Treatment outcomes in patients with acute thromboembolic occlusion of the superior mesenteric artery

OBJECTIVES

The goals of this study were to investigate the treatment outcomes of acute thromboembolic occlusion of the superior mesenteric artery (ATOS) and identify prognostic factors after treatment.

METHODS

The clinical data of 62 patients with ATOS between 2013 and 2021 were retrospectively reviewed. Patients were stratified by the treatment strategy, complications and mortality were compared in different group.

RESULTS

Sixty-two consecutive patients were identified with ATOS. The median patient age was 69 years (interquartile range 58-79 years). Endovascular therapy was initiated in 21 patients, and 4 patients received conservative treatment. Open surgery was performed first in the remaining 37 patients. The technical success rates of the endovascular first group and open surgery group were 90.5% and 97.3%, respectively. One patient in the conservative treatment group had progression of ischemia to extensive bowel necrosis. There was no difference in 30-day mortality between these groups. Predictors of 30-day mortality included initial neutrophil count > 12* 103/dL, age over 60 years old and history of chronic renal insufficiency.

CONCLUSIONS

Endovascular treatment or conservative treatment may be adopted in selected patients who do not exhibit signs and symptoms of bowel necrosis, and close monitoring for bowel necrosis is important. The increase in preoperative neutrophil count, age over 60 years old and history of chronic renal insufficiency were poor prognostic factors.

Portal venous contrast enhancement ratio of the adrenal glands and spleen as prognostic marker of mortality in patients with acute mesenteric ischemia

PURPOSE

Contrast enhancement of the adrenal gland defined by computed tomography (CT) was previously analyzed as a prognostic factor for critically ill patients in various diseases. However, no study investigated this quantitative parameter in patients with acute mesenteric ischemia. Therefore, the aim of this study was to evaluate the prognostic value of the contrast enhancement of the adrenal glands in patients with clinically suspected AMI.

METHODS

All patients with clinically suspected AMI were retrospectively assessed between 2016 and 2020. All patients underwent surgical exploration after CT imaging. Overall, 134 patients (52 female patients, 38.8%) with a mean age of 69.2 ± 12.4 years were included into the present analysis. For all patients, the preoperative CT was used to calculate the contrast media enhancement of the adrenal glands and the spleen.

RESULTS

A total of 27 patients (18.5%) died within the first 24 h and over the following 30-day 94 patients (68.6%) died. There were statistically significant differences regarding the mean values for adrenal-to-spleen ratio for 24-h mortality (p = 0.001) and 30-day mortality (p = 0.004), whereas the radiodensity of the inferior vena cava and the radiodensity of the spleen was statistically significant between survivors and non-survivors after 30 days (p = 0.037 and p = 0.028, respectively). In Cox regression analysis, mean adrenal radiodensity was associated with 24-h mortality (HR 1.09, 95% CI 1.02-1.16, p = 0.01) but not with 30-day mortality (HR 1.03, 95% CI 0.99-1.07, p = 0.13).

CONCLUSION

The contrast media enhancement of the adrenal gland is associated with the 24-h and 30-day mortality in patients with AMI. However, the prognostic relevance for translation into clinical routine needs to be validated in other cohorts.

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.

Acute mesenteric ischemia: A case report

Acute mesenteric ischemia is a rare life-threatening diagnostic and therapeutic emergency. Lack of clinical and biological specificity makes the diagnosis difficult. Imaging, particularly computed tomography can help confirm the diagnosis. An underlying cause is identified in about 30%-70% of cases and should always be sought. We report a case of a 51-year-old man with chronic alcoholic liver disease admitted to the emergency department for abdominal pain. Computed tomography showed mesenteric venous thrombosis with signs of small bowel ischemia and cirrhosis with portal hypertension. Through this observation, we describe the imaging aspects of mesenteric ischemia and emphasize the necessity of seeking underlying pathological condition.

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.

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.

Long-term outcome after implementation of endovascular-first strategy to treat acute mesenteric ischemia

OBJECTIVE

To evaluate the rationale of an aggressive endovascular-first strategy to treat elderly patients with acute mesenteric ischemia (AMI) by studying long-term survival, readmissions, and patients' discharge to home vs nursing facility a decade after an episode of AMI.

METHODS

The retrospective study cohort included 66 consecutive patients (all-comers) treated for arterial occlusive AMI between 2009 and 2013. Endovascular revascularization (EVR) was attempted in 50 patients (EVR+), whereas 16 patients were treated without attempted revascularization (EVR-). All patients were followed until death or September 2022. Studied outcomes included discharge status, long-term survival and cause of death and readmissions related to AMI.

RESULTS

The mean age of all 66 patients was 78 ± 10 years: 79 ± 9 years in the EVR+ group and 76 ± 12 years in the EVR- group. EVR was technically successful in 44 patients (88%); three patients underwent subsequent open revascularization after EVR failure. One-third required bowel resection after EVR. The 30-day mortality for all patients was 44%; 32% in the EVR+ group and 81% in the EVR- group. Only two survivors were permanently institutionalized, whereas all others were discharged to the same place they lived prior to the AMI episode. There were four AMI-related readmissions during the follow-up; all were in the EVR+ group. Two patients underwent reinterventions for recurrent AMI. One-year survival was 52% for EVR+ and 19% for EVR- patients. Five-year survival rates were 18% and 13%, respectively. The causes of deaths were mesenteric ischemia in 22, other cardiovascular event in 21, and non-cardiovascular cause in 19 patients. Four patients were alive at the end of the follow-up.

CONCLUSIONS

In this unselected elderly population with AMI, the aggressive strategy to attempt EVR resulted in a high revascularization rate and favorable outcomes. The high proportion of patients returning to their prior living status and low readmission rate after survival from AMI encourages active treatment of high-functioning elderly patients.

Penumbra aspiration thrombectomy of the superior mesenteric artery for mesenteric ischemia

Acute mesenteric ischemia from thromboembolic occlusion is a life-threatening emergency associated with a high mortality rate. Prompt diagnosis and intervention are vital to preserve viable bowel and prevent mortality. In the past decade, a shift has occurred toward minimally invasive alternatives such as endovascular therapies. We present a case of acute mesenteric ischemia from superior mesenteric artery thrombosis treated promptly with the Penumbra suction thrombectomy device (Penumbra Inc).

Evaluation of the possible effects of the COVID-19 period on the clinical outcomes of acute mesenteric ischemia

Objective

The objective of the study was to investigate the possible effects of the coronavirus disease 2019 (COVID-19) period on the frequency and clinical course of acute mesenteric ischemia (AMI) cases.

Material and methods

A total of 35 patients who were treated and followed up with a diagnosis of AMI over 44 months were included.

Results

The mean age of the patients was 69 ± 12 years. Of these patients, 22 were male (63%). The most common cause of AMI in the patients was arterial embolism/thrombosis (68.6%). Thirty-three (94%) of the patients underwent surgical intervention. The duration of the pre-COVID-19 and COVID-19 periods was equal as 22 months, and 18 (51%) of the patients were admitted during the pandemic period. The mortality rate of the patients admitted during the COVID-19 period was also significantly higher than that of the patients admitted during the pre-COVID-19 period (61% and 29%) (p = 0.05).

Conclusions

Although the COVID-19 period did not cause a significant increase in the number of AMI cases when compared to the pre-COVID-19 period, the mortality rate was higher in this period. It is thought that further studies are required to investigate the cause of this increased mortality rate during the pandemic period.

