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JoVE Journal Medicine

Medicine

Multimodality Diagnosis of Mesenteric Ischemia

Published: July 21, 2023 doi: 10.3791/65095
Automatic Translation
1
1Liaison Healthcare Engineering Section, Kochi Medical School

Summary

This article presents a multimodal approach that aims to overcome the limitations of traditional methods in detecting mesenteric ischemia and preventing bowel necrosis. The presented technique offers a promising solution by combining state-of-the-art ultrasonography with cutting-edge near-infrared light technologies.

Abstract

Early diagnosis of mesenteric ischemia remains challenging because mesenteric ischemia presents with no key symptoms or physical findings, and no laboratory data specifically indicates intestinal tissue ischemic status before necrosis develops. While computed tomography is the standard for diagnostic imaging, there are several limitations: (1) repeated assessments are associated with increased radiation exposure and risk of renal damage; (2) the computed tomography findings can be misleading because necrosis occasionally occurs despite opacified mesenteric arteries; and (3) computed tomography is not necessarily available within the golden time of salvaging the intestines for those patients in the operating room or at a place far from the hospital. This article describes a challenge to overcome such limitations using ultrasonography and near-infrared light, including clinical studies. The former is capable of providing not only morphologic and kinetic information of the intestines but also perfusion of the mesenteric vessels in real-time without transferring the patient or exposing them to radiation. Transesophageal echocardiography enables precise assessment of mesenteric perfusion in the OR, ER, or ICU. Representative findings of mesenteric ischemia in seven aortic dissection cases are presented. Near-infrared imaging with indocyanine green helps visualize the perfusion of vessels and intestinal tissues although this application requires laparotomy. Findings in two cases (aortic aneurysm) are shown. Near-infrared spectroscopy demonstrates oxygen debt in the intestinal tissue as digital data and can be a candidate for early detection of mesenteric ischemia without laparotomy. The accuracy of these assessments has been confirmed by intraoperative inspections and postoperative course (prognosis).

Introduction

Acute mesenteric ischemia can be life-threatening unless diagnosed and treated without delay1,2; however, early diagnosis followed by restoration of perfusion before progressing to bowel necrosis, preferably within 4 h, remains challenging for several reasons: (1) mesenteric ischemia is caused via multiple mechanisms and associated with several diseases managed by different specialties; (2) there are no symptoms, signs, or laboratory data specific for mesenteric ischemia; and (3) computed tomography (CT), the gold standard for diagnostic imaging, is misleading because ischemia can be present despite an opacified superior mesenteric artery (SMA)2,3,4,5.

Causes of mesenteric ischemia include embolism, thrombosis, dissection, or non-occlusive mesenteric ischemia (NOMI)3,6. Embolism is caused by a cardiogenic thrombus in patients with atrial fibrillation, dilated left ventricle, or atheroma in the aorta, which is asymptomatic until embolization. Occasionally, a thrombus is generated in the SMA or superior mesenteric vein. It has recently been shown that COVID-19 can lead to thrombus formation7. In aortic dissection, the intimal flap in the aorta occludes the orifice of the SMA, or dissection extends into the SMA, and an expanded false lumen compresses the true lumen. Because this obstruction is "dynamic," mesenteric ischemia occurs even when the SMA is shown to be opacified on contrast CT. It is not uncommon for mesenteric ischemia to appear together with other critical conditions, such as stroke, myocardial infarction, or aortic rupture, thus necessitating a prompt and accurate diagnosis to prioritize treatment. In patients who undergo blood dialysis for years, the SMA is often narrowed due to calcifications, and the blood flow can be critically reduced following cardiac surgery using extracorporeal circulation or various types of stress8,9,10. NOMI can be caused by inadequate oxygen supply to the SMA due to heart failure, cardiac arrest, or hypoxemia despite a patent SMA11,12,13. Considering various etiologies and patterns of occurrence, not only blood flow in the SMA but also ischemic status in the intestinal wall must be assessed.

