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Background: Ischemic colitis (IC) is a known significant complication after repair of a ruptured abdominal aortic aneurysm (rAAA). Lower endoscopy (colonoscopy or flexible sigmoidoscopy) is a helpful adjunct to aid decision making for surgical exploration. We believe routine use of lower endoscopy after rAAA repair provides better patient care through expeditious diagnosis and surgical care., Methods: We performed a retrospective chart review of rAAA repairs from 2008 to 2019. All patients undergo screening lower endoscopy after rAAA repair at our institution. The incidence of IC, mortality, and diagnostic characteristics of routine lower endoscopy was analyzed., Results: Of these, 182 patients underwent rAAA repair, among which 139 (76%) underwent routine lower endoscopy. Ischemic colitis of any grade was diagnosed in 25% of patients. The 30-day mortality was 11% compared to 19% in those without lower endoscopy. The presence of IC portended a 4-fold increase in mortality rate compared to those without (26% vs 6%, P = .005). Surgical exploration rate was 8% after routine lower endoscopy. Grade III ischemia on lower endoscopy had a sensitivity of 50% (95% CI 12-88) and specificity of 99% (95% CI 94-100) for transmural necrosis., Discussion: We found increased incidence of IC and reliable diagnostic characteristics of routine lower endoscopy in predicting the presence of transmural colonic ischemia. There was decreased mortality with use of routine lower endoscopy but this was not statistically significant.

Objectives: Diagnosing colonic ischaemia (CI) after ruptured abdominal aortic aneurysm (RAAA) repair is challenging. This study determined the diagnostic value of sigmoidoscopy in patients suspected of CI after RAAA repair., Methods: This was a retrospective multicentre cohort study. Patients who underwent RAAA repair in three hospitals in Amsterdam, the Netherlands, between 2004 and 2011 (AJAX cohort) were included. Sigmoidoscopies were carried out based on clinical judgment. Endoscopy results were classified as "no ischaemia," "mild CI," or "moderate to severe CI." The surgical diagnosis was classified as "transmural" or "no transmural" CI. The value of sigmoidoscopy was assessed with calculation of positive and negative predictive values (PPV, NPV) with 95% CI for transmural CI. Logistic regression analysis was used to express the association of risk factors with CI as adjusted OR., Results: Transmural CI was diagnosed in 23 of 351 patients (6.6%). Thirteen of sixteen patients (81%) who underwent direct laparotomy for high suspicion of CI indeed had transmural CI. Forty-six patients (13%) underwent sigmoidoscopy. The prevalence of transmural CI was 22% (10/46; 95% CI 12-36%) in these patients. The PPV for transmural CI of "moderate to severe CI" on sigmoidoscopy was 73% (8/11; 95% CI 43-90%). The PPV of "mild CI" on sigmoidoscopy was 11% (2/19; 95% CI 2.9-31%). The NPV of "no ischaemia" on sigmoidoscopy was 100% (95% CI 78-100%). Cardiac comorbidity (OR 3.1, 95% CI 1.19-7.97), low first haemoglobin (OR 0.6, 95% CI 0.47-0.87), and high vasopressor administration (OR 9.4, 95% CI 1.99-44.46) were independently associated with CI., Conclusions: Sigmoidoscopy increases the likelihood of correctly identifying the presence or absence of transmural CI, especially in patients with a moderate clinical suspicion for CI after RAAA repair., (Copyright © 2018 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Background: Ischemic colitis (IC) is a well-described complication of ruptured abdominal aortic aneurysms (rAAAs). The purpose of this study was to compare the incidence of IC in patients with rAAA undergoing open repair (OR) versus endovascular aneurysm repair (EVAR) at a single institution. In addition, we analyzed the incidence of IC before and after the implementation of a formal rupture AAA protocol (rEVAR protocol)., Methods: A retrospective analysis of prospectively collected data on all patients presenting with rAAA to our institution between January 2002 and October 2013 was performed. Variables were analyzed for association with IC. Comparisons were made using Pearson's chi-squared test or Fisher's exact test for categorical variables, Student's t-test for continuous variables, and logistic regression for multivariate analysis. Significance was set at P < 0.05., Results: Three hundred three patients with rAAA presented over the 10-year study period. One hundred ninety-one patients underwent OR and 89 patients underwent endovascular repair. Twenty-three patients died either in the emergency department, en route to the operating room, or after choosing comfort care. Predictive factors of IC included estimated blood loss, corresponding need for resuscitation, and duration of procedure. Of patients who underwent OR, the rate of IC was 21% (40/191). This was significantly higher than patients who underwent EVAR, 7% (6/89), P < 0.05. The type of intervention did not influence 30-day mortality in patients with IC. However, only 17% (1/6) of patients who had IC following EVAR required colectomy versus 48% (19/40) of patients with IC following OR (P = 0.21). Implementation of our formal rEVAR protocol decreased the incidence of IC significantly from 37.1% (36/97) to 6.4% (10/157), P < 0.001., Conclusions: The incidence of IC has decreased significantly in the endovascular era but continues to portend a poor prognosis. Implementation of a formal, multidisciplinary rEVAR protocol in our institution decreased the incidence of IC., (Published by Elsevier Inc.)

