Surgical treatment of acute mesenteric ischemia

Abstract

Introduction: Acute mesenteric ischemia (AMI) is an abdominal catastrophe. Advanced age and diagnosis delay are associated with increased morbidity and mortality rates. The optimal surgical strategy for AMI is under evaluation. Aim: To evaluate the early results of different treatment strategies for AMI. Material and methods: During last three years a total of 35 consecutive pts with AMI were admitted to our unit. The mean (±SD) time interval between AMI symptoms onset and admission was 34.7±2.1 h. Physiological parameters (mean±SD) of pts were: ASA score - 3.3±0.1, APACHE score - 25.2±1.6 and POSSUM - 36.9±1.8. In most cases AMI was induced by superior mesenteric artery (SMA) embolism (54.3%, n = 19) followed by SMA thrombosis (25.7%, n= 9) and venous thrombosis (VT) (20%, n=7). Results: The affected bowel segments were: small intestine (n=16), small intestine + colon (n=13) and total ischemia (n=6). Surgical procedures were as follows: small intestine resection (n=14) with SMA embolectomy (n=2), small intestine + right colon (n=12) and small intestine + subtotal colectomy (n=l). In two cases of VT affected intestinal segments were not resected, instead anticoagulation treatment was initiated and the intestinal viability was confirmed by second-look laparotomy. Explorative laparotomy was used only in advanced intestinal gangrene (n=6). Twenty five pts with massive injury were scheduled for staged damage control approach (immediate resection of the involved bowel without gastrointestinal continuity reconstruction, patients’ resuscitation in ICU) combined with Negative Pressure Wound Therapy (V.A.C., KCI or homemade) and later on definitive reconstructive procedure (delayed anastomosis). Primary anastomoses were performed only in 2 pts with short segmental intestinal infarction. The overall 30-days mortality rate was 24/35, 68.5% (in non-total AMI - 18/29, 62%, in VT zero). Conclusions: Early diagnosis and prompt surgery improves the AMI outcome. Colon involved in AMI is a poor prognosis sign. Damage control approach improves the AMI patients’ survival.