Increase In Intra-abdominal Pressure Research Articles

S3122 Portal Vein Thrombosis Post Laparoscopic Sleeve Gastrectomy

Introduction: Portal vein thrombosis (PVT) is a clot formation in one of the branches of the portal vein. It is a well-known complication in patients with cirrhosis or post-abdominal surgery. Data on PVT post laparoscopic bariatric surgeries are scarce. Here we present a case of PVT post laparoscopic sleeve gastrectomy. Case Description/Methods: A 43- years-old female with a known past medical history of hypertension, Asthma, and obesity underwent a robotic-assisted laparoscopic sleeve gastrectomy. She presented to the Emergency Department (ED) complaining of Abdominal pain 2 days after the sleeve gastrectomy operation. The patient reported doing well postoperatively till 2 days when she developed sudden epigastric abdominal pain and generalized abdominal discomfort, associated with nausea and anorexia. On arrival at the ED, her vital signs were stable and liver enzymes were normal. She had RUQ tenderness on the physical exam without guarding or rebound. The patient then had a Computed tomography (CT) of the abdomen and pelvis with IV contrast which showed occlusive left portal vein thrombosis extending to branches. She was started on oral direct Anticoagulant (DOAC) with Rivaroxaban. She had complete hypercoagulable work up with hematology which was unremarkable (Figure 1). Discussion: PVT is a well-described complication of cirrhosis. in non-cirrhotic patients, the etiology of PVT can be due to systemic or local factors. A hypercoagulable state such as Factor V Leiden, antithrombin III deficiency, protein C and S deficiency, or Methylenetetrahydrofolate reductase (MTHFR) mutation is associated with higher thrombosis risk. Local factors include direct manipulation of portosystemic vessels such as during splenectomy with resultant endothelial damage and increase vascular thrombogenicity. A gastric sleeve is less likely to cause PVT since it only involves the short gastric vein. However, with the use of laparoscopic surgical techniques, there has been an increase in reported PVT. It is suspected that an increase in intra-abdominal pressure during carbon dioxide insufflation causes a pro-thrombotic state by decreasing venous and portal blood flow. The diagnosis of PVT post-operatively requires a high level of suspicion and can be made with abdominal imaging such as Ultrasound with color doppler or CT with IV contrast. The treatment is usually anticoagulation with the goal of recanalization of the portal vein on repeat imaging to prevent the development of non-cirrhotic portal hypertension in these patients.Figure 1.: Color doppler showing left portal vein thrombosis.

Physiotherapy exercise protocol of pelvic floor muscles for young female athletes with urinary incontinence

Intense physical activity or certain branches of sport have many health benefits but can also have harmful effects on the pelvic floor. In medical literature, intensive exercise is mentioned as a risk factor for urinary incontinence by loss of anticipated cushion contraction during physical exertion, impairment of pelvic muscle tone and strength, lack of pelvic floor muscle relaxation, which may lead to muscle exhaustion, all of this causing a lack of response during the rapid increase of intra-abdominal pressure. This study aims to design a recovery protocol to reduce or eliminate symptoms of urinary incontinence in young female athletes affected by this condition through a complex approach to the rehabilitation of pelvic floor muscle tone and strength and specific training programmes to create a “perineal blockage”, the automatic contraction of pelvic floor muscles during physical exertion and relaxation at rest, the correction of both lumbar posture and muscle imbalance in the abdominal-lumbo-pelvic (core) area. The case studies included two patients, young female athletes aged 15 and 20, suffering from urinary incontinence. The methods used were: literature review, observation, questionnaire survey (Contilife questionnaire), graphical method, mathematical and statistical method. The results show that the symptoms of involuntary urine leakage have disappeared from the physiotherapy treatment of patients and their quality of life has increased. However, it is recommended that this exercise protocol be continued at home or introduced to sports training at least once a week to maintain the outcome and prevent recurrence.

Edema formation in congestive heart failure and the underlying mechanisms.

