מצגת של PowerPoint · History 1951,Klass AA: Embolectomy in acute mesenteric occlusion. Ann Surg 134:913-917 Mortality rate 70-90% up to 1970 1970,Boley and Clark: Angiography,

Israel Surgical Israel Surgical

Association Association

Dead Sea Dead Sea 66//20122012

Ahmed Eid, MDAhmed Eid, MD

HeadHead, , Department Of Department Of Surgery, HadassahSurgery, Hadassah

Mount Scopus CampusMount Scopus Campus

JerusalemJerusalem

Mesenteric Ischemia

Mesenteric IschemiaMesenteric Ischemia

HistoryHistory 1951,Klass AA: Embolectomy in acute mesenteric occlusion.

Ann Surg 134:913-917

Mortality rate 70-90% up to 1970

1970,Boley and Clark: Angiography, Vasodilators

Mortality rate 60-80%

2000, introduction of MD –CTA in the diagnosis of AMI

No improvement in mortality rate for

the last four decades

Delay in diagnosis(8hours) and initiation of revascularization(2.5 hours)

Mesenteric blood flowMesenteric blood flow

CACA

SMASMA

IMAIMA

MCAMCA

Arc of Buhler Marginal artery of Drummond and the arc

of Riolan ( meandering mesenteric artery)

Auto regulatory ability

שאלה ראשונהשאלה ראשונה

??מה נכון לגבי הספקת דם מזנטריאליתמה נכון לגבי הספקת דם מזנטריאלית

מתפוקת הלב ורובה מכוון למוקוזהמתפוקת הלב ורובה מכוון למוקוזה 20%20% --מהווה כמהווה כ. . 11

מתפוקת הלב ורובה מכוון למוקוזהמתפוקת הלב ורובה מכוון למוקוזה 40%40%מהווה מהווה . . 22

לאחר ארוחהלאחר ארוחה 30%30% --מתפוקת הלב ועולה למתפוקת הלב ועולה ל 10%10% --מהווה רק כמהווה רק כ. . 33

מתפוקת הלב ורובה מכוון לשריריתמתפוקת הלב ורובה מכוון לשרירית 20%20% --מהווה כמהווה כ. . 44



2020--25%25% of CO (of CO (25 25 ml/KG BW/min)ml/KG BW/min) ( intensively perfused organ at rest)( intensively perfused organ at rest)

Increase to Increase to 3030% postprandial % postprandial

7070% is directed to mucosa/submucosa% is directed to mucosa/submucosa

Mesenteric Ischemia

Definition

Inadequate blood flow (Oxygen Delivery) to

visceral tissues which leads initially to

mucosal ischemia but eventually may lead

to necrosis of the entire bowel wall

Acute Mesenteric IschemiaAcute Mesenteric Ischemia

PathophysiologyPathophysiology

Inflammatory cell response, mediator surge and

breakdown of the epithelial barrier function with bacterial

translocation, and development of a systemic inflammatory

response.

Warm Ischemia Time (WIT)Warm Ischemia Time (WIT)

שאלה שניהשאלה שניה ::זמן האיסכמיה החמה של המעי הדק הוא זמן האיסכמיה החמה של המעי הדק הוא

עד שעהעד שעה. . 11

שעותשעות 66עד עד . . 22



Acute Mesenteric IschemiaAcute Mesenteric Ischemia PerspectivePerspective

WIT- 6 hours

Abdominal (Vascular ) Emergency

שאלה שלישיתשאלה שלישית

איסכמיה מזנטריאלית חריפה כוללת את המצבים איסכמיה מזנטריאלית חריפה כוללת את המצבים

::הבאים מלבדהבאים מלבד

חסימה אמבולית של עורק מזנטריאלית עליוןחסימה אמבולית של עורק מזנטריאלית עליון. . 11

חסימה טרומבוטית של עורק מזנטריאלית עליוןחסימה טרומבוטית של עורק מזנטריאלית עליון. . 22

קוליטיס איסכמית קוליטיס איסכמית . . 33

44 . .Mesenteric Vein ThrombosisMesenteric Vein Thrombosis

Classification of Intestinal Classification of Intestinal

IschemiaIschemia

Intestinal IschemiaIntestinal Ischemia

Acute Mesenteric IschemiaAcute Mesenteric Ischemia SMA Embolic OcclusionSMA Embolic Occlusion

