Laparotomy For Abdominal Compartment Syndrome Research Articles

Characteristics and Outcome Analysis for Intensive Care Patients Undergoing Decompressive Laparotomy for Abdominal Compartment Syndrome: Impact of Extracorporeal Membrane Oxygenation Support

(1) Background: Abdominal compartment syndrome (ACS) is a life-threatening situation and is associated with high mortality in the intensive care unit (ICU). Decompressive laparotomy represents the last therapeutic option. This cohort study aims to optimize the selection of ICU patients suffering from ACS who benefit from decompressive laparotomy. (2) Methods: All available data from adult patients treated at the 12 ICUs of a university hospital between 2011 and 2019 were included. Outcome parameters for patients with and without extracorporeal membrane oxygenation (ECMO) were compared. (3) Results: 207 ICU patients with ACS undergoing surgery were identified. Laparotomy resulted in immediate improvement of organ functions in 15% of patients, who then survived more frequently. The overall mortality rate in our cohort was 69%. The group of ECMO patients—including va- and vv-ECMO—showed significantly less organ function improvement and a higher mortality rate of 79% compared to a better postoperative improvement and a lower mortality rate of 62% in non-ECMO patients. (4) Conclusions: There are ICU patients who benefit from decompressive laparotomy—nevertheless, mortality is high. Non-ECMO patients have a better prognosis than ECMO patients. Our findings can support clinical decision-making on emergency surgery and the development of future guidelines.

P-108 MARJOLIN'S ULCER AS A COMPLICATION OF UNRESOLVED OPEN ABDOMEN

Abstract Introduction Marjolin's ulcer (MU) is a rare cutaneous tumour, commonly associated with chronic wounds with difficult healing. We present a case of UM diagnosed on a persistent unresolved open abdominal closure wound. Materials and Methods 80-year-old male with a history of ruptured infrarenal aortic aneurysm (2010) that required aorto-unifemoral repair. Postoperative period requiring decompressive laparotomy for abdominal compartment syndrome and treated with negative pressure therapy, and impossibility of definitive abdominal closure due to abdominal muscle retraction. Loss of outpatient follow-up for 10 years. Consultation for worsening of the surgical wound with abdominal pain. Examination revealed abdominal incisional hernia M2–4W3 and large abdominal ulcer. Biopsies positive results for squamous cell carcinoma with infiltrative pattern. A computed tomography describes an abdominal wall mass of 14×6×11cm and space-occupying lesion in the left hepatic lobe. Liver biopsy showed a moderately differentiated hepatocarcinoma. Surgical management consist in intramuscular injection of botulinum toxin and en bloc resection of granulation and ulcerated tissue and ileal loop attached to the lesion. Wall reconstruction with anterior separation of components and supraponeurotic mesh. Conclusions Marjolin's ulcer is associated with squamous cell carcinoma with a high rate of metastasis and mortality. This tumour is considered infrequent, of long-term duration and associated with developing societies. In our environment, this neoplasia can develop in patients with open abdomen treated partially or with closure by second intention, so we consider it necessary to have a high index of diagnostic suspicion in these cases and to perform biopsies for its detection.

Early Decompressive Laparotomy for Intra-Abdominal Hypertension Following Initiation of Venovenous Extracorporeal Membrane Oxygenation.

Patients supported with venovenous extracorporeal membrane oxygenation are at risk for intra-abdominal hypertension and abdominal compartment syndrome. Flow through the return cannula may be compromised in these patients, resulting in inadequate support and end-organ malperfusion. Early decompressive laparotomy can mitigate these complications and potentially improve outcomes. Here we review a series of nine patients undergoing early decompressive laparotomy for abdominal compartment syndrome at a single institution and propose an algorithmic approach to the management of these patients.

