Surgical decompression for the management of abdominal compartment syndrome with severe acute pancreatitis: A narrative review

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) play a pivotal role in the pathophysiology of severe acute pancreatitis (SAP) and contribute to new-onset and persistent organ failure. The optimal management of ACS involves a multi-disciplinary approach, from its early recognition to measures aiming at an urgent reduction of intra-abdominal pressure (IAP). A targeted literature search from January 1, 2000, to November 30, 2022, revealed 20 studies and data was analyzed on the type and country of the study, patient demographics, IAP, type and timing of surgical procedure performed, post-operative wound management, and outcomes of patients with ACS. There was no randomized controlled trial published on the topic. Decompressive laparotomy is effective in rapidly reducing IAP (standardized mean difference = 2.68, 95% confidence interval: 1.19-1.47, P < 0.001; 4 studies). The morbidity and complications of an open abdomen after decompressive laparotomy should be weighed against the inadequately treated but, potentially lethal ACS. Disease-specific patient selection and the role of less-invasive decompressive measures, like subcutaneous linea alba fasciotomy or component separation techniques, is lacking in the 2013 consensus management guidelines by the Abdominal Compartment Society on IAH and ACS. This narrative review focuses on the current evidence regarding surgical decompression techniques for managing ACS in patients with SAP. However, there is a lack of high-quality evidence on patient selection, timing, and modality of surgical decompression. Large prospective trials are needed to identify triggers and effective and safe surgical decompression methods in SAP patients with ACS.

Abdominal Compartment Syndrome in Acute Pancreatitis: A Narrative Review

Abdominal compartment syndrome (ACS) represents a severe complication of acute pancreatitis (AP), resulting from an acute and sustained increase in abdominal pressure >20 mmHg, in association with new organ dysfunction. The harmful effect of high intra-abdominal pressure on regional and global perfusion results in significant multiple organ failure and is associated with increased morbidity and mortality. There are several deleterious consequences of elevated intra-abdominal pressure on end-organ function, including respiratory, cardiovascular, gastrointestinal, neurologic, and renal effects. It is estimated that about 15% of patients with severe AP develop intra-abdominal hypertension or ACS, with a mortality rate around 50%. The treatment of abdominal compartment syndrome in acute pancreatitis begins with medical intervention and percutaneous drainage, where possible. Abdominal compartment syndrome unresponsive to conservatory treatment requires immediate surgical decompression, along with vacuum-assisted closure therapy techniques, followed by early abdominal fascia closure.

Midline fasciotomy for severe acute pancreatitis with abdominal compartment syndrome: Case report

Introduction and importance

The abdominal compartment syndrome (ACS) is defined as new-onset organ failure induced by sustained elevated intra-abdominal pressure (IAP). Surgical decompression to decrease IAP may be performed in addition to supportive therapy.

Case presentation

A 42-year-old woman with a history of type 2 diabetes, dyslipidemia, alcohol disorder (130 g of daily alcohol intake), and schizophrenia presented to the emergency department with worsening abdominal pain and anorexia for 2 days. On arrival, her Glasgow Coma Scale score was 14 (E3V5M6). Physical examination revealed tachypnea with a respiratory rate of 26 breaths/min; other vital signs were stable. She was diagnosed with severe acute pancreatitis and required massive transfusions to stabilize her hemodynamic status from the time of admission to the intensive care unit (ICU). Acute blood purification was initiated. Bilateral pleural effusions increased from the second day, and despite the evacuation of the intraluminal contents, muscle relaxation was initiated because her IAP had increased to 52 mmHg and remained the same. Therefore, midline fasciotomy was performed instead of a midline incision through the linea alba on day 4, and the patient was managed with negative pressure wound therapy thereafter. Blood purification was completed on day 15, extubation was performed on day 17, and the patient was discharged from the ICU on day 29.

Clinical discussion and conclusion

Midline fasciotomy can have a decompressive effect in patients with primary ACS. This technique may be an alternative to decompressive laparotomy because of its less invasive nature.

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A 42-year-old woman was diagnosed with severe acute pancreatitis.

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Muscle relaxation was initiated because of elevated intra-abdominal pressure.

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Midline fasciotomy was successfully performed instead of a midline incision.

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Midline fasciotomy may be an alternative to decompressive laparotomy.

Prevalence and mortality of abdominal compartment syndrome in severely injured patients: A systematic review

BACKGROUND

Abdominal compartment syndrome (ACS) in severely injured patients is associated with high morbidity and mortality. Many efforts have been made to improve outcome of patients with ACS. A treatment algorithm for ACS patients was introduced on January 1, 2005 by the World Society of the Abdominal Compartment Syndrome. The aim of this study was to determine the prevalence and mortality rate of ACS among severely injured patients before and after January 1, 2005 using a systematic literature review.

METHOD

Databases of Embase, Medline (OvidSP), Web of Science, CINAHL, CENTRAL, PubMed publisher, and Google Scholar were searched for terms related to severely injured patients and ACS. Original studies reporting ACS in trauma patients were considered eligible. Data on study design, population, definitions, prevalence, and mortality rates were extracted. Pooled prevalence and mortality of ACS among severely injured patients were calculated for both time periods using inversed variance weighting assuming a random effects model. Tests for heterogeneity were applied.

