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1.
BMC Surg ; 21(1): 89, 2021 Feb 18.
Artigo em Inglês | MEDLINE | ID: mdl-33602217

RESUMO

BACKGROUND: Mesenteric ischemia is associated with poor outcome and high overall mortality. The aim was to analyze an interdisciplinary treatment approach of vascular and visceral specialists focusing on the in-hospital outcome and follow-up in patients with acute and acute-on-chronic mesenteric ischemia. METHODS: From 2010 until 2017, 26 consecutive patients with acute or acute on chronic mesenteric ischemia were treated by an interdisciplinary team. Data were prospectively collected and retrospectively evaluated. Throughout the initial examination, the extent of bowel resection was determined by the visceral surgeon and the appropriate mode of revascularization by the vascular surgeon. The routine follow-up included clinical examination and ultrasound- or CT-imaging for patency assessment and overall survival as primary endpoint of the study. RESULTS: Out of 26 patients, 18 (69.2%) were rendered for open repair. Ten patients (38.5%) received reconstruction of the superior mesenteric artery with an iliac-mesenteric bypass. Seven patients (26.9%) underwent thrombembolectomy of the mesenteric artery. One patient received an infra-diaphragmatic aorto-celiac-mesenteric bypass. Out of the 8 patients, who were not suitable for open revascularization, 2 patients (7.7%) were treated endovascularly and 6 (23.1%) underwent explorative laparotomy. The in-hospital mortality was 23% (n = 6). The mean survival of the revascularized group (n = 20) was 51.8 months (95% CI 39.1-64.5) compared to 15.7 months in the non-revascularized group (n = 6) (95% CI - 4.8-36.1; p = 0.08). The median follow-up was 64.6 months. Primary patency in the 16 patients after open and 2 after interventional revascularization was 100% and 89.9% in the follow-up. CONCLUSION: The interdisciplinary treatment of mesenteric ischemia improves survival if carried out in time. Hereby open revascularization measures are advantageous as they allow bowel assessment, resection, and revascularization in a one-stop fashion especially in advanced cases.


Assuntos
Serviços Médicos de Emergência , Isquemia Mesentérica , Equipe de Assistência ao Paciente , Doença Aguda , Serviços Médicos de Emergência/métodos , Humanos , Artéria Mesentérica Superior/cirurgia , Isquemia Mesentérica/cirurgia , Estudos Retrospectivos , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/métodos
2.
Kyobu Geka ; 73(10): 783-788, 2020 Sep.
Artigo em Japonês | MEDLINE | ID: mdl-33130766

RESUMO

Mesenteric malperfusion is reported as a complication associated with acute aortic dissection(AAD) in 3~5% cases, and one of the adverse risk factors for survival. The mortality rate associated with malperfusion due to AAD is higher than that without malperfusion. To improve the clinical outcome, it is important to address the mesenteric malperfusion appropriately. Mesenteric malperfusion remains a diagnostic challenge. Abdominal pain is the most common symptom, but a nonspecific of acute mesenteric ischemia. Computed tomography(CT) including CT angiography is the gold standard in the diagnosis of aortic dissection and the mesenteric malperfusion. No single serum marker, including lactate, is reliable enough to diagnosis mesenteric ischemia. The optimal treatment for mesenteric malperfusion due to AAD is to restore blood flow to the ischemic area as early as possible, while minimizing the risk of thoracic aortic rupture. Those patients with malperfusion but no significant organ ischemia should be treated with immediate surgical repair. Those patients with malperfusion and significant organ ischemia and hemodynamically stable should be treated with mesenteric reperfusion, followed by surgical repair. The management of mesenteric malperfusion associated with AAD requires a tailored approach to improve outcomes. After successful restoration of mesenteric perfusion, patients should be monitored closely, and the bowel should be inspected when there is doubt regarding its viability.