Congestive heart failure (HF) is a complex disease state characterized by impaired ventricular function and insufficient peripheral blood supply. The resultant reduced blood flow characterizing HF promotes activation of neurohormonal systems which leads to fluid retention, often exhibited as pulmonary congestion, peripheral edema, dyspnea, and fatigue. Despite intensive research, the exact mechanisms underlying edema formation in HF are poorly characterized. However, the unique relationship between the heart and the kidneys plays a central role in this phenomenon. Specifically, the interplay between the heart and the kidneys in HF involves multiple interdependent mechanisms, including hemodynamic alterations resulting in insufficient peripheral and renal perfusion which can lead to renal tubule hypoxia. Furthermore, HF is characterized by activation of neurohormonal factors including renin-angiotensin-aldosterone system (RAAS), sympathetic nervous system (SNS), endothelin-1 (ET-1), and anti-diuretic hormone (ADH) due to reduced cardiac output (CO) and renal perfusion. Persistent activation of these systems results in deleterious effects on both the kidneys and the heart, including sodium and water retention, vasoconstriction, increased central venous pressure (CVP), which is associated with renal venous hypertension/congestion along with increased intra-abdominal pressure (IAP). The latter was shown to reduce renal blood flow (RBF), leading to a decline in the glomerular filtration rate (GFR). Besides the activation of the above-mentioned vasoconstrictor/anti-natriuretic neurohormonal systems, HF is associated with exceptionally elevated levels of atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP). However, the supremacy of the deleterious neurohormonal systems over the beneficial natriuretic peptides (NP) in HF is evident by persistent sodium and water retention and cardiac remodeling. Many mechanisms have been suggested to explain this phenomenon which seems to be multifactorial and play a major role in the development of renal hyporesponsiveness to NPs and cardiac remodeling. This review focuses on the mechanisms underlying the development of edema in HF with reduced ejection fraction and refers to the therapeutic maneuvers applied today to overcome abnormal salt/water balance characterizing HF.

Abdominal fascia dehiscence: is there a connection to a special microbial spectrum?

IntroductionAcute fascia dehiscence (FD) is a threatening complication occurring in 0.4–3.5% of cases after abdominal surgery. Prolonged hospital stay, increased mortality and increased rate of incisional hernias could be following consequences. Several risk factors are controversially discussed. Even though surgical infection is a known, indisputable risk factor, it is still not proven if a special spectrum of pathogens is responsible. In this study, we investigated if a specific spectrum of microbial pathogens is associated with FD.MethodsWe performed a retrospective matched pair analysis of 53 consecutive patients with an FD after abdominal surgery in 2010–2016. Matching criteria were gender, age, primary procedure and surgeon. The primary endpoint was the frequency of pathogens detected intraoperatively, the secondary endpoint was the occurrence of risk factors in patients with (FD) and without (nFD) FD.ResultsIntraabdominal pathogens were detected more often in the FD group (p = 0.039), with a higher number of Gram-positive pathogens. Enterococci were the most common pathogen (p = 0.002), not covered in 73% (FD group) compared to 22% (nFD group) by the given antibiotic therapy. Multivariable analysis showed detection of Gram-positive pathogens, detection of enterococci in primary laparotomy beside chronic lung disease, surgical site infections and continuous steroid therapy as independent risk factors.ConclusionRisk factors are factors that reduce wound healing or increase intra-abdominal pressure. Furthermore detection of Gram-positive pathogens especially enterococci was detected as an independent risk factor and its empirical coverage could be advantageous for high-risk patients.

Impact of lidocaine on hemodynamic and respiratory parameters during laparoscopic appendectomy in children

We assessed the influence of systemic lidocaine administration on ventilatory and circulatory parameters, and the pneumoperitoneum impact on the cardiopulmonary system during a laparoscopic appendectomy in children. A single-center parallel single-masked randomized controlled study was carried out with 58 patients (3–17 years). Intravenous lidocaine bolus of 1.5 mg/kg over 5 min before induction of anesthesia followed by lidocaine infusion at 1.5 mg/kg/h intraoperatively. Respiratory system compliance (C, C/kg), Ppeak-PEEP and Pulse rate (Pulse), systolic, diastolic and mean blood pressure (NBPs, NBPd, NBPm), assessed in the Lidocaine and Control group, at the: beginning (P1), minimum lung compliance (P2) and at the end of surgery (P3) were compared. The respiratory/hemodynamic parameters did not differ between the groups at any stage of operation. Blood Pressure and Ppeak-PEEP were significantly higher at the P2 compared to P1 and P3 stages (P < 0.001, 1 − β ≥ 0.895) that correlated with lung compliance changes: C/kg vs. NBPs and Ppeak-PEEP (− 0.42, − 0.84; P < 0.001); C vs. Pulse and Ppeak-PEEP (− 0.48, − 0.46; P < 0.001). Although an increase in intraabdominal pressure up to 12(15) mmHg causes significant changes in hemodynamic/respiratory parameters, there appears to be no risk of fatal reactions in 1E, 2E ASA patients. Systemic lidocaine administration doesn’t alleviate circulatory/respiratory alterations during pneumoperitoneum. No lidocaine related episode of anaphylaxis, systemic toxicity, circulatory disturbances or neurological impairment occurred.ClinicalTrials.gov: 22/03/2019.Trial registration number: NCT03886896.