SMA Thrombotic occlusionSMA Thrombotic occlusion

Non Non ––Occlusive Mesenteric Ischemia (NOMI)Occlusive Mesenteric Ischemia (NOMI)

Mesenteric Vein Thrombosis (MVTMesenteric Vein Thrombosis (MVT))

Chronic Mesenteric IschemiaChronic Mesenteric Ischemia

Ischemic colitisIschemic colitis

American Gastroenterological Association American Gastroenterological Association

20002000


EpidemiologyEpidemiology

שאלה ארבעשאלה ארבע

::הסיבה השכיחה ביותר כיום לאיסכמיה מזנטריאלית חריפההסיבה השכיחה ביותר כיום לאיסכמיה מזנטריאלית חריפה

חסימה של עורק מזנטריאלי עליוןחסימה של עורק מזנטריאלי עליון. . 11

Mesenteric Vein Thrombosis .Mesenteric Vein Thrombosis .22

NOMINOMI-- Non Occlusive Mesenteric Ischemia .Non Occlusive Mesenteric Ischemia .33

44 . .Ischemic colitisIschemic colitis


6767..22%%

1515..77%%

1515..44%%

Epidemiology of Mesenteric Vascular Disease: Clinical Implications

Stefan Acosta

Semin Vasc Surg 23:4-8 , 2010

Incidence Of AMIIncidence Of AMI

Dr Dr EitanEitan

How common AMI is relative to other How common AMI is relative to other

abdominal emergenciesabdominal emergencies

Age influenceAge influence

IncidenceIncidence 1212..99//100100,,000 000 personperson--yearyear

11//1000 1000 Hospital AdmissionsHospital Admissions

11//100 100 Acute abdomenAcute abdomen

Toney RJ, Cunningham CG. Acute mesenteric ischemia. Surgery 1993;114(3):489–90.

Schneider TA, Longo WE, Ure T, et al. Mesenteric ischemia. Acute arterial syndromes

. Dis Colon Rectum 1994;37(11):1163–74.

Schoots IG, Levi MM, Reekers JA, et al. Thrombolytic therapy for acute superior mesenteric

artery occlusion. J Vasc Interv Radiol 2005;16(3):317–29.

1% of all patients with acute abdomen have AMI

10% of patients aged over 70

Major IssuesMajor Issues

DiagnosisDiagnosis

Risk profilingRisk profiling

Targeted diagnosis (CT/ANGIO)Targeted diagnosis (CT/ANGIO)

Initial treatment Initial treatment EGDR EGDR

Fluid resuscitation, Antibiotic, Fluid resuscitation, Antibiotic,

HeparinHeparin

Surgery/Surgery/Endovascular/Combined Endovascular/Combined logistic, sequence, teamlogistic, sequence, team

Extent of resectionExtent of resection

Need for revascularizationNeed for revascularization

Second look policySecond look policy

Chronic anticoagulation policyChronic anticoagulation policy

Diagnosis

Nonspecific clinical presentationNonspecific clinical presentation

High index of suspicionHigh index of suspicion

Acute mesenteric Ischemia is a rather common

cause of acute abdominal pain

Only one third of patients who had acute mesenteric Only one third of patients who had acute mesenteric

ischemia were correctly diagnosed before surgical ischemia were correctly diagnosed before surgical

exploration or deathexploration or death

Mamode N, Pickford I, Leiberman P. Failure to improve outcome in acute mesentericMamode N, Pickford I, Leiberman P. Failure to improve outcome in acute mesenteric

ischaemia: sevenischaemia: seven--year review. Eur J Surg year review. Eur J Surg 19991999;;165165((33):):203203––88..

