Authors: Dong Xiaoyu, Gao Yunhe, George
Source: International Journal of Surgery, 2023, 50(12)
summary
Acute mesenteric ischemic disease (AMI) is a critical surgical acute abdomen. Due to the insidious and atypical nature of the initial symptoms, the mortality rate of patients with AMI increases significantly once the diagnosis is delayed. The diagnosis and treatment process of AMI often involves close collaboration and communication between multiple disciplines and departments, and our team deeply understands that the standardized application of multidisciplinary comprehensive treatment (MDT) diagnosis and treatment mode in AMI can significantly improve the efficiency of disease diagnosis, delay disease progression, timely treatment of diseases, improve the poor prognosis of patients, and reduce the mortality rate of patients. Therefore, based on the experience of implementing the MDT diagnosis and treatment model in the treatment of AMI patients in the center, the author expounds the key steps and quality control points of standardizing the application of the MDT diagnosis and treatment model in AMI, in order to provide a theoretical basis and experience reference for peers in the industry.
Acute mesenteric ischemia (AMI) is a critical surgical acute abdomen caused by acute mesenteric arterial or venous obstruction or decreased circulatory pressure, resulting in insufficient blood flow in the mesentery to meet the metabolic demands of the corresponding organs for blood supply or return [1]. The difficulty of early diagnosis of AMI lies in its early diagnosis, which increases the mortality rate of patients with AMI once the diagnosis is delayed due to the insidious nature of the etiology and the atypical nature of the symptoms [2]. There are three main types of treatment for AMI: conservative medical treatment, interventional treatment, and surgical treatment [3]. When the patient progresses to irreversible transmural intestinal necrosis, surgical removal of the necrotic bowel is indicated [4]. At present, there is a lack of unified standards for the treatment of AMI, and once the diagnosis of AMI is confirmed, what treatment measures to take and determine the timing of surgery are the difficulties and priorities in the current diagnosis and treatment process [5]. The multidisciplinary team (MDT) model is based on a fixed working group composed of two or more related disciplines to comprehensively analyze patient data and develop a standardized, individualized, and sustainable comprehensive treatment plan for a specific patient [6,7]. In the past ten years, the First Medical Center of the PLA General Hospital where the author works has diagnosed and treated more than 100 cases of AMI, and most of the patients have progressed to the stage of irreversible transmural intestinal necrosis and have to undergo damage-controlled bowel resection, with a postoperative mortality rate of about 10%.
1 The significance of MDT team building in AMI
The incidence of AMI increases exponentially with the age of patients, and the incidence rate of patients older than 60 years increases overall, while there is no statistically significant difference in the incidence between men and women, and the overall case fatality rate is 50%~80%[8]. In the early stage of AMI, most of the symptoms are insidious, and abdominal pain is the first symptom, and the most typical manifestation is severe pain and mild signs. Computed tomography (CT) angiography has replaced angiography as the gold standard for the diagnosis of AMI [9]. However, when AMI progresses to an advanced stage, intestinal ischemia necrosis progresses from the intestinal mucosa to irreversible transmural intestinal necrosis, resulting in the advanced intestinal ischemic triad of fever, bloody stool, and abdominal pain [10,11,12]. If AMI is treated in time 6 hours after the onset of the disease, the overall mortality rate will be reduced to 10%~20%, so the early diagnosis of AMI and the adoption of appropriate treatment measures are particularly important [13,14,15,16,17].
AMIs are classified as arterial embolism, arterial thrombosis, mesenteric venous thrombosis, and nonocclusive mesenteric ischemia [18,19]. The timing of progression and the treatment used for each type of AMI also vary [20,21,22]. Therefore, the construction of MDT teams in AMI can select an accurate diagnostic algorithm for patients at an early stage when they have similar symptoms. AMI is a critical surgical acute abdomen, and the basic conditions of patients such as underlying diseases, age of onset, and nutritional status are different, and the treatment measures that should be taken for each patient should be individualized, and experts from each department need to provide their own opinions, and finally organically integrate them through discussion, so as to formulate a reasonable treatment plan. The advantages of the standardized application of the MDT diagnosis and treatment model are reflected in its fixed composition and organization, which will treat patients with acute abdomen from a more comprehensive perspective, ensure that the multidisciplinary team can detect the underlying disease problems of the patients in time and correctly determine the degree of infection, so as to provide more comprehensive diagnosis and treatment for patients.