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.

Acute mesenteric ischemia: which predictive factors of delayed diagnosis at emergency unit?

PURPOSE

Acute mesenteric ischemia (AMI) is frequently diagnosed late, leading to a poor prognosis. Our aims were to identify predictive factors of delayed diagnosis and to analyze the outcomes of patients with AMI admitted in emergency units.

METHODS

All the patients with AMI (2015-2020), in two Emergency units, were retrospectively included. Two groups were defined according to the time of diagnosis between the arrival at emergency unit and the CT scan: ≤ 6 h (early), > 6 h (delayed).

RESULTS

119 patients (mean age = 71 ± 7 years) were included. The patients with a delayed diagnosis (n = 33, 28%) were significantly associated with atypical presentation, including lower rates of abdominal pain (73 vs 89%, p = 0.003), abdominal tenderness (33 vs 43%, p = 0.03), and plasma lactate (4 ± 2 vs 6 ± 7 mmol/l, p = 0.03) when compared with early diagnosis. After multivariate analysis, the absence of abdominal pain was the only independent predictive factor of delayed diagnosis (Odd Ratio = 0.17; 95% CI = 0.03-0.88, p = 0.03). Patients with delayed diagnosis tended to be associated to lower rates of revascularization (9 vs 17%, p = 0.4), higher rates of major surgical morbidity (90 vs 57%, p = 0.1), longer length of stay (16 ± 23 vs 13 ± 15 days, p = 0.4) and, at the end of follow-up, higher rate of short small bowel syndrome (18 vs 7%, p = 0.095).

CONCLUSION

AMI is a challenge for emergency physicians. History of patient, physical exam, biological data are not sufficient to diagnose AMI. New biomarkers, and awareness of emergency physicians should improve and accelerate the diagnosis of AMI.

Outcome of laparotomy and conservative treatment of patients with acute mesenteric venous ischemia with viable bowel

BACKGROUND

Acute mesenteric ischemia (AMI) is one of the most serious abdominal emergencies. Predicting the onset of bowel necrosis that warrants surgical intervention is of paramount importance in AMI. The present study aimed to investigate the outcome of patients with AMI secondary to mesenteric venous occlusion (MVO) and the consequence of non-therapeutic exploratory laparotomy.

METHODS

The records of 132 patients with AMI were retrospectively reviewed. The outcome of patients with acute mesenteric venous ischemia (AMVI) and viable bowel was analyzed based on the method of treatment: conservative versus surgical. The impact of non-therapeutic laparotomy on the outcome of patients with AMVI in terms of morbidity, readmission, and mortality was analyzed.

RESULTS

Forty-seven patients (34 male) with AMVI had viable bowel. Of the 47 patients with viable bowel, 8 (17%) had an exploratory non-therapeutic laparotomy, whereas 39 patients were treated conservatively. Patients who had non-therapeutic laparotomy had significantly higher complication (50 vs 5.1%, p = 0.005) and readmission rates (37.5 vs 5.1%, p = 0.03) and longer hospital stay (8.5 vs 7 days, p = 0.02) than those treated conservatively. Patients with bowel necrosis who had a therapeutic laparotomy had slightly lower rates of morbidity and mortality as compared to patients with viable bowel who underwent a non-therapeutic laparotomy.

CONCLUSION

Careful assessment and informed decision-making in patients with AMVI are crucial to avoid unnecessary surgical intervention that can result in higher rates of complications and readmission and extended hospital stay.

Prognostic factors after acute mesenteric ischemia: which patients require specific management?

PURPOSE

Diagnosis and treatment of AMI are a real issue for implicating physicians. In the literature, only one AMI stroke center has reported its results so far, with increasing survival rates. Our aim was to analyze acute mesenteric ischemia (AMI) related mortality and predictive factors, in a single academic center, before creating a dedicated intestinal stroke center.

METHODS

All the patients with an AMI, between January 2015 and December 2020, were retrospectively included. They were divided into 2 groups according to the early mortality: death during the first 30 days and alive. The 2 groups were compared.

RESULTS

173 patients (57% of men), were included, with a mean age of 68 ± 16 years. Overall mortality rate was 61%. Mortality occurred within the first 30 days in 78% of dead cases. Dead patients were significantly older, more frequently admitted from intensive care, with more serious clinical, laboratory and radiological characteristics. We have identified 3 protective factors - history of abdominal surgery (Odd Ratio = 0.1; 95%CI = 0.01-0.8, p = 0.03), medical management with curative anticoagulation (OR = 0.09; 95%CI = 0.02-0.5, p = 0.004) and/or antiplatelets (OR = 0.04; 95%CI = 0.006-0.3, p = 0.001)-, and 2 predictive factors of mortality - age > 70 years (OR = 7; 95%CI = 1.4-37, p = 0.02) and previous history of coronaropathy (OR = 13; 95%CI = 1.7-93, p = 0.01).

CONCLUSIONS

AMI is a severe disease with high morbidity and mortality rates. Even if its diagnosis is still difficult because of non-specific presentation, its therapeutic management needs to be changed in order to improve survival rates, particularly in patients older than 70 years with history of coronaropathy. Developing a dedicated organization would improve the diagnosis and the management of patients with AMI.

Computed Tomography-Defined Body Composition as Prognostic Parameter in Acute Mesenteric Ischemia

INTRODUCTION

Body composition comprising low-skeletal muscle mass (LSMM) and subcutaneous and visceral adipose tissue (SAT and VAT) can be assessed by using cross-sectional imaging modalities. Previous analyses suggest that these parameters harbor prognostic relevance in various diseases. Aim of this study was to analyze possible associations of body composition parameters on mortality in patients with clinically suspected acute mesenteric ischemia (AMI).

METHODS

All patients with clinically suspected AMI were retrospectively assessed between 2016 and 2020. Overall, 137 patients (52 female patients, 37.9%) with a median age of 71 years were included in the present analysis. For all patients, the preoperative abdominal computed tomography (CT) was used to calculate LSMM, VAT, and SAT.

RESULTS

Overall, 94 patients (68.6%) of the patient cohort died within 30 days within a median of 2 days, range 1-39 days. Of these, 27 patients (19.7%) died within 24 h. According to the CT, 101 patients (73.7%) were classified as being visceral obese, 102 patients (74.5%) as being sarcopenic, and 69 patients (50.4%) as being sarcopenic obese. Skeletal muscle index (SMI) was lower in non-survivors compared to survivors (37.5 ± 12.4 cm2/m2 vs. 44.1 ± 13.9 cm2/m2, p = 0.01). There were no associations between body composition parameters with mortality in days (SMI r = 0.07, p = 0.48, SAT r = -0.03, p = 0.77, and VAT r = 0.04, p = 0.68, respectively). In Cox regression analysis, a nonsignificant trend for visceral obesity was observed (HR: 0.62, 95% CI: 0.36-1.05, p = 0.07).

CONCLUSION

SMI might be a valuable CT-based parameter, which could help discriminate between survivors and non-survivors. Further studies are needed to elucidate the associations between body composition and survival in patients with AMI.

Treatment of acute mesenteric ischemia between 2010 and 2020 - a German nation-wide study

BACKGROUND

Aim of this study was to analyze long-term trends of hospitalizations, treatment regimen and in-hospital mortality of in-patients with acute mesenteric ischemia (AMI) over the past decade and effects of the SARS-CoV2-pandemic.