Assuntos
Aneurisma Dissecante , Aneurisma Aórtico , Procedimentos Endovasculares , Isquemia Mesentérica , Doença Aguda , Aneurisma Dissecante/complicações , Aneurisma Dissecante/diagnóstico por imagem , Aneurisma Dissecante/cirurgia , Aneurisma Aórtico/complicações , Aneurisma Aórtico/diagnóstico por imagem , Aneurisma Aórtico/cirurgia , Humanos , Isquemia/etiologia , Isquemia/cirurgia , Isquemia Mesentérica/diagnóstico por imagem , Isquemia Mesentérica/cirurgia , Resultado do Tratamento
3.
Arch Iran Med ; 23(9): 639-643, 2020 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-32979913

RESUMO

The severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) presents clinical manifestations similar to the influenza, severe acute respiratory syndrome (SARS-CoV), and Middle East respiratory syndrome (MERS-CoV). However, in the course of the coronavirus disease 2019 (COVID-19), various pathological complications of high clinical significance have remained unknown. Impaired blood supply to the visceral vascular system can cause serious life-threatening acute damage. We report a case of extensive acute mesenteric ischemia associated with SARS-CoV-2 infection confirmed in a patient hospitalized in Amin Hospital - a COVID-19 referral center in Isfahan University of Medical Sciences, Isfahan, Iran. This case highlights the importance of paying attention to serious and less common or less known clinical manifestations other than fever, dry cough, dyspnea, and myalgia.


Assuntos
Betacoronavirus , Infecções por Coronavirus/complicações , Isquemia Mesentérica/etiologia , Pneumonia Viral/complicações , Doença Aguda , Idoso , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/epidemiologia , Evolução Fatal , Humanos , Laparotomia , Masculino , Isquemia Mesentérica/diagnóstico , Isquemia Mesentérica/cirurgia , Pandemias , Pneumonia Viral/diagnóstico , Pneumonia Viral/epidemiologia , Radiografia Torácica , Tomografia Computadorizada por Raios X
6.
J Surg Res ; 254: 7-15, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32402834

RESUMO

BACKGROUND: Acute mesenteric ischemia is a life-threatening acute condition, which requires an interdisciplinary approach, including vascular recanalization and surgical treatment. Visual evaluation of intestinal perfusion might be misleading, and therefore, additional tools are necessary to reliably be able to resect the ischemic intestine. Hyperspectral imaging (HSI) has been shown to be feasible and safe for real-time assessment of tissue perfusion in visceral surgery but has never been used in cases of acute mesenteric ischemia. Therefore, we applied HSI in acute mesenteric ischemia to evaluate it for potential aid in the objectively discriminating ischemic and well-perfused intestine during explorative laparotomy. METHODS: We recorded HSI measurements in 11 cases of acute mesenteric ischemia during explorative laparotomy. We evaluated the recorded images for macroscopic visual perfusion quality and divided it into three groups. Of those three groups, we calculated and compared the HSI indexes of tissue saturation, near-infrared perfusion index, organ hemoglobin index, and tissue water index, as well as the reflectance spectra. RESULTS: We found significant differences in tissue saturation (0.7% versus 0.45%; P = 0.002) and near-infrared perfusion index (0.58 versus 0.23; P < 0.001) in poorly perfused intestinal segments compared with the viable intestine. Furthermore, we could detect an increasing peak at 630 nm of the reflectance spectra in less viable tissues, indicating a maximum in necrotic tissues. We attributed this peak to an increase in met-hemoglobin content in necrotic tissues, which is supported by the increase in the HSI organ hemoglobin index. CONCLUSIONS: HSI is able to discriminate tissue perfusion in acute mesenteric ischemia reliably and therefore might be helpful for resection. In addition, HSI gives information on tissue viability via reflectance spectra.


