Abdominal Compartment Syndrome in Severe Acute Pancreatitis – When to Decompress?

Abstract

Intra-abdominal hypertension is increasingly reported in patients with severe acute pancreatitis, and is caused by several factors, including visceral edema and ascites associated with massive fluid resuscitation, paralytic ileus and retroperitoneal inflammation. There is a strong relation with early organ dysfunction and mortality in these patients, which makes intraabdominal hypertension an attractive target for intervention. Several reports conclude that this phenomenon occurs within the first 5 days after admission, and that the kinetics of IAH is important: patients with persistent IAH seem to be at the highest risk for mortality. Several strategies to reduce IAP have been developed, and given the pathophysiology, percutaneous drainage of ascites is a first logical step. However, if conservative measures fail to reduce IAP in a setting with ongoing or worsening organ dysfunction, abdominal decompression is recommended.

Laparostomy management using the ABThera™ open abdomen negative pressure therapy system in a grade IV open abdomen secondary to acute pancreatitis

“…While, decompressive laparotomy and resulting laparostomy have been shown to effectively reduce intra-abdominal pressure and symptoms of abdominal compartment syndrome (16), the timing and indicators for this remain an area of ongoing research. A recent review by De Waele et al suggests surgical decompression should be considered in all acute pancreatitis patients with intra-abdominal hypertension and persistent organ dysfunction after 3 days or later (17). In this case, rising intra-abdominal pressure accompanied by persistent two organ failure necessitated a laparostomy on day 5.…”

“…A recent review by De Waele et al . suggests surgical decompression should be considered in all acute pancreatitis patients with intra‐abdominal hypertension and persistent organ dysfunction after 3 days or later (17). In this case, rising intra‐abdominal pressure accompanied by persistent two organ failure necessitated a laparostomy on day 5.…”

Changes in the Management of Treatment in Acute Pancreatitis Patients

“…However, if conservative measures fail to reduce intra-abdominal pressure in a setting with ongoing or worsening organ dysfunction, abdominal decompression is recommended. Intra-abdominal hypertension and intra-abdominal compartment syndrome have been described most often in patients with abdominal trauma or after emergency abdominal surgical procedures such as aortic aneurysm repair (De Waele, 2008). The intra-abdominal hypertension is defined as a sustained or repeated pathologic elevation of the intraabdominal pressure above 12mm Hg.…”

“…Intra-abdominal pressure monitoring is mandatory for all patients who develop organ dysfunction, and intra-abdominal pressure should be a target for intervention when intra-abdominal hypertension and organ dysfunction persist. Surgical decompression should be considered in all patients with persistent organ dysfunction after 3 days or later (Sugrue et al, 2007;De Waele, 2008).…”

Focus on Emergency Surgery of the Pancreas

“…The indications for decompressive surgery, and the techniques and management of the ensuing open abdomen are challenging issues explored in this Focus on-issue that hopefully stimulates the discussion for future options and trends, and helps the readers in updating their knowledge in trauma and emergency surgery of the pancreas. I wish to express my gratitude to Dr. Subramanian [6], Dr. Feliciano [6], and Dr. De Waele [7] for their excellent contributions and thank for their support over the years.…”