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Wang P, Song M, Zhu X, Ren W, Li H, Cao S, Sun S, Pan W, Shi S. Nonocclusive mesenteric ischemia after percutaneous kyphoplasty: A case report. Medicine (Baltimore) 2024; 103:e39390. [PMID: 39183426 PMCID: PMC11346888 DOI: 10.1097/md.0000000000039390] [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] [Received: 04/23/2024] [Revised: 07/27/2024] [Accepted: 08/01/2024] [Indexed: 08/27/2024] Open
Abstract
RATIONALE Percutaneous kyphoplasty (PKP) is a minimally invasive technique employed for treating vertebral compression fractures. Although PKP is simple and relatively safe, severe complications are possible. Here, we report a new, severe complication linked to this procedure, namely nonocclusive mesenteric ischemia (NOMI). PATIENT CONCERNS An 83-year-old female patient, previously in good health, fell backward, landing on her buttocks, and subsequently experienced persistent low-back pain that exacerbated during turning or sitting up. DIAGNOSES Lumbar spine radiography revealed wedge deformity of the L1 vertebral body. Lumbar spine magnetic resonance imaging indicated a fresh compression fracture of the L1 vertebral body. INTERVENTIONS On the 2nd day following the trauma, the patient underwent PKP under local anesthesia. Anesthesia was satisfactory, and the procedure progressed smoothly. OUTCOMES The patient experienced mild discomfort in the right abdomen within the 1st hour to 3 days postoperatively, mild abdominal distension on the 4th day, and sudden severe abdominal pain on the 5th day. Immediate abdominal computed tomography revealed ischemic changes in the ascending colon and hepatic flexure, accompanied by hepatic portal venous gas. An hour later, abdominal pain spontaneously subsided. Approximately 5 hours later, an enhanced abdominal computed tomography revealed no filling defects in the mesenteric vasculature, absence of luminal narrowing or occlusion, enhanced intestinal walls, and a notable improvement in hepatic portal venous gas. Considering NOMI and ischemia related to superior mesenteric artery spasm, vasodilator therapy (papaverine hydrochloride) was initiated, leading to favorable outcomes. On day 17, pathological examination of the hepatic flexure revealed moderate, acute, and chronic mucosal inflammation, along with interstitial fibrous tissue proliferation, providing clear evidence supporting ischemic changes. She was discharged on day 18 after a successful recovery. LESSONS The occurrence of NOMI after PKP is uncommon. Yet, once it happens, delayed diagnosis or misdiagnosis can lead to serious consequences such as intestinal necrosis and abdominal infection, even endangering the patient's life. We currently lack experience in preventing this complication, but timely diagnosis and appropriate intervention are effective measures in treating such complications.
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Affiliation(s)
- Pengrui Wang
- Department of Orthopedic Trauma, Aviation General Hospital, Beijing, PR China
| | - Meina Song
- Department of Radiology, Aviation General Hospital, Beijing, PR China
| | - Xinxin Zhu
- Department of General Surgery, Aviation General Hospital, Beijing, PR China
| | - Weihong Ren
- Department of Pathology, Aviation General Hospital, Beijing, PR China
| | - Haixiao Li
- Department of Orthopedic Trauma, Aviation General Hospital, Beijing, PR China
| | - Sanli Cao
- Department of Orthopedic Trauma, Aviation General Hospital, Beijing, PR China
| | - Shuhua Sun
- Department of Orthopedic Trauma, Aviation General Hospital, Beijing, PR China
| | - Wei Pan
- Department of Orthopedic Trauma, Aviation General Hospital, Beijing, PR China
| | - Shaohui Shi
- Department of Orthopedic Trauma, Aviation General Hospital, Beijing, PR China
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Tanaka Y, Matsumura Y, Aoki M, Hayashi Y, Izawa Y, Endo K, Mato T. Establishment of a swine experimental model of non-occlusive mesenteric ischemia: Combining induced hemorrhagic shock and vasopressor administration. Acute Med Surg 2024; 11:e982. [PMID: 39045518 PMCID: PMC11263749 DOI: 10.1002/ams2.982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 07/05/2024] [Accepted: 07/11/2024] [Indexed: 07/25/2024] Open
Abstract
Aim Non-occlusive mesenteric ischemia (NOMI) is associated with high mortality rates, but definitive treatments have not yet been established. Although experimental animal models are worthwhile, reproducible models that reflect the pathophysiology of NOMI have not been developed. Methods We combined risk factors for NOMI, comprising hemorrhagic shock, systemic vasopressor infusion, and local vasopressor infusion from the superior mesenteric artery (SMA) in swine under maintained anesthesia. Experiment 1 involved full-intensity (40%) phlebotomy and systemic vasopressor (norepinephrine and epinephrine). Experiment 2 involved full-intensity (40%) phlebotomy, systemic norepinephrine, and local vasopressor infusion into the SMA. Experiment 3 involved moderate (27%) phlebotomy, systemic norepinephrine infusion, and local epinephrine infusion. We evaluated serum lactate levels, intestinal serosa color, computed tomography (CT) angiography, and pathological findings. Results After inducing hemorrhage, systemic vasopressor alone and in combination with local vasopressin or norepinephrine infusion did not induce ischemic color changes in the intestine. The combination of systemic norepinephrine and local epinephrine (0.5 μg/kg/min) after moderate (27% blood loss) hemorrhage induced gross color change, pathological destruction, and elevation of serum lactate. Patent flow in the SMA was confirmed on CT angiography. Conclusion We established a swine NOMI model with systemic norepinephrine infusion and local epinephrine with moderate hemorrhagic shock.
