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Nigerian Journal of Surgical Research
Surgical Sciences Research Society, Zaria and Association of Surgeons of Nigeria
ISSN: 1595-1103
Vol. 8, Num. 3-4, 2006, pp. 119-122
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Nigerian Journal of Surgical Research, Vol. 8, No. 3-4, Jul-Dec, 2006, pp. 119-122
Mesenteric
ischemia: Results of surgical treatment and a review of literature
1M Mozaffar, 2P
Kharazm , 3M Talebian Far and 4K Firoozi
1Department of general and vascular surgery,
Shohada-E-Tajrish medical center, Tehran, Iran
2Request for Reprints to Dr P Kharazm, Department of
general and vascular surgery, Shohada-E-Tajrish medical center, Tehran, Iran, Tel: 0098 21 22718001-9 3Resident, Department of general and vascular
surgery,
Shohada-E-Tajrish medical center, Tehran, Iran 4General
surgeon
E-mail: pezhmankh@yahoo.com
Code Number: sr06028
Abstract
Background:
Acute Mesenteric Ischemia (AMI) is one of the causes of acute abdomen which
occurs because of significant decrement in bowel perfusion. Mortality rates of 60
to 100 percent have been reported in different studies in relation to this
fatal disease(1, 5, ,11, 16,18,28). In this study, we review clinical features,
laboratory findings, abdominal x rays, ECGs, intraoperative findings and
results of treatment in 32 patients who were admitted in Shohada-E-Tajrish hospital
with final diagnosis of AMI from March 1996 to March 2002.
Methods:
32 patients with final diagnosis of AMI who were admitted in Shohada-E-Tajrish
hospital were included in this retrospective study by means of review of their
files and medical records.
Results:The disease was more common in men
than women, with a 2:1 male: female ratio. The mean age of patients was 60
years. Abdominal pain was the most common symptom of patients followed by
nausea, vomiting, obstipation, hematemesis, and melena. On physical exam
tachycardia was prevalent. Oliguria was seen in approximately 70% of patients
and it was related to mortality. 10% of patients were in shock status related
to mortality. 30% of patients had peritoneal signs, but it was not related to
mortality. In laboratory tests, leukocytosis was present in 95% of patients,
and in 50% of cases it was more than 20000/mm³. Acidosis was seen in 80% of
patients and overall mortality rate was 75%.
Conclusion:
The final advice of the study is to pay intensive attention to resuscitation of
the patients, correction of metabolic and homodynamic derangements, and
performing laparotomy as soon as these derangements were corrected. In some
patients it is necessary to perform second look operation to evaluation of the
viability of the intestine.
Key words:
Mesenteric ischemia, second look, colectomy
Introduction
Acute
mesenteric ischemia is one of the most fatal diseases with a mortality rate of
60- 100%1,2,4,5,11,16,18,28. The severity of injury depends on
etiology of ischemia, systemic blood pressure, collateral circulation flow,
response of mesenteric vessels to autonomic stimulators, amounts of circulatory
autonomic stimulators, regional hormonal factors, presence of cellular
metabolites after reperfusion of the ischemic bowel, and duration of ischemia2,7,11,12,17,23,24,25,26 Four pathologic factors have been described as the
cause of acute mesenteric ischemia including: superior or inferior mesenteric
artery emboli, thrombosis of these vessels, venous thrombosis, and non
occlusive mesenteric ischemia5,9,12,21 Emboli is the most common cause of AMI1,14,15,25 Appropriate diagnosis of this disease depends on a
high clinical suspicion particularly in elderly an patient who has history of
cardiovascular disease14,7,21,22
Early diagnosis and early intervention to ameliorate vascular obstruction are
critical in patients salvage1,4,9,22,27 . Appropriate resuscitation of the patient and
diagnostic studies and early surgical or non surgical intervention is the most
effective approach to save the patient1,3,9,28 . Non surgical interventions are still investigatory,3,15 . However, recent studies have shown that angiography
and vasodilator or thrombolytic agent injection before appearance of peritoneal
signs or hemodynamic derangements, is beneficial and may replace surgical
intervention in a large number of this patients1,3,13,15,16,21. At this time, appropriate surgical intervention,
embolectomy, thrombectomy, vascular bypass, and resection of frankly gangrene
bowel and second look is the standard treatment of this fatal disease
6,10,22,27. In this study we decided to
review our experience in the management of mesenteric ischemia over a 6 year
period in Shohada-E-Tajrish Hospital Iran .