Assuntos
Diagnóstico por Imagem/métodos , Intestinos/irrigação sanguínea , Isquemia Mesentérica/diagnóstico por imagem , Isquemia Mesentérica/cirurgia , Idoso , Idoso de 80 Anos ou mais , Colectomia , Corantes , Feminino , Humanos , Verde de Indocianina , Intestino Delgado/cirurgia , Masculino , Isquemia Mesentérica/mortalidade , Pessoa de Meia-Idade , Imagem Óptica , Complicações Pós-Operatórias , Estudos Prospectivos , Síndrome do Intestino Curto/etiologia
8.
Vasc Health Risk Manag ; 16: 87-97, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32256075

RESUMO

Background: Laparoscopic aortomesenteric bypass may be performed to treat the chronic mesenteric ischemia patients who are not suitable for endovascular treatment. This study presents an initial experience with a limited series of laparoscopic mesenteric artery revascularization for the treatment of mesenteric ischemia. Methods: Chronic mesenteric ischemia (CMI) patients with previous unsuccessful endovascular treatment or with arterial occlusion and extensive calcification precluding safe endovascular treatment were offered laparoscopic mesenteric revascularization. From October 2015 until November 2018, nine patients with CMI underwent laparoscopic revascularization. In addition to demographic data and perioperative results of the treatment, graft patency was assessed with Duplex ultrasound at 1, 3, 6 and 12 months, and annually thereafter. A descriptive analysis of the data was performed. Results: All bypasses were constructed with an 8 mm ring enforced expanded polytetrafluoroethylene graft in a retrograde fashion (from infrarenal aorta or iliac artery) to either superior mesenteric artery or splenic artery (2 cases). Median operation time was 356 mins (range 247-492 mins). Five patients had a history of unsuccessful endovascular treatment. Laparoscopic technical success was 78%, and the primary open conversion rate was 22%. All laparoscopic revascularization procedures remained patent after discharge during a median follow-up time of 26 months (range 18-49 months). The primary graft patency at 30 days was 78%. Primary assisted, and secondary graft patency was 78% and 100%, respectively. Median weight gain was 2 kg (range 2-18 kg), and all patients achieved relief from postprandial pain and nausea. No mortality was observed during the follow-up period. Conclusion: Laparoscopic aortomesenteric revascularization procedures for chronic mesenteric ischemia are feasible but require careful patient selection. These procedures should only be performed at referral centers by vascular surgeons with prior experience in laparoscopic vascular surgery.


Assuntos
Implante de Prótese Vascular , Laparoscopia , Artérias Mesentéricas/cirurgia , Isquemia Mesentérica/cirurgia , Oclusão Vascular Mesentérica/cirurgia , Idoso , Implante de Prótese Vascular/efeitos adversos , Doença Crônica , Feminino , Oclusão de Enxerto Vascular/diagnóstico por imagem , Oclusão de Enxerto Vascular/fisiopatologia , Oclusão de Enxerto Vascular/cirurgia , Humanos , Laparoscopia/efeitos adversos , Masculino , Artérias Mesentéricas/diagnóstico por imagem , Artérias Mesentéricas/fisiopatologia , Isquemia Mesentérica/diagnóstico por imagem , Isquemia Mesentérica/fisiopatologia , Oclusão Vascular Mesentérica/diagnóstico por imagem , Oclusão Vascular Mesentérica/fisiopatologia , Pessoa de Meia-Idade , Estudos Prospectivos , Reoperação , Circulação Esplâncnica , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução Vascular
9.
Khirurgiia (Mosk) ; (3): 61-66, 2020.
Artigo em Russo | MEDLINE | ID: mdl-32271739

