Acute mesenteric ischemia (AMI) is a rare but catastrophic abdominal vascular emergency associated with daunting mortality comparable to myocardial infarction or cerebral stroke. Damage control surgery has been extensively used in severe traumatic patients. Very urgent, there was no large-scale in-depth study when extended to a nontrauma setting, especially in the intestinal stroke center. Recently, the liberal use of OA as a damage control surgery adjunct has been proved to improve the clinical outcome in acute superior mesenteric artery occlusion patients. However, there was little information when extended to a prospective study. The purpose of this prospective cohort study was to evaluate whether the application of damage control surgery concept in AMI was related to avoiding postoperative abdominal infection, reduced secondary laparotomy, reduced mortality and improved the clinical outcomes in short bowel syndrome.
Acute mesenteric ischemia (AMI) is a rare but catastrophic abdominal vascular emergency associated with daunting mortality comparable to myocardial infarction or cerebral stroke. Computed tomographic angiography is the initial diagnostic examination of choice for patients in whom AMI is a consideration. Computed tomographic angiography can be performed rapidly and can be used to identify critical arterial stenosis or occlusion as well as providing information concerning the presence of bowel infarction. An uncommon cause of presentation to emergency rooms, lack of clinical suspicion often leads to delayed presentation, development of peritoneal signs, and subsequent staggeringly high mortality rates. Now in use for over 2 decades, the concept of damage control surgery (DCS) has become an accepted, proven surgical strategy with wide applicability and success in severe trauma patients. The concept has been mostly used in the massively injured, exsanguinating patients with multiple competing surgical priorities. With growing experiences in the application, the strategy continues to evolve into a nontrauma setting, especially in AMI. Although an increasing development of endovascular techniques, AMI remains a morbid condition with a poor short-term and long-term survival rate. Some authors advocated that laparotomy after mesenteric revascularization serves to evaluate the possible damage to the visceral organs. Bowel resection as a result of transmural necrosis is carried out according to the principles of DCS. Bowel resections are performed with staples, leaving the creation of stomas until the second-look laparotomy. The abdominal wall can be left unsutured and temporary abdominal closure (TAC) was applied. However, the use of DCS in the setting of AMI was limited in case series and mostly confined in large university teaching hospitals. The timing and details of how the DCS incorporated into the treatment algorithm of AMI deserved further investigations. An integrated intestinal stroke center (ISC) was established in our department, a national cutting-edge referral center for intestinal failure, to build up ideal coordination among gastroenterology physician, gastrointestinal and vascular surgeon, and intervention radiologist for this therapeutic challenge. DCS was liberally used since ISC was established in 2010. In this prospective cohort study, we aimed to compare the clinical outcomes of patients receiving DCS and non-DCS in the devastating conditions in our single center.
Study Type
INTERVENTIONAL
Allocation
NON_RANDOMIZED
Purpose
TREATMENT
Masking
NONE
Enrollment
60
1. Emergency surgery stage, (a) the hybrid operating room restores mesenteric vascular patency. (b) excision of the necrotic intestine (c) retention of suspicious intestinal ducts, double stoma (d) establishment of catheter thrombolysis pathway (e) apply TAC to maintain open abdominal. 2. ICU phase, including (a) fluid resuscitation; (b) anti-infective and organ function support therapy; (c) continued local anticoagulation, thrombolysis (d) arrange planned re-laparotomy (e) early EN. 3. Definitive surgical procedures, including (a) Deterministic fascia closure or further removal of the necrotic intestine. (b) Intestinal stoma care and enteral nutrition support treatment. (c) An enterostomy was performed about 6 months after the first operation.
The patients are diagnosed with AMI and treated for mesenteric thrombosis and ischemic bowel. 1. The patient retains the endoluminal catheter after the DSA was diagnosed as AMI. 2. After diagnosis, the operation is performed in the general operating room, and the intestinal fistula double or the anastomosis is performed according to the judgment of the surgeon. 3. After the operation, re-laparotomy is performed on demand.
