Acute mesenteric ischaemia.

The experience of acute mesenteric ischaemia at St Vincent's Hospital, Melbourne, has been reviewed over 17 years. The mortality remains appallingly high. This applies particularly to those patients who had thrombosis of the superior mesenteric artery, amongst whom the mortality in this series was 97%. The mortality was slightly less in the group suffering from embolic occlusion of the superior mesenteric artery (66%), and in those suffering from thrombosis of the superior mesenteric vein (60%). A mortality of 66% was also found in patients suffering from non-occlusive gut ischaemia. Delay in diagnosis accounted for this high mortality. Early diagnosis is all-important, and this depends on the performance of mesenteric angiography in any patient suspected of having mesenteric ischaemia. Appropriate surgery may then be carried out in the occlusive group and supportive treatment, including intraarterial papaverine infusion, given to those with non-occlusive ischaemia. There is a pressing need for simple non-invasive tests to segregate those patients suffering from acute mesenteric ischaemia from those whose acute abdomen is due to some other cause.     

62例急性肠系膜上动脉栓塞的诊断和治疗

目的探讨急性肠系膜上动脉栓塞的临床表现及早期诊断和治疗方法。方法回顾性分析62例急性肠系膜上动脉栓塞患者的临床资料。结果术前确诊22例(35.5%)。62例患者均行肠系膜上动脉切开取栓,58例患者行坏死肠管切除术,其中35例患者行多次肠管切除术。术后16例患者死亡(25.8%)。术后随访3～24个月。结论肠系膜上动脉栓塞误诊率高,病死率高。对心律失常特别是房颤、心脏瓣膜病及既往有急性动脉栓塞病史患者突发剧烈腹痛,应警惕肠系膜上动脉栓塞可能。肠系膜上动脉切开取栓是治疗急性肠系膜上动脉栓塞缩小肠管切除范围有效方法。     

RENAL ANGIOGRAPHY AND THE MANAGEMENT OF SEVERE CLOSED RENAL TRAUMA1

The purpose of this study was to determine the place of selective renal angiography in the assessment of major renal trauma. Thirty-one cases of renal injury assessed by urography and angiography were reviewed, and the radiological features correlated with the subsequent clinical course. Based on the angiographic findings, a classification of these more severe injuries is proposed, and the prognostic significance of renal ischæmia demonstrated. Because conservative treatment in those cases with significant ischæmia is likely to fail, early elective surgery is recommended. In this selected group, viable renal tissue can be preserved, and the necessity for subsequent nephrectomy due to secondary hæmorrhage, or continuing urine leakage, is avoided.     

急性肠系膜上动脉闭塞的诊断与治疗

目的 探讨急性肠系膜上动脉闭塞的诊断与治疗.方法 对2000-2007年收治的15例急性肠系膜上动脉闭塞患者的临床资料进行回顾性分析.结果 本组15例患者中肠系膜上动脉栓塞11例,肠系膜上动脉血栓形成4例.入院后均行急诊剖腹探查术,其中2例行肠系膜上动脉取栓术,11例行肠系膜上动脉取栓加坏死肠管切除术,2例放弃手术.术后均行肝素等抗凝治疗.4例死亡,总病死率为27%.结论 对于有器质性心脏病的患者,如突然出现腹部疼痛,应警惕肠系膜上动脉闭塞的可能.早期诊断、早期行肠系膜上动脉取栓术是提高治愈率的关键.     

THE ROLE OF BRADYKININ IN ENDOTOXIC SHOCK OF INTESTINAL ORIGIN

A relationship was looked for between blood levels of bradykinin and endotoxæmia produced by superior mesenteric artery occlusion in the rabbit. The levels of bradykinin were unrelated to and unaltered by the degree of endotoxæmia observed in the systemic and portal circulations. These findings suggest that bradykinin is not responsible for the release of endotoxin from the gut, or for the circulatory collapse which follows.     

