Surgical management of peritonitis secondary to acute superior mesenteric artery occlusion

Mesenteric venous thrombosis in a young adult: A case report and review of the literature

BACKGROUND

Acute mesenteric vein thrombosis (MVT) accounts for only 2%-10% of all cases of acute mesenteric ischaemia, with an incidence rate of ~0.1% in Europe and the United States. It represents < 10% of mesenteric infarction cases and is seen predominantly in older adults. In younger individuals, MVT is uncommon, with 36% of cases having unidentified mechanisms and causes.

CASE SUMMARY

A 27-year-old man presented to the emergency department on February 29, 2024, with a chief complaint of intermittent abdominal pain for 3 day. He was previously in good health. As the abdominal pain was not alleviated by conventional treatment, an abdominal computed tomography (CT) scan was performed, which showed increased density in the portal and mesenteric veins. Further imaging, including portal vein ultrasound, mesenteric CT angiography, and enhanced abdominal CT, revealed widespread thrombosis of the portal vein system (including the main portal vein, left and right branches, proximal mesenteric vein, and splenic vein). After 10 day of thrombectomy and anticoagulation therapy, the patient's abdominal pain had improved significantly. Follow-up assessments indicated that portal venous blood flow had largely returned to normal. He was discharged on March 9, 2024. During a follow-up exam 2 months later, repeat abdominal enhanced CT showed that the previously detected thrombi were no longer visible.

CONCLUSION

Clinicians should remain vigilant for acute MVT in young patients presenting with abdominal pain, to prevent misdiagnosis of this fatal condition.

A Case Series on Acute Mesenteric Ischemia (AMI) Leading to Intestinal Gangrene Following Blunt Trauma to the Abdomen

The term "acute mesenteric ischemia" (AMI) refers to a set of conditions where the blood supply to various segments of the small intestine is cut off, causing ischemia and subsequent inflammatory changes that might result in bowel gangrene. Estimates place the incidence between 0.09% and 0.2% of all acute surgical hospitalizations. Early diagnosis is essential, despite the entity being a rare cause of abdominal discomfort, because if left untreated, mortality is 50%. Herein, we present a case series of three patients with bowel ischemia following blunt abdominal trauma.

Factors associated with the need for long-term total parenteral nutrition in survivors of acute superior mesenteric artery occlusion

BACKGROUND

Acute superior mesenteric artery (SMA) occlusion is an uncommon condition associated with high mortality. If extensive bowel resection is performed for patients with acute SMA occlusion and the patient survives, long-term total parenteral nutrition (TPN) may be needed due to short bowel syndrome. This study examined factors associated with the need for long-term TPN after the treatment of acute SMA occlusion.

METHODS

We retrospectively analyzed 78 patients with acute SMA occlusion. Patients were abstracted from a Japanese database from institutions with at least 10 patients with acute SMA occlusive disease from January 2015 through December 2020 RESULTS: Among the initial cohort there were 41/78 survivors. Of these, 14/41 (34%) required permanent TPN who were compared with those who did not require long-term TPN (27/41, 66%). Compared to patients in the non-TPN group, those in the TPN group had significantly shorter remaining small intestine (90.7 cm vs. 218 cm, P<0.01), more patients with time from onset to intervention >6 hours (P=0.02), pneumatosis intestinalis on enhanced computed tomography scan (P=0.04), ascites (Odds Ratio 11.6, P<0.01), and a positive smaller superior mesenteric vein sign (P= 0.03). These were considered significant risk factors for needing long-term TPN. Age, gender, underlying disease, presence of peritoneal sign, presence of shock requiring vasopressors, site of obstruction (proximal vs. distal), and initial treatment (surgery vs. interventional radiology vs. thrombolytic therapy) were not significantly different between the two groups. Long-term TPN was significantly associated with longer hospital stay (52 vs. 35 days, P=0.04). Multivariate analysis identified the presence of ascites as an independent risk factor for needing long-term TPN.

CONCLUSION

The need for permanent TPN after treatment of acute SMA occlusion is significantly associated with longer hospital stay, longer time to intervention, and characteristic imaging findings (pneumatosis intestinalis, ascites, Smaller SMV sign). Ascites is an independent risk factor.

LEVEL OF EVIDENCE

III.

Immediate postoperative parenteral anticoagulant therapy in patients with mesenteric ischemia after intestinal resection: a retrospective cohort study at a single institute

BACKGROUND

Bowel gangrene represents a major fatal event in acute mesenteric ischemia. Intestinal resection is inevitable in patients with peritonitis and bowel gangrene. This retrospective study aimed to elucidate the benefit of postoperative parenteral anticoagulation in patients with intestinal resection.

METHODS

Patients with acute mesenteric ischemia and bowel gangrene were recruited retrospectively between January 2007 and December 2019. All patients underwent bowel resection. They were categorized into two groups: patients without immediate parenteral anticoagulant therapy (Group A) and those with immediate parenteral anticoagulant therapy (Group B). Thirty-day mortality and survival were analyzed.

RESULTS

A total of 85 patients were included, with 29 patients in Group A and 56 patients in Group B. Patients in Group B had lower 30-day mortality (16.1%) and a higher 2-year survival rate (45.4%) than patients in Group A (30-day mortality: 51.7%, p = 0.001; 2-year survival rate: 19.0%, p = 0.001). In the 30-day mortality multivariate analysis, patients in Group B had a better outcome (odds ratio = 0.080, 95% confidence interval between 0.011 and 0.605, p = 0.014). Patients in Group B also had a better outcome in the survival multivariate analysis (hazard ratio: 0.435, 95% confidence interval between 0.213 and 0.887, p = 0.022).

CONCLUSIONS

Immediate postoperative parenteral anticoagulant therapy improves prognosis in patients with acute mesenteric ischemia treated by intestinal resection. Trial registration This research was retrospectively approved by the Institutional Review Board (IRB) I&II of Taichung Veterans General Hospital (TCVGH-IRB No.CE21256B) on July 28th, 2021. The informed consent waiver was also approved by IRB I&II of Taichung Veterans General Hospital. The Declaration of Helsinki and ICH-GCP guidelines were followed during this study.

