Management of acute mesenteric isxcaemia: A retrospective analysis

Abstract

Aim-Background

Acute mesenteric ischaemia (AMI), although an uncommon condition with a difficult diagnosis, has a high rate of complications and is associated with a high mortality rate. We reviewed our experience of patients presenting with AMI in order to evaluate the current management and factors associated with survival in a tertiary care hospital.

Material and Methods

Clinical data of all patients who were diagnosed with AMI between 01 January 2012 and 30 June 2013 were retrospectively reviewed. Preoperative presentation, investigation, management and outcome in this group of patients were analyzed.

Results

Thirteen patients were included in the study, of whom twelve were male and one female, mean age 44.5 years ranging from 35 to 78 years. The cause of AMI was embolism in three patients (23.1%), and thrombosis in ten patients (76.9%). Abdominal pain was the most common presenting symptom (100%). Four patients (30.8%) had previous symptoms of chronic mesenteric ischaemia in the form of postprandial pain. Nine patients (69.2%) had been exposed to high altitude for more than two weeks, four of whom displayed a procoagulant state. Eleven patients underwent abdominal exploration and endovascular treatment. Percutaneous transcatheter balloon angioplasty was performed in two (15.4%) cases. Eight out of eleven patients (72.7%) who underwent exploratory laparotomy had major small bowel resections involving more than 200 cms of small bowel. However, none of these patients underwent any reconstructive procedures due to extensive thrombus within the SMA and late presentation. Six patients were submitted to second-look exploration within 48 hours, all of whom underwent repeat resections of the bowel. Laparostomies were performed in two patients. None of these patients had a primary anastomosis. End jejunostomy/ileostomy was performed with mucous fistula in all 11 patients. Two patients died within a month, and the 30-day mortality rate was 15.4%; severe sepsis with multiorgan failure was the cause of death in both patients. Four patients (30.8%) had permanent intestinal failure without intestinal adaptation requiring permanent total parenteral nutrition (TPN) with indications for intestinal transplant. The survival rate at one year was 69.2%. Two late deaths occurred owing to complications of TPN.

Conclusion

A relatively uncommon diagnosis, AMI is often identified late and invariably with complications. Exploratory laparotomy with resection of the bowel is the most viable option in such a situation. The individuals exposed to high altitude and displaying a procoagulant state that present with AMI tend to belong to a much younger age group than that reported in the literature. Short bowel syndrome is a frequent long-term complication in surviving patients. Administration of TPN in strict aseptic conditions, control of sepsis, intestinal adaptation and intestinal transplant will increase the long-term survival of these patients.