2 cases of hemostatic suture in decompressive laparotomy for abdominal compartment syndrome after transcatheter arterial embolization of ruptured visceral artery aneurysm

2 cases of hemostatic suture in decompressive laparotomy for abdominal compartment syndrome after transcatheter arterial embolization of ruptured visceral artery aneurysm

GUILLAIN-BARRÉ SYNDROME AS A COMPLICATION OF EXTRACORPOREAL MEMBRANE OXYGENATION

SESSION TITLE: Critical Care Devices SESSION TYPE: Med Student/Res Case Report PRESENTED ON: 10/23/2019 8:45 AM - 9:45 AM INTRODUCTION: Extracorporeal membrane oxygenation (ECMO) is considered the highest form of life support. Despite its expanded use and improved success, adverse issues including hemostatic, thrombotic and hemolysis still occur at high rates. Guillain-Barre syndrome (GBS), a demyelinating polyneuropathy, is not documented in the literature as an adverse issue. We present a case of massive pulmonary embolism (PE) requiring ECMO complicated by GBS. CASE PRESENTATION: A 54-year-old female with a history of breast cancer in remission, deep vein thrombosis formerly on rivaroxaban, discontinued after cancer remission, presented with acute onset severe chest pain. She was in severe respiratory distress, tachycardic and in shock. She was intubated with cardiac arrest soon after, with successful resuscitation. Computed-tomography angiography (CTA) scan confirmed massive bilateral PE and she was administered tenecteplase. Her hemodynamics worsened necessitating maximal vasopressor support. Labs showed an acute drop in hematocrit from 32% to 14% with increasing abdominal distension, rigidity and decreased bowel sounds alarming for compartment syndrome. Bedside ultrasound revealed signs of retroperitoneal bleed, an adverse effect of tenecteplase. Despite massive transfusion protocol, she continued to worsen necessitating venous-arterial ECMO to support cardiogenic shock. Within 30 minutes of ECMO support, vasopressors were weaned and underwent exploratory laparotomy for abdominal compartment syndrome. She remained on ECMO for 17 days with improvement. While on ECMO, she developed progressive ascending lower extremity weakness. Lumbar puncture was done, with a WBC of 0, Glucose 107 mg/dL and Protein 77 mg/dL with cytoalbumincytologic dissociation. Magnetic resonance imaging showed diffuse nerve root and cord enhancement, findings consistent with GBS. She subsequently received full treatment of intravenous immunoglobulin with improvement in her symptoms. DISCUSSION: GBS has a pathogenesis related to aberrant immune response against the peripheral nervous system. Infections are known to be a cause, but there is literature about surgery as a potential trigger, often spinal surgery. One study cited an attributable risk of 4.1 cases per 100000 surgeries with most attributed to spinal surgery. To our knowledge this is the first case of GBS with ECMO exclusive of preceding infection. Initiation of ECMO is associated with an immediate inflammatory reaction. As blood enters the circuit, levels of pro-inflammatory cytokines increase causing leukocyte activation. Simultaneously, there is antigen release and autoimmunization to antigens, similar to GBS in surgical patients. CONCLUSIONS: As ECMO patients are critically ill, they are more prone to develop critical care neuropathy. It is important that in patients with neuromuscular weakness in the setting of ECMO use, that GBS be amongst the differential of critical care neuropathy. Reference #1: Dowling JR, Dowling TJ. A Rare Axonal Variant of Guillain-Barré Syndrome following Elective Spinal Surgery. Case Rep Orthop. 2018;2018:2384969. Published 2018 Aug 7. https://doi.org/10.1155/2018/2384969 Reference #2: Millar JE, Fanning JP, McDonald CI, McAuley DF, Fraser JF. The inflammatory response to extracorporeal membrane oxygenation (ECMO): a review of the pathophysiology. Crit Care. 2016;20(1):387. https://doi.org/10.1186/s13054-016-1570-4. DISCLOSURES: No relevant relationships by Abhas Khurana, source=Web Response No relevant relationships by Gaurav Manek, source=Web Response No relevant relationships by Varun Tandon, source=Web Response No relevant relationships by Aysha Tandon, source=Web Response

Decompressive laparotomy for abdominal compartment syndrome resulting from severe acute pancreatitis: a case report

BackgroundAbdominal compartment syndrome (ACS) is associated with mortality in patients with critical illness such as severe acute pancreatitis, but it remains unclear whether decompressive laparotomy for ACS can improve the prognosis of patients.Case presentationA woman in her 60s visited our hospital because of upper abdominal pain. On the basis of her laboratory data and abdominal contrast-enhanced computed tomography findings, acute gallstone pancreatitis was diagnosed. She underwent endoscopic sphincterotomy for the removal of the common bile duct stone. Then, a drainage tube was placed in the bile duct. However, on the 5th hospital day, her intra-abdominal pressure increased to 22 mmHg and renal dysfunction was observed, which led to the diagnosis of ACS. As intensive medical treatments did not improve her ACS, she underwent decompressive laparotomy on the 9th hospital day. Postoperatively, her laboratory data and intravesical pressure improved, and she was discharged from the hospital after abdominal closure, continuous drainage, and antibiotic therapy.ConclusionAs the effectiveness of decompressive laparotomy for ACS has not been established, this treatment indication remains controversial. Decompressive laparotomy is considered useful for the management of ACS, if it is performed at an appropriate time, as in the present case.