If patients with AMI must undergo injury-controlled surgical bowel resection, the prognosis of patients will have to face the serious nutrition-related complication of short bowel syndrome [23], and the mortality rate of patients with short bowel syndrome after surgical bowel resection in the past ten years is as high as 80%, so the length of the bowel resection and the appropriate postoperative nutrition regimen are also important aspects of the guidance that the MDT team can provide.
2 Composition and collaboration process of the MDT team in AMI
The MDT team is generally composed of the initiating department, the leading department and the collaborating department. AMI's MDT team consists of professionals from Emergency Medicine, Imaging, Gastrointestinal Surgery, Vascular Surgery, Interventional Radiology, Gastroenterology, Anesthesiology, Critical Care Medicine and Nutrition. In the experience of the author's center, the initiating department of AMI is generally the department where the patient or suspected AMI is currently located, and the leading department is determined according to the clinical type and stage of disease progression of the AMI. When a patient presents with the first symptom, the emergency medicine department will judge the possibility of AMI according to the patient's symptoms and signs and auxiliary examinations, and the imaging department will further confirm the diagnosis. In the progression phase, the decision on whether interventional radiology should be followed by conservative thrombolysis, vascular surgery, or gastrointestinal surgery for abdominal exploration and necrotic bowel resection is discussed, and the lead department for the next stage of treatment is decided [24,25,26]. When the patient is determined to be treated with invasive procedures, the Department of Anesthesiology and the Department of Critical Care Medicine should join the MDT team to discuss the patient's next treatment plan, and the Department of Anesthesiology will conduct anesthesia evaluation and provide anesthesia assurance, usually by endotracheal intubation and general anesthesia; Patients with AMI who progress to irreversible transmural intestinal necrosis often have severe septic shock, so the role of postoperative intensive care is also indispensable [27,28]. When the patient completes the invasive surgical operation, the nutrition department should formulate a nutritional plan for the patient's recovery period according to the scope of the patient's intestinal resection and the recovery of gastrointestinal function, so as to reduce the probability of short bowel syndrome and dystrophic events.
3 The focus of MDT diagnosis and treatment modes in different types of AMI
Of the four clinical subtypes of AMI, arterial embolism is the most prevalent, accounting for approximately 50 percent of AMI [16]. It is common in patients with atrial fibrillation, rheumatic heart disease, and recent myocardial infarction, and is often caused by the detachment of vascular vegetations such as emboli and occlusion of the superior or inferior mesenteric artery and its branches [25]. These patients usually have an acute-onset onset with severe symptoms and dissociative clinical features of mild signs. In the face of the etiology of such AMI patients, the MDT team should join the cardiology department and other relevant internal medicine departments to make a judgment on the primary disease that causes the patient's embolus to fall off and clarify the cause.
Acute superior mesenteric artery thrombosis accounts for about 25 percent of AMI incidences and is mostly based on arteriosclerosis [29]. It is difficult to distinguish it from arterial embolism in imaging manifestations, and its onset time is slower than that of arterial embolism, and most of them are diagnosed in postoperative pathology. Early diagnosis of such patients in the MDT team and early thrombolytic therapy can reduce the probability of irreversible bowel resection. Identifying the cause of AMI as early as possible under the guidance of the MDT team can also play a crucial role in treatment.
Mesenteric venous thrombosis accounts for 5%~10% of the incidence of AMI, and is mostly secondary to severe intra-abdominal infection, liver disease or portal hypertension, blood stasis, polycythemia vera, human blood hypercoagulability, and vascular injury [30]. Based on the experience of treating AMI patients in the center in the past ten years, the incidence rate should be higher than the epidemiological data described in the literature. The MDT team of such patients should include experts in hepatobiliary surgery, hematology, and other departments related to the primary disease. With the relatively slow onset of mesenteric vein thrombosis and its progression to intestinal necrosis is prolonged, anticoagulation can be initiated at an early stage to minimize progression to irreversible bowel resection under the care of the MDT team.
Non-occlusive mesenteric ischemia accounts for about 10% of the incidence of AMI, and is often secondary to peripheral arterial hypoperfusion caused by dialysis and heart failure, which is difficult to diagnose due to atypical imaging findings. The MDT team that suspects this type of AMI should join experts from nephrology, cardiology and other relevant departments to give guidance on diagnosis and treatment decisions to improve the diagnosis and treatment of this type of AMI.
