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Background: The increasing aging and frailty of the population make the management of acute limb ischemia (ALI) more difficult, with decision‐making far from being guided by evidence. The aim of the study was to evaluate the characteristics and results of ALI treatment in nonagenarians. Materials and Methods: Retrospective analysis of a consecutive series of nonagenarian patients with ALI attended at our institution between 2008 and 2021. The primary outcomes of the study were 1‐year limb salvage and survival rates. Results: A total of 102 patients were included (mean age 92.38, 78.4% women). In 83 cases (81.4%) ALI was attributed to embolism, and 19 (18.6%) to acute arterial thrombosis. One‐month overall survival was 70.6%. Fifteen patients (14.7%) were treated palliatively, including 8 (53.3%) irreversible ALI with associated malignancy/advanced dementia, 5 (33.3%) with associated cerebral/intestinal ischemia and 2 (13.3%) with aortic occlusion and poor medical condition. None of these patients survived after 10 days. The remaining 87 patients (85.3%) were treated with isolated anticoagulation (n = 8, 9.1%), primary major amputation (n = 1, 1.1%) or revascularization (n = 78, 89.6%), including 69 (67.6%) embolectomies, 6 (5.9%) bypass and 3 (2.9%) endovascular techniques. One‐year limb salvage and survival rates were 96% and 48%, respectively. Predictive factors of lower survival included anemia (HR = 1.81, p = 0.014) and ALI severity (HR = 1.73, p = 0.032), but not cognitive or functional status. Patients surviving the ALI episode had a 1‐year survival rate significantly below that of a similar matched population. Conclusion: Although nonagenarians with an ALI are often functionally and cognitively impaired and have a limited life expectancy, most patients need revascularization for limb salvage and this can be done successfully with a low invasive surgery. [ABSTRACT FROM AUTHOR]

Three subtypes of small bowel neuroendocrine tumours (SBNETs) have been described: Type A: SBNET with resectable mesenteric disease that does not involve the mesenteric root; Type B: "Borderline resectable" SBNET presenting with mesenteric nodal metastases and fibrosis adjacent but not encasing the main trunk of the superior mesenteric artery (SMA) and superior mesenteric vein (SMV); and Type C: "Locally advanced or irresectable" SBNET where tumour deposits and fibrosis encase the SMA and SMV. Type C SBNETs are rare and constitute around 5% of patients in reported series, although this may underestimate the prevalence. In these patients, almost all will present with symptoms of intestinal ischemia or obstruction and symptom management should be a primary main focus of treatment. All patients should be carefully staged with cross-sectional imaging and 68 Ga-dotate positron emission tomography, and discussed at a dedicated neuroendocrine tumour multidisciplinary meeting. Expert surgical review should always be sought as experienced centers have a high rate of successful resection of primary tumours and mesenteric disease. If resection is not feasible, surgical bypass should be considered in patients with a discrete and symptomatic point of obstruction. Non-operative management should emphasize symptomatic treatment with somatostatin analogs, nutritional advice and support and palliative care. Successful neoadjuvant approaches utilizing peptide radionucleide receptor therapy and systemic chemotherapy with everolimus or temazolamide/capecitabine have not been reported. [ABSTRACT FROM AUTHOR]

Objectives: Management of acute abdomen (AA) differs due to the heterogeneity of underlying pathophysiology. Complications of AA and its overall outcome after cardiac surgery are known to be associated with poor results. The aim of this retrospective analysis was to evaluate risk factors for AA in patients undergoing cardiac surgery. Methods: Between December 2011 and December 2014, a total of 131 patients with AA after cardiac surgery were identified and retrospectively analyzed using our institutional database. Statistical analysis of risk factors concerning in-hospital mortality of mentioned patient cohort was performed using IBM SPSS Statistics. Results: Overall in-hospital mortality was 54.2% (71/131). Analyzing in-hospital non-survivors (NS) versus in-hospital survivors (S) peripheral artery disease (28.2% vs. 11.7%; p = 0.03), the need for assist device therapy (33.8% vs. 16.7%; p = 0.03) and the requirement of hemodialysis (67.6% vs. 23.3%; p < 0.01) were significantly higher in NS. Furthermore, lactic acid values at onset of symptoms were shown to be significantly higher in NS (5.7 ± 5.7 mmol/L vs. 2.8 ± 2.9 mmol/L; p < 0.01). Assured diagnosis of mesenterial ischemia was strongly associated with worse outcome (odds ratio 10.800, 95% confidence interval 2.003–58.224; p = 0.006). Conclusion: In conclusion, in critically ill patients after performed cardiac surgery peripheral vascular disease, need for supportive hemodynamic assist device systems and occurrence of renal failure are risk factors associated with worsen outcome. Additionally, rise of lactic acid could potentially be associated with onset of intestinal malperfusion and should be taken into account in therapeutic decisions preventing fatal mesenterial ischemia. [ABSTRACT FROM AUTHOR]

