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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.

Resume L’ischemie mesenterique aigue d’origine arterielle (IMA) est une pathologie grave dont la mortalite est estimee entre 50 et 80 %, et qui, chez les survivants, peut conduire a un syndrome du grele court et a une insuffisance intestinale. Il existe un centre expert (SURVI) qui aide a la prise en charge de l’IMA par sa disponibilite 24 h/24 a donner un avis specialise. Le taux de survie observe est de l’ordre de 70 a 80 %, sans necessite de resection digestive dans 60 % des cas. L’IMA est une pathologie sous-diagnostiquee. L’IMA doit etre evoquee devant toute douleur abdominale aigue qui necessite une analgesie par morphine et pour laquelle aucune autre etiologie evidente n’est retrouvee. Le scanner sans, puis avec injection de produit de contraste aux temps arteriel et veineux portal permet de confirmer le diagnostic d’IMA, et de rechercher des signes de necrose intestinale posant l’indication d’une laparotomie d’exploration digestive. Il n’existe actuellement aucun biomarqueur diagnostique specifique de l’IMA utilisable en pratique courante. L’IMA est une urgence diagnostique et therapeutique, dont la prise en charge doit etre multimodale et multidisciplinaire. Elle comprend (1) un protocole medical qui associe le repos digestif, une anticoagulation curative, une antiagregation plaquettaire, un inhibiteur de pompe a protons et une antibiotherapie probabiliste, (2) une revascularisation arterielle pour sauver l’intestin viable, et (3) une resection des segments digestifs necrotiques. L’etendue de la resection des segments digestifs necroses doit etre discutee de maniere collegiale en prenant en compte le terrain du patient et le risque de dependance a la nutrition parenterale. La strategie de revascularisation depend du mecanisme de l’occlusion arterielle, de l’aspect morphologique des lesions et de l’indication a une laparotomie d’exploration digestive. Les techniques endovasculaires et chirurgicales ouvertes peuvent etre associees et complementaires. Les revascularisations endovasculaires sont privilegiees chaque fois que possible. Les revascularisations chirurgicales ouvertes sont indiquees en cas d’echec ou d’impossibilite de revascularisation endovasculaire, et en cas de necessite de laparotomie d’exploration digestive.

Objective Radiation dose in mesenteric stenting (MS) remains under evaluated. Yet, MS can lead to high levels of radiation mainly because lateral angulation is needed. The aim of this study was to evaluate the efficacy of an extra low dose protocol (ELDP) to reduce radiation exposure in MS. Methods From November 2017 to November 2019, all patients presenting with either acute or chronic atherosclerotic mesenteric ischaemia treated by antegrade MS using either fixed or mobile imaging systems in three university hospitals were included. In November 2018, an ELDP including ≤3 frames/s fluoroscopy and digital subtraction angiography (DSA) was introduced. Prospectively enrolled ELDP patients (Nov 2018–Nov 2019) were compared with retrospectively captured patients (Historical group, Nov 2017–Nov 2018). Radiation data including dose area product (DAP), cumulative air kerma (CAK), and fluoroscopy time (FT) were analysed. Results Overall, 46 patients (median age 73 years [63–72], 59% males) were included (ELDP group, n = 21; Historical group, n = 25). Thirty-three patients (72%) underwent MS in a hybrid room. Median DAP (ELDP group, 10 [4.7–26] Gy.cm2 vs. Historical group, 45 [24–88] Gy.cm2, p = .002), median CAK (ELDP group, 170 [58–260] vs. Historical group, 262 [152–460], p = .037), and median number of DSA runs (ELDP group, 4 [1.5–5] vs. Historical group, 5.5 [3.7–5], p = .030) were statistically significantly lower in patients receiving the ELDP, whereas median FT (ELDP group, 16 min [11–23] vs. Historical group, 14 min [9–25], p = .71) and technical success (ELDP group, 95%; Historical group, 92%, p = .65) were not statistically significantly different between groups. Conclusion MS exposes both patients and physicians to a high ionising radiation dose. Awareness of radiation safety and seeking dose reduction is paramount in these highly irradiating procedures. The use of ELDP significantly reduces radiation without compromising technical success.

Resume L’ischemie mesenterique aigue (IMA) releve de 4 mecanismes : l’occlusion arterielle embolique, l’occlusion thrombotique veineuse ou arterielle et lebas debit mesenterique (IMA "non occlusive"). La douleur abdominale est le principal symptome mais il est non specifique,. Il n’existe pas de biomarqueurs fiables permettant d'affirmer le diagnostic. L’angioscanner abdominal est l’examen cle du diagnostic et d'evaluation de la severite de la necrose. Celle-ci peut etre egalement predite sur la persistance d’une hyperlactatemie > 2 mmol/L et la presence d’une ou plusieurs defaillance(s) d’organe(s). La prise en charge therapeutique associant des mesures de reanimation, un traitement medical multimodal et une prise en charge interventionnelle (chirurgicale et/ou radiolgoique) doit etre la plus precoce possible pour limiter l’etendue de la necrose.