Intraabdominal pressure as a marker for physiologic and pathologic processes in pregnancy

ABSTRACT Increased intraabdominal pressure (IAP) can result in compression of the abdominal-pelvic venous system leading to signs and symptoms of end organ dysfunction. It has been hypothesized as a pathophysiologic process of preeclampsia. We aim to evaluate the role of IAP in normotensive vs preeclamptic, and singleton vs twin pregnancies. We hypothesized that IAP would be higher in preeclamptics and twins. Women undergoing scheduled cesarean delivery were enrolled in four groups: Singletons- Preeclamptic and Normotensive, Twins- Preeclamptic and Normotensive. Elevated IAP was seen in singleton pregnancies with preeclampsia, representing a pathologic process; and in all twin pregnancies, suggesting a physiologic process.

Assessment of changes in intra-abdominal pressure and abdominal perfusion pressure in late-term pregnant queens undergoing elective ovariohysterectomy.

Compare changes in intra-abdominal pressure (IAP), abdominal perfusion pressure (APP), hemodynamics, and clinicopathological variables in nonpregnant and late-term pregnant queens undergoing elective ovariohysterectomy (OHE) and evaluate the effect of patient positioning on IAP and APP measurements. 18 late-term pregnant queens and 25 nonpregnant controls. Temperature, heart rate (HR), Doppler blood pressure (DBP), IAP (dorsal and right lateral), PCV, total protein (TP), and lactate were recorded preoperatively, at abdominal wall closure (dorsal IAP only), and postoperatively under general anesthesia. Uterine weight, blood loss, and surgical duration were recorded. Abdominal perfusion pressure was calculated as DBP minus IAP. Pre- and postoperatively, pregnant queens had lower DBP, APP, and PCV compared to controls (P < 0.001). IAP was higher in pregnant queens preoperatively (P < 0.001). Controls had a decrease in HR and increase in IAP, while both groups had a decrease in body temperature, DBP, APP, and lactate over time (P < 0.05). Pregnant queens had a decrease (P = 0.029), and controls had an increase in TP (P = 0.001). Blood loss and surgical time were greater for pregnant queens (P < 0.001). Dorsal IAP and APP were higher and lower than right lateral measurements (P < 0.001), respectively, and correlation was strong. Hemodynamics and APP are impaired in late-term pregnant queens undergoing OHE, and increased monitoring is warranted. Although strongly correlated, feline IAP and APP measurements in dorsal and right lateral recumbency are not interchangeable.

Pre-Clinical Validation of A Novel Continuous Intra-Abdominal Pressure Measurement Equipment (SERENNO)

Introduction: Increased intra-abdominal pressure (IAP) has an important impact on morbidity and mortality in critically ill patients. The SERENNO Sentinel system (Serenno Medical, Yokne’am Illit, Israel) is a novel device that allows automatic and continuous IAP measurements. Aims: Pre-clinical validation in a bench model study comparing the new device with the gold standard method and two other continuous IAP measurement devices. Methods: IAP measurement with the novel SERENNO device (IAPSER) was compared with the gold standard IAPH2O (water column height) and two other automatic and continuous IAP measurement devices: IAPCiM measured via the CiMON device (Pulsion Medical Systems, Munich, Germany) and IAPSPIE measured using the Spiegelberg device (Spiegelberg, Hamburg, Germany), which previously received the CE mark for clinical applications. The IAP measurement was performed six times (n = 6) at each pressure value (between 0 and 35 mmHg) with different methods and the height of the water column in a bench-top phantom was used as the reference IAP for further interpretations. In addition to the quadruple comparisons, intra- and inter-observer variability of IAP measurements were also calculated. Correlation studies and Bland and Altman’s analyses were performed in addition to the concordance study. Results: The CiMON and Spiegelberg devices showed a greater dynamic range and standard deviation when recording IAPCiM and IAPSPIE compared with IAPSER. In general, the maximum and minimum values of IAP recorded with each device (at each level of IAPH2O) were significantly different from each other. However, the average values were in very good agreement. The highest correlation was observed between IAPSER and IAPH2O, and IAPSER and IAPSPIE (R = 0.99, p = 0.001 for both comparisons and intra- and inter-observer measurements). Although the CiMON and SERENNO systems were in very good agreement with each other, a slightly smaller correlation coefficient was found between them (R = 0.95, p = 0.001, and R = 0.96, p = 0.001 for intra- and inter-observer measurements, respectively). When compared to the gold standard (IAPH2O), Bland and Altman’s analysis showed a mean difference of +0.44, −0.25, and −0.04 mmHg for the intra-observer measurements and +0.18, −0.75, and −0.58 mmHg for the inter-observer measurements for IAPSER, IAPCiM, and IAPSPIE, respectively. IAPSER showed a small positive bias (overestimation), while IAPCiM and IAPSPIE showed a negative bias (underestimation) when compared to IAPH2O. Further statistical analysis showed a concordance coefficient of 100% with an excellent ability of the SERENNO system in tracking IAPH2O changes. Conclusions: Pre-clinical validation of a new IAP monitoring device (SERENNO) showed very promising results when compared with the gold standard and other continuous techniques; however, clinical trials should be followed as the next stage of the validation process. Based on the actual research guidelines, the SERENNO system can be used interchangeably with the gold standard.

