ESTES guidelines: acute mesenteric ischaemia

Abstract

PurposeAcute mesenteric ischaemia (AMI) accounts for about 1:1000 acute hospital admissions. Untreated, AMI will cause mesenteric infarction, intestinal necrosis, an overwhelming inflammatory response and death. Early intervention can halt and reverse this process leading to a full recovery, but the diagnosis of AMI is difficult and failure to recognize AMI before intestinal necrosis has developed is responsible for the high mortality of the disease. Early diagnosis and prompt treatment are the goals of modern therapy, but there are no randomized controlled trials to guide treatment and the published literature contains a high ratio of reviews to original data. Much of that data comes from case reports and often small, retrospective series with no clearly defined treatment criteria.MethodsA study group of the European Society for Trauma and Emergency Surgery (ESTES) was formed in 2013 with the aim of developing guidelines for the management of AMI. A comprehensive literature search was performed using the Medical Subject Heading (MeSH) thesaurus keywords “mesenteric ischaemia”, “bowel ischaemia” and “bowel infarction”. The bibliographies of relevant articles were screened for additional publications. After an initial systematic review of the literature by the whole group, a steering group formulated questions using a modified Delphi process. The evidence was then reviewed to answer these questions, and recommendations formulated and agreed by the whole group.ResultsThe resultant recommendations are presented in this paper.ConclusionsThe aim of these guidelines is to provide recommendations for practice that will lead to improved outcomes for patients.

Secondary peritonitis: principles of diagnosis and intervention

“…Patients with localized peritonitis who are hemodynamically stable should receive broad spectrum antibiotics and cross sectional imaging 5414243. Those with evidence of bowel compromise, feculent, or four quadrant contamination should have laparotomy 1944. Patients with acute appendicitis, acute cholecystitis, or perforated peptic ulcer may undergo laparoscopic resection or repair.…”

Predictors of mortality in acute mesenteric vascular ischemia with bowel gangrene

“…Presence of more than 2 system failures was also a significant predictor of mortality in our study. 11 But laboratory values like haemoglobin, leucocyte count, serum creatinine and bicarbonate levels had no roll as per our study in mortality prediction. We could not study the correlation of serum lactate levels as facility was not available at our centre though it is significant factor reported in study by Kougias P et al 1 Ddimer as a marker of thrombotic activity has also been proposed by Altinyollar H et al based on experimental animal models for early diagnosis of mesenteric ischemia.…”

“…Another significant factor deciding mortality was delay in presentation to emergency department after beginning of symptoms which ultimately decides delay of definitive surgical intervention. 1,11 Kassahun et al reported survival rate of 50% in patients diagnosed within first 24 hours and less than 30% in those presenting after 24 hours of symptoms. 12 Majority of the times the delay in presentation to our tertiary referral centre was due to delayed referral from other hospitals due to diagnostic dilemma.…”

Factors affecting surgical outcomes after superior mesenteric artery thromboembolism

“…[9] Biphasic contrast CT scanning is the gold standard in the diagnosis of AMI. [10,11] Due to non-specific symptoms and clinical manifestations, accurate diagnosis may be delayed, and this delay may increase the mortality and morbidity rates. In our study, we diagnosed the AMI patients by dynamic CT angiography and we recommended it for all patients suspected for AMI.…”