RESUMO

OBJECTIVE: To demonstrate the results of endovascular treatment of 15 patients with acute mesenteric ischemia. MATERIAL AND METHODS: There were 15 patients with acute mesenteric ischemia who underwent surgery (9 men and 6 women). Mean age was 77±11 years. Acute intestinal ischemia was caused by thromboembolism of superior mesenteric artery (9 patients), thrombosis of superior mesenteric artery (5 patients) and critical stenosis of the ostia of superior mesenteric artery and celiac trunk (1 patient). Mean time from clinical manifestation of disease to admission to the hospital was 13 hours (range 2-72 hours). In-hospital development of acute mesenteric ischemia was noted in 2 patients. Indications for endovascular intervention and techniques of endovascular revascularization of superior mesenteric artery are described in the article. RESULTS: Blood flow restoration in superior mesenteric artery was achieved in 14 (93%) out of 15 patients. Laparotomy was required in 4 (27%) patients for extensive resection of necrotic intestine (n=1, 6.7%), local resection of small bowel (n=2, 13%). In another (6.7%) patient, intestine was recognized as viable after laparotomy. A bulk of intestine was preserved in most patients (n=14, 93%). In-hospital mortality rate was 47% (7 patients died). The main cause of nosocomial death (6 cases) was reperfusion syndrome followed by respiratory distress syndrome and multiple organ failure. CONCLUSION: New methods of prevention and treatment of reperfusion syndrome can improve the results of treatment of acute mesenteric ischemia.


Assuntos
Procedimentos Endovasculares , Intestinos/irrigação sanguínea , Artéria Mesentérica Superior/cirurgia , Isquemia Mesentérica/cirurgia , Oclusão Vascular Mesentérica/cirurgia , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Artéria Celíaca/cirurgia , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Intestinos/patologia , Intestinos/cirurgia , Masculino , Isquemia Mesentérica/etiologia , Isquemia Mesentérica/mortalidade , Oclusão Vascular Mesentérica/etiologia , Oclusão Vascular Mesentérica/mortalidade , Estudos Retrospectivos , Resultado do Tratamento
11.
Am J Surg ; 220(2): 309-315, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32067703

RESUMO

Acute mesenteric ischemia (AMI) is a deadly and common surgical emergency. While several imaging modalities aid in the diagnosis of AMI preoperatively, there are limited intraoperative tools for surgeon decision making regarding bowel viability. Here we offer a review of the utility and limitations of the many extensively studied techniques. We classify each of these modalities into three hallmarks of healthy bowel: oxygenation, myoelectric activity and perfusion. Finally, we offer a brief discussion of emerging and promising techniques to assist surgeons in intraoperative decision making for patients with mesenteric ischemia.


Assuntos
Intestinos/irrigação sanguínea , Intestinos/diagnóstico por imagem , Isquemia Mesentérica/cirurgia , Monitorização Intraoperatória , Tomada de Decisões , Eletromiografia , Fluoresceínas , Humanos , Verde de Indocianina , Oximetria , Fotopletismografia , Espectroscopia de Luz Próxima ao Infravermelho , Ultrassonografia Doppler
12.
Ann Vasc Surg ; 66: 263-271, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31931133