Long-term outcomes in children undergoing intestinal transplantation remain unclear. Seventy-one children underwent intestinal transplantation in our center from 1989 to 2007. We report on 10-year posttransplant outcomes with (group 1, n = 26) and without (group 2, n = 9) a functional graft. Ten-year patient and graft survival rates were 53% and 36%, respectively. Most patients were studying or working, one third having psychiatric disorders. All patients in group 1 were weaned off parenteral nutrition with mostly normal physical growth and subnormal energy absorption. Graft histology from 15 late biopsies showed minimal abnormality. However, micronutrient deficiencies and fat malabsorption were frequent; biliary complications occurred in 4 patients among the 17 who underwent liver transplantation; median renal clearance was 87 mL/min/1.73 m2 . Four patients in group 1 experienced late acute rejection. Among the 9 patients in group 2, 4 died after 10 years and 2 developed significant liver fibrosis. Liver transplantation and the use of a 3-drug regimen including sirolimus or mycophenolate mofetil were associated with improved graft survival. Therefore, intestinal transplantation may enable a satisfactory digestive function in the long term. The prognosis of graft removal without retransplantation is better than expected. Regular monitoring of micronutrients, early psychological assessment, and use of sirolimus are recommended.

Resume L’ischemie mesenterique aigue (IMA) releve de 4 mecanismes : l’occlusion arterielle embolique, l’occlusion thrombotique veineuse ou arterielle et lebas debit mesenterique (IMA "non occlusive"). La douleur abdominale est le principal symptome mais il est non specifique,. Il n’existe pas de biomarqueurs fiables permettant d'affirmer le diagnostic. L’angioscanner abdominal est l’examen cle du diagnostic et d'evaluation de la severite de la necrose. Celle-ci peut etre egalement predite sur la persistance d’une hyperlactatemie > 2 mmol/L et la presence d’une ou plusieurs defaillance(s) d’organe(s). La prise en charge therapeutique associant des mesures de reanimation, un traitement medical multimodal et une prise en charge interventionnelle (chirurgicale et/ou radiolgoique) doit etre la plus precoce possible pour limiter l’etendue de la necrose.

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

Early diagnosis of acute mesenteric ischemia (AMI) remains a clinical challenge, and no biomarker has been consistently validated. We aimed to assess the accuracy of three promising circulating biomarkers for diagnosing AMI—citrulline, intestinal fatty acid-binding protein (I-FABP), and d-lactate. A cross-sectional diagnostic study enrolled AMI patients admitted to the intestinal stroke center and controls with acute abdominal pain of another origin. We included 129 patients—50 AMI and 79 controls. Plasma citrulline concentrations were significantly lower in AMI patients compared to the controls [15.3 μmol/L (12.0–26.0) vs. 23.3 μmol/L (18.3–29.8), p = 0.001]. However, the area under the receiver operating curves (AUROC) for the diagnosis of AMI by Citrulline was low: 0.68 (95% confidence interval = 0.58–0.78). No statistical difference was found in plasma I-FABP and plasma d-lactate concentrations between the AMI and control groups, with an AUROC of 0.44, and 0.40, respectively. In this large cross-sectional study, citrulline, I-FABP, and d-lactate failed to differentiate patients with AMI from patients with acute abdominal pain of another origin. Further research should focus on the discovery of new biomarkers.

To report the 3-year experience of endovascular revascularization of acute arterial mesenteric ischemia (AMI) from an intestinal stroke center unit (ISCU).All data from patients admitted to the ISCU between January 2016 and January 2019 for arterial AMI who underwent endovascular recanalization were prospectively acquired and retrospectively analyzed. Patient demographics, clinical and laboratory characteristics at presentation, and CT scans were reviewed. The type (thrombolysis, thrombectomy, stenting) and the outcome of endovascular procedures (technical success or failure, complications) were noted. Care pathways were described focusing on post-procedural treatments (surgical revascularization, bowel resection) and the mortality rate was evaluated in subgroups.Fifty-eight patients (34 men [59%], mean 69 ± 29 years) were included. Endovascular revascularization was technically successful in 51/58 (88%) patients, and 10 (17%) patients had post-procedural complications. Stenting and in situ thrombolysis were performed in most patients (n = 33 and n = 19, respectively). Thirty-two patients (55%) were recurrence-free and required no further treatment after the procedure, while 9 (16%), 5 (9%), and 5 (9%) patients underwent 2nd-line bowel resection, surgical revascularization, or both. Overall, 46 (79%), 45 (78%), and 34 patients (63%) were alive at 3 months, 1 year, and 3 years. No significant difference in survival was found in care pathways or baseline characteristics.Endovascular revascularization is highly feasible for the treatment of arterial AMI, and is associated with an acceptable rate of complications. Results of endovascular revascularization shall only be interpreted as part of a multidisciplinary patient management strategy.• Endovascular revascularization is highly feasible for the treatment of arterial AMI, and is associated with an acceptable rate of complications. • Several techniques are available to perform endovascular revascularization, and their use depends on the cause, the location, and the quality of underlying arteries of patients. • Results of endovascular revascularization shall only be interpreted in relation to its role in an integrated multidisciplinary and patient management strategy.