Patients
and Methods
32
patients with final diagnosis of acute mesenteric ischemia who were admitted in
Shohada-E-Tajrish hospital from March 1996 to March 2002 were included in this
study. Two patients died before operation and the diagnosis was based on
clinical findings and analysis of fluid aspiration from the abdomen. All others
had an intraoperative diagnosis of mesenteric ischemia. Biodata clinical
findings, laboratory results,operative technique, intraoperative findings and etiology
, and postoperative progression were recorded and classified and evaluated in
relation to mortality. Intra operative diagnosis of etiology was based on
presence of pulse at the origin of mesenteric arteries, location of injured
bowel, and evaluation of mesenteric veins. Presence of pulse at the origin of mesenteric
arteries signified the presence of an emboli and absence pulse suggested the diagnosis
was thrombosis, segmental intestinal involvement and presence of underlying
disease suggests non occlusive disease and at last, thrombosis of main veins
means venous thrombosis.
Results
There
were 32 patients; 21 men and 11 women were included in this study. The mean
age of patients was 60.8±16.9 years. All 32 patients had abdominal pain which was
sudden onset in 12 patients (37.5%) and recurrent and chronic in 20 patients
(62.5%). 31 (96.9%) patients had nausea, 28(87.5%) patients were vomiting.
Nineteen(59.3%) patients were constipated 5(15.6%) patients had
hematemesis,and 5(15.6%) patients had hematochesia. 13 (40.6%) patients had
cardiac disease,4 (12.5%) patients had atherosclerosis , 5 (15.6%) patients
had vasculitis , 1(3.1%) patient each had peritonitis,and abdominal aortic aneurysm
.Systemic diseases encountered in patients consisted of diabetes mellitus in 5(15.6%)
patients, hypertension in 5(15.6%) patients, Cardiomyopathy in 2(6.2%) patients
and scleroderma in 1(3%) patient. 17(53.1%) were previously healthy with no
prior systemic disease .
On
physical examination 17(53.1%) patients were conscious, 11(34.4%) patients were
lethargic, and 4(12.5%) patients had restless.Core body temperature (sublingual)
was normal in 26(81.2%) patients. There was slight elevation to 37.8º c
in 6 (18.7%).10(31.2%) patients presented in shock and 16(50%) patients
had symptoms of peritonitis.Mean systolic blood pressure on admission and mean
diastolic blood pressure were 113.8±26.1 and 67.3±15.2 mm Hg. Mean pulse rate
was 106.8±19 per minute and respiratory rate was 25.6±6.1 per minute. In
abdominal exam, 32(100%) patients had tenderness, 18(56.2%) patients had
guarding, and 10(31.2% patients had rebound tender ness. 31(96.9%) patients had
abdominal distention. Bowel sounds were decreased in 28(87.5%), patients, increased
in 2(6.3%) patients and normal in 2(6.3%) patients.
Central
venous catheters were inserted for all of patients and CVP was normal in 20 (62.5%),
patients increased in 9 (28.1%) patients and decreased in 3 patients (9.4%).
Urinary output was less than 30cc per hour in 23 patients (71.9%) and more than
30cc per hour in 9(28.1%) patients. There was AF rhythm on electocardiography
in 12(37.7%), patients and sinus tachycardia in 11 (34.4%) patients and normal
sinus rhythm in 8(25%) There was myocardial Infarction in 1 (3.1%)patient .White
blood cell count was greater than 20000/mm 3in 16(50%), patients 10000
to 20000 in 13(40.6%) patients and less than 10000 in 3(9.4%)patients. On
laboratory investigations, blood sugar was high in 20(62.5%) patients and
normal in other 12 patients. Hemoglobin was normal in 22(68.7%), and low in 10(31.2%).
