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Coutureau J, Millet I, Taourel P. CT of acute abdomen in the elderly. Insights Imaging 2025; 16:95. [PMID: 40335795 PMCID: PMC12058634 DOI: 10.1186/s13244-025-01955-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2024] [Accepted: 03/17/2025] [Indexed: 05/09/2025] Open
Abstract
Abdominal disorders represent 10 to 15% of all Emergency Department visits in elderly patients. This educational review focuses on acute abdomen pathologies specific to the elderly and on their imaging patterns and proposes a strategy for performing CT scans in this population. Bowel obstruction is the most common cause of emergency surgery in the elderly with a higher proportion of colonic obstructions, in particular obstructive colorectal cancer and sigmoid volvulus. Concerning abdominal inflammatory processes, such as cholecystitis, appendicitis, and diverticulitis, gangrenous cholecystitis and complicated appendicitis are relatively frequently encountered due to delayed diagnoses. Bowel ischemia, which includes acute mesenteric ischemia (AMI) and ischemic colitis (IC), is also much more common after the age of 80. Although ischemic colitis is mainly related to cardiovascular risk factors, it can also result from a persistent distension above a colonic cancer or from fecal impaction. Finally, extra-abdominal pathologies responsible for acute abdominal pain, such as inferior myocardial infarction, should not be overlooked. In clinical practice, when possible thanks to sufficient and appropriate radiological resources, we recommend a scan without injection of contrast and an injection depending on the results of the unenhanced scan, decided by the radiologist present at the CT scan room during the examination. CRITICAL RELEVANCE STATEMENT: CT is critical in the diagnosis and management of patients over 75 years old with an acute abdomen, given the difficulty of clinico-biological diagnosis, the frequency of complicated forms, and the morbidity induced by delayed diagnosis. KEY POINTS: The most common site and cause of bowel obstruction in the elderly is large bowel obstruction due to colon cancer. Discrepancy between a poor clinical examination and complicated forms on imaging, particularly for inflammation and infections, is responsible for late diagnosis and increased morbidity. Ischemia, including of the small bowel, colon, and gallbladder are common cause of acute abdomen in elderly. In patients with upper quadrant pain, consider extra-abdominal causes such as pneumonia or myocardial infarction.
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Affiliation(s)
- Juliette Coutureau
- Department of Medical Imaging, Lapeyronie University Hospital, Montpellier, France
| | - Ingrid Millet
- Department of Medical Imaging, Lapeyronie University Hospital, Montpellier, France
- Desbrest Institute of Epidemiology and Public Health (IDESP), Univ Montpellier, INSERM, Montpellier, France
| | - Patrice Taourel
- Department of Medical Imaging, Lapeyronie University Hospital, Montpellier, France.
- Desbrest Institute of Epidemiology and Public Health (IDESP), Univ Montpellier, INSERM, Montpellier, France.
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De Simone B, Abu-Zidan FM, Boni L, Castillo AMG, Cassinotti E, Corradi F, Di Maggio F, Ashraf H, Baiocchi GL, Tarasconi A, Bonafede M, Truong H, De'Angelis N, Diana M, Coimbra R, Balogh ZJ, Chouillard E, Coccolini F, Kelly MD, Di Saverio S, Di Meo G, Isik A, Leppäniemi A, Litvin A, Moore EE, Pasculli A, Sartelli M, Podda M, Testini M, Wani I, Sakakushev B, Shelat VG, Weber D, Galante JM, Ansaloni L, Agnoletti V, Regimbeau JM, Garulli G, Kirkpatrick AL, Biffl WL, Catena F. Indocyanine green fluorescence-guided surgery in the emergency setting: the WSES international consensus position paper. World J Emerg Surg 2025; 20:13. [PMID: 39948641 PMCID: PMC11823064 DOI: 10.1186/s13017-025-00575-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2024] [Accepted: 01/04/2025] [Indexed: 02/16/2025] Open
Abstract
BACKGROUND Decision-making in emergency settings is inherently complex, requiring surgeons to rapidly evaluate various clinical, diagnostic, and environmental factors. The primary objective is to assess a patient's risk for adverse outcomes while balancing diagnoses, management strategies, and available resources. Recently, indocyanine green (ICG) fluorescence imaging has emerged as a valuable tool to enhance surgical vision, demonstrating proven benefits in elective surgeries. AIM This consensus paper provides evidence-based and expert opinion-based recommendations for the standardized use of ICG fluorescence imaging in emergency settings. METHODS Using the PICO framework, the consensus coordinator identified key research areas, topics, and questions regarding the implementation of ICG fluorescence-guided surgery in emergencies. A systematic literature review was conducted, and evidence was evaluated using the GRADE criteria. A panel of expert surgeons reviewed and refined statements and recommendations through a Delphi consensus process, culminating in final approval. RESULTS ICG fluorescence imaging, including angiography and cholangiography, improves intraoperative decision-making in emergency surgeries, potentially reducing procedure duration, complications, and hospital stays. Optimal use requires careful consideration of dosage and timing due to limited tissue penetration (5-10 mm) and variable performance in patients with significant inflammation, scarring, or obesity. ICG is contraindicated in patients with known allergies to iodine or iodine-based contrast agents. Successful implementation depends on appropriate training, availability of equipment, and careful patient selection. CONCLUSIONS Advanced technologies and intraoperative navigation techniques, such as ICG fluorescence-guided surgery, should be prioritized in emergency surgery to improve outcomes. This technology exemplifies precision surgery by enhancing minimally invasive approaches and providing superior real-time evaluation of bowel viability and biliary structures-areas traditionally reliant on the surgeon's visual assessment. Its adoption in emergency settings requires proper training, equipment availability, and standardized protocols. Further research is needed to evaluate cost-effectiveness and expand its applications in urgent surgical procedures.
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Affiliation(s)
- Belinda De Simone
- Department of Emergency and General Minimally Invasive Surgery, Infermi Hospital, AUSL Romagna, Rimini, Italy.
- Department of Theoretical and Applied Sciences, eCampus University, Novedrate, CO, Italy.
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al‑Ain, UAE
| | - Luigi Boni
- Department of General and Minimally Invasive Surgery, Fondazione IRCCS - Ca' Granda - Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Ana Maria Gonzalez Castillo
- Emergency Surgery Unit, Department of General Surgery, Pompeu Fabra University, Hospital del Mar, Barcelona, Spain
| | - Elisa Cassinotti
- Department of General and Minimally Invasive Surgery, Fondazione IRCCS - Ca' Granda - Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Francesco Corradi
- Department of Surgical, Medical andMolecularPathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Francesco Di Maggio
- Upper Gastro-Intestinal Surgery Unit, Department of General Surgery, Croydon University Hospital, London, UK
| | - Hajra Ashraf
- Upper Gastro-Intestinal Surgery Unit, Department of General Surgery, Croydon University Hospital, London, UK
| | - Gian Luca Baiocchi
- Unit of General Surgery, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | | | | | - Hung Truong
- Acute Care and Minimally Invasive Surgery, Scripps Memorial Hospital - La Jolla, Green, and Encinitas, La Jolla, USA
| | - Nicola De'Angelis
- Unit of Robotic and Minimally Invasive Digestive Surgery, Ferrara University Hospital, Ferrara, Italy
| | - Michele Diana
- Department of Surgery, University Hospital of Geneva, 1205, Geneva, Switzerland
- ICube Laboratory, Photonics Instrumentation for Health, 67034, Strasbourg, France
| | - Raul Coimbra
- Riverside University Health System Medical Center, Riverside, CA, USA
| | - Zsolt J Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia
| | - Elie Chouillard
- General Surgery Department, American Hospital of Paris, Paris, France
| | | | | | - Salomone Di Saverio
- General Surgery Unit, Madonna del Soccorso Hospital, AST Ascoli Piceno, San Benedetto del Tronto, Italy
| | - Giovanna Di Meo
- Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery, University of Bari "A. Moro", Bari, Italy
| | - Arda Isik
- Istanbul Medeniyet University, Istanbul, Turkey
| | - Ari Leppäniemi
- Division of Emergency Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Andrey Litvin
- Department of Surgical Diseases No. 3, Gomel State Medical University, University Clinic, Gomel, Belarus
| | - Ernest E Moore
- Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO, USA
| | - Alessandro Pasculli
- Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery, University of Bari "A. Moro", Bari, Italy
| | - Massimo Sartelli
- Department of General Surgery, Macerata Hospital, Macerata, Italy
| | - Mauro Podda
- Department of Surgical Science, Unit of Emergency Surgery, University of Cagliari, Cagliari, Italy
| | - Mario Testini
- Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery, University of Bari "A. Moro", Bari, Italy
| | - Imtiaz Wani
- Department of Surgery, Government Gousia Hospital, DHS, Srinagar, India
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Novena, Singapore
| | - Dieter Weber
- Department of General Surgery, Royal Perth Hospital & The University of Western Australia, Perth, Australia
| | - Joseph M Galante
- UC Davis Health, Hospital Clinical Care Services, University of California, Davis, USA
| | - Luca Ansaloni
- Department of General Surgery, University of Pavia, Pavia, Italy
| | - Vanni Agnoletti
- Level 1 Trauma Center, Bufalini Hospital, AUSL Romagna, Cesena, Italy
| | - Jean-Marc Regimbeau
- Service de Chirurgie Digestive du CHU d'Amiens, CHU Sud, Centre Hospitalier Universitaire Amiens-Picardie Site Sud, 80054, Amiens, France
| | - Gianluca Garulli
- Department of Emergency and General Minimally Invasive Surgery, Infermi Hospital, AUSL Romagna, Rimini, Italy
| | - Andrew L Kirkpatrick
- Departments of Surgery and Critical Care Medicine, University of Calgary, Foothills Medical Centre, Calgary, AB, Canada
| | - Walter L Biffl
- Division of Trauma/Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, CA, USA
| | - Fausto Catena
- Department of General and Emergency Surgery, Bufalini Hospital-Level 1 Trauma Center, AUSL Romagna, Cesena, Italy
- Alma Mater Studiorum, University of Bologna, Bologna, Italy
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Holleck JL, Han L, Skanderson M, Bastian LA, Gunderson CG, Brandt CA, Perkal M, Chang JJ, Akgün KM. Risk of Serious Adverse Gastrointestinal Events with Potassium Binders in Hospitalized Patients: A National Study. J Gen Intern Med 2025; 40:518-524. [PMID: 39103605 PMCID: PMC11861845 DOI: 10.1007/s11606-024-08979-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 07/26/2024] [Indexed: 08/07/2024]
Abstract
BACKGROUND Concerns about serious adverse gastrointestinal (GI) events with sodium polystyrene sulfonate (SPS) led to development of two new potassium binders, patiromer and sodium zirconium cyclosilicate (SZC), for treatment of hyperkalemia. OBJECTIVE To compare risk of intestinal ischemia/thrombosis or other serious GI events associated with SPS, patiromer, or SZC in hospitalized patients. DESIGN Retrospective cohort study. PARTICIPANTS National sample of 3,144,960 veterans hospitalized 2016-2022 in the U.S. Department of Veterans Affairs Healthcare System. MAIN MEASURES Demographics, comorbidities, medications and outcomes were ascertained from the VA Corporate Data Warehouse. Exposures were SPS, patiromer, SZC. Outcomes were 30-day intestinal ischemia/thrombosis, and a composite of intestinal ischemia/thrombosis, peptic ulcer/perforation or bowel resection/ostomy. KEY RESULTS Potassium binders were used during 39,270 (1.3%) hospitalizations: SPS = 30,040 (1.0%), patiromer = 3,750 (0.1%), and SZC = 5,520 (0.2%). Intestinal ischemia/thrombosis occurred with 106/30,040 (0.4%) SPS, 12/3750 (0.3%) patiromer and 24/5520 (0.4%) SZC, vs. 6998/3,105,650 (0.2%) without potassium binder. Adjusted odds ratios (aOR) were 1.40 [95% CI, 1.16 to 1.69] with SPS, 1.36 [CI, 0.79 to 2.36] with patiromer, and 1.78 [CI, 1.21 to 2.63] with SZC exposures. Composite GI adverse events occurred with 754/30,040 (2.5%) SPS, 96/3750 (2.6%) patiromer, 2.6% SZC, vs. 144/5520 (2.4%) without binder; aOR were 1.00 [CI, 0.94 to 1.08] with SPS, 1.08 [CI, 0.89 to 1.32] with patiromer, and 1.08 [CI, 0.93 to 1.27] with SZC exposures. No statistical difference in intestinal ischemia/thrombosis between each new agent and SPS was seen (p = 0.274 for SPS vs. SZC; p = 0.916 for SPS vs. patiromer). CONCLUSION Risk of intestinal ischemia/thrombosis or other serious adverse GI events was low and did not differ across three potassium-binding drugs.
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Affiliation(s)
- Jürgen L Holleck
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA.
- Department of Medicine, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA.
| | - Ling Han
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Melissa Skanderson
- Department of Medicine, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
| | - Lori A Bastian
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Medicine, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
| | - Craig G Gunderson
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Medicine, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
| | - Cynthia A Brandt
- Department of Medicine, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Department of Biomedical Informatics & Data Science, Yale School of Medicine, New Haven, CT, USA
| | - Melissa Perkal
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA
- Department of Surgery, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
| | - John J Chang
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Medicine, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
| | - Kathleen M Akgün
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Medicine, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
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Osaki Y, Maeoka Y, Sami M, Takahashi A, Ishiuchi N, Sasaki K, Masaki T. Peritoneal dialysis-associated peritonitis, caused by superior mesenteric artery thrombosis with intestinal necrosis: a case report. CEN Case Rep 2025; 14:1-5. [PMID: 38825653 PMCID: PMC11785861 DOI: 10.1007/s13730-024-00894-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 05/14/2024] [Indexed: 06/04/2024] Open
Abstract
Peritoneal dialysis (PD)-associated peritonitis is a common complication of PD. Enteric peritonitis is defined as peritonitis arising from an intestinal or intra-abdominal organ source. The delay in the diagnosis or treatment of enteric peritonitis has been reported to increase mortality. Therefore, the early consideration of enteric peritonitis, particularly in cases of culture-negative peritonitis, is imperative. A 67-year-old Japanese man who had been undergoing PD for 3 years, was admitted to our hospital with a diagnosis of PD-associated peritonitis. A month previously, he experienced a bleeding gastric ulcer, which led to severe anemia (hemoglobin 6.3 mg/dL), followed by thrombocytosis. On admission, peritoneal fluid analysis showed a high white blood cell count (WBC: 8,570 /µL), with neutrophils predominating (74.5%). Cultures of both his dialysis effluent and blood were negative. After admission, the WBC count of the dialysis effluent gradually decreased alongside antibiotic therapy, but the patient's abdominal pain did not improve. After 4 days, enhanced computed tomography showed superior mesenteric artery (SMA) thrombosis and intestinal necrosis. Therefore, emergency intestinal resection and PD catheter removal were performed, and then antithrombosis therapy was initiated. Because the patient's abdominal pain was improved and platelet count and D-dimer concentration were reduced by these treatments, he was discharged from the hospital after 47 days. Thus, we report a rare case of culture-negative PD-associated peritonitis, which was caused by SMA thrombosis and intestinal necrosis. It is likely that combination of severe calcification of SMA and prolonged thrombocytosis secondary to the severe anemia contributed to the thrombosis.