RESUMO

BACKGROUND: Mesenteric bypass grafts can be constructed either antegrade or retrograde. There is debate regarding which is the optimal approach. We have modified the technique for retrograde mesenteric revascularization using a direct open retrograde revascularization (DORR) technique. This report is a retrospective single-institution study that describes the DORR technique and compares it with antegrade mesenteric bypass. METHODS: The medical records of patients undergoing open mesenteric bypass between January 2001 and December 2017 for mesenteric ischemia were reviewed. Patients who underwent mesenteric thromboembolectomy, retrograde stenting, or bypass for aneurysmal disease were excluded. Patient demographics, operative details, and follow-up data were recorded. Antegrade bypasses were constructed using a polyester, collagen-coated, knitted, (Maquet, Getinge Group)- bifurcated graft. The supraceliac aorta was exposed, and the Dacron graft limbs were tunneled to the celiac and/or superior mesenteric artery (SMA). The DORR was constructed by anastomosing a vein graft to an iliac artery. The vein was tunneled through the base of the small bowel mesentery to create a direct course to the SMA. When revascularization to both the SMA and celiac vessels was indicated, the vein was anastomosed to the SMA in a side-to-side fashion with the distal vein tunneled through the mesocolon and anastomosed in a end-to-side fashion to the hepatic artery. Statistical analysis was done using Student's t-test, Mann-Whitney U test, Fisher's exact test, and log-rank test with a P ≤ 0.05 considered significant. RESULTS: Forty-one patients underwent open mesenteric bypass: 16 antegrade and 25 retrograde. Patient age, gender, and body mass index were similar. Indication for operation was acute ischemia in a greater portion of patients undergoing retrograde bypass (P = 0.025). For antegrade bypasses, Dacron was used in 15 and saphenous vein in 1. The DORR bypass originated from an iliac artery (21), limb of an aortofemoral graft (2), or infrarenal aorta (2). All DORR were constructed using veins (19 femoral veins and 6 greater saphenous veins). In DORR configurations, the bypass was created to only the SMA in 23 cases (92%). By comparison, in antegrade bypasses, the bypass was constructed to both the SMA and celiac arteries in all but 1 case (P < 0.00001). Median operative time was significantly shorter for DORR compared with antegrade bypass (282 vs. 375 min; P < 0.05). Blood loss, need for second-look laparotomy, morbidity, mortality, length of stay, and discharge disposition were similar between groups. There was a shift in favor of the DORR technique in the second half of the study (4 of 15 [27%] DORR from 2001 to 2009 vs. 21 of 26 [81%] DORR from 2010 to 2017). In survivors, 57% of the antegrade cohort and 74% of the DORR cohort had documented follow-up (average, 47.5 ± 59.9 and 28.8 ± 31.3 months, respectively). No difference was noted in survival between groups. All grafts in both cohorts were patented at follow-up. CONCLUSIONS: Direct tunneling of the graft under the mesentery with the DORR technique avoids concern for kinking and has shorter operative time despite the need for vein harvest. No differences were noted in long-term survival between patient groups. The use of a venous conduit makes DORR adaptable for both chronic and acute mesenteric ischemia. These factors have resulted in the DORR technique to be our preferred method for open mesenteric revascularization.


Assuntos
Implante de Prótese Vascular , Artéria Celíaca/cirurgia , Veia Femoral/transplante , Artéria Mesentérica Superior/cirurgia , Isquemia Mesentérica/cirurgia , Oclusão Vascular Mesentérica/cirurgia , Veia Safena/transplante , Adolescente , Adulto , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Artéria Celíaca/diagnóstico por imagem , Artéria Celíaca/fisiopatologia , Feminino , Humanos , Masculino , Artéria Mesentérica Superior/diagnóstico por imagem , Artéria Mesentérica Superior/fisiopatologia , Isquemia Mesentérica/diagnóstico por imagem , Isquemia Mesentérica/fisiopatologia , Oclusão Vascular Mesentérica/diagnóstico por imagem , Oclusão Vascular Mesentérica/fisiopatologia , Duração da Cirurgia , Complicações Pós-Operatórias/etiologia , Desenho de Prótese , Estudos Retrospectivos , Fatores de Risco , Circulação Esplâncnica , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução Vascular , Adulto Jovem
13.
Acta Chir Belg ; 120(1): 1-5, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31580204

RESUMO

Chronic mesenteric ischemia is a rare and challenging clinical entity with non-specific complaints. It concerns mainly elderly patients with a diffuse atherosclerotic burden affecting other vascular beds. Most surgeons have limited experience with the management of symptomatic occlusive disease of the superior mesenteric artery or coeliac trunk. Last decades, the mesenteric revascularisation debate has also been implicated by the endovascular vogue. An endovascular-first strategy has been adopted in most centres, considering its less invasive character, with lower peri-procedural morbidity and mortality and more rapid recovery. The volume of mesenteric artery stenting has steadily increased over time. However, the long-term results of percutaneous mesenteric angioplasty and stenting are worse than those obtained with open surgery. Currently, many centres reserve open repair for cases in whom PTA failed. This extensive literature review aims to orientate decision-making and choice of revascularisation modality for chronic mesenteric ischemia, considering a significant patient heterogeneity.