METHODS

We analyzed fully anonymized data from the German Federal Statistical Office of patients with AMI between 2010 and 2020. Besides descriptive analyses of age, gender, in-hospital mortality, comorbidity burden and treatment regimen, multivariable logistic regression analyses were performed to identify independent variables associated with in-hospital mortality and different treatment.

RESULTS

A total of 278,121 hospitalizations (120,667 male [43.4%], mean age 72.1 years) with AMI were included in this study. The total number of hospitalizations increased from 2010 (n = 24,172) to 2019 (n = 26,684) (relative increase 10.4%). In-hospital mortality decreased over the past decade from 36.6% to 2010 to 31.1% in 2019 (rel. decrease 15.2%). Independent risk factors for in-hospital mortality were older age (OR = 1.03 per year), higher comorbidity burden (OR = 1.06 per point in van Walraven score [vWs]), male gender (OR = 1.07), AMI as a secondary diagnosis (OR = 1.44), and the need for surgical (visceral surgery: OR = 1.38, vascular surgery: OR = 3.33) and endovascular treatment (OR = 1.21). We report a decline in hospitalizations during the first wave of infection in spring 2020 (rel. decrease 9.7%).

CONCLUSION

In-hospital mortality rate has declined over the past decade, but remains high at above 30%. Older age, increased comorbidity and male gender are independent factors for in-hospital mortality. Hospitalizations requiring vascular surgery are associated with high in-hospital mortality, followed by visceral surgery and endovascular approaches. The first wave of the SARS-CoV2-pandemic in spring 2020 implied a decrease in hospital admissions.

Results after intraoperative open and endovascular revascularization of acute mesenteric ischemia requiring a laparotomy

BACKGROUND

Acute mesenteric ischemia (AMI) is a dreaded condition with a difficult diagnosis and high mortality. Due to different baseline situations, the frequently performed comparison between endovascular and open surgical treatment is interfered with selection bias. The purpose of this study was to review outcomes in AMI treatment with an open or endovascular approach in association with laparotomy and to evaluate the endovascular-first strategy in similar clinical situations.

METHODS

The clinical data of 74 patients treated for AMI from 2007 to 2021 were retrospectively reviewed and compared. In-hospital mortality was appointed as the primary study endpoint. Risk factors for mortality were identified by using univariate and multivariate analysis.

RESULTS

In total, 61 patients (82%) were treated open surgically (OT) and, 13 patients (18%) with an endovascular approach (ET) in combination with laparatomy. The etiology of AMI was 49% arteriosclerotic and 51% thromboembolic occlusions. The total in-hospital mortality manifested at 43% (n =32) (OT 41% vs. ET 53.8%; P=0.54). As independent risk factors for in-hospital mortality, pneumatosis intestinalis (P=0.01), increased lactate concentration (P=0.04), and ischemic intestinal sections (P=0.01) were identified. Additionally, on univariate analysis patient age, congestive heart failure (> NYHA II) and atrial fibrillation were related with higher mortality.

CONCLUSIONS

Morbidity and mortality of AMI remains at a high level. Conventional open or intraoperative endovascular therapy achieved similar results in patients with indication for laparotomy. Advanced disease stage with ischemic intestinal sections at presentation and cardiovascular comorbidities were associated with adverse outcome.

Acute management of mesenteric emergencies: Tailoring the solution to the problem

Acute mesenteric ischemia (AMI) constitutes a life-threatening problem that can result in death, multiorgan failure, and severe nutritional disability. Although AMI is a rare cause of acute abdominal emergencies, ranging between 1 and 2 individuals per 10,000, the morbidity and mortality rates are high. Arterial embolic etiology composes nearly one-half of AMIs, with a sudden onset of severe abdominal pain considered the most common symptom. Arterial thrombosis is the second most common cause of AMI, which presents similarly to arterial embolic AMI, although often more severe due to anatomic differences. Veno-occlusive causes of AMI are the third most common and are associated with an insidious onset of vague abdominal pain. Each patient is unique, and the treatment plan should be tailored to their individual needs. This may include considering the patient's age, comorbidities, and overall health, as well as their preferences and personal circumstances. A multidisciplinary approach involving specialists from different fields, such as surgeons, interventional radiologists, and intensivists, is recommended for the best possible outcome. Potential challenges in tailoring an optimal treatment plan for AMI may include delayed diagnosis, limited availability of specialized care, or patient factors that make some interventions less feasible. Addressing these challenges requires a proactive and collaborative approach, with regular review and adjustment of the treatment plan as needed to ensure the best possible outcome for each patient.

Exploring Outcomes Related to Residential Determinants in Acute Mesenteric Ischemia Patients

INTRODUCTION

To access the relationship between residential status and outcomes in surgical acute mesenteric ischemia (AMI) patients.

METHODS

Retrospective chart review of 153 AMI patients admitted to our institution between 2007 and 2021. Residential median income and Rural-Urban Commuting Area (RUCA) code were used as residential proxies.

RESULTS

Being of the female sex (odds ratio [OR] = 3.116 [1.276-7.609] P = 0.013) and having a vascular intervention performed (OR = 2.927 [1.087-7.883] P = 0.034) were both associated with a threefold increase in the risk of mortality. Increased age (OR = 1.037 [1.002-1.073] P = 0.039), elevated blood urea nitrogen (OR = 1.032 [1.012-1.051] P = 0.001), and living in higher residential income area (OR = 1.049 [1.009-1.091] P = 0.017) had a small, but statistically significant, increased risk of mortality. Patients in higher median income areas were less likely to undergo colonic resection (OR = 0.953 [0.911-0.997] P = 0.038) and tended to have a lower likelihood of receiving an ostomy (OR = 0.963 [0.927-1] P = 0.051). Being from urban or rural areas was not associated with mortality (OR = 1.565 [0.647-3.790] P = 0.321, although rural patients were more likely to undergo colon resection (OR = 2.183 [0.938-5.079] P = 0.070). Furthermore, rural patients were much more likely to be readmitted than urban dwellers (OR = 4.700 [1.022-21.618] P = 0.047).

CONCLUSIONS

AMI patients living in rural or small-town areas were more likely to be readmitted and tended to undergo colonic resection. Patients residing in higher income areas had a slightly higher risk of mortality but tended to be less likely to require ostomy or colonic resection. These findings suggest a potential need for postoperative care initiatives focused on AMI patients living in rural and lower income areas.

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.

FAR Ratio as Prognostic Biomarker in AMI

Acute mesenteric ischemia (AMI) is a vascular emergency resulting from decreased blood flow caused by the occlusion of the mesenteric vessels, hypoperfusion, or vasospasm. This study aimed to investigate the prognostic value of the fibrinogen-to-albumin (FAR) ratio in patients with acute mesenteric ischemia. A total of 91 patients were enrolled in the study. Patients' demographics such as age and gender, pre- and postoperative hemoglobin, CRP, white blood cell (WBC), neutrophils, preoperative lymphocyte, alanine transaminase (ALT), aspartate transaminase (AST), thrombocytes, and postoperative D-dimer values were recorded. In addition, pre- and postoperative fibrinogen and albumin levels were recorded, and FAR was calculated. Patients were divided into two groups, survivors and non-survivors. The mean pre- and postoperative fibrinogen levels were statistically significantly higher in the non-survivor group than in the survivor group (p < 0.001). The mean pre- and postoperative albumin levels were significantly lower in the non-survivors than in the survivors (p = 0.059, p < 0.001; respectively). The mean pre- and postoperative FAR ratios were considerably higher in the non-survivor than in the survivor groups (p < 0.001). The change between pre- and postoperative fibrinogen, albumin, and FAR values was statistically significant between the non-survivors and the survivors (for all, p < 0.05). The preoperative and postoperative fibrinogen levels were significantly lower, and albumin levels were significantly higher in the survivor compared to the non-survivor patients with AMI. Furthermore, the preoperative and postoperative FAR ratio was significantly higher in the non-survivors. The FAR ratio may be a valuable prognostic biomarker for patients with AMI.