An Assessment of the Xenon- 133 Method of Measuring Muscle Blood Flow1

The ¹¹³Xe method for measuring muscle blood flow is discussed, and has been evaluated in both normal and ischæmic limbs, a standard amount of ischæmic exercise being employed as the stimulus to hyperæmia. This is considered to be a reliable technique with a high degree of reproducibility, which may be applied to advantage in the clinical assessment of patients with peripheral vascular disease.     

Acute intestinal ischemia. A 14-year retrospective investigation

The records of 60 patients with acute intestinal ischemia treated between 1969 and 1982 were studied retrospectively. Fifty-three patients (88%) had thrombosis or embolus of the superior mesenteric artery and 7 patients (12%) occlusion of the superior mesenteric vein. Initial symptoms were obscure, although 25% presented with signs of peritonitis. The most frequently used investigation was plain abdominal X-ray with a positive finding in only 1/3. Forty-three patients (72%) were operated on. In 18 patients irreversible changes were found. Total mortality rate was 82%, in SMA-thromboembolism 85% and in SMV-thrombosis 57%. To improve the prognosis clinical awareness of the problem and attempts towards early diagnosis should be raised.     

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??Surgery of acute mesenteric artery embolism??the earlier the better XIN Shi-jie??WANG Lei. Department of Vascular and Thyroid Surgery, the First Affiliated Hospital of China Medical University, Shenyang 110001??China
Corresponding author??XIN Shi-jie??E-mail??xinshijie1963@aliyun.com
Abstract Acute mesenteric artery embolism (AMAE) is a clinically rarely acute severe vascular surgical disease??usually caused by emboli or thrombosis??partially caused by arteriosclerosis. Acute onset??rapid progression??misdiagnosed and high mortality are the main features of the disease. Such patients have a complex underlying disease??short-term occurrence of section or all of the small intestine dysfunction or necrosis is the main reason for poor prognosis. Early diagnosis and early medical or surgery intervention to remove the superior mesenteric artery occlusion state and restore intestinal blood flow??and conserve not necrotic bowel as much as possible is to reduce mortality and improve quality of life of patients. Long-term clinical work confirmed that occasion of open surgery for AMAE was generally partial late??and efficacy of endovascular treatment is less than satisfactory. It should encourage surgeon to grasp surgery gold points??perform more active and effective treatment of AMAE in order to make patient avoid suffering from a large area of intestinal necrosis and hazard multiple organ dysfunction then seek surgery.     

Deciphering mesenteric venous thrombosis: imaging and treatment

The principal cause of a high mortality rate in mesenteric vein thrombosis (MVT) is a delay in diagnosis. Recent data indicate that the mortality rate is decreasing owing to earlier diagnosis and anticoagulation. The authors examined the treatment profile of MVT to see how the increased use of imaging and early anticoagulation has impacted this process. They retrospectively analyzed the treatment paradigm with acute MVT at one institution over a 10-year period. Twenty-three patients were identified. Data were analyzed using chi-squares and Student's t tests. Twenty-three patients (11 men and 12 women with an average age of 51.74 +/-14.8 years) were identified with acute MVT between the years of 1993 and 2003. Five patients had splenic vein thrombosis, 17 had superior mesenteric vein thrombosis, 1 had inferior mesenteric vein thrombosis, and 12 had portal vein thrombosis. Nine patients had combination mesenteric vein segment thrombosis. Thrombolytics were utilized in a total of 6 patients. Four of the 6 patients in whom lytics were utilized had combined mesenteric vein thrombosis; however, these 4 patients did not require surgical intervention. There was no significant difference in length of hospital stay between patients taking lytics versus patients treated with traditional anticoagulation with heparin (p = 0.291). A hypercoagulable state was identified in 66.7% of the patients. Four patients required surgical intervention. The overall mortality rate was 8.7% (2 of 23). The use of thrombolytics was associated with a significant mortality (p = 0.04). The use of antibiotics made no difference in mortality (p = 0.235), nor did antibiotic use influence length of hospitalization (p = 0.192). MVT is relatively rare, and often the delay in diagnosis increases the mortality rate. In the majority of cases prompt anticoagulation will preserve bowel viability and decrease mortality and morbidity rates. The majority of patients do not need surgery. There is a marked increase in mortality rate when these patients progress to surgical intervention. An increased awareness and early diagnosis has led to decreased morbidity and mortality rates.     

