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A Short Series of Laparoscopic Mesenteric Bypasses for Chronic Mesenteric Ischemia.

ABSTRACT: Background:Laparoscopic aortomesenteric bypass may be performed to treat the chronic mesenteric ischemia patients who are not suitable for endovascular treatment. This study presents an initial experience with a limited series of laparoscopic mesenteric artery revascularization for the treatment of mesenteric ischemia. Methods:Chronic mesenteric ischemia (CMI) patients with previous unsuccessful endovascular treatment or with arterial occlusion and extensive calcification precluding safe endovascular treatment were offered laparoscopic mesenteric revascularization. From October 2015 until November 2018, nine patients with CMI underwent laparoscopic revascularization. In addition to demographic data and perioperative results of the treatment, graft patency was assessed with Duplex ultrasound at 1, 3, 6 and 12 months, and annually thereafter. A descriptive analysis of the data was performed. Results:All bypasses were constructed with an 8 mm ring enforced expanded polytetrafluoroethylene graft in a retrograde fashion (from infrarenal aorta or iliac artery) to either superior mesenteric artery or splenic artery (2 cases). Median operation time was 356 mins (range 247-492 mins). Five patients had a history of unsuccessful endovascular treatment. Laparoscopic technical success was 78%, and the primary open conversion rate was 22%. All laparoscopic revascularization procedures remained patent after discharge during a median follow-up time of 26 months (range 18-49 months). The primary graft patency at 30 days was 78%. Primary assisted, and secondary graft patency was 78% and 100%, respectively. Median weight gain was 2 kg (range 2-18 kg), and all patients achieved relief from postprandial pain and nausea. No mortality was observed during the follow-up period. Conclusion:Laparoscopic aortomesenteric revascularization procedures for chronic mesenteric ischemia are feasible but require careful patient selection. These procedures should only be performed at referral centers by vascular surgeons with prior experience in laparoscopic vascular surgery.

SUBMITTER: Kazmi SSH

PROVIDER: S-EPMC7098165 | biostudies-literature | 2020

REPOSITORIES: biostudies-literature

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A Short Series of Laparoscopic Mesenteric Bypasses for Chronic Mesenteric Ischemia.

Kazmi Syed Sajid Hussain SSH Berge Simen Tveten ST Sahba Mehdi M Medhus Asle Wilhelm AW Sundhagen Jon Otto JO

Vascular health and risk management 20200320

<h4>Background</h4>Laparoscopic aortomesenteric bypass may be performed to treat the chronic mesenteric ischemia patients who are not suitable for endovascular treatment. This study presents an initial experience with a limited series of laparoscopic mesenteric artery revascularization for the treatment of mesenteric ischemia.<h4>Methods</h4>Chronic mesenteric ischemia (CMI) patients with previous unsuccessful endovascular treatment or with arterial occlusion and extensive calcification precludi ...[more]

PMID: 32256075

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Project description:This This Dutch Mesenteric Ischemia Study group consists of: Ron Balm, Academic Medical Center, Amsterdam Gert Jan de Borst, University Medical Center Utrecht, Utrecht Juliette T Blauw, Medisch Spectrum Twente, Enschede Marco J Bruno, Erasmus MC University Medical Center, Rotterdam Olaf J Bakker, St Antonius Hospital, Nieuwegein Louisa JD van Dijk, Erasmus MC University Medical Center, Rotterdam Hessel CJL Buscher, Gelre Hospitals, Apeldoorn Bram Fioole, Maasstad Hospital, Rotterdam Robert H Geelkerken, Medisch Spectrum Twente, Enschede Jaap F Hamming, Leiden University Medical Center, Leiden Jihan Harki, Erasmus MC University Medical Center, Rotterdam Daniel AF van den Heuvel, St Antonius Hospital, Nieuwegein Eline S van Hattum, University Medical Center Utrecht, Utrecht Jan Willem Hinnen, Jeroen Bosch Hospital, 's-Hertogenbosch Jeroen J Kolkman, Medisch Spectrum Twente, Enschede Maarten J van der Laan, University Medical Center Groningen, Groningen Kaatje Lenaerts, Maastricht University Medical Center, Maastricht Adriaan Moelker, Erasmus MC University Medical Center, Rotterdam Desirée van Noord, Franciscus Gasthuis & Vlietland, Rotterdam Maikel P Peppelenbosch, Erasmus MC University Medical Center, Rotterdam André S van Petersen, Bernhoven Hospital, Uden Pepijn Rijnja, Medisch Spectrum Twente, Enschede Peter J van der Schaar, St Antonius Hospital, Nieuwegein Luke G Terlouw, Erasmus MC University Medical Center, Rotterdam Hence JM Verhagen, Erasmus MC University Medical Center, Rotterdam Jean Paul PM de Vries, University Medical Center Groningen, Groningen Dammis Vroegindeweij, Maasstad Hospital, Rotterdam review provides an overview on the clinical management of chronic mesenteric ischemia (CMI). CMI is defined as insufficient blood supply to the gastrointestinal tract, most often caused by atherosclerotic stenosis of one or more mesenteric arteries. Patients classically present with postprandial abdominal pain and weight loss. However, patients may present with, atypically, symptoms such as abdominal discomfort, nausea, vomiting, diarrhea or constipation. Early consideration and diagnosis of CMI is important to timely treat, to improve quality of life and to prevent acute-on-chronic mesenteric ischemia. The diagnosis of CMI is based on the triad of clinical symptoms, radiological evaluation of the mesenteric vasculature and if available, functional assessment of mucosal ischemia. Multidisciplinary consensus on the diagnosis of CMI is of paramount importance to adequately select patients for treatment. Patients with a consensus diagnosis of single-vessel or multi-vessel atherosclerotic CMI are preferably treated with endovascular revascularization.