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Affiliation(s)
- Yosuke Osaki
- Department of Nephrology, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551, Japan
| | - Yujiro Maeoka
- Department of Nephrology, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551, Japan
| | - Mai Sami
- Department of Nephrology, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551, Japan
| | - Akira Takahashi
- Department of Nephrology, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551, Japan
| | - Naoki Ishiuchi
- Department of Nephrology, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551, Japan
| | - Kensuke Sasaki
- Department of Nephrology, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551, Japan
| | - Takao Masaki
- Department of Nephrology, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551, Japan.
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Rasslan R, de Oliveira Ferreira F, Parra JAP, da Costa Ferreira Novo F, Menegozzo CAM, Alves PHF, Bertolli E, Damous SHB, Rasslan S, Utiyama EM. Damage control surgery in non-traumatic abdominal emergencies: prognostic value of SOFA, APACHEII, and Mannheim peritonitis index. Updates Surg 2025; 77:255-262. [PMID: 39266908 DOI: 10.1007/s13304-024-01984-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 08/30/2024] [Indexed: 09/14/2024]
Abstract
This study aimed to analyze the prognostic value of the SOFA, APACHE II, and MPI (Mannheim Peritonitis Index) scores in the indication for Damage Control Surgery (DCS) in non-trauma. Retrospective analysis of patients undergoing DCS between 2014 and 2019. SOFA and APACHE II scores were calculated using parameters preceding DCS, while MPI was based on surgical descriptions. Statistical analysis: Qualitative variables were compared using the Chi-square test or Fisher's exact test, and quantitative variables using Pearson's correlation coefficient. The Student's T test was employed for mean comparisons. The sample comprised 104 patients (59 males), with a median age of 63.5 years, of whom 52 (50%) were ASA IV. Operative findings leading to DCS included peritonitis (54; 51.9%), intestinal ischemia (39; 37.5%), inability to close the abdomen (8; 7.6%), and bleeding (3; 2.9%). The mortality rate was 75% (78/104). Thirty patients (28.8%) died after DCS; the remainder underwent one (35; 33.6%), two (21; 20.2%); three (8; 7.7%), and four or more (10;9.7%) revision procedures. The median lengths of ICU and hospital stays were 12.5 and 20.5 days, respectively. The median score values were as follows: SOFA: 12 (0-38), APACHE II: 25 (2-47), and MPI: 26 (8-43). Besides ASA classification (p = 0.03), mortality risk was influenced by: age (≤ 65 years vs. > 65 years; p = 0.04), SOFA (≤ 10 vs. > 10; p = 0.03), APACHE II (≤ 25 vs. > 25; p = 0.04), and MPI (≤ 25 vs. > 25; p = 0.003). The SOFA, APACHE II, and MPI scores proved to be valuable tools in the prognostic assessment of patients undergoing DCS in non-traumatic abdominal emergencies.
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Affiliation(s)
- Roberto Rasslan
- Departament of Surgery, Division of General Surgery and Trauma, Universidade de São Paulo, Av. Dr Enéas de Carvalho Aguiar, no. 255, 8th. Floor, São Paulo, Brazil.
| | - Fábio de Oliveira Ferreira
- Departament of Surgery, Division of General Surgery and Trauma, Universidade de São Paulo, Av. Dr Enéas de Carvalho Aguiar, no. 255, 8th. Floor, São Paulo, Brazil
| | - Jeammy Andrea Perez Parra
- Departament of Surgery, Division of General Surgery and Trauma, Universidade de São Paulo, Av. Dr Enéas de Carvalho Aguiar, no. 255, 8th. Floor, São Paulo, Brazil
| | - Fernando da Costa Ferreira Novo
- Departament of Surgery, Division of General Surgery and Trauma, Universidade de São Paulo, Av. Dr Enéas de Carvalho Aguiar, no. 255, 8th. Floor, São Paulo, Brazil
| | - Carlos Augusto Metidieri Menegozzo
- Departament of Surgery, Division of General Surgery and Trauma, Universidade de São Paulo, Av. Dr Enéas de Carvalho Aguiar, no. 255, 8th. Floor, São Paulo, Brazil
| | - Pedro Henrique Ferreira Alves
- Departament of Surgery, Division of General Surgery and Trauma, Universidade de São Paulo, Av. Dr Enéas de Carvalho Aguiar, no. 255, 8th. Floor, São Paulo, Brazil
| | - Eduardo Bertolli
- Departament of Surgery, Division of General Surgery and Trauma, Universidade de São Paulo, Av. Dr Enéas de Carvalho Aguiar, no. 255, 8th. Floor, São Paulo, Brazil
| | - Sérgio Henrique Bastos Damous
- Departament of Surgery, Division of General Surgery and Trauma, Universidade de São Paulo, Av. Dr Enéas de Carvalho Aguiar, no. 255, 8th. Floor, São Paulo, Brazil
| | - Samir Rasslan
- Departament of Surgery, Division of General Surgery and Trauma, Universidade de São Paulo, Av. Dr Enéas de Carvalho Aguiar, no. 255, 8th. Floor, São Paulo, Brazil
| | - Edivaldo Massazo Utiyama
- Departament of Surgery, Division of General Surgery and Trauma, Universidade de São Paulo, Av. Dr Enéas de Carvalho Aguiar, no. 255, 8th. Floor, São Paulo, Brazil
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Pan S, Yang J, Liu Z, Nai R, Chen Z. A prediction model to differentiate transient ischemia from irreversible transmural necrosis in closed-loop small bowel obstruction. Front Med (Lausanne) 2024; 11:1466754. [PMID: 39323473 PMCID: PMC11422149 DOI: 10.3389/fmed.2024.1466754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2024] [Accepted: 08/26/2024] [Indexed: 09/27/2024] Open
Abstract
Introduction The study aims to develop a prediction model to differentiate transient ischemia from irreversible transmural necrosis in closed-loop small bowel obstruction (CL-SBO). Methods A total of 180 participants with CL-SBO between January 2010 and December 2019, of which 122 had complete radiologic data, were included to investigate the significant clinical and imaging characteristics for differentiating patients with necrosis from transient ischemia. A logistic regression model was developed and validated. Results In a multivariate analysis, the American Society of Anesthesiologists physical status classification system >2 is the independent predictor for transmural necrosis. Another multivariate analysis, including clinical and imaging factors, revealed that the imaging sign of mesenteric vessel interruption was an independent risk factor for necrosis. The diagnostic model developed using these two factors has excellent performance among the validation sets, with an area under the curve of 0.89. Conclusion The diagnostic model and innovative imaging signs have substantial potential in solving this complex clinical problem.
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Affiliation(s)
- Shaorong Pan
- Department of Gastrointestinal Surgery, Peking University First Hospital, Peking University, Beijing, China
| | - Jiejin Yang
- Department of Radiology, Peking University First Hospital, Peking University, Beijing, China
| | - Zining Liu
- Department of Gynecologic Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Rile Nai
- Department of Radiology, Peking University First Hospital, Peking University, Beijing, China
| | - Zeyang Chen
- Department of Gastrointestinal Surgery, Peking University First Hospital, Peking University, Beijing, China
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Luitel P, Paudel S, Shrestha A, Gyawali P, Gaire R, Dev S. Acute mesenteric ischemia due to superior mesenteric artery thrombosis in a patient with protein S deficiency: A case report. Int J Surg Case Rep 2024; 122:110080. [PMID: 39088974 PMCID: PMC11342903 DOI: 10.1016/j.ijscr.2024.110080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2024] [Revised: 07/17/2024] [Accepted: 07/23/2024] [Indexed: 08/03/2024] Open
Abstract
INTRODUCTION Protein S deficiency resulting in mesenteric vein thrombosis has been reported in previous studies however those causing SMA thrombosis has been rarely reported. Multidisciplinary approach involving general surgeon, a vascular surgeon, an interventional radiologist, and an intensivist are crucial for management of SMA thrombosis. CASE PRESENTATION A 39-year-old non-smoker hypertensive female who was diagnosed with partially occlusive thrombus in the superior mesenteric artery via Contrast-enhanced computed tomography (CECT) re-presented after 5 days and CECT revealed a partially occlusive thrombus in the superior mesenteric artery and Protein S deficiency (free protein S:15 %). She was managed by lysis of thrombus with streptokinase by interventional radiology team. The patient is on anticoagulants and without abdominal complaints on follow-up at 24 months. DISCUSSION Computed tomography angiography should be done immediately in any patient suspected of AMI since delay in diagnosis accounts for high mortality rates of 30-70 %. The surgical treatment of the condition is well established and consists of revascularization and/or resection of nonviable bowel. Endovascular techniques have emerged as an alternative for occlusion of the SMA. Patients with protein C and/or S deficiency treated for AMI require lifelong anticoagulant/antiplatelet therapy to prevent relapse. CONCLUSION Hereditary thrombophilia should be suspected in young people with unusual thrombotic presentations. Earlier diagnosis and aggressive antithrombotic therapy in individuals with hypercoagulable states can improve outcomes. Treatment involving a multidisciplinary approach improves outcomes.
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Affiliation(s)
- Prajjwol Luitel
- Maharajgunj Medical Campus, Tribhuvan University Teaching Hospital, Nepal
| | - Sujan Paudel
- Maharajgunj Medical Campus, Tribhuvan University Teaching Hospital, Nepal
| | - Aron Shrestha
- Maharajgunj Medical Campus, Tribhuvan University Teaching Hospital, Nepal.
| | - Prashant Gyawali
- Maharajgunj Medical Campus, Tribhuvan University Teaching Hospital, Nepal
| | - Roshan Gaire
- Department of Radiology, Maharajgunj Medical Campus, Tribhuvan University Teaching Hospital, Nepal
| | - Santosh Dev
- Department of General Surgery, Maharajgunj Medical Campus, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
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Rizzo R, Vallicelli C, Ansaloni L, Coccolini F, Fugazzola P, Sartelli M, Agnoletti V, Baiocchi GL, Catena F. Usefulness of fluorescence imaging with indocyanine green for evaluation of bowel perfusion in the urgency setting: a systematic review and meta-analysis. Int J Surg 2024; 110:5071-5077. [PMID: 38768464 PMCID: PMC11325932 DOI: 10.1097/js9.0000000000001529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 04/14/2024] [Indexed: 05/22/2024]
Abstract
INTRODUCTION Fluorescence imaging with indocyanine green (ICG) has been extensively utilized to assess bowel perfusion in oncologic surgery. In the emergency setting, there are many situations in which bowel perfusion assessment is required. Large prospective studies or RCTs evaluating feasibility, safety and utility of ICG in the emergency setting are lacking. The primary aim is to assess the usefulness of ICG for evaluation of bowel perfusion in the emergency setting. MATERIALS AND METHODS The manuscript was drafted following the recommendations of Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (PRISMA). A systematic literature search was carried out through Pubmed, Scopus, and the ISI Web of Science. Assessment of included study using the methodological index for nonrandomized studies (MINORS) was calculated. The meta-analysis was carried out in line with recommendations from the Cochrane Collaboration and Meta-analysis of Observational Studies in Epidemiology guidelines, and the Mantel-Haenszel random effects model was used to calculate effect sizes. RESULTS 10 093 papers were identified. Eighty-four were reviewed in full-text, and 78 were excluded: 64 were case reports; 10 were reviews without original data; 2 were letters to the editor; and 2 contained unextractable data. Finally, six studies 22-27 were available for quality assessment and quantitative synthesis. The probability of reoperation using ICG fluorescence angiography resulted similar to the traditional assessment of bowel perfusion with a RD was -0.04 (95% CI: -0.147 to 0.060). The results were statistically significant P =0.029, although the heterogeneity was not negligible with a 59.9% of the I2 index. No small study effect or publication bias were found. CONCLUSIONS This first metanalysis on the use of IGC fluorescence for ischemic bowel disease showed that this methodology is a safe and feasible tool in the assessment of bowel perfusion in the emergency setting. This topic should be further investigated in high-quality studies.
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Affiliation(s)
- Roberta Rizzo
- Urgency and Emergency Surgery Department, Bufalini Hospital
| | | | - Luca Ansaloni
- Unit of General Surgery I, IRCCS San Matteo Hospital, University of Pavia, Pavia
| | | | - Paola Fugazzola
- Unit of General Surgery I, IRCCS San Matteo Hospital, University of Pavia, Pavia
| | | | - Vanni Agnoletti
- Anesthesia and Intensive Care Department, Bufalini Hospital, Cesena
| | | | - Fausto Catena
- Urgency and Emergency Surgery Department, Bufalini Hospital
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9
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Zhou Y, Zhang L, Huang D, Zhang Y, Zhu L, Chen X, Cui G, Chen Q, Chen X, Ali S. Hyperspectral imaging combined with blood oxygen saturation for in vivo analysis of small intestinal necrosis tissue. SPECTROCHIMICA ACTA. PART A, MOLECULAR AND BIOMOLECULAR SPECTROSCOPY 2024; 315:124298. [PMID: 38642522 DOI: 10.1016/j.saa.2024.124298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 04/14/2024] [Accepted: 04/14/2024] [Indexed: 04/22/2024]
Abstract
Acute mesenteric ischemia (AMI) is a clinically significant vascular and gastrointestinal condition, which is closely related to the blood supply of the small intestine. Unfortunately, it is still challenging to properly discriminate small intestinal tissues with different degrees of ischemia. In this study, hyperspectral imaging (HSI) was used to construct pseudo-color images of oxygen saturation about small intestinal tissues and to discriminate different degrees of ischemia. First, several small intestine tissue models of New Zealand white rabbits were prepared and collected their hyperspectral data. Then, a set of isosbestic points were used to linearly transform the measurement data twice to match the reference spectra of oxyhemoglobin and deoxyhemoglobin, respectively. The oxygen saturation was measured at the characteristic peak band of oxyhemoglobin (560 nm). Ultimately, using the oxygenated hemoglobin reflectance spectrum as the benchmark, we obtained the relative amount of median oxygen saturation in normal tissues was 70.0 %, the IQR was 10.1 %, the relative amount of median oxygen saturation in ischemic tissues was 49.6 %, and the IQR was 14.6 %. The results demonstrate that HSI combined with the oxygen saturation computation method can efficiently differentiate between normal and ischemic regions of the small intestinal tissues. This technique provides a powerful support for internist to discriminate small bowel tissues with different degrees of ischemia, and also provides a new way of thinking for the diagnosis of AMI.