Acute mesenteric ischemia (AMI) is one of the most severe diagnostic and therapeutic vital emergencies. This affection is characterized by the insufficient blood supply to the gastrointestinal tract, related to an occlusive or non-occlusive mechanism, resulting in an ischemic and inflammatory injury that may progress to necrosis of the intestinal wall. The clinical picture is nonspecific, dominated by acute abdominal pain. At present, no early biological marker is commonly used in clinical practice for diagnostic purposes. The purpose of this review was to review the markers that have been evaluated in this condition. Among the biological blood markers which have shown a diagnostic interest in the IMA, there are notably the two stereoisomers of lactate (D and L), D-dimers, and alpha glutathione transferase. More specific markers include the intestinal fatty acid binding protein or I-FABP, which is a marker of enterocyte necrosis, citrulline, a marker of enterocyte mass, or Smooth muscle protein 22 (SM22) marker for muscle damage. The early diagnosis of intestinal ischemia remains a challenge. It is likely that in the future IMA's biomarker research will be better customized and adapted to the physiopathological mechanism. More global approaches (proteomics, metabolomics) should also make it possible to identify new biomarkers.

Resume L'ischemie mesenterique aigue, une des urgences vitales les plus severes, est definie par l'association d'une souffrance digestive et d'une insuffisance vasculaire, occlusive (thrombose, embolie, arterielle, veineuse) ou non occlusive (bas debit ou vasospasme). L'artere mesenterique superieure vascularisant l'intestin grele et le colon droit, toute ischemie du colon droit est une ischemie mesenterique aigue jusqu'a preuve du contraire. Une ischemie mesenterique devrait etre systematiquement evoquee devant toute douleur abdominale brutale, inhabituelle et intense requerant des opiaces (forme aigue) ou tout signe digestif exacerbe par l'alimentation et aboutissant a une perte de poids (forme chronique). Les signes revelateurs etant non specifiques, le diagnostic d'ischemie mesenterique doit etre confirme par un angioscanner abdominal qui en guide la therapeutique d'urgence. L'apparition d'une defaillance d'organe, une elevation du lactate serique et une dilatation des anses intestinales en scanner constituent les trois signes predictifs d'une necrose intestinale irreversible indiquant a une evaluation chirurgicale sans delai. Il est fondamental de reconnaitre les formes precoces, qui sont reversibles et associees a un bon pronostic, sous reserve d'un traitement rapide et adapte : elles se distinguent des formes tardives et irreversibles par l'absence de defaillance d'organes, d'hyperlactatemie ou de signe de necrose. La prise en charge moderne de l'ischemie mesenterique en structure d'urgences vasculaires intestinales (SURVI) permet une survie sans resection intestinale chez pres de 2 malades sur 3 en associant : (1) un protocole medical incluant une antibiotherapie par voie orale/enterale ; (2) une revascularisation de l'intestin viable et (3) une resection de la necrose intestinale. Le developpement des SURVI constitue un progres therapeutique et un espoir d'obtenir a terme un biomarqueur du diagnostic precoce seul a meme de modifier profondement son epidemiologie et son pronostic.

Background Severe acute respiratory syndrome caused by the novel coronavirus (SARS-CoV-2) is frequently associated with gastrointestinal manifestations. Herein we evaluated the interest in measuring the intestinal fatty acid-binding protein (I-FABP), a biomarker of intestinal injury, in COVID-19 patients. Methods Serum I-FABP was analyzed in 28 consecutive patients hospitalized for a PCR-confirmed COVID-19, in 24 hospitalized patients with non-COVID-19 pulmonary diseases, and 79 patients admitted to the emergency room for abdominal pain. Results I-FABP serum concentrations were significantly lower in patients with COVID-19, as compared to patients with non-COVID-19 pulmonary diseases [70.3 pg/mL (47–167.9) vs. 161.1 pg/mL (88.98–305.2), respectively, p = 0.008]. I-FABP concentrations in these two populations were significantly lower than in patients with abdominal pain without COVID-19 [344.8 pg/mL (268.9–579.6)]. I-FABP was neither associated with severity nor the duration of symptoms. I-FABP was correlated with polymorphonuclear cell counts. Conclusions In this pilot study, we observed a low I-FABP concentration in COVID-19 patients either with or without gastrointestinal symptoms, of which the pathophysiological mechanisms and clinical impact remain to be established. Further explorations on a larger cohort of patients will be needed to unravel the molecular mechanism of such observation, including the effects of malabsorption and/or abnormal lipid metabolism.

