Mesenteric ischemia surgery
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Feham Tariq, MD [2]
Overview
Surgery in mesenteric ischemia is performed to resect the ischemic bowel in order to prevent the complications. However, in the case of acute embolic type of mesenteric ischemia, early laparotomy and surgical resection is the mainstay of treatment.
Surgery
- The goals of surgical therapy are as follows:
- Intestinal viability is defined as the maximum vital element influencing outcome in patients with AMI.
- Non-viable bowel, if unrecognized, can cause multi-organ failure and lead to death.
Approach to treatment
The treatment modality chosen for the patient depends on the type and the location of occlusion, along with hemodyanamic stability.
Surgical versus endovascular intervention
Endovascular intervention
- Hemodyanamically stable patients and those who do not have clinical or radiological signs of ischemia are preferred candidates for endovascular intervention.[5][6][7][8]
- Using endovascular intervention as the primary modality of treatment helps reduce complications, provides better outcome and shortens the length of hospital stay.[9][10]
- Two types of endovascular interventions have been described:[11][12]
(a)Pharmacomechanical thrombolysis
(b)Mesenteric angioplasty/stenting
(a)Pharmacomechanical thrombolysis:
- It is performed in the following patients:
- Who can undergo arteriography within eight hours of the onset of abdominal pain
- No contraindications to fibrinolytic therapy
- No clinical signs of ischemia
- Procedure:
Retrograde open mesenteric stenting
Revascularization
- Embolectomy:
The conventional treatment offered for mesenteric embolism is embolectomy. It clears the thrombus and helps assess the bowel viability.
- Mesenteric bypass:
For mesenteric thrombosis, open surgical intervention is done followed by intraoperative retrograde superior mesenteric artery angiplasty and stenting for the atherosclerotic plaques.
Lapratomy and damage control:
Lapratomy is performed once bowel infarction has occurred. It has the following indications and uses:
- Acute abdominal findings on physical exam consistent with peritonitis.
- Facilitates general abdominal exploration for gross pathology and other signs of visceral thrombosis.
- Allows to determine the viability of the bowel.
- Determines the extent and severity of intestinal ischemia.
- Assessment of arterial pulsations in the mesenteric vasculature and bleeding from cut surfaces.
Procedure:
- After preliminary resuscitation, midline laparotomy should be done to observe the areas of gut with choices for resection of all the necrotic areas. In instances of uncertainty, intraoperative Doppler can be beneficial.
Postprocedural care and follow up:
Second-look lapratomy and abdominal wall closure:
It is performed in patients who undergo revascularization for mesenteric ischemia for the following reasons:
- Reevaluate the bowel after 24-48 hours of initial operation
- Assessment of bowel viability after revascularization
- Resection of irreversibly ischemic bowel
- Significantly reduces the mortality after surgery
Surgical procedure options:
- Balloon catheter embolectomy of the superior mesenteric artery
- For restoration of blood flow in acute mesenteric ischemia, antegrade aorto-mesenteric bypass from supraceliac aorta is the best choice.
- Percutaneous transluminal angioplasty is also considered for revascularization in some case reports.
- A new hybrid endovascular-surgical technique for managing mesenteric ischemia has been proposed.
- Laprotomy is done when transmural bowel infarction has occurred.
Treatment strategy of acute embolic mesenteric ischemia:
Treatment for acute embolic mesenteric ischemia is mainly surgical and is managed according to the hemodyanamic stability or the presence/absence of peritoneal signs.
| Embolic mesenteric arterial occlusion | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Anticoagulation with heparin Pain management | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Peritoneal signs | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Computed tomographic angiography | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Embolus present | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Thrombolysis | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Repeat imaging Resolution of thrombus and no persistent symptoms | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| No | Yes | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Observe | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Signs of non-viable bowel | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Initiate oral diet | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Exploration and open surgical embolectomy | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Non-viable bowel | Surgical revascularization for unsuccessful embolectomy | A03 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| No | Yes | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Temporary abdominal closure | Bowel resection | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Second look lapratomy | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| No additional resection | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Delayed abdominal closure | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
References
- ↑ Arthurs ZM, Titus J, Bannazadeh M, Eagleton MJ, Srivastava S, Sarac TP; et al. (2011). "A comparison of endovascular revascularization with traditional therapy for the treatment of acute mesenteric ischemia". J Vasc Surg. 53 (3): 698–704, discussion 704-5. doi:10.1016/j.jvs.2010.09.049. PMID 21236616.
