Abdominal compartment syndrome in severe acute pancreatitis: an indication for a decompressing laparotomy?

BACKGROUND: The currently prevailing paradigm calls for non-operative management of severe acute pancreatitis for as long as there is no evidence of infection. Our purpose in presenting this anecdotal experience is to propose that there is a subset of patients who may need a laparotomy in the absence of infection in order to decompress a clinically significant abdominal compartment syndrome (ACS), which is associated with the acute pancreatitis. METHODS: We present our recent experience with three patients suffering from severe acute pancreatitis. The three developed intra-abdominal hypertension (IAHT) and clinical ACS, which necessitated abdominal decompression and a laparostomy. One patient survived. CONCLUSIONS: The notion that patients with severe acute pancreatitis may develop ACS, which necessitate emergency abdominal decompression, has been ignored by current surgical literature. Only increased awareness to the syndrome of IAHT-ACS in acute pancreatitis and transvesical measurement of intra-abdominal pressure will reveal its prevalence and significance.     

Abdominal compartment syndrome. A still underestimated problem?

The abdominal compartment syndrome (ACS) is a life threatening disorder in critically ill patients caused by rapidly decreasing intra-abdominal pressure (IAP) > 12 mm Hg, which may result in multiple organ dysfunctions with a possibly fatal outcome. Under various causes for the development of an ACS, pelvic trauma, volume resuscitation after severe hemorrhage and reperfusion after aortic aneurysm repair as well as intra-abdominal packing figure at the first place. An increased BMI is a risk factor for patients to suffer from ACS. In addition, excessive volume requirement and significantly increasing airway pressures within the first 24 hrs after admission in the ICU are indicators for an impending ACS. Increased IAP causes venous stasis and arterial malperfusion of all intra- and extra-abdominal organs thus resulting in ischemia, hypoxia and necrosis. In parallel, respiratory, cardiocirculatory, renal, intestinal and cerebral decompensation can be registered. Final multiorgan failure has a mortality around 60-70 %. Timely diagnosis of ACS remains sometimes difficult in spite of clinical indicators such as increased airway pressure, hypoxia, oliguria, shock and acidosis. For the early recognition of intra-abdominal hypertension repetitive measurement of the intra-vesical pressure (> 20 mm Hg) can be helpful. Besides intensive care treatment with artificial ventilation, circulatory support with volume and catecholamines, the decision for a prompt abdominal decompression and open abdominal treatment is life-saving and can preserve further functional damage to vital organ systems.     

Acute compartment syndrome. Who is at risk?

We have analysed associated factors in 164 patients with acute compartment syndrome whom we treated over an eight-year period. In 69% there was an associated fracture, about half of which were of the tibial shaft. Most patients were men, usually under 35 years of age. Acute compartment syndrome of the forearm, with associated fracture of the distal end of the radius, was again seen most commonly in young men. Injury to soft tissues, without fracture, was the second most common cause of the syndrome and one-tenth of the patients had a bleeding disorder or were taking anticoagulant drugs. We found that young patients, especially men, were at risk of acute compartment syndrome after injury. When treating such injured patients, the diagnosis should be made early, utilising measurements of tissue pressure.     

Can secondary extremity compartment syndrome be diagnosed earlier?

BACKGROUND: In 2002, our institution published a 5-year retrospective review of 10 patients who developed secondary extremity compartment syndrome (SECS) with a mortality rate of 70%. Since then, we have aggressively screened for the development of SECS in high-risk patients. We postulate that awareness of SECS and vigilant monitoring for its development would result in earlier diagnosis and treatment and improved outcome. METHODS: Retrospective review of all patients at a level I trauma center developing SECS from 2002 to 2006. Data collected included demographics, mechanism of injury, injury complex, blood transfused prior to development of SECS, affected extremities, creatinine, creatine phosphokinase, management, and outcome. RESULTS: Seventeen of 11,468 trauma patients (.148%) developed SECS. Mean admission hematocrit was 31.7 +/- 8.9, mean admission base deficit was -13.3, mean worst base deficit was -17.8, and average Injury Severity Score was 36.3 +/- 16.6. Patients received 20.9 +/- 11.0 units of blood and 24.6 +/- 14 L of crystalloid prior to the development of SECS. Average time from admission to diagnosis of the SECS was 32.6 hours. Acute renal failure developed in 6 (35%) patients; 4 required dialysis, and 3 died. The number of affected extremities ranged from 1 to 4. Of the 46 affected extremities, 39 were salvaged and 7 required amputation. Mortality was 35.3%. CONCLUSIONS: SECS is an uncommon, but devastating complication in severely injured patients with hypotension undergoing massive transfusion, and developing systemic inflammatory response syndrome. Vigilance increases detection. While the overall mortality was reduced by half, patients requiring dialysis have a 75% mortality.     

Is lymphocele in renal transplantation an avoidable complication?

BACKGROUND: This study evaluated the impact of surgery in the incidence of lymphocele after kidney transplantation (KTx). METHODS: A prospective randomized study was conducted during a 6-year period on a group of patients undergoing KTx and operated on by the same surgeon (CVS). A total of 280 patients undergoing KTx were randomly allocated into two groups: (1) group C (control group) was 140 patients who were submitted to KTx with standard technique: implantation of the kidney in the controlateral iliac fossa with vascular anastomoses on the external iliac vessels; and (2) group M (modified technique group) was 140 patients who underwent a modified technique with a cephalad implantation of the graft in the ipsilateral iliac fossa and vascular anastomoses in the common iliac vessels. Both groups were comparable for age, cold ischemia time, incidence of rejection episodes, presence of adult polycystic kidney disease, and source of donor graft. RESULTS: Group M showed an incidence of lymphocele production (3 patients, 2.1%) significantly lower than group C (12 patients, 8.5%). Eight patients (1 in group M and 7 in group C) required surgical treatment by peritoneal fenestration. No allograft or recipient was lost as a result of fluid collection but the hospitalization was shorter in group M than in group C. CONCLUSIONS: A cephalad implantation of the renal graft in the ipsilateral iliac fossa has been associated with a lower incidence of lymphocele, probably because vascular anastomoses on the common iliac vessels cause less lymphatic derangement than those performed on the external iliac vessels.     

