Journal reading and guideline review

1. Presenter: R 蔡逸文

2.  Literature review.
 MEDLINE/PubMed
 MeSH term keyword: “mesenteric ischemia”,
“bowel ischemia”, and “bowel infarction”
 Exclusion: Isolated colonic ischemia and focal
segmental ischemia secondary to adhesions,
hernias or other forms of extrinsic compression.

3.  Classification system used to determine
strength of evidence

4.  Presentation and clinical diagnosis
 etiology
 Diagnosis
 Image
 Treatment
 Vascular procedure
 Damage control surgery
 prevention

5. Presentation and clinical diagnosis

6.  Acute abdominal pain is disproportionate to
the physical examination findings
 Early:
 Nausea, vomiting and initial forced evacuation
 Late if transmural infarction:
 Fever, bloody diarrhea and shock

7. Presentation and clinical diagnosis

8.  Arterial thrombosis
(TAMI): 25%
 Arterial Embolic
(EAMI): 45%
 Non-occlusive
(NOMI): 20%
 Venous thrombosis
(VAMI): 10%

9. CHARACTERISTICS
 The sudden onset of severe
pain
 spontaneous emptying of
the bowel (vomiting and
diarrhea)
 no significant physical
findings(40-80%)
RISK FACTOR
 Atrial fibrillation
 Rheumatic heart disease
 Myocardial infarction
 Prosthetic valve
 Ventricular aneurism

10. CHARACTERISTICS
 Acute episode, may be
recurrent
 Prodromal symptoms of
mesenteric angina
 postprandial abdominal pain
 Nausea
 weight loss
RISK FACTOR
 Atherosclerosis
 Dyslipidemia
 History of other vascular
events, previous vascular
surgery

11. CHARACTERISTICS
 Subacute abdominal pain
 Vague complaints
 Younger population
 Thromboembolic AMI in the
over 60s
 VAMI in the over 40s
RISK FACTOR
 Hypercoagulability states
 Abdominal trauma
 Acute pancreatitis
 Malignancy
 Nephrotic syndrome,
 portal hypertension or
cirrhosis or splenomegaly
 Oral contraceptives
 Pregnancy and the
puerperium

12. CHARACTERISTICS
 Critically ill, sedated and
artificially ventilated Vague
complaints
 Acute or insidious pain
(without defecation)
 Mesenteric hypoperfusion
secondary to circulatory
shock or vasoactive drugs
RISK FACTOR
 Shock, hypovolemia,
hypotension
 Digitalis
 Diuretics
 beta-blockers, alpha-
adrenergics
 Enteral nutrition,
 Critical care support

13. Presentation and clinical diagnosis

14.  Older age
 Bandemia, Elevated serum aspartate
aminotransferase, Increased blood urea nitrogen,
Metabolic acidosis
 Significant co-morbidities and poor
performance status
 Intestinal necrosis
 Increased elapsed time to laparotomy(24hr)
 When the colon was involved
Aliosmanoglu I et al. Int Surg. 2013
Huang HH, et al. Chin Med Assoc. 2005
Gupta PK et al. Surgery. 2011

15. Presentation and clinical diagnosis

16.  Multi-detector computerized tomography
scanning (MDCT) with intravenous contrast
(LOE: III)
 Percutaneous angiography for suspected
NOMI (LOE:III)

18. Pneumatosis intestinalis +
hepatic portal or portomesenteric venous gas
↑the likelihood of transmural bowel infarction
Lisa M. Ho, et al. American Journal of Roentgenology. 2007
Melanie S. Morris, et al .The American Journal of Surgery. 2008

19. Treatment

20.  Vasopressor drugs should be avoided in AMI.
 Minimal effect on the splanchnic circulation
 Dobutamine, low dose dopamine, or milrinone
 Cardiac glycosides should not be used as first
line treatment of atrial fibrillation/flutter in
AMI (LOE: IV).

21. Treatment

22.  Open embolectomy
 Endovascular embolectomy
 percutaneous mechanical aspiration or
thrombolysis
 percutaneous transluminal angioplasty (PTA) with
or without stenting

23.  Endovascular procedure
 PTA and stenting
 Percutaneous aspiration thrombectomy, local
fibrinolysis or intra-arterial drug perfusion
 Retrograde open mesenteric stenting
 After resection of ischemic bowel
 Failed percutaneous treatment

24.  Bypass procedures
 Antegrade bypass from supraceliac aorta to
superior mesenteric trunk
 Retrograde bypass from the infra-renal aorta and
iliac arteries