The preoperative SOFA score and remnant small intestine length are postoperative risk factors for mortality in patients with non-occlusive mesenteric ischemia: a case-control study

Aim

Non-occlusive mesenteric ischemia (NOMI) is a fatal condition with a low survival rate in most cases. The risk factors for perioperative mortality in NOMI cases are unclear. The purpose of this study was to define the risk factors for mortality in patients with NOMI undergoing surgery.

Methods

Thirty-eight consecutive patients who underwent surgery for NOMI at Teine Keijinkai Hospital between 2012 and 2020 were included in the study. Patient information, including age, sex, physical findings, comorbidities, laboratory data, and computed tomography and surgical findings were retrospectively analyzed.

Results

Of the 38 patients, 18 (47%) died before discharge. Significant univariate predictors of mortality were a high Sequential Organ Failure Assessment (SOFA) score, high lactate level, low blood pH, and short intestinal length after surgery. In the multivariate analysis, a high SOFA score (odds ratio 1.33, P = 0.036) and short intestine length after surgery (odds ratio 34.7, P = 0.003) were identified as independent risk factors for perioperative mortality.

Conclusion

The preoperative SOFA score and postoperative residual intestinal length may be predictors of death in NOMI surgical patients, not age and the content of comorbidities.

Potential for intestinal transplantation after acute mesenteric ischemia in patients aged less than 70 years: A population-based study

BACKGROUND AND OBJECTIVE

Acute mesenteric ischemia (AMI) has a high mortality rate due to the development of bowel necrosis. Patients are often ruled outside active care if a large proportion of small bowel is necrotic. With the development of treatment for short bowel syndrome (SBS) and intestinal transplantation methods, long-term survival is possible even after extensive small bowel resections. This study aims to assess the incidence of SBS and potentially suitable candidates for intestinal transplantation among patients treated for AMI.

METHODS

This population-based retrospective study comprised patients aged less than 70 years and diagnosed with AMI between January 2006 and October 2020 in Helsinki and Uusimaa health care district, Finland.

RESULTS

Altogether, AMI was diagnosed in 711 patients, of whom 133 (19%) were aged below 70. An intervention was performed in 110 (83%) patients. Of these 133 patients, 16 (12%) were ruled outside active treatment due to extensive small bowel necrosis at exploratory laparotomy, of whom 6 (5%) were potentially suitable for intestinal transplantation. Two patients were considered as potential candidates for intestinal transplantation at bowel resection but died of AMI. Nine (7%) patients needed parenteral nutrition after resection, and two of them (2%) developed SBS. Only one patient needed long-term parenteral nutrition after hospital discharge. This patient remained dependent on parenteral nutrition but died before evaluation of intestinal transplantation could be carried out while the other patient was able to return to enteral nutrition.

CONCLUSIONS

A small number of patients with AMI below 70 years of age are potentially eligible for intestinal transplantation.

Mesanteric ischemia in a COVID-19 patient with no risk factors: A case report

BACKGROUND

Acute mesenteric ischemia (AMI) may present in COVID-19 patients without the classic risk factors of AMI, and the symptoms might confuse physicians, leading to delayed diagnosis and increased mortality. In this manuscript, we report a patient with COVID-19 who presented with AMI as its initial presenting symptom.

CASE PRESENTATION

A 68-year-old man presented to the emergency room with periumbilical non-radiating pain that had started three days before the admission. He had no defecation or gas passing in the past three days. In the physical exam, the patient had guarding of the abdomen, generalized tenderness, and rebound tenderness. C-reactive protein, Creatine phosphokinase and WBC count were elevate. Abdominal X-ray in the supine position was suggestive of obstruction of the small intestine. Diagnostic laparotomy was performed because of peritonitis and acute abdominal pain. The diagnosis was mesenteric ischemia due to vein thrombosis based on laparotomy and paraclinic findings. In the post-surgery evaluations COVID-19 infection was confirmed based on PCR and chest CT scan.

DISCUSSION

Based on paraclinical, clinical, and diagnostic laparotomy findings, the patient was diagnosed with small bowel obstruction and gangrene due to acute mesenteric ischemia (AMI). But as described, this patient didn't have any history of medical diseases that cause a hypercoagulable state, in the past. While AF was ruled out because his ECG was normal. We concluded that in this patient AMI was due to his infection with COVID-19.

CONCLUSION

Patients with COVID-19 may not have the typical risk factors for AMI, and AMI diagnosis should be considered in patients presenting with acute abdominal pain, even without the routine risk factors.

Hand-Sewn Versus Stapled Small Bowel Anastomoses in Patients With Secondary Mesenteric Ischemia

INTRODUCTION

Although stapled anastomoses have been widely evaluated in the context of the elective surgery, few reports compared manual with stapled anastomoses in patients undergoing emergency surgery. The aim of this study is to compare the outcome of hand-sewn end-to-end anastomoses with stapled side-to-side and stapled end-to-side anastomoses in patients undergoing small bowel resection for acute mesenteric ischemia secondary to intestinal obstruction.

METHODS

From January 2015 to June 2021 all the hemodynamically stable patients undergoing emergency surgery with small bowel resection for intestinal obstruction were enrolled in this study. According to surgical technique in performing anastomosis, the patients were divided into three groups: group 1: hand-sewn end-to-end anastomosis, group 2: stapled end-to-side anastomosis, and group 3: stapled side-to-side anastomosis.

RESULTS

Although the anastomosis failure rate was higher in group 3, it was not significantly different between the three groups (P = 0.78: chi-square test). Likewise, no significant differences in the median hospital stay were found between the patients' groups (P = 0.87: Kruskal-Wallis test). The median operating time was similar in patients undergoing stapled anastomoses and was significantly higher in patients undergoing hand-sewn anastomoses (P = 0.0009: Kruskal-Wallis test).

CONCLUSIONS

In patients undergoing emergency small bowel resection for complicated intestinal obstruction, a similar outcome in terms of dehiscence rate and hospital stay can be achieved performing stapled or hand-sewn anastomoses, even if restoring the intestinal continuity with stapled technique is associated with lower operating time.