Background: Extracorporeal membrane oxygenation (ECMO) induces coagulation disorders increasing the risk of bleeding during invasive procedures. We aimed to describe the outcomes of critically ill ECMO patients undergoing emergency abdominal surgery compared to non-ECMO patients. Study design: This is a retrospective case-matched single-center study with propensity score analysis in a tertiary ICU. All patients who underwent abdominal surgery were included. Results: From 2006 to 2014, 77 patients admitted in our ICU underwent emergency abdominal surgery, 35 were on ECMO. Surgery indications were comparable for ECMO and non-ECMO patients: mostly intestinal ischemia (42%) and cholecystectomy (25%). Postoperative bleeding was significantly more frequent in ECMO group versus non-ECMO: 77% versus 40% transfused, with medians of 13 (6–22) versus 3 (0–5) packed red blood cell; 9 (3–17) versus 0 (0–4) fresh frozen plasma and 12 (3–22) versus 0 (0–8) platelet units (p < 0.001 for all items). Reintervention for hemorrhage was required in 20% versus 2%, respectively, p = 0.02. At multivariable analysis, ECMO was strongly associated with bleeding (OR, 5.6 [95% CI, 2.0–15.4]; p = 0.001). ICU mortality was higher for ECMO-treated patients (69% vs. 33%; p = 0.003), but perioperative mortality remained comparable between groups (11% vs. 12%, NS). Propensity score-matched analysis confirmed more frequent and severe bleeding in ECMO patients. Conclusions: Abdominal surgery procedures on ECMO-treated patients are associated with a higher risk of hemorrhage compared to non-ECMO ICU patients. Further studies are needed to optimize ECMO patient management during such interventions. [ABSTRACT FROM AUTHOR]

Objective: To assess results of open repair (OR) of AAA in a single high volume center. Methods: We analyzed prospectively collected data of 450 patients who underwent elective OR of AAA at the Clinic for Vascular and Endovascular Surgery of the Serbian Clinical Centre in the period between January 2013 and September 2014. Results: Postoperative death occurred in seven patients (1. 55%) during the first 30 postoperative days. The mortality was caused by: uncontrolled bleeding-1, acute myocardial infarction-1, ischemic colitis-2, MOFS-2, sepsis due to infection and dehiscence of laparotomy wound-1. Coronary artery disease (OR 3.89; CI 0.85-17.7; p = 0.0058), postoperative acute myocardial infarction (OR 29.9; CI 2.56-334.95; p = 0.0053), chronic renal failure (OR 7.5; CI 1.35-8.5; p = 0.0073), colonic necrosis (OR 88.2; CI 4.77-1629.69; p = 0.0026), occlusion of the both hypogastric arteries and the inability to preserve at least one hypogastric artery (OR 17.4; CI 1.99-178.33; p = 0.0230), aortobifemoral reconstruction (OR 9.06; CI 1.76-46.49; p = 0.016), significant perioperative bleeding (>2 L) (OR 7.32; CI 1.31-10.79; p = 0.0001), hostile abdomen (OR 5.25; CI 1.3-21.1; p = 0.0055), inflammatory aneurysm (OR 13.99; CI 2.88-65.09; p = 0.0002), supraceliac aortic cross-clamping (OR 18.7; CI 3.8-90.6; p = 0.0003), prolonged aortic cross-clamping (>60 min) (OR 14.25; CI 2.75-64.5; p = 0.0003), the intraoperative hypotension (OR 6.61; CI 0.71-61.07; p = 0.0545), the prolonged operation (>240 min) (OR 8.66; CI 0.91-81.56; p = 0.0585) and complete dehiscence of the laparotomy (OR 44.1; CI 3.39-572.78; p = 0.0396) increased the 30-day mortality in our study. Conclusions: Early mortality after open repair of AAA in high volume center might be very low due to experienced multidisciplinary team. Centralized open aortic surgery might be solution for effective treatment of patients with unsuitable anatomy or for young patients with long life expectancy. [ABSTRACT FROM AUTHOR]

