Original Article
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World J Gastroenterol. May 14, 2014; 20(18): 5483-5492
Published online May 14, 2014. doi: 10.3748/wjg.v20.i18.5483
Initial transcatheter thrombolysis for acute superior mesenteric venous thrombosis
Shuo-Fei Yang, Bao-Chen Liu, Wei-Wei Ding, Chang-Sheng He, Xing-Jiang Wu, Jie-Shou Li
Shuo-Fei Yang, Bao-Chen Liu, Wei-Wei Ding, Chang-Sheng He, Xing-Jiang Wu, Jie-Shou Li, Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing 210002, Jiangsu Province, China
Author contributions: Yang SF and Wu XJ designed the study and performed the data analysis and interpretation; Yang SF, Liu BC, Ding WW and He CS were the treating physicians; Yang SF and Liu BC performed the literature search; Yang SF wrote the manuscript; Wu XJ and Li JS revised the manuscript for critical intellectual content; all of the authors read and approved the final version of the manuscript.
Supported by Grants from the National Science Foundation of China, No. 81300278; the Natural Science Foundation of Jiangsu Province, No. BK20130697; and the Jiangsu Provincial Special Program of Medical Science, No. BL2012006
Correspondence to: Xing-Jiang Wu, MD, Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing 210002, Jiangsu Province, China. wuxingjiang@sohu.com
Telephone: +86-13-815429309 Fax: +86-25-84803956
Received: November 14, 2013
Revised: January 15, 2014
Accepted: February 20, 2014
Published online: May 14, 2014

AIM: To determine the optimal initial treatment modality for acute superior mesenteric vein thrombosis (ASMVT) in patients with circumscribed peritonitis.

METHODS: A retrospective review was made of the Vascular Surgery Department’s medical records to identify adult patients (≥ 18 years old) presenting with circumscribed peritonitis and diagnosed with ASMVT by imaging or endoscopic examination. Patients were selected from the time period between October 2009 and October 2012 to assess the overall performance of a new first-line treatment policy implemented in May 2011 for patients with circumscribed peritonitis, which recommends transcatheter thrombolysis with local anticoagulation and endovascular mechanical thrombectomy. Of the 25 patients selected for study inclusion, 12 had undergone emergency surgical exploration (group 1) and 13 had undergone the initial catheter-directed thrombolysis (group 2). Data extracted from each patient’s records for statistical analyses included method of diagnosis, symptoms, etiology and risk factors, thrombus location, initial management, morbidity, mortality, duration and total cost of hospitalization (in Renminbi, RMB), secondary operation, total length of bowel resection, duration of and findings in follow-up, and death/survival.

RESULTS: The two treatment groups showed similar rates of morbidity, 30-d mortality, and 1-year survival, as well as similar demographic characteristics, etiology or risk factors, computed tomography characteristics, symptoms, findings of blood testing at admission, complications, secondary operations, and follow-up outcomes. In contrast, the patients who received the initial non-operative treatment of transcatheter thrombolysis had significantly shorter durations of admission to symptom elimination (group 1: 18.25 ± 7.69 d vs group 2: 7.23 ± 2.42 d) and hospital stay (43.00 ± 13.77 d vs 20.46 ± 6.59 d), and early enteral or oral nutrition restoration (20.50 ± 5.13 d vs 8.92 ± 1.89 d), as well as significantly less total length of bowel resection (170.83 ± 61.27 cm vs 29.23 ± 50.24 cm) and lower total cost (200020.4 ± 91505.62 RMB vs 72785.6 ± 21828.16 RMB) (P < 0.05 for all). Statistical analyses suggested that initial transcatheter thrombolysis is correlated with quicker resolution of the thrombus, earlier improvement of symptoms, stimulation of collateral vessel development, reversal of intestinal ischemia, receipt of localizing bowel resection to prevent short bowel syndrome, shorter hospitalization, and lower overall cost of treatment.

CONCLUSION: For ASMVT patients with circumscribed peritonitis, early diagnosis is key to survival, and non-operative transcatheter thrombolysis is feasible and effective as an initial treatment.

Keywords: Acute superior mesenteric venous thrombosis, Transcatheter thrombolysis, Initial management, Circumscribed peritonitis

Core tip: There is no consensus on the recommendation of initial management of acute superior mesenteric venous thrombosis (ASMVT) with moderate, circumscribed peritonitis and suspected bowel infarction. Signs of peritonitis have traditionally been considered an indicator for prompt surgery, but patients undergoing extensive bowel resection during an acute inflammatory phase frequently manifest short bowel syndrome. A non-operative treatment modality was recently developed to overcome this clinical challenge. Intravascular thrombolysis therapy has since been widely applied and favorable clinical outcomes have been reported. This study systematically investigates the outcome of transcatheter thrombolysis as a first-line treatment for ASMVT patients with circumscribed peritonitis.