Outcome of aggressive surveillance colonoscopy in ruptured abdominal aortic aneurysm

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  • From the Eastern Vascular Society

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    bowel resection because of grade III ischemia; two procedures were performed because of worsening ischemia discoveredat repeat colonoscopy. In patients with colonoscopic findings of bowel ischemia the mortality rate was 50% (13 of 26patients). In those with grade III necrosis who underwent resection the mortality rate was 55%. Elevated lactate levels,

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    79immature white blood cells, and increased fluid sequestration were all variables associated with the occurrence of colonischemia.Conclusions: Bowel ischemia is a frequent postoperative complication (42%) of repaired rAAA. Performing mandatorysurveillance colonoscopy in these patients may be associated with a decrease in overall mortality and improved survival inpatients with transmural bowel necrosis with no comorbid condition. (J Vasc Surg 2004;39:792-6.)

    Surgical repair of a ruptured abdominal aortic aneu-m (rAAA) continues to be associated with high morbid-and mortality.1 Despite improvements in pre-hospitale, changes in operative strategies, and advancements instoperative care, the mortality of rAAA repair has notnged over several decades, with a rate of 50% to 70%.1,2

    tients who survive rAAA are susceptible to a variety ofrbid conditions, including colonic ischemia. Clinically andoscopically proved ischemia of the colon complicates elec-

    e reconstruction in 1% to 7% of cases, and 60% of patientsh rAAA.3 Prospective studies with selective colonoscopyve documented ischemic mucosal changes in 3% to 20%patients undergoing elective aortic procedures, and in asny as 60% of patients with rAAA. When transmuralcrosis is present the mortality rate can be as high as 90%.4

    Although postoperative clinical assessment with physi-cal examination and laboratory tests is unreliable in predict-ing ischemic colitis, several intraoperative methods havebeen promising. These include inferior mesenteric artery(IMA) stump pressure measurements, transserosal tissueoxygen tension measurements (tPO2), laparoscopy, andtonometry.2,4,5 Of these, selective ligation of the IMA onthe basis of intraoperative bowel inspection, colonic mes-enteric Doppler signals, and IMA stump pressure has beenthe most encouraging.6 However, use of these techniquesto predict colon ischemia are single intraoperative measure-ments and may not reflect subsequent ischemic events.

    Colonoscopy remains the diagnostic procedure ofchoice for assessing ischemic colitis. Although clinical pre-dictors of ischemic colitis after rAAA are lacking and mor-tality is high, mandatory routine colonoscopy after rAAAhas not been universally adopted.

    Most reports of ischemic colitis after rAAA are based onpatients with profound clinical symptoms. We instituted anaggressive approach with routine colonoscopy after rAAAin an attempt to identify the true incidence of postoperativebowel ischemia and to reduce overall mortality throughearly detection and treatment.

    m the Institute for Vascular Health and Disease, Albany Medical College.mpetition of interest: none.sented at the Seventeenth Annual Meeting of the Eastern Vascularociety, New York, NY, May 1-4, 2003.rint requests: R. Clement Darling III, MD, Vascular Institute (MC157),lbany Medical College, 47 New Scotland Ave, Albany, NY 12208

    e-mail: DarlinC@mail.amc.edu).1-5214/$30.00

    pyright 2004 by The Society for Vascular Surgery.:10.1016/j.jvs.2003.12.002

    2Outcome of aggressive suruptured abdominal aorticBradley J. Champagne, MD, R. Clement Darling III,MD, Edward C. Lee, MD, Manish Mehta, MD, MPHPhilip S. K. Paty, MD, Kathleen J. Ozsvath, MD, and

    Purpose: Emergent repair of ruptured abdominal aortic amorbidity and mortality. One of the significant complicationas high as 80% when this condition is realized. The objectiveeffect of mandatory postoperative colonoscopy on outcomeMethods: From July 1995 to September 2002 all patients wiwere included in this review. All colonoscopies were performtreatment was initiated per protocol based on grade of ischemwith medical management and repeat colonoscopy. All patPreoperative, intraoperative, and postoperative variables werpredictors of bowel ischemia.Results: Eighty-eight patients underwent emergent aortic recoage was 73 years, and 64 patients (72%) were men. Operative24 hours, and 24% died between 1 and 30 days after surgesurvived more than 24 hours. Bowel ischemia was documentgrade I or grade II ischemia at both initial and repeat endosceillance colonoscopy inneurysm, Mani Daneshmand, BS, Paul B. Kreienberg,an P. Roddy, MD, Benjamin B. Chang, MD,iraj M. Shah, MD, Albany, NY

    ysms (rAAAs) is associated with high perioperativethis surgery is bowel ischemia. Reports detail mortalityis project was to determine both the incidence and thelon ischemia after rAAA.rAAA who underwent emergent aortic reconstructionithin 48 hours, ischemia was graded consistently, andatients with grades I and II ischemia were followed upwith grade III ischemia underwent bowel resection.