Advantages of using nanomodified polypropylene mesh in the surgical treatment of postoperative large abdominal hernia

Surgical treatment of large postoperative abdominal hernias (PAH) with the use of classic techniques of allogeneoplasty (sublay, onlay) is often accompanied by an increase in intra-abdominal pressure (IAP) and a decrease in the volume of the abdominal cavity, which in the postoperative period leads to abdominal compartment syndrome (ACS). 2.4 - 3.6% of cases and mortality in 1.2 - 3.4% of observations [1, 2]. This requires a special method of closing a large defect of the abdominal wall, which would not increase IAP. The use of the method of dividing the anatomical components of the anterior abdominal wall according to the modified technique of Ramirez operation in combination with sublay alloplasty contributes to the creation of the optimal volume of the abdominal cavity and improves the results of treatment, in particular, the frequency of ACS decreases [3, 4, 5]. However, the use of a combined operation with a classic polypropylene mesh leads to a high frequency of complications from the postoperative wound, such as seroma (30.8 - 60.4%), suppuration of the postoperative wound (4.8 - 6.4%), ligature fistula (1 .2 - 3.0%), meshoma (0.06 - 1.60%) [6, 7]. One of the causes of postoperative wound complications is the development of aseptic inflammation of the tissues of the abdominal wall as a result of their contact with the classic polypropylene mesh. Long-term aseptic inflammation of the subcutaneous base, muscles, aponeurosis, and fascia inhibits the process of germination of the polypropylene mesh by the connective tissue, which leads to its shrinkage, and in the case of infection, to the migration of the mesh and recurrence of the hernia. In our opinion, the use of a modified polypropylene mesh with an antiseptic of polyhexamethyleneguanidine chloride and carbon nanotubes in combination with a modified technique of the Ramirez operation will make it possible to improve the results of operative treatment of PAH.&#x0D; Aim – to improve the results of surgical treatment of large postoperative abdominal hernias (PAH) by using a modified technique of the Ramirez operation in combination with «sublay» alloplasty using a modified polypropylene mesh.&#x0D; Materials and methods. An analysis of the surgical treatment of 164 patients with large-sized PAH was performed. Depending on the type of mesh implant used during operative treatment, the patients were divided into two groups. In 82 (50%) patients of group I, surgery was performed according to the modified Ramirez technique in combination with «sublay» alloplasty using a modified polypropylene mesh, in group II, 82 (50%) patients underwent surgery according to the modified Ramirez technique in combination with «sublay alloplasty using classic polypropylene mesh.&#x0D; Results and discussion. Statistically significantly better results were obtained in patients of group I compared to group II. The duration of inpatient treatment in group I was (7.0±1.0) days, in group II – (12.0±2.2) days.&#x0D; Conclusion. Operative treatment of large PAH using the modified technique of the Ramirez operation, combined with the «sublay» technique using the modified polypropylene mesh, is much more effective compared to the use of the classic polypropylene mesh, which was evidenced by a decrease in the frequency of postoperative complications.

Modern possibilities for the prevention of pelvic organ prolapse

In the practice of an obstetrician-gynecologist, the problem of pelvic organ prolapse is increasingly being raised. Symptoms of pelvic organ prolapse are noted from a young age, gradually progressing and reducing the patient’s quality of life. Various surgical methods of treatment also don’t solve the problem of prolapse. The recurrence rate after correction of prolapse with own tissues reaches 40%, and operations using mesh implants have a number of specific complications, the fight against which sometimes becomes more difficult than primary intervention. Despite the steady increase in the prevalence of the disease, effective methods of dealing with it have not yet been developed. Also, the tactics of managing patients at the initial stage of prolapse, when there are complaints, but they are not given enough attention, both by the doctor and the patient, are not defined. The main risk factors for the disease are: perineal ruptures during childbirth, episiotomy, menopause, repeated pregnancies and childbirth, polyhydramnios, multiple pregnancy, fetal macrosomia, conditions accompanied by a chronic increase in intraabdominal pressure, heavy physical labor, impaired innervation and circulation of the pelvic floor, genetic predisposition, hysterectomy and connective tissue dysplasia. The review is devoted to the causes and methods of prevention of pelvic organ prolapse at the present stage. Methods such as pelvic floor muscles training, including in the biofeedback mode using vaginal simulators, electrical impulse stimulation, high-intensity focused electromagnetic stimulation, and non-ablative Er:YAG laser therapy are considered. A systematic literature search was carried out using Scopus, web of Science, MedLine, PubMed and eLibrary data base system.