Diagnosis

Major symptom Abdominal Pain

Associated Symptoms: Bloating, Vomiting, Diarrhea

Embolic Thrombosis MVT NOMI

Clin sudden, rapid progression Subacute acute, subcaute vaiable

RISK F AF,LVaneurysm Abd. Angina ,sitophobia Hypercog State CHF,Dialysis

Recent MI,valvular dis Fem,HT,DM,Smoking Thrombophylia post heart surg

Cardiomyo,other emboli sec sepsis

LAB Hemoconcentration ,WBC>15000,Anion gap acidosis

Amylase,LDH

D-dimer, αα--GST, GST, D-lactate, I-FABP

Diagnostic MD-CT A MD-CTA MD-CT A ANGIO

Case PresentationCase Presentation

Dr. Chapchay KatherineDr. Chapchay Katherine

CaseCase

66 66 y.oy.o. male. male

Pacemaker Pacemaker 20082008

AtrialAtrial fibrillationfibrillation

HyperlipidemiaHyperlipidemia

AnkylosingAnkylosing spondilitisspondilitis

ObesityObesity

Meds: Meds: propafenonpropafenon, , coumadincoumadin, , simvastatinsimvastatin

Major ComplainMajor Complain

Diffuse abdominal pain for Diffuse abdominal pain for 6 6 hours hours

bloody diarrhea and vomitingbloody diarrhea and vomiting

Physical examinationPhysical examination

Fully conscious, Fully conscious, 170170//103103, pulse , pulse 6060, , 3636..44, ,

sat sat 9898%%

Heart, lungs normalHeart, lungs normal

Abdomen: soft, not tenderAbdomen: soft, not tender

Periphery: normal pulses, no signs of DVTPeriphery: normal pulses, no signs of DVT

PR : normal color of feces, with some PR : normal color of feces, with some

bloodblood

LabsLabs

PlanPlan

Working diagnosis Working diagnosis –– GE / lower GI GE / lower GI

bleedingbleeding

Admitted to surgical ward for observation Admitted to surgical ward for observation

and treatmentand treatment..

DrDr AsafAsaf

Assessment of the presented case Assessment of the presented case

((Risk Profiling for AMIRisk Profiling for AMI))

Evaluation ANGIO/CTEvaluation ANGIO/CT

Logistic of ORLogistic of OR

MD-CTA

SMA Embolic OcclusionSMA Embolic Occlusion MDMD--CTA Sagittal ViewCTA Sagittal View

SMA Embolic OcclusionSMA Embolic Occlusion

Multiple emboli Mural Thickening ,Intramural gas

Absence of mural enhancement

SMA Thrombotic OcclusionSMA Thrombotic Occlusion

MD-CTA Acute Mesenteric Ischemia

Mural thickening ( symmetric and circumferential, usually does not exceed 1.5cm in thickness) .

Lack of mural enhancement

Intramural gas

Other CT findings:

Increased attenuation in the mesentery ( from mesenteric vascular

engorgement or mesenteric fluid)

Small intestinal dilatation

Ascites


ContinuedContinued

During the first During the first 2 2 days of hospitalization days of hospitalization

the patient was intermittently painful, but the patient was intermittently painful, but

stable, soft abdomen , normal labsstable, soft abdomen , normal labs

On the third day after admission the On the third day after admission the

patient developed increasing pain and patient developed increasing pain and

peritonitisperitonitis

labslabs

MD-CTA

MD-CTA


ContinuedContinued

Exploratory laparotomyExploratory laparotomy

Large amount of free turbid fluidLarge amount of free turbid fluid

Severe Ischemia from duodenum until Severe Ischemia from duodenum until

20 20 cm from ileocm from ileo--cecal valvececal valve

Case Presentation

Continued

Dr Dr OvnatOvnat

Heparin Y/N ,WhenHeparin Y/N ,When

Extent of resectionExtent of resection

Second LookSecond Look

ProceduresProcedures

Heparin Heparin

SMA EmbolectomySMA Embolectomy

Resection of distal Resection of distal 2 2 meters of small bowelmeters of small bowel

Bogota’s bag closureBogota’s bag closure

Case Presentation

Continued

Second lookSecond look

( ( 24 24 hours after hours after 11stst operationoperation))

Necrosis of the small bowel Necrosis of the small bowel beginning from distal duodenum up beginning from distal duodenum up to the terminal ileum.to the terminal ileum.

Procedure: total small bowel Procedure: total small bowel resection and primary anastomosis resection and primary anastomosis of duodenum to terminal ileum (of duodenum to terminal ileum (10 10 cm from ileocm from ileo--cecal valve).cecal valve).


ContinuedContinued

Uneventful recoveryUneventful recovery

Transthoracic Echo: No thrombiTransthoracic Echo: No thrombi

TreatmentTreatment SMA Thrombotic occlusion SMA Thrombotic occlusion

Exploratory laparotomy :Confluent necrosisExploratory laparotomy :Confluent necrosis

EndarterectomyEndarterectomy

Bypass: Antegrade/Retro multivessel bypassBypass: Antegrade/Retro multivessel bypass

Hybrid Procedure : Retrograde Open Mesenteric Stent

(ROMS)

Bowel resection Bowel resection ±± Second lookSecond look

Endovascular therapy :Endovascular therapy :Thrombolysis ± PTA/ Stent

Emerging approach in selectedEmerging approach in selected

Dr Dr YofeYofe

Endovascular Vs Open Surgical TreatmentEndovascular Vs Open Surgical Treatment

Endovascular Revascularization

VS Traditional (surgical) Therapy in Acute

Mesenteric Ischemia

Successful endovascular treatment was achieved in 87%.

