Emergent Surgical Resection for Acute Mesenteric Ischemia - An ACS-NSQIP Analysis from 2005 to 2013

John M Shellenberger MD, James W Clevenger, Linda Hanley RN, Jacob A Quick MD, Stephen L Barnes MD, Salman Ahmad MD

Salman Ahmad MD, FACS, Emergent Surgical Resection for Acute Mesenteric Ischemia - An ACS-NSQIP Analysis from 2005 to 2013(2017)SDRP Journal Of Anesthesia & Surgery 2(1)

Introduction
Acute mesenteric ischemia is a surgical emergency with a historical thirty-day mortality of 30%. We analyzed the largest set of ACS-NSQIP data in the literature to identify perioperative variables that affect mortality for acute mesenteric ischemia.

Methods
We utilized the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to study demographic and perioperative variables that may be associated with morbidity and mortality after emergent surgical management of acute mesenteric ischemia. ACS-NSQIP participant user files (PUF) from 2005 to 2013 were queried for emergent cases of enterectomies, colectomies or both procedures at the initial operation with a postoperative diagnosis of vascular insufficiency of the intestine. Univariate correlations with mortality were analyzed. A multivariate logistic regression model was also developed using significant univariate correlations and controlling for age, gender and race.

Results
5237 cases met the inclusion criteria and constituted the analysis group. Overall mortality rate was 28.7%. There were 1978 cases of isolated enterectomies, 2949 cases of isolated colectomies and 310 cases of combined resections. Mortality rates were 24.2%, 29.4% and 50.6% respectively. Pre-operative variables most significantly associated with mortality were ventilator dependence (OR 4.76, 95% CI 4.14-5.46), sepsis (OR 3.37, 95% CI 2.85-3.99), renal failure (OR 2.59, 95% CI 2.16-3.11), blood transfusion (OR 2.39, 95% CI 1.94 – 2.95) and time to OR from hospital admission greater than one day (OR 1.91, 95% CI 1.68-2.17). Post-operative outcomes most significantly associated with death were comatose state (OR 14.73, 95% CI 6.94-31.29), cardiac arrest (OR 13.2, 95% CI 9.63-18.10), renal failure (OR 3.9, 95% CI 3.13-4.86), septic shock (OR 3.24, 95% CI 2.80-3.75), combined small and large intestinal resection (OR 2.74, 95% CI 2.17-3.45) and blood transfusion (OR 2.07, 95% CI 1.71-2.5). In a multivariate logistic regression model the most likely contributors to death were postoperative comatose state (OR 11.14, 95% CI 4.11-30.16), preoperative ventilator dependence (OR 3.39, 95% CI 2.82-4.09) and postoperative septic shock (OR 3.17, 95% CI 2.63-3.82). A combined small and large intestinal resection also doubled mortality in this model (OR 2.06, 95% CI 1.54-2.76). Age over 60 years (OR 1.65, 95% CI 1.38-1.97) and white race (OR 1.26, 95% CI 1.01-1.57) were also significant for mortality.

Conclusion
Our analysis suggests an increased risk of death with a combined small intestinal and colonic resection for acute mesenteric ischemia. Comorbidities, postoperative complications and timing of surgical intervention all contribute significantly to the persistent high mortality rate in the emergent surgical management of acute mesenteric ischemia. Our results emphasize the continued need for early operation, aggressive resuscitation, limiting blood loss and need to transfusion and controlling perioperative infectious events. Earlier diagnostic methodologies need to be employed to intervene sooner and limit its morbidity and mortality.

Key Words: ACS-NSQIP, mesenteric ischemia, acute mesenteric ischemia, intestinal mesenteric ischemia, colonic mesenteric ischemia, ischemic colitis.?