Objective: Hypogastric artery embolization (HAE) is associated with significant risk of ischemic complications. We assessed the impact of HAE on 30-day outcomes of endovascular aneurysm repair (EVAR) of infrarenal abdominal aortic aneurysms., Methods: We queried the American College of Surgeons National Surgical Quality Improvement Program database from 2011 to 2014 to identify and to compare clinical features, operative details, and 30-day outcomes of EVAR with those of concomitant HAE with EVAR (HAE + EVAR). Multivariate analysis was performed to determine preoperative and intraoperative factors associated with development of significant complications observed in patients with HAE + EVAR., Results: In a cohort of 5881 patients, 387 (6.6%) underwent HAE + EVAR. Compared with EVAR, a higher incidence of ischemic colitis (2.6% vs 0.9%; P = .002), renal failure requiring dialysis (2.8% vs 1%; P = .001), pneumonia (2.6% vs 1.3%; P = .039), and perioperative blood transfusion (17% vs 13%; P = .024) was noted after HAE + EVAR. Thirty-day thromboembolic events, strokes, myocardial infarction, lower extremity ischemia, reoperation, and readmission rates were not significantly different (P > .05). Mortality at 30 days in HAE + EVAR patients was 4.1% compared with 2.5% with EVAR (P = .044). HAE was independently associated with increased risk of colonic ischemia (adjusted odds ratio, 2.98; 95% confidence interval, 1.44-6.14; P = .003) and renal failure requiring dialysis (adjusted odds ratio, 2.22; 95% confidence interval, 1.09-4.53; P = .029). However, HAE was not an independent predictor of mortality. Average length of hospital stay was 4 ± 8.5 days after HAE + EVAR vs 3.3 ± 5.9 days after EVAR (P = .001)., Conclusions: Concomitant HAE with EVAR is associated with longer and more complicated hospital stays. Ischemic colitis is a rare complication of EVAR. HAE increases the risk of ischemic colitis and renal failure requiring dialysis. This study highlights the importance of hypogastric artery preservation during EVAR., (Copyright © 2016 Society for Vascular Surgery. All rights reserved.)

