Title : Ischemic bowel: Impact of revascularization on outcomes
Abstract:
Acute bowel ischaemia (ABI) is a life-threatening abdominal emergency characterized by sudden interruption of intestinal blood flow, leading to bowel infarction if not rapidly treated. Timely diagnosis and definitive management, particularly revascularization of the affected vasculature, are essential to improving outcomes. European guidelines suggest that damage control surgery be reserved for patients with peritonitis, non-responsive to resuscitation or where bowel viability is indeterminate. In practice, damage control surgery is often first line due to a lack of access to vascular services or difficulty in early diagnosis of ABI. We aimed to study the outcomes of patients who received damage control surgery alone to those who also have revascularisation.
Methods: We performed a retrospective review of patients presenting ABI between 2020 and 2025 to a tertiary level hospital and studied the patient characteristics, intervention, outcomes in those receiving only damage control surgery with those also having revascularisation procedure. The end points included mortality rates, post operative complication rates, number of relook procedures, length bowel resected and representation.
Results: A total of 37 out of 76 patients treated during the study period met the inclusion criteria. Patients who received an exploratory laparotomy (EL) only (n=17) and those who received both laparotomy and revascularisation (EL+ RE) procedure cohort (n=20) were of similar size but differed in certain sociodemographic characteristics. The average ages of the EL and EL+RE groups were 66.85 and 67.2 years, respectively. Gender distribution varied between cohorts. In the EL+RE group, males comprised the majority (60%, n=12), whereas in the EL only group, females were more prevalent (52.9%, n=9). Among those the EL+RE group, 45% (n=9) were local patients, while 55% (n=11) were transferred from regional hospitals up to 6 hours away. In contrast, the majority of patients in the EL only group were local (76.4%, n=13). The ASA and POSSUM scores were comparable between the groups. In terms of underlying pathology, 65% (n=13) of patients in the EL+RE group had a thromboembolic event as the primary etiology whereas in the EL group, non-occlusive mesenteric ischemia (n=6, 35.3%) and acute on chronic mesenteric ischemia (n=6, 35.3%) were the predominant pathologies. The average time to surgical review in the EL only group was 20.92 hours (1-504 hours) compared to 24.55hours (1-48hours) in the EL+RA group. The average time till intervention was in the EL only group was 39.43 (1-120 hours) whereas in the EL+RA group it was 44.96 hours till revascularisation (1-432 hours). Mean bowel resection lengths were slightly shorter in the EL+RE group (52.08 cm) compared to the EL group (56.58 cm). The mean number of re-look operations was similar between the two groups, at 0.5 and 0.48 (SD: 0.95), respectively. Mortality rates were also comparable: 50% (n=10) in the EL+RE group and 47% (n=8) in the EL only group. However, the EL+RE group experienced significantly higher rates of 30-day complications (80%, n=16) and hospital re-presentations (40%, n=8) compared to the EL only group.
Conclusion: ABI is associated with a high mortality rate irrespective of whether a revascularisation was performed or not. Revascularisation may save the amount of bowel resected in non necrotic bowel, however these patients had higher rates of representation and post op complications. Further studies are required to analyse other factors that impact on outcomes such as the time to intervention/revascularisation and time to presentation.