Another reason for delayed diagnosis is a lack of key symptoms or physical findings. Defense becomes obvious after the intestine is necrotized. Although several laboratory tests, such as C-reactive protein, lactate, citrulline, or intestinal fatty acid-binding protein, have been investigated as potential indicators of mesenteric ischemia4,14, no laboratory test has been shown to detect an early stage of mesenteric ischemia to date15. Although CT is the standard diagnostic imaging modality of mesenteric ischemia16,17,18, there can be errors in diagnosis or pitfalls in the filming technique5,19, and thus expertise is needed for an accurate diagnosis, which may necessitate the transfer of the patient to another facility. In addition, CT is not available for patients in the operating room (OR), emergency department (ER), or intensive care unit (ICU) who cannot be transferred to the Radiology Department. Allergies to contrast media, renal toxicity, or radiation exposure also limit CT as the initial diagnostic examination for every patient with abdominal pain.

Bowel ischemia is also problematic for plastic and reconstructive surgeons. During radical surgery for pharyngeal cancer, a free jejunal flap is used to reconstruct the resected pharynx. A portion of the jejunum is harvested with an artery and vein pedicle, which is anastomosed to the vessels in the cervical region, followed by anastomosis of the jejunal flap to the pharynx and esophagus. To confirm the competency of the vascular anastomosis, indocyanine (ICG) imaging was performed intraoperatively (sections 3). However, there are occasions when the flap develops necrosis within several days after surgery. Although rare, flap necrosis can be fatal unless detected and treated without delay. Thus, various attempts for detecting jejunal ischemia have been developed, such as frequent ultrasonography (US) to confirm blood flow, repeated endoscopy to verify mucosal color, or designating a sentinel portion of the jejunum to monitor perfusion, which is buried afterward by an additional surgical procedure20,21,22; however, such maneuvers are difficult for both patients and physicians. Other modalities applied to the clinical use for diagnosing bowel ischemia include optical coherence tomography23, laser speckle contrast imaging24, sidestream dark field imaging25, and incident dark field imaging26. These promising modalities are expected to become widely available through further development.

Considering the nature of mesenteric ischemia, which affects several fields in various situations, it is important to have multiple measures for detecting it. This article proposes two potential candidates for this purpose, US and near-infrared light and presents the representative findings.

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Protocol

A clinical investigation of ICG imaging was performed under approval by the Ethics Committee of Kochi Medical School with informed consent from every patient. A total of 25 patients were included, who underwent reconstructive surgery using free jejunal graft following resection of cancer of the pharynx or cervical esophagus between 2011 and 2016. Regarding the US, the video records obtained in clinical practice between 2000 and 2018 have been reviewed. Ethical approval was waived on this, according to the institutional ethical review committee.

1. Transesophageal echocardiography (TEE)

NOTE: TEE, which necessitates the insertion of an esophageal probe, is suitable for making a diagnosis or monitoring in the OR or ICU where CT assessment is not available. TEE provides morphologic and kinetic information as well as the perfusion status of the intestine27,28. Although it requires expertise in visualizing the SMA, it is not so hard for experienced heart and thoracic aorta examiners. The SMA can be visualized with the TEE probe (see Table of Materials) advanced into the stomach and the transducer directed posteriorly (Figure 1A).

  1. Visualize the descending aorta on the short axis (scanning plane 0°), then advance the probe into the stomach with the image of the aorta kept in view by rotating the probe counterclockwise with a slight anteflexion of the probe tip to keep the transducer in contact with the esophageal wall.
  2. If the image of the aorta moves downward, bend the probe tip further (Figure 1B).
  3. Use color Doppler mode to facilitate the identification of visceral branches by flow signal, and ensure that the orifice of the celiac artery appears at the 12 o'clock position of the abdominal aorta (Figure 1C). It divides into two or three arteries within a few centimeters of the orifice.
  4. Advance the probe one inch further so that the SMA appears at the 12-2 o'clock position.
    NOTE: A leftward bending of the probe tip is helpful to rotate the image and depict the SMA at 12 o'clock position.
  5. Ensure that the distal portion of the SMA is located between the pancreas (splenic vein) and abdominal aorta, where the left renal vein crosses behind the SMA.
  6. Rotate the scanning plane to 90° to visualize the long-axis view of the aorta and visceral branches. The distal portion of the SMA can be assessed more easily (Figure 1D).
    NOTE: Figure 1C,D show the TEE findings in a cardiovascular surgical case without mesenteric ischemia.