Objective: Postoperative ischemic colitis (IC) can be a serious complication following infrarenal abdominal aortic aneurysm (AAA) repair. We sought to identify risk factors and outcomes in patients developing IC after open AAA repair and endovascular aneurysm repair (EVAR)., Methods: The American College of Surgeons National Surgical Quality Improvement Program database was used to examine clinical data of patients undergoing AAA repair from 2011 to 2012 who developed postoperative IC. Multivariate regression analysis was performed to identify risk factors and outcomes., Results: We evaluated a cohort of 3486 patients who underwent AAA repair (11.6% open repair and 88.4% EVAR). The incidence of postoperative IC was 2.2% (5.2% for open repair and 1.8% for EVAR). Surgical treatment was needed in 49.3% of patients who developed IC. The mortality of patients with IC was higher than that of patients without IC (adjusted odds ratio [AOR], 4.23; 95% confidence interval [CI], 2.26-7.92; P < .01). The need for surgical treatment (AOR, 7.77; 95% CI, 2.08-28.98; P < .01) and age (AOR, 1.11; 95% CI, 1.01-1.22; P = .01) were mortality predictors of IC patients. Predictive factors of IC included need for intraoperative or postoperative transfusion (AOR, 6; 95% CI, 3.08-11.72; P < .01), rupture of the aneurysm before surgery (AOR, 4.07; 95% CI, 1.78-9.31; P < .01), renal failure requiring dialysis (AOR, 3.86; 95% CI, 1.18-12.62; P = .02), proximal extension of the aneurysm (AOR, 2.19; 95% CI, 1.04-4.59; P = .03), diabetes (AOR, 1.87; 95% CI, 1.01-3.46; P = .04), and female gender (AOR, 1.75; 95% CI, 1.01-3.02; P = .04). Although open AAA repair had three times higher rate of postoperative IC compared with endovascular repair, in multivariate analysis we did not find any statistically significant difference between open repair and EVAR in the development of IC (5.2% vs 1.8%; AOR, 1.25; 95% CI, 0.70-2.25; P = .43)., Conclusions: Postoperative IC has a rate of 2.2% after AAA repair. However, it is associated with 38.7% mortality rate. Rupture of the aneurysm before surgery, need for transfusion, proximal extension of the aneurysm, renal failure requiring dialysis, diabetes, and female gender were significant predictors of postoperative IC. AAA patients who develop IC have four times higher mortality compared with those without IC. Surgical treatment is needed in nearly 50% of IC patients and is a predictor of higher mortality., (Copyright © 2016. Published by Elsevier Inc.)