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Affiliation(s)
- Yasutaka Tanaka
- Department of Emergency and Critical Care MedicineJichi Medical UniversityShimotsukeJapan
| | - Yosuke Matsumura
- Department of Intensive CareChiba Emergency Medical CenterChibaJapan
- Department of Emergency and Critical Care MedicineChiba UniversityChibaJapan
| | - Makoto Aoki
- Division of TraumatologyNational Defense Medical College Research InstituteTokorozawaJapan
| | - Yosuke Hayashi
- Department of Emergency and Critical Care MedicineChiba UniversityChibaJapan
| | - Yoshimitsu Izawa
- Department of Emergency and Critical Care MedicineJichi Medical UniversityShimotsukeJapan
| | - Kazuhiro Endo
- Center for Development of Advanced Medical TechnologyJichi Medical UniversityShimotsukeJapan
| | - Takashi Mato
- Department of Emergency and Critical Care MedicineJichi Medical UniversityShimotsukeJapan
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Murata T, Yamaguchi N, Shimomoto Y, Mikajiri Y, Sasaki Y, Konagaya K, Igarashi Y, Sawamura N, Yamamoto K, Kume N, Suno Y, Kurata S, Kasetani T, Kato I, Nishida T, Hirata H, Miyake K, Oonishi T, Isogai N, Fukai R, Kanomata H, Shimoyama R, Kashiwagi H, Takenoue T, Terashima T, Murayama H, Kohriki S, Morita T, Takaki M, Ogino H, Kanemaru T, Sano K, Kurogi N, Watanabe K, Hirata M, Kawachi J. Preoperative prognostic predictors and treatment strategies for surgical procedure focused on the sequential organ failure assessment score in nonocclusive mesenteric ischemia: a multicenter retrospective cohort study. Int J Surg 2023; 109:4119-4125. [PMID: 37720948 PMCID: PMC10720829 DOI: 10.1097/js9.0000000000000733] [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: 06/12/2023] [Accepted: 08/21/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND Several large-scale studies have assessed endovascular and surgical treatment methods for nonocclusive mesenteric ischemia (NOMI); however, the prognostic factors for NOMI remain unclear. Therefore, this study aimed to evaluate risk factors for in-hospital mortality among patients with NOMI who underwent laparotomy and to examine therapeutic strategies that may improve the prognosis. MATERIALS AND METHODS In this multicenter retrospective study, the authors reviewed the electronic medical records retrieved from the inpatient database of patients with NOMI at eight district general hospitals between January 2011 and January 2021. A total of 88 patients who underwent laparotomies were divided into survivor and nonsurvivor groups, and statistical analysis was performed to determine clinical and physiological factors. RESULTS Exploratory laparotomy based on second-look surgery was the first treatment choice. The overall mortality rate was 48.8%, with a male-to-female ratio of 1.1:1. The median Sequential Organ Failure Assessment (SOFA) score was 8 [interquartile range: 3.75-14.2], and the median SOFA scores were 5 [3-7] in the survivor group and 13 [9-17.5] in the nonsurvivor group. Univariate analysis revealed a significant difference in BMI ( P <0.001), hypoglycemia ( P =0.0012), previous cardiovascular surgery ( P =0.0019), catecholamine use ( P <0.001), SOFA score ( P <0.001), platelet count ( P =0.0023), and lactate level ( P <0.001). Logistic regression analysis using the factors with significant differences revealed that SOFA score ≥10 (odds ratio 23.3; 95% CI: 1.94-280.00; P =0.013) was an independent prognostic factor. In addition, catecholamine use was suggested as a factor with a SOFA score greater than or equal to 10. CONCLUSION This study confirmed that a SOFA score of greater than or equal to 10 may be associated with increased mortality. While closely monitoring low blood pressure and renal dysfunction, survival rates may be improved if surgical intervention is performed before the SOFA score reaches greater than or equal to 10.