Non-neoplastic disorders in an aging gut: concise review

The spectrum of gastrointestinal (GI) issues in the older population varies from common physiological age-related changes to devastating, less common sinister pathological illness. GI system has direct exposure to external environment. Thus, it is modeled to embrace the pathophysiological changes that occur due to interaction with external factors. Gastrointestinal tract (GIT) per se is more resilient to aging as compared to other organ systems. On the other hand, elderly may present with a large plethora of GI symptoms. This presents a challenge to all echelons of medical consultation for accurate attribution for the aging process or pathophysiological causation of GI symptoms. This dichotomy leads to hindrance in adequate and appropriate treatment of GI ailments. In GI system, non-neoplastic disorders are far more common than neoplastic disorders. Hence, it becomes imperative to understand the aging evolution of the GI system and management of GI disorders in the older population.

Understanding CT imaging findings based on the underlying pathophysiology in patients with small bowel ischemia

Because acute small bowel ischemia has a high mortality rate, it requires rapid intervention to avoid unfavorable outcomes. Computed tomography (CT) examination is important for the diagnosis of bowel ischemia. Acute small bowel ischemia can be the result of small bowel obstruction or mesenteric ischemia, including mesenteric arterial occlusion, mesenteric venous thrombosis, and non-occlusive mesenteric ischemia. The clinical significance of each CT finding is unique and depends on the underlying pathophysiology. This review describes the definition and mechanism(s) of bowel ischemia, reviews CT findings suggesting bowel ischemia, details factors involved in the development of small bowel ischemia, and presents CT findings with respect to the different factors based on the underlying pathophysiology. Such knowledge is needed for accurate treatment decisions.

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

Acute mesenteric ischemia (AMI) is a group of diseases characterized by an interruption of the blood supply to varying portions of the intestine, leading to ischemia and secondary inflammatory changes. If untreated, this process may progress to life-threatening intestinal necrosis. The incidence is low, estimated at 0.09-0.2% of all acute surgical admissions, but increases with age. Although the entity is an uncommon cause of abdominal pain, diligence is required because if untreated, mortality remains in the range of 50%. Early diagnosis and timely surgical intervention are the cornerstones of modern treatment to reduce the high mortality associated with this entity. The advent of endovascular approaches in parallel with modern imaging techniques is evolving and provides new treatment options. Lastly, a focused multidisciplinary approach based on early diagnosis and individualized treatment is essential. Thus, we believe that updated guidelines from World Society of Emergency Surgery are warranted, in order to provide the most recent and practical recommendations for diagnosis and treatment of AMI.

Two cases of intestinal perforation due to mesenteric artery embolism during extracorporeal membrane oxygenation and intra-aortic balloon pumping

The patient in case 1 was a 50-year-old man who presented to the emergency department of the local hospital with chest pain and syncope for 3 hours due to acute myocardial infarction. He underwent cardiopulmonary resuscitation (CPR) followed by extracorporeal membrane oxygenation (ECMO), and intestinal perforation was detected on day 9. The patient in case 2 was a 58-year-old man who was admitted to the hospital with abdominal pain lasting for 3 days. He also required CPR and ECMO for cardiogenic shock, and intestinal perforation was identified on day 7 of ECMO. We believe that this case report will be important to alert clinicians to the possibility of this complication and to encourage early detection and intervention to improve prognosis. Conventionally, the gastrointestinal tract has received secondary attention in patients receiving ECMO support because the vital organs tend to be considered first. However, this case report illustrates the importance of monitoring gastrointestinal function in patients undergoing ECMO.

Acute Mesenteric Ischemia

The surgical treatment of occlusive acute mesenteric ischemia (AMI) without revascularization is associated with an 80% overall mortality. Early diagnosis is crucial, and revascularization may reduce overall mortality in AMI by up to 50%. A diagnosis of AMI requires a high index of clinical suspicion and the collaborative effort of emergency department physicians, general and vascular surgeons, and radiologists. This article provides an overview of the etiology, physiology, evaluation, and management of acute mesenteric ischemia.

Post traumatic arterial occlusive mesenteric ischemia: a rare case report

Mesenteric ischemia is an uncommon condition with very high mortality rates characterized by inadequate blood supply, inflammatory injury, and subsequent necrosis of the bowel wall. Acute arterial mesenteric ischemia is usually caused by cardiac emboli, atherosclerotic vascular disease, aortic aneurysm, or dissection. We report a case of a 60-year-old male who presented to the accident and emergency department complaining of abdominal pain following blunt abdominal trauma. An urgent contrast enhanced computed tomography scan demonstrated superior mesenteric artery thrombosis with ischemic small bowel. Surgical intervention was carried out with resection of the necrotic bowel followed by anastomosis. Acute occlusive mesenteric ischemia needs to be considered in cases of blunt trauma presenting with abdominal pain. Proper early diagnosis and management is essential as it carries a high risk of morbidity and mortality.

Usefulness of damage control approach in patients with limited acute mesenteric ischemia: a prospective study of 85 patients

To evaluate the efficacy of the damage control approach by two-step surgical procedure in not critical patients (without sepsis or septic shock) with peritonitis from limited acute mesenteric ischemia. From April 2013 to April 2020, 85 patients [49 (57.7%) women and 36 (42.3%) men, median age 69.5 (range 38-92)] were enrolled in this study and underwent emergency surgery. After resection of ischemic bowel, basing on the individual decision of the single surgeon, the patients underwent primary end-to-end anastomosis (Group 1) or damage control approach (Group 2) including primary laparotomy with resection of ischemic bowel, temporary abdominal closure and a second-look procedure at 48 h with re-evaluation of bowel vitality. Forty-seven (55.3%) patients underwent one-stage surgical treatment and 38 (44.7%) patients received a two-step procedure. In the latter group, at second exploration, 8 (21%) patients required a further intestinal resection, due to mesenteric ischemia progression. Both anastomosis dehiscence rate and need for ileostomy in Group 1 patients were significantly higher than in Group 2 (23.4% vs 5.3%: p = 0.03 and 19.1% vs 2.6%: p = 0.03; Fisher's exact test). No significative differences in mortality and morbidity rate were found between the two groups. The damage control approach by two-step surgical procedure may represent a valid innovative option in the management of not critical patients with limited acute mesenteric ischemia, achieving a better clinical outcome if compared with surgical treatment by one-step procedure.