Valsalva Retinopathy: A Case Report

Valsalva retinopathy is characterised by pre-retinal haemorrhage which presents with unilateral, sudden, painless diminution of vision. Pre-retinal haemorrhage caused by sudden rise in venous pressure was first termed as Valsalva haemorrhage by Duane TD in 1972. It is caused by rupture of superficial retinal capillaries due to increased intra-ocular venous pressure following increase in intra-thoracic or intraabdominal pressure. It resolves in few weeks or month and vision returns to normal depending on the location of the bleed on the retina. Observation, Nd:YAG (neodymium-doped yttrium aluminium garnet) laser and Argon laser hyaloidotomy, vitrectomy are effective treatment options for eyes with Valsalva retinopathy. Here we present a case of a 32 year old female with Valsalva retinopathy with subhyaloid haemorrhageafter an episode of vomiting who was treated with Nd:YAG laser hyaloidotomy with a good visual outcome.The novelty of this case report lies in the fact that although conservative management is practiced more often with similar prognosis, early intervention by Nd:YAG laser hyaloidotomycan benefit the patient with marked improvement and rapid recovery. Key words: Valsalva retinopathy, subhyaloid haemorrhage, Nd:YAG laser hyaloidotomy.

The Relationship Between Nutritional Status with Post Dural Puncture Headache Incident in Sectio Caesarea Patients with Spinal Anesthesi

Background: Post dural puncture headache (PDPH) is one of the most common complications of spinal anesthesia caused by leakage of cerebrospinal fluid (CSS) after anesthesia procedures. One of the factors that influence the incidence of PDPH is nutrional status where obese patients tend not to experience PDPH. This is based on an increase intraabdominal pressure in obese patients which can reduce CSF leakage in the epidural space. Purpose: Purpose of this study to determine whether there was a relationship between nutritional status and post dural puncture headache incident in sectio caesarea patients with spinal anesthesia at Aliyah 2 Hospital. Methods: This study used an observational analytic study with a cross sectional approach carried out at Aliyah 2 Hospital. The number of samples in this study was 51 people who were taken using total sampling technique. Data collection was obtained from medical records and filling out observation sheets for post-sectio caesarea patients with spinal anesthesia and then analyzed using the Fisher’s Exact Test. The dependent variable in this study was PDPH and the independent variables was the nutrional status. Result: This study showed that nutritional status (p = 0.007) had a significant relationship with the incidence of PDPH at Aliyah Hospital 2. Conclusion: From this study it could be concluded that the incidence of PDPH after spinal anasthesia is higher in patients with low BMI.

Diastasis recti abdominis (DRA): review of risk factors, diagnostic methods, conservative and surgical treatment

Diastasis recti abdominis (DRA) is an acquired condition defined as a thinning, widening and protruding of the linea alba following an increase in intra-abdominal pressure. The aim of this review is to provide insight in the pathophysiology, risk factors, diagnostic methods and treatment modalities of DRA. DRA occurs in both women and in men, however, it is extraordinarily common and even expected condition affecting over half of women during pregnancy and one third 12 months after childbirth. There is no consensus of risk factors for DRA. Proposed risk factors include multiparity, maternal age and high age, caesarean section, macrosomia, multiple pregnancy, ethnicity, heavy lifting, body mass index (BMI) and diabetes. To diagnose the presence of DRA and its severity the interrecti distance (IRD) is measured. Palpation, caliper, ultrasound, computed tomography (CT) and magnetic resonance (MR) are applied to measure IRD and exclude concurrent hernias. DRA is mostly treated conservatively by physiotherapists. However, physiotherapy is unlikely to prevent or completely treat DRA. Over four fifth of patients are unsatisfied with the results of training programmes and opted for surgical intervention. Thereby the main purpose of physical training is to restore function, not to reduce the DRA. Physiotherapy may be an alternative for those who cannot undergo surgery. In case if severe cosmetic and functional impairment patients are referred for surgery. Patients with severe symptoms benefit more from surgery. Surgery is challenging since guidelines almost do not exist. Plication and mesh reinforcement are recommended by most authors, however whether it should be open or laparoscopic remains debatable.