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Affiliation(s)
| | | | - Yutaro Shimomoto
- Department of General Surgery, Tokyo Nishi Tokushukai Hospital, Tokyo, Japan
| | - Yumi Mikajiri
- Department of General Surgery, Shonan Atsugi Hospital
| | - Yuki Sasaki
- Department of General Surgery, Shonan Fujisawa Tokushukai Hospital
| | - Kensuke Konagaya
- Department of General Surgery, Narita Tomisato Tokushukai Hospital, Chiba
| | | | - Naoki Sawamura
- Department of General Surgery, Shonan Fujisawa Tokushukai Hospital
| | - Kota Yamamoto
- Department of General Surgery, Shonan Atsugi Hospital
| | - Nao Kume
- Department of General Surgery, Narita Tomisato Tokushukai Hospital, Chiba
| | | | - Shuji Kurata
- Department of General Surgery, Shonan Fujisawa Tokushukai Hospital
| | - Tetsuya Kasetani
- Department of General Surgery, Matsubara Tokushukai Hospital, Osaka
| | - Ichiro Kato
- Department of General Surgery, Sendai Tokushukai Hospital, Miyagi
| | | | - Hirohisa Hirata
- Department of General Surgery, Matsubara Tokushukai Hospital, Osaka
| | | | - Takahisa Oonishi
- Department of General Surgery, Yamato Tokushukai Hospital, Kanagawa
| | | | | | | | | | | | | | | | - Hiroyuki Murayama
- Department of General Surgery, Narita Tomisato Tokushukai Hospital, Chiba
| | - Shunsaku Kohriki
- Department of General Surgery, Shonan Fujisawa Tokushukai Hospital
| | - Takeshi Morita
- Department of General Surgery, Matsubara Tokushukai Hospital, Osaka
| | - Mutsuo Takaki
- Department of General Surgery, Tokyo Nishi Tokushukai Hospital, Tokyo, Japan
| | - Hidemitsu Ogino
- Department of General Surgery, Narita Tomisato Tokushukai Hospital, Chiba
| | | | - Ken Sano
- Department of General Surgery, Sendai Tokushukai Hospital, Miyagi
| | | | - Kazunao Watanabe
- Center for Clinical and Translational Science, Shonan Kamakura General Hospital
| | - Masahiro Hirata
- Center for Clinical and Translational Science, Shonan Kamakura General Hospital
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Garzelli L, Ben Abdallah I, Nuzzo A, Zappa M, Corcos O, Dioguardi Burgio M, Cazals-Hatem D, Rautou PE, Vilgrain V, Calame P, Ronot M. Insights into acute mesenteric ischaemia: an up-to-date, evidence-based review from a mesenteric stroke centre unit. Br J Radiol 2023; 96:20230232. [PMID: 37493183 PMCID: PMC10607400 DOI: 10.1259/bjr.20230232] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 05/16/2023] [Accepted: 05/17/2023] [Indexed: 07/27/2023] Open
Abstract
Radiologists play a central role in the diagnostic and prognostic evaluation of patients with acute mesenteric ischaemia (AMI). Unfortunately, more than half of AMI patients undergo imaging with no prior suspicion of AMI, making identifying this disease even more difficult. A confirmed diagnosis of AMI is ideally made with dynamic contrast-enhanced CT but the diagnosis may be made on portal-venous phase images in appropriate clinical settings. AMI is diagnosed on CT based on the identification of vascular impairment and bowel ischaemic injury with no other cause. Moreover, radiologists must evaluate the probability of bowel necrosis, which will influence the treatment options.AMI is usually separated into different entities: arterial, venous, non-occlusive and ischaemic colitis. Arterial AMI can be occlusive or stenotic, the dominant causes being atherothrombosis, embolism and isolated superior mesenteric artery (SMA) dissection. The main finding in the bowel is decreased wall enhancement, and necrosis can be suspected when dilatation >25 mm is identified. Venous AMI is related to superior mesenteric vein (SMV) thrombosis as a result of a thrombophilic state (acquired or inherited), local injury (cancer, inflammation or trauma) or underlying SMV insufficiency. The dominant features in the bowel are hypoattenuating wall thickening with submucosal oedema. Decreased enhancement of the involved bowel suggests necrosis. Non-occlusive mesenteric ischaemia (NOMI) is related to impaired SMA flow following global hypoperfusion associated with low-flow states. There are numerous findings in the bowel characterised by diffuse extension. An absence of bowel enhancement and a thin bowel wall suggest necrosis in NOMI. Finally, ischaemic colitis is a sub-entity of arterial AMI and reflects localised colon ischaemia-reperfusion injury. The main CT finding is a thickened colon wall with fat stranding, which seems to be unrelated to SMA or inferior mesenteric artery lesions. A precise identification and description of vascular lesions, bowel involvement and features associated with transmural necrosis is needed to determine patient treatment and outcome.