Decompressive Laparotomy for Abdominal Compartment Syndrome Following Transcatheter Arterial Embolization of a Ruptured Splenic Artery Aneurysm : Report of A Case

Decompressive Laparotomy for Abdominal Compartment Syndrome Following Transcatheter Arterial Embolization of a Ruptured Splenic Artery Aneurysm : Report of A Case

Decompressive laparotomy for abdominal compartment syndrome in patient on extracorporeal life support: A first survival case among adults with literature review

Here, we report a case of successful treatment for a patient with abdominal compartment syndrome who was on venoarterial extracorporeal life support. A 33-year-old man visited the emergency room with cardiac arrest. Extracorporeal cardiopulmonary resuscitation was performed, and massive volume infusion was needed to maintain adequate perfusion pressure. After 6 h, his abdomen was distended, and venous drain was decreased. His bladder pressure was more than 25 mm Hg. Abdominal compartment syndrome was suspected, and prompt decompressive laparotomy was performed to restore venous drain, resulting in stabilization hemodynamically. The patient made a full recovery. He was discharged after implantation of internal cardiac defibrillator.

Caring for critically injured children: An analysis of 56 pediatric damage control laparotomies.

Injury is the leading cause of death in children under 18 years. Damage control principles have been extensively studied in adults but remain relatively unstudied in children. Our primary study objective was to evaluate the use of damage control laparotomy (DCL) in critically injured children. An American College of Surgeons-verified Level 1 trauma center review (1996-2013) of pediatric trauma laparotomies was undertaken. Exclusion criteria included: age older than 18 years, laparotomy for abdominal compartment syndrome or delayed longer than 2 hours after admission. Demographics, mechanism, resuscitation variables, injuries, need for DCL, and outcomes were evaluated. Independent t test, Mann-Whitney U test, Fisher's exact test, and single-factor analysis of variance assessed statistical significance. Study endpoints were hospital survival and DCL complications. Of 371 children who underwent trauma laparotomy, the median age (IQR; LQ-UQ) age was 16 (5; 11-17) years. Most (73%) were male injured by blunt mechanism (65%). Fifty-six (15%) children (Injury Severity Score [ISS], 33 (25; 17-42), pediatric trauma score 5 (6; 2-8), penetrating abdominal trauma index score [PATI] 29 (32; 12-44)) underwent DCL after major solid organ (63%), vascular (36%), thoracic (38%) and pelvic (36%) injury. DCL patients were older (16.5 (4; 14-18) vs. 16 (7; 10-17)) and were more severely injured (ISS, 33 [25; 17-42] vs. 16 [16; 9-25]), requiring greater intraoperative packed red blood cell transfusion (8 [13; 3.5-16.5] vs. 1 (0; [0-1] units) than definitive laparotomy counterparts. Nonsurvivors arrived in severe physiologic compromise (base deficit, 17 [17; 8-25] vs. 7 [4; 4-8]), requiring more frequent preoperative blood product transfusion (67% vs. 10%) after comparable injury (ISS survivors, 36 [23; 18-41] vs. nonsurvivors 26 (7; 25-32), p = 0.8880). Fifty-five percent of DCL patients survived (length of stay, 26 [21; 18-39] days) requiring 3 (2; 2-4) laparotomies during 4 (6; 2-8) days until closure (fascial, 90%; vicryl/split thickness skin grafting, 10%). DCL complications (surgical site infection, 18%; dehiscence, 2%; enterocutaneous fistula, 2%) were analyzed. When stratified by age (<15 years vs. 15-18 years) and period (1996-2006 vs. 2007-2013), no differences were found in injury severity or DCL outcomes (p > 0.05). After controlling for DCL, age, and gender, multivariate analysis indicated only ISS (odds ratio, 1.10 [95% confidence interval, 1.01 - 1.19], p = 0.0218) and arrival systolic blood pressure (odds ratio, 0.96 [95% confidence interval, 0.93-0.99], p = 0.0254) predicted mortality after severe injury. DCL is a proven, lifesaving surgical technique in adults. This report is the first to analyze the use of DCL in children with critical abdominal injuries. With similar survival and morbidity rates as critically injured adults, DCL merits careful consideration in children with critical abdominal injuries. Therapeutic study, level IV.