Background: Left-sided colonic and rectal ischemia is commonly seen after surgery for ruptured abdominal aortic aneurysms (rAAAs) and is associated with increased mortality. Earlier studies have shown that flexible sigmoidoscopy (FS) may detect ischemia when performed postoperatively, and suggestions have been made that patients can be selected for FS based on clinical and biochemical parameters. We sought to perform FS in all patients surviving the first 24 hours after surgery for rAAA and to compare the findings of FS to clinical and biochemical parameters., Methods: All patients undergoing emergency surgery for rAAA and surviving the first 24 hours underwent FS to assess any degree of ischemia., Results: During the study period, 41 patients survived the first 24 hours after surgery. In 9 (22%) patients, some degree of colonic ischemia was found. Segmental necrosis was only shown in 5% at first FS. Patients with ischemia received more blood transfusions intraoperatively than those with normal findings at FS. They also had longer periods with mean blood pressure <60 mm Hg postoperatively, and lower arterial pH on the first postoperative day. Blood lactate levels did not differ between the groups. None of the parameters were sufficiently discriminative to be used for distinguishing between patients with and without ischemia., Conclusions: Severe colonic ischemia was less common than previously reported. All cases of colonic ischemia were identified by early FS, but none of the clinical and biochemical parameters were sufficiently reliable to distinguish between patients with and without ischemia. It is suggested that all patients initially surviving surgery for rAAA should be offered FS to screen for colonic ischemia., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Introduction: Using retrospective analysis, we sought to investigate the incidence, risk factors and therapeutic outcomes of ischemic colitis in patients after surgical and endovascular repair of abdominal aortic aneurysms (AAA)., Material and Methods: The complete inpatient and outpatient medical records of all patients undergoing surgical or endovascular AAA repair in our Department from January 2005 to December 2009 were retrospectively reviewed. We selected all patients who had developed an acute or chronic form of postoperative large or small bowel ischemia. We carried out data analysis and focused on determining the incidence and risk factors of this complication and the outcomes of its treatment., Results: Two hundred and seven AAA repairs were performed in the 2nd Department of Surgery of St. Anne's University Hospital in Brno and the Faculty of Medicine of Masaryk University in Brno during the studied period. This number includes endovascular AAA repairs (13 patients; 6.3%) as well as one robot-assisted operation, and also the whole clinical spectrum of AAA manifestations, from non-symptomatic forms to ruptured aneurysm forms. The rest of the patients underwent open operation. Bowel ischemia developed in a total of 11 patients (5.3 %), who all underwent open AAA repair. Six of these patients presented with non-ruptured AAA and the remaining 5 with ruptured AAA. In 3 patients, bowel ischemia was diagnosed with a delay of several months from the original revascularization operation in the clinical form of postischemic stricture of the large bowel (2 patients) or postischemic colitis (1 patient). 8 patients were diagnosed with acute ischemic colitis affecting an isolated segment of the small bowel in one patient, extended segments of the large bowel (descending colon + sigmoid colon + rectum) in 2 patients, and typically the descending and sigmoid colon in 5 patients. None of the three patients with late manifestation of ischemic colitis died. Of the 8 patients with acute presentation, resection of the ischemic bowel +/- the rectum was performed in 6 patients. 3 of them died and 3 survived the operation and have been followed up in our outpatient department. 2 patients with acute manifestation did not undergo bowel resection. Both of them died. The overall mortality of all patients with ischemic colitis was 45.5% (5 patients out of 11 died) in our study. When considering only patients suffering from the acute form of ischemic colitis, the mortality rate in our studied cohort amounts to 62.5% (5 patients out of 8 died)., Conclusion: Bowel ischemia after AAA repair remains to be a serious complication. Besides the acute form of ischemic colitis, its possible late clinical manifestation in the form of postischemic stricture of the large bowel or postischemic large bowel colitis must also be kept in mind when following up patients. The analysis of our patient's data shows that conditions requiring the use of vasopressors and an increased need of transfusions (more than 7 units of packed red blood cells) intraoperatively represent important predictors of colon ischemia after AAA repair.

Introduction: Bowel ischemia following the AAA operation is a rare complication. However, it is the most common reason of death after elective AAA operation with the incidence of 5-9% and 30-60% following RAAA operation with mortality rate around 60%., Methods: Retrospective analysis of 207 patients undergoing elective and emergent AAA operation between 1st January 2007 and 31st July 2010 was made. We evaluated clinical and para clinical symptoms leading to the observed diagnosis., Results: During the observed period we have treated 207 patients with the AAA. 174 (84%) patients were elective, 33 (16%) were urgent (RAAA). Postoperative mortality of the entire group was 19 patients (9.2%). The most common reason of death was found to be ischemic colitis--8 patients (42%). Ischemic colitis was diagnosed in 17 patients (8.2%) with the mortality 41.2%. Diagnosis was made by colonoscopy in 58.8% of patients, the rest was operated on following the clinical finding of an acute abdomen. In a group of patients with an early diagnosis and treatment of ischemic colitis (until the 4th post operative day) the mortality rate was 20%, increasing till 71.4% when the diagnosis was done later than on 4th postoperative day., Discussion: Nevertheless the ischemic colitis is a rare complication following AAA operation the surgeon must be proactive regarding this severe complication especially in high risk patients. Clinical symptoms are not specific, most often too early peristaltic and diarrhoea with addition of blood is apparent. Procalcitonine and D-lactate seem to be promising among the blood markers. Colonoscopy is a method of choice if there is any doubt in postoperative process. The need of relaparotomy is given by colonoscopy finding together with clinical, biochemical symptoms, signs and the clinical status of the patient. The resection of diseased part of bowel with the colostomy is mandatory., Conclusion: The final diagnosis of ischemic colitis is difficult and the decision for reoperation is a matter of surgeons' experience despite of clinical and paraclinical findings. Only fast and adequate treatment can be successful. Any delay in diagnosis is fatal for the patients.