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Affiliation(s)
| | - Iannis Ben Abdallah
- Université Paris Cité, France & Service de chirurgie vasculaire, Hôpital Bichat, APHP.Nord, Paris, France
| | - Alexandre Nuzzo
- Intestinal Stroke Center, Service de gastroenterologie, MICI et Insuffisance intestinale, Hôpital Beaujon, APHP.Nord, Clichy, France
| | - Magaly Zappa
- Université des Antilles & Service de radiologie, Centre Hospitalier André Rosemon, Cayenne, France
| | - Olivier Corcos
- Intestinal Stroke Center, Service de gastroenterologie, MICI et Insuffisance intestinale, Hôpital Beaujon, APHP.Nord, Clichy, France
| | - Marco Dioguardi Burgio
- Université Paris Cité, France & Service de radiologie, Hôpital Beaujon, APHP.Nord, Clichy, France
| | - Dominique Cazals-Hatem
- Université Paris Cité, France & Service d’anatomopathologie, Hôpital Beaujon, APHP.Nord, Clichy, France
| | - Pierre-Emmanuel Rautou
- Université Paris Cité, France & Service d’hépatologie, Hôpital Beaujon, APHP.Nord, Clichy, France
| | - Valérie Vilgrain
- Université Paris Cité, France & Service de radiologie, Hôpital Beaujon, APHP.Nord, Clichy, France
| | - Paul Calame
- Université Bourgogne Franche-comté, Service de radiologie, CHU Besançon, France
| | - Maxime Ronot
- Université Paris Cité, France & Service de radiologie, Hôpital Beaujon, APHP.Nord, Clichy, France
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5
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Reichert M, Roller FC, Kalder J, Hecker M, Bala M, Catena F, Biffl W, Coccolini F, Moore EE, Ansaloni L, Damaskos D, Sartelli M, Padberg W, Hecker A. [Acute mesenteric ischemia-An overview and recommendations (S2k analogous) of the World Society of Emergency Surgery]. CHIRURGIE (HEIDELBERG, GERMANY) 2023:10.1007/s00104-023-01913-x. [PMID: 37335317 DOI: 10.1007/s00104-023-01913-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/24/2023] [Indexed: 06/21/2023]
Abstract
Acute mesenteric ischemia is a severe illness, which if untreated, rapidly leads to a critical condition with sepsis, multiple organ failure and death in affected patients. The diagnosis and initiation of treatment of acute mesenteric ischemia should be performed as early and expeditiously as possible and follows the principle of the shortest possible time to reperfusion. Otherwise, the outcome of the patient rapidly deteriorates. The treatment algorithm should be adapted to the pathogenesis of the ischemia, the clinical condition and symptoms of the patients. With clinical signs of peritonitis, intestinal gangrene must be assumed and the abdomen should be surgically explored to detect and treat possible foci of sepsis at an early stage. The treatment of acute mesenteric ischemia should always be performed by an interdisciplinary team with all surgical and interventional options for intestinal revascularization as well as comprehensive intensive care medicine according to the standards of the Intestinal Stroke Center described in the literature. A short duration to revascularization and treatment in this interdisciplinary concept improves the outcome of patients with acute mesenteric ischemia. The World Society of Emergency Surgery provides expert consensus-based recommendations for the diagnosis and treatment of acute mesenteric ischemia; however, there is still a significant lack of broad high-quality evidence for this critical illness. Recommendations of the German specialist societies are urgently needed to ensure appropriate care, from the initial diagnostics to treatment and aftercare, for patients with suspected mesenteric ischemia in this country.