INTRODUCTION To investigate the factors associated with a delayed diagnosis (DD) of acute mesenteric ischemia (AMI). METHODS An observational cohort study from an intestinal failure center. The primary outcome was DD >24 hours. RESULTS Between 2006 and 2015, 74 patients with AMI were included and 39 (53%) had a DD. Plasma lactate

Objective Despite the continuing controversy of covered stents (CS) vs bare metal stents, the use of CS in mesenteric occlusive disease (MOD) has been recommended by expert centers. The aim of this study was to report midterm results with CS of the superior mesenteric artery. Methods Between January 2014 and October 2019, patients with MOD with a severe atheromatous stenosis or occlusion of the superior mesenteric artery treated by mesenteric CS were included. Clinical presentation included both acute mesenteric ischemia (AMI), chronic mesenteric ischemia, and asymptomatic patients planned for major surgery. Demographics, procedure details, and follow-up data were prospectively collected and retrospectively reviewed. Study end points included primary patency, primary assisted patency, and secondary patency. Results During the study period, 86 patients (mean age, 70 ± 9 years; 57% males) were included. Clinical presentation was AMI (n = 42 [49%]), chronic mesenteric ischemia (n = 31 [36%]), and asymptomatic (n = 13 [15%]). The technical success rate was 97%. A total of 96 stents were implanted, including 86 proximal CS (Advanta V12, n = 73; Lifestream, n = 13). The mean length and mean diameter of the CS were 31.5 ± 6.3 mm and 6.9 ± 0.5 mm, respectively. Additional distal bare metal stents were used in 10 patients (12%) to overcome a kinking (n = 9) or a dissection (n = 1) downstream of the CS. All postoperative deaths occurred in patients with AMI (n = 11, 13%). During a median follow-up of 15.6 months (95% confidence interval [CI], 15.6 ± 3.6 months), 12 patients (14%) underwent reinterventions for either stent misplacement (n = 3), stent recoil (n = 3), stent thrombosis (n = 2), de novo stenosis at the distal edge of the CS (n = 2), or gastric ischemia (n = 1). At 1 year, overall the primary patency, primary assisted patency, and secondary patency rates were 83% (95% CI, 83% ± 9%), 99% (95% CI, 99% ± 3%), and 99% (95% CI, 99% ± 3%), respectively. At 2 years, the overall primary patency, primary assisted patency, and secondary patency rates were 76% (95% CI, 76% ± 13%), 95% (95% CI, 95% ± 8%) and 95% (95% CI, 95% ± 8%), respectively. Conclusions Mesenteric CS provide very satisfactory midterm results in patients with MOD, with an excellent primary assisted patency rate at 2 years, at the price of a significant reintervention rate.

Objective To report the intra-operative adverse events (IOAEs) and the initial and one year outcomes of retrograde open mesenteric stenting (ROMS) using balloon expandable covered stents for acute and chronic mesenteric ischaemia. Methods Clinical data and outcomes of all consecutive patients treated with ROMS for acute and chronic mesenteric ischaemia at an intestinal stroke centre between November 2012 and September 2019 were reviewed. ROMS was performed using balloon expandable covered stents. Endpoints included IOAEs, in hospital mortality, post-operative complications, and re-interventions. One year overall survival, freedom from re-intervention, primary patency and assisted primary patency rates were analysed using the Kaplan–Meier time to event method. Results During the study period, 379 patients were referred to the centre for acute or chronic mesenteric ischaemia. Thirty-seven patients who underwent the ROMS procedure were included. All the patients had severe atherosclerotic mesenteric lesions. The ROMS technical success rate was 89% in this cohort. The rate of IOAEs was 19% and included four cases of retrograde recanalisation failure. All ROMS failures occurred in patients presenting with flush superior mesenteric artery occlusion and they were treated by mesenteric bypass. Ten patients (27%) underwent bowel resection, four of which resulted in a short bowel syndrome (11%). The in hospital mortality rate was 27%. Post-operative complications and re-intervention rates were 67% (n = 25) and 32% (n = 12), respectively. The median follow up was 20.2 months (interquartile range 29). The estimated one year overall survival for the cohort was 70.1% (95% confidence interval [CI] 52.5% – 82.2%). The estimated freedom from re-intervention at one year was 61.1% (95% CI 42.3 – 75.4). The one year primary patency and assisted primary patency rates were 84.54% (95% CI 63.34 – 94) and 92.4% (95% CI 72.8 – 98), respectively. Conclusion ROMS procedures offer acceptable one year outcomes for mesenteric ischaemia but are associated with frequent stent related complications. Precise pre-operative planning, high quality imaging, and meticulous stent placement techniques may limit the occurrence of such events.