4 Quality control of MDT diagnosis and treatment mode in AMI
The MDT diagnosis and treatment mode is different from the traditional consultation mode, and in the discussion of MDT cases of suspected AMI, it is necessary to give full play to the professional ability of experts in each department and provide the best treatment plan based on the disease and overall situation of each patient. The following is the experience of the author's team in applying the MDT diagnosis and treatment model in the diagnosis and treatment of AMI in the past ten years.
4.1 Timeliness of the MDT team
AMI is a critical surgical acute abdomen, and its MDT diagnosis and treatment mode is different from that of cancer patients: the MDT diagnosis and treatment mode of cancer patients can integrate the common time of the expert team of various departments to make the optimal choice of treatment plan for patients with limited or elective surgery; The diagnosis and treatment process of AMI has strong timeliness, which requires the fastest speed to make research and judgment and integrate resources. However, due to the limitation of medical resources, it is difficult to set up a 24-hour standby MDT team for each department for AMI, so the key link to achieve the timeliness of MDT is the initiating organization department. Based on past experience, the author suggests that the emergency department should take the initiating and leading role of the MDT team, which is conducive to the improvement of efficiency, and that the emergency department should quickly organize the MDT team consultation of the relevant departments after first suspecting AMI, and due to the particularity of emergency cases, even if all experts cannot attend the meeting together, the emergency department can be responsible for recording and sorting out the diagnosis and treatment opinions of the relevant departments for a certain type of AMI patients, and coordinate and communicate with other departments from them, so as to clarify the next diagnosis and treatment measures for the patient. It is then handed over to the relevant leading department to be further responsible for diagnosis and treatment. In view of the increasing perfection and convenience of online remote meetings, department experts who cannot participate in offline and timely time can also use online conferences to conduct online consultations and discussions, and put forward corresponding professional opinions. The emergency department initiates or dominates the MDT team, helping to organize expert team consultations with the fastest efficiency and make decisions about the next phase of care as quickly as possible.
4.2 MDT team collaboration and communication mode
Due to the timeliness of the MDT discussion model required by AMI, the mode of communication and exchange of opinions among all the participating experts is particularly important [31]. First of all, it is necessary to ensure that the experts from each department can quickly arrive at the emergency department, familiarize themselves with the overall situation of the patient as soon as possible, and give the opinions and guidance of the corresponding specialists. Secondly, if the participating experts are unable to attend the meeting in time or participate online, the physician of the initiating department is responsible for sorting out and recording the opinions of other participating experts, and timely feedback to the experts who are not present in time, so as to make the fastest judgment. If the opinion of one expert is different from that of other experts, the next step of diagnosis and treatment should be finalized by the experts of all participating departments.
4.3 Implementation and feedback of MDT team decisions
The authors believe that the MDT team's decision on the diagnosis of AMI should be initiated and organized by the emergency department or the patient's department, and the next treatment decision should be led by the relevant department. If surgery is performed, general surgery or gastrointestinal surgery should be led, conservative treatment should be led by gastroenterology, interventional or surgical thrombectomy should be led by interventional radiology or vascular surgery, etc. Secondly, the MDT discussion opinions are recorded by the initiating department, and the MDT discussion results are fed back to the patient's family in a timely manner to protect the patient's right to know and the right to life and health. If the patient and family do not agree with the MDT team's discussion plan, their wishes should be respected. Secondly, the relevant responsible personnel of the leading department should feedback the final treatment plan and the final outcome of the patient to the MDT discussion group, so as to accumulate experience for optimizing the diagnosis and treatment process and decision-making of AMI in the future.
5 Conclusion
In summary, due to the insidious nature of AMI, the complexity of diagnosis and the comprehensiveness of treatment, it is necessary to introduce the MDT diagnosis and treatment model in time to guide the diagnosis and treatment process, and standardize the construction and application of the team around the composition and collaboration process of the MDT team, the focus of the MDT diagnosis and treatment mode for different AMI patients, and the quality control aspects of implementation, so as to scientifically diagnose AMI in time and determine the next treatment plan to improve the overall diagnosis and treatment effect of patients.
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