Relationship of superior mesenteric artery thrombus density with transmural intestinal necrosis on multidetector computed tomography in acute mesenteric ischemia

BACKGROUND

Acute arterial occlusive mesenteric ischemia with transmural intestinal necrosis (TIN) is a fatal disease, which is difficult to diagnose on multidetector computed tomography (MDCT). The aim of the present study was to determine the relationship of superior mesenteric artery (SMA) thrombus density with TIN on MDCT in patients with acute mesenteric ischemia (AMI) due to SMA thromboembolism.

METHODS

In this retrospective study, 33 patients who underwent abdominal MDCT and angiography for AMI due to SMA thromboembolism were divided into two groups: the AMI with TIN group and the AMI without TIN group. We analyzed the relationships of clinical characteristics, qualitative MDCT signs, and SMA thrombus density with TIN. The SMA thrombus density was measured on non-contrast MDCT. Univariate and multivariate analyses were performed to determine the risk factors for predicting TIN. The diagnostic performances of risk factors were evaluated by receiver-operating characteristic (ROC) curve analysis.

RESULTS

Of the patients with AMI enrolled in this study, 33.3% (11/33) were diagnosed with TIN. Peritonitis (P=0.042), bowel wall thinning (P=0.033), and pneumatosis/portomesenteric gas (P=0.010) were significantly associated with TIN. AMI patients with TIN exhibited a higher SMA thrombus density than AMI patients without TIN [41.2±6.1 vs. 34.2±3.0 Hounsfield unit (HU), P=0.003]. Multivariate analysis showed that SMA thrombus density was an independent predictor of TIN [P=0.044, hazard ratio (HR): 1.82, 95% confidence interval (CI): 1.02-3.25]. For diagnosing AMI with TIN, the area under the ROC curve (AUC) of SMA thrombus density (0.83) was larger than those of peritonitis (0.68), bowel wall thinning (0.66), and pneumatosis/portomesenteric gas (0.71).

CONCLUSIONS

In patients with AMI, erythrocyte-rich thrombus blocking the SMA trunk which has a higher density on MDCT is prone to the occurrence of TIN compared with erythrocyte-scarce thrombus with a lower density. SMA thrombus density could be an independent risk factor for TIN in patients with AMI due to SMA thromboembolism.

Many faces of acute bowel ischemia: overview of radiologic staging

Acute bowel ischemia (ABI) can be life threatening with high mortality rate. In spite of the advances made in diagnosis and treatment of ABI, no significant change has occurred in the mortality over the past decade. ABI is potentially reversible with prompt diagnosis. The radiologist plays a central role in the initial diagnosis and preventing progression to irreversible intestinal ischemic injury or bowel necrosis. The most single imaging findings described in the literature are either non-specific or only present in the late stages of ABI, urging the use of a constellation of features to reach a more confident diagnosis. While ABI has been traditionally categorized based on the etiology with a wide spectrum of imaging findings overlapped with each other, the final decision for patient's management is usually made on the stage of the ABI with respect to the underlying pathophysiology. In this review, we first discuss the pathologic stages of ischemia and then summarize the various imaging signs and causes of ABI. We also emphasize on the correlation of imaging findings and pathological staging of the disease. Finally, a management approach is proposed using combined clinical and radiological findings to determine whether the patient may benefit from surgery or not.

Interdisciplinary Management of Visceral Artery Aneurysms and Visceral Artery Pseudoaneurysms

The paper presents the results of treating 14 patients, namely eight patients with visceral artery aneurysms and six patients with visceral artery pseudoaneurysms. In 64.3% of the patients, the initial diagnosis was made based on the ultrasound examination. All the patients (100%) underwent CT angiography, while angiography was performed in 71.4% of the cases. Five (35.7%) patients with visceral artery pseudoaneurysms were emergently hospitalized; among them, the signs of bleeding were observed in 2 patients. In 9 patients, pathology was detected during tests for other conditions. Five (35.7%) patients underwent endovascular treatment, while 9 (64.3%) patients received surgical treatment. Endovascular interventions and open surgery demonstrated a nil mortality rate. After endovascular treatment, stent thrombosis was found in 1 patient. In the case of surgical treatment, visceral artery aneurysm was observed in 1 patient who underwent the resection of superior mesenteric artery pseudoaneurysm. Conclusions. The choice of the method of treating visceral artery aneurysms and visceral artery pseudoaneurysms depends on the location, size, anatomic features of the visceral arteries and the clinical course of the disease. Both endovascular and surgical treatment demonstrate good postoperative outcomes. Visceral ischemia is one of the most serious complications in the postoperative period, which can complicate both the diagnosis and the choice of treatment tactics.

Bowel ischemia and gangrene-primary true enterolith

Enterolithiasis, or presence of stone concretions in the gastrointestinal tract, is an important but relatively uncommon clinical condition that has recently gained significant attention with advances in the gastrointestinal field. Here, we present a case of an old male having features of bowel Ischemia and gangrene formation. Patient underwent exploratory laparotomy and there was a presence of inflamed Gut with a perforation just one and half feet away from IC junction and an obstruction was also identified by following the dilated bowel loops distally, palpation revealed a hard stone and enterotomy incision at the site delivered a stone. Following it, resection of thickened mesentery was done and loop ileostomy was made. The most important prognostic factor in such cases relies on time interval between onset of symptoms and definitive treatment. By improving the awareness and early recognition of mesenteric ischemia will lead to improved survival in the condition.