The free intestinal flap has become a recognized part of the surgical armamentarium for the reconstruction of the cervical esophagus and in the treatment of severe short bowel syndrome. However, the intestinal flap is difficult to monitor postoperatively and is susceptible to ischemia. Entire avoidance of neglected ischemia and false alarms require a monitoring system with sensitivity and specificity of 100%. The aim of this study was to investigate the value of microdialysis (MD) as a monitoring method for detecting ischemia in intestinal transplants. In 12 pigs the entire small intestine was divided into three segments, each isolated on a vascular pedicle consisting of one artery and one vein. For metabolic monitoring of the intestinal segments, one CMA 63 MD catheter was placed in each segment in the mesentery just at the border of the intestinal wall. After 1 h of arterial ischemia followed by 2 h of reperfusion, the three intestinal segments in each pig were allocated to arterial ischemia, venous ischemia, or no ischemia. A total of 10 control segments, 10 segments with arterial ischemia, and nine segments with venous ischemia were provided for evaluation of metabolic changes. One hour of secondary ischemia induced considerable metabolic changes, with a decrease in the concentration of glucose ( CGlucose) followed by an increase in the concentration of lactate ( CLactate) as well as in the lactate:pyruvate (L/P) and lactate:glucose (L/G) ratios. The changes became even more pronounced after 1½ h when the L/P and L/G ratios had increased 9 and 30 times, respectively, in the ischemic segments and without overlap in values between the ischemic and the nonischemic segments. When using CGlucose < 0.2 mmol/l or L/G > 50 as cutoff levels for detection of ischemia, a sensitivity and a specificity of 100% could be achieved. An increase in CGlucose of more than 2 mmol/l, after the infusion of glucose, could be used as a challenge test to exclude ischemia. A monitoring system based on the determination of the CGlucose and CLactate by using microdialysis can be used for positive differentiation between ischemic and nonischemic intestinal segments. [ABSTRACT FROM AUTHOR]

Proper management of small bowel obstruction (SBO) requires a methodology to prevent nontherapeutic laparotomy while minimizing the chance of overlooking strangulation obstruction causing intestinal ischemia. Our aim was to identify preoperative risk factors associated with strangulating SBO and to develop a model to predict the need for operative intervention in the presence of an SBO. Our hypothesis was that free intraperitoneal fluid on computed tomography (CT) is associated with the presence of bowel ischemia and need for exploration. We reviewed 100 consecutive patients with SBO, all of whom had undergone CT that was reviewed by a radiologist blinded to outcome. The need for operative management was confirmed retrospectively by four surgeons based on operative findings and the patient’s clinical course. Patients were divided into two groups: group 1, who required operative management on retrospective review, and group 2 who did not. Four patients who were treated nonoperatively had ischemia or died of malignant SBO and were then included in group 1; two patients who had a nontherapeutic exploration were included in group 2. On univariate analysis, the need for exploration ( n = 48) was associated ( p < 0.05) with a history of malignancy (29% vs. 12%), vomiting (85% vs. 63%), and CT findings of either free intraperitoneal fluid (67% vs. 31%), mesenteric edema (67% vs. 37%), mesenteric vascular engorgement (85% vs. 67%), small bowel wall thickening (44% vs. 25%) or absence of the “small bowel feces sign” (so-called fecalization) (10% vs. 29%). Ischemia ( n = 11) was associated ( p < 0.05 each) with peritonitis (36% vs. 1%), free intraperitoneal fluid (82% vs. 44%), serum lactate concentration (2.7 ± 1.6 vs. 1.3 ± 0.6 mmol/l), mesenteric edema (91% vs. 46%), closed loop obstruction (27% vs. 2%), pneumatosis intestinalis (18% vs. 0%), and portal venous gas (18% vs. 0%). On multivariate analysis, free intraperitoneal fluid [odds ratio (OR) 3.80, 95% confidence interval (CI) 1.5–9.9], mesenteric edema (OR 3.59, 95% CI 1.3–9.6), lack of the “small bowel feces sign” (OR 0.19, 95% CI 0.05–0.68), and a history of vomiting (OR 4.67, 95% CI 1.5–14.4) were independent predictors of the need for operative exploration ( p < 0.05 each). The combination of vomiting, no “small bowel feces sign,” free intraperitoneal fluid, and mesenteric edema had a sensitivity of 96%, and a positive predictive value of 90% (OR 16.4, 95% CI 3.6–75.4) for requiring exploration. Clinical, laboratory, and radiographic factors should all be considered when making a decision about treatment of SBO. The four clinical features—intraperitoneal free fluid, mesenteric edema, lack of the “small bowel feces sign,” history of vomiting—are predictive of requiring operative intervention during the patient’s hospital stay and should be factored strongly into the decision-making algorithm for operative versus nonoperative treatment. [ABSTRACT FROM AUTHOR]

