Hospital-based delays to revascularization increase risk of postoperative mortality and short bowel syndrome in acute mesenteric ischemia.

OBJECTIVE: Acute mesenteric ischemia (AMI) is a surgical emergency for which delays in treatment have been closely associated with high morbidity and mortality. Although the duration of ischemia as a determinant of outcomes for AMI is well known, the objective of this study was to identify hospital-based determinants of delayed revascularization and their effects on postoperative morbidity and mortality in AMI. METHODS: All patients who underwent any surgery for AMI from a multi-center hospital system between 2010 and 2020 were divided into two groups based on timeliness of mesenteric revascularization after presentation. Early revascularization (ER) was defined as having both vascular consultation ≤12 hours of presentation and vascular surgery performed at the patient's initial operation. Delayed revascularization (DR) was defined as having either delays to vascular consultation or vascular surgery. A retrospective review of demographic and postoperative data was performed. The effect of DR on major postoperative outcomes, including 30-day and 2-year mortality, total length of bowel resection, and development of short bowel syndrome, were analyzed. Effects of delayed vascular consultation alone, delayed vascular surgery alone, no revascularization during admission, and admitting service on outcomes were also examined on subgroup analyses. RESULTS: A total of 212 patients were analyzed. Ninety-nine patients received ER, whereas the remaining 113 patients experienced a DR after hospital presentation. Among the DR group, 55 patients (25.9%) had delayed vascular consultation, whereas vascular surgery was deferred until after the initial operation in 37 patients (17.4%). Fifty-one patients (24.0%) were never revascularized during admission. DR was a significant predictor of 30-day (odds ratio [OR], 2.09; 95% confidence interval [CI], 1.4-4.9; P = .03) and 2-year mortality (hazard ratio, 1.55, 95% CI, 1.0-2.3; P = .04). DR was also independently associated with increased bowel resection length (OR, 7.47; P < .01) and postoperative short bowel syndrome (OR, 2.4; P = .03) on multivariate analyses. When examined separately on subgroup analysis, both delayed vascular consultation (OR, 3.38; P = .03) and vascular surgery (OR, 4.31; P < .01) independently increased risk of 30-day mortality. Hospital discharge after AMI without mesenteric revascularization was associated with increased risk of short bowel syndrome (OR, 2.94; P < .01) and late mortality (hazard ratio, 1.60; P = .04). CONCLUSIONS: Delayed vascular consultation and vascular surgery are both significant hospital-based determinants of postoperative mortality and short bowel syndrome in patients with AMI. Timing-based management protocols that emphasize routine evaluation by a vascular surgeon and early, definitive mesenteric revascularization should be established and widely adopted for all patients with clinically suspected AMI at presentation.

Retrograde open mesenteric stenting should be considered as the initial approach to acute mesenteric ischemia.

OBJECTIVE: Retrograde open mesenteric stenting (ROMS) is an alternative to traditional bypass in patients who present with acute mesenteric ischemia (AMI). However, there is a paucity of data comparing outcomes of ROMS with other open surgical approaches. This study represents the largest single-institution experience with ROMS and aims to compare outcomes of ROMS with those of conventional mesenteric bypass. METHODS: All patients who presented with AMI from 2008 to 2019 and who were treated with either ROMS or mesenteric bypass were included in the study. Patient, procedure, and outcome variables were compared. Bypass and ROMS patients were compared using univariate statistics. RESULTS: A total of 34 patients who presented with AMI needing bypass were included in the study; 16 underwent mesenteric bypass, and 18 underwent ROMS. ROMS patients tended to be older than bypass patients and had higher rates of comorbidities. Bypass patients were more likely to have a history of chronic mesenteric symptoms (68.8% vs 27.8%; P = .019). Bypass procedures also took longer than ROMS procedures (302 vs 189 minutes; P < .01). The majority of ROMS procedures were not performed in a hybrid room (77.8%). Within 1 year, one stent thrombosed in a ROMS patient, requiring later mesenteric bypass. In the bypass group, one conduit thrombosed, ultimately resulting in perioperative death, and one bypass anastomosis stenosed, requiring angioplasty. Complication, unanticipated reintervention, and mortality rates were otherwise similar between groups. CONCLUSIONS: Complication, reintervention, and mortality rates after ROMS are similar to those of mesenteric bypass in the setting of AMI. Given similar postoperative outcomes and ability to perform these procedures in a conventional operating room but with significantly shorter operative times, ROMS should be considered a first-line option in acute situations when the operator is comfortable performing the procedure.

