[The acute mesenteric ischemia - not understood or incurable?]

Abstract

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.