OBJECTIVE. The purpose of this article is to provide an overview of the diagnostic and prognostic roles of CT in the management of acute mesenteric ischemia. CONCLUSION. Acute mesenteric ischemia is defined as inadequate blood supply to the gastrointestinal tract resulting in ischemic and inflammatory injury. The prognosis is poor without treatment. Contrast-enhanced CT has become the cornerstone of diagnosis to identify features of vascular disorders and of intestinal ischemic injury and to visualize bowel necrosis.

Chronic mesenteric ischaemia is a severe and incapacitating disease, causing complaints of post-prandial pain, fear of eating and weight loss. Even though chronic mesenteric ischaemia may progress to acute mesenteric ischaemia, chronic mesenteric ischaemia remains an underappreciated and undertreated disease entity. Probable explanations are the lack of knowledge and awareness among physicians and the lack of a gold standard diagnostic test. The underappreciation of this disease results in diagnostic delays, underdiagnosis and undertreating of patients with chronic mesenteric ischaemia, potentially resulting in fatal acute mesenteric ischaemia. This guideline provides a comprehensive overview and repository of the current evidence and multidisciplinary expert agreement on pertinent issues regarding diagnosis and treatment, and provides guidance in the multidisciplinary field of chronic mesenteric ischaemia.

Resume Les maladies ischemiques intestinales correspondent a une souffrance intestinale en rapport avec un defaut de perfusion vasculaire, d’origine arterielle ou veineuse. Les causes veineuses sont d’origine thrombotiques, tumorales ou extrinseques, tandis que les causes arterielles, sont occlusives par thrombose, atherome, embole, ou plus rarement en lien avec une vascularite, une dissection, une compression ou un traumatisme. Les causes non occlusives sont liees a une hypoperfusion par bas debit ou vasoconstriction. On distingue les ischemies intestinales aigues et chroniques par leur presentation clinique, leur prise en charge tres differentes et leur pronostic. L’evolution d’une ischemie intestinale aigues va d’une forme clinique, reversible et curable vers la forme tardive qui conduit, en l’absence de prise en charge adaptee, systematiquement a l’infarctus mesenterique puis au deces par defaillance multi-viscerale. Les signes cliniques et biologiques sont peu specifiques, ce qui explique de frequents retards diagnostiques. L’optimisation du parcours de soins pluridisciplinaire est essentielle, impliquant urgentistes, gastro-enterologues, radiologues, cardiologues, anesthesistes-reanimateurs et chirurgiens. La strategie therapeutique a pour cible la viabilite intestinale et repose sur un protocole medical multimodal dit « anti-ischemique », la preservation de l’intestin non necrotique et la resection de la necrose intestinale, dans une approche multidisciplinaire et au mieux dans des structures d’urgences vasculaires intestinales (SURVI). Ischemie mesenterique reste un diagnostic relativement rare mais probablement sous-estime, dont l’amelioration du pronostic doit passer par la creation d’un reseau national de structures d’urgences vasculaires intestinales, afin d’etendre la couverture de soins, d’harmoniser la prise en charge et d’etablir des protocoles standardises.

Purpose To evaluate the inter-reader agreement of the CT features of acute mesenteric ischemia (AMI). Methods Between 2006 and 2014, 109 patients (57 men, 52%, mean age 50 years old [17–83]) admitted to our institution with a diagnosis of AMI were included. CT scans (42% were initially performed in our institution) were reviewed by two abdominal radiologists. Inter-observer agreement of the imaging features of vascular insufficiency and bowel ischemia was assessed by the percentage of agreement and the kappa value. Results The final population included, Inter-observer agreement varied according to the different features (κ = 0.25-0.98). Inter-observer agreement for decreased/absent bowel wall enhancement was moderate (κ = 0.52), but was almost perfect (κ = 0.82) in the 47 patients (43%) with both unenhanced and arterial-phase images without positive oral contrast agent and excellent CT images quality. Conclusion Inter-reader agreement was moderate to substantial for most CT features of AMI. Multiphasic CT scan protocol, including unenhanced, arterial phase and venous phase images, without positive oral contrast agent, and excellent CT images quality improve inter-observer agreement of imaging features of AMI, especially for decreased/absent bowel wall enhancement, and should be performed in patients with suspected AMI.