Objective: To examine the incidence, cause, and outcomes of ischemic colitis after endovascular stent graft repair of aortoiliac aneurysms (EVAR)., Design: Medical record review., Setting: University teaching hospital., Patients: Eight hundred nine patients treated during 10 years were included in the study. Preoperative data regarding the size of the aneurysm, hypogastric coil embolization, and inferior mesenteric artery patency were evaluated by means of computed tomographic scans and aortograms. Ischemic colitis was diagnosed by lower endoscopy or pathology reports., Main Outcome Measures: Ischemic colitis after EVAR., Results: Eleven patients (1.4%) developed ischemic colitis. Seven patients' episode occurred less than 30 days from repair (early), whereas 4 occurred 30 days or more from repair (late). Ten of 11 patients had preoperative inferior mesenteric artery occlusion. Microembolization was seen histologically in 2 patients in the early group, both of whom died. A significant increase in ischemic colitis was seen in patients undergoing preoperative unilateral hypogastric coil embolization (P = .02). Three of the patients with late ischemic colitis had comorbidities other than the EVAR to explain the ischemia., Conclusions: The incidence of ischemic colitis is decreased in patients undergoing EVAR vs open repair. The cause of the ischemia is multifactorial and seems to differ between patients in the early and late groups. Microembolization tends to produce severe ischemic colitis and is usually fatal. There should be a low threshold for performing endoscopy in any patient thought to have ischemic colitis after EVAR.

Clinically relevant rates of ischemic colitis (IC) causing diarrhea, systemic involvement, colon necrosis, and, ultimately, death by multiple organ failure affect only a small proportion of patients after aortic reconstructions, with reported incidences of 2.7 to 3.3%. The key to treating and saving patients with this complication remains early detection and consequent treatment. The aim of this retrospective analysis of prospectively collected data was to compare the diagnostic accuracy of colonoscopy for detecting postoperative IC compared with histology and to evaluate the interobserver difference of two experienced surgeons. One hundred patients with infrarenal aortic aneurysms, operated on electively from March 2001 to December 2003, who had on postoperative days 3 to 6 a sigmoidoscopy by two independent surgeons and a histologic sample of the sigmoid mucosa, were included in the study. Patients with previous colon resection or inflammatory bowel disease were excluded from the study. All patients gave written informed consent. The study was approved by the Institutional Review Board. Histologic examination of the sigmoid mucosa revealed IC in 13 patients. The combined sensitivity of both investigators for detecting IC by sigmoidoscopy compared with histology was 84%, the specificity was 92.0%, the positive predictive value was 61.1%, the negative predictive value was 97.6%, and the diagnostic accuracy was 91.0%. There was no statistically significant difference between investigator 1 and investigator 2 (p=1.0) and between both investigators and histology (p=.380). Histology remains the gold standard for detecting IC after aortic surgery. Sigmoidoscopy, however, is a valid diagnostic tool allowing immediate clinical decision making with a negative predictive value of more than 94% and a diagnostic accuracy of 92%.

