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Ischämische Colitis nach rekonstruktiven Eingriffen im aorto-iliacalen Gefäßabschnitt

Ischemic colitis after aortoiliac vascular reconstructions

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Summary

Ischemic colitis after aortoiliac vascular reconstructions represents a seldom but life-threatening postoperative complication (incidence: 1.6%, mortality rate: 50–70%). The authors present a retrospective evaluation of 10 cases observed in a consecutive series of 1121 reconstructive aorto-iliac procedures. The incidence of ischemic bowel complications was 1.3% in the group of abdominal aortic aneurysms but only 0.6% in the group of arterial occlusive disease. The pathogenesis including new approaches of prophylaxis, diagnostic and therapeutical measures are discussed. The risk of ischemic damage to the bowel may be best assessed from the preoperative aortogram (special vascular patterns), the intraoperative stump-pressure measurement in the inferior-mesenteric artery and the pre- and postoperative PB-Index. In contrast to earlier reports the leading clinical symptom is an unexplained prolonged gastrointestinal paralysis during the first postoperative week. Early diagnosis is most important and best realized by the routine use of colonoscopy in all risk cases in the first 48 h. Such an aggressive diagnostic approach offers the possibility of early relaparotomy in a pretoxic stage and a better outcome for the patient than heretofore with a median delay of 11 days between vascular reconstruction and relaparotomy.

Zusammenfassung

Eine ischämische Darmwandschädigung im Gefolge aortoiliacaler Gefäßrekonstruktionen stellt zwar eine seltene, aber unmittelbar lebensbedrohliche postoperative Komplikation dar (Häufigkeit: 1–6%; Letalität: 50–70%). An Hand einer retrospektiven Analyse von 10 eigenen Beobachtungen im Gefolge von 1121 rekonstruktiven Eingriffen geben die Verff. eine Übersicht über die formale Genese, die Prophylaxe, Diagnostik und Therapie dieser Komplikation. Die Häufigkeit in der Aneurysmagruppe lag mit 1,3% doppelt so hoch wie in der AVK-Gruppe mit 0,6%. Das Ischämierisiko läßt sich in erster Linie an Hand des präoperativen Arteriogramms, einer routinemäßigen Stumpfdruckbestimmung in dér A. mesenterica inferior, ferner durch die Ermittlung des prä- und postoperativen PB-Indexes abschätzen. Klinisches Leitsymptom stellt eine protrahierte postoperative Magen-Darmatonie dar. Die Frühdiagnose ist von ausschlaggebender Bedeutung (routinemäßige Colonoskopie bei allen Risikofällen innerhalb der ersten 48 h). Relaparotomie mit Colonresektion können dann in einem prätoxischen Frühstadium mit größerer Erfolgschance durchgeführt werden.

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Literatur

  1. Baer U, Häring R, Bauknecht KJ, Tung LC (1983) Kolonnekrose als Komplikation nach Aortenaneurysmaexstirpation. Angio 5:21–24

    Google Scholar 

  2. Bernatz PE (1960) Necrosis of the colon following resection for abdominal aortic aneurysms. Arch Surg 81:373

    Google Scholar 

  3. Bernstein WC, Bernstein EF (1963) Ischemic ulcerative colitis following inferior mesenteric arterial ligation. Dis Colon Rectum 6:54

    Google Scholar 

  4. Bertelsen S, Egeblad K (1968) Necrosis of the colon and the rectum complicating abdominal aortic resection. Acta Chir Scand 134:151

    Google Scholar 

  5. Bicks RO, Bale GF, Howard H et al (1968) Acute and delayed colon ischemia after aorta aneurysm surgery. Arch Intern Med 122:249

    Google Scholar 

  6. Birnbaum W, Rudy L, Wylie EJ (1964) Colonic and rectal ischemia following abdominal aneurysmectomy. Dis Colon Rectum 7:293

    Google Scholar 

  7. Bulkley GB, Zuidema GD, Hamilton SR, O'Mara CS, Klacsmann PG, Horn SD (1981) Intraoperative determination of small intestinal viability following ischemic injury. Ann Surg 193:628–637