Association of COVID-19 Infection and Acute Mesenteric Ischemia

COVID-19 is an infectious disease that is considered to be a thromboinflammatory disorder. The study was aimed to determine the prevalence of COVID-19 in patients with acute mesenteric ischemia (AMI) and the outcomes of surgical treatment in relation to COVID-19. A total of 140 patients were included in this multicentric study divided into two groups: the test group (n=65) consisted of cases of AMI detected during the COVID-19 pandemic and the control group (n=65) consisted of cases of AMI detected before the pandemic. Test group patients were classified as COVID-positive (COVID+), or COVID-negative (COVID-) if they tested positive, respectively negative test for COVID-19 on admission. Primary outcomes were: prevalence of COVID-19 infection among test group patients, association between COVID-19 infection and inoperability, and between COVID-19 and treatment outcome. Secondary outcomes were association between each blood parameter and inoperability and treatment outcome. There were no statistically significant differences between inoperability and COVID-19 positivity on admission, overall mortality between the control group and the test group and overall mortality between COVID+ and COVID- patients, as well as among those patients that have been surgically treated (p>0.05). There were statistically significant differences between serum amylase levels (p=0.034), and serum LDH levels (p=0.0382) and inoperability, between serum LDH levels and postoperative mortality (p=0.0151), and overall mortality (p=0.00163). High level of LDH and serum pancreatic amylase are associated with a higher rate of inoperability and a higher postoperative and overall mortality rate. COVID-19 does not seem to independently influence the treatment outcome of AMI.

Acute Mesenteric Ischemia: Preexisting Comorbidity Determines Short-Term Outcome and Quality of Life in Long-Term Survivors

Introduction

Acute mesenteric ischemia (AMI), either arterial or venous, is still a devastating disease with poor prognosis. It is unknown, whether AMI is associated with impaired quality of life (QoL) in long-term survivors.

Material and Methods

This retrospective analysis includes 64 patients with occlusive arterial or venous mesenteric ischemia treated operatively between 2008 and 2016 at the University Medical Center Rostock. Short-term outcome with focus on comorbidities was measured by the Charlson comorbidity index (CCI) an instrument that operationally measures comorbidity based on 17 clinical parameters including age. Operative outcome in view of enterostomy placement and long-term outcome measured as QoL by the EQ-5D in the long-term survivors were evaluated. The EQ-5D is a standardized, self-reported five-dimension QoL questionnaire built to provide a simple and generic measure of health.

Results

Thirty-day mortality was 60.9%, and in-hospital mortality was 70.3% (n = 45). No patient was discharged with a stoma. Patients with a primary anastomosis after the initial operation for AMI had a high leak rate of 27% (4/15 patients) compared to no dehiscence in the group of patients who had secondary anastomosis during second or third laparotomy. The long-term survivors had significantly lower CCI compared to the 45 nonsurvivors (median 4 [3, 4, 5, 6] vs. 6 [4, 5, 6, 7]). All long-term survivors had QoL assessment. QoL score was significantly impaired compared to an age- and sex-matched reference population. This impairment was not due to disease-specific sequelae such as presence of stool deviation or intestinal failure but due to preexisting risk factors as shown by an inverse relation between the CCI and QoL score.

Conclusion

Herein, we show for the first time that long-term QoL in patients with AMI is impaired but this impairment is not due to disease-specific aspects but rather general risk factors underlying the presence of a higher level of comorbidities at the time of AMI.

Severe Klebsiella pneumoniae pneumonia complicated by acute intra-abdominal multiple arterial thrombosis and bacterial embolism: A case report

BACKGROUND

Klebsiella pneumoniae (K. pneumoniae) is a clinically common Gram-negative bacillus that can cause community- and hospital-acquired infections and lead to pneumonia, liver abscesses, bloodstream infections, and other infectious diseases; however, severe pneumonia caused by hypervirulent K. pneumoniae (hvKp) complicated by acute intra-abdominal multiple arterial thrombosis and bacterial embolism is rarely seen in the clinical setting and has not been reported in the literature.

CASE SUMMARY

A 51-year-old man was hospitalized with fever and dyspnea. Persistent mild pain in the middle and upper abdomen began at dawn on the 3^rd day following admission and developed into persistent severe pain in the left upper abdomen 8 h later. Based on chest computed tomography (CT), bronchoscopy, bronchoalveolar lavage fluid metagenomic next-generation sequencing, abdominal aortic CT angiography (CTA), and culture of the superior mesenteric artery embolus, adult community-acquired severe hvKp pneumonia complicated by acute intra-abdominal multiple arterial thrombosis and bacterial embolism was diagnosed. Notably, he recovered and was discharged from the hospital after receiving effective meropenem anti-infection, endovascular contact thrombolytic, and systemic anticoagulant therapies and undergoing percutaneous thrombus aspiration. Ten days later, the patient returned to the hospital for abdominal CTA examination, which indicated blocked initial common pathway of the celiac trunk and superior mesenteric artery, and local stenosis. Therefore, celiac trunk artery stenting was performed in Chongqing Hospital, and postoperative recovery was good.

CONCLUSION

We report a case of hvKp severe pneumonia complicated by acute intra-abdominal multiple arterial thrombosis and bacterial embolism and suggest that clinicians should consider the possibility of a Gram-negative bacillus infection and conduct effective pathogen detection in a timely fashion when managing patients with severe community-acquired pneumonia before obtaining bacteriologic and drug sensitivity results. At the same time, when patients have severe pulmonary infection complicated by severe abdominal pain, an acute mesenteric artery embolism should be considered to avoid delays in treatment.

Acute mesenteric ischemia due to percutaneous coronary intervention: A case report

BACKGROUND

Percutaneous coronary intervention (PCI) is extensively used to treat acute coronary syndromes (ACS). Acute mesenteric ischemia is a life-threatening disease if untreated.

CASE SUMMARY

An 81-year-old female presented with 3 d of lethargy and 1 d of dyspnea. On November 16, 2021, the patient developed a coma. Her oxygen saturation dropped to 70%-80%, the patient was admitted to the intensive care unit for further treatment. Chest computed tomography (CT) showed chronic bronchitis, emphysema, and multiple lung infections. Abdominal CT scan showed no obvious abnormalities, but have severely calcified abdominal vessels. The patient received assisted ventilation, and vasoactive, and anti-infection drugs. Troponin level was elevated. Since the patient was in a coma, it could not be determined whether she had chest pain. The cardiologist assumed that the patient had developed ACS; therefore, the patient underwent PCI via the left femoral artery approach, and no obvious abnormalities were found in the left and right coronary arteries. On the second postoperative day, the patient presented with abdominal distension and decreased bowel sounds; constipation was considered and a glycerin enema was administered. On day 4, the patient suddenly lost consciousness, and had decreased blood pressure, abdominal wall swelling with increased tension, and absence of bowel sounds. An urgent abdominal CT scan revealed gas in her hepatic portal system with extensive bowel wall necrosis. The patient died on day 5 due to intractable shock.

CONCLUSION

The potential serious complications in patients undergoing PCI, especially the patients who are hemodynamically unstable and have severely calcified abdominal vessels, should all be considered.

The psoas muscle density as a predictor of postoperative complications and 30-day mortality for acute mesenteric ischemia patients

OBJECTIVE

Low muscle mass and quality is associated with poor surgical outcomes. Psoas muscle density (PMD)is a validated surrogate for muscle quality that can be easily measured from a clinical computed tomography (CT) scan. The objective of this study was to investigate the association between PMD and short-term postoperative outcomes in patients with acute mesenteric ischemia (AMI).

METHODS

From April 2006 and September 2019, the clinical data of all patients who underwent surgical intervention with a preoperative diagnosis of AMI and had preoperative non-contrast CT images available were retrospectively reviewed. PMD was measured by CT at the third lumbar vertebra. The lowest quartile of PMD for men and women in all patients was used as sex-specific cut-off values for low PMD. Univariate and multivariate analyses evaluating risk factors of postoperative complications and 30-day mortality were performed.

