Acute mesenteric ischemia: updated guidelines of the World Society of Emergency Surgery
急性腸系膜缺血：世界急診外科學會更新指南

Abstract  抽象

Acute mesenteric ischemia (AMI) is a group of diseases characterized by an interruption of the blood supply to varying portions of the intestine, leading to ischemia and secondary inflammatory changes. If untreated, this process may progress to life-threatening intestinal necrosis. The incidence is low, estimated at 0.09–0.2% of all acute surgical admissions, but increases with age. Although the entity is an uncommon cause of abdominal pain, diligence is required because if untreated, mortality remains in the range of 50%. Early diagnosis and timely surgical intervention are the cornerstones of modern treatment to reduce the high mortality associated with this entity. The advent of endovascular approaches in parallel with modern imaging techniques is evolving and provides new treatment options. Lastly, a focused multidisciplinary approach based on early diagnosis and individualized treatment is essential. Thus, we believe that updated guidelines from World Society of Emergency Surgery are warranted, in order to provide the most recent and practical recommendations for diagnosis and treatment of AMI.
急性腸系膜缺血 （AMI） 是一組以腸道不同部位的血液供應中斷為特徵的疾病，導致缺血和繼發性炎症變化。如果不及時治療，這個過程可能會發展為危及生命的腸壞死。發病率較低，估計佔所有急性手術入院率的 0.09-0.2%，但隨著年齡的增長而增加。儘管該實體是腹痛的罕見原因，但需要勤奮，因為如果不治療，死亡率仍保持在 50% 的範圍內。早期診斷和及時的手術干預是現代治療的基石，以降低與該實體相關的高死亡率。血管內入路與現代成像技術並行的出現正在不斷發展，並提供了新的治療選擇。最後，基於早期診斷和個體化治療的有針對性的多學科方法至關重要。因此，我們認為有必要更新世界急診外科學會的指南，以便為 AMI 的診斷和治療提供最新和實用的建議。

Background  背景

Acute mesenteric ischemia (AMI) is caused by sudden interruption of blood supply to the intestine, leading to cellular damage, intestinal necrosis, and commonly patient death if untreated [1]. AMI may be occlusive or non-occlusive (NOMI), with the primary etiology further defined as mesenteric arterial embolism (50%), mesenteric arterial thrombosis (15–25%), or mesenteric venous thrombosis (5–15%) [2, 3]. The overall incidence is low (0.09–0.2% of all acute admissions to emergency departments), representing an infrequent cause of abdominal pain [4,5,6], but a common cause of emergent intestinal resection. Prompt diagnosis and intervention are essential to reduce the mortality rates that exceed 50% [7,8,9,10].
急性腸系膜缺血（acute mesenteric ischeme， AMI）是由於腸道血液供應突然中斷，如果不及時治療，可導致細胞損傷、腸壞死，通常會導致患者死亡[1]。AMI 可為閉塞性或非閉塞性（non-occlusive， NOMI），原發病因進一步定義為腸系膜動脈栓塞（50%）、腸系膜動脈血栓形成（15-25%）或腸系膜靜脈血栓形成（5-15%）[2， 3]。總體發病率較低（佔所有急診科急性入院患者的 0.09-0.2%），是腹痛的罕見病因[4,5,6]，但卻是急診腸切除術的常見病因。及時診斷和干預對於降低超過 50%的死亡率至關重要[7,8,9,10]。

Traditionally, AMI has been treated with open surgery. Over the past two decades, the rapid development of endovascular techniques has made this approach an important alternative for patients with occlusion of the superior mesenteric artery (SMA). Some studies have shown that endovascular therapy is associated with lower rates of mortality and bowel resection than the traditional, open approach [11,12,13].
傳統上，AMI 通過開放手術治療。在過去的二十年裡，血管內技術的快速發展使這種方法成為腸系膜上動脈 （SMA） 閉塞患者的重要替代方案。一些研究表明，與傳統的開放性方法相比，血管內治療的死亡率和腸切除率更低[11,12,13]。

The assessment and therapy carried out by an interdisciplinary team should keep the time-to-reperfusion interval as short as possible. In addition, advances in postoperative care have improved outcome for patients with short bowel syndrome [14, 15]. Both in-hospital care and further bowel rehabilitation lead to increase survival and better long-term outcome with acceptable quality of life [16, 17].
跨學科團隊進行的評估和治療應儘可能縮短再灌注間隔。此外，術后護理的進步改善了短腸綜合征患者的預後[14,15]。 住院護理和進一步的腸道康復都可以提高生存率和更好的長期結果，並具有可接受的生活品質 [16， 17]。

Introducing a clinical pathway and centers of excellence results in higher awareness of AMI, more appropriate imaging, less delays, increased number of revascularizations, and, therefore, lower mortality [18, 19].
引入臨床路徑和卓越中心可提高對 AMI 的認識、更合適的影像學檢查、更少的延遲、增加血運重建的次數，從而降低死亡率[18,19]。

Accordingly, the present paper aims to provide an update with recommendations based on the most currently accepted concepts in the management of AMI [20].
因此，本文旨在根據 AMI 管理中目前最公認的概念提供最新建議[20]。

Methods  方法

The World Society of Emergency Surgery (WSES) endorsed a team of experts to develop specific questions about diagnosis and management of AMI. This group performed a thorough literature review and presented its findings during the WSES World Congress, September 2021 in Edinburg, Scotland. The quality of the evidence available was evaluated according to the GRADE methodology, and recommendations were classified into two levels: strong recommendation in favor or against; weak recommendation (suggestion) in favor or against. [21,22,23,24]
世界急診外科學會 （WSES） 認可了一個專家小組來制定有關 AMI 診斷和管理的具體問題。該小組進行了徹底的文獻綜述，並在 2021 年 9 月在蘇格蘭愛丁堡舉行的 WSES 世界大會期間展示了其發現。根據 GRADE 方法對現有證據的質量進行評估，並將建議分為兩個級別：贊成或反對的強烈建議;贊成或反對的弱推薦（建議）。[21,22,23,24]

During the Congress, the Board of the Society approved the proposed statements. After the acceptance, the update of the guidelines was further discussed by the Board of the WSES and approved.
在大會期間，協會董事會批准了擬議的聲明。在接受后，WSES 董事會進一步討論了指南的更新並獲得批准。

Pathophysiology and epidemiology
病理生理學和流行病學

Acute mesenteric arterial embolism
急性腸系膜動脈栓塞

Half of cases of AMI are due to acute SMA embolism [2, 3]. Mesenteric emboli can originate from the left atrium (e.g., atrial fibrillation), left ventricle (e.g., left ventricular dysfunction with poor ejection fraction), or cardiac valves (e.g., endocarditis). Occasionally emboli are generated from an atherosclerotic aorta. Emboli typically lodge at points of normal anatomic artery narrowing. The SMA is particularly vulnerable because of its relatively large diameter and low takeoff angle from the aorta. The majority of emboli lodge 3–10 cm distal to the origin of the SMA, thus sparing the proximal jejunum and colon. More than 20% of SMA emboli are associated with concurrent emboli to another arterial bed including the spleen and kidney [25].
一半的 AMI 病例是由急性 SMA 栓塞引起的[2,3]。 腸系膜栓子可起源於左心房（例如心房顫動）、左心室（例如射血分數差的左心室功能障礙）或心臟瓣膜（例如心內膜炎）。有時栓子是由動脈粥樣硬化的主動脈產生的。栓子通常停留在正常解剖動脈狹窄的點。SMA 特別脆弱，因為它的直徑相對較大且距主動脈的起飛角較低。大多數栓子位於 SMA 起點遠端 3-10 釐米處，從而保留了近端空腸和結腸。超過 20%的 SMA 栓子與併發栓子到另一個動脈床（包括脾臟和腎臟）有關[25]。

Acute mesenteric arterial thrombosis
急性腸系膜動脈血栓形成

Thrombosis of the SMA (approximately 25% of cases) is usually associated with pre-existing chronic atherosclerotic disease leading to stenosis. Many of these patients have a history consistent with chronic mesenteric ischemia (CMI), including postprandial pain, weight loss, or “food fear.” A detailed medical history is important when evaluating a patient suspected to have AMI. Thrombosis usually occurs at the origin of visceral arteries. An underlying plaque in the SMA usually progresses eventually to a critical stenosis resulting in collateral beds. Accordingly, symptomatic SMA thrombosis most often accompanies celiac occlusion [26]. SMA thrombosis may also occur due to vasculitis, mesenteric dissection, or mycotic aneurysm. Involvement of the ileocolic artery will result in necrosis of the proximal colon.
SMA 血栓形成（約佔病例的 25%）通常與導致狹窄的先前存在的慢性動脈粥樣硬化疾病有關。其中許多患者有與慢性腸系膜缺血 （CMI） 一致的病史，包括餐后疼痛、體重減輕或“食物恐懼”。在評估疑似 AMI 患者時，詳細的病史很重要。血栓形成通常發生在內臟動脈的起點。SMA 中的潛在斑塊通常最終發展為嚴重狹窄，從而導致側支床。因此，有癥狀的 SMA 血栓形成最常伴有腹腔閉塞[26]。SMA 血栓形成也可能由血管炎、腸系膜夾層或真菌性動脈瘤引起。回結腸動脈受累會導致近端結腸壞死。

Acute non-occlusive mesenteric ischemia
急性非閉塞性腸系膜缺血

NOMI occurs in approximately 20% of cases, and is usually a consequence of SMA vasoconstriction associated with low splanchnic blood flow [27]. The compromised SMA blood flow also affects the proximal colon due to involvement of the ileocolic artery. Patients with NOMI typically suffer from severe coexisting illness, commonly cardiac failure which may be precipitated by sepsis. Hypovolemia and the use of vasoconstrictive agents may precipitate NOMI.
約 20%的病例發生 NOMI，通常是 SMA 血管收縮與內臟血流量低所致[27]。由於回結腸動脈受累，受損的 SMA 血流也會影響近端結腸。NOMI 患者通常患有嚴重的並存疾病，通常是心力衰竭，可能由膿毒症誘發。 低血容量和血管收縮劑的使用可能誘發 NOMI。