The thickness of the anterior compartment does not indicate compartment syndrome in acutely traumatised legs?

Background

The study was conducted to achieve early detection of increased compartment pressure by comparing the changes between the thickness and pressure within the musculofascial compartments after lower leg injury.

Methods

We included cases of a lower-leg fracture between January and December 2007. Bilateral lower leg compartment pressure and thickness were measured before the surgery and post-anaesthesia, and the surgery was performed within 12 h after the initial trauma. The intracompartment pressure (ICP) was measured with a Wick catheter pressure monitor. The thickness (width) of the anterior compartment of lower leg was measured using ultrasound.

Results

All data were measured within 4–6 h of the injury. The average thickness in injured legs versus uninjured was 30 mm (15–46 mm) versus 20.4 mm (13–30 mm), P < 0.001. The average intracompartment pressure (ICP) in injured leg versus uninjured was 45.3 mmHg (26–80 mmHg) versus 17.5 mmHg (15–20 mmHg), P < 0.001. The thickness and ICP were significantly increased for injured lower legs compared to the uninjured legs, but the increase in ICP did not show a significant relationship with the change in thickness of the injured lower leg.

Conclusion

In this study, the results of ICP and thickness changes of injury lower leg compared with uninjured leg revealed no statistically significant correlation. Some injuries showed a high ICP with only mild changes in thickness, while some showed a high ICP with significant changes. Although ultrasound has many advantages for the evaluation of soft tissue changes after trauma, this study revealed that thickness changes are not a predicable parameter for determining pressure on the acute fracture of lower leg.     

Is postoperative haematoma an avoidable complication of intracranial surgery?

Postoperative intracranial haematoma is a serious complication of intracranial surgery with a mortality rate of around 30%. There have been reports implicating abrupt rises of blood pressure during the last stages or immediately after the procedure, in the production of the clot. This prospective study examined this hypothesis. Over the last 7 years, 526 consecutive patients underwent craniotomy under a strict anaesthesiological protocol based on deep opioid analgesia which virtually eliminated any acute elevations of the arterial pressure during and immediately after craniotomy. Emergence from anaesthesia was delayed for an average of 1 1/2-2 h following the procedure. Postoperative CT was obtained in every patient. There have been no cases of postoperative clot formation in this series of patients. The results of the study suggest that postoperative haematoma is probably an avoidable complication of intracranial surgery.     

Intraoperative hyperkalemia - initial sign of an incipient compartment syndrome?

We report the case of a 50 years old male patient who underwent an elective resection of the rectum in the Lloyd-Davis-position. During the surgery, first endoscopically and then by open laparatomy, which lasted 7.5 hours and the following postoperative time, plasma potassium concentration continuously increased up to 6.7 mval/l. On the first postoperative day, a compartment syndrome of the right lower limb was diagnosed.     

Is levosimendan an inoprotective drug in patients with acute coronary syndrome undergoing surgical revascularization?

Levosimendan, is a new calcium sensitiser with 2 major effects. First, levosimendan acts as a positive inotropic agent by binding calcium dependently to cardiac troponin C. Second, levosimendan activates adenosine triphosphate-regulated potassium (K (ATP)) channels. Thus it has vasodilatory properties and cardioprotective effects at a dose enhancing myocardial contractility. These unique properties of levosimendan might be of great advantage in patients with myocardial ischemia simultaneously requiring inotropic support. The concept of perioperative inoprotection is presented in 6 patients with acute ischemia undergoing emergent cardiac surgery.     

Is acute appendicitis a surgical emergency?

Urgent appendectomy has become the basis of management for acute appendicitis because of the disparity in morbidity and mortality rates between perforated and nonperforated appendicitis. Immediate surgery results in the confirmation of diagnosis and the control of sepsis without the risk of recurrent appendicitis. However, when notified by the emergency room of the diagnosis, many surgeons are opting to begin antibiotics and intravenous fluids and to schedule the appendectomy at their convenience. We hypothesize that using intravenous antibiotics and hydration to delay appendectomy until "normal business hours" has a negative impact on patient morbidity and mortality. During a 23-month period, the medical records of 81 patients at a single institution who underwent appendectomy were reviewed. All patients had preoperative CT scans and all operations were performed by one of two surgeons. Group A included those patients who underwent appendectomy within 10 hours of CT diagnosis and group B included those appendectomies performed greater than 10 hours after diagnosis. Wound complications, antibiotic use, total analgesic requirements, length of operation, and hospital length of stay were used for comparison. The average time to operation (3.18 vs 15.85 hours), operative time (54.1 vs 55.7 minutes), length of stay (2.65 vs 2.09 days), wound infections (4 vs 0), and antibiotic use at discharge (19 vs 3) for group A and B were not statistically different. This data suggests that delaying operative intervention for acute appendicitis to accommodate a surgeon's preference or to maximize a hospital's efficiency does not pose a significant risk to the patient.