New aspects in cardiorenal syndrome and HFpEF.

ABSTRACTCardiorenal syndrome (CRS) is a complex disease in which the heart and kidneys are simultaneously affected, and subsequently, the malfunction of one organ promotes the deterioration of the other. Heart failure (HF) with preserved ejection fraction (HFpEF) is the most common form of HF. The pathophysiology of CRS is not well known and several mechanisms have been proposed. An elevation of central venous pressure seems to be one of the key points to consider, among others such as an increase in intraabdominal pressure. Several diagnostic tools have been identified to establish the diagnosis of CRS in patients with HFpEF. Currently, the availability of biomarkers of renal and cardiac injury, the use of pulmonary ultrasound, the monitoring of the size of the inferior vena cava and the study of the renal venous pattern offer a new dimension in accurately diagnosing and quantifying organ damage in CRS. Beyond the symptomatic treatment of congestion, until recently specific therapeutic tools for patients with CRS and HFpEF were not available. Interestingly, the development of new drugs such as the angiotensin/neprilysin inhibitors and sodium-glucose cotransporter-2 (SGLT-2) inhibitors offer new therapeutic strategies with potential benefits in reduction of cardiorenal adverse outcomes in this population. Randomized clinical trials that focus on patients with HFpEF are currently ongoing to delineate optimal new treatments that may be able to modify their prognosis. In addition, multidisciplinary teamwork (nephrologist, cardiologist and nurse) is expected to decrease the number of visits and the rate of hospitalizations, with a subsequent patient benefit.

MO1003: Role of Tacrolimus Trough Levels on Intra-Abdominal Pressure After Kidney Transplantation

Abstract BACKGROUND AND AIMS Increased intra-abdominal pressure (IAP) is common after kidney transplantation (KT). However, the role of potential transplant-specific predictors of this complication, such as tacrolimus-associated endothelial dysfunction, remains unclear. We aimed to describe the relationship between tacrolimus trough levels and IAP in a sample of incident KT patients. METHOD Single-centre prospective cohort of deceased-donor KTs. Anesthesia, surgical technique and immunosuppression induction therapy were the same in all cases. IAP monitoring was performed according to WSACS guidelines using the urinary bladder technique (UnoMeter Abdo-Pressure kit). IAP values were registered every 8h during the first 72 h after surgery or until reoperation. Mean IAP values during the first 7 2h (72 h-IAP) were used in this analysis. The first measured tacrolimus trough levels after transplantation were included as a potential predictor of IAP. Patients without recorded tacrolimus trough levels during the first 7 days after surgery were excluded. The study was approved by the local ethics committee. RESULTS A total of 192 patients were enrolled in the study. Table 1A summarizes relevant patient and haemodynamic variables. Subjects with more severe intra-abdominal hypertension were more commonly males, with longer dialysis vintage, higher BMI and suffered diabetes more frequently. Multivariate linear regression analysis was used to examine potential predictors of 72 h-IAP, including male sex, months on dialysis, body mass index (BMI) (Table 1B), 72 h-fluid balance and tacrolimus trough levels. Recipient age, months on dialysis, BMI and tacrolimus trough levels were independent predictors of 72 h-IAP. CONCLUSION Tacrolimus-associated endothelial dysfunction may play a role in the increase of IAP after transplantation. In contrast, accumulated fluid balance, one of the strongest predictors of IAP in the ICU setting, failed to predict IAP values in our sample. These results offer new insight both into the pathophysiology of increased IAP and into the complex mechanisms of tacrolimus-associated nephrotoxicity in the early post-transplant period.

Evaluation of lung ventilation distribution using electrical impedance tomography in standing sedated horses with capnoperitoneum