Assuntos
Isquemia Mesentérica/cirurgia , Doença Crônica , Humanos , Stents , Procedimentos Cirúrgicos Vasculares
14.
Cardiovasc Intervent Radiol ; 43(1): 46-54, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31650241

RESUMO

PURPOSE: To evaluate the safety and the efficacy of percutaneous pharmaco-mechanical thrombectomy (PPMT) of acute superior mesenteric vein (SMV) thrombosis. METHODS: A database of patients treated between 2011 and 2018 with acute venous mesenteric ischemia (VMI) was reviewed. VMI was diagnosed in the presence of SMV thrombosis and CT evidence of jejunal thickening. All patients presented with mild to moderate peritonism, which allowed surgery to be postponed. Initial treatment consisted of heparinization. PPMT was indicated in case of worsening abdominal pain despite anticoagulation and was performed via a transjugular or transhepatic approach, using a rotational aspiration thrombectomy catheter, followed by transcatheter thrombolysis. Clinical success was defined as symptoms resolution. Technical success was defined as patency of > 50% of SMV at venography and resolution of jejunal thickening. Patients were discharged on lifelong oral anticoagulation (INR 2.5-3.5). Follow-ups were performed using CT and color Doppler ultrasound. RESULTS: Population consisted of eight males, aged 37-81 (mean 56.5 years). Causes for thrombosis were investigated. Urokinase infusion time ranged from 48 to 72 h (3,840,000-5,760,000 IU). Clinical and technical success was obtained in all cases. One patient experienced bleeding from the superior epigastric artery and was treated with embolization. One patient died of multi-organ failure after 35 days, despite resolution of SMV thrombosis. In no case was surgery required after PPMT; mean hospitalization was 14.1 days (9-24). Mean follow-up of remaining seven patients was 37.7 months (12-84 months). CONCLUSION: PPMT of acute SMV thrombosis seems safe and effective, with an 87.5% long-term survival rate and a 12.5% major complication rate.


Assuntos
Isquemia Mesentérica/tratamento farmacológico , Isquemia Mesentérica/cirurgia , Trombectomia/métodos , Trombose Venosa/tratamento farmacológico , Trombose Venosa/cirurgia , Doença Aguda , Adulto , Idoso , Idoso de 80 Anos ou mais , Angiografia por Tomografia Computadorizada , Feminino , Humanos , Masculino , Isquemia Mesentérica/diagnóstico por imagem , Veias Mesentéricas/diagnóstico por imagem , Veias Mesentéricas/cirurgia , Pessoa de Meia-Idade , Flebografia/métodos , Estudos Retrospectivos , Resultado do Tratamento , Ultrassonografia Doppler em Cores , Ativador de Plasminogênio Tipo Uroquinase/administração & dosagem , Ativador de Plasminogênio Tipo Uroquinase/uso terapêutico , Trombose Venosa/diagnóstico por imagem
15.
J Endovasc Ther ; 27(1): 124-129, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31789079

RESUMO

Purpose: To demonstrate the feasibility of a physician-modified endograft (PMEG) with inner branches for 2 mesenteric arteries as an alternative to fenestrations or directional branches. Technique: A symptomatic 60-year-old man presented with supraceliac para-anastomotic pseudoaneurysm involving an antegrade aorta to celiac artery and superior mesenteric artery bypass. Since an off-the-shelf multibranched endograft was inappropriate, a Zenith Alpha thoracic stent-graft was modified with 2 inner branches fashioned of 8-mm Viabahn endoprostheses with preloaded guidewires. The procedure was technically successful, and the patient had no postoperative complications. Conclusion: Inner branches might offer an alternative to fenestrations or directional branches in patients with narrow aortas.


