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Background: Acute mesenteric ischaemia (AMI) is a condition with high mortality. This survey assesses current attitudes and practices to manage AMI worldwide.Methods: A questionnaire survey about the practices of diagnosing and managing AMI, endorsed by several specialist societies, was sent to different medical specialists and hospitals worldwide. Data from individual health care professionals and from medical teams were collected.Results: We collected 493 individual forms from 71 countries and 94 team forms from 34 countries. Almost half of respondents were surgeons, and most of the responding teams (70%) were led by surgeons. Most of the respondents indicated that diagnosis of AMI is often delayed but rarely missed. Emergency revascularisation is often considered for patients with AMI but rarely in cases of transmural ischaemia (intestinal infarction). Responses from team hospitals with a dedicated special unit (14 team forms) indicated more aggressive revascularisation. Abdominopelvic CT-scan with intravenous contrast was suggested as the most useful diagnostic test, indicated by approximately 90% of respondents. Medical history and risk factors were thought to be more important in diagnosis of AMI without transmural ischaemia, whereas for intestinal infarction, plasma lactate concentrations and surgical exploration were considered more useful. In elderly patients, a palliative approach is often chosen over extensive bowel resection. There was a large variability in anticoagulant treatment, as well as in timing of surgery to restore bowel continuity.Conclusions: Delayed diagnosis of AMI is common despite wide availability of an adequate imaging modality, i.e. CT-scan. Large variability in treatment approaches exists, indicating the need for updated guidelines. Increased awareness and knowledge of AMI may improve current practice until more robust evidence becomes available. Adherence to the existing guidelines may help in improving differences in treatment and outcomes. Background: Acute mesenteric ischaemia (AMI) is a condition with high mortality. This survey assesses current attitudes and practices to manage AMI worldwide.Methods: A questionnaire survey about the practices of diagnosing and managing AMI, endorsed by several specialist societies, was sent to different medical specialists and hospitals worldwide. Data from individual health care professionals and from medical teams were collected.Results: We collected 493 individual forms from 71 countries and 94 team forms from 34 countries. Almost half of respondents were surgeons, and most of the responding teams (70%) were led by surgeons. Most of the respondents indicated that diagnosis of AMI is often delayed but rarely missed. Emergency revascularisation is often considered for patients with AMI but rarely in cases of transmural ischaemia (intestinal infarction). Responses from team hospitals with a dedicated special unit (14 team forms) indicated more aggressive revascularisation. Abdominopelvic CT-scan with intravenous contrast was suggested as the most useful diagnostic test, indicated by approximately 90% of respondents. Medical history and risk factors were thought to be more important in diagnosis of AMI without transmural ischaemia, whereas for intestinal infarction, plasma lactate concentrations and surgical exploration were considered more useful. In elderly patients, a palliative approach is often chosen over extensive bowel resection. There was a large variability in anticoagulant treatment, as well as in timing of surgery to restore bowel continuity.Conclusions: Delayed diagnosis of AMI is common despite wide availability of an adequate imaging modality, i.e. CT-scan. Large variability in treatment approaches exists, indicating the need for updated guidelines. Increased awareness and knowledge of AMI may improve current practice until more robust evidence becomes available. Adherence to the existing guidelines may help in improving differences in treatment and outcomes.

To provide an accurate 3D volumetric analysis of one-year remodeling in patients with isolated mesenteric artery dissection (IMAD).Patients with type I/II (classification of Yun) treated by conservative therapy between January 2018 and January 2020 were prospectively included. The semi-automatic morphological analysis of the superior mesenteric artery (SMA) included volumetric measurements of the true (TL), false (FL) and overall lumen (OL), and 3D aortomesenteric angles from computed tomography angiogram data at admission (T0), one month (T1) and twelve months (T12). The SMA morphology of IMAD patients (n=15, 53±7 years; 87% male) was also compared to control individuals (n=51, 56±4 years; 94% male).A significant reduction of the OL volume was observed (p0.001) whereas the TL volume remained stable (p=0.23). The (TL/OL) volume ratio significantly increased over time (p=0.001), from 53% at T1 to 78% at T12. Aortomesenteric 3D angles at 2, 4 and 6 cm from the ostium showed a progressive decrease towards values observed in the control group (p=0.013, p=0.002 and p=0.027, respectively). At T12, five patients (33%) had a complete remodeling and aneurysmal change was observed in two (20mm). Smoking and (T0) SMA angle at 6 cm distance from the ostium were the only factors affecting negatively remodeling at T12.One-year remodeling in IMAD followed an overall decrease of the OL volume related to FL volume decrease. Smokers and patients with larger SMA angles at baseline showed a poorer remodeling. Spontaneous arterial remodeling in IMAD might favor conservative therapy.

This study aimed to report outcomes of patients with symptomatic acute isolated mesenteric artery dissection (IMAD) treated within a French intestinal stroke centre (ISC).All patients with symptomatic IMAD referred to the ISC from January 2016 to January 2020 were included prospectively. Patients with aortic dissection and asymptomatic IMAD were not included. The standardised medical protocol included anticoagulation and antiplatelet therapy, gastrointestinal resting, and oral antibiotics. Operations were considered for acute mesenteric ischaemia (AMI).Among the 453 patients admitted to an ISC during the study period, 34 (median age, 53 years [41 - 67]; 82% men) with acute symptomatic IMAD were included. According to the classification of Yun et al., IMADs were reported as follows: type I (n = 7, 20%), type IIa (n = 6, 18%), type IIb (n = 15, 44%), and type III (i.e., complete superior mesenteric artery [SMA] occlusion; n = 6, 18%). Overall, nine (26%) patients had AMI (type I/II, n = 3; type III, n = 6). On initial computerised tomography angiogram, nine (26%) patients had an associated visceral arterial dissection or pseudoaneurysm. All patients with types I/II (n = 28, 82%) followed a favourable clinical course with conservative therapy, with no need for any operation. All patients with type III (n = 6, 18%) underwent urgent laparotomy with SMA revascularisation (open, n = 4; stenting, n = 1) and or bowel resection (early, n = 3; late, n = 1). Rates of intestinal resection and short bowel syndrome were 12% and 8.8%, respectively. After a median follow up of 26 months [18 - 42], recurrence of symptoms occurred in four (12%) patients and aneurysmal change in 14 (41%), with no re-intervention.Although IMAD was associated with a high frequency of AMI, a standardised protocol produced a low rate of intestinal resection. Conservative therapy seems appropriate in types I/II patients, whereas urgent SMA revascularisation should aim to avoid intestinal resection or death in type III patients.