25.  Correcting the underlying cause
 Improving mesenteric perfusion by direct
infusion of vasodilators.
 Prostaglandin E1 (alprostadil): 20 mcg bolus
followed by 60–80 mcg/24 h infusion;
 papaverine (30–60 mg/h)
 Infarcted bowel resection(LOE: III)

26.  Systemic anticoagulation (LOE: III)
 Vascular
 Failed medical therapy
 Transjugular intrahepatic portosystemic shunting
(TIPS) with mechanical aspiration thrombectomy
and direct thrombolysis
 Percutaneous transhepatic thrombolysis
 Indirect thrombolysis via the SMA

27. Treatment

28.  Immediate surgery if comorbidities and
clinical condition make curative treatment
possible (LOE: III)
 Patients considered unsalvageable should
have palliative care (LOE: IV)

29. Treatment

30.  Laparotomy with resection of ischemic bowel
(and no anastomosis or stoma)
 open thrombectomy (if indicated)
 A temporary abdominal closure via a negative
pressure wound therapy
 ICU and continue resuscitation
 scheduled ‘second-look’ procedure within 48 h
(LOE: III)

31. Treatment

32.  Reassessed after adequate fluid resuscitation
and revascularization.
 Intra-operative assessment:
 Doppler ultrasound of the vascular arcade,
fluorescein angiography, indocyanine
angiography
 A second-look procedure for the doubts of
viability of the bowel(LOE: IV).

33. Treatment

34.  Restoration of bowel continuity following
extensive resection (LOE: III).
 Improve functional results
 May avoid the need for long termTPN

35.  Short bowel syndrome often occurs when
residual small bowel length <200 cm
 The following minimum remaining intestinal
lengths must be respected :
 100 cm for terminal jejunostomy (colon removed)
 65 cm for jejunocolic anastomosis (colon retained)
 35 cm for jejunoileal anastomosis with retention
of the ileocecal region.
Messing B, et al. Gastroenterology.1999

36.  In the elderly patients and in those with
significant co-morbidities
 Significant risk of resection
 In younger patients
 Long term parenteral nutrition
 The option of subsequent intestinal
transplantation

37. Treatment

38.  Anastomosis should be avoided in patients
with shock or multiple organ dysfunction.
(LOE: III)
 Stoma avoid risks of anastomotic failure and
permit easy examination of the bowel by
inspection or endoscopy

39. Treatment

40.  Access bowel viability after revascularization
and resuscitation
 possible progression of bowel ischemia?
 If doubt about the viability of the bowel,
resection of it (LOE: IV).
 Bowel anastomosis(LOE: III).
 Close the wound

41. Treatment

42.  Symptoms >24hr=> Mortality increases
dramatically
 Symptoms <12hr=> lowest mortality
 Gut viability 100% when <12h
56% when 12~24hr
18% when >24hr
Aliosmanoglu I et al. Int Surg. 2013
Lobo Martinez E , et al. Rev Esp Enferm Dig. 1993

43.  Revascularization performed within 12 h from
the onset of symptoms. (LOE: III)
 Resection of non-viable bowel should be
performed without delay. (LOE: III)

44. Treatment

45.  ~60%TAMI have previous symptoms of
chronic mesenteric ischemia
 ~30% EAMI have inadequately treated atrial
fibrillation at presentation
Edwards MS, et al. AnnVasc Surg. 2003
Edwards MS, et al. AnnVasc Surg. 2003

46.  Elective revascularization for patients with
proven CMI (LOE: IV)
 Anticoagulants or antiplatelet therapy and
statin therapy for patients with mesenteric
artery thrombosis (LOE: IV).
 High risk of coronary thrombosis
Bj ¨ ornsson S, et al. J Gastrointest Surg 2013
Cho JS, et al. JVasc Surg. 2002

47.  Life-long anticoagulation, unless
contraindicated, for EAMI, prevent
recurrence (LOE: IV).
 A minimum of 6 months of anticoagulation
and survey for thrombophilia or
hypercoagulability forVAMI. (LOE: III).
Klempnauer J, Surgery. 1997
Daniel G. et al. N Engl J Med 2016
Acosta S, et al. Br J Surg 2008;

48.  History, physical examination
 prompt diagnosis should be achieved and
revascularization performed within 12 h from
the onset of symptoms.
 Resection of non-viable bowel should be
performed without delay

49. Presentation and clinical diagnosis

50.  Routine laboratory tests reflect disease
progression in AMI (LOE: III).
 Leukocytosis, metabolic acidosis with high anion gap
 High level of Lactate, amylase, AST(GOT), lactate
dehydrogenase(LDH) and creatine
phosphokinase(CPK)
 A normal serum lactate level does not exclude
AMI and not be used for diagnosis (LOE: III).