The development of mesenteric venous thrombosis (MVT) does not necessarily require surgical intervention. The aim of this study was to assess the efficacy of avoiding early operative intervention, which can lead to significant sacrifice of the small bowel. Patients with MVT were identified using the inpatient registry for the years between 2003 and 2007. Each patient’s past medical history, history of prior deep venous thrombosis or hypercoagulable state, clinical and biologic presentation, and computed tomography (CT) results were analyzed. The proportion of ischemic bowel observed on the CT scans was compared with the length of the bowel resected. Nine patients were admitted for extensive MVT during the time period evaluated (six men, three women). All CT scans demonstrated signs of severe bowel ischemia, with a mean ischemic bowel proportion of 21% (range 5–45%). Four patients received medical management alone. Five patients underwent surgery. The mean admission time for these patients prior to the operation was 14.8 days (6–36 days). Surgery was required only in cases of intestinal perforation. The mean length of the bowel resections was 33 cm (20–45 cm). At 6 months after admission, none of the patients required parenteral nutrition. The mean follow-up evaluation period was 27 months (15–38 months). One patient died secondary to amyotrophic lateral sclerosis during the follow-up. Initial nonsurgical management comprised of inpatient observation on a surgical ward along with systemic anticoagulation must be considered an alternative treatment strategy for MVT. This strategy delays surgery and therefore avoids short bowel syndrome. [ABSTRACT FROM AUTHOR]

Intestinal ischemia is a potentially catastrophic abdominal emergency that presents a significant diagnostic challenge in the critical care setting. We performed a systematic review of the literature to define the diagnostic accuracy of serological markers of intestinal ischemia. Observational studies on the performance of markers of intestinal ischemia were identified within the MEDLINE and EMBASE electronic databases. All studies from which it was possible to derive true positive, false positive, false negative, and true negative results were included. A random-effects model was used to calculate the pooled estimates of diagnostic accuracy. A total of 20 articles examining 18 different serological markers were identified that met the inclusion criteria. The global measures of test performance (diagnostic odds ratio and area under the summary receiver operating characteristic curve) for markers investigated in three or more studies were d-lactate (10.75 and 0.86, respectively), glutathione S-transferase (GST; 8.82 and 0.87, respectively), intestinal fatty-acid binding protein (i-FABP; 7.62 and 0.78, respectively), and d-dimer (5.77 and 0.53, respectively). The performance of the currently available serological markers is suboptimal for routine clinical use, but novel markers of intestinal ischemia such as d-lactate, GST, and i-FABP may offer improved diagnostic accuracy. The early diagnosis of intestinal ischemia remains a challenge, and further research is required to identify improved serological markers and to demonstrate their clinical utility in the individual patient. [ABSTRACT FROM AUTHOR]