2. Abdominal US

NOTE: This modality is suitable for suspecting or excluding mesenteric ischemia among several patients with abdominal pain, together with physical examination. It is used for assessing the morphology and kinetics of the intestine and the blood flow in the SMA. Figure 2A shows the place of the probe (see Table of Materials) for each purpose.

  1. Use a convex or sector probe with a frequency range of 2 to 5 MHz to facilitate visualization and above assessment of the intestine via the abdominal wall with adequate resolution and sensitivity.
    NOTE: Use a transducer with a frequency range between 2.5 and 5 MHz for visualizing the bowels in the abdomen with the gain setting maximal without generating background noise.
  2. Place the probe on the abdominal wall around the navel to visualize the intestine (Figure 2B). Find any acoustic window (yellow arrow) between the intestinal gas (blue dotted line).
  3. Check the size and peristaltic movement of the intestine, mucosal edema, or the presence of ascites around it. The latter indicates that intestinal necrosis takes place.
  4. For assessing the SMA flow, the probe was placed vertically above the navel level. Find the SMA, which arises from the abdominal aorta and directs caudally within a few centimeters (Figure 2C).
    ​NOTE: The US findings in Figure 2B,C was recorded in healthy individuals.

3. ICG imaging

NOTE: This modality is suitable for assessing the perfusion of the tissues in the surgical field.

  1. Prepare the ICG imaging system following the manufacturer's instructions (see Table of Materials).
  2. Inject a total of 2.5 mg ICG (see Table of Materials) dissolved in 10 mL of distilled water (0.25 mg/mL) into the central venous line, followed by flushing with 10 mL of saline (Figure 3A).
  3. Visualize the perfused ICG into the mesenteric artery and then the intestinal tissue on display (Figure 3B). It usually appears approximately 10 to 20 s after injection.
    ​NOTE: The ICG imaging findings in Figure 3B were recorded in a reconstruction case with a free jejunal graft enrolled in the above study.

4. Near-infrared spectroscopy (NIRS)

NOTE: To solve the problem in plastic and reconstructive surgery (as mentioned in the Introduction section), this study proposed the use of the NIRS system, which has been used in cardiovascular surgery29; however, validation to confirm that rSO2 reflects the ischemic status of the jejunum was needed. When the jejunal flap was harvested, an NIRS sensor was placed on the jejunum, and changes in rSO2 were monitored when the artery and vein were clamped, and perfusion was resumed after reconstruction. In addition, rSO2 changes were observed for 3 days postoperatively with the NIRS sensor placed on the skin of the neck. The recommended procedures for assessing the rSO2 of the intestine directly in the surgical field are described here.

  1. Prepare the NIRS system following the manufacturer's instructions (see Table of Materials) (Figure 4A).
  2. Use an appropriate sensor for measuring the rSO2 of the tissue according to the depth of the target region to be assessed (Figure 4B). Place the sensor directly on it with light contact so as not to press excessively.
    NOTE: This study used a sensor with a distance between the emitter and receiver of 2 cm.
  3. Check the rSO2 value indicated on display, updated every 5 s (Figure 4B).

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Representative Results

TEE
There were two types of findings: (1) "branch type" with a true compressed lumen in the SMA by an expanded false lumen without blood flow, and (2) "aortic type" with the intimal flap at the orifice of the SMA and lack of blood flow in the SMA (Figure 5A). The representative TEE findings of three cases with bowel necrosis caused by acute aortic dissection are shown. In one case of the former type, the true lumen in the SMA were severely compressed (Figure 5B). Bowel necrosis was confirmed upon laparotomy, and bowel resection was performed. The findings of the aortic-type mesenteric ischemia vary among cases. Here two cases are shown. TEE revealed that the true lumen in the aorta was compressed (Figure 5C). The celiac artery was well perfused in one case, whereas blood flow could not be detected in the SMA. In another case, both were not perfused. In both cases, bowel necrosis was confirmed on laparotomy.