Mesenteric venous thrombosis
腸系膜靜脈血栓形成

Mesenteric venous thrombosis (MVT) accounts for less than 10% of cases of mesenteric infarction. Thrombosis is attributed to a combination of Virchow’s triad; stagnant blood flow, hypercoagulability, and endothelial damage. In young patients, 36% of MVT occurs without an obvious cause [28]. An inflammatory process around the superior mesenteric vein (SMV) due to acute pancreatitis or inflammatory bowel disease may cause thrombosis. Surgical trauma such as splenectomy or bariatric surgery may also provoke SMV thrombosis. Hypercoagulability may be due to inherited disease such as Factor V Leiden, prothrombin mutation, protein S deficiency, protein C deficiency, antithrombin deficiency, and antiphospholipid syndrome. Additionally, recent work suggests that fibrinolysis shutdown (resistance to tissue plasminogen activator—tPA) is a significant risk factor for hypercoagulability [29]. Thrombophilia may also be acquired due to malignancies, hematologic disorders, and oral contraceptives [30].
腸系膜靜脈血栓形成（MVT）佔腸系膜梗死病例的不到 10%。血栓形成歸因於 Virchow 三聯征的組合;血流停滯、高凝狀態和內皮損傷。在年輕患者中，36%的 MVT 發生無明顯原因[28]。急性胰腺炎或炎症性腸病引起的腸系膜上靜脈 （SMV） 周圍的炎症過程可能導致血栓形成。脾切除術或減肥手術等手術創傷也可能引發 SMV 血栓形成。高凝狀態可能是由於遺傳性疾病，如因數 V 萊頓、凝血酶原突變、蛋白 S 缺乏、蛋白 C 缺乏、抗凝血酶缺乏和抗磷脂綜合征。此外，最近的研究表明，纖維蛋白溶解關閉（對組織纖溶酶原啟動劑的耐藥性，tPA）是高凝狀態的重要危險因素[29]。血栓形成傾向也可能由惡性腫瘤、血液系統疾病和口服避孕藥引起[30]。

Recent trends: prevalence, pathophysiology
近期趨勢：患病率、病理生理學

The prevalence of AMI has changed in recent decades. The prevalence of acute mesenteric occlusion among patients with an acute abdomen may vary from 17.7% in emergency laparotomy and 31.0% in laparotomy for elderly non-trauma patients [31].
近幾十年來，AMI 的患病率發生了變化。對於老年非創傷患者，急腹症患者急性腸系膜閉塞的患病率可能從急診剖腹手術的 17.7%和剖腹手術的 31.0%不等[31]。

Mesenteric arterial embolism decreased to 25% of cases [3, 32]. Mesenteric arterial thrombosis was the second most common cause of mesenteric ischemia, which historically accounted for 20–35% and recently increased to 40% [32]. NOMI accounts for 25% of cases [3], which is also increasing, compared to the historical cohort, because of increased number of critically ill patients and overall improvement of intensive care. Although the mechanism is still unknown, heart failure, renal failure, cardiac surgery using cardiopulmonary bypass, and the use of catecholamine are reported as risk factors [33].
腸系膜動脈栓塞減少至 25%的病例[3,32]。 腸系膜動脈血栓形成是腸系膜缺血的第二大常見原因，歷來佔 20-35%，最近增加至 40%[32]。NOMI 占病例的 25%[3]，與歷史佇列相比，這一比例也在增加，這是由於危重患者數量的增加和重症監護的整體改善。雖然其機制尚不清楚，但心力衰竭、腎功能衰竭、體外循環心臟手術和兒茶酚胺的使用是危險因素[33]。

The etiology of AMI has changed over the years with increasing percentages of acute arterial thrombosis due to atherosclerosis which may in part be explained by modern anticoagulant therapy used for the treatment of atrial fibrillation.
多年來，隨著動脈粥樣硬化引起的急性動脈血栓形成百分比的增加，AMI 的病因發生了變化，這可能部分解釋為用於治療心房顫動的現代抗凝療法。

The incidence of AMI increases exponentially with age. In patients aged 75 years or older, AMI is a more prevalent cause of acute abdomen than appendicitis [1]. The incidence of AMI in an 80-year-old is roughly tenfold that of a 60-year-old patient [34].
AMI 的發病率隨著年齡的增長呈指數級增長。在 75 歲或以上的患者中，AMI 是比闌尾炎更常見的急性腹症病因[1]。80 歲患者 AMI 的發病率約為 60 歲患者的 10 倍[34]。

Abdominal compartment syndrome with very high intraabdominal pressure may cause bowel ischemia that is complicated with ischemia–reperfusion injury when decompression laparotomy is performed [35].
腹內壓極高的腹筋膜室綜合征可引起腸缺血，並在進行減壓剖腹手術時併發缺血-再灌注損傷[35]。

AMI has been described in patients with coronavirus disease (COVID -19), probably related to large vessel thromboembolic events as well as to small vessel thrombosis linked to hypercoagulability and fibrinolysis shutdown [36].
COVID-19 患者中已有 AMI 的報導，可能與大血管血栓栓塞事件以及與高凝和纖溶關閉相關的小血管血栓形成有關[36]。

• 1. Severe abdominal pain out of proportion to physical examination findings should be assumed to be AMI until disproven. (Strong recommendation based on low-quality evidence 1C)
  與體格檢查結果不成比例的嚴重腹痛應假定為 AMI，直到被證實。（基於低質量證據 1C 的強烈推薦）

The key to early diagnosis is a high level of clinical suspicion.
早期診斷的關鍵是高度的臨床懷疑。

The clinical scenario of a patient complaining of excruciating abdominal pain with an unrevealing abdominal examination is classic for early AMI [37]. The reason for the pain being disproportionate to the clinical findings is that ischemia starts from the mucosa toward the serosa. That is why initially there is severe pain without clinical findings.
早期 AMI 的典型臨床表現是早期 AMI 的典型表現，即患者主訴腹痛，腹部檢查不明顯[37]。疼痛與臨床表現不成比例的原因是缺血從粘膜開始向漿膜延伸。這就是為什麼最初有劇烈疼痛而沒有臨床發現的原因。

If the physical examination demonstrates signs of peritonitis, there is likely irreversible intestinal ischemia with bowel necrosis. In a study on AMI, 95% of patients presented with abdominal pain, 44% with nausea, 35% with vomiting, 35% with diarrhea, and 16% with blood per rectum [38]. Approximately, one-third of patients present with the triad of abdominal pain, fever, and hemoccult-positive stool. Other patients, particularly those with delayed diagnosis, may present in extremis with septic shock. Clinical signs of peritonitis may be subtle. Accordingly, one must have a high index of suspicion, because such findings are predictive of intestinal infarction.
如果體格檢查顯示腹膜炎跡象，則可能存在不可逆的腸缺血伴腸壞死。一項關於 AMI 的研究顯示，95%的患者出現腹痛，44%出現噁心，35%出現嘔吐，35%出現腹瀉，16%出現直腸血樣[38]。大約 1/3 的患者表現為腹痛、發熱和大便積血陽性的三聯征。其他患者，尤其是那些診斷延遲的患者，可能出現感染性休克。腹膜炎的臨床癥狀可能很微妙。因此，必須有很高的懷疑指數，因為這些發現可以預測腸梗死。

The classic presentation of AMI, i.e., “severe, poorly localized abdominal pain that is out of proportion to the physical examination,” is becoming less common, while the “acute on chronic” presentations of mesenteric ischemia are more typical, and probably underdiagnosed [39]. Patients presenting with symptomatic chronic mesenteric ischemia are at high risk of developing in-hospital AMI.
AMI 的典型表現，即“與體格檢查不成比例的嚴重、局部性不良的腹痛”，正變得越來越少見，而腸系膜缺血的“急性加慢性”表現更為典型，且可能診斷不足[39]。出現有癥狀的慢性腸系膜缺血的患者發生院內 AMI 的風險很高。

Severe COVID-19 infection and AMI have a poor prognosis, delay in diagnosis, and intervention [40,41,42]. AMI should be suspected in patients with COVID-19 who present with nausea, vomiting, diarrhea, abdominal pain, and abdominal distension because of hypercoagulability and hypoperfusion. Blood tests will not aid in the diagnosis of AMI, though essential in patient management. CTA is the diagnostic modality of AMI along with clinical correlation.
重症 COVID-19 感染和 AMI 預後較差，診斷和干預延遲[40,41,42]。COVID-19 患者因高凝和灌注不足而出現噁心、嘔吐、腹瀉、腹痛和腹脹，應懷疑 AMI。血液檢查無助於 AMI 的診斷，但對患者管理至關重要。CTA 是 AMI 的診斷方式以及臨床相關性。

• 2. Clinical scenario and risk factors differentiate AMI as mesenteric arterial emboli, mesenteric arterial thrombosis, NOMI, or mesenteric venous thrombosis. (Weak recommendation based on low-quality evidence 1C)
  臨床情況和危險因素將 AMI 區分為腸系膜動脈栓塞、腸系膜動脈血栓形成、NOMI 或腸系膜靜脈血栓形成。（基於低質量證據 1C 的弱推薦）

Types of AMI  AMI 的類型

A careful medical history is important because distinct clinical scenarios are associated with the pathophysiological form of AMI [43]. Patients with mesenteric arterial thrombosis often have a history of chronic postprandial abdominal pain, progressive weight loss, and previous revascularization procedures for mesenteric arterial occlusion. Patients with NOMI have pain that is generally more diffuse and episodic associated with poor cardiac performance. These patients are more likely to have suffered from cardiac failure, and recent surgery. Several other smaller cohorts also reported hemodialysis as a risk factor of NOMI [44, 45]. Furthermore, NOMI represents a cause of secondary worsening in septic shock, particularly in septic patients treated with high-dose vasoactive drugs.
仔細的病史很重要，因為不同的臨床情況與 AMI 的病理生理形式相關[43]。腸系膜動脈血栓形成患者通常有慢性餐后腹痛、進行性體重減輕以及既往因腸系膜動脈閉塞而進行血運重建手術的病史。NOMI 患者的疼痛通常更瀰漫性和發作性，與心臟功能差相關。這些患者更有可能患有心力衰竭和最近的手術。其他幾個較小的佇列也報告血液透析是 NOMI 的危險因素[44,45]。 此外，NOMI 是感染性休克繼發性惡化的原因，特別是在接受高劑量血管活性藥物治療的膿毒症患者中。

Patients with MVT present with a mixture of nausea, vomiting, diarrhea, and abdominal cramping. Gastrointestinal bleeding occurs in 10% [46].
MVT 患者表現為噁心、嘔吐、腹瀉和腹部絞痛的混合癥狀。消化道出血發生率為 10%[46]。

Nearly 50% of patients presenting with embolic AMI have atrial fibrillation, and approximately one-third of patients have a prior history of arterial embolus with preexisted peripheral vascular disease [38].
近 50%的栓塞性 AMI 患者有心房顫動，約 1/3 的患者既往有動脈栓塞史，並伴有既往外周血管疾病[38]。

Risk factors for specific phenotypes of AMI are presented in Table 1.
AMI 特定表型的危險因素見表 1。^.