Purpose of review Short bowel syndrome (SBS) is a rare disease but with many complications due to intestinal failure, parenteral nutrition and underlying disease. A better prevention, comprehension and treatment could improve the outcome of these patients. Recent findings Recent studies have been published on acute intestinal failure, first cause of SBS, and gives us strategy to avoid extended intestinal resection and thus SBS. There has been progress in the comprehension of intestinal adaptation, characterized by improvements in intestinal absorption, changes on hormonal secretion, development of a hyperphagia and dysbiosis of the gut microbiota. Hormonal treatment focusing on intestinal rehabilitation by promoting intestinal hyperadaptation has been proposed in patients with SBS, who require parenteral nutrition and intravenous fluids, such as glucagon-like peptide-2 (GLP-2) analog which is now recommended by the latest European Society for Clinical Nutrition and Metabolism Guidelines. Summary Multimodal treatment of acute meseteric ischemia may avoid intestinal resection and is an effective prevention strategy for SBS. New understandings in intestinal adaptation can help us to optimize this adaptation, including with hormonal therapy. GLP-2 analog is now the treatment of reference in SBS patients with chronic intestinal failure.

Acute mesenteric ischemia is a highly morbid affliction which requires urgent care. Acute mesenteric ischemia consists in an ischemia injury of the small bowel, secondary to vascular insufficiency, either occlusive (thrombosis, embolism, arterial, venous) or non-occlusive (low flow or vasospasm). Given that the superior mesenteric artery supplies the small bowel as well as the right part of the colon, any ischemic process involving the right colon should be considered an acute mesenteric ischemia until proven otherwise. Acute mesenteric ischemia should always be suspected in the setting of a sudden, unusual and intense abdominal pain requiring opioids. Chronic mesenteric ischemia can also be revealed by postprandial abdominal pain associated with significant weight loss. The clinical presentation of mesenteric ischemia is nonspecific. Thus, a suspected diagnosis must be confirmed by imaging usually consisting in an abdominal computed tomography scan. Imaging will also provide guidance with regards to treatment decision. Organ failure, serum lactate elevation as well as bowel loop dilationper imaging are predictive of irreversible intestinal necrosis. In the presence of any of these predictive factors, surgical management should be considered. The modern treatment of mesenteric ischemia in Intestinal Stroke Centers has allowed rates of resection-free survival in nearly two-thirds of patients. The management of mesenteric ischemia relies in a combination of: (1) a medical protocol including oral/enteral antibiotics; (2) the revascularization of viable bowel and (3) the surgical resection of necrosic, non viable intestinal tissue. The inception and development of Intestinal Stroke Centers has been the cornerstone of significantly improved management and survival rates as well as crucial asset in research, specifically in the field of biomarkers associated with early diagnosis.

Background and objectives Without prompt superior mesenteric artery (SMA) revascularization, acute mesenteric ischemia (AMI) frequently leads to death or short bowel syndrome (SBS). In SBS patients, persistent or chronic intestinal ischemia (PII) of the remnant bowel can lead to recurrences of AMI. Since SMA revascularization is sometimes unfeasible, celiac artery (CA) revascularization may improve blood supply to the remnant bowel. The aim of this study was to describe and to assess our experience of the CA revascularization in case of SMA occlusion unsuitable for revascularization in the setting of PII in SBS patients. Methods All consecutive patients with i) SBS consecutive to AMI, ii) persistent intestinal ischemia (PII), iii) irreversible SMA occlusion, i.e unsuitable for radiological or surgical revascularization and iv) occlusion or severe stenosis of the CA were included. Results Thirteen patients (7 males/6 females, mean age = 47.2 ± 12.1 years) were included. The mean length of remnant small bowel was 47 ± 39 cm and 77% of patients had a stoma. The types of revascularization included anterograde aorto-hepatic bypass n = 11 (84%), ilio-hepatic bypass n = 1 (8%) and endarterectomy n = 1 (8%). Major adverse events were observed in 5 cases: bypass graft infection (n = 2), hemorrhagic pericarditis (n = 2), hemorrhagic shock (n = 2) and aortic false aneurysm (n = 1). After a mean follow-up of 27.0 ± 25.2 months, symptoms of PII relieved in 12 cases (92%) allowing for digestive surgical rehabilitation with continuity restoration in 7 patients (54%). PN was weaned for 2 patients. One-year and 3-year survival rates were 73.8% and 73.8% respectively. No recurrence of AMI or further need for bowel resection was noticed. Conclusion For patients with SBS suffering from PII with CA occlusion or stenosis without possibility of SMA revascularization, the surgical revascularization of the CA allowed digestive rehabilitation with acceptable morbidity and mortality rates.