Creatinine was high in 21(65.6%) patients and normal in 11 (34.4%). PaO2 was
low in 2(68.8%) 2 patients and normal in 10 (31.2%) patients. There was
acidosis with a low bicarbonate level in 25(78.1%), patients normal in 5(15.6%)
patients and high in 2 (6.3%) patients. Potassium was high in 7(21.9%) patients,
normal in 17(53.1%) patients and low in 8 (25) % patients . On plain abdominal
x-rays, there were distended intestinal loops in 1(3.1%) patient, diffuse
haziness in one patient , diffuse haziness and air-fluid level in 7 patients ,
diffuse haziness and distended loops and air-fluid levels in 3(9. %4) patients,
There were no x-rays reports in 20(62.5%)patients. The interval between onset
of pain and operation was greater than 10 hours in 25 (78.1%) patients and
lower than 10 hours in 25 (15.6%) patients. 2 patients died before operation. Peritoneal
fluid was aspirated looked dark in 28 patients (87.5%) and clear in 4 (12.5%)patients.
Intra operative findings consisted of: gangrene Jejunum in 13 patients (43.3%),
normal in 12(40%) patients and suspicious in 5 patients (16.7%). There was gangrene
Ileum in 24 patient (80%) and normal in 6 patients (20%). There was gangrene
cecum in 13 patients (43.3%), normal in 15 patients (50%) and suspicious in 2
patients (6.7%). Gangrene ascending colon in 17 patients (56.7%), normal in 11
patients (36.7%) and suspicious in 2 patients (6.7%). Gangrene Transverse
colon in 15 patients (50%), normal in 12 patients (40%) and suspicious in 3
patients (10%). Gangrene descending colon in 7 patients (23.3%), normal in 22
patients (73.3%) and suspicious in 1 patient (3.3%).Intra operative diagnosis
of patients was emboli in19 patients (63.3%1), thrombosis in 9 patients (30%),
non occlusive in 1 patient (3.3%), and venous thrombosis in 1 patient (3.3%). The
mucosa of the transected bowel was well perfused in 16 patient (53.3%), poorly
perfused in 12 patients (40%) and suspicious in 2 patients (6.7%) .
Discussion
The mean age of patients was 60.8 ± 19.6 years which is
approximately 10 years younger comparing to other studies2711,19. Women11,19.
are more commonly affected though sixty seven percent of our patients were
male. Tachycardia was a common mode of presentation among our patients and there
was leukocytosis evidence of overwhelming in ongoing inflammatory reaction. Renal
function was compromised as evidenced by acidosis , hypo/hyperkalemia and
raised creatinine . Mesenteric ischemia was complicated by atrial fibrillation
, , vasculitis , peritonitis , sclerodermia, vomiting hematemesis, constipation,
and melena. There was associated comorbdities noted in some patients notably
cardiac disease, atherosclerosis and diabetes mellitus . The commonest
presenting sign was abdominal pain, nausea, vomiting and hematemesis. Resuscitation
was meant to be improve urinary output as most patients whose output were
compromised had a poor outcome. Thirty four percent of patients presenting in
Shock did not recover and all 84% of patient who were not in shock or were
resuscitated all survived. Plain abdominal x rays did not provide specifc
information to support diagnosis in 13 patients but in 50% of patients there
were features suggestive of peritonitis .There were no imaging characteristics
useful in the prediction of mortality. It is usually not easy to identify clinically
the patient AMI due to an embolus different from the patient with thrombosis.
Several studies indicate that AMI following emboli do worse than those caused
by thrombi17,21. Patients who had a second look operation were more
likely to survive compared to those who never had it.. SMA embolectomy was performed on two patients, one
died on the table and the other one was discharged after 1 week. Over all mortality rate for all operations in the long run was
75%.
Conclusion
The
patient with AMI is a surgical emergency due to derangement in electrolytes with
severe inflammatory reaction. The initial effort is to resuscitate efficiently
and take a good clinical history and exam thoroughly.. Intervention should be urgent with the aim of resection
of gangrene loops of gut ,embolectomy and vascular bypass as necessary .Accurate
postoperative monitoring of the patient is critical and oral feeding should be
started as soon as possible. In this situation TPN may be helpful in managing
the patient. If short bowel syndrome or other complications of bowel resection
occur, continuing the TPN until bowel adaptation is recommended.
Acknowledgements:
Dr.
Mozaffar, the chief surgeon and leader of the study. Dr. Kharazm, corresponding
author, medical records and literature researcher, Dr. Talebian far, literature
researcher. Dr. Firoozi, medical records reviewer.
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