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Affiliation(s)
- Martin Reichert
- Klinik für Allgemein‑, Viszeral‑, Thorax‑, Transplantations- und Kinderchirurgie, Universitätsklinikum Gießen, Rudolf-Buchheim-Straße 7, 35392, Gießen, Deutschland
| | - Fritz C Roller
- Klinik für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Gießen, Klinikstraße 33, 35392, Gießen, Deutschland
| | - Johannes Kalder
- Klinik für Herz‑, Kinderherz- und Gefäßchirurgie, Universitätsklinikum Gießen, Rudolf-Buchheim-Straße 7, 35392, Gießen, Deutschland
| | - Matthias Hecker
- Klinik für Innere Medizin II - Pneumologie, Gastroenterologie, Nephrologie und internistische Intensivmedizin, Universitätsklinikum Gießen, Klinikstraße 33, 35392, Gießen, Deutschland
| | - Miklosh Bala
- Trauma and Acute Care Surgery Unit, Hadassah - Hebrew University Medical Center, Jerusalem, Israel
| | - Fausto Catena
- Department of General and Emergency Surgery, "Maurizio Bufalini" Hospital, Cesena, Italien
| | - Walter Biffl
- Department of Trauma and Acute Care Surgery, Scripps Memorial Hospital La Jolla, La Jolla, USA
| | - Federico Coccolini
- Department of General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italien
| | - Ernest E Moore
- Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, USA
| | - Luca Ansaloni
- Department of Surgery, Pavia University Hospital, Pavia, Italien
| | - Dimitrios Damaskos
- Department of Surgery, Royal Infirmary of Edinburgh, Edinburgh, Schottland, United Kingdom
| | | | - Winfried Padberg
- Klinik für Allgemein‑, Viszeral‑, Thorax‑, Transplantations- und Kinderchirurgie, Universitätsklinikum Gießen, Rudolf-Buchheim-Straße 7, 35392, Gießen, Deutschland
| | - Andreas Hecker
- Klinik für Allgemein‑, Viszeral‑, Thorax‑, Transplantations- und Kinderchirurgie, Universitätsklinikum Gießen, Rudolf-Buchheim-Straße 7, 35392, Gießen, Deutschland.
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Kobayashi T, Hidaka E, Ando A, Koganezawa I, Nakagawa M, Yokozuka K, Ochiai S, Gunji T, Sano T, Tomita K, Tabuchi S, Chiba N, Kawachi S. Risk factors for postoperative disseminated intravascular coagulation in surgical patients with non-occlusive mesenteric ischemia. Int J Colorectal Dis 2023; 38:146. [PMID: 37247011 DOI: 10.1007/s00384-023-04449-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/25/2023] [Indexed: 05/30/2023]
Abstract
PURPOSE The prognostic impact of disseminated intravascular coagulation (DIC) in surgical patients with non-occlusive mesenteric ischemia (NOMI) is unclear. This study aimed to confirm the association between postoperative DIC and prognosis and to identify preoperative risk factors associated with postoperative DIC. METHODS This retrospective study included 52 patients who underwent emergency surgery for NOMI between January 2012 and March 2022. Kaplan-Meier curve analysis with the log-rank test was used to compare 30-day survival and hospital survival between patients with and without postoperative DIC. In addition, univariable and multivariable logistic regression analyses were performed to identify the preoperative risk factors for postoperative DIC. RESULTS The 30-day and hospital mortality rates were 30.8% and 36.5%, respectively, and the incidence rate of DIC was 51.9%. Compared to patients without DIC, patients with DIC showed significantly lower rates of 30-day survival (41.5% vs 96%, log-rank P < 0.001) and hospital survival (30.2% vs 86.4%, log-rank, P < 0.001). Logistic regression analyses showed that the Japanese Association for Acute Medicine (JAAM) DIC score (OR = 2.697; 95% CI, 1.408-5.169; P = 0.003) and Sequential Organ Failure Assessment (SOFA) score (OR = 1.511; 95% CI, 1.111-2.055; P = 0.009) were independent risk factors for postoperative DIC in surgical patients with NOMI. CONCLUSION The development of postoperative DIC is a significant prognostic factor for 30-day and hospital mortalities in surgical patients with NOMI. In addition, the JAAM DIC score and SOFA score have a high discriminative ability for predicting the development of postoperative DIC.