Intestinal ischemia/reperfusion (IR) induces a systemic inflammatory response and releases harmful substances that may affect the function and integrity of distant organs such as lung, liver, and kidney. We conducted this study to find out if proanthocyanidins (PA) has protective effects against mesenteric IR injury and mesenteric IR-induced intestinal and distant organ injury. Thirty-two Sprague-Dawley rats were divided into four groups: control, control + PA, IR, IR + PA. The IR and IR + PA groups were subjected to mesenteric arterial ischemia for 60 min and reperfusion for 6 h. The Control + PA and IR + PA groups were administered PA (100 mg/kg/day via oral gavage) for 7 days prior to injury insult. We collected ileal and distant organ tissues, such as pulmonary, hepatic, and kidney specimens to measure tissue levels of malondialdehyde (MDA), superoxide dismutase (SOD), glutathione peroxidase (GPx), and nitrite plus nitrate (NOx), and we then evaluated histological changes. In the IR group, significant increases in MDA and NOx levels and significant increases in SOD and GPx activities of intestine, liver, kidney, and lung were observed. The MDA and NOx levels were significantly lower, as were the SOD and GPx activities in the IR + PA group than that in the IR group. Although the intestine and distant organs damage scores were significantly higher in the IR group, these injuries were prevented by PA in the IR + PA group. This study demonstrates that PA has a significant effect in the protection of the intestine and the remote organs against mesenteric IR injury. [ABSTRACT FROM AUTHOR]

The tissue oxygenation index (TOI), measured by spatially resolved spectroscopy (SRS), reflects the ratio between oxygenated and deoxygenated tissue hemoglobin. We investigated whether liver TOI is a noninvasive parameter for early detection of intestinal ischemia. In seven adult New Zealand rabbits the superior mesenteric artery (SMA) and vein were exposed by laparotomy. The SRS probe was attached at the skin above the liver to calculate the TOI. The bowel (SbO2) and peripheral (SpO2) oxygen saturation were continuously measured. The SMA was occluded, creating small bowel ischemia for 90 minutes. Then reperfusion was started for 1 hour. The median TOI and interquartile range (IQR) of the TOI were calculated. A paired Wilcoxon test was used to evaluate changes in the liver TOI and SpO2 during ischemia and reperfusion. The median TOI was 54.3% (IQR 8) at the start of ischemia, 54.9% (IQR 9) after 30 minutes, 51% (IQR 11) after 60 minutes, and 50.3% (IQR 10) after 90 minutes. The median TOI values were 46.3% (IQR 5) after 30 minutes of reperfusion and 41.2% (IQR 5) after 60 minutes. The decrease in TOI became significant ( p < 0.05) after 90 minutes of ischemia. The SpO2 was stable during the experiment. A significant decrease in liver TOI was seen after 90 minutes of occlusion of the SMA and is likely to be the consequence of bowel ischemia. The further decrease after reperfusion might reflect reperfusion injury. Liver TOI may be a new tool for noninvasive early detection of intestinal ischemia and reperfusion. Further study is needed to confirm these findings. [ABSTRACT FROM AUTHOR]

We describe a new surgical technique of in situ intestinal ischemia–reperfusion injury in the pig, which includes transection of the small bowel, extrinsic autonomic denervation, lymphatic disruption, and finally in-situ cold ischemia of the graft by flushing through the first jejunal artery. Ten female pigs were used for the study. All neural and lymphatic connections to the jejunoileum were transected. The stripped superior mesenteric vessels remained as the only connections. The skeletonized mesenteric vessels were clamped and the superior mesenteric artery was cannulated through the first jejunal artery. The isolated jejunoileum was flushed with cold IGL-1 solution. A small incision on the superior mesenteric vein was made to allow outflow of the effluent. After the flushing process was complete, the small incision in the superior mesenteric vein was closed and the vascular clamps were removed. The proximal 70% of the graft was resected. The mean preoperative weight of the animals was 25.8 ±7.6 kg. The mean duration of the operation was 242.0 ± 28.6 min. The mean cold ischemia time was 47.6 ± 3.9 min. All animals survived the procedure and were sacrificed at day 8. At sacrifice, there were no adhesions. The small bowel appeared normal. On intestinal histology, there were no significant changes between specimens obtained from the animal immediately at the end of cold flushing (T0), 2 h after reperfusion (T1), and at sacrifice (T2). This novel technique for intestinal ischemia–reperfusion injury in the pig provides an extremely useful model for experimental studies of immunological and cold ischemia–reperfusion injury of transplanted small bowels. [ABSTRACT FROM AUTHOR]

