DOI: http://dx.doi.org/10.18203/2349-2902.isj20163540

Predictors of mortality in acute mesenteric vascular ischemia with bowel gangrene

Suchin S. Dhamnaskar, Prashant C. Sawarkar, Sumit Mandal, Preeti Vijaykumaran

Abstract


Background: Acute mesenteric vascular event can be thrombotic, embolic, vasospatic, or venous thrombosis. These patients present with nonspecific signs disproportionate to symptoms making early diagnosis difficult. Mortality remains high (30-100%). This prompted us to undertake this study to find predictors of mortality in these patients.

Methods: This was prospective non-study carried out at our tertiary referral hospital over defined period of 22 months during which all patients operated for acute mesenteric ischemic bowel gangrene were included. Variable data regarding demographics, clinical and biochemical parameters, operative findings and their association with mortality was recorded in predesigned case sheets. Chi-square test was applied to determine significance.

Results: Advanced age, presence of co-morbid conditions, delayed (>24 hours) presentation, hypotension, tachypnea, hypoxia, more than two system failures, more than three feet length of resected gangrenous bowel, < 100 cms of remnant viable bowel, need for second look surgery, complications of surgery and more than one mesenteric arterial involvement are negative predictors of mortality. Whereas laboratory parameters like haemoglobin, leucocyte count, serum creatinine and metabolic acidosis have no statistically significant correlation to mortality. Similarly presence of perforation of gangrenous intestine, ileocaecal resection, amount of contamination have no effect on morality rate.

Conclusions: One of the reasons for persistant high mortality of this disease is it’s occurance in higher age group and frequent association with comorbidities. Difficulties in diagnosis leads to delayed treatments; adding to mortality burden. Mesenteric angiography is underutilised diagnostic tool. Endovascular revascularisation procedures are not widely available and many patients are unsuitable due to clinical condition and risk of reperfusion injury. In presence of peritoneal signs and suspicion of disease urgent exploratory laparotomy is the gold standard.


Keywords


Acute mesenteric ischemia,Bowel gangrene,Mesenteric angiography,Mortality

Full Text:

PDF

References


Kougias P, Lau D, Sayed HF, Zhou W, Huynn TT, Lin PH. Determinants of mortality and treatment outcome following surgical interventions for acute mesenteric ischemia. J Vasc Surg. 2007;46(3):467-74.

Stamafokos M, Stefanki C, Mastrokalos D, Arampatzi H, Safioleas P, et al. Mesenteric ischemia: still a deadly puzzle for medical community. Tohoku J Exp Med. 2008;216(3):197-204.

Clark ET, Gerwitz BL. Mesenteric ischemia In: Hall JB, Schmidt GA, Wood LD eds. Principals of Critical Care. New York; McGraw- Hill. 1998:1276-86.

Aliosmanoglu I, Gul M, Kapan M, Arikanoglu M. Risk factors effecting mortality in acute mesenteric ischemia and mortality rates: a single centre experience. Int Surg. 2013;98:76-81.

Aschoff AJ, Stuber G, Becker BWW, Hoffmann MH, Schmitz BL, Schelzig H, et al. Evaluation of acute mesenteric ischemia by biphasic mesenteric multidetector CT angiography. Abdomen Imaging. 2009;34(3):345-57.

Nonthasoot B, Tullavardhana T, Sirichindakul B, Suphapol J. Acute Mesenteric ischemia: high mortality in the era of 24 hour availability of angiography. J Med Assoc Thai. 2005;88(4):46-50.

Huang HH, Chang YC, Yen DH, Kao WF. Clinical factors and outcomes in patients with acute mesenteric ischemia in emergency department. J Chin Med Assoc. 2005;68(7):299-306.

Merke C, Lepouse C, Garine A, Fressinet N. Surgery For mesenteric infarction:prognostic factors associated with early death within 72 hours. J Cardiothorac Vasc Anaesthe. 2004;18(6):734-41.

Kaleya RN, Boley SJ. Acute mesenteric ischemia. Crit Care Clin. 1995;11(2):479.

Merida MA, Gomez MJ, Miller HM, Castellano RC, Romero JM. Identification of factors for per-operative mortality in acute mesenteric ischemia. World J Surg. 2006;30(8):1579-85.

Tilsed JVT, Casamassima A, Kurihara H, Mariani D, Martinez I. ESTES guidelines: Acute mesenteric ischemia. Eur J Trauma Emerg Surg. 2016;42:253-70.

Kassahun WT, Schulz T, Richter O, Hauss J. Unchanged high mortality rates from acute mesenteric ischemia: six years review. Langenbecks Arch Surg. 2008;393(2):163-71.

Oldenburg WA, Lau LL, Rodenberg TJ, Edmond HJ, Burger CD. Acute mesenteric ischemia: a clinical review. Arch Int Med. 2004;164(10):1054-62.

Bradbery AW, Brittenden J, McBride K, Ruckley CV. Mesenteric ischemia: multidisciplinary approach. Br J Surg. 1995;82(11):1446-59.

Altiyollar H, Boyabatli M, Berberoglu U. D-dimer as a marker for early diagnosis of mesenteric ischemia. Thrombo Res. 2006;117:463-7.

Yashuhara H. Acute mesenteric ischemia: the challenge of gastroenterology. Surg Today. 2005;35(3):185-95.