RESULTS

A total of 80 publications were included. Prevalence of studies that finished enrolling patients before January 1, 2005 ranged from 0.5% to 36.4% and 0.0% to 28.0% in studies after that date. For severely injured patients admitted to the ICU, this range was 0.5% to 1.3% before 2005 and 0% in one publication in the second time period. For patients with visceral injuries, ACS prevalence ranged 1.0% to 20.0%; one study in the second time period reported 11.1%. The prevalence among severely injured patients who underwent trauma laparotomy ranged from 0.9% to 36.4% in the first time period. Two studies after January 1, 2005 reported ACS prevalence of 2.3% and 13.2%, respectively. The mortality rate in both time periods ranged between 0.0% and 100.0%.

CONCLUSION

The overall prevalence of ACS ranged from 0.0% to 36.4%. Future studies are needed to measure the effect of improved trauma care and effectiveness of the World Society of the Abdominal Compartment Syndrome Consensus Statements.

LEVEL OF EVIDENCE

Systematic review/meta-analysis, level III.

Management of the lower gastrointestinal system in burn: A comprehensive review

BACKGROUND

Burn produces complex gastrointestinal (GI) responses. Treatment, including large volume fluid resuscitation and opioid analgesia, may exacerbate GI dysfunction. Complications include constipation and opioid-induced bowel dysfunction (OBD), acute colonic pseudo-obstruction (ACPO), bacterial translocation and sepsis, and abdominal compartment syndrome (ACS). Contamination of perineal burns contributes to delayed healing, skin graft failure and sepsis and may impact upon morbidity and mortality. The authors carried out a literature review on management of the lower GI system in burn. This study aimed to explain: current prevention and treatment modalities; drawbacks and complications associated with available treatments, and to provide direction for development of best practice guidelines. ACS is associated with high mortality and should be treated with careful fluid resuscitation and diuresis, to minimise and remove oedema.

METHODS

A comprehensive search of English language literature was performed on PubMed, Medline and Embase. Both MeSH and keywords searches were used.

RESULTS

Evidence available on the management of lower gastrointestinal system in burn is summarised. Levels of evidence available are generally low (level III-IV).

CONCLUSION

Structured, graded interventions are required for prevention and treatment of constipation and OBD. Correction of electrolyte imbalance, adequate enteral intake and mobilisation are pre-requisites. Laxatives should be used according to World Gastroenterology Organisation recommendations. Resistant constipation may respond to changes in medication, but ACPO should be suspected and treated when present. Other complications, such as bacterial translocation and ACS are common in major burns. There is evidence that selective digestive tract decontamination reduces mortality and infectious episodes in major burns. ACS is associated with high mortality and should be treated with careful fluid resuscitation and diuresis. Surgery is reserved for non-responsive and severe cases. Perineal burns present challenges in wound and bowel management. Faecal management systems and negative pressure wound therapy (NPWT) may improve wound control and hygiene, but diversion colostomy will still be beneficial in some cases. There is a clear need for rigorous studies to guide practice more effectively in these challenging conditions.

Postinjury abdominal compartment syndrome: from recognition to prevention

Postinjury abdominal compartment syndrome (ACS) is an example of a deadly clinical occurrence that was eliminated by strategic research and focused preventions. In the 1990s, the syndrome emerged with the widespread use of damage control surgery and aggressive crystalloid-based resuscitation. Patients who previously exsanguinated on the operating table made it to intensive care units, but then developed highly lethal hyperacute respiratory, renal, and cardiac failure due to increased abdominal pressure. Among many factors, delayed haemorrhage control and preload driven excessive use of crystalloid resuscitation were identified as modifiable predictors. The surrogate effect of preventive strategies, including the challenge of the 40-year-old standard of large volume crystalloid resuscitation for traumatic shock, greatly reduced cases of ACS. The discoveries were rapidly translated to civilian and military trauma surgical practices and fundamentally changed the way trauma patients are resuscitated today with substantially improved outcomes.

Abdominal decompression in children

Abdominal compartment syndrome (ACS) increases the risk for mortality in critically ill children. It occurs in association with a wide variety of medical and surgical diagnoses. Management of ACS involves recognizing the development of intra-abdominal hypertension (IAH) by intra-abdominal pressure (IAP) monitoring, treating the underlying cause, and preventing progression to ACS by lowering IAP. When ACS is already present, supporting dysfunctional organs and decreasing IAP to prevent new organ involvement become an additional focus of therapy. Medical management strategies to achieve these goals should be employed but when medical management fails, timely abdominal decompression is essential to reduce the risk of mortality. A literature review was performed to understand the role and outcomes of abdominal decompression among children with ACS. Abdominal decompression appears to have a positive effect on patient survival. However, prospective randomized studies are needed to fully understand the indications and impact of these therapies on survival in children.