The goal of this study was to assess the relevance of serum D-dimer measurement as a possible reliable marker for the diagnosis of strangulated intestinal hernia. Consecutive patients admitted with nontraumatic acute abdominal gastrointestinal disorders were recruited prospectively in a tertiary referral hospital. The study was conducted in 159 patients between August 2002 and April 2004. D-dimer, lactate dehydrogenase, serum amylase, and international normalized ratio (INR) levels were tested in the emergency room prior to surgical intervention. For each patient, 15 variables, including D-dimer, were available for analysis. Thirty-three (20.7%) of the 159 patients had intestinal ischemia, and 28 (85%) of these 33 patients had D-dimer level > 300 ng/ml. Plasma levels of D-dimer in patients with intestinal ischemia were significantly higher than in patients without ischemia ( P < 0.05). There were 29 (18.2%) patients in the hernia group with incarceration (n = 22) or strangulation requiring resection (n = 7). D-dimer levels in patients requiring intestinal resection were insignificantly higher than in patients without resection ( P > 0.05). Six (85%) of the 7 hernia patients requiring resection had D-dimer levels > 360 ng/ml. The D-dimer variable correlated best with the leukocyte count in patients with hernia requiring resection. Levels of lactate dehydrogenase, serum amylase, and INR did not show any correlation with D-dimer levels. To help predict ischemic events, the increasing use of the D-dimer assay in clinical practice could be extended to patients presenting with intestinal emergencies. An elevated D-dimer level on admission had a high sensitivity for identifying patients with intestinal ischemia, although it had a low specificity. Whether it is predictive or preventive for resection in strangulated intestinal hernia patients still remains a question. [ABSTRACT FROM AUTHOR]

Acute intestinal ischemic disorder (AIID) is an uncommon vascular disease with high mortality. According to etiology, it can be categorized into three groups: arterial occlusive mesenteric ischemia (AOMI), mesenteric venous thrombosis (MVT), and nonocclusive mesenteric ischemia (NOMI). This study analyzes the effect of classification on surgical outcome. All AIID patients who underwent operative treatment at National Cheng Kung University Hospital between January 1989 and August 2003 were enrolled in this study. Preoperative information on these patients was compared to find predictors of outcome. Data from 77 patients (49 men and 28 women, median age 70 years) were analyzed. The etiology was AOMI in 30 patients, MVT in 19 patients, and NOMI in 28 patients. Median age was younger in MVT (54 years) than in AOMI (70 years) or NOMI (72 years). In addition, MVT usually involved the jejunum (74%, versus 31% in AOMI and 46% in NOMI), whereas both AOMI and NOMI involved ileum and colon. The patients with AOMI had shorter duration of symptoms and higher ratio of underlying hypertension than those with MVT. The overall mortality rate was 53.2% (41/77). The day 1 and day 30 mortality were 0% and 10.5% in MVT, 16.7% and 30% in AOMI, and 42.9% and 67.9% in NOMI, respectively ( P < 0.05). Both the etiology and the APACHE II scores were significant risk factors for day 30 and long-term mortality. The patients with NOMI had higher POSSUM physiologic scores than patients with MVT. The P-POSSUM regression equation can accurately predict mortality. Patients with MVT had a more favorable prognosis, whereas those with NOMI had the worst outlook. The APACHE II and POSSUM scoring systems are useful in predicting the clinical outcome. Early diagnosis and classification of AIID patients are useful for aggressive treatment to improve the clinical outcome. [ABSTRACT FROM AUTHOR]

In 36 consecutive patients with a foregut carcinoid with extensive local tumor growth and liver metastases with a carcinoid syndrome, six patients had complaints of postprandial abdominal pain and attacks of subileus based on segmental intestinal ischemia. A diagnosis of abdominal angina was supported by a positive response to nitroglycerin in two and Ischemia of the ileum demonstrated by angiography in two other patients. Complaints were reduced in all patients after surgery. Histopathology of the resected small bowel specimens showed elastic vascular sclerosis in three patients and ischemic changes in three other patients, confirming the clinical diagnosis. Resection of ischemic bowel can provide relief in patients with segmental intestinal ischemia caused by carcinoid-induced vascular sclerosis. [ABSTRACT FROM AUTHOR]

The author reflects on the post operative impact of APACHE II and POSSUM Scores on acute intestinal ischemic disorders. The author discusses that APACHE II and POSSUM Scores have a significant role in determining the mortality rate caused due to intestinal ischemia. The author also discusses that increased age accompanied by many etiologic Factors effect POSSUM score.