Risk factors of geriatrics index of comorbidity and MDCT findings for predicting mortality in patients with acute mesenteric ischemia due to superior mesenteric artery thromboembolism

OBJECTIVES

To identify risk factors of geriatrics index of comorbidity (GIC) and multidetector CT (MDCT) findings for predicting mortality in patients with acute mesenteric ischemia (AMI) due to superior mesenteric artery (SMA) thromboembolism.

METHODS

33 patients with AMI due to SMA thromboembolism underwent abdominal MDCT and angiography. Patients' comorbidities and MDCT findings of ischemic bowel/mesenteric injuries, regions of SMA involved by thromboembolism, and degrees of SMA stenosis were retrospectively reviewed. The comorbidities were classified into 1-4 levels according to GIC. The association of MDCT signs and GIC classification with mortality were analyzed. Diagnostic performances of risk factors associated with mortality were evaluated by receiver operating characteristic (ROC) curve analyses.

RESULTS

Eighteen patients (54.5%) died during hospitalization or follow-up, including one patient with class 1, two patients with class 2, eight patients with class 3, and seven patients with class 4 according to GIC. Three risk factors significantly associated with mortality were identified, including pneumatosis and/or portomesenteric venous gas (PPMVG) (p = 0.017), four regions of SMA involved by thromboembolism (region I + II + III + IV) (p = 0.036), and class 3 + 4 of comorbidities (p = 0.001). The sensitivity and specificity of PPMVG, region I + II + III + IV, class 3 + 4 of comorbidities, and the three risk factors combined for diagnosing mortality were 33.3 and 100%, 27.8 and 100%, 83.3 and 73.3%, and 88.9 and 73.3%, respectively. The areas under the ROC curve (AUC) of the three risk factors combined (0.88) and class 3 + 4 of comorbidities (0.78) were larger than that of PPMVG (0.67) and region I + II + III + IV (0.64). The mortality rate rose from 15.4% in patients without risk factor to 66.7%, 100%, and 100% in patients with one, two, and three factors, respectively.

CONCLUSION

Three risk factors for mortality were identified in patients with AMI due to SMA thromboembolism, including PPMVG and four regions of SMA involved by thromboembolism on MDCT images, and class 3 + 4 of comorbidities. Close monitoring of these risk factors could possibly lower the mortality.

ADVANCES IN KNOWLEDGE

Risk factors based on GIC and MDCT findings may be used to predict mortality in patients with AMI. Close monitoring of these risk factors could possibly lower the mortality.

Clinical Features and Factors Affecting Postoperative Mortality for Obstructive Acute Mesenteric Ischemia in China: A Hospital- Based Survey

PURPOSE

The study aimed to report the clinical manifestation and identify the risk factors for postoperative mortality in patients who were diagnosed with obstructive acute mesenteric ischemia (AMI) based on a survey of a hospital in western China.

PATIENTS AND METHODS

We reviewed clinical data of 108 patients with obstructive AMI at West China Hospital, Sichuan University, from 2011 to 2017. Clinical characteristic was described and compared. Factors affecting postoperative survival were analyzed.

RESULTS

A total of 108 obstructive AMI cases were included in this study, with an overall average age of 57.1 years, including 58 arterial occlusive mesenteric ischemia (AOMI) and 50 mesenteric venous thrombosis (MVT). AOMI patients were older and had a significantly higher frequency of these comorbidities, including heart disease, hypertension, and diabetes. In comparison, MVT had a significantly higher proportion of male patients and a higher frequency of liver disease. A total of 77 patients underwent laparotomy, and the 30-day postoperative mortality rate was 29.9%. Multivariate logistic regression analysis showed that the time interval from admission to surgery (adjust OR 1.19; 95% CI [1.07-1.34], P = 0.005), platelet count (adjust OR = 0.98; 95% CI [0.97-0.99], P = 0.008) and AOMI (adjust OR = 5.55; 95% CI [1.36-22.55], P = 0.017) were independent predictors of 30-day mortality after exploratory laparotomy for obstructive AMI. Further analysis of the 45 AOMI showed that the time interval from admission to surgery (adjustOR 1.22; 95% CI [1.01-1.47], P = 0.036) and platelet count (adjustOR = 0.98; 95% CI [0.97-0.99], P = 0.020) were independent risk factors for 30-day postoperative mortality of AOMI.

CONCLUSION

Early identification of AOMI, improving the efficiency of enhanced CT examination, strengthening doctor-patient communication, active laparotomy, and optimize platelet management may also help reduce the overall short-term mortality of obstructive AMI. Building the multidisciplinary team model of diagnostic imaging, vascular intervention, and surgical treatment to manage obstructive AMI may be urgently needed in western China.

Preoperative Risk Factors for Short-Term Postoperative Mortality of Acute Mesenteric Ischemia after Laparotomy: A Systematic Review and Meta-Analysis

OBJECTIVE

Our objective was to comprehensively present the evidence of preoperative risk factors for short-term postoperative mortality of acute mesenteric ischemia after laparotomy.

METHODS

PubMed, Embase, and Google Scholar were searched from January 2000 to January 2020. Studies evaluating the postoperative risk factors for short-term postoperative mortality of acute mesenteric ischemia after laparotomy were included. The outcome extracted were patients' demographics, medical history, and preoperative laboratory tests.

