Factors predetermining intestinal necrosis in patients with acute mesenteric ischemia

Intestinal necrosis is a life-threatening condition characterized by the death of tissue in the intestinal wall. It can occur as a complication of an oncological process, severe inflammation, infection, or intestinal obstruction. In adults, this pathology is rare, most often with colon cancer. It is often accompanied by septic shock and a poor prognosis.

Our expert in this field:

Sergeev Pyotr Sergeevich

Oncologist, surgeon, chemotherapist, Ph.D. Member of the international society of surgical oncologists EESG

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If intestinal necrosis is suspected, you need to act very quickly, otherwise the patient may die. Surgeons at the Medica24 International Clinic are ready to provide all the necessary assistance in full at any time of the day.

Briefly about the treatment method

Bowel resection is an operation to remove part of the small or large intestine. This is a fairly traumatic procedure, so it is not performed without very compelling reasons.

Types of bowel resection

Different types of resections are performed to remove different parts of the intestine. Each type of bowel resection is named based on what it removes: Segmental small bowel resection: A portion of the small bowel is removed. The surgeon may also remove part of the mesentery (the fold of tissue that supports the small intestine) and lymph nodes in the area. This type is used to remove tumors in the lower duodenum (upper part of the small intestine), jejunum (middle part of the small intestine), or ileum (lower part of the small intestine). Right hemicolectomy: removes part of the ileum, cecum (part of the large intestine), ascending colon (part of the large intestine), hepatic flexure (flexure of the colon), first part of the transverse colon (middle of the large intestine), appendix. Transverse colectomy: the transverse colon, hepatic and splenic flexures are removed. This surgery may be used to remove a tumor in the middle of the colon when the cancer has not spread to other parts of the colon. Left hemicolectomy: Part of the transverse and descending colon, the splenic flexure (the curve in the colon near the spleen), and part or all of the sigmoid colon are removed. Sigmoid colectomy: The sigmoid colon is removed. Low anterior resection: the sigmoid colon and part of the rectum are removed. Proctocomectomy with ileoanal anastomosis: the entire rectum and part of the sigmoid colon are removed. An ileoanal anastomosis is a procedure that a surgeon does to attach the lower portion of the small intestine to the anus. Abdominoperineal resection: The rectum, anus, anal sphincter and muscles around the anus are removed. The surgeon makes one cut or incision in the abdomen and another in the perineum (the area between the anus and vulva in women or between the anus and scrotum in men). This procedure requires a permanent colostomy (taking a section of the colon out) because the anal sphincter is removed. Partial and total colectomy: Surgery to remove part or all of the colon (including the cecum).

Classification of the disease

By etiology

• Ischemic. It occurs due to blockage of the lumen of a large blood vessel responsible for the blood supply to the intestines (vein or artery).
• Toxigenic. It develops when intestinal tissues are damaged by rotaviruses, coronaviruses, candida or clostridia.
• Trophoneurotic. Associated with circulatory disorders due to pathology of the central or peripheral nervous system.

According to clinical and morphological characteristics

• Dry (coagulation). Formed due to dehydration and coagulation of proteins in intestinal tissues.
• Wet (colliquation). Occurs when a bacterial infection joins the necrosis of cells.
• Strangulational. It develops as a result of intestinal obstruction, which occurs due to obstruction by internal contents or compression of the intestine by adjacent formations.
• Gangrene. The last stage of necrosis, characterized by the spread of purulent inflammation to adjacent organs and tissues.

By prevalence

• Local. Necrosis affects only part of the intestine.
• Total. Tissue death spreads throughout the intestines.

Indications and contraindications for the treatment method

Bowel resection is performed to treat the following diseases:

• Cancer in the small intestine, colon, rectum, or anus;
• Cancer that has spread to the intestines (treatment and symptom relief);
• Blockage in the intestines (intestinal obstruction);
• Precancerous polyps before they become cancer (called preventative surgery);
• Inflammatory bowel disease or diverticulitis;
• Ulcerative colitis (characterized by chronic inflammation of the colon and rectum, resulting in bloody diarrhea). Surgery may be indicated when drug therapy does not improve the condition.
• Mesenteric thrombosis or abdominal ischemia;
• Intestinal necrosis.

In addition, surgery is used for intestinal trauma, bleeding, and to close a hole in the intestine (intestinal perforation). The reasons for resection are always carefully assessed by the attending physician. There are a number of contraindications for the operation:

• critical condition of the patient, leading to the inappropriateness of resection,
• coma or unconsciousness of the patient,
• pathology of the heart, kidneys or respiratory system, which can lead to serious complications during or after surgery,
• inoperable tumor.

Diagnostics

Laboratory research

• General blood analysis. ESR increases and leukocytosis occurs in the presence of areas of necrosis.
• Blood chemistry. The level of total protein, C-reactive protein, increases.
• Coagulogram. When the blood supply to the intestinal walls is disrupted, the D-dimer level increases.