Abdominal US
The US could visualize reduced or absent peristalsis or dilatation of the intestines (Figure 6A). While the normal intestine was usually smaller than 2 cm in diameter (Figure 2B), the dilated intestine was larger than 3 cm with debris swaying in the dilated lumen, and the thickened Kerckring folds28 were obvious. Ascites around the intestines were often seen. In these two cases with aortic dissection, the intestines were already necrotic and necessitated resection.

Figure 6B shows the US findings of thrombosis in the portal vein. Blood flow signals were absent in the left branch of the portal vein to the umbilical portion. The extrahepatic portal vein was dilated with a flow signal defect. Behind the pancreatic body, the superior mesenteric vein was narrowed by a thrombus with accelerated flow into the portal vein visualized on a longitudinal scan. In this particular case, thrombolytic therapy was carried out.

A case involving an acute aortic dissection associated with mesenteric ischemia is presented in which the intestines could be salvaged. The patient presented with mild abdominal pain but significant metabolic acidosis. Despite opacified SMA on CT assessment (Figure 7B), abdominal US revealed a hypokinetic intestine. The blood flow signal was poor in the SMA, whereas it was apparent in the abdominal aorta (Figure 7A). Accelerated blood flow at the SMA orifice and reverse flow into the distal SMA from the jejunal branch were noted, indicating a significant mesenteric ischemia. At emergent laparotomy (Figure 7C), the intestines appeared pale and peristalsis was slightly reduced. After revascularization, the color and peristalsis of the intestines improved (Figure 7D). The intestine was salvaged in this case. Although it was fortunate that the SMA flow could be visualized in this case, there are cases in which the visualization of the intestines or blood flow is difficult.

ICG imaging
Figure 8 shows the images of two cases with bowel necrosis before and after ICG administration. In the former case, segmental necrosis was apparent only by inspection (Figure 8A). The mesenteric arteries were visualized first, and then the tissue brightened. In the latter case, however, the difference in perfusion was unclear by inspection (Figure 8B). ICG imaging showed a patchy brightening on the left side. The lower portion was totally necrotic. A region on the right brightened with obvious peristalsis. In these two cases, necrotic portions of the intestine were resected. Such information may be available with CT assessment but is not necessarily helpful during laparotomy because the location of the intestine changes.

NIRS
Figure 9A shows the rSO2 changes in the jejunum, which was harvested for use as a free jejunum flap to reconstruct the resected pharynx30. As the artery was clamped, the rSO2 >60% in every case dropped to a level <60% in many cases. When the flap was reperfused, rSO2 recovered to >60% in every case. After surgery, rSO2 remained >60% without any case of developing necrosis of the jejunal flap. In contrast, as the vein was clamped, rSO2 was slightly reduced, and the hemoglobin index (HbI), which is the relative change in hemoglobin density, was markedly elevated. Application of NIRS to this field was proposed based on the author's experience with cerebral perfusion monitoring with NIRS in aortic cases25 (Figure 9B) and a case of transient bowel ischemia due to aortic dissection associated with reversible changes of rSO2, which were measured from the surface of the abdominal wall using the conventional NIRS sensor with the distance between emitter and receiver of 4 cm31.

Sensitivity and specificity
While the results of the NIRS assessment were compatible with the uneventful postoperative course in every enrolled case, the data in the other three applications was not enough to perform statistical analysis, but the assessment was rather "precision medicine"-like one in each individual case. The accuracy of the assessment was individually confirmed by the intraoperative inspection of the laparotomy.

Figure 1
Figure 1: Visualization of visceral branches using transesophageal echocardiography (TEE). (A) Scanning planes for visualizing the celiac artery (CEA) and superior mesenteric artery (SMA). (B) Tips for manipulating the probe to visualize a better image at the 12 o'clock position. (C)TEE images of CEA, SMA, and surrounding structures. (D) Long-axis view of CEA and SMA. In (C) and (D), blood flow is shown in red or blue according to the flow direction. Abbreviations: AB-AO: abdominal aorta, L-RA: left renal artery, L-RV: left renal vein. Please click here to view a larger version of this figure.