Purpose: Emergent repair of ruptured abdominal aortic aneurysms (rAAAs) is associated with high perioperative morbidity and mortality. One of the significant complications of this surgery is bowel ischemia. Reports detail mortality as high as 80% when this condition is realized. The objective of this project was to determine both the incidence and the effect of mandatory postoperative colonoscopy on outcome of colon ischemia after rAAA., Methods: From July 1995 to September 2002 all patients with an rAAA who underwent emergent aortic reconstruction were included in this review. All colonoscopies were performed within 48 hours, ischemia was graded consistently, and treatment was initiated per protocol based on grade of ischemia. Patients with grades I and II ischemia were followed up with medical management and repeat colonoscopy. All patients with grade III ischemia underwent bowel resection. Preoperative, intraoperative, and postoperative variables were collected to assess possible independent risk factors for and predictors of bowel ischemia., Results: Eighty-eight patients underwent emergent aortic reconstruction because of rAAA in the study period. Their mean age was 73 years, and 64 patients (72%) were men. Operative mortality was 42%. Eighteen percent of patients died within 24 hours, and 24% died between 1 and 30 days after surgery. Colonoscopy was performed in 62 of 72 patients who survived more than 24 hours. Bowel ischemia was documented in 26 of the 72 patients (36%). Of these, 16 patients had grade I or grade II ischemia at both initial and repeat endoscopy. Nine patients underwent exploratory laparotomy with bowel resection because of grade III ischemia; two procedures were performed because of worsening ischemia discovered at repeat colonoscopy. In patients with colonoscopic findings of bowel ischemia the mortality rate was 50% (13 of 26 patients). In those with grade III necrosis who underwent resection the mortality rate was 55%. Elevated lactate levels, immature white blood cells, and increased fluid sequestration were all variables associated with the occurrence of colon ischemia., Conclusions: Bowel ischemia is a frequent postoperative complication (42%) of repaired rAAA. Performing mandatory surveillance colonoscopy in these patients may be associated with a decrease in overall mortality and improved survival in patients with transmural bowel necrosis with no comorbid condition.

Ischemic colitis resulting in colonic infarction after aortic reconstruction is a highly lethal complication. The etiology and pathogenesis of this condition demonstrate that in many instances it may be prevented. Early recognition, particularly of the transmural ischemic injury is essential. Numerous techniques used during surgery for assessing the adequacy of colonic perfusion have been evaluated and found to be inaccurate in terms of predicting colonic ischemia. The purpose of this study is to assess the main monitoring technique for prediction of ischemic colitis during aortic surgery as: colonic mesenteric Doppler signal, inferior mesenteric arteries stump pressure, sigmoidal intramucosal pH and measurement of mucosal capillary haemoglobin oxygen saturation by reflectance spectrophotometry. A 15-year experience with 1912 patients undergoing abdominal aortic reconstruction was reviewed to determined both the incidence of intestinal ischemia and the clinical anatomic, and technical factors associated with this complication of aortic surgery

Unlabelled: Ischemic colitis (IC) is an important clinical problem, and may present after aortic surgical procedures. The aim of this work was to establish risk factors for IC presentation in aortic surgical replacement patients., Material and Methods: A retrospective study of patients with aortic surgical replacement in a 3-year period was carried out. Patients were divided into two groups: patients without IC and patients with IC, the later group subdivided into patients with gangrenous ischemic colitis and without gangrenous ischemic colitis. Multiple logistic regressions was used to obtain the variables for possible risk factor for IC., Results: We included 101 patients in the study; ischemic colitis was present in 16.8% of all cases, with 47.1% of gangrenous type. Metabolic acidosis was the most frequent alteration. Diagnosis was made by endoscopy in 94.1%. Mortality in IC group was 18.2% with an increase in the gangrenous group to 62.5%. Identified risk factors were disrupted aneurysm, previous colonic surgery, emergency surgery, and hemodynamic instability., Conclusions: Ischemic colitis is most frequent in emergency surgery for disrupted aneurysm in the hemodynamically unstable patient with retroperitoneal hematoma. We must entertain a high suspicion index for IC in all patients with aortic surgical procedures for early detection and adequate treatment.