    Google Scholar 

  8. Carrel A (1982) Technique and results of vascular anastomoses. Surg Gynecol Obstet 14:246

    Google Scholar 

  9. Carter R, Vannix R, Hinshaw DB et al (1959) Inferior mesenteric vascular occlusion. Sigmoidoscopic diagnosis. Surgery 46:845

    Google Scholar 

  10. Conn J (1979) Colon ischemia following abdominal aortic surgery. In: Bergan JJ, Yao JST (eds) Surgery of the aorta and its body branches. Grune & Stratton, New York London Toronto, pp 231–240

    Google Scholar 

  11. Connolly JE, Kwaan JHM (1979) Prophylactic revascularization of the gut. Ann Surg 190:514

    Google Scholar 

  12. Delaney JP, Custer J (1965) Gastrointestinal blood flow in the dog. Circ Res 7:394

    Google Scholar 

  13. DePalma RG (1980) Impotence as a complication of aortic reconstruction. In: Bernhard VM, Towne JB (eds) Complications in vascular surgery. Grune & Stratton, New York London Toronto, pp 427–442

    Google Scholar 

  14. Diemel H, Rau G, Schmitz-Dräger HG (1964) Die Riolan'sche Kollaterale. Ihre diagnostische Bedeutung für die Angiographie bei Verschlußkrankheiten der Mesenterialarterien. RöFo 101:253

    Google Scholar 

  15. Ernst CB, Haghara PF, Daugherty ME et al (1976) Ischemic colitis incidence following abdominal aortic reconstruction: A prospective study. Surgery 80:417

    Google Scholar 

  16. Ernst CB, Haghara PF, Daugherty ME et al (1978) Inferior mesenteric artery stump pressure: A reliable index for safe IMA ligation during abdominal aortic aneurysmectomy. Ann Surg 187:641

    Google Scholar 

  17. Ernst CB (1980) Colon ischemia following abdominal aortic reconstruction. In: Bernhard VM, Towne JB (eds) Complications in vascular surgery. Grune & Stratton, New York London Toronto, pp 379–426

    Google Scholar 

  18. Folkow B, Neil E (1971) Gastrointestinal and liver circulations. In: Circulation. Oxford University Press, New York

    Google Scholar 

  19. Geber WF (1960) Quantitative measurement of blood flow in various areas of small and large intestine. Am J Physiol 198:985

    Google Scholar 

  20. Gibson WE III, Pearce CW, Creech O Jr (1960) Infarction of the left hemicolon due to primary vascular occlusion. Dis Colon Rectum 12:323

    Google Scholar 

  21. Goodhead B (1969) Distribution of blood flow in various selected areas of small and large intestine in the dog. Am J Physiol 217:835

    Google Scholar 

  22. Griffiths JD (1956) Surgical anatomy of the blood supply of the distal colon. Ann R Coll Surg Engl 19:241

    Google Scholar 

  23. Haghara PF, Ernst CB, Griffen WO Jr (1979) Incidence of ischemic colitis following abdominal aortic reconstruction. Surg Gynecol Obstet 149:571

    Google Scholar 

  24. Hagmüller GW, Janda Ä, Denck H (1983) Diagnose akuter intestinaler Gefäßverschlüsse mittels Serumlactat. Langenbecks Arch Chir (Kongreßber) 361:717

    Google Scholar 

  25. Hardy JD (1966) Preservation of accessory arterial supply in abdominal aneurysm resection. Surg Gynecol Obstet 123:1318

    Google Scholar 

  26. Hardy JD, Timmis HH (1971) Abdominal aortic aneurysms. Special problems. Ann Surg 173:945

    Google Scholar 

  27. Haug M, Müller-Wiefel H (1981) Die transmurale Colongangrän als Komplikation rekonstruktiver Eingriffe im aorto-iliakalen Bereich. Aktuel Chir 16:121–127

    Google Scholar 

  28. Hobson RWH, Wright CB, Rich MN et al (1979) Assessment of colonic ischemia during aortic surgery by Doppler ultrasound. Arch Surg 114:165

