Surgical technical guidelines in intestinal ischemia

Abstract

Acute occlusive mesenteric ischemia is caused by a local impairment of splanchnic blood flow and poses a particular surgical challenge. Acute superior mesenteric occlusion is a medical/surgical emergency mandating prompt diagnosis (clinical awareness, angiography) and therapy (exploratory laparotomy with possible arterial reconstruction; embolectomy, thrombectomy; and/or bowel resection). The difficulty of early diagnosis is probably the most important cause of the high mortality which varies from 70% to 90% in arterial and functional mesenteric ischemia and from 20% to 70% in an acute thrombosis of the mesenteric veins. Improved survival from nonocclusive mesenteric ischemia is dependent upon the identification of high-risk groups and on aggressive diagnostic and therapeutic measures (intra-arterial infusion of papaverine through the angiographic catheter with or without bowel resection). For assessment of bowel viability, the clinical judgement during first- or second-look exploration is still the most reliable parameter. The surgical management of chronic mesenteric ischemia includes aortomesenteric grafting and transaortic endarterectomy in the majority of patients with comorbidity of cardiovascular arteriosclerotic diseases and results in a high rate of symptom-free patients. Prophylactic reconstruction of visceral arteries is indicated only in certain limited circumstances.