TCTAP C-171 Successful Decompressive Laparotomy for Abdominal Compartment Syndrome After EVAR Due to Ruptured Abdominal Aortic Aneurysm

TCTAP C-171 Successful Decompressive Laparotomy for Abdominal Compartment Syndrome After EVAR Due to Ruptured Abdominal Aortic Aneurysm

Decompressive laparotomy for abdominal compartment syndrome.

BackgroundThe effect of decompressive laparotomy on outcomes in patients with abdominal compartment syndrome has been poorly investigated. The aim of this prospective cohort study was to describe the effect of decompressive laparotomy for abdominal compartment syndrome on organ function and outcomes.MethodsThis was a prospective cohort study in adult patients who underwent decompressive laparotomy for abdominal compartment syndrome. The primary endpoints were 28‐day and 1‐year all‐cause mortality. Changes in intra‐abdominal pressure (IAP) and organ function, and laparotomy‐related morbidity were secondary endpoints.ResultsThirty‐three patients were included in the study (20 men). Twenty‐seven patients were surgical admissions treated for abdominal conditions. The median (i.q.r.) Acute Physiology And Chronic Health Evaluation (APACHE) II score was 26 (20–32). Median IAP was 23 (21–27) mmHg before decompressive laparotomy, decreasing to 12 (9–15), 13 (8–17), 12 (9–15) and 12 (9–14) mmHg after 2, 6, 24 and 72 h. Decompressive laparotomy significantly improved oxygenation and urinary output. Survivors showed improvement in organ function scores, but non‐survivors did not. Fourteen complications related to the procedure developed in eight of the 33 patients. The abdomen could be closed primarily in 18 patients. The overall 28‐day mortality rate was 36 per cent (12 of 33), which increased to 55 per cent (18 patients) at 1 year. Non‐survivors were no different from survivors, except that they tended to be older and on mechanical ventilation.ConclusionDecompressive laparotomy reduced IAP and had an immediate effect on organ function. It should be considered in patients with abdominal compartment syndrome.

Decompressive laparotomy for abdominal compartment syndrome in children on ECMO: Effect on Support and Survival

PurposeAbdominal compartment syndrome (ACS) may complicate ECMO due to significant fluid shifts resulting in tense ascites and interstitial edema. This compromises venous cannula flow leading to inadequate patient support. It is debatable whether decompressive laparotomy should be performed in these patients due to the risk of bleeding and poor prognosis. We sought to evaluate the effect of decompressive laparotomy on ECMO support and patient survival. MethodsWe reviewed our tertiary care children's hospital ECMO registry (2000–2011) identifying those who underwent decompressive laparotomy. All had ACS as characterized by abdominal hypertension with abdominal distention, hemodynamic instability, oliguria, rising central venous pressures, and inadequate venous return to the ECMO circuit. Physiologic parameters immediately before and 60min after laparotomy were compared using a signed rank test. ResultsSeven patients were identified. ACS developed within 8h of initiating ECMO in 6 patients. Decompressive laparotomy resulted in significant improvement of patient physiologic parameters and ECMO venous return. One patient had significant bleeding following laparotomy. There were no survivors but three were organ donation candidates after stabilization via decompressive laparotomy. ConclusionDecompressive laparotomy for ACS in patients on ECMO markedly improves support and tissue perfusion. While in our series ECMO complicated by ACS carries a poor prognosis, we cannot confidently define this as futile therapy due to the limited sample size.

Curativo à vácuo para cobertura temporária de peritoneostomia

The advances in patient care with trauma or severe intra-abdominal infections, brought important gains in survival with the use of peritoneostomies. But the management of patients brought a difficult problem: the primary closure without tension of the abdominal cavity. To present a proposal for temporary coverage of peritoneostomies in patients undergoing damage control laparotomy or decompressive laparotomy for abdominal compartment syndrome. Isolation of the small intestine loops from abdominal internal; coverage of the intestinal surface with a polyethylene film multiperforated with sterile scissors or scalpel blade, to prevent direct contact with the foam. It is placed below the edges of the defect between the parietal and visceral peritoneum. Over it, a polyurethane sterile foam is fixed to the edges, leaving the defect tension free to the vacuum be applied. Another coverage with a plastic adhesive polyester impregnated with iodine stuck to skin is done, and, at the end, is added a drainage continuous aspiration system. The dressing is changed between three and five days. It was used successfully in four patients with primary closure of the abdominal cavity after seven to 21 days. Of these, three had open abdomen after laparotomy for trauma (two due to damage control and one for lack of primary closure); the fourth had been previously submitted to decompressive laparotomy for abdominal compartment syndrome. The vacuum dressing proved to be good choice for temporary coverage of peritoneostomies allowing faster closure of the abdominal wound, reducing the number of reoperations and providing protection against bacterial contamination of the intestinal loops.