RESULTS

The cohort consisted of 88 patients with a mean age of 58.8 ± 16.2 years, of whom 21 (23.9%) patients had low PMD based on the diagnostic cut-off values (40.5 HU for men and 28.4 HU for women), 35 (39.8%) patients developed complications within 30 days of the operation, and 10 (11.3%) patients died within 30 days of surgery. Low PMD patients had a higher risk of postoperative complications and 30-day mortality than patients without low PMD patients. In a multivariate analysis, low PMD and low psoas muscle area (PMA) were independent predictors of postoperative complications. However, only low PMD remained an independent risk factor for 30-day mortality.

CONCLUSIONS

Preoperative assessment of the PMD on CT can be a practical method for identifying AMI patients at risk for postoperative complications and 30-day mortality.

Predictors of transmural intestinal necrosis in patients presenting with acute mesenteric ischemia on computed tomography

PURPOSE

The purpose of this study was to identify the significant imaging predictors of transmural intestinal necrosis in patients with acute mesenteric ischemia (AMI).

METHODS

The medical records and CT imaging of 48 patients between 2011 and 2019 suspected of having AMI that underwent exploratory laparotomy with bowel resection and pathological confirmation of ischemic bowel injury were retrospectively reviewed. Using histopathology as a gold standard, various parameters related to vascular insufficiency and bowel injury were analyzed and correlated with outcome of ischemic bowel necrosis using nonparametric tests. Univariate analysis was performed using Fisher's exact test followed by binary logistic regression test for multivariate analysis.

RESULTS

48 Patients (19 females, 40%) with a median age of 68.5 years (IQR of 17 years) built our retrospective cohort. 26 (54%) patients were found to have transmural intestinal necrosis on histopathology (case group) whereas 22 (46%) patients had partial mucosal injury (control group). Pneumatosis intestinalis (p = 0.005, odd's ratio of 2.07-63.14) and severity (> 70% or complete occlusion) of vascular narrowing (p = 0.019, odd's ratio of 1.39-42.30) were identified as the most significant predictors of transmural ischemic necrosis on imaging. Dilatation of bowel did not approach the statistical significance on multivariate analysis although it was found significant on univariate analysis (p = 0.041).

CONCLUSION

Pneumatosis intestinalis and severity of vascular luminal narrowing are the most important imaging predictors of transmural ischemic bowel necrosis in patients presenting with AMI. The presence of these findings on CT scan should raise high index of suspicion for irreversible transmural ischemic necrosis. In the absence of these factors, endovascular management might be beneficial.

Errors in MDCT diagnosis of acute mesenteric ischemia

The causes of diagnostic errors during daily medical practice can be several, mainly attributable to perceptual, interpretive and communication factors. The eventuality of radiological error is much more amplified in the emergency setting where a high number of complex multidetector-row computed tomography (MDCT) images must be evaluated quickly and critical time decisions need to be taken. In particular, in this context, the diagnosis of vascular intestinal diseases represents a crucial and difficult challenge in case of acute abdominal pain given the importance of being able to identify patient with high suspicious for intestinal ischemia and for a specific patient to judge if his ischemia is reversible or irreversible. Awareness of potential biases which can lead to diagnostic errors together with an extensive knowledge of the imaging features of these pathologies can lead to promptly recognize them with fewer mistakes, improving patients' outcome. This article reviews the MDCT findings of acute intestinal ischemia and acute colonic ischemia and analyzes the main types of diagnostic errors, underlining the importance of being familiarized with them to avoid misdiagnosis.

Factors associated with acute mesenteric ischemia among critically ill ventilated patients with shock: a post hoc analysis of the NUTRIREA2 trial

PURPOSE

Acute mesenteric ischemia (AMI) is a rare, but life-threatening condition occurring among critically ill patients. Several factors have been associated with AMI, but the causal link is debated, most studies being retrospective. Among these factors, enteral nutrition (EN) could be associated with AMI, in particular among patients with shock. We aimed to study the factors independently associated with AMI in a post hoc analysis of the NUTRIREA-2 trial including 2410 critically ill ventilated patients with shock, randomly assigned to receive EN or parenteral nutrition (PN).

METHODS

Post hoc analysis of the NUTRIREA-2 trial was conducted. Ventilated adults with shock were randomly assigned to receive EN or PN. AMI was assessed by computed tomography, endoscopy, or laparotomy. Factors associated with AMI were studied by univariate and multivariate analysis.

RESULTS

2410 patients from 44 French intensive care units (ICUs) were included in the study: 1202 patients in the enteral group and 1208 patients in the parenteral group. The median age was 67 [58-76] years, with 67% men, a SAPS II score of 59 [46-74], and a medical cause for ICU admission in 92.7%. AMI was diagnosed among 24 (1%) patients, mainly by computed tomography (79%) or endoscopy (38%). The mechanism of AMI was non-occlusive mesenteric ischemia (n = 12), occlusive (n = 4), and indeterminate (n = 8). The median duration between inclusion in the trial and AMI diagnosis was 4 [1-11] days. Patients with AMI were older, had a higher SAPS II score at ICU admission, had higher plasma lactate, creatinine, and ASAT concentrations and lower hemoglobin concentration, had more frequently EN, dobutamine, and CVVHDF at inclusion, developed more frequently bacteremia during ICU stay, and had higher 28-day and 90-day mortality rates compared with patients without AMI. By multivariate analysis, AMI was independently associated with EN, dobutamine use, SAPS II score ≥ 62 and hemoglobin concentration ≤ 10.9 g/dL.

CONCLUSION

Among critically ill ventilated patients with shock, EN, dobutamine use, SAPS II score ≥ 62 and hemoglobin ≤ 10.9 g/dL were independently associated with AMI. Among critically ill ventilated patients requiring vasopressors, EN should be delayed or introduced cautiously in case of low cardiac output requiring dobutamine and/or in case of multiple organ failure with high SAPS II score.

Acute Mesenteric Ischemia in Patients with COVID-19: Review of the literature

The coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has resulted in a global health emergency. In addition to common respiratory symptoms, some patients with COVID-19 infections may experience a range of extra-pulmonary manifestations, such as digestive system involvement. Patients with COVID-19 have been reported to suffer from acute mesenteric ischemia (AMI) that is associated with disease-related severity and mortality. However, in the context of COVID-19, the exact cause of AMI has yet to be clearly defined. This review provides a comprehensive overview of the available data and elucidates the possible underlying mechanisms linking COVID-19 to AMI, in addition to highlighting therapeutic approaches for clinicians. Finally, given the severe global impact of COVID-19, we emphasize the importance of coordinated vaccination programs.

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.

The role of adropin, HIF-1α and apelin biomarkers in the diagnosis of acute mesentaric ischemia

OBJECTIVE

The absence of a specific biomarker for acute mesenteric ischemia diagnosis results in a delay in diagnosis and treatment, as well as a high mortality rate. The current research examined whether the proteins adropin, HIF-1α, and apelin may be used to help in the early detection of acute mesenteric ischemia.

MATERIALS AND METHODS

A total of 20 patients with acute mesenteric ischemia, 20 patients with abdominal pain, and 20 healthy controls were included in the study. The levels of adropin, HIF-1, and apelin in the serum were determined using the ELISA method.