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Affiliation(s)
- Yao Zhou
- College of Optoelectronic Engineering, Changchun University of Science and Technology, Changchun 130000, China; Zhongshan Research Institute, Changchun University of Science and Technology, Zhongshan 528400, China
| | - LeChao Zhang
- College of Optoelectronic Engineering, Changchun University of Science and Technology, Changchun 130000, China; Zhongshan Research Institute, Changchun University of Science and Technology, Zhongshan 528400, China
| | - DanFei Huang
- College of Optoelectronic Engineering, Changchun University of Science and Technology, Changchun 130000, China; Zhongshan Research Institute, Changchun University of Science and Technology, Zhongshan 528400, China.
| | - Yong Zhang
- College of Optoelectronic Engineering, Changchun University of Science and Technology, Changchun 130000, China; Zhongshan Research Institute, Changchun University of Science and Technology, Zhongshan 528400, China
| | - LiBin Zhu
- Pediatric General Surgery, The Second Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Xiaoqing Chen
- Pediatric General Surgery, The Second Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Guihua Cui
- College of Electrical and Electronic Engineering, Wenzhou University, Wenzhou 325000, China
| | - Qifan Chen
- Zhongshan Research Institute, Changchun University of Science and Technology, Zhongshan 528400, China
| | - XiaoJing Chen
- College of Electrical and Electronic Engineering, Wenzhou University, Wenzhou 325000, China.
| | - Shujat Ali
- College of Electrical and Electronic Engineering, Wenzhou University, Wenzhou 325000, China
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10
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Pfister F, Mehdorn M, Schwartner C, Seehofer D, Tautenhahn HM, Struck MF, Denecke T, Meyer HJ. Portal venous contrast enhancement ratio of the adrenal glands and spleen as prognostic marker of mortality in patients with acute mesenteric ischemia. Abdom Radiol (NY) 2024; 49:1376-1384. [PMID: 38528270 PMCID: PMC11108938 DOI: 10.1007/s00261-024-04247-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 02/07/2024] [Accepted: 02/08/2024] [Indexed: 03/27/2024]
Abstract
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.
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Affiliation(s)
- Felix Pfister
- Department of Diagnostic and Interventional Radiology, University of Leipzig, Leipzig, Germany
| | - Matthias Mehdorn
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University of Leipzig, Leipzig, Germany
| | - Christoph Schwartner
- Department of Diagnostic and Interventional Radiology, University of Leipzig, Leipzig, Germany
| | - Daniel Seehofer
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University of Leipzig, Leipzig, Germany
| | - Hans-Michael Tautenhahn
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University of Leipzig, Leipzig, Germany
| | - Manuel Florian Struck
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Leipzig, Germany
| | - Timm Denecke
- Department of Diagnostic and Interventional Radiology, University of Leipzig, Leipzig, Germany
| | - Hans-Jonas Meyer
- Department of Diagnostic and Interventional Radiology, University of Leipzig, Leipzig, Germany.
- Department of Diagnostic and Interventional Radiology, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany.
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11
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Blauw JTM, Metz FM, Nuzzo A, van Etten-Jamaludin FS, Brusse-Keiser M, Boermeester MA, Peppelenbosch M, Geelkerken RH. The Diagnostic Value of Biomarkers in Acute Mesenteric Ischaemia Is Insufficiently Substantiated: A Systematic Review. Eur J Vasc Endovasc Surg 2024; 67:554-569. [PMID: 37640253 DOI: 10.1016/j.ejvs.2023.08.059] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 07/30/2023] [Accepted: 08/23/2023] [Indexed: 08/31/2023]
Abstract
OBJECTIVE There is an urgent need for accurate biomarkers to support timely diagnosis of acute mesenteric ischaemia (AMI) and thereby improve clinical outcomes. With this systematic review, the aim was to substantiate the potential diagnostic value of biomarkers for arterial occlusive AMI. DATA SOURCES The Pubmed, Embase, and the Cochrane Library electronic databases were searched. REVIEW METHODS A systematic review of the literature has been conducted to define the potential diagnostic value of biomarkers for arterial occlusive AMI. All studies including ≥ 10 patients describing biomarkers for macrovascular occlusive AMI between 1950 and 17 February 2023 were identified within the Pubmed, Embase, and the Cochrane Library electronic databases. There were no restrictions to any particular study design, but letters and editorials were excluded. The QUADAS-2 tool was used for the critical appraisal of quality. The study protocol was registered on Prospero (CRD42021254970). RESULTS Fifty of 4334 studies were eligible for inclusion in this review. Ninety per cent of studies were of low quality. A total of 60 biomarkers were identified, with 24 in two or more studies and 15 in five or more studies. There was variation in reported units, normal range, and cut off values. Meta-analysis was not possible due to study heterogeneity. Biomarkers currently recommended by the European Journal of Vascular and Endovascular Surgery, European Society for Trauma and Emergency Surgery 2016, and World Society of Emergency Surgery 2017 guidelines also had heterogeneous low quality data for use in the diagnosis of AMI. CONCLUSION This systematic review demonstrates high heterogeneity and low quality of the available evidence on biomarkers for arterial occlusive AMI. No clinical conclusions can be drawn on a biomarker or combination of biomarkers for patients suspected of arterial occlusive AMI. Restraint is advised when rejecting or determining AMI solely based on biomarkers.
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Affiliation(s)
- Juliëtte T M Blauw
- Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, The Netherlands; Department of Surgery, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Flores M Metz
- Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, The Netherlands; Dutch Expert Centre for Gastrointestinal Ischaemia, Enschede, The Netherlands; Multi-Modality Medical Imaging group, TechMed Centre, University of Twente, Enschede, The Netherlands
| | - Alexandre Nuzzo
- Structure d'Urgences Vasculaires Intestinales Gastroentérologie, MICI et Assistance Nutritive, Hôpital Beaujon APHP, Université de Paris, France
| | | | - Marjolein Brusse-Keiser
- Dutch Expert Centre for Gastrointestinal Ischaemia, Enschede, The Netherlands; Medical School Twente, Medisch Spectrum Twente, Enschede, The Netherlands; Health Technology and Services Research (HTSR), BMS Faculty, University of Twente, Enschede, The Netherlands
| | - Marja A Boermeester
- Department of Surgery, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Maikel Peppelenbosch
- Department of Gastroenterology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Robert H Geelkerken
- Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, The Netherlands; Dutch Expert Centre for Gastrointestinal Ischaemia, Enschede, The Netherlands; Multi-Modality Medical Imaging group, TechMed Centre, University of Twente, Enschede, The Netherlands.
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12
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Zhang J, Zhang X, Liu Y, Shi Y, Chen F, Leng Y. Recent insights into the effect of endoplasmic reticulum stress in the pathophysiology of intestinal ischaemia‒reperfusion injury. Biochem Biophys Res Commun 2024; 701:149612. [PMID: 38316091 DOI: 10.1016/j.bbrc.2024.149612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 01/29/2024] [Accepted: 01/30/2024] [Indexed: 02/07/2024]
Abstract
Intestinal ischaemia‒reperfusion (I/R) injury is a surgical emergency. This condition is associated with a high mortality rate. At present, there are limited number of efficient therapeutic measures for this injury, and the prognosis is poor. Therefore, the pathophysiological mechanisms of intestinal I/R injury must be elucidated to develop a rapid and specific diagnostic and treatment protocol. Numerous studies have indicated the involvement of endoplasmic reticulum (ER) stress in the development of intestinal I/R injury. Specifically, the levels of unfolded and misfolded proteins in the ER lumen are increased due to unfolded protein response. However, persistent ER stress promotes apoptosis of intestinal mucosal epithelial cells through three signalling pathways in the ER, impairing intestinal mucosal barrier function and leading to the dysfunction of intestinal tissues and distant organ compartments. This review summarises the mechanisms of ER stress in intestinal I/R injury, diagnostic indicators, and related treatment strategies with the objective of providing novel insights into future therapies for this condition.
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Affiliation(s)
- Jianmin Zhang
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, 730000, China
| | - Xiaohui Zhang
- The Department of Anaesthesiology, The First Hospital of Lanzhou University, Lanzhou, 730000, China
| | - Yongqiang Liu
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, 730000, China; The Department of Anaesthesiology, The First Hospital of Lanzhou University, Lanzhou, 730000, China
| | - Yajing Shi
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, 730000, China
| | - Feng Chen
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, 730000, China
| | - Yufang Leng
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, 730000, China; The Department of Anaesthesiology, The First Hospital of Lanzhou University, Lanzhou, 730000, China.
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13
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Niang FG, Faye I, Ndong A, Diedhiou M, Niang I, Diop AD, Diop AN. Acute mesenteric ischemia: A case report. Radiol Case Rep 2024; 19:150-152. [PMID: 37954676 PMCID: PMC10632305 DOI: 10.1016/j.radcr.2023.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 10/04/2023] [Accepted: 10/05/2023] [Indexed: 11/14/2023] Open
Abstract
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.
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Affiliation(s)
- Fallou Galass Niang
- Department of Radiology, Saint-Louis Regional Hospital, Saint-Louis, Senegal
- Gaston Berger University (Saint-Louis - SENEGAL), Senegal
| | - Ibrahima Faye
- Department of Radiology, Saint-Louis Regional Hospital, Saint-Louis, Senegal
| | | | | | - Ibrahima Niang
- Department of Radiology, Fann University Hospital, Dakar, Senegal
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14
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Martin J, Depietro R, Bartoli A, Markarian T, De Maria L, Di Bisceglie M, Persico N, Michelet P, Mege D. Acute mesenteric ischemia: which predictive factors of delayed diagnosis at emergency unit? Eur J Trauma Emerg Surg 2023; 49:1999-2008. [PMID: 36129476 DOI: 10.1007/s00068-022-02112-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 09/09/2022] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Julie Martin
- Department of Emergency, Timone Hospital, Aix Marseille Univ, APHM, Marseille, France
| | - Rémi Depietro
- Department of Digestive Surgery, Timone Hospital, Aix Marseille Univ, APHM, Marseille, France
| | - Axel Bartoli
- Department of Radiology, Timone Hospital, Aix Marseille Univ, APHM, Marseille, France
| | - Thibaut Markarian
- Department of Emergency, Timone Hospital, Aix Marseille Univ, APHM, Marseille, France
| | - Lucille De Maria
- Department of Biochemistry, Timone Hospital, Aix Marseille Univ, APHM, Marseille, France
| | - Mathieu Di Bisceglie
- Department of Medical Imaging, North Hospital, Aix Marseille Univ, APHM, Marseille, France
| | - Nicolas Persico
- Department of Emergency, North Hospital, Aix Marseille Univ, APHM, Marseille, France
| | - Pierre Michelet
- Department of Emergency, Timone Hospital, Aix Marseille Univ, APHM, Marseille, France
| | - Diane Mege
- Department of Digestive Surgery, Timone Hospital, Aix Marseille Univ, APHM, Marseille, France.
- Department of Digestive and Oncology Surgery, Timone University Hospital, Aix Marseille Univ, APHM, 264 rue Saint-Pierre, 13005, Marseille, France.
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15
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De Pietro R, Martin J, Tradi F, Chopinet S, Barraud M, Gaudry M, Bourenne J, Nafati C, Boussen S, Guidon C, Bartoli M, Mege D. Prognostic factors after acute mesenteric ischemia: which patients require specific management? Int J Colorectal Dis 2023; 38:242. [PMID: 37777708 DOI: 10.1007/s00384-023-04540-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/20/2023] [Indexed: 10/02/2023]
Abstract
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.
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Affiliation(s)
- Remi De Pietro
- Department of Digestive Surgery, Aix Marseille Univ, APHM, Timone University, 264 rue Saint-Pierre, 13005, Marseille, France
| | - Julie Martin
- Department of Emergency, Aix Marseille Univ, APHM, Timone University, Marseille, France
| | - Farouk Tradi
- Department of Radiology, Aix Marseille Univ, APHM, Timone University, Marseille, France
| | - Sophie Chopinet
- Department of Digestive Surgery, Aix Marseille Univ, APHM, Timone University, 264 rue Saint-Pierre, 13005, Marseille, France
| | - Marine Barraud
- Department of Gastro-enterology, Aix Marseille Univ, APHM, Timone University, Marseille, France
| | - Marine Gaudry
- Department of Vascular Surgery, Aix Marseille Univ, APHM, Timone University, Marseille, France
| | - Jeremy Bourenne
- Department of Emergency Critical Care Medicine, Aix Marseille Univ, APHM, Timone University, Marseille, France
| | - Cyril Nafati
- Department of Intensive Care of Liver Diseases, Aix Marseille Univ, APHM, Timone University, Marseille, France
| | - Salah Boussen
- Department of Intensive Care and Anesthesiology Department2, Aix Marseille Univ, APHM, Timone University, Marseille, France
| | - Catherine Guidon
- Department of Anaesthesiology and Critical Care Medicine, Aix Marseille Univ, APHM, Timone University, Marseille, France
| | - Michel Bartoli
- Department of Vascular Surgery, Aix Marseille Univ, APHM, Timone University, Marseille, France
| | - Diane Mege
- Department of Digestive Surgery, Aix Marseille Univ, APHM, Timone University, 264 rue Saint-Pierre, 13005, Marseille, France.