RESULTS

Twenty studies (5011 patients) met the inclusion criteria. Studies were of high quality, with a median Newcastle-Ottawa Scale Score of 7. Summary short-term postoperative mortality was 44.38% (range, 18.80%-67.80%). Across included studies, 49 potential risk factors were examined, at least two studies. Meta-analysis of predictors based on more than three studies identified the following preoperative risk factors for higher short-term postoperative mortality risk: old age (odds ratio [OR], 1.90, 95% confidence interval [CI], 1.57-2.30), arterial occlusive mesenteric ischemia versus mesenteric venous thrombosis (OR, 2.45, 95% CI 1.12-5.33), heart failure (OR 1.33, 95% CI 1.03-1.72), renal disorders (OR 1.61, 95% CI 1.24-2.07), and peripheral vascular disease (OR 1.38, 95% CI 1.00-1.91). Nonsurvivors were older (standardized mean difference [SMD], 0.32, 95% CI 0.24-0.40), had higher creatinine levels (SMD 0.50, 95% CI 0.25-0.75), and had lower platelet counts (SMD -0.32, 95% CI -0.50 to -0.14).

CONCLUSION

The short-term postoperative mortality of acute mesenteric ischemia who underwent laparotomy is still high. A better understanding of these risk factors may help in the early identification of high-risk patients, optimization of surgical procedure, and improvement of perioperative management.

Review Article: Mesenteric Ischemia

PURPOSE OF REVIEW

Mesenteric ischemia (MI), both acute (AMI) and chronic (CMI), is a challenging diagnosis to make, and early diagnosis and treatment are vital to improve outcomes. This manuscript summarizes the most up to date information on diagnosis and treatment of these disorders.

RECENT FINDINGS

There have been several significant advancements in the computed tomography (CT) diagnostic imaging as well as medical and endovascular management of AMI and CMI. In appropriate populations, endovascular interventions appear superior to open surgical management with lower mortality, morbidity, and cost of care. Efficient clinical identification and targeted testing are essential to diagnose AMI and CMI. Aggressive resuscitation and early endovascular (or in select cases, surgical) intervention improve outcomes in those with AMI. In those with CMI, considering this on the differential diagnosis and imaging appropriately can identify those that might benefit from intervention and halt progression to acute episodes.

Treatment of Superior Mesenteric Vein Thrombus by Catheter-Directed Thrombolysis

Contrast-enhanced computed tomography (CT) greatly improves the diagnosis of superior mesenteric vein (SMV) thrombosis, which presents as the unspecific symptom of abdominal pain. Prothrombotic states or thrombophilia and local intra-abdominal infections are major causes of SMV thrombosis. A 37-year-old Chinese woman was diagnosed with SMV and portal vein thrombosis. The patient was initially given 40 mg of heparin sodium every 12 hr and 80,0000 U/day of urokinase using superior mesenteric artery angiography. The abdominal pain was not relieved after treatment. The patient then underwent open surgery, where an ileal branch of the SMV was punctured, a 4F sheath was introduced into the vein toward the portal vein, and a 20-cm Unifuse catheter was placed inside the thrombus for further thrombolysis. Both heparin sodium and urokinase were infused through catheter-directed thrombolysis. The patient's symptoms then gradually resolved.

Aspiration therapy for acute embolic occlusion of the superior mesenteric artery

BACKGROUND

Embolic superior mesenteric artery (SMA) occlusion is associated with high mortality rates. Delayed treatment often leads to serious consequences, including intestinal necrosis, resection, and even patient death. Endovascular repair is being introduced, which can improve clinical symptoms and prognosis and decrease the incidence of exploratory laparotomy. Many reports have described successful endovascular revascularization of embolic SMA occlusion. However, most of those reports are case reports, and there are few reports on Chinese patients. In this paper, we describe the technical and clinical outcomes of aspiration therapy using a guiding catheter and long sheath technique which facilitates the endovascular repair procedure.

AIM

To evaluate the complications, feasibility, effectiveness, and safety of endovascular treatment for the acute embolic occlusion of the SMA.

METHODS

This retrospective study reviewed eight patients (six males and two females) from August 2013 to October 2018 at Xuanwu Hospital, Capital Medical University. The patients presented with acute embolic occlusion of the SMA on admission and were initially diagnosed by computed tomography angiography (CTA). The patients who underwent endovascular treatment with a guiding catheter had no obvious evidence of bowel infarct. No intestinal necrosis was identified by gastrointestinal surgeons through peritoneal puncture or CTA. The complications, feasibility, effectiveness, safety, and mortality were assessed.

RESULTS

Six (75%) patients were male, and the mean patient age was 70.00 ± 8.43 years (range, 60-84 years). The acute embolic occlusion of the SMA was initially diagnosed by CTA. All patients had undertaken anticoagulation primarily, and percutaneous aspiration using a guiding catheter was then undertaken because the emboli had large amounts of thrombus residue. No death occurred among the patients. Complete patency of the suffering artery trunk was achieved in six patients, and defect filling was accomplished in two patients. The in-hospital mortality was 0%. The overall 12-mo survival rate was 100%. All patients survived, and two of the eight patients had complications (the clot broke off during aspiration).

CONCLUSION

Aspiration therapy is feasible, safe, and beneficial for acute embolic SMA occlusion. Aspiration therapy has many benefits for reducing patients’ death, resolving thrombi, and improving symptoms.

Review: Acute superior mesenteric artery embolism: A vascular emergency cannot be ignored by physicians

BACKGROUND

Acute mesenteric ischemia (AMI) is a life-threatening medical condition that occurs when a sudden decreased perfusion to the intestines which leads to bowel infarction, and acute superior mesenteric artery embolism (ASMAE) is the main cause of AMI. Unfortunately, with the improvement of diagnosis and treatment technology, the mortality remains high due to less frequent clinical suspicion resulted from the unclear clinical manifestation and non-specific laboratory findings.

METHODS

Relevant studies published were identified by searching the PubMed, Embase and Cochrane Library databases. This review presented the literatures to introduce the research progress of ASMAE in recent years.

RESULTS

Patients with the history of atrial fibrillation, heart valve disease and atherosclerosis should be considered as ASMAE. Laboratory findings are insensitive and unspecific, however, angiography and Computed tomography angiography (CTA) can provide a clear diagnosis sensitively and specifically. Endovascular approaches have been increasingly reported in multiple case series. The key to successful treatment of AMI involves early clinical recognition and early intervention to move the embolus, which can reduce the rate of misdiagnosis and save the precious time and lives of patients.