• 3. Plain X-ray is not recommended in evaluating patients for intestinal ischemia. (Strong recommendation based on moderate-quality evidence 1B)
  不建議在評估患者是否存在腸缺血時進行 X 線平片檢查。（基於中等質量證據 1B 的強烈推薦）

Table 1 Risk factors for specific types of AMI
表 1 特定類型 AMI 的危險因素

A radiograph is usually the initial test ordered in patients with acute abdominal pain but has a limited role in the diagnosis of mesenteric ischemia, especially in the early setting. A negative radiograph does not exclude mesenteric ischemia [47]. Plain radiography only becomes positive when bowel infarction has developed and intestinal perforation manifests as free intraperitoneal air.
X 光片通常是急性腹痛患者的初始檢查，但在腸系膜缺血的診斷中作用有限，尤其是在早期。X 線片陰性不能排除腸系膜缺血[47]。只有當腸梗死發生並且腸穿孔表現為腹膜內遊離空氣時，X 線平片才會變為陽性。

• 4. There are no laboratory parameters that are sufficiently accurate to conclusively identify the presence or absence of ischemic or necrotic bowel, although elevated l-lactate, leukocytosis, and D-dimer may assist. (Weak recommendation based on moderate-quality evidence 2B)
  沒有足夠準確的實驗室參數來最終確定是否存在缺血性或壞死性腸，儘管升高的 L-乳酸、白細胞增多和 D-二聚體可能會有所説明。（基於中等質量證據 2B 的弱推薦）

Although laboratory results are not definitive, they may help to corroborate clinical suspicion. More than 90% of patients will have an abnormally elevated leukocyte count [48]. The second most commonly encountered abnormal finding is metabolic acidosis with elevated lactate level, which occurs in 88% [49].
雖然實驗室結果不是確定的，但可能有助於證實臨床懷疑。超過 90%的患者白細胞計數異常升高[48]。第二常見的異常表現是代謝性酸中毒伴乳酸水準升高，88%發生率[49]。

Patients may present with lactic acidosis due to dehydration and decreased oral intake. Thus, differentiation of early ischemia versus irreversible bowel injury based upon the lactate level alone is not reliable unless accompanied by other clinical evidence. Elevated serum lactate levels > 2 mmol/l is associated with irreversible intestinal ischemia hazard ratio: 4.1 (95% CI: 1.4–11.5; p < 0.01) in case of AMI [50].
患者可能因脫水和口服攝入量減少而出現乳酸性酸中毒。因此，除非有其他臨床證據，否則僅根據乳酸水準區分早期缺血與不可逆性腸損傷是不可靠的。血清乳酸水準升高 > 2 mmol/l 與不可逆的腸缺血風險比：4.1（95% CI：1.4–11.5;p < 0.01）在 AMI 的情況下[50]。

It should be emphasized that the presence of lactic acidosis in combination with abdominal pain when the patient may not otherwise appear clinically ill should lead to consideration of early CTA.
應該強調的是，當患者可能沒有臨床疾病時，乳酸性酸中毒合併腹痛的存在應導致早期 CTA 的考慮。

Based on the current literature, no accurate biomarkers have been identified to diagnose AMI [51, 52]. D-dimer has been reported to be an independent risk factor for intestinal ischemia [52], reflecting ongoing clot formation and endogenous degradation via fibrinolysis. No patient presenting with a normal D-dimer had intestinal ischemia and D-dimer > 0.9 mg/L had a specificity, sensitivity, and accuracy of 82%, 60%, and 79%, respectively [53]. Thus, D-dimer may be useful in the early assessment.
根據目前的文獻，尚未確定準確的生物標誌物來診斷 AMI [51， 52]。據報導，D-二聚體是腸缺血的獨立危險因素[52]，反映了持續的凝塊形成和通過纖維蛋白溶解的內源性降解。D-二聚體正常的患者沒有腸缺血，D-二聚體> 0.9mg /L 的特異性、敏感性和準確度分別為 82%、60%和 79%[53]。因此，D-二聚體可能在早期評估中有用。

Elevated amylase has been reported in roughly a half of patients with AMI. [54] This is important to note to as patient may be misdiagnosed as having acute pancreatitis, and delay in critical interventions could impact survival outcomes.
據報導，大約一半的 AMI 患者澱粉酶升高。[54]這一點很重要，因為患者可能會被誤診為急性胰腺炎，關鍵干預的延遲可能會影響生存結果。

Other biomarkers reported to be of use in the diagnosis of AMI include intestinal fatty acid-binding protein (I-FABP), serum alpha-glutathione S-transferase (alpha-GST), and cobalt–albumin binding assay (CABA) [55, 56]. A cross-sectional diagnostic study of 129 patients admitted for acute abdominal pain found that the three most promising circulating biomarkers for AMI—citrulline, I-FABP, and d-lactate—were neither sensitive nor specific enough for the differential diagnosis of AMI [57].
據報導，其他可用於診斷 AMI 的生物標誌物包括腸道脂肪酸結合蛋白（intestary fatty acid-binding protein， I-FABP）、血清α-谷胱甘肽 S-轉移酶（sluum α-glutathione S-transferase， alpha-GST）和鈷-白蛋白結合試驗（cobalt-albumin binding assay， CABA）[55， 56]。一項 橫斷面診斷研究納入了 129 例急性腹痛患者，發現 AMI 最有希望的 3 種迴圈生物標誌物——瓜氨酸、I-FABP 和 d-乳酸——對於 AMI 的鑒別診斷既不敏感也不夠特異[57]。

These results, however, contrast with other published reports [56, 58]. This could be explained by selection bias (established severe AMI cases were included) leading to an overestimated performance of the studied biomarkers.
然而，這些結果與其他已發表的報告形成鮮明對比[56,58]。 這可以通過選擇偏差（包括已確定的嚴重 AMI 病例）導致高估所研究生物標誌物的性能來解釋。

• 5. Computed tomography angiography (CTA) should be performed without delay in any patient with suspicion for AMI. (Strong recommendation based on high-quality evidence 1A)
  對於任何懷疑 AMI 的患者，都應立即進行電腦斷層掃描血管造影 （CTA）。（基於高質量證據 1A 的強烈推薦）

Delay in diagnosis is the dominant factor that accounts for high mortality rates of 30–70% despite increased knowledge of this entity [59, 60]. Every 6 h of delay in diagnosis (actually—delay in CTA) doubles mortality [61]. The multidetector CTA has replaced formal angiography as the diagnostic study of choice. Volume rendering is now a semiautomatic workflow component of many CT machines. These can aid remote communities with less experienced staff.
儘管對這一實體的瞭解有所增加，但延遲診斷是導致 30-70% 高死亡率的主要因素 [59， 60]。診斷每延遲 6 小時（實際上是 CTA 延遲），死亡率就會增加一倍[61]。多檢測器 CTA 已取代正式血管造影，成為首選的診斷研究。體積渲染現在是許多 CT 機器的半自動工作流程元件。這些可以幫助員工經驗不足的偏遠社區。

In the presence of advanced AMI, the CTA findings reflect irreversible ischemia (intestinal dilatation and thickness, reduction or absence of visceral enhancement, pneumatosis intestinalis, and portal venous gas, especially the combination of all) and free intraperitoneal air [62].
在存在晚期 AMI 的情況下，CTA 表現反映了不可逆的缺血（腸道擴張和增厚、內臟增強減少或無、腸充氣和門靜脈氣體，尤其是全部合併）和腹腔內遊離空氣[62]。

Comprehensive biphasic CTA includes the following important steps:
全面的雙相 CTA 包括以下重要步驟：

• (a)  （一） Pre-contrast scans to detect vascular calcification, hyper-attenuating intravascular thrombus, and intramural hemorrhage.
  造影前掃描以檢測血管鈣化、過度減弱的血管內血栓和壁內出血。

• (b)  （二） Arterial and venous phases to demonstrate thrombus in the mesenteric arteries and veins, abnormal enhancement of the bowel wall, and the presence of embolism or infarction of other organs.
  動脈和靜脈期顯示腸系膜動脈和靜脈血栓、腸壁異常增強以及存在其他器官栓塞或梗塞。

• (c)  （三） Multiplanar reconstructions (MPR) to assess the origin of the mesenteric arteries [63].
  多平面重建（Multiplanar reconstructions， MPR）評估腸系膜動脈起源[63]。

The oral contrast is not indicated and even harmful. CTA should be performed despite the presence of acute kidney injury, as the consequences of delayed or missed diagnosis are far more detrimental for patients than exposure to the iodinated contrast agent. A recent study found that in 27 of 28 patients (96.4%) MDCT correctly diagnosed AMI (specificity of 97.9%) [27, 64]. A sensitivity of 93%, specificity of 100%, and positive and negative predictive values of 100% and 94%, respectively, were achieved [65, 66].
口服造影劑沒有指示，甚至有害。儘管存在急性腎損傷，仍應進行 CTA，因為延遲或漏診的後果對患者的危害遠大於接觸碘造影劑。最近的一項研究發現，在 28 名患者中，有 27 名（96.4%）MDCT 正確診斷了 AMI（特異性為 97.9%）[27,64]。 靈敏度為 93%，特異性為 100%，陽性和陰性預測值分別為 100%和 94%[65,66]。

Six radiological findings (bowel loop dilatation, pneumatosis intestinalis, SMV thrombosis, free intraperitoneal fluid, portal vein thrombosis, and splenic vein thrombosis) were found to be predictors of bowel necrosis in patients with AMI [67]. The clinical significance of pneumatosis intestinalis as a single radiological finding remains the challenge. In a biggest multicentral retrospective study, 60% of patients had benign disease [68].
研究發現，6 種影像學表現（腸袢擴張、腸充氣、SMV 血栓形成、遊離腹腔內積液、門靜脈血栓形成和脾靜脈血栓形成）是 AMI 患者腸壞死的預測因數[67]。腸充氣作為單一放射學發現的臨床意義仍然是一個挑戰。一項規模最大的多中心回顧性研究顯示，60%的患者為良性[68]。

In NOMI, CTA may demonstrate bowel ischemia and free fluid in the face of patent mesenteric vessels. In MVT, the most common positive radiological finding on venous phase CTA is thrombus in the superior mesenteric vein described as the target sign [69].
在 NOMI 中，CTA 可能在腸系膜血管未閉時表現出腸缺血和遊離液體。在 MVT 中，靜脈期 CTA 最常見的陽性影像學表現是腸系膜上靜脈血栓，被描述為目標體征[69]。