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16
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Jiang T, Cai Z, Mu M, Zhao Z, Shen C, Zhang B. The Global Burden of Vascular Intestinal Disorders in 204 Countries and Territories From 1990 to 2019: Global Burden of Diseases Study. Int J Public Health 2023; 68:1606297. [PMID: 37822566 PMCID: PMC10562586 DOI: 10.3389/ijph.2023.1606297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 08/21/2023] [Indexed: 10/13/2023] Open
Abstract
Objectives: Assess the prevalence, mortality, and disability-adjusted life years (DALYs) of vascular intestinal disorders (VID) from 1990 to 2019. Methods: This study conducted a secondary data analysis utilizing the Global Burden of Diseases Study 2019. The prevalence, mortality and DALYs of VID were analyzed by sex, age and socio-demographic index (SDI), respectively. Analyses were performed by using R software. Results: Globally, the number of prevalent VID cases increased from 100,158 (95% uncertainty interval: 89,428-114,013) in 1,990-175,740 (157,941-198,969) in 2019. However, the age-standardized rates (ASR) of VID prevalence declined from 2.47 (95% uncertainty interval: 2.24-2.76) per 100,000 population to 2.21 (1.98-2.48) per 100,000 population between 1990 and 2019. Furthermore, the ASR of mortality also decreased from 1990 to 2019. Between 1990 and 2019, the regions with high and high-middle level exhibited the highest diseases burden. Conclusion: Globally, the diseases burden associated with VID demonstrated a decline from 1990 to 2019. However, concerted efforts are still required to enhance measures to combat VID within countries categorized as high and high-middle SDI.
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Affiliation(s)
- Tianxiang Jiang
- Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
- Gastric Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Zhaolun Cai
- Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
- Gastric Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Mingchun Mu
- Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
- Gastric Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Zhou Zhao
- Department of Gastrointestinal Cancer Center, Chongqing University Cancer Hospital, Chongqing, China
| | - Chaoyong Shen
- Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
- Gastric Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Bo Zhang
- Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
- Gastric Cancer Center, West China Hospital, Sichuan University, Chengdu, China
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17
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Schwartner C, Mehdorn M, Gockel I, Struck MF, Leonhardi J, Rositzka M, Ebel S, Denecke T, Meyer HJ. Computed Tomography-Defined Body Composition as Prognostic Parameter in Acute Mesenteric Ischemia. Dig Surg 2023; 40:225-232. [PMID: 37708859 PMCID: PMC10716866 DOI: 10.1159/000534093] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 09/09/2023] [Indexed: 09/16/2023]
Abstract
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.
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Affiliation(s)
- Christoph Schwartner
- Department of Diagnostic and Interventional Radiology, University of Leipzig, Leipzig, Germany
| | - Matthias Mehdorn
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University of Leipzig, Leipzig, Germany
| | - Ines Gockel
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University of Leipzig, Leipzig, Germany
| | - Manuel Florian Struck
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Leipzig, Germany
| | - Jakob Leonhardi
- Department of Diagnostic and Interventional Radiology, University of Leipzig, Leipzig, Germany
| | - Markus Rositzka
- Department of Diagnostic and Interventional Radiology, University of Leipzig, Leipzig, Germany
| | - Sebastian Ebel
- Department of Diagnostic and Interventional Radiology, University of Leipzig, Leipzig, Germany
| | - Timm Denecke
- Department of Diagnostic and Interventional Radiology, University of Leipzig, Leipzig, Germany
| | - Hans-Jonas Meyer
- Department of Diagnostic and Interventional Radiology, University of Leipzig, Leipzig, Germany
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18
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Connell L. NELA Risk Calculator Significantly Underestimates Mortality Risk of Laparotomy for Mesenteric and Colonic Ischaemia in Older Adult Surgical Patients. OPEN ACCESS SURGERY 2023. [DOI: 10.2147/oas.s401635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
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Topolsky A, Pantet O, Liaudet L, Sempoux C, Denys A, Knebel JF, Schmidt S. MDCT-findings in patients with non-occlusive mesenteric ischemia (NOMI): influence of vasoconstrictor agents. Eur Radiol 2023; 33:3627-3637. [PMID: 36692594 PMCID: PMC10121529 DOI: 10.1007/s00330-023-09415-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 11/02/2022] [Accepted: 01/01/2023] [Indexed: 01/25/2023]
Abstract
OBJECTIVES To evaluate the influence of vasoconstrictor agents (VCAs) on signs of vasoconstriction and bowel ischemia on MDCT detected in patients with non-occlusive mesenteric ischemia (NOMI). METHODS This 8-year single-center retrospective study consecutively included all patients with histopathologically proven NOMI who underwent MDCT ≤ 48 h prior to surgical bowel resection. Two blinded radiologists jointly reviewed each examination for signs of bowel ischemia, abdominal organ infarct, mesenteric vessel size and regularity, and ancillary vascular findings. VCA administration (length and dosage), clinical and biochemical data, risk factors, and outcomes were retrieved from patients' medical records. Subgroup comparisons were performed. RESULTS Ninety patients were included (59 males, mean age 65 years); 40 (44.4%) had received VCAs before MDCT. Overall mortality was 32% (n = 29), with no significant difference between the two groups. In patients treated with VCAs, the calibre of the superior mesenteric artery (SMA) was smaller (p = 0.032), and vasoconstriction of its branches tended to be more important (p = 0.096) than in patients not treated with VCAs. The presence and extent of bowel ischemia did not significantly correlate with VCA administration, but abdominal organ infarcts tended to be more frequent (p = 0.005) and involved more organs (p = 0.088). The VCA group had lower mean arterial pressure (p = 0.006) and lower hemoglobin levels (p < 0.001). Several biomarkers of organ failure and inflammation, differed significantly with VCA use, proving worse clinical condition. CONCLUSIONS MDCT demonstrates more severe SMA vasoconstriction and tends to show increased abdominal organ infarcts after VCA administration in NOMI patients compared to NOMI patients not treated with VCAs. KEY POINTS • In critically ill patients with NOMI, MDCT demonstrates VCA support via increased vasoconstriction of the main SMA and its branches. • VCA administration in NOMI patients tends to contribute to the development of organ infarcts, as shown on MDCT. • An important degree of vasoconstriction in NOMI patients may indicate insufficient resuscitation and, thus, help clinicians in further patient management.
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Affiliation(s)
- Antoine Topolsky
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Olivier Pantet
- Service of Adult Intensive Care Medicine and Burns, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Lucas Liaudet
- Service of Adult Intensive Care Medicine and Burns, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Christine Sempoux
- Service of Clinical Pathology, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Alban Denys
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Jean-François Knebel
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Sabine Schmidt
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Rue du Bugnon 46, 1011, Lausanne, Switzerland.
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Watada S, Obara H, Okui J, Hosokawa K, Matsubara K, Harada H, Fujimura N, Fujii T, Shimogawara T, Kitagawa Y. Prediction of need for bowel resection in acute superior mesenteric artery occlusion: A retrospective study of 48 Japanese patients. Ann Gastroenterol Surg 2023; 7:175-181. [PMID: 36643371 PMCID: PMC9831903 DOI: 10.1002/ags3.12614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 08/08/2022] [Indexed: 01/18/2023] Open
Abstract
Aim This study aimed to predict cases of acute superior mesenteric artery (SMA) occlusion requiring bowel resection using occlusion site and time from symptom onset to diagnosis at five Japanese institutions. Advances in imaging, endovascular treatment, and perioperative management have improved the clinical outcomes of patients with acute SMA occlusion; however, in clinical practice it remains difficult to effectively determine patients requiring bowel resection. Methods We retrospectively analyzed the data of 48 patients (mean age: 82.5 y; male: 37.5%) diagnosed with acute SMA occlusion between June 2009 and August 2018. Background data of patients who required and did not require bowel resection were compared. A multivariable predictive model was developed using the time from symptom onset to diagnosis and whether SMA occlusion was proximal, including the origin of the middle colic artery. Results Fifteen patients (31.3%) died during the hospital stay. Atrial fibrillation (83.3%) was the most common comorbidity. The median time from symptom onset to diagnosis was 13.0 (interquartile range, 4.75-24.0) h. Laparotomy, bowel resection, and thrombus embolectomy were performed in 41 (85.4%), 26 (54.2%), and 21 (43.8%) patients, respectively. A logistic regression model achieved 78.6% sensitivity in predicting cases not requiring bowel resection. Proximal occlusion was significantly associated with the requirement for bowel resection (P = .039). Conclusion The time from symptom onset to diagnosis and occlusion site contributed to high sensitivity in determining the need for bowel resection in patients with acute SMA occlusion. Further prospective studies are warranted to investigate the clinical impact of this model.
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Affiliation(s)
- Susumu Watada
- Department of SurgeryKawasaki Municipal HospitalKawasakiJapan
| | - Hideaki Obara
- Department of SurgeryKeio University School of MedicineTokyoJapan
| | - Jun Okui
- Department of SurgeryKeio University School of MedicineTokyoJapan
- Department of Preventive Medicine and Public HealthKeio University School of MedicineTokyoJapan
| | | | | | - Hirohisa Harada
- Division of Vascular SurgeryTokyo Saiseikai Central HospitalTokyoJapan
| | - Naoki Fujimura
- Division of Vascular SurgeryTokyo Saiseikai Central HospitalTokyoJapan
| | - Taku Fujii
- Department of SurgerySaitama City HospitalSaitamaJapan
| | - Tatsuya Shimogawara
- Department of Vascular SurgerySaisekai Yokohamashi Tobu HospitalKawasakiJapan
| | - Yuko Kitagawa
- Department of SurgeryKeio University School of MedicineTokyoJapan
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Conde Monroy DM, Girón Arango F, Rodríguez Moreno L, Rey Chaves CE, Donoso-Samper A, Nassar R, Isaza-Restrepo A. Succoring the challenging acute mesenteric ischemia: Feasibility of lactate dehydrogenase for evaluation of intestinal necrosis extension and mortality. Ann Med Surg (Lond) 2022; 84:104922. [DOI: 10.1016/j.amsu.2022.104922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 10/23/2022] [Accepted: 11/12/2022] [Indexed: 11/19/2022] Open
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22
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Tamme K, Reintam Blaser A, Laisaar KT, Mändul M, Kals J, Forbes A, Kiss O, Acosta S, Bjørck M, Starkopf J. Incidence and outcomes of acute mesenteric ischaemia: a systematic review and meta-analysis. BMJ Open 2022; 12:e062846. [PMID: 36283747 PMCID: PMC9608543 DOI: 10.1136/bmjopen-2022-062846] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To estimate the incidence of acute mesenteric ischaemia (AMI), proportions of its different forms and short-term and long-term mortality. DESIGN Systematic review and meta-analysis. DATA SOURCES MEDLINE (Ovid), Web of Science, Scopus and Cochrane Library were searched until 26 July 2022. ELIGIBILITY CRITERIA Studies reporting data on the incidence and outcomes of AMI in adult populations. DATA EXTRACTION AND SYNTHESIS Data extraction and quality assessment with modified Newcastle-Ottawa scale were performed using predeveloped standard forms. The outcomes were the incidence of AMI and its different forms in the general population and in patients admitted to hospital, and the mortality of AMI in its different forms. RESULTS From 3064 records, 335 full texts were reviewed and 163 included in the quantitative analysis. The mean incidence of AMI was 6.2 (95% CI 1.9 to 12.9) per 100 000 person years. On average 5.0 (95% CI 3.3 to 7.1) of 10 000 hospital admissions were due to AMI. Occlusive arterial AMI was the most common form constituting 68.6% (95% CI 63.7 to 73.2) of all AMI cases, with similar proportions of embolism and thrombosis.Overall short-term mortality (in-hospital or within 30 days) of AMI was 59.6% (95% CI 55.5 to 63.6), being 68.7% (95% CI 60.8 to 74.9) in patients treated before the year 2000 and 55.0% (95% CI 45.5 to 64.1) in patients treated from 2000 onwards (p<0.05). The mid/long-term mortality of AMI was 68.2% (95% CI 60.7 to 74.9). Mortality due to mesenteric venous thrombosis was 24.6% (95% CI 17.0 to 32.9) and of non-occlusive mesenteric ischaemia 58.4% (95% CI 48.6 to 67.7). The short-term mortality of revascularised occlusive arterial AMI was 33.9% (95% CI 30.7 to 37.4). CONCLUSIONS In adult patients, AMI is a rarely diagnosed condition with high mortality, although with improvement of treatment results over the last decades. Two thirds of AMI cases are of occlusive arterial origin with potential for better survival if revascularised. PROSPERO REGISTRATION NUMBER CRD42021247148.
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Affiliation(s)
- Kadri Tamme
- Department of Anaesthesiology and Intensive Care, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Anaesthesiology and Intensive Care Clinic, Tartu University Hospital, Tartu, Estonia
| | - Annika Reintam Blaser
- Department of Anaesthesiology and Intensive Care, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Department of Intensive Care Medicine, Luzerner Kantonsspital, Luzern, Luzern, Switzerland
| | - Kaja-Triin Laisaar
- Department of Epidemiology and Biostatistics, Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia
| | - Merli Mändul
- Department of Anaesthesiology and Intensive Care, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Department of Statistics, Institute of Mathematics and Statistics, University of Tartu, Tartu, Estonia
| | - Jaak Kals
- Department of Surgery, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Surgery Clinic, Tartu University Hospital, Tartu, Estonia
| | - Alastair Forbes
- Department of Internal Medicine, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Internal Medicine Clinic, Tartu University Hospital, Tartu, Estonia
| | - Olga Kiss
- Anaesthesiology and Intensive Care Clinic, Tartu University Hospital, Tartu, Estonia
| | - Stefan Acosta
- Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Martin Bjørck
- Department of Surgery, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Joel Starkopf
- Department of Anaesthesiology and Intensive Care, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Anaesthesiology and Intensive Care Clinic, Tartu University Hospital, Tartu, Estonia
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Bala M, Catena F, Kashuk J, De Simone B, Gomes CA, Weber D, Sartelli M, Coccolini F, Kluger Y, Abu-Zidan FM, Picetti E, Ansaloni L, Augustin G, Biffl WL, Ceresoli M, Chiara O, Chiarugi M, Coimbra R, Cui Y, Damaskos D, Di Saverio S, Galante JM, Khokha V, Kirkpatrick AW, Inaba K, Leppäniemi A, Litvin A, Peitzman AB, Shelat VG, Sugrue M, Tolonen M, Rizoli S, Sall I, Beka SG, Di Carlo I, Ten Broek R, Mircea C, Tebala G, Pisano M, van Goor H, Maier RV, Jeekel H, Civil I, Hecker A, Tan E, Soreide K, Lee MJ, Wani I, Bonavina L, Malangoni MA, Koike K, Velmahos GC, Fraga GP, Fette A, de'Angelis N, Balogh ZJ, Scalea TM, Sganga G, Kelly MD, Khan J, Stahel PF, Moore EE. Acute mesenteric ischemia: updated guidelines of the World Society of Emergency Surgery. World J Emerg Surg 2022; 17:54. [PMID: 36261857 PMCID: PMC9580452 DOI: 10.1186/s13017-022-00443-x] [Citation(s) in RCA: 123] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 06/17/2022] [Indexed: 02/08/2023] Open
Abstract
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.