Jinling Hospital
Nanjing, Jiangsu, China
RECRUITINGPostoperative 30-day mortality
All cause mortality within 30 days
Time frame: 30 days
Rate of postoperative abdominal sepsis
All cause postoperative abdominal infection
Time frame: 30 days
Rate of postoperative re-laparotomy
All cause postoperative re-laparotomy
Time frame: 30 days
Postoperative short bowel syndrome rate
All cause postoperative short bowel syndrome
Time frame: 30 days
Rate of abdominal septic complications
Including wound infections, anastomotic leakage/anastomotic fistula, and intra-abdominal abscess
Time frame: 30 days
Rate of non-abdominal septic complications
Including thromboembolic complications
Time frame: 30 days
Rate of abdominal non-septic complications
including pneumonia and urinary tract infections
Time frame: 30 days
Rate of systematic complications
including thromboembolic complications
Time frame: 30 days
Length of preoperative stay
Number of days from admission to operation
Time frame: 30 days
Operative information
Including postoperative diagnosis, surgical name, surgical procedure (laparoscopic, open)
Time frame: 30 days
Recovery of intestinal function
first ventilation time after surgery (length in days), first defecation time (length in days), first recovery of semi-flow diet time (length in days);
Time frame: 30 days
The amount of nutritional support treatment
The amount (ml) of nutritional support daily
Time frame: 30 days
Catheter condition
whether to indwell the stomach tube (yes, no) with its extraction time (day)
Time frame: 30 days
Postoperative activity time
Time (hour) of getting out of bed every day after surgery;
Time frame: 30 days
Inflammatory markers
Serum IL-6 and CRP levels in preoperative and postoperative patients
Time frame: Postoperative day-1, 3, 5, 7
Infectious markers
Pre- and post-operative patients with procalcitonin levels
Time frame: Postoperative day-1, 3, 5, 7
Coagulation markers
Blood PT, APTT, INR levels before and after surgery
Time frame: Postoperative day-1, 3, 5, 7
Fibrinolytic markers
Blood D-dimer, FDP levels before and after surgery
Time frame: Postoperative day-1, 3, 5, 7
Intestinal barrier function markers
Urinary citrulline and I-FABP in preoperative and postoperative patients
Time frame: Postoperative day-1, 3, 5, 7
General nutritional information measurement
Preoperative and postoperative patient weight (kg) and weight change (kg);
Time frame: Postoperative day-1, 3, 5, 7
Immunological markers
Levels of blood T cell subsets (including CD3+ (%), CD4+ (%), and CD4+/CD8+);
Time frame: Preoperative day-1 and postoperative day-1, 3, 5, 7
Re-admission rate 30 days after discharge
Re-admission time (day), cause;
Time frame: 30 days
Postoperative hospital stay
Number of days in hospital (day)
Time frame: 1 year
Postoperative ICU stay
Number of days in ICU (day)
Time frame: 1 year
Hospital costs
Cost from the hospital's financial system statistics (RMB)
Time frame: 1 year
Intraoperative intestinal length
length of intestine (length in centimetre), length of remaining intestine (length in centimetre)
Time frame: 30 days
Type of intestinal anastomosis
whether one-stage anastomosis (yes, no)
Time frame: 30 days
Operation time
operation time (hour)
Time frame: 30 days
Amount of fluid input and output during operation
intraoperative blood loss (ml), surgery Middle infusion volume (ml), intraoperative blood transfusion volume (ml)
Time frame: 30 days
Embolus size measurement
embolus size (cm)
Time frame: 30 days
Type of abdominal closure
(normal, temporary abdominal closure)
Time frame: 30 days
Type of abdominal drainage
abdominal drainage tube (yes, no) with an extraction time (day)
Time frame: 30 days
The time of nutritional support treatment
The start and end time of parenteral nutrition and enteral nutrition (days);
Time frame: 30 days
Degree of postoperative activity
Distance (m) of getting out of bed every day after surgery;
Time frame: 30 days
Serum nutrition marker
Preoperative and postoperative serum albumin (g/L), prealbumin (mg/L), transferrin (g/L), hemoglobin (g/L), white blood cell count (10\^9/L), platelet count (10\^9/L), and hematocrit (L/L);
Time frame: Postoperative day-1, 3, 5, 7
Marker of neutrophil extracellular traps markers
Levels of blood neutrophil extracellular traps markers (including CitH3 (IU/mL), cf-DNA (ng/mL), MPO-DNA (Abs405)) levels
Time frame: Preoperative day-1 and postoperative day-1, 3, 5, 7
The composition of nutritional support treatment
Composition of enteral nutrition daily (%)
Time frame: 30 days
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