Associated findings that suggest MVT include bowel wall thickening, pneumatosis, splenomegaly, and ascites [69]. Portal or mesenteric venous gas strongly suggests the presence of bowel infarction.
提示 MVT 的相關表現包括腸壁增厚、充氣、脾腫大和腹水[69]。門靜脈或腸系膜靜脈氣體強烈提示存在腸梗死。

Diagnostic angiography can differentiate occlusive, embolic, and thrombotic from non-occlusive AMI.
診斷性血管造影可以區分閉塞性、栓塞性和血栓性 AMI 與非閉塞性 AMI。

Duplex ultrasonography has a limited role in this entity, but may be helpful if obtained early in chronic cases [47]. It could be useful to monitor the bowel’s peristalsis or the amount of free peritoneal fluid especially in NOMI.
雙工超聲檢查在該實體中的作用有限，但如果在慢性病例中及早進行，可能會有所説明[47]。監測腸道蠕動或遊離腹膜液量可能很有用，尤其是在 NOMI 中。

MRA is an established technique in the evaluation of the mesenteric arterial and venous vasculature in patients with suspected AMI. It has been well accepted for chronic mesenteric ischemia cases and functional assessment of bowel insufficiency as a result of SMA pathology [70]. Nevertheless, its use is limited in the emergency setting.
MRA 是評估疑似 AMI 患者腸系膜動脈和靜脈脈管系統的一種成熟技術。它已被廣泛接受用於慢性腸系膜缺血病例和 SMA 病理導致的腸功能不全的功能評估 [70]。然而，它在緊急情況下的使用受到限制。

• 6. Non-occlusive mesenteric ischemia (NOMI) should be suspected in critically ill patients with abdominal pain or distension requiring vasopressor support and evidence of multiorgan dysfunction. (Weak recommendation based on low-quality evidence 2C)
  對於需要血管加壓藥支援且有多器官功能障礙證據的腹痛或腹脹的危重患者，應懷疑非閉塞性腸系膜缺血 （NOMI）。（基於低質量證據 2C 的弱推薦）

Clinical examination and routine laboratory tests are of only little value in reaching an early and reliable diagnosis of NOMI. Unexplained abdominal distension or gastrointestinal bleeding may be the only signs of acute intestinal ischemia in NOMI and may be undetectable in sedated patients in the ICU in approximately 25% of cases [71, 72]. Patients surviving cardiopulmonary resuscitation who develop bacteremia and diarrhea should be suspected of having NOMI, regardless of presence or absence of abdominal pain. Right-sided abdominal pain associated with the passage of maroon or bright red blood in the stool is highly suggestive of NOMI.
臨床檢查和常規實驗室檢查對於早期可靠診斷 NOMI 的價值很小。不明原因的腹脹或消化道出血可能是 NOMI 急性腸缺血的唯一體征，在 ICU 中約 25%的鎮靜患者中可能檢測不到[71,72]。 心肺復甦倖存的患者出現菌血症和腹瀉，無論是否存在腹痛，都應懷疑患有 NOMI。與糞便中栗色或鮮紅色血液排出相關的右側腹痛高度提示 NOMI。

Gastrointestinal perfusion is often impaired early in critical illnesses, major surgery, or trauma, all of which are characterized by increased demands on the circulation to maintain tissue oxygen delivery [73].
在危重疾病、大手術或創傷的早期，胃腸道灌注常常受損，其特徵是維持組織氧輸送的迴圈需求增加[73]。

Most of the symptoms listed in this section are often not clinically apparent in a critically ill and ventilated patients. Accordingly, any negative changes in a patient's physiology, including new onset of organ failure, increase in vasoactive support, and nutrition intolerance, should raise the suspicion of AMI.
本節中列出的大多數癥狀在危重和通氣患者中通常在臨床上並不明顯。因此，患者生理機能的任何負面變化，包括新發器官衰竭、血管活性支援增加和營養不耐受，都應引起 AMI 的懷疑。

Experimental and observational studies suggest that the use of vasopressors such as norepinephrine and epinephrine might result in impaired mucosal perfusion [74, 75]. Other pharmacological agents such as vasopressin and digoxin [76] as well as acute profound hypovolemia could also worsen ischemia.
實驗和觀察性研究表明，使用去甲腎上腺素和腎上腺素等血管加壓藥可能會導致粘膜灌注受損[74,75]。 其他藥物，如加壓素和地高辛[76]，以及急性深度低血容量，也可能加重缺血。

Lastly, the role of enteral nutrition in critically ill patients on development of intestinal ischemia is controversial. In general, enteral and parenteral nutrition is complementary to meet patient’s daily caloric requirements. In the recent randomized controlled trial “NUTRIREA 2” [77], enteral nutrition was compared to parenteral nutrition: Mortality did not differ between the two groups, but a significantly higher rate of bowel ischemia was reported in the enteral group.
最後，腸內營養在危重患者中對腸缺血發展的作用存在爭議。一般來說，腸內和腸外營養是互補的，可以滿足患者的日常熱量需求。在最近的隨機對照試驗“NUTRIREA 2”[77]中，將腸內營養與腸外營養進行了比較：兩組之間的死亡率沒有差異，但腸內組的腸缺血率明顯更高。

• 7. When the diagnosis of AMI is made, fluid resuscitation should commence immediately to enhance visceral perfusion. Electrolyte abnormalities should be corrected, and nasogastric decompression initiated. (Strong recommendation based on moderate-quality evidence 1B)
  診斷為 AMI 后，應立即開始液體復甦，以增強內臟灌注。應糾正電解質異常，並開始鼻胃管減壓。（基於中等質量證據 1B 的強烈推薦）

Fluid resuscitation with crystalloid and blood products is essential for the management of the patient with suspected AMI. Preoperative resuscitation is important to prevent cardiovascular collapse on induction of anesthesia. To guide effective resuscitation, early hemodynamic monitoring should be implemented [78]. Assessment of electrolyte levels and acid–base status should be performed. This is especially true in patients with AMI, where severe metabolic acidosis and hyperkalemia may result from underlying bowel infarction and reperfusion [79]. Vasopressors should be used with caution. Dobutamine, low-dose dopamine, and milrinone to improve cardiac function have been shown to have less impact on mesenteric blood flow [80, 81]. The fluid volume requirement in these patients may be high, due to extensive capillary leakage, but the infusion of large volume of crystalloid should be utilized carefully to optimize bowel perfusion [82]. The goals of therapy should address physiologic levels of oxygen delivery with continued monitoring of lactate level as an indication of perfusion improvement. Supra-physiologic level of oxygen delivery was suggested in the past which is not supported by the current evidence [83].
使用晶體液和血液製品進行液體復甦對於疑似 AMI 患者的治療至關重要。術前復甦對於防止麻醉誘導時心血管衰竭很重要。為了指導有效的復甦，應實施早期血流動力學監測[78]。應評估電解質水準和酸鹼狀態。AMI 患者尤其如此，嚴重代謝性酸中毒和高鉀血症可能由潛在的腸梗死和再灌注引起[79]。血管加壓藥應謹慎使用。多巴酚丁胺、低劑量多巴胺和米力農改善心功能已被證明對腸系膜血流的影響較小[80,81]。 由於毛細血管大量滲漏，這些患者的液體量需求可能較高，但應謹慎使用大量晶體液以優化腸灌注[82]。治療目標應解決氧輸送的生理水準，並持續監測乳酸水準作為灌注改善的指標。過去有人提出超生理水準的氧氣輸送，但目前的證據並不支援[83]。

• 8. Broad-spectrum antibiotics should be immediately administered. (Strong recommendation based on moderate-quality evidence 1C)
  應立即給予廣譜抗生素。（基於中等質量證據 1C 的強烈推薦）

The high risk of infection among patients with AMI outweighs the risks of acquired antibiotic resistance, and therefore, broad-spectrum antibiotics should be administered early in the course of treatment [84]. Intestinal ischemia leads to early loss of the mucosal barrier, which facilitates bacterial translocation and the risk of septic complications. Antibiotic therapy should be administered for at least 4 days in immunocompetent stable patients with consideration given to a longer duration of therapy for signs of ongoing infection [85]. As soon as possible, antibiotic regimen should be tailored according to the microbial isolation. Prolonged course of empiric antibiotics, if clinically deemed necessary, should be guided in accordance with local antibiotic stewardship team.
AMI 患者的感染風險高於獲得性抗生素耐葯的風險，因此應在治療過程早期給予廣譜抗生素[84]。腸缺血導致粘膜屏障過早喪失，從而促進細菌易位和膿毒症併發症的風險。對於免疫功能正常、穩定的患者，抗生素治療應至少 4 日，如果出現持續感染的徵象，應考慮延長治療時間[85]。應儘快根據微生物分離情況調整抗生素方案。如果臨床認為有必要，應根據當地抗生素管理團隊進行指導，延長經驗性抗生素療程。

• 9. Prompt laparoscopy/laparotomy should be done for patients with an overt peritonitis. (Strong recommendation based on low-quality evidence 1C)
  對於明顯性腹膜炎的患者，應及時進行腹腔鏡檢查/剖腹手術。（基於低質量證據 1C 的強烈推薦）

When physical findings suggestive of an acute intraabdominal catastrophe are present, bowel infarction has already occurred, and the chance of survival in this patient population with significant associated comorbidity is reduced dramatically. Peritonitis secondary to bowel necrosis mandates surgery without delay.
當存在提示急性腹腔內災難的體格檢查結果時，腸梗死已經發生，並且該具有顯著相關合併症的患者群體的生存機會顯著降低。繼發於腸壞死的腹膜炎需要立即進行手術。

The goal of surgical intervention for AMI includes:
AMI 手術干預的目標包括：

• 1) Re-establishment of the blood supply to the ischemic bowel.
  重建缺血性腸的血液供應。

• 2) Resection of all non-viable regions.
  切除所有不可存活的區域。

• 3) Preservation of all viable bowel.
  保存所有活腸。

Intestinal viability is the most important factor influencing outcome in patients with AMI. Non-viable intestine, if unrecognized, results in multisystem organ dysfunction and ultimately death. Prompt laparotomy allows for direct assessment of bowel viability.
腸道活力是影響 AMI 患者預後的最重要因素。如果不被識別，無法存活的腸道會導致多系統器官功能障礙並最終死亡。及時剖腹手術可以直接評估腸道活力。