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Affiliation(s)
- Miklosh Bala
- Director of Acute Care Surgery and Trauma Unit, Department of General Surgery, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem Kiriat Hadassah, POB 12000, 91120, Jerusalem, Israel.
| | - Fausto Catena
- General and Emergency Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Jeffry Kashuk
- Tel Aviv Sackler School of Medicine, Tel Aviv, Israel
| | - Belinda De Simone
- Department of General, Digestive and Metabolic Minimally Invasive Surgery, Centre Hospitalier Intercommunal De Poissy/St Germain en Laye, Poissy, France
| | - Carlos Augusto Gomes
- Department of Surgery, Faculdade de Ciências Médicas e da Saúde de Juiz de Fora, Hospital Universitário Terezinha de Jesus, Juiz de Fora, Brazil
| | - Dieter Weber
- Department of General Surgery, Royal Perth Hospital, The University of Western Australia, Perth, Australia
| | | | - Federico Coccolini
- Department of General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Yoram Kluger
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Parma, Parma, Italy
| | - Luca Ansaloni
- Department of Surgery, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Goran Augustin
- Department of Surgery, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Walter L Biffl
- Division of Trauma/Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, CA, USA
| | - Marco Ceresoli
- Emergency and General Surgery Department, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Osvaldo Chiara
- Emergency Department, Niguarda Ca'Granda Hospital, Milan, Italy
| | - Massimo Chiarugi
- Department of General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Raul Coimbra
- CECORC Research Center, Riverside University Health System, Loma Linda University, Loma Linda, USA
| | - Yunfeng Cui
- Department of Surgery, Nankai Clinical School of Medicine, Tianjin Nankai Hospital, Tianjin Medical University, Tianjin, China
| | | | - Salomone Di Saverio
- General Surgery Department Hospital of San Benedetto del Tronto, Marche region, Italy
| | - Joseph M Galante
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of California Davis, Sacramento, CA, USA
| | - Vladimir Khokha
- Department of Emergency Surgery, City Hospital, Mozyr, Belarus
| | - Andrew W Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, AB, Canada
| | - Kenji Inaba
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Ari Leppäniemi
- Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Andrey Litvin
- Department of Surgical Disciplines, Regional Clinical Hospital, Immanuel Kant Baltic Federal University, Kaliningrad, Russia
| | - Andrew B Peitzman
- Department of Surgery, University of Pittsburgh School of Medicine, UPMC-Presbyterian, Pittsburgh, USA
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Novena, Singapore
| | - Michael Sugrue
- Donegal Clinical Research Academy Emergency Surgery Outcome Project, Letterkenny University Hospital, Donegal, Ireland
| | - Matti Tolonen
- Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Sandro Rizoli
- Surgery Department, Section of Trauma Surgery, Hamad General Hospital (HGH), Doha, Qatar
| | - Ibrahima Sall
- General Surgery Department, Military Teaching Hospital, Dakar, Senegal
| | | | - Isidoro Di Carlo
- Department of Surgical Sciences and Advanced Technologies, General Surgery Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Richard Ten Broek
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Chirika Mircea
- Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Giovanni Tebala
- Department of Digestive and Emergency Surgery, S.Maria Hospital Trust, Terni, Italy
| | - Michele Pisano
- General and Emergency Surgery, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Harry van Goor
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ronald V Maier
- Harborview Medical Center, University of Washington School of Medicine, Seattle, WA, USA
| | - Hans Jeekel
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Ian Civil
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Andreas Hecker
- Emergency Medicine Department of General and Thoracic Surgery, University Hospital of Giessen, Giessen, Germany
| | - Edward Tan
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Kjetil Soreide
- HPB Unit, Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Matthew J Lee
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | | | - Luigi Bonavina
- Department of Surgery, IRCCS Policlinico San Donato, University of Milano, Milano, Italy
| | - Mark A Malangoni
- Case Western Reserve University School of Medicine, Cleveland, USA
| | | | - George C Velmahos
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, PA, USA
| | - Gustavo P Fraga
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas (Unicamp), Campinas, Brazil
| | - Andreas Fette
- Pediatric Surgery, Children's Care Center, SRH Klinikum Suhl, Suhl, Thueringen, Germany
| | - Nicola de'Angelis
- Unit of Digestive and HPB Surgery, Faculty of Medicine, University of Paris, Paris, France
| | - Zsolt J Balogh
- John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia
| | - Thomas M Scalea
- Cowley Shock Trauma Center at the University of Maryland, Baltimore, MD, USA
| | - Gabriele Sganga
- Emergency Surgery and Trauma, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Michael D Kelly
- Department of General Surgery, Albury Hospital, Albury, Australia
| | - Jim Khan
- University of Portsmouth, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Philip F Stahel
- College of Osteopathic Medicine, Rocky Vista University, Parker, CO, USA
| | - Ernest E Moore
- Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO, USA
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Peres EC, Victorio JA, Nunes-Souza V, Breithaupt-Faloppa AC, Rabelo LA, Tavares-de-Lima W, Davel AP, Rossoni LV. Simvastatin protects against intestinal ischemia/reperfusion-induced pulmonary artery dysfunction. Life Sci 2022; 306:120851. [PMID: 35926590 DOI: 10.1016/j.lfs.2022.120851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 07/26/2022] [Accepted: 07/27/2022] [Indexed: 10/16/2022]
Abstract
AIMS The lung is an important target organ damage in intestinal ischemia/reperfusion (II/R), but mechanisms involved in II/R-induced pulmonary artery (PA) dysfunction, as well as its treatment, are not clear. The present study aimed to investigate the mechanisms involved in the II/R-induced PA dysfunction and a possible protective role of acute simvastatin pretreatment. MAIN METHODS Male Wistar rats were subjected to occlusion of the superior mesenteric artery for 45 min followed by 2 h reperfusion (II/R) or sham-operated surgery (sham). In some rats, simvastatin (20 mg/kg, oral gavage) was administrated 1 h before II/R. KEY FINDINGS II/R reduced acetylcholine-induced relaxation and phenylephrine-induced contraction of PA segments, which were prevented by acute simvastatin pretreatment in vivo or restored by inducible nitric oxide synthase (iNOS) inhibition in situ with 1400 W. Elevated reactive oxygen species (ROS) levels and higher nuclear translocation of nuclear factor kappa B (NFκB) subunit p65 were observed in PA of II/R rats and prevented by simvastatin. Moreover, simvastatin increased superoxide dismutase (SOD) activity and endothelial nitric oxide synthase (eNOS) expression in PA of the II/R group as well as prevented the increased levels of interleukin (IL)-1β and IL-6 in lung explants following II/R. SIGNIFICANCE The study suggests that pretreatment with a single dose of simvastatin prevents the II/R-induced increase of inflammatory factors and oxidative stress, as well as PA endothelial dysfunction and adrenergic hyporreactivity. Therefore, acute simvastatin administration could be therapeutic for pulmonary vascular disease in patients suffering from intestinal ischemic events.
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Affiliation(s)
- Emília C Peres
- Department of Physiology and Biophysics, Institute of Biomedical Sciences, University of Sao Paulo, Sao Paulo, Brazil
| | - Jamaira A Victorio
- Department of Structural and Functional Biology, Institute of Biology, University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - Valéria Nunes-Souza
- Department of Physiology and Pharmacology, Federal University of Pernambuco, Recife, Brazil
| | - Ana Cristina Breithaupt-Faloppa
- Laboratório de Cirurgia Cardiovascular e Fisiopatologia da Circulação (LIM-11), Instituto do Coração (InCor), Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Luiza A Rabelo
- Laboratory of Cardiovascular Reactivity, Department of Physiology and Pharmacology, Institute of Biological Sciences, Federal University of Alagoas, Brazil
| | - Wothan Tavares-de-Lima
- Department of Pharmacology, Institute of Biomedical Sciences, University of Sao Paulo, Sao Paulo, Brazil
| | - Ana Paula Davel
- Department of Structural and Functional Biology, Institute of Biology, University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - Luciana V Rossoni
- Department of Physiology and Biophysics, Institute of Biomedical Sciences, University of Sao Paulo, Sao Paulo, Brazil.
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Mesenteric Ischemia and Its Need for Timely Recognition and Management. Case Rep Surg 2022; 2022:7370634. [PMID: 36213588 PMCID: PMC9534705 DOI: 10.1155/2022/7370634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 08/23/2022] [Accepted: 09/02/2022] [Indexed: 11/17/2022] Open
Abstract
Mesenteric ischemia is a fatal vascular emergency of the small intestine which, if not diagnosed and treated in time, has a very high mortality rate. Presenting with nonspecific symptoms such as abdominal pain, nausea, constipation, tachycardia, and gastrointestinal bleeds, it can masquerade as other causes of acute abdomen, particularly bowel obstruction. Ideal laboratory tests and markers are still lacking due to complexity in bowel's anatomy, physiology, blood supply, and drainage. We report 10 cases of mesenteric ischemia presented in our center with their demography, laboratory findings, approach to diagnosis, and treatment along with their outcomes at discharge. Out of the ten cases, six cases presented with signs and symptoms of acute bowel obstruction without passage of stool and one with passage of black stool. These seven patients underwent laparotomy, while the remaining three cases who either presented with milder symptoms or refused surgical interventions were managed conservatively. All patients were diagnosed with either acute or chronic mesenteric ischemia based on their operative and/or radiographic findings.
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Ultrasound Detection of Portomesenteric Venous Gas Is an Early Sign of Bowel Ischaemia in Non-Traumatic Abdominal Pain: Old Dogs, New Tricks—Four Cases Report. Case Rep Crit Care 2022; 2022:1734612. [PMID: 36051608 PMCID: PMC9427313 DOI: 10.1155/2022/1734612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 07/21/2022] [Accepted: 07/28/2022] [Indexed: 11/23/2022] Open
Abstract
Acute bowel ischemia is a severe disease often with a poor outcome. Early diagnosis can improve outcome, but atypical clinical manifestations and nonspecific laboratory and instrumental diagnostic findings may delay computed tomographic angiography (CTA). Portomesenteric venous gas (PVG), indirect sign of pneumatosis intestinalis, is considered a late finding with poor prognosis. We report four cases where PVG, easily identified through point-of-care ultrasonography (POCUS), was an early sign of bowel ischemia leading to a precocious diagnosis confirmed at CTA. In acute non-traumatic abdominal pain, an evidence of PVG could be an early ultrasonographic finding of bowel ischemia in the emergency department.
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Mak AK, Andraska EA, Reitz KM, Chaer R, Eslami MH, Avgerinos E. A single institutional experience with suction thrombectomy in acute mesenteric ischemia. ANNALS OF VASCULAR SURGERY. BRIEF REPORTS AND INNOVATIONS 2022; 2:100070. [PMID: 36733720 PMCID: PMC9890405 DOI: 10.1016/j.avsurg.2022.100070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Acute mesenteric ischemia (AMI) is typically treated by open surgery or hybrid techniques. Catheter-based aspiration thrombectomy represents another minimally invasive alternative with a potential additional safety benefit of minimizing the bleeding risk associated with thrombolytics. In this institutional case series, we present five clinical cases of aspiration thrombectomy for high-risk AMI using the Penumbra aspiration system. All patients underwent technically successful endovascular thrombectomy as demonstrated by intraoperative angiography results. However, bowel necrosis and sepsis adversely affected postoperative outcomes. Lack of intraoperative bowel assessment is a limitation of endovascular methods, highlighting the importance of patient selection.
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Affiliation(s)
- Allison K Mak
- University of Pittsburgh School of Medicine, United States
| | - Elizabeth A Andraska
- Department of Surgery, Division of Vascular Surgery, UPMC Heart and Vascular Institute, UPMC Presbyterian Hospital, Room E362.4, South Tower, 200 Lothrop Street, Pittsburgh, PA 15213-2582, United States
| | - Katherine M Reitz
- Department of Surgery, Division of Vascular Surgery, UPMC Heart and Vascular Institute, UPMC Presbyterian Hospital, Room E362.4, South Tower, 200 Lothrop Street, Pittsburgh, PA 15213-2582, United States
| | - Rabih Chaer
- Department of Surgery, Division of Vascular Surgery, UPMC Heart and Vascular Institute, UPMC Presbyterian Hospital, Room E362.4, South Tower, 200 Lothrop Street, Pittsburgh, PA 15213-2582, United States
| | - Mohammed H Eslami
- Department of Surgery, Division of Vascular Surgery, UPMC Heart and Vascular Institute, UPMC Presbyterian Hospital, Room E362.4, South Tower, 200 Lothrop Street, Pittsburgh, PA 15213-2582, United States
| | - Efthymios Avgerinos
- Department of Surgery, Division of Vascular Surgery, UPMC Heart and Vascular Institute, UPMC Presbyterian Hospital, Room E362.4, South Tower, 200 Lothrop Street, Pittsburgh, PA 15213-2582, United States
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Miao SL, Ye XN, Lin TT, Qiu YH, Huang JY, Zheng XW, Chen FF. The psoas muscle density as a predictor of postoperative complications and 30-day mortality for acute mesenteric ischemia patients. Abdom Radiol (NY) 2022; 47:1644-1653. [PMID: 32892241 DOI: 10.1007/s00261-020-02714-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 08/09/2020] [Accepted: 08/21/2020] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Shou-Liang Miao
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang, Ouhai District, Wenzhou, 325015, Zhejiang, People's Republic of China
| | - Xiao-Ning Ye
- The First Clinical Medical Institute, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Ting-Ting Lin
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang, Ouhai District, Wenzhou, 325015, Zhejiang, People's Republic of China
| | - Yi-Hui Qiu
- Department of Vascular Surgery, The First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang, Ouhai District, Wenzhou, 325015, Zhejiang, People's Republic of China
| | - Jing-Yong Huang
- Department of Vascular Surgery, The First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang, Ouhai District, Wenzhou, 325015, Zhejiang, People's Republic of China
| | - Xiang-Wu Zheng
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang, Ouhai District, Wenzhou, 325015, Zhejiang, People's Republic of China.
| | - Fan-Feng Chen
- Department of Vascular Surgery, The First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang, Ouhai District, Wenzhou, 325015, Zhejiang, People's Republic of China.