急性肠系膜上动脉栓塞的诊断与治疗

目的: 探讨急性肠系膜上动脉栓塞的诊断与治疗。方法:对近10年收治的急性肠系膜上动脉栓塞患者22例临床资料进行回顾分析。结果:术前确诊率为77.3%，2例非手术治疗者均死亡（病死率100.0%）。20例经手术治疗，其中5例行单纯坏死肠管切除，端端吻合术，3例死亡（病死率60.0%）；15例行肠系膜上动脉取栓加坏死肠管切除，5例死亡（病死率33.3%）。总病死率为45.5%。结论:对于有器质性心脏病的患者，突然出现腹部疼痛，应警惕肠系膜上动脉栓塞的可能。CTA是诊断急性肠系膜上动脉栓塞的有效手段。早诊断、早期行肠系膜上动脉取栓术是提高治愈率的关键。     

Acute mesenterial infarcts--results of surgical therapy

Forty-five patients with mesenteric infarction documented by laparotomy or autopsy were reviewed. 35% of the patients had superior mesenteric artery occlusion by embolus, 27% by thrombosis, 11% had venous thrombosis, 9% nonocclusive mesenteric ischemia, and 18% were unclear. The mortality rate was 60% within half a year postoperatively. 22% had inoperable lesions, 46% underwent bowel resection, and 32% were managed by revascularization. In the group treated by bowel resection (n = 21) 30% died, in the group treated by revascularization 80% of the patients died.     

Acute mesenteric ischemia

Acute mesenteric ischemia is not an isolated clinical entity, but a complex of diseases, including acute mesenteric arterial embolus and thrombus, mesenteric venous thrombus, and nonocclusive mesenteric ischemia. These diseases have common clinical features caused by impaired blood perfusion to the intestine, bacterial translocation, and systemic inflammatory response syndrome. There is substantial evidence that the mortality associated with acute mesenteric ischemia varies according to its trigger cause. Nonocclusive mesenteric ischemia is the most lethal form of the acute mesenteric ischemia, because of the poor understanding of its pathophysiology and its mild and nonspecific symptoms, which often delay its diagnosis. Mesenteric venous thrombosis is much less lethal than acute thromboembolism of the superior mesenteric artery and nonocclusive mesenteric ischemia. In this articles we presents an overview of acute mesenteric ischemia, based on the research. Although the mortality rates, in acute mesenteric ischemia, have remained high over the last few decades, accumulated knowledge on this condition is expected to improve its prognosis.     

急性原发性肠系膜上静脉血栓形成17例临床诊治分析

目的:探讨急性原发性肠系膜上静脉血栓形成(APSMVT)的临床诊断与治疗。方法:回顾性分析我院1998年至2007年收治的17例APSMVT的临床资料。结果:17例病人(100%)均有持续性渐行加重的腹痛,常见伴随症状有恶心呕吐(82%)、消化道出血(53%)、肠梗阻(53%)、发热(59%)等。11例(65%)腹腔穿刺获血性腹水。17例均行超声检查,1例术前明确诊断;14例CT检查中2例增强扫描后得以确诊,12例平扫可见间接征象。16例行坏死肠段切除手术及抗凝治疗,其中3例首次剖腹探查未见异常,在症状未缓解或加重后再次手术发现肠坏死并行肠切除。2例病人行经皮肝穿刺肠系膜上静脉导管溶栓治疗,1例血栓复发者行肠系膜上动脉导管溶栓后治愈。3例术后因脓毒症死亡。结论:APSMVT术前诊断困难,对不明原因急性剧烈腹痛者应及时怀疑本症,早期发现、早期治疗方能提高本病的治愈效果。病程早期可采用介入溶栓疗法,后期出现肠坏死征象者应及时手术,并予以抗凝治疗。     