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Affiliation(s)
- Toshimichi Kobayashi
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo 193-0998, Japan
| | - Eiji Hidaka
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo 193-0998, Japan
| | - Akitoshi Ando
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo 193-0998, Japan
| | - Itsuki Koganezawa
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo 193-0998, Japan
| | - Masashi Nakagawa
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo 193-0998, Japan
| | - Kei Yokozuka
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo 193-0998, Japan
| | - Shigeto Ochiai
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo 193-0998, Japan
| | - Takahiro Gunji
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo 193-0998, Japan
| | - Toru Sano
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo 193-0998, Japan
| | - Koichi Tomita
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo 193-0998, Japan
| | - Satoshi Tabuchi
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo 193-0998, Japan
| | - Naokazu Chiba
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo 193-0998, Japan
| | - Shigeyuki Kawachi
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi Hachioji, Tokyo 193-0998, Japan.
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7
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Schaab F. Nichtokklusive mesenteriale Ischämie. COLOPROCTOLOGY 2023. [DOI: 10.1007/s00053-023-00692-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
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8
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Yamada A, Nishina Y, Ohta H, Mekata E, Sugimoto T. Non-occlusive Mesenteric Ischemia with Significant Hyperphosphatemia. Intern Med 2023; 62:729-732. [PMID: 35908963 PMCID: PMC10037015 DOI: 10.2169/internalmedicine.0074-22] [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] [Indexed: 11/06/2022] Open
Abstract
An 86-year-old Japanese woman was referred to our hospital due to the sudden onset of abdominal pain. Abdominal contrast-enhanced computed tomography (CT) revealed no signs of ischemic bowel; however, laboratory investigations revealed metabolic lactic acidosis, elevation of inflammatory markers, and a remarkable elevation in the serum phosphate level. A prompt surgical evaluation revealed non-occlusive mesenteric ischemia (NOMI). Elevated serum phosphate levels may suggest extensive bowel ischemia or infarction, which can lead to a prompt surgical evaluation, even in the absence of specific radiological findings.
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Affiliation(s)
- Aki Yamada
- Department of Medicine, National Hospital Organization Higashi-ohmi General Medical Center, Japan
| | - Yusuke Nishina
- Department of Surgery, National Hospital Organization Higashi-ohmi General Medical Center, Japan
| | - Hiroyuki Ohta
- Department of Surgery, National Hospital Organization Higashi-ohmi General Medical Center, Japan
| | - Eiji Mekata
- Department of Surgery, National Hospital Organization Higashi-ohmi General Medical Center, Japan
| | - Toshiro Sugimoto
- Department of Medicine, Shiga University of Medical Science, Japan
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9
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Lam A, Kim YJ, Fidelman N, Higgins M, Cash BD, Charalel RA, Guimaraes MS, Kwan SW, Patel PJ, Plett S, Scali ST, Stadtlander KS, Stoner M, Tong R, Kapoor BS. ACR Appropriateness Criteria® Radiologic Management of Mesenteric Ischemia: 2022 Update. J Am Coll Radiol 2022; 19:S433-S444. [PMID: 36436968 DOI: 10.1016/j.jacr.2022.09.006] [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: 08/30/2022] [Accepted: 09/01/2022] [Indexed: 11/27/2022]
Abstract
Mesenteric ischemia is a serious medical condition characterized by insufficient vascular supply to the small bowel. In the acute setting, endovascular interventions, including embolectomy, transcatheter thrombolysis, and angioplasty with or without stent placement, are recommended as initial therapeutic options. For nonocclusive mesenteric ischemia, transarterial infusion of vasodilators, such as papaverine or prostaglandin E1, is the recommended initial treatment. In the chronic setting, endovascular means of revascularization, including angioplasty and stent placement, are generally recommend, with surgical options, such as bypass or endarterectomy, considered alternative options. Although the diagnosis of median arcuate ligament syndrome remains controversial, diagnostic angiography can be helpful in rendering a diagnosis, with the preferred treatment option being a surgical release. Systemic anticoagulation is recommended as initial therapy for venous mesenteric ischemia with acceptable rates of recanalization. If anticoagulation fails, transcatheter thrombolytic infusion can be considered with possible adjunctive placement of a transjugular intrahepatic portosystemic shunt to augment antegrade flow. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
- Alexander Lam
- University of California, San Francisco, San Francisco, California.
