Daniela RADU - Chief Editor

Up to Date in the Diagnosis and Treatment of Intestinal Infraction

Review made at the Surgical Clinic I, Timisoara, Professor Marius Teodorescu

Dr. Daniela Radu

We define the ischemic intestinal syndrome by the totality of the clinical manifestations caused by the total or partial reduction, abruptly or slowly, of the intestinal circulation. This syndrome is to be found in literature under different denominations :

○ abdominal angina
○ arterial disease of the digestive tract
○ mesenteric vascular occlusion

The ischemic abdominal angina was described for the first time by Vichov and Chiene over hundred years ago.

With the development of the arteriographic techniques, the diagnosis of arterial obstruction may be established easier. There are several double blind, randomised controlled trials and the number of healed patients has increased due to different surgical procedures.

The conservative treatment does not heal, while the mortality surpasses 75%.
In case of mesenteric embolia the success of the intervention is mainly dependent on the rapid diagnosis. The vascular surgery has improved significantly since 1950.

The curative treatment. The indication of emergency surgical intervention, although very risky, is absolute and the only one that may save the patient’s life.

There are several possibilities to re-establish the intestinal circulation in acute intestinal ischemia in early stages before the appearance of irreversible intestinal lesions:
○ embolectomy
○ aorto-mesenteric by-pass
○ thrombendartectomy

If there are irreversible intestinal lesions in certain areas, the association of the intestinal resection with the opening of the intestinal obstruction is recommended, reducing in this way significantly the postoperative mortality.

The postoperative treatment: heparin treatment is indicated in spite of the hemorrhagic risk.

In the chronic intestinal ischemia, once the diagnosis is established, the only rational treatment is the revascularisation associated with the specific medical treatment. As procedures there are the endartectomy, the by-pass, the resection of the stenotic process with termino-terminal sutures, aortic re-implantation, freeing of the external compression with celiac sympathectomy.

The first mesenteric embolectomy was made by Stewart in 1951 and since there were few successful published cases due to late diagnosis.

The Surgery Clinic I from the Medical University in Timisoara, had in the period 01.01.2003 to 01.07.2005, 12 operated patients with intestinal infraction, out of a total of 5549 operated patients in the same period, so the cases of intestinal infraction represent 0,21%

Number of cases	Period
12	2003-2005

Cases of intestinal infraction at the Surgery Clinic I in the period 01.01.2003 – 01.07.2005

If we analyse the sex distribution of this pathology, the ratio of female is significantly greater, 58,33%.

 

Number of cases	Female	Male
12	7(58,33%)	5(41,7%)

Case distribution on sexes

It is known that this pathology is specific for advanced age, but we have in our study one case at 45 years, while the mean age was 64,5 years.

 

Age	Mean age
45-82 years	64,5 years

Age limits and mean age

All the patients came to hospital and were operated on as emergency cases, after a minimum period of time necessary for biological investigations and preoperative preparation, which is absolutely necessary before large surgical procedures. Most of these patients had also associated diseases and came to hospital when they already had complications, which made the vital risk even greater.

Diagnostic laparoscopy is very useful for critical patients under suspicion of intestinal mesenteric infraction without a relevant clinical picture. If a severe intestinal ischemia is found, with necrotic lesions, the intestinal resection is made either laparoscopically or by laparotomy.

The laparoscopic diagnosis of intestinal ischemia is useful also in the postoperative stage in order to evaluate the abdominal pain of ischemic origin. Generally, these are old patients who suffer of other illnesses too, which implies that the associated morbidity and mortality is high. Laparoscopy may avoid a laparotomy, which increases the morbidity and mortality rates. There is, though, a high incidence of false negative diagnosis by laparoscopy. If the laparoscopic diagnosis does not confirm the clinical one, the patient must be kept under clinical and para-clinical observation and eventually, if necessary, repeat the exploration.

The fluorescein examination may be used in the laparoscopic diagnosis. 2-3 minutes after the i.v. injection of 1 gram of fluorescein, the normal intestines become yellow greenish while there is no colour change in the ischemic intestine.

The laparoscopic Doppler ultrasound may furnish data regarding the mesenteric vascularization.