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Dual-energy CT of acute bowel ischemia. Abdom Radiol (NY) 2022; 47:1660-1683. [PMID: 34191075 DOI: 10.1007/s00261-021-03188-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 06/17/2021] [Accepted: 06/18/2021] [Indexed: 12/17/2022]
Abstract
Acute bowel ischemia is a condition with high mortality and requires rapid intervention to avoid catastrophic outcomes. Swift and accurate imaging diagnosis is essential because clinical findings are commonly nonspecific. Conventional contrast enhanced CT of the abdomen has been the imaging modality of choice to evaluate suspected acute bowel ischemia. However, subtlety of image findings and lack of non-contrast or arterial phase images can make correct diagnosis challenging. Dual-energy CT provides valuable information toward assessing bowel ischemia. Dual-energy CT exploits the differential X-ray attenuation at two different photon energy levels to characterize the composition of tissues and reveal the presence or absence of faint intravenous iodinated contrast to improve reader confidence in detecting subtle bowel wall enhancement. With the same underlying technique, virtual non-contrast images can help to show non-enhancing hyperdense hemorrhage of the bowel wall in intravenous contrast-enhanced scans without the need to acquire actual non-contrast scans. Dual-energy CT derived low photon energy (keV) virtual monoenergetic images emphasize iodine contrast and provide CT angiography-like images from portal venous phase scans to better evaluate abdominal arterial patency. In Summary, dual-energy CT aids diagnosing acute bowel ischemia in multiple ways, including improving visualization of the bowel wall and mesenteric vasculature, revealing intramural hemorrhage in contrast enhanced scans, or possibly reducing intravenous contrast dose.
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Yu Z, Wang S, Lang D, Yin X, Lin Z, Hu S, Wang D, Xu Q, Hu J. Percutaneous mechanical thrombectomy in the management of early acute superior mesenteric artery embolism. Vascular 2022:17085381221085150. [PMID: 35420466 DOI: 10.1177/17085381221085150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE This study was performed to summarize our experience in the management of early-stage acute superior mesenteric artery embolism (ASMAE) by percutaneous mechanical thrombectomy (PMT). METHODS The clinical data of 12 patients with early-stage ASMAE treated by PMT in our institution from November 2019 to September 2021 were retrospectively analyzed. The patients had no obvious evidence of bowel infarction as shown by peritoneal puncture and computed tomography angiography. Thrombectomy of the superior mesenteric artery was performed using a 6F AngioJet catheter. RESULTS The emboli were completely removed in 10 (83.3%) patients. Six patients were treated only by the AngioJet device. The other six patients underwent combined treatment with a 6F multipurpose drainage catheter after PMT, including one patient who underwent simultaneous stent implantation. Two patients showed no significant improvement in their symptoms after the operation; one was found to have intestinal necrosis and underwent resection by exploratory laparotomy, and the other died of septic shock 3 days after PMT (further intervention had been discontinued because of complications with multiple underlying diseases). No other PMT-related complications occurred. Only one patient was found to have a pseudoaneurysm of the superior mesenteric artery 1 week after PMT and underwent resection by exploratory laparotomy. The 11 surviving patients were smoothly discharged from the hospital after their symptoms were relieved. At a mean follow-up of 13.2 months, computed tomography angiography showed smooth patency of the superior mesenteric artery. No patients developed serious symptoms during follow-up. CONCLUSIONS PMT by the AngioJet device is a minimally invasive, safe, and effective technique to remove ASMAE. Early application of PMT can avoid acute intestinal necrosis. Combining the AngioJet device with a 6F multipurpose drainage catheter might be more helpful to remove residual emboli.
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Affiliation(s)
- Zuanbiao Yu
- Department of Vascular Surgery, Hwa Mei Hospital, University of Chinese Academy of Sciences, Ningbo, China
| | - Shuyuan Wang
- Department of Vascular Surgery, Hwa Mei Hospital, University of Chinese Academy of Sciences, Ningbo, China
| | - Dehai Lang
- Department of Vascular Surgery, Hwa Mei Hospital, University of Chinese Academy of Sciences, Ningbo, China
| | - Xiaoliang Yin
- Department of Vascular Surgery, Hwa Mei Hospital, University of Chinese Academy of Sciences, Ningbo, China
| | - Zuodong Lin
- Department of Vascular Surgery, Hwa Mei Hospital, University of Chinese Academy of Sciences, Ningbo, China
| | - Songjie Hu
- Department of Vascular Surgery, Hwa Mei Hospital, University of Chinese Academy of Sciences, Ningbo, China
| | - Di Wang
- Department of Vascular Surgery, Hwa Mei Hospital, University of Chinese Academy of Sciences, Ningbo, China
| | - Qiyang Xu
- Department of Vascular Surgery, Hwa Mei Hospital, University of Chinese Academy of Sciences, Ningbo, China
| | - Jiangnan Hu
- Department of Pharmaceutical Sciences, 538800University of North Texas Health Science Center, Fort Worth, TX, USA
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Role of Platelet to Lymphocyte Ratio and Red Cell Distribution Width in Predicting Postoperative Complications in Patients with Acute Mesenteric Ischemia. Ann Vasc Surg 2022; 84:298-304. [PMID: 35247535 DOI: 10.1016/j.avsg.2022.01.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 12/20/2021] [Accepted: 01/26/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND The predictive values of the platelet to lymphocyte ratio (PLR) and red cell distribution width (RDW) have been demonstrated in different types of abdominal surgery. The aim of this study was to investigate the interest of the preoperative PLR and RDW as predictors of 30-day postoperative complications in patients with acute mesenteric ischemia (AMI). METHODS Clinical data of 105 AMI patients were retrospectively reviewed. Postoperative complications were evaluated by the Clavien-Dindo classification. The cutoff values for neutrophil to lymphocyte ratio (NLR), PLR, and RDW were determined by receiver operating characteristic curves. Univariate and multivariate analyses evaluating the risk factors for postoperative complications were performed. RESULTS In the univariate analyses, advanced age, female, anemia, high white blood cell (WBC), high PLR, high NLR, high RDW, Charlson comorbidity index (CCI) score ≥2, and bowel resection were associated with the postoperative complications. A multivariable analysis revealed that advanced age, high PLR, high RDW, and bowel resection were independent predictors of postoperative complications. CONCLUSIONS The PLR and RDW might play important roles in evaluation of the risk of postoperative complications in AMI patients. The preoperative PLR and RDW are simple and useful predictors of postoperative complications in AMI patients.
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Rebelo A, Mammadov M, Partsakhashvili J, Sekulla C, Ronellenfitsch U, Kleeff J, John E, Ukkat J. Acute and chronic mesenteric ischemia: single center analysis of open, endovascular, and hybrid surgery. BMC Surg 2022; 22:56. [PMID: 35152898 PMCID: PMC8842922 DOI: 10.1186/s12893-022-01511-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 02/07/2022] [Indexed: 01/16/2023] Open
Abstract
Abstract
Background
The aim of the study was to analyse the outcome of open surgical, endovascular, and hybrid interventions in the treatment of acute (AMI) and chronic (CMI) mesenteric ischemia.
Methods
Retrospective review of a cohort of mesenteric ischemia patients at a single tertiary referral center from 2015 to 2021. Primary end point was postoperative in-hospital mortality. Secondary end points were the number of bowel resections, duration of the procedure, length of postoperative intensive care treatment, length of hospital stay, revision surgery (number and type), and the nature and severity of postoperative complications according to Dindo-Clavien.
Results
A total of 64 patients, 20 with CMI and 44 with AMI, underwent open, hybrid or endovascular surgery. Bowel resection was performed in 45.5% of the patients with AMI (29.5% small intestine, 2.3% colon and 13.6% both). There was no in-hospital mortality in the CMI cohort as compared to 29.5% in the AMI cohort (p = 0.03), with no differences regarding endovascular and open surgery (29.6 vs 29.4%). Severe postoperative morbidity (Dindo-Clavien ≥ 3) was also significantly more frequent in the AMI group when compared to the CMI group (20 vs 77.3%, p < 0.001). ASA classification and intensive care stay were identified as factors associated with mortality in AMI patients.
Conclusions
Morbidity and in-hospital mortality are low in CMI patients, but substantial in AMI patients. Early diagnosis and open or endovascular treatment may be decisive for the outcome of these patients.
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Bergamini C, Alemanno G, Giordano A, Pantalone D, Fontani G, Di Bella AM, Iacopini V, Prosperi P, Martellucci J. The role of bed-side laparoscopy in the management of acute mesenteric ischemia of recent onset in post-cardiac surgery patients admitted to ICU. Eur J Trauma Emerg Surg 2022; 48:87-96. [PMID: 32951071 DOI: 10.1007/s00068-020-01500-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 09/08/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Acute mesenteric ischemia with non-occlusive mechanism (NOMI) is a possible complication after cardiac surgery in patients admitted to Intensive Care Unit (ICU). Since the diagnosis is often difficult with CT-scan, some authors have evaluated the role of bed-side diagnostic laparoscopy (DL). We aimed to contribute to this topic with a personal series. METHODS We retrospectively evaluated patients admitted to ICU after cardiac surgery since 2009 up to 2019, successively operated on for a suspected NOMI of recent onset with non-conclusive CT. They were divided into laparoscopic (Ls) and laparotomic (Lt) group, depending on whether or not they had a DL. They were compared for the CT false-positive (FP) and true-positive (TP) rate and the surgical outcome. RESULTS Seventy-three patients were enrolled. Lt included 30 patients (41%), Ls 43 (59%). The overall FP were 38 (52%), with a higher incidence in Ls. There was no difference in the mortality rate. The morbidity rate was higher in Lt, and especially in Lt-FP. The TP were 35 (47.9%). The mean operating time (OT) in the Lt-TP group was similar to the sum of the mean OT of the laparotomies plus that of the laparoscopies in the Ls-TP group. Conversely, when considering only laparotomic procedures, the Lt-TP had higher mean OT, such as an increased blood loss CONCLUSIONS: Post-cardiosurgical patients admitted to ICU have a relatively high rate of NOMI, in which CT-scan is often initially non-conclusive. Our data and those from the literature seem to show that in such cases bed-side DL may be an advantageous and safe procedure to avoid needless laparotomy and enables a more tailored open surgery.
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Affiliation(s)
- Carlo Bergamini
- Department of Emergency Surgery, University Hospital of Careggi, Largo Brambilla n° 3, 50134, Florence, Italy.
| | - Giovanni Alemanno
- Department of Emergency Surgery, University Hospital of Careggi, Largo Brambilla n° 3, 50134, Florence, Italy
| | - Alessio Giordano
- Department of Emergency Surgery, University Hospital of Careggi, Largo Brambilla n° 3, 50134, Florence, Italy
| | - Desiré Pantalone
- Medical School, Department of Surgery, University of Florence, Largo Brambilla n° 3, 50134, Florence, Italy
| | - Giovanni Fontani
- Medical School, Department of Surgery, University of Florence, Largo Brambilla n° 3, 50134, Florence, Italy
| | - Anna Maria Di Bella
- Medical School, Department of Surgery, University of Florence, Largo Brambilla n° 3, 50134, Florence, Italy
| | - Veronica Iacopini
- Medical School, Department of Surgery, University of Florence, Largo Brambilla n° 3, 50134, Florence, Italy
| | - Paolo Prosperi
- Department of Emergency Surgery, University Hospital of Careggi, Largo Brambilla n° 3, 50134, Florence, Italy
| | - Jacopo Martellucci
- Department of Emergency Surgery, University Hospital of Careggi, Largo Brambilla n° 3, 50134, Florence, Italy
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Kaçer İ, Çağlar A, Akıllı NB. The Prognostic Value of C-Reactive Protein/Albumin Ratio in Acute Mesenteric Ischemia. Am Surg 2022:31348221074220. [DOI: 10.1177/00031348221074220] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background Diagnosis of acute mesenteric ischemia (AMI) in its early stages is important for reversing ischemic damage. The CRP to albumin (CRP/Alb) ratio has been defined as an inflammatory indicator and is associated with the severity of inflammation and mortality rates. However, the prognostic value of CRP/Alb has not been evaluated in patients with AMI. Here, we aimed to examine the prognostic significance of CRP/Alb and compare it with other inflammatory markers. Materials and Methods In this retrospective, case-control study, we included patients diagnosed with AMI at the emergency department between January 1, 2016, and December 31, 2020. In addition to demographic characteristics, lactate, D-dimer, white blood cell (WBC), CRP/Alb, and neutrophil/lymphocyte ratio (NLR) were recorded. Testing characteristics of CRP/Alb in predicting in-hospital mortality were studied. Results The mean age of 132 patients was 66.48 ± 15.95 years and 71 (53.8%) of them were male. The cut-off value obtained using the receiver operating characteristic (ROC) curve for in-hospital mortality was a CRP/Alb ratio of >1.32 (sensitivity, 93.65%; specificity, 69.57%; +LR, 3.08; −LR, .091; AUC, .782; 95% CI, .70-.85; P < .0001). The comparison of ROC curves between CRP/Alb and WBC, NLR, and lactate revealed a statistically significant difference ( P < .05), whereas there was not any statistically significant difference between the ROC curves of CRP/Alb and D-dimer ( P = .47). Conclusion C-reactive protein/albumin ratio is a powerful predictor of in-hospital mortality for AMI patients. It was superior to WBC, NLR, and lactate. It could be used to determine low-risk patients and help clinicians with treatment options.