Abdominal Compartment Syndrome is an Early, Lethal Complication of Acute Pancreatitis

Data defining the optimal management of abdominal compartment syndrome resulting from acute pancreatitis are lacking. We investigated the outcomes of patients with acute pancreatitis who underwent surgery for treatment of abdominal compartment syndrome at a tertiary referral center. An electronic database was searched to identify patients with acute pancreatitis who underwent laparotomy between January 1, 2000, and December 31, 2009, for treatment of abdominal compartment syndrome. Twelve patients underwent decompressive laparotomy for abdominal compartment syndrome. The median interval between onset of pancreatitis and laparotomy was 4.5 days. Nine patients underwent a laparotomy within seven days of onset of pancreatitis. As a result of cardiopulmonary instability, four decompressive laparotomies were performed in the intensive care unit. In 11 patients, cardiopulmonary improvement was observed. Statistically significant improvements were seen across multiple physiologic parameters. Despite this initial improvement, six patients (50%) died from multisystem organ failure. Two patients survived without need for pancreatic débridement. Abdominal compartment syndrome is an uncommon but likely underrecognized and highly lethal complication of acute pancreatitis that should be considered in patients who become critically ill early in the course of their pancreatitis. Prompt recognition and decompressive laparotomy may rescue some of these patients and does not mandate future débridement.

Failure of both suction catheter passage and bronchoscopy to diagnose an obstructing tracheal mucus plug

To the Editor, The patient’s spouse gave informed consent for publication of this report. A 55-yr-old male sustained burns in a welding accident extending caudad from shoulder level over 65% of his body surface area. In the intervening two months, he required multiple surgeries, including debridement and skin grafting, a laparotomy for abdominal compartment syndrome, and a tracheostomy. Presenting on this occasion for further skin grafting, he was breathing easily and spontaneously through a size 8 fenestrated Shiley tracheostomy cannula (Covidien, Mansfield, MA, USA) capped with a decannulation plug. In the operating room, the fenestrated inner cannula was exchanged for a non-fenestrated tube. Shortly after this change, the patient indicated some dyspnea. A suction catheter was introduced and moderate amounts of sputum were obtained, after which the patient signalled at least partial relief. Following application of routine monitors, anesthesia was induced using sevoflurane in oxygen through a circle system connected to the tracheostomy tube, supplemented with midazolam 2 mg and propofol 30 mg iv. After induction, it was almost impossible to ventilate the patient’s lungs. We detected a markedly prolonged expiratory phase and made a working diagnosis of severe bronchospasm although minimal rhonchi were present. We administered rocuronium 50 mg iv, increased the inspired sevoflurane concentration to 4%, and administered salbutamol, magnesium sulphate, and small doses (50–100 lg) of intravenous epinephrine. Although the oxygen saturation remained [ 90%, little improvement was achieved in response to these measures. An 18-Fr suction catheter was introduced on at least three further occasions. Each time, a scant amount of sputum was obtained, but no improvement in ventilation resulted. We twice passed a fibreoptic bronchoscope, but saw no obvious impediment to ventilation, and the tracheobronchial tree looked normal. Interestingly, when the tracheostomy tube was disconnected from the circuit for suctioning or bronchoscopy, we observed the patient’s chest gradually fall with loud yet slow gas egress from the tracheostomy cannula, suggesting gas escaping under conditions of high intrathoracic pressure. Following each such thoracic decompression, ventilation was easier for the next two or three positive pressure inspirations. Eventually, an inspiratory:expiratory (i:e) ratio of about 1:10 was observed to allow sufficient time for expiration, such that ventilation was now possible, albeit with ongoing high airway pressures. To rule out a circuit or machine problem, ventilation was assessed with a manual resuscitator, which confirmed that the high airway pressures originated from either the tracheostomy cannula or the patient. A portable chest radiograph showed only bilateral lung hyperinflation. Although substantially hypercarbic (PetCO2 up to 93 mmHg), fortunately, the patient suffered no cardiovascular instability. Ultimately, a change of tracheostomy was planned given the poor response to treatment for bronchospasm, ongoing problems with positive pressure ventilation, evidence of air trapping, and the initial history of dyspnea with tracheostomy manipulation. Repeat bronchoscopy was performed by a different clinician using a videobronchoscope. The visual field was briefly obscured as the videobronchoscope was advanced beyond the distal end of the tracheostomy cannula, after which a clear view of the trachea was observed. At this point, the possibility of cuff herniation was considered. Direct laryngoscopy prior to tracheostomy J. A. Law, MD (&) C. Mariotti, MD T. Mullen, MD Dalhousie University/QEII Health Sciences Centre, Halifax, NS, Canada e-mail: jlaw@dal.ca