Assuntos
Falso Aneurisma/cirurgia , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Artéria Celíaca/cirurgia , Procedimentos Endovasculares/instrumentação , Artéria Mesentérica Superior/cirurgia , Isquemia Mesentérica/cirurgia , Desenho de Prótese , Stents , Anastomose Cirúrgica/efeitos adversos , Falso Aneurisma/diagnóstico por imagem , Falso Aneurisma/etiologia , Falso Aneurisma/fisiopatologia , Artéria Celíaca/diagnóstico por imagem , Artéria Celíaca/fisiopatologia , Humanos , Masculino , Artéria Mesentérica Superior/diagnóstico por imagem , Artéria Mesentérica Superior/fisiopatologia , Pessoa de Meia-Idade , Resultado do Tratamento
17.
J Vasc Surg ; 71(6): 2170-2176, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-31882314

RESUMO

BACKGROUND: Median arcuate ligament syndrome (MALS) describes the clinical presentation associated with direct compression of the celiac artery by the median arcuate ligament. The poorly understood pathophysiologic mechanism, variable symptom severity, and unpredictable response to treatment make MALS a controversial diagnosis. METHODS: This review summarizes the literature pertaining to the pathophysiologic mechanism, presentation, diagnosis, and management of MALS. A suggested diagnostic workup and treatment algorithm are presented. RESULTS: Individuals with MALS present with signs and symptoms of foregut ischemia, including exercise-induced or postprandial epigastric pain, nausea, vomiting, and weight loss. Consideration of MALS in patients' diagnostic workup is typically delayed. Currently, no group consensus agreement as to the diagnostic criteria for MALS exists; duplex ultrasound, angiography, and gastric exercise tonometry are used in different combinations and with varying diagnostic values throughout the literature. Surgical management involves decompression of the median arcuate ligament's constriction of the celiac artery; robotic, laparoscopic, endoscopic retroperitoneal, and open surgical intervention can provide effective symptom relief, but long-term follow-up data (>5 years) are lacking. Patients treated nonoperatively appear to have worse outcomes. CONCLUSIONS: MALS is an important clinical entity with significant impact on affected individuals. Presenting symptoms, patient demographics, and radiologic signs are generally consistent, as is the short-to medium-term (<5 years) response to surgical intervention. Future prospective studies should directly compare long-term symptomatic and quality of life outcomes after nonoperative management with outcomes after open, laparoscopic, endoscopic retroperitoneal, and robotic celiac artery decompression to enable the development of evidence-based guidelines for the management of MALS.


Assuntos
Artéria Celíaca , Descompressão Cirúrgica , Ligamentos/cirurgia , Síndrome do Ligamento Arqueado Mediano/cirurgia , Isquemia Mesentérica/cirurgia , Oclusão Vascular Mesentérica/cirurgia , Artéria Celíaca/diagnóstico por imagem , Artéria Celíaca/fisiopatologia , Constrição Patológica , Descompressão Cirúrgica/efeitos adversos , Humanos , Ligamentos/diagnóstico por imagem , Síndrome do Ligamento Arqueado Mediano/complicações , Síndrome do Ligamento Arqueado Mediano/diagnóstico por imagem , Síndrome do Ligamento Arqueado Mediano/fisiopatologia , Isquemia Mesentérica/diagnóstico por imagem , Isquemia Mesentérica/etiologia , Isquemia Mesentérica/fisiopatologia , Oclusão Vascular Mesentérica/diagnóstico por imagem , Oclusão Vascular Mesentérica/etiologia , Oclusão Vascular Mesentérica/fisiopatologia , Circulação Esplâncnica , Resultado do Tratamento , Grau de Desobstrução Vascular
18.
Ann Vasc Surg ; 63: 170-178.e1, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31629853