Instrumental studies

• X-ray of the intestines. The study is informative in the last stages of necrosis.
• Radioisotope scanning. The method allows you to identify affected areas of the intestine, determine their location and extent of damage.
• Angiography. The procedure allows you to detect blocked vessels using contrast MRI or CT. Contrast radiography of blood vessels is also used.
• Dopplerography. An ultrasound research method that is used to identify disorders of the blood supply to an organ in the early stages.
• Diagnostic laparoscopy. An invasive research method that involves performing an operation to visually assess the organ and take samples of affected tissue for further research.
• Colonoscopy. Endoscopic examination of the intestine, allowing you to assess the condition of the walls of the large intestine from the inside.

Preparing for treatment

Before surgery, diagnostic tests are usually performed to check your general health and ensure that the surgery can be performed. This may include blood sampling, chest x-ray, electrocardiogram (ECG), angiography, CT or ultrasound, or endoscopy. You should follow a diet that excludes legumes, baked goods, alcohol, fresh fruits and vegetables. A liquid diet is administered at least the day before surgery, with nothing taken on the day of surgery. Depending on the type of bowel resection, it may be necessary to cleanse the bowel. This usually involves taking a laxative 1-2 days before surgery. Cleansing enemas may also be given in the hospital. Immediately before the procedure, antibiotics are prescribed to help prevent infection. You should also tell your doctor about all the medications, supplements, and herbal products you take.

Prices

• Consultation with an oncologist— RUB 5,100.
• Consultation with a chemotherapist— RUB 6,900.
• Restoring the continuity of the colon after a previously imposed colostomy - 119,700 rubles.
• Photodynamic therapy for tumor stenosis of the colon (without the cost of a photosensitizer) - 178,300 rubles.
• Endoscopic resection of the colon mucosa - 69,000 rubles.

Make an appointment with an oncologist

In a separate material on the site, we discuss in detail the treatment of colon cancer.

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How the treatment method works

The surgeon may use open or laparoscopic techniques. With an open technique (laparotomy), the surgeon makes a large longitudinal incision to reach the intestine. In the laparoscopic technique, small holes are made in the abdomen, and then an endoscope (a thin, tubular instrument with a light and lens) and instruments are inserted to perform the operation. The laparoscopic technique tends to result in shorter hospital stays, faster recovery times, fewer complications, and less pain during incisions. However, not all patients can undergo laparoscopic bowel resection due to the location and stage of the disease or other factors. In addition, surgeons require specialized training, skills, and equipment to use laparoscopic techniques. The surgeon examines the cavity and removes the diseased or damaged part of the intestine within healthy tissue. However, some healthy tissue on either side of the affected part may also be removed.

Anastasmosis

When part of the intestine is removed, the surgeon connects the remaining ends of the intestine together using stitches or staples. This procedure is called anastomosis. When the entire large intestine is removed and the anastomosis is between the small intestine and the anus, it is called an ileoanal anastomosis. When it is between the sigmoid colon and the anus, it is called a coloanal anastomosis. For any of these procedures, the surgeon may create a pocket before attaching the intestine to the anus. The pocket creates a place for stool when the rectum is removed. It helps reduce the number of bowel movements a person has and manage incontinence (the inability to control bowel movements).

In some cases, the surgeon does not connect the ends of the intestine together. Instead, it attaches one or both ends of the intestines to an opening in the abdomen. This procedure is called a colostomy or ileostomy (depending on the part of the intestine used) and is an artificial anus. A colostomy can be temporary or permanent.

Stages of the disease

There are several stages of development of this disease. The first stage is characterized by a slight change in bone tissue, when the hip joint maintains functionality, and painful sensations are periodic. At the second stage, cracks begin to form on the surface of the joint, its mobility is impaired, and the person experiences constant pain. The third stage is called secondary arthrosis, when the acetabulum is involved in the process. There is a significant decrease in joint mobility. This stage is manifested by constant and severe pain. At the fourth stage, the bone begins to deteriorate, the muscles atrophy, and the pain is not eliminated by medications.

Possible complications during treatment

The side effects that may occur depend mainly on the type of bowel resection and your overall health. They include:

• obstruction (obstruction) of the intestine,
• paralyzed or inactive bowel
• damage to nearby organs such as the bladder, ureter or spleen, anastomotic leak associated with infectious problems,
• excessive bleeding wound infection,
• hernia,
• thrombophlebitis,
• inability to control urination.

The attending physician should be informed of any of the following problems after surgery: severe pain, swelling, redness, drainage or bleeding in the incision area, muscle pain, dizziness or fever, constipation, nausea or vomiting, rectal bleeding or black, tarry stools.