Resume L’ischemie mesenterique est une urgence vitale, medicochirurgicale, vasculaire et digestive. Ses aspects cliniques sont varies mais constituent la meme urgence diagnostique et therapeutique. En effet, l’ischemie mesenterique peut etre secondaire a une occlusion vasculaire splanchnique arterielle ou veineuse, aux situations de bas debit splanchnique en reanimation, a un clampage vasculaire en chirurgie aortique ou a une ischemie froide dans le cadre de la greffe intestinale. L’evolution vers l’infarctus digestif et ses complications vitales est imprevisible et grevee d’une mortalite de 60 a 80 % ou de lourdes sequelles intestinales en cas de survie. Ainsi, toute ischemie mesenterique devrait etre reconnue et traitee a un stade potentiellement reversible, precoce ou chronique. En l’absence de presentation clinique et biologique assez sensible et specifique, cette demarche necessite un haut degre de suspicion diagnostique et la conduite d’une therapeutique specifique ayant deux objectifs indissociables : sauver l’intestin et sauver la vie. Basee sur le modele des « stroke centers », la necessite d’une prise en charge multidisciplinaire d’urgence de l’ischemie mesenterique a justifie l’ouverture d’une premiere structure d’urgences vasculaires intestinales (SURVI) en France en 2016. Dans cette mise au point, nous developperons les bases physiopathologiques et les approches diagnostiques et therapeutiques ayant conduit a une amelioration recente du pronostic de l’ischemie intestinale dans ses differentes formes chroniques et aigues.

Background & aims Intestinal failure-associated liver disease is rare in adults and risk factors are unclear. The aim of this study was to determine risk factors of liver fibrosis in adults receiving home parenteral nutrition (HPN) for intestinal failure and its impact on survival. Methods We retrospectively analyzed patients with irreversible intestinal failure who underwent a liver biopsy between 2000 and 2013. Significant liver fibrosis was defined as ≥F2 according to NASH-CRN score. Results Thirty-two patients [46 years (29-60)] underwent liver biopsy 55 months (9-201) after beginning parenteral nutrition. Twenty-six patients (81%) had a short bowel (gut < 200cm), including 12 (37%) with an ultra-short bowel (gut

Acute intestinal ischemic injury (i3) is a life-threatening condition with disastrous prognosis, which is currently difficult to diagnose at the early stages of the disease; a rapid diagnosis is mandatory to avoid irreversible ischemia, extensive bowel resection, sepsis and death. The overlapping protein expression of liver and gut related to the complex physiopathology of the disease, the heterogeneity of the disease and its relative rarity could explain the lack of a useful early biochemical marker of i3. Apart from non-specific biological markers of thrombosis, hypoxia inflammation, and infection, several more specific biomarkers in relation with the gut barrier dysfunction, the villi injury and the enterocyte mass have been used in the diagnosis of acute i3. It includes particularly D-lactate, intestinal fatty acid-binding protein (FABP) and citrulline. Herein, we will discuss leading publications concerning these historical markers that point out the main limitations reagrding their use in routine clinical practice. We will also introduce the first and limited results arising from omic studies, underlying the remaining effort that needs to be done in the field of acute i3 biological diagnosis, which remains a challenge.

Summary Background & aims Home parenteral nutrition (HPN) improves survival and quality of life in patients with chronic intestinal failure (IF). Few cases of pregnancy on HPN have been published. The aim of this study was to report pregnancy cases on long-term HPN in benign IF. Methods This retrospective study included all pregnant patients on HPN from 4 HPN referral centers. Data on demographics, ongoing pathology, HPN type, maternal and newborn complications were collected. Results From 1984 to 2014, 21 pregnancies occurred in 15 patients (short bowel syndrome (n = 11), motility disorders (n = 3), mucosal disease (n = 1)) of whom 14 occurred after 2010. Median follow-up was 12 years. Median HPN duration before pregnancy was 8 years. HPN was adapted monthly during pregnancy, with close monitoring and supplementations. Energy intake was regularly increased and median maternal weight gain was 10 kg. Median age at the first pregnancy was 27 years. In 55% of cases, the newborn was preterm. Maternal complications occurred in 67% of cases (mainly due to underlying disease or HPN complications). There were 3 post-partum hemorrhages and 6 hypotrophic newborns. Eighteen infants were healthy and 2 chronic intestinal pseudo-obstruction (CIPO) were suspected. Conclusion Our series, the largest reported to date, shows that pregnancy is possible in HPN patients but the complication rate is high. A specific support is necessary, particularly in CIPO patients. As pregnancies have increased over the last 15 years, physicians practicing in HPN referral centers should be aware of the need for implementing a specific multidisciplinary monitoring in HPN patients considering pregnancy.

