Outcome after surgery for acute right-sided colonic ischemia without feasible vascular intervention: a single center experience of 58 patients over 6 years

Non-occlusive mesenterial ischemia (NOMI) is a rare but life-threatening condition caused by severe hypotension in the critically ill. It often occurs after myocardial infarction, after cardio-vascular surgery and due to hypovolemia after hemodialysis [1-3]. Furthermore NOMI is a rare adverse event of medication with beta-blockers or digitalis [4,5]. The incidence of NOMI increases with age [2]. NOMI is about five times less common than acute bowel infarction caused by vascular occlusion of the superior or inferior mesenteric artery with its distinct morphological patterns [6-8].

The predilection site of NOMI is the right-sided colon [1]. However, as arteriosclerotic mesenteric disease is found very often in patients at risk for NOMI and the results of imaging and the intraoperative findings regarding occlusion of branches of the superior mesenteric artery are often equivocal, it is difficult to distinguish NOMI from bowel infarction caused by vascular occlusion.

Other entities with bowel infarction to be ruled out are ischemic colitis (rarely requiring surgical therapy, without predilection site) [9], venous mesenteric infarction [10], infarction due to strangulation ileus [11] or bowel ischemia due to local compression [12]. However, these entities are diagnosed by histological examination of the resected specimen.

Early diagnosis of NOMI remains a challenge as symptoms are often non-specific [13]. If acute mesenteric ischemia is suspected, the diagnostic method of choice is multi-detector row computed tomography with intravascular contrast enhancement with the possibility to detect alterations of the colonic wall [7]. Diagnostic laparoscopy could be a valuable option, although the estimation of bowel viability by means of laparoscopy is limited [14]. Some authors recommend conventional intra-arterial angiography with its possibility of intervention [15]. If NOMI is diagnosed early, a conservative treatment with prostaglandin infusion is an option [15,16]. However, bowel resection is often required as bowel infarction is already present in most cases at the time NOMI is diagnosed [13]. Primary anastomosis is only recommended if systemic conditions have improved [16] and most cases need an ileostomy without primary anastomosis. As an option, some authors recommend primary anastomosis with planned second look in patients with acute right-sided colonic ischemia in absence of peritonitis [14]. In small case series this planned second look has been successfully done laparoscopically [17], but as mentioned above surgeons have to consider that the estimation of bowel viability by means of laparoscopy is limited [14]. Another possibility could be damage control surgery with abdominal vacuum and delayed bowel reconstruction as proposed for perforated diverticulitis Hinchey III/IV [18].

However, due to low incidence of NOMI the knowledge about this disease is only based on small case series [19]. Furthermore little is known about the optimal surgical treatment and outcome of patients with this rare but life-threatening disease.

As it was not possible to unequivocally distinguish NOMI from mesenterial infarction caused by occlusion of branches of the superior mesenteric artery, we assessed the short and long-term outcome and especially the rate of ostomy reversal in patients with acute right-sided colonic ischemia without feasible vascular intervention as a surrogate for NOMI.