CONCLUSIONS

Loss of time eventually leads to progression of ischemia to transmural bowel necrosis with peritonitis and septicemia, which may further worsen patients' outcomes. It is important for physicians to make a timely and accurate diagnosis, which can save precious time and reduce the mortality.

Factors Associated With in-Hospital Death in Patients with Acute Mesenteric Artery Ischemia

Objective: The aim of the study was to assess the factors associated with increased mortality in patients with acute mesenteric ischemia, emphasizing the importance of an early diagnosis and a prompt surgical intervention in order to avoid lesion progression. Materials and method: A retrospective analytical study was conducted on a study population of 50 male and female patients with acute ischemia of the mesenteric arteries, aged between 36-92 years. Demographic and pathological history characteristics were assessed, together with presented symptoms, laboratory and CT findings, as well as surgical outcome and time-related aspects between presentation in the emergency department and time of surgery, as well as the hospitalization period until discharge or death. Results: Muscular defense (OR = 23.05) and shock (OR = 13.24) as symptoms were strongly associated with a poor prognosis, while elevated values of lactate dehydrogenase (p = 0.0440) and creatine kinase (p = 0.0025) were associated with higher death rates. The time elapsed during investigations in the emergency room was significantly higher in patients who deceased (p = 0.0023), similarly to the total time from the onset of symptoms to the beginning of surgery (p = 0.0032). Surgical outcomes showed that patients with segmental ischemia of the small bowel had significantly higher chances of survival (p <0.0001). Conclusion: Increased mortality rates in patients presenting in the emergency department for acute mesenteric ischemia were observed in patients with occlusion of the superior mesenteric artery, with higher levels of CK and LDH, as well as with longer periods of stay in the emergency department for diagnostic procedures until the commencement of the surgical intervention. Therefore, proper investigations in a timely manner followed by a specific and prompt surgical intervention may avoid unfavorable evolution of patients towards death.

The Ongoing Challenge of Acute Mesenteric Ischemia

Background

The lethality of acute mesenteric ischemia (AMI) remains quite high with 50-70%. The main reasons for that are the fact that AMI is rarely taken into consideration by the differential diagnosis of acute abdomen, the time-consuming diagnostic process, and the lack of a standardized therapeutic concept. The present interdisciplinary review aims to increase awareness among physicians and to help improve clinical outcomes.

Methods

This clinical therapeutic review is based on author expertise as well as a selective literature survey in PubMed based on the term 'mesenteric ischemia', combined with the terms 'arterial', 'clinical presentation', 'diagnosis', 'therapy', 'surgery', and 'interventional radiology'. Based on these search results as well as on the guidelines of the German Society of Vascular Surgery, the American College of Cardiology, and the American Heart Association, we present an interdisciplinary treatment concept.

Results

AMI is a vascular emergency that can be successfully treated only within the first hours after the onset of symptoms. Computed tomography angiography is the diagnostic method of choice. Intensive care unit treatment can prevent the occurrence of multiple organ failure. Treatment primarily consists of the revascularization of the mesenteric arteries. Endovascular techniques should be given priority, whereas signs of peritonitis or a central arterial occlusion with high thrombus load primarily require a surgical approach in order to save time and increase patient safety. Additional bowel resections can play a significant role in the treatment of intestinal sepsis.

Conclusion

Prompt and goal-oriented diagnosis and consistent treatment of AMI within 4-6 h from the onset of symptoms can be decisive for the reduction of AMI-associated lethality. In order for this to happen, a standardized concept of emergency treatment needs to be implemented.

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

Acute mesenteric ischemia (AMI) is typically defined as a group of diseases characterized by an interruption of the blood supply to varying portions of the small intestine, leading to ischemia and secondary inflammatory changes. If untreated, this process will eventuate in life threatening intestinal necrosis. The incidence is low, estimated at 0.09–0.2% of all acute surgical admissions. Therefore, although the entity is an uncommon cause of abdominal pain, diligence is always required because if untreated, mortality has consistently been reported in the range of 50%. Early diagnosis and timely surgical intervention are the cornerstones of modern treatment and are essential to reduce the high mortality associated with this entity. The advent of endovascular approaches in parallel with modern imaging techniques may provide new options. Thus, we believe that a current position paper from World Society of Emergency Surgery (WSES) is warranted, in order to put forth the most recent and practical recommendations for diagnosis and treatment of AMI. This review will address the concepts of AMI with the aim of focusing on specific areas where early diagnosis and management hold the strongest potential for improving outcomes in this disease process.

Some of the key points include the prompt use of CT angiography to establish the diagnosis, evaluation of the potential for revascularization to re-establish blood flow to ischemic bowel, resection of necrotic intestine, and use of damage control techniques when appropriate to allow for re-assessment of bowel viability prior to definitive anastomosis and abdominal closure.

Acute mesenteric ischemia (Part II) - Vascular and endovascular surgical approaches

The modern treatment of acute mesenteric ischemia (AMI) requires seamless collaboration of gastrointestinal surgeons, vascular surgeons, and interventional radiologists. The treatment strategy is straightforward aiming at rapid restoration of blood flow to the intestine. Bowel resection is performed on demand. The first thing to consider is the patient's clinical condition at presentation, whether there are signs of peritonitis or not, and whether the patient is hemodynamically stable or not. Second, there are four etiologies of AMI that need to be distinguished as they differ in treatment: superior mesenteric artery embolism, mesenteric arterial occlusive disease, mesenteric venous thrombosis, and non-occlusive mesenteric ischemia. In this review, we describe the basic vascular and endovascular treatment modalities accompanied by a simple algorithm for the various situations in AMI. Furthermore, the indications for damage control and primary definitive surgery are discussed.

