Stefan Acosta

Epidemiology, risk and prognostic factors in mesenteric venous thrombosis

Epidemiological reports on risk and prognostic factors in patients with mesenteric venous thrombosis (MVT) are scarce.

Multicentre prospective study of fascial closure rate after open abdomen with vacuum and mesh-mediated fascial traction.

Damage control surgery and temporary open abdomen (OA) have been adopted widely, in both trauma and non‐trauma situations. Several techniques for temporary abdominal closure have been developed. The main objective of this study was to evaluate the fascial closure rate in patients after vacuum‐assisted wound closure and mesh‐mediated fascial traction (VAWCM) for long‐term OA treatment, and to describe complications.

Vacuum-assisted wound closure and mesh-mediated fascial traction - A novel technique for late closure of the open abdomen

BackgroundOpen abdomen (OA) treatment often results in difficulties in closing the abdomen. Highest closure rates are seen with the vacuum-assisted wound closure (VAWC) technique. However, we have experienced occasional failures with this technique in cases with severe visceral swelling needing longer treatment periods with open abdomen. Feasibility and short-term outcome of a novel combination of techniques for managing the open abdomen are presented.MethodsThe VAWC technique was combined with medial traction of the fasciae through a temporary mesh in seven consecutive patients. The VAWC-system was changed and the mesh tightened every 2–3 days.ResultsMedian (range) age in the 7 men was 65 (17–78) years. The diagnoses were ruptured abdominal aortic aneurysm (AAA) (3), operation for juxtarenal AAA (1), iatrogenic aortic lesion (1), trauma (1) and abdominal abscesses (1). Four patients were decompressed due to abdominal compartment syndrome (ACS) or intra-abdominal hypertension, and 3 could not be closed after laparotomy. Intra-abdominal pressure prior to OA treatment was 24 (17–36) mmHg. Maximal separation of the fasciae was 16 (7 –30) cm. Delayed primary closure was achieved in all patients after 32 (12–52) days with OA. No recurrent ACS was seen. No technique-specific complication was observed. Two small incisional hernias, one intra-abdominal abscess and one wound infection occurred in three patients.ConclusionsDelayed primary closure in cases with severe visceral swelling and long periods of OA seems feasible with this technique.

Epidemiology of Mesenteric Vascular Disease: Clinical Implications

The overall incidence rate of acute mesenteric ischemia between 1970 and 1982, diagnosed at either autopsy or operation, in the population of Malmö, Sweden was estimated at 12.9/100,000 person-years. Autopsy rate was 87%. Acute superior mesenteric artery (SMA) occlusion (embolus/thrombus ratio = 1.4), mesenteric venous thrombosis (MVT), and nonocclusive mesenteric ischemia (NOMI) were found in approximately 68%, 16%, and 16%, respectively. Acute SMA occlusion was found to be more common than ruptured abdominal aortic aneurysms. The incidence increased exponentially with age, equally distributed among men and women after adjusting for age and gender in the population. Thrombotic occlusions were located more proximally than embolic occlusions and intestinal infarction was more extensive, whereas patients with embolus had a higher frequency of acute myocardial infarction, and had cardiac thrombi in 48% and synchronous emboli in 68% of the patients. The proportion of patients with symptoms inherent with chronic mesenteric ischemia prior to onset of acute thrombotic occlusion has been reported to occur in 73%. Cardiac failure, history of atrial fibrillation, and recent surgery have all been associated with fatal NOMI. MVT is either caused by thrombophilia, direct injury, or local venous congestion or stasis. Multidetector row computed tomography with intravenous contrast enhancement and imaging in the arterial phase for suspicion of acute SMA occlusion and imaging in the venous phase for MVT has become the diagnostic method of choice. In-hospital mortality is highest for NOMI, lower for acute SMA occlusion, and lowest, around 20%, for MVT.

Diagnostic accuracy of plasma biomarkers for intestinal ischaemia

Objective. Intestinal ischaemia is a life‐threatening condition with high mortality, and the lack of accurate and readily available diagnostic methods often results in delay in diagnosis and treatment. The aim of this study was to investigate the accuracy of different plasma biomarkers in diagnosing intestinal ischaemia. Material and methods. Prospective inclusion of patients older than 50 years with acute abdomen admitted to hospital in Karlskrona, Sweden, between 2001 and 2003. Venous blood was sampled prior to any surgery and within 24 h from onset of pain. D‐lactate, alpha glutathione S‐transferase, intestinal fatty acid binding protein, creatine kinase B, isoenzymes of lactate dehydrogenase (LD) and alkaline liver phosphatase (ALP) were analysed. D‐dimer was analysed using four different commercially available test kits. Results. In‐hospital mortalities among patients with (n = 10) and without (n = 61) intestinal ischaemia were 40 % and 3 %, respectively (p = 0.003). D‐dimer was associated with intestinal ischaemia (p = 0.001) independently of which assay was used. No patient presenting with a normal D‐dimer had intestinal ischaemia. D‐dimer >0.9 mg/L had a specificity, sensitivity and accuracy of 82 %, 60 % and 79 %, respectively. Total LD, isoenzymes of LD 1–4 and liver isoenzyme of ALP (ALP liver) were significantly higher in patients with intestinal ischaemia, and accuracies for LD 2 (cut‐off 2.3 µkat/L) and ALP liver (cut‐off 0.7 µkat/L) were 69 % and 66 %, respectively. Conclusions. D‐dimer may be used as an exclusion test for intestinal ischaemia, but lacks specificity. The other plasma biomarkers studied had insufficient accuracy for this group of patients. Further studies are needed.

