TP5.2.11 Intervention for mesenteric arterial insufficiency in octogenarians

Introduction Mesenteric ischaemia is associated with significant morbidity and mortality. The poor prognosis associated with mesenteric ischaemia may prejudice decision-making, particularly for an older patient group. We have explored outcomes following intervention for mesenteric ischaemia in patients aged over 80-years old. Methods This was a retrospective analysis of a database of intervention for mesenteric ischaemia from 2010 to 2020 from a regional vascular unit covering two Health Boards in Scotland. Patients aged 80-years and over were identified and patterns of intervention and outcome described. Results There were 23 procedures performed – there were 17 patients aged 80-years or over. There were 8 patients with acute presentations, 6 had isolated superior mesenteric artery occlusion and thromboembolectomy was the most common procedure (n = 4). Laparotomy was performed in all cases and bowel resection required in 3. At 30-days 4 patients had died, but patients who survived the index admission were still alive at 1-year and symptom free. Elective was performed on 9 patients. An endovascular approach was favoured (n = 7) with the superior mesenteric artery the preferred target. At 30-days 2 had died, but at 1-year there had only been 1 further death. Three patients experienced recurrent symptoms. The remaining patients were symptom free. Conclusion It is appropriate to consider mesenteric intervention for older patients with both acute and chronic mesenteric ischaemia. Meaningful survival can be achieved with good relief of symptoms and return to meaningful quality of life.

SP3.1.17 Assessment of the utility of CT to predict the requirement for resection at laparotomy in patients presenting with acute mesenteric arterial insufficiency

Introduction Mesenteric ischaemia as a consequence of arterial atherosclerosis is associated with significant morbidity and mortality. Practice has been influenced by the rise in cross-sectional imaging. In Glasgow a policy of laparotomy for patients presenting with acute mesenteric ischaemia at the time of mesenteric revascularisation has been adopted. We have sought to define whether CT can predict visceral necrosis and a requirement for tissue resection at the primary revascularisation. Methods This was a retrospective review of interventions performed for mesenteric ischaemia. Radiological variables described in the context of mesenteric ischaemia were defined. The primary CT report was reviewed to define whether these features were recorded and whether a diagnosis of mesenteric ischaemia was suggested. Imaging was then retrospectively reviewed with reference to the dataset by a radiologist. The radiologist was asked to offer a subjective opinion as to whether there was mesenteric infarction. These data were compared with laparotomy findings. Results There were 129 interventions performed for mesenteric ischaemia over the study period and 147 laparotomies. There was no specific radiological variable that was consistently reported in the primary or secondary CT review. However when bowel wall thinning, hypoattenuation or portal venous gas reported (independently) they seemed to be specific as in each case there was mesenteric infarction at laparotomy. Conclusion Even with retrospective radiological assessment there is no reliable feature that will predict mesenteric infarction and a requirement for tissue resection. As such a policy of laparotomy in patients who considered physiologically well enough would appear to be justified.

Vasoactive agents in acute mesenteric ischaemia in critical care. A systematic review

Background: Acute mesenteric ischaemia (AMI) is a surgical emergency which has an associated high mortality. The mainstay of active treatment includes early surgical intervention, with resection of non-viable bowel, and revascularisation of the ischaemic bowel where possible. Due to the physiological insult of AMI however, perioperative care often involves critical care and the use of vasoactive agents to optimise end organ perfusion. A number of these vasoactive agents are currently available with varied mechanism of action and effects on splanchnic blood flow. However, specific guidance on which is the optimal vasoactive drug to use in these settings is limited. This systematic review aimed to evaluate the current evidence comparing vasoactive drugs in AMI. Methods: A systematic search of Ovid Medline, Ovid Embase, Cochrane CENTRAL and the Cochrane Database of Systematic Review was performed on the 5th of November 2020 to identify randomised clinical trials comparing different vasoactive agents in AMI on outcomes including mortality. The search was performed through the Royal College of Surgeons of England (RCSEng) search support library. Results were analysed using the Rayyan platform, and independently screened by four investigators. Results: 614 distinct papers were identified. After screening, there were no randomised clinical trials meeting the inclusion criteria. Conclusions: This review identifies a gap in literature, and therefore recommends an investigation into current practice and clinician preference in relation to vasoactive agents in AMI. Multicentre randomised controlled trials comparing these medications on clinical outcomes will therefore be required to address this question.

Getting around the gut: a unique management challenge of thyroid storm precipitated by amphetamine-associated duodenal ischaemia leading to compromised enteric absorption

Thyroid storm is a rare, life-threatening endocrine emergency with a high mortality rate of up to 30%. We present a unique management challenge of a critically ill patient who developed thyroid storm in the setting of a duodenal perforation from amphetamine-associated non-occlusive mesenteric ischaemia. The diagnosis of ‘thyroid storm’ was made based on clinical criteria and a Burch-Wartofsky score of 100. During emergent exploratory laparotomy, a 1 cm duodenal perforation with surrounding friable tissue was found and repaired. Intraoperatively, a nasogastric tube was guided distal to the area of perforation to allow for enteric administration of medications, which was critical in the setting of thyroid storm. Therapeutic plasma exchange achieved biochemical control of our patient’s thyroid storm but ultimately did not prevent in-hospital mortality.

Vasoactive agents in acute mesenteric ischaemia in critical care. A systematic review

Background: Acute mesenteric ischaemia (AMI) is a surgical emergency which has an associated high mortality. The mainstay of active treatment includes early surgical intervention, with resection of non-viable bowel, and revascularisation of the ischaemic bowel where possible. Due to the physiological insult of AMI however, perioperative care often involves critical care and the use of vasoactive agents to optimise end organ perfusion. A number of these vasoactive agents are currently available with varied mechanism of action and effects on splanchnic blood flow. However, specific guidance on which is the optimal vasoactive drug to use in these settings is limited. This systematic review aimed to evaluate the current evidence comparing vasoactive drugs in AMI. Methods: A systematic search of Ovid Medline, Ovid Embase, Cochrane CENTRAL and the Cochrane Database of Systematic Review was performed on the 5th of November 2020 to identify randomised clinical trials comparing different vasoactive agents in AMI on outcomes including mortality. The search was performed through the Royal College of Surgeons of England (RCSEng) search support library. Results were analysed using the Rayyan platform, and independently screened by four investigators. Results: 614 distinct papers were identified. After screening, there were no randomised clinical trials meeting the inclusion criteria. Conclusions: This review identifies a gap in literature, and therefore recommends an investigation into current practice and clinician preference in relation to vasoactive agents in AMI. Multicentre randomised controlled trials comparing these medications on clinical outcomes will therefore be required to address this question.