急性肠系膜上动脉栓塞的手术探讨

目的总结手术治疗急性肠系膜上动脉栓塞的临床体会,探讨常见并发血管病变的处理方法。方法1990年1月～2005年12月年收治32例急性肠系膜上动脉栓塞患者,均在全身麻醉下行肠系膜动脉切开取栓,同时处理合并的内脏血管病变。结果30例获得临床治愈,2例分别死于呼吸衰竭和心力衰竭。术后1年复查无栓塞及局部狭窄,CTA示肠系膜上动脉通畅,侧枝循环正常。30例术后随访2～15年,23例无局部狭窄或复发,7例死于心肌梗塞或脑出血。结论早期诊断、早期切开取栓同时处理伴发疾病,可显著提高急性肠系膜上动脉栓塞的临床治愈率。     

Embolization of the mesenteric arteries: Surgical treatment in twenty-three consecutive cases

Twenty-three patients with acute embolization of the superior mesenteric acrtery are presented. Twenty-one of them presented with sudden abdominal pain but no other remarkable physical findings. One had diffuse abdominal pain while one did not have any abdominal pain. Twenty-two, patients underwent direct surgical revascularization and one patient, refused operation. The total mortality in this series was 27%. Eighteen patients underwent revascularization without resection and 15 of them (83%) survived. Early diagnosis is the key to improved results in acute mesenteric ischemia. It relies on the aggressive utilization of arteriography to identily patients with superior mesenteric artery embolization before intestinal infarction takes place.     

外科治疗肠系膜上动脉栓塞的临床分析

目的: 探讨急性肠系膜上动脉栓塞早期诊断及取栓的临床疗效。方法:回顾性分析1999－2005年，21例肠系膜上动脉栓塞的临床资料。根据患者从发病到手术间隔的时间长短分为2组：Ι组为发病后6h内进行手术治疗者，9例;Ⅱ组为发病6h后进行手术治疗者，12例。所有取栓患者术中在动脉内灌注尿激酶，术后应用肝素抗凝。结果:取栓和局部应用尿激酶后，观察30min，发现12例小肠血运恢复正常，其中Ι组9例全部恢复，Ⅱ组有3例恢复。Ι组无行肠切除者;Ⅱ组中有9例（75.0%）进行了肠切除，4例为局部切除，5例为长段肠管切除。Ι组病死率为0，Ⅱ组为41.6%。结论:早期诊断及及时治疗有助于减少肠坏死及降低病死率。     

Lysis therapy of thrombosis of the superior mesenteric artery

INTRODUCTION: For surgeons the acute intestinal ischaemia is still a diagnostic and therapeutic challenge. If clinically suspected, the diagnostic procedures such as duplex sonography and arterial angiography should be carried out immediately. Although the diagnosis is often quickly clear, perioperative mortality rate remains high. We report the acute local thrombolytic therapy as an alternative treatment. CASE REPORT: A 80-year-old male patient was referred to our hospital with a complete occlusion of the superior mesenteric artery. Duplex sonography and the arterial angiogram confirmed the clinical diagnosis. Because the patient was assessed to be at high risk we decided to avoid an operation and local thrombolytic therapy using rt-PA and urokinase was carried out. RESULT: The local thrombolytic therapy was successful and led to a complete restoration of the arterial flow within the superior mesenteric artery. The clinical symptoms subsided and no complications were observed. CONCLUSION: Local thrombolytic therapy appears to be a suitable therapeutic option in patients suffering of mesenteric arterial occlusion. Although the duplex sonography often confirms the diagnosis with high accuracy the angiography remains the diagnostic gold standard.     