RESULTS

Adropin concentrations were significantly higher in the acute mesenteric ischemia group than in the abdominal pain and healthy control groups (p < 0.05). HIF-1α levels were considerably greater in patients with acute mesenteric ischemia compared to both the abdominal pain group and the healthy control group (p < 0.05). There was no difference in apelin levels between the acute mesenteric ischemia and abdominal pain groups (p > 0.05). HIF-1α was found to be moderate (AUC: 0.705) and adropin was found to be a weak biomarker (AUC: 0.692) in the ROC analysis for acute mesenteric ischemia.

CONCLUSION

In this study of 20 patients with acute mesenteric ischemia, we found adropin and HIF-1α levels to be increased compared to patients with abdominal pain who did not have acute mesenteric ischemia.

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.

Incidence of contrast-induced acute kidney injury in patients with acute mesenteric ischemia and identification of potential predictive factors

OBJECTIVE

Contrast-enhanced computed tomography angiography (CTA) is commonly used to investigate acute abdominal conditions, but the risk of contrast-induced acute kidney injury (CI-AKI) has been poorly investigated in patients with acute mesenteric ischemia. The aim of the present study was to evaluate the incidence of CI-AKI in these patients and identify potential predictive factors.

METHODS

Patients admitted for acute mesenteric ischemia who had a diagnostic CTA with contrast medium and a follow-up of creatinine concentration were retrospectively included.

RESULTS

Among 53 patients included, 9 (16.9%) developed CI-AKI. The prevalence of chronic kidney disease did not differ significantly between those who developed CI-AKI and those who did not (33.3 vs 18.2%, p=.372). Plasma total bilirubin and conjugated bilirubin levels were significantly higher in patients who developed CI-AKI (17.5 vs 8.0 μmol/L, p=.013 and 8.0 vs 3.0 μmol/L, p=.031, respectively). The proportion of patients who had revascularization was similar between patients who developed CI-AKI and those who did not (11.1 vs 20.5%, p>.999). No significant difference was observed for 30-day mortality and all-cause mortality for a median follow-up of 168 days (22.2 vs 13.6%, p=.611; and 33.3 vs 61.4%, p=.153, respectively).

CONCLUSION

This study reports the incidence of CI-AKI in patients with acute mesenteric ischemia after diagnostic CTA with contrast medium. Plasma bilirubin levels were a predictive factor of CI-AKI in these patients. The administration of contrast media during revascularization was not associated with an increased risk of CI-AKI.

Hospital-based Delays to Revascularization Increase Risk of Post-operative Mortality and Short Bowel Syndrome in Acute Mesenteric Ischemia

OBJECTIVE

Acute mesenteric ischemia (AMI) is a surgical emergency for which delays in treatment have been closely associated with high morbidity and mortality. Although the duration of ischemia as a determinant of outcomes for AMI is well known, the objective of this study was to identify hospital-based determinants of delayed revascularization and their effects on post-operative morbidity and mortality in AMI.

METHODS

All patients who underwent any surgery for acute mesenteric ischemia (AMI) from a multi-center hospital system between 2010 and 2020 were divided into two groups based on timeliness of mesenteric revascularization after presentation. Early revascularization (ER) was defined as having both vascular consultation ≤ 12 hours of presentation and vascular surgery performed at the patient's initial operation. Delayed revascularization (DR) was defined as having either delays to vascular consultation or vascular surgery. A retrospective review of demographic and post-operative data was performed. Effect of DR on major post-operative outcomes including 30-day and 2-year mortality, total length of bowel resection, and development of short bowel syndrome were analyzed. Effects of delayed vascular consultation alone, delayed vascular surgery alone, no revascularization during admission, and admitting service on outcomes were also examined on sub-group analyses.

RESULTS

A total of 212 patients were analyzed. 99 patients received ER while the remaining 113 patients experienced a delay to revascularization after hospital presentation. Among the DR group, 55 (25.9%) patients had delayed vascular consultation while vascular surgery was deferred until after the initial operation in 37 (17.4%) patients. 51 (24.0%) patients were never revascularized during admission. DR was a significant predictor of 30-day (odds ratio (OR) 2.09, 95% confidence interval (CI) [1.4-4.9], P=0.03) and 2-year mortality (hazard ratio (HR) 1.55, CI [1.0-2.3], P= 0.04). DR was also independently associated with increased bowel resection length (OR 7.47, P <0.01) and post-operative short bowel syndrome (OR 2.4, P=0.03) on multivariate analyses. When examined separately on sub-group analysis, both delayed vascular consultation (OR 3.38, P=0.03) and vascular surgery (OR 4.31, P <0.01) independently increased risk of 30-day mortality. Hospital discharge after AMI without mesenteric revascularization was associated with increased risk of short bowel syndrome (OR 2.94, P <0.01) and late mortality (HR 1.60, P=0.04).

CONCLUSIONS

Delayed vascular consultation and vascular surgery are both significant hospital-based determinants of post-operative mortality and short bowel syndrome in AMI. Timing-based management protocols which emphasize routine evaluation by a vascular surgeon and early, definitive mesenteric revascularization should be established and widely adopted for all patients with clinically suspected AMI at presentation.

Multidisciplinary management of acute mesenteric ischemia: Surgery and endovascular intervention

Acute mesenteric ischemia (AMI) is a rare cause of the “acute abdomen”, characterized by impaired blood flow to the intestine. The principle of treatment is restoration of perfusion to ischemic bowel and resection of any necrotic intestine. Surgery and endovascular intervention are two complementary approaches to mesenteric ischemia. Endovascular intervention is not an alternative to the surgical approach, but it has the potential to improve the prognosis of patients with AMI when judiciously combined with a surgical approach. Due to the need for emergent treatment of patients with acute mesenteric ischemia, the treatment strategy needs to be modified for each facility. This review aims to highlight cutting-edge studies and provide reasonable treatment strategies for patients with acute mesenteric ischemia based on available evidence.

Ischemic bowel disease in 2021

Ischemic bowel disease (ISBODI) includes colon ischemia, acute mesenteric ischemia (AMI) and chronic mesenteric ischemia (CMI). Epidemiologically, colon ischemia is the most common type followed by AMI and CMI. There are various risk factors for the development of ISBODI. Abdominal pain is the common presenting symptom of each type. High clinical suspicion is essential in ordering appropriate tests. Imaging studies and colonoscopy with biopsy are the main diagnostic tests. Treatment varies from conservative measures to surgical resection and revascularization. Involvement of multidisciplinary team is essential in managing ISBODI. Although open surgery with revascularization plays an important role, recently there is an increasing interest in percutaneous endovascular treatment.

Post-COVID-19 Gastrointestinal Invasive Mucormycosis

Thrombo-embolic episodes and invasive mucormycosis (IM) have shown a sudden surge after the second wave of novel coronavirus infection in India. Acute mesenteric ischemia secondary to coronavirus-19 is rare and that too due to invasive mesenteric mucormycosis has not yet been reported in Indian literature. We present a case of post-COVID diabetic woman who was on steroids and had mesenteric thrombosis with IM. The disease is associated with high mortality. Treatment of choice is wide surgical resection and iv liposomal amphotericin B. Since the pre-operative as well as intra-operative diagnosis is difficult, high index of suspicion for IM is necessary in post-COVID-19 patients presenting with mesenteric ischemia or bowel perforation.

Outcomes of different acute mesenteric ischemia therapies in the last 20 years: A meta-analysis and systematic review

OBJECTIVE

Acute mesenteric ischemia is a disease with high morbidity and mortality, and it is traditionally treated with open surgery. Endovascular therapy and hybrid techniques are alternative treatments that are also currently available. We performed a meta-analysis to evaluate the outcomes of the different treatment approaches in the last 20 years.

