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Mesenteric Ischaemia - Overview of management approach Joint Hospital Surgical Grand Round Dr Shirley Liu Department of Surgery North District Hospital.

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Presentation on theme: "Mesenteric Ischaemia - Overview of management approach Joint Hospital Surgical Grand Round Dr Shirley Liu Department of Surgery North District Hospital."— Presentation transcript:

1 Mesenteric Ischaemia - Overview of management approach Joint Hospital Surgical Grand Round Dr Shirley Liu Department of Surgery North District Hospital

2 Mesenteric Ischaemia “Occlusion of the mesenteric vessels is apt to be regarded as one of those condition of which …the diagnosis is impossible, …the prognosis hopeless, …and the treatment almost useless” A.J. Cokkinis 1926 Cokkinis AJ. Mesenteric vascular occlusion. London, Bailliere, Tindall and Cox. 1926pp1-93

3 Commonest outcome…

4 Pathophysiology Resting bowel: 20% cardiac output Postprandial bowel: 35% cardiac output Bradbury AW, et al. Br J Surg 1995;82:

5 Mesenteric arteries SMA IMA Affect small and large bowelAffect large bowel alone Acute SMA occlusionIschaemic colitis

6  15 mins - Structural changes to intestinal villi  3 hours - Mucosal sloughing - Still reversible  6 hours - Transmural necrosis - Gangrene - Perforation 15 mins 3 hours6 hours Udassin R, et al. J Surg Res 1994;56:221-5 Absolute ischaemia What happens to bowel during absolute ischaemia? Time is crucial !

7 Mesenteric ischaemia Acute Mesenteric Ischaemia Chronic Mesenteric Ischaemia Arterial occlusion Venous occlusion Non-occlusive Embolism 20-30% Thrombosis 50% Mesenteric Venous thrombosis (MVT) 15% Non-occlusive Mesenteric ischaemia (NOMI) 15% Bradbury AW, et al. Br J Surg 1995;82:

8 Management of acute mesenteric ischaemia Clinical suspicion Exclude other non-vascular abdominal emergencies Ischaemic bowel cannot be excluded Unstable/ Peritonism present Stable & Peritonism absent CT scan or angiography SMA occlusion Non-occlusive mesenteric ischaemia Mesenteric Venous thrombosis Surgical treatment Trans-arterial vasodilator infusion Immediate heparinization No improvement Diagnosis not certain negative finding Positive finding

9 Management of acute mesenteric ischaemia Clinical suspicion Exclude other non-vascular abdominal emergencies Ischaemic bowel cannot be excluded

10 Clinical suspicion… Elderly patients Associated comorbidities: Hypertension 60% IHD 58% Diabetes 35% AF 28% Renal failure 25% Peripheral vascular disease 18% Past history of atherosclerotic diseases Park WM, et al. J Vasc Surg 2002;35:445-52

11 Clinical suspicion… Symptoms and signs –Abdominal pain 95% - Pain out of proportion of signs –Nausea 44% –Vomiting 35% –Diarrhea 35% –PR bleeding 16% –Fever 46% –Tachycardia 58% –Abd distension 66% Laboratory tests –Leukocytosis –Elevated urea –Elevated creatinine –Elevated lactate –Metabolic acidosis –DIC Endean ED, et al. Ann Surg 2001;233: Park WM, et al. J Vasc Surg 2002;35: Sreedharan S, et al. Singapore Med J 2007;48: Most symptoms and signs are non-specific Need to exclude other non-vascular emergencies

12 Clinical suspicion… Normal plain X-ray Signs suggestive of bowel infarction: - Dilated thickened bowel loops - Ground glass appearance - Thumb printing - Pneumatosis intestinalis - Gas in portal vein

13 Clinical triad… Klass AA. Ann Surg 1951;134: Acute Mesenteric ischaemia Sudden abdominal pain Gut emptying Cardiac source of embolization

14 Management of acute mesenteric ischaemia Clinical suspicion Exclude other non-vascular abdominal emergencies Ischaemic bowel cannot be excluded CT scan or angiography Unstable/ Peritonism present Surgical treatment Stable & Peritonism absent Diagnosis not certain

15 Park WM, et al. J Vasc Surg 2002;35: CT scanConventional angiography Diagnostic role Sensitivity - SMA occlusion 78% - Bowel ischaemia 61% - Either one 89% Sensitivity - SMA occlusion 100% - Bowel ischaemia N/A Exclude other sources of acute abdomen Can identify venous thrombosis Can identify NOMI Therapeutic role Allow endovascular interventions

16 Features in CT scan SMA thrombus Bowel wall thickening Non-enhanced bowel wall Pneumatosis intestinalisPortal venous gas Fluid collection Wiesner W, et al. Radiology 2003;226:635-50

17 CT angiogram Kirkpatrick ID, et al. Radiology 2003;229:91-98

18 CT scan vs Angiography CT scan - More preferred choice - Can exclude other non-vascular emergencies if diagnostic confusion Both are time-consuming - introduce critical delay in management

19 Management of acute mesenteric ischaemia Clinical suspicion Exclude other non-vascular abdominal emergencies Ischaemic bowel cannot be excluded Unstable/ Peritonism present Stable & Peritonism absent CT scan or angiography Surgical treatment Diagnosis not certain negative finding SMA occlusion Positive finding