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Affiliation(s)
- İlker Kaçer
- Department of Emergency Medicine, Aksaray University Training and Research Hospital, Aksaray, Turkey
| | - Ahmet Çağlar
- Department of Emergency Medicine, Aksaray University Training and Research Hospital, Aksaray, Turkey
| | - Nazire Belgin Akıllı
- Department of Emergency Medicine, University of Health Science, Konya Training and Research Hospital, Konya, Turkey
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Martini V, Lederer AK, Fink J, Chikhladze S, Utzolino S, Fichtner-Feigl S, Kousoulas L. Clinical characteristics and outcome of patients with acute mesenteric ischemia: a retrospective cohort analysis. Langenbecks Arch Surg 2022; 407:1225-1232. [PMID: 35043258 PMCID: PMC9151533 DOI: 10.1007/s00423-021-02423-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 12/23/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Acute mesenteric ischemia (AMI) is an uncommon, but life-threatening clinical entity due to late diagnosis resulting in irreversible ischemic bowel necrosis. The most common causes of AMI are the embolic occlusion and the acute thrombosis of the mesenteric circulation. Typical treatment is composed of an early revascularization of the mesenteric circulation followed by abdominal surgery for resection of nonviable intestine and restoration of the intestinal continuity, but the mortality rates remain high. METHODS A retrospective cohort analysis was conducted, aiming to evaluate clinical characteristics, performed surgical procedures and outcomes of patients with acute mesenteric ischemia who underwent emergency abdominal surgery at a high volume surgical center in Germany. RESULTS Overall, 53 patients were identified with the intraoperatively proven diagnosis of AMI. Overall hospital mortality was with 62% comparable to the literature. Nineteen patients presented with an intraoperatively verified complete and non-reversible intestinal infarction without any angiographic or surgical option for a revascularization of the mesenteric circulation or an option for intestinal resection. From the rest of the patients, 14 underwent intestinal resection of the ischemic area without restoration of intestinal continuity; the other 20 underwent resection with a primary anastomosis to restore intestinal continuity. The mortality rate of these patients with curative-intended surgery remained high (41% of patients died). Pre- and postoperative hyperlactatemia were associated with lower survival of these patients. CONCLUSION AMI remains a life-threatening abdominal emergency. Therapeutic approaches are highly depended on acting surgeon's decision, being affected by subjectively rated bowel viability and physical condition of the affected patient. Only selected patients with good bowel viability appear to be suitable for receiving primary anastomosis. The results clearly indicate the need for further research to develop therapeutic approaches for a better management of AMI and to improve outcome of affected patients.
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Affiliation(s)
- Verena Martini
- Center of Surgery, Department of General and Visceral Surgery, Medical Center, University of Freiburg, Faculty of Medicine, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Ann-Kathrin Lederer
- Center of Surgery, Department of General and Visceral Surgery, Medical Center, University of Freiburg, Faculty of Medicine, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Jodok Fink
- Center of Surgery, Department of General and Visceral Surgery, Medical Center, University of Freiburg, Faculty of Medicine, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Sophia Chikhladze
- Center of Surgery, Department of General and Visceral Surgery, Medical Center, University of Freiburg, Faculty of Medicine, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Stefan Utzolino
- Center of Surgery, Department of General and Visceral Surgery, Medical Center, University of Freiburg, Faculty of Medicine, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Stefan Fichtner-Feigl
- Center of Surgery, Department of General and Visceral Surgery, Medical Center, University of Freiburg, Faculty of Medicine, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Lampros Kousoulas
- Center of Surgery, Department of General and Visceral Surgery, Medical Center, University of Freiburg, Faculty of Medicine, Hugstetter Straße 55, 79106, Freiburg, Germany.
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Plessier A. Extrahepatic Portal Vein Obstruction: Recent Portal Vein Thrombosis and Portal Cavernoma in the Absence of Cirrhosis. VASCULAR DISORDERS OF THE LIVER 2022:93-109. [DOI: 10.1007/978-3-030-82988-9_7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
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Kip AM, Valverde JM, Altelaar M, Heeren RMA, Hundscheid IHR, Dejong CHC, Olde Damink SWM, Balluff B, Lenaerts K. Combined Quantitative (Phospho)proteomics and Mass Spectrometry Imaging Reveal Temporal and Spatial Protein Changes in Human Intestinal Ischemia-Reperfusion. J Proteome Res 2021; 21:49-66. [PMID: 34874173 PMCID: PMC8750167 DOI: 10.1021/acs.jproteome.1c00447] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
![]()
Intestinal ischemia–reperfusion
(IR) injury is a severe
clinical condition, and unraveling its pathophysiology is crucial
to improve therapeutic strategies and reduce the high morbidity and
mortality rates. Here, we studied the dynamic proteome and phosphoproteome
in the human intestine during ischemia and reperfusion, using liquid
chromatography-tandem mass spectrometry (LC-MS/MS) analysis to gain
quantitative information of thousands of proteins and phosphorylation
sites, as well as mass spectrometry imaging (MSI) to obtain spatial
information. We identified a significant decrease in abundance of
proteins related to intestinal absorption, microvillus, and cell junction,
whereas proteins involved in innate immunity, in particular the complement
cascade, and extracellular matrix organization increased in abundance
after IR. Differentially phosphorylated proteins were involved in
RNA splicing events and cytoskeletal and cell junction organization.
In addition, our analysis points to mitogen-activated protein kinase
(MAPK) and cyclin-dependent kinase (CDK) families to be active kinases
during IR. Finally, matrix-assisted laser desorption ionization time-of-flight
(MALDI-TOF) MSI presented peptide alterations in abundance and distribution,
which resulted, in combination with Fourier-transform ion cyclotron
resonance (FTICR) MSI and LC-MS/MS, in the annotation of proteins
related to RNA splicing, the complement cascade, and extracellular
matrix organization. This study expanded our understanding of the
molecular changes that occur during IR in the human intestine and
highlights the value of the complementary use of different MS-based
methodologies.
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Affiliation(s)
- Anna M Kip
- Department of Surgery, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
| | - Juan Manuel Valverde
- Biomolecular Mass Spectrometry and Proteomics, Bijvoet Center for Biomolecular Research and Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Padualaan 8, Utrecht 3584 CH, The Netherlands
| | - Maarten Altelaar
- Biomolecular Mass Spectrometry and Proteomics, Bijvoet Center for Biomolecular Research and Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Padualaan 8, Utrecht 3584 CH, The Netherlands
| | - Ron M A Heeren
- Maastricht Multimodal Molecular Imaging Institute (M4i), Maastricht University, 6200 MD Maastricht, The Netherlands
| | - Inca H R Hundscheid
- Department of Surgery, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
| | - Cornelis H C Dejong
- Department of Surgery, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands.,Department of General, Visceral- and Transplantation Surgery, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Steven W M Olde Damink
- Department of Surgery, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands.,Department of General, Visceral- and Transplantation Surgery, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Benjamin Balluff
- Maastricht Multimodal Molecular Imaging Institute (M4i), Maastricht University, 6200 MD Maastricht, The Netherlands
| | - Kaatje Lenaerts
- Department of Surgery, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
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The role of adropin, HIF-1α and apelin biomarkers in the diagnosis of acute mesentaric ischemia. Am J Emerg Med 2021; 51:223-227. [PMID: 34775196 DOI: 10.1016/j.ajem.2021.10.058] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 10/25/2021] [Accepted: 10/28/2021] [Indexed: 01/10/2023] Open
Abstract
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.
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Xu XY, Shen W, Li G, Wang XF, Xu Y. Ileal hemorrhagic infarction after carotid artery stenting: A case report and review of the literature. World J Clin Cases 2021; 9:6410-6417. [PMID: 34435006 PMCID: PMC8362577 DOI: 10.12998/wjcc.v9.i22.6410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 04/25/2021] [Accepted: 05/27/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Ileal hemorrhagic infarction after carotid artery stenting (CAS) is a fatal complication. The prognosis of ileal hemorrhagic infarction after CAS is very poor if not treated in a timely manner. We describe a rare case of ileal hemorrhagic infarction due to acute embolism of the mesenteric artery after CAS.
CASE SUMMARY A 67-year-old man with acute ischemic stroke underwent CAS via the right femoral artery approach 21 d after intensive medical treatment. On the first day after surgery, the patient had abdominal distension and abdominal pain. Abdominal enhanced computed tomography revealed intestinal obstruction, severe stenosis of the superior mesenteric artery, and poor distal angiography. An exploratory laparotomy was performed, and pathological examination showed hemorrhagic ileal infarction. It was subsequently found that the patient had intestinal flatulence. With the guidance of an ultrasound scan, the patient underwent abdominal puncture, drainage, and catheterization. After 58 d of treatment, the patient was discharged from hospital with a National Institutes of Health Stroke Scale score of 2 points, and a Modified Rankin Scale score of 1 point. At the 6-mo follow-up, the patient had an excellent functional outcome without stroke or mesenteric ischemia. Furthermore, computed tomography angiography showed that the carotid stent was patent.
CONCLUSION Ileal hemorrhagic infarction is a fatal complication after CAS, usually caused by mesenteric artery embolism. Thus, more attention should be paid to the complications of embolism in the vascular system as well as the nervous system after CAS, and the complications should be identified and treated as early as possible.
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Affiliation(s)
- Xue-Yu Xu
- Department of Neurology, Wuhan Fourth Hospital, Wuhan 430000, Hubei Province, China
| | - Wei Shen
- Department of Neurology, Wuhan Fourth Hospital, Wuhan 430000, Hubei Province, China
| | - Gang Li
- Department of Neurology, Wuhan Fourth Hospital, Wuhan 430000, Hubei Province, China
| | - Xi-Feng Wang
- Department of Neurology, Wuhan Fourth Hospital, Wuhan 430000, Hubei Province, China
| | - Yang Xu
- Department of Pharmacy, Wuhan Fourth Hospital, Wuhan 430000, Hubei Province, China
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Triple “L” (Leukocytosis, Lactate, and LDH): Predictors of Mesenteric Ischemia. Indian J Surg 2021. [DOI: 10.1007/s12262-020-02495-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Intraoperative quality assessment of tissue perfusion with indocyanine green (ICG) in a porcine model of mesenteric ischemia. PLoS One 2021; 16:e0254144. [PMID: 34283875 PMCID: PMC8291700 DOI: 10.1371/journal.pone.0254144] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 06/18/2021] [Indexed: 11/19/2022] Open
Abstract
Background Mesenteric ischemia is a severe and potentially lethal event. Assessment of intestine perfusion is eminently depending on the skills, and the experience of the surgeon. Thus, the therapy is biased by the right evaluation. Aim of this study is to determine the applicability, and the usefulness of fluorescent-imaging (FI) with indocyanine green (ICG) in a porcine model of mesenteric ischemia. Second end-point is the verification of a visual and quantitative assessment tool of the intestinal perfusion. Methods In 18 pigs (54,2 ±2,9kg) an occlusion of a side-branch of the mesenteric artery was performed for 3 (group I, n = 7), 6 (group II, n = 7), and 10 hours (group III, n = 4). After reperfusion a 60 minutes observation period was carried out. 3 regions of interest were defined: ischemic bowel (D1), transitional zone (D2), and non-ischemic bowel (D3). ICG-FI was performed during baseline (T0), occlusion (T1), reperfusion (T2) and after an observation period of 60 minutes (T4). Results All experiments could be finished successfully. ICG-FI was assessed using assessment of background-subtracted peak fluorescence intensity (BSFI), slope of fluorescence intensity (SFI), and a baseline adjusted ratio of both parameters. ICG-FI confirmed loss of perfusion in D1, decreased perfusion in D2, and increased perfusion in D3. After reperfusion ICG-FI increased in group 2 due to a severe tissue damage resulting in a capillary leakage. In group I ICG-FI was equal to baseline values indicating the totally reversible loss of perfusion. Conclusion Using ICG-FI to estimate intestine perfusion after different durations of ischemia is viable using a porcine model of mesenteric ischemia. Even small differences in perfusion can be reliably determined by ICG-FI. Thus, ICG-FI is an encouraging method to evaluate intestine perfusion intraoperatively.
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Yu Z, Hu J, Lang D. Pseudoaneurysm as a rare complication in the treatment of superior mesenteric artery embolism via percutaneous mechanical thrombectomy: a case report. J Int Med Res 2021; 49:3000605211022941. [PMID: 34162263 PMCID: PMC8236792 DOI: 10.1177/03000605211022941] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Percutaneous mechanical thrombectomy is a safe and effective treatment for addressing thrombosis in various embolic diseases. In recent years, this approach has also been actively applied in the management of acute embolic occlusion of the superior mesenteric artery. A pseudoaneurysm as a complication of this operation is remarkably rare. This is the first case report of the diagnosis and treatment of a pseudoaneurysm that developed as a complication after the application of percutaneous mechanical thrombectomy via an AngioJet device for thrombolysis in the superior mesenteric artery.
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Affiliation(s)
- Zuanbiao Yu
- Department of Vascular Surgery, Hwa Mei Hospital, University of Chinese Academy of Sciences; Ningbo Institute of Life and Health Industry, Ningbo, Zhejiang, China
| | - Jiangnan Hu
- Department of Pharmaceutical Sciences, University of North Texas Health Science Center, Fort Worth, Texas, USA
| | - Dehai Lang
- Department of Vascular Surgery, Hwa Mei Hospital, University of Chinese Academy of Sciences; Ningbo Institute of Life and Health Industry, Ningbo, Zhejiang, China
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Hou L, Wang T, Wang J, Zhao J, Yuan D. Outcomes of different acute mesenteric ischemia therapies in the last 20 years: A meta-analysis and systematic review. Vascular 2021; 30:669-680. [PMID: 34154466 DOI: 10.1177/17085381211024503] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- Li Hou
- West China School of Medicine, West China Hospital, 12530Sichuan University, Chengdu, China.,Department of Vascular Surgery, West China Hospital, 12530Sichuan University, Chengdu, China
| | - Tiehao Wang
- Department of Vascular Surgery, West China Hospital, 12530Sichuan University, Chengdu, China
| | - Jiarong Wang
- Department of Vascular Surgery, West China Hospital, 12530Sichuan University, Chengdu, China
| | - Jichun Zhao
- Department of Vascular Surgery, West China Hospital, 12530Sichuan University, Chengdu, China
| | - Ding Yuan
- Department of Vascular Surgery, West China Hospital, 12530Sichuan University, Chengdu, China
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Al Mahruqi G, Stephen E, Abdelhedy I, Al Wahaibi K. Our early experience with mesenteric ischemia in COVID-19 positive patients. Ann Vasc Surg 2021; 73:129-132. [PMID: 33508450 PMCID: PMC7839392 DOI: 10.1016/j.avsg.2021.01.064] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 01/12/2021] [Indexed: 12/17/2022]
Abstract
Literature has been published stating that thrombosis is occurring at higher rates in patients who are positive for COVID-19. This experience is more with limb ischemia. Reports of mesenteric ischemia are coming in from different parts of the globe. We share our early experience of managing two patients with acute mesenteric ischemia.