Figure 2
Figure 2: Visualization of the intestine and superior mesenteric artery (SMA). (A) Places and directions of the probe for each assessment. (B) An acoustic window between the intestinal gas (blue dotted lines) toward the intestine and an image of the normal intestine. (C) An acoustic window for SMA and images of SMA visualized using a palm-sized ultrasonography device. Abbreviations: AB-AO: abdominal aorta, CEA: celiac artery. Please click here to view a larger version of this figure.

Figure 3
Figure 3: Indocyanine green (ICG) imaging. (A) Mechanism of imaging. As near-infrared light is irradiated to the injected ICG in the tissue, it emits fluorescent light, which is recorded by the camera along with the images of the surgical field. (B) Sequential images of ICG imaging showing perfusion in the free jejunal flap. The fluorescence image is superimposed on the image of the surgical field. Please click here to view a larger version of this figure.

Figure 4
Figure 4: Near-infrared spectroscopy (NIRS) system and application to the jejunal flap. (A) NIRS system. (B) A sensor made for assessing regional oxygen saturation in the surgical field, with a distance between the emitter and receiver of 2 cm. It was covered by a sterile sheath and placed on the jejunum. Please click here to view a larger version of this figure.

Figure 5
Figure 5: Transesophageal echocardiographic findings of mesenteric ischemia caused by the aortic dissection. (A) Two types of mechanisms for malperfusion. (B) Branch type with the compressed true lumen (TL) in the superior mesenteric artery (SMA). (C) Aortic type. In the abdominal aorta (AB-AO), the flap was compressed to the wall. In one case, no flow was detected in the SMA, whereas a good flow signal was in the celiac artery (CEA). In another case, both arteries were malperfused. The absence of color coding indicates that there is no blood flow in the corresponding site. Please click here to view a larger version of this figure.

Figure 6
Figure 6: Abdominal ultrasonographic images of mesenteric ischemia. (A) Images of the ischemic intestine, which was akinetic and dilated, associated with obvious Kerckring folds and ascites. (B) Images of portal vein (PV) thrombosis. There was a flow signal defect by the thrombus (TH) in the PV, which was dilated and larger than the inferior vena cava (IVC). The portion in the vessel where color coding is absent indicates the loss of blood flow because of thrombus formation. Please click here to view a larger version of this figure.

Figure 7
Figure 7: Findings in a case of salvaged intestine associated with acute aortic dissection. (A) The blood flow was poor in the superior mesenteric artery (SMA), but an accelerated flow was noted with the reverse flow into the distal portion from the branch artery. (B) The SMA was opacified. (C) Upon laparotomy, the intestine appeared slightly pale with reduced peristalsis. (D) After revascularization, color and movement improved. Please click here to view a larger version of this figure.

Figure 8
Figure 8: Indocyanine green imaging of the ischemic intestine. (A) Segmental ischemia. (B) Diffuse ischemia with some portions less ischemic. Peristalsis was noted in the latter portion. Please click here to view a larger version of this figure.

Figure 9
Figure 9: Changes in regional oxygen saturation (rSO2). (A) The rSO2 changes of the jejunal flap. (B) Changes in rSO2 in the bilateral frontal lobes during arch surgery. Please click here to view a larger version of this figure.

Figure 10
Figure 10: Ischemic cascade and multimodality approach to mesenteric ischemia. (A) Ischemic cascade for mesenteric ischemia. The cascade is assessed by ultrasonography (US) and is affected by the severity and duration of malperfusion. The former can be assessed by employing color Doppler mode, indocyanine green (ICG) imaging, and near-infrared spectroscopy (NIRS). (B) Multimodality approach by locations. The abdominal US and transesophageal echocardiography (TEE) emit ultrasound and assess the intestine as well as the abdominal aorta (AB-AO) and superior mesenteric artery (SMA). ICG imaging and NIRS emit near-infrared light. (C) The target of assessment is different in these modalities. Please click here to view a larger version of this figure.

Figure 11
Figure 11: Mechanism of changes in regional oxygen saturation (rSO2). As arterial blood flow is interrupted, oxygenated hemoglobin decreases and rSO2 is reduced. As venous congestion occurs, the venous component with rich deoxygenated hemoglobin increases, reducing rSO2 and increasing the hemoglobin index (HbI), which indicates the relative changes in the cumulative amount of hemoglobin in the tissue. Please click here to view a larger version of this figure.