20 Acute SMA Occlusion SMA Embolism Aortic ostium ~15% Around Middle colic artery ~40% Distal branches ~45% SMA Thrombosis Aortic ostium ~60-80% Distal branches ~5% Around Middle colic artery ~15% Acosta S, et al. Ann Surg 2005;241:516-22

21 Immediate resuscitation… Before operation –Bowel rest –Fluid resuscitation –Close hemodynamic monitoring –Nasogastric decompression –Indwelling urinary catheterization –Parenteral antibiotics –Anticoagulation by heparin Schwartz LB, et al. Surg Clin North Am 1997;77:

22 Definitive surgical exploration 1. Assessment of bowel viability 2. Determination of underlying cause 3. Mesenteric revascularization 4. Resection of necrotic bowel 5. Second look laparotomy Midline laparotomy

23 Assessment of bowel viability 1. Clinical Judgment - pink serosa - visible peristalsis - positive pulsations - bleeding from cut edges (Ballard JL, et al. Am Surg 1993;59:309-11) 2. Doppler USG - hand-held doppler (Hobson RW, et al. J Surg Res 1976;20:231-5) 3. Fluorescein -Injection of fluorescein and inspection under Wood’s lamp (Bergman RT, et al. Ann Vasc Surg 1992; 6:74-9)

24 Assessment of bowel viability Necrotic bowel Extensive infarction Tender loving care Limited infarction Equivocal viability Revascularization procedures

25 Determination of underlying cause: Thrombosis or embolism? Palpate Main trunk of SMA Absent pulse Thrombosis Pulse present proximally but not distally Embolism

26 Mesenteric Revascularization Embolism Balloon catheter embolectomy ± Vein patch angioplasty Thrombosis Thrombectomy Bypass graftingReimplantation of SMA

27 Revascularization procedures…(1) Bypass grafting –Direction Antegrade bypass from supraceliac aorta Retrograde bypass from infrarenal aorta Both are equally good –Conduit Autologous graft –Propensity to kink Synthetic graft –Contamination during bowel resection may cause synthetic graft infection Foley MI, et al. J Vasc Surg 2000;32:37-47 Bradbury AW, et al. Br J Surg 1995;82:

28 Revascularization procedures…(2) Reimplantation of SMA –Aortomesenteric bypass is time-consuming –Direct reimplantation of SMA is quicker –Recommended as procedure of choice Testart J, et al. Int Angiol 1992;11:181-5

29 Resection of necrotic bowel Anastomosis should not be attempted –Equivocal viability at cut ends –Exteriorize as stomas

30 Second look laparotomy Who should undergo second look laparotomy? Routine after hours - allow reassessment of bowel viability - claim to have reduced mortality Levy PJ, et al. Surg Gynecol Obstet 1990;170: Selective approach - increased operative risks for second operation - suggest only when clinical deterioration - but means further infarction with worse outcome Hagmuller GW, et al. Langenbecks Arch Chir 1990:311-15

31 Alternative to surgery… Endovascular therapy Acute SMA thrombosis NOMI Percutaneous balloon angioplasty ± stenting Transarterial thrombolysis Transarterial infusion of vasodilator Limited use in acute situations –Cannot assess bowel viability –Only indicated in early cases without bowel infarction

32 Management of acute mesenteric ischaemia Clinical suspicion Exclude other non-vascular abdominal emergencies Ischaemic bowel cannot be excluded Unstable/ Peritonism present Stable & Peritonism absent CT scan or angiography SMA occlusion Non-occlusive mesenteric ischaemia Mesenteric Venous thrombosis Surgical treatment Trans-arterial vasodilator infusion Immediate heparinization No improvement Diagnosis not certain negative finding

33 Non-occlusive mesenteric ischaemia (NOMI) Etiology: no occlusion –Low cardiac output –Mesenteric vasospasm Treatment is non-surgical –Treat underlying cause –Transarterial infusion of vasodilator (papeverine) Bradbury AW, et al. Br J Surg 1995;82:

34 Mesenteric venous thrombosis (MVT) Bradbury AW, et al. Br J Surg 1995;82: Primary MVT (40%) - any hypercoagulable states Secondary MVT (60%) - Portal hypertension - Intraabdominal sepsis - Intraabdominal neoplasia - Pancreatitis - Trauma Treatment is non-surgical 1.Heparinization 2.Thrombophilia screening

35 Prognosis of acute mesenteric ischaemia Overall average mortality 60-80% Park WM, et al. J Vasc Surg 2002;35: Ischaemic reperfusion injury Multiorgan failure

36 Conclusion Acute mesenteric ischaemia –Morbid condition –High mortality rate High index of suspicion –Pain out of proportion of signs –Early recognition is crucial

37 Management of acute mesenteric ischaemia Clinical suspicion Exclude other non-vascular abdominal emergencies Ischaemic bowel cannot be excluded Unstable/ Peritonism present Stable & Peritonism absent CT scan or angiography SMA occlusion Non-occlusive mesenteric ischaemia Mesenteric Venous thrombosis Surgical treatment Trans-arterial vasodilator infusion Immediate heparinization No improvement Diagnosis not certain negative finding Positive finding

38 Thank you Welcome to NDH


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