Ischemic bowel after open heart surgery

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Ischemic bowel after open heart surgery

• Presented by Ri ???

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Introduction

• Acute mesenteric ischemia is a rare but severe
  complication after open heart surgery.
• Incidence 0.2-0.4
• Mortality rates 70-100.
• In 0.94 abdominal complication following cardiac
  surgery, GI bleeding33 and mesenteric
  ischemia27

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Risk factor

• Emergency cardiac surgery
• The use of IABP
• Failed angioplasty requiring emergency surgery
• Prolonged pump time
• Advanced age

Allen KB. et al. Acute mesenteric ischemia after
cardiopulmonary bypass. Journal of Vascular
Surgery. 16(3)391-5 discussion 395-6, 1992 Sep.

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Cause

• Arterial emboli
• Arterial thrombosis
• Nonocclusive ischemia

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Nonocclusive ischemia(I)

• Low cardiac output state?? blood flow in
  mesenteric vessel? mesenteric vasoconstriction
  and redistribution of blood flow
• Nonpulsatile blood flow during CPB angiotensin
  II release Huddy SPJ. et al.Gastrointestinal
  complication in 4473 patients who underwent
  cardiopulmonary bypass surgery.Br J Surg
  199178293-6

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Nonocclusive ischemia(II)

• Catecholamines use in early postoperative phase
• Changes in microcirculation because of ?blood
  viscosity via fluid restriction and diuretic
  therapy

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Diagnosis

• Ventilator support and heavy sedation, making
  communication and PE difficult.
• Delay in diagnosis of 9.5 days Allen KB. et al.
  Acute mesenteric ischemia after cardiopulmonary
  bypass. Journal of Vascular Surgery. 16(3)391-5
  discussion 395-6, 1992 Sep.
• Angiography is the golden standard of diagnosis.
  Other methods were not reliable.

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Presentation

• Abdominal pain with tenderness
• Diffuse abdomen pain with flatulence and absence
  of bowel sounds
• Abdominal guardingperitonitis
• Renal insufficiency
• Hemodynamic instability

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Laboratory

• Hyperamylasemia
• Metabolic acidosis
• Hyperkalemia
• Leukocytosis
• Fever
• no single lab test is both sensitive and specific

• Leukocytosis--91.7
• Metabolic acidosis--83.3
• Lactate ?--100
• Cre.?--100
• Osmolality ?--100
• sodium?--75
• Lactate acidosis type A with hyperosmotic
  dehydration was revealed in 100

Allen KB. et al. Acute mesenteric ischemia after
cardiopulmonary bypass. Journal of Vascular
Surgery. 16(3)391-5 discussion 395-6, 1992 Sep.
Schutz A. et al.Acute mesenteric ischemia after
open heart surgery. Angiology. 49(4)267-73, 1998
Apr.
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Angiography

• The gold standard
• Whenpt with one or more risk criteria,
  suspicious abd. symptoms, leukocytosis, lactate
  acidosis, severe hyperosmotic dehydration.
• Whatnonocclusive(58.3) and occlusive proximal
  mesenteric artery(41.7) Schutz A. et al.Acute
  mesenteric ischemia after open heart surgery.
  Angiology. 49(4)267-73, 1998 Apr.
• Howballoon angioplasty(PTA), infusion of
  Papaverine(60 survival)

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Conservative treatment with local vasodilation(I)

• Typical sign
• narrow and spastic branches,
• irregular spasm(string of sausage sign)
• impaired filling of arcades and intramural
  vessels
• Method intraarterial perfusion of
  Papaverin(30mg/h)

Niederhauser U. Mesenteric ischemia after a
cardiac operation conservative treatment with
local vasodilation. Annals of Thoracic Surgery.
61(6)1817-9, 1996 Jun.
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Conservative treatment with local vasodilation(II)

• Angiography 16 hrs later ?vasospasm
• Local application of vasodilators
• ?mortality(60-90 to 40-50),
• ?extent of bowel resection if laparotomy

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Laparotomy

• Laparotomy should not be delayed
• Missed intestinal infarction 100 mortality rate
• Grossly infarction bowel should be resected

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Conclusion

• Occurrence of typical symptoms angiogrphy and
  laparotomy must be done very urgently.
• Prognosis of mesenteric gangrene very poor,
  despite extensive bowel resection.
• Preventive measure in high-risk pt
  perioperative hyperosmotic dehydration should be
  avoided.

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Thank you very much!