ObjectiveTo determine changes in distribution of lung ventilation with increasing intra-abdominal pressure (IAP) from carbon dioxide (CO2) insufflation in standing sedated horses. Study designProspective experimental study. AnimalsA group of six healthy adult horses. MethodsEach horse was sedated with acepromazine, detomidine and butorphanol and sedation maintained with a detomidine infusion. The horse was restrained in a stocks system and a 32 electrode electrical impedance tomography (EIT) belt was wrapped around the thorax at the fifth–sixth intercostal space. EIT images and arterial blood samples for PaO2 and PaCO2, pH and lactate concentration were obtained during capnoperitoneum at 0 (baseline A), 5, 8 and 12 mmHg as IAP increased and at 8, 5, 0 (baseline B) mmHg as IAP decreased. At each IAP, after a 2 minute stabilization period, EIT images were recorded for ≥ 2 minutes to obtain five consecutive breaths. Statistical analysis was performed using anova for repeated measures with Geisser-Greenhouse correction and a Tukey’s multiple comparison test for parametric data. The relationship between PaO2 and the center of ventilation in the ventral-dorsal (CoV-VD) and right-left (CoV-RL) directions or total impedance change as a surrogate for tidal volume (ΔZVT) were tested using linear regression analysis. Significance was assumed when p ≤ 0.05. ResultsThere were no significant changes in CoV-VD, CoV-RL, PaO2, PaCO2, lactate concentration, pH, heart rate and respiratory rate with targeted IAP. There was a significant decrease in ΔZVT compared with baseline A at 5 mmHg IAP as IAP was increased. Conclusions and clinical relevanceCapnoperitoneum causes a significant decrease in ΔZVT in standing sedated horses with increasing IAP.

Validity and reliability of a novel, non-invasive tool and method to measure intra-abdominal pressure in vivo

Intra-abdominal hypertension has been recorded in between 20 and 50% of intensive care unit patients, with rates increasing in ventilated patients. This increased intra-abdominal pressure (IAP) can reduce blood flow to vital organs, perpetuating further pressure build-up as organs become unable to drain excess fluids. Measurement of IAP for the diagnosis of intra-abdominal hypertension remains highly invasive, thus, a non-invasive alternative to traditional IAP measurement was developed and validated, herein. Fourteen living participants and 13 cadaveric specimen were tested with this novel device for IAP measurement. Living participant results were compared to published IAP averages, while cadavers were tested against the existing gold standard: intra-vesical pressure (IVP). Intra- and inter-rater reliability in both living and cadaveric tests presented excellent results. Convergent validity against published IAP values was also excellent (in living participants) and moderate (in cadavers), while convergent validity against IVP was inconclusive. These promising results support the interest in further research, particularly with IVP comparisons in living participants.

Internal herniation of the right colon through the foramen of Winslow: A case report.

Introduction and importanceHerniation through the Foramen of Winslow, also known as the epiploic foramen, is an extremely rare phenomenon with less than 200 cases reported in medical literature. Internal hernias account for less than 1% of all hernias and roughly 8% of all internal hernias occur through the foramen of Winslow. We present a case of a foramen of Winslow hernia that was not detected until direct visualization with laparoscopy.Presentation of caseA 52 year-old healthy female with a surgical history of a Caesarean section presented to the ER with severe epigastric pain radiating to her back. Physical exam was positive for abdominal tenderness and guarding. Vital signs were within normal limits. Murphy’s sign and Rovsing’s sign were negative. Initial imaging studies, including a CT scan of the abdomen, and laboratory findings were unremarkable. A hepatobiliary iminodiacetic acid (HIDA) scan was performed and demonstrated non-visualization of the gallbladder suggestive of acute vs. chronic cholecystitis. Following these results the patient elected to undergo exploratory laparoscopy with potential cholecystectomy. Intra-operatively, the colon was noted to be herniated through the foramen of Winslow. The procedure was converted to an open laparotomy. The hernia was manually reduced, and a right hemicolectomy was performed to prevent recurrence of the hernia.DiscussionReports list an enlarged foramen of Winslow, excessive viscera mobility (i.e., persistent ascending mesocolon or long small bowel mesentery), and an increase in intra-abdominal pressure as potential risk factors for this particular hernia. In our case, the patient was noted to have excessive mobility of the viscera with the presence of persistent ascending mesocolon and an abnormally long right mesentery. Physical exam is usually nonspecific and laboratory findings are typically unremarkable, posing a diagnostic challenge. Additionally, radiological findings indicating presence of an internal hernia were missed in the initial CT scan read by the radiologist. Internal hernias need to be managed surgically as there is a risk of strangulation with bowel ischemia.ConclusionThis rare radiographic phenomenon is difficult to diagnose radiographically and warrants further workup due to the potential risk of bowel strangulation despite negative clinical and laboratory findings.