Mortality rate dropped from 50% to 36% mainly in thrombotic

SMA occlusion

Necrotic bowel resection decreased from 160 cm to 52 cm

69% required adjuvant laparotomy ( 31% no need for

laparotomy)

Acute renal failure decreased from 50% to 27%

Pulmonary failure decreased from 64% to 27%

A comparison of endovascular revascularization with traditional

therapy for the treatment of acute mesenteric ischemia

Zachary M,… and Daniel G. Clair, MD, Cleveland, Ohio

J Vasc Surg 2011;53:698-705

TreatmentTreatment SMA Thrombotic occlusionSMA Thrombotic occlusion

Summary

Acute mesenteric ischemia is still a challenging diagnosis to

do in the light of its relative rarity, NONSPECIFIC CLINICAL

PICTURE AND ABSENCE OF DIANOSTIC CHEMICAL TEST

High index of suspicion following risk profiling patients with

acute abdominal pain should prompt Diagnostic targeting

using MD-CTA or angiogram

Once the diagnosis of SMA occlusive mesenteric ischemia is

maid

Swift bowel revascularization should

be the aim

Summary

Heparin

OR1 setup

Recruit vascular surgeon

Vascular prep and drape

Peritonitis: Open surgery

Thrombectomy, bypass ,or ROM

Bowel resection

Schedule second look

No Peritonitis ,High risk: Endovascular

Adjuvant laparotomy

MVTMVT

Case presentation Case presentation ––Dr David HochsteinDr David Hochstein

History

63 y.o.m

Severe right upper quadrant pain of one

day duration

Vomiting

Physical examination

Full consciousness, in pain, vomiting

100, 147/87, 36.5 c, 98%

Abdomen: diffuse peritonitis

Labs

WBC 19000

CRP 4.5

Chemistry, renal function, liver

function, pro time - normal

X-Rays

Exploratory laparotomy

Necrotic small bowel loop, 60 cm from

ICV, with bloody fluid

Resection of small bowel loop and

primary anastomosis

Post operative course

Anticoagulation

Antibiotics

Pathology report

22 cm segment of small bowel

Hemorrhagic necrosis

Blood clots in mesenteric veins

MVTMVT

Clinical PresentationClinical Presentation

MVT

Hypo attenuating

SMV thrombus Mural thickening

Mural enhancement

TreatmentTreatment MVTMVT

Nonoperative management: HeparinNonoperative management: Heparin

Exploratory laparotomy :peritonitisExploratory laparotomy :peritonitis

Only clearly nonviable or perforated Only clearly nonviable or perforated

intestine should be resentedintestine should be resented

secondsecond--look look laparotomieslaparotomies are frequently are frequently

necessary to preserve as much viable necessary to preserve as much viable

intestine as possibleintestine as possible

Thrombolysis:PTC,TIPS,SMA,IntraoperativeThrombolysis:PTC,TIPS,SMA,Intraoperative

( ( Esp. Portal vein Thrombosis)Esp. Portal vein Thrombosis)

ThrombectomyThrombectomy

NOMI

Clinical PresentationClinical Presentation

NOMI

TreatmentTreatment NOMINOMI

Systemic anticoagulationSystemic anticoagulation

CatheterCatheter--based directed arterial infusion of based directed arterial infusion of

papaverine at papaverine at 30 30 to to 60 60 mg/h or mg/h or prostaglandin E1

AfterloadAfterload--reducing agents and vasodilatorsreducing agents and vasodilators

Laparotomy: signs of peritonitis, worsening Laparotomy: signs of peritonitis, worsening

sepsis suggestive of intestinal necrosis or sepsis suggestive of intestinal necrosis or

perforationperforation

End End

QuestionsQuestions

Documents

מצגת של PowerPoint · History 1951,Klass AA: Embolectomy in acute mesenteric occlusion. Ann Surg 134:913-917 Mortality rate 70-90% up to 1970 1970,Boley and Clark: Angiography,