| | - Yoon-Jin Kim
- Research Author, University of California, San Francisco, San Francisco, California
| | - Nicholas Fidelman
- Panel Chair, University of California, San Francisco, San Francisco, California
| | - Mikhail Higgins
- Panel Vice-Chair, Boston University School of Medicine, Boston, Massachusetts
| | - Brooks D Cash
- Chief of Gastroenterology, Hepatology, and Nutrition Division, University of Texas Health Science Center at Houston and McGovern Medical School, Houston, Texas; American Gastroenterological Association
| | | | - Marcelo S Guimaraes
- Division Chief Pediatric Radiology, Medical University of South Carolina, Charleston, South Carolina
| | | | - Parag J Patel
- Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Sara Plett
- Department of Radiology Chair, Sonoran Crossing Medical Center, Southwest Medical Imaging, Scottsdale, Arizona
| | - Salvatore T Scali
- University of Florida, Gainesville, Florida; Society for Vascular Surgery; SVS PSO VQI EVAR Registry Chair
| | | | - Michael Stoner
- Chief, Division of Vascular Surgery, Vice-Chair, Clinical Operations, University of Rochester Medical Center, Rochester, New York; Society for Vascular Surgery
| | - Ricky Tong
- Main Line Health, Bryn Mawr, Pennsylvania; Peer Review Committee
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10
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Sumbal R, Ali Baig MM, Sumbal A. Predictors of Mortality in Acute Mesenteric Ischemia: A Systematic Review and Meta-Analysis. J Surg Res 2022; 275:72-86. [DOI: 10.1016/j.jss.2022.01.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 12/24/2021] [Accepted: 01/27/2022] [Indexed: 12/12/2022]
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11
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Bagnacci G, Guerrini S, Gentili F, Sordi A, Mazzei FG, Pozzessere C, Guazzi G, Mura G, Savelli V, D'Amico S, Calomino N, Volterrani L, Mazzei MA. Non-occlusive mesenteric ischemia (NOMI) and prognostic signs at CT: reperfusion or not reperfusion that is the question! Abdom Radiol (NY) 2022; 47:1603-1613. [PMID: 34755202 DOI: 10.1007/s00261-021-03317-z] [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: 08/09/2021] [Revised: 10/07/2021] [Accepted: 10/07/2021] [Indexed: 12/19/2022]
Abstract
PURPOSE Non-occlusive mesenteric ischemia (NOMI) is a misdiagnosed and dangerous condition. To our knowledge, a comprehensive evaluation of CT parameters that can predict the outcome of patients suffering from NOMI is still missing. MATERIALS AND METHODS Contrast-enhanced CT examination of 84 patients with a confirmed diagnosis of NOMI (37 with clinical and laboratory confirmation and 47 biopsy or surgery proven) was retrospectively reviewed by assessing vessels, mesentery, bowel, and peritoneal cavity CT quantitative and dichotomous parameters, and data were analyzed with Fisher's test. Diameter of superior mesenteric artery (SMA), celiac trunk (CT), inferior vena cava (IVC), superior mesenteric vein (SMV), and differences in CT HU (Delta HU) of the bowel wall before and after intravenous contrast media (ICM) administration were correlated to the patients' outcome using ANOVA test. Receiver operating characteristic (ROC) curves were elaborated after a binary logistic regression was performed. RESULTS Increased number and diameter of vessels, bowel wall thickening, and hypervascularity were more frequent in patients with good prognosis. Conversely, pale mesentery, paper thin, hypovascularity, and aeroportia were more frequent in patients with bad prognosis. A significant correlation between diameters of SMA, CT, IVC, IMA, and SMV and outcome was found at univariate analysis. Also Delta HU resulted to be correlated with the outcome. At multivariate analysis only IVC and Delta HU were significant (p = 0.038 and 0.01) and the combined AUC resulted in 0.806 (CI 0.708-0.903). CONCLUSION Dichotomous signs of reperfusion and quantitative CT parameters can predict the outcome of patients with NOMI. In particular the combination of IVC diameter and Delta HU of bowel wall allows to predict the prognosis with the highest accuracy.
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Affiliation(s)
- Giulio Bagnacci
- Unit of Diagnostic Imaging, Department of Medical, Surgical and Neuro Sciences and of Radiological Sciences, University of Siena, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Susanna Guerrini
- Unit of Diagnostic Imaging, Department of Radiological Sciences, Azienda Ospedaliero-Universitaria Senese, "Santa Maria Alle Scotte" General Hospital, Viale Mario Bracci, 16, 53100, Siena, Italy.