    Google Scholar 

  29. Hobson RWH, Wright CB, O'Donnell JA et al (1979) Determination of intestinal viability by Doppler ultrasound Arch Surg 114:165

    Google Scholar 

  30. Huber FB (1981) Ischämische Entero-Kolopathien. Huber, Bern

    Google Scholar 

  31. Javid H, Julian OC, Dye WS et al (1962) Complications of abdominal aortic grafts. Arch Surg 85:142

    Google Scholar 

  32. Johnson WC, Nabseth DC (1974) Visceral infarction following aortic surgery. Ann Surg 180:312

    Google Scholar 

  33. Langer W (1984) Sexualfunktionen vor und nach aorto-femoralen Gefäßrekonstruktionen. Eine prospektive klinische Erhebung zur Beurteilung vaskulogener Impotenz. Inauguraldissertation —Klinisch-Medizinische Fakultät Universität Ulm 1984

  34. Launer DP, Miscall BG, Beil AR, Jr (1978) Colorectal infarction following resection of abdominal aortic aneurysms. Dis Colon Rectum 21:613

    Google Scholar 

  35. Marston A, Pheils MT, Thomas ML, Marson BC (1966) Ischemic colitis. J Br Soc Gastroenterol 7:1

    Google Scholar 

  36. McBurney RP, Howard H, Bicks RO et al (1970) Ischemia and gangrene of the colon following abdominal aortic resection. Ann Surg 36:205

    Google Scholar 

  37. Miller RE, Knox WG (1966) Colon ischemia following infrarenal aorta surgery: Report of four cases. Ann Surg 163:639

    Google Scholar 

  38. Morris GC, Jr (1978) Discussion of Ernst CB, Haghara PF, Daugherty ME et al: Inferior mesenteric artery stump pressure. A reliable index for safe IMA ligation during abdominal aortic aneurysmectomy. Ann Surg 187:641

    Google Scholar 

  39. Moskowitz M, Zimmermann H, Felson B (1964) The meandering mesenteric artery of the colon. Am J Roentgenol 92:1088

    Google Scholar 

  40. Muggia FW (1967) Hemorrhagic necrosis of the intestine: Its occurence with digitalis intoxication. Am J Med Sci 253:263

    Google Scholar 

  41. Nelson RL, Schuler JJ (1982) Ischemic proctitis. Surg Gynecol Obstet 154:27–33

    Google Scholar 

  42. Ochsner JL, Cooley DA, DeBakey ME (1960) Associated intraabdominal lesions encountered during resection of aortic aneurysms. Dis Colon Rectum 3:485

    Google Scholar 

  43. O'Connell TX, Kadell B, Tompkins RK (1976) Ischemia of the colon. Surg Gynecol Obstet 142:337–342

    Google Scholar 

  44. Ottinger IW, Darling RC, Nathan MJ et al (1972) Left colon ischemia complicating aorto-iliac reconstruction. Arch Surg 105:481

    Google Scholar 

  45. Papachristou D, Fortner JG (1976) Prediction of intestinal viability by intra-arterial dye injection: A simple test. Am J Surg 132:572

    Google Scholar 

  46. Papadopoulos CD, Maneini HW, Marino AWM Jr (1974) Ischemic necrosis of the colon following aortic aneurysmectomy. J Cardiovasc Surg 15:494

    Google Scholar 

  47. Perdue GD, Lowry K (1962) Arterial insufficiency to the colon following resection of abdominal aortic aneurysms. Surg Gynecol Obstet 115:39

    Google Scholar 

  48. Queseda C, Dupré A, Carpentier E, Guidicelli H, Meauville PY, Gauthier R (1980) Le risque colique en chirurgie aorto-iliac. Chirurgie 106:362

    Google Scholar 

  49. Rausis C, Robinson JWI, Mirkovitch V, Saegesser F (1972) Perspectives exspéctives expérimentales et cliniques dans l'insuffisance vasculaire du gros intestin. J Chir (Paris) 6:569–576