Unidad de Medicina Fetal Hospital Regional "Rio Gallegos" Santa Cruz Argentina. Experiencia de trabajo Estadística Febrero/Diciembre 2019 / FETAL UNIT. HOSPITAL REGIONAL "RIO GALLEGOS". SANTA CRUZ ARGENTINA. EXPERIENCIA DE TRABAJO ESTADÍSTICA FEBRERO/DICIEMBRE 2019

La isquemia mesentérica aguda (IMA) es consecuencia de la oclusión de la arteria mesentérica superior (AMS) por trombosis o embolia, es considerada como la más letal del síndrome de abdomen agudo. Se presenta el caso de paciente femenina de 69 años con clínica difusa y confirmación diagnóstica radiológica, El objetivo de este caso clínico es proporcionar una revisión bibliográfica actual del tema y facilitar la adecuada actuación ante este problema de salud de amplio compromiso sistémico, de aparición no tan infrecuente.

Acute mesenteric ischemia (IMA) is a consequence of occlusion of the superior mesenteric artery (AMS) by thrombosis or embolism, it is considered the most lethal of acute abdomen syndrome. The case of a 69-year-old female patient with diffuse clinic and radiological diagnostic confirmation is presented. The objective of this clinical case is to provide a current bibliographic review of the topic and facilitate adequate action in the face of this health problem with a broad systemic commitment, with no appearance. so infrequent.

Bacterial translocation and mortality on rat model of intestinal ischemia and obstruction.

PURPOSE:: To develop an experimental model of intestinal ischemia and obstruction followed by surgical resection of the damaged segment and reestablishment of intestinal transit, looking at bacterial translocation and survival. METHODS:: After anesthesia, Wistar rats was subject to laparotomy, intestinal ischemia and obstruction through an ileal ligature 1.5cm of ileum cecal valve; and the mesenteric vessels that irrigate upstream of the obstruction site to approximately 7 to 10 cm were ligated. Abdominal wall was closed. Three, six or twenty-four hours after, rats were subject to enterectomy followed by an end to end anastomosis. After 24h, mesenteric lymph nodes, liver, spleen and lung tissues were surgically removed. It was studied survival rate and bacterial translocation. GraphPadPrism statistical program was used. RESULTS:: Animals with intestinal ischemia and obstruction for 3 hours survived 24 hours after enterectomy; 6hx24h: survival was 70% at 24 hours; 24hx24h: survival was 70% and 40%, before and after enterectomy, respectively. Culture of tissues showed positivity on the 6hx24h and negativity on the 3hx24h. CONCLUSION:: The model that best approached the clinic was the one of 6x24h of ischemia and intestinal obstruction, in which it was observed bacterial translocation and low mortality rate.

Bacterial translocation and mortality on rat model of intestinal ischemia and obstruction

Abstract Purpose: To develop an experimental model of intestinal ischemia and obstruction followed by surgical resection of the damaged segment and reestablishment of intestinal transit, looking at bacterial translocation and survival. Methods: After anesthesia, Wistar rats was subject to laparotomy, intestinal ischemia and obstruction through an ileal ligature 1.5cm of ileum cecal valve; and the mesenteric vessels that irrigate upstream of the obstruction site to approximately 7 to 10 cm were ligated. Abdominal wall was closed. Three, six or twenty-four hours after, rats were subject to enterectomy followed by an end to end anastomosis. After 24h, mesenteric lymph nodes, liver, spleen and lung tissues were surgically removed. It was studied survival rate and bacterial translocation. GraphPadPrism statistical program was used. Results: Animals with intestinal ischemia and obstruction for 3 hours survived 24 hours after enterectomy; 6hx24h: survival was 70% at 24 hours; 24hx24h: survival was 70% and 40%, before and after enterectomy, respectively. Culture of tissues showed positivity on the 6hx24h and negativity on the 3hx24h. Conclusion: The model that best approached the clinic was the one of 6x24h of ischemia and intestinal obstruction, in which it was observed bacterial translocation and low mortality rate.

[Disseminated peritoneal hydatidosis manifested as intestinal ischaemia]. / Hidatidosis peritoneal diseminada manifestada como isquemia intestinal.

BACKGROUND: The hydatid disease, or echinococcosis, is endemic in Mediterranean countries, as well as in Australia, Asia, Africa, South America, and Canada. Among its complications is intraperitoneal rupture, a rare form of presentation, with highly variable symptoms. The treatment of choice is surgery plus adjuvant medical treatment in most patients. OBJECTIVE: A case is presented of a patient with disseminated peritoneal hydatidosis manifested as intestinal ischaemia. CLINICAL CASE: A 50-year-old male was admitted to the emergency room with a history of chronic abdominal pain that worsened in the last 24hours. He showed signs of sepsis in the physical examination and was subjected to surgery, in which intestinal ischaemia was found due to a disseminated peritoneal cystic disease, which had led to mesentery retraction. An intestinal resection with an end-ileostomy was performed. The results of the biopsy of the cystic lesions was disseminated peritoneal echinococcosis. Medical treatment was started with albendazole and praziquantel. CONCLUSION: This case shows a rare presentation of disseminated peritoneal hydatidosis, which led to intestinal ischaemia.