Emergency laparotomy  緊急剖腹手術

After initial resuscitation, midline laparotomy should be performed, followed by the assessment of all areas of the intestine with decisions for resection of all frankly necrotic areas. The SMA is easily palpated by placing fingers behind the root of the mesentery. The SMA is identified as a firm tubular structure, which may have or not a palpable pulse. Otherwise, the SMA can also be reached by following the middle colic artery where it enters the SMA at the mesentery. Direct sharp dissection, exposing the artery from its surrounding mesenteric tissue, is required for proper exposure to perform revascularization. In cases where there is diagnostic uncertainty, arteriogram is the study of choice. It can be done intraoperatively especially in hybrid suites. Intraoperative duplex is a simple, rapid, repeatable, and often definitive alternative diagnostic modality.
初次復甦後，應進行中線剖腹手術，然後評估腸道的所有區域，並決定切除所有坦率的壞死區域。將手指放在腸系膜根部後面很容易觸診 SMA。SMA 被確定為堅固的管狀結構，可能有或沒有可觸及的脈搏。否則，也可以通過沿著中絞痛動脈到達 SMA，在腸系膜處進入 SMA。需要直接銳利的夾層，將動脈從周圍的腸系膜組織中暴露出來，以便正確暴露以進行血運重建。在診斷不確定的情況下，動脈造影是首選研究。它可以在術中進行，尤其是在混合套房中。術中雙聯手術是一種簡單、快速、可重複且通常具有明確性的替代診斷方式。

Re-establishment of the blood supply to the ischemic bowel
重建缺血性腸的血液供應

Revascularization when relevant has an essential role in the multidisciplinary approach to AMI. As an example, among the 104 patients who did not undergo revascularization, 64 (62%) died within 30 days compared to 36 out of 85 (42%) patients who were re-vascularized (p = 0.01) [86].
血運重建（如果相關）在 AMI 的多學科方法中起著至關重要的作用。例如，在 104 例未進行血運重建的患者中，64 例（62%）在 30 日內死亡，而 85 例（42%）患者中，血運重建患者中有 36 例（42%）死亡（p = 0.01）[86]。

Different techniques of blood flow restoration are used depending on the AMI pathophysiology. Embolectomy and angioplasty are a well-established definitive treatment for SMA emboli. On the other hand, thrombosis of the SMA at the origin of the aorta (a common pathology in diffuse atherosclerosis) will require a bypass procedure. Bypass may be performed in either an antegrade fashion from the supraceliac aorta or retrograde fashion from the infrarenal aorta or common iliac arteries. Single-vessel revascularization (SMA) is usually sufficient in the acute setting. However, it increases the magnitude of the procedure and may require prosthetics in the presence of contaminated field. Nowadays endovascular procedures reduce the requirement for surgical bypasses. Thus, multidisciplinary collaborative approach including specialists from multiple disciplines is integral for good clinical outcomes.
根據 AMI 病理生理學，使用不同的血流恢復技術。栓塞切除術和血管成形術是 SMA 栓子的行之有效的根治性治療方法。另一方面，主動脈起點的 SMA 血栓形成（瀰漫性動脈粥樣硬化的常見病理）將需要搭橋手術。搭橋術可以從顱上主動脈順行方式進行，也可以從腎下主動脈或髂總動脈逆行方式進行。在急性情況下，單血管血運重建 （SMA） 通常就足夠了。然而，它增加了手術的規模，並且可能需要在存在受污染的場的情況下使用假肢。如今，血管內手術減少了對手術搭橋手術的需求。因此，包括來自多個學科的專家在內的多學科協作方法對於良好的臨床結果至關重要。

Temporary SMA shunting may spare considerable bowel. For patients in extremis, or where the necessary technical skillset is not available, temporary SMA shunting should be considered.
臨時 SMA 分流可能會節省相當大的腸道。對於處於極端狀態或無法獲得必要技術技能的患者，應考慮臨時 SMA 分流。

Neither NOMI nor MVT typically requires vascular repair. Full-dose anticoagulation should be initiated on all patients prior to the surgical procedure. Unfractionated heparin is effective and easy to manage, especially in patients with acute kidney failure.
NOMI 和 MVT 通常都不需要血管修復。在手術前，所有患者都應開始全劑量抗凝治療。普通肝素有效且易於管理，特別是對於急性腎功能衰竭患者。

Intraoperative bowel viability assessment
術中腸道活力評估

There are limited intraoperative tools to help surgeons in decision making regarding bowel viability, especially in circumstances in which the bowel appears to be “dusky” or threatened but not clearly ischemic. In this case, a temporary abdominal closure via a negative pressure wound therapy device or temporary dressing (custom made with plastic sheets, gauzes, and drains) is convenient in order to provide an opportunity for a second-look surgery. Clear documentation of bowel length is crucial in every operation note.
術中工具有限，可以説明外科醫生做出有關腸道活力的決策，尤其是在腸道看起來“暗淡”或受到威脅但沒有明顯缺血的情況下。在這種情況下，通過負壓傷口治療裝置或臨時敷料（用塑膠布、紗布和引流管定製）進行臨時腹部閉合很方便，以便為二次手術提供機會。清晰記錄腸長在每個手術記錄中都至關重要。

In addition to traditional surgical inspection of the bowel, available techniques of intraoperative assessment of bowel viability rely on bowel oxygenation, myoelectric activity, and perfusion. The intraoperative absence of any one of these criteria is a sufficient predictor of bowel non-viability.
除了傳統的腸道手術檢查外，術中評估腸道活力的現有技術還依賴於腸道氧合、肌電活動和灌注。術中缺乏這些標準中的任何一項都足以預測腸道無法存活。

Many surgeons use their hands and eyes to look for the presence or absence of peristalsis or mesenteric pulsation to evaluate whether blood flow is adequate.
許多外科醫生用手和眼睛尋找是否存在蠕動或腸系膜搏動，以評估血流是否充足。

Doppler ultrasonography (DUS) is a safe and noninvasive technique to measure blood flow and is popular for its easiness of use and relatively low cost [87].
多普勒超聲檢查（Doppler ultrasonography， DUS）是一種安全、無創的血流量測量技術，因其易於使用和成本相對較低而廣受歡迎[87]。

Flowmetry with fluorescein dye is currently part of the accepted standard of clinical care for intraoperative assessment of bowel viability. Fluorescein can therefore be used to visualize perfusion in open laparotomies using a Woods Lamp or laparoscopically using an endoscope with appropriate filters [88, 89].
螢光素染料血流法目前是公認的臨床護理標準的一部分，用於術中評估腸道活力。因此，螢光素可用於使用伍茲燈觀察開放式剖腹手術中的灌注情況，或使用帶有適當篩檢程式的內窺鏡進行腹腔鏡觀察[88,89]。

Indocyanine Green (ICG) is a near-infrared (NIR) fluorophore with an emission peak of 832 nm in whole blood [90]. It has been used in the same way as fluorescein, but primarily in the elective surgical setting [91]. ICG utilization in the emergent setting, particularly in AMI, has not been well investigated to date, although early animal models, isolated cases, and cohort studies show promise.
吲哚菁綠（Incog）是一種近紅外螢光團，在全血中的發射峰為 832nm[90]。它的使用方式與螢光素相同，但主要用於擇期手術[91]。迄今為止，ICG 在緊急環境中的使用，特別是在 AMI 中的應用尚未得到很好的研究，儘管早期動物模型、孤立病例和佇列研究顯示出希望。

The potential for combining modalities for intraoperative bowel assessment warrants further studies [92].
術中腸道評估聯合方式的潛力值得進一步研究[92]。

Laparoscopy in AMI  AMI 中的腹腔鏡檢查

Diagnostic laparoscopy is feasible as a bedside procedure in the intensive care unit (ICU) with the advantage of avoiding time delay for awaiting operating room availability and preventing adverse events during critically ill patients transfer. However, the routine use of diagnostic laparoscopy in AMI has not been generally adopted [6].
診斷性腹腔鏡檢查可作為重症監護病房 （ICU） 的床邊手術，其優點是避免等待手術室可用性的時間延遲並防止危重患者轉移期間的不良事件。然而，診斷性腹腔鏡檢查在 AMI 中的常規應用尚未被普遍採用[6]。

When a second-look surgery is indicated, second-look laparoscopy may be a useful alternative to conventional surgery, because it prevents critically ill patients from the trauma and risks of relaparotomy and can be performed as an ICU bedside operation. In one study, only 20% of patients underwent a second-look laparoscopy within first 72 h, but this did not change the outcome and complication rate [93]. In another case series, non-therapeutic laparotomy was avoided in 9/20 patients with NOMI [94].
當需要進行二次手術時，二次腹腔鏡檢查可能是傳統手術的有用替代方案，因為它可以防止危重患者免受再剖腹手術的創傷和風險，並且可以作為 ICU 床邊手術進行。一項研究顯示，只有 20%的患者在前 72h 內接受了腹腔鏡二次檢查，但這並沒有改變結局和併發症發生率[93]。在另一個病例系列中，9/20 例 NOMI 患者避免了非治療性剖腹手術[94]。

The European Association for Endoscopic Surgery (EAES) consensus for the laparoscopic approach to the acute abdomen states that there is no published data demonstrating advantages in the diagnosis and treatment of acute bowel ischemia by laparoscopy [95]. However, laparoscopy can be useful in confirming the diagnosis in doubtful cases, evaluate the extension of the ischemic small bowel segment, and offer a treatment option in cases of segmental necrosis.
歐洲內鏡外科協會（European Association for Endoscopic Surgery， EAES）對腹腔鏡急腹症的共識指出，尚無已發表的數據表明腹腔鏡診斷和治療急性腸缺血具有優勢[95]。然而，腹腔鏡檢查可用於在可疑病例中確認診斷，評估缺血性小腸段的擴展，並在節段壞死的情況下提供治療選擇。

In addition, post-cardiac surgery patients admitted to the ICU have a relatively high rate of NOMI, where the CT-scan can be equivocal. In these cases, bedside diagnostic laparoscopy may be a safe and effective procedure that avoids needless laparotomy and can direct further management steps [96].
此外，入住 ICU 的心臟手術後患者的 NOMI 發生率相對較高，其中 CT 掃描可能模棱兩可。在這些情況下，床旁診斷性腹腔鏡檢查可能是一種安全有效的手術，可以避免不必要的剖腹手術，並可以指導進一步的治療步驟[96]。

• 10. Endovascular revascularization procedures are the primary option in cases of arterial occlusion when sufficient expertise is available. (Strong recommendation based on low-quality evidence 1C)
  在有足夠專業知識的情況下，血管內血運重建手術是動脈閉塞病例的主要選擇。（基於低質量證據 1C 的強烈推薦）