Figure 12
Figure 12: Optimization of measurement of regional oxygen saturation (rSO2) of the intestine from the body surface. (A,B) As the rSO2 is sampled mainly at a depth of one- to two-thirds of the distance between the emitter and receiver of the sensor, that of the abdominal wall muscle is measured. (C) As the sensor is pressed toward the abdomen according to the ultrasonographic information, it reaches the depth of the intestine. The red marking indicates the path of infrared light. The yellow arrow shows how the sensor is pressed. Please click here to view a larger version of this figure.

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Discussion

Mesenteric ischemia remains an unsolved problem beyond the clinical field. To solve such a common problem, similar pathology in other organs may be helpful to take a hint. The concept of "ischemic cascade" was proposed for acute myocardial infarction32, and regional wall motion abnormalities (hypokinesis, akinesis, and dyskinesis) located at the early stage of the cascade have been used as an indicator of myocardial infarction instead of coronary blood flow, which cannot be assessed noninvasively in real-time. This concept was applied to the intestine, which is also a muscular organ, to explore the diagnostic measures for mesenteric ischemia (Figure 10A).

Two axes of malperfusion were placed around the cascade, i.e., "severity" and "duration". For assessing mesenteric perfusion, four modalities using ultrasound and near-infrared light are available in different ways (Figure 10B). They are related to each event that occurs in the ischemic cascade (Figure 10C). The cascade starts from loss of perfusion, followed by reduced distribution of arterial blood, which contains abundant oxygenated hemoglobin, which leads to oxygen deficiency in the tissue. It causes dysfunction of organs, that is, hypokinesis of the intestine. Although it is reversible initially, irreversible damage progresses if perfusion is not restored. The above four modalities can assess each of these steps. Color Doppler mode visualizes blood flow in real-time and can be used for decision making of intervention and for evaluating the efficacy of measures taken. Two modalities, TEE and abdominal US, are used according to the patient's situation. ICG imaging visualizes how blood is distributed into the tissue. This helps determine the extent of resecting necrotic intestinal segments32,33,34,35. The application of ICG imaging is now spreading among various specialties including cardiovascular surgery36,37, thoracic surgery38, plastic and reconstructive surgery39. Although the use of ICG imaging is available only during laparotomy, it may improve the accuracy of probe laparotomy in which visual inspection and digital palpation of the mesenteric artery have been used.

The severity of damage can be assessed first by kinetic changes, then by morphological changes employing the B mode of US40. Based on the author's experience, the intestine was already necrotic when the latter five findings in this cascade were obvious. Because hypokinesis appears instantaneously in the intestine and becomes ischemic, abdominal US seems to be the most suitable tool for physicians in various specialties, including general physicians, for distinguishing patients with mesenteric ischemia among patients with abdominal pain. Palm-sized US devices equipped with B and color Doppler modes are already available, and dilatation and/or reduced peristalsis as well as even SMA flow can be examined wherever the patient is situated (Figure 2C). In this sense, US may be included in the physical examination as a "visual stethoscope", as it is noninvasive and can provide useful information at the bedside. US is currently used for diagnosing bowel diseases41 as well as focusing on events in the ER setting (point-of-care US [POCUS]) such as acute aortic dissection42. As it can visualize blood flow in the SMA43 it is used for the initial diagnosis and/or follow-up of localized SMA dissection44. However, the visualization of the SMA is often challenging in obese patients or those with abundant intestinal gas. As the gas collects at the upper side, the intestine may be depicted from the side of the body. Other findings of mesenteric ischemia include intestinal pneumatosis or hepatic portal venous gas45,46, but these findings result from necrotized intestinal tissue. It is crucial to transfer the patient to the surgical team at this stage as soon as possible. Emergency setting as acute aortic dissection is different because bedside assessment without CT is needed in the OR. To overcome these issues, this study introduced TEE to visualize the visceral arteries in the OR47 and assess mesenteric ischemia41. Other reports recently cited such TEE applications48 and may be used for more patients.