    Google Scholar 

  50. Rob C, Snyder M (1966) Chronic intestinal ischemia: A complication of surgery of the abdominal aorta. Surgery 60:1141

    Google Scholar 

  51. Robicsek F (1972) Discussion of Ottinger IW, Darling RC, Nathan MJ et al (1972) Left colon ischemia complication aorto-iliac reconstruction. Arch Surg 105:841

    Google Scholar 

  52. Rötzscher VM, Kremer K, Zehle A, Imig H, Sandmann W (1976) Ischämische Nekrosen des Colons und Rectums nach alloplastischem Gefäßersatz. Chirurg 47:192–197

    Google Scholar 

  53. Ruckert RF, Buchmann P (1982) Ischämische Colon- und Rectumnekrosen nach Resektion der Aorta abdominalis. Chirurg 53:556–562

    Google Scholar 

  54. Sachs SM, Morton JH, Schwartz SI (1982) Acute mesenteric ischemia. Surgery 92:646–653

    Google Scholar 

  55. Saegesser F, Roenspies U, Garcia-Gil A, Boumghar M (1978) Recto-sigmoidites nécrosantes d'origine ischémique. Rev Méd Suisse rom 98:387–401

    Google Scholar 

  56. Sandmann W, Kremer K, Rötzscher VM, Knieriem HJ (1975) Ungewöhnliche Komplikationen nach Ersatz der terminalen Aorta abdominalis. Aktuel Chir 10:361

    Google Scholar 

  57. Schwering H, Lingemann B, Müller KM, Rühland D, Wittrin G (1980) Klinik und Morphologie der ischämischen Proktitis. Leber Magen Darm 10:46

    Google Scholar 

  58. Siddharth P, Smith NL (1981) An anatomic basis to prevent ischemia of the colon during operations upon the aorta. Surg Gynecol Obstet 153:71–73

    Google Scholar 

  59. Smith RF, Szilagyi DE (1960) Ischemia of the colon as a complication in the surgery of the abdominal aorta. Arch Surg 80:806

    Google Scholar 

  60. Steiner SH, Müller GCE (1961) Distribution of blood flow in the digestive tract of the rat. Circ Res 9:99

    Google Scholar 

  61. Steward JA, Rankin FW (1933) Blood supply of large intestine: Its surgical considerations. Arch Surg 26:843

    Google Scholar 

  62. Stolar CJH, Randolph JG (1978) Evaluation of ischemic bowel viability with a fluorescent technique. J Pediatr Surg 13:221

    Google Scholar 

  63. Sudek P (1907) Über die Gefäßversorgung des Mastdarms in Hinsicht auf die operative Gangrän. Münch Med Wochenschr 54:1314

    Google Scholar 

  64. Vollmar J (1982) Rekonstruktive Chirurgie der Arterien. Thieme, Stuttgart New York, 3. Aufl.

    Google Scholar 

  65. Williams IF, Wittenberg J (1975) Ischemic colitis. A useful clinical diagnosis. But is it ischemic? Ann Surg 182:439

    Google Scholar 

  66. Wittenberg J, Athanasoulis CA et al (1975) Ischemic colitis. Radiology and pathophysiology. Radiology 2:287–300

    Google Scholar 

  67. Wright CB, Hobson RW (1975) Prediction of intestinal viability using Doppler ultrasound technique. Am J Surg 129:642–645

    Google Scholar 

  68. Young JR, Humphries AW, De Wolle VG et al (1963) Complications of aortic surgery. Part H: Intestinal ischemia. Arch Surg 86:85

    Google Scholar 

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  1. Abteilung für Thorax- und Gefäßchirurgie, Zentrum für Chirurgie der Universität Ulm, Steinhövelstraße 9, D-7900, Ulm

    J. F. Vollmar & W. Fleischmann

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  1. J. F. Vollmar
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Vollmar, J.F., Fleischmann, W. Ischämische Colitis nach rekonstruktiven Eingriffen im aorto-iliacalen Gefäßabschnitt. Langenbecks Arch Chiv 363, 165–178 (1985). https://doi.org/10.1007/BF01261290

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