Endovascular techniques have become popular in revascularization of the SMA. No randomized control trial has been performed to assess and compare open surgery to an endovascular approach, as patients with AMI are very heterogenic and physiologically different [97]. Much controversy surrounds the use of endovascular techniques as primary management of AMI [98]. Some studies report lesser need for laparotomy, less bowel resection, and significantly lower mortality rate with endovascular techniques compared to surgery [99].
血管內技術在 SMA 血運重建中變得流行。目前尚無隨機對照試驗來評估和比較開放手術與血管內入路，因為 AMI 患者異質性很強，生理上也不同[97]。血管內技術作為 AMI 的主要治療存在很多爭議[98]。一些研究報告稱，與手術相比，血管內技術對剖腹手術的需求更少，腸切除術更少，死亡率也顯著降低[99]。

Open surgery is effective in assessing the viability of the bowel and hence preventing delay in revascularization especially when an endovascular approach is unavailable [1].
開放手術可有效評估腸道的活力，從而防止血運重建延遲，尤其是在無法進行血管內入路時[1]。

Different endovascular procedures are summarized in Table 2.
表 2 總結了不同的血管內手術。

Table 2 Endovascular procedures in occlusion of SMA
表 2 SMA 閉塞的血管內手術

Comparison of endovascular intervention and surgery
血管內介入治療與手術的比較

Publications related to endovascular treatment of AMI have been evolving since 2010 [11, 12]. Several observational studies and meta-analyses comparing the outcomes of endovascular interventions and surgery have been published [13, 107,108,109,110].
自 2010 年以來，與 AMI 血管內治療相關的出版物一直在不斷發展 [11， 12]。已經發表了幾項比較血管內介入治療和手術結局的觀察性研究和 meta 分析[13,107,108,109,110]。

All studies have shown a benefit for endovascular therapy compared to open surgery in terms of lower bowel resection rates and lower 30-day mortality rates.
所有研究都表明，與開放手術相比，血管內治療在較低的腸切除率和較低的 30 天死亡率方面具有益處。

The latest study using the National Inpatient Sample database included 4665 patients who underwent interventional treatment (24% endovascular and 76% open revascularization) from 2005 through 2009 showed that endovascular intervention is associated with lower mortality compared to open surgery (24.9% vs 39.3%) [111]. Another meta-analysis including nineteen observational studies also showed that endovascular intervention was associated with a lower prevalence of bowel resection (OR 0.45, 95%CI 0.34–0.59) and 30-day mortality (OR 0.45, 95%CI 0.34–0.59) compared with open surgery [112].
一項使用國家住院患者樣本資料庫的最新研究納入了 2005-2009 年接受介入治療（24%為血管內血運重建術，76%為開放性血運重建術）的患者，結果顯示，與開放手術相比，血管內介入治療的死亡率更低（24.9% vs 39.3%）[111]。另一項納入 19 項觀察性研究的 meta 分析也顯示，與開放手術相比，血管內介入治療與腸切除術的患病率（OR 0.45,95%CI 0.34-0.59）和 30 日死亡率（OR 0.45,95%CI 0.34-0.59）相關[112]。

The Guidelines of the European Society of Vascular Surgery showed a pooled overall 30-day mortality rate after endovascular therapy of 17.2% (367/2131), compared to 38.5% after open surgery (1582/4111) [113].
歐洲血管外科學會指南顯示，血管內治療后 30d 總死亡率為 17.2%（367/2131），而開放手術后為 38.5%（1582/4111）[113]。

It is important to note that all studies that were focused on endovascular revascularization have high levels of heterogeneity. It is possible that patients undergoing open repair have more advanced disease resulting in long-segment bowel resection rates and poorer outcome. The 5-year survival following endovascular treatment and open vascular surgery was 40% and 30%, respectively [108].
值得注意的是，所有專注於血管內血運重建的研究都具有高度的異質性。接受開放性修復的患者可能患有更晚期的疾病，導致長段腸切除率和較差的結果。血管內治療和開放血管手術后的 5 年生存率分別為 40%和 30%[108]。

The pooled estimate of technical success of endovascular intervention was 94%, based on a recent meta-analysis [100]. On the other hand, the pooled estimate of the unplanned surgery rate of endovascular therapy was 40%.
根據最近的一項 meta 分析，血管內介入治療技術成功的匯總估計為 94%[100]。另一方面，血管內治療計劃外手術率的匯總估計值為 40%。

In patients with acute embolic SMA occlusion, there are no data suggesting a superiority of open versus endovascular treatment [114].
在急性栓塞性 SMA 閉塞患者中，沒有數據表明開放治療優於血管內治療[114]。

Aspiration embolectomy with thrombolytic treatment should be considered in patients with no clinical signs of acute peritonitis. In a study that analyzed the Swedish Vascular Registry (SWEDVASC) between 1987 and 2009, 34 patients that received thrombolysis for acute SMA occlusion were identified. In-hospital mortality was 26%, and technical success was 88%. Patients who needed explorative laparotomy after lysis had an in-hospital mortality rate of 38% [102].
對於沒有急性腹膜炎臨床癥狀的患者，應考慮抽吸性栓子切除術和溶栓治療。在一項分析 1987 年至 2009 年間瑞典血管登記處 （SWEDVASC） 的研究中，確定了 34 名因急性 SMA 閉塞而接受溶栓治療的患者。院內死亡率為 26%，技術成功率為 88%。裂解術後需要剖腹探查術的患者院內死亡率為 38%[102]。

Hybrid approach: endovascular intervention and surgery
混合方法：血管內介入治療和手術

Retrograde open mesenteric stenting (ROMS) is an emerging hybrid technique utilized in cases of AMI. This procedure includes a laparotomy and retrograde endovascular revascularization of the superior mesenteric artery [115]. One of the advantages of this method over vascular bypass is significantly shorter operative time. One of the major concerns after stenting is patency. However, patency rates similar to bypass were reported (76–88%) [116].
逆行開放式腸系膜支架置入術 （ROMS） 是一種用於 AMI 病例的新興混合技術。該手術包括剖腹手術和腸系膜上動脈逆行血管內血運重建術[115]。與血管搭橋相比，這種方法的優點之一是手術時間顯著縮短。支架置入術后的主要問題之一是通暢性。然而，據報導，通暢率與旁路相似（76-88%）[116]。

Theoretically, if technical capabilities and infrastructure for hybrid procedures are available, ROMS may be a good treatment option for patients who require laparotomies. It is possible that ROMS may avoid the need for second-look surgeries.
從理論上講，如果混合手術的技術能力和基礎設施可用，ROMS 對於需要剖腹手術的患者來說可能是一個不錯的治療選擇。ROMS 可能會避免需要進行二次檢查。

Centers of excellence equipped with hybrid operating rooms may provide further data supporting the use of an endovascular strategy [117]. The raised awareness of AMI, low threshold for suspicion, immediate CTA with real-time radiology report, and early involvement of senior staff members are increase rapid access and utilization of hybrid operating rooms.
配備混合手術室的卓越中心可以提供進一步的數據，支援血管內策略的使用[117]。對 AMI 意識的提高、懷疑門檻低、具有即時放射學報告的即時 CTA 以及高級工作人員的早期參與，增加了混合手術室的快速訪問和利用率。

• 11. Damage control surgery (DCS) with temporary abdominal closure is an important adjunct for patients who require intestinal resection allowing reassessment of bowel viability and in situations of severe abdominal sepsis. (Strong recommendation based on low-quality evidence 1B)
  臨時腹部閉合損傷控制手術 （DCS） 是需要腸切除術的患者的重要輔助手段，可以重新評估腸道活力和嚴重腹部敗血症的情況。（基於低質量證據 1B 的強烈推薦）

The damage control laparotomy strategy (abbreviated laparotomy) is an accepted technique in trauma care for the past 30 years. It is an important option in the patient with AMI [118]. Damage control is the surgical modality of choice in the critically ill patient with AMI for physiological and technical reasons. The decision to utilize DCS should be made early based upon the response to resuscitation [119]. Advanced age is not a contraindication to DCS as good outcomes have been observed in the elderly [120].
損傷控制剖腹手術策略（縮寫為剖腹手術）是過去 30 年來創傷護理中公認的技術。它是 AMI 患者的重要選擇[118]。損傷控制是 AMI 危重患者出於生理和技術原因的首選手術方式。應根據復甦反應及早決定是否使用 DCS[119]。高齡不是 DCS 的禁忌證，因為在老年人中觀察到良好的預後[120]。

Planned second-look techniques are required after restoration of SMA flow, with or without resection of ischemic bowel (and no anastomosis or stoma) following resuscitation in the ICU [120, 121]. If there is an uncertainty regarding bowel viability, the stapled off bowel ends should be left in discontinuity and re-inspected after a period of continued ICU resuscitation to restore physiological balance. Often, bowel which is borderline ischemic at the initial exploration will improve after restoration of blood supply and physiologic stabilization. Multiple adjuncts have been suggested to assess intestinal viability, but none have proven to be uniformly reliable [122, 123].
在 ICU 復甦后，SMA 血流恢復后需要有計劃的二次檢查技術，有或沒有缺血性腸切除（無吻合或造口）[120,121]。 如果腸道活力存在不確定性，則應將吻合的腸末端保持不連續狀態，並在持續 ICU 復甦一段時間后重新檢查以恢復生理平衡。通常，在初始探查時處於邊緣缺血的腸道在恢復血液供應和生理穩定後會得到改善。有人建議使用多種輔助手段來評估腸道活力，但沒有一種被證明是統一可靠的[122,123]。

Most often, re-exploration should be accomplished within 24–48 h and decisions regarding anastomosis, stoma, or additional resection can be made with plans for sequential abdominal closure.
大多數情況下，重新探查應在 24-48 小時內完成，並且可以通過計劃進行序貫腹部閉合來決定有關吻合、造口或額外切除的決定。

In a review of 43 patients undergoing open mesenteric revascularization, the authors noted that 11 of the 23 patients undergoing a second-look operation required bowel resection [32]. The bowel in these patients is often very swollen and poses a high risk for anastomotic leak. Recent studies suggest that careful hand sewn techniques are preferable to staples use in this group [124, 125].
在一項納入 43 例開放性腸系膜血運重建術的患者中，作者指出，在接受二次檢查的 23 例患者中，有 11 例需要腸切除術[32]。這些患者的腸道通常非常腫脹，吻合口漏的風險很高。最近的研究表明，在這一群體中，仔細的手工縫製技術比使用訂書釘更可取[124,125]。

These patients often suffer from acidosis, hypothermia, and coagulopathy, which require prompt and ongoing correction. Physiologic restoration is multifactorial and includes careful and limited crystalloid infusion to avoid abdominal compartment syndrome, frequent monitoring of lactate clearance and central venous oxygen saturation, and the use of viscoelastic techniques (TEG, ROTEM) to assess coagulation status and guide ongoing blood product administration. Recent evidence suggests that direct peritoneal resuscitation techniques can be useful in this scenario [126, 127].
這些患者經常患有酸中毒、體溫過低和凝血病，需要及時和持續的糾正。生理恢復是多因素的，包括仔細和有限的晶體液輸注以避免腹筋膜室綜合征，經常監測乳酸清除率和中心靜脈血氧飽和度，以及使用粘彈性技術（TEG、ROTEM）來評估凝血狀態並指導持續的血液製品給葯。最近的證據表明，直接腹膜復甦技術在這種情況下可能很有用[126,127]。