Project description:BackgroundLittle is known about the microcirculatory alterations in patients with chronic mesenteric ischemia (CMI). We hypothesized that patients with CMI have an impaired microcirculatory function and show an oral microcirculatory response after caloric challenge compared to healthy controls.MethodsAll patients and controls received the standard workup for CMI. Sublingual micro-circulation was evaluated before (T0) and 20 minutes after (T1) feeding. The total vessel density (TVD; mm/mm2), perfused vessel density (PVD; mm/mm2), proportion of perfused vessels (PPV; %) and microvascular flow index (MFI; AU) were assessed.ResultsWe included 12 patients (63.2 years [IQR 48.8-70.4 years], 67% males) and 12 controls (32.7 years [IQR 27.7-38.1 years], 42% males). At baseline, patients with CMI had a decreased PPV of the sublingual small vessels (median 84.8% vs 95.7%, P=0.006), PPV of all vessels (PPV median 85.4% vs 95.3%, P=0.007) and microvascular flow index of all vessels (MFIa; median 3.00 vs 2.80, P=0.039) compared to healthy controls. After caloric challenge, PVD increased significantly in both small vessels (perfused vessel density of the small vessels [PVDs]) and all vessels (perfused vessel density of all vessels [PVDa]; PVDs [T0]) median 16.3 [IQR 13.3-22.1] vs [T1] median 19.9 [IQR 14.2-26.2], P=0.008; PVDa [T0] median 19.1 [IQR 16.2-23.6] vs [T1] median 22.2 [IQR 16.5-28.9], P=0.02; proportion of perfused vessels of the small vessels (PPVs; [T0] median 84.8% [IQR 75.3-90.4] vs [T1] median 91.0% [IQR 80.1-93.8], P=0.010). In contrast, no significant changes in microcirculatory parameters were observed after caloric challenge in healthy controls.ConclusionPatients with CMI have an impaired sublingual microcirculation at baseline and show a significant response in the sublingual microcirculation after caloric challenge, whereas healthy controls have a normal microcirculation at baseline and show no reactive response upon a caloric challenge as seen in CMI patients. Sublingual microcirculation visualization may offer a rapid noninvasive method to identify patients at risk for having CMI.

Project description:ObjectiveAcute mesenteric ischemia (AMI) is a surgical emergency for which delays in treatment have been closely associated with high morbidity and mortality. Although the duration of ischemia as a determinant of outcomes for AMI is well known, the objective of this study was to identify hospital-based determinants of delayed revascularization and their effects on postoperative morbidity and mortality in AMI.MethodsAll patients who underwent any surgery for AMI from a multi-center hospital system between 2010 and 2020 were divided into two groups based on timeliness of mesenteric revascularization after presentation. Early revascularization (ER) was defined as having both vascular consultation ≤12 hours of presentation and vascular surgery performed at the patient's initial operation. Delayed revascularization (DR) was defined as having either delays to vascular consultation or vascular surgery. A retrospective review of demographic and postoperative data was performed. The effect of DR on major postoperative outcomes, including 30-day and 2-year mortality, total length of bowel resection, and development of short bowel syndrome, were analyzed. Effects of delayed vascular consultation alone, delayed vascular surgery alone, no revascularization during admission, and admitting service on outcomes were also examined on subgroup analyses.ResultsA total of 212 patients were analyzed. Ninety-nine patients received ER, whereas the remaining 113 patients experienced a DR after hospital presentation. Among the DR group, 55 patients (25.9%) had delayed vascular consultation, whereas vascular surgery was deferred until after the initial operation in 37 patients (17.4%). Fifty-one patients (24.0%) were never revascularized during admission. DR was a significant predictor of 30-day (odds ratio [OR], 2.09; 95% confidence interval [CI], 1.4-4.9; P = .03) and 2-year mortality (hazard ratio, 1.55, 95% CI, 1.0-2.3; P = .04). DR was also independently associated with increased bowel resection length (OR, 7.47; P < .01) and postoperative short bowel syndrome (OR, 2.4; P = .03) on multivariate analyses. When examined separately on subgroup analysis, both delayed vascular consultation (OR, 3.38; P = .03) and vascular surgery (OR, 4.31; P < .01) independently increased risk of 30-day mortality. Hospital discharge after AMI without mesenteric revascularization was associated with increased risk of short bowel syndrome (OR, 2.94; P < .01) and late mortality (hazard ratio, 1.60; P = .04).ConclusionsDelayed vascular consultation and vascular surgery are both significant hospital-based determinants of postoperative mortality and short bowel syndrome in patients with AMI. Timing-based management protocols that emphasize routine evaluation by a vascular surgeon and early, definitive mesenteric revascularization should be established and widely adopted for all patients with clinically suspected AMI at presentation.

Dataset Information

A Short Series of Laparoscopic Mesenteric Bypasses for Chronic Mesenteric Ischemia.

Publications

A Short Series of Laparoscopic Mesenteric Bypasses for Chronic Mesenteric Ischemia.

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