Separation plasty in the treatment of large and giant postoperative hernias of the anterior abdominal wall

Introduction. Surgical treatment of patients with large and giant ventral hernias presents significant difficulties. The occurrence of an extensive defect of the anterior abdominal wall entails severe disorders of the functioning of internal organs and systems due to the lack of abdominal function. Significant progress in providing care to patients with large and giant postoperative hernias of the anterior abdominal wall occurred after Novitsky.W. et al. proposed in 2012 posterior separation plastic surgery of the abdominal wall (TAR-transversus abdominis release).The aim of the study was to present the operative technology and the results of surgical treatment of large and giant postoperative hernias of the anterior abdominal wall.Materials and methods. 158 TAR (transversus abdominis release) was performed for postoperative hernias of the anterior abdominal wall. Patients with large and giant postoperative hernias of the anterior abdominal wall W3 – 42 (26.8%) and W4 – 113 (71.5%) prevailed according to the classification of J. P. Chevrel and A.M. Rath, 1999. The modified posterior separation plastic surgery was performed by separating all the muscles of the anterior abdominal wall. The medial edges of the internal oblique muscles were fixed to the mesh implant in order to create an attachment point. With an increase in intra-abdominal pressure, the transverse abdominal muscle was partially or completely crossed. The intersected transverse abdominal muscle with the internal oblique muscle was also fixed to a mesh implant. Two groups of patients were compared: those operated by the TAR (transversus abdominis release) method and by the developed modified technology.Results. The main task of the modified plastic surgery of the anterior abdominal wall – the maximum preservation of the anatomical and functional state of the transverse abdominal muscle – was performed by refusing to cross it or creating new fixation points for its crossed parts (patent for invention No. 2715095 of 27.11.2019). There are no statistically significant differences in the degree of complications according to the Clavien – Dindo criteria in group I and II, although there is a degree V complication in the second group. The greatest number of postoperative complications is observed in patients with obesity of 2-3 degrees. The total mortality rate was 0.6%. Discussion. The indisputable advantage of the TAR (transversus abdominis release) technique is the possibility of a significant increase in the volume of the abdominal cavity and, as a result, the prevention of intraabdominal hypertension and abdominal compartment syndrome. It is difficult to assess in detail the shortcomings of the technique in samples from 30 to 42 patients, but it is still established that the stage of hernioplasty in the form of the intersection of the transverse abdominal muscle determines the subsequent dysfunction of the abdominal muscles, with the formation of a barrelshaped abdomen, reduces the quality of life. The operative technology proposed by us is an anatomically and functionally justified direction of modification of the Novitsky Y. W. et al. technique, which allows preserving the physiological attachment of the transverse abdominal muscle, preventing its atrophy and, thereby, reducing the number of relapses and improving the quality of life of the patient.Conclusions. The modified separation plastic surgery of the anterior abdominal wall in large and giant ventral hernias has advantages in terms of the anatomical and functional state of the muscles of the anterior abdominal wall compared to the method of Novitsky. W. et al, and there were no significant differences in complications according to the Clavien – Dindo criteria in the studied groups.

INDICATIONS AND RESULTS OF PREVENTIVE MINIMALLY INVASIVE SURGICAL DECOMPRESSION IN INTRAPERITONEAL HYPERTENSION IN PATIENTS WITH STERILE PANCREATIC NECROSIS WITH CARDIAC AND PULMONARY COMORBIDITY

Resume. Intra-abdominal hypertension (IBH) in patients with sterile pancreatic necrosis (SP) leads to the formation of abdominal compartment syndrome (ACS) in 6-8 96. The most vulnerable in this regard are patients with cardiac and pulmonary comorbidity (CLC). Difficulties in predicting the development of ACS in most cases do not allow making a timely decision on surgical decompression, which leads to delayed surgical treatment and associated high mortality. Objective: to develop and conduct a clinical evaluation of a method for determining indications for preventive minimally invasive surgical decompression in IBH in patients with SP with cardiac and pulmonary comorbidity. Materials and methods. Prospective cohort studies were performed in 84 patients with sterile pancreatic necrosis with CLC, of which 40 patients were in the main group and 44 in the comparison group. Results and discussion. IBH I-II art. was formed in the main group in 32 (80 %) patients, in the comparison group in 34 (77 %). In 10 (29,4 %) patients from group for comparison, ACS developed, while in all 5 (5/22 - 22,7 %) patients with IBH of the first art., it was not possible to diagnose the syndrome in vivo. Categorically, it became possible to verify ACS only in 5 (5/12 - 41,6 %) patients with type II IBH, however, delayed surgical decompression in 60 % (3 out of 5) cases led to mortality. In the main group of patients with SP with CLC, the developed method for determining indications for preventive surgical decompression in IBH I-II art., allowed to prevent the development of ACS in 34 % (11 out of 32) patients, to reduce the number of intraoperative complications by 43 %, and the minimally invasive variant of operations reduced the number of early postoperative complications by 75 %. Conclusions. The developed method for determining indications for preventive minimally invasive surgical decompression in patients with SP with CLC allowed to reduce the mortality associated with an increase in intra-abdominal pressure by more than 2 times, and the overall mortality by 5,5 %.