Search

Objective: Although extensive collateral arterial circulation will prevent ischemia in most patients with stenosis of a single mesenteric artery, mesenteric ischemia may occur in these patients, for example, in patients with celiac artery compression syndrome (CACS). Variation in the extent of collateral circulation may explain the difference in clinical symptoms and variability in response to therapy; however, evidence is lacking. The objective of the study was to classify the presence of mesenteric arterial collateral circulation in patients with CACS and to evaluate the relation with clinical improvement after treatment.Methods: Collateral mesenteric circulation was classified on the basis of angiographic findings. Collaterals were categorized in three groups: no visible collaterals (grade 0), collaterals seen on selective angiography only (grade 1), and collaterals visible on nonselective angiography (grade 2). Surgical release of the celiac artery in patients with suspected CACS was performed by arcuate ligament release. Clinical success after surgical revascularization was defined as an improvement in abdominal pain.Results: Between 2002 and 2013, there were 135 consecutive patients with suspected CACS who were operated on. In 129 patients, preoperative angiograms allowed classification of collateral circulation. Primary assisted anatomic success was 93% (120/129). In patients with grade 0 collaterals, clinical success was 81% (39 of 48 patients); with grade 1 collaterals, 89% (25 of 28 patients); and with grade 2 collaterals, 52% (23 of 44 patients; P Conclusions: Patients with CACS and with extensive collateral mesenteric arterial circulation are less likely to benefit from arcuate ligament release than are patients without this type of collateral circulation. The classification of the extent of mesenteric collateral circulation may predict and guide shared decision-making in patients with CACS.

Dedication These guidelines are dedicated to Paola De Rango, University of Perugia, Italy. She participated very actively in the process of developing these guidelines, in particular the important chapters on chronic arterial and venous mesenteric ischaemia. Six days after the second meeting of the task force she died unexpectedly, to our great despair and loss. We honour her dedication and scientific integrity by completing these guidelines. Among many other commitments she was a very productive reviewer and an associate editor of this journal. You can read more about Paola's important contributions to science and to the vascular community in the April 2016 issue of the European Journal of Vascular and Endovascular Surgery. 1 Download : Download high-res image (56KB) Download : Download full-size image Dr Paola De Rango, July 28, 1966 – February 21, 2016

Seventy-three Helicobacter pylori-positive patients were treated with a combination of clarithromycin and ranitidine in order to eradicate the bacterium. Eradication was successful in 79.5%. In 15 patients eradication failed, and in 11 cases this was due to clarithromycin resistance. In one patient the infecting strain was resistant at the onset of treatment, while in the remaining 10 patients resistance developed during therapy. These isolates had also become resistant to various other antibiotics. Random amplified polymorphic DNA and restriction fragment end-labeling analysis of the isolates showed close genetic relatedness between pre- and post-treatment isolates, indicating that resistance was the result of selection of variants of the infecting strain rather then infection with an exogenous resistant strain. Nucleotide sequence comparisons revealed that all resistant isolates had a single base pair mutation in the 23S rRNA. Since this single point mutation results in co-resistance to various antibiotics at high frequencies, caution should be taken when using clarithromycin as a single antibiotic.

Tonometry of PCO2 is a promising method for assessing the oxygen supply to demand ratio of the gastrointestinal mucosa in critically ill patients. A balloon-tipped tonometer is introduced into the stomach or sigmoid colon, and saline is instilled into the balloon. After a time to allow partial equilibration with intraluminal PCO2, saline is aspirated and PCO2 is measured. Intermittent instillation and aspiration of saline allows serial PCO2 measurements, provided correction factors are used to calculate the PCO2 value expected at full equilibration from the PCO2 values measured after short dwell times. The technique is not yet widely applied, partly because of methodological controversies. We evaluated the role of the catheter deadspace as a source of error during PCO2 tonometry. The increase in PCO2 in sigmoid-type tonometers with a normal length (normal tonometer (NT)) and in those with a 50% increase in length and thus deadspace (extended tonometer (ET)), in a saline bath at a PCO2 of 4.8 kPa was assessed. Saline dwell times were 10, 20, 30, 45, 60 and 90 min and the time-dependent PCO2 increase was determined at deadspace PCO2 values of approximately 4.0 and 8.0 kPa following contamination of the catheter deadspace after immersion in saline baths at PCO2 values of 4.8 and 9.6 kPa, respectively, before each measurement cycle. In another experiment, the tonometer was rinsed between measurement cycles to remove deadspace saline containing carbon dioxide and to obviate contamination of instilled saline. PCO2 was measured in a blood-gas analyser, taking into account measurement bias in saline. Failure to remove deadspace saline between measurement cycles resulted in an overestimation of 10% and 6% for the NT and 16% and 10% for the ET, at saline dwell times of 10 and 20 min, respectively, at a deadspace PCO2 of approximately 4.0 kPa. At a deadspace PCO2 of approximately 8.0 kPa, PCO2 was overestimated by 17%, 11% and 5% for the NT and 31%, 20% and 11% for the ET, at dwell times of 10, 20 and 30 min, respectively. Rinsing the NT/ET resulted in accurate assessment of PCO2 at all dwell times, but the dwell time-dependent increase in PCO2 was slightly slower in the ET, particularly at 10 min, after a sink effect of the increased deadspace. Hence, a previously unrecognized deadspace effect caused error during PCO2 tonometry, particularly with short dwell times. This potentially large error can be avoided by rinsing the tonometer before each measurement cycle, allowing accurate PCO2 tonometry even at 10-min saline dwell times, provided that correction factors are used that are specific for catheter size. These findings may help to widen the clinical applicability of tonometry.