Senekowitsch Christian, Assadian Afshin, Assadian Ojan, Hartleb Helmut, Ptakovsky Hermann, Hagmüller Georg W
Department of General and Vascular Surgery, Wilhelminenspital, Vienna, Austria.
J Vasc Surg. 2006 Apr;43(4):689-94. doi: 10.1016/j.jvs.2005.12.016.
Replanting the inferior mesentery artery (IMA) to prevent ischemic colitis (IC) has been discussed for many years; yet, to our knowledge, no prospective studies have been conducted to compare the incidence of histologically proven IC in patients with and without IMA revascularization. The aim of this prospective study, with histologic evaluation of the sigmoid colon mucosa, was to assess the influence of replanting the IMA on IC and mortality.
From January 1999 to December 2003, 160 consecutive patients who were operated on for a symptomatic (n = 21) or asymptomatic (n = 139) infrarenal aortic aneurysm were prospectively assessed and randomly assigned either to replanting or ligating the IMA. Sigmoidoscopy with biopsy was performed on day 4 or 5 after surgery; an autopsy was performed on patients not surviving to day 5 after surgery. All patients gave written informed consent.
Of the 160 randomized patients, 128 had a confirmed patent IMA and formed the basis of this study. Their age was 70 +/- 8 years (men, 70 +/- 8 years; women, 73 +/- 7 years). The IMA was replanted in 67 patients (52%) and ligated in 61 (48%) intraoperatively. IC developed in six patients with a replanted IMA and in 10 with a ligated IMA (relative risk [RR], 0.55; 95% confidence interval [CI], 0.21 to 1.41; chi2 = 1.62; P = .203). Blood loss in the two cohorts did not differ significantly (P = .788); however, patients with IC had a significantly higher blood loss compared with the cohort without IC (P = .012) and were older (P = .017). Age, sex distribution, clamping time, the use of tube or bifurcated grafts, and intraoperative hypotension did not differ between patients with ligated or replanted IMA.
Although replanting the IMA did not confer a statistically significant reduction of perioperative morbidity or mortality in this study, it appears that older patients and patients with increased intraoperative blood loss might benefit from IMA replantation, because this maneuver does not increase perioperative morbidity or substantially increase operation time.
关于重新植入肠系膜下动脉（IMA）以预防缺血性结肠炎（IC）的讨论已有多年；然而，据我们所知，尚未进行前瞻性研究来比较有和没有IMA血运重建的患者中经组织学证实的IC发生率。这项对乙状结肠黏膜进行组织学评估的前瞻性研究的目的是评估重新植入IMA对IC和死亡率的影响。
从1999年1月至2003年12月，对160例因有症状（n = 21）或无症状（n = 139）的肾下腹主动脉瘤而接受手术的连续患者进行前瞻性评估，并随机分配为重新植入或结扎IMA。术后第4天或第5天进行乙状结肠镜检查并活检；对术后未存活至第5天的患者进行尸检。所有患者均签署了书面知情同意书。
在160例随机分组的患者中，128例IMA通畅得到确认，并构成了本研究的基础。他们的年龄为70±8岁（男性，70±8岁；女性，73±7岁）。术中67例患者（52%）重新植入IMA，61例（48%）结扎IMA。重新植入IMA的6例患者和结扎IMA的10例患者发生了IC（相对风险[RR]，0.55；95%置信区间[CI]，0.21至1.41；χ2 = 1.62；P = 0.203）。两组的失血量无显著差异（P = 0.788）；然而，与无IC的队列相比，IC患者的失血量显著更高（P = 0.012），且年龄更大（P = 0.017）。结扎或重新植入IMA的患者在年龄、性别分布、夹闭时间、使用管状或分叉移植物以及术中低血压方面无差异。
尽管在本研究中重新植入IMA并未使围手术期发病率或死亡率在统计学上显著降低，但似乎老年患者和术中失血量增加的患者可能会从IMA重新植入中获益，因为这种操作不会增加围手术期发病率或大幅增加手术时间。