• 12. Mesenteric venous thrombosis can often be successfully treated with a continuous infusion of unfractionated heparin. (Strong recommendation based on moderate-quality evidence 1B)
  腸系膜靜脈血栓形成通常可以通過持續輸注普通肝素來成功治療。（基於中等質量證據 1B 的強烈推薦）

MVT has a distinctive clinical finding on CTA scan, and when noted in a patient without findings of peritonitis, non-operative management should be considered. The first line treatment for mesenteric venous thrombosis is anticoagulation. Systemic thrombolytic therapy is rarely indicated. When clinical signs demand operative intervention, one should resect only obviously necrotic bowel utilizing damage control techniques since anticoagulation therapy may improve the clinical picture over the ensuing 24–48 h. Early use of heparin has been associated with improved survival [128].
MVT 在 CTA 掃描上具有獨特的臨床表現，當在沒有腹膜炎發現的患者中發現時，應考慮非手術治療。腸系膜靜脈血栓形成的一線治療是抗凝。很少需要全身溶栓治療。當臨床癥狀需要手術干預時，應僅使用損傷控制技術切除明顯壞死的腸道，因為抗凝治療可能會在隨後的 24-48 小時內改善臨床表現。早期使用肝素與提高生存率有關[128]。

Patients with peritonitis require emergency surgery. Intraoperative management is dictated by the surgical findings ranging from a segmental infarction of small bowel to necrosis of the entire bowel, with or without perforation. The aim of resection is to conserve as much bowel as possible. Second-look laparotomy, 24–48 h later, may avoid the resection of potentially viable bowel. A second-look procedure is mandatory in patients who have extensive bowel involvement.
腹膜炎患者需要緊急手術。術中管理取決於手術結果，從小腸節段性梗死到整個腸道壞死，有或沒有穿孔。切除的目的是盡可能多地保存腸道。24-48小時後進行二次剖腹手術，可避免切除潛在存活的腸。對於腸道廣泛受累的患者，必須進行二次檢查。

There are no high-quality studies suggesting that endovascular therapy has a proven role in the treatment of MVT but may be an option in selected patients not responding to anticoagulation therapy. Most published data on interventional radiological treatments for MVT refer to small case series. The use of systemic intravenous tPA has been successfully reported [129]. Thrombolysis via the SMA is ineffective and associated with an increased risk of bleeding [130]. The role of open surgical thrombectomy in modern practice is uncertain [131].
沒有高品質的研究表明血管內治療在 MVT 的治療中具有證實的作用，但對於抗凝治療無反應的特定患者可能是一種選擇。大多數已發表的關於 MVT 介入放射治療的數據都是小病例系列。全身靜脈注射 tPA 的應用已有成功報導[129]。通過 SMA 進行溶栓無效，並且會增加出血風險[130]。開放式取卵術在現代實踐中的作用尚不確定[131]。

Supportive measures include nasogastric suction, fluid resuscitation, and bowel rest.
支援措施包括鼻胃管抽吸、液體復甦和腸道休息。

• 13. When NOMI is suspected, the focus is to correct the underlying cause and improve mesenteric perfusion. Infarcted bowel should be resected promptly. (Strong recommendation based on low-quality evidence 1C).
  當懷疑 NOMI 時，重點是糾正根本原因並改善腸系膜灌注。梗腸應及時切除。（基於低質量證據 1C 的強烈推薦）。

The central principle of NOMI management is the treatment of the underlying precipitating cause. Fluid resuscitation, optimization of cardiac output, and elimination of vasopressors remain important primary measures. Additional treatment may include systemic anticoagulation (heparin) and the use of catheter-directed infusion of vasodilatory and antispasmodic agents, most commonly papaverine hydrochloride [132]. The decision to intervene surgically is based on the presence of peritonitis, perforation, or overall worsening of the patient’s condition [81].
NOMI 管理的核心原則是治療潛在的誘發原因。液體復甦、優化心輸出量和消除血管加壓藥仍然是重要的主要措施。其他治療可能包括全身抗凝（肝素）和導管定向輸注血管舒張劑和解痙劑，最常見的是鹽酸罌粟鹼[132]。手術干預的決定取決於患者是否存在腹膜炎、穿孔或病情總體惡化[81]。

If a patient presents with peritoneal signs, an exploratory laparotomy is required for resection of frankly necrotic bowel. Unfortunately, these patients are often in critical condition and the mortality remains very high (50–85%) [9]. Damage control surgery is an important adjunct, given the critical state of these patients.
如果患者出現腹膜體征，則需要進行剖腹探查術以切除坦率的壞死腸。不幸的是，這些患者通常病情危重，死亡率仍然很高（50-85%）[9]。鑒於這些患者的危急狀態，損傷控制手術是一項重要的輔助手段。

Direct vasodilator treatment is not commonly used in real-world practice. Despite several clinical guidelines mentioning vasodilator therapy for NOMI [133,134,135], only a few small studies have been published [136, 137]. Direct vasodilator infusion of papaverine into the SMA showed reduced mortality associated with AMI [138]. Another study demonstrated that early treatment with continuous IV prostaglandin E1 (PGE1) reduced mortality in patients with NOMI [136].
直接血管擴張劑治療在實際實踐中並不常用。儘管多項臨床指南提到血管擴張劑治療 NOMI[133,134,135]，但僅發表了少數小型研究[136,137]。 將罌粟鹼直接輸注血管擴張劑到 SMA 中可降低 AMI 相關死亡率[138]。另一項研究表明，早期靜脈注射前列腺素 E1（prostaglandin E1， PGE1）可降低 NOMI 患者的死亡率[136]。

A nationwide study from Japan focused on vasodilator therapy using papaverine, and/or PGE1 in NOMI patients (161 patients vs. 1676 in control group) showed vasodilator therapy was associated with significantly lower in-hospital mortality and need for abdominal surgery [139]. This was a highly selected patient cohort with mild disease.
日本一項全國性研究重點關注 NOMI 患者使用罌粟鹼和/或 PGE1 進行血管擴張治療（161 例患者 vs. 對照組 1676 例），結果顯示血管擴張治療與顯著降低院內死亡率和腹部手術需求相關[139]。這是一個經過精心挑選的輕度疾病患者佇列。

• 14. Postoperative intensive care of AMI patients is directed toward the improved intestinal perfusion and the prevention of a multiple organ failure. (Strong recommendation based on low-quality evidence 1C)
  AMI 患者的術后重症監護旨在改善腸道灌注和預防多器官衰竭。（基於低質量證據 1C 的強烈推薦）

Release of toxic products following bowel resection and restoration of blood flow induce inflammatory processes that can lead to multiorgan failure (MOF) even in the absence of necrotic bowel. Capillary leakage resulting from reperfusion injury leads to volume sequestration into the third space. Systemic hypotension often requires catecholamine administration.
腸切除術和血流恢復后有毒產物的釋放會誘發炎症過程，即使在沒有壞死的腸的情況下，也可能導致多器官衰竭 （MOF）。再灌注損傷導致毛細血管滲漏導致體積隔離到第三空間。全身性低血壓通常需要兒茶酚胺給葯。

In such a scenario, depending on cardiac output and peripheral vascular resistance, a combination of noradrenaline and dobutamine rather than vasopressin should be considered to minimize the possible negative impact on the intestinal microcirculation [140]. Renal replacement therapy, which is often required in case of acute kidney injury, may contribute to hemodynamic stabilization and facilitate optimization of fluid balance. Because of the potential bacterial translocation from the injured gut, broad-spectrum antibacterial treatment according to current guidelines should be continued after surgery based upon the degree of contamination and culture results [141]. Systemic heparin is administered postoperatively (with activated partial thromboplastin time (aPTT) between 40 and 60) in all patients. Low-molecular weight heparin (LMWH) in therapeutic doses is a good alternative if no surgical interventions are planned. Enteral feeding is preferred, but some patients may need parenteral nutrition for a prolonged time due to short bowel and intestinal failure.
在這種情況下，根據心輸出量和外周血管阻力，應考慮聯合使用去甲腎上腺素和多巴酚丁胺，而不是加壓素，以盡量減少對腸道微迴圈可能產生的負面影響[140]。在急性腎損傷的情況下通常需要腎臟替代治療，可能有助於血流動力學穩定並促進體液平衡的優化。由於受傷腸道可能存在細菌易位，術后應根據污染程度和培養結果繼續根據現行指南進行廣譜抗菌治療[141]。所有患者術后給予全身性肝素（活化部分凝血活酶時間 （aPTT） 在 40 至 60 之間）。如果沒有計劃進行手術干預，治療劑量的低分子肝素 （LMWH） 是一個不錯的選擇。腸內餵養是首選，但部分患者可能因腸短和腸衰竭而需要長期腸外營養。

• 15. Treatment of AMI is optimal in a dedicated center using a focused care bundle and a multidisciplinary team. (Strong recommendation based on low-quality evidence 1C)
  AMI 的治療最好在專門的中心使用集中護理包和多學科團隊進行。（基於低質量證據 1C 的強烈推薦）

Recent published evidence suggests that treatment of occlusive AMI in “intestine stroke centers” using a multidisciplinary approach improves outcomes [142, 143]. Improving survival rates can be obtained if mesenteric ischemia is diagnosed and treated early. The goal of multidisciplinary approach is to keep the time to reperfusion as short as possible. The team often includes general surgeon (preferably an emergency surgery specialist), vascular surgeon, interventional radiologist, and intensivist. The concept of “intestinal stroke centers” has been promulgated in France and in China [144, 145].
最近發表的證據表明，在「腸卒中中心」使用多學科方法治療閉塞性 AMI 可改善結局[142,143]。 如果及早診斷和治療腸系膜缺血，可以提高生存率。多學科方法的目標是盡可能縮短再灌注時間。該團隊通常包括普通外科醫生（最好是急診外科專家）、血管外科醫生、介入放射科醫生和重症監護醫師。“腸卒中中心”的概念已在法國和中國頒布[144,145]。

