laparoscopic approach was found to be safe, feasible and effective as a therapeutic tool or helpful to identify further management steps and needs, resulting in improved outcomes, regardless of conversion. Appropriate patient selection, surgeon experience and rigorous minimally invasive surgical training, remain crucial factors to increase the adoption of laparoscopy in emergency general surgery and abdominal trauma.

CONCLUSIONS

The WSES expert panel suggests laparoscopy as the first approach for stable patients undergoing emergency abdominal surgery for general surgery emergencies and abdominal trauma.

Gastric, Duodenal, and Small Bowel Emergencies

Gastric and small bowel emergencies are often seen in the emergency department and require rapid assessment and intervention as patients can deteriorate quickly. Some of the more frequently seen gastric emergencies include gastric volvulus and peptic ulcer disease, which can present with ischemia, strangulation, perforation, or severe bleeding. Swift diagnosis is crucial to ensuring the proper management whether that is endoscopic or with surgical exploration. Perforated peptic ulcers that are not contained will require surgical intervention, whereas bleeding ulcers can often be controlled with endoscopic interventions.

Damage control surgery: old concepts and new indications

PURPOSE OF REVIEW

While the principles of damage control surgery - rapid hemorrhage and contamination control with correction of physiologic derangements followed by delayed definitive reconstruction - have remained consistent, forms of damage control intervention have evolved and proliferated dramatically. This review aims to provide a historic perspective of the early trends of damage control surgery as well as an updated understanding of its current state and future trends.

RECENT FINDINGS

Physiologically depleted patients in shock due to both traumatic and nontraumatic causes are often treated with damage control laparotomy and surgical principles. Damage control surgery has also been shown to be safe and effective in thoracic and orthopedic injuries. Damage control resuscitation is used in conjunction with surgical source control to restore patient physiology and prevent further collapse. The overuse of damage control laparotomy, however, is associated with increased morbidity and complications. With advancing technology, catheter- and stent-based endovascular modalities are playing a larger role in the resuscitation and definitive care of patients.

SUMMARY

Optimal outcome in the care of the most severely injured patients requires judicious use of damage control surgery supplemented by advancements in resuscitation and surgical adjuncts.

Causes of adverse outcomes in acute intestinal obstruction

OBJECTIVES

The purpose of this study is to analyse the effectiveness of methods of diagnosis and treatment of patients with acute intestinal obstruction.

METHODS

A total of 123 patients were examined, who were diagnosed based on history, an overview X-ray of the abdominal cavity, a contrast examination of the intestine, and contrast marks according to Yu. L. Shalkov and irrigoscopy. 57.4 % of patients had all typical aspects of the disease, 17.7 % - indolent aspects, and 4.8 % - atypical. In the case of colonic obstruction, the method of irrigoscopy is informative. To restore intestinal function, patients with acute intestinal obstruction of the small intestine are indicated with a Yu. L. Shalkov nasogastroenteral tube or a double-drainage nasointestinal tube. And with the colonic form of the disease, it is necessary to perform a Hartmann-type operation and establish a Maidl-type anastomosis.

RESULTS

It was noted that with indolent or atypical aspects of the disease, patients received medical care late. It is shown that in the case of resection of necrotic areas of the intestine, it is informative to determine the resection boundary using the vasoscopy method using a 1 % aqueous solution of methylene blue. It was found that the optimal distance from the edge of the resection is 3 cm.

CONCLUSIONS

The results of this study are of interest to clinicians who are engaged in the diagnosis and treatment of patients with acute intestinal obstruction.