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Davarpanah AH, Ghamari Khameneh A, Khosravi B, Mir A, Saffar H, Radmard AR. Many faces of acute bowel ischemia: overview of radiologic staging. Insights Imaging 2021; 12:56. [PMID: 33914188 PMCID: PMC8085211 DOI: 10.1186/s13244-021-00985-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 03/16/2021] [Indexed: 12/12/2022] Open
Abstract
Acute bowel ischemia (ABI) can be life threatening with high mortality rate. In spite of the advances made in diagnosis and treatment of ABI, no significant change has occurred in the mortality over the past decade. ABI is potentially reversible with prompt diagnosis. The radiologist plays a central role in the initial diagnosis and preventing progression to irreversible intestinal ischemic injury or bowel necrosis. The most single imaging findings described in the literature are either non-specific or only present in the late stages of ABI, urging the use of a constellation of features to reach a more confident diagnosis. While ABI has been traditionally categorized based on the etiology with a wide spectrum of imaging findings overlapped with each other, the final decision for patient's management is usually made on the stage of the ABI with respect to the underlying pathophysiology. In this review, we first discuss the pathologic stages of ischemia and then summarize the various imaging signs and causes of ABI. We also emphasize on the correlation of imaging findings and pathological staging of the disease. Finally, a management approach is proposed using combined clinical and radiological findings to determine whether the patient may benefit from surgery or not.
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Affiliation(s)
- Amir H Davarpanah
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, USA
| | - Afshar Ghamari Khameneh
- Department of Radiology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Bardia Khosravi
- Department of Radiology, Shariati Hospital, Tehran University of Medical Sciences, 14117, North Kargar St., Tehran, Iran
| | - Ali Mir
- Department of Surgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Hiva Saffar
- Department of Pathology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Reza Radmard
- Department of Radiology, Shariati Hospital, Tehran University of Medical Sciences, 14117, North Kargar St., Tehran, Iran.
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Parys S, Daneshmand A, Sieunarine K, Watanabe Y. The effect of comorbidity on early clinical decision making in acute mesenteric ischemia. Acta Chir Belg 2021; 122:341-345. [PMID: 33870863 DOI: 10.1080/00015458.2021.1916281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Simon Parys
- General Surgery Department, Royal Perth Hospital, Perth, Australia
| | - Ali Daneshmand
- General Surgery Department, Royal Perth Hospital, Perth, Australia
| | | | - Yuki Watanabe
- General Surgery Department, Royal Perth Hospital, Perth, Australia
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Spangler R, Manning S. Disaster Diagnoses in Geriatric Patients with Abdominal Pain. Emerg Med Clin North Am 2021; 39:347-360. [PMID: 33863464 DOI: 10.1016/j.emc.2021.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Care of geriatric patients with abdominal pain can pose significant diagnostic and therapeutic challenges to emergency physicians. Older adults rarely present with classic signs, symptoms, and laboratory abnormalities. The incidence of life-threatening emergencies, including abdominal aortic aneurysm, mesenteric ischemia, perforated viscus, and other surgical emergencies, is high. This article explores the evaluation and management of several important causes of abdominal pain in geriatric patients with an emphasis on high-risk presentations.
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Affiliation(s)
- Ryan Spangler
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
| | - Sara Manning
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA
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Fitzpatrick LA, Rivers-Bowerman MD, Thipphavong S, Clarke SE, Rowe JA, Costa AF. Pearls, Pitfalls, and Conditions that Mimic Mesenteric Ischemia at CT. Radiographics 2021; 40:545-561. [PMID: 32125953 DOI: 10.1148/rg.2020190122] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Acute mesenteric ischemia (AMI) is a life-threatening condition with a high mortality rate. The diagnosis of AMI is challenging because patient symptoms and laboratory test results are often nonspecific. A high degree of clinical and radiologic suspicion is required for accurate and timely diagnosis. CT angiography of the abdomen and pelvis is the first-line imaging test for suspected AMI and should be expedited. A systematic "inside-out" approach to interpreting CT angiographic images, beginning with the bowel lumen and proceeding outward to the bowel wall, mesentery, vasculature, and extraintestinal viscera, provides radiologists with a practical framework to improve detection and synthesis of imaging findings. The subtypes of AMI are arterial and venoocclusive disease, nonocclusive ischemia, and strangulating bowel obstruction; each may demonstrate specific imaging findings. Chronic mesenteric ischemia is more insidious at onset and almost always secondary to atherosclerosis. Potential pitfalls in the diagnosis of AMI include mistaking pneumatosis as a sign that is specific for AMI and not an imaging finding, misinterpretation of adynamic ileus as a benign finding, and pseudopneumatosis. Several enterocolitides can mimic AMI at CT angiography, such as inflammatory bowel disease, infections, angioedema, and radiation-induced enterocolitis. Awareness of pitfalls, conditions that mimic AMI, and potential distinguishing clinical and imaging features can assist radiologists in making an early and accurate diagnosis of AMI. ©RSNA, 2020.
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Affiliation(s)
- Laura A Fitzpatrick
- From the Department of Diagnostic Radiology, Queen Elizabeth II Health Sciences Centre and Dalhousie University, Victoria General Building, 1276 S Park St, 3rd Floor, Halifax, NS, Canada B3H 2Y9 (L.A.F., M.D.R.B., S.E.C., J.A.R., A.F.C.); and Joint Department of Medical Imaging, University Health Network, Mount Sinai Hospital, Women's College Hospital, and University of Toronto, Toronto, Ontario, Canada (S.T.)
| | - Michael D Rivers-Bowerman
- From the Department of Diagnostic Radiology, Queen Elizabeth II Health Sciences Centre and Dalhousie University, Victoria General Building, 1276 S Park St, 3rd Floor, Halifax, NS, Canada B3H 2Y9 (L.A.F., M.D.R.B., S.E.C., J.A.R., A.F.C.); and Joint Department of Medical Imaging, University Health Network, Mount Sinai Hospital, Women's College Hospital, and University of Toronto, Toronto, Ontario, Canada (S.T.)
| | - Seng Thipphavong
- From the Department of Diagnostic Radiology, Queen Elizabeth II Health Sciences Centre and Dalhousie University, Victoria General Building, 1276 S Park St, 3rd Floor, Halifax, NS, Canada B3H 2Y9 (L.A.F., M.D.R.B., S.E.C., J.A.R., A.F.C.); and Joint Department of Medical Imaging, University Health Network, Mount Sinai Hospital, Women's College Hospital, and University of Toronto, Toronto, Ontario, Canada (S.T.)
| | - Sharon E Clarke
- From the Department of Diagnostic Radiology, Queen Elizabeth II Health Sciences Centre and Dalhousie University, Victoria General Building, 1276 S Park St, 3rd Floor, Halifax, NS, Canada B3H 2Y9 (L.A.F., M.D.R.B., S.E.C., J.A.R., A.F.C.); and Joint Department of Medical Imaging, University Health Network, Mount Sinai Hospital, Women's College Hospital, and University of Toronto, Toronto, Ontario, Canada (S.T.)
| | - Judy A Rowe
- From the Department of Diagnostic Radiology, Queen Elizabeth II Health Sciences Centre and Dalhousie University, Victoria General Building, 1276 S Park St, 3rd Floor, Halifax, NS, Canada B3H 2Y9 (L.A.F., M.D.R.B., S.E.C., J.A.R., A.F.C.); and Joint Department of Medical Imaging, University Health Network, Mount Sinai Hospital, Women's College Hospital, and University of Toronto, Toronto, Ontario, Canada (S.T.)
| | - Andreu F Costa
- From the Department of Diagnostic Radiology, Queen Elizabeth II Health Sciences Centre and Dalhousie University, Victoria General Building, 1276 S Park St, 3rd Floor, Halifax, NS, Canada B3H 2Y9 (L.A.F., M.D.R.B., S.E.C., J.A.R., A.F.C.); and Joint Department of Medical Imaging, University Health Network, Mount Sinai Hospital, Women's College Hospital, and University of Toronto, Toronto, Ontario, Canada (S.T.)
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Zhuang X, Chen F, Zhou Q, Zhu Y, Yang X. A rapid preliminary prediction model for intestinal necrosis in acute mesenteric ischemia: a retrospective study. BMC Gastroenterol 2021; 21:154. [PMID: 33827660 PMCID: PMC8028195 DOI: 10.1186/s12876-021-01746-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 03/30/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Acute mesenteric ischemia (AMI) is a life-threatening condition. However, there is no accurate method to predict intestinal necrosis in AMI patients that may facilitate early surgical intervention. This study thus aimed to explore a simple and accurate model to predict intestinal necrosis in patients with AMI. METHODS A single-center retrospective study was performed on the data of 132 AMI patients treated between October 2011 and June 2020. The patients were divided into the intestinal necrosis and non-intestinal necrosis groups. The clinical characteristics and laboratory data were analyzed by univariate analysis, and the variables with statistical significance were further analyzed by multivariate logistic regression analysis. The independent predictors of intestinal necrosis were determined and a logistic prediction model was established. Finally, the accuracy, sensitivity, and specificity of the model in predicting intestinal necrosis were evaluated. RESULTS Univariate analysis showed that white blood cell (WBC) count, blood urea nitrogen (BUN) level, neutrophil ratio, prothrombin time (PT), and LnD-dimer were associated with intestinal necrosis. According to logistic regression multivariate analysis, WBC count, BUN level and LnD-dimer were independent predictors of intestinal necrosis. These parameters were used to establish a clinical prediction model of intestinal necrosis (CPMIN) as follows: model score = 0.349 × BUN (mmol/L) + 0.109 × WBC × 109 (109/L) + 0.394 × LnD - Dimer (ug/L) - 7.883. The area under the receiver operating characteristics (ROC) curve of the model was 0.889 (95% confidence interval: 0.833-0.944). Model scores greater than - 0.1992 predicted the onset of intestinal necrosis. The accuracy, specificity, and sensitivity of the model were 82.6%, 78.2%, and 88.3%, respectively. The proportion of intestinal necrosis in the high-risk patient group (CPMIN score ≥ - 0.1992) was much greater than that in the low-risk patient group (CPMIN score < - 0.1992; 82.7% vs. 15.0%, p < 0.001). CONCLUSION The CPMIN can effectively predict intestinal necrosis and guide early surgical intervention to improve patient prognosis. Patients with AMI who are classified as high-risk should be promptly treated with surgery to avoid the potential complications caused by delayed operation. Patients classified as low-risk group can receive non-surgical treatment. This model may help to lower the morbidity and mortality from AMI. However, this model's accuracy should be validated by larger sample size studies in the future.
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Affiliation(s)
- Xinsuo Zhuang
- Emergency and Trauma Center, The International Medical Center, The First Affiliated Hospital, Zhejiang University School of Medicine, 1367 West Wenyi Rd.Zhejiang Province, Hangzhou, 310058 China
| | - Fumei Chen
- Emergency and Trauma Center, The International Medical Center, The First Affiliated Hospital, Zhejiang University School of Medicine, 1367 West Wenyi Rd.Zhejiang Province, Hangzhou, 310058 China
| | - Qian Zhou
- Emergency and Trauma Center, The International Medical Center, The First Affiliated Hospital, Zhejiang University School of Medicine, 1367 West Wenyi Rd.Zhejiang Province, Hangzhou, 310058 China
| | - Yuanrun Zhu
- Emergency and Trauma Center, The International Medical Center, The First Affiliated Hospital, Zhejiang University School of Medicine, 1367 West Wenyi Rd.Zhejiang Province, Hangzhou, 310058 China
| | - Xiaofeng Yang
- Emergency and Trauma Center, The International Medical Center, The First Affiliated Hospital, Zhejiang University School of Medicine, 1367 West Wenyi Rd.Zhejiang Province, Hangzhou, 310058 China
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50
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Chou EL, Wang LJ, McLellan RM, Feldman ZM, Latz CA, LaMuraglia GM, Clouse WD, Eagleton MJ, Conrad MF. Evolution in the Presentation, Treatment, and Outcomes of Patients with Acute Mesenteric Ischemia. Ann Vasc Surg 2021; 74:53-62. [PMID: 33823263 DOI: 10.1016/j.avsg.2021.01.116] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 01/19/2021] [Accepted: 01/28/2021] [Indexed: 01/16/2023]
Abstract
OBJECTIVES Acute mesenteric ischemia (AMI) is a life-threatening condition associated with dismal outcomes. This study sought to evaluate the evolution of presentation, treatment, and outcomes of AMI over the past two decades. METHODS AMI patients presenting at a single institution were reviewed (1993-2016). Venous thrombosis patients were excluded. Primary outcome was 30-day mortality. Patients were stratified by etiology and diagnosis date (before 2004 versus 2004 and later). Ordered logistic regression was performed for longitudinal temporal analysis. RESULTS 303 patients were identified. AMI mechanisms included: embolic (49%), thrombotic (29%), and non-occlusive (NOMI) (22%). The majority were women (55%), 50% had atrial fibrillation, and 23% were on anticoagulation (AC) therapy. Mean age was 72±13 years. 345 procedures were performed in 242 patients: 321 open and 24 hybrid/endovascular. Among the 189 embolic/thrombotic patients who were managed operatively, 45% (n=85) underwent mesenteric revascularization while 39 (21%) had findings of non-survivable bowel necrosis (NSBN). Among the 104 patients who did not undergo revascularization, 64 (62%) died within 30-days compared to 36 out of 85 (42%) patients who were revascularized (P=0.01). 30-day mortality was 61% and stable over time (P=0.91); when stratified by AMI etiology, the thrombotic cohort had worse survival than embolic and NOMI patients (P=0.04). Since 2000, there was a significant decrease in the percentage of embolic AMI events (P=0.04). The percentage of patients who underwent operative management decreased also over time (P=0.01, 81% → 61%), which was correlated with an increasing number of patients being made comfort measures only (CMO) prior to surgical intervention (50% → 70%, P=0.02). The majority of patients (55%) were ultimately made CMO during their hospitalization. Predictors of 30-day mortality included a preoperative white blood cell count (WBC) ≥ 25 K/ µL. (OR 3.0, P=0.002) and lactate ≥ 2.3 mmol/L (OR 2.8, P=0.045). NSBN predictors included WBC ≥ 24 K/ µL. (OR 3.4 P=0.03) and lactate ≥ 3.8 mmol/L (OR 3.6, P=0.04). CONCLUSIONS Despite advances in critical care over the past 25 years, AMI continues to be associated with poor prognosis. The survival benefit observed in patients who undergo revascularization supports an aggressive approach towards early vascular intervention, although this requires further study. The importance of early diagnosis, prognostication and advanced directives is highlighted given the high morbidity, mortality and use of comfort measures associated with AMI.
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Affiliation(s)
- Elizabeth L Chou
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA.
| | - Linda J Wang
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Rachel M McLellan
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Zach M Feldman
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Christopher A Latz
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Glenn M LaMuraglia
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - W Darrin Clouse
- Division of Vascular and Endovascular Surgery, University of Virginia
| | - Matthew J Eagleton
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Mark F Conrad
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
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