Clinical Implications for the Management of Acute Thromboembolic Occlusion of the Superior Mesenteric Artery: Autopsy Findings in 213 Patients

Objective:To study findings at autopsy in patients with fatal acute thromboembolic occlusion of the superior mesenteric artery (SMA). Summary Background Data:Acute occlusion of the SMA is difficult to diagnose and mortality remains high. In Malmö, Sweden, the autopsy rate between 1970 and 1982 was 87%, creating possibilities for a population-based study. Methods:Among 23,496 clinical autopsies and 7569 forensic autopsies, 213 cases with acute thromboembolic occlusion of the SMA and intestinal infarction were identified. Results:A clinical suspicion of intestinal infarction was documented in 32% of the patients, only 35% being in the care of surgeons. The embolus/thrombus ratio was 1.4 to 1. Thrombotic occlusions were located more proximally than embolic occlusions (P < 0.001), intestinal infarction was more extensive (P = 0.025) and thrombotic occlusions were associated with old brain infarction (P = 0.048), aortic wall thrombosis (P = 0.080), and disseminated cancer (P = 0.079). Patients with embolic occlusions (n = 122) had a higher frequency of acute myocardial infarction (AMI) than patients with thrombotic occlusions (P = 0.049). The embolic source was identified in 80%. In 115 (94%), synchronous embolism and/or source of embolus were present. There were findings of remaining cardiac thrombi in 58 (48%) and synchronous emboli affected 273 other arterial segments in 83 (68%). Conclusions:Early recognition and revascularization would have been a prerequisite for survival in at least half of the patients, since the jejunum, ileum, and colon were affected by infarction. A minority of all patients were under surgical care. AMI, cardiac thrombi, and synchronous emboli were common findings among patients with embolic occlusions.

Fatal nonocclusive mesenteric ischaemia: population-based incidence and risk factors

Objectives.  To estimate the incidence and extension of visceral organ infarction, and to evaluate potential causes, in patients with autopsy‐verified nonocclusive mesenteric ischaemia (NOMI) and transmural intestinal infarction.

Modern treatment of acute mesenteric ischaemia.

Diagnosis of acute mesenteric ischaemia in the early stages is now possible with modern computed tomography (CT), using intravenous contrast enhancement and imaging in the arterial and/or portal venous phase. The availability of CT around the clock means that more patients with acute mesenteric ischaemia may be treated with urgent intestinal revascularization.

Endovascular and open surgery for acute occlusion of the superior mesenteric artery

BACKGROUND Acute thromboembolic occlusion of the superior mesenteric artery (SMA) is associated with high mortality. Recent advances in diagnostics and surgical techniques may affect outcome. METHODS Through the Swedish Vascular Registry (Swedvasc), 121 open and 42 endovascular revascularizations of the SMA at 28 hospitals during 1999 to 2006 were identified. Patient medical records were retrieved, and survival was analyzed with multivariate Cox-regression analysis. RESULTS The number of revascularizations of the SMA increased over time with 41 operations in 2006, compared to 10 in 1999. Endovascular approach increased sixfold by 2006 as compared to 1999. The endovascular group had thrombotic occlusion (P < .001) and history of abdominal angina (P = .042) more often, the open group had atrial fibrillation more frequently (P = .031). All the patients in the endovascular group, but only 34% after open surgery, underwent completion control of the vascular reconstruction (P < .001). Bowel resection (P < .001) and short bowel syndrome (SBS; P = .009) occurred more frequently in the open group. SBS (hazard ratio [HR], 2.6; 95% confidence interval [CI], 1.3-5.0) and age (HR, 1.03/year; 95% CI, 1.00-1.06) were independently associated with increased long-term mortality. Thirty-day and 1-year mortality rates were 42% vs 28% (P = .03) and 58% vs 39% (P = .02), for open and endovascular surgery, respectively. Long-term survival after endovascular treatment was better than after open surgery (log-rank, P = .02). CONCLUSION The results after endovascular and open surgical revascularization of acute SMA occlusion were favorable, in particular among the endovascularly treated patients. Group differences need to be confirmed in a randomized trial.

Predictors for outcome after vacuum assisted closure therapy of peri-vascular surgical site infections in the groin.

OBJECTIVES To assess outcomes (wound healing, amputation and mortality) after vacuum assisted closure (VAC) therapy of peri-vascular surgical site infections in the groin after arterial surgery. DESIGN Retrospective study. MATERIALS Thirty-three groins received VAC therapy between August 2004 and December 2006 at Vascular Centre, Malmö University Hospital. METHODS Following surgical revision, VAC therapy was applied in the groin at a continuous topical negative pressure of 125 mmHg. The median follow up time was 16 months. RESULTS Median age was 75 years. Twenty-three (70%) cases underwent surgery for lower limb ischaemia. Intestinal flora was present in 88% of the wound cultures. Median duration of VAC therapy was 20 days and 27 (82%) wounds healed within 55 days. One serious VAC associated bleeding and three late false femoral artery aneurysms were reported. The median cost of VAC treatment was 2.7% of the in-hospital costs. Synthetic vascular graft infection (n=21) was associated with adverse infection-related events (n=9; p=0.012). Non-healing wounds were associated with amputation (p=0.005) and death (p<0.001). CONCLUSIONS VAC treated synthetic vascular graft infections in the groin were at a greater risk of developing infection-related complications. Non-healing surgical site infections after VAC therapy were associated with amputation and death.