The analysed patients, according to the type of intestinal infraction are :
• 7 patients presented intestinal infraction of arterial type (58,33%), out of these 4 were males (33,33%) and 3 females (25%)
• 3 patients had venous infraction, 1 male (8,33%) and 2 females (16,66)
• one female patient had mixed intestinal infraction (8,33%)
• one case had intestinal infraction without vascular lesions (8,33%) , she was a female.

 

Regarding the associated diseases in our group there were:
○ Diabetes
○ Chronic peripheric arteriopathy
○ Congestive cardiac insufficiency
○ Biliary lithiasis
○ Hypertension
○ Acute myocardial infraction
○ Chronic ischemic cardiopathy with rhythm disturbances
○ Rheumatoid polyarthritis
○ Colo-aortic fistula
○ Postoperative eventration
○ One special case with post-esophagoplasty with transverse colon for post-caustic stenosis

In the chronic intestinal ischemias, once the diagnosis is established, the only rational treatment is the re-vascularization associated with the specific medical treatment. As usable procedures we have the endarterectomy, the by-pass, the resection of the stenotic process with termino-terminal suture, aorta re-implantation, freeing of the external compression with celiac sympathectomy.

In order to extract the embolus, a longitudinal mesenteric arteriotomy is usually performed and rarely a transversal one. The peripheric end is disobliterated first, where the embolus is prolonged with a secondary thrombus and then the proximal end. Sometimes, it is necessary to continue the embolectomy with a segmental endarterectomy. If the suture of the arteriotomy risks to lead to a stenosis, it is necessary to put a patch using the saphena vein. In spite of the sustained anticoagulation treatment after the embolectomy , the postoperative thrombosis appears in a rather high percentage of cases.

The aorto-mesenteric by-pass presents the great advantage that it does not necessitate the dissection of the origin of the mesenteric artery. It may be performed using synthetic materials, venous transplantation or the splenic artery after splenectomy (Lucke). The major inconvenience is the change of the sanguine flow, which favours the appearance of thrombosis.

The thrombendarterectomy is practised since 1956 but the success rates are quite low.

The re-implantation of the superior mesenteric artery proposed by Mikkelsen in 1957 implies a termino-terminal anastomosis with the aorta in a point distally situated from the usual origin place of the mesenteric artery. It is essential that the wall of the two vessels does not present advanced atherosclerotic lesions.

In contrast to the arterial thrombosis, the venous thrombosis appears more frequently on the small vessels rather than on the principal vein. Accordingly, only a short segment of the intestine is affected and the intestinal resection is easier to perform.

The treatment of the infraction of venous origin: the only treatment that may save the patient’s life is the intestinal resection and this is possible as the infraction is localised only in one intestinal segment.

In the majority of cases an intestinal resection was performed (9 cases) with termino-terminal anastomosis (5 cases) and a latero-lateral one (4 cases). In 3 of the 9 cases the intestinal resection was extensive, in one case including also a partial colon resection.

 

Surgical procedure
Segmental enterectomy	8 cases
Jejunoileal + colon resection	1 case
Explorative laparotomy	3 cases

Two of the patients from the studied group had only an explorative laparotomy. One of them, a 47-years old male, who has had several post-caustic interventions for re-establishing the stenotic intestinal transit, had an esophagoplasty with transversal colon placed retrosternally. He came in as emergency with superior digestive hemorrhage, colo-aortic fistula, severe hemorrhagic shock and extensive intestinal infraction. He died during the operation.
 

Surgical Intervention	Cases	Additional interventions
Intestinal resection	9 (75%)	Partial colon resection (1 case)
Explorative laparotomy	3 (25%)	Eventration teratment  (1 case)

H.T. 66 years old, came in from the hospital in Lugoj in a severe state, with multiple organ insufficiency, extensive intestinal infraction probably of embolic origin. The patient had permanent heart rhythm disturbances and rapid atrial fibrillation. When the peritoneal cavity was opened, the peritoneal liquid had a fetid smell with modified coloration, the intestinal ansae and the ascendant colon were paretic with a macroscopic aspect of parietal ischemia of different degrees. The superior mesenteric pedicle is put in evidence and its artery is thrombotic and atheromanous .