急性肠系膜血管缺血性疾病16例诊治体会

目的探讨急性肠系膜血管缺血性疾病(acute mesenteric ischemia,AMI)的诊断和治疗方法。方法回顾性分析16例AMI患者的临床资料。16例急诊行64排128层螺旋CT扫描及三维重建,诊断为肠系膜上动脉栓塞6例、肠系膜下动脉栓塞1例、肠系膜上静脉血栓形成7例(同时伴有门静脉血栓形成2例),阳性率87.5%,阴性结果2例,再行选择性肠系膜上动脉造影,诊断为肠系膜上动脉血栓形成。4例接受以溶栓为主的非手术治疗,12例行急诊手术。结果非手术治疗的4例症状、体征均消失,肠管功能恢复正常,痊愈出院。12例手术患者中11例痊愈出院,1例死亡,死亡原因为MODS。结论AMI早期诊断意义重大,128层加强螺旋CT肠系膜血管成像有助于AMI的早期诊断,早期溶栓和及时手术切除坏死肠管,对挽救患者的生命有重要意义。     

The acute mesenteric ischemia - not understood or incurable?

PURPOSE: Despite surgical research and progress, the high mortality of acute intestinal ischemia seems to be improved insignificantly over the past fifty years. In this study we analyzed the specific diagnostic and therapeutic problems of the disease in order to improve further management of acute mesenteric ischemia. Methods: From 1979 until 2000 64 patients (female 31, male 33) with a mean age of 64 (30-89) years underwent operation for primary intestinal ischemia at our institution. All medical and surgical records and imaging studies were reviewed retrospectively. Follow up consisted of clinical examination and duplex sonography. RESULTS: Only in 26 patients (41 %) a preoperative diagnostic work-up including angiography 12 and CT 14 was performed, whereas in 42 cases the intestinal ischemia was diagnosed during surgical exploration. Intestine malperfusion was caused primarily by venous thrombosis in 9 cases (14 %) and by arterial occlusive disease in 55 cases (86 %). Arterial disorders consisted of arterial thrombosis in 19 cases (30 %), arterial embolism in 18 cases (28 %), aortic or mesenteric artery dissection in 10 cases (15 %), non occlusive disease (NOD) in 5 cases (8 %), trauma 3 cases (5 %). Five different therapeutic strategies were applied: group I: Intestinal resection: 24 patients, anastomotic insufficiency 5 (39 %), mortality 11 (46 %), group II: intestinal artery revascularization: 5 patients, secondary patency rate 80 %, mortality 40 %, GROUP III: Intestinal artery revacularization and perfusion with Ringer's solution: 11 patients, mortality 8 (73 %), group IV intestinal artery revascularization and intestinal resection: 3 patients, mortality 100 %, group V intestinal artery revascularization and perfusion and intestinal resection: 3 patients, mortality 33 %. A second look operation was performed in 29 cases (40 %) and displayed malperfusion in 72 %. Only 21 of 64 patients survived the acute intestinal ischemia (in hospital mortality was 67 %). Delayed diagnostic and operation caused higher mortality (interval 10 hours: mortality 59 %, interval 37 hours mortality; 71 %, p = 0,06). Follow up after 61 (4-72) months of 21 patients (100 %) could be achieved. Ten patients (48 %) had meanwhile died, 5 patients (50) % as consequence of mesenteric ischemia, the others of unrelated reasons. Eleven patients are still alive without clinical signs of intestinal ischemia. CONCLUSIONS: Early diagnosis before hospitalisation and in-hospital (arteriography) and operation are essential to improve the outcome of patients with acute intestinal ischemia. To avoid short bowel syndrome bowel resection should be combined with mesenteric revascularization. Resection of malperfused bowel should be done cautiously and should be followed automatically by second look operations. Special expertise and good team work of visceral and vascular surgeons are required to achieve better therapeutic results.     

Acute mesenteric ischaemia.

To identify any differences in presentation among the four types of acute mesenteric ischaemia, and to correlate time between presentation and treatment with outcome, we retrospectively analysed 100 cases of acute mesenteric ischaemia at a University hospital diagnosed by radiography (n = 21), at laparotomy (n = 61), or at necropsy (n = 18). A total of 68 patients died. Mortality was 50% when the aetiology was embolic occlusion of the superior mesenteric artery and 95% when the occlusion was thrombotic; 67% when the disease was "non"-occlusive; and 30% in cases of splanchnic vein thrombosis. We conclude that early diagnosis is critical for successful management of acute mesenteric ischaemia, but outcome is also influenced by the aetiology.