A 62-year-old man with grade III ischemia of the legs and occlusion of an aortofemoral shunt underwent axillofemoral bypass and bilateral profundoplasty. During surgery, an aneurysm in the aortic origin of the right common iliac artery ruptured, requiring ligation of the inferior vena cava, the iliac veins and the right common iliac artery. Upon transfer of the patient to the recovery unit, the sigmoid intramucosal pH (pHi) was 6.83 (arterial pH 7.35), the regional CO2 pressure (PrCO2) was 100 mmHg (arterial PCO2 35.2 mmHg), and the lactic acid concentration was 3.6 mmol/L. Ischemic colitis was suspected and colonoscopy confirmed the presence of severe rectal and moderate sigmoid inflammation. An extended sigmoidectomy was performed with colostomy. The patient died from multiorgan failure 48 hours after surgery. Ischemic colitis is a severe complication of aortic surgery. Sigmoid pHi monitoring is non-invasive and highly useful for the early diagnosis of ischemic colitis.

All patients with an abdominal aortic aneurysm treated during a 27-year period by one surgical group at the MidAmerica Heart Institute were included in this study. A prospective routine postaneurysmectomy hemodynamic assessment of the inferior mesenteric artery (IMA) circulation was performed in a test group of consecutive patients operated on by one surgeon. When a mean IMA stump pressure

Background: Patients with a ruptured abdominal aortic aneurysm (AAA) are at risk of developing colonic ischaemia after surgery. It is difficult to diagnose this ischaemia at an early stage. D-lactate is produced by intestinal bacteria after ischaemia. L-lactate is released in increased amounts during hypoxia by anaerobic metabolism. This study investigated both variables as a marker for intestinal ischaemia in patients with a ruptured AAA., Methods: Twenty-four patients with ruptured AAA were divided retrospectively into two groups with and without ischaemic complications, as verified by colonoscopy. Blood had been taken on admission to the intensive care unit (ICU). Median time to colonoscopy was 9 days after surgery. As controls, four patients with pneumonia, six healthy subjects, five patients with an elective AAA repair, and six patients with sepsis and acute tubular necrosis were included., Results: D-lactate level on admission was significantly increased in patients with colonic ischaemia after ruptured AAA compared with the level in patients without ischaemia (P< 0.05), patients with sepsis (P< 0.001), those with pneumonia and healthy subjects (P< 0.01). L-lactate concentration was similar in the group with intestinal complications and in patients without colonic ischaemia; however, L-lactate levels were higher in patients with pneumonia and sepsis than in healthy subjects (P < 0.05)., Conclusion: On admission to the ICU, D-lactate, but not L-lactate, levels may predict later colonic ischaemia following repair of a ruptured AAA.

Background: Ischaemic colitis is an infrequent, but potentially fatal, complication of abdominal aortic surgery. Its presentation is often underestimated on account of a paucity of symptoms, thus the real incidence of ischaemic colitis may be higher., Aim: To determine the prognostic value and sensitivity of endoscopy, early postoperative endoscopic findings were evaluated., Methods: Over a period of three years a prospective study was undertaken in a consecutive series of 105 patients (mean age 68.9 years, range 51-85) undergoing routine rectosigmoidoscopy within 72 hours of aortic reconstructive surgery., Results: Colonic ischaemia was found in 12 patients (11.4%); five had endoscopic evidence of mild ischaemic colitis, ulcerations were identified in five and diffuse superficial necrosis in two. Seven of the 12 patients were symptomatic. Laparotomy was never deemed necessary and all patients were successfully treated with a conservative regimen. There were no deaths. Elective reconstruction or urgent procedure did not correlate with the development of colonic ischaemia, nor did duration of aortic cross-clamp time, patency of the inferior mesenteric artery and its possible ligation or reimplantation or patency of the hypogastric arteries., Conclusions: Rectosigmoidoscopy is effective for early diagnosis of ischaemic colitis. Early endoscopy should be routinely performed only for patients in whom impaired blood flow is suspected on the basis of the intraoperative objective assessment of the colon and in presence of symptoms.