NIRS is the next promising candidate for early diagnosis. The rSO2 has been shown to accurately reflect the perfusion status in the frontal lobe via the skull31 or in the free jejunal flap via the neck skin30 (Figure 10B). Figure 11 schematically illustrates that reduced rSO2 and increased HbI are good indicators of arterial supply and venous congestion, respectively. As the artery is clamped, the supply of oxi-Hb is reduced, leading to a decreased rSO2. As the vein is congested, the rSO2 slightly decreases while the HbI is markedly increased. A NIRS system that provides an absolute rSO2 value of the tissues would enable the detection of reduced intestinal rSO2 from the abdominal surface without laparotomy. Unlike the sensor on the cervical surface, however, the intestines in the abdomen are farther from the sensor and may be beyond the region of detecting rSO2, thus, the provided rSO2 is that of the abdominal wall (Figure 12). To solve this problem, ultrasonography may help determine the distance to the intestines. If the distance is farther than one-half to two-thirds of the distance between the emitter and receiver of the NIRS sensor, the sensor may be compressed toward the abdomen so that the intestines are located within the region for assessing rSO228.

These assessments possess certain limitations. The extent to which data are obtained is limited. The abdominal US readily detects akinetic and dilated intestines, but the blood flow in the SMA is not always easy. Visualization of visceral arterial flow by TEE is limited to the vicinity of its orifice, but the peristalsis of the intestine and mesenteric perfusion around the stomach can be visualized. As TEE necessitates the insertion of a probe, it is suitable for use in anesthetized patients. The use of ICG imaging assessment is limited to laparotomy cases, and penetration of fluorescent light is only a few millimeters. The NIRS assessment appears to provide the information beneath the skin but only collects the data along the path of infrared light, and thus, feasibility on the intestine in the abdomen needs further investigation.

In summary, four modalities are available in addition to CT, potentially helpful for salvaging the intestine and rescuing the patient. In brief, potential ischemia is detected by hypokinesis of the intestine by US, and then the rSO2 of the intestine is measured via the abdominal wall by NIRS. Because the time for salvaging the intestine is limited, it is of primary importance to take the patient to an institute where appropriate intervention can be provided. For this purpose, it is important to have multifaceted solutions against such a multiphasic problem. With the recent development of a palm-sized device, US assessment would be the only modality available everywhere and helpful for distinguishing patients who need a prompt referral to the facilitated hospitals. It may help monitor the perfusion status of patients at risk in any hospital ward. NIRS assessment may be an additional tool as pulse oximetry has become widely used during the COVID-19 pandemic. TEE is useful for perioperative assessment/monitoring, especially in cases with aortic dissection and potential NOMI. ICG imaging is to be used for visually confirming organ/graft perfusion and determining the extent of necrotic dissection.

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Disclosures

The author has no conflicts of interest regarding this work.

Acknowledgments

The section on the free jejunal flap is the result of work with Akiko Yano, MD, Kochi Medical School.

Materials

Name Company Catalog Number Comments
HyperEye Medical System Mizuho Ikakogyo Co., Ltd. ICG imaging system used in Figure 3
Indocyanine green  Daiichi Sankyo Co., Ltd. ICG used for ICG imaging in Figure 3
TEE system Philips Electronics iE33 TEE system used in Figure 5
TOS-96, TOS-OR TOSTEC Co. NIRS system used in Figure 4
Ultrasonographic system Hitachi, Co. EUB-555, EUP-ES322 echo system used in Figure 1
Ultrasonographic system Aloka Co. SSD 5500 echo system used in Figure 2
Vscan GE Healthcare Co. Palm-sized echo used in Figure 2

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Mesenteric Ischemia Diagnosis Multimodality Diagnosis Challenges Computed Tomography Limitations Radiation Exposure Renal Damage Necrosis Ultrasonography Near-infrared Light Clinical Studies Morphologic Information Kinetic Information Mesenteric Vessels Transesophageal Echocardiography Perfusion Assessment Aortic Dissection Cases Near-infrared Imaging Indocyanine Green Vessel Perfusion Intestinal Tissue Perfusion
Multimodality Diagnosis of Mesenteric Ischemia
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Orihashi, K. Multimodality Diagnosis … More

Orihashi, K. Multimodality Diagnosis of Mesenteric Ischemia. J. Vis. Exp. (197), e65095, doi:10.3791/65095 (2023).

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