METHODS

Studies on acute mesenteric ischemia that were indexed in PubMed, Embase, and MEDLINE databases (from January 1, 2000, to April 1, 2021) were reviewed. All related retrospective observational studies and case series were included. A random-effects model was used to calculate pooled estimates, and the results were reported as proportions and 95% confidence intervals (CIs).

RESULTS

In our study, a total of 2369 patients (in 39 studies) underwent endovascular, open surgery, or retrograde open mesenteric stenting. The pooled mortality estimates for open surgery, endovascular therapy, and retrograde open mesenteric stenting were 40% (95% CI, 0.33-0.47; I² = 84%), 26% (95% CI, 0.19-0.33; I² = 33%), and 32% (95% CI, 0.21-0.44; I² = 26%), respectively.

CONCLUSIONS

The mortality associated with open surgical treatment, endovascular therapy, and retrograde open mesenteric stenting tend to be similar in the last 20 years.

Cervical cord injury complicated by acute mesenteric ischemia

Acute mesenteric ischemia is a rare, life-threatening complication of cervical cord injury. This case report emphasized the importance of prompt diagnosis and treatment of this complication.

A 60-year old Japanese man with no co-morbidities was diagnosed as a C2 cervical cord injury and traumatic brain injury after a fall-down trauma. He was admitted to the intensive care unit after cord decompression surgery. Nine days later, he presented tachycardia and hypotension. Ultrasound showed dilated intestines and ascites. Intestinal ischemia was suspected based on the contrast-enhanced computed tomography scan. We performed prompt surgical resection of a broad part of the small intestines. The ischemic region of the intestines was segmental and the cause was attributed to a non-occlusive mechanism.

Acute mesenteric ischemia can be fatal and a delay in diagnosis leads to poor outcomes. We focus on predisposing factors in patients with cervical cord injuries and how to prevent this serious diagnosis.

Staged acute mesenteric and peripheral ischemia treatment in COVID-19 patient: Case report

Introduction

COVID-19 is an infectious disease that has been associated not only with respiratory complications. The COVID-19 disease includes, also damage to other organ systems as well as coagulopathy. The present report describes a case of COVID-19 presenting with acute mesenteric ischemia (AMI) and subsequent acute limb ischemia (ALI).

Presentation of case

An 84-years old hospitalized female patient presenting diabetes and recent COVID-19 reported acute onset of abdominal pain and typical findings of AMI. The CT-angiography confirmed the AMI secondary to a superior mesenteric artery (SMA) occlusion. The patient was managed through an endovascular approach using a SMA mechanical thrombectomy and stenting with a good result.

Discussion

Treatment of this life-threatening condition includes surgical resection of the necrotic bowel, restoration of blood flow to the ischemic intestine and supportive measure - gastrointestinal decompression, fluid resuscitation, hemodynamic support. Endovascular management of AMI is preferred over the standard surgical approach due to a reduced mortality and morbidity rates. Imaging findings of intestinal necrosis, however, represent an indication for AMI surgical treatment with explorative laparotomy. Different endovascular solutions have been employed to address AMI including mechanical thrombectomy, local thrombolysis, and PTA-stenting.

Conclusion

COVID-19 clinical presentation can be atypical, including gastrointestinal symptoms. If a first embolic event occurs, an aggressive anticoagulation treatment could be inefficient to reduce the risk of subsequent embolization events. The limited life expectancy of such revascularization procedures should orientate towards less invasive treatments.

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The COVID-19 disease includes damage to other organ systems as well as coagulopathy.

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COVID-19 clinical presentation can be atypical, including gastrointestinal symptoms.

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Endovascular approach of AMI is preferred due to a reduced mortality.

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Few cases of COVID-related AMI have been reported.

The effect of comorbidity on early clinical decision making in acute mesenteric ischemia

INTRODUCTION

Acute mesenteric ischemia (AMI) is a surgical emergency with a high mortality and morbidity rate. Prompt diagnosis and early surgical management are the cornerstones of management. In certain patients, however, treatment is futile and early palliative care, lessens patient, and family distress. The aim of this study was to investigate factors, focusing on patient comorbidity, that may predict futility of treatment and hence, guide clinicians in their decision making.

PATIENTS AND METHODS

Consecutive adult patients with AMI diagnosed on imaging were reviewed for demographics, comorbidity, imaging, and biochemical results.

RESULTS

Seventy patients were identified with average age of 67 (range 33 - 94). Overall hospital mortality was 72%. Patients were divided into three distinct groups, patients who recovered (27%), patients deceased despite surgical treatment (18%), and patients palliated on presentation (54%). Age was comparable between groups (61 vs. 69 vs. 69; p=.2). Length of stay was highest in the recovered group (41.6 vs. 12.3 vs. 2.8 d). Biochemically, only lactate level differed (3.1 vs. 2.3 vs. 5.3 mmol/L, p=.03). Both deceased and palliative group scored similarly but significantly higher than the recovered group in both the Charlson comorbidity index (CCI) (4.2 and 5.6 vs. 3.4, p=.02) and age-adjusted CCI (ACCI) (6.7 and 8.2 vs. 5; p<.01). Other co-morbidities of atrial fibrillation (AF) and hypertension were comparable.

CONCLUSIONS

Raised ACCI confers poor outcomes in AMI despite surgical management. ACCI may be used to aid early decision making in AMI, predicting futility of treatment, and altering management goals to palliative comfort care.

Intestinal thromboangiitis obliterans: a case report

Background

Thromboangiitis obliterans or Buerger’s disease is a form of peripheral vascular disease in young male smokers. The involvement of the intestine occurs in only about 2% of the cases, when they may present as acute abdomen due to mesenteric ischemia. The uncommonness of the condition makes it a less suspected differential diagnosis, leading to a delay in appropriate management, thereby increasing chances of morbidity or mortality. Cessation of smoking is known to stall the disease progression including visceral involvement, but may not always be the case as happened in the case being presented.

Case presentation

Our Indian Hindu male patient, a known smoker, presented with diffuse abdominal pain along with bouts of vomiting and loose motions. He had a prior history of amputation of the right foot, 4 years before. At presentation he had abdominal distension with diffuse tenderness and guarding. An omental band attached to the tip of the appendix was discovered at the initial exploration along with dilated proximal bowel loops, for which a release of the omental band along with appendectomy was done. He developed an enterocutaneous fistula on the 6th postoperative day for which he had to be reexplored, and multiple jejunal perforations were found. Segmental jejunal resection and a Roux-en-Y gastrojejunostomy with distal ileostomy were done along with a feeding jejunostomy. The patient however again had feculent discharge from the wound for which a third exploration was done. The gastrojejunostomy and feeding jejunostomy sites were leaky, both of which were repaired primarily. The patient developed septicemia which progressed to refractory septic shock, and he ultimately succumbed to his illness on the 23rd postoperative day of the index surgery.

Conclusion

Acute abdomen in a young man who is a chronic smoker and having an antecedent history of amputation of some part of an extremity for a nontraumatic cause should raise the suspicion of Buerger’s disease of the intestine. Although it is a progressive disease and the situation has already progressed by the time intestinal symptoms manifest, early detection may give some scope of salvage and decrease the morbidity and mortality.