Background: The development of colonic ischemia following repair of ruptured abdominal aortic aneurysm (AAA) is associated with significant morbidity and timely diagnosis is essential. The purpose of this study was to determine the efficacy of endoscopy in the diagnosis of colonic ischemia and in prediction of need for resection., Methods: Patients who underwent postoperative lower endoscopy after ruptured AAA from 1986 to 1995 were reviewed for endoscopic findings, clinical course, and patient outcome., Results: A total of 80 patients had ruptured AAA during the study period, of which 56 survived for longer than 24 h postoperatively. Flexible lower endoscopy was done in 18 patients (32%) on an average of 4.4 days following AAA repair (range 1-16). Indications for initial endoscopy included early or bloody stools in 12 (67%), hemodynamic instability or sepsis in eight (44%), and acidosis in four (22%). The extent of the examination was sigmoid or descending colon in 13, cecum in four, and transverse colon in one. Endoscopic findings were normal in four patients. Five examinations showed only areas of hemorrhagic mucosa. Absence of full-thickness ischemia was confirmed by clinical course or autopsy in these nine patients. Two examinations demonstrated full-thickness necrosis which was confirmed at subsequent laparotomy. In six examinations, ischemia was noted but judged to be limited to mucosa only. Absence of full-thickness disease was demonstrated by laparotomy in three and subsequent course in three. Eight patients (57%) with initial abnormal examinations underwent repeat endoscopy showing improved interval appearance in seven cases and progression to full-thickness ischemia in one patient., Conclusions: Flexible sigmoidoscopy reliably predicts full-thickness colonic ischemia following repair of ruptured aortic aneurysms. Patients with non-confluent ischemia limited to the mucosa can be safely followed by serial endoscopic examinations.

Acute ischemic colitis is noted as a rare but lethal complication of abdominal aortic aneurysm (AAA) surgery. Because of its high mortality a reliable method of monitoring colonic blood perfusion to predict the possible occurrence of ischemic colitis is highly desirable for AAA surgery. We have tested the use of a laser Doppler flowmeter placed on the surface of the sigmoid colon for intraoperative monitoring in 31 patients with AAA. Although most of the patients showed the same flow levels after aorto-iliac or aorto-femoral grafting (at least unilaterally the internal iliac artery was perfused), in 6 cases poor colonic perfusion (below 50% of the basal flow) was observed and inferior mesentric arterial reconstruction was performed. In these 6 patients, sigmoid colonic blood perfusion returned from 37% to 82% of preoperative value after the reconstructions. No ischemic colitis was noted in this series of patients. We suggest that monitoring of serosal blood flow in the sigmoid colon using a laser Doppler flowmeter is useful for the management of patients during abdominal aortic aneurysm surgery.

Objectives: To study the incidence and clinical presentation of intestinal ischaemia after aortoiliac/femoral surgery, and to validate a vascular registry concerning a serious complication., Design and Setting: In the Swedish Vascular Registry (SWEDVASC) the outcome and complications of all vascular procedures are registered prospectively., Materials and Methods: All 2930 patients operated in 1987-93 were analysed for notified complications. A 5% random sample of all patients and a 20% random sample of fatal cases were analysed for un-notified complications. Of 415 requested patient records 413 were analysed., Results: The estimated incidence of bowel ischaemia was 2.8%. Among patients operated on for a ruptured aneurysm in shock it was 7.3%. Of the 63 patients with intestinal ischaemia only 15 presented with early passage of bloody stools. In 60 patients (95%) the lesion affected the left colon within the reach of a sigmoidoscope. Bowel ischemia was unnotified only in fatal cases, the estimated un-notified complication rate was 0.7%., Conclusions: The incidence in this study on unselected patients did not differ from previous reports from specialised centres. Diagnosis is difficult and justifies a high index of suspicion and early use of sigmoidoscopy. The validity of the SWEDVASC registry was confirmed by a high report-rate for this complication.