Surgery for acute exacerbation of chronic mesenteric ischemia: a case report

BACKGROUND

Chronic mesenteric ischemia (CMI) is a rare disease; however, symptomatic CMI has a risk of acute exacerbation without timely revascularization.

CASE PRESENTATION

A 54-year-old man who had had postprandial pain for 6 months was admitted to our hospital because of vomiting and diarrhea. Although the celiac and superior mesenteric arteries were occluded at the proximal portion, contrast enhancement of the bowel wall was good in contrast-enhanced computed tomography (CECT). Endoscopic examination revealed only a healed gastric ulcer and slight mucosal erosions in the colon. He was diagnosed as having acute enteritis or inflammatory digestive disease and observed with conservative therapy, which improved his acute symptoms. On hospitalization day 42, he suddenly complained of lower back pain. CECT showed abdominal free air, which indicated gastrointestinal perforation. Emergency surgery was performed for jejunum resection. Two days later, a second operation was performed for a leak in the anastomotic site of the jejunum. Necrotic change in the small intestinal serosa was also observed and required broad resection of the small intestine. He was diagnosed with acute exacerbation of CMI, and we performed surgical retrograde bypass to the gastroduodenal artery using a saphenous vein graft as the third operation. After the surgery, he was free from digestive symptoms and was discharged.

CONCLUSIONS

When patients complain of chronic and gradual digestive symptoms, we should always consider symptomatic CMI. Timely mesenteric revascularization is important for symptomatic CMI before severe complications occur.

ESTES guidelines: acute mesenteric ischaemia

PURPOSE

Acute mesenteric ischaemia (AMI) accounts for about 1:1000 acute hospital admissions. Untreated, AMI will cause mesenteric infarction, intestinal necrosis, an overwhelming inflammatory response and death. Early intervention can halt and reverse this process leading to a full recovery, but the diagnosis of AMI is difficult and failure to recognize AMI before intestinal necrosis has developed is responsible for the high mortality of the disease. Early diagnosis and prompt treatment are the goals of modern therapy, but there are no randomized controlled trials to guide treatment and the published literature contains a high ratio of reviews to original data. Much of that data comes from case reports and often small, retrospective series with no clearly defined treatment criteria.

METHODS

A study group of the European Society for Trauma and Emergency Surgery (ESTES) was formed in 2013 with the aim of developing guidelines for the management of AMI. A comprehensive literature search was performed using the Medical Subject Heading (MeSH) thesaurus keywords "mesenteric ischaemia", "bowel ischaemia" and "bowel infarction". The bibliographies of relevant articles were screened for additional publications. After an initial systematic review of the literature by the whole group, a steering group formulated questions using a modified Delphi process. The evidence was then reviewed to answer these questions, and recommendations formulated and agreed by the whole group.

RESULTS

The resultant recommendations are presented in this paper.

CONCLUSIONS

The aim of these guidelines is to provide recommendations for practice that will lead to improved outcomes for patients.

Mesenteric ischemia: Pathogenesis and challenging diagnostic and therapeutic modalities

Mesenteric ischemia (MI) is an uncommon medical condition with high mortality rates. ΜΙ includes inadequate blood supply, inflammatory injury and eventually necrosis of the bowel wall. The disease can be divided into acute and chronic MI (CMI), with the first being subdivided into four categories. Therefore, acute MI (AMI) can occur as a result of arterial embolism, arterial thrombosis, mesenteric venous thrombosis and non-occlusive causes. Bowel damage is in proportion to the mesenteric blood flow decrease and may vary from minimum lesions, due to reversible ischemia, to transmural injury, with subsequent necrosis and perforation. CMI is associated to diffuse atherosclerotic disease in more than 95% of cases, with all major mesenteric arteries presenting stenosis or occlusion. Because of a lack of specific signs or due to its sometime quiet presentation, this condition is frequently diagnosed only at an advanced stage. Computed tomography (CT) imaging and CT angiography contribute to differential diagnosis and management of AMI. Angiography is also the criterion standard for CMI, with mesenteric duplex ultrasonography and magnetic resonance angiography also being of great importance. Therapeutic approach of MI includes both medical and surgical treatment. Surgical procedures include restoration of the blood flow with arteriotomy, endarterectomy or anterograde bypass, while resection of necrotic bowel is always implemented. The aim of this review was to evaluate the results of surgical treatment for MI and to present the recent literature in order to provide an update on the current concepts of surgical management of the disease. Mesh words selected include MI, diagnostic approach and therapeutic management.

Rectus sheath block for postoperative analgesia in patients with mesenteric vascular occlusion undergoing laparotomy: A randomized single-blinded study

Background:

Acute mesenteric ischemia is a life-threatening vascular emergency that requires early diagnosis, immediate anticoagulation, and intervention to restore mesenteric blood flow adequately.

Aims:

To investigate the effect of rectus sheath block (RSB) for postoperative analgesia in patients with mesenteric vascular occlusion.

Settings and Design:

Forty patients with mesenteric vascular occlusion, American Society of Anesthesiologists physical status I or II or III, scheduled for laparotomy were enrolled in this study.

Subjects and Methods:

Patients were randomized into two groups; control group (C Group) and rectus block group (RB Group). In both groups, general anesthesia was induced fentanyl 1 μg/kg with sleeping dose of propofol and 0.15 mg/kg cisatracurium. Then, anesthesia was maintained with sevoflurane in oxygen 100%. In RB Group, under aseptic condition, RSB guided by ultrasound was performed. Surgery is then continued and intravenous fentanyl patient-controlled analgesia pump started. Postoperative pain, sedation, and opioid side effects were assessed.

Statistical Analysis Used:

Statistical analysis was done using Statistical Package for Social Sciences (SPSS 19.0, Chicago, IL, USA).