Types of colon cancer

About 96% of malignant colon tumors are adenocarcinomas. They arise as a result of malignant degeneration of glandular cells of the mucous membrane that produce mucus. When people say the phrase “colon cancer,” they usually mean adenocarcinoma of the colon. There are different subtypes of it. Some, such as mucinous adenocarcinoma and signet ring cell carcinoma, behave more aggressively and have a poorer prognosis.

Prognosis after treatment method

The period of time required for recovery varies depending on the initial condition, type of resection, the patient's general health prior to surgery, and the length of bowel removed. The prognosis of bowel resection depends on the severity of the disease. For example, in the case of patients with ulcerative colitis, the disease is cured and most people go on to live normal, active lives. Patients with cancer will have a less positive prognosis (due to possible relapses). Alternatives to bowel resection depend on the specific medical condition being treated.

Diagnostic measures

If necrosis is suspected, the patient may be sent for an X-ray examination. However, it should be taken into account that this method does not detect pathology at the initial stage of development. An X-ray can reveal pathology if it has progressed to the second or third stage. During the study of this disease, taking a blood test will also not bring an effective result. Thanks to modern devices that are used for magnetic resonance and computed tomography, it is possible to detect changes in tissue structure in a timely manner and with maximum accuracy.

Observation program after treatment method

After your bowel resection you will need to stay in the hospital for several days. The patient should be given warm, liquid food for 1-2 days after surgery. Solid foods and meals will be introduced gradually. If a colostomy or ileostomy has been performed, a specially trained health care professional will teach the patient how to care for themselves. Temporary ostomies usually remain in place for several months. After the rest of the colon has healed, another operation, an anastomosis, will be performed. The hole in the stomach will be closed. A nasogastric tube is inserted through the nose into the stomach during surgery and may be left in place for 24 to 48 hours after surgery. This eliminates stomach secretions and prevents nausea and vomiting. It will remain until bowel activity resumes. Postoperative patient care also includes monitoring of blood pressure, pulse, respiration and temperature. Fluid intake and output are measured, and the color and amount of drainage from the wound is observed at the incision site. The patient can get out of bed approximately 8-24 hours after surgery. Most patients will stay in the hospital for 5-7 days, although laparoscopic surgery can reduce this stay to 2-3 days. Postoperative weight loss accompanies almost all bowel resections. Weight and strength are slowly restored over several months. You will need to follow a diet prescribed by your doctor. Full recovery from surgery may take two months. Laparoscopic surgery can reduce this time to one to two weeks.

Symptoms

The clinical picture of intestinal necrosis is caused by pain, severe intoxication of the body due to tissue breakdown and dehydration.

Specific manifestations

• intense, constant abdominal pain;
• bloating and passing gas in the absence of stool or bloody bowel movements;
• vomiting (possibly mixed with blood or a specific smell of intestinal contents);
• increased intestinal motility.

As the pathological process progresses, pain and peristalsis gradually weaken. The disappearance of pain in the abdomen is considered an extremely unfavorable sign, requiring immediate surgical intervention.

General manifestations

• sudden, increasing weakness;
• nausea;
• decreased blood pressure;
• sudden increase in heart rate;
• dizziness, sometimes loss of consciousness;
• dry mouth and thirst;
• increase in body temperature.

Doctor's comment

The prescribed operation - resection of the sigmoid colon - raises many questions in you, which is understandable: the quality of life in the future depends on the experience of surgeons and the techniques used in treatment. In our clinic, we always strive to perform low-traumatic operations, after which there are no noticeable marks left, and recovery takes a minimum of time. Moreover, in 90% of patients we manage to do without an ileostomy, preserving the function of natural movement of intestinal contents. If, for a number of reasons, it is necessary to temporarily remove the end of the intestine to the abdominal wall, then after a couple of months we carry out reconstruction—restoring the passage of feces through the intestines. Of course, to choose the most effective treatment method, you need to undergo a high-quality examination. All necessary studies can be done in our clinic, equipped with the most modern expert-class equipment. To receive more complete information regarding your specific case, make an appointment at a time convenient for you, and together we will discuss all the possibilities for solving your problem.

Head of the surgical service at SwissClinic Konstantin Viktorovich Puchkov

Why is it better to perform sigmoid colon resection at the Swiss University Hospital?

• At the SwissClinic Center for Coloproctology, low-traumatic operations on the intestines have been carried out for more than 20 years; every month our surgeons perform about 120 surgical interventions, including high-tech and minimally invasive operations.
• More than 100 types of operations were developed by the doctors of our Center, some of them are performed only by us.
• In our coloproctology clinic, you can undergo all the necessary tests; if necessary, you can get advice from other specialists: gastroenterologist, endoscopist, gynecologist, urologist, etc.
• We have only modern equipment from leading companies, our staff includes experienced specialists of the highest category, many are known not only in the country, but also abroad, and the Center also welcomes foreign specialists.
• Our clinic is one of the few in the country where treatment is carried out in accordance with the best traditions of Western European clinics; we cooperate with famous university clinics in France, Germany, and Switzerland.