FROM DIAGNOSIS TO MULTIDISCIPLINARY TREATMENT IN INTESTINAL STOKE UNIT Acute mesenteric ischemia (AMI) is a severe vascular and intestinal emergency, most commonly related to the occlusion (mesenteric occlusive disease or emboli) of the superior mesenteric artery (SMA). Such as myocardial infarction or stroke, SMA occlusion is responsible of an intestinal infarction. In case of an early revascularization of the SMA, AMI can be reversible with no need for bowel resection. However, when left untreated, AMI fatally leads to irreversible intestinal necrosis and death following multiple organ failure. Considering its poor prognosis, AMI might be systematically suspected in case of a sudden, unusual and intense abdominal pain. Because AMI has a nonspecific clinical presentation, delayed diagnosis are frequent and unfortunately associated with poor outcomes. Therefore, general and emergency doctors, along with gastroenterologists, have a key role to play in the recognition of early AMI. In any case of clinically suspected AMI, an abdominal computed tomography angiogram might be urgently performed. Chronic mesenteric ischemia can also be revealed by postprandial abdominal pain associated with food fear and weight loss. In recent years, there has been a major improvement in the treatment of AMI following the creation of a French intestinal stroke center, gathering the expertise of specialized gastroentorologists, vascular and digestive surgeons, radiologists and intensivists. A multimodal and multidisciplinary approach combining the use of a systematic medical protocol, early revascularization of viable bowel and resection of non viable bowel when needed, has dramatically improved the prognosis of AMI, with current survival rates of 80 % and bowel resection being avoided in nearly two thirds of patients.ISCHÉMIE MÉSENTÉRIQUE ARTÉRIELLE : DU DIAGNOSTIC À LA DÉCISION L’ischémie mésentérique aiguë (IMA) artérielle, ou ischémie intestinale aiguë, est une urgence vasculaire et intestinale. En l’absence de prise en charge précoce, l’ischémie évolue vers l’infarctus intestinal, caractérisé par une nécrose transmurale irréversible, conduisant inexorablement au décès par défaillance multiviscérale. Du fait de ce pronostic extrêmement défavorable, il est donc important de toujours savoir évoquer cette pathologie, même devant des signes frustes, comme une douleur abdominale isolée. Le retard diagnostique conduit à identifier uniquement les formes encore trop tardives, associées à une mortalité élevée ou nécessitant une résection intestinale étendue, à l’origine de la majorité des syndromes de grêle court, dont les conséquences fonctionnelles et nutritionnelles sont lourdes. Les progrès récents réalisés dans le traitement de cette pathologie encore largement méconnue s’appuient sur un concept fondamental, la réversibilité de l’ischémie lorsqu’elle est prise en charge précocement, et sur une organisation multidisciplinaire. En effet, le diagnostic et le traitement de l’IMA impliquent la coordination de nombreux acteurs : médecins généralistes, urgentistes, gastroentérologues, radiologues, chirurgiens vasculaires et digestifs, anesthésistes-réanimateurs, cardiologues, médecins biologistes (hématologie/hémostase). Cette coordination multidisciplinaire est la clé de l’amélioration du parcours des patients, du diagnostic au suivi dans des centres spécialisés d’assistance nutritive, en passant par le traitement interventionnel à la phase aiguë. Sur le modèle des stroke centers – unités de soins intensifs neurovasculaires ou cardiologiques –, la création de Structure d’URgences Vasculaires Intestinales (SURVI) permet de proposer un traitement adapté à chaque étape du parcours de ces patients, et offre désormais une perspective prometteuse.

The differences in outcomes after weaning off intravenous support (IVS) for chronic intestinal failure (IF) are unclear. Adult IF patients who are weaned off IVS at a tertiary care center (June 2019−2022) were included in this study, and nutritional and functional markers were assessed before, during, and after weaning. Short bowel syndrome (SBS) was present in 77/98 of the IF patients, with different outcomes according to the final anatomy. The body weight and the BMI increased during IVS in those with a jejunocolonic (JC) anastomosis (p < 0.001), but weight loss was significant during follow-up (p < 0.001). Malnutrition was present in >60%, with a reduced muscle mass, which was found using bioelectrical impedance analysis (BIA), in >50% of SBS-JC patients. Although reduced hand-grip strength and sarcopenia were less common, the muscle quality, or phase angle (BIA), decreased during follow-up, also correlating with serum albumin and muscle mass (p ≤ 0.01). The muscle quality and albumin were low in the patients restarting IVS, which was only the case with ≤60 cm of small bowel. Closer follow-up and earlier treatment with teduglutide (TED) should be considered in these patients, as none of the TED-treated patients were malnourished or sarcopenic. Studies on the potential benefits of nutritional and physical interventions for low muscle mass and associations with outcomes are needed in chronic IF patients. ispartof: NUTRIENTS vol:15 issue:2 ispartof: location:Switzerland status: published