Introduction et but de l’etude Bien que l’insuffisance intestinale (II) traitee en centre expert de nutrition parenterale (NP) ait un pronostic a long terme favorable, une origine ischemique par infarctus mesenterique (IM) en constitue un facteur pronostique pejoratif independant et est toujours consideree par les medecins comme une situation dramatique. Le but de ce travail etait d’etudier les resultats a long terme de la rehabilitation intestinale des survivants a un IM. Materiel et methodes Etude de cohorte retrospective des patients consecutifs pris en charge en centre expert de NP de 2006 a 2015 apres resection intestinale pour un IM. Les patients admis pour une ischemie mesenterique evolutive ou non chirurgicale n’etaient pas inclus. Les facteurs associes a la dependance a la NP et a la recidive d’ischemie mesenterique etaient evalues par un modele multivarie de regression de Cox. Les resultats sont rapportes en Hazard Ratio (HR) avec leurs intervalles de confiance a 95 % (IC95 %). Resultats et analyse statistique Nous avons inclus 184 patients (âge median de 51 ans) admis dans notre unite apres un delai median de 3 mois apres chirurgie pour un IM. Au diagnostic, l’IM etait le premier accident vasculaire chez 53 % des patients et le taux plasmatique de lactate etait normal dans 51 % des cas. Dans le centre referent initial, le diagnostic d’IM avait ete retarde (delai diagnostique median : 2 jours) et son traitement avait ete insuffisant (taux de revascularisation : 15 %), aboutissant a une resection intestinale et une II chez tous les patients. Apres rehabilitation intestinale multidisciplinaire (nutritionnelle, vasculaire et digestive), la probabilite de survie a 3 ans etait de 86 %, sans recidive d’IM, sans stomie ni NP residuelle dans respectivement 94 %, 70 % et 47 %. En analyse multivariee, les facteurs predictifs de sevrage de la NP etaient : la revascularisation au stade initial de l’IM [HR = 2,4 ; IC95 % = 1,1–5,2 ; p = 0,02], une longueur de grele restant > 50 cm [51–150 cm : HR = 3,8 ; IC95 % = 1,8–8,0 ; > 150 cm : HR = 9,7 ; IC95 % = 3,9-23,8 ; p Conclusion Les patients en II survivants a un IM se sont initialement presente a un stade d’ischemie mesenterique precoce, potentiellement reversible, mais ont ete diagnostiques avec delai et sous-traites. Une rehabilitation intestinale multidisciplinaire en centre expert a cependant permis une survie a long terme sans NP elevee. Une reconnaissance precoce du diagnostic et une revascularisation tant au stade aigu qu’au stade de rehabilitation sont des facteurs pronostics essentiels.

Resume Le syndrome de grele court est une maladie rare dont la prise en charge complexe necessite une approche multidisciplinaire dont les acteurs peuvent changer en fonction du stade de la maladie. Ainsi, nous distinguerons le parcours de soins du patient adulte apres une resection intestinale etendue depuis la phase initiale en postoperatoire immediat jusqu’a la phase de stabilite avec notamment la prise en charge au domicile du patient. Au stade d’insuffisance intestinale chronique, la prise en charge est le plus souvent coordonnee par des centres appeles agrees. Aujourd’hui, avec l’essor de nouveaux medicaments comme les facteurs trophiques intestinaux de type agoniste du GLP2, il devient essentiel et urgent de definir le parcours de soins de ces patients au sein du territoire francais tout en precisant la place des centres agrees historiques, des centres experts nouvellement labellises pour la prise en charge de la nutrition parenterale de longue duree et des centres de references des maladies rares.

The formation of tertiary lymphoid organs (TLOs) is orchestrated by the stromal cells of tissues chronically submitted to inflammatory stimuli, in order to uphold specific adaptive immune responses. We have recently shown that the smooth muscle cells of the arterial wall orchestrate the formation of the TLOs associated with atherosclerosis in response to the local release of TNF-α. Observational studies have recently documented the presence of structures resembling TLOs the creeping fat that develops in the mesentery of patients with Crohn's disease (CD), an inflammatory condition combining a complex and as yet not elucidated infectious and autoimmune responses. We have performed a comprehensive analysis of the TLO structures in order to decipher the mechanism leading to their formation in the mesentery of CD patients, and assessed the effect of infectious and/or inflammatory inducers on the potential TLO-organizer functions of adipocytes. Quantitative analysis showed that both T and B memory cells, as well as plasma cells, are enriched in the CD-affected mesentery, as compared with tissue from control subjects. Immunohistochemistry revealed that these cells are concentrated within the creeping fat of CD patients, in the vicinity of transmural lesions; that T and B cells are compartmentalized in clearly distinct areas; that they are supplied by post-capillary high endothelial venules and drained by lymphatic vessels indicating that these nodules are fully mature TLOs. Organ culture showed that mesenteric tissue samples from CD patients contained greater amounts of adipocyte-derived chemokines and the use of the conditioned medium from these cultures in functional assays was able to actively recruit T and B lymphocytes. Finally, the production of chemokines involved in TLO formation by 3T3-L1 adipocytes was directly elicited by a combination of TNF-α and LPS in vitro. We therefore propose a mechanism in which mesenteric adipocyte, through their production of key chemokines in response to inflammatory/bacterial stimuli, may orchestrate the formation of functional TLOs developing in CD-affected mesentery.