Insuficiencia mesentérica crónica luego de radioterapia para aórtica / Surgical revascularization for treatment of chronic mesenteric ischemia secondary to radiotherapy

Background: Chronic mesenteric ischemia is observed in older people and is often due to atherosclerosis. Radiotherapy is an important risk factor for atherosclerosis. Aim: To report our experience with chronic mesenteric ischemia secondary to retroperitoneal radiotherapy. Material and methods: Review of medical records of four male patients aged 39 to 65 years, treated for chronic mesenteric ischemia secondary to para-aortic radiotherapy between 1993 and 2011. Results: All of them had the classic symptoms of ischemia characterized by post prandial abdominal pain and weight loss. One had also isolated diarrhea episodes. Revascularization was achieved with open or endovascular surgery, with good results during a follow up period ranging from two to 20 years. Conclusions: Surgical revascularization is a good treatment for chronic mesenteric ischemia secondary to radiotherapy.

Introducción: La insuficiencia mesentérica crónica es un diagnóstico infrecuente, generalmente secundario a enfermedad aterosclerótica, siendo considerada una enfermedad de pacientes añosos. Se sabe que la radioterapia es un factor de riesgo importante para aterosclerosis. Describimos nuestra experiencia en el manejo de la isquemia mesentérica crónica secundaria a radioterapia retroperitoneal. Materiales y métodos: Análisis retrospectivo de las fichas clínicas de los pacientes tratados en nuestro centro por insuficiencia mesentérica crónica posterior a radioterapia del territorio para-aórtico entre 1993 y 2011. Resultados: Un total de 4 pacientes de sexo masculino fueron identificados. Edad promedio: 49 +/- 12 años (rango 39-65). Todos presentaron los síntomas clásicos de insuficiencia mesentérica caracterizados por dolor abdominal postprandial y baja de peso. Uno de ellos además tenía episodios repetidos de diarrea. La revascularización mesentérica se obtuvo mediante cirugía abierta o endovascular con excelentes resultados a corto y largo plazo con un seguimiento promedio de 9,3 años (rango 2-20). Discusión: El curso acelerado de la aterosclerosis posterior a radioterapia se ha descrito en múltiples territorios vasculares. Síntomas de insuficiencia mesentérica crónica pueden ser malinterpretados en estos pacientes debido a su similitud con los síntomas observados en la ileitis actínica. Un diagnóstico y tratamiento oportuno son críticos para evitar complicaciones mayores y deterioro de calidad de vida de estos pacientes. Conclusión: La insuficiencia mesentérica crónica inducida por radioterapia es una condición infrecuente. El manejo con cirugía abierta o endovascular son seguras y otorgan resolución sintomática a largo plazo.

Evaluation of Pulmonary Reperfusion Injury in Rats Undergoing Mesenteric Ischemia and Reperfusion and Protective Effect of Postconditioning on this Process.

INTRODUCTION: Some publications have demonstrated the presence of lung reperfusion injury in mesenteric ischemia and reperfusion (I/R), but under to diverse methods. Postconditioning has been recognized as effective in preventing reperfusion injury in various organs and tissues. However, its effectiveness has not been evaluated in the prevention of lung reperfusion injury after mesenteric ischemia and reperfusion. OBJECTIVE: To evaluate the presence of pulmonary reperfusion injury and the protective effect of ischemic postconditioning on lung parenchyma in rats submitted to mesenteric ischemia and reperfusion. METHODS: Thirty Wistar rats were distributed into three groups: group A (10 rats), which was held mesenteric ischemia (30 minutes) and reperfusion (60 minutes); group B (10 rats), ischemia and reperfusion, interspersed by postconditioning with two alternating cycles of reperfusion and reocclusion, for two minutes each; and group C (10 rats), ischemia and reperfusion interleaved by postconditioning with four alternating cycles of reperfusion and reocclusion of 30 seconds each. Finally, it was resected the upper lung lobe for histological analysis. RESULTS: There were mild lung lesions (grade 1) in all samples. There was no statistical difference between groups 1 and 2 (P >0.05). CONCLUSION: The mesenteric ischemia and reperfusion in rats for thirty and sixty minutes, respectively, caused mild reperfusion injury in lung. Postconditioning was not able to minimize the remote reperfusion injury and there was no difference comparing two cycles of two minutes with four cycles of 30 seconds.