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Acute mesenteric ischemia: updated guidelines of the World Society of Emergency Surgery.

ABSTRACT: Acute mesenteric ischemia (AMI) is a group of diseases characterized by an interruption of the blood supply to varying portions of the intestine, leading to ischemia and secondary inflammatory changes. If untreated, this process may progress to life-threatening intestinal necrosis. The incidence is low, estimated at 0.09-0.2% of all acute surgical admissions, but increases with age. Although the entity is an uncommon cause of abdominal pain, diligence is required because if untreated, mortality remains in the range of 50%. Early diagnosis and timely surgical intervention are the cornerstones of modern treatment to reduce the high mortality associated with this entity. The advent of endovascular approaches in parallel with modern imaging techniques is evolving and provides new treatment options. Lastly, a focused multidisciplinary approach based on early diagnosis and individualized treatment is essential. Thus, we believe that updated guidelines from World Society of Emergency Surgery are warranted, in order to provide the most recent and practical recommendations for diagnosis and treatment of AMI.

SUBMITTER: Bala M

PROVIDER: S-EPMC9580452 | biostudies-literature | 2022 Oct

REPOSITORIES: biostudies-literature

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Acute mesenteric ischemia: updated guidelines of the World Society of Emergency Surgery.

Bala Miklosh M Catena Fausto F Kashuk Jeffry J De Simone Belinda B Gomes Carlos Augusto CA Weber Dieter D Sartelli Massimo M Coccolini Federico F Kluger Yoram Y Abu-Zidan Fikri M FM Picetti Edoardo E Ansaloni Luca L Augustin Goran G Biffl Walter L WL Ceresoli Marco M Chiara Osvaldo O Chiarugi Massimo M Coimbra Raul R Cui Yunfeng Y Damaskos Dimitris D Di Saverio Salomone S Galante Joseph M JM Khokha Vladimir V Kirkpatrick Andrew W AW Inaba Kenji K Leppäniemi Ari A Litvin Andrey A Peitzman Andrew B AB Shelat Vishal G VG Sugrue Michael M Tolonen Matti M Rizoli Sandro S Sall Ibrahima I Beka Solomon G SG Di Carlo Isidoro I Ten Broek Richard R Mircea Chirika C Tebala Giovanni G Pisano Michele M van Goor Harry H Maier Ronald V RV Jeekel Hans H Civil Ian I Hecker Andreas A Tan Edward E Soreide Kjetil K Lee Matthew J MJ Wani Imtiaz I Bonavina Luigi L Malangoni Mark A MA Koike Kaoru K Velmahos George C GC Fraga Gustavo P GP Fette Andreas A de'Angelis Nicola N Balogh Zsolt J ZJ Scalea Thomas M TM Sganga Gabriele G Kelly Michael D MD Khan Jim J Stahel Philip F PF Moore Ernest E EE

World journal of emergency surgery : WJES 20221019 1

Acute mesenteric ischemia (AMI) is a group of diseases characterized by an interruption of the blood supply to varying portions of the intestine, leading to ischemia and secondary inflammatory changes. If untreated, this process may progress to life-threatening intestinal necrosis. The incidence is low, estimated at 0.09-0.2% of all acute surgical admissions, but increases with age. Although the entity is an uncommon cause of abdominal pain, diligence is required because if untreated, mortality ...[more]

PMID: 36261857

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Project description:BackgroundAcute calculus cholecystitis (ACC) has a high incidence in the general population. The presence of several areas of uncertainty, along with the availability of new evidence, prompted the current update of the 2016 WSES (World Society of Emergency Surgery) Guidelines on ACC.Materials and methodsThe WSES president appointed four members as a scientific secretariat, four members as an organization committee and four members as a scientific committee, choosing them from the expert affiliates of WSES. Relevant key questions were constructed, and the task force produced drafts of each section based on the best scientific evidence from PubMed and EMBASE Library; recommendations were developed in order to answer these key questions. The quality of evidence and strength of recommendations were reviewed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria (see https://www.gradeworkinggroup.org/ ). All the statements were presented, discussed and voted upon during the Consensus Conference at the 6th World Congress of the World Society of Emergency Surgery held in Nijmegen (NL) in May 2019. A revised version of the statements was voted upon via an online questionnaire until consensus was reached.ResultsThe pivotal role of surgery is confirmed, including in high-risk patients. When compared with the WSES 2016 guidelines, the role of gallbladder drainage is reduced, despite the considerable technical improvements available. Early laparoscopic cholecystectomy (ELC) should be the standard of care whenever possible, even in subgroups of patients who are considered fragile, such as the elderly; those with cardiac disease, renal disease and cirrhosis; or those who are generally at high risk for surgery. Subtotal cholecystectomy is safe and represents a valuable option in cases of difficult gallbladder removal.Conclusions, knowledge gaps and research recommendationsELC has a central role in the management of patients with ACC. The value of surgical treatment for high-risk patients should lead to a distinction between high-risk patients and patients who are not suitable for surgery. Further evidence on the role of clinical judgement and the use of clinical scores as adjunctive tools to guide treatment of high-risk patients and patients who are not suitable for surgery is required. The development of local policies for safe laparoscopic cholecystectomy is recommended.

Project description:ObjectiveRecruitment of neutrophils and formation of neutrophil extracellular traps (NETs) contribute to lethality in acute mesenteric infarction. To study the impact of the gut microbiota in acute mesenteric infarction, we used gnotobiotic mouse models to investigate whether gut commensals prime the reactivity of neutrophils towards formation of neutrophil extracellular traps (NETosis). Approach and Results: We applied a mesenteric ischemia-reperfusion (I/R) injury model to germ-free (GF) and colonized C57BL/6J mice. By intravital imaging, we quantified leukocyte adherence and NET formation in I/R-injured mesenteric venules. Colonization with gut microbiota or monocolonization with Escherichia coli augmented the adhesion of leukocytes, which was dependent on the TLR4 (Toll-like receptor-4)/TRIF (TIR-domain-containing adapter-inducing interferon-β) pathway. Although neutrophil accumulation was decreased in I/R-injured venules of GF mice, NETosis following I/R injury was significantly enhanced compared with conventionally raised mice or mice colonized with the minimal microbial consortium altered Schaedler flora. Also ex vivo, neutrophils from GF and antibiotic-treated mice showed increased LPS (lipopolysaccharide)-induced NETosis. Enhanced TLR4 signaling in GF neutrophils was due to elevated TLR4 expression and augmented IRF3 (interferon regulatory factor-3) phosphorylation. Likewise, neutrophils from antibiotic-treated conventionally raised mice had increased NET formation before and after ischemia. Increased NETosis in I/R injury was abolished in conventionally raised mice deficient in the TLR adaptor TRIF. In support of the desensitizing influence of enteric LPS, treatment of GF mice with LPS via drinking water diminished LPS-induced NETosis in vitro and in the mesenteric I/R injury model.ConclusionsCollectively, our results identified that the gut microbiota suppresses NETing neutrophil hyperreactivity in mesenteric I/R injury, while ensuring immunovigilance by enhancing neutrophil recruitment.

Dataset Information

Acute mesenteric ischemia: updated guidelines of the World Society of Emergency Surgery.

Publications

Acute mesenteric ischemia: updated guidelines of the World Society of Emergency Surgery.

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