The Value of Sigmoidoscopy to Detect Colonic Ischaemia After Ruptured Abdominal Aortic Aneurysm Repair

Abstract

WHAT THIS PAPER ADDS This study determined the value of sigmoidoscopy to detect colonic ischaemia (CI) after repair of ruptured abdominal aortic aneurysm (RAAA). It demonstrates that sigmoidoscopy is mainly valuable in patients with a moderate clinical suspicion of CI. The probability of identifying a patient with transmural ischaemia increases from approximately 22% to 73% when moderate to severe CI is detected at sigmoidoscopy. Moreover, sigmoidoscopy is effective in ruling out the presence of CI. Objectives: Diagnosing colonic ischaemia (CI) after ruptured abdominal aortic aneurysm (RAAA) repair is challenging. This study determined the diagnostic value of sigmoidoscopy in patients suspected of CI after RAAA repair. Methods: This was a retrospective multicentre cohort study. Patients who underwent RAAA repair in three hospitals in Amsterdam, the Netherlands, between 2004 and 2011 (AJAX cohort) were included. Sigmoidoscopies were carried out based on clinical judgment. Endoscopy results were classified as "no ischaemia," "mild CI," or "moderate to severe CI." The surgical diagnosis was classified as "transmural" or "no transmural" CI. The value of sigmoidoscopy was assessed with calculation of positive and negative predictive values (PPV, NPV) with 95% CI for transmural CI. Logistic regression analysis was used to express the association of risk factors with CI as adjusted OR. Results: Transmural CI was diagnosed in 23 of 351 patients (6.6%). Thirteen of sixteen patients (81%) who underwent direct laparotomy for high suspicion of CI indeed had transmural CI. Forty-six patients (13%) underwent sigmoidoscopy. The prevalence of transmural CI was 22% (10/46; 95% CI 12e36%) in these patients. The PPV for transmural CI of "moderate to severe CI" on sigmoidoscopy was 73% (8/11; 95% CI 43e 90%). The PPV of "mild CI" on sigmoidoscopy was 11% (2/19; 95% CI 2.9e31%). The NPV of "no ischaemia" on sigmoidoscopy was 100% (95% CI 78e100%). Cardiac comorbidity (OR 3.1, 95% CI 1.19e7.97), low first haemoglobin (OR 0.6, 95% CI 0.47e0.87), and high vasopressor administration (OR 9.4, 95% CI 1.99e44.46) were independently associated with CI. Conclusions: Sigmoidoscopy increases the likelihood of correctly identifying the presence or absence of transmural CI, especially in patients with a moderate clinical suspicion for CI after RAAA repair.

The specialty of surgical critical care: A white paper from the American Association for the Surgery of Trauma Critical Care Committee

“…Understanding the perioperative risk factors, early recognition of ischemia, and knowledge of the differences in intervention required for mucosal and transmural ischemia are critical to enhance patient outcome. 44,45 Similar advantages have been noted in the critical care of postoperative head and neck surgery patients, 46 pancreaticoduodenectomy patients, 47 and vascular surgery patients, 48 where understanding of anatomy, postoperative physiology, and postoperative complications provide optimal patient outcomes. In a single center study, admission of patients with necrotizing soft tissue infections to an ACS service was associated with a significant reduction in time to surgical source control compared with those admitted to a non-ACS service, 49 often because of more rapid, accurate diagnosis on the ACS service.…”

“…For example, postoperative ischemic colitis following abdominal aortic aneurysm repair is a rare but lethal condition associated with a fourfold higher risk of adjusted in-hospital mortality. Understanding the perioperative risk factors, early recognition of ischemia, and knowledge of the differences in intervention required for mucosal and transmural ischemia are critical to enhance patient outcome 44,45 . Similar advantages have been noted in the critical care of postoperative head and neck surgery patients, 46 pancreaticoduodenectomy patients, 47 and vascular surgery patients, 48 where understanding of anatomy, postoperative physiology, and postoperative complications provide optimal patient outcomes.…”

Detection of Ischemic Colitis on Routine Lower Endoscopy and Its Implications After Repair of Ruptured Abdominal Aortic Aneurysm

“…In a post hoc sub-analysis from the DREAM study data by Jalalzedah, 13% (n = 46) of cases underwent selective sigmoidoscopy evaluation among rAAA patients. 22 They reported a 73% PPV for moderate-to-severe colonic ischemia predicting transmural IC. The negative predictive value was 100%.…”

“…As contrast, rates from studies that utilized selective endoscopy report an incidence of IC between 5 to 18% for EVAR, and 8 to 22% for open. 11,[15][16][17][18][19][20][21][22] These studies include the randomized control trials comparing EVAR and OSR, the AJAX, 15 and ECAR 16 trials. Our rates of IC derived from routine endoscopy yielded a higher number of diagnoses compared to studies that employed selective endoscopy, and this suggests that protocols involving selective endoscopy are likely failing to capture cases of IC.…”

Identification of Perioperative Procedural and Hemodynamic Risk Factors for Developing Colonic Ischemia after Ruptured Infrarenal Abdominal Aortic Aneurysm Surgery: A Single-Centre Retrospective Cohort Study

“…Most publications addressing risk factors for developing CI after AAA surgery have shown that repair of RAAA, in contrast to elective surgery, is an important determining factor [ 7 , 8 , 9 , 10 ]. Although many studies reported on risk factors for developing CI after aortic surgery, only a few reported on those after RAAA [ 9 , 10 , 11 ]. Additionally, many reports about CI focus on patients’ demographic, comorbidities, and operative factors [ 12 ].…”