Dedicated “intestinal stroke centers” have highlighted the effectiveness of a multidisciplinary approach focusing on: (1) removal of non-viable ischemic bowel, (2) preservation of intestine with revascularization, and (3) intensive care treatment to prevent progression to multiorgan failure. Utilizing this approach, Corcos et al. reported a 30-day survival of 95% in a small single-center study involving 18 patients presenting with occlusive AMI [146].
專門的「腸中風中心」強調了多學科方法的有效性，重點關注：（1） 切除無法存活的缺血性腸，（2） 通過血運重建保留腸道，以及 （3） 重症監護治療以防止進展為多器官衰竭。Corcos 等人在一項涉及 18 例閉塞性 AMI 患者的小型單中心研究中報告稱，利用這種方法，30 日生存率為 95%[146]。

Recently, an implemented pathway and care bundle for patients with suspected AMI was introduced in Meilahti Helsinki University Hospital [18]. The key aspects of the “bundle” were elevated awareness, rapid diagnostics, and interventions including hybrid OR with endovascular treatment capacity. Patients treated under the bundle protocol were more often diagnosed with CT, had shorter mean in-hospital delay to operating room (median 3 h), and had revascularization done more often. The thirty-day mortality was lower in this group [17 (25%) compared with 23 (51%), p = 0.001] [18].
最近，Meilahti 赫爾辛基大學醫院推出了針對疑似 AMI 患者的實施途徑和護理包[18]。“捆綁”的關鍵方面是提高認識、快速診斷和干預措施，包括具有血管內治療能力的混合手術室。在捆綁方案下治療的患者更常被診斷為 CT，平均住院延遲到手術室的時間更短（中位 3 小時），並且更頻繁地進行血運重建。該組的 30 天死亡率較低[17 例（25%），而 23 例（51%），p=0.001][18]。

Well-designed multidisciplinary teams tend to optimize perioperative care for all involved patients. This includes patients with non-favorable prognosis. Efforts to improve surgical care should employ multidisciplinary teams to promote both quality and cost-effective care.
精心設計的多學科團隊往往會優化所有相關患者的圍手術期護理。這包括預後不良的患者。改善外科護理的努力應採用多學科團隊來促進優質和具有成本效益的護理。

The management of patients with AMI is summarized in Fig. 1
AMI 患者的管理總結如圖。1

• 16. Patients with short bowel syndrome following extensive bowel resection should have restoration of digestive continuity in association with hormonal therapy to optimize absorptive function and achieve nutritional autonomy. (Weak recommendation, low-quality evidence 1C)
  廣泛腸切除術后出現短腸綜合征的患者應恢復消化連續性，並結合激素治療，以優化吸收功能並實現營養自主。（弱推薦，低質量證據 1C）

Fig. 1  圖1

Management algorithm for patients with AMI
AMI 患者的管理演算法

The loss of large amounts of small bowel due to AMI can result in short bowel syndrome (SBS) and intestinal failure. SBS is associated with poor quality of life and a morbidity, which increases with age and comorbidities [147]. Management of patients with SBS can be challenging, especially in case of ostomies with associated large fluid losses and electrolyte imbalances [148]. Studies have shown that sparing the ileocecal valve and the colon is associated with nutritional independency in adults with SBS.
AMI 導致大量小腸丟失可導致短腸綜合征 （SBS） 和腸功能衰竭。SBS 與生活品質差和併發症有關，併發症隨著年齡和合併症的增加而增加[147]。SBS 患者的治療可能具有挑戰性，尤其是造口伴有大量液體丟失和電解質失衡的情況[148]。研究表明，保留回盲瓣和結腸與成人 SBS 的營養獨立性有關。

Recently, the use of synthetic growth agents such as the Glucagon-like peptide-2 (GLP-2) analog teduglutide has substantially changed the management of intestinal failure [149]. Multiple studies have shown that the use of a GLP-2 analog allowed a significant reduction of total parenteral nutrition (TPN) dependence and improved quality of life in patients with intestinal failure [150, 151].
最近，胰高血糖素樣肽-2（GLP-2）類似物替度魯肽等合成生長劑的使用極大地改變了腸衰竭的管理[149]。多項研究表明，使用 GLP-2 類似物可顯著降低腸外營養（TPN）依賴性，改善腸衰竭患者的生活品質[150,151]。

Restoration of bowel continuity following extensive resection will improve functional outcome. If gastrointestinal tract reconstruction is not feasible, patients should be referred early for intestinal transplantation.
廣泛切除后恢復腸道連續性將改善功能結果。如果胃腸道重建不可行，應及早轉診患者進行腸移植。

• 17. In case of massive gut necrosis, a careful assessment of the patients underlying comorbidities and advanced directives is advisable to find the optimal therapeutic strategy which could include palliation. (Weak recommendation, low-quality evidence 1C)
  在大面積腸道壞死的情況下，建議仔細評估潛在的合併症患者和預先指示，以找到最佳治療策略，其中可能包括姑息治療。（弱推薦，低質量證據 1C）

In cases of extensive infarction of most of the small bowel with or without a portion of the colon, the surgeon could face an ethical decision whether to do anything. Resection of the entire involved bowel will result in SBS with serious consequences.
如果大部分小腸大面積梗塞，有或沒有結腸的一部分，外科醫生可能會面臨是否採取任何行動的倫理決定。切除整個受累腸道會導致 SBS，後果嚴重。

The group from the Massachusetts General Hospital observed a decrease in the percentage of patients who underwent operative management of AMI over the last 25 years. This was correlated with an increase in the number of documented increased rates of “comfort measures only” status prior to surgical intervention from 50 to 70% [86].
來自馬薩諸塞州總醫院的小組觀察到，在過去 25 年中接受 AMI 手術治療的患者比例有所下降。這與手術干預前記錄的「僅舒適措施」狀態增加率從 50%增加到 70%相關[86]。

Surgery may not be the best solution especially in elderly frail patients unable to tolerate long-term parenteral nutrition. In this regard, a preoperative discussion with the patient and their family is essential in guiding clinical decisions [152]. Shared decision making is very appropriate for this situation.
手術可能不是最好的解決方案，尤其是對於無法耐受長期腸外營養的老年體弱患者。在這方面，術前與患者及其家屬的討論對於指導臨床決策至關重要[152]。共同決策非常適合這種情況。

• 18. Patients undergoing revascularization should have surveillance imaging and long-term anticoagulation. (Strong recommendation based on moderate-quality evidence 1B)
  接受血運重建的患者應進行監測成像和長期抗凝治療。（基於中等質量證據 1B 的強烈推薦）

The majority of patients treated for AMI will require lifelong anticoagulant/antiplatelet therapy to prevent relapse. In patients following endovascular stent placement, clopidogrel is administered for 6 months and acetylsalicylic acid as lifelong maintenance treatment. However, there is no scientific data on dual antiplatelet therapy after SMA stenting and the recommendation is based on experience from coronary interventions. When recovered following acute illness, most patients can switch to direct oral anticoagulants (DOACs) or vitamin K antagonists (VKA). Anticoagulation is given for 6 months, but most patients with underlying hypercoagulability should be considered for lifelong anticoagulation [113].
大多數接受 AMI 治療的患者需要終生抗凝/抗血小板治療以防止復發。在血管內支架置入術后的患者中，氯吡格雷給葯 6 個月，乙醯水楊酸作為終身維持治療。然而，尚無關於 SMA 支架置入術后雙重抗血小板治療的科學數據，該建議是基於冠狀動脈介入治療的經驗。急性疾病后康復后，大多數患者可以改用直接口服抗凝劑 （DOAC） 或維生素 K 拮抗劑 （VKA）。抗凝治療為期 6 個月，但大多數有基礎高凝的患者應考慮終生抗凝治療[113]。

Continued surveillance for stent or graft restenosis is important, as AMI after mesenteric revascularization accounts for 6–8% of late deaths [153].
持續監測支架或移植物再狹窄很重要，因為腸系膜血運重建后的 AMI 佔晚期死亡的 6-8%[153]。

Patients undergoing revascularization should have surveillance imaging obtained via CTA or duplex ultrasound within 6 months, with frequent follow-up to enable early intervention for recurrent disease [135]. Current Society for Vascular Surgery guidelines recommend duplex ultrasonography at 1, 6, and 12 months after the intervention, and then annually thereafter [154].
接受血運重建的患者應在 6 個月內通過 CTA 或雙工超聲進行監測影像學檢查，並經常隨訪，以便早期干預復發性疾病[135]。目前血管外科學會指南建議在干預后 1、6 和 12 個月進行雙面超聲檢查，此後每年進行一次[154]。

Long-term care should be focused on the patient’s underlying medical comorbidities in order to minimize the risk of relapse. Lifestyle modification as well as management of hyperlipidemia, hypertension, and diabetes is necessary.
長期護理應側重於患者的潛在醫學合併症，以盡量減少復發風險。生活方式的改變以及高脂血症、高血壓和糖尿病的管理是必要的。

All established statements and recommendations are presented in Additional file 1: Table S3.
所有既定的發言和建議載於附加檔 1：表 S3。

Conclusions  結論

AMI is a serious surgical emergency. The most important message is to have a high index of suspicion based on the combination of history of abrupt onset of abdominal pain, acidosis, and organ failure. This clinical scenario should prompt imaging (CTA) in order to establish the diagnosis. In parallel with rapid resuscitation and after careful assessment of the CTA, the patient should be explored to assess bowel viability, re-establish vascular flow, and resect non-viable bowel.
AMI 是一種嚴重的外科急症。最重要的資訊是，根據突然發作的腹痛、酸中毒和器官衰竭的病史，要有高度的懷疑。這種臨床情況應提示影像學檢查 （CTA） 以確定診斷。在快速復甦的同時，在仔細評估 CTA 后，應探索患者以評估腸道活力、重建血管血流並切除無法存活的腸道。

In the operating room, a focus on revascularization should take priority.
在手術室，應優先考慮血運重建。

Classically open revascularization approaches have been used and described, in combination with damage control laparotomy. Recent developments, with improvement in early diagnosis, have allowed endovascular techniques to be implemented. Although evidence for the impact of endovascular interventions is limited at this time, they have apparent advantages over open surgery in some patients.
已經使用和描述了經典的開放血運重建方法，並結合損傷控制剖腹手術。隨著早期診斷的改進，最近的發展使得血管內技術得以實施。儘管目前關於血管內介入治療影響的證據有限，但對於某些患者來說，它們比開放手術具有明顯的優勢。

Preliminary evidence suggests that treatment of AMI in especially dedicated centers using a multidisciplinary approach improves outcomes. The evaluation and treatment of these patients by an interdisciplinary team reduce the time to reperfusion as short as possible.
初步證據表明，在特別專門的中心使用多學科方法治療 AMI 可以改善結果。跨學科團隊對這些患者的評估和治療儘可能縮短再灌注時間。