- ↑ Björnsson S, Resch T, Acosta S (2013). "Symptomatic mesenteric atherosclerotic disease-lessons learned from the diagnostic workup". J Gastrointest Surg. 17 (5): 973–80. doi:10.1007/s11605-013-2139-z. PMID 23307340.
- ↑ Sharafuddin MJ, Nicholson RM, Kresowik TF, Amin PB, Hoballah JJ, Sharp WJ (2012). "Endovascular recanalization of total occlusions of the mesenteric and celiac arteries". J Vasc Surg. 55 (6): 1674–81. doi:10.1016/j.jvs.2011.12.013. PMID 22516890.
- ↑ Bobadilla JL (2013). "Mesenteric ischemia". Surg Clin North Am. 93 (4): 925–40, ix. doi:10.1016/j.suc.2013.04.002. PMID 23885938.
- ↑ Ryer EJ, Kalra M, Oderich GS, Duncan AA, Gloviczki P, Cha S; et al. (2012). "Revascularization for acute mesenteric ischemia". J Vasc Surg. 55 (6): 1682–9. doi:10.1016/j.jvs.2011.12.017. PMID 22503176.
- ↑ Kougias P, Huynh TT, Lin PH (2009). "Clinical outcomes of mesenteric artery stenting versus surgical revascularization in chronic mesenteric ischemia". Int Angiol. 28 (2): 132–7. PMID 19367243.
- ↑ Block TA, Acosta S, Björck M (2010). "Endovascular and open surgery for acute occlusion of the superior mesenteric artery". J Vasc Surg. 52 (4): 959–66. doi:10.1016/j.jvs.2010.05.084. PMID 20620006.
- ↑ Schermerhorn ML, Giles KA, Hamdan AD, Wyers MC, Pomposelli FB (2009). "Mesenteric revascularization: management and outcomes in the United States, 1988-2006". J Vasc Surg. 50 (2): 341–348.e1. doi:10.1016/j.jvs.2009.03.004. PMC 2716426. PMID 19372025.
- ↑ 9.0 9.1 Sarac TP, Altinel O, Kashyap V, Bena J, Lyden S, Sruvastava S; et al. (2008). "Endovascular treatment of stenotic and occluded visceral arteries for chronic mesenteric ischemia". J Vasc Surg. 47 (3): 485–491. doi:10.1016/j.jvs.2007.11.046. PMID 18295100.
- ↑ Cai W, Li X, Shu C, Qiu J, Fang K, Li M; et al. (2015). "Comparison of clinical outcomes of endovascular versus open revascularization for chronic mesenteric ischemia: a meta-analysis". Ann Vasc Surg. 29 (5): 934–40. doi:10.1016/j.avsg.2015.01.010. PMID 25757988.
- ↑ McBride KD, Gaines PA (1994). "Thrombolysis of a partially occluding superior mesenteric artery thromboembolus by infusion of streptokinase". Cardiovasc Intervent Radiol. 17 (3): 164–6. PMID 8087835.
- ↑ Calin GA, Calin S, Ionescu R, Croitoru M, Diculescu M, Oproiu A (2003). "Successful local fibrinolytic treatment and balloon angioplasty in superior mesenteric arterial embolism: a case report and literature review". Hepatogastroenterology. 50 (51): 732–4. PMID 12828073.
- ↑ Luo QZ, Lin L, Gong Z, Mei B, Xu YJ, Huo Z; et al. (2011). "Positive association of major histocompatibility complex class I chain-related gene A polymorphism with leukemia susceptibility in the people of Han nationality of Southern China". Tissue Antigens. 78 (3): 178–84. doi:10.1111/j.1399-0039.2011.01748.x. PMID 21810082.
- ↑ Lee RW, Bakken AM, Palchik E, Saad WE, Davies MG (2008). "Long-term outcomes of endoluminal therapy for chronic atherosclerotic occlusive mesenteric disease". Ann Vasc Surg. 22 (4): 541–6. doi:10.1016/j.avsg.2007.09.019. PMID 18620112.