| | - Francesco Gentili
- Unit of Diagnostic Imaging, Department of Radiological Sciences, Azienda Ospedaliero-Universitaria Senese, "Santa Maria Alle Scotte" General Hospital, Viale Mario Bracci, 16, 53100, Siena, Italy
| | - Alessandra Sordi
- Unit of Diagnostic Imaging, Department of Medical, Surgical and Neuro Sciences and of Radiological Sciences, University of Siena, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Francesco Giuseppe Mazzei
- Unit of Diagnostic Imaging, Department of Radiological Sciences, Azienda Ospedaliero-Universitaria Senese, "Santa Maria Alle Scotte" General Hospital, Viale Mario Bracci, 16, 53100, Siena, Italy
| | - Chiara Pozzessere
- Department of Radiology, AUSL Toscana Centro, San Giuseppe Hospital, Empoli, Italy
| | - Gianni Guazzi
- Unit of Emergency Radiology, Department of Emergency and Transplantations, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Gianni Mura
- Department of Surgery, AUSL Toscana SUD EST, San Donato Hospital, Arezzo, Italy
| | - Vinno Savelli
- Unit of General Surgery and Surgical Oncology, Department of Medical, Surgical and Neuro Sciences and of Surgical Sciences, University of Siena, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Silvia D'Amico
- Department of Surgery, AUSL Toscana Centro, San Giuseppe Hospital, Empoli, Italy
| | - Natale Calomino
- Unit of Clinical Surgery, Department of Medical, Surgical and Neuro Science and of Surgery and Bioengineering, University of Siena, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Luca Volterrani
- Unit of Diagnostic Imaging, Department of Medical, Surgical and Neuro Sciences and of Radiological Sciences, University of Siena, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Maria Antonietta Mazzei
- Unit of Diagnostic Imaging, Department of Medical, Surgical and Neuro Sciences and of Radiological Sciences, University of Siena, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
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Abstract
Ischemic bowel disease (ISBODI) includes colon ischemia, acute mesenteric ischemia (AMI) and chronic mesenteric ischemia (CMI). Epidemiologically, colon ischemia is the most common type followed by AMI and CMI. There are various risk factors for the development of ISBODI. Abdominal pain is the common presenting symptom of each type. High clinical suspicion is essential in ordering appropriate tests. Imaging studies and colonoscopy with biopsy are the main diagnostic tests. Treatment varies from conservative measures to surgical resection and revascularization. Involvement of multidisciplinary team is essential in managing ISBODI. Although open surgery with revascularization plays an important role, recently there is an increasing interest in percutaneous endovascular treatment.
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Affiliation(s)
- Monjur Ahmed
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, PA 19107, United States
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13
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Kühn F, Schiergens TS, Klar E. Acute Mesenteric Ischemia. Visc Med 2020; 36:256-262. [PMID: 33005650 DOI: 10.1159/000508739] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Accepted: 05/16/2020] [Indexed: 12/15/2022] Open
Abstract
Background Despite constant improvements in diagnostic as well as interventional and surgical techniques, acute mesenteric ischemia (AMI) remains a life-threatening emergency with high mortality rates. The time to diagnosis of AMI is the most important predictor of patients' outcome; therefore, prompt diagnosis and intervention are essential to reduce mortality in patients with AMI. The present review was performed to analyze potential risk factors and to help find ways to improve the outcome of patients with AMI. Summary Whereas AMI only applies to approximately 1% of all patients with an "acute abdomen," its incidence is rising up to 10% in patients >70 years of age. The initial clinical stage of AMI is characterized by a sudden onset of strong abdominal pain followed by a painless interval. Depending on the extent of disease, the symptoms of nonocclusive mesenteric ischemia (NOMI) and patients with a venous thrombosis can be very different from those of acute occlusive ischemia. Biphasic contrast-enhanced CT represents the gold standard for the diagnosis of arterial and venous occlusion. In case of a central occlusion of the superior mesenteric artery or signs of peritonitis, immediate surgery should be performed. If major bowel resection becomes necessary, critical residual intestinal length limits must be kept in mind. Endovascular techniques for arterial occlusion have taken on a much greater importance today. For stable patients with NOMI, interventional catheter angiography is recommended because it enables diagnosis and treatment with selective application of vasodilators. Depending on its degree, interventional treatment with a transhepatic catheter lysis should be considered for acute and chronic portal vein thrombosis. Key Message The prompt and targeted use of the appropriate diagnostics and interventions appears to be the only way to reduce the persistently high mortality rates for AMI.
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Affiliation(s)
- Florian Kühn
- Department of General, Visceral, and Transplantation Surgery, Ludwig Maximilian University of Munich, Munich, Germany
| | - Tobias S Schiergens
- Department of General, Visceral, and Transplantation Surgery, Ludwig Maximilian University of Munich, Munich, Germany
| | - Ernst Klar
- Department of General, Visceral, Vascular and Transplantation Surgery, University Medical Center Rostock, Rostock, Germany
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