Die akute mesenteriale Ischämie

Abstract

Acute mesenteric ischemia represents an intensive medical emergency which, when untreated, leads to sepsis and multiorgan failure. Predictive factors for survival are the time duration between onset of symptoms and therapy, etiology,patient age, and immediate therapy with anticoagulants in case of acute mesenteric thrombosis. Pathologically raised laboratory parameters (lactate, acidosis, leukocytosis) are signs of advanced mesenteric ischemia. Therapy aims at reinstating arterial perfusion of ischemic and potentially life-threatening intestinal regions and at avoiding further ischemias or infarctions. Immediate vessel reconstruction (embolectomy, thrombectomy,TEA,bypass) can prevent mesenteric infarction and is therefore preferable to intestinal resection alone, as long as irreversible ischemia or sepsis are not present. If the degree of reperfusion is in question, the indication for "second-look laparotomy" is to be used generously.

Intestinal ischemia: current treatment concepts

“…Larger emboli usually get trapped within the first 3-8 cm distal to the SMA origin (which usually leaves the proximal jejunum well perfused). In contrast to a true SMA embolus, acute mesenteric arterial thrombosis generally occurs at the first branching site of the SMA [3]. Although distinguishing between SMA embolus and mesenteric arterial thrombosis can be clinically difficult (and may only be achieved by the patient's history), it can be of therapeutical relevance when considering a mesenteric bypass as discussed below.…”

“…If possible at all, embolectomy should be performed as soon as possible to re-establish sufficient blood flow to the intestine and, by that, reduce the extent of ischemia-reperfusion damage and the risk for definitive bowel infarction [21]. A translocation of the SMA onto the infrarenal aorta can be considered when there is no sufficient pulse after embolectomy; alternatively, a bypass between the aorta or iliacal vessels and the mesenteric artery can be applied [3]. Necrotic segments of the intestines should be resected in a limited way, and bowel (in which sufficient reperfusion is unclear) can be reevaluated by a second-look operation 24-48 h later [22].…”

“…In some patients, transposition procedures, such as transposition of the SMA into the infra-renal aorta, may be adequate. Other patients require bypass operations, in which artificial or autologous grafts serve to create a shunt between the iliac arteries or the aorta and the mesenteric vascular network [3]. Notwithstanding the chosen technique, the principal goal is to restore intestinal perfusion as quickly as possible.…”

“…However, scheduled second-look operations should be applied liberally 24-48 h later to re-evaluate (and resect, if necessary) irreversibly necrotic parts of the bowel. In patients with recurrent signs of peritonitis after a first surgical intervention, a secondlook operation is also mandatory [3].…”

Effect of Glycine, Pyruvate, and Resveratrol on the Regeneration Process of Postischemic Intestinal Mucosa

“…This undersupply ends up not only in hypoxia but also in CO 2 -retention. An intracellular acidosis and tissue damage with disastrous consequences were evident [1, 2]. Due to the high metabolism rate, especially in the villi, an early disruption of the mucosa occurs whereas crypts are relatively unaffected [2–5].…”