After the re-establishment of the arterial flow at the level of the ischemic intestine, two possible complications are remarked:
1. severe metabolic deficiency characterized by hyponatremia, hypopotasemia, acidosis and fall of blood pressure.
2. an enterorrhagia followed by diarrhea and by a bad absorption syndrome until the destroyed intestinal mucosa heals.
After the arterial or venous permeability is re-established, the compromised intestinal parts have to be resected. In some cases where the vitality of the intestine is questionable, a new deliberate intervention was proposed after 12-24 hours from the first operation. During this time the patient is under sustained medical treatment. Antibiotics are prescribed pre- and postoperatively.

Anticoagulation treatment is installed starting with the intra-operative determined diagnosis. Some authors have no mortality in the primary venous thrombosis treated with anticoagulants compared to a mortality surpassing 50% in the cases without anticoagulation treatment. The anticoagulation treatment may be curative in the first hours from the start of the venous infraction.

 

Hospitalization time	1-19 days
Mean	7,5 days

The immediate prognosis of the venous infraction is better than in the arterial infraction and this is due to the limited lesions that make possible a limited intestinal resection. The rapid establishment of the diagnosis and the immediate start of the surgical emergency treatment is of vital importance, before an extensive thrombosis is installed.

 

Nr cases	Healed	Ameliorated	Aggravated	Deceased
12	3	1	1	7

Case evolution
 

The medium and long-term prognosis is, on the other hand, more cautious with a mortality rate approaching 100% if we take into consideration that this type of infraction appears as a terminal stage in another severe disease.

In what the mortality is concerned, it was 58,33% (7 cases) in our group and the causes of death were :

• decompensated toxico-septic shock       1 case
• irreversible cardiac insufficiency             3 cases
• renal insufficiency                                1 case
• severe hemorrhagic shock                     1 case
• acute myocardic infraction                    1 case

One patient went home at the family’s request, aggravated in the 48 hours after the operation.

The statistical study made for this period of time contains only 12 cases, seemingly modest compared to the large studies published in the country and abroad, as the one of Ottinger made on 132 cases and that of Lepadat on 126 cases, but these represent the cases treated in several surgical clinics.

The present study, being made on the cases from a single surgical clinic and in a rather short period of time, but on relatively constant treatment approaches, enables us to draw some useful and interesting conclusions:

Conclusions

1.  It is known that this pathology is common for old people. In this study we have one patient where the disease appears at the age of 45, while the mean age was of 64,5 years.

2. The mean yearly frequency was of 0,13-0,27%, a relatively low frequency of this disease compared to the rest of the pathology hospitalized and operated in the clinic in the same period of time.

3. In case of mesenteric embolism, the success of the operative intervention depends largely on the rapidity of the diagnosis.

4. The diagnostic laparoscopy was very useful for the critical patients, where there was a suspicion of mesenteric intestinal infraction but presented an irrelevant clinical picture.

5. The laparoscopic diagnosis is useful in the absence of a certain diagnosis, avoiding in this way an unnecessary laparotomy and having a low complication rate.

6. There are several possibilities to re-establish the intestinal circulation in the acute intestinal ischemia, before the installation of irreversible intestinal lesions:

   • Embolectomy

   • Aorto-mesenteric by-pass

   • thrombendartectomy

7. If there are irreversible intestinal lesions in certain areas, it is recommended to associate the intestinal resection with arterial disobstruction, lowering considerably the post-operative mortality.

8. After the intestinal flow is re-established at the level of the ischemic intestine, two possible complications may appear:

   a. severe metabolic deficiency characterized by hyponatremia, hypopotasemia, acidosis and fall of blood pressure.
   b. an enterorrhagia followed by diarrhea and by a bad absorption syndrome until the destroyed intestinal mucosa heals.

9. The postoperative mortality remains rather high, in our study we had 7 deaths (58,33%)

10. In spite of the major progresses of modern medicine this affection is a surgical emergency with a severe prognosis.

11. The appearance of new surgical, laparoscopic instruments and an increased laparoscopic training and experience, as well as their use on a large scale will probably lead to important progresses in this area, making the surgical intervention easier, shortening the hospitalization time and giving a quicker recovery.

References

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