RESUMO

BACKGROUND: Sarcopenia has been identified as a prognostic factor in several diseases. The aim of this study was to investigate the impact of sarcopenia in patients with acute mesenteric ischemia. METHODS: Consecutive patients admitted for acute mesenteric ischemia were retrospectively included at the University Hospital of Nice. Sarcopenia was assessed by the measurement of total psoas area normalized for height (TPA/H) on CT-scan and was defined as a TPA/H inferior to the lowest sex-specific quartile. The management of the patients and the 30-day outcomes were compared between sarcopenic and nonsarcopenic patients. Correlations between the TPA/H and biological characteristics were investigated. RESULTS: Among the 80 patients included, the lowest quartile of TPA/H that defined sarcopenia was 406.1 mm2/m2 for men and 307 mm2/m2 for women. The rate of revascularization or the need of intestinal resection did not significantly differ between sarcopenic and nonsarcopenic patients (10.5% vs. 26.2%, P = 0.214 and 26.3% vs. 47.5%, P = 0.118 respectively). The 30-day mortality did not significantly differ between the two groups (63.2% vs. 47.5%, P = 0.297). The TPA/H was significantly negatively correlated with the neutrophil, thrombocyte, and monocyte counts (r = -0.283; -0.288, -0.225, P < 0.05) and positively correlated with the hemoglobin concentration and the glomerular filtration rate (r = 0.368; 0.261, P < 0.05). CONCLUSIONS: Further studies on longer follow-up period would be of interest to fully understand the prognostic value of sarcopenia in patients with acute mesenteric ischemia.


Assuntos
Isquemia Mesentérica/cirurgia , Oclusão Vascular Mesentérica/cirurgia , Músculos Psoas , Sarcopenia/complicações , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Isquemia Mesentérica/complicações , Isquemia Mesentérica/diagnóstico por imagem , Isquemia Mesentérica/mortalidade , Oclusão Vascular Mesentérica/complicações , Oclusão Vascular Mesentérica/diagnóstico por imagem , Oclusão Vascular Mesentérica/mortalidade , Pessoa de Meia-Idade , Músculos Psoas/diagnóstico por imagem , Estudos Retrospectivos , Fatores de Risco , Sarcopenia/diagnóstico por imagem , Sarcopenia/mortalidade , Fatores de Tempo , Resultado do Tratamento
20.
World J Surg ; 44(1): 100-107, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31531725

RESUMO

BACKGROUND: Despite increases in knowledge and advances in the management of acute mesenteric ischemia syndrome (AMI), there have been no significant improvements in mortality in recent years. The objective of this study was to assess the changes in clinical characteristics and surgical outcomes in patients who underwent AMI over time. METHODS: A total of 323 consecutive patients who underwent acute mesenteric ischemia at our institution between 1990 and 2015 were examined. The occurrence of significant changes over this 25-year period in demographic data, comorbidity, clinical characteristics, laboratory results, operative findings, etiology of the AMI, and operative mortality were evaluated. The evolution mortality rates for the studied period were analyzed using the additive logistic regression, and the significant effect was determined using the Akaike Information Criterion (AIC). RESULTS: A significant increasing linear trend was observed in recent years in Charlson score values (p = 0.008), antiplatelet drug intake (p < 0.001), use of CT scan (p < 0.001), arterial thrombosis (p < 0.001), and intestinal resection (p = 0.047), while a decreasing linear trend was observed in digoxin intake (p < 0.001), angiography use (p = 0.004), and embolia (p < 0.001). The rest of the parameters did not present changes over time. Regarding the evolution of the adjusted surgical mortality, a significant decrease according the AIC criterion was observed. CONCLUSIONS: In recent years, the characteristics of patients with AMI requiring surgery have changed. Changes in operative mortality have also been detected, showing a tendency toward a progressive and significant decrease.


Assuntos
Isquemia Mesentérica/cirurgia , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Modelos Logísticos , Masculino , Isquemia Mesentérica/mortalidade , Pessoa de Meia-Idade
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