Enterocutaneous Fistulas in the Setting of Trauma and Critical Illness

One of the most devastating complications to develop in the general surgical patient is an enterocutaneous fistula (ECF). Critically ill patients suffering trauma, thermal injury, infected necrotizing pancreatitis, and other acute intraabdominal pathology are at unique risk for this complication as well. By using decompressive laparotomy for abdominal compartment syndrome and leaving the abdomen open temporarily for other acute processes, survival in some instances may be improved. However, the exposed viscera are at risk for fistulization in the presence of an open abdomen, a newly defined entity termed the enteroatmospheric fistula (EAF). The purpose of this article is to describe the epidemiology of ECF in the setting of trauma and critical illness, nutrition in injured/critically ill patients with ECF, pharmacologic adjuncts to decrease fistula effluent, wound care, surgical management of the EAF/ECF, and techniques for prevention of these dreaded complications in patients with an open abdomen.

Decompressive laparotomy for abdominal compartment syndrome in children: before it is too late

Purpose Abdominal compartment syndrome (ACS) in children is an infrequently reported, rapidly progressive, and often lethal condition underappreciated in the pediatric population. This underrecognition can result in a critical delay in diagnosis causing increased morbidity and mortality. This study examines the clinical course of patients treated for ACS at our institution. Methods A review of children requiring an emergency laparotomy (n = 264) identified 26 patients with a diagnosis of ACS. ACS was defined as sustained intraabdominal hypertension (bladder pressure >12 mm Hg) that was associated with new onset organ dysfunction or failure. Results Patients ranged in age from 3 months to 17 years old and were cared for in the pediatric intensive care unit (PICU). Twenty-seven percent (n = 7) were transferred from referring hospitals, 50% (n = 13) were admitted directly from the emergency department, and 23% (n = 6) were inpatients before being transferred to PICU. Admission diagnoses included infectious enterocolitis (n = 12), postsurgical procedure (n = 10), and others (n = 4). Patients progressed to ACS rapidly, with most requiring decompressive laparotomy within 8 hours of PICU admission (range, <1-96 hours). Preoperatively, all patients had maximum ventilatory support and oliguria, 85% (n = 22) required vasopressors/inotropes, and 31% (n = 8) required hemodialysis. Mean bladder pressure was 25 mm Hg (range, 12-44 mm Hg). In 42% (n = 11), cardiac arrest preceeded decompressive laparotomy. All patients showed evidence of tissue ischemia before decompressive laparotomy with an average preoperative lactate of 8 (range, 1.2-20). Decompressive laparotomy was done at the bedside in the PICU in 13 patients and in the operating room in 14 patients. Abdominal wounds were managed with open vacuum pack or silastic silo dressings. Physiologic data including fluid resuscitation, oxygen index, mean airway pressure, vasopressor score, and urine output were recorded at 6-hour intervals beginning 12 hours before decompressive laparotomy and extending 12 hours after operation. The data demonstrate improvement of all physiologic parameters after decompressive laparotomy except for urine output, which continued to be minimal 12 hours post intervention. Mortality was 58% (n = 15) overall. The only significant factor related to increased mortality was bladder pressure ( P = .046; odds ratio, 1.258). Cardiac arrest before decompressive laparotomy, need for hemodialysis, and transfer from referring hospital also trended toward increased mortality but did not reach significance. Conclusion Abdominal compartment syndrome in children carries a high mortality and may be a consequence of common childhood diseases such as enterocolitis. The diagnosis of ACS and the potential need for emergent decompressive laparotomy may be infrequently discussed in the pediatric literature. Increased awareness of ACS may promote earlier diagnosis, treatment, and possibly improve outcomes.