Results:

Patients in the RB Group consumed statistically significant less opioid in comparison to control group either intraoperatively or postoperatively. Mean pain scores were statistically significant less in RB Group than in the control group at 2, 4, and 6 h postoperatively. Sedation score, incidence of nausea and vomiting were statistically significant less in the RB Group in comparison to control group. More patients’ satisfaction was reported in the RB Group.

Conclusions:

Ultrasound-guided RSB resulted in postoperative reduction of pain scores and opioid consumption compared with general anesthesia alone. Moreover, RSB was associated with better patient satisfaction and less nausea and vomiting.

Transcatheter thrombolysis combined with damage control surgery for treatment of acute mesenteric venous thrombosis associated with bowel necrosis: a retrospective study

OBJECTIVE

This study aims to evaluate the clinical outcomes of transcatheter thrombolysis in acute superior mesenteric venous thrombosis (ASMVT) associated with bowel necrosis.

METHODS

A retrospective study of six patients with ASMVT treated with catheter-directed thrombectomy/thrombolysis and damage control surgery at Jinling Hospital (Nanjing, China) between 2010 and 2013 was conducted. Demographics, past medical history, risk factors, therapeutic methods and effects, mortality, and follow-up of the study population were assessed.

RESULTS

Five of six patients underwent arteriovenous combined thrombolysis, while one patient underwent arterial thrombolysis. All patients required damage control surgery, and four of these patients underwent temporary abdominal closure. All patients survived and were free of recurrence.

CONCLUSIONS

Transcatheter thrombectomy/thrombolysis and damage control surgery could help avoid extensive bowel resection, prevent short bowel syndrome and reduce mortality for critically ill patients with acute mesenteric venous thrombosis associated with bowel necrosis.

Protective effect of melatonin-supported adipose-derived mesenchymal stem cells against small bowel ischemia-reperfusion injury in rat

We tested the hypothesis that combined melatonin and autologous adipose-derived mesenchymal stem cells (ADMSC) was superior to either alone against small bowel ischemia-reperfusion (SBIR) injury induced by superior mesenteric artery clamping for 30 min followed by reperfusion for 72 hr. Male adult Sprague Dawley rats (n = 50) were equally categorized into sham-operated controls SC, SBIR, SBIR-ADMSC (1.0 × 10(6) intravenous and 1.0 × 10(6) intrajejunal injection), SBIR-melatonin (intraperitoneal 20 mg/kg at 30 min after SI ischemia and 50 mg/kg at 6 and 18 hr after SI reperfusion), and SBIR-ADMSC-melatonin groups. The results demonstrated that the circulating levels of TNF-α, MPO, LyG6+ cells, CD68+ cells, WBC count, and gut permeability were highest in SBIR and lowest in SC, significantly higher in SBIR-ADMSC group and further increased in SBIR-melatonin group than in the combined therapy group (all P < 0.001). The ischemic mucosal damage score, the protein expressions of inflammation (TNF-α, NF-κB, MMP-9, MPO, and iNOS), oxidative stress (NOX-1, NOX-2, and oxidized protein), apoptosis (APAF-1, mitochondrial Bax, cleaved caspase-3 and PARP), mitochondrial damage (cytosolic cytochrome C) and DNA damage (γ-H2AX) markers, as well as cellular expressions of proliferation (PCNA), apoptosis (caspase-3, TUNEL assay), and DNA damage (γ-H2AX) showed an identical pattern, whereas mitochondrial cytochrome C exhibited an opposite pattern compared to that of inflammation among all groups (all P < 0.001). Besides, antioxidant expressions at protein (NQO-1, GR, and GPx) and cellular (HO-1) levels progressively increased from SC to the combined treatment group (all P < 0.001). In conclusion, combined melatonin-ADMSC treatment offered additive beneficial effect against SBIR injury.

[Management of complications after reconstruction of mesenteric arteries]

Because of the low ischemia tolerance of abdominal organs and the comorbidities of patients with abdominal ischemic syndromes, complications after the reconstruction of visceral arteries are often severe and associated with a significant mortality rate. The possible complications after interventions on the visceral arteries and their treatment are presented. Endovascular procedures have gained an increasingly important role in many primary interventions as well as in the treatment of complications.

Endovascular Therapy as a Primary Revascularization Modality in Acute Mesenteric Ischemia

PURPOSE

To evaluate endovascular therapy (EVT) as the primary revascularization method for acute mesenteric ischemia (AMI).

METHODS

A retrospective review was performed on all consecutive patients treated for AMI during a 5-year period (January 2009 to December 2013). EVT was attempted in all patients referred for emergent revascularization. Surgical revascularization was performed selectively after failure of EVT. Patient characteristics, clinical presentation, and outcomes were studied. Failures and complications of EVT were recorded.

RESULTS

Fifty patients, aged 79 ± 9 years (mean ± SD), out of 66 consecutive patients with AMI secondary to embolic or thrombotic obstruction of the superior mesenteric artery were referred for revascularization. The etiology of AMI was embolism in 18 (36 %) and thrombosis in 32 (64 %) patients. EVT was technically successful in 44 (88 %) patients. Mortality after successful or failed EVT was 32 %. The rates of emergency laparotomy, bowel resection, and EVT-related complication were 40, 34, and 10 %, respectively. Three out of six patients with failure of EVT were treated with surgical bypass. EVT failure did not significantly affect survival.

CONCLUSIONS

EVT is feasible in most cases of AMI, with favorable patient outcome and acceptable complication rate.

[Endovascular interventions for acute ischemia of intestine]

It is presented 5 clinical observations of acute ischemia of intestine in which different endovascular interventions including isolated superior mesenteric artery stenting, rheolytic and aspiration thrombectomy and combination of techniques were applied. Surgical success with blood flow restoration in superior mesenteric artery was achieved in 4 of 5 patients. 2 patients have required laparotomy and intestinal resection. In 1 case extent of resection was significantly reduced after previous endovascular thrombectomy. There were no deaths. It is concluded that endovascular interventions may be considered as independent method of treatment of patients with acute mesenteric ischemia.