    ected to assess possible independent risk factors for and

    uction because of rAAA in the study period. Their meanality was 42%. Eighteen percent of patients died withinolonoscopy was performed in 62 of 72 patients who26 of the 72 patients (36%). Of these, 16 patients hadNine patients underwent exploratory laparotomy with

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    JOURNAL OF VASCULAR SURGERYVolume 39, Number 4 Champagne et al 793ETHODS

    Using data from our vascular surgery registry, we ret-pectively reviewed the charts of all patients with rAAAo underwent repair between July 1995 and September02. Data were evaluated for demographics and postop-tive factors, including symptoms, laboratory values, he-dynamics, aortic crossclamp time, perioperative hypo-sion, blood transfusions, and fluid sequestration.

    rioperative hypotension was defined as mean arterialod pressure less than 65 mm Hg for at least 10 minutes.ta were analyzed with an unpaired Student t test, and.05 indicated statistical significance.Patients with rAAA underwent emergent repair via a

    t retroperitoneal approach, as described by Shah et al.7

    sessment of ischemic colitis included visual inspectiond Doppler scan evaluation of mesenteric blood flow. Allients with rAAA were offered colonoscopy within 48urs of completion of the repair, regardless of clinical andoratory findings. In all cases in which colonoscopy wast performed the reason was patient or family refusal.The bowel was prepared with a sodium phosphate

    ema (Clisma Fleet, 133 mL) to avoid fecal soiling. Tapter enemas were used in patients with evidence of renalsfunction (creatinine concentration 2). Colonoscopys performed to at least 40 cm in all patients, except whenep ulcers or suspected necrosis was identified, to avoidrforation. The rectosigmoid junction was always exam-d.Furthermore, all instances of colon ischemia were

    ded consistently on the basis of published criteria. Gradechemia was defined as mucosal ischemia; grade II isch-ia was characterized by involvement of the mucosa andmuscularis layers; and grade III ischemia was described

    transmural ischemia, gangrene, and perforations.Severe ischemia (grade III) was treated with immediateloratory laparotomy and resection of the ischemic bowelue. Mild and moderate ischemia (grades I and II) wasnaged nonoperatively, and repeat colonoscopy was per-med every 48 hours until improvement, to ascertain theponse to management. Nonoperative management con-ed of a conservative regimen of bowel rest, intravenous

    dration, parenteral nutrition, and broad-spectrum anti-tic therapy. Low-grade ischemia that progressed at re-

    at colonoscopy was treated with exploratory laparotomyd resection of the ischemic bowel tissue.

    SULTS

    From July 1995 to September 2002, 88 patients (64n, 24 women) underwent rAAA repair. Their averagewas 73.4 years. Postoperative mortality was 18% (16 ofpatients) within 24 hours and 24% (21 of 88 patients)hin 30 days. Seventy-two patients survived longer thanhours and were offered colonoscopy. Sixty-two patients%) underwent colonoscopy, 9 patients (13%) declinedprocedure, and 1 patient required laparotomy and artmann procedure while awaiting colonoscopy. riskSixty-one percent (38 of 62 patients) had no evidencecolonic ischemia. Twenty-nine percent (18 of 62 pa-nts) had evidence of grade I or grade II ischemia, and% (6 of 62 patients) had evidence of grade III ischemia attial colonoscopy. Of 38 patients with normal findings atlonoscopy, cholecystitis developed in 1, and in this pa-nt transmural colonic necrosis was discovered at laparot-y. Of 18 patients with grade I or II ischemia, 2 patients%) had progression to grade III ischemia at repeat

    lonoscopy performed within 48 hours. Overall, transmu-ischemia (grade III) developed in 10 patients (14%).

    ne required laparotomy and a Hartmann procedure, ande family declined further intervention and withdrewport (Table I).Of 37 patients without evidence of ischemic colitis, 10

    ients (27%) died secondary to adult respiratory distressdrome (n 3), multisystem organ failure with with-wal of support (n 3), cardiac arrest (n 2), cerebralcular accident (n 1), or massive gastrointestinal hem-hage (n 1). Of 16 patients with grade I or II ischemia,atients (31%) died, of cardiac arrest (n 2), multipletem organ failure