Abdominal Compartment Syndrome After Hip Arthroscopy

As hip arthroscopy becomes a more common procedure, more complications may occur. We present a case of abdominal compartment syndrome resulting from fluid extravasation in a 42-year-old man who underwent routine hip arthroscopy for femoral acetabular impingement. He had not had previous surgeries to that hip, and arthroscopy was performed in the supine position. After adequate distraction, arthroscopy was performed with an automated pressure- and flow-controlled pump with the pressure maintained between 40 and 60 mm Hg. We performed debridement of a degenerative tear of the anterosuperior labrum, removal of a pincer lesion, and a psoas tenotomy through a capsular window. A distended abdomen was noted on drape removal, and the patient required decompressive laparotomy for abdominal compartment syndrome. Extravasation of arthroscopy fluid is a potentially devastating complication during hip arthroscopy, and there should be careful monitoring by the surgeons, anesthesiologists, and operating room staff.

Secondary abdominal compartment syndrome in a case of pediatric trauma shock resuscitation

To report a rare case of secondary abdominal compartment syndrome during shock resuscitation in a pediatric trauma patient. Case report and literature review. A community hospital and a designated children's trauma hospital. A 17-yr-old trauma patient. Advanced trauma life support, trauma laparotomy, and superficial temporal artery ligation. A 17-yr-old trauma patient with ongoing blood loss from a lacerated superficial temporal artery received aggressive crystalloid resuscitation before arrival at a designated trauma hospital. His injury severity score was 16. The first hemoglobin drawn was 55 g/L with a hematocrit of 0.16 L/L. Within 3 hrs of the trauma, an abdominal computed tomography scan demonstrated a moderate amount of free peritoneal fluid, edematous bowel with marked enhancement, and a compressed inferior vena cava. Shortly after completion of imaging studies, the patient's abdomen became increasingly tense with poor perfusion to the lower extremities. Urgent laparotomy for abdominal compartment syndrome identified excessive ascites and extensive bowel edema with no blood or traumatic injuries. Abdominal decompression resulted in immediate improvement of hemodynamics and restored lower limb perfusion. Primary abdominal closure was obtained and the patient recovered fully with gentle diuresis. Secondary abdominal compartment syndrome developed in this pediatric trauma patient with hemorrhagic shock, possibly from aggressive crystalloid resuscitation. This trauma case highlights the importance of early hemorrhagic control with balanced crystalloid/transfusion therapy. Secondary abdominal compartment syndrome in pediatric trauma is rare and may reflect physiologic differences during development, less aggressive resuscitation practices, and/or underrecognition.

One hundred percent fascial approximation with sequential abdominal closure of the open abdomen

Background Damage-control surgery and the recognition of the abdominal compartment syndrome have improved patient outcomes but at the cost of an open abdomen. Multiple techniques have been introduced to obtain fascial closure for the open abdomen to minimize morbidity and cost of care. We performed a modification of the vacuum-assisted closure (VAC) technique that provided constant fascial tension, hypothesizing this would result in a higher rate of primary fascial closure. Methods After initial temporary closure of the abdomen after post-injury damage control or decompressive laparotomy for abdominal compartment syndrome, we began the sequential closure technique. The technique begins by covering the bowel with the multiple white sponges overlapped like patchwork, and the fascia is placed under moderate tension over the white sponges with #1-PDS sutures. Large black VAC sponges are placed on top of the white sponges and affixed with an occlusive dressing and standard suction tubing is placed. Patients are returned to the operating room for sequential fascial closure and replacement of the sponge sandwich every 2 days, with a resulting decrease in the fascial defect. Results Fourteen patients underwent sequential abdominal closure during the study period: 9 owing to damage control surgery and 5 owing to secondary abdominal compartment syndrome. Average time to closure was 7.5 ± 1.0 days (range 4–16) and average number of laparotomies to closure was 4.6 ± 0.5 (range 3–8). All patients attained primary fascial closure. Conclusion We propose a modification of the previously described vacuum-assisted closure technique that achieves 100% fascial approximation in our limited experience. Further application and refinement of this technique may eliminate the need for delayed complex and costly reconstructive abdominal wall procedures for the open abdomen.