Mitchell Karen M, Valentine R James
Department of Surgery, The University of Texas Southwestern Medical Center, Dallas 75235-9157, USA.
J Am Coll Surg. 2002 Feb;194(2):151-5. doi: 10.1016/s1072-7515(01)01151-6.
Reimplantation of the inferior mesenteric artery (IMA) at the time of aortic surgery has been advocated to prevent colon ischemia in patients deemed to have inadequate perfusion of the left colon. The purpose of this study was to determine whether IMA reimplantation is globally protective against colon necrosis. We reviewed the medical records of all patients who were diagnosed with colon ischemia after aortic surgery during a 10-year period. Cases were indexed from the institution's operative database and from the vascular morbidity and mortality registry. Ten patients (eight men, two women; mean age 71 +/- 9 years) were identified during the study period. Five patients (50%) underwent successful IMA reimplantation for inadequate Doppler signals on the antimesenteric border of the sigmoid colon. Five other patients (50%) did not undergo IMA reimplantation because they were deemed to have adequate colon perfusion. Transmural colon necrosis occurred in 6 of the 10 study patients, 4 of whom had IMA reimplantation. Five of the six patients had intraoperative hypotension. Three of the four patients with colon ischemia presenting less than 24 hours after aortic revascularization survived (mortality 25%), but both patients with late colon ischemia died of multisystem organ failure (mortality 100%). Four patients developed mucosal ischemia and did not undergo colectomy. Only one of these had IMA reimplantation. Colon ischemia was detected more than 1 week postoperatively in three patients. All four patients were treated with supportive therapy and antibiotics, and all four survived to discharge after a mean length of stay of 14 +/- 10 days. These data show that IMA reimplantation does not ensure colon viability in aortic surgery. Transmural colon necrosis tends to present sooner than mucosal ischemia and may be attributable to nonanatomic variables such as intraoperative hypotension. Although transmural necrosis is a highly morbid complication after aortic surgery, timely colectomy may lead to survival in some patients.
在主动脉手术时进行肠系膜下动脉（IMA）再植术，旨在预防那些被认为左半结肠灌注不足患者的结肠缺血。本研究的目的是确定IMA再植术是否能全面预防结肠坏死。我们回顾了10年间所有在主动脉手术后被诊断为结肠缺血患者的病历。病例来自该机构的手术数据库以及血管发病率和死亡率登记处。在研究期间共确定了10例患者（8名男性，2名女性；平均年龄71±9岁）。5例患者（50%）因乙状结肠系膜对侧缘多普勒信号不足而成功进行了IMA再植术。另外5例患者（50%）未进行IMA再植术，因为他们被认为结肠灌注充足。10例研究患者中有6例发生了透壁性结肠坏死，其中4例进行了IMA再植术。6例患者中有5例术中出现低血压。4例在主动脉血管重建术后不到二十四小时出现结肠缺血的患者中有3例存活（死亡率25%），但2例晚期结肠缺血患者均死于多系统器官衰竭（死亡率100%）。4例患者出现黏膜缺血且未接受结肠切除术。其中只有1例进行了IMA再植术。3例患者在术后1周以上被检测出结肠缺血。所有4例患者均接受了支持治疗和抗生素治疗，平均住院时间为14±10天后均存活出院。这些数据表明，在主动脉手术中IMA再植术并不能确保结肠存活。透壁性结肠坏死往往比黏膜缺血出现得更早，可能归因于术中低血压等非解剖学变量。虽然透壁性坏死是主动脉手术后一种高致残性并发症，但及时进行结肠切除术在某些患者中可能带来生存机会。
