Shock/Sepsis/Trauma/Critical CareComparisons of Three Surgical Procedures on Intestine Ischemia Reperfusion Injury in a Superior Mesenteric Artery Injury Model
Introduction
Superior mesenteric arteries (SMA) injury remains a devastating abdominal vascular injury; their rarity and difficulty of rapidly exposing and repairing this vessel under the severely compromised physiologic conditions prevent surgeons from developing significant experience with their management. Currently, there is a paucity of data in the literature describing their managements. Asensio et al. [1] reported an incidence of 1% for proximal mesenteric artery injuries. Most experiences were drawn from small series and individual case reports 2, 3, 4, 5, 6.
Temporary artery ligation 3, 4, 5, 6, primary anastomosis 2, 7, 8, 9, and temporary intravascular shunts (TIVS) [10] have been reported to deal with SMA injuries. Some authors suggested that the proximal injuries (Fullen's zones I and II) that were subjected to ligation might have preservation of blood flow through collaterals from the celiac axis, IMA, or both 2, 11. However, others argued that it was difficult to determine the presence or functionality of these collateral channels, and one should restore distal perfusion as soon as possible. Furthermore, intense vasoconstriction can result in the loss of viability of the midgut 1, 12. Nevertheless, more and more surgeons realize that repair of these vascular injuries may be laborious and time consuming under the austere and dangerous conditions, especially in the combat field with massive casualty and limited medical care. Because of the complex anatomy, high possibility of concomitant injuries, and exsanguinating hemorrhage, the victims often present with a dying situation and need a strategy of damage control surgery (DCS). TIVS is advocated to be used as a DCS adjunct in this setting 10, 13, 14, 15, 16, 17, 18. However, controversy still exists regarding the most effective surgical procedure to deal with the complex injury.
Mesenteric ischemia/reperfusion (I/R) has been invoked to play a pivotal role in post injury multiple organ failure, and correlates with the prognosis. Ischemia/reperfusion injury of the gut invariably leads to loss of intestinal barrier functions. In a previous study, we successfully developed a hypothermic traumatic shock swine model of SMA injury [19]. In the present study we aimed to determine which of the three surgical operations brought the minimal ischemia reperfusion injury in a hypothermic traumatic shock model.
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Animal Model
This study was approved by the Institutional Animal Care and Use Committee of Jinling Hospital and followed national guidelines for the treatment of animals. Twenty-eight domestic female pigs (weight 23.8 ± 4.6 kg) were used for the study, whose vascular systems were very close to human. After preparation, a transected SMA injury model was developed as described previously [19]. Briefly, through a midline laparotomy, the splenectomy was performed to reduce autotransfusion during hemorrhage. To
Survivals and Intestine Ischemia Time
All animals survived the hemorrhage, shock, and hypothermia period. However, four animals in group A died because of profound hypotension and hypothermia, and progressed to cardiovascular collapse at the end of experiment. Two animals in group B had a devitalized bowel after artery anastomosis and received intestinal resection and anastomosis, but eventually died. All shunts were patent throughout the resuscitation period. Overall mortality rate was 50%, 25%, and zero in groups A, B, and C,
Discussion
Injuries to the superior mesenteric artery are uncommon but are devastating entities that incur extremely high rates of mortality [2]. The reasons of the high mortality may include complex anatomy, high possibility of concomitant injuries, exsanguinating hemorrhage, and limited experience of trauma surgeons. Ligation, end-to-end anastomosis and temporary intravascular shunt have been reported in the literature. Controversy still exits on how to deal with such injuries. However, it is the
Conclusions
In this novel experiment, we compared three different surgical operations of the proximal transected SMA injury in a swine model on the degree of intestinal ischemia/reperfusion injury. Our study suggests that temporary shunt insertion decreases early mortality through the mechanisms of reducing intestinal ischemia time and alleviating ischemia/reperfusion injury in SMA injury model.
Acknowledgments
This work was supported by a grant from the Medicine and Pharmacy Research Project of China (grant number 06Z017). Dr. Weiwei Ding appreciates the financial support from the China Scholarship Council for pursuing his Ph.D. study at the University of Pennsylvania School of Medicine.
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The "pavia model" of experimental small bowel transplantation in pigs: Technical variations for ischemia reperfusion injury studies
2014, Transplantation ProceedingsCitation Excerpt :However, exteriorization of the proximal and/or the distal part of the graft can be easily realized with the same techniques described in the SBT models [2]. If this model is used in experimental IRI studies for SMA obstruction or injury, cold perfusion is not required [7]. For studies of intestinal IRI for transplantation, the graft can be perfused through a cannula inserted in the SMA between its origin from the aorta and the first jejunal artery.
Diagnosis and treatment of acute mesenteric ischemia: Clinical analysis for 40 cases of the patients
2015, Journal of the Medical Association of Thailand
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The abstract will be presented at the AAST/IATSIC session of the 43rd World Congress of Surgery of ISS/SIC in Adelaide, Australia on September 8, 2009.